Alessandro Crestani

The Relationship between Characteristics of Inguinal Lymph Nodes and Pelvic Lymph Node Involvement in Penile Squamous Cell Carcinoma: A Single Institution Experience

PURPOSE We determined predictors of pelvic lymph node metastases in patients with penile cancer. MATERIALS AND METHODS We retrieved a total of 188 node positive inguinal groins from 142 patients treated for penile cancer. Logistic regression models were fitted to test for predictors of pelvic lymph node metastases. The minimum p value method was used to determine the most significant cutoff values of each predictor. RESULTS Pelvic lymph node metastases were observed in 45 cases (31.7%). The 5-year cancer specific survival rate was 71.0% vs 33.2% in patients with inguinal vs pelvic lymph node metastases. The most significant cutoff values were 3 inguinal lymph node metastases and a metastasis diameter of 30 mm. According to univariable logistic regression models the number of inguinal metastases (OR 1.92, p <0.001), the diameter of the metastases (OR 1.03, p = 0.001) and extranodal extension (OR 8.01, p <0.001) were significant predictors of pelvic lymph node metastases. These variables were also independent predictors of metastases in multivariable logistic regression models (p ≤ 0.012). Patients with 3 or more inguinal lymph node metastases and those with a metastasis diameter of 30 mm or greater were at 4.77 and 2.53-fold higher risk, respectively, of harboring pelvic lymph node metastases (p ≤ 0.006). The proportion of metastases increased significantly from 0% in cases with no risk factors to 57.1% when all 3 risk factors were observed (p <0.001). CONCLUSIONS The number and diameter of inguinal lymph node metastases as well as extranodal extension are significantly associated with pelvic lymph node metastases. These variables should be considered to determine the need for pelvic lymph node dissection. Patients with no risk factors may be spared this dissection.

Spermatic Cord Sarcoma: Our Experience and Review of the Literature

Introduction: Spermatic cord tumors represent 4% of scrotal tumors. The most common neoplasms are lipomas. Spermatic cord sarcomas (SCS) of the genitourinary tract account for 2% of all urological tumors. Herein we presented our experience in the treatment of these tumors and a review of the literature. Patients and Methods: A review of the literature was performed using the Medline database with no restriction on language and date of published papers. The literature search used the following terms: epidemiology, surgery, chemotherapy, radiotherapy and spermatic cord sarcomas. Four cases treated from December 2009 to May 2010 are described. Results: All patients were treated with radical orchiectomy. The final pathological report showed different types of sarcomas. Two of the patients were treated with adjuvant chemotherapy. 12 months after surgery, 2/4 patients were alive without signs of relapse. Conclusion: SCS are very rare tumors with a poor prognosis. SCS’s prognostic factors have been identified in grading, size, depth of invasion and surgical margin status. Age and performance status of the patient are however very important. Lymphatic and hematogenous dissemination is uncommon. Surgery is the most important treatment both in the first approach and in local relapse. The role of adjuvant chemotherapy and radiation therapy is still debated.

Antegrade scrotal sclerotherapy of internal spermatic veins for varicocele treatment: technique, complications, and results

 Varicocele repair is mainly indicated in young adult patients with clinical palpable varicocele and abnormal semen parameters. Varicocele treatment is associated with a significant improvement in sperm concentration, motility, morphology, and pregnancy rate. Antegrade scrotal sclerotherapy (ASS) represented one of the main alternatives to the traditional inguinal or suprainguinal surgical ligation. This article reviews the use of ASS for varicocele treatment. We provide a brief overview of the history of the procedure and present our methods used in ASS. In addition, we review complication and success of ASS, including our own retrospective data of treating 674 patients over the last 17 years. Herein, we analyzed step by step the ASS technique and described our results with an original modified technique with a long follow-up. Between December 1997 and December 2014, we performed 674 ASS. Mean operative time was 14 min (range 9 to 50 min). No significant intraoperative complications were reported. Within 90 days from the procedure, postoperative complications were recorded in overall 49 (7.2%) patients. No major complications were recorded. A persistent/recurrent varicocele was detected in 40 (5.9%) cases. In 32/40 (80%) cases, patients showed preoperative grade III varicoceles. In patients with a low sperm number before surgery, sperm count improved from 13 × 10 6 to 21 × 10 6 ml−1 (P < 0.001). The median value of the percentage of progressive motile forms at 1 h improved from 25% to 45% (P < 0.001). Percentage of normal forms increased from 17% before surgery to 35% 1 year after the procedure (P < 0.001). In the subgroup of the 168 infertile patients, 52 (31%) fathered offspring at a 12-month-minimum follow-up. Therefore, ASS is an effective minimal invasive treatment for varicocele with low recurrence/persistence rate.

Combined Robotic-Assisted Retroperitoneoscopic Partial Nephrectomy and Extraperitoneal Prostatectomy. First Case Reported:

A 54-year-old man with a history of prostate cancer and clear cell renal cell carcinoma of the left kidney underwent concomitant robot-assisted laparoscopic partial nephrectomy and radical prostatectomy. We report, to our knowledge, the first case of a concomitant retroperitoneal robotic-assisted partial nephrectomy and extraperitoneal radical prostatectomy.

Anatomical study of renal arterial vasculature and its potential impact on partial nephrectomy

To validate Graves’ classification of the intrarenal arteries and to verify the absence of collateral arterial blood supply between different renal segments, in order to maximize peri‐operative and functional outcomes of partial nephrectomy.

Dismiss Systematic Transrectal Ultrasound-guided and Embrace Targeted Magnetic Resonance Imaging-informed Prostate Biopsy: Is the Paradigm Ready to Shift?

Prostate biopsy (PB) is, and is likely to remain, one of the most commonly performed urologic procedures worldwide. Until recently, it has been performed using blinded, systematic, template-based sampling under transrectal ultrasound (TRUS) guidance, with inherent drawbacks of undersampling of significant and oversampling of insignificant prostate cancer (PCa). The introduction of prostate magnetic resonance imaging (MRI) and the increasing use of functional sequences (so-called multiparametric MRI [mpMRI]) and refinements in equipment, protocols, and standardisation of data reporting have revolutionised this practice, and a rationale for image-based targeted sampling has rapidly been built. Data available so far have demonstrated the advantage of mpMRI-targeted PB in detecting a higher proportion of clinically significant cancers using fewer cores compared to conventional sampling [1,2]. Since a substantial change in how PB is performed will have enormous consequences for routine clinical practice anddiagnostic/treatmentpathwaysofone themost common malignancies (ie, PCa), it is legitimate to pose the question as to whether the urologic community on a global scale is truly ready to absorb this change. This approach has rapidly attracted interest among practicing urologists, and is now considered a possible new gold standard, especially in the repeat PB setting. However, despite accumulating evidence favouring mpMRI-targeted PB, there are still some open questions and concerns.

The Value of Open Conversion Simulations During Robot-Assisted Radical Prostatectomy: Implications for Robotic Training Curricula

INTRODUCTION There is a lack of protocols, formal guidance, and procedural training regarding open conversions from robot-assisted radical prostatectomy (RARP) to open radical prostatectomy (ORP). An open conversion places complex demands on the healthcare team and has recently been shown to be associated with adverse perioperative outcomes. AIMS To perform a root cause analysis of open conversion simulations from RARP to ORP to identify errors that may contribute to adverse events. METHODS From May 2013 to December 2013, with a team of two surgeons, an anesthesiologist, and three nurses, we simulated 20 emergencies during RARP that require open conversion. A human simulation model was intubated and prepared in the Trendelenburg position; a robot da Vinci SI was locked to it. All simulations were timed, transcribed, and filmed to identify errors and areas for improvement. An institutional conversion protocol was developed at the end of the conversion training. RESULTS The average conversion time was 130.9 (interquartile range [IQR] 90-201) seconds. Frequencies of the observed errors were as follows: lack of task sequence (70%), errors in robot movements (50%), loss of sterility (50%), space conflict (40%), communication errors (25%), lack of leadership (25%), and accidental fall of surgical devices (25%). Four main strategies were implemented to reduce errors: improving leadership, clearly defining roles, improving knowledge base, and surgical room reorganization. By the last simulation, conversions were performed without errors and using 55.2% less time compared with initial simulations. CONCLUSIONS In this preliminary study, repeated simulations, increased leadership, improved role delineation, and surgical room reorganization enabled faster and less flawed conversions. Further studies are needed to identify if such protocols may translate to actual safety improvement during open conversions.

Anesthesiologic Effects of Transperitoneal Versus Extraperitoneal Approach During Robot-Assisted Radical Prostatectomy: Results of a Prospective Randomized Study

ABSTRACT Objectives: To compare the effects of CO2 insufflation on hemodynamics and oxygen levels and on acid-base level during Robot-Assisted Radical Prostatectomy (RARP) with transperitoneal (TP) versus extra-peritoneal (EP) accesses. Materials and Methods: Sixty-two patients were randomly assigned to TP (32) and EP (30) to RARP. Pre-operation data were collected for all patients. Hemodynamic, respiratory and blood acid-base parameters were measured at the moment of induction of anesthesia (T0), after starting CO2 insuffation (T1), and at 60 (T2) and 120 minutes (T3) after insufflation. In all cases, the abdominal pressure was set at 15 mmHg. Complications were reported according to the Clavien-Dindo classification. Students two–t-test, with a significance level set at p<0.05, was used to compare categorical values between groups. The Mann-Whitney U-test was used to compare the median values of two nonparametric continuous variables. Results: The demographic characteristics of the patients in both groups were statistically comparable. Analysis of intra-operative anesthesiologic parameters showed that partial CO2 pressure during EP was significantly higher than during TP, with a consequent decrease in arterial pH. Other parameters analysed were similar in the two groups. Postoperative complications were comparable between groups. The most important limitations of this study were the small size of the patient groups and the impossibility of maintaining standard abdominal pressure throughout the operational phases, despite attempts to regulate it. Conclusions: This prospective randomized study demonstrates that, from the anesthesiologic viewpoint, during RARP the TP approach is preferable to EP, because of lower CO2 reabsorption and risk of acidosis.

Enhanced Recovery After Surgery Pathway in Patients Undergoing Open Radical Cystectomy Is Safe and Accelerates Bowel Function Recovery

OBJECTIVE To assess whether an Enhanced Recovery After Surgery pathway was associated with a faster bowel function recovery and no increase in morbidity compared with standard perioperative care in a contemporary series of patients undergoing radical cystectomy. METHODS A prospective single-center single-surgeon cohort of 114 consecutive patients treated with open radical cystectomy between July 2013 and June 2016 was analyzed. A study group of 74 patients with Enhanced Recovery After Surgery pathway was compared with a control group of 40 patients with standard perioperative care. Primary outcome was recovery of bowel function, measured by resumption of bowel sounds, passage of flatus, and passage of stool. Secondary outcome was rate of overall and major 90-day postoperative complications. RESULTS Bowel function recovery was significantly faster in the study group. Resumption of bowel sounds on postoperative day 1 was recorded in 43 (58%) vs 4 (10%) patients, passage of flatus within postoperative day 2 in 41 (55%) vs 11 (28%) patients, and passage of stool within postoperative day 3 in 37 (50%) vs no patients in the study vs control group, respectively (P < .01 for all). Overall and major 90-day complications were observed in 35 (47.3%) and 13 (17.6%) patients in the study group, and in 25 (62.5%) and 9 (22.5%) patients in the control group (P = .14 and 0.38, respectively). CONCLUSION In patients undergoing open radical cystectomy, an Enhanced Recovery After Surgery pathway allowed a significantly faster bowel function recovery with no increase in 90-day postoperative complications compared with standard perioperative care.

Multiparametric Magnetic Resonance Imaging Targeted Biopsy for Early Detection of Prostate Cancer: All That Glitters Is Not Gold!

One of the major unmet needs in early detection of prostate cancer (PCa) is the lack of a biopsy test capable of identifying clinically significant disease with high accuracy and efficiency. Current practice supported by most representative guidelines, that is, systematic, template-based sampling under transrectal ultrasound (TRUS) guidance, has the inherent drawbacks of missing PCa and of undersampling significant disease and oversampling insignificant disease in a substantial proportion of cases [1]. The recent advent of multiparametric magnetic resonance imaging (MP-MRI) with high field strength has revolutionised this practice, and rapidly built a rationale for targeted sampling of suspicious regions of interest (ROIs) identified on imaging. Available data, mainly from highvolume tertiary centres of excellence, have shown that targeted MRI-informed biopsy detects a higher proportion of clinically significant cancers with fewer cores compared to systematic sampling [1]. Enthusiasm has grown to the point that several researchers have elected targeted MRIinformed biopsy as the new gold standard. However, as experience with MP-MRI and targeted MRI-informed biopsy matures, pitfalls and limitations emerge. In this issue of European Urology, Schouten and colleagues report a critical analysis of potential reasons for failure of targeted in-bore MRI-guided biopsy in detecting clinically significant cancers by studying the spatial distribution of ROIs and cancers [2]. This is a secondary analysis of a previously published prospective trial of diagnostic accuracy comparing targeted MRI-guided biopsy and systematic TRUS-guided biopsy in biopsy-naı̈ve men [3]. ROIs were originally scored by three independent