35 research outputs found
T1G3 high-risk NMIBC (non-muscle invasive bladder cancer): conservative treatment versus immediate cystectomy
Background The management of stage T1 poorly
differentiated G3 bladder cancer invading the lamina
propria continues to be debated. These tumours are
associated with a high risk of recurrence and
progression; concomitant carcinoma in situ and/or
multifocality are negative prognostic factors. Choosing
between a preserving approach such as transurethral
resection of the bladder (TURB) followed by
maintenance bacillus Calmette-Guerin (BCG) and an
invasive approach like cystectomy is critical.
Patients and methods Overall, 80 patients underwent
TURB and RE-TURB followed by intra-vesical
induction treatment with BCG plus maintenance
(Group A) while 72 patients underwent immediate
radical cystectomy with extended lymphadenectomy
(Group B). Patients were divided into 3 subgroups:
uni-focal tumours, multi-focal tumours and carcinoma
in situ associated lesions. In Group A, time to
first recurrence and time to progression were analysed.
A comparison was made between Group A and
Group B regarding progression-free survival, cancerspecific
survival and overall survival with a median
follow-up time of 8.3 years.
Results As far as concerns Group A patients, 42
recurrences (52.5%) were reported in a median time
of 10.4 months (range 3â26) and 25 progressions
(31.2%) in a median time of 25 months (range 3â68).
As far as concerns time to first recurrence and time to
progression, both the KaplanâMeier survival curves
obtained are significant and P values are, respectively,
0.0263 and 0.0011. Comparing Groups A and
B patients, 25 progressions (31.2%) in a median time
of 25 months (range 3â68) and 18 progressions
(25%) in a median time of 25.9 months (range
4â72), respectively, were recorded. Regarding overall
survival, at 10 years, 24 deaths (42.5%) occurred in a
median time of 55.4 months (range 12â94) in Group
A and 42 deaths (58.3%) in a median time of
54.9 months (10â100) in Group B. Cancer-specific
survival was evaluated in Group A with a total of 18
deaths (22.5%) in a median time of 47.5 months
(range 16â78), and in Group B with a total of 16
deaths (22.2%) in a median time of 45.7 months
(range 16â88). The progression-free survival Kaplanâ
Meier curve is not significant, the P value being
0.3801; the overall survival curve is significant with a
P value of 0.0487 while the cancer-specific survival
curve is not significant with a P value of 0.9762.
Discussion In Group A, considering ââtime to first
recurrenceââ, the difference is greater between unifocal
lesions and multifocal or Cis-associated lesions.
Conversely, for ââtime to progressionââ, there is a
greater difference between unifocal and multifocal
tumours and Cis-associated tumours. Looking at
ââprogression-free survivalââ in Group A and Group B
patients, there is no statistically significant difference,
like in cancer-specific survival. A statistically significant
difference was observed in overall survival
being in favour of conservative treatment thus
reflecting that conservative treatment is not burdened
by all the surgical and post-operative complications
of cystectomy.
Conclusions Although NMIBC invading the lamina
propria, stage G3, with or without Cis-associated
lesions are burdened both by a high volume of
recurrences and progressions, cystectomy could be
considered an aggressive approach. New biological
markers are now needed which are able to predict the
behaviour of the cancer and to guide the decisionmaking
process between conservative or aggressive
treatment
Knotless "three-U-stitches" technique for urethrovesical anastomosis during laparoscopic radical prostatectomy
We describe a new technique for urethrovesical anastomosis that consists
of placing three âUâ stitches of Monocryl 2-0 to connect the bladder neck and urethral
stump together. The margins are united by a double passage of the suture, without tying
any knots. The sutures are tied on the bladderâs surface using Lapra-Ty clips fixed at a
certain distance from where to two mucosal margins have been joined. We carried out
this technique on 90 patients who underwent laparoscopic extraperitoneal radical prostatectomy.
The good joining of the margins, the absence of knots and the minimum
trauma to the urethral wall together enable to create an anastomosis that is both
âsealedâ and âtension freeâ, allowing a quick âweldingâ of the margins and an early
catheter removal. Regarding urinary continence, 56.6% (51) of patientswere continent at
catheter removal, 87.6% (78) were continent 3 months later and 98.9% (89) were continent
after 6 months. In nine patients (10%), an episode of acute urinary retention
occurred within 24 h after the removal of the catheter. We did not encounter any cases
of vesicourethral anastomosis stenosis
Penile prosthesis implant for erectile dysfunction: A new minimally invasive infrapubic surgical technique
Erectile dysfunction, the most common
male sexual disorder after premature ejaculation,
with its important impact on man and partnerâs sexuality
and quality of life is a persistent inability to obtain and
maintain an erection sufficient to permit satisfactory sexual
performance. Non-surgical treatments with controversial
results are usually applyed before surgical treatment that has
reached high levels of satisfaction.
We describe a new surgical technique to implant three-pieces
penile prosthesis in patients suffering from erectile dysfunction
(ED) not responding to conventional medical therapy or
reporting side effects with such a therapy.
Implantation of an inflatable prosthesis, for treatment of ED,
is a safe and efficacious approach with high satisfaction
reported by patients and partners. Surgical technique should
be minimally invasive and latest technology equipment should
be implanted in order to decrease common complications and
to obtain a better aesthetic result
Incidental prostatic stromal tumor of uncertain malignant potential (STUMP): histopathological and immunohistochemical findings
Stromal prostate tumors are rare neoplastic proliferative lesions that have been classified into prostatic
stromal tumor of uncertain malignant potential (STUMP) and prostatic stromal sarcoma (SS) based
on these criteria: stromal cellularity, presence of mitotic figures, necrosis, and stromal overgrowth. A
prostatic stromal tumor of uncertain malignant potential (STUMP) is a non-epithelial, mesenchymal
spindle-cell tumor that can be classified as a specialized stromal tumor of the prostate. STUMPs have
the capability to diffusely infiltrate the prostate gland and extend into adjacent tissues. Furthermore,
they often recur and this is why they are considered as neoplastic entities. STUMPs usually tend to be
not aggressive, but occasional cases have been reported with an extension into adjacent tissues. A
few cases develop a sarcomatous dedifferentiation.
A 67-year-old male referred to the Department of Urology, Sapienza Rome University, with acute urinary
retention (AUR) and bladder overdistention. Digital rectal examination (DRE) showed the presence
of a severe prostatic hyperplasia and a transvesical prostatic adenomectomy (TVPA) was performed.
The pathological evaluation performed at the Department of Pathology, Sapienza Rome University,
revealed an incidental diagnosis of prostatic STUMP. The patientâs follow-up is made every year with
transrectal ultrasonography and nuclear magnetic resonance with spectroscopy, and every two years
with a transperineal prostate biopsy to exclude a progression to a stromal sarcoma. After 5 years of
follow-up the STUMP is still detectable but there is no sign of sarcoma. As a result of its relative rarity
and lack of long-term follow-up, the prognosis of STUMP is unclear. Therapy varies from a wait-andsee
approach to a radical retropubic prostatectomy
Prostate Cancer Gene 3 and Multiparametric Magnetic Resonance Can Reduce Unnecessary Biopsies: Decision Curve Analysis to Evaluate Predictive Models
OBJECTIVE To overcome the well-known prostate-specific antigen limits, several new biomarkers have been
proposed. Since its introduction in clinical practice, the urinary prostate cancer gene 3 (PCA3)
assay has shown promising results for prostate cancer (PC) detection. Furthermore, multiparametric
magnetic resonance imaging (mMRI) has the ability to better describe several aspects
of PC.
METHODS A prospective study of 171 patients with negative prostate biopsy findings and a persistent high
prostate-specific antigen level was conducted to assess the role of mMRI and PCA3 in identifying
PC. All patients underwent the PCA3 test and mMRI before a second transrectal ultrasoundguided
prostate biopsy. The accuracy and reliability of PCA3 (3 different cutoff points) and
mMRI were evaluated. Four multivariate logistic regression models were analyzed, in terms of
discrimination and the cost benefit, to assess the clinical role of PCA3 and mMRI in predicting
the biopsy outcome. A decision curve analysis was also plotted.
RESULTS Repeated transrectal ultrasound-guided biopsy identified 68 new cases (41.7%) of PC. The
sensitivity and specificity of the PCA3 test and mMRI was 68% and 49% and 74% and 90%,
respectively. Evaluating the regression models, the best discrimination (area under the curve
0.808) was obtained using the full model (base clinical model plus mMRI and PCA3). The
decision curve analysis, to evaluate the cost/benefit ratio, showed good performance in predicting
PC with the model that included mMRI and PCA3.
CONCLUSION mMRI increased the accuracy and sensitivity of the PCA3 test, and the use of the full model significantly
improved the cost/benefit ratio, avoiding unnecessary biopsies
Minimally invasive infrapubic inflatable penile prosthesis implant for erectile dysfunction: evaluation of efficacy, satisfaction profile and complications
Erectile dysfunction (ED), the second most common male sexual disorder, has an important impact on man sexuality and quality of
life affecting also female partnerâs sexual life. ED is usually related to cardiovascular disease or is an iatrogenic cause of pelvic
surgery. Many non-surgical treatments have been developed with results that are controversial, while surgical treatment has
reached high levels of satisfaction. The aim is to evaluate outcomes and complications related to prosthesis implant in patients
suffering from ED not responding to conventional medical therapy or reporting side effects with such a therapy. One hundred
eighty Caucasian male suffering from ED were selected. The patient population were divided into two groups: 84 patients with
diabetes and metabolic syndrome (group A) and 96 patients with dysfunction following laparoscopic radical prostatectomy for
prostate cancer (group B). All subjects underwent primary inflatable penile prosthesis implant with an infrapubic minimally invasive
approach. During 12 months of follow-up, we reported 3 (1.67%) explants for infection, 1 (0.56%) urethral erosion, 1 (0.56%)
prosthesis extrusion while no intraoperative complications were reported. Mean International Index of Erectile Function-5 (IIEF-5)
was 8.2 ± 4.0 and after the surgery (12 months later) was 20.6 ± 2.7. The improvement after the implant is significant in both groups
without a statistically significant difference between the two groups (P-value 0.65). Mean Erectile Dysfunction Inventory of
Treatment Satisfaction (EDITS) score 1 year after the implant is 72.2 ± 20.7, and there was no statistically significant difference
between groups A and B (P-value 0.55). Implantation of an inflatable prosthesis, for treatment of ED, is a safe and efficacious
approach; and the patient and partner satisfaction is very high. Surgical technique should be minimally invasive and latest
technology equipment should be implanted in order to decrease after surgery common complications (infection and mechanical
failure)
Circulating tumor cells detection has independent prognostic impact in high-risk non-muscle invasive bladder cancer
High-risk non-muscle invasive bladder cancer (NMIBC) progresses to metastatic disease in 10â15% of cases, suggesting that
micrometastases may be present at first diagnosis. The prediction of risks of progression relies upon EORTC scoring systems,
based on clinical and pathological parameters, which do not accurately identify which patients will progress. Aim of the study
was to investigate whether the presence of CTC may improve prognostication in a large population of patients with Stage I
bladder cancer who were all candidate to conservative surgery. A prospective single center trial was designed to correlate the
presence of CTC to local recurrence and progression of disease in high-risk T1G3 bladder cancer. One hundred two patients
were found eligible, all candidate to transurethral resection of the tumor followed by endovesical adjuvant immunotherapy
with BCG. Median follow-up was 24.3 months (minimumâmaximum: 4â36). The FDA-approved CellSearch System was used to
enumerate CTC. KaplanâMeier methods, log-rank test and multivariable Cox proportional hazard analysis was applied to establish
the association of circulating tumor cells with time to first recurrence (TFR) and progression-free survival. CTC were
detected in 20% of patients and predicted both decreased TFR (log-rank p < 0.001; multivariable adjusted hazard ratio [HR]
2.92 [95% confidence interval: 1.38â6.18], p 5 0.005), and time to progression (log-rank p < 0.001; HR 7.17 [1.89â27.21], p
5 0.004). The present findings provide evidence that CTC analyses can identify patients with Stage I bladder cancer who have
already a systemic disease at diagnosis and might, therefore, potentially benefit from systemic treatment
Primary Metastatic Neuroendocrine Small Cell Bladder Cancer: A Case Report and Literature Review
Small cell carcinoma of the urinary bladder (SCCUB) is a rare
variant of neuroendocrine nonepithelial tumor. Clinically,
SCCUB appears like a flat or ulcerated lesion and microscopically
can cause microvascular invasion and necrosis. Small
cell cancer, rarely found in the urogenital tract in a primitive
form, usually coexists with urothelial bladder cancers. It has
an incidence of 0.35â0.7% of all bladder neoplasms and survival
at 5 years is estimated to be around 8%. A 60-year-old
man who was a smoker was referred to our department with
episodes of gross hematuria and pain in the lumbar region.
After an extensive transurethral resection of the bladder, including
of the muscular layer, the diagnosis of small cell carcinoma
of the bladder was made. The neoplastic cells were
positive with immunohistochemical staining for chromogranin
A, paranuclear reactivity to cytokeratin and neuronspecific
enolase. A total-body CT scan revealed lymph node
involvement and hepatic, adrenal and lung metastases. Be-
cause of the advanced stage it was decided to avoid radical
cystectomy and perform chemotherapy. The patient underwent
two different cycles of cisplatin chemotherapy following
international recommendations, but unfortunately without
any response. After palliative therapy, the patient died in
January 2010
Disfunzione Erettile: ruolo dellâiperomocisteinemia quale fattore predittivo precoce
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