Re-treatment by intravesical therapy in recurring patients affected by intermediate risk non-muscle invasive bladder cancer (NMIBC)

Introduction & Objectives: Up to 70% of patients affected by intermediate risk NMI-BC recur after intravesical therapy (IT). The majority of them will be retreated by IT. The therapeutic strategy for these patients is not well defined. BCG is advocated when intravesical chemotherapy (ICH) fails. However, some patients are retreated by ICH and some others repeat BCG adopted as the first treatment. Not many studies have been published on second line IT. A retrospective analysis on 179 intermediate-risk patients undergoing re-treatment by IT is presented. Materials & Methods: The clinical files of patients affected by NMI-BC recurring after TUR and IT and retreated by IT were reviewed. The patients not receiving at least 6 instillations of BCG or ICH after the first diagnosis and again after the TUR of the first recurrence were excluded. Only mitomycin c and epirubicin were accepted as chemotherapy. Only intermediate-risk tumours with a recurrencerisk score between 5 and 9 according to the EORTC Risk Tables and in absence of Tis were selected. A multivariate analysis was performed for recurrence-free interval (RFI) and progression considering, first line IT (BCG versus ICH), previous recurrence free interval, tumour’s T-category, G-grade, multiplicity, second line IT (BCG versus ICH) and maintenance regimen. Results: The study included 179 patients. The first line IT was ICH in 131 (73.2%) and BCG in 48 (26.8%) patients. The median RFI was 16 months. At recurrence, BCG in 83 (46.4%) and ICH in 96 (53.6%) patients were administered, with maintenance of at least 12 months in 31% and 38% of patients respectively. Of the 48 patients previously treated by BCG, 40 (83.3%) received BCG again, while of the 131 previously treated by ICH, 88 (67.2%) received ICH again and 43 (32.8%) BCG. Thus, only 8 patients received ICH at recurrence after BCG. At a median follow-up of 29 months, 65 (36.3%) patients recurred with a median RFI of 15 months, 25 (30.1%) and 40 (41.7%) after BCG and ICH respectively. Thirteen patients showed progression at a median interval of 19 months. At multivariate analysis no statistically significant correlation was detected among the considered parameters. Surprisingly, no statistical difference emerged in terms of RFI between first and second line IT (16 versus 15 months), and between patients receiving BCG or ICH as second line therapy at recurrence after ICH (=0.28). Conclusions: No reduction in RFI emerged in patients with intermediate-risk NMIBC recurring after a first cycle of intravesical therapy and retreated by intravesical chemotherapy or BCG. In patients recurring after intravesical chemotherapy, intravesical chemotherapy and BCG, as a second line therapy, resulted equally effective in preventing recurrence

The genitourinary diseases health-care among patients and general practitioner

Introduction: A general awareness of the most common genitourinary diseases is often lacking.The aim of the present study was to investigate the attention of the general practitioner and of the patient to the genitourinary diseases. An incomplete medical history and/or an inadequate physical examination might be responsible of late diagnosis and improper management. Patients and Methods: A self administered questionnaire was obtained by our outpatients before the urological visit. As a preliminary step we administered a very simple questionnaire consisting of four multiple choice questions: 1) Did your general practitioner examine your external genitalia in the last five years? Did you ask for this examination? 2) Did your general practitioner prescribe any clinical investigations? 3) Have you ever seen blood in your urine? Did you advise your doctor? 4) How long time did elapse between the first symptom and our councelling? The study should be closed if less than 5 patients among the first 20 showed an improper attention to genitourinary pathology, otherwise, 200 consecutive patients at least should be entered. A further structured interview was planned in the case of doubtful results. Results: From December 2011 to February 2012, 327 questionnaires were obtained from 358 patients with a compliance of 91.3%. The median age of the patients was 61 years (range: 15-91). Two hundred fiftyfive (78%) were men. Out of 327 patients only 72 (22%) underwent a physical examination comprehensive of the external genitalia in the previous five years. The remaining 250 (76.4%) patients were not examined and, more relevant, they did not ask for. Forty-nine (63.6%) out of the 77 patients were examined on their specific request. Only 172 (52.6%) patients underwent laboratory and/or imaging assessment before urological councelling. Gross haematuria was the main urological symptom in 91 (27.8%) of cases. The general practitioner was not adviced of patients’ symptom in 13% of cases and, when informed, a urological assessment was required in only 47%. Discussion and Conclusion: Our preliminary survey point out a limited attention to the genitourinary diseases both from the general practitioner and the patient. Noteworthy, in case of gross haematuria 20% of the patients did not inform the family doctor and a urological assessment was indicated in only 50% of cases

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

Correlation between BMI and the pathological features of prostate cancer at biopsy

Introduction/Aim: Numerous clinical trials investigated the association between obesity and prostate cancer, but they yielded inconsistent results (1). Obesity has been found to be related to prostatic tumors at more advanced stages and higher Gleason grade when compared with normal population (2). An increased number of biopsy cores has been advocated by some Authors in obese and overweight men due to an increased difficulty and delay in cancer detection (3). The main aim of our research was to correlate Body Mass Index (BMI) with the pathological characteristics of prostate cancer at biopsy. Patients and Methods: Patients with positive prostate biopsy performed for palpable prostate nodule and/or elevated PSA levels were considered in the present study. A transrectal prostate biopsy procedure, not less than 12 cores, was performed. The number of specimens was increased in case of re-biopsy (18-24 cores or more). After informed consent, a database has been created, including clinical and pathological data: demographics, PSA, digital rectal examination, transrectal ultrasound and prostate cancer features at biopsy. Patients were divided into four categories according to their BMI as follows: 16-19,9 (underweight), 20.0-24.9 (normal weight), 25.0-29.9 (overweight) and ≥30.0 (obese). The statistical analysis was conducted with Fisher’s exact test for Gleason pattern 4 (<4 or ≥4) and BMI for single weight class and the Pearson’s Chisquared test with Yates’ continuity correction for aggregate BMI classes. Results: Out of 149 patients diagnosed with prostate cancer, the Gleason score was available for 121 (81.2%), ASAP or PIN were found in 5 more patients (3.4%). Twenty-seven (21.4%) patients had a previous negative biopsy. The median age was 71 years (range 45-86). The median BMI was 26.7 kg/m2 (range 17.5-37.4). Two patients (1.3%) were underweight, 43 (28,6%)patients had normal weight (median BMI 23), 70 (47%) were overweight (median BMI 26.8) and 34 (22.8%) were obese (median BMI 35.3). Median PSA was 9.5 ng/ml (range 0,41- 1339). A prostate nodule was palpable in 45 (30.2%) patients. The median prostate volume was 44.5 cc. A Gleason pattern of 4 or more was evident in 49 (40.5%) patients, while it was not detected in the remaining 72 (59.5%) patients. The presence of Gleason pattern 4 did not result in relation to the class of BMI (p-value=0.9814), neither combining different classes: normal weight and overweight men versus obese ones (p-value=0.7696); normal weight versus overweight and obese men (p-value=0.9678). Discussion and Conclusion: Our study, in contrast with some evidence in literature, did not show any significant correlation between BMI and the presence of Gleason pattern 4. However, the small number of patients did not allow to include in our analysis important factors, such as biological, hormonal, environmental and life-style factors, involved in the pathogenesis of prostate cancer. A larger, prospective, multicenter investigation is on going. References 1 Howlader N, Krapcho M, Neyman N et al: SEER Cancer statistics review, 1975-2008. National Cancer Institute, Bethesda,http://seer.cancer.gov/csr/1975_2008/, based on November 2010 SEER data submission. 2 Nunzio CD, Freedland S, Miano L, Agrò EF, Bañez L and Tubaro A: The uncertain relationship between obesity and prostate cancer: an Italian biopsy cohort analysis. European Journal of Surgical Oncology 37(12): 1025-1029, 2011. 3 Wallner LP, Morgenstern H, McGree ME et al: The effects of body mass index on changes in prostate-specific antigen levels and prostate volume over 15 years of follow-up: implications for prostate cancer detection. Cancer Epidemiol Biomarkers Prev 20(3): 501-508, 2011. Doi: 10.1158/1055-9965. EPI-10-1006. Epub 2011 Jan 17. 3

Ureteral stent encrustation: evaluation of available scores as predictors of a complex surgery

Background: Stent Encrustation is an uncommon event (13%) with a significant impact in patients' management. Aim of our study was to evaluate the available grading systems for encrusted stents. Methods: A retrospective analysis of encrusted stents was performed in four Italian centers between 2006 and 2020. Encrusted stents were classified according to four classifications: the Forgotten Encrusted Calcificated (FECal) score, the Kidney Ureter Bladder (KUB) score, the Visual Grading for Ureteral Encrusted Stent Classification and the Encrustation Burden Score (EBS). Classifications were evaluated to predict complex surgery defined as: long operative time (&gt;60min); need of more than one surgery; need of a percutaneous approach. The scores were compared with Receiver Operating Characteristic (ROC) analysis as predictors of complex surgery. Results: 77 patients were evaluated with a median age of 62 years (65/70). Overall FECal score &gt;2 was present in 45/77 (58%) patients, median KUB score was 9 (6/14) and severe EBS was found in 47/77 (63%) patients. Patients were managed with cystolithotripsy in 13/77 (17%), with ureteroscopy in 58/77 (75%) and with Percutaneous Nephrolithotomy (PCNL) in 6/77 (8%). Overall, 6/77 (8%) patients required a second intervention to remove the encrusted stent. All classifications predicted the need of complex surgery. On ROC analysis KUB score presented a better accuracy in predicting complex surgery compared to FECal, V-GUES and encrusted burden. Conclusions: KUB score, FECal score, V-GUES score and encrustation burden accurately predict the need of a complex surgery. KUB showed to be superior to other classifications according to our results