Marco Cossu

Diagnostic Pathway with Multiparametric Magnetic Resonance Imaging Versus Standard Pathway: Results from a Randomized Prospective Study in Biopsy-naïve Patients with Suspected Prostate Cancer

BACKGROUND An approach based on multiparametric magnetic resonance imaging (mpMRI) might increase the detection rate (DR) of clinically significant prostate cancer (csPCa). OBJECTIVE To compare an mpMRI-based pathway with the standard approach for the detection of prostate cancer (PCa) and csPCa. DESIGN, SETTING, AND PARTICIPANTS Between November 2014 and April 2016, 212 biopsy-naïve patients with suspected PCa (prostate specific antigen level ≤15 ng/ml and negative digital rectal examination results) were included in this randomized clinical trial. Patients were randomized into a prebiopsy mpMRI group (arm A, n=107) or a standard biopsy (SB) group (arm B, n=105). INTERVENTION In arm A, patients with mpMRI evidence of lesions suspected for PCa underwent mpMRI/transrectal ultrasound fusion software-guided targeted biopsy (TB) (n=81). The remaining patients in arm A (n=26) with negative mpMRI results and patients in arm B underwent 12-core SB. OUTCOMES MEASUREMENTS AND STATISTICAL ANALYSIS The primary end point was comparison of the DR of PCa and csPCa between the two arms of the study; the secondary end point was comparison of the DR between TB and SB. RESULTS AND LIMITATIONS The overall DRs were higher in arm A versus arm B for PCa (50.5% vs 29.5%, respectively; p=0.002) and csPCa (43.9% vs 18.1%, respectively; p<0.001). Concerning the biopsy approach, that is, TB in arm A, SB in arm A, and SB in arm B, the overall DRs were significantly different for PCa (60.5% vs 19.2% vs 29.5%, respectively; p<0.001) and for csPCa (56.8% vs 3.8% vs 18.1%, respectively; p<0.001). The reproducibility of the study could have been affected by the single-center nature. CONCLUSIONS A diagnostic pathway based on mpMRI had a higher DR than the standard pathway in both PCa and csPCa. PATIENT SUMMARY In this randomized trial, a pathway for the diagnosis of prostate cancer based on multiparametric magnetic resonance imaging (mpMRI) was compared with the standard pathway based on random biopsy. The mpMRI-based pathway had better performance than the standard pathway.

Real time ultrasound in laparoscopic bladder diverticulectomy

Abstract  We describe our technique of laparoscopic diverticulectomy under ultrasound (US) guidance after a transurethral resection of prostate (TURP) in the treatment of patients with benign prostatic hyperplasia and bladder diverticulum. A standard TURP is performed with an Iglesias resectoscope. A 12‐Fr Foley catheter is positioned in the diverticulum and the catheter balloon is then inflated with 30 mL of water; then a Tiemann catheter is placed through the urethra into the bladder. A US probe is inserted through the 12 mm port placed in the right side by the surgeon, then laparoscopic transperitoneal bladder diverticulectomy is performed under US guidance. In our experience, the use of endolaparoscopic US makes identification and dissection of the diverticulum easy, safe and effective, even when the procedure has to be performed in disadvantageous anatomic conditions such as lateral‐posterior diverticulum or post‐TURP imbibition of pelvic tissue.

Treatment of the pyelocalyceal tumors with laser

Transitional cell carcinoma of the upper urinary tract (UUT-TCC) is relatively uncommon, accounting for 2-5% of all urothelial tumors. Its incidence appears to be increasing as a result of progress in imaging, endoscopy, and improved survival from bladder cancer. Renal pelvis tumors represent 10% of all renal cancers. Pyelic neoplasms occur at a rate twice to four times the incidence of tumors in the ureter, where the common site is the distal tract (about 70%). One third of UUT-TCC ore multifocal, and about 1% are simultaneous and bilateral. The introduction of lasers represented a big step in the diagnosis and endoscopic treatment of upper urinary tract tumors. A successful laser treatment is defined by the careful selection of the patients affected by urinary tract lesions. Usually, only patients affected by low grade and papillary lesion should be treated endoscopically with laser. Patients with high grade and invasive lesions should rather be submitted to surgical procedure. Actually, the urologist has a wide choice in laser technology (Holmium laser, Thulium laser). For a correct and safe treatment of ureteral and pyelic lesions with lasers it is mandatory to respect some technical advises. First of all, an adequate access for a good vision of ureter and renal pelvis is imperative. In fact, the urologist should always work in safety, with an optimal control of the instrumentation. Then, it is important to define the laser type and its energy level. The development in laser technology (i.e. small and flexible laser fibers) allows also a radical, safe and minimally invasive treatment of urothelial lesions using flexible ureteroscopes. Of course it is mandatory to evaluate the grade and stage of the tumors by means of the ureteroscopic biopsies: invasive tumors must be treated by immediate nephroureterectomy while the endoscopic treatment should be reserved to those patients with a solitary kidney, renal failure, bilateral tumors, severe comorbities or affected by a solitary tumors with <15 mm in diameter and of low-grade/stage.

Combined endoscopic and laparoscopic en bloc resection of the urachus and the bladder dome in a rare case of urachal carcinoma

Abstract:  Urachal carcinoma is a rare neoplasm treated with surgical resection. We report a case of adenocarcinoma of the urachus treated with a new surgical technique. In a 44‐year‐old man affected by urachal carcinoma we performed a combined endoscopic–laparoscopic surgical en bloc resection of the urachus and bladder dome. The procedure lasted 240 min, and no postoperative complications were recorded. The patient was discharged on fourth day and the catheter was removed on eighth day. Bladder capability resulted normal with no evident physical change. Multiple bladder biopsy and computed tomography scans at 6, 12 and 18 months proved negative.

Ureteroscopy: is it the best?:

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in ‘80s many technological improvements allowed to reduce endourological instruments’ size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.

Early Ligature of the Renal Artery During Laparoscopic Radical Nephrectomy

Abstract Introduction: The aim of this video is to describe four alternatives for early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy. Materials and Methods: (i) Standard early right renal artery ligature: Patient is placed in the extended lateral decubitus position. Four 12-mm ports are used. The first is placed just to the right of or inside the umbilicus, the second at the midclavicular line 2 cm below the costal margin, the third on the anterior axillary line 3 cm below the umbilicus, and the fourth along the midaxillary line. The visceral posterior peritoneum is incised in the mesocolic space along the anterior vena cava wall. The duodenum is reflected medially. The right renal vein is identified and the medial margin of Gerotas fascia is dissected from the lateral wall of the vena cava. The right renal artery is identified, isolated, and closed with a Hem-o-Lok® clip. (ii) Early right renal artery ligature in the interaortocaval space: The patient and ports ar...

FLUORESCENCE CYSTOSCOPY WITH HEXAMINOLEVULINATE IN THE DIAGNOSIS OF BLADDER CANCER: OUR EXPERIENCE

physical therapy. He received adjuvant chemotherapy and is alive without evidence of disease recurrence at 1 year. CONCLUSIONS: There is a risk of obturator nerve injury during pelvic lymph node dissection. Hem-o-lock clips may be removed with the use of a clip remover or harmonic instrument. If transected and recognized, immediate apposition of the nerve is necessary to yield recovery. Robotic suturing of the transected nerve was technically feasible in this case.