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Reitano G, Ceccato T, Botti S, Bruniera M, Carrozza S, Bovolenta E, Randazzo G, Minardi D, Ruggera L, Gardi M, Novara G, Dal Moro F, Zattoni F. Treatment and Staging Intensification Strategies Associated with Radical Prostatectomy for High-Risk Prostate Cancer: Efficacy Evaluation and Exploration of Novel Approaches. Cancers (Basel) 2024; 16:2465. [PMID: 39001527 PMCID: PMC11240638 DOI: 10.3390/cancers16132465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/27/2024] [Accepted: 07/04/2024] [Indexed: 07/16/2024] Open
Abstract
The management of high-risk prostate cancer (PCa) presents a significant clinical challenge, often necessitating treatment intensification due to the potential presence of micrometastases. While radical prostatectomy (RP) constitutes one of the primary treatment modalities, the integration of neoadjuvant and adjuvant therapies suggests a paradigm shift towards more aggressive treatment strategies, also guided by new imaging modalities like positron emission tomography using prostate-specific membrane antigen (PSMA-PET). Despite the benefits, treatment intensification raises concerns regarding increased side effects. This review synthesizes the latest evidence on perioperative treatment intensification and de-escalation for high-risk localized and locally advanced PCa patients eligible for surgery. Through a non-systematic literature review conducted via PubMed, Scopus, Web of Science, and ClinicalTrials.gov, we explored various dimensions of perioperative treatments, including neoadjuvant systemic therapies, adjuvant therapies, and the role of novel diagnostic technologies. Emerging evidence provides more support for neoadjuvant systemic therapies. Preliminary results from studies suggest the potential for treatments traditionally reserved for metastatic PCa to show apparent benefit in a non-metastatic setting. The role of adjuvant treatments remains debated, particularly the use of androgen deprivation therapy (ADT) and adjuvant radiotherapy in patients at higher risk of biochemical recurrence. The potential role of radio-guided PSMA lymph node dissection emerges as a cutting-edge approach, offering a targeted method for eradicating disease with greater precision. Innovations such as artificial intelligence and machine learning are potential game-changers, offering new avenues for personalized treatment and improved prognostication. The intensification of surgical treatment in high-risk PCa patients is a dynamic and evolving field, underscored by the integration of traditional and novel therapeutic approaches. As evidence continues to emerge, these strategies will refine patient selection, enhance treatment efficacy, and mitigate the risk of progression, although with an attentive consideration of the associated side effects.
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Affiliation(s)
- Giuseppe Reitano
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
- Department of Urology, Mayo Clinic, Rochester, MN 55905, USA
| | - Tommaso Ceccato
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Simone Botti
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Martina Bruniera
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Salvatore Carrozza
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Eleonora Bovolenta
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Gianmarco Randazzo
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Davide Minardi
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Lorenzo Ruggera
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Mario Gardi
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Giacomo Novara
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Fabrizio Dal Moro
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
| | - Fabio Zattoni
- Department of Urology, Azienda Ospedale-Università Padova, 35122 Padova, Italy
- Department of Medicine (DIMED), University of Padua, 35128 Padova, Italy
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Małkiewicz B, Knura M, Łątkowska M, Kobylański M, Nagi K, Janczak D, Chorbińska J, Krajewski W, Karwacki J, Szydełko T. Patients with Positive Lymph Nodes after Radical Prostatectomy and Pelvic Lymphadenectomy—Do We Know the Proper Way of Management? Cancers (Basel) 2022; 14:cancers14092326. [PMID: 35565455 PMCID: PMC9104304 DOI: 10.3390/cancers14092326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Prostate cancer (PCa) is the second most frequent malignancy in the male population worldwide. Men with a nodal invasion established after radical prostatectomy with lymph node dissection are a heterogeneous group of patients who require more thorough stratification and therapy individualization, which remain uncovered by current guidelines. Considering a multitude of prognostic factors and novel diagnostic techniques, classifying patients into narrower and more specified risk groups should be a vital part of lymph node positive PCa management in the future. Abstract Lymph node invasion in prostate cancer is a significant prognostic factor indicating worse prognosis. While it significantly affects both survival rates and recurrence, proper management remains a controversial and unsolved issue. The thorough evaluation of risk factors associated with nodal involvement, such as lymph node density or extracapsular extension, is crucial to establish the potential expansion of the disease and to substratify patients clinically. There are multiple strategies that may be employed for patients with positive lymph nodes. Nowadays, therapeutic methods are generally based on observation, radiotherapy, and androgen deprivation therapy. However, the current guidelines are incoherent in terms of the most effective management approach. Future management strategies are expected to make use of novel diagnostic tools and therapies, such as photodynamic therapy or diagnostic imaging with prostate-specific membrane antigen. Nevertheless, this heterogeneous group of men remains a great therapeutic concern, and both the clarification of the guidelines and the optimal substratification of patients are required.
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Affiliation(s)
- Bartosz Małkiewicz
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
- Correspondence: (B.M.); (J.K.); Tel.: +48-506-158-136 (B.M.)
| | - Miłosz Knura
- Department of Biochemistry, Faculty of Medical Sciences in Katowice, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Małgorzata Łątkowska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Maximilian Kobylański
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Krystian Nagi
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Dawid Janczak
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Joanna Chorbińska
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Wojciech Krajewski
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
| | - Jakub Karwacki
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
- Correspondence: (B.M.); (J.K.); Tel.: +48-506-158-136 (B.M.)
| | - Tomasz Szydełko
- Department of Minimally Invasive and Robotic Urology, University Center of Excellence in Urology, Wroclaw Medical University, 50-566 Wroclaw, Poland; (M.Ł.); (M.K.); (K.N.); (D.J.); (J.C.); (W.K.); (T.S.)
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Miura N, Sugihara N, Funaki K, Kakuda T, Koyama K, Watanabe R, Sawada Y, Noda T, Nishimura K, Fukumoto T, Miyauchi Y, Kikugawa T, Saika T. Extended robot-assisted laparoscopic prostatectomy and extended pelvic lymph node dissection as a monotherapy in patients with very high-risk prostate cancer Patients. Cancer Med 2021; 10:7968-7976. [PMID: 34562303 PMCID: PMC8607267 DOI: 10.1002/cam4.4308] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/03/2021] [Accepted: 08/23/2021] [Indexed: 01/18/2023] Open
Abstract
Background Patients with very‐high‐risk prostate cancer (VHRPCa) have earlier biochemical recurrences (BCRs) and higher mortality rates. It remains unknown whether extended robot‐assisted laparoscopic prostatectomy (eRALP) without neoadjuvant or adjuvant therapy can improve the outcomes of VHRPCa patients. We aimed to determine the feasibility and efficacy of eRALP as a form of monotherapy for VHRPCa. Methods Data from 76 men who were treated with eRALP without neoadjuvant/adjuvant therapy were analyzed. eRALP was performed using an extrafascial approach. Extended pelvic lymph node (LN) dissection (ePLND) included nodes above the external iliac axis, in the obturator fossa, and around the internal iliac artery up to the ureter. The outcome measures were BCR, treatment failure (defined as when the prostate‐specific antigen level did not decrease to <0.1 ng/ml postoperatively), and urinary continence (UC). Kaplan–Meier, logistic regression, and Cox proportional‐hazards model were used to analyze the data. Results The median operative time was 246 min, and median blood loss was 50 ml. Twenty‐one patients experienced postoperative complications. Median follow‐up was 25.2 months; 19.7% of patients had treatment failure. Three‐year, BCR‐free survival rate was 62.0%. Castration‐resistant prostate cancer‐free survival rate was 86.1%. Overall survival was 100%. In 55 patients who had complete postoperative UC data, 47 patients (85.5%) recovered from their UC within 12 months. Clinical stage cT3b was an independent preoperative treatment failure predictor (p = 0.035), and node positivity was an independent BCR predictor (p = 0.037). The small sample size and retrospective nature limited the study. Conclusions This approach was safe and produced acceptable UC‐recovery rates. Preoperative seminal vesicle invasion is associated with treatment failure, and pathological LN metastases are associated with BCR. Therefore, our results may help informed decisions about neoadjuvant or adjuvant therapies in VHRPCa cases. Precis Extended robot‐assisted laparoscopic prostatectomy and extended pelvic lymph node dissection without adjuvant therapy is safe and effective for some patients with very‐high‐risk prostate cancer. The clinical stage and node positivity status predicted monotherapy failure, which may indicate good adjuvant therapy candidate.
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Affiliation(s)
- Noriyoshi Miura
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Naoya Sugihara
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Keisuke Funaki
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Toshio Kakuda
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Kanae Koyama
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Ryuta Watanabe
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yuichiro Sawada
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Terutaka Noda
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Kenichi Nishimura
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Tetsuya Fukumoto
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Yuki Miyauchi
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Tadahiko Kikugawa
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
| | - Takashi Saika
- Department of Urology, Ehime University Graduate School of Medicine, Toon, Ehime, Japan
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Cai J, Yang F, Chen X, Huang H, Miao B. Signature Panel of 11 Methylated mRNAs and 3 Methylated lncRNAs for Prediction of Recurrence-Free Survival in Prostate Cancer Patients. PHARMACOGENOMICS & PERSONALIZED MEDICINE 2021; 14:797-811. [PMID: 34285549 PMCID: PMC8285280 DOI: 10.2147/pgpm.s312024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Accepted: 06/16/2021] [Indexed: 11/23/2022]
Abstract
Background Radical prostatectomy is the main treatment for prostate cancer (PCa), a common cancer type among men. Recurrence frequently occurs in a proportion of patients. Therefore, there is a great need to early screen those patients to specifically schedule adjuvant therapy to improve the recurrence-free survival (RFS) rate. This study aims to develop a biomarker to predict RFS for patients with PCa based on the data of methylation, an important heritable contributor to carcinogenesis. Methods Methylation expression data of PCa patients were downloaded from The Cancer Genome Atlas (TCGA), Gene Expression Omnibus database (GSE26126), and the European Bioinformatics Institute (E-MTAB-6131). The stable co-methylation modules were identified by weighted gene co-expression network analysis. The genes in modules were overlapped with differentially methylated RNAs (DMRs) screened by MetaDE package in three datasets, which were used to screen the prognostic genes using least absolute shrinkage and selection operator analyses. The prognostic performance of the prognostic signature was assessed by survival curve analysis. Results Five co-methylation modules were considered preserved in three datasets. A total of 192 genes in these 5 modules were overlapped with 985 DMRs, from which a signature panel of 11 methylated messenger RNAs and 3 methylated long non-coding RNAs was identified. This signature panel could independently predict the 5-year RFS of PCa patients, with an area under the receiver operating characteristic curve (AUC) of 0.969 for the training TCGA dataset and 0.811 for the testing E-MTAB-6131 dataset, both of which were higher than the predictive accuracy of Gleason score (AUC = 0.689). Also, the patients with the same Gleason score (6–7 or 8–10) could be further divided into the high-risk group and the low-risk group. Conclusion These results suggest that our prognostic model may be a promising biomarker for clinical prediction of RFS in PCa patients.
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Affiliation(s)
- Jiarong Cai
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Fei Yang
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Xuelian Chen
- Department of Urology, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510630, People's Republic of China
| | - He Huang
- General Surgery Department, the Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510630, People's Republic of China
| | - Bin Miao
- Department of Organ Transplantation, the Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, Guangdong, 510630, People's Republic of China
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Wilke D, Wood L, Cwajna S, Rutledge R, Hollenhorst H, Bowes D, Patil N, Ago CT, Pignol JP. Sequence Inversion to Facilitate Concurrent Radiotherapy and Systemic Therapy. A Proof of Principle Study in the Setting of a Phase II Randomized Trial in Prostate Cancer. Front Oncol 2020; 10:570660. [PMID: 33102224 PMCID: PMC7556110 DOI: 10.3389/fonc.2020.570660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 08/24/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Concomitant chemo-radiation for pelvic cancers remains challenging to be delivered at full doses. We hypothesized that fewer delays in chemotherapy would occur if the sequence of radiotherapy would be reversed, starting with the boost volume followed by the elective nodal volume. We report the result of a Phase II randomized study for high risk prostate cancer. Patients and Method: The study was a double-blinded phase II randomized trial. Patients were eligible if they had non-metastatic high-risk prostate cancer. All patients received 2.5 years of hormonal therapy and 46.5 Gy in 25 fractions to the pelvic lymph nodes. Patients received a radiation boost to the prostate, either before or after whole pelvic irradiation. Concurrent (20 mg/m2) Docetaxel was given on the first day of radiotherapy and weekly thereafter for a total of eight treatments until predefined toxicity stopping rules. Results: Ninety patients were included and randomized. Four were ineligible for the analysis. In total, 42 patients were randomized to the standard sequence, 44 patients to the experimental sequence. There were statistically fewer GI or GU toxicities leading to a docetaxel dose reduction or omission in the experimental sequence compared to the standard sequence, 5 vs. 15 events (p = 0.027). There was no difference in overall survival, cause-specific survival, or biochemical-relapse free survival between the two sequences. Conclusions: This is the first study to test sequence inversion for pelvic radio-chemotherapy in a randomized double-blind trial. Less chemotherapy interruptions or dose reductions occurred by inverting the radiation sequence of the large field and the boost. The trial was registered with Clinicaltrials.gov: NCT00452556.
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Affiliation(s)
- Derek Wilke
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Lori Wood
- Division of Medical Oncology, Department of Internal Medicine, Dalhousie University, Halifax, NS, Canada
| | - Slawa Cwajna
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Robert Rutledge
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Helmut Hollenhorst
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - David Bowes
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Nikhilesh Patil
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
| | - Casely T Ago
- Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada
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Antonelli A, Palumbo C, Noale M, Artibani W, Bassi P, Bertoni F, Bracarda S, Bruni A, Corvò R, Gacci M, Magrini SM, Montironi R, Porreca A, Tubaro A, Zagonel V, Maggi S. Overview of potential determinants of radical prostatectomy versus radiation therapy in management of clinically localized prostate cancer: results from an Italian, prospective, observational study (the Pros-IT CNR study). MINERVA UROL NEFROL 2020; 72:595-604. [PMID: 31920063 DOI: 10.23736/s0393-2249.19.03637-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We assessed patients and tumor characteristics, as well as health-related quality of life (HRQoL) items, associated with curative intent treatment decision-making in clinically localized prostate cancer (PCa) patients. METHODS Clinically localized PCa treated with either radical prostatectomy (RP) or radiation therapy (RT) within 12 months from diagnosis were abstracted from The PROState cancer monitoring in ITaly, from the National Research Council (Pros-IT CNR) database. Multivariable logistic regression (MLR) models predicting RT vs. RP were fitted, after adjustment for HRQoL items, patients and tumor characteristics. RESULTS Of 1041 patients, 631 (60.2%) were treated with RP and 410 (39.8%) with RT. Relative to RT, RP patients were younger age (mean age 64.5±6.6 vs. 71.4±4.9, P<0.001) and had higher rates of D'Amico low-intermediate risk groups (31.8 vs. 21.9% low, 46.3% vs. 43.5% intermediate and 21.9% vs. 34.6% high risk, P<0.001). Overall, 93.2% of RP patients were enrolled by urologists and 82.7% of RT patients by radiation oncologists. RP patients had generally higher means values of HRQoL items. In MLR models, higher RT rates were independently associated with more advanced age (odds ratio [OR] 6.14, P<0.001) and BMI≥30 kg/m<sup>2</sup> (OR 1.78, P<0.001). Conversely, lower rates of RT were independently associated with married (OR 0.55, P=0.01) and worker status (OR 0.52, P=0.004), enrollment in academic centers (OR 0.59, P=0.005) and higher physical composite score (OR 0.88, P=0.03) and baseline sexual function items (OR 0.92, P<0.001). CONCLUSIONS Most patients with clinically localized prostate cancer undergoing definitive treatment at Italian institutions receive RP instead of RT. Moreover, those who are younger, married, working, as well as those with better physical and sexual function are more likely to undergo surgery.
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Affiliation(s)
- Alessandro Antonelli
- Unit of Urology, Department of Medical and Surgical Specialties, Radiological Science and Public Health, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy -
| | - Carlotta Palumbo
- Unit of Urology, Department of Medical and Surgical Specialties, Radiological Science and Public Health, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Marianna Noale
- Aging Branch, Neuroscience Institute, Section of Padua, National Research Council of Italy, Padua, Italy
| | - Walter Artibani
- Unit of Urology, University Hospital of Verona, Verona, Italy
| | - Pierfrancesco Bassi
- Department of Urology, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Filippo Bertoni
- Prostate Group of AIRO (Italian Association for Radiation Oncology), Milan, Italy
| | - Sergio Bracarda
- Department of Medical Oncology, USL Toscana Sud-Est, IRCCS Istituto Nazionale Tumori Foundation, Arezzo, Italy
| | - Alessio Bruni
- Unit of Radiotherapy, University Hospital of Modena, Modena, Italy
| | - Renzo Corvò
- Unit of Radiation Oncology, IRCCS San Martino University Hospital, Genoa, Italy
| | - Mauro Gacci
- Unit of Urology, Careggi Hospital, University of Florence, Florence, Italy
| | - Stefano M Magrini
- Unit of Radiation Oncology, ASST Spedali Civili of Brescia, University of Brescia, Brescia, Italy
| | - Rodolfo Montironi
- Section of Pathological Anatomy, School of Medicine, United Hospitals, Marche Polytechnic University, Ancona, Italy
| | - Angelo Porreca
- Unit of Urology, Polyclinic of Abano Terme, Padua, Italy
| | - Andrea Tubaro
- Unit of Urology, Sant'Andrea Hospital, Sapienza University, Rome, Italy
| | | | - Stefania Maggi
- Aging Branch, Neuroscience Institute, Section of Padua, National Research Council of Italy, Padua, Italy
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