Compliance to therapy with Dapoxetine in comparison to a conventional selective serotonin reuptake inhibitor (Citalopram) in 118 patients with premature ejaculation.

Premature Ejaculation (PE) is a sexual dysfunction that concern 20-30% of the male population. Dapoxetine is a new serotonine re-uptake inhibitor (SSRI)specific for PE treatment.Aim of the study is to assess compliance and effectiveness of the treatment with dapoxetine compared to the treatment with citalopram (a classic SSRI used to treat PE)

LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR

LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR Cristina Scalici Gesolfo1, Sebastiano Billone1, Alessio Guarneri1, Marco Vella1, Alessandro Perez2, Graziella Cangemi2, Antonio Russo2, Alchiede Simonato1,Vincenzo Serretta1 and GSTU Foundation3 1Section of Urology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Palermo, Italy; 2Section of Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy; 3Palermo, Italy Introduction: Studies on the role of EGFR in non-muscleinvasive bladder cancer (non-MIBC) are lacking. EGFR expression has been determined mainly in tissue specimens of MIBC and its overexpression has been associated with worse prognosis and shorter survival. Urothelial EGFR status after transurethral resection (TUR) of non-MIBC could indicate the risk of recurrence and progression. We investigated the feasibility of EGFR measurement in bladder washings of patients undergoing intravesical adjuvant therapy for non-MIBC and its usefulness in identifying risk subgroups. Patients and Methods: Our prospective study included patients after TUR of non-MIBC and healthy controls. Samples of bladder washings were centrifuged at 4˚C for 10 minutes at 1500 rpm, washed in cold phosphate buffer saline solution and centrifuged again obtaining a cellular pellet stored at −80˚C until RNA extraction was performed by miRNeasy Mini Kit (QiagenR). A Nanodrop ND-2000 spectrophotometer was used to check for good quality of RNA. RNA criteria to proceed with reverse transcription to cDNA: minimum 500 ng/ml, protein (260/280) solvents and organic compounds (260/230), contamination ratio 1.7-2.5. The cDNA obtained from RNA by High Capacity cDNA Reverse Transcription Kit (Life TechnologiesR) was used to perform a gene expression analysis by a real-time PCR, according to the method of the comparative quantification (ΔΔCt) with an endogenous control (cyclophilin). Every reaction was set in triplicate as a further guarantee of quality. The patients were grouped for EAU risk class and maintained in follow-up. EGFR expressions were statistically analyzed according to EAU risk groups and to patients’ outcomes. EGFR gene expression values were expressed in folds of change compared to healthy controls (EGFR=1). Results: Fifty-eight patients and 21 healthy age-matched controls were entered. An adequate cellular pellet was obtained in 50 patients (86.2%) showing a median EGFR expression of 2.0-fold (IQR=0.6-4.3-fold, p=0.0004). The median level of EGFR varied considerably among the EAU risk classes. After TUR and adjuvant intravesical therapy, in 22 (55%) out of 40 high-risk patients, EGFR decreased to 1.3-fold (IQR=0.9-1.5-fold), while 18 (45%) showed elevated EGFR, median=4.7-fold (IQR=4.1-11.6-fold). At 25 months median follow-up (IQR=19.0-34.8 months), 20 (40%) patients experienced recurrence and six (12%) progression. Among patients with and those without EGFR gene increase, disease in nine (22.5%) and five (12.5%) recurred and in five (12.5%) and one (2.5%) progressed, respectively. Conclusion: In our experience EGFR expression measurement was feasible in more than 85% of patients and was related to EAU risk classes for recurrence and progression, showing different behavior during intravesical therapy. It was possible to identify a subgroup of high-risk patients overexpressing EGFR in spite of intravesical adjuvant therapy. EGFR evaluation in bladder washing could represent a repeatable and useful tool to identify a subgroup of patients at risk for progression predicted as not being responsive to intravesical adjuvant therapy and candidates for early radical cystectomy. We wish to thank GSTU Foundation for data and statistical management

WHATSAPP MESSENGER AS A REAL-TIME TOOL FOR A LONG-DISTANCE ACTIVITY OF A MULTIDISCIPLINARY

Introduction: Communication between doctors is traditionally conducted by written clinical charts. Mobile health is becoming an integral part of modern medical systems, improving accessibility and quality of medical care. Recent papers suggest that an increasing number of doctors are using in their clinical practice mobile tools to communicate clinical informations (1, 2). The aim of our study was to verify the adoption of WhatsApp Messenger in everyday clinical practice to obtain a real-time multidisciplinary collaboration among medical centers located in different areas of the city. Materials and Methods: In January 2016 a WhatsApp Messenger group was created among 25 specialists: 9 urologists, 9 oncologists, 3 urology residents, 3 radiotherapists and 1 general practitioner. A general coordinator and a group coordinator for each specialty was monthly appointed. The participants were invited to interact within the group clinical cases of genitourinary tumors of particular complexity requiring a multidisciplinary approach. All the chats were registered. A preliminary analysis of the activity of the group was planned after the first 10 entered patients. An evaluation questionnaire was sent after 6 months to evaluate the level of appreciation. The questionnaire was composed of a first section investigating the appreciation among the members of the group and a second section analyzing the impact in their everyday clinical practice of whatsapp multidisciplinary consultation. Results: In 10 (91%) out of 11 patients the WhatsApp consultation was completed, one case was not of oncological interest. An average of 8 (range=2-13) specialists joined the chat for each patient. An average of 17.6 (range: 4-43) interventions for each clinical case was recorded. On the average, 27%, 54% and 19% of the interventions for each clinical case were provided by oncologists, urologists and radiotherapists respectively. In 9 (81.8%) cases a final agreement on the patient's management was reached. At the evaluation questionnaire in a scale 1-10, the average rating score of appreciation was 7.8 (range=4-10). Relevant suggestions to improve the Whatsapp Messenger consultation were obtained and will be considered for future application the ameliorate the tool. Discussion: WhatsApp is a useful alternative and powerful complementary communication tool because of its capability to rapidly transfer large amount of clinical and radiological data. In our experience this new approach for multidisciplinary consultations improved collaboration among different specialist in different areas of the city through an easier and more informal change of opinions. In difficult and complex cases a rapid multidisciplinary approach allowed to offer the patient a personalized and tailored therapy management. GSTU Foundation. 1Sidhoum N, Dast S, Abdulshakoor A, Assaf N, Herlin C and Sinna R: WhatsApp: Improvement tool for surgical team communication. J Plast Reconstr Aesthet Surg 69: 1562-1563, 2016. 2 Gould G and Nilforooshan R: WhatsApp Doc? BMJ Innov 2(3): 109-110, 201

Clinical pitfalls in diagnosis of nonmuscle-invasive bladder cancer

Current global economic crisis imposes healthcare system to reduce unnecessary investigations and increase early detection of tumors, to decrease the costs of an advanced disease. Several diagnostic pitfalls may occur dealing with bladder cancer (BC), particularly in nonmuscle-invasive (NMIBC) one. Hematuria, the commonest sign in NMIBC, is often underestimated. Urinary cytology is highly specific for high-grade tumors, but has a low sensitivity for low-grade BC, is operator dependent, and not always obtainable in clinical practice. Numerous urinary tests are available to ameliorate the accuracy of cytology, but none of them is routinly used in urological practice. Ultrasound could hardly detect a small bladder tumor, especially if located in the bladder neck or in the anterior wall. Computed tomography (CT) is widely adopted as an alternative to conventional urography, but its usefulness in patients with hematuria is still debated. MRI has a higher accuracy than CT for staging BC and evaluate the bladder-wall invasion. A negative cystoscopy cannot exclude Tis and should be accompanied by urinary cytology in patients with suspected Tis or high-risk NMIBC; however, new techniques such as narrow band imaging (NBI) and photodynamic (PDD) increase the detection rate of BC and flat lesions. Nearly half of all diagnostic resections present omission of muscle in the specimen or its mention in the pathology report, which is associated with an increased mortality. An adequate muscle sampling during endoscopic resection is mandatory, particularly in patients with high-grade disease. Recognition of pitfalls in diagnosis and management of BC represents the first step for a correct approach

Mitomycin C from birth to adulthood

Mitomycin C (MMC) intravesical therapy for "superficial" papillary bladder tumors was firstly introduced in the early seventies with promising results. In the following years, several pharmacokinetic studies investigated its mechanism of action to optimize the intravesical administration. Numerous studies confirmed thereafter both the ablative and the prophylactic efficacy and the low toxicity of MMC when intravesically given. In 1984, a complete response rate of 42% in 60 patients not responsive to thiotepa was reported with intravesical MMC at the dose of 40 mg diluted in 40 ml for 8 weeks. In the following decades, many large randomized studies showed the benefit of intravesical prophylaxis with MMC versus transurethral resection (TUR) alone. Since 2002, the role of adjuvant intravesical chemotherapy and of an early MMC instillation in preventing recurrence compared with TUR alone has been confirmed by large meta-analyses and stated by the European Association of Urology (EAU) guidelines. The need for further intravesical chemotherapy after the early instillation in patients at intermediate-high risk of recurrence has been proved by several trials. Although intravesical Bacillus Calmette-Guerìn (BCG) is considered the best choice for high-risk patients and MMC for the low-risk group, both MMC and BCG can be given to prevent recurrence in intermediate-risk patients. However, the higher efficacy of BCG over MMC is evident only if maintenance regimen is administered. Despite its proven efficacy, immediate intravesical MMC is not yet fully entered in common clinical practice and efforts should be made by the urologists to optimize its adoption

Does the Compliance to Intravesical BCG Differ between Common Clinical Practice and International Multicentric Trials?

INTRODUCTION: The aim of this study was to analyze the reasons for intravesical BCG interruption in clinical practice. BCG for at least one year is advocated as the best regimen to treat high-risk non-muscle invasive bladder cancer (NMIBC). However, almost 50% of patients don't complete it. Toxicity accounts for 10% of dropouts in international trials. MATERIALS AND METHODS: Patients with T1HG NMIBC undergoing 1-year BCG were enrolled in this study. BCG was administered for one year. Toxicity and causes of treatment interruption were recorded. RESULTS: A total of 411 patients were enrolled in the study. Out of these total number of patients, 380 (92.5%) completed the induction cycle and 215 (52.3%) completed one year. Toxicity requiring interruption or postponement was recorded in 25 (6.1%) and 60 (14.6%) patients. Ninety-three patients (30.2%) stopped BCG, 9 (9.7%) for recurrence and 14 (15.1%) for grade-3 toxicity. Intriguingly, 55 (59.1%) patients refused BCG due to mild discomfort and deterioration in quality of social life. CONCLUSIONS: Grades 2-3 toxicity causes BCG interruption in a few cases. Almost 60% of interruptions are attributable to persistent grade-1 toxicity, which is inadequately treate

LIMITS OF TRANSURETHRAL RESECTION IN DETECTING UNCOMMON HISTOLOGICAL VARIANTS WITHIN BULKY BLADDER TUMORS IN REAL-LIFE CLINICAL PRACTICE

INTRODUCTION AND OBJECTIVES: Rare histotypes represent almost 10% of bladder tumors, more often represented within large and muscle invasive transitional cell carcinomas of the bladder (MIBC). Neoadjuvant chemotherapy is recommended (Grade A) by international guidelines. Rare histological variants, more aggressive and less responsive to systemic chemotherapy might remain unrecognized at initial transurethral resection (TURBT) in everyday clinical practice. We investigated the accuracy of TURBT in detecting rare histological variants in patients with large bladder tumors candidate to cystectomy. METHODS: The clinical and pathologic data of 540 patients submitted to TURBT and/or cystectomy for bladder cancer between Jan. 2010 and Oct. 2016, were reviewed. The presence of uncommon histotypes within urothelial bladder carcinoma has been assessed. Rare variants were diagnose according WHO criteria. Standard hematoxilyn-eosin stain was adopted and further immunohistochemistry was performed. Inferential statistical analysis was performed.RESULTS: Out of 540 patients, 43 (7,9%) showed rare histotypes of bladder cancer. In 5 (11,6%) cases the uncommon histotypes was revealed by palliative TURBT . The remaining 38 patients were submitted to cystectomy for bladder tumors of considerable size (mean diameter 7,8 cm; range of 5-11 cm); 14 (36,8%) harbored a pT4 tumor. The rare histotypes were: squamous carcinoma 6 (13,9%), sarcomatoid 2 (4,8%), undifferentiated 5 (11,6%), neuroendocrine 3 (6,9%), mixed 27 (62,8%). TUR revealed an uncommon histotypes in 26 (68,4%) cases only. Moreover, in 5 (23.8%) patients an additional uncommon histology not detected by previous TUR, was demonstrated in cystectomy specimens. CONCLUSIONS: The prognostic role of uncommon histotypes in bladder cancer is well documented. Unrecognized rare histotypes might have important therapeutic implications since possibly less responsive to neoadjuvant chemotherapy. These patients could benefit from an immediate cystectomy avoiding neo-adjuvant chemotherapy. The inaccuracy of TUR in everyday clinical practice in detecting uncommon variants could be explained by an inadequate sampling of large tumors. The 00pre-cystectomy00 TUR is often performed only to confirm the infiltration. As a matter of fact, the pathologists might not receive an adequate amount of tissue. To standardize the TURBT strategy including sampling of different areas of bulky tumors could be of clinical value in patients undergoing neoadjuvant chemotherapy

Sexual dysfunctions after transurethral resection of the prostate (TURP): evidence from a retrospective study on 264 patients

Objectives: Benign prostatic hyperplasia (BPH) and sexual dysfunctions are diseases with a high prevalence in aged men. Several studies have found a link between BPH and LUTS resulting from deterioration in sexual function in men aged 50 years and older for whom TURP is considered the gold standard. The impact of TURP on sexual functions still remain uncertain, nor is it clear what pathophysiological mechanism underlying the emergence of new episodes of Erectile Dysfunction (ED) following TURP in patients with normal sexual function before surgery, while retrograde ejaculation and ejaculate volume reduction represent a clear side effect; derived from BPH treatment. The aim of this study was to retrospectively evaluate the effects of transurethral resection of the prostate (TURP) on sexual function in patients operated in the period 2008-2012 at the Department of Urology of the University Hospital P. Giaccone, and at Villa Sofia-Cervello Hospital- Palermo. Secondary objective was to reconnect the sample data to interventional practice and international standards. Materials and methods: The retrospective longitudinal study was conducted on 264 of the 287 recruitable patients, aged between 50 and 85 years, suffering from BPH who underwent to TURP in the period 2008-2012. Telephone interviews were conducted and the International Index of Erectile Function (IIEF) was administered to assess sexual function. Patients enrolled were asked to respond to the test by referring at first to their sexual status in the period before surgery and subsequently to the state of their sexual function after treatment so as to obtain, for each patient, a pre- and post-TURP questionnaire in order to get comparisons that corresponding to reality and to avoid overestimation of the dysfunctional phenomenon. Results: In the pre-TURP, the 94.32% of the sample reported being sexually active, with good erectile function in 41.3% of cases, ED mild/moderate in 51.5% and complete ED in 1, 5% of cases; good libido in 62.9% of cases, lack of libido in 31.4% of cases and absent in 5.7% of cases (the latter data corresponded to patients not sexually active); to be sexually satisfied in 29.5% of cases, slightly dissatisfied in 11, 7% of cases, moderately in 35.3% of cases, dissatisfied and very dissatisfied in 23.5% of cases (of which 17.8% sexually active and 5.7% non-active).In the post-TURP 89.4% of the sample reported being sexually active, with good erectile function in 39.1% of cases, DE mild/moderate in 46.9% and complete DE in 4% of cases; good libido in 53.8% of cases, lack of libido in 33.7% of cases and absent in 13.5% of cases (including 1.9% of sexually active and 10.6% of non-active); to be sexually satisfied in 29.5% of cases, slightly dissatisfied in 9.5% of cases, moderately in 35.3% of cases, dissatisfied and very dissatisfied in 17.8% of cases (of which 14.8% sexually active and 10.6% inactive). Retrograde ejaculation was referred in 47.8% of those sexually active after TURP (42.8% if we consider the whole sample). Conclusions: TURP had no negative impact on erectile function in contrast to ejaculatory function. Of the109 patients with good erectile function in pre-TURP, 5.8% reported a worsening of erectile function after TURP. Among the 136 patients with ED moderate/mild pre-TURP 3.7% reported a worsening in the post-TURP, 16.2% reported an improvement, while 9.5% stopped any sexual activity. In 3.7% of the cases a complete ED was reported after TURP, while a decline of libido and sexual satisfaction was detected in all patients with worsening of sexual function. Retrograde ejaculation was observed in 48% of those sexually active after TURP. Particular attention has to be paid to the psychological aspects, bothbefore surgery and in the postoperative period, which may become an important factor in the decline of sexual activity

Genitourinary Symptoms-Patient Help-Seeking and General Practitioner Management: An Outpatient Based Survey at a Tertiary Hospital in Southern Italy

Introduction: General knowledge of most common genitourinary diseases is often lacking. In this survey we evaluated the attention given by patients and general practitioners to genitourinary symptoms, and particularly to hematuria and potential early signs of genitourinary cancer. Methods: A structured self-administered questionnaire was administered to outpatients before the urological consultation. The questionnaire consisted of 4 multiple choice questions to record the level of patient awareness of urological symptoms, the importance given to gross hematuria, the interval between the onset and the visit, the regularity of physical examination and the first-level investigations indicated by the general practitioner before the urological consultation. Results: A total of 327 self-administered questionnaires were obtained from 358 consecutive patients for a compliance rate of 91.3%. Asymptomatic gross hematuria was present in 91 cases (27.8%). The first episode of hematuria was not reported by 20% of the patients, with a median delay of 11 months. Only 77 patients (23.6%) in the last 5 years had received a physical examination including the external genitalia. Laboratory and/or imaging investigations were indicated before urological counseling in 172 (52.6%) patients. Conclusions: The majority of patients underestimated urological symptoms. Less than 25% and 50% of patients had a physical examination and first-level investigations performed before urological counseling, respectively. Our survey reveals an important lack of awareness of genitourinary symptoms that could be responsible for delayed diagnosis and inappropriate treatment