Extended pelvic lymph node dissection at the time of robot-assisted radical prostatectomy: Impact of surgical volume on efficacy and complications in a single-surgeon series

INTRODUCTION: We assessed the impact of surgical volume on perioperative outcomes and complications of robotic extended pelvic lymph node dissection (ePLND). METHODS: From November 2008 to October 2012, a total of 233 consecutive patients with intermediate- or high-risk clinically localized prostate cancer underwent robot-assisted radical prostatectomy (RARP) and ePLND by a single, experienced open and laparoscopic surgeon. Data were prospectively collected. Complications were classified according to the Modified Clavien System. Complications potentially related to ePLND were documented. The minimum follow-up was 3 months. To evaluate the impact of surgical volume on the results, 4 patient subgroups (subgroup 1: cases 1-59; 2: 60-117; 3: 118-175; 4: 176-233) were compared using the Chi-squared and Kruskal-Wallis tests. RESULTS: The mean (range) operative time for ePLND was 79 minutes (range: 48-144), with a steady performance over time (p = 0.784). The count of resected lymph nodes plateaued after 60 procedures (mean [range]: 13 [range: 6-32], 15 [range: 7-34], 17 [range: 8-41], 16 [range: 8-42] in Groups 1 to 4, respectively, p = 0.001). Tumour lymph node involvement was 12% in Groups 1 and 2, 7% in Group 3 and 9% in Group 4 (p = 0.075). Overall, 115 complications were reported in 98/233 patients (42%), with a significant decrease after 175 cases (p = 0.028). In Group 4, 3 patients reported an ePLND-related bleeding requiring open revision. Lymphoceles were detected in 10/233 patients (4.2%) and 1 patient (1.7%) in each of the Groups 2 to 4 required a percutaneous drainage. CONCLUSIONS: A surgeon with extensive experience is expected to achieve a safe learning curve for ePLND during RARP. A learning curve of 60 cases is suggested for optimal lymph node yield

Unexpected discovery of surgical gauze during a robotic radical prostatectomy identified as a capturing lymph node on magnetic resonance

Multiparametric magnetic resonance, plays a crucial role in several steps of the management of prostate cancer. Various factors could alter the interpretation and reduce the accuracy of MR. Among these the group of the retained surgical items, can produce serious implications for the health of patient, as well as medical-legal consequences. Here we report the case of a patient, with a prostate tumor, who performed a mp-MRI of the prostate, where it was reported as collateral finding, compatible thesis with lymphadenopathy. During robotic assisted radical prostatectomy, was found a gauze, which persisted asymptomatic, retained after a previous right inguinal hernioplast

Diagnostic value of qualitative and strain ratio elastography in the differential diagnosis of non-palpable testicular lesions

The purpose of this study was to evaluate prospectively the accuracy of qualitative and strain ratio elastography (SE) in the differential diagnosis of non-palpable testicular lesions. The local review board approved the protocol and all patients gave their consent. One hundred and six patients with non-palpable testicular lesions were consecutively enrolled. Baseline ultrasonography (US) and SE were correlated with clinical and histological features and ROC curves developed for diagnostic accuracy. The non-palpable lesions were all ≤1.5 cm; 37/106 (34.9%) were malignant, 38 (35.9%) were benign, and 31 (29.2%) were non-neoplastic. Independent risk factors for malignancy were as follows: size (OR 17.788; p = 0.002), microlithiasis (OR 17.673, p < 0.001), intralesional vascularization (OR 9.207, p = 0.006), and hypoechogenicity (OR, 11.509, p = 0.036). Baseline US had 89.2% sensitivity (95% CI 74.6-97.0) and 85.5% specificity (95% CI 75.0-92.8) in identifying malignancies, and 94.6% sensitivity (95% CI 86.9-98.5) and 87.1% specificity (95% CI 70.2-96.4) in discriminating neoplasms from non-neoplastic lesions. An elasticity score (ES) of 3 out of 3 (ES3, maximum hardness) was recorded in 30/37 (81.1%) malignant lesions (p < 0.001). An intermediate score of 2 (ES2) was recorded in 19/38 (36.8%) benign neoplastic lesions and in 22/31 (71%) non-neoplastic lesions (p = 0.005 and p = 0.001 vs. malignancies). None of the non-neoplastic lesions scored ES3. Logistic regression analysis revealed a significant association between ES3 and malignancy (χ2 = 42.212, p < 0.001). ES1 and ES2 were predictors of benignity (p < 0.01). Overall, SE was 81.8% sensitive (95% CI 64.8-92.0) and 79.1% specific (95% CI 68.3-88.4) in identifying malignancies, and 58.6% sensitive (95% CI 46.7-69.9) and 100% specific (95% CI 88.8-100) in discriminating non-neoplastic lesions. Strain ratio measurement did not improve the accuracy of qualitative elastography. Strain ratio measurement offers no improvement over elastographic qualitative assessment of testicular lesions; testicular SE may support conventional US in identifying non-neoplastic lesions when findings are controversial, but its added value in clinical practice remains to be proven

Comparison of the clinical usefulness of different urinary tests for the initial detection of bladder cancer: a systematic review

Objectives: The standard initial approach in patients with hematuria or other symptoms suggestive of bladder cancer (BC) is a combination of cystoscopy and urine cytology (UC); however, UC has low sensitivity particularly in low-grade tumors. The aim of the present review was to critically analyze and compare results in the literature of promising molecular urinary tests for the initial diagnosis of BC. Methods: We searched in the Medline and Cochrane Library databases for literature from January 2009 to January 2019, following the PRISMAguidelines. Results: In terms of sensitivity, ImmunoCyt showed the highest mean and median value, higher than UC. All tests analyses showed higher mean and median sensitivity when compared with UC. In terms of specificity, only UroVysion and Microsatellite analyses showed mean and median values similar to those of UC, whereas for all other tests, the specificity was lower than UC. It is evident that the sensitivity of UC is particularly low in low grade BC. Urinary tests mainly had improved sensitivity when compared to UC, and ImmunoCyt and UroVysion had the highest improvement in low grade tumors. Conclusions: Most of the proposed molecular markers were able to improve the sensitivity with similar or lower specificity when compared to UC. However, variability of results among the different studies was strong. Thus, as of now, none of these markers presented evidences so as to be accepted by international guidelines for diagnosis of BC

Science with the ASTRI mini-array for the Cherenkov Telescope Array: Blazars and fundamental physics

ASTRI ("Astronomia a Specchi con Tecnologia Replicante Italiana") is a flagship project of the Italian Ministry of Research (MIUR), devoted to the realization, operation and scientific validation of an end-to-end prototype for the Small Size Telescope (SST) envisaged to become part of the Cherenkov Telescope Array (CTA). The ASTRI SST-2M telescope prototype is characterized by a dual mirror, Schwarzschild-Couder optical design and a compact camera based on silicon photo-multipliers. It will be sensitive to multi-TeV very high energy (VHE) gamma rays up to 100 TeV, with a PSF ∼ 6′ and a wide (9.6°) unaberrated optical field of view. Right after validation of the design in single-dish observations at the Serra La Nave site (Sicily, Italy) during 2015, the ASTRI collaboration will be able to start deployment, at the final CTA southern site, of the ASTRI mini-array, proposed to constitute the very first CTA precursor. Counting 9 ASTRI SST-2M telescopes, the ASTRI mini-array will overtake current IACT systems in differential sensitivity above 5 TeV, thus allowing unprecedented observations of known and predicted bright TeV emitters in this band, including some extragalactic sources such as extreme high-peaked BL Lacs with hard spectra. We exploited the ASTRI scientific simulator ASTRIsim in order to understand the feasibility of observations tackling blazar and cosmic ray physics, including discrimination of hadronic and leptonic scenarios for the VHE emission from BL Lac relativistic jets and indirect measurements of the intergalactic magnetic field and of the extragalactic background light. We selected favorable targets, outlining observation modes, exposure times, multi-wavelength coverage needed and the results expected. Moreover, the perspectives for observation of effects due to the existence of axion-like particles or to Lorentz invariance violations have been investigated

Qualitative assessment of contrast-enhanced ultrasound in differentiating clear cell renal cell carcinoma and oncocytoma

Background: We aimed to assess whether clear cell renal cell carcinoma (ccRCC) can be differentiated from renal oncocytoma (RO) on a contrast-enhanced ultrasound (CEUS). Methods: Between January 2021 and October 2022, we retrospectively queried and analyzed our prospectively maintained dataset. Renal mass features were scrutinized with conventional ultrasound imaging (CUS) and CEUS. All lesions were confirmed by histopathologic diagnoses after nephron-sparing surgery (NSS). A multivariable analysis was performed to identify the potential predictors of ccRCC. The area under the curve (AUC) was depicted in order to assess the diagnostic accuracy of the multivariable model. Results: A total of 126 renal masses, including 103 (81.7%) ccRCC and 23 (18.3%) RO, matched our inclusion criteria. Among these two groups, we found significant differences in terms of enhancement (homogeneous vs. heterogeneous) (p < 0.001), wash-in (fast vs. synchronous/slow) (p = 0.004), wash-out (fast vs. synchronous/slow) (p = 0.001), and rim-like enhancement (p < 0.001). On the multivariate logistic regression, heterogeneous enhancement (OR: 19.37; p = <0.001) and rim-like enhancement (OR: 3.73; p = 0.049) were independent predictors of ccRCC. Finally, these two variables had an AUC of 82.5% and 75.3%, respectively. Conclusions: Diagnostic imaging for presurgical planning is crucial in the choice of either conservative or radical management. CEUS, with its unique features, revealed its usefulness in differentiating ccRCC from RO

Cribriform pattern does not have a significant impact in Gleason Score ≥7/ISUP Grade ≥2 prostate cancers submitted to radical prostatectomy

The aim of this study was to correlate cribriform pattern (CP) with other parameters in a large prospective series of Gleason score ≥7/ISUP grade ≥2 prostate cancer (PC) cases undergoing radical prostatectomy (RP)

Safety and feasibility of outpatient surgery in benign prostatic hyperplasia: a systematic review and meta-analysis

Purpose: Most of endourological procedures along the urinary tract have been widely practiced as outpatient operations, including surgery for BPH. This systematic review and meta-analysis was conducted to assess safety and feasibility of outpatient surgery for patients suffering from symptomatic BPH candidate for endoscopic disobstruction. Materials and methods: PubMed, Web of Science, Cochrane, and Embase were searched up until March 30, 2020. MINORS tool was utilized to assess the quality of included studies and a pooled measure of failure or event rate (FR, ER) estimate was calculated. Further sensitivity analysis, subgroup analysis, and meta-regression were conducted to investigate contribution of moderators to heterogeneity. Results: Twenty studies with a total of 1626 patients treated according to outpatient criteria for endoscopic BPH surgery were included. In total, 18 studies reporting data on immediate hospital readmission and/or inability to discharge after endoscopic procedure presented FR estimates ranging from 1.7% to 51.1%. Pooled FR estimate was 7.8% (95% confidence interval [CI]: 5.2%-10.3%); Heterogeneity: Q=76.85; d.f.=17, p<.001; I2= 75.12%. Subgroup analysis according to surgical technique revealed difference among the three approaches with pooled FR of 3% (95%CI: 1%-4.9%), 7.1% (95%CI: 3.9-10.4) and 11.8% (95%CI: 7-16.7%) for TURP, Green-light and HoLEP respectively (p<.001). At meta-regression analysis, none of the retrieved covariates were able to significantly influence the cumulative outcomes reported. ER for postoperative complications and early outpatient visit showed a pooled estimate of 18.6% (95%CI: 13.2%-23.9%) and 7.7% (95%CI: 4.3%-11%) respectively. Conclusions: Our analysis revealed how transurethral procedures for BPH on an outpatient setting are overall reliable and safe. Of note, there were significant outcome differences between groups with regard of type of surgical procedure, perioperative prostate volume and discharge protocol suggesting the need for further prospective analysis to better elucidate the best strategy in such outpatient conduct

Impact of uni- or multifocal perineural invasion in prostate cancer at radical prostatectomy

Background: Aim of this study was to correlate perineural invasion (PNI) with other clinical-pathological parameters in terms of prognostic indicators in prostate cancer (PC) cases at the time of radical prostatectomy (RP). Methods: Prospective study of 288 consecutive PC cases undergoing RP. PNI determination was performed either in biopsy or in RP specimens classifying as uni- and multifocal PNI. The median follow-up time was 22 (range, 6-36) months. Results: At biopsy PNI was found in 34 (11.8%) cases and in 202 (70.1%) cases at the time of surgery. Among those identified at RP 133 (46.1%) and 69 (23.9%) cases had uni- and multi-PNI, respectively. Presence of PNI was significantly (P<0.05) correlated with unfavorable pathological parameters such higher stage and grade. The percentage of extracapsular extension in PNI negative RP specimens was 18.6% vs. 60.4% of PNI positive specimens. However, the distribution of pathological staging and International Society of Urological Pathology (ISUP) grading did not vary according to whether PNI was uni- or multifocal. The risk of biochemical progression increased 2.3 times in PNI positive cases was significantly associated with the risk of biochemical progression (r=0.136; P=0.04). However, at multivariate analysis PNI was not significantly associated with biochemical progression [hazard ratio (HR): 1.87, 95% confidence interval (CI): 0.68-3.12; P=0.089]. Within patients with intermediate risk disease, multifocal PNI was able to predict cases with lower mean time to biochemical and progression free survival (chi-square 5.95; P=0.04). Conclusions: PNI at biopsy is not a good predictor of the PNI incidence at the time of RP. PNI detection in surgical specimens may help stratify intermediate risk cases for the risk of biochemical progression