Gianluca Giubilei

Histopathologic Analysis of Peritumoral Pseudocapsule and Surgical Margin Status after Tumor Enucleation for Renal Cell Carcinoma

BACKGROUNDnThe oncologic safety of blunt tumor enucleation (TE) of renal cell carcinoma (RCC) depends on the presence of a continuous pseudocapsule (PS) around the tumor and on the possibility of obtaining negative surgical margins (SMs).nnnOBJECTIVEnTo investigate the PS and SMs after TE to define the real need to take a rim of healthy parenchyma around the tumor to avoid the risk of positive SMs. The risk of PS invasion related to other clinical and pathologic variables was also evaluated.nnnDESIGN, SETTING, AND PARTICIPANTSnBetween September 2006 and December 2007, data were gathered prospectively from 187 consecutive patients who had kidney surgery. Overall, 90 consecutive patients who had TE for RCC were eligible for the study. All specimens were evaluated using an image analyzer by a dedicated uropathologist.nnnINTERVENTIONnTE was done by blunt dissection using the natural cleavage plane between the tumor and the normal parenchyma.nnnMEASUREMENTSnPS, SM, and routinely available clinical and pathologic variables were recorded.nnnRESULTS AND LIMITATIONSnIn 60 RCC tumors (67%) the PS was intact and free from invasion (PS-) while in 30 (33%) there were signs of penetration within its layers, with or without invasion beyond it. Indeed, 26.6% had PS that had been penetrated on the parenchymal side and 6.6% had penetration on the perirenal fat tissue side. The odds of having PS penetration increased significantly with an increase in clinical tumor size. PS penetration was also significantly associated with pathologic tumor dimensions and grade. In all cases the SMs were negative after TE. The present patients, followed for >2 yr, will enable us to correlate the risk of local recurrence with PS status.nnnCONCLUSIONSnThe risk of PS penetration is associated with clinical and pathologic tumor dimensions and grade. If there is PS invasion into normal parenchyma, the presence of a thin layer of tissue allows for negative SM even if a TE is performed.

ORIGINAL RESEARCH—PEYRONIE'S DISEASE Use of Penile Extender Device in the Treatment of Penile Curvature as a Result of Peyronie's Disease. Results of a Phase II Prospective Study

INTRODUCTIONnPilot experiences have suggested that tension forces exerted by a penile extender may reduce penile curvature as a result of Peyronies disease.nnnAIMnTo test this hypothesis in a Phase II study using a commonly marketed brand of penile extender.nnnMETHODSnPeyronies disease patients with a curvature not exceeding 50 degrees with mild or no erectile dysfunction (ED) were eligible. Fifteen patients were required to test the efficacy of the device assuming an effect size of >0.8, consistent with an important reduction in penile curvature. Changes in penile length over baseline and erectile function (EF) domain scores of the International Index of Erectile Function (IIEF) constituted secondary end points.nnnMAIN OUTCOME MEASURESnPatients were counselled on the use of the penile extender for at least 5 hours per day for 6 months. Photographic pictures of the erect penis and measurements were carried out at baseline, at 1, 3, 6, and 12 months (end of study). The IIEF-EF domain scores were administered at baseline and at the end of study. Treatment satisfaction was assessed at end of study using a nonvalidated institutional 5-item questionnaire.nnnRESULTSnPenile curvature decreased from an average of 31 degrees to 27 degrees at 6 months without reaching the effect size (P = 0.056). Mean stretched and flaccid penile length increased by 1.3 and 0.83 cm, respectively at 6 months. Results were maintained at 12 months. Overall treatment results were subjectively scored as acceptable in spite of curvature improvements, which varied from no change to mild improvement.nnnCONCLUSIONSnIn our study, the use of a penile extender device provided only minimal improvements in penile curvature but a reasonable level of patient satisfaction, probably attributable to increased penile length. The selection of patients with a stabilized disease, a penile curvature not exceeding 50 degrees, and no severe ED may have led to outcomes underestimating the potential efficacy of the treatment.

A pilot phase‐II prospective study to test the ‘efficacy’ and tolerability of a penile‐extender device in the treatment of ‘short penis’

To assess a commonly marketed brand of penile extender, the Andro‐Penis® (Andromedical, Madrid, Spain), widely used devices which aim to increase penile size, in a phase II single‐arm study powered to detect significant changes in penile size, as despite their widespread use, there is little scientific evidence to support their potential clinical utility in the treatment of patients with inadequate penile dimensions.

Clinical importance of lymph node density in predicting outcome of prostate cancer patients.

BACKGROUNDnTo evaluate the prognostic role of lymph node density (LND) in patients affected by prostate cancer (PCa) and treated with radical prostatectomy (RP), pelvic lymph node dissection (PLND), and adjuvant hormonal blockade.nnnMETHODSnA total of 124 consecutive patients with lymph node positive PCa formed the basis of this report. Clinical and pathological parameters were collected. All patients were stratified in two groups according to LND: Group A (LND ≤ 32%) and Group B (LND ≥ 33%). Time to the first biochemical recurrence (BCR) was the main measure of outcome.nnnRESULTSnMean number of lymph nodes removed was 5.2 (range 1-17). The mean number of positive lymph nodes was 1.6 (range 1-5). At a mean follow-up of 84.3 mo, 22 patients in Group A (43.1%) and 40 in Group B (54.7%) had BCR. The mean overall BCR-free survival was 46.2 mo (range 8-90). No significant correlation was found between the number of positive lymph nodes and BCR-free survival (P = 0.68). In addition, the patients with LND ≥ 33% had a poor prognosis with significantly decreased disease-specific and BCR-free survival rates (hazard ratio: 0.48; 95% CI, 0.28-0.78; P = 0.0039). At multivariate and artificial neural network (ANN) analyses, LND, Gleason score, and stage were identified as independent prognostic factors of BCR-free survival (P = 0.002; P = 0.003; P = 0.003).nnnCONCLUSIONSnThe current study highlights the role of LND in predicting BCR-free survival in patients with lymph node positive PCa after prostatectomy. It also reinforces the need for a stratification of patients with nodal metastasis.

Sacral neuromodulation for lower urinary tract dysfunction and impact on erectile function.

INTRODUCTIONnThe first sacral nerve stimulators were for urinary urgency incontinence, urgency-frequency, and nonobstructive urinary retention. Since then, observations have been made for benefits beyond voiding disorders.nnnAIMnTo evaluate if sacral neuromodulation (SNM) using the InterStim system (Medtronic Inc., Minneapolis, MN, USA) improves erectile function.nnnMETHODSnFrom January 1999 to January 2007, 54 males, mean age 42.8, underwent a permanent SNM for lower urinary tract symptoms (LUTS). Pre-SNM only subjects with concomitant erectile impairment according to the five-item version of the International Index of Erectile Function (IIEF-5), with normal blood sexual hormonal status, and responding to an intracavernous injection test 10 microg were enrolled in our study. Three months after permanent implantation, the IIEF-5 was completed again. Those who benefited significantly in erectile function completed the IIEF-5 semiannually. A final checkup was performed in July 2007.nnnMAIN OUTCOME MEASURESnA score of IIEF-5 equal to or higher than 25% compared to baseline indicated remarkable clinical enhancement.nnnRESULTSnPresurgery, two patients were excluded. Overall, 22 subjects (42.3%) showed erectile impairment (14 were neurogenic). In the first visit post-SNM, five retentionists of neurogenic origin and two with overactive bladder syndrome of idiopathic origin achieved noticeable erectile improvement. Their median IIEF-5 score shifted from 14.6 to 22.2, and 15.5 to 22.5, respectively. During follow-up, two neurogenics lost the benefits concerning voiding and erection and recovered them after a new implant in the contralateral sacral S3 root. In the final visit, the seven responders reached an IIEF-5 score of at least 22.nnnCONCLUSIONSnOur study showed a clinically important benefit of sexual function mainly for neurogenic retentionists. Future research should test SNM in a larger sample of subjects, exclusively with sexual dysfunctions, in order to better understand the mechanism of action of SNM on erectile function.

Simple enucleation for the treatment of renal angiomyolipoma

To report on the role of simple enucleation for treating renal angiomyolipoma (AML) in a series of patients treated in our department.

Predictors of Quality of Life after Radical Treatment for Prostate Cancer

Introduction: The usual treatment options for clinically localized prostate cancer carry a significant risk of lasting side effects, including urinary, bowel, and sexual dysfunction, that can alter overall the patient’s quality of life. The aim of this research is to evaluate the impact of treatment timing (age at time of treatment, follow-up duration, age at time of follow-up), pretreatment tumor characteristics (clinical stage, Gleason score, PSA), and posttreatment outcomes (hormonal status, biochemical recurrence), on health-related quality of life (HRQOL) among men who had undergone radical treatment for prostate cancer. Materials and Methods: 595 patients with prostate cancer who had undergone either radical prostatectomy or external beam radiation as primary therapy between 1988 and 2000 were selected for this retrospective, cross-sectional study. The enrolled subjects were asked to complete the Italian validated version of University of California-Los Angeles Prostate Cancer Index. Clinical parameters, hormone therapy status and posttreatment outcomes were considered to perform uni- and multivariate analyses. Results: Both uni- and multivariate analyses demonstrated that timing of radical treatment is a critical predictive factor for sexual activity. Pretreatment tumor characteristics had a significant impact on urinary function, urinary bother and sexual function. Hormone treatment exclusively influenced sexual function and sexual bother, while biochemical recurrence can also worsen urinary symptoms and urinary bother. Conclusion: Our findings suggest that treatment timing, pretreatment tumor characteristics and posttreatment outcomes may have an impact on HRQOL in patients who have undergone radical treatment for prostate cancer: all these items should be considered in order to achieve an accurate interpretation of prostate cancer treatment outcomes.

Multiple ipsilateral renal tumors: Retrospective analysis of surgical and oncological results of tumor enucleation vs radical nephrectomy

AIMSnTo evaluate the role of nephron-sparing surgery (NSS) compared to radical nephrectomy (RN) for treating multiple ipsilateral renal tumors.nnnMETHODSnWe retrospectively reviewed the clinical and pathological data of 960 patients who had surgery for pathologically confirmed RCC between 1986 and 2006. Thirty-four patients were diagnosed as having at least one ipsilateral smaller solid lesion associated with the primary RCC: 22 had RN while 12 had NSS for tumor enucleation.nnnRESULTSnAll patients who had NSS had tumors confined within the kidney, as did 82% of patients treated with RN. The sole presence of concomitant accompanying benign histology to the primary RCC was diagnosed in 20% of patients. The mean (median, range) follow-up for patients treated with RN and NSS was 69 (58, 12-214) and 58 (44, 12-151) months. Tumor stage was significantly associated with tumor-specific survival (TSS) in the RN group (p<0.001). None of the patients who had tumor enucleation had positive surgical margins. Two patients recurred locally after NSS, elsewhere in the kidney, resulting in a crude ipsilateral recurrence rate of 17%. The analysis of TSS for patients with multiple ipsilateral tumors with a pT1 primary lesion showed no statistically significant differences between patients who had RN or NSS. Two patients had contralateral recurrence, resulting in a crude rate of 6%.nnnCONCLUSIONSnFor patients with multiple ipsilateral renal tumors, 20% of the satellite lesions are benign and 6% develop a contralateral metachronous recurrence. We also observed similar TSS for patients treated with NSS and RN.

A Rare Case of Lethal Retroperitoneal Abscess Caused by Citrobacter koseri

Retroperitoneal abscesses are very uncommon clinical conditions. The characteristically vague symptomatology of retroperitoneal abscess and the inherent difficulty of identifying retroperitoneal disease by physical examination contributed to these dismal therapeutic outcomes. We present an unusual case of lethal retroperitoneal abscess, caused by Citrobacter diversus(koseri), treated with surgical drainage. Citrobacter species have rarely been involved in deep tissue infection and there is no reported case of lethal retroperitoneal abscess caused by C. koseri. This case is the only reported case of C. koseri as the sole pathogen associated with a lethal retroperitoneal abscess in immunocompetent patient. The case is also notable because it confirms the recent bacterial resistance to β-lactam antibiotics and to other antimicrobical agents, like chloramphenicol or cotrimoxazol.

Accuracy of prostate volume measurements using transrectal multiplanar three-dimensional sonography

Abstractu2003 The aim of this study is to evaluate the accuracy of three‐dimensional (3D) ultrasound in comparison with conventional bidimensional (2D) sonography in prostatic calculations. The study was performed using a Kretztechnik Voluson 530D machine with a 7.5u2003MHz endocavitary transducer. From March 1998 to March 2000, we examined 80 patients (63–74u2003years, mean 68u2003years). There were 59 patients with benign prostate hypertrophy (BPH) and 21 with prostate cancer awaiting a radical prostatectomy. The mean absolute error in 3D ultrasound measurement wasu2003±0.2–3u2003mL. (range of error was 6.5%). Volume measurement using 2D ultrasound methods was much less accurate than 3D ultrasound methods:u2003±0.4–5u2003mL. (range of error was 35%). Both 2D and 3D measurements show that the margin of error depends on the frequent presence of a third prostatic lobe, on the morphology, and on the size of the prostatic gland. The precise estimation of prostate volumes may provide information on the real effectiveness of some therapies that act on the reduction in volume of benign alteration, such as in prostatic hypertrophy, and may eliminate the current limits of 2D sonography with a significant clinical contribution for virtually no extra cost.