F. Chessa

Differing Risk of Cancer Death Among Patients With Pathologic T3a Renal Cell Carcinoma: Identification of Risk Categories According to Fat Infiltration and Renal Vein Thrombosis

OBJECTIVES The study objectives were to evaluate the prognostic impact of fat infiltration and renal vein thrombosis in patients with pT3a renal cell carcinoma (RCC) and to identify new prognostic groups. MATERIAL AND METHODS We analyzed 122 consecutive patients with pT3a who underwent radical nephrectomy for RCC between 2000 and 2011 at the University of Bologna. Cancer-specific survival (CSS) rates were estimated using Kaplan-Meier survival curves; univariable and multivariable analyses were performed with Cox analysis. RESULTS The mean follow-up was 41.7 ± 35.4 months. Patients with peritumoral/hilar fat infiltration (n = 63) and patients with renal vein thrombosis (n = 18) experienced comparable CSS rates, whereas patients with both fat infiltration plus renal vein thrombosis (n = 41) showed worse survival outcomes than the first group (P = .026). Patients were divided in 2 groups: group A, with fat invasion or renal vein thrombosis, and group B, with concomitant fat invasion and renal vein invasion. Group B showed worse cancer-specific survival than group A (P = .024). At multivariate analysis, this new risk-group stratification was found to be an independent prognostic predictor of CSS (P < .05). CONCLUSIONS Patients with T3a RCC with both fat invasion and renal vein thrombosis experience worse survival rates when compared with those patients with only 1 prognostic factor. The TNM classification should consider the concomitant presence of those parameters as a different prognostic predictor.

Survival, Continence and Potency (SCP) recovery after radical retropubic prostatectomy: a long-term combined evaluation of surgical outcomes.

OBJECTIVE To offer a comprehensive account of surgical outcomes on a defined series of patients treated with radical retropubic prostatectomy (RRP) for prostate cancer in a single European Center after 5-year minimum follow-up according to the Survival, Continence and Potency (SCP) system. MATERIAL AND METHODS We evaluated our Institutional database of patients who underwent RRP from November 1995 to September 2008. Oncological and functional outcomes were reported according to the recently proposed SCP system. RESULTS The 5- and 10-year biochemical recurrence-free survival rates were 80.1% and 55.8%, respectively. At the end of follow-up, 611 (78.5%) patients were fully continent (C0), 107 (13.8%) used 1 pad for security (C1) and 60 (7.7%) patients were incontinent (C2). Of the 112 patients who underwent nerve-sparing RRP, 22 (19.6%) were fully potent without aids (P0), 13 (11.6%) were potent with assumption of PDE-5 inhibitors (P1) and 77 (68.8%) experienced erectile dysfunction (P2). The combined SCP outcomes were reported together only in 95 (12.2%) evaluable patients. In patients preoperatively continent and potent, who received a nerve-sparing and did not require adjuvant therapy, oncological and functional success was attained by 29 (30.5%) patients. In the subgroup of 508 patients not evaluable for potency recovery, oncological and continence outcomes were obtained in 357 patients (70.3%). CONCLUSION Survival, Continence and Potency (SCP) classification offer a comprehensive report of surgical results, even in those patients who do not represent the best category, thus allowing to provide a much more accurate evaluation of outcomes after RP.

In-bore MRI-guided Prostate Biopsy Using an Endorectal Nonmagnetic Device: A Prospective Study of 70 Consecutive Patients

Micro‐Abstract In a cohort of 70 consecutive patients with suspected prostate cancer and ≥ 1 suspicious area at the preliminary multiparametric magnetic resonance imaging study, in‐bore endorectal magnetic resonance imaging‐guided biopsy demonstrated a high detection rate, especially for clinical significant tumors and lesions located in the central and anterior regions of the gland, with a very low number of cores needed and a negligible incidence of complications. Introduction: We investigated the diagnostic performance of in‐bore endorectal magnetic resonance imaging‐guided biopsy (MRI‐GB) with a 1.5‐T MRI scanner using a 32‐channel coil in patients with suspected prostate cancer (PCa). Patients and Methods: Seventy patients with ≥ 1 suspicious area found on the preliminary multiparametric MRI scan were enrolled. The index lesion was defined as the lesion with the greatest Prostate Imaging Reporting and Data System, version 2 (PIRADS‐v2), score. MRI‐GBs were performed with a nonmagnetic biopsy device, needle guide, and titanium double‐shoot biopsy gun with dedicated software for needle tracking. Clinically significant PCa was defined as the presence of Gleason score ≥ 7 in the biopsy specimen. Results: Seventy index lesions were scheduled for MRI‐GB. The median PIRADS‐v2 score and the median number of cores per patient was 4 of 5 (interquartile range, 3‐5) and 2 (interquartile range, 1‐3), respectively. The PCa detection rate was 45.7%. Of the 70 patients, 24 (75%) had clinically significant PCa, with a significant correlation between the PIRADS‐v2 score and the Gleason score in the MRI‐GB cores (r = 0.839; 95% confidence interval, 0.535‐0.951; P = .003). According to the PIRADs‐v2 scheme, the proportion of PCa in the central and anterior regions of the gland was greater in the entire population and in the subgroup of patients with a history of negative transrectal ultrasound‐guided biopsy findings (P ≤ .01 for all). On multivariate analysis, a PIRADS‐v2 score of 5 of 5 correlated significantly with the likelihood of PCa at biopsy (hazard ratio, 4.69; 95% confidence interval, 0.92‐23.74; P = .04). No major complications were recorded. Conclusion: MRI‐GB has a high detection rate for PCa, especially for lesions located in the central and anterior regions of the prostate.

MRI Displays the Prostatic Cancer Anatomy and Improves the Bundles Management Before Robot-Assisted Radical Prostatectomy

OBJECTIVES To evaluate the impact of multiparametric magnetic0 resonance imaging (mpMRI) to guide the nerve-sparing (NS) surgical plan in prostate cancer (PCa) patients referred to robot-assisted radical prostatectomy (RARP). METHODS One hundred thirty-seven consecutive PCa patients were submitted to RARP between September 2016 and February 2017 at two high-volume European centers. Before RARP, each patient was referred to 1.5T or 3T mpMRI. NS was recorded as Grade 1, Grade 2, Grade 3, and Grade 4 according to Tewari and colleagues classification. A preliminary surgical plan to determinate the extent of NS approach was recorded based on clinical data. The final surgical plan was reassessed after mpMRI revision. The appropriateness of surgical plan change was considered based on the presence of extracapsular extension or positive surgical margins (PSMs) at level of neurovascular bundles area at final pathology. Furthermore, we analyzed a control group during the same period of 166 PCa patients referred to RARP in both institutions without preoperative mpMRI to assess the impact of the use of mpMRI on the surgical margins. RESULTS Considering 137 patients with preoperative mpMRI, the mpMRI revision induced the main surgeon to change the NS surgical plan in 46.7% of cases on patient-based and 56.2% on side-based analysis. The surgical plan change results equally assigned between the direction of more radical and less radical approach both on patient-based (54.7% vs 54.3%) and on side-based levels (50% vs 50%), resulting an overall appropriateness of 75%. Moreover, patients staged with mpMRI revealed significant lower overall PSMs compared with control group with no mpMRI (12.4% vs 24.1%; p ≤ 0.01). CONCLUSIONS mpMRI induces robotic surgeons to change the surgical plan in almost half of individuals, thus tailoring the NS approach, without compromising the oncologic outcomes. Compared to patients treated without mpMRI, the use of preoperative mpMRI can significantly reduce the overall PSMs.

Persistent Mullerian duct syndrome: Report of two cases with phenotypical immunohistochemical profiling

Introduction: Persistent Mullerian duct syndrome is a rare disorder of male organ development characterized by internal male pseudohermaphroditism. Persistent Mullerian duct syndrome is usually an incidental finding in patients presenting cryptorchidism, inguinal hernia, or a previous story of undescended testes. Case description: We report on two cases of persistent Mullerian duct syndrome: an adult fertile male with uterus and ectopic prostate occurring as pelvic mass and a 75-year-old organ donor with uterus and two fallopian tubes, discovered in course of organ recruitment. We performed routine histological analysis and immunohistochemical profiling of the different tissue components. Examined tissues were all benign, and the living patient is well after surgery. Conclusion: In order to prevent further complications such as infertility and potential malignant change, surgeons and surgical pathologists must be aware of this condition and should consider excision of the Mullerian remnant where possible.

State‐of‐the‐art imaging techniques in the management of preoperative staging and re‐staging of prostate cancer

We aimed to review the current state‐of‐the‐art imaging methods used for primary and secondary staging of prostate cancer, mainly focusing on multiparametric magnetic resonance imaging and positron‐emission tomography/computed tomography with new radiotracers. An expert panel of urologists, radiologists and nuclear medicine physicians with wide experience in prostate cancer led a PubMed/MEDLINE search for prospective, retrospective original research, systematic review, meta‐analyses and clinical guidelines for local and systemic staging of the primary tumor and recurrence disease after treatment. Despite magnetic resonance imaging having low sensitivity for microscopic extracapsular extension, it is now a mainstay of prostate cancer diagnosis and local staging, and is becoming a crucial tool in treatment planning. Cross‐sectional imaging for nodal staging, such as computed tomography and magnetic resonance imaging, is clinically useless even in high‐risk patients, but is still suggested by current clinical guidelines. Positron‐emission tomography/computed tomography with newer tracers has some advantage over conventional images, but is not cost‐effective. Bone scan and computed tomography are often useless in early biochemical relapse, when salvage treatments are potentially curative. New imaging modalities, such as prostate‐specific membrane antigen positron‐emission tomography/computed tomography and whole‐body magnetic resonance imaging, are showing promising results for early local and systemic detection. Newer imaging techniques, such as multiparametric magnetic resonance imaging, whole‐body magnetic resonance imaging and positron‐emission tomography/computed tomography with prostate‐specific membrane antigen, have the potential to fill the historical limitations of conventional imaging methods in some clinical situations of primary and secondary staging of prostate cancer.

Preoperative Staging With 11 C-Choline PET/CT Is Adequately Accurate in Patients With Very High-Risk Prostate Cancer

Micro‐Abstract We retrospectively evaluated 262 individuals with intermediate‐ or high‐risk prostate cancer. Among patients at high risk, we identified a subgroup of individuals harboring very high‐risk (VHR) disease. Considering men with VHR disease (n = 28), 11C‐choline positron emission tomography/computed tomography versus contrast‐enhanced computed tomography had sensitivity and specificity of 71% and 92% versus 25% and 79%, respectively. Purpose: To evaluate the accuracy of 11C‐choline positron emission tomography (PET)/computed tomography (CT) for nodal staging of prostate cancer (PCa) in different populations of high‐risk patients. Patients and Methods: We evaluated 262 individuals with intermediate‐ or high‐risk PCa submitted to radical prostatectomy and extended pelvic lymph node dissection. Within men with high‐risk disease, we identified a subgroup of individuals harboring very high‐risk (VHR, n = 28) disease: clinical stage ≥ T2c and more than 5 cores with Gleason score 8‐10; primary biopsy Gleason score of 5; 3 high‐risk features; or prostate‐specific antigen ≥ 30 ng/mL. The diagnostic accuracy of PET/CT and contrast‐enhanced CT (CECT) was assessed after stratifying patients according to risk group classification on a patient‐ and anatomic region–based analysis. Results: On patient‐based analysis, considering high‐risk patients (n = 155), 11C‐choline PET/CT versus CECT had sensitivity and specificity of 50% and 76% versus 21% and 92%, respectively. Considering VHR men as separate subgroups (n = 28), 11C‐choline PET/CT versus CECT had sensitivity and specificity of 71% and 93% versus 25% and 79%, respectively. Accordingly, in the VHR category, the area under the curve of 11C‐choline PET/CT versus CECT was 0.86 (95% confidence interval, 0.71‐1.0) versus 0.69 (95% confidence interval, 0.52‐0.86), respectively. On anatomic region–based analysis, considering the VHR group, 11C‐choline PET/CT versus CECT had sensitivity and specificity of 70.6% and 95.5% versus 35.3% and 98.5%, respectively. Conclusion: Patients with VHR characteristics could represent the ideal candidate to undergo disease staging with PET/CT before surgery with the highest cost efficacy.

MP64-16 ADVERSE FEATURES AND COMPETING RISK MORTALITY IN PATIENTS WITH HIGH-RISK PROSTATE CANCER

INTRODUCTION AND OBJECTIVES: We present here oncological outcome for patients with International Society of Urological Pathology (ISUP) Grade 5 prostate cancer (PC) who underwent primary treatment with robotic assisted laparoscopic radical prostatectomy (RALP). METHODS: Using a prospectively collected institutional registry, we identified patients with clinically organ confined and locally advanced (cT1-T3N0M0) ISUP Grade 5 PC who underwent RALP with bilateral pelvic lymphadenectomy as primary treatment between 2005 and 2013. RESULTS: We included 106 patients with median age of 65 years (IQR 58.5-68). The majority of patients had clinically organconfined disease (90%). Following surgery, 71 patients (67%) were upstaged to pT3 and 40 patients (38%) were downgraded to Gleason score 8 or 7. With median follow-up of 63.5 months (IQR 34-85), 50 patients (48%) had biochemical failure: 24 patients (23%) had PSA persistence and 26 patients (24%) had biochemical recurrence (BCR). Adjuvant and salvage RT were administered to 12 (11%) and 34 (32%) patients, respectively; adjuvant and salvage ADT were given to two (2%) and 31 (29%) patients, respectively; 9 patients (8%) received subsequent therapies. Eleven patients (10%) had systemic failure and 10 patients (9.5%) died: 3 (3%) from prostate cancer and 7 (7%) from other causes. Using Kaplan-Meier estimate, the 5-year overall, disease specific, metastasis-free and disease-free survivals are 91%, 96%, 88%, and 59% respectively. Using univariate analysis, pre-operative PSA, number of cores involved with ISUP grade 5 PC on biopsy, percentage of positive cores on biopsy, and pathological T stage were all correlated with both biochemical and systemic failure. CONCLUSIONS: The disease volume on pre-operative biopsy and specifically the amount of Gleason 5 pattern predicted both biochemical and systemic failure. RALP in ISUP grade 5 PC is a viable treatment option in the multimodality management of PC, it affords local control and might improve long-term oncologic outcomes. Source of Funding: none

Retroperitoneal Robot-Assisted Versus Open Partial Nephrectomy for cT1 Renal Tumors: A Matched-Pair Comparison of Perioperative and Early Oncological Outcomes

Background The objective of this study was to compare perioperative and early oncological outcomes of a matched cohort of patients who underwent retroperitoneal robot‐assisted partial nephrectomy (RP‐RAPN) and open partial nephrectomy (OPN) for clinically localized renal tumors. Patients and Methods We performed a retrospective analysis of patients who underwent RP‐RAPN and OPN treated at 2 referral centers from January 2011 to December 2015. We focused on the following postoperative outcomes: warm ischemia time (WIT), operative time, blood loss, intra‐ and postoperative complications, estimated glomerular filtration rate (eGFR), hospital stay, and positive surgical margins. Because of inherent differences between patients in terms of baseline and disease characteristics, we relied on a propensity score‐matched analysis to adjust for these differences. Results Globally, 104 patients were retrospectively evaluated and compared (52 matched individuals). RP‐RAPN and OPN groups were comparable in terms of median age, body mass index, Charlson Comorbidity Index, clinical tumor size, preoperative aspects and dimensions used for anatomic classification and radius, exophyic/endophytic, nearness, anterior/posterior location score. Overall median operative time and WIT were significantly higher in the RP‐RAPN group compared with the OPN group (P < .001). Intraoperative (3.8% vs. 0%) and postoperative (21.2% vs. 7.7%) complication rates were higher in the OPN group (P < .001). No statistically significant differences in postoperative eGFR were found. Median length of stay was significantly shorter in the RP‐RAPN group (3 vs. 5 days; P < .001). The incidence of positive surgical margins was comparable (3.8%). Trifecta was reached in 82.6% after RP‐RAPN and 71.1% after OPN (P = .002). Conclusion Retroperitoneal robot‐assisted partial nephrectomy offered promising perioperative, early oncological, and functional outcomes, reinforcing the role of robotics as an alternative to open approach for partial nephrectomy. Micro‐Abstract We report a propensity score‐matched analysis of 104 patients who underwent retroperitoneal robot‐assisted partial nephrectomy (RP‐RAPN) or extraperitoneal open partial nephrectomy (OPN). Despite quite higher warm ischemia time, RP‐RAPN offered lower intraoperative and postoperative complications compared with OPN, with shorter length of stay. These data reinforce the role of robotics as a valid alternative to the open approach for partial nephrectomy.

[Predictors of positive surgical margins after nephron-sparing surgery for renal cell carcinoma: retrospective analysis on 298 consecutive patients].

OBJECTIVES Aim of our study was to evaluate the predictive factors of positive surgical margins (PSM) in a cohort of patients who underwent partial nephrectomy (PN) for renal cell carcinoma. MATERIAL AND METHODS We retrospectively evaluated our Institutional database of patients treated with open or laparoscopic PN between 200 and 2013. Categorical variables were compared using Pearsons chi-square test and linear-by-linear association. Multivariable Cox analysis was used in order to evaluate independent predictors of PSM. RESULTS Surgical margins were found to be negative in 274 out of 298 patients (91.9%), and the remaining 24 (8.1%) patients had PSM at the final pathological exam. The median clinical size was significantly lower in patients with PSM than those with negative margins (2.6 vs. 3 cm, p=0.03). At univariable analysis, a shorter operative time (p=0.04), a malignant histotype (p=0.04) and higher Fuhrman grade (p=0.02) were observed in patients with positive surgical margins compared to those without PSM. At multivariable analysis, median tumor dimension (p=0.02), the malignant histotype (p=0.01) and the high Fuhrman grade (3-4) (p=0.01) were found to be independent predictive factors of PSM. CONCLUSIONS The most important goal of any PN is to reach negative surgical margins. In our study, clinical tumor dimensions, malignant tumor histotype and the high Fuhrman grade demonstrated to be independent predictive factors of PSM after nephron sparing surgery for renal cell carcinoma. Other prospective, multi-institutional studies are needed in order to confirm these results.Objectives: Aim of our study was to evaluate the predictive factors of positive surgical margins (PSM) in a cohort of patients who underwent partial nephrectomy (PN) for renal cell carcinoma. Material and MethOds: We retrospectively evaluated our Institutional database of patients treated with open or laparoscopic PN between 200 and 2013. Categorical variables were compared using Pearson’s chi-square test and linear-by-linear association. Multivariable Cox analysis was used in order to evaluate independent predictors of PSM. results: Surgical margins were found to be negative in 274 out of 298 patients (91.9%), and the remaining 24 (8.1%) patients had PSM at the final pathological exam. The median clinical size was significantly lower in patients with PSM than those with negative margins (2.6 vs. 3 cm, p=0.03). At univariable analysis, a shorter operative time (p=0.04), a malignant histotype (p=0.04) and higher Fuhrman grade (p=0.02) were observed in patients with positive surgical margins compared to those without PSM. At multivariable analysis, median tumor dimension (p=0.02), the malignant histotype (p=0.01) and the high Fuhrman grade (3-4) (p=0.01) were found to be independent predictive factors of PSM. cOnclusiOns: The most important goal of any PN is to reach negative surgical margins. In our study, clinical tumor dimensions, malignant tumor histotype and the high Fuhrman grade demonstrated to be independent predictive factors of PSM after nephron sparing surgery for renal cell carcinoma. Other prospective, multi-institutional studies are needed in order to confirm these results.