Cristina Scalici Gesolfo

Sexual dysfunctions after transurethral resection of the prostate (TURP): Evidence from a retrospective study on 264 patients

OBJECTIVES Benign prostatic hyperplasia (BPH) and sexual dysfunctions are diseases with a high prevalence in aged men. Several studies have found a link between BPH and LUTS resulting from deterioration in sexual function in men aged 50 years and older for whom TURP is considered the gold standard. The impact of TURP on sexual functions still remain uncertain, nor is it clear what pathophysiological mechanism underlying the emergence of new episodes of Erectile Dysfunction (ED) following TURP in patients with normal sexual function before surgery, while retrograde ejaculation and ejaculate volume reduction represent a clear side effect; derived from BPH treatment. The aim of this study was to retrospectively evaluate the effects of transurethral resection of the prostate (TURP) on sexual function in patients operated in the period 2008-2012 at the Department of Urology of the University Hospital P. Giaccone, and at Villa Sofia-Cervello Hospital- Palermo. Secondary objective was to reconnect the sample data to interventional practice and international standards. MATERIALS AND METHODS The retrospective longitudinal study was conducted on 264 of the 287 recruitable patients, aged between 50 and 85 years, suffering from BPH who underwent to TURP in the period 2008-2012. Telephone interviews were conducted and the International Index of Erectile Function (IIEF) was administered to assess sexual function. Patients enrolled were asked to respond to the test by referring at first to their sexual status in the period before surgery and subsequently to the state of their sexual function after treatment so as to obtain, for each patient, a pre- and post-TURP questionnaire in order to get comparisons that corresponding to reality and to avoid overestimation of the dysfunctional phenomenon. RESULTS In the pre-TURP, the 94.32% of the sample reported being sexually active, with good erectile function in 41.3% of cases, ED mild/moderate in 51.5% and complete ED in 1, 5% of cases; good libido in 62.9% of cases, lack of libido in 31.4% of cases and absent in 5.7% of cases (the latter data corresponded to patients not sexually active); to be sexually satisfied in 29.5% of cases, slightly dissatisfied in 11, 7% of cases, moderately in 35.3% of cases, dissatisfied and very dissatisfied in 23.5% of cases (of which 17.8% sexually active and 5.7% non-active). In the post-TURP 89.4% of the sample reported being sexually active, with good erectile function in 39.1% of cases, DE mild/moderate in 46.9% and complete DE in 4% of cases; good libido in 53.8% of cases, lack of libido in 33.7% of cases and absent in 13.5% of cases (including 1.9% of sexually active and 10.6% of non-active); to be sexually satisfied in 29.5% of cases, slightly dissatisfied in 9.5% of cases, moderately in 35.3% of cases, dissatisfied and very dissatisfied in 17.8% of cases (of which 14.8% sexually active and 10.6% inactive). Retrograde ejaculation was referred in 47.8% of those sexually active after TURP (42.8% if we consider the whole sample). CONCLUSIONS TURP had no negative impact on erectile function in contrast to ejaculatory function. Of the 109 patients with good erectile function in pre-TURP, 5.8% reported a worsening of erectile function after TURP. Among the 136 patients with ED moderate/mild pre-TURP 3.7% reported a worsening in the post-TURP, 16.2% reported an improvement, while 9.5% stopped any sexual activity. In 3.7% of the cases a complete ED was reported after TURP, while a decline of libido and sexual satisfaction was detected in all patients with worsening of sexual function. Retrograde ejaculation was observed in 48% of those sexually active after TURP. Particular attention has to be paid to the psychological aspects, both before surgery and in the postoperative period, which may become an important factor in the decline of sexual activity.

Mitomycin C from birth to adulthood.

Mitomycin C (MMC) intravesical therapy for “superficial” papillary bladder tumors was firstly introduced in the early seventies with promising results. In the following years, several pharmacokinetic studies investigated its mechanism of action to optimize the intravesical administration. Numerous studies confirmed thereafter both the ablative and the prophylactic efficacy and the low toxicity of MMC when intravesically given. In 1984, a complete response rate of 42% in 60 patients not responsive to thiotepa was reported with intravesical MMC at the dose of 40 mg diluted in 40 ml for 8 weeks. In the following decades, many large randomized studies showed the benefit of intravesical prophylaxis with MMC versus transurethral resection (TUR) alone. Since 2002, the role of adjuvant intravesical chemotherapy and of an early MMC instillation in preventing recurrence compared with TUR alone has been confirmed by large meta-analyses and stated by the European Association of Urology (EAU) guidelines. The need for further intravesical chemotherapy after the early instillation in patients at intermediate-high risk of recurrence has been proved by several trials. Although intravesical Bacillus Calmette-Guerìn (BCG) is considered the best choice for high-risk patients and MMC for the low-risk group, both MMC and BCG can be given to prevent recurrence in intermediate-risk patients. However, the higher efficacy of BCG over MMC is evident only if maintenance regimen is administered. Despite its proven efficacy, immediate intravesical MMC is not yet fully entered in common clinical practice and efforts should be made by the urologists to optimize its adoption.

The clinical value of PSA increase during intravesical adjuvant therapy for nonmuscle-invasive bladder cancer

Introduction Prostatic Specific Antigen (PSA), Bacillus Calmette-Guerin (BCG) increase after intravesical BCG has been reported. The need of prostate biopsy in these patients is object of debate. The aim of our study was to evaluate the effect of intravesical therapy on PSA after transurethral resection (TUR) of nonmuscle-invasive bladder cancer (NMIBC). Materials and methods Patients undergoing intravesical chemotherapy or immunotherapy for NMIBC were entered. PSA was measured before TUR, before the first and after the sixth instillation, 30 and 90 days after the last instillation. Patients with PSA ≥4 ng/ml or palpable prostate nodule were excluded. Results Out of 130 patients, 105 were evaluable. PSA increase (mean: 7.15 ng/ml) was detected after TUR and before intravesical therapy in 14 patients (13.3%). Of the remaining 91 patients, 65 (71.4%) received chemotherapy and 26 (28.6%) BCG. Median PSA before and during therapy was 1.80 and 1.97 ng/ml, with a 36% median increase in 66 patients (72.5%) (p = 0.13). No statistically significant difference emerged between chemotherapy and BCG (p = 0.22). PSA higher than 4 ng/ml was detected in six (6.3%) and two (2.1%) patients after chemotherapy and BCG, respectively, and was no more evident at 90 days. Discussion PSA increase due to intravesical therapy is rare and usually not clinically significant. PSA rising above 4 ng/ml during intravesical treatment was evident only in 8% of patients. PSA before TUR should be available and considered as the basal value. Elevated PSA detected during therapy should be monitored and biopsy proposed only if persisting more than 3 months after the end.

Compliance to therapy with Dapoxetine in patients affected by Premature Ejaculation

Introduction Premature ejaculation (PE) is a sexual dysfunction with high prevalence. According to some reports, it is present in about 20-30% of the male population. Since 2009 PE has been treated with a novel inhibitor of serotonin re-uptake, Dapoxetine, which has been reported to be specifically active for PE. Materials and Methods 59 patients have been selected among the patients affected by PE observed at the outpatient department of Urology and Andrology of the “Paolo Giaccone” University Policlinic Hospital of Palermo. Diagnosis was confirmed unequivocally in all patients, who were suitable for drug treatment and accepted to participate in the study. They were divided in 2 groups: one receiving Dapoxetine (41 patients), another (18 patients) receiving Citalopram. Patients were followed up by telephone at monthly intervals, in order to compare compliance, efficacy and side effects. Results Compliance to treatment was obtained in 56% of patients treated with Dapoxetine and in 61% of those treated with Citalopram. In the Dapoxetine group side effects were reported in 14.6% versus 38.4% in the Citalopram group. Benefit from the treatment was reported in 82% and 69.2%, respectively.

MP58-14 LIMITS OF TRANSURETHRAL RESECTION IN DETECTING UNCOMMON HISTOLOGICAL VARIANTS WITHIN BULKY BLADDER TUMORS IN REAL-LIFE CLINICAL PRACTICE

render accurate pre-operative staging paramount. Incidental indeterminate pulmonary nodules (IPNs) are a common pre-operative finding in clinical practice, thus representing a significant management challenge since metastatic patients are unlikely to benefit from extirpation. Thus, we sought to evaluate the natural history of IPNs in a large institutional cohort that underwent RC. METHODS: We reviewed our institutional database for patients who underwent RC from 2000-2014 for urothelial carcinoma (UCC) of the bladder & had 1 identifiable pulmonary lesion on preoperative staging imaging measuring <2cm in any axis. Patients who were M1 at surgery or had non urothelial histology were excluded. Cumulative incidence of any lung metastasis was estimated, adjusting for competing risk of death; overall survival (OS) was estimating using Kaplan Meier methods. We sought to determine the natural history of these pulmonary lesions and evaluated predictors of metastatic etiology. RESULTS: During the study period, 681 RC were performed at our institution. Of which, 73 patients with an identifiable preoperative IPN met inclusion criteria & underwent RC. In this subset, 23% were female, 22% were active smokers & 55% former smokers. The median age at surgery was 70 yrs (range 43-88). 51% received neoadjuvant chemotherapy & 62% of RC were performed using the traditional open approach (vs 38% robotically). Final pathologic staging included 16% pT0N0Mx, 19% pTa/Tis/T1N0Mx, 43% pT2-4N0Mx, & 22% pTanyN+Mx. Median IPN size was 0.7 0.3cm. At median follow up of 23.5 months, the IPNs in 92% (67/73) of patients were clinically benign, with metastatic urothelial cancer confirmed in only 5 patients, & a primary lung malignancy diagnosed in 1 patient. In the IPN cohort, lung metastasis at non-IPN sites were detected in 2 additional patients. Cumulative incidence of any lung metastasis at 12, 24 & 36 months was 5.9% (95%CI 1.9-13.3%), 7.6% (95%CI 2.8-15.7%), & 10.3% (95%CI 3.9-20.2%), respectively. OS at 12, 24 & 36 months was 75.3% (95%CI 62.3-83.9%), 65.8% (95%CI 53-1-75.9%), & 54.0% (95%CI 39.766.2%), respectively. CONCLUSIONS: The majority of IPNs in patients who proceeded to RC for UCC of the bladder were stable upon follow-up & rarely represented malignancy. Patients with IPNs have OS consistent with previously published literature. As such, in appropriately screened UCC patients, IPNs should not be a barrier to proceeding with extirpative surgical therapy.

Clinical implications of a rare renal entity: Pleomorphic Hyalinizing Angiectatic Tumor (PHAT)

Pleomorphic Hyalinizing Angiectatic Tumor (PHAT) is a rare benign lesion characterized by slow growth, infiltrative behavior and high rate of local recurrences. Only one case has been described in retroperitoneum, at renal hilum, but not involving pelvis or parenchyma. Here we present the first case of PHAT arising in the renal parenchyma. A nodular lesion in right kidney lower pole was diagnosed to a 61 year old woman. The patient underwent right nephrectomy. Microscopically, the lesion showed solid and pseudo-cystic components with hemorrhagic areas characterized by aggregates of ectatic blood vessels. Pleomorphic cells were characterized by large eosinophilic cytoplasm with irregular and hyperchromatic nuclei. Immunohistochemistry was performed and the lesion was classified as a Pleomorphic Hyalinizing Angiectatic Tumor (PHAT). Due to the clinical behavior of this tumor, in spite of its benign nature, review of the surgical margins and close follow up after partial nephrectomy are mandatory.

An uncommon case of sarcomatoid urothelial carcinoma in covered bladder exstrophy

Abstract We report a case of a woman affected by covered exstrophy, uterus didelphys and external genital malformation presenting with advanced bladder cancer. After neoadjuvant therapy and anterior pelvic exenteration, the abdominal wall was reconstructed with a pedicled myocutaneous muscle-sparing vastus lateralis flap.

Genitourinary Symptoms—Patient Help-Seeking and General Practitioner Management: An Outpatient Based Survey at a Tertiary Hospital in Southern Italy

Introduction: General knowledge of most common genitourinary diseases is often lacking. In this survey we evaluated the attention given by patients and general practitioners to genitourinary symptoms, and particularly to hematuria and potential early signs of genitourinary cancer. Methods: A structured self‐administered questionnaire was administered to outpatients before the urological consultation. The questionnaire consisted of 4 multiple choice questions to record the level of patient awareness of urological symptoms, the importance given to gross hematuria, the interval between the onset and the visit, the regularity of physical examination and the first‐level investigations indicated by the general practitioner before the urological consultation. Results: A total of 327 self‐administered questionnaires were obtained from 358 consecutive patients for a compliance rate of 91.3%. Asymptomatic gross hematuria was present in 91 cases (27.8%). The first episode of hematuria was not reported by 20% of the patients, with a median delay of 11 months. Only 77 patients (23.6%) in the last 5 years had received a physical examination including the external genitalia. Laboratory and/or imaging investigations were indicated before urological counseling in 172 (52.6%) patients. Conclusions: The majority of patients underestimated urological symptoms. Less than 25% and 50% of patients had a physical examination and first‐level investigations performed before urological counseling, respectively. Our survey reveals an important lack of awareness of genitourinary symptoms that could be responsible for delayed diagnosis and inappropriate treatment.

Intravesical chemotherapy for intermediate risk non‑muscle invasive bladder cancer recurring after a first cycle of intravesical adjuvant therapy

Context: The therapeutic strategy in intermediate risk (IR) non-muscle invasive bladder cancer (NMIBC) recurring after intravesical therapy (IT) is not well defined. Most patients are usually retreated by Bacillus Calmette-Guerin (BCG). Aims: To evaluate the efficacy of intravesical chemotherapy (ICH) given at recurrence after the first cycle of ICH in IR-NMIBC recurring 6 months or later. Settings and Design: Retrospective analysis of the efficacy of ICH given after previous IT. Materials and Methods: The clinical files of IR-NMIBC patients recurring later than 6 months after transurethral resection (TUR) and IT and retreated by IT were reviewed. The patients should be at intermediate risk both initially and at the first recurrence. BCG should have been given at full dose. Cytology and cystoscopy were performed 3 monthly for 2 years and then 6 monthly. Statistical Analysis: The RFS was estimated by the Kaplan-Meier method and the differences between treatment groups were compared by log-rank test. Mann Whitney U-test was used to compare the parameters′ distribution for median time to recurrence. Multivariate Cox proportional hazards models were used. Results: The study included 179 patients. The first IT was ICH in 146 (81.6%) and BCG in 33 (18.4%), re-IT was ICH in 112 (62.6%) and BCG in 67 (37.4%) patients. Median time to recurrence was 18 and 16 months after first and second IT (P = 0.32). At 3 years, 24 (35.8%) and 49 (43.8%) patients recurred after BCG and ICH, respectively (P = 0.90). No difference in RFS was found between BCG and ICH given after a first cycle of ICH (P = 0.23). Conclusions: Re-treatment with ICH could represent a legitimate option to BCG in patients harboring IR-NMIBC recurring after TUR and previous ICH. Prospective trials are needed.

Clinical pitfalls in diagnosis of nonmuscle-invasive bladder cancer.

Current global economic crisis imposes healthcare system to reduce unnecessary investigations and increase early detection of tumors, to decrease the costs of an advanced disease. Several diagnostic pitfalls may occur dealing with bladder cancer (BC), particularly in nonmuscle-invasive (NMIBC) one. Hematuria, the commonest sign in NMIBC, is often underestimated. Urinary cytology is highly specific for high-grade tumors, but has a low sensitivity for low-grade BC, is operator dependent, and not always obtainable in clinical practice. Numerous urinary tests are available to ameliorate the accuracy of cytology, but none of them is routinly used in urological practice. Ultrasound could hardly detect a small bladder tumor, especially if located in the bladder neck or in the anterior wall. Computed tomography (CT) is widely adopted as an alternative to conventional urography, but its usefulness in patients with hematuria is still debated. MRI has a higher accuracy than CT for staging BC and evaluate the bladder-wall invasion. A negative cystoscopy cannot exclude Tis and should be accompanied by urinary cytology in patients with suspected Tis or high-risk NMIBC; however, new techniques such as narrow band imaging (NBI) and photodynamic (PDD) increase the detection rate of BC and flat lesions. Nearly half of all diagnostic resections present omission of muscle in the specimen or its mention in the pathology report, which is associated with an increased mortality. An adequate muscle sampling during endoscopic resection is mandatory, particularly in patients with high-grade disease. Recognition of pitfalls in diagnosis and management of BC represents the first step for a correct approach.