Perioperative and oncologic outcomes of open radical nephrectomy and inferior vena cava thrombectomy with liver mobilization and Pringle maneuver for Mayo III level tumor thrombus: single institution experience.

BACKGROUND: Scarce data are available regarding the technique and outcomes for patients with RCC and Mayo III caval thrombi. The aim of this study was to report surgical and oncological outcomes of RCC patients with Mayo III thrombi treated with radical nephrectomy and thrombectomy after liver mobilization (LM) and Pringle maneuver (PM). METHODS: Retrospective analysis of surgical technique, outcomes and cancer control in 19 patients undergoing LM and PM in a single tertiary care institution were analyzed. RESULTS: Overall, 78% of the patients had performance status ECOG 1 and 58% had a Comorbidity Index >2. Median surgical time was 305 minutes (IQR 264-440). Intraoperative complications were reported for 39% of patients and postoperative complications for 58% (only grade 1 and 2). Intensive Care Unit support was necessary in 16% of the cases. Median length of hospital stay was 9 days (IQR: 7-11). Thirty- and 90-day mortality were 5% and 15%. Two-year overall survival and cancer-specific survival were 60% and 62%, respectively. CONCLUSIONS: We reported surgical techniques, intra- and perioperative complications and follow-up in the largest cohort of RCC patients requiring LM and PM.

Proper 6-branch suburethral autologous sling tensioning during robotic assisted radical prostatectomy with the intraopeartive use of retrograde perfusion sphincterometry: the technique.

The aim of this paper is to describe our surgical technique and results of proper 6-branch autologous sling tensioning during RALP employing intraoperatively the Retrograde Perfusion Sphincterometry (RPS). Between May 2016 and February 2020, 374 patients underwent RALP with the 6-branch suburethral autologous sling tensioned under intraoperative guidance of RPS. Surgical procedure: Retrograde Leak Point pressure (RLPP) was evaluated by means of RPS after pneumoperitoneum induction (RLPPp), after urethrovescical anastomosis (RLPPa) and during proper sling tensioning (RLPPs). The goal of the sling tensioning was to obtain at the end of the procedure similar pressures as after pneumoperitoneum induction (RLPPs ≅ RLPPp). Intraoperative variables, postoperative complications, and continence recovery outcomes were assessed. A descriptive statistical analysis was performed. Sling positioning and tensioning was feasible in all patients. Mean operative time was 215 min. Proper sling tensioning allowed for the possibility to restore sphincteric efficacy to preoperative value (RLPPs vs. RLPPp (42.5 vs. 42.6) cmH2O). Urinary continence was achieved, respectively, in 58%, 67%, 74%, 88% and 92% of patients after 24 h, 10 days, 1 month, 6 months and 1 year after catheter removal. In conclusion, RPS revealed a valid option for proper autologous 6-branch sling tensioning during RALP, offering the possibility to restore sphincteric apparatus efficiency to its preoperative status to improve EUC.

A rare case of multi-focal human TB after BCG instillation for non-muscle-invasive bladder cancer.

OBJECTIVE: To describe a left epididymitis and para-aortical involvement caused by Mycobacterium tuberculosis hominis reactivation after bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer. PATIENT AND METHODS: A Caucasian male, aged 76 years, exposed to bacillus Calmette-Guérin for a high-grade non-muscle-invasive bladder cancer in 2015, reported painful and progressive left scrotal swelling with purulent discharge from a cutaneous fistulous track that yielded, on liquid culture, a pan-susceptible Mycobacterium tuberculosis hominis strain. Moreover, after 6 months of anti-tuberculosis treatment, an abdominal peri-aortic mass, sized 4 cm, was found and a surgical biopsy showed necrotizing granulomas; however, although smear microscopy and Xpert MTB/Rif™ performed on fresh biopsy sample were positive, liquid cultures resulted negative, indicating treatment efficacy. RESULTS: Numerous peculiar and multi-organ involvement due to BCGitis after intravesical immunotherapy have been previously described, including 17 scientific articles about epididymitis, however, no reports so far showed reactivation of Mycobacterium tuberculosis hominis after bacillus Calmette-Guérin treatment. CONCLUSION: Although BCGitis is more prevalent in patients undergoing bacillus Calmette-Guérin instillation for non-muscle-invasive bladder cancer, tuberculosis by other species of Mycobacterium tuberculosis should be always ruled out by molecular and conventional microbiology in patients with a history of Mycobacterium tuberculosis hominis exposure.

Perioperative and Oncologic Outcomes of Nephrectomy and Caval Thrombectomy Using Extracorporeal Circulation and Deep Hypothermic Circulatory Arrest for Renal Cell Carcinoma Invading the Supradiaphragmatic Inferior Vena Cava and/or Right Atrium.

BACKGROUND: Radical nephrectomy (RN) and caval thrombectomy (CT) for renal cell carcinoma, with extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA) is a challenging surgical approach. OBJECTIVE: To assess peri-operative and oncologic outcomes of renal cell carcinoma patients treated with RN and CT, using ECC and DHCA. DESIGN, SETTING, AND PARTICIPANTS: We retrospectively evaluated 46 patients who underwent RN and CT using ECC and DHCA. SURGICAL PROCEDURE: After retroperitoneal nodal dissection and RN, a cardiopulmonary bypass was placed and DHCA achieved. A combined approach through the abdomen and the thorax was described. MEASUREMENTS: Perioperative and long-term survival outcomes were reported. RESULTS AND LIMITATIONS: Median operative time and length of hospital stay were 545min and 22 d. Overall, 33 patients (72%) did not require any additional interventional or surgical treatment. Thirty-day and 90-d mortality were 11% (5/46) and 15% (7/46). The 1-yr, 2-yr, and 3-yr cancer specific mortality (CSM)-free survival rates were 77%, 62%, and 56%, respectively. After stratification, according to metastatic status at diagnosis, CSM-free survival rates were significantly lower for cM1 patients compared with cM0 patients (1-yr 46% vs 93%, 2-yr 23% vs 81%, 3-yr 23% vs 73%, p<0.01). Our study is limited by its retrospective and uncomparative nature. CONCLUSIONS: RN with CT using ECC and DHCA is a challenging procedure which requires a dedicated multidisciplinary working team to minimise complications and maximise patients' outcomes. PATIENT SUMMARY: Patients with kidney cancer and a thrombus within the inferior vena cava, which reaches above the diaphragm, can be treated with surgery. However, this kind of surgical treatment is challenging and requires a dedicated multidisciplinary team in order to accomplish the task.

Intraoperative Retrograde Perfusion Sphincterometry to Evaluate Efficacy of Autologous Vas Deferens 6-Branch Suburethral Sling to Properly Restore Sphincteric Apparatus During Robot-Assisted Radical Prostatectomy.

OBJECTIVE: The aim of this study is to describe (urodynamically) the effect of the use of a 6-branch autologous suburethral sling, made with absorbable sutures and vas deferens, to support the bladder neck and urethra during robot-assisted laparoscopic prostatectomy (RALP) to improve early urinary continence (EUC) recovery. MATERIALS AND METHODS: Retrograde leak point pressure (RLPP) was intraoperatively evaluated, by means of retrograde perfusion sphincterometry (RPS), in 77 patients (mean age ± standard deviation [SD]: 65.64 ± 7.23 years, mean body mass index ± SD: 26.69 ± 3.89) scheduled to undergo RALP at our institution. RLPP was evaluated before (RLPPb) and after pneumoperitoneum induction (RLPPp). RLPP was then evaluated after urethrovesical anastomosis (RLPPa) and after proper sling tensioning (RLPPs), with the aim to obtain the same pressure as after pneumoperitoneum induction. EUC recovery, defined as the use of no pad, was assessed 10 days, 30 days, and 6 months after catheter removal. RESULTS: RPS and proper autologous 6-branch sling positioning were feasible in all patients, without perioperative complications and negligible impact on overall operative time. Pneumoperitoneum induction increased, similarly, RLPP in all patients. An important decrease of sphincteric capability was evident after prostate removal and the following urethrovesical anastomosis, while proper sling tensioning allowed for restoration of sphincteric apparatus capability to its presurgical status (mean RLPPs 40.84 cmH2O vs RLPPp 40.39 cmH2O, p = 0.942). EUC recovery within 10 days after catheter removal was achieved in 59 (77%) patients and progressively improved over time. CONCLUSIONS: RPS, intraoperatively performed during RALP, allows for precise evaluation of the impact of the surgical procedure on sphincteric apparatus competence. Moreover, the use of the 6-branch suburethral sling, in association with RPS, allows for restoration of the proper supporting system to the urethral sphincter, similar to the preoperative condition, offering the basis for EUC recovery after radical prostate surgery.

Simple vs six-branches autologous suburethral sling during robot-assisted radical prostatectomy to improve early urinary continence recovery: prospective randomized study.

We have recently described the use of a retropubic suburethral autologous sling created and placed during robotic radical prostatectomy (RARP). In this study, we assess the effectiveness of newly designed six-branches compared to two-branches suburethral autologous sling in improving early urinary continence (UC) recovery. 120 patients submitted to RARP were prospectively randomized according to the intraoperative positioning of six-branches (group 1, n = 60) or two-branches autologous sling (group 2, n = 60) obtained by different configuration of a same tract of vas deferens removed. Early UC recovery was assessed at 5 (catheter removal), 10 and 30 days postoperatively through the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. UC was defined as the non-use of pad. Chi square test and Wilcoxon test were used to investigate UC recovery between the two groups. Moreover, post-voiding residual was evaluated in each patient at the same time. At catheter removal, UC rate was in groups 1 and 2, 60 and 35% (p = 0.02); at 10 days 70 and 46% (p = 0.03); at 30 days 87 and 70% (p = 0.04), respectively. One patient in group 1 experienced acute urinary retention at the time of catheter removal and was treated uneventfully with a further 7-day catheterization. These preliminary data indicate that newly designed six-branches suburethral autologous sling is able to increase the rate of early UC recovery compared to the two-arms sling previously described by us.

Radical Prostatectomy in Men with Oligometastatic Prostate Cancer: Results of a Single-institution Series with Long-term Follow-up.

In the absence of data from randomized trials, the role of local treatment in metastatic prostate cancer (PCa) is gaining interest. Our study aimed to assess perioperative and long-term oncologic outcomes of radical prostatectomy (RP) in a selected cohort of 11 patients with oligometastatic disease treated with RP and extended pelvic lymph node dissection between 2006 and 2011. Oligometastatic disease was defined as the presence of five or fewer bone lesions at bone scan with or without suspicious pelvic or retroperitoneal nodal involvement at preoperative imaging. The minimum follow-up for survivors was 5 yr. Perioperative outcomes, clinical progression, and cancer-specific mortality (CSM) were evaluated. Median age was 72 yr. Median operative time, blood loss, and length of hospitalization were 170min, 750ml, and 13 d, respectively. Overall, two patients (18%) experienced grade 3 complications in the postoperative period, and eight (73%) received blood transfusions. Overall, 10 (91%) and 8 (73%) patients had lymph node invasion and positive surgical margins, respectively. Adjuvant androgen deprivation therapy was administered to 10 patients (91%). Median follow-up for survivors was 63 mo. The 7-yr clinical progression- and CSM-free survival rates were 45% and 82%, respectively. Our findings support the safety and effectiveness of RP in a highly selected cohort of PCa patients with bone metastases and long-term follow-up. PATIENT SUMMARY: We evaluated the outcomes of patients with oligometastatic prostate cancer treated with radical prostatectomy with a minimum of 5-yr follow-up. This surgical procedure performed with a multimodal approach might represent a safe and feasible option in selected men and provide acceptable oncologic outcomes at long-term follow-up.

(18)F-FACBC (anti1-amino-3-(18)F-fluorocyclobutane-1-carboxylic acid) versus (11)C-choline PET/CT in prostate cancer relapse: results of a prospective trial.

PURPOSE: To compare the accuracy of (18)F-FACBC and (11)C-choline PET/CT in patients radically treated for prostate cancer presenting with biochemical relapse. METHODS: This prospective study enrolled 100 consecutive patients radically treated for prostate cancer and presenting with rising PSA. Of these 100 patients, 89 were included in the analysis. All had biochemical relapse after radical prostatectomy (at least 3 months previously), had (11)C-choline and (18)F-FACBC PET/CT performed within 1 week and were off hormonal therapy at the time of the scans. The two tracers were compared directly in terms of overall positivity/negativity on both a per-patient basis and a per-site basis. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and accuracy were calculated for both the tracers; follow-up at 1 year (including correlative imaging, PSA trend and pathology when available) was considered as the standard of reference. RESULTS: In 51 patients the results were negative and in 25 patients positive with both the tracers, in eight patients the results were positive with (18)F-FACBC but negative with (11)C-choline, and in five patients the results were positive with (11)C-choline but negative with (18)F-FACBC. Overall in 49 patients the results were false-negative (FN), in two true-negative, in 24 true-positive (TP) and in none false-positive (FP) with both tracers. In terms of discordances between the tracers: (1) in one patient, the result was FN with (11)C-choline but FP with (18)F-FACBC (lymph node), (2) in seven, FN with (11)C-choline but TP with (18)F-FACBC (lymph node in five, bone in one, local relapse in one), (3) in one, FP with (11)C-choline (lymph node) but TP with (18)F-FACBC (local relapse), (4) in two, FP with (11)C-choline (lymph nodes in one, local relapse in one) but FN with (18)F-FACBC, and (5) in three, TP with (11)C-choline (lymph nodes in two, bone in one) but FN with (18)F-FACBC. With (11)C-choline and (18)F-FACBC, sensitivities were 32 % and 37 %, specificities 40 % and 67 %, accuracies 32 % and 38 %, PPVs 90 % and 97 %, and NPVs 3 % and 4 %, respectively. Categorizing patients by PSA level (<1 ng/ml 28 patients, 1 - <2 ng/ml 28 patients, 2 - <3 ng/ml 11 patients, ≥3 ng/ml 22 patients), the number (percent) of patients with TP findings were generally higher with (18)F-FACBC than with (11)C-choline: six patients (21 %) and four patients (14 %), eight patients (29 %) and eight patients (29 %), five patients (45 %) and four patients (36 %), and 13 patients (59 %) and 11 patients (50 %), respectively. CONCLUSION: (18)F-FACBC can be considered an alternative tracer superior to (11)C-choline in the setting of patients with biochemical relapse after radical prostatectomy.

Side docking of the da Vinci robotic system for radical prostatectomy: advantages over traditional docking.

The standard low lithotomic position, used during robot-assisted radical prostatectomy (RARP), with prolonged positioning in stirrups together with steep Trendelenburg may expose the patient to neurapraxia phenomena of the lower limbs and can rarely be used in patients with problems of hip abduction. To overcome these hurdles, we evaluated the clinical benefits of "side docking" (SD) of the da Vinci(®) robotic system in comparison to "traditional docking" (TD). A cohort of 120 patients submitted to RARP were prospectively randomized into two groups by docking approach: SD with the patient supine with lower limbs slightly abducted on the operating table, and TD docking time, intraoperative number of collisions between the robotic arms and postoperative neurological problems in the lower limbs were noted. Descriptive statistics was used to analyze outcomes. Docking time was shorter for the SD group [SD: median 13 min (range 10-18); TD: median 21 min (range 15-34)]. None in the SD group and six of 60 patients (10%) in the TD group suffered from temporary (<30 days) unilateral neurological deficits of the lower limbs. In both groups no collisions between the robotic arms occurred. The SD approach is technically feasible. It does not cause collisions between the robotic arms, and is a reliable method for reducing the setup time of RARP. The supine position of the patient may prevent neurological complications of the lower limbs. Based on these results, SD has become the standard docking technique used by our department.

Incidental retroperitoneal paraganglioma in patient candidate to radical prostatectomy: Concurrent surgical treatments by robotic approach.

We report a case of a 75-year-old male with biopsy-proven prostate cancer and candidate for radical prostatectomy. The patient's medical history includes hypertension and atrial fibrillation in prophylactic treatment; however, he was suffering from recurrent paroxysmal episodes of supraventricular tachycardia. Abdominal magnetic resonance performed for prostate cancer staging detected a non-lymphatic inter-cavo-aortic mass of 42 × 37 × 43 cm. Results of biochemical screening confirmed the clinical diagnosis of symptomatic paraganglioma. The patient was subjected in a single robotic session for concurrent excision of the inter-aortocaval mass and radical prostatectomy with bilateral pelvic lymph-node dissection. During the procedure, there were no anesthesiological or surgical complications. The postoperative course was uneventful and the patient was discharged on postoperative day 5. Six months after surgery, his prostate-specific antigen level was undetectable and the abdominal magnetic resonance imaging was negative for local recurrence or metastasis of paraganglioma. No more episodes of tachycardia were reported or antihypertensive therapy was necessary.

Retropubic Intracorporeal Placement of a Suburethral Autologous Sling During Robot-Assisted Radical Prostatectomy to Improve Early Urinary Continence Recovery: Preliminary Data.

BACKGROUND AND PURPOSE: Urinary continence (UC) recovery remains bothersome for patients even after robot-assisted radical prostatectomy (RARP). We describe the first retropubic suburethral autologous sling created and placed during RARP. The surgical technique and preliminary data regarding its effectiveness in improving early UC recovery are presented. PATIENTS AND METHODS: Between November 2013 and February 2014, 60 patients who underwent RARP at a single high-volume center were prospectively randomized into sling and nonsling groups. Early UC was assessed at 5 days (time of catheter removal), 10 days, and 30 days postoperatively by the daily number of pads used and the International Consultation on Incontinence Questionnaire-Urinary Incontinence-Short Form (ICIQ-UI-SF) score. Sling-related operative time and urethral erosion were also analyzed. Chi-square and independent sample t tests were used to investigate surgical and functional outcomes between groups. RESULTS: Complete data were available for all patients. Mean ± standard deviation (SD) numbers of pads used daily in nonsling and sling groups, respectively, were 1.9 ± 1.2 versus 1.7 ± 1.4 (P = 0.5) at 5 days, 1.8 ± 1.3 versus 1.3 ± 1.3 (P = 0.1) at 10 days, and 1.1 ± 1.2 versus 0.4 ± 0.8 (P = 0.01) at 30 days. At 1 month, mean ± SD ICIQ-UI-SF scores in nonsling and sling groups, respectively, were 4.8 ± 4.6 versus 1.8 ± 3.4 (P = 0.01); sling patients were associated with pad-free status (76% vs 46%, P = 0.03). The advantage in UC recovery was also observed in sling patients at 3, 6, and 12 months postoperatively. Surgical time did not differ between groups, and in sling patients, no cases of urethral erosion or uroflowmetry suggestive of urinary obstruction were found. Limitations included the small sample size and the lack of assessment of morphologic and urodynamic changes produced by the sling. CONCLUSIONS: The suburethral autologous sling is technically feasible and may improve early UC recovery after RARP. These preliminary results should be confirmed in a larger sample of patients.

Onset of hydronephrosis and lower urinary tract symptoms in a previously healthy young man: Phyllodes tumour of the prostate as a potential diagnosis.

We report the case of a 50-year-old healthy man with early onset of micturition symptoms associated with an elevated total prostate-specific antigen. On physical examination, we found an enlarged prostate; a first-line ultrasound of the urinary tract revealed local disease which covered the entire small pelvis. A computed tomography scan confirmed the presence of a 12.5 × 11.0 × 9.5-cm multicystic prostatic mass, compressing the bladder and pelvic ureters, associated with right hydronephrosis. Renal function was preserved and prostatic biopsies was negative for malignant disease. The mass was completely removed through transvesical approach and histological analysis diagnosed a low-grade phyllodes tumour of the prostate. The patient was free of local recurrence and metastasis 36 months after surgery.

Head-to-head comparison of lymph node density and number of positive lymph nodes in stratifying the outcome of patients with lymph node-positive prostate cancer submitted to radical prostatectomy and extended lymph node dissection.

OBJECTIVE: The aim of this study was to compare the predictive ability of lymph node density (LND) and number of positive lymph nodes in patients with prostate cancer and lymph node invasion. MATERIALS AND METHODS: We included 568 patients with lymph node invasion treated with radical prostatectomy and extended pelvic lymph node dissection between January 1990 and July 2011 at a single center. The Kaplan-Meier method and multivariable Cox regression models tested the association between the number of positive lymph nodes or LND and cancer-specific survival (CSS). The predictive accuracy of a baseline model was assessed using Harrell's concordance index and then compared with that of a model including either the number of positive nodes or LND. RESULTS: The median number of positive lymph nodes was 2, whereas the median LND was 11.1%. At 5, 8, and 10 years, CSS rates were 92.5%, 83.9%, and 82.8%, respectively. At multivariable analyses, number of positive lymph nodes and LND, considered as continuous variables, were independent predictors of CSS (all P≤0.01). A 30% LND cutoff was found to be highly predictive of CSS (P = 0.004), and a cutoff of 2 positive nodes was confirmed to be a strong predictor of CSS (P = 0.02). The number of positive nodes and LND similarly, continuous or dichotomized, increased the accuracy for CSS predictions (0.68-0.69 vs. 0.61 of baseline model). LND cutoff of 30% increased the discrimination the most (0.69; +0.083). CONCLUSIONS: The number of positive lymph nodes and LND showed comparable discriminative power for long-term CSS predictions. A cutoff of 30% LND might be suggested for the selection of patients candidate for adjuvant systemic therapy, because it increased the model's discrimination the most.

The key role of time in predicting progression-free survival in patients with renal cell carcinoma treated with partial or radical nephrectomy: conditional survival analysis.

INTRODUCTION: In surgically treated patients with renal cell carcinoma (RCC), the progression-free survival (PFS) rate may significantly change according to the progression-free postoperative period. To test this hypothesis, we set to evaluate the conditional PFS rate in surgically treated patients with RCC. METHODS: We evaluated 1,454 patients with RCC, surgically treated between 1987 and 2010, at a single institution. Cumulative survival estimates were used to generate conditional PFS rates. Separate Cox regression models were fitted to predict clinical-progression risk in patients who were progression free from 1 to 10 years after surgery. RESULTS: During the immediate postoperative period, the 5-year PFS rate was 88%, and it increased to 92%, 94%, and 97% in patients who remained progression free at, respectively, 1, 5, and 10 years after surgery. At multivariable analyses, where patients with stage I disease were considered as a reference, the highest clinical-progression risk was observed at the eighth postoperative year in patients with stage II disease (hazard ratio [HR]: 2.9) and during the immediate postoperative period in patients with stage III to IV disease (HR: 5.5). In comparison with patients with grade I disease, the highest clinical-progression risk was observed at the fourth (as well as eighth) postoperative year in patients with grade II disease (HR: 5.7), sixth postoperative year in patients with grade III disease (HR: 7.2), and during the immediate postoperative period in patients with grade IV disease (HR: 8.5). CONCLUSIONS: The postoperative progression-free period has an important effect on the subsequent clinical-progression risk. This aspect should be considered along with tumor characteristics to plan the most cost-effective follow-up scheme for surgically treated patients with RCC.

Sexual function in adult life following Passerini-Glazel feminizing genitoplasty in patients with congenital adrenal hyperplasia.

PURPOSE: We assessed external genitalia sensitivity and sexual function in adults with congenital adrenal hyperplasia who had undergone Passerini-Glazel feminizing genitoplasty as children, and compared them to a control group of healthy counterparts. MATERIALS AND METHODS: Inclusion criteria were congenital adrenal hyperplasia, Passerini-Glazel feminizing genitoplasty, adult age and penetrative vaginal intercourse. Thermal and vibratory sensitivity of the clitoris, vagina and labia minora were analyzed using the Genito Sensory Analyzer (Medoc Ltd., Minnetonka, Minnesota). Psychosexual outcome was assessed with the Beck Depression Inventory, Zung Self-Rating Anxiety Scale, Female Sexual Distress Scale and Female Sexual Function Index. Matched analyses were performed to compare outcomes in patients to controls (healthy medical students). All statistical tests were performed using SPSS®, version 18.0 RESULTS: A total of 12 patients (10%) entered the study. Thermal and vibratory clitoral sensitivity was significantly decreased in all patients compared to healthy controls (p <0.01). There was no difference in thermal or vibratory vaginal sensitivity between patients and controls. On the Female Sexual Distress Scale 11 patients (91.6%) and 11 controls (91.6%) described a stable satisfactory relationship. All patients reported active sexual desire, good arousal, adequate lubrication and orgasm. No significant difference in Female Sexual Function Index global score or single domain scores was observed between patients and controls. CONCLUSIONS: Although clitoral sensitivity in sexually active patients with congenital adrenal hyperplasia treated with Passerini-Glazel feminizing genitoplasty is significantly reduced compared to controls, sexual function in those patients is not statistically or clinically significantly different from their healthy counterparts. Finally, 1-stage Passerini-Glazel feminizing genitoplasty seems to allow normal adult sexual function.

Spatial distribution of positive cores improves the selection of patients with low-risk prostate cancer as candidates for active surveillance.

OBJECTIVE: To test the hypothesis that spatial distribution of positive cores at biopsy is a predictor of unfavourable prostate cancer characteristics at radical prostatectomy (RP) in active surveillance (AS) candidates. PATIENTS AND METHODS: We examined the data of 524 patients treated with RP, between 2000 and 2012. All fulfilled at least one of four commonly used AS criteria. Regression models tested the relationship between positive cores spatial distribution, defined as the number of positive zones at biopsy (PBxZ) and tumour laterality at biopsy and two endpoints: (i) unfavourable prostate cancer at RP (Gleason score ≥ 4 + 3, and/or pT3 disease), and (ii) clinically significant prostate cancer (tumour volume ≥ 2.5 mL). RESULTS: Unfavourable prostate cancer and clinically significant prostate cancer rates were 8 and 25%, respectively. Patients with more than one PBxZ had a 3.2-fold higher risk of harbouring unfavourable prostate cancer, and a 2.3-fold higher risk of harbouring clinically significant prostate cancer compared with their counterparts with one PBxZ (both P = 0.01). Patients with bilateral tumour at biopsy had a 3.3-fold higher risk of harbouring unfavourable prostate cancer and a 1.7-fold higher risk of harbouring clinically significant prostate cancer compared with their counterparts with unilateral tumour at biopsy (both P ≤ 0.04). Some of these results did not reach a statistically significant level, when the analyses were restricted to patients that fulfilled the most stringent AS criteria. CONCLUSIONS: Positive cores spatial distribution at biopsy should be considered, when advising patients about AS. The addition of this predictor to AS inclusion criteria can help identifying patients at a higher risk of progression, and reduce the rate of inappropriate surveillance of aggressive tumours. However, the most stringent AS criteria (namely John-Hopkins criteria and Prostate Cancer Research International: Active Surveillance criteria) might not benefit from the addition of this predictor. This point warrants further investigation in future studies.

Ureteral endometriosis: proposal for a diagnostic and therapeutic algorithm with a review of the literature.

INTRODUCTION: The ureteral involvement in deep pelvic endometriosis in usually asymptomatic and might lead to a silent loss of renal function. As a matter of fact, the diagnosis and the treatment modalities are still a matter of debate. MATERIALS AND METHODS: We performed a literature review by searching the MEDLINE database for articles published in English between 1996 and 2010, using the key words urinary tract endometriosis, ureteral endometriosis, diagnosis and treatment. We found more than 200 cases of ureteral endometriosis (UE). RESULTS: The disease most commonly affects a single distal segment of the ureter, with a left predisposition in most of the patients. Two major pathological types of UE may be distinguished: intrinsic and extrinsic. The symptoms are usually nonspecific and owing to secondary obstruction. The diagnosis has to be considered as a step- by-step procedure, starting from physical examination to highly detailed imaging methods. Nowadays, the treatment is usually chosen according to the type of UE, the site lesion and the distance to the ureteral orifice, with the use of JJ stents remaining a matter of debate. CONCLUSIONS: A close collaboration between the gynecologist and the urologist is advisable, especially in referral centers. Surgical treatment can lead to good results in terms of both patient compliance and prognosis.

Inhibition of phosphodiesterase 4 enhances clitoral and vaginal blood flow responses to dorsal clitoral nerve stimulation or PGE1 in anesthetized female rats.

INTRODUCTION.: Cyclic adenosine 3'5' monophosphate (cAMP) is produced by adenylate cyclase after activation by, e.g., vasoactive intestinal polypeptide or prostaglandin E1 (PGE1). The cAMP-degrading phosphodiesterase 4 (PDE4) is expressed in the vagina and clitoris, but no information is available on the functional role for PDE4-related signals in the female neurovascular genital response. AIM.: The aim of this study is to study the effect of inhibition of PDE4 with rolipram on nerve- and PGE1-induced vaginal and clitoral blood flow responses of rat. METHODS.: Measure of clitoral and vaginal blood flow and blood pressure in anesthetized rats during activation of the dorsal clitoral nerve (DCN) before and after intraperitoneal administration of rolipram or sildenafil (phosphodiesterase type 5 inhibitors [PDE5]) and nitro-L-arginine (L-NNA) (nitric oxide synthase inhibitor). Effect by topical administration of PGE1 on genital blood flow was also evaluated. MAIN OUTCOME MEASURE.: Blood flow was recorded as tissue perfusion units (TPU) by a Laser Doppler Flowmeter. Mean arterial blood pressure (MAP) was recorded (cmH2 O) in the carotid artery. Blood flow responses are expressed as TPU/MAP. Unpaired t-test and an analysis of variance were used. RESULTS.: Compared with control stimulations, rolipram (0.3 mg/kg) caused a twofold increase in peak blood flow (P < 0.05) and fourfold increase of the rate of clitoral blood flow during activation of the DCN (P < 0.05). Simultaneously, a twofold increase in peak blood flow and threefold increase in rate of blood flow were noted in the vagina (P < 0.05). Similar effects were noted for sildenafil (0.2 mg/kg) (P < 0.05). Inhibitory effects by L-NNA (60 mg/kg) on blood flow responses to DCN activation were significantly lower for rats treated with rolipram than with sildenafil (P < 0.05). PGE1-induced (10 µg) blood flow responses were significantly higher (P < 0.05) in rats treated with rolipram than with sildenafil. CONCLUSIONS.: These findings suggest that the cAMP/PDE4 system may be of similar functional importance as the nitric oxide/cyclic guanosine monophosphate/PDE5 pathway for neurovascular genital responses of the female rat.

Circulating sex steroids and prostate cancer: introducing the time-dependency theory.

PURPOSE: We sought whether serum total testosterone (tT), estradiol (E2), tT/E2 ratio, and sex hormone-binding globulin (SHBG) significantly fluctuate throughout time in men with prostate cancer (PCa). METHODS: Circulating hormones were measured in a cohort of 631 candidates for radical prostatectomy. Hormone levels were analyzed according to either patient age, stratified into quartiles, or body mass index (BMI). Linear regression analyses tested the association between sex steroids and continuously coded patient age and BMI values. RESULTS: No significant differences were found among age quartiles regarding serum tT levels and tT/E2 ratio. Conversely, E2 and SHBG levels significantly increased throughout time (all, p ≤ 0.001). Total T did not linearly change according to continuously coded patient age; in contrast, E2 and SHBG linearly increased (all, p ≤ 0.001), whereas tT/E2 decreased (p = 0.016) with aging. Rate of hypogonadism significantly increased with aging (p = 0.04). Total T, T/E2 ratio, and SHBG linearly decreased along with BMI increases (all p ≤ 0.02), whereas serum E2 did not significantly change. Rate of hypogonadism significantly increased with BMI increases (p < 0.001). CONCLUSIONS: In contrast with longitudinal studies in the general male population, these data indirectly suggest that serum tT levels could be stable over time in PCa patients. This finding led to formulation of a "time-dependency theory", which postulates that the endocrine biology of prostate tissue is dependent on the exposure time at a given concentration of sex steroid, which, in turn, fluctuates throughout the lifespan of the individual.