H. Dababneh

Can Testis-Sparing Surgery for Small Testicular Masses Be Considered a Valid Alternative to Radical Orchiectomy? A Prospective Single-Center Study

BACKGROUND The aim of this study was to evaluate the incidence of malignancy in small testicular masses (STMs) treated with testis-sparing surgery (TSS) with intraoperative frozen section analysis and to assess the safety of this surgical procedure. PATIENTS AND METHODS From January 2009 to January 2013, 15 consecutive patients underwent TSS for STMs in a third-referral academic institution. Every patient was preoperatively evaluated with clinical examination and scrotal ultrasonography (US) performed by the same radiologist. Tumor markers were assessed in all cases. All the procedures were performed through inguinal access; the small mass was identified by straight palpation of the testis or with intraoperative ultrasonography (IUS). Frozen-section examination (FSE) was performed in all patients in association with multiple biopsies of the surrounding tissue. Follow-up was carried out in all patients with an ultrasonographic exploration at 6 and 12 months. RESULTS Preoperative tumor markers were normal in all patients. The mean operative time was 90 ± 31 minutes. The warm ischemia time was 18 ± 3 minutes. The mean size on US was 9.5 ± 4.4 mm. FSE results were confirmed by the final pathologic analysis in 14 patients. At final pathologic analysis, 6 patients (40%) were found not to have tumors, another 7 patients (46.7%) had benign neoplasms, and malignant tumor was found in only 2 patients (13.3%). There was no disease recurrence after a mean follow-up of 19.2 ± 11.5 months. CONCLUSION Our experience shows that TSS performed for STMs may represent a safe procedure with optimal results in terms of functional and oncologic end points.

Small Renal Masses Initially Managed Using Active Surveillance: Results From a Retrospective Study With Long-Term Follow-Up

BACKGROUND The purpose of this study was to provide outcomes of patients managed using active surveillance (AS) for small renal masses (SRMs). PATIENTS AND METHODS We retrospectively reviewed data of 62 patients diagnosed with 64 contrast enhancing SRMs suspicious for renal cell carcinoma. We evaluated the differences between patients who remained on AS and those who underwent delayed surgical intervention. RESULTS The mean age of patients was 75 years and the mean follow-up was 91.5 months. The median tumor size and the median estimated tumor volume were 2.6 cm and 8.7 cm(3), respectively. The median linear growth rate and the median volumetric growth rate were 0.7 cm/y and 8.8 cm(3)/y, respectively. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4 cm/y and 16.1 vs. 4.6 cm(3)/y, respectively; P < .001). CONCLUSION Most SRMs show an indolent course, with low metastatic potential. Faster linear and volumetric growth rates could be the expression of malignant disease, thus suggesting the need for a delayed surgical intervention. AS is a reasonable option for the management of SRMs in properly selected patients with low life expectancy.

Active surveillance for clinically localized renal tumors: An updated review of current indications and clinical outcomes

The widespread use of abdominal imaging has led to an increasing detection of small renal masses, and approximately 20–30% of those tumors will prove to be benign, with low metastatic potential if not immediately treated. In elderly or comorbid patients diagnosed with small renal masses, competing cause mortality seems to exceed cancer‐specific mortality at short‐ and intermediate‐term follow up. In these cases, surgery might represent an overtreatment, and an expectant management, such as active surveillance, might be proposed. According to the current available evidence, active surveillance is a safe and reasonable option for patients with renal tumors ≤4 cm (cT1a) and short life expectancy. A few studies with short‐term follow up reported the preliminary results of active surveillance even in cT1b–cT2 tumors, with acceptable risk of disease progression and mortality, even if this approach should be considered in this setting only for highly‐selected and well‐informed patients. Furthermore, surveillance protocols can be proposed in selected patients with uncomplicated benign tumors, such as angiomyolipomas, in which active surveillance should be considered the initial standard management. At present, reliable clinical predictors of a tumors growth rate and aggressiveness are not available. Renal tumor biopsy is useful in the clinical work‐up of patients who are candidates for active surveillance, in order to improve patient selection based on tumor histological characterization. Despite the proof of safety offered by expectant management for small renal masses in selected patients, further prospective studies with longer follow up are required in order to confirm the indications and long‐term oncological outcomes of active surveillance protocols for renal tumors.

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.

The biopsy Gleason score 3+4 in a single core does not necessarily reflect an unfavourable pathological disease after radical prostatectomy in comparison with biopsy Gleason score 3+3: looking for larger selection criteria for active surveillance candidates

Background:To assess whether the addition of clinical Gleason score (Gs) 3+4 to the Prostate Cancer Research International: Active Surveillance (PRIAS) criteria affects pathologic results in patients who are potentially suitable for active surveillance (AS) and to identify possible clinical predictors of unfavourable outcome.Methods:Three hundred and twenty-nine men who underwent radical prostatectomy with complete clinical and follow-up data and who would have fulfilled the inclusion criteria of the PRIAS protocol at the time of biopsy except for the addition of biopsy Gs=3+4 and with at least 10 cores taken have been evaluated. One experienced genitourinary pathologist selected those with real Gs=3+3 and 3+4 in only one core according to the 2005 International Society of Urological Pathology criteria. The primary end point was the proportion of unfavourable outcome (nonorgan confined disease or Gs⩾4+3). Logistic regressions explored the association between preoperative characteristics and the primary end point.Results:Two hundred and four patients were evaluated and 46 (22.5%) patients harboured unfavourable disease at final pathology. After a median follow-up of 73.5 months, there was no cancer-specific death, and 4 (2.0%) patients had biochemical relapse. There were no significant differences in terms of high Gs, locally advanced disease, unfavourable disease and biochemical relapse-free survival among patients with clinical Gs=3+3 vs Gs=3+4. At multivariable analysis, the presence of atypical small acinar proliferation (ASAP) and lower number of core taken were independently associated with a higher risk of unfavourable disease.Conclusion:The inclusion of Gs=3+4 in patients suitable to AS does not enhance the risk of unfavourable disease after radical prostatectomy. Additional factors such as number of cores taken and the presence of ASAP should be considered in patients suitable for AS.

Sex-related penile fracture with complete urethral rupture: A case report and review of the literature

OBJECTIVE To present the management of a patient with partial disruption of both cavernosal bodies and complete urethral rupture and to propose a non-systematic review of literature about complete urethral rupture. MATERIAL AND METHOD - CASE REPORT: A 46 years old man presented to our emergency department after a blunt injury of the penis during sexual intercourse. On physical examination there was subcutaneous hematoma extending over the proximal penile shaft with a dorsal-left sided deviation of the penis and urethral bleeding. Ultrasound investigation showed an hematoma in the ventral shaft of the penis with a discontinuity of the tunica albuginea of the right cavernosal corporum. The patient underwent immediate emergency surgery consisted on evacuation of the hematoma, reparation the partial defect of both two cavernosal bodies and end to end suture of the urethra that resulted completely disrupted. RESULTS The urethral catheter was removed at the 12-th postoperative day without voiding symptoms after a retrograde urethrography. 6 months postoperatively the patients was evaluated with uroflowmetry demonstrating a max flow rate of 22 ml/s and optimal functional outcomes evaluated with validated questionnaires. 8 months after surgery the patients was evaluated by dynamic magnetic resonance (MRI) of the penis showing only a little curvature on the left side of the penile shaft. CONCLUSION Penile fracture is an extremely uncommon urologic injury with approximately 1331 reported cases in the literature till the years 2001. To best of our knowledge from 2001 up today, 1839 more cases have been reported, only in 159 of them anterior urethral rupture was associated and in only 22 cases a complete urethral rupture was described. In our opinion, in order to prevent long term complications, in case of clinical suspicion of penile fracture, especially if it is associated to urethral disruption, emergency surgery should be the first choice of treatment.

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.

Molecular diagnostic tools for the detection of nodal micrometastases in prostate cancer patients undergoing radical prostatectomy with extended pelvic lymph node dissection: a prospective study

Background Routine pathological examination can miss micro-metastatic tumor foci in the lymph nodes (LN) of patients with prostate cancer (PCa) that undergo radical prostatectomy and pelvic lymph node dissection (PLND). The aim of the present prospective study was to evaluate the impact of micrometastases assessed by serial section (SS), immunohistochemistry (IHC), and Real-time Polymerase Chain Reaction (RT-PCR) in patients undergoing radical prostatectomy with extended PLND. Materials and methods 32 consecutive patients who underwent radical prostatectomy with extended PLND (obturator, internal/external and distal 2cm common iliac lymph-nodes (LN)) for intermediate (clinical T1c-T2 and PSA:10–20 ng/mL and clinical Gleason Score = 7) or high (clinical stage T3 or PSA>20 or clinical Gleason Score = 8–10) PCa were enrolled. The nodes were processed by the one uropathologist, both according to the routine pathological examination (analysis of the central section for 4 mm nodes or every 2 mm for LN>4 mm), which served as comparative method, both according to SS, IHC with antibodies against PSA and broad-spectrum Cytokeratins (BSCK), and quantitative RT-PCR targeting PSA, PSMA (PS Membrane Antigen), and Glucuronidase-S-Beta (GUSB) mRNA, that are over-expressed in prostatic cancer cells. Results A total of 628 LN were analyzed, with a mean number of LN removed of 19.6 (SD = 7.2). Applying the routine pathological examination, 10 (31.2%) patients and 23 (3.9%) LN resulted positive for nodal involvement, with mean positive LN of 2.2 (SD = 1.4). After applying the SS and the molecular method of analysis (IHC and RT-PCR), micrometastases were found in 7 LN (SS showed micrometastases in 3 of them, IHC in 6 of them and RT-PCR in 7 of them); a total of 3 (9.3%) node-negative patients showed micrometastases at routine pathological examination (in 2 patients with RT-PCR and in 1 with IHC). Conclusions The significance of micrometastases in PCa and the potential therapeutic role of PLND is not yet clarified, but the molecular analysis of the LN can detect a significant percentage of patients who harbor micro-metastatic PCa missed at routine pathological examination, and can enhance the accuracy of lymphadenectomy as a staging method.

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.

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.