Roberto Peschechera

Sky is no limit for ureteroscopy: extending the indications and special circumstances

AbstractPurposeTo critically review and synthesize data of ureteroscopy (URS) in different circumstances that all urologists may encounter during everyday clinical practice, such as pregnancy, obesity, bleeding diathesis, renal stones larger than 2 cm, calyceal diverticula, and kidney malformations.MethodsAccording to PRISMA guidelines, a systematic literature review was performed to identify articles published between 1990 and December 2013 that reported different indications and special circumstances for URS. Articles were separated into the following categories: pregnancy, obesity, bleeding diathesis, stones larger than 2 cm in diameter, calyceal diverticula, and kidney malformations. We used a narrative synthesis for the analyses of the studies, including a description of the characteristics and main outcomes reported in the articles.ResultsRecords identified through database searching were 1396; at the end of study selection, articles included were 57. The majority of these are retrospective studies and involve small cohorts of patients. There does not exist a consensus about important parameters in ureterorenoscopy like stone size, stone free status and complication rate.ConclusionUreteroscopy is effective and reliable tool capable of treating the majority of stones even in the most complicated clinical scenarios and will have more fundamental roles in endourology. The lack of definitive conclusions is due to the great heterogeneity in collecting study’s results; multicentric randomized trials that define in advance the parameters to be studied should be encouraged.

A prospective multicenter European study on flexible ureterorenoscopy for the management of renal stone.

ABSTRACT Purpose The aim of this study was to describe the outcomes and the complications of retrograde intrarenal surgery (RIRS) for renal stones in a multi-institutional working group. Materials and Methods From 2012 to 2014, we conducted a prospective study including all RIRS performed for kidney stones in 4 European centers. Demographic information, disease characteristics, and perioperative and postoperative data were gathered. Patients and stone data, procedure characteristics, results and safety outcomes were analyzed and compared by descriptive statistics. Complications were reported using the standardized Clavien system. Results Three hundred and fifty-six patients underwent 377 RIRS with holmium laser lithotripsy for renal stones. The RIRS was completed in all patients with a mean operative time of 63.5 min. The stone-free status was confirmed endoscopically and through fluoroscopic imaging after the first procedure in 73.6%. The second procedure was performed in twenty patients (5.6%) achieving an overall stone free rate of 78.9%. The overall complication rate was 15.1%. Intra-operative and post-operative complications were seen in 24 (6.7%) and 30 (8.4%) cases, respectively. Conclusions RIRS is a minimally invasive procedure with good results in terms of stone-free and complications rate.

Preoperative prostate health index is an independent predictor of early biochemical recurrence after radical prostatectomy: Results from a prospective single-center study.

BACKGROUND The aim of this study was to test the hypothesis that preoperative prostate health index (PHI) levels could help to predict early biochemical recurrence (BCR) in a contemporary population of patients with prostate cancer treated with robot-assisted radical prostatectomy (RARP). METHODS The study population consisted of 313 patients treated with RARP for clinically localized prostate cancer at a single institution between 2010 and 2011. Patients subjected to neoadjuvant or adjuvant therapies and patients with a follow-up of<2 years were excluded. BCR was defined as a postoperative level of total prostate-specific antigen ≥0.2 ng/ml and elevating after RARP. The minimum P-value method was used to determine the most significant PHI cutoff value to discriminate between patients with and without BCR. The Kaplan-Meier method was used to determine BCR-free survival rates. Finally, Cox regression models were fitted to determine the predictors of BCR, and the predictive accuracy (area under the curve) of each predictor was determined with the Harrell concordance index. RESULTS Mean total prostate-specific antigen and mean PHI levels were 5.76 ng/ml (interquartile range: 4.2-8.7) and 46.0 (35-62), respectively. Biopsy Gleason score was 6 in 173 (55.3%), 7 in 121 (38.7%), and ≥8 in 19 (6.1%) patients. At final pathology, extracapsular extension was observed in 59 (18.8%), seminal vesicle invasion in 24 (7.7%), and lymph node invasion in 11 (3.5%) patients, whereas 228 (72.8%) patients had organ-confined disease. The 2-year BCR-free survival rate was 92.5% in the overall population and was 96.7% in patients with organ-confined disease. The most significant PHI cutoff value to discriminate between patients with and without BCR was 82. Specifically, the 2-year BCR-free survival rate was 97.7% in patients with a preoperative PHI level<82 relative to 69.7% in patients with a PHI level ≥82 (log-rank test: P<0.001). Finally, in multivariable Cox regression analyses, PHI level emerged as an independent predictor of BCR in both the preoperative and the postoperative settings and was more accurate than several established BCR predictors were. CONCLUSIONS Preoperative PHI levels may discriminate between patients who are at a high risk vs. low risk of BCR after RARP. External validation of our findings within a larger population with a longer follow-up time is needed.

Active surveillance for low-risk non-muscle-invasive bladder cancer: Mid-term results from the Bladder cancer Italian Active Surveillance (BIAS) project.

To report the oncological safety and the risk of progression for patients with non‐muscle‐invasive bladder cancer (NMIBC) included in an active surveillance (AS) programme after the diagnosis of recurrence.

Unclassified Renal Cell Carcinoma With Medullary Phenotype Versus Renal Medullary Carcinoma: Lessons From Diagnosis in an Italian Man Found to Harbor Sickle Cell Trait

Medullary carcinoma is a rare malignant tumor of the kidney. It affects individuals of African descent and all cases reported show evidence of sickle cell trait. We reviewed an unusual carcinoma arising in a white man, the ninth in the literature. The tumor demonstrated features associated with renal medullary carcinoma, or unclassified renal cell carcinoma, medullary phenotype as recently described; the presence of sickle cell trait confirmed the diagnosis of medullary carcinoma. This case is helpful in the differential diagnosis with non-sickle cell associated “renal cell carcinoma, unclassified with medullary phenotype,” and study of this spectrum of tumors is ongoing.

Active Surveillance for Low Risk Nonmuscle Invasive Bladder Cancer: A Confirmatory and Resource Consumption Study from the BIAS Project

Purpose: We investigated predictive factors of failure and performed a resource consumption analysis in patients who underwent active surveillance for nonmuscle invasive bladder cancer. Materials and Methods: This prospective observational study monitored patients with a history of pathologically confirmed stage pTa (grade 1‐2) or pT1a (grade 2) nonmuscle invasive bladder cancer, and recurrent small size and number of tumors without hematuria and positive urine cytology. The primary end point was the failure rate of active surveillance. Assessment of failure predictive variables and per year direct hospital resource consumption analysis were secondary outcomes. Descriptive statistical analysis and Cox regression with univariable and multivariable analysis were done. Results: Of 625 patients with nonmuscle invasive bladder cancer 122 with a total of 146 active surveillance events were included in the protocol. Of the events 59 (40.4%) were deemed to require treatment after entering active surveillance. Median time on active surveillance was 11 months (IQR 5–26). Currently 76 patients (62.3%) remain under observation. On univariable analysis only time from the first transurethral resection to the start of active surveillance seemed to be inversely associated with recurrence‐free survival (HR 0.99, 95% CI 0.98–1.00, p = 0.027). Multivariable analysis also revealed an association with age at active surveillance start (HR 0.97, 95% CI 0.94–1.00, p = 0.031) and the size of the lesion at the first transurethral resection (HR 1.55, 95% CI 1.06–2.27, p = 0.025). The average specific annual resource consumption savings for each avoided transurethral bladder tumor resection was &U20AC;1,378 for each intervention avoided. Conclusions: Active surveillance might be a reasonable clinical and cost‐effective strategy in patients who present with small, low grade pTa/pT1a recurrent papillary bladder tumors.

Managing chronic bladder diseases with the administration of exogenous glycosaminoglycans: an update on the evidence

Although the pathophysiology of acute chronic cystitis and other ‘sensory’ disorders, i.e. painful bladder syndrome (PBS) or interstitial cystitis (IC), often remains multifactorial, there is a wide consensus that such clinical conditions may arise from a primary defective urothelium lining or from damaged glycosaminoglycans (GAGs). A ‘cascade’ of events starting from GAG injury, which fails to heal, may lead to chronic bladder epithelial damage and neurogenic inflammation. To restore the GAG layer is becoming the main aim of new therapies for the treatment of chronic cystitis and PBS/IC. Preliminary experiences with GAG replenishment for different pathological conditions involving the lower urinary tract have been reported. There is a range of commercially available intravesical formulations of these components, alone or in combination. Literature evidence shows that exogenous intravesical hyaluronic acid markedly reduces recurrences of urinary tract infections (UTIs). Patients treated with exogenous GAGs have fewer UTI recurrences, a longer time to recurrence and a greater improvement in quality of life. Exogenous intravesical GAGs have been used for the treatment of PBS/IC. Despite the limitations of most of the studies, findings confirmed the role of combination therapy with hyaluronic acid and chondroitin sulfate as a safe and effective option for the treatment of PBS/IC. To prevent and/or treat radiotherapy and chemotherapy induced cystitis, GAG replenishment therapy has been used showing preliminary encouraging results. The safety profile of exogenous GAGs has been reported to be very favourable, without adverse events of particular significance.

68Ga-PSMA Positron Emission Tomography/Computerized Tomography for Primary Diagnosis of Prostate Cancer in Men with Contraindications to or Negative Multiparametric Magnetic Resonance Imaging: A Prospective Observational Study

Purpose: 68Ga labeled prostate specific membrane antigen positron emission tomography/computerized tomography may represent the most promising imaging modality to identify and risk stratify prostate cancer in patients with contraindications to or negative multiparametric magnetic resonance imaging. Materials and Methods: In this prospective observational study we analyzed 68Ga labeled prostate specific membrane antigen positron emission tomography/computerized tomography in a select group of patients with persistently elevated prostate specific antigen and/or Prostate Health Index suspicious for prostate cancer, negative digital rectal examination and at least 1 negative biopsy. The cohort comprised men with equivocal multiparametric magnetic resonance imaging (Prostate Imaging‐Reporting and Data System, version 2 score of 2 or less), or an absolute or relative contraindication to multiparametric magnetic resonance imaging. Sensitivity, specificity and CIs were calculated compared to histopathology findings. ROC analysis was applied to determine the optimal cutoff values of 68Ga labeled prostate specific membrane antigen uptake to identify clinically significant prostate cancer (Gleason score 7 or greater). Results: A total of 45 patients with a median age of 64 years were referred for 68Ga labeled prostate specific membrane antigen positron emission tomography/computerized tomography between January and August 2017. The 25 patients (55.5%) considered to have positive positron emission tomography results underwent software assisted fusion biopsy. We determined the uptake values of regions of interest, including a median maximum standardized uptake value of 5.34 (range 2.25 to 30.41) and a maximum‐to‐background standardized uptake value ratio of 1.99 (range 1.06 to 14.42). Mean and median uptake values on 68Ga labeled prostate specific membrane antigen positron emission tomography/computerized tomography (ie the maximum standardized uptake value or the maximum‐to‐background standardized uptake value ratio) were significantly higher for Gleason score 7 lesions than for Gleason score 6 or benign lesions (p <0.001). On ROC analysis a maximum standardized uptake value of 5.4 and a maximum‐to‐background standardized uptake value ratio of 2 discriminated clinically relevant prostate cancer with 100% overall sensitivity in each case, and 76% and 88% specificity, respectively. Conclusions: Our findings support the use of 68Ga labeled prostate specific membrane antigen positron emission tomography/computerized tomography for primary detection of prostate cancer in a specific subset of men.

MP64-07 VASCULAR HURST INDEX IN NON-TUMORAL BIOPSY CORES AS POTENTIAL HISTOPATHOLOGICAL PARAMETER TO SELECT PATIENTS WITH HIDDEN PROSTATE CANCER

METHODS: 44 cases were analyzed that are surgically operated with robot-assisted radical prostatectomy performed from February to September in 2016. Preoperative MRI have been conducted for all 44 cases, and the prostate cancer local diagnoses (Region of Interest: ROI) were determined by radiologists using MRI T2 weighed image and Diffusion Weighed Image (DWI), then finally the scores of ADC were calculated. IHC for aSMA, vimentin, CD105, and Tenascin-C (TNC-C) were conducted and classified into three group (none stained, weakly stained, strongly stained) to check the relation of those IHC findings to MRI ADC score before the treatment. RESULTS: The average of minimum ADC scores in ROC of these prostate cancer patients before surgery was 0.779 (SD1⁄40.173). IHC comparison were made according to the cut off value of the minimum ADC scores between more (n1⁄418, group A) and less (n1⁄426, group B) than 0.800. 66% (12/18) patients showed strongly stained findings for aSMA in group A. Meanwhile, vimentin, CD105, and TNC-C showed strong stained in B group, 22.2% (4/18) and 61.5% (16/26), 22.2% (4/18) and 0% (0/26), and, 33.3% (6/18) and 76.9% (20/26) in group A and B, respectively.(Conclusions) CONCLUSIONS: To use these multi-parametric MRI findings, especially pretreatment ADC scores, our results suggested postoperative IHC findings and more to address, tumor microenvironment could be predicted.Themorevarious treatmentselectionhavebeenandcouldbeapplied to prostate cancer, such as upfront chemotherapy and wide resection for surrounding tissues, themorepreciseprocedureareneeded topredict tumor microenvironment in order to detect potentially aggressive prostate cancer.

MP64-17 EXTRACELLULAR COLLAGENIC TYPE AND STRUCTURAL ORGANIZATION CHANGES IN PROSTATE CANCER AND BENIGN PROSTATIC HYPERPLASIA

Fabio Grizzi*, Rozzano (MI), Italy; Alberto Mandressi, Castellanza (VA), Italy; Piergiuseppe Colombo, Rozzano (MI), Italy; Sara Melegari, Matteo Justich, Giorgio Bozzini, Mauro Seveso, Oliviero De Francesco, Castellanza (VA), Italy; Nicol o Buffi, Giovanni Lughezzani, Massimo Lazzeri, Rodolfo Hurle, Luisa Pasini, Alessio Benetti, Silvia Zandegiacomo, Roberto Peschechera, Paolo Casale, Giorgio F. Guazzoni, Rozzano (MI), Italy; Gianluigi Taverna, Castellanza (VA), Italy