Open versus Robot-Assisted Radical Cystectomy for the Treatment of pT4a Bladder Cancer: Comparison of Perioperative Outcomes

We compared the perioperative outcomes of open (ORC) vs. robot-assisted (RARC) radical cystectomy in the treatment of pT4a MIBC. In total, 212 patients underwent ORC (102 patients, Group A) vs. RARC (110 patients, Group B) for pT4a bladder cancer. Patients were prospectively followed and retrospectively reviewed. We assessed operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of stay, transfusion rate, and oncological outcomes. Preoperative features were comparable. The mean operative time was 232.8 vs. 189.2 min (p = 0.04), and mean EBL was 832.8 vs. 523.7 mL in Group A vs. B (p = 0.04). An intraoperative transfusion was performed in 32 (31.4%) vs. 11 (10.0%) cases during ORC vs. RARC (p = 0.03). The intraoperative complications rate was comparable. The mean length of stay was shorter after RARC (12.6 vs. 7.2 days, p = 0.02). Postoperative transfusions were performed in 36 (35.3%) vs. 13 (11.8%) cases (p = 0.03), and postoperative complications occurred in 37 (36.3%) vs. 29 (26.4%) patients in Groups A vs. B (p = 0.05). The positive surgical margin (PSM) rate was lower after RARC. No differences were recorded according to the oncological outcomes. ORC and RARC are feasible treatments for the management of pT4a bladder tumors. Minimally invasive surgery provides shorter operative time, bleeding, transfusion rate, postoperative complications, length of stay, and PSM rate.

Patient and Context Factors in the Adoption of Active Surveillance for Low-Risk Prostate Cancer

Importance

Although active surveillance for patients with low-risk prostate cancer (LRPC) has been recommended for years, its adoption at the population level is often limited.

Objective

To make active surveillance available for patients with LRPC using a research framework and to compare patient characteristics and clinical outcomes between those who receive active surveillance vs radical treatments at diagnosis.

Design, Setting, and Participants

This population-based, prospective cohort study was designed by a large multidisciplinary group of specialists and patients' representatives. The study was conducted within all 18 urology centers and 7 radiation oncology centers in the Piemonte and Valle d'Aosta Regional Oncology Network in Northwest Italy (approximate population, 4.5 million). Participants included patients with a new diagnosis of LRPC from June 2015 to December 2021. Data were analyzed from January to May 2023.

Exposure

At diagnosis, all patients were informed of the available treatment options by the urologist and received an information leaflet describing the benefits and risks of active surveillance compared with active treatments, either radical prostatectomy (RP) or radiation treatment (RT). Patients choosing active surveillance were actively monitored with regular prostate-specific antigen testing, clinical examinations, and a rebiopsy at 12 months.

Main Outcomes and Measures

Outcomes of interest were proportion of patients choosing active surveillance or radical treatments, overall survival, and, for patients in active surveillance, treatment-free survival. Comparisons were analyzed with multivariable logistic or Cox models, considering centers as clusters.

Results

A total of 852 male patients (median [IQR] age, 70 [64-74] years) were included, and 706 patients (82.9%) chose active surveillance, with an increasing trend over time; 109 patients (12.8%) chose RP, and 37 patients (4.3%) chose RT. Median (IQR) follow-up was 57 (41-76) months. Worse prostate cancer prognostic factors were negatively associated with choosing active surveillance (eg, stage T2a vs T1c: odds ratio [OR], 0.51; 95% CI, 0.28-0.93), while patients who were older (eg, age ≥75 vs <65 years: OR, 4.27; 95% CI, 1.98-9.22), had higher comorbidity (Charlson Comorbidity Index ≥2 vs 0: OR, 1.98; 95% CI, 1.02-3.85), underwent an independent revision of the first prostate biopsy (OR, 2.35; 95% CI, 1.26-4.38) or underwent a multidisciplinary assessment (OR, 2.65; 95% CI, 1.38-5.11) were more likely to choose active surveillance vs active treatment. After adjustment, center at which a patient was treated continued to be an important factor in the choice of treatment (intraclass correlation coefficient, 18.6%). No differences were detected in overall survival between active treatment and active surveillance. Treatment-free survival in the active surveillance cohort was 59.0% (95% CI, 54.8%-62.9%) at 24 months, 54.5% (95% CI, 50.2%-58.6%) at 36 months, and 47.0% (95% CI, 42.2%-51.7%) at 48 months.

Conclusions and Relevance

In this population-based cohort study of patients with LRPC, a research framework at system level as well as favorable prognostic factors, a multidisciplinary approach, and an independent review of the first prostate biopsy at patient-level were positively associated with high uptake of active surveillance, a practice largely underused before this study.

The Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration Project: Development of Criteria for Reporting Adverse Events During Surgical Procedures and Evaluating Their Impact on the Postoperative Course

BACKGROUND

Intraoperative adverse events (iAEs) are surgical and anesthesiologic complications. Despite the availability of grading criteria, iAEs are infrequently reported in the surgical literature and in cases for which iAEs are reported, these events are described with significant heterogeneity.

OBJECTIVE

To develop Intraoperative Complications Assessment and Reporting with Universal Standards (ICARUS) Global Surgical Collaboration criteria to standardize the assessment, reporting, and grading of iAEs. The ultimate aim is to improve our understanding of the nature and frequency of iAEs and our ability to counsel patients regarding surgical procedures.

DESIGN, SETTING, AND PARTICIPANTS

The present study involved the following steps: (1) collecting criteria for assessing, reporting, and grading of iAEs via a comprehensive umbrella review; (2) collecting additional criteria via a survey of a panel of experienced surgeons (first round of a modified Delphi survey); (3) creating a comprehensive list of reporting criteria; (4) combining criteria acquired in the first two steps; and (5) establishing a consensus on clinical and quality assessment utility as determined in the second round of the Delphi survey.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Panel inter-rater agreement and consistency were assessed as the overall percentage agreement and Cronbach's α.

RESULTS AND LIMITATIONS

The umbrella review led to nine common criteria for assessing, grading, and reporting iAEs, and review of iAE grading systems led to two additional criteria. In the first Delphi round, 35 surgeons responded and two criteria were added. In the second Delphi round, 13 common criteria met the threshold for final guideline inclusion. All 13 criteria achieved the consensus minimum of 70%, with agreement on the usefulness of the criteria for clinical and quality improvement ranging from 74% to 100%. The mean inter-rater agreement was 89.0% for clinical improvement and 88.6% for quality improvement.

CONCLUSIONS

The ICARUS Global Collaboration criteria might aid in identifying important criteria when reporting iAEs, which will support all those involved in patient care and scientific publishing.

PATIENT SUMMARY

We consulted a panel of experienced surgeons to develop a set of guidelines for academic surgeons to follow when publishing surgical studies. The surgeon panel proposed a list of 13 criteria that may improve global understanding of complications during specific procedures and thus improve the ability to counsel patients on surgical risk.

Perioperative outcomes of patients undergoing urological elective surgery during the COVID-19 pandemic: a national overview across 28 Italian institutions

Introduction

The aim of this study was to assess the safety of elective urological surgery performed during the pandemic by estimating the prevalence of COVID-19-like symptoms in the postoperative period and its correlation with perioperative and clinical factors.

Material and methods

In this multicenter, observational study we recorded clinical, surgical and postoperative data of consecutive patients undergoing elective urological surgery in 28 different institutions across Italy during initial stage of the COVID-19 pandemic (between February 24 and March 30, 2020, inclusive).

Results

A total of 1943 patients were enrolled. In 12%, 7.1%, 21.3%, 56.7% and 2.6% of cases an open, laparoscopic, robotic, endoscopic or percutaneous surgical approach was performed, respectively. Overall, 166 (8.5%) postoperative complications were registered, 77 (3.9%) surgical and 89 (4.6%) medical. Twenty-eight (1.4%) patients were readmitted to hospital after discharge and 13 (0.7%) died. In the 30 days following discharge, fever and respiratory symptoms were recorded in 101 (5.2%) and 60 (3.1%) patients. At multivariable analysis, not performing nasopharyngeal swab at hospital admission (HR 2.3; CI 95% 1.01–5.19; p = 0.04) was independently associated with risk of developing postoperative medical complications. Number of patients in the facility was confirmed as an independent predictor of experiencing postoperative respiratory symptoms (p = 0.047, HR:1.12; CI95% 1.00–1.05), while COVID-19-free type of hospitalization facility was a strong independent protective factor (p = 0.02, HR:0.23, CI95% 0.07–0.79).

Conclusions

Performing elective surgery during the COVID-19 pandemic does not seem to affect perioperative outcomes as long as proper preventive measures are adopted, including nasopharyngeal swab before hospital admission and hospitalization in dedicated COVID-19-free facilities.

The dramatic COVID 19 outbreak in Italy is responsible of a huge drop of urological surgical activity: a multicenter observational study

Objective

To describe the trend in surgical volume in urology in Italy during the coronavirus disease 2019 (COVID‐19) outbreak, as a result of the abrupt reorganisation of the Italian national health system to augment care provision to symptomatic patients with COVID‐19.

Methods

A total of 33 urological units with physicians affiliated to the AGILE consortium (Italian Group for Advanced Laparo‐Endoscopic Surgery; www.agilegroup.it) were surveyed. Urologists were asked to report the amount of surgical elective procedures week‐by‐week, from the beginning of the emergency to the following month.

Results

The 33 hospitals involved in the study account overall for 22 945 beds and are distributed in 13/20 Italian regions. Before the outbreak, the involved urology units performed overall 1213 procedures/week, half of which were oncological. A month later, the number of surgeries had declined by 78%. Lombardy, the first region with positive COVID‐19 cases, experienced a 94% reduction. The decrease in oncological and non‐oncological surgical activity was 35.9% and 89%, respectively. The trend of the decline showed a delay of roughly 2 weeks for the other regions.

Conclusion

Italy, a country with a high fatality rate from COVID‐19, experienced a sudden decline in surgical activity. This decline was inversely related to the increase in COVID‐19 care, with potential harm particularly in the oncological field. The Italian experience may be helpful for future surgical pre‐planning in other countries not so drastically affected by the disease to date.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy.

MATERIALS AND METHODS

A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes.

RESULTS

Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05).

CONCLUSION

In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Urology in the Time of Coronavirus: Reduced Access to Urgent and Emergent Urological Care during the Coronavirus Disease 2019 Outbreak in Italy

PURPOSE

The coronavirus disease 2019 (COVID-19) pandemic has put a substantial burden on the Italian healthcare system, resulting in the restructuring of hospitals to care for COVID-19 patients. However, this has likely impacted access to care for patients experiencing other conditions. We aimed to quantify the impact of COVID-19 on access to care for patients with urgent/emergent urological conditions throughout Italy.

MATERIALS AND METHODS

A questionnaire was sent to 33 urological units in the AGILE consortium, asking clinicians to report on the number of urgent/emergent urological patients seen and/or undergoing surgery over a 3-week period during the peak of the COVID-19 outbreak and a reference week prior to the outbreak. ANOVA and linear regression models were used to quantify these changes.

RESULTS

Data from 27 urological centres in Italy showed a decrease from 956 patients/week seen just prior to the outbreak to 291 patients/week seen by the end of the study period. There was a difference in the number of patients with urgent/emergent urological disease seen within/during the different weeks (all p values < 0.05). A significant decrease in the number of patients presenting with haematuria, urinary retention, urinary tract infection, scrotal pain, renal colic, or trauma and urgent/emergent cases that required surgery was reported (all p values < 0.05).

CONCLUSION

In Italy, during the COVID-19 outbreak there has been a decrease in patients seeking help for urgent/emergent urological conditions. Restructuring of hospitals and clinics is mandatory to cope with the COVID-19 pandemic; however, the healthcare system should continue to provide adequate levels of care also to patients with other conditions.

Large bladder diverticula: a comparison between laparoscopic excision and endoscopic fulguration

OBJECTIVE

The treatment of bladder diverticula consists of diverticulectomy, mainly by a laparoscopic approach or transurethral resection of the diverticular neck and fulguration of the mucosa. The endoscopic approach is generally dedicated to small diverticula. The aim of this study was to compare laparoscopic diverticulectomy versus endoscopic fulguration for bladder diverticula larger than 4 cm.

MATERIALS AND METHODS

A retrospective review of the medical records of consecutive patients undergoing endoscopic or laparoscopic treatment for bladder diverticula larger than 4 cm at two tertiary hospitals was performed. Therapeutic success was defined as either complete resolution or a decrease of at least 80% in the size of the diverticulum. Complications were recorded and graded according to the Clavien-Dindo classification.

RESULTS

All patients were treated with transurethral resection of the prostate in the same operative session. The endoscopic group included a cohort of 20 male patients. The median age, diverticular diameter and operative time were 65 years, 7 cm and 62.5 min, respectively. No early postoperative complications were observed. Therapeutic success was achieved in 15 cases (75%). The laparoscopic group included a cohort of 13 male patients with a median age of 63 years and median diverticular diameter of 7.0 cm. The median operative time was 185 min (p < 0.0001). Two grade III postoperative complications were observed (15.3%). Therapeutic success was achieved in all patients (100%).

CONCLUSIONS

Acquired bladder diverticula larger than 4 cm can be effectively managed either by a laparoscopic approach or by endoscopic fulguration.

Multicenter analysis of pathological outcomes of patients eligible for active surveillance according to PRIAS criteria

BACKGROUND

The aim of this study was to retrospectively analyze the pathological outcomes of patients meeting the Prostate Cancer Research International Active Surveillance (PRIAS) criteria who had undergone radical prostatectomy (RP).

METHODS

Out of 2014 patients recruited for minimally invasive RP between 2008 and 2014 in 7 centers, 226 (11.2%) met the modified PRIAS criteria (clinical stage T1c/T2, PSA<10 ng/mL, 1-2 positive biopsy cores and Gleason Score<6).

RESULTS

At pathological evaluation, Gleason Score upgrade was reported in 47.3% of patients; 74 (32.7%), 10 (4.4%), 9 (3.9%) patients showed RP Gleason sum 7, 8 and 9, respectively. Upstaging was reported in 135 patients (59.7%). Twelve (5.3%) and 4 (1.7%) patients had T3a and T3b pathological stage respectively.

CONCLUSIONS

Notwithstanding the PRIAS criteria can identify some PCa patients as low-risk, at pathological evaluation some of them harbored intermediate- or high-risk disease. According to our data, patients eligible for AS should be carefully counseled about possible disease understaging.

Laparoscopic and robotic ureteral stenosis repair: a multi-institutional experience with a long-term follow-up

The treatment of ureteral strictures represents a challenge due to the variability of aetiology, site and extension of the stricture; it ranges from an end-to-end anastomosis or reimplantation into the bladder with a Boari flap or Psoas Hitch. Traditionally, these procedures have been done using an open access, but minimally invasive approaches have gained acceptance. The aim of this study is to evaluate the safety and feasibility and perioperative results of minimally invasive surgery for the treatment of ureteral stenosis with a long-term follow-up. Data of 62 laparoscopic (n = 36) and robotic (n = 26) treatments for ureteral stenosis in 9 Italian centers were reviewed. Patients were followed according to the referring center's protocol. Laparoscopic and robotic approaches were compared. All the procedures were completed successfully without open conversion. Average estimated blood loss in the two groups was 91.2 ± 71.9 cc for the laparoscopic and 47.2 ± 32.3 cc for the robotic, respectively (p = 0.004). Mean days of hospitalization were 5.9 ± 2.4 for the laparoscopic group and 7.6 ± 3.4 for the robotic group (p = 0.006). No differences were found in terms of operative time and post-operative complications. After a median follow-up of 27 months, the robotic group yielded 2 stenosis recurrence, instead the laparoscopic group shows no cases of recurrence (p = 0.091). Minimally invasive approach for ureteral stenosis is safe and feasible. Both robotic and pure laparoscopic approaches may offer good results in terms of perioperative outcomes, low incidence of complications and recurrence.

The prognostic role of preoperative chromogranin A expression in prostate cancer after radical prostatectomy

PURPOSES

The aim was to analyze the prognostic role of preoperative chromogranin A CgA) as a marker of poor prognosis and recurrence after radical prostatectomy (RP) and to find a correlation with the other well known prognostic variables.

MATERIALS AND METHODS

This study comprises 306 patients with prostate cancer prospectively recruited who underwent RP from between 2000 and 2005. A blood sample for the determination of serum preoperative CgA value was obtained in all cases. Spearman correlation test was used to compare CgA to other variables, Kruskal-Wallis test to analyze CgA differences among > or = 3 groups (PSA, GS, Stage), Mann-Whitney test for 2 grouping variables. Survival analysis was estimated by Kaplan-Meier method, log-rank test to estimate differences among the analyzed variables.

RESULTS

Median CgA level was 68 ng/ml. Correlation between age and CgA levels was positive and statistically significant (p < 0.001). Patient were divided in 2 groups based on median age.The difference was statistically significant (p = 0.002). Comparison of CgA among patients grouped according to other variables and patient stratified on normal (123 ng/ml) and cut-off value (68 ng/ml) of CgA did not achieve significant risk stratification.

CONCLUSION

Studies on a possible prognostic role of CgA have provided conflicting results. In our series we found a significant positive correlation between CgA and age, but no significant statistical correlation with other available variables analyzed.

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.

Is Radical Prostatectomy Feasible in All Cases of Locally Advanced Non-Bone Metastatic Prostate Cancer? Results of a Single-Institution Study

OBJECTIVES

Previous prospective studies of the surgical treatment of locally advanced prostate cancer have enrolled patients selected on the basis of a limited T3 disease extension. The aim of the present study was to assess the feasibility and the oncologic outcome of radical prostatectomy administered to a consecutive unselected series of advanced, non-bone metastatic prostate cancers.

METHODS

Between March 1998 and February 2003 radical prostatectomy was offered at our institution to any patient diagnosed with prostate cancer with no sign of extranodal metastatic disease. Data on morbidity and survival for 51 clinically advanced cases (any T>/=3, N0-N1, or any N1 or M1a disease according to the TNM 2002 classification system) operated on by a single expert surgeon were compared with a series of 152 radical prostatectomies performed during the same period by the same operator for clinically organ-confined disease. Adjuvant treatment was administered according to current guidelines.

RESULTS

The two groups did not differ significantly in surgical morbidity except for blood transfusion, operative time, and lymphoceles, which showed a higher rate in patients with advanced disease. The Kaplan-Meier estimate of overall survival and prostate cancer-specific survival at 7 yr were 76.69% and 90.2% in the advanced disease group and 88.4% and 99.3% in the organ-confined disease group, respectively.

CONCLUSIONS

Even in the scenario of extensive surgical indications up to M1a disease, radical prostatectomy proved to be technically feasible and to have an acceptable morbidity rate compared with organ-confined disease. Our initial survival data strengthen the role for surgery as an essential part in the multimodal approach to treating advanced prostate cancer.

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.