The Role of [18F]Fluciclovine PET/CT in the Characterization of High-Risk Primary Prostate Cancer: Comparison with [11C]Choline PET/CT and Histopathological Analysis.

The primary aim of the study was to evaluate the role of [18F]Fluciclovine PET/CT in the characterization of intra-prostatic lesions in high-risk primary PCa patients eligible for radical prostatectomy, in comparison with conventional [11C]Choline PET/CT and validated by prostatectomy pathologic examination. Secondary aims were to determine the performance of PET semi-quantitative parameters (SUVmax; target-to-background ratios [TBRs], using abdominal aorta, bone marrow and liver as backgrounds) for malignant lesion detection (and best cut-off values) and to search predictive factors of malignancy. A six sextants prostate template was created and used by PET readers and pathologists for data comparison and validation. PET visual and semi-quantitative analyses were performed: for instance, patient-based, blinded to histopathology; subsequently lesion-based, un-blinded, according to the pathology reference template. Among 19 patients included (mean age 63 years, 89% high and 11% very-high-risk, mean PSA 9.15 ng/mL), 45 malignant and 31 benign lesions were found and 19 healthy areas were selected (n = 95). For both tracers, the location of the "blinded" prostate SUVmax matched with the lobe of the lesion with the highest pGS in 17/19 cases (89%). There was direct correlation between [18F]Fluciclovine uptake values and pISUP. Overall, lesion-based (n = 95), the performance of PET semiquantitative parameters, with either [18F]Fluciclovine or [11C]Choline, in detecting either malignant/ISUP2-5/ISUP4-5 PCa lesions, was moderate and similar (AUCs ≥ 0.70) but still inadequate (AUCs ≤ 0.81) as a standalone staging procedure. A [18F]Fluciclovine TBR-L3 ≥ 1.5 would depict a clinical significant lesion with a sensitivity and specificity of 85% and 68% respectively; whereas a SUVmax cut-off value of 4 would be able to identify a ISUP 4-5 lesion in all cases (sensitivity 100%), although with low specificity (52%). TBRs (especially with threshold significantly higher than aorta and slightly higher than bone marrow), may be complementary to implement malignancy targeting.

Preoperative Staging With 11C-Choline PET/CT Is Adequately Accurate in Patients With Very High-Risk Prostate Cancer.

PURPOSE: To evaluate the accuracy of 11C-choline positron emission tomography (PET)/computed tomography (CT) for nodal staging of prostate cancer (PCa) in different populations of high-risk patients. PATIENTS AND METHODS: We evaluated 262 individuals with intermediate- or high-risk PCa submitted to radical prostatectomy and extended pelvic lymph node dissection. Within men with high-risk disease, we identified a subgroup of individuals harboring very high-risk (VHR, n = 28) disease: clinical stage ≥ T2c and more than 5 cores with Gleason score 8-10; primary biopsy Gleason score of 5; 3 high-risk features; or prostate-specific antigen ≥ 30 ng/mL. The diagnostic accuracy of PET/CT and contrast-enhanced CT (CECT) was assessed after stratifying patients according to risk group classification on a patient- and anatomic region-based analysis. RESULTS: On patient-based analysis, considering high-risk patients (n = 155), 11C-choline PET/CT versus CECT had sensitivity and specificity of 50% and 76% versus 21% and 92%, respectively. Considering VHR men as separate subgroups (n = 28), 11C-choline PET/CT versus CECT had sensitivity and specificity of 71% and 93% versus 25% and 79%, respectively. Accordingly, in the VHR category, the area under the curve of 11C-choline PET/CT versus CECT was 0.86 (95% confidence interval, 0.71-1.0) versus 0.69 (95% confidence interval, 0.52-0.86), respectively. On anatomic region-based analysis, considering the VHR group, 11C-choline PET/CT versus CECT had sensitivity and specificity of 70.6% and 95.5% versus 35.3% and 98.5%, respectively. CONCLUSION: Patients with VHR characteristics could represent the ideal candidate to undergo disease staging with PET/CT before surgery with the highest cost efficacy.

The impact of a structured intensive modular training in the learning curve of robot assisted radical prostatectomy.

AIM: The success of Robot Assisted Laparoscopic Prostatectomy (RALP) is mainly due to his relatively short learning curve. Twenty cases are needed to reach a "4 hours-proficiency". However, to achieve optimal functional outcomes such as urinary continence and potency recovery may require more experience. We aim to report the perioperative and early functional outcomes of patients undergoing RALP, after a structured modular training program. METHODS: A surgeon with no previous laparoscopic or robotic experience attained a 3 month modular training including: a) e-learning; b) assistance and training to the operating table; c) dry console training; d) step by step in vivo modular training performing 40 surgical steps in increasing difficulty, under the supervision of an experienced mentor. Demographics, intraoperative and postoperative functional outcomes were recorded after his first 120 procedures, considering four groups of 30 cases. RESULTS: All procedures were completed successfully without conversion to open approach. Overall 19 (15%) post operative complications were observed and 84% were graded as minor (Clavien I-II). Overall operative time and console time gradually decreased during the learning curve, with statistical significance in favour of Group 4. The overall continence rate at 1 and 3 months was 74% and 87% respectively with a significant improvement in continence rate throughout the four groups (p = 0.04). Considering those patients submitted to nerve-sparing procedure we found a significant increase in potency recovery over the four groups (p = 0.04) with the higher potency recovery rate up to 80% in the last 30 cases. CONCLUSIONS: Optimal perioperative and functional outcomes have been attained since early phase of the learning curve after an intensive structured modular training and less than 100 consecutive procedures seem needed in order to achieve optimal urinary continence and erectile function recovery.

MRI Displays the Prostatic Cancer Anatomy and Improves the Bundles Management Before Robot-Assisted Radical Prostatectomy.

OBJECTIVES: To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical prostatectomy (RARP). METHODS: One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins. RESULTS: Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01). CONCLUSIONS: mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.

Adverse Features and Competing Risk Mortality in Patients With High-Risk Prostate Cancer.

PURPOSE: To assess survival and competing causes of mortality in prostate cancer (PCa) patients referred to radical prostatectomy through a combination of unfavorable characteristics. PATIENTS AND METHODS: We evaluated 615 PCa patients referred to radical prostatectomy and pelvic lymph node dissection at single tertiary-care center with at least one adverse feature (AF): preoperative prostate-specific antigen ≥ 20 ng/mL, pathologic Gleason score 8 to 10, and no organ-confined disease at final pathology (seminal vesicle involvement, positive surgical margins, and/or lymph node invasion). Kaplan-Meier analyses were used to assess cancer-specific mortality (CSM)-free survival rates by stratifying patients into 3 risk categories according to the number of AFs (namely, 1, 2, and 3 AFs). Multivariable competing risk Cox regression analyses were used to assess CSM and other cause of mortality. RESULTS: Significant differences were found in terms of preoperative and pathologic tumor characteristics, adjuvant therapies, and biochemical recurrence (BCR). Men with 1 AF had higher CSM-free survival estimates compared to those with 2 and 3 AFs (92.8% vs. 84.2% vs. 27.7% at 10 years' follow-up, P < .001). Moreover, the presence of 3 AFs (hazard ratio [HR], 2.96), postoperative adjuvant treatment status (HR, 2.44), and time to BCR (HR, 0.96) were all independent predictors of CSM (P ≤ .04). Age at surgery and time to BCR were the only independent predictors of other causes of mortality (P ≤ .0009). CONCLUSION: The risk group stratification according to the number of AFs could help physicians to accurately predict oncologic outcomes and to select PCa patients for the most appropriate postoperative strategies.

Laparoscopic and robotic ureteral stenosis repair: a multi-institutional experience with a long-term follow-up.

The treatment of ureteral strictures represents a challenge due to the variability of aetiology, site and extension of the stricture; it ranges from an end-to-end anastomosis or reimplantation into the bladder with a Boari flap or Psoas Hitch. Traditionally, these procedures have been done using an open access, but minimally invasive approaches have gained acceptance. The aim of this study is to evaluate the safety and feasibility and perioperative results of minimally invasive surgery for the treatment of ureteral stenosis with a long-term follow-up. Data of 62 laparoscopic (n = 36) and robotic (n = 26) treatments for ureteral stenosis in 9 Italian centers were reviewed. Patients were followed according to the referring center's protocol. Laparoscopic and robotic approaches were compared. All the procedures were completed successfully without open conversion. Average estimated blood loss in the two groups was 91.2 ± 71.9 cc for the laparoscopic and 47.2 ± 32.3 cc for the robotic, respectively (p = 0.004). Mean days of hospitalization were 5.9 ± 2.4 for the laparoscopic group and 7.6 ± 3.4 for the robotic group (p = 0.006). No differences were found in terms of operative time and post-operative complications. After a median follow-up of 27 months, the robotic group yielded 2 stenosis recurrence, instead the laparoscopic group shows no cases of recurrence (p = 0.091). Minimally invasive approach for ureteral stenosis is safe and feasible. Both robotic and pure laparoscopic approaches may offer good results in terms of perioperative outcomes, low incidence of complications and recurrence.

Three Unusual Cases of Nutcracker Syndrome Caused by Increased Blood Flow within the Left Renal Vein.

Nutcracker syndrome (NCS) refers to the compression of the left renal vein (LRV) between the aorta and the superior mesenteric artery. It can cause both microscopic and gross haematuria, with or without flank pain. The diagnosis is often delayed in a majority of symptomatic patients. On the other hand, the use of CT in routine abdominal explorations has increased the detection of the compression of the LRV in healthy and asymptomatic patients, but its diagnostic value remains uncertain. In this paper, we report 3 cases of the NCS associated with an increased blood flow in the LRV, due to different conditions, which we believe could produce the appearance of clinical symptoms.

State of the art of PET/CT with 11-choline and 18F-fluorocholine in the diagnosis and follow-up of localized and locally advanced prostate cancer.

OBJECTIVE: To provide an updated state of the art about the role of positron emission tomography/computed tomography (PET/CT) with 11C-Choline and 18F-fluorocholine in the localized and locally advanced Prostate Cancer (PCa) in the staging and restaging setting. METHODS: We performed a non-systematic review of the literature based on a free-text search in the National Library of Medicine Database (MEDLINE) to select English-language published papers evaluating PET and PET/CT imaging with radiolabelled choline in initial diagnosis and in post-treatment phase in PCa patients. RESULTS: PET and PET/CT with 11C-choline and 18F-fluorocholine have been largely investigated as non-invasive diagnostic tools in PCa. Actually, the relatively high rate of false negative findings due to the small dimension of neoplastic lesions and the available spatial resolution of PET tracers limits the routine use of choline PET and PET/CT in staging setting; moreover, it cannot reliably replace the lymph node (LN) dissection for detecting LN involvement. On restaging setting, Choline PET/CT showed a higher accuracy than conventional imaging modalities, especially in the detection of LN and systemic metastases, while it is less accurate than magnetic resonance imaging in the detection of local relapse. CONCLUSION: In the Prostate Specific Antigen (PSA) era with a large number of localized disease, the diagnostic performance of choline PET and PET/CT lack of reliability in initial diagnosis of PCa. The major clinical role of choline PET/CT is the re-staging of patients with a biochemical relapse after radical treatment; the promising performance of choline PET/CT scan in patients with low levels of PSA could also lead the clinicians for to perform PET-guided adjuvant curative therapies or palliative treatments in patients already treated radically for PCa.

Active surveillance for clinically localized renal tumors: An updated review of current indications and clinical outcomes.

The widespread use of abdominal imaging has led to an increasing detection of small renal masses, and approximately 20-30% of those tumors will prove to be benign, with low metastatic potential if not immediately treated. In elderly or comorbid patients diagnosed with small renal masses, competing cause mortality seems to exceed cancer-specific mortality at short- and intermediate-term follow up. In these cases, surgery might represent an overtreatment, and an expectant management, such as active surveillance, might be proposed. According to the current available evidence, active surveillance is a safe and reasonable option for patients with renal tumors ≤4 cm (cT1a) and short life expectancy. A few studies with short-term follow up reported the preliminary results of active surveillance even in cT1b-cT2 tumors, with acceptable risk of disease progression and mortality, even if this approach should be considered in this setting only for highly-selected and well-informed patients. Furthermore, surveillance protocols can be proposed in selected patients with uncomplicated benign tumors, such as angiomyolipomas, in which active surveillance should be considered the initial standard management. At present, reliable clinical predictors of a tumor's growth rate and aggressiveness are not available. Renal tumor biopsy is useful in the clinical work-up of patients who are candidates for active surveillance, in order to improve patient selection based on tumor histological characterization. Despite the proof of safety offered by expectant management for small renal masses in selected patients, further prospective studies with longer follow up are required in order to confirm the indications and long-term oncological outcomes of active surveillance protocols for renal tumors.

Preservation of the smooth muscular internal (vesical) sphincter and of the proximal urethra for the early recovery of urinary continence after retropubic radical prostatectomy: a prospective case-control study.

OBJECTIVES: To evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy. METHODS: This was a prospective single-center, case-control study. A total of 40 consecutive patients with organ-confined prostate cancer were submitted to radical prostatectomy with the preservation of the muscular internal sphincter and the proximal urethra (group 1), and their outcomes were compared with those of 40 patients submitted to a standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7 and 30 days, and 3 and 12 months after removal of the catheter. RESULTS: Group 1 had a faster recovery of early continence than group 2 at day 3 (45% vs 22%; P = 0.029) and at day 7 (75% vs 50%; P = 0.018). Considering the number of pads, group 1 had a faster recovery of continence at 3, 7 and 30 days, and also had less incidence of severe incontinence. There was no statistically significant difference in terms of continence at 3 and 12 months among the two groups. Multivariate logistic regression analysis showed that surgical technique and young age were significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins. CONCLUSIONS: Our modified technique of radical retropubic prostatectomy with preservation of the smooth muscular internal sphincter, as well as of the proximal urethra during bladder neck dissection, results in a significantly increased urinary continence at 3, 7 and 30 days after catheter removal, with a minor incidence of severe incontinence. The technique is also oncologically safe, and it does not increase the operative duration of the procedure.

Testis-sparing surgery for the conservative management of small testicular masses: an update.

BACKGROUND: Malignant germ cell tumours represent the vast majority of palpable testicular masses, and radical orchiectomy is still considered the standard-of-care. Testis-sparing surgery (TSS) could be an alternative to radical orchiectomy in patients diagnosed with small testicular masses (STMs). The aim of this article was to review the current indications and the oncological and functional outcomes of TSS when performed for STMs. MATERIALS AND METHODS: We performed a non-systematic review of literature using the Medline database, including a free-text protocol using the terms "testis sparing surgery", "partial orchiectomy", "testis tumour" and "sex cord tumour". Only the articles reporting data on organ-sparing surgery for testicular neoplasms were evaluated. RESULTS: No randomized controlled trials comparing TSS with radical orchiectomy have been reported. Indications for TSS are controversial, especially for patients with normal contra-lateral testis. For testicular masses of less then 2 cm, TSS seems to be the best treatment option. Frozen-section examination is an essential assessment at the time of TSS, and allows for discrimination of benign from malignant neoplasms. Intermediate- and long-term follow-up results showed no significant risk of local and distant recurrences in the main series reported in literature. CONCLUSION: According to currently available data, TSS is a safe and effective treatment for STMs in selected patients, and bypasses surgical overtreatment, without compromising oncological and functional outcomes. Further studies are needed in order to confirm the oncological safety of this procedure.

Massive hematuria due to ruptured iatrogenic aortic pseudoaneurysm: a case report.

We report an interesting case of massive haematuria secondary to a rupture of a pseudoa- neurysm of the abdominal aorta below the renal vessels. A 65-year-old woman present- ed at our institution with a painful massive haematuria and anaemia. Two months before, she undergone a pelvic surgery complicated by an accidental injury of the right ureter sutured with a end-to-end anastomosis. An abdominal computed tomography (CT) scan with intravenous contrast showed a right-sided hydronephrosis with clots in the lumen of the right pelvis with a massive retroperitoneal hematoma due to a rupture of a iatrogenic pseudoaneurysm of the abdominal aorta below the origin of the renal arteries.

Tubeless procedure reduces hospitalization and pain after percutaneous nephrolithotomy: results of a multivariable analysis.

The objective of the study was to assess the efficacy and safety of tubeless percutaneous nephrolithotomy (t-PCNL) in comparison with standard PCNL (s-PCNL). We retrospectively evaluated 317 consecutive PCNL and compared perioperative results, time of hospitalization and analgesic requirement of t-PCNL (114; 36.0 %) to s-PCNL (203; 64.0 %). The decision to perform a tubeless PCNL was made at the end of the procedures depending on the surgeon's preference and according to the following inclusion criteria: (a) no serious bleeding or perforation in the collecting system during the procedure; (b) patients with no more than one access; and (c) residual stone burden needing a second-stage nephroscopy. Staghorn stones and anatomic anomalies were not considered as exclusion criteria for t-PCNL. Univariate analyses were conducted with one-way ANOVA, Fisher's exact test, Pearson's Chi-square and linear-by-linear association test as appropriate. Stepwise multivariable regression analyses were used to assess the independent correlation between demographics and clinical variables and the clinical outcomes. There were no significant differences between the two groups in terms of stone-free rate, hemoglobin decrease, blood transfusion and complication rate. Mean hospital stay was significantly shorter in the t-PCNL group (3.3 vs. 4.6 days; P < 0.001). Tubeless PCNL was associated with less analgesia requirement (68.4 vs. 86.7 %; P < 0.001) and with lower analgesic dose requirement (1.6 vs. 2.1 mean doses; P = 0.010). Multivariable analyses showed that t-PCNL (P < 0.001), postoperative fever (P < 0.001), transfusions (P < 0.001), operative time (P = 0.002), postoperative hydronephrosis (P = 0.005) and residual fragment dimension (P = 0.024) were independently correlated with duration of hospitalization, while analgesic dose requirement was independently influenced by hemoglobin decrease (P < 0.001), t-PCNL (P = 0.005) and stone number (P = 0.044). Our study confirmed that t-PCNL has similar outcomes to s-PCNL in terms of stone-free rate without increasing complications in selected cases. t-PCNL is a factor independently associated with shorter hospitalization and lower analgesic requirement.

Differing risk of cancer death among patients with lymph node metastasis after radical prostatectomy and pelvic lymph node dissection: identification of risk categories according to number of positive nodes and Gleason score.

OBJECTIVES: To evaluate the outcomes in patients with node-positive prostate cancer (PCa) after radical prostatectomy (RP) and pelvic lymph node dissection (PLND) according to the number of positive lymph nodes (LNs). To identify different risk groups among patients with node-positive PCa. PATIENTS AND METHODS: We evaluated 98 consecutive patients with pN1M0 PCa who underwent RP between November 1995 and May 2011. Kaplan-Meier and Cox proportional univariable and multivariable regression models were used to analyse the survival rates. Patients were divided into two groups according to number of positive LNs using the most informative positive LN theshold for predicting survival, then into three different risk groups according to number of positive LNs and pathological Gleason score (GS). RESULTS: Mean (range) follow-up was 68.4 (10-192) months. Patients with 1-3 positive LNs (n = 75; 76.5%) had significantly better cancer-specific survival (CSS) and overall survival (OS) compared with those with >3 positive nodes (n = 23; 23.4%; P < 0.01). Patients with 1-3 positive LNs and pathological GS ≤7 (Group 1) had significantly better CSS than those with >3 positive LNs or GS 8-10 (Group 2 [P = 0.015]). Group 2 patients, moreover, had significantly better CSS (P = 0.019) and OS (P = 0.021) than those with >3 positive LNs and GS 8-10 (Group 3). CONCLUSIONS: Patients with 1-3 positive LNs have higher CSS and OS rates than those with >3 metastatic LNs. Taking into account the pathological GS, as well as the number of positive nodes, three risk group categories with considerable differences in terms of survival can be found. Patients with LN-positive PCa should be stratified into different groups according to these two measures, to obtain a better prediction of oncological outcomes.

Testicular sclerosing Sertoli cell tumor: an additional case and review of the literature.

Sertoli cell tumours are very rare testicular tumours accounting for 0.4-1.5% of all testicular neoplasms. In the current report, we present a case of sclerosing Sertoli cell tumour. The histology and clinical features were compared to those of other Sertoli cell tumour subtypes in order to assess if the different subtypes really represent distinct clinical and prognostic entities. The current literature was also reviewed. Only 20 cases of sclerosing Sertoli cell tumours have been encountered. Our case, a 38-year-old man represents the 21st case. Distinction among Sertoli cell tumours is important not only histologically; sclerosing Sertoli cell tumours have a distinct clinical behaviour and prognosis, different from those of classic and large-cell calcifying Sertoli cell tumours. Pathologists and urologists should know and understand all the types of Sertoli cell tumours in order to be able to choose the correct therapeutical approach when they encounter these tumours.

Renal leiomyoma: Case report and literature review.

Renal leiomyomas are rare benign tumours of the kidney originating from muscle cells. They are usually found by an autopsy, whether the patient is asymptomatic or has symptoms (i.e., abdominal/flank pain, hematuria, palpable mass). Today the widespread use of ultrasonography and computed tomography has increased the detection of clinically asymptomatic renal leiomyomas. The differential diagnosis between leiomyomas and other malignant lesions (above all renal cell carcinoma or leiomyosarcoma) is still possible by histological examination. Radiological examinations are not sufficient for the differential diagnosis. Renal leiomyomas have no aggressive behaviour and they usually do not metastasize. The prognosis, after surgery, is excellent without recurrence. We report a case of leiomyoma in a 31-year-old man who presented hematuria and flank pain. We also review the literature and provide a summary of clinical, radiological and histological features of renal leiomyomas.