Cognitive zonal fusion biopsy of the prostate: Original technique between target and saturation.

We describe our experience in prostate biopsy using a new standardized cognitive fusion techniques, that we call "cognitive zonal fusion biopsy". This new technique is based on two operative options: the first based on target biopsies, the Cognitive Target Biopsy (CTB) if the same target was detected with transrectal ultrasound (TRUS) and multiparametric magnetic resonance (mpMRI); the second based on saturation biopsies, the Zonal Saturation Biopsy (ZSB) on anatomical zone/s containing the region of interest if the same target was not evident with TRUS and MRI. We evaluated results of our technique compared to standard biopsy in order to identify clinically relevant prostate cancer. METHODS: This is a single-center prospective study conducted in 58 pts: 25 biopsy-naïve, 25 with previous negative biopsy and in 8 with cancer in active surveillance. Based on mpMRI and transrectal ultrasonography (TRUS), all patients were scheduled for standard 12-core TRUS-guided biopsy. If mpMRI was suggestive or positive (PI-RADS 3, 4 or 5): patients underwent additional targeted 2 to 6 cores using cognitive zonal fusion technique. RESULTS: 31/58 (53.4%) patients had a cancer. Our technique detected 80.6% (25 of 31) with clinically significant prostate cancer, leading to detection of insignificant cancer in 20%. Using standard mapping in MR negative areas we found 5 clinically significant cancer and 4 not significant cancers. MRI cancer detection rate was 18/31 (58.1%), and 9/18 (50%) in high grade tumors. Therefore MRI missed 50% of high grade cancers. The mean number of cores taken with cognitive zonal fusion biopsy was 6.1 (2-17), in addition biopsy sampling was done outside the ROI areas. Overall 15.4 cores (12-22) were taken. Cancer amount in Zonal Biopsy was larger than 7.3 mm (1-54.5) in comparison with 5.2 mm (1-23.5) in standard mapping. Largest percentage of cancer involvement with cognitive zonal fusion technique was detected in 19.4% vs 15.9%. CONCLUSIONS: Cognitive Zonal Saturation Biopsies should be used to reduce operator variability of cognitive fusion biopsy in addition to standard biopsy. Cognitive zonal biopsy based on mpMRI findings identifies clinically relevant prostate in 80%, has larger cancer extension in fusion biopsies than in random biopsies, and reduce the number of cores if compared to saturation biopsy.

Rare presentation of a testicular angiofibroma treated with testis sparing surgery.

INTRODUCTION: Testicular benign tumors are very rare (< 5%). Testicular Angiofibroma (AF) is one of those, however the gold standard of treatment and follow-up is still unclear. CASE REPORT: A 47 years-old man with only one functioning testis was referred to our clinic for a palpable right testicular mass and atrophic contralateral testis. Patient underwent testis-sparing surgery with inguinal approach and intraoperative frozen sections examination with diagnosis of AF. Final histology confirmed AF. Post-operative follow-up was uneventful. Clinical and ultrasonographic follow-up was negative after 8 months. CONCLUSION: We report a conservative surgery in a patient with AF of the solitary testis. AF is a benign para-testicular fibrous neoplasm that could be misinterpreted as malignant tumor and treated with orchiectomy. Testis-sparing surgery is recommended in this case with intraoperative pathological examination. The excision of the mass is enough but in front of a possible recurrence a long follow-up is advisable.

Biopsy follow-up in patients with isolated atypical small acinar proliferation (ASAP) in prostate biopsy.

The incidence of prostate cancer (PCA) was evaluated in 155 patients with isolated Atypical Small Acinar Proliferation (ASAP) found on initial prostate biopsy, after a medium-term follow-up (40 months) with at least one re-biopsy. Clinical and histological data were analysed. Cancer was detected in 81 of 155 (52.3%). The cancer detection rate was 71.6%, 91.3%, 97.5%, 100% at the 1st re-biopsy, 2nd, 3rd, and 4th rebiopsy respectively. At the uni- and multivariate analyses, prostate volume (≤ 30 cc), transition zone volume (≤ 10 cc), small core length at the initial biopsy (≤ 10 mm) and few number of cores at initial biopsy (≤ 8) are predictive of cancer. Furthermore, tumour characteristics on the whole surgical specimens was assessed in 30 men: 13 of 30 (43 %) had clinically relevant cancer (volume > 0.5 ml or/and Gleason score ≥ 7, or pT3). Most of relevant cancers were detected in the distal apex, anterior gland and midline. These anatomical sites could be under-sampled at the initial biopsy using the transrectal approach. Our data suggest that follow-up biopsy is recommended in all cases of isolated ASAP detected after biopsy using endfire transrectal probe. The re-biopsy strategy should increase the number of cores (or a saturation biopsy), focusing on area of ASAP in the initial biopsy, but also including the under-sampled areas (anterior gland, distal apex and midline) to detect clinically relevant cancers.

Prostatic fiducial markers implantation by transrectal ultrasound for adaptive image guided radiotherapy in localized cancer: 7-years experience.

OBJECTIVE: we present our 7-years' experience with fiducial gold markers inserted before Image-Guided Radiotherapy (IGRT) focusing on our echo-guided technique reporting early and late complications. MATERIAL AND METHODS: 78 prostate cancer (PCA) patients who underwent fiducial markers placement for adaptive IGRT (period 2007-2014) were selected. Mean patient age was 75 years (range 60-81), mean PSA 7.8 ng/ml (range 3.1-10), clinical stage < T3, mean Gleason Score 6.4 (range 6-7). We recorded early and late complications. Maximum distance between the Clinical Target Volume (CTV) and Planning Target Volume (PTV) was assessed for each direction and the mean PTV reduction was estimated. RESULTS: we describe in details our echo-guided technique of intraprostatic gold fiducial markers insertion prior to adaptative IGRT. We report rare early toxicity (5-7% grade 1-2), a mean PTV reduction of 37% and a very low late toxicity (only 3.4% bladder G3 and 8% rectal G2 side effects). CONCLUSION: Our technique of fiducial gold markers implantation for adaptative IGRT is safe and well-tolerated and it resulted helpful to reduce CTV-PTV margin in all cases; the effects on clinical practice seem significant in terms of late toxicity but further investigations are needed with longer follow-up.

Improvement of lower urinary tract symptoms and sexual activity after open simple prostatectomy: prospective analysis of 50 cases.

OBJECTIVES: To evaluate the improvement of Lower Urinary Tract Symptoms (LUTS) and Erectile Function (EF) evaluated before and after Open Simple Prostatectomy, focusing on which patients this procedure allows better outcomes in term of sexual activity. MATERIAL AND METHODS: 50 men with large size benign prostatic hyperplasia (BHP) greater than 80 gr were prospectively evaluated before and 6 months after Open Simple Prostatectomy (Freyer procedure) between October 2012 to September 2013. Patients had a pre-operative transrectal ultrasound (TRUS) for volume evaluation and filled pre and post operative questionnaires for International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) score. RESULTS: Mean patients age was 71 years (D.S. 3,5), mean prostate volume results 103 ml (D.S. 23,7); regarding LUTS and EF, mean improvement of IPSS score was 15,3 (D.S. 4) and mean increase of IIEF-5 score was 3,4 (D.S.3). This study highlights a correlation between patients' age and increase of IIEF-5 score; no correlation with prostate size was found. CONCLUSION: According to the EAU Guidelines 2014, large size BPH (over 80-100 mL) with LUTS refractory to medical management continue to have open prostatectomy as the treatment of choice. In our experience we found not only an reduction of LUTS after the procedure but also an improvement of erectile function; this improvement was related with patient's age.

Inflammatory abdominal aortic aneurysm presenting as bilateral hydroureteronephrosis: a case report and review of literature.

We report a case of Inflammatory Abdominal Aortic Aneurysm (IAAA) producing bilateral hydro-ureteronephrosis. A 74-year-old patient presented to urologist office for bilateral hydronephrosis detected by kidney and bladder ultrasound (US). Patient reported lower urinary tract symptoms and inconstant and slight low back pain irradiated to inguinal region dating 3 weeks. Renal function, urine analysis and abdominal examination were normal. However the repeated ultrasound in the urologist office revealed abdominal aortic aneurism extended to iliac vessels. The patient was sent directly to vascular surgery unit where contrast computerized tomography (CT) and successful surgical repair were done. Final diagnosis was IAAA. The post-operative course was uneventful. Renal function was regular and the hydronephrosis reduced spontaneously under monitoring by CT and US. We review diagnosis and management of hydronephrosis that is sometimes linked to IAAA rather than standard AAA. Abdominal ultrasound is mandatory in any bilateral hydronephrosis and it could save lives.

Prolonged antibiotic therapy increases risk of infection after transrectal prostate biopsy: a case report after pancreasectomy and review of the literature.

Infection due to prostate biopsy afflicted more than 5% of patients and is the most common reason for hospitalization. A large series from US SEER-Medicare reported that men undergoing biopsy were 2.26 times more likely to be hospitalized for infectious complications within 30 days compared with randomly selected controls. The factors predicting a higher susceptibility to infection remain largely unknown but some authors have higlighted in the etiopathogenesis the importance of the augmented prevalence of ciprofloxacin resistant variant of bacteria in the rectum flora. We present one case of sepsis after transrectal prostate biopsy in a patient with history of pancreatic surgery. Based on our experience patients candidated to prostate biopsy with transrectal technique with history of recent major surgery represent an high risk category for infective complication. Also major pancreatic surgery should be consider an high risk category for infection. A transperineal approach and preventive measures (such as rectal swab) should be adopted to reduce biopsy driven infection.

Perivascular epithelioid cell tumor (PEC-ome) of the prostate: ultrasound feature in case report.

INTRODUCTION: We describe a rare tumor arising from the prostate gland: Perivascular Epithelioid Cells tumor (PEC-ome). A 54-years old was treated for acute urinary retention with alpha-blockers at presentation due to benign prostate enlargement (65 cc) with asymmetric middle lobe and regular PSA (0.92 ng/ml). After 5 months, patient developed a second acute urinary retention episode and nodules in the left lung; he was treated with transurethral resection of the prostate and left lobectomy. RESULTS: Histological examination of prostate and lung tissue gave the same diagnosis: leiomyosarcoma with atypical morphological features and patient was observed for 4 months. Considering the uncommon diagnosis, pathological review by the uro-pathologist at our Hospital was done. Additional immunohistochemistry was done and both tumors showed similar and typical features of metastatic PEC-ome (T1b N0 M1). Therefore a new staging showed local and distant progression with prostatic mass and small lung metastasis. Three cycles of Gemcitabine and Pazopanib were administered, but 2 months later a new urinary retention occurred, despite chemotherapy. Patient referred to our Hospital for salvage pelvic surgery with lymph node dissection. Final pathological diagnosis was PEC-ome of the prostate stage pT4 pN0 R0 M1. CONCLUSIONS: PEC-ome is a rare but rapidly invasive mesothelial tumor with early metastatic potential. When this tumors originates from the fibromuscular stroma of the prostate it mimics benign prostatic enlargement and causes LUTS. Expert pathology aided by immunoisthochemistry is the cornerstone of diagnosis. There are no pathognomonic imaging on ultrasound or symptoms suggesting the presence of PEC-ome in early stage. A multidisciplinary approach is necessary and radical surgery should be done to treat this aggressive cancer.

Diagnostic-therapeutic pathway for small lesions of the testis.

Objective of our study was to define a diagnostic-therapeutic pathway for proper treatment of not-palpable testicular masses, that may be benign in 38% of cases. Since the intraoperative diagnosis is difficult to reach in particular in small lesion (< 8 mm) and the risk of tissue loss in frozen section analysis occurs frequently, we propose a diagnostic flow chart for the best management of small testis lesions. This proposed protocol has to be shown in details to physicians and patients, who must understand the clinical implications and the risk to undergo a second radical surgery.