A. Saccà

The Optimal Rebiopsy Prostatic Scheme Depends on Patient Clinical Characteristics: Results of a Recursive Partitioning Analysis Based on a 24-Core Systematic Scheme

BACKGROUND The most beneficial number and the location of prostate biopsies remain matters of debate, especially after an initial negative biopsy. OBJECTIVE To identify the optimal combination of sampling sites (number and location) to detect prostate cancer (PCa) in patients previously submitted to an initial negative prostatic biopsy. DESIGN, SETTING, AND PARTICIPANTS A transrectal ultrasound-guided systematic 24-core prostate biopsy (24PBx) was performed prospectively in 340 consecutive patients after a first negative biopsy (at least 12 cores). MEASUREMENTS We relied on a classification and regression tree analysis to identify three clinically different subgroups of patients at dissimilar risk of harboring PCa at second biopsy. Subsequently, we set the cancer-positive rate of the 24PBx at 100% and calculated PCa detection rates for 255 possible combinations of sampling sites. We selected the optimal biopsy scheme (defined as the combination of sampling sites that detected 95% of all the cancers with the minimal number of biopsy cores) for each patient subgroup. RESULTS AND LIMITATIONS After an initial negative biopsy, cancer was detected at rebiopsy in 95 men (27.9%). At a given number of cores, the cancer detection rates varied significantly according to the different combination of sites considered. Three different PCa risk groups were identified: (1) previous report of atypical small acinar proliferation of the prostate (ASAP), (2) no previous ASAP and ratio of free prostate-specific antigen (fPSA) to total PSA (%fPSA) ≤10%, and (3) no previous ASAP and %fPSA >10%. For patients with previous ASAP or patients with no previous ASAP and %fPSA ≤10%, two schemes with different combinations of 14 cores were most favorable. The optimal sampling in patients with no previous ASAP and %fPSA >10% was a scheme with a combination of 20 cores. CONCLUSIONS Both the number and the location of biopsy cores taken affect cancer detection rates in a repeated biopsy setting. We developed an internally validated flowchart to identify the most advantageous set of sampling sites according to patient characteristics.

Postoperative Orgasmic Function Increases over Time in Patients Undergoing Nerve‐Sparing Radical Prostatectomy

INTRODUCTION Postprostatectomy orgasmic function (OF) remains poorly defined. AIMS To assess OF over time in patients who underwent bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP) for organ-confined prostate cancer (PCa). METHODS Baseline data were obtained from 334 consecutive preoperatively sexually active PCa patients at hospital admission; data included a medical and sexual history, IIEF domain scores, and ICIQ-SF. Questionnaire were then completed every 12 months postoperatively, and patients participated in a semistructured interview at the 12-month (191/334 [57.2%] patients), 24-month (95/334 [28.4%] patients), 36-month (42/334 [12.6%] patients), and 48-month (19/334 [5.7%] patients) follow-up (FU). MAIN OUTCOME MEASURES IIEF-OF domain values throughout the FU. Multivariate linear regression analysis (MVA) of the association between predictors (patients age, IIEF-erectile function [EF], ICIQ-SF, and the use of postoperative proerectile pharmacological treatments) and the IIEF-OF at 12-month, 24-month, and 36-month FU. RESULTS Preoperative mean (median) IIEF-OF was 7.6 (10). The anova analysis showed an increase of the IIEF-OF values (P = 0.008; F = 4.009) throughout the FU (namely, IIEF-OF 12-month: 6.1 [6]; 24-month: 7.2 [8]; 36-month: 7.3 [8]; and 48-month: 7.7 [9.50]). The 12-month MVA showed that while proerectile oral therapy did not affect postoperative OF (P = 0.150; Beta 0.081), IIEF-OF linearly increased with IIEF-EF (P < 0.001; Beta 0.425). Conversely, IIEF-OF linearly decreased with patients age (P < 0.001; Beta -0.135) and with ICQ-SF scores (P < 0.001; Beta -0.438). The 24-month and 36-month analyses showed that IIEF-OF still linearly increased with IIEF-EF (P < 0.001; Beta 0.540, and P < 0.001; Beta 0.536 respectively at the 24- and 36-month FU), whereas pharmacological therapy, rate of urinary continence, and patients age did not significantly affect postoperative OF. CONCLUSIONS Postoperative OF significantly ameliorates over time in patients undergoing BNSRRP. The higher the postoperative EF score, the higher the OF throughout the FU time frame.

Conventional testicular sperm extraction (TESE) and non-obstructive azoospermia: is there still a chance in the era of microdissection TESE? Results from a single non-academic community hospital.

Spermatozoa can be retrieved in non‐obstructive azoospermia (NOA) patients despite the absence of ejaculated spermatozoa in their semen because of the presence of isolated foci with active spermatogenesis. Conventional testicular sperm extraction (c‐TESE) in patients with NOA has been partially replaced by micro‐TESE. It is still under debate the problem regarding the higher costs related to micro‐TESE when compared with c‐TESE. In this study, we evaluated sperm retrieval rate (SRR) of c‐TESE in naive NOA patients. Sixty‐three NOA patients were referred to our centre for a c‐TESE. For every subject, we collected demographic data, cause of infertility, time to first infertility diagnosis, serum levels of LH, FSH, total testosterone and prolactin. A statistical analysis was conducted to correlate all the clinical variables, the histology and the Johnsen score with the SRR. Sixty‐three consecutive NOA patients with a mean age of 37.3 years were included. The positive SRR was 47.6%. No statistical differences were observed between positive vs. negative SRR regarding mean FSH (17.12 vs. 19.03 mUI/mL; p = 0.72), and LH (9.72 vs. 6.92 mUI/mL; p = 0.39) values. Interestingly, we found a statistically significant difference in terms of time to first infertility diagnosis (+SRR vs. −SRR; 44.5 vs. 57 months; p = 0.02) and regarding to age (+SSR vs. −SRR; 40.1 vs. 35.3; p = 0.04). There was a statistically significant decrease in SRRs with the decline in testicular histopathology from hypospermatogenesis to maturation arrest, and SCO. The mean Johnsen score was 5.9 with a mean percentage of Johnsen score ≥8 tubules equal to 19%. The overall pregnancy rate was 26.6%. In our prospective cohort of patients successful SRR with c‐TESE was 47.6%. Lower costs and high reproducibility of this technique still support this procedure as an actual reliable option in NOA patients for sperm retrieval.

79 PREDICTING ERECTILE FUNCTION RECOVERY AFTER BILATERAL NERVE SPARING RADICAL PROSTATECTOMY: A PROPOSAL OF A NOVEL RISK STRATIFICATION

Introduction. No multivariable model is currently available for the prediction of erectile function (EF) recovery after bilateral nerve sparing radical prostatectomy (BNSRP). Aim. The aim of this study was to develop a novel preoperative risk stratification aimed at assessing the probability of EF recovery after BNSRP. Main Outcome Measure. The International Index of Erectile Function (IIEF) was used to evaluate EF after BNSRP. Methods. This study included 435 patients treated with retropubic BNSRP between 2004 and 2008 at a single Institution. Preoperative data, including age, IIEF, Charlson comorbidity index (CCI), and body mass index (BMI) were available for all patients. Moreover, all patients were assessed postoperatively every 3 months and were asked to complete the IIEF during each visit. Cox regression models tested the association between preoperative predictors (age at surgery, preoperative IIEF-EF domain score, CCI, BMI) and EF recovery. Independent predictors of EF recovery were then used to stratify patients into three groups according to the risk of erectile dysfunction (ED) after surgery: low (age 65 years, IIEF-EF 26, CCI 1; n = 184), intermediate (age 66–69 years or IIEF-EF 11-25,CCI 1; n = 115), and high (age 70 years or IIEF-EF 10 or CCI 2; n = 136). Kaplan-Meier curves assessed the time to EF recovery (defined as IIEF-EF score 22). Predictive accuracy of our proposed classification was quantified using the AUC method. Results. Of 435 patients, 242 (55.6%) received phosphodiesterase type 5 inhibitors (PDE5-I) either on demand or every day for a period of 3–6 months. Overall, EF recovery rate was 58% at 3-year follow-up. Patients treated with PDE5-I had significantly higher 3-year EF recovery rate as compared with patients left untreated after surgery (73 vs. 37%; P < 0.001). Except for BMI (P = 0.7), all preoperative covariates showed a significant association with EF recovery (all P 0.04). The 3-year EF recovery rate significantly differed between the three groups, being 85, 59, and 37% in patients with low, intermediate, and high risk of postoperative ED, respectively (P < 0.001). Multivariable Cox regression analysis confirmed a highly significant association between the risk classification and EF recovery (P < 0.001). The proposed patient stratification tool showed a 69.1% accuracy. Similar results were achieved when patients were stratified according to the use of ED treatment after surgery (all P < 0.001). Conclusions. We report the first preoperative risk stratification tool aimed at assessing the probability of EF recovery after BNSRP. It is based on routinely available baseline data such as patient age, preoperative erectile function, and comorbidity profile. Briganti A, Gallina A, Suardi N, Capitanio U, Tutolo M, Bianchi M, Passoni N, Salonia A, Colombo R, Di Girolamo V, Guazzoni G, Rigatti P, and Montorsi F. Predicting erectile function recovery after bilateral nerve sparing radical prostatectomy: A proposal of a novel preoperative risk stratification. J Sex Med 2010;7:2521–2531.

Corpus Cavernosum Atypical Metastasis of Renal Cell Carcinoma: Presurgical Therapy and Complete Surgical Resection. Case Report and Review of the Literature

Renal-Cell Carcinoma (RCC) accounts for 2% of all cancers. Metastases are present in up to 30% of patients at diagnosis or appeared during follow up [1]. Atypical RCC metastases are sites, other than chest, liver, bone, adrenal, brain, and nodes, and their presentation is very rare. We describe the case of a 71-years-old male, who was submitted to a left laparoscopic radical nephrectomy for Clear Renal Cell Carcinoma (CRCC). After a 14-year follow-up, MRI scan showed a 5-cm solid lesion of the perineum, that originates from the right corpus cavernosum. A percutaneous trans-perineal biopsy revealed an atypical metastasis of CRCC. To reduce surgical risk during the exeresis of the mass, the patient received 4 cycles of pazopanib as presurgical treatment, with a shrinking of the lesion at follow-up MRI scan. He underwent a complete resection of the residual mass. Histopathology confirmed the diagnosis of atypical corpus cavernosum metastasis of CRCC. Presurgical therapy with Target Molecular Therapy (TMT) is feasible and might have several potential advantages for patients in case of complex metastasectomy.