Rodolfo Hurle

Impact on sexual function of holmium laser enucleation versus transurethral resection of the prostate : Results of a prospective, 2-center, randomized trial

PURPOSE We compared the impact of HoLEP and TURP on sexual function. MATERIALS AND METHODS Between January 2002 and January 2003, 120 patients with a mean age +/- SD of 65.2 +/- 7.1 years who had benign prostatic hyperplasia were enrolled in this 2-center, prospective, randomized study. A total of 60 patients with a mean age of 65.25 +/- 6.9 years underwent HoLEP (group 1) and 60 with a mean age of 64.18 +/- 7.2 years underwent TURP (group 2). Patients were assessed before surgery, and at 12 and 24-month followup visits. Subjective symptoms were scored by the International Prostate Symptom Score, the International Prostate Symptom Score quality of life question, IIEF, 10 nonvalidated general assessment questions, physical examination, serum prostate specific antigen and transrectal ultrasonography. RESULTS A total of 32 patients (53.3%) in group 1 and 31 (51.6%) in group 2 reported various degrees of erectile dysfunction before surgery according to the IIEF-EF score. Differences between preoperative and postoperative orgasmic domain scores in each group were significant (p <0.001). A slight but not significant increase in the mean IIEF-EF domain score was reported in each group at postoperative assessments without any difference between the 2 surgical approaches. According to general assessment question analysis the prevalence of subjectively reported postoperative retrograde ejaculation was significantly higher than at baseline assessment in the 2 groups with no differences between the 2 surgical procedures. CONCLUSIONS TURP and HoLEP significantly lowered the IIEF orgasmic function domain with no differences between techniques. This was caused by retrograde ejaculation. Marginal, nonsignificant erectile function improvement was reported after surgery in the 2 groups.

Holmium Laser Enucleation of the Prostate Combined with Mechanical Morcellation: Two Years of Experience with 196 Patients

BACKGROUND AND PURPOSE For 2 years, we followed a cohort of consecutive men who underwent holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation to relieve bladder outlet obstruction with the goal of determining the safety, efficacy, and durability of this procedure. PATIENTS AND METHODS From January 2000 to June 2001, 196 men with symptomatic bladder outlet obstruction were treated with HoLEP at our institution. A pulsed high-power 80 W holmium laser was used, with the enucleated tissue being removed with a transurethral mechanical morcellator. All patients underwent volume evaluation, peak urinary flow rate estimation (Qmax), postvoiding residual urine volume measurement, International Prostate Symptom Score determination, and a single-question quality of life (QoL) score. Immediate and long-term complications were assessed. RESULTS The total operative time averaged 83.2 +/- 42.5 minutes, and the average resected weight was 36 +/- 26 g. The morcellation efficiency was 2.8 +/- 1.0 g/min. The mean catheter time was 19 +/- 13 hours, and the hospital stay averaged 1.5 +/- 1.0 days. The mean hemoglobin value and serum sodium concentration did not change, and no patient needed a blood transfusion or experienced hyponatremia. With a mean follow-up of 12.6 +/- 4.9 months (range 6-24 months), significant improvement has been seen in all voiding measures, with a 148% increase in Qmax and a 60% improvement in the symptom score at 1 year postoperatively. Overall, 89% of the patients noticed an improvement in QoL. The complications have been irritative urinary symptoms in 23%, bladder mucosal injury in 6.6%, and transient stress incontinence in 7.1%. Eight patients (4.0%) have required reoperation. CONCLUSION The HoLEP procedure is an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Wider application and technical refinement will allow the surgeon to reduce the operative time and to render mechanical morcellation safer.

Holmium laser enucleation of the prostate combined with mechanical morcellation in 155 patients with benign prostatic hyperplasia.

OBJECTIVES To report our experience with holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS From January 2000 to May 2001, 155 consecutive patients with BPH underwent HoLEP combined with mechanical morcellation and were followed up for at least 6 months. A pulsed high-powered 80-W holmium-neodymium:yttrium-aluminum-garnet laser was used (power setting 2.0 J/pulse, 35 pulses/s, and 70 W). The enucleated tissue was removed by a transurethral mechanical morcellator. RESULTS The preoperative mean prostate volume was 53 +/- 39 cm3; 38.7% of patients had an estimated gland volume greater than 50 cm3; 30.8% had BPH complicated by urinary retention, bladder calculi, bladder diverticula, or urethral stricture. The total mean operative time was 87 +/- 44 minutes, the resected weight was 37 +/- 26 g, and the morcellation efficiency was 1.9 +/- 1.6 g/min. The catheter time was 18 +/- 13.5 hours and the hospital stay 1.5 +/- 1.0 days. No patient needed a blood transfusion or experienced hyponatremia. The patients were followed up for a mean of 13 +/- 5 months (range 6 to 24). The International Prostate Symptom Score, quality-of-life score, and peak urinary flow rate had improved significantly 1 month after HoLEP and continued to improve in the next few months, regardless of whether the gland volume was more or less than 50 cm3. CONCLUSIONS HoLEP combined with mechanical morcellation is an efficient surgical intervention for BPH, regardless of gland size.

Olfactory System of Highly Trained Dogs Detects Prostate Cancer in Urine Samples

PURPOSE We established diagnostic accuracy in terms of the sensitivity and specificity with which a rigorously trained canine olfactory system could recognize specific volatile organic compounds of prostate cancer in urine samples. MATERIALS AND METHODS Two 3-year-old female German Shepherd Explosion Detection Dogs were trained to identify prostate cancer specific volatile organic compounds in urine samples. They were tested on 362 patients with prostate cancer (range low risk to metastatic) and on 540 healthy controls with no nonneoplastic disease or nonprostatic tumor. This cross-sectional design for diagnostic accuracy was performed at a single Italian teaching hospital and at the Italian Ministry of Defense Military Veterinary Center. RESULTS For dog 1 sensitivity was 100% (95% CI 99.0-100.0) and specificity was 98.7% (95% CI 97.3-99.5). For dog 2 sensitivity was 98.6% (95% CI 96.8-99.6) and specificity was 97.6% (95% CI 95.9-98.7). When considering only men older than 45 years in the control group, dog 1 achieved 100% sensitivity and 98% specificity (95% CI 96-99.2), and dog 2 achieved 98.6% sensitivity (95% CI 96.8-99.6) and 96.4% specificity (95% CI 93.9-98.1). Analysis of false-positive cases revealed no consistent pattern in participant demographics or tumor characteristics. CONCLUSIONS A trained canine olfactory system can detect prostate cancer specific volatile organic compounds in urine samples with high estimated sensitivity and specificity. Further studies are needed to investigate the potential predictive value of this procedure to identify prostate cancer.

Pelvic lymphadenectomy during radical cystectomy: A review of the literature

Currently, radical cystectomy associated with pelvic lymph node dissection is the gold standard surgical treatment for muscle invasive bladder cancer. However, although there is consensus on the need for pelvic lymph node dissection, controversies still exist regarding its extent and exact role. Evidence from the literature is based on retrospective data from high volume, often multicentre studies. Different series report very different templates of lymphadenectomy, thereby complicating data analysis. Furthermore, morbidity related to lymphadenectomy does not seem to be influenced by the extent of the procedure. The role of the pathologist and the modality of node retrieval have a pivotal role in the quality of node assessment. Different prognostic factors regarding node status (number of nodes retrieved, lymphovascular invasion, lymph node density, extracapsular extension, gross node involvement, and extent of primary bladder tumour related to positive nodes) have been introduced and analysed, although the impact on staging and survival are still under investigation. The correct use and assessment of these prognostic factors should help to provide an accurate staging in order to identify those patients who need adjuvant therapy. Future studies should, therefore, be prospective and include all information achievable from a lymphadenectomy.

Mast cells as a potential prognostic marker in prostate cancer.

Despite years of intensive investigation that has been made in understanding prostate cancer, it remains one of the major mens health issues and the leading cause of death worldwide. It is now ascertained that prostate cancer emerges from multiple spontaneous and/or inherited alterations that induce changes in expression patterns of genes and proteins that function in complex networks controlling critical cellular events. It is now accepted that several innate and adaptive immune cells, including T- and B-lymphocytes, macrophages, natural killer cells, dendritic cells, neutrophils, eosinophils, and mast cells (MCs), infiltrate the prostate cancer. All of these cells are irregularly scattered within the tumor and loaded with an assorted array of cytokines, chemokines, and inflammatory and cytotoxic mediators. This complex framework reflects the diversity in tumor biology and tumor-host interactions. MCs are well-established effector cells in Immunoglobulin-E (Ig-E) associated immune responses and potent effector cells of the innate immune system; however, their clinical significance in prostate cancer is still debated. Here, these controversies are summarized, focusing on the implications of these findings in understanding the roles of MCs in primary prostate cancer.

Impact of Real-Time Elastography versus Systematic Prostate Biopsy Method on Cancer Detection Rate in Men with a Serum Prostate-Specific Antigen between 2.5 and 10 ng/mL.

The actual gold standard for the diagnosis of prostate cancer includes the serum prostate-specific antigen, the digital rectal examination, and the ultrasound-guided systematic prostate biopsy sampling. In the last years, the real-time elastography has been introduced as an imaging technique to increase the detection rate of prostate cancer and simultaneously reduce the number of biopsies sampled for a single patient. Here, we evaluated a consecutive series of 102 patients with negative digital-rectal examination and transrectal ultrasound, and prostate-specific antigen value ranging between 2.5 ng/mL and 10 ng/mL, in order to assess the impact of real-time elastography versus the systematic biopsy on the detection of prostate cancer. We found that only 1 out of 102 patients resulted true positive for prostate cancer when analysed with real-time elastography. In the other 6 cases, real-time elastography evidenced areas positive for prostate cancer, although additional neoplastic foci were found using systematic biopsy sampling in areas evidenced by real-time elastography as negative. Although additional studies are necessary for evaluating the effectiveness of this imaging technique, the present study indicates that the limited accuracy, sensitivity, and specificity do not justify the routine application of real-time elastography in prostate cancer detection.

Application and Uses of Electronic Noses for Clinical Diagnosis on Urine Samples: A Review.

The electronic nose is able to provide useful information through the analysis of the volatile organic compounds in body fluids, such as exhaled breath, urine and blood. This paper focuses on the review of electronic nose studies and applications in the specific field of medical diagnostics based on the analysis of the gaseous headspace of human urine, in order to provide a broad overview of the state of the art and thus enhance future developments in this field. The research in this field is rather recent and still in progress, and there are several aspects that need to be investigated more into depth, not only to develop and improve specific electronic noses for different diseases, but also with the aim to discover and analyse the connections between specific diseases and the body fluids odour. Further research is needed to improve the results obtained up to now; the development of new sensors and data processing methods should lead to greater diagnostic accuracy thus making the electronic nose an effective tool for early detection of different kinds of diseases, ranging from infections to tumours or exposure to toxic agents.

Robot-assisted Surgery for Benign Ureteral Strictures: Experience and Outcomes from Four Tertiary Care Institutions

BACKGROUND Minimally invasive treatment of benign ureteral strictures is still challenging because of its technical complexity. In this context, robot-assisted surgery may overcome the limits of the laparoscopic approach. OBJECTIVE To evaluate outcomes for robotic ureteral repair in a multi-institutional cohort of patients treated for ureteropelvic junction obstruction and ureteral stricture (US) at four tertiary referral centres. DESIGN, SETTING, AND PARTICIPANTS This retrospective study reports data for 183 patients treated with standard robot-assisted pyeloplasty (PYP) and robotic uretero-ureterostomy (UUY) at four high-volume centres from January 2006 to September 2014. SURGICAL PROCEDURE Robotic PYP and robot-assisted UUY were performed according to previously reported surgical techniques. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Preoperative, intraoperative, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS No robot-assisted UUY cases required surgical conversion, while 2.8% of PYP cases were not completed robotically. The median operative time was 120 and 150min for robot-assisted PYP and robot-assisted UUY, respectively. No intraoperative complications were reported. The overall complication rate for all procedures was 11% (n=20) and complications were mostly of low grade. The high-grade complication rate was 2.2% (n=4). At median follow-up of 24 mo, the overall success rate was >90% for both procedures. The study limitations include its retrospective nature and the heterogeneity of the study population. CONCLUSIONS Robotic surgery for benign US is safe and effective, with limited risk of high-grade complications and good intermediate-term results. PATIENT SUMMARY In this study we review the use of robotic surgery at four different tertiary care centres in the treatment of patients affected by benign ureteral strictures. Our results demonstrate that robotic surgery is a safe alternative to the standard open approach in the treatment of ureteral strictures.

Modified Glasgow Prognostic Score is Associated With Risk of Recurrence in Bladder Cancer Patients After Radical Cystectomy: A Multicenter Experience

Abstract Recently, many studies explored the role of inflammation parameters in the prognosis of urinary cancers, but the results were not consistent. The modified Glasgow Prognostic Score (mGPS), a systemic inflammation marker, is a prognostic marker in various types of cancers. The aim of the present study was to investigate the usefulness of the preoperative mGPS as predictor of recurrence-free (RFS), overall (OS), and cancer-specific (CSS) survivals in a large cohort of urothelial bladder cancer (UBC) patients. A total of 1037 patients with UBC were included in this study with a median follow-up of 22 months (range 3–60 months). An mGPS = 0 was observed in 646 patients (62.3%), mGPS = 1 in 297 patients (28.6 %), and mGPS = 2 in 94 patients (9.1%). In our study cohort, subjects with an mGPS equal to 2 had a significantly shorter median RFS compared with subjects with mGPS equal to 1 (16 vs 19 months, hazard ratio [HR] 1.54, 95% CI 1.31–1.81, P < 0.001) or with subjects with mGPS equal to 0 (16 vs 29 months, HR 2.38, 95% CI 1.86–3.05, P < 0.001). The association between mGPS and RFS was confirmed by weighted multivariate Cox model. Although in univariate analysis higher mGPS was associated with lower OS and CSS, this association disappeared in multivariate analysis where only the presence of lymph node-positive bladder cancer and T4 stage were predictors of worse prognosis for OS and CSS. In conclusion, the mGPS is an easily measured and inexpensive prognostic marker that was significantly associated with RFS in UBC patients.