Diagnosis of prostate cancer with magnetic resonance imaging in men treated with 5-alpha-reductase inhibitors

Purpose The primary aim of this study was to evaluate if exposure to 5-alpha-reductase inhibitors (5-ARIs) modifies the effect of MRI for the diagnosis of clinically significant Prostate Cancer (csPCa) (ISUP Gleason grade >= 2).Methods This study is a multicenter cohort study including patients undergoing prostate biopsy and MRI at 24 institutions between 2013 and 2022. Multivariable analysis predicting csPCa with an interaction term between 5-ARIs and PIRADS score was performed. Sensitivity, specificity, and negative (NPV) and positive (PPV) predictive values of MRI were compared in treated and untreated patients.Results 705 patients (9%) were treated with 5-ARIs [median age 69 years, Interquartile range (IQR): 65, 73; median PSA 6.3 ng/ml, IQR 4.0, 9.0; median prostate volume 53 ml, IQR 40, 72] and 6913 were 5-ARIs naive (age 66 years, IQR 60, 71; PSA 6.5 ng/ml, IQR 4.8, 9.0; prostate volume 50 ml, IQR 37, 65). MRI showed PIRADS 1-2, 3, 4, and 5 lesions in 141 (20%), 158 (22%), 258 (37%), and 148 (21%) patients treated with 5-ARIs, and 878 (13%), 1764 (25%), 2948 (43%), and 1323 (19%) of untreated patients (p < 0.0001). No difference was found in csPCa detection rates, but diagnosis of high-grade PCa (ISUP GG >= 3) was higher in treated patients (23% vs 19%, p = 0.013). We did not find any evidence of interaction between PIRADS score and 5-ARIs exposure in predicting csPCa. Sensitivity, specificity, PPV, and NPV of PIRADS >= 3 were 94%, 29%, 46%, and 88% in treated patients and 96%, 18%, 43%, and 88% in untreated patients, respectively.Conclusions Exposure to 5-ARIs does not affect the association of PIRADS score with csPCa. Higher rates of high-grade PCa were detected in treated patients, but most were clearly visible on MRI as PIRADS 4 and 5 lesions.Trial registration The present study was registered at ClinicalTrials.gov number: NCT05078359

Role of cultural analysis in patients with indwelling ureteral stent submitted to ureteroscopy for stones

Aim of our study is to analyze the incidence of postoperative infectious complications and to assess its predictors in patients with indwelling ureteral stent treated with ureteroscopy (URS)

Robotic revision of vesicourethral stricture after robot-assisted radical prostatectomy

Vesicourethral anastomotic stenosis is an uncom- mon complication following radical prostatectomy (RP). The incidence is 1–26% and after surgery most strictures occur within the first 6 months and are rare after 24 months. In 2007, the CAPSURE study, on 3310 men, found an incidence of vesico- urethral anastomotic stenosis in 8.4% of patients following RP. Nathan et al. reported an incidence rate between 22 and 26% in salvage RARP (robot- assisted radical prostatectomy) post radiotherapy or brachytherapy. The exact pathophysiology needs to be better defined. There are different factors in- volved: patient-related factors such as body mass index (BMI) and age; and technical factors such as number of surgical procedures performed by the surgeon, absence of mucosal eversion, poor vesico- urethral mucosal apposition, urinary extravasation, increased blood loss, ischemia of the bladder neck/ membranous urethra, or excessive narrowing of the urethral anastomosis at the time of the procedure. The first-line treatment of vesicourethral anasto- motic stenosis includes endoscopic dilation, inter- nal urethrotomy, and transurethral resection of the strictured fragment. Further treatment options are bladder neck reconstruction or urinary diversion. We present a case of robotic revision of urethro- vescical stricture in a 62-year-old man treated with robot-assisted radical prostatectomy for acinar adenocarcinoma of prostate International Society of Urological Pathology (ISUP) 2, pT2c R1. Oncological follow-up was negative. The last pros- tate-specific antigen (PSA) level was 0.03 ng/mL. The postoperative course was complicated by steno- sis of vesicourethral anastomosis. The patient underwent transurethral resection (TUR) of the stenotic vesicourethral anastomosis, followed by urethrotomy for stenosis 2 cm before anastomosis. During the urethrocystography, no micturition occurred, so it was necessary to posi- tion an epicystostomy. A standard transperitoneal robotic approach was planned to correct the vesicourethral anastomotic stenosis. After removing the suprapubic catheter, the first step was the dissection of the bladder from the walls of the pelvis, anteriorly and laterally, try- ing to identify the levator ani muscle and the cor- rect anatomy, which was very difficult due to fibro- sis and adhesions. We opened the cystotomy site close to the bladder neck to highlight the anatomy of the bladder neck and the bladder more clearly regarding the position of the urethral orifice. Then the next step was to reach the site of the blad- der neck and of the stenotic anastomosis location with white light from the cystoscope inserted from the urethra. The robot's light was reduced to see the light from the cystoscope: the diameter of the urethra was very nar- row even after these first incisions. The dissection of the stenotic fibrotic part of the anastomosis was not excessively close to the bladder trigone to avoid injury. The bladder neck was separated from the urethra to dissect this fibrotic tissue and then make the anas- tomosis on healthy, well-vascularized tissue, paying attention to the rectal wall posteriorly. The scar tissue was excised. We then inserted a 20 Fr silicone catheter on a wire. We developed a posterior plane between the bladder neck and the rectum in the pouch of Douglas, rejoin- ing the lateral and the anterior planes of the dissection started at the beginning of the surgery. We obtained an isolated bladder neck from the urethral stump gaining healthy tissue to redo the vesicourethral anastomosis. Performing the vesicourethral re-anastomosis is similar to the standard surgery, but the posterior reconstruction should lower the tension in the new anastomosis. When the stricture is too close to the ureteral ostia, postoperative edema could obliterate them. To avoid this, the placement of Bracci ure- teral catheters is needed and the ureteral orifices should be checked during surgery. The operative time was 150 minutes. The hospital stay was 3 days. The urethral catheter was kept indwelling for 12 days. At the removal of the urinary catheter, micturition resumed. Five months after surgery, urethrocystography demonstrated regular bladder walls, better bladder lumen expansion, and complete bladder emptying after micturition, with bladder neck within radio- logical limits

Validation of real-time prostatic biopsies evaluation with fluorescence laser confocal microscopy

Background: Routine processing of prostate biopsies requires conventional steps that usually take a few days. The aim of this study was to validate the use of fluorescence laser confocal microscopy (FCM) for real-time diagnostics. Methods: We prospectively tested images from prostate needle biopsies (75 images were evaluated by FCM and conventional slides). Two pathologists reviewed the images and assessed agreements between FCM versus conventional slides and between pathologists (κ-values). Interpretation was performed on digital images from the VivaScope 2500 confocal microscope (MAVIG GmbH, Munich, Germany; Caliber I.D., Rochester, NY, USA) placed in the urological operating room. Cancerous versus benign tissue was the primary focus, then the application of the grading system. Results: Cancer was diagnosed in 24 conventional slides (on 75 images) in which agreement among pathologists was high for both conventional (κ=0.96) and FMC (κ=0.84). 1/24 (4%) was ISUP/WHO grade group I, 12/24 (50%) II, 8/24 (33%) III, 2/24 (8%) IV and 1/24 (4%) grade V. Near perfect agreement was obtained for grades I, IV and V (κ=0.85). Grade III values achieved a moderate agreement (κ=0.55). The mean time for laser scanning was 9 minutes. For the remaining non-tumor images, agreement was nearly perfect (κ=0.81). Conclusions: We validated the use of FCM for real-time cancer detection in prostate biopsies

Acute kidney injury strongly influences renal function after radical nephroureterectomy for upper tract urothelial carcinoma: A single-centre experience

The aim of our study was to investigate frequency and predictors both of postoperative acute kidney injury (AKI) and renal function decline in a population of consecutive upper tract urothelial carcinoma (UTUC) patients who underwent radical nephroureterectomy (RNU)

Preoperative endogenous testosterone density predicts disease progression from localized impalpable prostate cancer presenting with PSA levels elevated up to 10 ng/mL

To investigate endogenous testosterone density (ETD) predicting disease progression from clinically localized impalpable prostate cancer (PCa) presenting with prostate-specific antigen (PSA) levels elevated up to 10 ng/mL and treated with radical prostatectomy

Clinical implications of endogenous testosterone density on prostate cancer progression in patients with very favorable low and intermediate risk treated with radical prostatectomy

: We tested the association between endogenous testosterone density (ETD; the ratio between endogenous testosterone [ET] and prostate volume) and prostate cancer (PCa) aggressiveness in very favorable low- and intermediate-risk PCa patients who underwent radical prostatectomy (RP). Only patients with prostate-specific antigen (PSA) within 10 ng ml-1, clinical stage T1c, and International Society of Urological Pathology (ISUP) grade group 1 or 2 were included. Preoperative ET levels up to 350 ng dl-1 were classified as abnormal. Tumor quantitation density factors were evaluated as the ratio between percentage of biopsy-positive cores and prostate volume (biopsy-positive cores density, BPCD) and the ratio between percentage of cancer invasion at final pathology and prostate weight (tumor load density, TLD). Disease upgrading was coded as ISUP grade group >2, and progression as recurrence (biochemical and/or local and/or distant). Risk associations were evaluated by multivariable Cox and logistic regression models. Of 320 patients, 151 (47.2%) had intermediate-risk PCa. ET (median: 402.3 ng dl-1) resulted abnormal in 111 (34.7%) cases (median ETD: 9.8 ng dl-1 ml-1). Upgrading and progression occurred in 109 (34.1%) and 32 (10.6%) cases, respectively. Progression was predicted by ISUP grade group 2 (hazard ratio [HR]: 2.290; P = 0.029) and upgrading (HR: 3.098; P = 0.003), which was associated with ISUP grade group 2 (odds ratio [OR]: 1.785; P = 0.017) and TLD above the median (OR: 2.261; P = 0.001). After adjustment for PSA density and body mass index (BMI), ETD above the median was positively associated with BPCD (OR: 3.404; P < 0.001) and TLD (OR: 5.238; P < 0.001). Notably, subjects with abnormal ET were more likely to have higher BPCD (OR: 5.566; P = 0.002), as well as TLD (OR: 14.998; P = 0.016). Independently by routinely evaluated factors, as ETD increased, BPCD and TLD increased, but increments were higher for abnormal ET levels. In very favorable cohorts, ETD may further stratify the risk of aggressive PCa

Advanced age portends poorer prognosis after radical prostatectomy: a single center experience

Introduction and objective Although advanced age doesn't seem to impair oncological outcomes after robot-assisted radical prostatectomy (RARP), elderly patients have increased rates of prostate cancer (PCa) related deaths due to a higher incidence of high-risk disease. The potential unfavorable impact of advanced age on oncological outcomes following RARP remains an unsettled issue. We aimed to evaluate the oncological outcome of PCa patients > 69 years old in a single tertiary center. Materials and methods 1143 patients with clinically localized PCa underwent RARP from January 2013 to October 2020. Analysis was performed on 901 patients with available follow-up. Patients >= 70 years old were considered elderly. Unfavorable pathology included ISUP grade group > 2, seminal vesicle, and pelvic lymph node invasion. Disease progression was defined as biochemical and/or local recurrence and/or distant metastases. Results 243 cases (27%) were classified as elderly patients (median age 72 years). Median (IQR) follow-up was 40.4 (38.7-42.2) months. Disease progression occurred in 159 cases (17.6%). Elderly patients were more likely to belong to EAU high-risk class, have unfavorable pathology, and experience disease progression after surgery (HR = 5.300; 95% CI 1.844-15.237; p = 0.002) compared to the younger patients. Conclusions Elderly patients eligible for RARP are more likely to belong to the EAU high-risk category and to have unfavorable pathology that are independent predictors of disease progression. Advanced age adversely impacts on oncological outcomes when evaluated inside these unfavorable categories. Accordingly, elderly patients belonging to the EAU high-risk should be counseled about the increased risk of disease progression after surgery

Normal preoperative endogenous testosterone levels predict prostate cancer progression in elderly patients after radical prostatectomy

Background: The impact of senior age on prostate cancer (PCa) oncological outcomes following radical prostatectomy (RP) is controversial, and further clinical factors could help stratifying risk categories in these patients. Objective: We tested the association between endogenous testosterone (ET) and risk of PCa progression in elderly patients treated with RP. Design: Data from PCa patients treated with RP at a single tertiary referral center, between November 2014 and December 2019 with available follow-up, were retrospectively evaluated. Methods: Preoperative ET (classified as normal if >350 ng/dl) was measured for each patient. Patients were divided according to a cut-off age of 70 years. Unfavorable pathology consisted of International Society of Urologic Pathology (ISUP) grade group >2, seminal vesicle, and pelvic lymph node invasion. Cox regression models tested the association between clinical/pathological tumor features and risk of PCa progression in each age subgroup. Results: Of 651 included patients, 190 (29.2%) were elderly. Abnormal ET levels were detected in 195 (30.0%) cases. Compared with their younger counterparts, elderly patients were more likely to have pathological ISUP grade group >2 (49.0% versus 63.2%). Disease progression occurred in 108 (16.6%) cases with no statistically significant difference between age subgroups. Among the elderly, clinically progressing patients were more likely to have normal ET levels (77.4% versus 67.9%) and unfavorable tumor grades (90.3% versus 57.9%) than patients who did not progress. In multivariable Cox regression models, normal ET [hazard ratio (HR) = 3.29; 95% confidence interval (CI) = 1.27-8.55; p = 0.014] and pathological ISUP grade group >2 (HR = 5.62; 95% CI = 1.60-19.79; p = 0.007) were independent predictors of PCa progression. On clinical multivariable models, elderly patients were more likely to progress for normal ET levels (HR = 3.42; 95% CI = 1.34-8.70; p = 0.010), independently by belonging to high-risk category. Elderly patients with normal ET progressed more rapidly than those with abnormal ET. Conclusion: In elderly patients, normal preoperative ET independently predicted PCa progression. Elderly patients with normal ET progressed more rapidly than controls, suggesting that longer exposure time to high-grade tumors could adversely impact sequential cancer mutations, where normal ET is not anymore protective on disease progression

Positive independent association between preoperative endogenous testosterone density and tumor load density in surgical specimen of patients undergoing radical prostatectomy

Objective: To evaluate the influence of endogenous testosterone density (ETD) and tumor load density (TLD) in the surgical specimen of prostate cancer (PCa) patients. Methods: ETD was assessed as the ratio of endogenous testosterone (ET) to prostate volume (PV). TLD was calculated as the ratio of tumor load (TL) to prostate weight. Preoperative prostate-specific antigen relative densities (PSAD) and percentage of biopsy-positive cores (BPCD) were also assessed. The association of high TLD (above the first quartile) with clinical and pathological factors was assessed by the logistic regression model (univariate and multivariate analysis). Results: Between November 2014 and December 2019, ET was measured in 805 cases treated with radical prostatectomy (RP). Median (IQR) of ET and ETD was 412 (321.4-519 ng/dL) and 9.8 (6.8-14.4 ng/(dLxmL)) as well as for TL and TLD was 20 (10-30%) and 0.33 (0.17-0.58%/gr), respectively. As a result, high TLD was detected in 75% of cases. A positive independent association was found between high TLD and ETD. Accordingly, as ETD levels increased, the risk of detecting high TLD in the surgical specimen increased, regardless of PSAD and BPCD. Conclusions: At diagnosis of PCa, a positive independent association was found between ETD and risk of high TLD. Subjects with increasing ETD levels were more likely to have high TLD, associated with unfavorable pathology features. The positive association between ETD and TLD in the prostate microenvironment might adversely influence PCa's natural history