M. Borghesi

Complications After Systematic, Random, and Image-guided Prostate Biopsy

CONTEXT Prostate biopsy (PB) represents the gold standard method to confirm the presence of cancer. In addition to traditional random or systematic approaches, a magnetic resonance imaging (MRI)-guided technique has been introduced recently. OBJECTIVE To perform a systematic review of complications after transrectal ultrasound (TRUS)-guided, transperineal, and MRI-guided PB. EVIDENCE ACQUISITION We performed a systematic literature search of Web of Science, Embase, and Scopus databases up to October 2015, according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Complications and mortality following random, systematic, and image-guided PBs were reviewed. Eighty-five references were included. EVIDENCE SYNTHESIS The most frequent complication after PB was minor and self-limiting bleeding (hematuria and hematospermia), regardless of the biopsy approach. Occurrence of rectal bleeding was comparable for traditional TRUS-guided and image-guided PBs. Almost 25% of patients experienced lower urinary tract symptoms, but only a few had urinary retention, with higher rates after a transperineal approach. Temporary erectile dysfunction was not negligible, with a return to baseline after 1-6 mo. The incidence of infective complications is increasing, with higher rates among men with medical comorbidities and older age. Transperineal and in-bore MRI-targeted biopsy may reduce the risk of severe infectious complications. Mortality after PB is uncommon, regardless of biopsy technique. CONCLUSIONS Complications after PB are frequent but often self-limiting. The incidence of hospitalization due to severe infections is continuously increasing. The patients general health status, risk factors, and likelihood of antimicrobial resistance should be carefully appraised before scheduling a PB. PATIENT SUMMARY We reviewed the variety and incidence of complications after prostate biopsy. Even if frequent, complications seldom represent a problem for the patient. The most troublesome complications are infections. To minimize this risk, the patients medical condition should be carefully evaluated before biopsy.

18F-Fluciclovine PET/CT for the Detection of Prostate Cancer Relapse: A Comparison to 11C-Choline PET/CT.

Purpose In recent years, a new PET compound (anti-3-18F-FACBC or 18F-fluciclovine) was tested for the detection of prostate cancer relapse. Despite very promising results, only preliminary data were available with regard to the comparison to 11C-choline. The aim of this study was to compare the detection rate of 18F-FACBC and 11C-choline in patients presenting a biochemical relapse. Patients and Methods Fifty patients radically treated for prostate cancer and presenting with rising prostate-specific antigen (PSA) levels were consecutively and prospectively enrolled. All the patients were out of hormonal therapy and underwent both 11C-choline PET/CT and 18F-fluciclovine PET/CT within 1 week. The results were compared in terms of detection rate on a patient and lesion basis. Furthermore, a more detailed analysis regarding local, lymph node, and bone relapse was performed. Results On a patient-based analysis, 18F-fluciclovine detection turned out to be significantly superior to 11C-choline (P < 0.000001). This result was also true on lesion, lymph node, bone lesion, and local relapse analysis (P < 0.0001 in all the cases). There was no significant difference in terms of target to background of positive lesions between 11C-choline and 18F-fluciclovine. When the patients were divided into groups with different PSA levels, 18F-fluciclovine had a superior detection rate for low, intermediate, and high PSA levels. Conclusions In our experimental conditions, 18F-fluciclovine provided a statistically significant better performance in terms of lesion detection rate as compared with 11C-choline. However, more studies are required to evaluate the clinical significance of these results in terms of sensitivity, specificity, and accuracy.

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.

PADUA and R.E.N.A.L. nephrometry scores correlate with perioperative outcomes of robot-assisted partial nephrectomy: analysis of the Vattikuti Global Quality Initiative in Robotic Urologic Surgery (GQI-RUS) database.

To evaluate and compare the correlations between Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) and R.E.N.A.L. [Radius (tumour size as maximal diameter), Exophytic/endophytic properties of the tumour, Nearness of tumour deepest portion to the collecting system or sinus, Anterior (a)/posterior (p) descriptor and the Location relative to the polar line] nephrometry scores and perioperative outcomes and postoperative complications in a multicentre, international series of patients undergoing robot‐assisted partial nephrectomy (RAPN) for masses suspicious for renal cell carcinoma (RCC).

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.

68Ga-PSMA-PET/CT-Guided Salvage Retroperitoneal Lymph Node Dissection for Disease Relapse After Radical Prostatectomy for Prostate Cancer

Approximately 30% of patients submitted to radical therapy for prostate cancer will develop local or distant relapse within 10 years from primary treatment, thus receiving second-line treatment within 5 years. The efficacy of salvage lymph node dissection for prostate cancer relapse has been established. However, there is a lack of PET radiopharmaceuticals that might be considered a valid tool to identify nodal metastases. Ga-PSMA-PET/CT (Ga-labeled prostate-specific membrane antigen ligand HBED-CC positron emission tomography/positron emission tomography) showed higher performance compared to choline PET/CT, in particular during the early phase of biochemical relapse, with low prostate-specific antigen levels. We report a case of a patient with biochemical relapse who underwent salvage retroperitoneal lymph node dissection according to the results obtained by GaPSMA-PET/CT. The patient exhibited a complete biochemical response after surgery (prostate-specific antigen < 0.2 ng/mL) at short-term follow-up.

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.

A snapshot of nephron-sparing surgery in Italy: A prospective, multicenter report on clinical and perioperative outcomes (the RECORd 1 project)

INTRODUCTION Nephron-sparing surgery (NSS) has become the standard of care for the surgical management of small and clinically localized renal cell carcinoma (RCC). The conservative management of those RCCs is increasing over time. Aim of this study was to report a snapshot of the clinical, perioperative and oncological results after NSS for RCC in Italy. MATERIAL AND METHODS We evaluated all patients who underwent conservative surgical treatment for renal tumours between January 2009 and December 2012 at 19 urological Italian Centers (RECORd project). Perioperative, radiological and histopathological data were recorded. Surgical eras (2009 vs 2012 and year periods 2009-2010 vs 2011-2012) were compared. RESULTS Globally, 983 patients were evaluated. More recently, patients undergoing NSS were found to be significantly younger (p = 0.05) than those surgically treated in the first study period, with a significantly higher rate of NSS with relative and imperative indication (p < 0.001). More recently, a higher percentage of procedures for cT1b or cT2 renal tumours was observed (p = 0.02). Utilization rate of open partial nephrectomy (OPN) constantly decreased during years, laparoscopic partial nephrectomy (LPN) remained almost constant while robot-assisted partial nephrectomy (RAPN) increased. The rate of clampless NSS constantly increased over time. The use of at least one haemostatic agent has been significantly more adopted in the most recent surgical era (p < 0.001). CONCLUSIONS The utilization rate of NSS in Italy is increasing, even in elective and more complex cases. RAPN has been progressively adopted, as well as the intraoperative utilization of haemostatic agents and the rate of clampless procedures.

A Prospective, Multicenter Evaluation of Predictive Factors for Positive Surgical Margins After Nephron-Sparing Surgery for Renal Cell Carcinoma: The RECORd1 Italian Project

BACKGROUND The purpose of this study was to evaluate the predictors of positive margins in one of the largest available prospective multi-institutional studies. PATIENTS AND METHODS We evaluated all patients who underwent NSS for radiologically diagnosed kidney tumors between January 2009 and December 2012 at 19 urological Italian centers (Registry of Conservative Renal Surgery [RECORd] project). Preoperative and anthropometric data, comorbidities, intraoperative and postoperative outcomes, and histological findings were analyzed. The negative and PSMs were compared according to the clinical and surgical variables. Multivariable logistic regression models were applied to analyze predictors of PSMs. RESULTS Eight hundred consecutive patients were evaluated. Seven hundred sixty-one (95.1%) and 39 patients (4.9%) achieved negative and PSMs, respectively. Patients with PSMs were significantly older compared with those with negative margins (median age: 66.6 vs. 61.8 years, respectively; P = .001). A higher incidence of PSMs was observed when NSS was performed for renal masses located in the upper pole (P = .001). A lower rate of PSMs was found in patients treated with simple enucleation rather than standard PN (1.6% vs. 7.4%, respectively; P < .0001). A greater incidence of PSMs was found in Fuhrman 3/4 tumors (11.3%; P < .0001). At multivariable analysis, age (odds ratio [OR], 1.04; P = .01), upper pole tumor location (OR, 2.85; P = .005), standard PN (OR, 3.45; P = .004), and Fuhrman 3-4 nuclear grade (OR, 4.81; P = .001) were found to be independent predictors of PSMs. CONCLUSION In our multi-institutional report, young age, simple enucleation, middle or lower tumor location, and low-grade tumor were demonstrated to be independent predictors of negative SMs.

Vigilancia activa de masas renales pequeñas diagnosticadas en pacientes de edad avanzada o con comorbilidad: en busca de la mejor estrategia de tratamiento

INTRODUCTION Aim of this study is to provide our results after long-term active surveillance (AS) protocol for small renal masses (SRMs), and to report the outcomes of patients who remained in AS compared to those who underwent delayed surgical intervention. PATIENTS AND METHODS We retrospectively reviewed our database of 58 patients diagnosed with 60 contrast enhancing SRMs suspicious for renal cell carcinoma (RCC). All patients had clinical and radiological follow-up every 6 months. We evaluated the differences between patients who remained on AS and those who underwent surgical delayed intervention. RESULTS The mean age was 75 years, the mean follow-up was 88.5 months. The median initial tumor size at presentation was 2.6cm, and the median estimated tumor volume was 8.7cm(3). The median linear growth rate of the cohort was 0.7cm/year, and the median volumetric growth rate was 8.8 cm(3)/year. Death for metastatic disease occurred in 2 patients (3.4%). No correlation was found between initial tumor size and size growth rate. 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. 0.4cm/year and 16.1 vs. 4.6 cm(3)/year, respectively; P<.001). CONCLUSIONS Most of SRMs demonstrate to have an indolent course and low metastatic potential. Malignant disease could have faster linear and volumetric growth rates, thus suggesting the need for a delayed surgical intervention. In properly selected patients with low life-expectancy, AS could be a reasonable option in the management of SRMs.