R. Campi

Standardized Reporting of Resection Technique During Nephron- sparing Surgery: The Surface-Intermediate-Base Margin Score

A standardized reporting system of nephron-sparing surgery resection techniques is lacking. The surface-intermediate-base scoring system represents a formal reporting instrument to assist in interpretation of reported data and to facilitate comparisons in the urologic literature.

Histopathological Validation of the Surface-Intermediate-Base Margin Score for Standardized Reporting of Resection Technique during Nephron Sparing Surgery

PURPOSE The surface-intermediate-base margin score is a novel standardized reporting system of resection techniques during nephron sparing surgery. We validated the surgeon assessed surface-intermediate-base score with microscopic histopathological assessment of partial nephrectomy specimens. MATERIALS AND METHODS Between June and August 2014 data were prospectively collected from 40 consecutive patients undergoing nephron sparing surgery. The surface-intermediate-base score was assigned to all cases. The score specific areas were color coded with tissue margin ink and sectioned for histological evaluation of healthy renal margin thickness. Maximum, minimum and mean thickness of healthy renal margin for each score specific area grade (surface [S] = 0, S = 1 ; intermediate [I] or base [B] = 0, I or B = 1, I or B = 2) was reported. The Mann-Whitney U and Kruskal-Wallis tests were used to compare the thickness of healthy renal margin in S = 0 vs 1 and I or B = 0 vs 1 vs 2 grades, respectively. RESULTS Maximum, minimum and mean thickness of healthy renal margin was significantly different among score specific area grades S = 0 vs 1, and I or B = 0 vs 1, 0 vs 2 and 1 vs 2 (p <0.001). The main limitations of the study are the low number of the I or B = 1 and I or B = 2 samples and the assumption that each microscopic slide reflects the entire score specific area for histological analysis. CONCLUSIONS The surface-intermediate-base scoring method can be readily harnessed in real-world clinical practice and accurately mirrors histopathological analysis for quantification and reporting of healthy renal margin thickness removed during tumor excision.

Positive surgical margins and local recurrence after simple enucleation and standard partial nephrectomy for malignant renal tumors: Systematic review of the literature and meta-analysis of prevalence

INTRODUCTION The definition of the safest width of healthy renal margin to achieve oncological efficacy and therefore of the safest resection technique (RT) during partial nephrectomy (PN) continues to be widely debated. The aim of this study is to evaluate the prevalence of positive surgical margins (PSM), loco-regional recurrence (LRR) and renal recurrence (RER) rates after simple enucleation (SE) and standard partial nephrectomy (SPN) for malignant renal tumors. EVIDENCE ACQUISITION A systematic review of the English-language literature was performed through August 2016 using the Medline, Web of Science and Embase databases according to the PRISMA criteria. A systematic review and meta-analysis was performed in those studies that defined the exact anatomical location of recurrence after PN. EVIDENCE SYNTHESIS Overall, 33 studies involving 11,282 patients were selected for quantitative analysis. At a median follow-up of 43 (SE) and 52 (SPN) months, the pooled estimates of the prevalence of PSMs, LRR and RER were 2.7% (95% CI: 1.5-4.6%, P<0.001) and 0.4% (95% CI: 0.1-2.2%, P=0.018), 2.0% (95% CI: 1.4-2.8%, P<0.001) and 0.9% (95% CI: 0.5-1,7%, P=0.04), 1.5% (95% CI: 0.9-2.3%, P=0.001) and 0.9% (95% CI: 0.5-1,7%, P=0.40) in patients undergoing SPN and SE, respectively. CONCLUSIONS Our systematic analysis and meta-analysis demonstrates that SE is noninferior to SPN regarding PSM, LRR and RER rates in patients undergoing PN for malignant renal tumors. Further studies using standardized reporting tools are needed to evaluate the role of resection techniques for oncologic outcomes after PN.

Re: Raj Satkunasivam, Sheaumei Tsai, Sumeet Syan, et al. Robotic Unclamped "Minimal-margin" Partial Nephrectomy: Ongoing Refinement of the Anatomic Zero-ischemia Concept. Eur Urol 2015;68:705-12.

We read with great interest the article by Satkunasivam and colleagues [1] describing the novel technique of robotic unclamped ‘‘minimal-margin’’ partial nephrectomy (PN) and the subsequent letters to the editor regarding this paper [2,3]. The technical refinements of the novel technique are (1) complete elimination of all vascular clamping and (2) tumor excision with a minimal margin adjacent to the tumor capsular edge, aiming to maximize functional parenchymal mass preservation while ensuring oncologic efficacy. The amount of vascularized nephron mass preserved appears to be a primary (surgically modifiable) determinant of functional recovery after PN [4], and although possibly determined by the tumor’s size and location, it is ultimately linked to the resection technique performed for tumor excision [5]. In this regard, although the PN dogma has always advocated removal of a rim of uninvolved renal parenchyma to ensure oncologic efficacy [6] and despite the trend toward a reduction of the tumor-free ‘‘safety’’ margin thickness in past years [7], no standardization has been achieved to date in detailed reporting of tumor excision in PN series. As such, the debate about the oncologic safety of enucleative PN versus so-called standard PN is ongoing [2,3,8]. However, the oncologic safety of enucleative PN has been confirmed by several studies showing local recurrence-free and cancer-specific survival rates comparable to standard PN [8–10]. Moreover, there are currently no evidence-based contraindications for enucleative PN, with the only possible exception of Fuhrman grade IV renal tumors [11]. The article by Satkunasivam and colleagues and the subsequent letters offer insights for further consideration [1– 3]. In the ‘‘Surgery in Motion’’ video on robotic unclamped minimal margin PN, the tumor pseudocapsule is readily evident throughout the dissection, and it does not appear that the minimal-margin concept is at all different from enucleation; therefore, minimal-margin PN somehow resembles enucleative PN [2]. At the same time, minimal-margin PN is

Role of Clinical and Surgical Factors for the Prediction of Immediate, Early and Late Functional Results, and its Relationship with Cardiovascular Outcome after Partial Nephrectomy: Results from the Prospective Multicenter RECORd 1 Project

Purpose: We sought to determine the predictors of short‐term and long‐term renal function impairment after partial nephrectomy. Materials and Methods: Clinical data on 769 consecutive patients who underwent partial nephrectomy were prospectively recorded at a total of 19 urological Italian centers from 2009 to 2012 in the RECORd 1 (Italian Registry of Conservative Renal Surgery) Project. We extracted clinical data on 708 of these patients who were alive, free of recurrent disease and with a minimum 2‐year functional followup. Results: Of the patients 47.3% underwent open, 36.6% underwent laparoscopic and 16.1% underwent robot‐assisted partial nephrectomy. The median baseline estimated glomerular filtration rate was 84.5 ml/minute/1.73 m2 (IQR 69.9–99.1). Immediate (day 3 postoperatively), early (month 1) and late (month 24) renal function impairment greater than 25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and the baseline estimated glomerular filtration rate were independent predictors of immediate, early and late renal function impairment. Age at diagnosis was an independent predictor of immediate and late impairment. Uncontrolled diabetes was an independent predictor of late impairment only. Open and laparoscopic approaches, and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58 of 529 patients (11%) experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of those events. Conclusions: Surgically modifiable factors were significantly associated with worse immediate and early functional outcomes after partial nephrectomy while clinically unmodifiable factors affected renal function during the entire followup. Late renal function impairment is an independent predictor of postoperative cardiovascular events.

Anatomical templates of lymph node dissection for upper tract urothelial carcinoma: a systematic review of the literature

ABSTRACT Introduction: Indications and techniques of lymph node dissection (LND) for upper tract urothelial carcinoma (UTUC) are still controversial. Areas covered: In this study, a systematic review of the English-language literature was performed up to 1 July 2016 using the Medline, Scopus, Cochrane Library and Web of Sciences databases to provide a detailed overview of the most commonly dissected surgical templates of LND for UTUC according to laterality and location of the tumor. Overall, sixteen studies were analyzed. Based on the shared experiences in the scientific literature, the LND template typically included: for right-sided tumors of the renal pelvis, upper third and middle third of the ureter, the renal hilar, paracaval, precaval and retrocaval nodes, while for left-sided tumors the renal hilar, paraaortic and preaortic nodes. For tumors of the lower ureter, an extended pelvic LND was performed in most cases; however, the paracaval, paraaortic or presacral nodes were dissected in selected series. Expert commentary: LND is not routinely performed at the time of surgery for UTUC and both indication and extent of LND vary among surgeons and institutions. Future high-quality studies are needed to define the most accurate LND templates and to assess their oncological efficacy and surgical morbidity.

Reply to Vincenzo Ficarra, Vito Palumbo, Afrovita Kungulli and Gianluca Giannarini's Letter to the Editor re: Andrea Minervini, Marco Carini, Robert G. Uzzo, Riccardo Campi, Marc C. Smaldone, Alexander Kutikov. Standardized Reporting of Resection Technique During Nephron-sparing Surgery: The Surface–Intermediate–Base Margin Score. Eur Urol 2014;66:803–5

We read, with great interest, the thoughtful letter by Ficarra et al [1] regarding our recently proposed surface–intermediate–base (SIB) score for objectifying surgical technique reporting during nephron-sparing surgery (NSS) [2]. Some of the authors’ concerns address specific technical aspects of the SIB score assignment, whereas others offer opinions regarding the premise and purpose of the novel clinical research tool that we proposed. We thank Ficarra and colleagues for engaging us to clarify some of the nuances of the scoring system. Prior to our report, there were no standardised definitions for reporting NSS resection techniques in the literature. This void undermines objective and meaningful comparisons of outcomes between surgeons and institutions performing NSS. Indeed, many perioperative and postoperative outcomes are inherently influenced by the kidney surgeon’s resection strategy [3]. Consequently, standardised reporting of surgical techniques is essential. Below we address each of Ficarra and colleagues’ concerns.

Collagenase clostridium histolyticum for the treatment of Peyronie's disease: a prospective Italian multicentric study

Peyronies disease (PD) is a common condition which results in penile curvature making sexual intercourse difficult or impossible. Collagenase clostridium histolyticum (CCH) is the first licensed drug for the treatment of PD and is indicated in patients with palpable plaque and curvature deformity of at least 30° of curvature. However, only few monocentric studies are available in the current literature and this is the first national multicentric study focusing on this new treatment. In five Italian centres, 135 patients have completed the treatment with three injections of CCH using Ralphs shortened modified protocol. The protocol consisted of three intralesional injections of CCH (0.9 mg) given at 4‐weekly intervals in addiction to a combination of home modelling, stretching and a vacuum device on a daily basis. An improvement in the angle of curvature was recorded in 128/135 patients (94.8%) by a mean (range) of 19.1 (0–40)° or 42.9 (0–67)% from baseline (p < 0.001). There was also a statistically significant improvement in all IIEF and PDQ questionnaires subdomains (p < 0.001 in all subdomains). This prospective multicentric study confirms that the three‐injection protocol is effective enough to achieve a good result and to minimize the cost of the treatment.

Impact of Metabolic Diseases, Drugs, and Dietary Factors on Prostate Cancer Risk, Recurrence, and Survival: A Systematic Review by the European Association of Urology Section of Oncological Urology

CONTEXT To date, established risk factors for prostate cancer (PCa) are limited to age, race, family history, and certain genetic polymorphisms. Despite great research efforts, available evidence on potentially modifiable risk factors is conflicting. Moreover, most studies on PCa risk factors did not consider the impact of prostate-specific antigen (PSA) testing on PCa diagnosis. OBJECTIVE To provide a detailed overview of the latest evidence on the role of metabolic diseases, drugs, and dietary factors for risk of PCa incidence, recurrence, and survival in men exposed to PSA testing. EVIDENCE ACQUISITION A systematic review of the English-language literature was performed using the MEDLINE, Cochrane Central Register of Controlled Trials, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses recommendations. Randomized, case-control, or cohort studies published during the periods 2008-2017 (on drugs and metabolic diseases) and 2003-2017 (on dietary factors), with extensive follow-up (≥8-10yr for studies on PCa risk; ≥2-5yr for studies on PCa recurrence, progression, and survival, depending on the review subtopic) and adjusting of the analyses, beyond established risk factors, for either rate of PSA testing (for risk analyses) or PCa stage and primary treatment (for survival analyses), were eligible for inclusion. EVIDENCE SYNTHESIS Overall, 39 reports from 22 observational studies were included. Studies were heterogeneous regarding definitions of exposure or outcomes, length of follow-up, risk of bias, and confounding. For some risk factors, evidence was insufficient to assess potential effects, while for others there was no evidence of an effect. For selected risk factors, namely metformin, aspirin and statin use, diabetes, obesity, and specific dietary intakes, there was low-quality evidence of modest effects on PCa risk. CONCLUSIONS Current evidence from long-term observational studies evaluating the effect of drugs, metabolic diseases, and dietary factors for PCa risk considering the impact of PSA testing is still not conclusive. Future research is needed to confirm the associations suggested by our review, exploring their potential biological explanations and selecting those risk factors most likely to trigger effective public health interventions. PATIENT SUMMARY We reviewed the available studies published in the recent literature on the potential role of drugs, metabolic diseases, and food and dietary factors for the risk of prostate cancer, considering the impact of prostate-specific antigen testing on prostate cancer diagnosis. We found that for some factors data are currently insufficient to make definitive conclusions, while for others available studies seem to indicate an effect on the risk of prostate cancer.

Latest Evidence on the Impact of Smoking, Sports, and Sexual Activity as Modifiable Lifestyle Risk Factors for Prostate Cancer Incidence, Recurrence, and Progression: A Systematic Review of the Literature by the European Association of Urology Section of Oncological Urology (ESOU)

CONTEXT Smoking, sexual activity, and physical activity (PA) are discussed as modifiable lifestyle factors associated with prostate cancer (PCa) development and progression. OBJECTIVE To evaluate the available evidence concerning the association of smoking, sexual activity, and sports and exercise on PCa risk, treatment outcome, progression, and cancer-specific mortality. EVIDENCE ACQUISITION A systematic review of studies published between 2007 and 2017 using MEDLINE (via PubMed), Cochrane Central Register of Controlled Trials, and Web of Science databases according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement criteria was conducted. EVIDENCE SYNTHESIS While data concerning the impact of smoking on PCa development remain conflicting, there is robust evidence that smoking is associated with aggressive tumor features and worse cancer-related outcome, which seems to be maintained for 10 yr after smoking cessation. Less convincing and limited evidence exists for the association of sexual activity with PCa risk. The findings related to PA and PCa support the inference that exercise might be a useful factor in the prevention of PCa and tumor progression, while it is not finally proved under which specific conditions PA might be protective against disease development. CONCLUSIONS Smoking is associated with aggressive tumor features and worse cancer-related prognosis; as this negative impact seems to be maintained for 10yr after smoking cessation, urologists should advise men to quit smoking latest at PCa diagnosis to improve their prognosis. As several studies indicate a positive impact of exercise on tumor development, progression, and treatment outcome, it is certainly reasonable to advocate an active lifestyle. Least convincing evidence is available for the interaction of sexual activity and PCa, and well-conducted and longitudinal studies are clearly necessary to evaluate whether the suggested associations between PCa risk and sexual behavior are real or spurious. PATIENT SUMMARY In this systematic review, we looked at the impact of smoking, sexual activity, and sports and exercise on prostate cancer risk and outcome after treatment. While the evidence for sexual activity is not overall clear, we found that smoking might lead to more aggressive cancers and result in worse treatment outcome. Physical activity might prevent prostate cancer and improve cancer-related outcomes as well. Hence, it is certainly reasonable to advocate an active lifestyle and advise men to quit smoking.