What is the Best Number of Core to Improve Saturation Biopsy Detection Rate?

Prostate core saturation biopsy (SB) is today considered in patients where clinical or biochemical hypothesis of prostate cancer (PCa) is still present after previous normal core biopsies. The technique rationale is to increase the detection rate (DT) both by increasing the number of cores for the pathologist, in order to obtain more tissue to be analyzed, and both by mapping regions that are not usually investigated with a standard or extended prostate biopsy. Moreover, the technique is not free from complications and today, one of the main controversies about SB is how many cores have to be taken in order to maintain high detection rate with low complication rate. Aim of the present retrospective study is to compare safety and DT of 3 different schemes of SB, performed with different number of cores.

Materials and Methods

We retrospectively reviewed the data of 106 patients who underwent SB from January 2003 to December 2008 at 2 urological divisions. SB was performed in all cases as a further biopsy because of biochemical and/or clinical hypothesis of PCa, in patients previously undergoing one or more baseline core biopsies. SB was performed under general anesthesia by 3 urologists in each division. Core biopsies were obtained using a Boston Scientific TruPath 18G 15cm needle, in transrectal ultrasound-guided approach. All patients were submitted to a 32.core SB scheme. We compared the 32-core scheme with a 28 and a 24-core scheme, each one including peripheral, transitional and anterior prostatic portion biopsies. End-points of the study were: DT and safety. Statistical analysis was carried out using chi-square test (p<0.05).

Results

Mean age was 65.4 (50–79) years, mean PSA at biopsy was 11.2 ng/ml (3.23–30) and mean number of previous biopsies was 1.5 (1–5). Median value of cores positive for PCa in the 32, 28 and 24-core scheme was 2 (1–10), 2 (2–12) and 1.5 (0–11), respectively. Homogeneous distribution of positive cores was registered in all records, but in 3 areas (right base external, left base external, left transitional basal) the detection rate was very low (0–0.1%). PCa was found more frequently in base in median portion of left and right prostatic lobes. In the 32-core SB scheme, DT was 30.1 %, whereas in the 28 and 24-core SB scheme DT proved to be 28.7% and 29.1%, respectively. No statistical difference was found among the schemes in terms of detection rate (p>0.05). A Gleason score >7 was registered in 62.5% of cases. As far as safety is concerned, 20 patients (19%) developed complications. In all cases neither hospitalization nor surgery were required and all patients were treated by medical therapy (e.g. indwelling catheterization, antibiotics).

Conclusions

SB after a previous standard core biopsy is a safe technique and increases DT of PCa. Although there is a propensity in increasing the number of core biopsies to obtain higher DT, our data suggests that DT does not increase when more than 24 cores are taken. Therefore, SB should be considered as second biopsy in patients with previous negative first standard core biopsy.

Fatal Hemorrhage during Nephrolithotomy in a Patient with Unknown Vascular Ehlers-Danlos Syndrome Type IV

Ehlers-Danlos syndrome type IV (vascular EDS), is a life-threatening inherited connective tissue disorder resulting from mutations in the COL3A1 gene coding for type III procollagen. Vascular EDS causes severe fragility of connective tissues. We report a case of a 26-year-old male with bilateral staghorn renal calculi, the patient underwent a left nephrolithotomy, during the suspension of the renal artery incredibly, it was lacerated by the vessel loop, without any actraction. Subsequently, all hemostatic attempts, although gentle, resulted in important and catastrophic aortic and caval injures; the patient died due to an uncontrollable abdominal and thoracic hemorrhage. The early diagnosis of the vascular EDS is difficult if there are no known cases. Every surgical procedure in patients with Enlers-Danlos syndrome has a high risk of fatal vascular injuries.

Adjustable Continence Therapy for Female Sui

Since December 1999 a new adjustable device for female stress urinary incontinence called the ACT (Adjustable Continence Therapy) has been used in a multicentre study. The two year follow-up of the Italian multicentre study is presented.

Material & Methods

A group of 37 female patients, affected by SUI was evaluated before and after the positioning of the ACT with physical examination, urodynamic study and quality of life questionnaires (I-QOL) Mean age was 58,5 (range 21.9 – 84.6). 59% (22/37) had type II SUI while 42% (15/37) had type III SUI. 57% (21/37) had had prior urogenital surgery. The ACT device consists of an adjustable silicon balloon, a subcutaneously positioned titanium port and a two lumen tube in between. The devices are positioned via a percutaneous perineal approach, using either local or regional anaesthesia. A 2 cm skin incision is made on each labia majora and through these incisions a delivery trocar is directed toward the bladder neck. The trocar is manoeuvred into the desired position using tactile guidance and an image intensifier (III). Each ACT device is then inserted via the delivery tool. Each balloon is positioned lateral to the bladder neck, proximal to the vesico-vaginal space, below the endopelvic fascia. Each balloon is then filled with one to two millilitres of the isotonic contrast/sterile water mixture with X rays confirmation of the correct location. The injection ports attached to each balloon are then positioned subcutaneously in each labia majora; the balloons are subsequently adjusted, if this is required.

Results

15 patients reached 24 months of follow-up. 46% of them were dry at physical examination and wear no pads. Additional 26% were significantly improved. This group of patients had to wear 1 pad/daily. 56% of the patients required one adjustment to achieve continence, 10% two adjustments, 10% three adjustments 24% need no adjustments. No cases of urinary retention were reported out of 37 cases. One patient had a transient dyspareunia.

Conclusions

70 % of our patients where dry or substantially improved and the patients quality of life increases significantly, this results includes mainly the patient with sever intrinsic sphincter deficiency and failed previous incontinence surgery. The ability to post-operatively adjust the ACT permits to reach the appropriate volume to each patient. However a longer follow up and a bigger number of procedures are required for definitive conclusions.

ProACT: A New Surgical Therapy for the Male Sui

The incidence of reported male stress urinary incontinence (SUI) status prostate surgery varies widely between 2–40%. While the artificial urinary sphincter (AUS) reports good long-term efficacy, this procedure is associated with a high rate of reoperation. The aim of this study was to assess the results at 1 year of follow up of a new minimally invasive surgical technique called Pro ACT (Adjustable Continence Therapy).

Material & Methods

The ProACT is a new implant for post-prostatectomy incontinence. A balloon, a port and a tube of connection are the components of the Pro ACT. It is percutaneously implanted and is postoperatively adjustable. From September 2000 to December 2003 16 males underwent to the procedure. The mean age was 56.5 years (range 29–83). The SUI was due in 13 cases to radical retropubic prostatectomy, in one case to TURP, in one case to open prostatectomy for benign prostatic hypertrophy and one case to congenital incontinence associated with epispadia. The urodynamic exam revealed SUI due to intrinsic sphincteric deficiency in all patients. Efficacy was assessed by change in use of average number of pads used daily, and overall impression

Results

The average number of adjustments after the surgery was 1.6. The average number of pads used decreased from a mean 5.11 at baseline to 1.62 at 12 months. Overall 42.8% of the patients are now completely dry. 28% are improved and 30% are either not improved or only slightly improved. In three of these patients the adjustments are still on going. The only post-operative complication was a migration of both the balloons into the bladder in one patient, which necessitated the removal of both devices as a minor procedure under local anesthetic.

Conclusions

The ProACT is a new surgical therapy for the male SUI. This technique is easy, quick to learn and associated with a low rate of complications and a satisfactory rate of success. 70% patients were dry or improved at 1-year follow up. The device is well accepted from the patients because it doesn't require any manual skill to operate implanted components. Complications are easily managed because of the possibility to remove the Pro ACTs implants completely, or by simply deflating the balloons via percutaneous injection.

Morbility and Outcomes of Radical Prostatectomy in Patients with Clinically Advanced Prostatic Cancer

In this study we have reviewed patients with prostate cancer clinically advanced at the diagnosis, and subjected at radical prostatectomy, to evaluate the morbility, mortality, and results of the surgery. We have subjected 38 patients with sure clinically advanced disease to radical prostectomy (PSA average 80 ng/mL). An ureteral injury and no rectal lesion have been observed. The rate of urinary incontinence have not been increased in comparison with the literature data, while more frequently are been developed stenosis of bladder neck (26%).

At 2 years the 15% of the patients is disease free survival. Our opinion is that radical prostectomy in patients with locally advanced prostate cancer is feasible and the rate of the complications is acceptable.

Predictive Factors of Prostate Cancer in Patients Subjected a Prostatic Re-Biopsy, with Psa in the Grey Zone

In this study we have tried to define which are the most useful predictive factors in the diagnosis of the prostate cancer in patients with first negative biopsy and with PSA in the grey zone. We have therefore analysed 123 patients subjected at re-biopsy: in 25 patients (20%) it is been diagnosed a prostate cancer at the second biopsy, while in 98% (80%) also the second biopsy was negative.

The PSA ratio and the PSA density of the transitional zone have demonstrated having the highest sensitiveness in finding patients with cancer at the re-biopsy (92% and 88%) in comparison with the ER and the TRUS (20% and 32%). Moreover the PSA DTZ let spare the 41% of the re-biopsy that will result negatives.

Antisense activity of an anti-HIV oligonucleotide conjugated to linear and branched high molecular weight polyethylene glycols

An anti-HIV 12mer oligonucleotide (ODN) conjugated to two different high molecular weight monomethoxy polyethylene glycols (MPEGs) has been tested for its antisense activity. The capacity of these conjugates to protect the MT-4 cells against HIV infection has been compared to the unmodified, native ODN, and the effect of the different structures of the supporting polymer has been discussed. It was found that only the ODN conjugated to the linear MPEG shows an anti-HIV activity in the investigated conditions. The same 12mer, when conjugated to a branched (MPEG)2, is fully inactive, as well as the native, unmodified ODN.

Synthesis by High-Efficiency Liquid-Phase (HELP) Method of Oligonucleotides Conjugated with High-Molecular Weight Polyethylene Glycols (PEGs)

The chemical modification of synthetic oligonucleotides has recently been investigated to improve their pharmacological utilization. In addition to chemical alterations of the backbone and of the heterocyclic bases, their conjugation with amphiphylic moieties, such as the polyethylene glycol has been proposed. The large scale production of these molecules as demanded for commercial purposes is hampered by the heterogeneity of the solid-phase processes and by the low reactivity of high-molecular weight PEGs in solution. A new synthetic procedure based on the recently developed liquid-phase method (HELP), has been set up to overcome these limitations.