Urinary and sexual outcomes in long-term (5+ years) prostate cancer disease free survivors after radical prostatectomy

<p>Abstract</p> <p>Background</p> <p>After long term disease free follow up (FUp) patients reconsider quality of life (QOL) outcomes. Aim of this study is assess QoL in prostate cancer patients who are disease-free at least 5 years after radical prostatectomy (RP).</p> <p>Methods</p> <p>367 patients treated with RP for clinically localized pCa, without biochemical failure (PSA ≤ 0.2 ng/mL) at the follow up ≥ 5 years were recruited.</p> <p>Urinary (UF) and Sexual Function (SF), Urinary (UB) and Sexual Bother (SB) were assessed by using UCLA-PCI questionnaire. UF, UB, SF and SB were analyzed according to: treatment timing <it>(age at time of RP, FUp duration, age at time of FUp)</it>, tumor characteristics <it>(preoperative PSA, TNM stage, pathological Gleason score)</it>, nerve sparing (NS) procedure, and hormonal treatment (HT).</p> <p>We calculated the differences between 93 NS-RP without HT (group A) and 274 non-NS-RP or NS-RP with HT (group B). We evaluated the correlation between function and bother in group A according to follow-up duration.</p> <p>Results</p> <p>Time since prostatectomy had a negative effect on SF and a positive effect SB (both p < 0.001). Elderly men at follow up experienced worse UF and SF (p = 0.02 and p < 0.001) and better SB (p < 0.001).</p> <p>Higher stage PCa negatively affected UB, SF, and SB (all: p ≤ 0.05). NS was associated with better UB, SF and SB (all: p ≤ 0.05); conversely, HT was associated with worse UF, SF and SB (all: p ≤ 0.05).</p> <p>More than 8 years after prostatectomy SF of group A and B were similar. Group A subjects (NS-RP without HT) demonstrated worsening SF, but improved SB, suggesting dissociation of the correlation between SF and SB over time.</p> <p>Conclusion</p> <p>Older age at follow up and higher pathological stage were associated with worse QoL outcomes after RP. The direct correlation between UF and age at follow up, with no correlation between UF and age at time of RP suggests that other issues (i.e: vascular or neurogenic disorders), subsequent to RP, are determinant on urinary incontinence. After NS-RP without HT the correlation between SF and SB is maintained for 7 years, after which function and bother appear to have divergent trajectories.</p

The tongue as an alternative donor site for graft urethroplasty: a pilot study

PURPOSE: Urethroplasty with a buccal mucosal graft provides excellent clinical results but it may also cause oral complications in some cases. The mucosa covering the lateral and under surface of the tongue is identical in structure with that lining the rest of the oral cavity. We evaluated LMGs for urethroplasty. MATERIALS AND METHODS: From January 2001 to September 2004, 8 men 34 to 65 years old (mean age 46.1) with urethral strictures 1.5 to 4.5 cm long were selected for 1-stage dorsal onlay urethroplasty. The site of the harvest graft was the lateral mucosal lining of the tongue. Postoperatively all patients were followed with urethrography, uroflowmetry, cystourethrography and flexible urethroscopy after 3 and 12 months. Successful reconstruction criteria were peak flow rate greater than 15 ml per second and no need for postoperative urethral dilation. RESULTS: Median followup was 18 months (mean 22.1, range 3 to 47). Seven cases were successful. One patient had a partial urethral stricture. In successful cases cystourethrography revealed no significant graft contractures or sacculations and at flexible urethroscopy LMG was almost indistinguishable from native urethra. There were no pain, esthetic or functional complications at the donor site. CONCLUSIONS: Harvesting the LMG is feasible and easy to perform. Compared with the buccal mucosal graft the LMG seems to be associated with less postoperative pain and a minor risk of donor site complications. These preliminary functional and esthetic data are satisfactory

LIMITS OF TRANSURETHRAL RESECTION IN DETECTING RARE HISTOLOGICAL VARIANTS WITHIN LARGE UROTHELIAL BLADDER TUMORS

Introduction/Aim: Rare histotypes represent almost 10% of bladder tumors, although more often represented as small foci within large and invasive transitional cell tumors of the bladder (TCCB). It might be clinically relevant that rare histological variants remain unrecognized at transurethral resection (TURBT), since they could indicate more aggressive tumors, less responsive to systemic chemotherapy and unfit for “organsparing” management. We investigated the accuracy of TURBT to detect rare histological variants in patients-candidates to cystectomy for bladder cancer with clinical and radiological features of invasiveness. Materials and Methods: The clinical and pathologic data of 340 patients submitted to TURBT and/or cystectomy for bladder cancer, between January 2010 and July 2015, were reviewed. The presence of uncommon histotypes within urothelial bladder carcinoma has been assessed. The diagnosis of rare variants of bladder cancer was made according to WHO criteria. Standard hematoxilyn-eosin stain was adopted and further immunohistochemistry was performed as follows: Micro-papillary carcinoma, MUC1, EMA, CK7, CK20; Squamous cell carcinoma, CK5/6, CK5/14; Adenocarcinoma, CK7, CK20, CEA, EMA; Small cell carcinoma, EMA, CAM5.2, synaptophysin, vimentin, chromogranin, neurospecific enolase (NSE), CK7, c-kit and TTF1; Mesenchymal tumors, keratin, EMA, vimentin and CEA and, sometimes, hCG. Additional immunohistochemistry was adopted when required to improve the pathological diagnosis. Candidate patients to cystectomy, for reason other than large bladder tumor with radiologic imaging suggestive of bladder wall infiltration, i.e. Tis, multiple and/or recurrent non muscle invasive and patients submitted to TURBT at other centers, were excluded. Inferential statistical analysis was performed. Results: Out of 340 patients, 35 (10.3%) showed rare histotypes of bladder cancer, i.e. in 30 cases (32%) out of 94 radical cystectomies and in 5 (2%) out of 246 TURBTs. The rare histotypes were distributed as follows: squamous carcinoma 11 (31%), sarcomatoid 8 (23%), undifferentiated 6 (17%), neuroendocrine 3 (9%), micropapillary 2 (6%), adenocarcinoma 1 (3%), mixed 4 (11%). TCCB with histological rare variants showed at cystectomy considerable size (average diameter=7.7×6.7 cm; range=4.5×5-11×9 cm), while 13 (43%) were pT4 category. In 13 patients (37%), the uncommon histotype was detected at the pre-operative TURBT, while, in 22 (63%), it was recognized only in the cystectomy specimen. Regarding the correlation between TURBT and re-TUR, rare histotypes were not identified at the first TURBT in 9 patients (26%) but found at re-TURBT in 4 patients (44%) and at cystectomy in 5 patients (56%) (Figure 1). Conversely, an atypical component diagnosed at first TURBT was not confirmed by a subsequent re-TUR in only 1 patient (3%). Discussion: Although the important prognostic role of rare histologic variants of bladder cancer is well-recognized, TURBT is not standardized in relation to tumor size. Unrecognized rare histotypes might have important therapeutic implications since they are probably less responsive to neoadjuvant chemotherapy or bladder-sparing approaches, thus benefiting early cystectomy. The inaccuracy of TUR in everyday clinical practice in detecting uncommon variants could be explained by the inadequacy of sampling of large tumors. The “pre-cystectomy” TUR is often considered a limited biopsy to confirm the tumor and to demonstrate the infiltration of the muscular layer. As a matter of fact, pathologists often do not analyze a sufficient amount of tissue to identify different histological components. Standardization of the TURBT strategy, including sampling of different areas of bulky tumors, could be of clinical value

Microsurgical testis-sparing surgery in small testicular masses: seven years retrospective management and results.

OBJECTIVE: To retrospectively evaluate the clinical outcomes of 20 patients diagnosed with a nonpalpable or small testicular mass (2 cm) at 2 academic urological department. Testis-sparing surgery (TSS) is currently performed routinely for the management of nonpalpable testicular masses. High reliability of frozen section examination (FSE) and high-frequency ultrasound (US) and the adoption of microsurgical techniques improved safety and feasibility of this technique. METHODS: From January 2004 to March 2011, 23 patients underwent microsurgical TSS. An inguinal approach was performed in 22 cases and a suprapubic incision in one bilateral case. All procedures were performed with an operating microscope, with warm ischemia in 21 cases and cold ischemia in 2 cases. Intraoperative US was performed before opening the albuginea. Mean operative time was 89 minutes. RESULTS: After mass excision, FSE was performed; only 2 seminomatous tumors were identified, and the remaining masses were benign lesions. After a mean follow-up >12 months, all patients are free of disease; no hypogonadism developed. CONCLUSIONS: TSS performed using an operating microscope allowed the preservation of testes for 21 patients diagnosed with small testicular and/or nonpalpable mass (<2 cm), without evidence of disease recurrence or de novo onset. This approach could be mandatory in the treatment of bilateral tumors or in solitary testis. Maintaining fertility is not the main goal of TSS because a great number of patients affected by testicular tumors are already infertile. Esthetic outcomes and sparing hormonal function are the main reasons for TSS

Elective segmental ureterectomy for transitional cell carcinoma of the ureter: Long-term follow-up in a series of 73 patients

OBJECTIVES • To report the long-term oncological outcome in patients with transitional cell carcinoma of the ureter electively treated with kidney-sparing surgery. • To compare our data with the few series reported in the literature. PATIENTS AND METHODS • We considered 73 patients with transitional cell carcinoma of the distal ureter treated in five Italian Departments of Urology. • The following surgeries were carried out: 38 reimplantations on psoas hitch bladder (52%), 21 end-to-end anastomoses (28.8%), 11 direct ureterocystoneostomies (15.1%) and three reimplantations on Boari flap bladder (4.1%). • The median follow-up was 87 months. RESULTS • Tumours were pTa in 42.5% of patients, pT1 in 31.5%, pT2 in 17.8% and pT3 in 8.2%. • Recurrence of bladder urothelial carcinoma was found in 10 patients (13.7%) after a median time of 28 months. • The bladder recurrence-free survival at 5 years was 82.2%. • The overall survival at 5 years was 85.3% and the cancer-specific survival rate at 5 years was 94.1%. CONCLUSION • Our data show that segmental ureterectomy procedures do not result in worse cancer control compared with data in the literature regarding nephroureterectomy. © 2012 The Authors

Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: results of a retrospective, comparative, multi-institutional study.

OBJECTIVE: To compare the oncological outcomes of patients who underwent elective partial nephrectomy (PN) or radical nephrectomy (RN) for clinically organ-confined renal masses ≤7 cm in size (cT1). PATIENTS AND METHODS: The records of 3480 patients with cT1N0M0 disease were extracted from a multi-institutional database and analyzed retrospectively. RESULTS: In patients who underwent PN, the risk of clinical understaging was 3.2% in cT1a cases and 10.6% in cT1b cases. With regard to the cT1a patients, the 5- and 10-year cancer-specific survival (CSS) estimates were 94.7% and 90.4%, respectively, after RN and 96.1% and 94.9%, respectively, after PN (log-rank test: P = 0.01). With regard to cT1b patients, the 5-year CSS probabilities were 92.6% after RN and 90% after PN, respectively (log-rank test: P = 0.89). Surgical treatment failed to be an independent predictor of CSS on multivariable analysis, both for cT1a and cT1b patients. Interestingly, PN was oncologically equivalent to RN also in patients with pT3a tumours (log-rank test: P = 0.91). CONCLUSIONS: Elective PN is not associated with an increased risk of recurrence and cancer-specific mortality in both cT1a and cT1b tumours. Data from the present study strongly support the use of partial nephrectomy in patients with clinically T1 tumours, according to the current recommendations of the international guidelines