Active surveillance in prostate cancer: a critical review

The aim of this paper was to examine the eligibility criteria, surveillance protocols and oncological outcomes of published active surveillance (AS) series. We also assessed the evidence for utility of novel tools for optimal risk stratification and surveillance of men suitable for AS. A non-systematic literature search of the Medline, Embase, and Scopus databases was performed in April 2015 using medical subject headings and free-text protocol. The search was conducted by applying free-text protocol with the following search terms: "active surveillance", "prostate cancer", "prostatic neoplasm", "watchful waiting", "low risk prostate cancer" and "very low risk prostate cancer". The definition of insignificant disease remains debatable as criteria for patient selection vary among studies. Tools for better selection of candidates and monitoring of the disease process have evolved since the conception of AS, including new biomarkers like phi, mpMRI and alternate biopsy strategies. AS is a sound strategy for reducing overtreatment of men with low-risk, and potentially selected men with intermediate-risk prostate cancer and shorter life expectancy, without compromising overall and cancer specific survival. More data are needed on the optimal integration of the new tools on AS paradigms and on the long-term health impact of AS in different populations.

Robot-assisted renal surgery: current indications and results

Robotic technology is the natural evolution and simplification of traditional laparoscopy. Robotic surgery has the same benefits of traditional laparoscopic surgery in terms of cosmetic results, pain control and short in-hospital stay. However, magnified three-dimensional vision and the use of fully articulated wristed-instruments allow to increase the precision control. Recently, robotic surgery has been even more used in urology. In fact, robot-assisted radical prostatectomy (RARP) is currently the most common treatment used for localized prostate cancer in the United States. Perioperative and functional outcomes resulted significantly better after RARP. As a consequence of the diffusion of RARP, other urological procedures were performed using the robotic approach. Particular attention has been paid to the use of robotic surgery for the treatment of benign and malignant renal diseases. In 2002 the first robot-assisted pyeloplasty was performed followed by the first robot-assisted partial nephrectomy. This last procedure had widespread a lot in the last years and it can currently be considered as the main alternative to the traditional open partial nephrectomy. Finally, the evolution of technology and surgeon skills allowed us to consider the less invasive approaches also for renal transplantation surgery and vena cava tumor thrombectomy. The objective of this review was to analyze current indications and outcomes of robot-assisted procedures for the treatment of benign and malignant renal diseases.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES

To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project).

MATERIALS AND METHODS

patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status.

RESULTS

SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN.

CONCLUSIONS

Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Robot-assisted radical prostatectomy: tips, tricks and pitfalls

In the last decade, we have assisted to the progressive standardization of the surgical technique of robot-assisted radical prostatectomy (RARP). This article describes in details our current surgical technique to perform nerve-sparing RARP. Specifically, we took in consideration the tips, tricks and pitfalls of each step of RARP according to our experience.

Spermatogenesis in Klinefelter syndrome

BACKGROUND

Klinefelter syndrome (KS) (47,XXY) is the most common sex chromosomal disorder, and it is a frequent form of male hypogonadism and infertility. Although the majority of these patients are azoospermic, they might have severe oligozoospermia or residual single-residual foci with spermatogenesis in the testis.

AIM

We report our experience on sperm retrieval in the ejaculate and testis, and evaluate the frequency of chromosome abnormalities in sperm of KS.

SUBJECTS AND METHODS

Eighty-four 47,XXY KS were evaluated with seminal analysis, body hair distribution, reproductive hormones, ultrasonographic scanning of the testis and prostate, bilateral testicular sperm extraction (TESE), sperm or testicular cells sex chromosomes aneuploidies.

RESULTS

Out of 84 patients, 7 (7/84; 8.3%) had sperm in the ejaculate. Out of the 77 azoospermic patients, 24 underwent TESE and 9 (9/24; 37.5%) had successful sperm recovery. The comparison of reproductive hormones, age and testicular volume did not show significant differences between patients with and without successful sperm recovery in semen or TESE . Patients without successful sperm recovery in semen analysis or TESE had signs of hypoandrogenism more evident than patients with successful sperm recovery. Patients with KS produced a higher number of sperm aneuploidy with respect to normozoospermic fertile controls and non-genetic severely oligozoospermic men.

CONCLUSIONS

Men with KS are not always sterile. In some of these patients sperm can be found in semen or in the testis, but the proportion of sperm aneuploidy is high. Signs of hypoandrogenism seem to be associated with low sperm recovery rate.

[How radical nephrectomy compares to partial nephrectomy for the treatment of pT1a papillary renal cell carcinomas?]

PURPOSE

Our objective was to compare oncologic results of nephron sparing surgery (NSS) versus radical nephrectomy (RN) in T1aN0-x M0 papillary renal cell carcinoma (PRCC).

PATIENTS AND METHODS

We retrospectively reviewed 277 patients treated for a pT1aN0M0 PRCC selected from an academic database from 12 centres. We compared the clinico-pathological features by using Chi-square and Student statistical analyses. Survivals analyses using Kaplan-Meier and Log-rank models were performed.

RESULTS

The two groups were composed by 186 patients treated by NSS and 91 by RN. The TNM stage was fixed and the two groups were, in terms of age and Fuhrman grade, comparable. Median age at diagnosis was 59 years (27-85). Median tumor size was 2.7 cm (0.4-4). The average follow-up was 49 months (1-246). Very few events arose in both groups: two local recurrences were observed in the NSS group (1.07%), three patients died of cancer in the NSS treated group (1.6%) and five in the RN treated group (5.5%). The five and 10 cancer-specific survival rate were comparable in the two groups (98% vs. 100% and 98% vs. 97%). The specific survival curves were perfectly similar for both groups (log rank test, p=0.25).

CONCLUSION

NSS is equivalent to RN as far as oncologic control of pT1aN0M0 PRCC is concerned.

Fluorescent cytogenetics of renal cell neoplasms

Renal cell neoplasms are a heterogeneous group of tumours in terms of pathological features and prognostic behaviour. The genetics of these tumours may aid in correct diagnosis and accurate assessment of prognosis. In ambiguous cases it may be necessary to utilise new markers that are capable of further discerning renal cell neoplasms. Fluorescence in situ hybridization (FISH) on formalin-fixed, paraffin-embedded tissue is an increasingly useful technique in the detection of many diagnostic chromosomal abnormalities, among which chromosomes 1, 2, 3p, 6, 7, 10, 17 and Y are the most common. The addition of FISH to histological evaluation improves the diagnostic accuracy of core biopsies from renal masses, which may have an important impact in clinical management of many cases due to newer therapeutic approaches, including cryo- or radiofrequency ablation, nephron-sparing surgeries and target therapies.

Transperineal TRUS-Guided Prostate Biopsy

Prostate biopsy can be performed through different approaches, with several differences in patient preparation, procedural technique and post-biopsy patient management. On the basis of our personal experience, and comparing it with literature data, this paper presents our data reviews regarding enema and antibiotic prophylaxis administration, biopsy technique, prostate sampling, core pathological management and post-operative management. We also provide a possible standardization of these procedures in patients undergoing transperineal TRUS-guided prostate biopsy. We accordingly classify antibiotic prophylaxis and bowel preparation as optional/advisable, ultrasound prostate examination before biopsy and local anaesthesia as recommended. Prostate sampling should be performed with at least 8 cores, to be increased proportionally to prostate volume. Each sample should be sent to the pathologist in single containers, according to the pre-embedding sandwich method. Finally, the patient should be evaluated for early complications before discharging, and for delayed complications within one month after the procedure. (Urologia 2007; 74: 1–7)

Prognostic value of renal cell carcinoma nuclear grading: multivariate analysis of 333 cases

OBJECTIVE

To evaluate the independent predictive value of the nuclear grading system according to Fuhrman in relation to the disease-specific survival of patients with renal clear cell carcinoma.

MATERIAL AND METHODS

333 patients who underwent radical nephrectomy for renal clear cell carcinoma between 1983 and 1999 were evaluated. In all patients we retrospectively studied nuclear grading, average tumor size, multifocality, pathologic stage of primary tumor, vein invasion, lymph node involvement and distant metastases. The Kaplan-Meier method was applied to evaluate disease-specific survival rates. The log rank test was used to compare survival curves and for univariate analysis. The Cox proportional hazards model was used for the multivariate analysis.

RESULTS

Histologic grade was G1 in 83 cases (25%), G2 in 117 cases (35%), G3 in 110 cases (33%) and G4 in 23 cases (7%). Our data showed that nuclear grading according to Fuhrman is related to medium tumor size (p < 0.0001), pathologic stage of cancer (p < 0.001), venous system invasion (p < 0.001), lymph node involvement (p < 0.001) and distant metastases (p < 0.001). The disease-specific survival after 5 and 10 years was 94 and 88%, respectively, in patients with G1, 86 and 75% in patients with G2, 59 and 40% in patients with G3 and 31% in patients with G4 (log rank p value < 0.0001). Multivariate analysis showed that nuclear grading by Fuhrman has a prognostic independent predictive value (hazard ratio = 1.8461, p = 0.002).

CONCLUSIONS

Nuclear grading is an important independent predictive factor of disease-specific survival in patients with renal cell carcinoma.

Primary lymphoma of the epididymis: case report and review of the literature

OBJECTIVE

To report an extremely rare clinical pathological observation of a case of primary lymphoma of the epididymis, without testicular or systemic involvement, and to update the relevant literature.

MATERIALS AND METHODS

A 25-year-old white male patient complaining of right scrotal pain was referred to our department. Clinical examination detected a hard painful mass at the right epididymal head. Epididymitis was diagnosed and conservative therapy with antibiotics and anti-inflammatory drugs was given. After 2 months of therapy the patient was admitted to our department because a tumor was suspected. Tumor markers were normal. Right scrotal exploration was performed through a standard inguinal incision. The epididymal head was completely replaced by a hard white mass. Fresh frozen sections indicated a malignant tumor. Right radical orchiectomy was performed.

RESULTS

High-grade primary epididymal non-Hodgkin's lymphoma with diffuse large cells (group G according to the Working Formulation) was diagnosed. Clinical pathological staging detected stage IE (extranodal) primary epididymal lymphoma. The patient was referred to the Hematologic Unit for combined chemotherapy, according to the VACOP-B protocol. After an 18-month follow-up the patient is well and disease free.

CONCLUSIONS

When an epididymal mass does not benefit from medical treatment, scrotal exploration and fresh frozen sections of the lesion should be done. The possible bilateral involvement by primary epididymal lymphoma has to be kept in mind. Radical orchiectomy is the treatment of choice for primary lymphoma of the epididymis. Adjuvant chemotherapy is indicated in high-grade malignant lymphoma. Prognostic parameters of the disease may be the grade of malignancy and the size of the tumor.

Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study

OBJECTIVE

To assess the results of our experience in correcting primary varicocele using a modified technique of antegrade scrotal sclerotherapy.

PATIENTS AND METHODS

From December 1997 to February 2000, 201 patients with primary varicocele underwent antegrade scrotal sclerotherapy. Before treatment all patients were evaluated by a physical examination, colour Doppler ultrasonography of the spermatic cord, and abdominal and scrotal ultrasonography. Sperm samples were analysed only in patients aged > 18 years. The treatment was administered using a special venous catheter system with a Y-adapter. Complications after treatment and the rate of persistence of reflux were assessed 3 and 6 months after the antegrade scrotal treatment, by clinical examination and colour-Doppler ultrasonography of the spermatic cord.

RESULTS

The mean operative duration was 15 min; there were no significant complications during treatment and all patients were discharged within 4 h. Complications after treatment occurred in 10 of the 201 patients (5%); four patients had epididymo-orchitis, three a scrotal haematoma, one a surgical wound infection, one persistent scrotal pain and one persistent flank pain on the same side as the surgery. Reflux was persistent in 12 patients (6%).

CONCLUSIONS

Antegrade scrotal sclerotherapy is a simple, minimally invasive and highly effective technique for blocking spermatic vein reflux, with a low rate of complications. The technical changes simplified the cannulation of the spermatic vein and facilitated antegrade phlebography and sclerotherapy using the air-block technique.

Adrenal incidentalomas: surgical treatment in 28 patients and update of the literature

INTRODUCTION

Adrenal masses discovered by imaging techniques for reasons unrelated to adrenal diseases are called adrenal incidentalomas (Al). The aim of this study was to find out the clinical outcome of 28 patients operated for incidentally discovered adrenal mass and to update the literature concerning this topic.

PATIENTS AND METHODS

From September 1976 to December 1999 we operated on 28 patients for adrenal incidentaloma. Adrenal masses were unilateral in 25 cases and bilateral in 5. Average age was 57 years (range 10-73). Hormonal study was performed in all patients. All patients underwent adrenalectomy by the transabdominal subcostal approach.

RESULTS

Histopathology assessed the adrenal masses as primary in 19 patients and secondary in 9. 24-hour urinary vanillylmandelic acid (VMA) excretion was elevated in 2 patients. Adrenal insufficiency was detected in 1 case. Average tumor diameter resulted 5.8 cm (range 2-17). Histopathologic features of primary adrenal masses included pheochromocytoma in 5 cases, cysts in 4, myelolipomas in 3. nodular hyperplasia in 2, tuberculous mass in 1, cortical adenoma in 1, extra-bone marrow hemopoiesis in 1, cortical carcinoma in 1 and neuroendocrine tumor of the adrenal medulla in 1. The 9 adrenal metastasis resulted by renal cell carcinoma in 7 patients, urothelial carcinoma of the upper urinary tract in I and primary renal lymphoma in 1. Average follow-up was 68 months (range 6-246). Patients alive were 18 (64%), deal 10 (36%). Of the 19 patients with primary adrenal tumors 16 (84%) were alive and disease free and 3 (16%) died (I for disease and 2 for reasons unrelated to the primary tumor). Of the 9 patients with adrenal metastasis 2 (22%) were alive (I disease free and I with progression of the disease) and 7 (78%) died for disease. Replacement therapy for adrenocortical hormones was given 5 patients.

CONCLUSIONS

Management of Al need CT or MRI and hormonal investigation in order to detect malignancy and subclinical hypersecretory syndromes. Subclinical functional adrenal masses, single adrenal metastasis and primary nonhypersecretory adrenal tumors sized 4 cm are treated by surgery. A close morpho-functional follow-up is indicated for primary adrenal incidentalomas when nonhypersecretory and smaller than 4 cm.