Use of high-resolution micro-ultrasound to predict extraprostatic extension of prostate cancer prior to surgery: a prospective single-institutional study

PURPOSE

We aim to evaluate the accuracy of micro-ultrasound (microUS) in predicting extraprostatic extension (EPE) of Prostate Cancer (PCa) prior to surgery.

METHODS

Patients with biopsy-proven PCa scheduled for robot-assisted radical prostatectomy (RARP) were prospectively recruited. The following MRI-derived microUS features were evaluated: capsular bulging, visible breach of the prostate capsule (visible extracapsular extension; ECE), presence of hypoechoic halo, and obliteration of the vesicle-prostatic angle. The ability of each feature to predict EPE was determined.

RESULTS

Overall, data from 140 patients were examined. All predictors were associated with non-organ-confined disease (p < 0.001). Final pathology showed that 79 patients (56.4%) had a pT2 disease and 61 (43.3%) ≥ pT3. Rate of non-organ-confined disease increased from 44% in those individuals with only 1 predictor (OR 7.71) to 92.3% in those where 4 predictors (OR 72.00) were simultaneously observed. The multivariate logistic regression model including clinical parameters showed an area under the curve (AUC) of 82.3% as compared to an AUC of 87.6% for the model including both clinical and microUS parameters. Presence of ECE at microUS predicted EPE with a sensitivity of 72.1% and a specificity of 88%, a negative predictive value of 80.5% and positive predictive value of 83.0%, with an AUC of 80.4%.

CONCLUSIONS

MicroUS can accurately predict EPE at the final pathology report in patients scheduled for RARP.

Prospective comparative study of postoperative systemic inflammatory syndrome in robot-assisted vs. open kidney transplantation

PURPOSE

Robot-assisted kidney transplant (RAKT) recently proved to provide functional results similar to the preferred open kidney transplant (OKT), but with inferior wound morbidity. In a comparative prospective study, we explored the systemic inflammatory response syndrome (SIRS) after KT and compared OKT with RAKT.

METHODS

Forty-nine patients underwent pre-emptive ABO-compatible kidney transplantations (KT) between January 2017 and December 2018 in 2 centers: 25 RAKT, 24 OKT. Postoperative SIRS was biologically assessed by serum markers (NGAL, CRP and IL-6) measured at: T0 (preoperative/baseline), T1(H1), T2(H6), T3(H12), T4(H24), T5(D2), T6(D3) and T7(D5) after KT.

RESULTS

Inflammatory markers + eGFR were assessed in OKT vs. RAKT. IL-6 peak value occurred at H6 and reached ×9 from baseline. CRP peak occurred at H24 and reached ×28 from baseline (All P < 0.05). NGAL decreased after surgery with a plateau (divided by 2 from baseline) from H12 to D5. There was no significant difference in IL-6, CRP and NGAL kinetics and peak values between RAKT and OKT (All P > 0.05). Serum creatinine and eGFR on postoperative days 1, 3 and 7 were similar in RAKT and OKT (All P > 0.05). Delayed graft function was not observed.

CONCLUSION

In this exploratory study, the biological evaluation of postoperative SIRS after living-donor kidney transplant revealed no significant difference between OKT and RAKT and similar functional outcomes in the short term. These results highlight the safety of RAKT as an alternative to OKT in this setting.

Retrospective analysis of an alternative immuno-score in clinical management of patients with pT2 urothelial carcinoma

e17038

Background: Within the mapping of the genome through the TCGA collaborative project, the urothelial carcinoma (UC) has recently revealed major intrinsic molecular subtypes, Basal, Luminal and Neural muscle-invasive UC. Here we propose a fast and standardized immuno-phenotypical score classification (Piescore), as a surrogate, which may discriminate Luminal, Basal or Neural UC and may correlate with histological and clinical variables in a mono-institutional cohort of patients treated with trans-urethral resection (TURB) and radical cystectomy (RC). Methods: This is a retrospective study of TURB specimens that harbored foci of HG pT2 (MIBC) UC from 116 pts who underwent RC. All the samples were assessed for immunohistochemical pattern, using relevant gene-expression-based markers for Basal type (CD44, CK5/6) and Luminal type (CK20 and pPARg). Piescore, investigated in both superficial and muscle-invasive component of the tumors, divided Basal and Luminal UC-types when at least 3 of the 4 markers were consistent with a specific phenotype, Mixed if two luminal and two basal markers were present simultaneously, and Neural when all four markers were negative. Results: Overall in muscle-invasive component, Piescore identified Basal phenotypes in 49 pts (42,2%), Luminal in 38 pts (32,7%), and Mixed in 9 pts (7,8%). No expression was identified in 20 pts (17,2%): 7 cases with morphological neuroendocrine differentiation and 13 cases with classical urothelial histology, all consistent with Neural phenotype. In 26,7% of cases (31/116 pts) we observed an immuno-phenotypical switch from superficial to deep component: 16 of 31 (51,6%) switched to Basal, 10 (32,2%) switched to Neural, and 5 cases (16,2%) to Mixed phenotype. No cases switched to Luminal. No cases have lost Basal phenotype from superficial to deep component, with the exception of one (switched to Neural). No statistically significant differences in terms of staging, DFS, and OS were observed in the different phenotypes. The presence of phenotypical switch did not affect angioinvasion, staging, DFS, and OS compared to non-switched cases. Conclusions: Piescore immunophenotyping (CD44, CK5/6, CK20 and pPARg) could be a simple surrogate able to stratify UC-TURB patients between Luminal vs Basal type. To our knowledge, preliminary results using the Piescore identify for the first time a phenotypical switch (to basal, Mixed or Neural) between superficial and deeper side of the same tumor, although this phenomenon did not show any prognostic implication.

The neural phenotype in invasive urothelial carcinoma patients: Alternative score detection and prognostic implication

e17037

Background: Recent molecular subtyping studies (NGS) identified a subset (5-15%) of muscle invasive urothelial carcinoma (MIBC) with transcriptomic patterns consistent with neuroendocrine (NE) differentiation in the absence of NE histology (NE-like), representing a potentially high risk subgroup of carcinoma which may require a different treatment strategy. We recently set an alternative immuno-phenotypical score (Piescore), to discriminate Luminal from Basal from Neural carcinoma. Aim of this study was to test the ability of Piescore in identifying NE-like cases in a mono-institutional cohort of patients treated with trans-urethral resection and radical cystectomy (RC) and to correlate them with clinical outcomes. Methods: Transurethral resection specimens harbored foci of HG pT2 (MIBC) UC from 116 pts who subsequently underwent RC have been submitted for immunohistochemical analysis, using relevant gene-expression-based markers for Basal type (CD44, CK5/6) and Luminal type (CK20 and pPARg). Piescore divided Basal and Luminal types when at least 3 of the 4 markers were consistent with a specific phenotype; Mixed if two luminal and two basal markers were present simultaneously; NE-like when all four markers were negative. Results: Overall, the Piescore identified Basal phenotypes in 49 patients (42,2%), Luminal in 38 (32,7%), and Mixed in 9 (7,8%). No expression was identified in 20 patients (17,2%): 7 cases with morphological NE differentiation and 13 cases with classical urothelial histology, all consistent with NE-like phenotype. Interestingly, in 10/13 patients the NE-like phenotype was only documented in the muscle invasive component of the tumor whereas in the non-invasive component they retained Luminal phenotype in 9 cases and Basal in one. With a median follow up of 188 months, the pathological stage of disease (pT2 versus ≥pT3 and/or N+) and the tumor vascular invasion (absent versus present) resulted prognostic (Stage: 5-years DFS rate 65% versus 30%, p = 0.038; 5-years OS rate 69% versus 32%, p = 0.017) (vascular invasion: 5-years DFS rate 47% versus 24%, p = 0.020; 5-years OS rate 54% versus 21%, p < 0.001) in all population. No statistically significant differences in terms of pathological stage of disease, vascular invasion, DFS, and OS were observed in NE-like cases compared with non-NE-like cases. Conclusions: The NE-like urothelial carcinoma identified by Piescore immunophenotyping (CD44, CK5/6, CK20 and pPARg) did not show any statistically significant association with worse prognosis.

TMPRSS2: ERG expression in prostate cancer—Imaging and clinicopathological correlations

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Background: The TMPRSS2:ERG gene fusion (T:E) is found in up to 70% of prostate cancers (PCa) and results in androgen dependent overexpression of ERG, promoting tumor growth. The early identification of T:E may be helpful even in low-risk PCa. Although T:E can be non-invasively detected in urine, its correlation with new imaging tools (MRI and high-frequency ultrasound) and clinical outcome remains vague.This study investigates T:E expression in patients scheduled for random/software-assisted MRI or micro-ultrasound (29Mhz) fusion biopsy. Methods: This is a prospective cohort study in patients with suspected PCa enrolled between 2016 and 2019, approved by local authorities with Prot. N. 336/19, 14/05/2019. Patients underwent systematic US-guided biopsy, plus targeted biopsy if they had ³1 suspicious lesion (PI-RADS V.2 >2) at mpMRI or PRIMUS >2 at MICRO-US. For each patient, 1 prostatic core from the highest PI-RADS or PRIMUS lesion was collected for T:E analysis (a core from the right lobe in negative patients). Histological analyses were performed by experienced genitourinary pathologists. RNA was extracted from a dedicated fresh biopsy and RT-PCR was performed with different primer couples to detect the most frequent T:E fusions. All amplified products were checked by sequencing. Results: The cohort consists of 92 patients (median PSA 7.13 ng/ml, IQR 5.25-11.04 - average age 65ys), 81 with a diagnosis of PCa after biopsy. mpMRI was performed on 63 (68.5%) patients and was positive in 58 (92%), who underwent fusion biopsy. T:E fusion transcripts were detected in 23.5% of individuals with a diagnosis of PCa. Among patients positive for T:E, those analyzed by MRI were 100% positive (73% PI-RADS ≥4), those analyzed by MICRO-US were 83% positive. Sensitivity of the T:E assay for any PCa was 23.5%, specificity 100%, with negative and positive predicting values of 15% and 100%. There was no correlation between T:E and family history, PSA, PIRADS, PRI-MUS and Gleason score. Conclusions: Our finding showed a 100% of specificity making T:E an attractive tool for early cancer detection. In the future, identification of T:E in semen could represent a screening test for clinical stratification of patients with suspected PCa.

Predictive Factors of Patients' and Their Partners' Sexual Function Improvement After Collagenase Clostridium Histolyticum Injection for Peyronie's Disease: Results From a Multi-Center Single-Arm Study

BACKGROUND

Collagenase Clostridium histolyticum (CCH; Xiapex) injections represent the only licensed medical treatment for Peyronie's disease (PD).

AIM

To evaluate the efficacy and safety of CCH injections in men with stable PD, using a modified treatment protocol and to assess partners' bother improvement in a large cohort of White-European sexually active heterosexual men treated in a single tertiary-referral center.

METHODS

All the 135 patients enrolled underwent a thorough assessment, which included history taking, physical examination, and pharmacologically induced artificial erection test (intra-cavernous injection) to assess the degree of penile curvature (PC) at baseline and after the completion of the treatment. Patients with calcified plaque and/or ventral curvature were excluded. All patients underwent a modified treatment protocol, which consisted of 3 intra-lesional injections of 0.9 mg of CCH performed at 4-week intervals at the point of maximum curvature. After each injection, patients were instructed to follow a strict routine involving daily penile stretching in the intervals between injections.

OUTCOMES

International Index of Erectile Function (IIEF)-15, Global Assessment of PD, PD questionnaires (PDQ), and Female Sexual Function Index (FSFI) questionnaire were performed at baseline and at the end of treatment.

RESULTS

Overall, 135 patients completed the study protocol. Before treatment, 18 (13.33%) partners showed a degree of sexual dysfunction. Baseline median IIEF-15, FSFI, and PDQ scores were, respectively, 59.0, 35.0, and 23.0. Overall, both IIEF-total and all domains significantly improved after treatment (all P < .01). A PC mean change of 19.07 (P = .00) was measured. At the univariate linear regression analysis, IIEF-15, IIEF-erectile function, IIEF-sexual desire, and IIEF-intercourse satisfaction were positively associated with FSFI (all P ≤ .03); conversely, PDQ-penile pain, PDQ-symptom bother, and post-treament penile curvature (P ≤ .04) were associated with a decreased FSFI score. Furthermore, median change of PC was significantly associated with median change of FSFI (r = 0.25; 95% CI 0.02-0.11; P = .004). Global satisfaction after treatment was 89.6% (121/135).

CLINICAL TRANSLATION

This modified CCH treatment protocol could improve both patients' and partner's sexual function.

STRENGTH AND LIMITATIONS

This was an open-label, single-arm clinical study, without placebo. where only heterosexual couples in stable relationships were included. Furthermore, no real assessment of female sexual distress was carried out and long-term sexual function in both patients and female partners were not taken into account.

CONCLUSIONS

The modified treatment schedule with CCH injections for stable PD has a positive impact on both patients' and partners' sexual function in heterosexual couples with a stable sexual relationship. Cocci A, Russo GI, Salonia A, et al. Predictive Factors of Patients' and Their Partners' Sexual Function Improvement After Collagenase Clostridium Histolyticum Injection for Peyronie's Disease: Results From a Multi-Center Single-Arm Study. J Sex Med 2018;15:716-721.

Current status of robotic kidney transplant and its future

OBJECTIVES

Open kidney transplantation (OKT) represents the standard approach in patients with end-stage renal disease, but recently robotic-assisted kidney transplantation (RAKT) has also become an accepted approach.

METHODS

We conducted a systematic review using the PubMed/Medline and Embase databases and the keywords "Robotic kidney transplantation" and "Robotic-assisted kidney transplantation".

RESULTS

Past studies of RAKT have tended to suffer from patient selection bias, but, following completion of the learning curves in specialized centers, the indications for RAKT have recently been expanded to include more complex cases. The technique has evolved over the years, and currently both intraperitoneal and extraperitoneal approaches are accepted; however, it hasbeen suggested that the intraperitoneal technique offers advantages in obese patients. The Vattikuti-Medanta technique of RAKT with regional hypothermia, in which the graft is surrounded by a gauze jacket filled with ice slush, is the most widely accepted technique for maintenance of the graft temperature at below 18-20°C during surgery. A number of perioperative variables have been described, including operative time (145-255 min), total ischemia time (73-96 min),  rewarming time (40-73 min), blood loss (88-150 mL), high-grade complication rate (3.75%-12.5%), and hospital stay (6-14 days). The data regarding functional outcomes show that RAKT presents a similar profile to OKT in terms of functionality at short- and long-term follow-up. While RAKT has been proposed as a safe and effective alternative in obese patients, such patients should be included in a weight loss program or under go simultaneous bariatric surgery.

CONCLUSION

Despite its limitations, RAKT seems to be an attractive, feasible, safe, and reproducible surgery. It offers surgical advantages and a lower complication rate, especially in obese patients, and delivers functional outcomes comparable to those achieved using OKT.

The Effect of Anatomical Location of Lymph Node Metastases on Cancer Specific Survival in Patients with Clear Cell Renal Cell Carcinoma

Background

Positive nodal status (pN1) is an independent predictor of survival in renal cell carcinoma (RCC) patients. However, no study to date has tested whether the location of lymph node (LN) metastases does affect oncologic outcomes in a population submitted to radical nephrectomy (RN) and extended lymph node dissection (eLND).

Objective

To describe nodal disease dissemination in clear cell RCC (ccRCC) patients and to assess the effect of the anatomical sites and the number of nodal areas affected on cancer specific mortality (CSM).

Design, setting and partecipants

The study included 415 patients who underwent RN and eLND, defined as the removal of hilar, side-specific (pre/paraaortic or pre/paracaval) and interaortocaval LNs for ccRCC, at two institutions.

Outcome measurement and statistical analysis

Descriptive statistics were used to depict nodal dissemination in pN1 patients, stratified according to nodal site and number of involved areas. Multivariable Cox regression analyses and Kaplan-Meier curves were used to explore the relationship between pN1 disease features and survival outcomes.

Results and limitations

Median number of removed LN was 14 (IQR 9–19); 23% of patients were pN1. Among patients with one involved nodal site, 54 and 26% of patients were positive only in side-specific and interaortocaval station, respectively. The most frequent nodal site was the interaortocaval and side-specific one, for right and left ccRCC, respectively. Interaortocaval nodal positivity (HR 2.3, CI 95%: 1.3–3.9, p < 0.01) represented an independent predictor of CSM.

Conclusions

When ccRCC patient harbour nodal disease, its spreading can occur at any nodal station without involving the others. The presence of interoartocaval positive nodes does affect oncologic outcomes.

Patient summary

Lymph node invasion in patients with clear cell renal cell carcinoma is not following a fixed anatomical pattern. An extended lymph node dissection, during treatment for primary kidney tumour, would aid patient risk stratification and multimodality upfront treatment.

Association between dietary phytoestrogens intakes and prostate cancer risk in Sicily

OBJECTIVE

In this study we aimed to investigate the association between dietary phytoestrogen consumption and prostate cancer in a sample of southern Italian individuals.

METHODS

A population-based case-control study on the association between prostate cancer and dietary factors was conducted from January 2015 to December 2016 in a single institution of the municipality of Catania, southern Italy (Registration number: 41/2015). A total of 118 histopathological-verified prostate cancer (PCa) cases and a total of 222 controls were collected. Dietary data was collected by using two food frequency questionnaires.

RESULTS

Patients with PCa consumed significantly higher levels of phytoestrogens. Multivariate logistic regression showed that lignans (Q[quartile]4 vs. Q1, OR [odds ratio] = 4.72; p < .05) and specifically, lariciresinol (Q4 vs. Q1, OR = 4.60; p < .05), pinoresinol (Q4 vs. Q1, OR = 5.62; p < .05), matairesinol (Q4 vs. Q1, OR = 3.63; p < .05), secoisolariciresinol (Q4 vs. Q1, OR = 4.10; p < .05) were associated with increased risk of PCa. Furthermore, we found that isoflavones (Q3 vs. Q1, OR = 0.28; p < .05) and specifically, genistein (Q4 vs. Q1, OR = 0.40; p < .05) were associated with reduced risk of PCa.

CONCLUSION

We found of an inverse association between dietary isoflavone intake and PCa, while a positive association was found with lignans intake.

Dietary Consumption of Phenolic Acids and Prostate Cancer: A Case-Control Study in Sicily, Southern Italy

Dietary polyphenols gained the interest of the scientific community due to their wide content in a variety of plant-derived foods and beverages commonly consumed, such as fruits, vegetables, coffee, tea, and cocoa. We aimed to investigate whether there was an association between dietary phenolic acid consumption and prostate cancer (PCa) in South Italy. We conducted a population-based case-control study from January 2015 to December 2016 in a single institution of the municipality of Catania, southern Italy (Registration number: 41/2015). Patients with elevated PSA and/or suspicious PCa underwent transperineal prostate biopsy. A total of 118 histopathological-verified PCa cases were collected and a total of 222 controls were selected from a sample of 2044 individuals. Dietary data were collected by using two food frequency questionnaires and data on the phenolic acids content in foods was obtained from the Phenol-Explorer database (www.phenol-explorer.eu). Association between dietary intake of phenolic acids and PCa was calculated through logistic regression analysis. We found lower levels of caffeic acid (2.28 mg/day vs. 2.76 mg/day; p < 0.05) and ferulic acid (2.80 mg/day vs. 4.04 mg/day; p < 0.01) in PCa when compared to controls. The multivariate logistic regression showed that both caffeic acid (OR = 0.32; p < 0.05) and ferulic acid (OR = 0.30; p < 0.05) were associated with reduced risk of PCa. Higher intake of hydroxybenzoic acids and caffeic acids were associated with lower risk of advanced PCa. High intake of caffeic acid and ferulic acid may be associated with reduced risk of PCa.

Nephron-sparing surgery in multiple renal cancer: a case report

BACKGROUND: In the last decade, nephron-sparing surgery has largely supplanted the radical approach for the treatment of small renal masses. More recently, ablative technologies have been discussed as alternative in patients that are not eligible for surgical approach.CASE SUMMARY: A 54-year-old Caucasian man was referred to our Urology Clinic for multiple renal masses. A computed tomography (CT) scan revealed three contrast-enhanced lesions located in the upper pole, middle renal, and in the lower pole of the left kidney 20 mm, 25 mm, and 45 mm long, respectively. The patient underwent laparoscopic tumorectomy of two lesions and cryoablation of the left renal mass by the transperitoneal approach, performed without clamping the renal vessels. At the end of the procedure the operator posed a reno-ureteral ipsilateral stent to tutor the urinary tract. Tumor enucleation and cryoablation were chosen to preserve renal function.CONCLUSION: This case report shows that in young patients with multiple renal tumors, cryoablation treatment is feasible and outcomes are promising as well. However, risk of complications should be considered and discussed with patients.