Diagnostic Performance and Clinical Impact of PSMA PET/CT versus mpMRI in Patients with a High Suspicion of Prostate Cancer and Previously Negative Biopsy: A Prospective Trial (PROSPET-BX)

BACKGROUND

This prospective single-arm study is designed to compare in parallel 68Ga-PSMA PET/TRUS (transrectal or transperineal) fusion biopsy ("experimental test") with multiparametric MRI (mpMRI)/TRUS fusion prostate biopsy ("standard test") in men with a high suspicion of prostate cancer (PCa) after at least one negative biopsy. The primary objective was to evaluate the diagnostic performance of 68Ga-PSMA PET/TRUS fusion prostate biopsy in comparison to mpMRI/TRUS fusion prostate biopsy analyzed in parallel. Secondarily, we aimed to determine the relationship between the "experimental test" and the histopathological characteristics of the specimen, along with the clinical utility of the "experimental test" compared to the "standard test."

SUMMARY

To test the superiority of 68Ga-PSMA PET/CT compared to mpMRI, we will enroll a minimum cohort of 128 patients. Inclusion criteria comprise: age >18 years; blood PSA level >4.0 ng/mL; free-to-total PSA ratio <20%; progressive rise of PSA levels in two consecutive blood samples despite antibiotics; serum blood tests suspicious for PCa; at least one previous negative biopsy; ASAP and/or high-grade PIN; negative digital rectal examination. All eligible patients will undergo 68Ga-PSMA PET/CT and mpMRI scans within 1 month's distance from each other, followed by biopsy session to be completed within 1 month's distance. Targeted TRUS fusion needle biopsy will be performed for all lesions detected with PET and mpMRI. The total duration of the study is 36 months.

KEY MESSAGES

By comparing the "experimental test" and the "standard test" in parallel, we will be able to determine the superior diagnostic performance of 68Ga-PSMA PET/CT over mpMRI in detecting PCa, and in particular clinically significant PCa, in the specific cohort of patients with a high suspicion of PCa who are candidates to re-biopsy. The clinical impact of the "experimental test" will be subsequently analyzed in terms of the number of prostate biopsies that could be spared, time-consuming, patient friendliness, and cost-effectiveness.

Predictive factors for progression of patients with carcinoma in situ of the bladder at long-term follow-up: pure versus non-pure CIS

BACKGROUND

The aim of this study was to identify the predictive factors for progression defined as any event that shifted the management of the disease from a bladder sparing approach, by comparing patients with pure versus non-pure carcinoma in situ (CIS) of the bladder.

METHODS

A retrospective analysis was carried out in consecutive patients affected by newly-diagnosed pure CIS and non-pure CIS (excluding cases with concomitant muscle invasive cancer). All patients were enrolled a in our institution from 1998 to 2010. Data was prospectively collected. Main end point was progression-free survival.

RESULTS

Overall, 149 patients with CIS were identified for the analysis. A total of 98 patients had pure CIS (66%). Median follow-up was 103 months (range: 40-206 months). Progression occurred in 29 patients (19%). A total of 30 patients died during the follow-up (20%). In 13 cases (9%), the death was cancer specific. Progression-free survival estimate was 181 months (95% CI: 169-193 months) and 154 months (95% CI: 133-176 months) respectively for pure and non-pure CIS population (P=0.03). Among examined variables (age, gender, symptoms, smoking habit, ASA score, number of bacillus Calmette-Guérin [BCG] instillations), multivariate analysis disclosed that only CIS type was an independent predictor of progression (P=0.03) with a relative risk of 0.37 in favor of pure CIS.

CONCLUSIONS

Pure and non-pure CIS are efficiently treated by BCG therapy combined with trans-urethral resection and/or radical cystectomy, with relatively low rate of progression. CIS type was the only significant predictor of progression.

Early Catheter Removal After Robot-assisted Radical Prostatectomy: Results from a Prospective Single-institutional Randomized Trial (Ripreca Study)

BACKGROUND

The adoption of robotic technology in the treatment of prostate cancer (PCa) could lead to improvement in outcomes.

OBJECTIVE

To evaluate feasibility, to compare functional outcomes, and to assess the economic benefits of removing catheter on the postoperative day (POD) 3 versus POD 5 after robot-assisted radical prostatectomy (RARP).

DESIGN, SETTING, AND PARTICIPANTS

From September 2016 to May 2017, patients selected to undergo RARP for clinically localized PCa at a high-volume center were prospectively randomized into group 1 (POD 3; n=72) versus group 2 (POD 5, n=74).

INTERVENTION

All patients underwent RARP with anatomical posterior and anterior reconstruction.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary endpoint was to compare acute urinary retention (AUR) and urinary leakage rate in the two groups. The secondary endpoints were early and mid-term postoperative functional outcomes assessed through questionnaires (ICIQ-MLUTS, IPSS), early continence rate, and postoperative pain/discomfort (visual analog scale score). The economic impact of early catheter removal was also assessed.

RESULTS AND LIMITATIONS

AUR was reported in two (1.4%) cases, one for each study group (p=0.9). One case of vesicourethral leakage was reported (0.7%) in group 1. Urethral discomfort and pain at discharge was significantly higher in group 2 (p=0.03). In our clinical practice, POD 3 catheter removal approach would determine a saving of approximately €80 000 and 405 d of hospitalization yearly. The main limitation is the small sample size.

CONCLUSIONS

Early catheter removal after RARP does not lead to an increase in perioperative complications. No negative effect on early and mid-term functional outcomes was observed. A significant impact on saving economic resources was reported.

PATIENT SUMMARY

We demonstrated that early catheter removal has no negative effect on spontaneous voiding, complications, or urinary continence recovery after robot-assisted radical prostatectomy.

Long-term outcomes of high-grade T1 bladder cancer treated with intravesical bacillus Calmette-Guérin: experience of a single center

BACKGROUND

To assess the outcomes of patients with high-grade (HG) pT1 bladder cancer (BC) treated with intravesical BCG therapy.

METHODS

The study population consisted of 185 patients with HG pT1 BC treated between 1998 and 2010. We aimed to determine recurrence-free (RFS) and progression-free survival (PFS), as well as the predictors of RFS and PFS.

RESULTS

Overall, 143 (77.3%) patients were males. Median age was 72 years (IQR: 66-78). Tumor size was ≥3 cm in 100 (54.1%) individuals. Most patients had single tumors (125; 67.6%). Primary, progressive and recurrent patterns of presentation were observed in 146 (78.9%), 21 (11.4%), and 18 (9.7%) cases, respectively. After 2nd-look TURB, 127 (68.6%) patients had no residual disease, 44 (23.8%) had Ta/CIS, and 14 (7.6%) had T1 HG BC. Twenty-two (11.9%) patients experience early recurrence after BCG. Of these, 12 patients (54.5%) were diagnosed with Ta/CIS, while 10 (45.5%) were diagnosed with HG pT1 BC. The median follow-up was 93 months (IQR: 63-147). Ten-year RFS and PFS rates were 69.6 and 79.2%. In multivariable Cox regression models, female gender (HR=2.41; P=0.001), progressive (HR=2.03; P=0.030) and recurrent (HR=3.87; P<0.001) pattern of presentation emerged as independent predictors of RFS, while age ≥70 years (HR=2.13; P=0.027), presence of multiple tumors (HR=2.06; P=0.019), and early recurrence (HR=3.88; P<0.001) emerged as independent predictors of PFS.

CONCLUSIONS

Intravesical BCG appears to be an effective treatment for HG pT1 BC. Caution should be used in patients aged ≥70 years, with multiple tumors or experiencing early recurrence.

Targeted 11C-choline PET-CT/TRUS software fusion-guided prostate biopsy in men with persistently elevated PSA and negative mpMRI after previous negative biopsy

Background

We evaluated the feasibility and accuracy of 11C–choline PET-CT/TRUS fusion-guided prostate biopsy in men with persistently elevated PSA and negative mpMRI or contraindication to MRI, after previous negative biopsy. Clinical data were part of a prospective on-going observational clinical study: “Diagnostic accuracy of target mpMRI/US fusion biopsy in patients with suspected prostate cancer after initial negative biopsy”. Patients with a negative biopsy and negative mpMRI (PI-RADS v.2 < 3) or absolute contraindications to MRI and persistently elevated PSA, were included. All patients underwent 11C–choline PET with dedicated acquisition of the pelvis and PET-CT/TRUS-guided prostate biopsy by Bio-Jet™ fusion system (D&K Technologies, Germany). The primary endpoint was to assess the accuracy of 11C–choline PET-CT to determine the presence and the topographical distribution of PCa.

Results

Overall, 15 patients (median age 71 yrs. ± 8.89; tPSA 13.5 ng/ml ± 4.3) were analysed. Fourteen had a positive PET scan, which revealed 30 lesions. PCa was detected in 7/15 patients (46.7%) and four patients presented a clinically significant PCa: GS > 6. Over 58 cores, 25 (43.1%) were positive. No statistically significant difference in terms of mean and median values for SUVmax and SUVratio between benign and malignant lesions was found. PCa lesions with GS 3 + 3 (n = 3) showed a median SUVmax and SUVratio of 4.01 and 1.46, compared to 5.45 and 1.57, respectively for lesions with GS >6 (n = 4).

Conclusion

Software PET-CT/TRUS fusion-guided target biopsy could be a diagnostic alternative in patients with a suspected primary PCa and negative mpMRI, but its specificity appeared low.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone

Purpose

The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group.

Materials and Methods

From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system.

Results

Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively.

Conclusions

RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

Managing chronic bladder diseases with the administration of exogenous glycosaminoglycans: an update on the evidence

Although the pathophysiology of acute chronic cystitis and other 'sensory' disorders, i.e. painful bladder syndrome (PBS) or interstitial cystitis (IC), often remains multifactorial, there is a wide consensus that such clinical conditions may arise from a primary defective urothelium lining or from damaged glycosaminoglycans (GAGs). A 'cascade' of events starting from GAG injury, which fails to heal, may lead to chronic bladder epithelial damage and neurogenic inflammation. To restore the GAG layer is becoming the main aim of new therapies for the treatment of chronic cystitis and PBS/IC. Preliminary experiences with GAG replenishment for different pathological conditions involving the lower urinary tract have been reported. There is a range of commercially available intravesical formulations of these components, alone or in combination. Literature evidence shows that exogenous intravesical hyaluronic acid markedly reduces recurrences of urinary tract infections (UTIs). Patients treated with exogenous GAGs have fewer UTI recurrences, a longer time to recurrence and a greater improvement in quality of life. Exogenous intravesical GAGs have been used for the treatment of PBS/IC. Despite the limitations of most of the studies, findings confirmed the role of combination therapy with hyaluronic acid and chondroitin sulfate as a safe and effective option for the treatment of PBS/IC. To prevent and/or treat radiotherapy and chemotherapy induced cystitis, GAG replenishment therapy has been used showing preliminary encouraging results. The safety profile of exogenous GAGs has been reported to be very favourable, without adverse events of particular significance.

Unclassified Renal Cell Carcinoma With Medullary Phenotype Versus Renal Medullary Carcinoma: Lessons From Diagnosis in an Italian Man Found to Harbor Sickle Cell Trait

Medullary carcinoma is a rare malignant tumor of the kidney. It affects individuals of African descent and all cases reported show evidence of sickle cell trait. We reviewed an unusual carcinoma arising in a white man, the ninth in the literature. The tumor demonstrated features associated with renal medullary carcinoma, or unclassified renal cell carcinoma, medullary phenotype as recently described; the presence of sickle cell trait confirmed the diagnosis of medullary carcinoma. This case is helpful in the differential diagnosis with non-sickle cell associated “renal cell carcinoma, unclassified with medullary phenotype,” and study of this spectrum of tumors is ongoing.

Is retrograde intrarenal surgery a viable treatment option for renal stones in patients with solitary kidney?

PURPOSE

To evaluate the effectiveness and safety of retrograde intrarenal surgery (RIRS) for stones up to 2 cm in diameter in patients with solitary kidney.

METHODS

From January 2008 to January 2013, we prospectively enrolled all consecutive patients with solitary kidney and renal stones. Plain abdominal computed tomography scan was performed preoperatively and 1 month after the procedure to assess the stone-free rates (SFR). Serum creatinine levels were detected preoperatively, at day 1 postoperatively, at 1 month postoperatively, and then every 6 months postoperatively.

RESULTS

During the study period, we prospectively enrolled a total of 29 patients. The mean age was 55.7 ± 12.3 years; the mean stone size was 1.3 ± 0.4 cm. The primary SFR was 72.4 %; the secondary SFR was 93.1 %. The mean number of procedures per patient was 1.24. The mean serum creatinine levels were 1.5 ± 0.6, 1.6 ± 0.7, 1.6 ± 0.6, and 1.7 ± 0.7 mg/dl preoperatively, at 1 day after RIRS, at 1 month after RIRS, and at 1 year after RIRS, respectively, without detection of any statistical difference (p = 0.76). Median follow-up time was 35.7 ± 19.3 (12-72) months, but that was available for only 18 patients. The mean serum creatinine level at the last follow-up was 1.7 ± 0.9 mg/dl. No major complications were recorded. Grade I complications occurred in eight patients (27.4 %).

CONCLUSIONS

RIRS is safe and effective in the treatment of renal stones in patients with solitary kidney, without worsening renal function.

Is retrograde intrarenal surgery for the treatment of renal stones with diameters exceeding 2 cm still a hazard?

INTRODUCTION

Major kidney stones have traditionally been treated with percutaneous nephrolithotomy. However, retrograde intrarenal surgery (RIRS), which until a few years ago was considered inappropriate for this purpose, is becoming a viable, attractive alternative. The aim of the current study was to assess the efficacy and safety of RIRS combined with holmium laser lithotripsy for the treatment of stones > 2 cm in diameter in a large series of patients, reporting complications according to the Clavien-Dindo classification.

MATERIALS AND METHODS

By retrospective analysis, we identified a total of 162 patients who were affected by stones greater than 2 cm in diameter and who had undergone RIRS. We reviewed demographic and stone characteristics, intraoperative and postoperative outcomes, and complications.

RESULTS

The mean stone size was 2.7 cm +/- 0.6 cm. The primary, secondary, and tertiary stone-free rates were 66%, 80.9%, and 87.7%, respectively. The mean number of procedures per patient was 1.48. The complication rates according to the Clavien-Dindo classification were Clavien I in 20.4% of patients, Clavien II in 0%, Clavien III in 4.9%, Clavien IV in 0.6%, and Clavien V in 0%.

CONCLUSIONS

As an alternative to standard procedures for the treatment of renal calculi greater than 2 cm in diameter, RIRS is safe and effective, with a low complication rate.

Operative safety and oncologic outcome of laparoscopic radical nephrectomy for renal cell carcinoma >7 cm: a multicenter study of 222 patients

OBJECTIVE

To evaluate the safety of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) >7 cm, addressing the issue of modality and risk factors for complications and open conversion, and to assess the oncologic outcome.

METHODS

The data of 222 patients undergoing LRN for RCC >7 cm prospectively enrolled from 2002 to 2010 at 5 urologic centers were reviewed. Transperitoneal LRN was performed by 5 experienced laparoscopic surgeons. The Clavien-Dindo classification was used to assess complications. Multivariable analysis of factors predictive of conversions was performed. Oncologic outcomes for survival were estimated using the Kaplan-Meier method.

RESULTS

Median tumor size was 8.5 cm, operative time was 180 minutes, and blood loss was 280 mL. Forty-two patients (19%) received a blood transfusion. Six (2.7%) patients had grade III-IV complications: 2 with postoperative bleeding requiring abdominal re-exploration and 1 each with adrenal injury, splenic injury, wound diastasis, and respiratory insufficiency. Twelve patients (5.4%) were converted to open surgery. The diameter was 11.9 in converted groups and 8.5 cm in nonconverted groups (P = .001). Multivariable analysis revealed that pathologic stage was the only independent predictor of conversion (P = .002). The 5-year overall (OS), cancer-specific (CSS), and progression-free (PFS) survival was 74%, 78%, and 66%, respectively. The 5-year stage-adjusted CSS was 89% in pT2 and 40% in pT3 patients (P <.0001). Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome.

CONCLUSION

LRN for large RCC is a safe operation. Stage pT3 is a risk factor for open conversion and is associated to significantly lower cancer-specific survival compared with pT2 stage.

High energy microwave thermotherapy for symptomatic benign prostatic enlargment: predictive parameters of long term outcome

OBJECTIVES

High-energy transurethral microwave thermotherapy (HE-TUMT) has become one of the most preferred minimally invasive procedure for the treatment of benign prostatic enlargement (BPE). In this study we report the long term results in a subset of patients treated with the 30-minute high energy protocol.

PATIENTS AND METHODS

A total of 135 patients were treated with TUMT Prostasoft 3.5. The International Prostate Symptom Score (IPSS), Madsen Symptom Score (MSS), Quality of Life (QoL) score, peak urinary flow rate (Qmax) and post-voiding residual urine volume (PVR) were assessed at baseline and at 12, 24, 36, 48 and 60 months after treatment.

RESULTS

The mean follow-up period was 46.1 months. The mean IPSS at baseline was 17.8 and decreased to 5.6 at 60 months (p < 0.001). The MSS decreased from 12.6 at baseline to 4.3 at 5 years (p < 0.0001). The QoL score improved from 4.1 to 2.2 at 5 years (p < 0.001). The mean Qmax value at baseline was 9.4 ml/sec and it improved to 15.7 ml/sec at 60 months (p = 0.001), whereas PVR decreased from 97 to 24 ml at 5 years (p = 0.001). Retreatment was required for 47 patients (34.8%). Univariate and multivariate analysis showed that the only baseline parameters able to predict the long-term efficacy were a IPSS <18 and a Qm, > 10 ml/sec (p = 0.04).

CONCLUSIONS

These data shows a high response rate obtained with 30-minute TUMT protocol and a durability of response up to 5 years after treatment, making this procedure a safe and effective alternative to TURP in selected patients.

Tubeless percutaneous nephrolithotomy: Our experience

PURPOSE

To evaluate safety and outcomes of tubeless PCNL in comparison with standard PCNL.

MATERIALS AND METHODS

Since June 2002 we have performed 99 tubeless PCNL. Tubeless technique involves antegrade placement of a 6Fr double-J stent without nephrostomy tube at the end of the procedure. This series has been compared with a total of 110 patients in which revision of operative reports ruled out the presence of intraoperative conditions necessary to candidate a patient to tubeless procedure but standard PCNL was performed because prior to its introduction or because of surgeon's attitude afterward. Mean stone burden was 5.4 for standard group and 4.9 cm2 for tubeless group respectively. Mean BMI was 24.1 in the first group and 23.6 in the second one. In this retrospective study, complications rate, postoperative pain, length of hospitalization and convalescence were evaluated by chart review.

RESULTS

Hematocrit drop did not differ significantly between tubeless PCNL and standard PCNL (5.5% vs 5.90%). Conversely, there was statistically significant difference between tubeless and standard PCNL in terms of the amount of analgesics (49.5 vs. 84.2 mg), immediate postoperative patients' discomfort, hospitalization (2.2 vs 5.3 days) and time to resume normal activities (11.0 vs 16.5 days).

CONCLUSIONS

In our series, tubeless approach did not determine increase in complication rate. Conversely, tubeless PCNL reduced analgesics' requirement, patients' discomfort, hospitalization and time to recovery. As such, at our Institution, tubeless PCNL has become routine procedure that actually is feasible in almost 2/3 of renal calculi suitable for percutaneous treatment.

Double J Stent With Antireflux Device in the Prevention of Short-Term Urological Complications After Cadaveric Kidney Transplantation: Single-Center Prospective Randomized Study

The placement of a double J stent to protect a uretero-vesical anastomosis in a kidney transplant is a widespread procedure performed to reduce the incidence of fistula and stenosis at the anastomosis. However, the presence of a double J stent may cause vesicoureteral reflux (VUR), predisposing one to urinary tract infections (UTIs), which may be a significant source of morbidity for the graft. We evaluated whether a ureteral stent incorporating an antireflux device can reduce the incidence of ureteral reflux and UTIs. From January to December 2003, 44 kidney transplant recipients were randomized to receive a 14-cm 4.8-F double J stent with (group A) or without an anti-reflux device (group B). Primary end points were the reduction of the incidence of VUR and of UTIs. The secondary end point was the graft function, on the basis of mean serum creatinine level at 3, 6, and 12 months. We failed to observe statistically significant differences in terms of either the incidence of VUR and UTIs, or the short-term outcomes of the grafts. We concluded that the anti-reflux device does not have an impact on the incidence of stent-related side effects.

The role of ultrasound and echo-color Doppler in the diagnosis and follow-up of tuberculosis of the transplanted kidney

Tuberculosis is still a relatively frequent, serious disease developing in kidney transplant patients, having an overall incidence estimated to range between 0.35 and 15%. The disease often presents with unusual clinical manifestations, partly due to the more frequent extra-pulnipnary localizations. We describe the clinical case of a 49-year-old patient who had undergone a bilateral kidney transplant from a 70-year-old donor. About 8 months after the transplant he developed fever and raised serum creatinine values were found, together with subcutaneous abscesses in the groin, along both surgical wounds, and on the external genital area. Ultrasound and radiographic imaging demonstrated the presence of multiple intra-abdominal abscesses, localized at the level of the spleen hilus, of the left transplanted kidney and the right parietocolic retroperitoneum. Positive cultures were obtained to Mycobacterium Tuberculosis and the patient was administered anti-tubercular treatment with Etambutol, Isoniazide, and Rifabutin. The initially prescribed immune suppressive treatment (Corticosteroids, Cyclosporin and Micophenolate) was progressively reduced to only 5 mg/die of Prednisone. After 6 months from the start of the anti-tubercular treatment the patient showed an improvement of the clinical and radiological picture, as well as preservation of the renalfunction.

Medical and surgical complications after kidney transplantation from “suboptimal donors”: one centre's experience

To overcome the organ shortage, the pool of donors can be expanded to include aged donors (>55 years old) or patients with diabetes and long-standing hypertension, the so-called "suboptimal donors." Our experience on medical and surgical complications in kidney recipients from such donors and their impact on the graft and patient survival rates is reported. From January 1998 to April 2003, 276 kidney transplantation were performed: 107 from suboptimal donors (group A) and 169 from optimal ones (group B). After a mean follow-up of 26.8 months (range, 1-63 months), the 1-year graft survival rate was 89.3% and 97% for groups A and B, respectively. Medical complications were observed in 18.8% of group A and 6% of group B and surgical complications in 34.5% and 20%, respectively. In conclusion, even if the complication rate is higher among the suboptimal donor group, the patient and graft survival rates appear to be only slightly affected, therefore, validating the use of marginal donors.