Alberto Breda

Clinical performance of serum prostate-specific antigen isoform (-2)proPSA (p2PSA) and its derivatives, %p2PSA and the prostate health index (PHI), in men with a family history of prostate cancer: results from a multicentre European study, the PROMEtheuS project

To test the sensitivity, specificity and accuracy of serum prostate‐specific antigen isoform [‐2]proPSA (p2PSA), %p2PSA and the prostate health index (PHI), in men with a family history of prostate cancer (PCa) undergoing prostate biopsy for suspected PCa. To evaluate the potential reduction in unnecessary biopsies and the characteristics of potentially missed cases of PCa that would result from using serum p2PSA, %p2PSA and PHI.

Importance of surgical margins in the management of renal cell carcinoma.

Surgical resection remains the standard treatment for clinically localized renal cell carcinoma. Pathological features of the surgical specimen, including the margin status, play an important part in determining the patients prognosis. Negative surgical margins have traditionally been sought to maximize the efficacy of treatment. Initial concerns that partial nephrectomy might have high local recurrence rates compared with radical nephrectomy have now been minimized as a result of technological advances and refinements in surgical technique. Current concerns in relation to partial nephrectomy include the width of parenchymal tissue that should be removed to avoid positive surgical margins, effects of positive margins on recurrence-free survival, and the use of frozen-section analysis to determine margin status. Size of the surgical margin in partial nephrectomy does not seem to affect the risk of local tumor recurrence, and not all positive surgical margins lead to recurrent disease. Intraoperative frozen-section analysis is not definitive and its value in guiding the surgical management of renal tumors remains to be defined. Laparoscopic partial nephrectomy is emerging as an attractive approach for selected renal masses. Intraoperative use of ultrasound, cold-scissor parenchymal transection, embolization, and hilar clamping to achieve a bloodless operative field with clear visibility, may minimize the risk of positive margins during partial nephrectomy.

Evolving Principles of Surgical Management and Prognostic Factors for Outcome in Renal Cell Carcinoma

The generally accepted principles for the surgical management of renal cell carcinoma (RCC) were first described more than 30 years ago. Since then, much has changed in the understanding of the basic biology and genetics of kidney cancer. Improvements in cross-sectional imaging has allowed for more accurate preoperative clinical staging of renal tumors, and the necessity of completing all the components of the radical nephrectomy have been questioned. Surgical techniques have also evolved, and technology has advanced to make possible new methods of managing renal tumors. The TNM staging system is currently the most extensively used system to provide prognostic information for RCC. However, data published in the last few years has led to significant controversies as to whether further revisions are needed and whether improvements can be made with the introduction of new, more accurate and predictive prognostic factors. Furthermore, the recent discovery of molecular tumor markers are expected to revolutionize the staging of RCC and lead to the development of new therapies based on molecular targeting. This review will examine the evolving principles in the surgical management of RCC as well as provide an update on current staging modalities and prognostic factors.

Comparison of accuracy of 14-, 18- and 20-G needles in ex-vivo renal mass biopsy: a prospective, blinded study

Study Type – Diagnostic (exploratory cohort)
 Level of Evidence 2b

Benefits and risks of ureteral access sheaths for retrograde renal access.

Purpose of review Ureteral access sheath (UAS) became increasingly popular worldwide. However, the safety of its routine use remains controversial. The aim of the current revision is to provide a systematic review on the benefits and disadvantages of the UAS. Recent findings A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Two reviewers independently searched the literature, finally identifying 20 articles valuable for this review. The use of UAS demonstrated several advantages to facilitate retrograde intrarenal access, lower intrarenal pressure, protect the ureter, protect the scope, and expedite stone extraction. Despite this, there is also some evidence that UAS use may be associated with acute ureteral injury and long-term complications, apparently related to maneuvers for UAS insertion and mucosal or deeper layers of injury and ischemia. Furthermore, there are still pending questions on the possible increase in stone-free rates, and decrease in operative time and costs. Summary Although the use of UAS is associated with some risk and limiting factors, it appears from this systematic review that its use is common and safe for the retrograde intrarenal access. Therefore, UAS is highly recommended for the treatment of upper tract disease by means of retrograde intrarenal surgery.

The road to real zero ischemia for partial nephrectomy.

PURPOSE To evaluate our initial outcomes of retroperitoneal partial nephrectomy (RPN) performed by off-clamp excision. PATIENTS AND METHODS Between January 2011 and October 2102, patients with T1 posterior renal masses or in the renal convexity were selected for RPN with the intent of performing the modified zero ischemia technique. Patient characteristics, operative details, complications, and long-term outcomes were analyzed. RESULTS There were 19 patients included (mean age 60 years, range 37-81 years; body mass index 27.8 kg/m(2), range 25-34 kg/m(2)). Mean tumor size was 35 mm (20-50 mm), and preoperative aspects and dimensions used for an anatomical (PADUA) classification score was 9 (7-11). Surgical time was 182 minutes (110-255 min), and the series warm ischemia time was 4.9 minutes (0-28 min). The off-clamp procedure was performed in 15 (79%) patients. Mean estimated blood losses (EBL) were 414 mL (100-1600 mL). Transfusion was necessary in two cases, while one reoperation and one conversion to open surgery were needed. Mean hospital stay was 4.5 days (range 3-11). One (5.3%) case of positive margins was reported. Serum creatinine levels varied from 86 to 94 μmol/L (preoperative and 6-month follow-up). Considering the learning curve of the technique, separate analysis of the initial 9 and last 10 cases revealed that while tumor characteristics remained comparable (size 33 vs 37 mm; PADUA score 8.8 vs 9.2), no clamping was performed in the later cases with decreased EBL (544 vs 297 mL), surgical time (207 vs 159 min), and shorter hospital stay (5 vs 4 days). CONCLUSION Our preliminary results on off-clamp RPN are promising and may pave the way for a real zero ischemia nephron-sparing surgery. Larger and randomized studies should follow in to confirm our initial results.

The Risk of Tumour Recurrence in Patients Undergoing Renal Transplantation for End-stage Renal Disease after Previous Treatment for a Urological Cancer: A Systematic Review

CONTEXT Renal transplantation is the gold standard renal replacement therapy in end-stage renal disease owing to its superior survival and quality of life compared with dialysis. When the potential recipient has a history of cancer, the waiting period before renal transplantation is usually based on the Cincinnati Registry. OBJECTIVE To systematically review all available evidence on the risk of cancer recurrence in end-stage renal disease patients with a history of urological cancer. EVIDENCE ACQUISITION Medline, Embase, and the Cochrane Library were searched up to March 2017 for all relevant publications reporting oncologic outcomes of urological cancer in patients who subsequently received a transplantation or remained on dialysis. The primary outcome was time to tumour recurrence. Secondary outcomes included cancer-specific and overall survival. Data were narratively synthesised in light of methodological and clinical heterogeneity. The risk of bias of each included study was assessed. EVIDENCE SYNTHESIS Thirty-two retrospective studies enrolling 2519 patients (1733 dialysed, 786 renal transplantation) were included. For renal cell carcinomas, the risks of recurrence, cancer-specific, and overall survival were similar between transplantation and dialysis. For prostate cancer, most of the tumours had favourable prognoses consistent with nomograms. Studies dealing with urothelial carcinomas (UCs) mainly included upper urinary tract UC in the context of aristolochic acid nephropathy, for which the risks of synchronous bilateral tumour and recurrence were high. Data on testicular cancer were scarce. CONCLUSIONS Immunosuppression after renal transplantation does not affect the outcomes and natural history of low-risk renal cell carcinomas and prostate cancer. Therefore, the waiting time from successful treatment for these cancers to transplantation could be reduced. Except in the particular situation of aristolochic acid nephropathy, more studies are needed to standardise the waiting period after UC owing to the paucity of data. PATIENT SUMMARY Renal transplantation does not appear to increase the risk of recurrence of renal carcinoma or the recurrence of low-risk prostate cancer compared with dialysis. More reliable evidence is required to recommend a standard waiting period especially for urothelial and testicular carcinomas.

Cytoreductive nephrectomy in patients with metastatic renal cell carcinoma in the era of targeted therapy: a bibliographic review

PurposeTo evaluate the role of cytoreductive nephrectomy (CN) in metastatic renal cell carcinoma (mRCC), against a background of lack of evidence following the introduction of targeted therapy.MethodsA literature review was performed in January 2017 using the MEDLINE/PubMed and EMBASE databases. The PRISMA guidelines were followed for conduct of the study. Two authors independently screened the 270 papers retrieved from the search, and the finally selected publications were identified by consensus between the two reviewers. A total of 55 studies were included in the present review.ResultsGlobally, the indications for CN have decreased over recent years. Although current guidelines consider CN an adequate option in selected patients based on prospective studies in the cytokine era, evidence for CN in the era of targeted therapy is based on retrospective studies only.ConclusionsThe results of ongoing prospective studies are still awaited. Retrospective data suggest that young male patients with oligometastatic disease and a good performance status can be considered suitable surgical candidates who may benefit from CN.

Terapia focal en cáncer de próstata. Alternativas de tratamiento

CONTEXT The great controversy surrounding the treatment of localized prostate cancer is related with its possibilities of radical treatment or active surveillance. The objective of this paper is to analyze the rationale selection among current focal therapy modalities regarding tumor and patient selection. EVIDENCE ACQUISITION Current articles about advantages and disadvantages on the treatment of localized prostate cancer as well as information about focal therapy regarding tumour selection, characteristics and indications cited in MEDLINE search were reviewed. SUMMARY OF EVIDENCE Focal therapy standardized criteria must be: low risk tumors, PSA<10-15, Gleason score ≤ 6, and unilateral presentation all supported by image-guided biopsy and nuclear magnetic resonance (NMR). There are doubts about the suitability of focal therapy in cases of bilateralism or in those with Gleason score 3+4 or PSA>15. CONCLUSIONS Focal therapy is an alternative for localized prostate cancer treatment. However, some aspects of their diagnosis and selection criteria should be defined by prospective studies which should provide knowledge about the indication for focal therapy.

Correlation Between Confocal Laser Endomicroscopy (Cellvizio®) and Histological Grading of Upper Tract Urothelial Carcinoma: A Step Forward for a Better Selection of Patients Suitable for Conservative Management

BACKGROUND Despite the recent growing interest in the conservative management of upper tract urothelial carcinoma (UTUC), the diagnostic process is still a challenge for the risk of tumor undergrading. Real-time confocal laser endomicroscopy (CLE) provides in vivo microscopic images of tissues using a low-energy laser light source. OBJECTIVE To describe our initial experience with CLE for the real-time characterization of UTUC. DESIGN, SETTING, AND PARTICIPANTS Fourteen flexible ureteroscopies (f-URS) were performed at our center with CLE for UTUC. Lesions were preoperatively identified at computed tomography-intravenous urography. Cellvizio system was used during f-URS to perform CLE on the targeted lesions. Biopsies were then performed. INTERVENTION f-URS with CLE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Surgeons CLE readings (low-grade/high-grade/carcinoma in situ [CIS]) were documented in the operation notes. A dedicated genitourinary pathologist-blinded to the surgeon reading-examined all specimens. A third person collected prospectively the CLE readings and the histopathological reports. Cohens Kappa analysis was performed to test interobserver agreement. RESULTS AND LIMITATIONS The mean diameter of tumors at computed tomography scan was 26mm (range, 5-50mm). In eight patients, CLE allowed to obtain images compatible with low-grade UTUC, in five patients with high-grade UTUC, and in one case with CIS. We found correspondence between the CLE images and the final histopathological results in seven out of seven cases of low-grade UTUC (100%), in five out of six cases of high-grade UTUC (83%), and in one out of one case of CIS (100%). Substantial agreement was found at interobserver agreement (k=0.64) between CLE and histological reading. No complications and/or limitations related to the use of CLE were recorded. CONCLUSIONS CLE is a promising new technology in providing a reliable real-time histological characterization of UTUC lesions. Ideal targets might be UTUC patients potentially candidates for conservative management. PATIENT SUMMARY We believe that a conservative treatment for low-grade upper tract urothelial carcinoma is an option that must be considered. The diagnostic process is still lacking of accurate tools. In this study, we find that confocal laser endomicroscopy, using the Cellvizio system, seems to help the clinician to have a real-time histological characterization of upper tract urothelial carcinoma lesions. This could better select patients for a conservative treatment.