Predictors of complications occurring after open and robot-assisted prostate cancer surgery: a retrospective evaluation of 1062 consecutive patients treated in a tertiary referral high volume center.

To investigate factors associated with the risk of major complications after radical prostatectomy (RP) by the open (ORP) or robot-assisted (RARP) approach for prostate cancer (PCa) in a tertiary referral center. 1062 consecutive patients submitted to RP were prospectively collected. The following outcomes were addressed: (1) overall postoperative complications: subjects with Clavien-Dindo System (CD) one through five versus cases without any complication; (2) moderate to major postoperative complications: cases with CD < 2 vs. ≥ 2, and 3) major post-operative complications: subjects with CDS CD ≥ 3 vs. < 3. The association of pre-operative and intra-operative factors with the risk of postoperative complications was assessed by the logistic regression model. Overall, complications occurred in 310 out of 1062 subjects (29.2%). Major complications occurred in 58 cases (5.5%). On multivariate analysis, major complications were predicted by PCa surgery and intraoperative estimated blood loss (EBL). ORP compared to RARP increased the risk of major CD complications from 2.8 to 19.3% (OR = 8283; p < 0.0001). Performing ePLND increased the risk of major complications from 2.4 to 7.4% (OR = 3090; p < 0.0001). Assessing intraoperative blood loss, the risk of major postoperative complications was increased by BL above the third quartile when compared to subjects with intraoperative blood loss up to the third quartile (10.2% vs. 4.6%; OR = 2239; 95%CI: 1233-4064). In the present cohort, radical prostatectomy showed major postoperative complications that were independently predicted by the open approach, extended lymph-node dissection, and excessive intraoperative blood loss.

ABO blood group system and risk of positive surgical margins in patients treated with robot-assisted radical prostatectomy: results in 1114 consecutive patients.

To test the hypothesis of associations between the ABO blood group system (ABO-bg) and prostate cancer (PCa) features in the surgical specimen of patients treated with robot-assisted radical prostatectomy (RARP). Between January 2013 and October 2020, 1114 patients were treated with RARP. Associations of ABO-bg with specimen pathological features were evaluated by statistical methods. Overall, 305 patients were low risk (27.4%), 590 intermediate risk (50%) and 219 high risk (19.6%). Pelvic lymph node dissection was performed in 678 subjects (60.9%) of whom 79 (11.7%) had cancer invasion. In the surgical specimen, tumor extended beyond the capsule in 9.8% and invaded seminal vesicles in 11.8% of cases. Positive surgical margins (PSM) were detected in 271 cases (24.3%). The most frequently detected blood groups were A and O, which were equally distributed for both including 467 patients (41.9%), followed by groups B (127 cases; 11.4%) and AB (53 subjects; 4.8%). Among specimen factors, the ABO-bgs associated only with the risk of PSM, which was higher for blood group O (30.4%) compared with group A (19.5%) after adjusting for other standard clinical predictors (odds ratio, OR = 1.842; 95% CI 1.352-2.509; p < 0.0001). Along the ABO-bgs, the risk of PSM was increased by group O independently by other standard preoperative factors. The ABO-bgs may represent a further physical factor for clinical assessment of PCa patients, but confirmatory studies are required.

Severe intraoperative bleeding predicts the risk of perioperative blood transfusion after robot-assisted radical prostatectomy.

To evaluate potential factors associated with the risk of perioperative blood transfusion (PBT) with implications on length of hospital stay (LOHS) and major post-operative complications in patients who underwent robot-assisted radical prostatectomy (RARP) as a primary treatment for prostate cancer (PCa). In a period ranging from January 2013 to August 2019, 980 consecutive patients who underwent RARP were retrospectively evaluated. Clinical factors such as intraoperative blood loss were evaluated. The association of factors with the risk of PBT was investigated by statistical methods. Overall, PBT was necessary in 39 patients (4%) in whom four were intraoperatively. Positive surgical margins, operating time and intraoperative blood loss were associated with perioperative blood transfusion on univariate analysis. On multivariate analysis, the risk of PBT was predicted by intraoperative blood loss (odds ratio, OR 1.002; 95% CI 1.001-1.002; p < 0.0001), which was associated with prolonged operating time and elevated body mass index (BMI). PBT was associated with delayed LOHS and Clavien-Dindo complications > 2. In patients undergoing RARP as a primary treatment for PCa, the risk of PBT represented a rare event that was predicted by severe intraoperative bleeding, which was associated with increased BMI as well as with prolonged operating time. In patients who received a PBT, prolonged LOHS as well as an elevated risk of major Clavien-Dindo complications were seen.

American Society of Anesthesiologists' (ASA) Physical Status System and Risk of Major Clavien-Dindo Complications After Robot-Assisted Radical Prostatectomy at Hospital Discharge: Analysis of 1143 Consecutive Prostate Cancer Patients.

Objective: To test the hypothesis of associations of preoperative physical status system with major postoperative complications at hospital discharge in prostate cancer (PCa) patients treated with robot-assisted radical prostatectomy (RARP). Materials and Methods: In a period ranging from January 2013 to October 2020, 1143 patients were evaluated. The physical status was assessed by the American Society of Anesthesiologists' (ASA) system, which was computed trained anesthesiologists. The Clavien-Dindo system was used to classify postoperative complications, which were coded as major if greater than 1. Results: ASA physical status system included class I in 102 patients (8.9%), class II in 934 subjects (81.7%), and class III in 107 cases (9.4%). Clavien-Dindo complications were distributed as follows: grade 1: 141 cases (12.3%), grade 2: 108 patients (9.4%), grade 3a: 5 subjects (0.4%), grade 3b: 9 patients (0.8%), and grade 4a: 3 cases (0.3%). Overall, major complications were detected in 125 cases (10.9%). On multivariate analysis, major Clavien-Dindo complications were predicted by ASA score grade II (adjusted odds ratio, OR = 2.538; 95%CI 1.007-6.397; p = 0.048) and grade III (adjusted OR 3.468; 95%CI 1.215-9.896; p = 0.020) independently by pelvic lymph node dissection (PLND) and/or blood lost. Conclusion: In RARP surgery, the risk of major postoperative Clavien-Dindo complications increased as the physical status system deteriorated independently by performing or not a PLND and/or large intraoperative blood lost. The ASA score system was an effective predictor of major Clavien-Dindo complications, which delayed LOHS in RARP surgery. Confirmatory studies are required. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01577-9.

Association between ABO blood group and unfavorable prostate cancer features after radical prostatectomy: Retrospective study of 1149 patients.

Objectives: To test hypothesized associations between the ABO blood group (ABO-bg) system and the pathological features of prostate cancer (PCa). Material and methods: Between January 2013 and September 2019, 1173 patients underwent radical prostatectomy. Associations between ABO-bg levels and pathological features were evaluated using statistical methods. Results: Overall, 1149 consecutive patients were evaluated using the ABO-bg system, which was represented by O-bg (42.8%) and A-bg (41.3%), followed by B-bg (11.1%) and AB-bg (4.8%). Only positive surgical margins (PSMs) was correlated with ABO-bg (Pearson correlation coefficient, r = 0.071; p = 0.017), and the risk was increased in group-O (odds ratio [OR], 1.497; 95% confidence interval, 1.149-1.950; p = 0.003) versus non-O-bg. In clinical and pathological models, O-bg was at increased risk of PSM after the adjustment for prostate-specific antigen, percentage of biopsy-positive cores, and high surgical volume (adjusted OR, 1.546; 95% confidence interval, 1.180-2.026; p = 0.002); however, the adjusted OR did not change after the adjustment for tumor load and stage as well as high surgical volume. Conclusions: In clinical PCa, the risk of PSM was higher in O-bg versus non-O-bg patients after the adjustment for standard predictors. Confirmatory studies are needed to confirm the association between ABO-bg and unfavorable PCa features.

Endogenous testosterone density as ratio of endogenous testosterone levels on prostate volume predicts tumor upgrading in low-risk prostate cancer.

OBJECTIVES: To evaluate preoperative endogenous testosterone (ET) density (ETD), defined as the ratio of ET on prostate volume, and tumor upgrading risk in low-risk prostate cancer (PCa). MATERIALS AND METHODS: From November 2014 to December 2019, 172 low-risk patients had ET (nmol/L) measured. ETD, prostate-specific antigen density (PSAD) and the ratio of percentage of biopsy positive cores (BPC) to prostate volume (PV), defined as BPC density (BPCD), were evaluated. Associations with tumor upgrading in the surgical specimen were assessed by statistical methods. RESULTS: Overall, 121 patients (70.3%) had tumor upgrading, which was predicted by BPCD (odds ratio, OR = 4.640; 95% CI 1.903-11.316; p = 0.001; overall accuracy: 70.3%). On multivariate analysis, tumor upgrading and clinical density factors related to each other for BPCD being predicted by ETD (regression coefficient, b = 0.032; 95% CI 0.021-0.043; p < 0.0001), PSAD (b = 1.962; 95% CI 1.067-2.586; p < 0.0001) and tumor upgrading (b = 0.259; 95% CI 0.112-0.406; p = 0.001). According to the model, as BPCD increased, ETD and PSAD increased, but the increase was higher for upgraded cases who showed either higher tumor load but significantly lower mean levels of either ET or PSA. CONCLUSIONS: As ETD increased, higher tumor loads were assessed; however, in upgraded patients, lower ET was also detected. ETD might stratify low-risk disease for tumor upgrading features.

Endogenous testosterone as a predictor of prostate growing disorders in the aging male.

OBJECTIVE: To investigate the associations of endogenous testosterone with prostate growing disorders (PGD) including benign prostatic hyperplasia (BPH) and prostate cancer (PCA). METHODS: The study population was composed by 1176 cases including 371 BPH subjects (31.5%) without cancer who underwent prostate transurethral resection from January 2017 to November 2019 and 805 patients (68.5%) with PCA who underwent surgery from November 2014 to December 2019. The association of endogenous testosterone, which was measured before surgery, with the risk of PGD was evaluated by statistical methods. RESULTS: In the study population, endogenous testosterone levels were significantly lower in PCA cases compared to BPH patients who were older with larger prostates but lower prostate-specific antigen (PSA) levels. On multivariate analysis, the risk of PCA decreased by endogenous testosterone (odds ratio, OR = 0.957; 95% CI 0.930-0.984; p = 0.002) as by age (OR = 0.955; 95% CI  0.933-0.984; p < 0,0001) and prostate volume (OR = 0.930; 95% CI 0.919-0.940; p < 0.0001) but increased by PSA (OR = 1.652; 95% CI 1.542-1.769; p < 0.0001). On multivariate linear regression analysis, endogenous testosterone inversely associated with body mass index (BMI) (regression coefficient, b = - 0.279; p = 0.002) and PCA (b = - 2.935; p < 0.0001). CONCLUSIONS: In the aging male, endogenous testosterone independently predicted malignant prostate disorders, which associated with decreased hormone levels along BMI categories. Endogenous testosterone is a further marker for evaluating prostate growing disorders in clinical practice; however, controlled studies are required.

Accuracy of preoperative endo-rectal coil magnetic resonance imaging in detecting clinical under-staging of localized prostate cancer.

OBJECTIVES: To assess the accuracy of intra-rectal coil magnetic resonance imaging (ER-MRI) for staging early prostate cancer (EPC). MATERIALS AND METHODS: ER-MRI was performed with the Magnetom Symphony 1.5 Tesla system. ER-MRI and pathology findings were statistically correlated. RESULTS: One hundred and fifty-four consecutive patients underwent radical prostatectomy (RRP) for EPC (cT1c-2 Nx M0). An average age was 66, mean PSA 11.04 µg/L (median 7.33 µg/L) and mean pathologic Gleason score 6. Pathology detected 97 out of 154 patients (63 %) as EPC and 57 cases (37 %) as extra-prostate extension (EPED) (pT3) with extra-capsular extension (ECE) (pT3a) in 41 (27 %) and seminal vesicle invasion (SVI) (pT3b) in 16 (10 %). ER-MRI staged 100 patients (65 %) as cT2 and 54 (35 %) as EPED with ECE in 37 cases (24 %) and SVI in 17 (11 %). ER-MRI sensitivity, specificity, positive predictive value, negative predictive value, overall accuracy resulted respectively 0.78, 0.96, 0.86, 0.92, 0.91 for ECE as well as 0.88, 0.98, 0.82, 0.99 and 0.97 for SVI. CONCLUSION: ER-MRI was effective in detecting preoperative EPC under-staging. In the next future, multi-parametric 3-Tesla ER-MRI will be the procedure for diagnosing, staging and following-up prostate cancer patients.

Investigative clinical study on prostate cancer part II: on the role of the pretreatment total PSA to free testosterone ratio as a marker assessing prostate cancer prognostic groups after radical retropubic prostatectomy.

OBJECTIVES: To explore the significance of the pretreatment total prostate-specific antigen (PSA) to free testosterone (FT) ratio (PSA/FT) as a marker for assessing the pathologic Gleason sum (pGS) and levels of tumor extension (pT) in prostatectomy specimens. PATIENTS AND METHODS: 128 of 135 consecutive patients diagnosed with prostate cancer underwent radical prostatectomy. Simultaneous pretreatment serum samples were obtained to measure serum total testosterone, FT and total PSA levels. The statistical design of the study included 2 sections: the first part trying to explore the role of the PSA/FT ratio in clustering patients with different pathologic prognostic factors, and the second to investigate the PSA/FT ratio distribution in different groups of patients according to the pathologic stage and pGS of the specimen after radical prostatectomy. RESULTS: The average age was 65.80 (range 51.21-77.26) years, mean PSA was 8.88 (range 1.22-44.27) µg/l, mean FT was 35.32 (range 13.70-69.30) pmol/l, and the mean PSA/FT ratio was 0.27 (range 0.04-1.48). The PSA/FT ratio significantly clustered both the pT and pGS groups. Analysis of variance for the distribution of the PSA/FT ratio was significant for the pT model groups. The mean PSA/FT ratio increased as the tumor extended and grew through the prostate gland (high-stage disease). Analysis of variance for the different distributions of the PSA/FT ratio was significant for all model pGS groups. In our investigation we also found (data not shown) that a PSA/FT ratio of ≥0.40 was strongly correlated with large extensive (pT3b+pT4) and high-grade cancers (pGS8+pGS9). CONCLUSIONS: Prostate cancer patients may be classified into 3 different pathologic prognostic groups according to the PSA/FT ratio: low risk (PSA/FT ≤0.20), intermediate risk (PSA/FT >0.20 and ≤0.40), and high risk (PSA/FT >0.40 and ≤1.5). The PSA/FT ratio may be considered as the marker expressing different biology groups of prostate cancer patients, and it is strongly associated with pT and pGS.

Investigative clinical study on prostate cancer: on the role of the pretreatment total PSA to free testosterone ratio in selecting different biology groups of prostate cancer patients.

OBJECTIVES: To show that prostate cancer biology is related to serum levels of both free testosterone (FT) and prostate-specific antigen (PSA), that PSA level is linearly related to FT and that the PSA to FT ratio may be considered as the growth rate parameter expressing cancer phenotype biology. MATERIALS AND METHODS: The study includes 135 consecutive patients diagnosed with prostate cancer. Pretreatment simultaneous serum samples for analyzing total testosterone (TT), FT and total PSA levels were obtained. The study was assessed according to a multidimensional approach of the five continuous variables including TT, FT, PSA, AGE and percentage of positive biopsies (=P+). The all sets of data were considered as one--sample with no groupings among the observations. Multivariate analysis included factor analysis (FA) and principal component analysis (PCA). Multivariate inferential statistics for comparing different groups of patients according to the PSA to free testosterone ratio (PSA/FT) included Hotteling's multivariate two-sample T²-Test for comparing two mean vectors as well as Box's M-Test with the chi-square approximation for comparing multiple covariance matrices when patients were sampled in more than two groups. RESULTS: Factor analysis showed the two natural grouping of variables, FT-TT and PSA-P+. PCA assessed FT and PSA as the two variables with large variances having a notable influence on the first two principal components. Multiple linear regression analysis showed that all the income variables, except age, significantly predicted the PSA/FT ratio. Patients were first sampled according to the PSA/FT ratio in group 1 (PSA/FT ≤ 0.20) and group 2 (PSA/FT > 0.20), and Hotteling's multivariate two sample T²-Test was significant (P < 0.01). Patients were then sampled according to the PSA/FT ratio in group 1 (PSA/FT ≤ 0.20), group 2 (PSA/FT > 0.20 and ≤ 0.40), and group 3 (PSA/FT > 0.40), and Box's M-Test comparing the covariance matrices of the 3 groups differed significantly (P < 0.001). Finally, patients were sampled according to the PSA/FT ratio in 6 groups, and Box's M-Test was again significant (P < 0.001). CONCLUSIONS: The PSA to FT ratio is the growing rate parameter expressing different biology patterns and assessing different groups of prostate cancer patients. In our opinion, the results of the present study might have wide applications in understanding, assessing and planning prostate cancer studies including basic science, screening, assessing risk of the disease, predicting disease stage as well natural history after a planned treatment involving biochemical recurrence, progression, hormone refractory prostate cancer and disease-specific survival.

Short-term outcome after high-intensity focused ultrasound in the treatment of patients with high-risk prostate cancer.

OBJECTIVE: To assess the short-term outcome in patients with high-risk prostate cancer treated by transrectal high-intensity focused ultrasound (HIFU). PATIENTS AND METHODS: From April 2003 to November 2004, 30 patients with high-risk prostate cancer were enrolled in this prospective study; all had transurethral resection of the prostate before transrectal HIFU treatment, using the Ablatherm device (EDAP, Lyon, France) during the same session, associated with hormonal therapy with luteinizing hormone-releasing hormone analogues. After the procedure, all the patients were evaluated every 3 months by physical examination, prostate-specific antigen (PSA) assay and a continence questionnaire. The follow-up schedule also included a transperineal prostate biopsy 6 months after the treatment. All the patients had a minimum follow-up of 12 months. RESULTS: The HIFU treatment took a median (interquartile range, IQR) of 140 (100-160) min. No complications were reported during treatment. The mean (IQR) hospitalization was 2.2 (1-4) days, and the suprapubic drainage tube was removed after 12 (7-18) days. The complications after treatment were: urinary tract infections in five patients (16%), stenosis of the intraprostatic and membranous urethra in three (10%), and secondary infravesical obstruction in four (13%). At 12 months after the procedure, 28 patients (93%) were continent. Seven of the 30 men (23%) had a positive prostate biopsy. At the 1-year follow-up only three of the 30 patients with high-risk prostate cancer had a PSA level of >0.3 ng/mL. CONCLUSIONS: HIFU is a modern, minimally invasive therapy for prostate cancer, often used in selected patients with localized disease. The present results show that HIFU was also feasible in patients with high-risk prostate cancer. The low complication rates and favourable functional outcome support the planning of further larger studies in such patients. The oncological efficacy of HIFU should be assessed in further studies with a longer follow-up.

Use of transperineal fine needle aspiration of seminal vesicles to retrieve sperm in a man with obstructive azoospermia.

OBJECTIVE: To report the successful and feasible use of transperineal fine needle aspiration of seminal vesicles (FNASV) for sperm retrieval in obstructive azoospermia. DESIGN: Case report. SETTING: Outpatient care in institutional clinic. PATIENT(S): A 31-year-old man with obstructive azoospermia due to a middle prostatic müllerian cyst. INTERVENTION(S): Transperineal FNASV using a coaxial 17-gauge TruGuide needle. MAIN OUTCOME MEASURE(S): Feasibility of sperm retrieval suitable for future in vitro fertilization. RESULT(S): Transperineal FNASV made it possible to aspirate 11 mL of fluid with a sperm count of 100 million/mL and 15% motility. This sample was cryopreserved for in vitro fertilization using intracytoplasmic sperm injection. CONCLUSION(S): Transperineal FNASV using a coaxial needle may be a further method for sperm retrieval to add to the repertoire of assisted reproduction technologies.

Intraparenchymal renal artery aneurysms. Case report with review and update of the literature.

Increased interest in aneurysms involving the renal artery and its branches has occurred during the past 3 decades. The prevalence of renal artery aneurysms is approximately 0.01%-1% in the general population as well as 2.5% in hypertensive patients undergoing angiography. Intraparenchymal renal artery aneurysms (IPRAAs) are rare since being detected in less than 10% of patients with renal artery aneurysms. The Authors report an unusual case of multiple small intrarenal artery aneurysms associated with a large IPRAA located in the mid portion of the right kidney. Usually, IPRAAs are secondary to diseases or injuries of the kidney vascular network. They are classified as true, false, saccular, fusiform, dissecting, and microaneurysms. Potential complications of IPRAAs include peripheral dissection, thrombosis, hypertension, renal infarction and rupture. IRAAs may be detected incidentally as well as present with urologic symptoms and signs related to complications. Actually, IRAAs are investigated by non invasive modalities including duplex ultrasound, magnetic resonance angiography, spiral three-dimensional computed tomography angiography, and three-dimensional reconstructed rotational digital substraction angiography of the segmental and distant branches of the renal artery. Angiography with intrarterial injection of contrast material is the gold standard in diagnosing IPRAAs. Treatment options for IPRAAs include observation, aneurysmectomy with surgical repair, endovascular procedures, nephrectomy or partial nephrectomy. Observation is indicated for asymptomatic intraparenchymal renal artery aneurysms measuring less than 2 cm in diameter. Surgical repair of IPRAAs includes aneurysmectomy and reconstruction of the renal artery by in vivo or ex vivo technique. The procedure is indicated for IPRAAs causing renovascular hypertension, dissection, urologic symptoms, embolization, local expansion and women of childbearing age with a potential for pregnancy. In recent years, transcatheter arterial embolization has emerged as a simple, useful and effective technique in managing IRAAs. The procedure is performed by transfemoral catheterization as well as by superselective catheterization and embolization of interlobar arteries with 3F microcatheters. Endovascular occlusion is obtained by using gelatin sponge, steel coils, detachable baloons, and conventional non-detachable microcoils delivered through a microcatheter. Nephrectomy or partial nephrectomy are reserved for conditions precluding renal revascularization which include overt RAA rupture, covert RAA rupture, artery-to-vein fistula, renal cell carcinoma, end stage nephropaty, renal infarction, severe ischemic renal atrophy or complex intrarenal aneurysms. Recently, partial nephrectomy by the laparoscopic approach has been proposed for managing IPRAAs and the procedure is considered feasible and safe.

Primary lymphoepithelioma-like carcinoma of the urinary bladder: report of one case with review and update of the literature after a pooled analysis of 43 patients.

BACKGROUND AND OBJECTIVES: Lymphoepithelioma-like carcinoma (LELC) is an undifferentiated epithelial tumor with a dense inflammatory infiltrate that resembles the lymphoepithelioma of the nasopharinx occurring in other sites. Primary LELC of the bladder (LELCB) was first reported by Zukerberg et al in 1991. The incidence of LELCB is 0.4%-1.3% of all bladder carcinomas. The mean age at diagnosis is 69 years. Of the patient population 69% are men. Herein we report on one more case of primary predominant LELCB and review all the English literature concerning this subject after performing a pooled analysis of the cases recorded in the English literature including the present one. MATERIALS AND METHODS: The reports of 43 patients including the present case of primary LELCB from the English literature were collected from 1991 to 2002. Patients were evaluated for age, sex, primary and adjuvant treatments, clinical staging, follow-up and outcome, and disease related survival. The overall patient population was separated into 3 groups according to the LELCB classification of Amin. RESULTS: The overall patient population included 31 males and 12 females. Average age was 68.4 years (range 52-84). LELCB histological subtypes resulted pure in 17 cases (40%), predominant in 16 (37%) and focal in 10 (23%). Mean follow-up was 37.7 months (range 0-216). Outcome resulted as follows: 26 patients (62%) did not show evidence of diasease, 11 (26%) died of disease, 1 (2%) was alive with metastases, and 4 (10%) died for causes unrelated to the primary disease. Survival rate related to specific disease resulted 71%. Mean follow-up was 48.1 in the first group (pure LELCB), 32 in the second (predominant LELCB), and 30.3 in the third one (focal LELCB). Patients with not evidence of disease were 13 (81%) in group 1, 13 (82%) in group 2, and 0 in group 3. Patients who died of their disease resulted 1 (6%) in the first group, 1 (6%) in the second, and 9 (90%) in the third one. Patients who died for disease not related to the primary tumor were 2 (13%) in the first group, 1 (6%) in the second, and 1 (10%) in the third one. One patient (6%) was alive with metastases in group 2. Survival rate related to specific disease resulted 93% in the first group, 93% in the second one, and 0% in the third one. CONCLUSIONS: To date, there are no clear guide lines for the treatment of LELCB. Treatments performed include both deep transurethral resection of the tumor (TUR-B) as well as partial or radical cystectomy, with or without adjuvant treatments including systemic chemotherapy and radiotherapy. The prognosis is favorable for patients presenting with the pure and predominant forms with a diploid DNA pattern and very poor for patients presenting with focal LELCB. Bladder salvage therapy by performing both TUR-B alone or combined with adjuvant systemic chemotherapy may be a reasonable option for patients with pure or predominant LELCB, while radical surgery with adjuvant systemic therapy may be indicated for focal muscle invasive LELCB.

Incidental adrenal pheochromocytoma. Report on 5 operated patients and update of the literature.

INTRODUCTION: Adrenal masses discovered by imaging techniques for reasons unrelated to adrenal diseases are called incidentalomas with pheochromocytomas accounting for about 20%. The aim of this study was to report on our experience of 5 patients operated for incidentally discovered adrenal pheochromocytoma and update the literature concerning this subject. PATIENTS AND METHODS: From September 1976 to December 2000 we operated on 28 for adrenal incidentaloma, and pheochromocytoma was detected in 5 patients (19%). Average age was 61.4 years (range 54-65). All patients underwent adrenal hormonal as well as imaging investigation. Preoperative care for pheochromocytoma was performed in 3 patients. All patients were followed up. RESULTS: Average tumor diameter, as detected by CT, was 5.5 cm (range 3-10). Urinary 24/h excretion of VMA resulted elevated in 2 cases (40%). Two patients during adrenalectomy developed paroxysmal hypertension which was readily controlled by intravenous administration of nitroprussiate and trandate. Postoperative outcome was uneventful. Average tumor size, as detected by pathology, resulted 8.9 cm (range 3-12). Mean follow-up was 60.4 months (range 32-122) and overall survival rate was 60%. Three patients are alive and disease-free and 2 died after a follow-up of 32 and 36 months for reasons unrelated to the primary disease. CONCLUSIONS: Every incidentally discovered adrenal mass should be investigated for pheochromocytoma since accounting for about 20%. Undetected pheochromocytomas undergoing surgery without preoperative care for avoiding cardiovascular disturbances confer a high risk for morbidity and mortality, especially in pregnancy and childhood. Nonfunctional and small tumors sized 3 cm or lesser may be closely followed up by imaging and hormonal investigation. Surgery is indicated when tumors are functional or larger than 3 cm. Actually, laparoscopy is the new gold-standard in treating adrenal pheochromocytomas. Adrenal sparing surgery as well as autotransplantation of adrenal tissue are both effective and safe in treating patients with bilateral pheochromocytomas, thus improving quality of life since avoiding lifelong steroid dependency. When managed appropriately, the outlook for pheochromocytoma is excellent with a free survival rate of 92% and 80% at 5 and 10 years respectively. Unfortunately, malignant pheochromocytomas are still difficult to treat.

[Small cell carcinoma of the bladder. Report of 3 cases and review of the literature]. / Il carcinoma a piccole cellule della vescica. Descrizione di tre casi e revisione della letteratura.

Primary small cell carcinoma of the urinary bladder is a highly aggressive disease and accounts for less than 0.5% of all primary bladder tumors. Quite often, clinical presentation is related to local and/or systemic involvement of the disease. Histogenesis is still unknown, but investigators consider the tumor originating from a multipotent undifferentiated stem cell of the bladder urothelium. Hematuria is the first and most frequent symptom that patients complain at the clinical presentation of the disease. The primary local tumor is treated by radical surgery or radiation therapy, while systemic involvement requires polychemotherapy according to the M-VAC protocol. Prognosis is worse and related to the pathological stage of the disease and to chemotherapy reply. Herein we report on 3 cases of primary small cell carcinoma of the urinary biadder. We also review and update the literature concerning this topic.

Incidentally discovered adrenal myelolipoma. Report on 3 operated patients and update of the literature.

INTRODUCTION AND OBJECTIVES: Adrenal myelolipomas are rare benign non functioning tumors which are mostly detected incidentally by imaging (8-15%). The aim of this study was to find out the clinical outcome of 3 patients operated for incidentally discovered adrenal myelolipoma as well as to update the literature concerning this topic. PATIENTS AND METHODS: During a 24 year period (1976-2000) we operated on 28 of 39 (72%) patients for incidentally discovered adrenal mass and pathology assessed 3 myelolipomas (11%). All patients were males and average age was 54.3 years (range 46-66). Myelolipoma was associated with arterial hypertension in 2 patients and BPH in 1. Patients underwent unilateral adrenalectomy. Results Myelolipomas, all unilateral, were right-sided in 2 cases (67%) and left sided in 1. Average tumor diameter, as detected by CT scan, resulted 10.3 cm range (3-17). Endocrine investigation was negative. Average tumor size, as detected by pathology, resulted 9.3 cm (range 3-14) and mean weight 653 gr (range 210-980). Histopathology assessed primary adrenal myelolipoma in all cases. Mean follow-up is 110.6 months (range 102-128) and all patients are alive and disease free. CONCLUSIONS: Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are effective in diagnosing adrenal myelolipomas in about 90% of cases. Fine needle aspiration (FNA) cytology under CT or US control has an important role in investigating as well as diagnosing undefined masses suspected of adrenal or extraadrenal myelolipoma thus avoiding unnecessary surgery. The increasing number of incidentally discovered adrenal myelolipomas arise the question of appropriate treatment modalities which range from watchful waiting to surgical removal. Small asymptomatic tumors sized less than 4 cm can be monitored expectantly. Tumors when symptomatic or larger than 4 cm should be removed since the risk of spontaneous rupture with retroperitoneal hemorrhage and life threatening shock. Bilateral adrenalectomy for large and symptomatic tumors implies lifelong substitution with hydrocortisone. Actually, laparoscopic adrenalectomy is the new gold standard in treating myelolipomas since both showing more effective postoperative recovery than open surgery as well as reducing the number of patients who undergo long and close follow up.

Management of clinical stage I testicular pure seminoma. Report on 42 patients and review of the literature.

INTRODUCTION: Testis cancer is the most common tumor detected in men aged from 20 to 35 years accounting for 1-2%. About 20-30% of patients presenting with clinical stage I pure seminoma of the testis, which accounts for 45-50% of all germ cell tumors, present with occult metastases in the retroperitoneal lymph nodes. Currently, treatment options for clinical stage I seminoma include adjuvant radiotherapy (RT) as well as surveillance and adjuvant single agent chemotherapy. Herein, we review our experience in the management of 42 patients with clinical stage I pure seminoma of the testis and review the literature concerning this topic. MATERIALS AND METHODS: Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 42 (75%) were assessed as clinical stage I disease. Adjuvant RT was performed in 41 patients and surveillance in 1. Radiations fields included the para-aortic and ipsilateral pelvic lymph nodes. A radiation dose of 25 Gy in 20 daily fractions was given. All patients were followed up. RESULTS: Average age was 41.2 years (range 24-67). Mean follow-up was 85.3 months (range 12-279). Histopathology assessed classic seminoma in 41 cases (98%) and spermatocytic seminoma in 1 (2%). Small vessel invasion was detected in 8 cases (19%). Overall relapse rate was 4.7%. Overall survival rate resulted 97%. CONCLUSIONS: Adjuvant radiotherapy (RT) is a safe standard of care in controlling microscopic retroperitoneal disease in patients with clinical stage I seminoma. About 3 to 5% of patients undergo relapses, mostly after the first 18 months after orchiectomy. Overall cause-specific survival rates range between 96% to 100%. An alternative optional treatment for compliant patients presenting with low risk factors for relapse is surveillance with recurrences rates ranging between 15% to 20%. Surveillance avoids unnecessary treatment in about 80% of patients, thus it could be offered as a safe alternative option to adjuvant RT since imaging detects relapses at their early stages. Adjuvant chemotherapy with 1 or 2 courses of single-agent carboplatin is being investigated as an alternative adjuvant treatment to RT or surveillance in patients with moderate to high risk factors for relapse. The treatment is well tolerated and recurrence rate is 1%.

Management of testicular seminoma advanced disease. Report on 14 cases and review of the literature.

INTRODUCTION: About 25% of testicular seminomas present with advanced clinical stage disease. The retroperitoneal lymph nodes are more likely to be involved (20%) than distant organs (5%). Herein we review our experience in the management of 14 patients with clinical stage II pure seminoma of the testis and review the literature concerning this subject. MATERIALS AND METHODS: Between January 1977 and December 2000, of 56 patients with pure seminoma of the testis 14 (25%) were assessed as clinical stage II disease. RT was performed for clinical substage IIA-IIB and chemotherapy in for IIC disease. All patients were closely followed up. RESULTS: Average age was 39.3 years (range 23-47). Mean follow-up was 88.6 months (range 28-232). Clinical stage IIA-IIB was detected in 12 patients (86%) and IIC in 2 (14%). Relapse did not occur in any patient. At the last follow-up evaluation, all patients were alive and disease-free. CONCLUSIONS: Radiation therapy is the standard of care in managing seminoma small bulk retroperitoneal disease including substages IIA and IIB. Overall toxicity of RT is mild and treatment is well tolerated. After RT, about 20% of patients may undergo relapses. Chemotherapy is the choice treatment for advanced seminoma presenting with clinical stage IIC-III disease; recently, it has also been advocated for stage IIB when presenting with multiple small lymph nodes. Carboplatin and cisplatin are the most effective agents with complete response rates of 89-91%. Patients developing progressive disease after first-line chemotherapy undergo combined salvage chemotherapy with cisplatin, ifosfamide and vinblastine with complete response rate of 83%. Patients presenting salvage chemotherapy failure are treated with high-dose chemotherapy associated with autologous bone marrow transplantation. Residual retroperitoneal masses after chemotherapy for advanced seminoma may be assessed by imaging as poorly or well defined. Surveillance is indicated for residual masses smaller than 3 cm as well as for poorly defined masses equal or greater than 3 cm. Well defined masses equal or larger than 3 cm are treated with surgery or RT. Ongoing clinical trials for testicular germ cell metastatic disease are focused on reducing toxicity without compromising efficacy as well as exploring new salvage strategies and improving the prospect of cures and survival rates.