Advances in radiology and pathology of prostate cancer: a review for the pathologist.

Multiparametric magnetic resonance imaging (mpMRI) has improved systematic prostate biopsy procedures in the diagnosis of clinically significant prostate cancer (csPCa) by reducing the number of unnecessary biopsies; numerous level one evidence studies have confirmed the accuracy of MRI-targeted biopsy, but, still today, systematic prostate biopsy is recommended to reduce the 15-20% false negative rate of mpMRI. New advanced imaging has been proposed to detect suspicious lesions and perform targeted biopsies especially when mpMRI cannot be performed. Transrectal ultrasound (TRUS) modalities are emerging as methods with greater sensitivity and specificity for the detection of PCa compared to the traditional TRUS; these techniques include elastography and contrast-enhanced ultrasound, as well as improved B-mode and Doppler techniques. These modalities can be combined to define a novel ultrasound approach: multiparametric ultrasound (mpUS). More recently, micro-ultrasound (MicroUS) and prostate-specific membrane antigen (PSMA) positron emission tomography/computed tomography (PET/CT) have demonstrated to be sensitive for the detection of primary prostatic lesions resulting highly correlated with the aggressiveness of the primary prostatic tumor. In parallel, artificial intelligence is advancing and is set out to deeply change both radiology and pathology. In this study we address the role, advantages and shortcomings of novel imaging techniques for Pca, and discuss future directions including the applications of artificial intelligence-based techniques to imaging as well as histology. The significance of these findings for the practicing pathologist is discussed.

Testicular torsion: an avascular testis at color Doppler ultrasound is not enough to prove the diagnosis.

INTRODUCTION: A Doppler ultrasound (US) of the scrotum is commonly used to improve the diagnostic confidence for testicular torsion in an emergency setting. However, the sensitivity of this investigation to identify torsion varies largely. This is due, in part, to a lack of guidelines on how-to perform the US and therefore training is necessary. EVIDENCE ACQUISITION: The Scrotal and Penile Imaging Working Group of the European Society of Urogenital Radiology (ESUR-SPIWG) and the Section of Urological Imaging of the European Association of Urology (ESUI) established a joint panel of experts to standardize Doppler US investigation of patients with testicular torsion. The panel reviewed the available literature, identified accumulated knowledge and limitations, and released recommendations on how-to perform Doppler US in patients with acute scrotal pain. EVIDENCE SYNTHESIS: Diagnosis of testicular torsion is based on clinical evaluation and investigation of the cord, the testis, and the paratesticular structures. A preliminary clinical evaluation, including history and palpation, is necessary. Grey scale US, color Doppler US and spectral analysis must be performed by a sonologist with at least level 2 competence. Modern equipment with adequate grey-scale and Doppler capabilities are required. CONCLUSIONS: Standardization of Doppler US in suspicious testicular torsion is presented, with the aim to obtain comparable results among different centres, prevent unnecessary operations, and improve patient management.

Efficacy and safety of adjustable balloons (Proact™) to treat male stress urinary incontinence after prostate surgery: Medium and long-term follow-up data of a national multicentric retrospective study.

AIMS: Male stress urinary incontinence (SUI) represents a complication after radical prostatectomy or benign prostatic obstruction surgery. The artificial urinary sphincter is considered the standard treatment but interest on minimally invasive devices, such as adjustable balloons, has recently increased. Aim of this study is to evaluate the efficacy and safety of the ProACT system. METHODS: In this multicentric retrospective study, we reported the data from nine centers. Patients with SUI who underwent a ProACT device implantation for postoperative SUI and had a minimum follow-up of 24 months were included. Efficacy was evaluated at the maximum available follow-up and was assessed utilizing a 24-hour pad test. Patients were considered: "Dry" if presenting a urine leak weight lower than 8 g at the 24-hour pad test; "Improved" if presenting a reduction of urine leak higher than 50% (but >8 g/24 hours); "Failure" if presenting a reduction in urine leak lower than 50%. The evaluation included a record of intraoperative and long-term complications. RESULTS: Safety and efficacy results are reported on 240 patients. 29.6% of patients were dry at 24 months, 37.5% were improved and 32.9% of patients were considered failures. The baseline mean pad weight of 367 g was reduced to 123 g at 24 months. Five-year follow-up on 152 patients showed similar efficacy. The complication rate was 22.5%, with the top complication being long-term balloon failure. CONCLUSIONS: ProACT implantation represents a safe and efficacious treatment for male postoperative SUI at both medium and long-term follow up. 67.1% of patients were dry or improved at 24 months. The majority of complications are low grade.

Italian Prostate Biopsies Group: 2016 Updated Guidelines Insights.

AIM: To present a summary of the updated guidelines of the Italian Prostate Biopsies Group following the best recent evidence of the literature. MATERIALS AND METHODS: A systematic review of the new data emerging from 2012-2015 was performed by a panel of 14 selected Italian experts in urology, pathology and radiology. The experts collected articles published in the English-language literature by performing a search using Medline, EMBASE and the Cochrane Library database. The articles were evaluated using a systematic weighting and grading of the level of the evidence according to the Grading of Recommendations Assessment, Development and Evaluation framework system. RESULTS: An initial prostate biopsy is strongly recommended when i) prostate specific antigen (PSA) >10 ng/ml, ii) digital rectal examination is abnormal, iii) multiparametric magnetic resonance imaging (mpMRI) has a Prostate Imaging Reporting and Data System (PIRADS) ≥4, even if it is not recommended. The use of mpMRI is strongly recommended only in patients with previous negative biopsy. At least 12 cores should be taken in each patient plus targeted (fusion or cognitive) biopsies of suspicious area (at mpMRI or transrectal ultrasound). Saturation biopsies are optional in all settings. The optimal strategy for reducing infection complications is still a controversial topic and the instruments to reduce them are actually weak. The adoption of Gleason grade groups in adjunction to the Gleason score when reporting prostate biopsy results is advisable. CONCLUSION: These updated guidelines and recommendations are intended to assist physicians and patients in the decision-making regarding when and how to perform a prostatic biopsy.

Experience of percutaneous access under ultrasound guidance in renal transplant patients with allograft lithiasis.

OBJECTIVE: Urolithiasis of the transplanted kidney has an incidence of 0.2 to 1.7%, it increases the risk of infection in immunosuppressed patients and it can lead to ureteral obstruction that is often associated with deterioration of renal function. Urolithiasis of the transplanted kidney has different characteristics compared to the native kidney, due to the absence of innervation, which does not lead to colic pain. Percutaneous approach is an optimal choice in transplant patients. MATERIAL AND METHODS: Here we report our experience in two cadaveric transplant patients with urolithiasis. The first case was a patient of 68 years with a 20 mm stone located in the transplanted kidney pelvis and another smaller in a lower calyx. The second case was a patient of 65 years with a 15 mm stone in the distal part of the transplanted ureter. In both cases the patients were asymptomatic, but they had a reduction in urine output associated with worsening of the transplanted kidney function. The diagnosis was performed in both cases with ultrasound study, showing a severe hydronephrosis and it was confirmed by computed tomography scan. In both cases, we performed a Percutaneous Nephrolithotomy (PCNL). Access was made after targeting the stone, through a lower pole puncture under ultrasound guidance. The first case was treated with pneumatic and laser energy, breaking stones through a nephroscope. In the second case we performed a laser lithotripsy of the ureteral stone, using a flexible videoureteroscope. At the end of both procedures a Double-J stent and a 14 Fr Malecot nephrostomy were positioned, that were removed at 6 weeks and 10 days, respectively. RESULTS: Both patients achieved a resolution of the worsening of renal function, recovering the spontaneous diuresis. The surgical procedure using ultrasound guidance was safe and allowed quick access to the renal pelvis. Both patients experienced no bleeding or infection during hospitalization. CONCLUSIONS: Percutaneous Nephrolithotomy (PCNL) is an established safe and effective surgical treatment option for larger renal calculi in renal allografts. The ultrasound guided access to the transplanted kidney in percutaneous treatment of urolithiasis is useful and fast, minimizing patient exposure to ionizing radiation.

Practical recommendations for performing ultrasound scanning in the urological and andrological fields.

AIM: US scanning has been defined as the urologist's stethoscope. These recommendations have been drawn up with the aim of ensuring minimum standards of excellence for ultrasound imaging in urological and andrological practice. A series of essential recommendations are made, to be followed during ultrasound investigations in kidney, prostate, bladder, scrotal and penile diseases. METHODS: Members of the Imaging Working Group of the Italian Society of Urology (SIU) in collaboration with the Italian Society of Ultrasound in Urology, Andrology and Nephrology (SIEUN) identified expert Urologists, Andrologists, Nephrologists and Radiologists. The recommendations are based on review of the literature, previously published recommendations, books and the opinions of the experts. The final document was reviewed by national experts, including members of the Italian Society of Radiology. RESULTS: Recommendations are listed in 5 chapters, focused on: kidney, bladder, prostate and seminal vesicles, scrotum and testis, penis, including penile echo-doppler. In each chapter clear definitions are made of: indications, technological standards of the devices, the method of performance of the investigation. The findings to be reported are described and discussed, and examples of final reports for each organ are included. In the tables, the ultrasound features of the principal male uro-genital diseases are summarized. Diagnostic accuracy and second level investigations are considered. CONCLUSIONS: Ultrasound is an integral part of the diagnosis and follow-up of diseases of the urinary system and male genitals in patients of all ages, in both the hospital and outpatient setting. These recommendations are dedicated to enhancing communication and evidence-based medicine in an inter- and multi-disciplinary approach. The ability to perform and interpret ultrasound imaging correctly has become an integral part of clinical practice in uro-andrology, but intra and inter-observer variability is a well known limitation. These recommendations will help to improve reliability and reproducibility in uro-andrological ultrasound scanning.

Predictive value of resistive index in graft survival after kidney transplant.

INTRODUCTION: The intrarenal resistance index (RI) is a calculated parameter for the assessment of the status of the graft during the follow-up ultrasound of the transplanted kidney. Currently it is still unclear the predictive value of RI, also in function of the time. MATERIALS AND METHODS: We retrospectively investigated the correlation between the RI and the graft survival (GS) and the overall survival (OS) after transplantation. We evaluated 268 patients transplanted between 2003 and 2011, the mean followup was 73 months (12-136). The RI was evaluated at 8 days, 6 months, 1 year and 3 years. The ROC analysis was used to calculate the predictive value of RI and the Kaplan Mayer curves was used to evaluated the OS and PS. RESULTS: The ROC analysis, correlated to the GS, identified a value of RI equal to 0.75 as a cut-off. All patients was stratified according to the RI at 8 days (RI ≤ 0,75: 212 vs RI > 0.75: 56), at 6 months (RI ≤ 0.75: 237 vs RI > 0.75: 31), at 1 year (RI ≤ 0.75: 229 vs RI > 0.75: 39) and at 3 years (RI ≤ 0.75: 224 vs RI > 0.75: 44). The RI showed statistically significant differences between the two groups in favor of those who had an RI ≤ 0.75 only at 8 days and at 6 moths (p = 0.0078 and p = 0.02 to 8 days to 6 months) on the GS. On the contrary, we observed that the RI estimated at 1 year and 3 years has not correlated with the GS. The same RI cut-off was correlate with PS after transplantation. We observed that there are no correlations between the RI and OS. CONCLUSIONS: The RI proved to be a good prognostic factor on survival organ when it was evaluated in the first months of follow- up after transplantation. This parameter does not appear, however, correlate with OS of the transplanted subject.

Incidentally detection of non-palpable testicular nodules at scrotal ultrasound: what is new?

The increased use of ultrasound in patients with urological and andrological symptoms has given an higher detection of intra-testicular nodules. Most of these lesions are hypoechoic and their interpretation is often equivocal. Recently, new ultrasound techniques have been developed alongside of B-mode and color-Doppler ultrasound. Although not completely standardized, contrast-enhanced ultrasound (CEUS) and tissue elastography (TE), added to traditional ultrasonography, can provide useful information about the correct interpretation of incidentally detected non-palpable testicular nodules. The purpose of this review article is to illustrate these new techniques in the patient management.

Burned-out in a mixed germ cell tumor of the testis: the problem of pT0. Case report.

Germ cell tumors constitute the majority of all testicular tumors, which are relatively rare overall and are mainly encountered in young adults and teenagers. The term 'burned-out' germ cell tumor refers to the presence of a metastatic germ cell tumor with histological regression of the primary testicular lesion. Clinical examination of the testes and scrotal sonography is the initial diagnosis of such neoplasms. We report an unusual case of a burned-out testicular tumor with metastases to retroperitoneal lymphnodes in an asymptomatic patient with right testicular hypoechoic nodule associated with multiple calcifications of the testicular parenchyma.

Ultrasonographic findings in dual kidney transplantation.

INTRODUCTION: Organ shortage has led to using grafts from expanded criteria donors (ECD). Double kidney transplantation is an accepted strategy to increase the donor pool, using organs from an ECD which are not acceptable for single kidney transplantation (SKT). Aim of this retrospective study was to analyse the role of colour Doppler ultrasound (CDUS) in the diagnosis of major surgical complications in DKT, performed with unilateral or bilateral placement. MATERIALS AND METHODS: From 2000 to 2011 we performed 54 DKT. Unilateral placement of both kidneys was done in 26 patients and bilateral DKT in 28, through two separate Gibson incisions (18) or one midline incision (10). Each patient underwent at least 3 CDUS before hospital discharge. The main surgical complications, discovered initially thanks to ultrasound (US), were hydronephrosis from ureteral obstruction, lymphocele and deep venous thrombosis (DVT). RESULTS: Mean follow-up was 42.7 months. Good postoperative renalfunction was demonstrated in 25 patients (46.3%), while delayed graft function occurred in 29 (53.7%). US showed ureteral obstruction requiring surgery in 5 unilateral DKT while no patient subjected to bilateral DKT developed severe hydronephrosis. Lymphoocele, surgically drained, was demonstrated in 6 bilateral DKT with a midline incision, 2 bilateral DKT with two separate incisions and 3 unilateral DKT. CDUS also enabled diagnosis of 2 cases of DVT in ipsilateral DKTs. CONCLUSIONS: CDUS provides useful information in patients with DKT, allowing the detection of clinically unsuspected unilateral diseases. US study of our patients demonstrated that unilateral DKTs are more susceptible to the development of DVT and ureteral stricture, while the incidence of voluminous lymphocele is more frequent in bilateral DKT through a single midline incision. In this scenario, all patients undergoing DKT should be carefully monitored by US after surgery.

Modifications of the bladder wall (organ damage) in patients with bladder outlet obstruction: ultrasound parameters.

INTRODUCTION: Progressive changes in the bladder wall are observed in men with lower urinary tract obstruction secondary to benign prostatic enlargement (BPE). The high pressure voiding causes initially an increase in the proportion of smooth muscle (hyperplasia/hypertrophy of the detrusor) that develops to major changes in the advanced stages of bladder decompensationi (fibrosis), hyperactivity and decreased functional capacity. Early identification of bladder changes by noninvasive transabdominal ultrasound can suggest therapeutic choices that can prevent further organ damage in the bladder wall. Aim of our study is to review ultrasound (US) parameters, that could be considered reliable and reproducible, in order to demonstrate the damage of the bladder wall. METHODS: We performed a literature review to detect reported US parameters according to our aims. Our clinical experience was evaluated in retrospective manner to detect feasibility and limitations of the evaluation of these parameters in men with different degrees of bladder damage secondary to BPE. RESULTS: Measurement of the bladder wall thickness (BWT) or detrusor wall thickness (DWT) by US is reliable, with at least 3 measurements of the anterior bladder wall taken at a filling volume of 250 ml. In particular, the DWT [thickness of the hypoechoic muscle between two hyperechoic layers corresponding to serosa and mucosa] is considered the best diagnostic tool to measure detrusor hypertrophy using cut-off value > 2.9 mm in men. US derived measurements of bladder weight (Estimated Bladder Weight, EBW) is another noninvasive tool for assessing bladder modifications in patients with bladder outlet obstruction (BOO) with a cut-off value of 35 gr. Technique for measuring the BWT and EBW relies on conventional US 7.5-4 MHz using the automatic system of computation (BVM 6500 3.7 MHz). The variability of intra-operator (4.6 to 5.1%) and interoperator measurements (12.3%) is acceptable. Also conventional US detects established signs of bladder damage: diverticulosis, trabecolations in the bladder wall (pseudo-diverticula), calculi and post-void residual urine (PVR) (> 50 cc). Furthermore the Intravescical Prostate Protrusion (IPP), easy measured by transabdominal ultrasound, is strongly correlated to obstruction in men with BPE (cut-off 12 mm). Measurement, scoring and monitoring of the cervico-urethral obstruction in men with symptomatic BPE is possible by the non-invasive US of the bladder wall. Early identification by measuring DWTand EBW in addition to established US paremeters has the advantage of suggest the adoption of therapeutic measures sufficient to prevent progression of bladder damage. CONCLUSIONS: US derived measurements of DWT and EBW are reproducible and reliable. Transabdominal US also detect established bladder damage such as diverticula, stones and PVR, while IPP measurement seems to be correlated to BOO. US bladder parameters are considered potential noninvasive clinical tools for baseline assessment of patients with BOO. In particular noninvasive US parameters could be useful for longitudinal studies monitoring men with lower urinary tract obstruction secondary to BPE.

Value of the resistive index in patient and graft survival after kidney transplant.

INTRODUCTION: The resistive index (RI) obtained by performing doppler sonography is a hemodynamic index commonly used to measure flow resistance within an organ to assess if there is a vascular disease associated with that organ. It is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values on patient and graft survival, as well as kidney graft function during 5-year follow-up. MATERIALS AND METHODS: We retrospectively investigated 761 kidney transplant recipients from cadaveric donors performed between 1998 to 2011. RI was measured at hospital discharge after the kidney transplant. All the patients were divided into tertiles, according to the baseline RI value (group 1: RI < 0.70, group 2: RI between 0.70 and 0.79 and group 3: RI > 0.80). RESULTS: Patients with a low RI (<0.70) showed the lowest incidence of delayed graft function (DGF) compared to the other two groups (20.2% vs. 32.2% vs. 33%). Recipients with low RI values displayed significantly better creatinine clearance (70 vs. 55 vs 35 ml/min, respectively) than those with medium or high RI values at 5-year follow-up. Kaplan-Meier estimates of cumulative graft survival were significantly worse in patients who had a RI of 0.70 or more than in patients with a RI of less than 0.70 (p = 0.02). Cumulative patient survival showed the same behavior (0.01) CONCLUSIONS: Low RI values measured in segmental arteries in the very early post-transplant period predict better kidney graft function and reduce the risk of all-cause graft loss, including patient death in a 5-year follow-up period.

Ureteral strictures after kidney transplantation: risk factors.

INTRODUCTION: Ureteral obstruction is one of the most commonly reported urological complications after kidney transplantation often occurring within the first 3 months after surgery. Ischemia is the most frequent cause of ureteral stenosis and is the result of excessive hilar dissection and a poor anastomotic technique. Aim of this study was to identify the main risk factors for ureteral stenosis after kidney transplantation from cadaveric donors and to assess their impact on both graft survival and patient. MATERIALS AND METHODS: We retrospectively investigated 761 kidney transplants from cadaveric donors performed between 1998 to 2011. In all the patients, the ureteroneocystostomy was stented with a double J stent 4.7Ch x 12 cm held in place for an average time of 4-6 weeks post-operatively. Each patient underwent at least 3 ultrasound scans during hospital stay and subsequently during follow-up. All patients with severe hydronephrosis were followed by sequential renal scintigraphy with MAG3 and diuretic stimulus. RESULTS: After a mean follow-up of 60.1 (+/- 38.5) months, severe ureteral stenosis was discovered in 21 patients (2.76%), with exclusive involvement of the vesicoureteral junction. No statistically significant correlation was found with donor age and the incidence of delayed graft function, whereas a significant correlation between ureteral obstruction and unilateral placement of both grafts in dual kidney transplantation (DKT) (p < 0.001) was found. These patients had a longer mean hospital stay than the control group, but there was no influence on survival of the organ or patient. CONCLUSIONS: ureteral obstruction after renal transplantation often features subtle and late symptoms. Early ultrasound monitoring is therefore essential and in the presence of severe hydronephrosis, scintigraphic confirmation of the obstruction. In fact. early resolution of the stenosis appears to provide optimal graft and patient survival.

The European Union Interreg Program: Italian-Albanian experience with kidney transplants.

INTRODUCTION: A collaboration between the Regional Health Agency of Puglia (ARES), the Italian Ministry of Health and the Albanian Ministry of Health, was realized in 2008. One of the areas of interest was to promote the performance of kidney transplants in Albania by Albanian medical staff, funded with nearly 2 million euros. The program included two major goals: to transmit the required know-how to health care staff and to upgrade the Albanian facilities and equipment to the standards necessary for successful transplantation. MATERIALS AND METHODS: During the year 2008, two couples of Albanian patients were transplanted at the Department of Emergency and Organ Transplantation-Urology Unit in Bari, Italy. The surgical procedures were performed by mixed surgical teams, with the active participation of Albanian medical staff under the guidance of the Italian colleagues. The first kidney transplant was performed at the end of January 2008 and the second in June 2008. Both surgical procedures and post-transplant periods were clinically uneventful. RESULTS: After returning to Albania the trained team started to carry out team-work, preparing the patients for the first kidney transplantation. The first donor-patient couple was prepared for kidney transplantation at the end of 2008. On the 26th March 2009 the first kidney transplant was performed by the Albanian medical team, with the active participation of 2 Italian urologists from the University of Bari. CONCLUSIONS: Appropriate training, equipment, and infrastructure are necessary to build a rational, functional national system for organ transplantation. Continuous exchange of ideas and data on kidney transplantation between Albania and Italy will probably contribute to extend such forms of cooperation to the western Balkans in the near future.

High energy microwave thermotherapy for symptomatic benign prostatic enlargment: predictive parameters of long term outcome.

OBJECTIVES: High-energy transurethral microwave thermotherapy (HE-TUMT) has become one of the most preferred minimally invasive procedure for the treatment of benign prostatic enlargement (BPE). In this study we report the long term results in a subset of patients treated with the 30-minute high energy protocol. PATIENTS AND METHODS: A total of 135 patients were treated with TUMT Prostasoft 3.5. The International Prostate Symptom Score (IPSS), Madsen Symptom Score (MSS), Quality of Life (QoL) score, peak urinary flow rate (Qmax) and post-voiding residual urine volume (PVR) were assessed at baseline and at 12, 24, 36, 48 and 60 months after treatment. RESULTS: The mean follow-up period was 46.1 months. The mean IPSS at baseline was 17.8 and decreased to 5.6 at 60 months (p < 0.001). The MSS decreased from 12.6 at baseline to 4.3 at 5 years (p < 0.0001). The QoL score improved from 4.1 to 2.2 at 5 years (p < 0.001). The mean Qmax value at baseline was 9.4 ml/sec and it improved to 15.7 ml/sec at 60 months (p = 0.001), whereas PVR decreased from 97 to 24 ml at 5 years (p = 0.001). Retreatment was required for 47 patients (34.8%). Univariate and multivariate analysis showed that the only baseline parameters able to predict the long-term efficacy were a IPSS <18 and a Qm, > 10 ml/sec (p = 0.04). CONCLUSIONS: These data shows a high response rate obtained with 30-minute TUMT protocol and a durability of response up to 5 years after treatment, making this procedure a safe and effective alternative to TURP in selected patients.

Role of imaging and biopsy to assess local recurrence after definitive treatment for prostate carcinoma (surgery, radiotherapy, cryotherapy, HIFU).

PURPOSE: Defining the site of recurrent disease early after definitive treatment for a localized prostate cancer is a critical issue as it may greatly influence the subsequent therapeutic strategy or patient management. METHODS: A systematic review of the literature was performed by searching Medline from January 1995 up to January 2011. Electronic searches were limited to the English language, and the keywords prostate cancer, radiotherapy [RT], high intensity focused ultrasound [HIFU], cryotherapy [CRIO], transrectal ultrasound [TRUS], magnetic resonance [MRI], PET/TC, and prostate biopsy were used. RESULTS: Despite the fact that diagnosis of a local recurrence is based on PSA values and kinetics, imaging by means of different techniques may be a prerequisite for effective disease management. Unfortunately, prostate cancer local recurrences are very difficult to detect by TRUS and conventional imaging that have shown limited accuracy at least at early stages. On the contrary, functional and molecular imaging such as dynamic contrast-enhanced MRI (DCE-MRI), and diffusion-weighted imaging (DWI), offers the possibility of imaging molecular or cellular processes of individual tumors. Recently, PET/CT, using 11C-choline, 18F-fluorocholine or 11C-acetate has been successfully proposed in detecting local recurrences as well as distant metastases. Nevertheless, in controversial cases, it is necessary to perform a biopsy of the prostatic fossa or a biopsy of the prostate to assess the presence of a local recurrence under guidance of MRI or TRUS findings. CONCLUSION: It is likely that imaging will be extensively used in the future to detect and localize prostate cancer local recurrences before salvage treatment.

Surgery for renal cell carcinoma in two European urologic clinics: to compare or compete?

OBJECTIVES: To evaluate and compare the incidence, TNM staging and the current strate- gy for the surgical treatment of renal cell carcinoma (RCC) in two European urologic institutions, situated in Varna, Bulgaria and in Bari, Italy. Both clinics have sound experience of RCC surgery, and modern laparoscopic equipment. A retrospective chart review of all patients with RCC diagnosed and treated in the last year was conducted at the two sites. MATERIALS AND METHODS: In total, 88 patients (66 males and 22 females, mean age 58 years, range 24-81 years) were enrolled in the study. Comparisons were made between some clinical and pathologic parameters with an established prognostic and therapeutic impact. The type of surgery perormed at both sites was analyzed as well. All these comparative studies were performed in relation to the 2008 EAU guidelines on the current management of RCC. Commercially available statistical software was used for the purpose. RESULTS: The results showed no difference between the two sites regarding the RCC incidence and the patients' age and gender. Significant differences (p value < 0.0001) emerged in terms of: the median size of the tumors at surgery (8.5 cm in Varna, SD + 4.04 vs. 4.4 cm in Bari, SD _ 2.02); T-stage of the tumor (Varna T T2-30%, T3-22%, T4-15% vs. Bari T1-64%, T2-12%, T3-24%, T4-0%); N-positive disese (24% vs. 2%); distant metastases (20% vs. 2%) and presence of necrosis in the renal masses (37% vs. 19%). Thus, 85% of Varna patients underwent open radical nephrectomy, 11% nephron-sparing surgery and 4% explorative laparotomy, due to inoperability of the renal mass. Only 29% of Bari patients were treated by open radical nephrectomy, 12% underwent laparoscopic nephrectomy, 57% open partial nephrectomy and 2% laparoscopic partial tumor resection. CONCLUSIONS: These numbers demonstrate more advantageous tumour features at the Italian clinic in terms of organ-sparing surgical options (open and laparoscopic), whereas in the Bulgarian clinic the tumour features pose certain limitations to the application of modern surgical techniques. This difference is due to early diagnosis of RCC in Italy, allowing treatment of smaller volume tumors.

Transrectal ultrasound approach for identification and radioguided biopsy of sentinel node in lymph node staging of localized prostate cancer.

INTRODUCTION: The limited pelvic lymphadenectomy (LPL) is currently considered the referred method of identification of nodal micrometastases in localized prostate cancer. Lymphoscintigraphy (LS) and radioguided sentinel node biopsy (RSNB) could be an alternative method of nodal staging. MATERIALS AND METHODS: Between June 2003 and February 2007 19 patients with prostate cancer without metastases were included in the study. Mean age was 66 years, mean PSA 15.51 ng/ml, Gleason score > 6. A transrectal ultrasound was performed with intraprostatic administration of 0.2 ml/190 MBq 99 mTc bound to nanocolloid particles, prepared the day before surgery. Dynamic and static scans of the pelvis were obtained at 30', 60' and 120' after injection. Hot spots outside the site of administration were considered as sentinel nodes (SLNs). Prior to prostatectomy, LPL was performed. The presence of a labeled node after LPL, identified by a gamma probe slided slowly down the chain of lymphatic drainage, was indication for an LPE. RESULTS: A sentinel node was identified in 17/19 patients with preoperative lymphoscintigraphy (identification rate 89%) and in 16/19 patients during surgery (84%) with a negative predictive value of 97%. The most frequent site was identified at the level of hypogastric lymph nodes (56%), outside the standard of limited pelvic lymphadenectomy, followed by external iliac (33%), obturator (7%) and common iliac (4%) lymph nodes. Lymph node metastases were detected by histological examination in 2 patients (13%); total metastatic nodes found were 9: one in the first, and 8 in the second patient. Two metastatic nodes (22%) not removed by the limited pelvic lymphadenectomy were found with the sentinel lymph node dissection. CONCLUSIONS: Ultrasound approach for lymphoscintigraphy and sentinel node identification, is a valuable tool in the staging of localized prostate cancer.

Surgical complications of renal transplantation: ultrasound diagnosis.

OBJECTIVE: Ultrasound is the principal imaging technique for the evaluation of a renal allograft; it is a safe imaging technique to assess the structure of the graft and its perfusion without the need for intravenous contrast or ionizing radiation. The evaluation of kidney transplant complications is easy due to its presence in the iliac fossa lying anterior to the external iliac vessels. Complications may be classified as medical and surgical; the latter are classified in urologic, vascular and general surgical complications. MATERIALS AND METHODS: Our experience on surgical complications in kidney recipients from donors, on the role of ultrasound in the diagnosis of these complications and their impact on the graft and patient survival rates is reported. RESULTS: Ultrasonography represents a safe imaging technique to assess the structure of the graft and its perfusion without the use of ionizing radiation and iodinated contrast medium, and a quick, accurate method for the evaluation of complications. CONCLUSIONS: Although it possesses limitations and is ultimately operator dependent, ultrasound is considered an excellent tool for the assessment of the kidney transplant and in our experience it represents the main imaging technique used in the evaluation of graft complications.