Salvatore Butticè

Diagnostic Accuracy of 64Copper Prostate-specific Membrane Antigen Positron Emission Tomography/Computed Tomography for Primary Lymph Node Staging of Intermediate- to High-risk Prostate Cancer: Our Preliminary Experience

OBJECTIVE To assess the diagnostic accuracy of 64Copper prostate-specific membrane antigen (64Cu-PSMA) positron emission tomography/computed tomography (PET/CT) in the primary lymph node (LN) staging of a selected cohort of intermediate- to high-risk prostate cancer (PCa) patients. MATERIALS AND METHODS An observational prospective study was performed in 23 patients with intermediate- to high-risk PCa, who underwent 64Cu-PSMA PET/CT for local and lymph nodal staging before laparoscopic radical prostatectomy with an extended pelvic LN dissection. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) for LN status of 64Cu-PSMA PET/CT were calculated using the final pathological findings as reference. Furthermore, we evaluated the correlation of intraprostatic tumor extent and grading with 64Cu-PSMA intraprostatic distribution. RESULTS Pathological analysis of LN involvement in 413 LNs harvested from our study cohort identified a total of 22 LN metastases in 8 (5%) of the 23 (35%) PCa patients. Imaging-based LN staging in a per-patient analysis showed that 64Cu-PSMA PET/CT was positive in 7 of 8 LN-positive patients (22%) with a sensitivity of 87.5%, specificity of 100%, PPV of 100%, and NPV of 93.7%, considering the maximum standardized uptake value (SUVmax) at 4 hours as our reference. Receiver operating characteristic curve was characterized by an area under the curve of 0.938. A significant positive association was observed between SUVmax at 4 hours with Gleason score, index, and cumulative tumor volume. CONCLUSION In our intermediate- to high-risk PCa patients study cohort, we showed the high diagnostic accuracy of 64Cu-PSMA PET/CT for primary LN staging before radical prostatectomy.

Etiology, pathophysiology and biomarkers of interstitial cystitis/painful bladder syndrome

PurposeInterstitial cystitis/painful bladder syndrome (IC/PBS) is a chronic pain syndrome and a chronic inflammatory condition prevalent in women that leads to urgency, sleep disruption, nocturia and pain in the pelvic area, to the detriment of the sufferer’s quality of life. The aim of this review is to highlight the newest diagnostic strategies and potential therapeutic techniques.MethodsA comprehensive literature review was performed on MEDLINE, PubMed, and Cochrane databases gathering all literature about “Interstitial cystitis” and “Painful Bladder Syndrome”. Visual analogue scales, epidemiological strategies, pain questionnaires and similar techniques were not included in this literature survey.ResultsThe etiology, exact diagnosis and epidemiology of IC/PBS are still not clearly understood. To date, its prevalence is estimated to be in the range of 45 per 100,000 women and 8 per 100,000 men, whereas joint prevalence in both sexes is 10.6 cases per 100,000. There are no “gold standards” in the diagnosis or detection of IC/PBS, therefore, several etiological theories were investigated, such as permeability, glycosaminoglycans, mast cell, infection and neuroendocrine theory to find new diagnostic strategies and potential biomarkers.ConclusionDue to the fact that this disease is of an intricate nature, and that many of its symptoms overlap with other concomitant diseases, it could be suggested to classify the patients with emphasis on the phenotype, as well as their symptom clusters, to tailor the diagnostic and management choices according to the observed biomarkers.

Different patterns of pelvic ureteral endometriosis. What is the best treatment? Results of a retrospective analysis

OBJECTIVE Endometriosis is an estrogendependent disease. The incidence of urinary tract endometriosis (UE) increased during the last few years and, nowadays, it ranges from 0.3 to 12% of all women affected by the disease. The ureter is the second most common site affected. The ureteral endometriosis is classified in extrinsic and intrinsic. The aim of this study is to individuate the best treatments for each subset of ureteral endometriosis. MATERIALS AND METHODS 32 patients diagnosed with surgically treated UE were retrospectively reviewed. The patients were divided into 3 subsets (intrinsic UE, extrinsic UE with and without obstruction). The patients with intrinsic UE (n = 10) were treated with laser endoureterotomy. The patients with extrinsic UE (n = 22) were divided in two subsets with (n = 16) and without (n = 6) hydronephrosis. All the patients underwent ureteral stenting, and resection and reimplantation was performed in the first group, and when the mass was > 2.5 cm (n = 3) Boari flap was performed. Laparoscopic ureterolysis (shaving) was performed in the second group. RESULTS In the extrinsic subset of UE, we obtained an high therapeutic success (84%). Conversely, in the intrinsic subset there was a recurrence rate of the disease in 6/10 of the patients (60%). CONCLUSIONS Ureterolysis seems to be a good treatment in extrinsic UE without obstruction. Resection and reimplantation allows excellent results in the extrinsic UE with obstruction. In the intrinsic subset, the endoureterotomy approach is inadequate.

Hybrid Transvaginal NOTES Nephrectomy: Postoperative Sexual Outcomes. A Three-center Matched Study

OBJECTIVE To evaluate our experience in patients undergoing hybrid transvaginal natural orifices transluminal endoscopic surgery (NOTES) nephrectomy and evaluate the sexual functions in the postoperative period. MATERIALS AND METHODS Prospective data of 71 patients with renal tumors who underwent hybrid NOTES radical nephrectomy in three different centers were collected from March 2010 to October 2015. Patient and surgical characteristics were recorded. Sexual function was evaluated using the Female Sexual Function Index questionnaire the day prior to the operation and 3 months after. RESULTS The mean age, tumor size, and operation duration were 66.16 ± 11.21, 8.51 ± 3.31 cm, and 119.94 ± 21.38 minutes, respectively. Five patients were immediately reoperated due to bleeding from uterine veins. The complication risk increases significantly with increasing tumor size. Among the whole cohort, even the Female Sexual Function Index score differences are small; there is a statistically significant decrease in the postoperative period in all domains except sexual satisfaction. In fact, the patients reported unaltered sexual function after surgery and satisfaction with the result when asked directly. In subgroup analyses, in nulliparous patients (n = 60), arousal, sexual desire, orgasm, and satisfaction domains have no significant differences in pre- and postoperative periods. CONCLUSIONS Hybrid NOTES nephrectomy is a feasible, safe operation that can be performed for large renal tumors. Due to incisions in the vaginal wall for specimen retrieval, sexual function can be altered in the postoperative period. So patient selection, preoperative evaluation, and close follow-up are mandatory. With this in mind, we strongly support the use of hybrid transvaginal NOTES nephrectomy for large renal tumors especially in nulliparous patients.

Lumbar Ureteral Stenosis due to Endometriosis: Our Experience and Review of the Literature

Endometriosis is a chronic gynaecological disorder characterized by the presence of endometrial tissue outside the uterus. The disease most often affects the ovaries, uterine ligaments, fallopian tubes, and cervical-vaginal region. Urinary tract involvement is rare, accounting for around 1%-2% of all cases, of which 84% are in the bladder. We report a case of isolated lumbar ureteral stenosis due to endometriosis in a 37-year-old patient. The patient came to our observation complaining from lumbar back pain and presented with severe fever. The urological examination found monolateral left positive sign of Giordano. Blood tests evidenced marked lymphocytosis and increased valued of C-reactive protein. Urologic ultrasound showed hydronephrosis of first degree in the left kidney and absence of images related to stones bilaterally. Uro-CT scan evidenced ureteral stenosis at the transition between the iliac and pelvic tracts. We addressed the patient to surgery, and performed laparoscopic excision of the paraureteral bulk, endoscopic mechanical ureteral dilation, and stenting. The histological examination evidenced glandular structures lined by simple epithelium and surrounded by stroma. Immunohistochemical test of the glandular epithelium showed positivity for estrogen and progesterone receptors and moreover stromal cells were positive for CD10. The finding suggested a very rare diagnosis of isolated lumbar ureteral endometriosis.

Comment on “efficacy and safety of skeletonized mesh implants for advanced pelvic organ prolapse: 12 month follow up”

and validated questionnaires were used. As we previously indicated [3], several analytical tools are available in the literature for the evaluation of sexual function in patients undergoing surgery for POP and stress urinary incontinence, including the Female Sexual Function Index (FSFI) questionnaire [4, 5] and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12) [6]: these two questionnaires, in particular, are designed to measure objectively different areas of sexual function as well as behavioral/emotional and partner-related factors. Considering the lack of measurable elements and consequent reproducibility, the data analysis by Weintraub et al. [1] about sexual function could be considered severely biased, and the conclusion flawed. Previous data suggest that there is a corresponding association between sexual heath and clitoral vascularization evaluated by color Doppler sonography [7]. Regarding this point, we already indicated [8] that surgical techniques that provide perforation of the paraurethral spaces to place suburethral slings can diminish sexual function due to scars and reduced elasticity of the vaginal wall, which may result in reduced blood supply to the erectile tissues of the clitoris and, consequently, may have a detrimental effect on sexual function. Nevertheless, we previously showed [9] that the treatment of severe (third and fourth degree, according to Baden and Walker’s classification) cystocele using a biocompatible porcine dermis graft improves quality of life and sexual function without any change in clitoral blood flow, suggesting that this last parameter may be only partly responsible for the reported improvement and cannot allow us to draw a firm conclusion about sexual health if considered alone. Basing on these data and our experience, we strongly suggest the use of standardized and validated questionnaires (alone or in combination with clitoral vascularization Dear Editor,

Role of urocortin in pregnancy: An update and future perspectives

The activities of corticotropin-releasing factor (CRF) and related peptides are mediated a number of receptors with seven transmembrane domains that are coupled to the Gs and Gq proteins. These receptors are known as CRF-Rs. In vitro studies have evidenced that urocortin (UCN) and CRF provoke an increase in the contractility of the uterus which is induced by endometrial prostaglandin F2a. Furthermore, through trophoblasts, it stimulates the secretion of adrenocorticotropic hormone (ACTH) and prostaglandin PGE2 and has a vasodilatory effect on the placenta. While it is well known that the placenta produces considerable quantities of CRF, several studies have, however, excluded that the placenta can generate significant quantities of UCN. In the short term, the human fetal adrenal gland produces more cortisol and dehydroepiandrosterone sulfate. The gestational tissues express UCN3 and UCN2 mRNA in cytotrophoblast and syncytiotrophoblast cells, while UCN2 is only to be found in the maternal and fetal vessels and amniotic cells. Nevertheless, gestational tissues express UCN2 and UCN3 differentially and do not stimulate placental ACTH secretion. In term pregnancies, maternal plasma levels of CRF and UCN are lower than at the beginning of pregnancy and are correlated to labor onset. Conversely, they do not decrease in post-term pregnancies. This evidence would seem to indicate that the fine-regulated expression of these neuropeptides is important in determining the duration of human gestation. In this scenario, low concentrations of UCN in the amniotic fluid at mid-term may be considered a sign of predisposition to preterm birth.

Thulium Vaporesection of the Prostate and Thulium Vapoenucleation of the Prostate in Patients on Oral Anticoagulants: A Retrospective Three-Centre Matched-Paired Comparison

Introduction: To evaluate the short-term results of thulium vaporesection of the prostate (ThuVEP) and thulium vapoenucleation of the prostate (ThuVARP) in patients with benign prostatic obstruction on oral anticoagulants (OA). Methods: A 3-centre retrospective matched-paired comparison of patients treated by ThuVEP (n = 26) or ThuVARP (n = 26) was performed. Thirty-four patients were on aspirin/ticlopidin, 7 on clopidogrel or clopidogrel and aspirin, and 11 on phenprocoumon at the time of surgery. Results: Haemoglobin decrease was higher after ThuVEP compared to ThuVARP (1.5 vs. 0.3 g/dl, p < 0.001). The rate of postoperative blood transfusions (3.9 vs. 0%), clot retention (3.9 vs. 0%), and re-operation (7.7 vs. 0%) was not different between ThuVEP and ThuVARP (p = 0.274). Catheterization time was shorter for ThuVARP (1 vs. 2 days, p < 0.01). Qmax was significantly higher after ThuVEP at 6-month follow-up (31 vs. 21.5 ml/s, p < 0.001), while improvements in International Prostate Symptom Score, quality of life, and post-voiding residual urine showed no differences between the groups. Urethral or bladder neck strictures did not occur during the 6-month follow-up in both groups. Conclusions: ThuVEP and ThuVARP are safe and efficacious procedures in patients on OA. Although patients assigned to ThuVEP had higher Qmax at 6-month follow-up, ThuVARP resulted in similar functional outcomes.

Transvaginal Bilateral Sacrospinous Fixation after Second Recurrence of Vaginal Vault Prolapse: Efficacy and Impact on Quality of Life and Sexuality

Objective Our aim was to study the efficacy of transvaginal bilateral sacrospinous fixation (TBSF) and its impact on quality of life (QoL) and sexual functions in women affected by second recurrences of vaginal vault prolapse (VVP). Materials and Methods We performed a prospective observational study on 20 sexually active patients affected by second recurrence of VVP, previously treated with monolateral sacrospinous fixation. TBSF was performed in all the patients. They had been evaluated before the surgery and at 12-month follow-up through pelvic organ prolapse quantification (POP-Q) system, Short Form-36 (SF-36), and Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ-12). Results At 12-month follow-up, 18 out of 20 (90%) patients were cured of their recurrent VVP. No major intra- and postoperative complications occurred. We found a significant improvement in 4/5 POP-Q landmarks (excluding total vaginal length), SF-36, and PISQ-12 scores. Conclusion According to our data analysis, TBSF appears to be safe, effective, and able to improve both QoL and sexual functions in patients affected by second recurrence of VVP after previous monolateral sacrospinous fixation.

Correlation Between Advanced Glycation End-Products, Lower Urinary Tract Symptoms and Bladder Dysfunctions in Patients with type 2 Diabetes Mellitus

To explore whether serum and urinary advanced glycation end‐products (AGEs) are related to urinary symptoms and bladder dysfunctions in diabetic patients.