Alessandro Morlacco

Systematic review of surgical treatment of post radical prostatectomy stress urinary incontinence

Context Stress urinary incontinence (SUI) after radical prostatectomy (RP) continues to be a significant problem with several implications including patient quality of life and other critical postoperative outcomes.

Genomic tests to guide prostate cancer management following diagnosis

ABSTRACT Introduction: Prostate cancer (PCa) is a common cancer in men, but variable clinical behaviors make its management challenging. Risk stratification is a key issue in disease management. Patient-tailored strategies are strongly advocated to reduce unnecessary treatment while maximizing the oncological outcomes of patient who need active treatment in the primary, adjuvant or salvage setting. Recently, tissue-based biomarkers or genomic tests have become available to improve the clinical decision-making. Areas covered: In this review, the authors present recent evidence about these tissue-based biomarkers, discussing the application of each of them in the clinical setting, focusing on the tests aimed to provide a better risk stratification and to guide decision-making after the diagnosis of PCa (i.e. OncotypeDXⓇ, ProlarisⓇ, ProMarkⓇ, Ki-67, DecipherⓇ, PTEN, PORTOS, AR-V7 and DNA repair gene mutations). Expert commentary: Even if the clinicopathologic features are still the most frequently-used predictors of disease progression, these tools can be helpful in decision-making at every stage of the PCa management. Actually, OncotypeDXⓇ, ProlarisⓇ and DecipherⓇ are recommended in the clinical setting by guidelines at different steps of PCa management. Consequently, further studies are indispensable to better tailor the right therapy for the right patient and at the right time.

An unusual cystic presentation of ductal carcinoma of the prostate

A 74-year-old male came to our clinic for rectal tenesmus, lower urinary tract symptoms and a previous episode of acute retention of urine. Computed tomography (CT) and magnetic resonance imaging (MRI) scan of abdomen showed a multiloculated, cystic formation of 12 cm in the pelvic cavity to the left, with compression of the prostate, bladder, sigmoid and rectum, and its extension imprinted the back of the pubis and back bladder. Saturation prostate biopsy was negative for carcinoma. The histology of transurethral resection of bladder formation revealed flogistic tissue. Cistoprostatectomy and ureteroileal pouch with Wallace anastomosis, removal of the rectum and colostomy with Hartmann pouch were performed. The histopatology showed a ductal carcinoma of the prostate.

Preoperative chronic kidney disease before radical cystectomy as predictor of oncological outcomes: a pick of the iceberg?

We read with interest the paper by Akihiko Matsumoto dealing with preoperative chronic kidney disease as a predictor of oncological outcomes of radical cystectomy for bladder cancer [1]. We are grateful to the authors for their innovative study and recognize that they should be commended for their attempt to provide a scientific support to an idea with a fascinating biological rationale. However, we would like to point out several limitations of the study that in our opinion make the results rather difficult to apply to clinical practice.

Arterial Fistula With Severe Hematuria After Ileal Conduit Diversion

Iliac-urinary fistula is a rare cause of severe hematuria after urinary diversion. Indwelling stents and advanced atherosclerosis may be risk factors. Angiography with embolization is usually resolutive.

Role of Metabolic Syndrome on Perioperative and Oncological Outcomes at Radical Prostatectomy in a Low-risk Prostate Cancer Cohort Potentially Eligible for Active Surveillance

BACKGROUND Metabolic syndrome (MetS) is considered a potential risk factor for adverse outcomes after radical prostatectomy (RP). Furthermore, studies about the effect of MetS on low-risk prostate cancer (PCa) and its implications in active surveillance (AS) are limited. OBJECTIVE To investigate the role of MetS (using International Diabetes Federation-American Heart Association/National Heart, Lung, and Blood Institute criteria) on perioperative and oncological outcomes after RP in low-risk PCa and in a subgroup potentially eligible for AS. DESIGN, SETTING, AND PARTICIPANTS A total of 3662 patients treated with RP for low-risk PCa and further stratified as very low risk (VLR) PCa-prostate-specific antigen density of ≤0.15ng/ml/cm3, ≤2 cores involved, and no core with >50% cancer involvement-at a tertiary referral hospital were identified. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Outcomes analyzed were pathological outcomes, perioperative complications, biochemical failure (BCF), and overall survival. Pathological outcomes and complications were analyzed with logistic regression models. Kaplan-Meier curves and Cox proportional hazards models were used to analyze survival outcomes. RESULTS AND LIMITATIONS In univariate/multivariate analyses, MetS was associated with upgrading and positive surgical margins in the entire cohort, upgrading only in the VLR group. In Kaplan-Meier analysis, MetS patients had a higher rate of overall death (p<0.0001) and BCF (p=0.03) for MetS patients. In the VLR group, no differences were found for BCF (p=0.064). Further, in Cox proportional hazards models, MetS was not associated with BCF (hazard ratio=1.23; 95% confidence interval [CI]=0.95-1.60, p=0.12). MetS patients had a higher rate of complications compared with non-MetS patients (23.7% vs 19.7%; p=0.01). In multivariate analysis, MetS was associated with a higher rate of complications (odds ratio=1.24, 95% CI=1.04-1.49, p=0.018) but did not impact the rate of major ones. This study is limited by its retrospective design. CONCLUSIONS In low-risk PCa treated with RP but potentially eligible for AS, MetS impacted perioperative and pathological outcomes, suggesting further study of MetS in patients undergoing AS. PATIENT SUMMARY Metabolic syndrome negatively impacts perioperative and pathological outcomes in low-risk prostate cancer patients treated with radical prostatectomy but potentially eligible for active surveillance, in a large American single-center cohort. These findings suggest the need for a more cautious approach to low-risk prostate cancer in patients with metabolic syndrome.

Development of a Surgical Safety Training Program and Checklist for Conversion during Robotic Partial Nephrectomies

OBJECTIVE To evaluate the impact of standardized training and institutional checklists on improving teamwork during complications requiring open conversion from robotic-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS Participants to a surgical team safety training program were randomly divided into 2 groups. A total of 20 emergencies were simulated: group 1 performed simulations followed by a 4-hour theoretical training; group 2 underwent 4-hour training first and then performed simulations. All simulations were recorded and scored by 2 independent physicians. Time to conversion (TC) and procedural errors were analyzed and compared between the 2 groups. A correlation analysis between the number of previous conversion simulations, total errors number, and TC was performed for each group. RESULTS Group 1 showed a higher TC than group 2 (116.5 vs 86.5 seconds, P = .0.53). As the number of simulation increased, the numbers of errors declined in both groups. The 2 groups tend to converge toward 0 errors after 9 simulations; however, the linear correlation was more pronounced in group 1 (R2 = 0.75). TC shows a progressive decline for both groups as the number of simulations increases (group 1, R2 = 0.7 and group 2, R2 = 0.61), but it remains higher for group 1. Lack of task sequence and accidental falls or loss of sterility were higher in group 1. CONCLUSION OC is a rare but potentially dramatic event in the setting of RAPN, and every robotic team should be prepared to manage intraoperative emergencies. Training protocols can effectively improve teamwork and facilitate timely conversions to open surgery in the event of intraoperative emergencies during RAPN. Further studies are needed to confirm if such protocols may translate into an actual safety improvement in clinical settings.

The New Prostate Cancer Grading System in High-risk Disease: A Big Step Forward?

In this issue of European Urology, Ham et al [1] report on a study of the newly proposed five-tiered prostate cancer (PCa) grading system in predicting long-term survival outcomes after radical prostatectomy (RP). The question of how to improve prognostic substratification of high-risk disease is highly relevant. To provide an answer, they analyzed a large cohort of men who underwent RP with biopsy or pathologic Gleason score (GS) 8–10 at a single institution over a 30-yr period. With median follow-up ranging from 4 to 6 yr, the data show higher cancer-specific mortality for biopsy and RP GS 9–10 when compared to GS 8. This association remained significant after adjusting for possible known confounders in both the preoperative and postoperative phases. The authors should be commended for their efforts to test the new five-tiered grading system using a ‘‘hard’’ outcome such as PCa-specific mortality. Many previous studies on this topic, in fact, relied on only biochemical recurrence (BCR)–free survival to define the utility of the new system, with all the known limitations of this approach. In particular, Epstein et al [2] assessed the predictive ability of the system for median follow-up of 3 yr, and found only a slight increase in overall accuracy for BCR prediction when compared to the traditional Gleason grading system (0.008 and 0.012 increase in overall accuracy in the preand post-treatment models, respectively). Subsequently, Loeb et al [3] extended follow-up to a median of 4.6 yr and concluded that the increase in C-index between the five-tier Gleason grading system and the threetier GS system ranged from 0 to 0.01. As we know from previous works, prostate-specific antigen–only recurrence risk is not fully reliable in risk-adapting strategies [4], and use of stronger survival outcomes is recommended.

Syphilis or cancer? A urological challenge.

A 31-year-old male carne to our clinic for suspicious testicular masses. Frozen-section examination of an excisional biopsy revealed inflammatory tissue, so we did not perform orchifuniclectomy. Definitive hystopatology revealed mio-fibroblastic nodules, which were considered consistent with testicular localization of luetic lesions. The patient was tested for syphilis and was found to be positive. HIV and other sexually transmitted diseases (STDs) tests were negative. He underwent antibiotic treatment and is doing well.