Lorenzo Bianchi

Diagnostic Accuracy of 11C-Choline PET/CT in Preoperative Lymph Node Staging of Bladder Cancer: A Systematic Comparison With Contrast-Enhanced CT and Histologic Findings

Aim The aim of this study was to evaluate the role of 11C-choline PET/CT in the preoperative evaluation of the nodal involvement of patients with bladder carcinoma (BC) suitable for radical cystectomy and extended pelvic lymph node dissection in comparison with contrast-enhanced CT (CECT) using the pathologic specimen as reference standard. Patients and Methods Twenty-six consecutive patients (69.5 ± 9.3 years; range, 49–84) with histologically proven transitional cell BC were treated with radical cystectomy and pelvic lymph node dissection and were enrolled from April 2011 to January 2013. In all patients, paravesical, internal, eternal, and common iliac nodes as well as obturatory, presacral, preaortic, and precaval lymph nodes (LNs) were dissected up to the origin of the inferior mesentery artery. The areas of the LN dissection were grouped as follow: region A included preaortic and precaval LNs; region B included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the right pelvis; region C included paravesical, common, internal and external iliac, obturatory, and presacral LNs in the left pelvis. 11C-choline PET/CT and abdominal CECT were used to assess the presence of lymph node metastases on a per patient, region, and lesion analysis using the results of surgical specimens obtained at operation as criterion standard. Results Seven of 26 patients (26.9%) showed nodal metastases at pathologic analysis. Overall, 844 LNs were evaluated, and 38 of them (4.5%) showed metastatic involvement. On a patient-based analysis, 11C-choline PET/CT showed a sensitivity of 42% and specificity of 84%, whereas, CECT showed a sensitivity of 14% and specificity of 89%. On a region-based analysis, 11C-choline PET/CT showed a sensitivity of 11% and specificity of 82%, whereas CECT showed a sensitivity of 5% and specificity of 80%. On a lesion (LN)-based analysis, 11C-choline PET/CT showed a sensitivity of 10% and specificity of 64%, whereas CECT showed a sensitivity of 2% and specificity of 63%. Conclusions 11C-choline PET/CT could provide additional diagnostic information in preoperative nodal staging of patients with invasive BC in comparison with CECT. A study with a larger population should determine if 11C-choline PET/CT could be recommended as a routine technique in high-risk patients with BC.

11C-choline PET/CT and bladder cancer: lymph node metastasis assessment with pathological specimens as reference standard.

Aim The aim of this study was to evaluate the potential role of 11C-choline-PET/CT in nodal assessment in patients with bladder cancer (BCa) using the pathological specimen as reference standard. Patients and Methods Fifty-nine patients with proven BCa were retrospectively enrolled from April 2011 to January 2014 (mean [SD] age, 70.1 [9] years; range 49–85 years). Of 59 patients, 39 (staging group) were referred to 11C-choline-PET/CT for preoperative lymph node (LN) evaluation before radical cystectomy and extended pelvic LN dissection. Of the 59 patients, 29 (restaging group) had 11C-choline-PET/CT for suspected BCa relapse after primary radical surgery. In both groups, 11C-choline-PET/CT findings were correlated with histology. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated to assess 11C-choline-PET/CT feasibility in LN assessment. Age, TNM, histology, and previous chemotherapy were analyzed as additional predictive factors. Results 11C-choline-PET/CT overall detection rate was 62.7% (37/59 patients). On a regional-based analysis, 11C-choline-PET/CT was considered positive for primary cancer and/or local relapse in bladder bed in 54.2% of the patients (32/59). Pathological LN uptake was reported in 23.7% of the patients (14/59) and systemic choline deposit (bone or lung) in 11.8% of the patients (7/59). Considering LN metastasis detection, compared with histological analysis, 11C-choline-PET/CT showed in the whole population a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 59%, 90%, 71%, 84%, and 81%, respectively. No other investigated factors reached statistical significance. Conclusions 11C-choline-PET/CT may provide additional diagnostic information in preoperative nodal staging of patients with BCa and be considered a useful tool to restage patients with BCa suspected of relapse. Further studies are needed to assess if 11C-choline-PET/CT could have an influence on survival of patients with BCa.

11C-choline PET/CT for restaging of bladder cancer.

Aim The aim of this study was to evaluate of 11C-choline PET/CT in bladder cancer (BC) patients with suspected relapse after primary therapy. Methods Twenty-five BC patients with surgery (21 [84%]) or radiotherapy (4 [16%]) with curative intent had PET/CT for suspicion of relapse. Mean TNM was T2b N0 M0 (range, T1a N0 M0 to T4 N2 M0), whereas mean age was 71.3 years (range, 50-85 years). Nine (36%) of 25 were treated with adjuvant or salvage chemotherapy within 6 months before PET/CT. Positive findings were validated by histology or correlative imaging and/or clinical follow-up lasting at least 12 months. Age, TNM, histology, previous chemotherapy, and type of primary treatment were correlated with PET/CT positivity by univariate and multivariate binary logistic regression analysis. Results 11C-choline PET/CT was positive in 16 (64%) of 25. Six (37.5%) of 16 were positive in residual bladder/bladder bed, with 2 local false positive (FP) and 1 false negative (FN) on lymph nodes (LNs); 3 of 16 patients had PET-positive LNs with 1 FP; 1 of 16 patients showed distant metastases. Two (12.5%) of 16 had positive residual bladder/bladder bed and locoregional LNs; 1 (6.3%) of 16, residual bladder/bladder bed and bone; metastasis, 1 (6.3%) of 16 residual bladder/bladder bed and lung metastasis; 2 (12.5%) of 16, LN and distant metastasis. Five (56%) of 9 of PET negatives were FN in residual bladder/bladder bed. Eighteen (72%) of 25 were validated by histology, with 7 (18%) of 25 by correlative imaging and/or clinical follow-up. 11C-choline PET/CT was sensitive, specific, and accurate, with good positive and negative predictive values for local relapse of 66.7%, 84.6%, 76%, 80%, and 73.3% and 90%, 93.3%, 92%, 90%, and 93.3% for LNs and distant relapse, respectively. No FP or FN was detected for distant metastasis. None of the investigated factors were statistically significant. Conclusion 11C-choline PET/CT is useful for restaging BC suspected of relapse, especially for the evaluation of LN or distant metastases.

First case of 18F-FACBC PET/CT-guided salvage retroperitoneal lymph node dissection for disease relapse after radical prostatectomy for prostate cancer and negative 11C-choline PET/CT: new imaging techniques may expand pioneering approaches.

We present the first case of salvage retroperitoneal lymph node dissection based on the results of 18F-FACBC PET/CT performed for a prostate-specific antigen relapse after radical prostatectomy. The patients underwent 11C-choline PET/CT, which turned out negative, while 18F-FACBC PET/CT visualized two lymph node metastases confirmed at pathological examination. Preliminary clinical reports showed an improvement in the detection rate of 20-40% for 18F-FACBC in comparison with 11C-choline, rendering the 18F-FACBC the potential radiotracer of the future. Salvage surgery for prostate cancer is a fascinating but controversial approach. New diagnostic tools may improve its potential by increasing the assessment and the selection of the patients.

Non-surgically related causes of erectile dysfunction after bilateral nerve-sparing radical prostatectomy

Background:Erectile dysfunction (ED) represents one of the most common long-term side effects in prostate cancer (PCa) patients treated with bilateral nerve-sparing radical prostatectomy (BNSRP). The aim of our study was to assess the influence of non-surgically related causes of ED in patients treated with BNSRP.Methods:Overall, 716 patients treated with BNSRP were retrospectively identified. All patients had complete data on erectile function (EF) assessed by the Index of Erectile Function-EF domain (IIEF-EF) and depressive status assessed by the Center for Epidemiologic Studies-Depression (CES-D) questionnaire. EF recovery was defined as an IIEF-EF of ⩾22. Kaplan–Meier analyses assessed the impact of preoperative IIEF-EF, depression and adjuvant radiotherapy (aRT) on the time to EF recovery. Multivariable Cox regression models were used to test the impact of aRT on EF recovery after accounting for depression and baseline IIEF-EF.Results:Median follow-up was 48 months. Patients with a preoperative IIEF-EF of ⩾22 had substantially higher EF recovery rates compared with those with a lower IIEF-EF (P<0.001). Patients with a CES-D of <16 had significantly higher EF recovery rates compared to those with depression (60.8 vs 49.2%; P=0.03). Patients receiving postoperative aRT had lower rates of EF compared with their counterparts left untreated after surgery (40.7 vs 59.8%; P<0.001). These results were confirmed in multivariable analyses, where preoperative IIEF-EF (P<0.001), depression (P=0.04) and aRT (P=0.03) were confirmed as significant predictors of EF recovery.Conclusions:Preoperative functional status and depression should be considered when counseling PCa patients regarding the long-term side effects of BNSRP. Moreover, the administration of aRT has a detrimental effect on the probability of recovering EF after BNSRP. This should be taken into account when balancing the potential benefits and side effects of multimodal therapies in PCa patients.

The Role of Prostate-specific Antigen Persistence After Radical Prostatectomy for the Prediction of Clinical Progression and Cancer-specific Mortality in Node-positive Prostate Cancer Patients

BACKGROUND A complete biochemical response (BR) immediately after surgery could be considered an indicator of optimal cancer control after radical prostatectomy (RP). OBJECTIVE To evaluate the prognostic value of early postoperative prostate-specific antigen (PSA) levels after RP in patients with lymph node invasion (LNI). DESIGN, SETTING, AND PARTICIPANTS The study included 319 prostate cancer patients with LNI who were treated with RP and extended pelvic lymph node dissection (ePLND) at a single institution between 1998 and 2013. All men had complete clinical, pathologic, and follow-up data, including PSA value at 6 wk after surgery. Patients were divided into two groups according to PSA value at 6 wk after surgery: complete BR (PSA <0.1 ng/ml) and PSA persistence (PSA ≥0.1 ng/ml). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Kaplan-Meier analyses were used to assess 8-yr clinical recurrence (CR) and cancer-specific mortality (CSM) rates according to PSA persistence after RP. Multivariable Cox regression analysis was used to test the association between PSA persistence and CR. Covariates consisted of pathologic Gleason score (≤7 vs ≥8), number of positive nodes, surgical margins status (negative vs positive), and adjuvant therapies (none vs androgen deprivation therapy (ADT) vs adjuvant radiotherapy plus ADT). When we performed multivariable analyses assessing the association between PSA persistence and CSM pathologic Gleason score represented the only covariate due to the low number of events (n=13). RESULTS AND LIMITATIONS Overall, 83 patients (26%) had PSA persistence. Men with PSA persistence had higher 8-yr CR and CSM rates than those with complete BR (69% vs 12% and 16% vs 4.2%, respectively; all p≤0.002). This was confirmed in multivariable analyses, where PSA persistence at 6 wk after surgery was an independent predictor of both CR (hazard ratio [HR]: 8.3; 95% confidence interval [CI], 4.73-14.7; p≤0.001) and CSM (HR: 2.16; 95% CI, 1.63-2.86; p≤0.001). Pathologic stage lower than pT3a, biopsy and pathologic Gleason score ≥8, positive surgical margins, and three or more positive lymph nodes were significantly associated with PSA persistence (all p≤0.04). Our study is limited by its retrospective design. CONCLUSIONS Early BR can be achieved in approximately 75% of men with LNI submitted to RP and ePLND. PSA assessment early after surgery has an important prognostic role in the prediction of CR and CSM in node-positive patients. A risk stratification of these patients based on PSA persistence could guide physicians to properly select patients who may benefit the most from timely multimodal treatments. PATIENT SUMMARY The risk of clinical recurrence and cancer-specific mortality is heterogeneous in patients with prostate cancer with lymph node invasion. Node-positive patients with complete biochemical response early after surgery share more favorable oncologic outcomes than those with PSA persistence. These results are important to plan the optimal postoperative patient management.

Urology Residency Training in Italy: Results of the First National Survey

BACKGROUND Numerous surveys have been performed to determine the competence and the confidence of residents. However, there is no data available on the condition of Italian residents in urology. OBJECTIVE To investigate the status of training among Italian residents in urology regarding scientific activity and surgical exposure. DESIGN, SETTING, AND PARTICIPANTS A web-based survey that included 445 residents from all of the 25 Italian Residency Programmes was conducted between September 2015 and November 2015. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The main outcomes were represented by scientific activity, involvement in surgical procedures, and overall satisfaction. RESULTS AND LIMITATIONS In total, 324 out of 445 (72.8%) residents completed the survey. Overall, 104 (32%) residents had not published any scientific manuscripts, 148 (46%) published ≤5, 38 (12%) ≤10, 26 (8%) ≤15, four (1%) ≤20, and four (1%) >20 manuscripts, respectively. We did not observe any differences when residents were stratified by sex (p=0.5). Stent positioning (45.7%), extracorporeal shock wave lithotripsy (30.9%), transurethral resection of bladder tumor (33.0%), hydrocelectomy (24.7%), varicocelectomy (17%), ureterolithotripsy (14.5%), and orchiectomy (12.3%) were the surgical procedures more frequently performed by residents. Overall, 272 residents (84%) expressed a good satisfaction for urology specialty, while 178 (54.9%) expressed a good satisfaction for their own residency programme. We observed a statistically decreased trend for good satisfaction for urology specialty according to the postgraduate year (p=0.02). CONCLUSIONS Italian Urology Residency Programmes feature some heavy limitations regarding scientific activity and surgical exposure. Nonetheless, satisfaction rate for urology specialty remains high. Further improvements in Residency Programmes should be made in order to align our schools to others that are actually more challenging. PATIENT SUMMARY In this web-based survey, Italian residents in urology showed limited scientific productivity and low involvement in surgical procedures. Satisfaction for urology specialty remains high, demonstrating continuous interest in this field of study from residents.

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.

Pelvic lymph node dissection in prostate cancer: indications, extent and tailored approaches.

Purpose The purpose of this study is to review the current literature concerning the indication of pelvic lymph node dissection (PLND), its extent and complications in prostate cancer (PCa) staging, the available tools, and the future perspectives to assess the risk of lymph node invasion (LNI). Methods A literature review was performed using the Medline, Embase, and Web of Science databases. The search strategy included the terms pelvic lymph nodes, PLND, radical prostatectomy, prostate cancer, lymph node invasion, biochemical recurrence, staging, sentinel lymph node dissection, imaging, and molecular markers. Results PLND currently represents the gold standard for nodal staging in PCa patients. Available imaging techniques are characterized by poor accuracy in the prediction of LNI before surgery. On the contrary, an extended PLND (ePLND) would result into proper staging in the majority of the cases. Several models based on pre-operative disease characteristics are available to assess the risk of LNI. Although ePLND is not associated with a substantial risk of severe complications, up to 10% of the men undergoing this procedure experience lymphoceles. Concerns over potential morbidity of ePLND led many authors to investigate the role of sentinel lymph node dissection in order to prevent unnecessary ePLND. Finally, the incorporation of novel biomarkers in currently available tools would improve our ability to identify men who should receive an ePLND. Conclusions Nowadays, the most informative tools predicting LNI in PCa patients consist in pre-operative clinical nomograms. Sentinel lymph node dissection still remains experimental and novel biomarkers are needed to identify patients at a higher risk of LNI.