An Innovative Technique for Ejaculation-Sparing Prostatic Enucleation with Thulium:YAG Laser.

Purpose: We report our experience with 100 patients who underwent an innovative prostate enucleation technique that spares the complete urethral-plate from the veru montanum to the bladder neck using a low-energy thulium laser emission. The aim of our study was to evaluate the short-term effects of this procedure on ejaculation preservation and urinary obstruction. Materials and Methods: The International Prostate Symptom Index (IPSS), quality of life (QoL), and Male Sexual Health Questionnaire Ejaculatory Dysfunction (MSHQ-EJD) Short Form were used as validated instruments to quantify ejaculatory dysfunction before and 6 months after the surgery. Results: The median IPSS score pre- and postoperatively was 20 and 5, respectively (p < 0.0001); QoL dropped from a median of 4-1 (p < 0.0001); and the mean preoperative maximal flow rate improved significantly (8.5 vs 21.2 mL/min) (p < 0.0001). Furthermore, there was significant reduction in postvoid residual postoperatively (p < 0.0001). Postoperative ejaculatory function was preserved in 92/100 patients (92%). According to the MSHQ-EJD score, patients reported a slight nonsignificant decrease in frequency of ejaculation (item 1), force of expulsion (item 2) and reduction in semen volume during ejaculation (item 3), with the exception of ejaculation discomfort (item 4). Conclusion: According to our results, complete removal of the apical tissue, which has been advocated as an integral part of the so called ejaculatory hood, does not interfere with ejaculation if the ventral lissosphincter remains intact.

Radiological Wheeler staging system: a retrospective cohort analysis to improve the local staging of prostate cancer with multiparametric MRI.

BACKGROUND: The knowledge of tumor location and extension can allow a modulated radical prostatectomy in order to minimize positive surgical margins and reduce functional morbidity after surgery in patients with prostate cancer (PCa). Multiparametric (mp) magnetic resonance imaging (MRI) could allow the assessment of tumor extension and of its relationship with external structures. Aim of this study is to propose a new radiological Wheeler (rW) staging system applied to mp-MRI, based on the pathologic staging system (pW) for the local assessment of PCa. METHODS: This retrospective single-center multi-reader study included consecutive patients with PCa and preoperative mp-MRI, who underwent non-nerve sparing radical prostatectomy. Three radiologists reported on all examinations and classified each selected lesion according to imaging criteria following rW. Whole-mount histological sections were used as the reference standard. An experienced pathologist classified the extent of prostatic capsular invasion of each PCa according to the pW. Each histological section was scanned for comparison with mp-MRI findings. The rate of PCa correctly classified by radiologists using the pW was assessed. To evaluate the accuracy of mp-MRI in the discrimination between T2 and T3 PCa, the AUC was computed. RESULTS: One-hundred and five patients with a total of 195 PCa foci were included in the study. 130/195 tumors with a clear overlap between mp-MRI and surgical specimens were selected. The sensitivity of the most experienced reader was lower than that of the other two readers (48.6% vs. 68.6% and 62.9%, P>0.09) while specificity and PPV were higher (95.8% vs. 79.0% and 57.9%, P<0.001; 81.0% vs. 54.6% and 35.5%, P<0.041; respectively). The AUC values for the most and the intermediate experienced readers in the detection of extracapsular extension were in the range 0.72-0.74. CONCLUSIONS: The rW staging system has low accuracy in predicting each single pW class, while accuracy was over 80% for experienced readers in the identification of organ-confined (T2 stage class) tumors and non-organ confined cases (T3 stage class).

Comparing Image-guided targeted Biopsies to Radical Prostatectomy Specimens for Accurate Characterization of the Index Tumor in Prostate Cancer.

AIM: To evaluate the accuracy of multiparametric magnetic resonance-transrectal ultrasound fusion targeted biopsy (TBx) in the characterization of the index tumor, as confirmed by association with radical prostatectomy (RP) specimens. PATIENTS AND METHODS: A total of 152 patients with TBx-confirmed prostate cancer (PCa) underwent robot-assisted RP. Stained whole-mount histological sections were used as the reference standard. All lesions with a volume >0.5 ml and/or pathological Gleason score (GS) >6 were defined as clinically significant PCa. The index lesion was defined as the largest tumor focus within the prostate gland. RESULTS: The pathological index tumours included: 147 lesions (96.7%) with a volume >0.5 ml and five (3.3%) with a volume ≤0.5 ml, but with a pathological GS ≥7; 135 (88.8%) were located in the peripheral zone. TBx accuracy in the detection of the correct site of the index lesion by reference standard was 82.2%. Sensitivity, specificity, positive and negative predictive value were: 82.3%, 50.4%, 82.8% and 49.7%, respectively. The primary/secondary Gleason grade and GS of the 152 index tumors were properly estimated in 130 (85.5%), 115 (75.6%) and 127 (83.6%) cases, respectively. The concordance of TBx with pathological GS was 83.6%. The rate of up-grading and down-grading of TBx Gleason sum was 12.2% and 4.2%, respectively. CONCLUSION: TBx has a high sensitivity for characterization of index lesions, with a good concordance for topographic and Gleason grading accuracy between biopsy and surgical specimens.

Indication to pelvic lymph nodes dissection for prostate cancer: the role of multiparametric magnetic resonance imaging when the risk of lymph nodes invasion according to Briganti updated nomogram is <5.

BACKGROUND: The Briganti updated nomogram (BN) is the most popular predictive model aiming to predict the presence of lymph node invasion (LNI) in patients with prostate cancer (PCa), but it lacks information obtained by preoperative imaging. The primary aim of the study was to evaluate the role of multiparametric prostate magnetic resonance imaging (mp-MRI) in the indication to perform pelvic lymph nodes dissection (PLND) or not in patients with risk of LNI according to BN below 5%. METHODS: Since March 2012 and September 2016, 310 patients who underwent a preoperative mp-MRI for staging purpose and subsequent robot-assisted extended PLND (RAEPLND) were retrospectively evaluated. Mp-MRIs were prospectively analyzed by two experienced radiologists. The imaging parameters analyzed were the presence of extracapsular extension (ECE), seminal vesicles invasion (SVI) and predominant Gleason pattern 4 (pG4). All patients underwent RAEPLND by two experienced surgeons with a standardized technique. A dedicated uropathologist performed all pathological analysis. Univariate analysis and multivariate logistic regression analysis were used in order to identify the predictors of LNI in patients with PCa. RESULTS: In the overall population, 57 (18.4%) patients had histologically proven pN1 disease. 48/250 patients (19.2%) with a risk of LNI ≥5% as calculated by the BN were staged pN1 at final histopathological analysis. 9/60 patients (15.0%) with a risk of LNI <5% as calculated by BN, who underwent RAEPLND anyway according to the findings at mp-MRI, were staged pN1 at final histopathological analysis. At multivariate logistic regression analysis, all the three mp-MRI parameters were significant independent predictors of LNI after RAEPLND. CONCLUSIONS: The role of mp-MRI seemed to be crucial in patients with a risk of LNI <5% as calculated by the BN. The presence of ECE, SVI, or pG4 at mp-MRI was found to be an independent predictor of LNI by itself.

Multiparametric prostate MRI: technical conduct, standardized report and clinical use.

Multiparametric prostate MRI (mp-MRI) is an emerging imaging modality for diagnosis, characterization, staging, and treatment planning of prostate cancer (PCa). The technique, results reporting, and its role in clinical practice have been the subject of significant development over the last decade. Although mp-MRI is not yet routinely used in the diagnostic pathway, almost all urological guidelines have emphasized the potential role of mp-MRI in several aspects of PCa management. Moreover, new MRI sequences and scanning techniques are currently under evaluation to improve the diagnostic accuracy of mp-MRI. This review presents an overview of mp-MRI, summarizing the technical applications, the standardized reporting systems used, and their current roles in various stages of PCa management. Finally, this critical review also reports the main limitations and future perspectives of the technique.

Five-year Outcomes for a Prospective Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy.

BACKGROUND: The literature is lacking randomised controlled trials comparing robot-assisted (RARP) and laparoscopic (LRP) radical prostatectomy, especially for follow-up >1 yr. OBJECTIVE: To report 5-yr outcomes for our previously published prospective randomised study comparing RARP and LRP. DESIGN, SETTING, AND PARTICIPANTS: From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned to RARP or LRP. INTERVENTION: A single surgeon performed all interventions using the same transperitoneal anterograde technique. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Continence, potency, and serum prostate-specific antigen were assessed postoperatively at 1, 3, 6, and 12 mo, and then every 6 mo until 60 mo. At the end of the follow-up period, patients were administered questions 1 and 46 of the Expanded Prostate Cancer Index Composite questionnaire to assess their satisfaction with the intervention and general health status. A generalised estimating equations model was used to compare time series data for functional results, and Kaplan-Meier and Cox models were used to analyse oncologic outcomes. RESULTS AND LIMITATIONS: The probability of achieving continence (odds ratio [OR] 2.47, p<0.021) and potency (OR 2.35, p<0.028) over time was more than doubled for the RARP compared to the LRP group. There was no difference between the two approaches in terms of patient survival. Pathologic Gleason score, positive surgical margins, and pT stage were associated with significantly higher biochemical recurrence in Cox multivariate models. Patient satisfaction with the intervention and their general health status was significantly higher in the RARP group. CONCLUSIONS: Throughout the 5-yr follow-up, RARP yielded better functional results compared to LRP, without compromising oncologic outcomes. PATIENT SUMMARY: In this report we looked at 5-yr outcomes for a study comparing robot-assisted radical prostatectomy (RARP) and laparascopic radical prostatectomy for the treatment of prostate cancer. We found that continence and potency are better among patients treated with RARP, while oncologic results are comparable.

Robot-assisted laparoendoscopic single-site versus mini-laparoscopic pyeloplasty: a comparison of perioperative, functional and cosmetic results.

BACKGROUND: New approaches have been developed to further reduce the invasiveness of laparoscopic pyeloplasty (P) as treatment for uretero-pelvic junction obstruction (UPJO). Aim of the study was to compare perioperative, functional and cosmetic results of mini-laparoscopic (mL-P) versus robot-assisted laparoendoscopic single-site P (rLESS-P). METHODS: Since April 2009 to June 2010, 12 adult patients with primary UPJO, BMI<25 and no previous abdominal surgeries were enrolled undergoing mLP (3-mm instruments only). With the same indications since February 2012 to October 2013, 15 patients underwent rLESS-P with "single site"® platform (Intuitive Surgery Inc, Sunnyvale, CA, USA). Success of surgeries was determined by clinical parameters and renal scan (success if T 1/2<20 min) at 12 months postoperatively. Demographics and perioperative results were analyzed. Cosmetic results were assessed by using the Patient Scar Assessment Questionnaire (PSAQ). RESULTS: Groups were comparable at baseline. No differences were found in perioperative variables except for a longer operative time in rLESS-P group (128 vs. 190, P<0.001). Postoperative complications rate, analgesic consumption, pain visual analogue scale scores, hospital stay and success rate of surgeries were not significantly different between the groups. PSAQ revealed that in both the groups patients were satisfied with the cosmetic result. At one-year follow-up no recurrences were observed. Semiquantitative analysis of costs revealed an extra-cost for rLESS-P of € 3410 per procedure. CONCLUSIONS: In our experience, both mLP and rLESS-P appeared to be feasible and safe in the treatment of UPJO and allowed for excellent cosmetic results. r-LESS required longer operative times and higher costs.

Multiparametric Magnetic Resonance/Ultrasound Fusion Prostate Biopsy: Number and Spatial Distribution of Cores for Better Index Tumor Detection and Characterization.

PURPOSE: We evaluated the minimum core number for better index tumor detection to determine the best core site as well as biopsy Gleason score heterogeneity in the same index lesion. The aim was to optimize the highest Gleason score detection. MATERIALS AND METHODS: A total of 327 patients with negative digital rectal examination underwent magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy for elevated/rising prostate specific antigen and/or 1 or more detectable lesions on multiparametric magnetic resonance imaging after a previous negative standard biopsy. Depending on the diameter of each index lesion (8 or less, or greater than 8 mm) 4 or 6 cores, respectively, were taken according to a well determined sequence. RESULTS: Of the patients 166 (50.7%) had prostate cancer, including 79 (47.6%) with an 8 mm or less index lesion and 87 (52.4%) with a greater than 8 mm index lesion. Of patients with an index tumor 8 mm or less 7 (8.9%) had 1, 31 (39.2%) had 2, 27 (34.2%) had 3 and 14 (17.7%) had 4 positive cores. Similarly, of patients with a lesion greater than 8 mm 8 (9.2%) had 1, 30 (34.5%) had 2, 13 (14.9%) had 3, 14 (16.1%) had 4, 12 (13.8%) had 5 and 10 (11.5%) had 6 positive cores. The major prevalence of positive cores was observed in the center of the target. Gleason score heterogeneity was found in 12.6% of those with an 8 mm or less target vs 26.4% with a target greater than 8 mm. In the center of the target there was a slight prevalence of Gleason pattern 4 or greater, or a lesser pattern. CONCLUSIONS: Approaching magnetic resonance imaging/transrectal ultrasound fusion targeted biopsy with a single core might be inadequate. Rather, taking 2 cores in the center of the index lesion may provide more accurate cancer detection and optimize the chances of finding the highest Gleason pattern.

Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer.

BACKGROUND: An approach based on multiparametric magnetic resonance imaging (mpMRI) might increase the detection rate (DR) of clinically significant prostate cancer (csPCa). OBJECTIVE: To compare an mpMRI-based pathway with the standard approach for the detection of prostate cancer (PCa) and csPCa. DESIGN, SETTING, AND PARTICIPANTS: Between November 2014 and April 2016, 212 biopsy-naïve patients with suspected PCa (prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results) were included in this randomized clinical trial. Patients were randomized into a prebiopsy mpMRI group (arm A, n=107) or a standard biopsy (SB) group (arm B, n=105). INTERVENTION: In arm A, patients with mpMRI evidence of lesions suspected for PCa underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy (TB) (n=81). The remaining patients in arm A (n=26) with negative mpMRI results and patients in arm B underwent 12-core SB. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS: The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study; the secondary end point was comparison of the DR between TB and SB. RESULTS AND LIMITATIONS: The overall DRs were higher in arm A versus arm B for PCa (50.5% vs 29.5%, respectively; p=0.002) and csPCa (43.9% vs 18.1%, respectively; p<0.001). Concerning the biopsy approach, that is, TB in arm A, SB in arm A, and SB in arm B, the overall DRs were significantly different for PCa (60.5% vs 19.2% vs 29.5%, respectively; p<0.001) and for csPCa (56.8% vs 3.8% vs 18.1%, respectively; p<0.001). The reproducibility of the study could have been affected by the single-center nature. CONCLUSIONS: A diagnostic pathway based on mpMRI had a higher DR than the standard pathway in both PCa and csPCa. PATIENT SUMMARY: In this randomized trial, a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging (mpMRI) was compared with the standard pathway based on random biopsy. The mpMRI-based pathway had better performance than the standard pathway.

Multiparametric-Magnetic Resonance/Ultrasound Fusion Targeted Prostate Biopsy Improves Agreement Between Biopsy and Radical Prostatectomy Gleason Score.

AIM: To investigate if targeted prostate biopsy (TBx) has superior performance to standard untargeted biopsy (SBx) in determining the optimal agreement between biopsy and surgical Gleason Score (GS). PATIENTS AND METHODS: An analysis of our institutional longitudinal database identified 683 consecutive patients who underwent either SBx (18-20 standardized transrectal ultrasound peripheral/transitional zone cores) or TBx alone (4-6 cores for each multiparametric magnetic resonance suspicious lesion, Prostate Imaging Reporting and Data System [(PI-RADS)≥3] after a previous negative first SBx. A total of 246 consecutive patients with diagnosis of prostate cancer (117 SBx and 129 TBx diagnoses) who underwent robot-assisted radical prostatectomy between January 2014 and December 2015, were enrolled. The concordance of biopsy GS to pathological GS, as well as the association between categorical variables [age, digital rectal exam (DRE), TNM, PI-RADS], were analyzed by Fisher's exact test. RESULTS: Prostate cancer was diagnosed in 32.0% of the SBx group and in 49.3% of TBx. The rate of correctly classified, up-graded and down-graded GS was 53.8% vs. 91.5%, 39.3% vs. 7.8% and 6.8% vs. 0.8% for SBx and TBx, respectively (p<0.001). The GS concordance rates for SBx and TBx cohorts were: 14.3% vs. 41.7% for GS 6, 61.0% vs. 83.8% for GS 3+4, 56.3% vs. 75.0% for GS 4+3, 27.3% vs. 100% for GS 8 and 80% vs. 100% for GS 9, respectively. CONCLUSION: TBx ensured a higher of accuracy of prostate cancer detection and a better performance in discriminating significant from insignificant prostate cancer, when compared to SBx. TBx significantly reduced the risk of GS up-/down-grading at radical prostatectomy for all histopathological categories. This is a notable advance in the selection of candidates for active surveillance.

Multiparametric magnetic resonance imaging and active surveillance: How to better select insignificant prostate cancer?

OBJECTIVES: To evaluate the role of multiparametric magnetic resonance imaging in improving the predictive accuracy of the Prostate Cancer Research International: Active Surveillance and Epstein criteria for active surveillance in prostate cancer. METHODS: A retrospective study was carried out with 126 prostate cancer patients treated with robot-assisted radical prostatectomy, but eligible for active surveillance according to the Prostate Cancer Research International: Active Surveillance criteria; 63 patients were also eligible according to the Epstein criteria. All patients underwent preoperative multiparametric magnetic resonance imaging, after at least 6 weeks from biopsy. The images from the multiparametric magnetic resonance imaging were assessed, and diagrams showing prostate sextants were used to designate regions of abnormalities within the prostate. Findings in the prostate were assigned to one of five categories according the Prostate Imaging-Reporting and Data System guidelines (v1.0), and considered positive for prostate cancer if the final Prostate Imaging-Reporting and Data System guidelines were >3 and negative if ≤3. Multivariate logistic regression analysis was carried out to evaluate the gain in accuracy of the Prostate Cancer Research International: Active Surveillance and Epstein criteria when added to multiparametric magnetic resonance imaging. Decision curve analysis was carried out to identify the net benefit of each model. RESULTS: The inclusion of multiparametric magnetic resonance imaging to the Epstein criteria and the Prostate Cancer Research International: Active Surveillance multivariate model significantly increased their accuracy in predicting pathologically-confirmed insignificant prostate cancer by 7% and 5%, respectively. At the decision curve analysis evaluation, the model including the Prostate Cancer Research International: Active Surveillance criteria and multiparametric magnetic resonance imaging improved the clinical risk prediction over the other models. CONCLUSIONS: The present findings suggest that multiparametric magnetic resonance imaging is able to increase the predictive accuracy of Prostate Cancer Research International: Active Surveillance and Epstein criteria to identify prostate cancer patients eligible for active surveillance.

High prostate cancer gene 3 (PCA3) scores are associated with elevated Prostate Imaging Reporting and Data System (PI-RADS) grade and biopsy Gleason score, at magnetic resonance imaging/ultrasonography fusion software-based targeted prostate biopsy after a previous negative standard biopsy.

OBJECTIVE: To determine the association among prostate cancer gene 3 (PCA3) score, Prostate Imaging Reporting and Data System (PI-RADS) grade and Gleason score, in a cohort of patients with elevated prostate-specific antigen (PSA), undergoing magnetic resonance imaging/ultrasonography fusion software-based targeted prostate biopsy (TBx) after a previous negative randomised 'standard' biopsy (SBx). PATIENTS AND METHODS: In all, 282 patients who underwent TBx after previous negative SBx and a PCA3 urine assay, were enrolled. The associations between PCA3 score/PI-RADS and PCA3 score/Gleason score were investigated by K-means clustering, a receiver operating characteristic analysis and binary logistic regression. RESULTS: The PCA3 score difference for the negative vs positive TBx cohorts was highly statistically significant. A 1-unit increase in the PCA3 score was associated to a 2.4% increased risk of having a positive TBx result. A PCA3 score of >80 and a PI-RADS grade of ≥4 were independent predictors of a positive TBx. The association between the PCA3 score and PI-RADS grade was statistically significant (the median PCA3 score for PI-RADS grade groups 3, 4, and 5 was 58, 104, and 146, respectively; P = 0.006). A similar pattern was detected for the relationship between the PCA3 score and Gleason score; an increasing PCA3 score was associated with a worsening Gleason score (median PCA3 score equal to 62, 105, 132, 153, 203, and 322 for Gleason Score 3+4, 4+3, 4+4, 4+5, 5+4, and 5+5, respectively; P < 0.001). CONCLUSION: TBx improved PCA3 score diagnostic and prognostic performance for prostate cancer. The PCA3 score was directly associated both with biopsy Gleason score and PI-RADS grade: notably, in the 'indeterminate' PI-RADS grade 3 subgroup.

Preoperative prostate biopsy and multiparametric magnetic resonance imaging: reliability in detecting prostate cancer.

PURPOSE: The aim of the study was to analyse and compare the ability of multiparametric magnetic resonance imaging (mp-MRI) and prostate biopsy (PB) to correctly identify tumor foci in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa). MATERIALS AND METHODS: 157 patients with clinically localised PCa with a PSA <10 ng/ mL and a negative DRE diagnosed on the first (12 samples, Group A) or second (18 samples, Group B) PB were enrolled at our institution. All patients underwent mp-MRI with T2-weighted images, diffusion-weighted imaging, dynamic contrast enhanced-MRI prior to RP. A map of comparison describing each positive biopsy sample was created for each patient, with each tumor focus shown on the MRI and each lesion present on the definitive histological examination in order to compare tumor detection and location. The sensitivity of mp-MRI and PB for diagnosis was compared using Student's t-test. The ability of the two exams to detect the prevalence of Gleason pattern 4 in the identified lesions was compared using a chi-square test. RESULTS: Overall sensitivity of PB and mp-MRI to identify tumor lesion was 59.4% and 78.9%, respectively (p<0.0001). PB missed 144/355 lesions, 59 of which (16.6%) were significant. mp-MRI missed 75/355 lesions, 12 of which (3.4%) were significant. No lesions with a GS≥8 were missed. Sensitivity of PB and mp-MRI to detect the prevalence of Gleason pattern 4 was 88.2% and 97.4%, respectively. CONCLUSIONS: mp-MRI seems to identify more tumor lesions than PB and to provide more information concerning tumor characteristics.

Preoperative prostate biopsy and multiparametric magnetic resonance imaging: reliability in detecting prostate cancer

Purpose The aim of the study was to analyse and compare the ability of multiparametric magnetic resonance imaging (mp–MRI) and prostate biopsy (PB) to correctly identify tumor foci in patients undergoing radical prostatectomy (RP) for prostate cancer (PCa). Materials and Methods 157 patients with clinically localised PCa with a PSA <10 ng/mL and a negative DRE diagnosed on the first (12 samples, Group A) or second (18 samples, Group B) PB were enrolled at our institution. All patients underwent mp-MRI with T2-weighted images, diffusion-weighted imaging, dynamic contrast enhanced-MRI prior to RP. A map of comparison describing each positive biopsy sample was created for each patient, with each tumor focus shown on the MRI and each lesion present on the definitive histological examination in order to compare tumor detection and location. The sensitivity of mp-MRI and PB for diagnosis was compared using Student’s t-test. The ability of the two exams to detect the prevalence of Gleason pattern 4 in the identified lesions was compared using a chi-square test. Results Overall sensitivity of PB and mp-MRI to identify tumor lesion was 59.4% and 78.9%, respectively (p<0.0001). PB missed 144/355 lesions, 59 of which (16.6%) were significant. mp-MRI missed 75/355 lesions, 12 of which (3.4%) were significant. No lesions with a GS≥8 were missed. Sensitivity of PB and mp-MRI to detect the prevalence of Gleason pattern 4 was 88.2% and 97.4%, respectively. Conclusions mp-MRI seems to identify more tumor lesions than PB and to provide more information concerning tumor characteristics. .

Robot-Assisted Extended Pelvic Lymph Nodes Dissection for Prostate Cancer: Personal Surgical Technique and Outcomes.

OBJECTIVE: Extended pelvic lymph nodes dissection (EPLND) allows the removal of a higher number of lymph nodes than limited PLND. The aims of this study were to describe our robot-assisted EPLND (RAEPLND) technique with related complications, and to report the number of lymph nodes removed and the rate of lymph nodal metastasis. MATERIALS AND METHODS: 153 patients underwent RAEPLND prior to robot-assisted radical prostatectomy (RARP). Indications were defined according to Briganti nomogram, to predict risk of lymph-nodal metastasis. Lymphatic packages covering the distal tract of the common iliac artery, the medial portion of the external iliac artery, the external iliac vein and the internal iliac vessels, together with the obturator and the presacral lymphatic packages were removed on both sides. RESULTS: Median preoperative PSA was 7.5 ng/mL (IQR 5.5-11.5). Median operative time was 150 min (135-170). Median RAEPLND alone operative time was 38 min (32.75-41.25); for right and left side, 18 (15-29) and 20 min (15.75-30) (p=0.567). Median number of lymph nodes retrieved per patient was 25 (19.25-30); 13 (11-16) and 11 (8-15) for right and left side. In 19 patients (12.41%) metastasis was found at the level of pelvic lymph nodes. Median number of positive lymph nodes was 1 (1-4.6) per patient. Complications occurred in 11 patients (7.3%). CONCLUSIONS: the number of lymph nodes removed was comparable to published data about open series, allowing the increase of detection rate of lymph nodal metastasis for minimally invasive approach without compromising complications' rate if performing the procedure following reported technique.

[Ureteroscopy: is it the best?]. / Ureteroscopia: risolve molto di più?

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

The roles of multiparametric magnetic resonance imaging, PCA3 and prostate health index-which is the best predictor of prostate cancer after a negative biopsy?

PURPOSE: In patients with a negative prostate biopsy and persistent suspicion of prostate cancer, additional analyses such as the PCA3 score, PHI and multiparametric magnetic resonance imaging have been proposed to reduce the number of unnecessary repeat biopsies. In this study we evaluate the diagnostic accuracy of PCA3, PHI, multiparametric magnetic resonance imaging and various combinations of these tests in the repeat biopsy setting. MATERIALS AND METHODS: A total of 170 patients with an initial negative prostate biopsy and persistent suspicion of prostate cancer were enrolled in this prospective study. The patients underwent measurements of the total prostate specific antigen and free prostate specific antigen rate, along with PHI, PCA3 tests and multiparametric magnetic resonance imaging before standard repeat biopsy that was performed by urologists blinded to the multiparametric magnetic resonance imaging results. Multivariate logistic regression models with various combinations of PCA3, PHI and multiparametric magnetic resonance imaging were used to identify the predictors of prostate cancer with repeat biopsy, and the performance of these models was compared using ROC curves, AUC analysis and decision curve analysis. RESULTS: In the ROC analysis the most significant contribution was provided by multiparametric magnetic resonance imaging (AUC 0.936), which was greater than the contribution of the PHI+PCA3 model (p <0.001). In the multivariate logistic regression analysis only multiparametric magnetic resonance imaging was a significant independent predictor of prostate cancer diagnosis with repeat biopsy (p <0.001). The results of the decision curve analysis confirmed that the most significant improvement in the net benefit was provided by multiparametric magnetic resonance imaging. CONCLUSIONS: Multiparametric magnetic resonance imaging provides high diagnostic accuracy in identifying patients with prostate cancer in the repeat biopsy setting compared with PCA3 and PHI.

Randomised controlled trial comparing laparoscopic and robot-assisted radical prostatectomy.

BACKGROUND: The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials. OBJECTIVE: To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery. DESIGN, SETTING, AND PARTICIPANTS: From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group. INTERVENTION: All RARP and LRP interventions were performed with the same technique by the same single surgeon. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48 h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ(2) test, Pearson χ(2) test, and multiple regression analysis were used for statistics. RESULTS AND LIMITATIONS: The two groups (RARP: n=60; LRP: n=60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p=0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p=0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p=0.020). The limitations included the small number of patients. CONCLUSIONS: RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

Standard vs mini-laparoscopic pyeloplasty: perioperative outcomes and cosmetic results.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? New techniques and instrumentation in laparoscopy including the use of 'single-port' devices and natural orifice transluminal endoscopic surgery have been proposed to reduce the invasiveness of these procedures. The introduction of small laparoscopic instruments (<3 mm) continues to further the field. To date, mini-laparoscopic instruments have been used in many urological procedures, e.g. pyeloplasty in the paediatric population. However, data of pure mini-laparoscopic pyeloplasty (mLP) for the treatment of pelvi-ureteric junction obstruction in the adult population are lacking. In a selected adult population mLP is feasible and safe. Perioperative and 1-year functional results are comparable with those of standard LP, while cosmetic results of mLP are more appreciated by the patients. OBJECTIVE: To evaluate perioperative and cosmetic results after pure mini-laparoscopic pyeloplasty (mLP) compared with standard LP (sLP) in an adult population. PATIENTS AND METHODS: From April 2009 to June 2010, 12 patients underwent mLP for pelvi-ureteric junction (PUJ) obstruction (PUJO). For comparison, 24 patients that had previously undergone sLP were pooled from our institutional database. All patients were assessed preoperatively with physical examination, abdominal ultrasonography, intravenous urography or computed tomography and renal scintigraphy (RS). In all cases, an Anderson-Hynes transperitoneal approach was used. After surgery, cosmetic results were assessed using a Patient Scar Assessment Questionnaire (PSAQ), and RS measured reconstructive success at 1-year after LP. Demographic and perioperative variables were recorded. Groups were compared using chi-squared and Wilcoxon-Mann-Whitney tests (P < 0.05 was considered significant). RESULTS: Baseline characteristics were similar between the groups. There were no differences in operative duration or blood loss. One mLP required conversion to sLP due to minor bleeding. Analgesic consumption and the pain visual analogue scale scores were not significantly different between the sLP and mLP cohorts. The average postoperative hospital stay for the mLP group was significantly shorter than that for the sLP group (P = 0.024). Complication and success rates between the groups were not significantly different. PSAQ scores showed that mLP patients were significantly more satisfied with their cosmetic result. CONCLUSIONS: mLP appears to be safe, feasible and effective in the treatment of PUJOs. Cosmetically, mLP is better than sLP.

Pure mini-laparoscopic transperitoneal pyeloplasty in an adult population: feasibility, safety, and functional results after one year of follow-up.

OBJECTIVE: To report the results of mini-laparoscopic pyeloplasty (mLP) in an adult population. The feasibility of pure mLP has been previously reported in children. MATERIAL AND METHODS: From April 2009 to February 2010, 10 patients with ureteropelvic junction obstruction (UPJO) were enrolled in this prospective study and underwent pure mLP (using only 3-mm instruments) according to the Anderson-Hynes technique. Inclusion criteria were: age >18 years, body mass index <25, primary UPJO, and no previous surgery on the affected kidney or a history of major abdominal surgery. Demographic and perioperative data, as well as 1-, 3-, 6-, and 12-month follow-up data were collected. RESULTS: The mean operative time was 134 minutes, and blood loss was negligible. All procedures but one were completed using only 3.9-mm ports and 3-mm instruments. No perioperative complications occurred, and no patients had computed tomography evidence of hydronephrosis at 6 months after surgery. No functional obstructions were visualized with renal scintigraphy at 12 months after surgery. All patients were satisfied with the intervention and with their cosmetic results, as assessed by the Patient Scar Assessment Questionnaire and Scoring System. CONCLUSIONS: The results of our study suggest that pure mLP in an adult population is feasible and seems to be safe and effective in the treatment of UPJO. Furthermore, the patients tolerated the procedure well and appreciated its excellent cosmetic results. Further studies are required to determine the true advantages of mLP over standard laparoscopy.