Carlo De Dominicis

Real-time magnetic resonance-guided high-intensity focused ultrasound focal therapy for localised prostate cancer: preliminary experience.

Five patients with unifocal, biopsy-proven prostate cancer (PCa) evident on multiparametric magnetic resonance imaging (MRI) were treated with magnetic resonance-guided focused ultrasound (MRgFUS) ablation before radical prostatectomy (RP). An endorectal probe featuring a phased-array focused ultrasound transducer was positioned for lesion ablation under MRI guidance. The tissue temperature and accumulation of thermal damage in the target zone was monitored during the procedure by MRI thermometry. Overlap between the ablation area and the devascularisation of the target lesion was evaluated by contrast-enhanced MRI performed immediately after treatment. The procedure was uneventful, and no adverse events were observed. RP was safely performed without significant surgical difficulties in relation to the previous MRgFUS treatment. The histopathology report showed extensive coagulative necrosis, with no residual tumour in the ablated area. Significant bilateral residual tumour, not evident on pretreatment MRI, was observed outside the treated area in two patients. MRgFUS ablation of focal localised PCa is feasible and, if confirmed in appropriate studies, could represent a valid option for the focal treatment of localised PCa.

Ultrasound assessment of intravesical prostatic protrusion and detrusor wall thickness--new standards for noninvasive bladder outlet obstruction diagnosis?

PURPOSE We evaluated the accuracy of detrusor wall thickness and intravesical prostatic protrusion, and the association of each test to diagnose bladder prostatic obstruction in patients with lower urinary tract symptoms. MATERIALS AND METHODS We enrolled in the study 100 consecutive patients with lower urinary tract symptoms due to benign prostatic hyperplasia. Baseline parameters were International Prostate Symptom Score, prostate volume, urinary flow rate, intravesical prostatic protrusion, detrusor wall thickness, Schaefer obstruction class, minimal urethral opening pressure and the urethral resistance algorithm bladder outlet obstruction index. A ROC curve was produced to calculate AUC and evaluate the diagnostic performance of intravesical prostatic protrusion, detrusor wall thickness and prostate volume for bladder prostatic obstruction. RESULTS We noted a highly significant correlation between intravesical prostatic protrusion and the bladder outlet obstruction index (Spearmans rho = 0.49, p = 0.001), and Schaefer obstruction class (Spearmans rho = 0.51, p = 0.001). A highly significant correlation was also observed for detrusor wall thickness and the bladder outlet obstruction index (Spearmans rho = 0.57, p = 0.001), detrusor wall thickness and Schaefer obstruction class (Spearmans rho = 0.432, p = 0.02). On multivariate analysis intravesical prostatic protrusion and detrusor wall thickness were the only parameters associated with bladder prostatic obstruction (p = 0.015). The AUC for intravesical prostatic protrusion was 0.835 (95% CI 0.756-0.915) and for detrusor wall thickness it was 0.845 (95% CI 0.78-0.91). The association of intravesical prostatic protrusion and detrusor wall thickness produced the best diagnostic accuracy (87%) when the 2 tests were done consecutively. CONCLUSIONS Suprapubic ultrasound of detrusor wall thickness and intravesical prostatic protrusion is a simple, noninvasive, accurate system to assess bladder prostatic obstruction in patients with lower urinary tract symptoms due to benign prostatic hyperplasia.

Challenging the role of cremasteric reflux in the pathogenesis of varicocele using a new venographic approach.

PURPOSE Cremasteric or extrafunicular reflux is considered by many a major cause of primary and recurrent varicocele. Therefore, surgical techniques that allow ligation of the intrafunicular and extrafunicular veins are often performed. We evaluated the incidence of cremasteric reflux in patients with primary or recurrent varicocele with a new and simple venographic technique. MATERIALS AND METHODS A series of 73 patients with primary (54) or recurrent (19) varicocele underwent venography of the left iliac vein while standing and performing Valsalvas maneuver to reveal the possible presence of reflux in cremasteric or other extrafunicular veins. In patients with recurrent varicocele antegrade transcrotal spermatic venography was also performed immediately before surgery. RESULTS None of the patients presented with reflux of contrast material from the left iliac vein to the left pampiniform plexus via the extrafunicular veins. Cremasteric veins, in particular, were always continent at the confluence with the epigastric vein even when grossly dilated at spermatic antegrade venography in recurrent cases. CONCLUSIONS Cremasteric reflux seems to have a limited role if any in the pathogenesis of primary and even recurrent varicocele. Dilatation of the extrafunicular veins is not necessarily a sign of reflux but may represent only a consequence of venous overflow due to insufficiency of the internal spermatic vein and possibly partial obstruction of the left iliac vein. The rationale of surgical treatments aimed at ligation of the extrafunicular veins should be questioned.

Salvage Laparoscopic Radical Prostatectomy Following High-intensity Focused Ultrasound for Treatment of Prostate Cancer

OBJECTIVE To test the feasibility and safety of salvage laparoscopic radical prostatectomy (sLRP) for recurrent prostate cancer after high-intensity focused ultrasound (HIFU) treatment. METHODS Thirteen men (median age 61.3 years) fulfilled the criteria of recurrent prostate cancer after HIFU undergoing sLRP with HIFU performed using Ablatherm devices (EDAP TMS, Lyon, France). The median interval from primary treatment and biochemical recurrence was 38 months, and the median serum PSA nadir after primary therapy was 1.05 ng\mL. Perioperative data and functional outcome were recorded for each patient. Complications were recorded and graded according to Clavien scale. The prostatectomy specimens were analyzed for Gleason score, extracapsular extension, and surgical margins. Mean follow-up was 14 months. RESULTS There was no perioperative mortality and no conversion to open surgery was necessary. Mean operation time was 220 minutes, mean blood loss was 150 mL, and none of the patients received any transfusion. On histopathologic evaluation, 8 patients had extracapsular extension (pT3a) and 5 patients had intracapsular disease (pT2b). Positive surgical margins (PSMs) were detected in 2 patients in the pT3a group. Gleason score was 7 (3 + 4) in 6 patients and (4 + 3) in 5 patients. Two patients had a Gleason score of 8. The median time to achieve continence was 6 months. Four patients showed mild incontinence and used 2 pads per day. None of the patients in our series were potent after sLRP. CONCLUSION sLRP is feasible for men in whom HIFU has failed but has a higher morbidity rate than primary surgery.

Surgery of male infertility: an update

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval. Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein. Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART. In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

Malignant priapism due to penile metastases: Case series and literature review

Malignant priapism secondary to penile metastases is a rare condition. This term was originally used by Peacock in 1938 to describe a condition of painful induration and erection of the penis due to metastatic infiltration by a neoplasm. In the current literature there are 512 case reports. The primary tumor sites are bladder, prostate and rectum. The treatment has only palliative intent and consists of local tumor excision, penectomy, radiotherapy and chemotherapy. We present one case of malignant priapism originated from prostate cancer, and two from urothelial carcinoma of the bladder. Different approaches in diagnosis and therapy were performed. The entire three patient reported a relief of the pain following the treatment, with an improvement of their quality of life, even though it was only temporary as a palliative. Malignant priapism is a rare medical emergency. Penile/pelvis magnetic resonance imaging (MRI) scan and corporal biopsies are considered an effective method of diagnosis of the primary organ site.

Chirurgia dell'infertilità maschile: update

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval. Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein. Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART. In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.

Total phallic reconstruction after penile amputation for donkey bite: Case report and review of the literature

There are very few reported cases of traumatic amputation of the male genitalia due to animal bite. The management involves thorough washout of the wounds, debridement, antibiotic prophylaxis, tetanus and rabies immunization followed by immediate reconstruction or primary wound closure with delayed reconstruction, when immediate reconstruction is not feasible. When immediate reconstruction is not feasible, long-term good functional and cosmetic results are still possible in the majority of cases by performing total phallic reconstruction. In particular, it is now possible to fashion a cosmetically acceptable sensate phallus with incorporated neourethra, to allow the patient to void while standing and to ejaculate, and with enough bulk to allow the insertion of a penile prosthesis to guarantee the rigidity necessary to engage in penetrative sexual intercourse.

PD61-11 THE NEW EPSTEIN GLEASON SCORE CLASSIFICATION SIGNIFICANTLY REDUCES UPGRADING IN PROSTATE CANCER PATIENTS

INTRODUCTION AND OBJECTIVES: Aim of our study was to evaluate differences between the old and the new classification systems in upgrading and downgrading rates in a cohort of patients undergoing radical prostatectomy (RP) for PCa. METHODS: Between 2012 and 2016, 636 patients with clinically localized PCa were treated with RP at two tertiary referral centers. Blood samples were collected and tested for total PSA. All the patients included in the study presented a biopsy performed in the same center where the RP was performed. Biopsy specimens as well as RP specimens were graded according to both 2005 Gleason and 2015 Epstein Gleason grading systems. Upgrading and downgrading rates on RP were recorded for both classifications and then compared. Clinically significant upgrading was defined as: Epstein score raising from 2 to 3 or from 3 to 5 and Gleason (2005) raising from 6 to 7 or from 7 to 9. As well clinically significant downgrading was defined as: Epstein score decreasing from 3 to 2 or from 5 to 3 and Gleason (2005) decreasing from 7 to 6 or from 9 to 7. The accuracy of the biopsy for each Gleason score classification was determined using the kappa coefficient of agreement: <0.4 poor agreement, 0.4-0.75 good agreement and > 0.75 excellent agreement. RESULTS: Median age and preoperative PSA levels were 66 years (IQR: 61-69) and 7.1 ng/ml (IQR: 5.2-10.0), respectively. Overall 247/636 (39 %) had advanced disease (pT 3a). Pathological grading of biopsies and RP specimens according to both classifications are described in table 1. The Epstein Gleason score presented a lower upgrading rate (93/636:15% vs 150/636:24%; p1⁄40.000) and a similar downgrading rate (36/636:6 % vs 28/636:4% p1⁄40.194) when compared to the 2005 one. The kappa-statistics measures of agreement between needle biopsy and RP specimens was better for the Epstein score when compared to the 2005 Gleason score (k1⁄4 0.569 0.034 vs k1⁄4 0.481 0.033). CONCLUSIONS: The new Epstein Gleason score classification significantly reduces upgrading events in patients with PCa treated with RP. The implementation of this new classification could better define prostate cancer aggressiveness with important clinical implications particularly in PCa management. Further studies with a pathological review and reclassification of the specimens are needed to confirm our data.

Chirurgia dell'infertilità maschile

Surgery for male infertility includes three main areas: varicocele surgery, recanalization of seminal tract, sperm retrieval. Varicocele treatment in infertily is still controversial. Recent scientific evidence appears to demonstrate that in selected cases varicocele treatment is beneficial in improving semen parameters and pregnancy rate. The key for the success of treatment seems to be a correct indication. It is our opinion that varicocele should be treated in presence of abnormal semen parameters, when clinically significant, and in adolescents with atrophy of the affected testis. So far, no specific technique, either surgical, microsurgical or sclerotherapic, can be considered the gold standard. Good results in our hands have been obtained with the microsurgical lymphatic sparing high ligation of internal spermatic vein. Innovations in surgery for seminal tract obstructions include the new tubular invagination techniques for epididimovasostomy, which showed excellent results with a simplified and time-saving microsurgical approach. In distal obstructions, a new transperineal ultrasound-guided approach has been proposed for the diagnostic work-up and treatment. Advantages of this technique and of the TURED must be balanced with those of immediate sperm retrieval for ART. In sperm retrieval, microTESE represents the most important surgical evolution in non-obstructive azoospermia. We have recently proposed a new stepwise approach starting with a minimal equatorial incision for conventional testicular biopsy which is extended to perform microTESE only when no sperm is retrieved. In this way microTESE is offered only to patients who really need it. Another field of innovation is sperm retrieval for ICSI in patients with Klinefelter Syndrome.