2016 XXIII Congresso

Transcript

1
o
6
s
1
s
0
e
2 ngr
o
s
C
XXIII
t
I
I
c
I
a
r
t
s
Congresso
Nazionale
b
a
X
X
AURO
abstracts
abstracts XXIII Congresso Nazionale AURO.it - Roma 21-24 maggio 2016
22-24 maggio • ROMA
2016
1
2
o
6
s
1
s
0
e
r
2
g
F
l’indice:
n
o
s
C
t
I
I
c
I
a
X
r
X
t
Istruzioni per la consultazione
degli abstracts
t "MMFQBHJOF
USPWBUF
t PHOJQBHJOBDPOUJFOFMJOEJDFEFMMFTFTTJPOJFRVJOEJ
EFHMJBCTUSBDUQSFTFOUBUJOFMHJPSOP
t (MJBCTUSBDUTTPOPFTQPTUJDPOTFDVUJWBNFOUFOFMMFSJTQFUUJWFTFTTJPOJEJQSFTFOUB[JPOFDPNFEBQSPHSBNNB
t 1FSUBOUPBTFDPOEBEFMMFHJPSOBUFEFMMFTFTTJPOJDPNVOJDB[JPOJWJEFPQPTUFS
FEFHMJPSBSJQPUFUFJEFOUJĕDBSFMBCTUSBDUEFTJEFSBUP
t OFMCBOOFSEFMQEGJOBMUPBTJOJTUSBDMJDDBOEPAJOEJDF
DPNQBSFMFMFODPRVJTPUUPSBQQSFTFOUBUPDMJDDBOEPTVMMBEBUBBOEBUFBJTJOHPMJHJPSOJFEBMMFTJOHPMFTFTTJPOJ
s
b
a
22 maggio 2016
6
22 maggio 2016
18
22 maggio 2016
31
22 maggio 2016
34
23 maggio 2016
41
23 maggio 2016
52
23 maggio 2016
60
23 maggio 2016
63
24 maggio 2016
69
24 maggio 2016
81
24 maggio 2016
84
24 maggio 2016
87
Sommario
2
3
o
6
s
1
INDICE
☞
s
0
2 ngre
o
s
C
t
☞ XIII
c
a
r
X domenica
t
s
b
a 2016
22 maggio
Comunicazioni 1 - Tutto Rene o Quasi:
pag. 6
Comunicazioni 2 - Calcoli e Prostata:
pag. 18
Video 1 - Chirurgia no limits:
pag. 31
Poster digitali 1 - Male Oncology:
pag. 34
☞
da pagina 6 a pagina 40:
3
4
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
☞
X
X
a
r
t
s
lunedì
b
a
23 maggio 2016
pag. 41
Comunicazioni 4 - Andrologia:
pag. 52
Video 2 - Su e giù per le vie urinarie:
pag. 60
Poster digitali 2 - I grandi Classsici dell’Urologia: pag. 63
☞
Comunicazioni 3 - Male Oncology:
4
5
o
6
s
1
s
0
e
2 ngr
o
s
martedì
C
t
I
I
c
I
☞
a
X
r
X24 maggio t2016
s
b
a
Video 3 - Tips and Tricks:
pag. 81
Video 4 - Laparo e ri-laparo:
pag. 84
Poster digitali 3 - Oncologia per finire:
pag. 87
☞
fine a pag 95
Comunicazioni 5 - Urologia funzionale e altro: pag. 69
5
6
o
6
16:00
17:30
s
1
s
Dalì
0
e
2 ngr
Comunicazioni 1 o
s
C
t
Tutto Rene o Quasi:
I
I
c
I
a
X
r
X
t
s
22 maggio 2016
b
a
0/$0(&/*$ .*$303/"4 $)"3"$5&3*;"5*0/ */ $-&"3 $&-- 3&/"- $&--
$"3$*/0."
Inviato da: [email protected]
Argomenti: cancro del rene
A.L. Pastore1, G. Palleschi1, D. Autieri1, Y. Al Salhi1, S. Al Rawashdah1, A. Ripoli1, A. Leto1, A. Fuschi1, G. Velotti1, F. Fazi2, V.
Petrozza3, A. Carbone1
“Sapienza” Università di Roma, Facoltà di Medicina e Farmacia, Dipartimento di Scienze e Biotecnologie Medico-Chirurgiche,
U.O. Urologia (Latina)
U.O. Patologia (Rome)
U.O. Patologia (Latina)
Objective
A key challenge for the improvement of ccRCC management could derive from a deeper molecular characterization of these
neoplasms that could greatly improve the diagnosis, prognosis and treatment choice. In several tumors, miRNAs expression
profile is emerging as a relevant marker for diagnosis, prognosis and treatment of cancer . miRNAs are 22 nucleotides-long
double strand small RNAs, typically excised from 60 to 110 nucleotide RNA precursor structures, which modulate gene
expression generally at post-trascriptional level [6]. In fact, miRNAs show a developmental stage- and tissue-specific expression
pattern and are present in complex regulatory circuits to regulate stem cells function, tissue differentiation and maintenance
of cell identity during embryogenesis and adult life [7]. Notably, miRNA activity has also been correlated to the pathogenesis
of cancer, since miRNAs have also been recently identified as a new class of genes with tumor-suppressor and oncogenic
functions. To date, a molecular characterization of ccRCC is under investigation and several high-throughput analyses have
been recently performed in order to identify miRNAs putatively involved in ccRCC tumorigenesis and progression. By using
a retrospective cohort of 20 formalin-fixed paraffin-embedded (FFPE) tissue samples, we evaluated the levels of specific
miRNAs differentially expressed in ccRCC vs. matched normal tissues. We evidenced miR-21-5p and miR-210-3p as the most
significantly up-regulated in this patient cohort, highlighting these onco-miRNAs as possible relevant players involved in
ccRCC carcinogenesis.
Materials and Methods
This study was conducted on a retrospective cohort of ccRCC formalin-fixed paraffin-embedded (FFPE) tissue samples from 20
patients who underwent surgery between October 2011 and November 2013. For all the patients, FFPE-matched normal
peritumoral kidney tissues were also considered. The patients were not treated with any neo-adjuvant therapy before surgery.
Five patients were female (25%) and 15 patients were male (75%) with a mean age of 68.9 years old and a mean Body Mass
Index (BMI) of 27.4 kg/m2. All the cases presented a clear cell histotype of RCC at the histological examination. The surgery
16:00 - 17:30, Dalì - Comunicazioni 1 - Tutto Rene o Quasi
Moderatore: Michele Amenta
domenica 22 maggio 2016
sala
6
7
a
r
t
s
b
a
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
procedures performed as treatments for these patients were: (i) open radical nephrectomy in 4 cases (20%); (ii) laparoscopic
radical nephrectomy in 12 cases (60%); (iii) laparoscopic partial nephrectomy in 4 cases (20%). According to the tumor, node,
and metastasis (TNM) classification, 10 patients have been identified as Stage I (50%), 5 patients have been identified as Stage II
(25%), and 5 patients as Stage III (25%). Fuhrman’s grade has also been evaluated with 15% of cases belonging to the G1 grade
(3 patients), 50% of cases belonging to G2 (10 patients) and 30% of cases to the G3 grade (6 patients). Only 1 patient actually
showed a G2/3 grade. PCR quantification analysis of the SCARNA17 and miRNAs miR-21-5p, miR-210-3p, miR-185-5p,
miR-221-3p and miR-145-5p, was performed using the miScript SYBR Green PCR kit (Qiagen, Chatsworth) with the miScript
Primer Assay Hs-SCARNA17 (#MS00014014), Hs-miR-21-5p (#MS00009079), Hs-miR-210-3p (#MS00003801), Hs-miR185-5p (#MS00003647), Hs-miR-221-3p (#MS00003857), Hs-miR-145-5p (#MS00003528) (Qiagen, Chatsworth, CA, USA).
The expression analyses of RNU19 and RNU66 were performed by TaqMan MicroRNA RT assay and TaqMan MiRNA® Assays
according to the manufacturer’s protocol.
The p value was calculated by using a non-parametric Wilcoxon test with paired data and miRNAs whose differential expression
was statistically significant (< 0.01) was indicated.
Results
Among the miRNAs deregulated in several human cancers, we selected four miRNAs (miR-21-5p, miR-210-3p, miR-185-5p
and miR-221-3p) to evaluate their expression in a retrospective cohort of formalin-fixed paraffin-embedded (FFPE) tissues
obtained from 20 ccRCC patients undergoing surgical nephrectomy resection. The characteristics of ccRCC patients and tumor
specimens are reported in the Patients and Methods section and summarized in Table 1. A total of 20 matched ccRCC and
adjacent normal tissue samples were collected. Interestingly, miR-21-5p and miR-210-3p resulted significantly up-regulated in
ccRCC vs. normal tissues, with a p value of 0.0083 and 0.0010, respectively (Figure 1). miR-185-5p and miR-221-3p, although
did not show any statistically significant modulation between tumor and normal tissues, show a trend of expression similar to
miR-21-5p and miR-210-3p (Figure 1). Moreover, we analyzed miR-145-5p expression that usually results particularly downregulated in several tumor samples compared to normal tissues. We evidenced that miR-145-5p did not show any statistically
significant modulation between tumor and normal tissues.
Discussions
In this study we observed that specific miRNAs, previously reported as up-regulated in ccRCC vs. autologous normal tissues,
also show increased expression levels in our series of 20 FFPE tumor samples relatively to their matched normal counterparts.
Specifically, among the up-regulated miRNAs, we confirmed increased levels of miR-21-5p, miR-210-3p, miR-185-5p and
miR-221-3p. miR-21-5p and miR-210-3p resulted significantly up-regulated in this patient cohort highlighting these oncomiRNAs as relevant players involved in ccRCC tumorigenesis. Interestingly, the increased expression of miR-21, miR-210,
miR-185, miR-221 was previously reported in ccRCC patients and their contribution to ccRCC tumorigenesis is currently
under investigation. miR-221 was significantly increased in ccRCC tissues and cell lines, while its knock-down inhibited cell
proliferation, migration and invasion of renal cancer cells [25]. miR-210 was significantly overexpressed in ccRCC relatively to
normal kidney and patients with high levels of miR-210 show a statistically higher incidence of disease recurrence . Moreover,
the down-regulation of miR-210 also reduced the migratory and invasive potential of metastatic RCC cells. Using ccRCC and
matched normal kidney samples, it was also evidenced that the increased levels of miR-185 and miR-21 in tumors correlate
with the loss of function of specific tumor suppressors such as PTPN13, SLC12A1 and TCF21. Noteworthy is that miR-21 not
only shows up-regulated expression in tumor tissues but also its serum levels resulted to be significantly correlated with the
clinical staging of ccRCC patients.
Conclusion
The selected four miRNAs (miR-21-5p, miR-210-3p, miR-185-5p and miR-221-3p) and their expression were evaluated in a
retrospective cohort of formalin-fixed paraffin-embedded (FFPE) tissues from 20 ccRCC patients who underwent surgical
nephrectomy resection. miR-21-5p and miR-210-3p resulted the most significantly up-regulated miRNAs in this patient
cohort, highlighting these onco-miRNAs as possible relevant players involved in clear cell Renal Cancer Cell tumori – genesis.
Concluding, this study confirms the deregulation of specific oncogenic miRNAs in renal tumor, reporting the identification
of specific oncogenic miRNAs that are altered in ccRCC tissues, and further supports the potential clinical usefulness of these
miRNAs in ccRCC management.
References
1. Wu, X.; Weng, L.; Li, X.; Guo, C.; Pal, S.K.; Jin, J.M.; Li, Y.; Nelson, R.A.; Mu, B.; Onami, S.H.; et al. Identification of a
4-microRNA signature for clear cell renal cell carcinoma metastasis and prognosis. PLoS ONE 2012, 7, e35661
2. Xiao, H.; Zeng, J.; Li, H.; Chen, K.; Yu, G.; Hu, J.; Tang, K.; Zhou, H.; Huang, Q.; Li, A.; et al. miR-1 downregulation correlates
with poor survival in clear cell renal cell carcinoma where it interferes with cell cycle regulation and metastasis. Oncotarget
2015, 6, 13201–13215.
3. Samaan, S.; Khella, H.W.; Girgis, A.; Scorilas, A.; Lianidou, E.; Gabril, M.; Krylov, S.N.; Jewett, M.; Bjarnason, G.A.; El-said,
H.; et al. miR-210 is a prognostic marker in clear cell renal cell carcinoma. J. Mol. Diagn. 2015, 17, 136–144.
4. Lu, G.J.; Dong, Y.Q.; Zhang, Q.M.; Di, W.Y.; Jiao, L.Y.; Gao, Q.Z.; Zhang, C.G. miRNA-221 promotes proliferation, migration
and invasion by targeting TIMP2 in renal cell carcinoma. Int. J. Clin. Exp. Pathol. 2015, 8, 5224–5229.
5. Cheng, T.; Wang, L.; Li, Y.; Huang, C.; Zeng, L.; Yang, J. Differential microRNA expression in renal cell carcinoma. Oncol.
Lett. 2013, 6, 769–776.
7
8
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
13*."3:$&--$6-563&40#5"*/&%'30.$-&"3$&--3&/"-$&--$"3$*/0."
41&$*.&/43&5"*/5)&53"/4$3*150.*$130'*-&"/%.&5"#0-*$1)&/05:1&
0'$033&410/%*/(5*446&4
a
r
t
s
Objective
Renal cell carcinoma (RCC) accounts for approximately 2-3% of all adult malignancies and clear cell RCC (ccRCC) is the
most common subtype (1). In about 90% of its sporadic forms the bi-allelic inactivation of VHL prevents degradation of
hypoxia-inducible factor-1α and 2α (HIF-1α, HIF-2α) with constitutive activation of their function (2). However, about
40% of ccRCC have deletions that include HIF- α locus and thus VHL-deficient ccRCC can be distinguished based on
HIF-1α expression (3). HIF-1α and HIF-2α, through the regulation of different and specific hypoxia-inducible genes
(4), have also an important role in the development of the various metabolic alterations that characterize ccRCC and
are involved in its development (5). Recently, by combined proteomics and metabolomics analysis performed on ccRCC
tissues we found that the Warburg effect (aerobic glycolysis) is more prominent at the expense of tricarboxylic acid
cycle and oxidative metabolism pathway (6). Furthermore, the glutamine metabolism pathway acts to inhibit reactive
oxygen species, as evidenced by an upregulated glutathione pathway, whereas the β-oxidation pathway is inhibited,
leading to increased fatty acylcarnitines (6). To overcome the difficulties and limitation due to tissue heterogeneity that
characterizes ccRCC and to provide an in vitro model for functional studies, we established primary cell cultures (PCC)
from normal cortex and ccRCC specimens with high efficiency and reproducibility. These cultures, composed of more
than 90% of normal tubular or tumor cells respectively, were extensively characterized and showed to retain, at the
early passages, the proteomic, phenotypic and genomic profile of the corresponding tissues (7-10). In order to extend
the molecular characterization of our ccRCC PCC for their use in ccRCC metabolic alteration study with the final goal
of favoring metabolic targeted therapies, we investigated here for the PCC transcriptomic profile and validated the
molecular metabolic data obtained with phenotypic studies and metabolic assays.
PCC established from ccRCC and normal cortex tissue samples were characterized by FACS analysis (8). Total RNA
samples were extracted from PCC and the transcriptome profiling of 8 ccRCC versus 8 cortex PCC cultures was
performed by GeneChip Human Exon 1.0 ST array using Affymetrix technology. Functional enrichment analysis
on Gene Ontoloy (GO) biological processes terms was performed on PCC differential expressed gene (DEG-PC) by
ToppGene suite (https://toppgene.cchmc.org/). We compared our DEG-PC list to the list of differentially expressed
genes related to ccRCC tissues (2493 DEG-tissues, derived from RNA-seq analysis) reported as supplementary data
by Wozniak et al. (11). Comparison between GO biological processes enriched in ccRCC primary cultures and ccRCC
tissues was performed using the ToppCluster tool. Glycogen storage in PCC and corresponding tissues was evaluated
by PAS staining and commercial kit; neutral lipid storage by Oil Red “O” staining or by lipid droplet marker PLIN2
expression evaluated by western blot. LDHA expression was evaluated by western blot and lactate content by commercial
kit.
Results
We globally found that the gene expression profiling well discriminated tumor from normal cortex PCC evidencing
1049 differential expressed genes (DEG) (552 up- and 497 down-regulated genes) in ccRCC as compared to normal
kidney cultures. We found a significant functional enrichment for several biological processes, and among these also
those related to metabolic processes, particularly lipid and carbohydrate metabolism. To verify whether ccRCC primary
cultures can be considered a good in vitro model to represent and study ccRCC, we matched the transcriptomic analysis
of our PCC in a metanalysis approach with ccRCC tissue transcriptomic profile. We found that 552 (52.6 %) out of
1049 DEG of our cultures were shared. In addition, we found that ccRCC PCC and tissues shared many GO biological
processes, among which also several metabolic processes, indicating a good similarity between ccRCC cultures and
tissues. The molecular metabolic characterization evidenced from transcriptomic analysis of PCC was validated by
the metabolic phenotype of our ccRCC PCC, also retained in corresponding tissues. In fact, PCCs at the first passages
maintained the lipid and glycogen storage observed in corresponding tissues. Moreover, our ccRCC PCC maintain
LDHA overexpression and L-lactate overproduction previously described in tissues.
Discussions
The functional analysis of differentially modulated genes obtained comparing ccRCC versus normal cortex PCC showed
significant enrichments of several biological processes known to be important for ccRCC development, among which
those related to lipid and glucose metabolism. Moreover, by comparing the transcriptomic profile of the present study to
the transcriptomic profile obtained in ccRCC tissues, we found that biological process categories such as lipid metabolic
b
a
X
X
C. Bianchi1, C. Meregalli1, S. Bombelli1, B. Torsello1, S. De Marco1, I. Cifola2, E. Mangano2, C. Battaglia3, G. Bovo4, P.
Viganò5, G. Strada5, R.. Perego1
1
Università degli Studi di Milano Bicocca, Dipartimento di Medicina e Chirurgia (Monza)
2
Istituto di Tecnologie Biomediche, Consiglio Nazionale delle Ricerche (Segrate)
3
Università degli Studi di Milano, Dipartimento di Biotecnologie Mediche e Medicina Traslazionale (Segrate)
4
Ospedale San Gerardo, U.O. Patologia (Monza)
5
Ospedale Bassini - A.O. ICP, U.O. Urologia (Milano)
8
9
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
a
r
t
s
b
a
"44&44.&/5 0' -0/( 5&3. '6/$5*0/"- 065$0.&4 */ .03& 5)"/ 1"5*&/5453&"5&%8*5).*/*."--:*4$)&.*$1"35*"-/&1)3&$50.:
G. Simone1, L. Misuraca1, R. Papalia2, M. Ferriero1, R. Mastroianni2, F. Minisola1, G. Tuderti1, V. Pompeo1, M.. Costantini1,
S.. Guaglianone1, G. Muto2, M.. Gallucci1
1
Istituto Nazionale Tumori “Regina Elena” (Roma)
2
Università Campus Biomedico (Roma)
Introduction:
The negative impact of warm ischemia on renal function (RF) recovery has led surgeons to develop minimally ischemic
(MI) techniques to perform partial nephrectomy(PN). We evaluated long-term renal functional outcomes of a single
center series of >1000 consecutive patients treated with either MI or pure off-clamp PN.
Materials & Methods:
A retrospective analysis of a prospective renal cancer database was performed for all patients treated with MI or offclamp laparoscopic or robotic PN between 2002 and 2015. The 2-yr, 5-yr and 10-yr chronic kidney disease (CKD) stage
specific risks of developing RF deterioration after surgery were estimated with the Kaplan-Meier method. Univariable
and multivariable Cox regression analysis were performed to identify predictors of postoperative RF loss.
Results:
Overall, 1083 patients were evaluated. At Kaplan-Meier analysis, for patients with preoperative CKD-stages 1-2 the 5-yr
risk of developing an eGFR<60ml/min was 9% and 26%, respectively, while the 5-yr risk of developing an eGFR<30
ml/min was 0% and 0.9%, respectively (Figure 1). The 5-yr risk of developing CKD stage≥4 for patients with baseline
CKD stages 3a-3b was 7.5% and 10.7%, respectively. On multivariable analysis tumor size>7cm (p=0,026), age at
surgery (p<0.001), preoperative eGFR (p=0,001) and perioperative eGFR% decrease≥10% (p<0.001) were independent
predictors of developing a CKD stage≥3 in 920 patients with baseline CKD-stages 1-2 (Figure 2). In 163 patients with
preoperative CKD-stages 3a-3b, preoperative eGFR (p=0,049) and perioperative eGFR% decrease≥10% (p=0,034) were
the only predictors of a new onset 4-5 CKD-stages (Figure 2).
Conclusions:
MI and off-clamp PN have a negligible impact on functional outcomes. At 5-yr evaluation the occurrence of eGFR<30mL/
min was <1% in patients with baseline eGFR>60mL/min and about 10% in those with baseline eGFR between 30 and 60
mL/min. Baseline RF and early perioperative eGFR were the main determinants of long term renal functional outcomes
in patients undergoing MIPN.
X
X
process and glucose/carbohydrate metabolic process were represented among the highest enriched terms shared by the
two datasets. Thus, transcriptomic analysis of primary cell cultures indicated that our in vitro model well mimicked
the molecular signature of ccRCC tissues also at metabolic level, suggesting that our cultures could be suitable tools
to study the aspects related to ccRCC metabolism. The metabolic phenotype of our ccRCC PCCs, also observed in
corresponding tissues, validated transcriptomic data, and confirmed the reliability of in vitro model of PCC to study
ccRCC metabolism.
Conclusion
Here we described a further improvement in molecular characterization of our PCC, that will be instrumental for future
metabolic studies that will aim to improve our understanding of ccRCC metabolic dysregulation. In the future, these
PCC will be also used to evaluate the impact of the differential expression of HIF-a and of the clinical/pathological
characteristics of the tumor on the metabolic behavior of ccRCC cells. The achievement of a complete molecular and
metabolic characterization of ccRCC, based also on differential HIF-a expression, might pave the way to the discovery
of innovative therapeutic approaches based on targeting specific differential metabolic pathways.
References
1. Bini, Lancet 2009
2. Baldewins, J Pathol 2010
3. Shen, Cancer Discov 2011
4. Keith, Nature Rev Cancer 2012
5. Linehan, Nat Rev Urol 2010
6. Wettersten, Cancer Res 2015
7. Perego, J Proteome Res 2005
8. Bianchi, Am J Pathol 2010
9. Cifola, BMC Cancer 2011
10. Cifola, Mol Cancer 2008
11. Wozniak Plos one 2013
9
10
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
30#05*$ 3"%*$"- /&1)3&$50.: 8*5) */'&3*03 7&/" $"7" 56.03
5)30.#&$50.:*/*5*"-4&3*&4
a
r
t
s
b
a
"1"5)'03%*"(/04*45)&3"1:'0--0861"/%3&4&"3$)0',*%/&:$"/$&3
063&91&3*&/$&*/,*%/&:$"/$&3."/"(&.&/5
F. Chiancone1, C. Meccariello1, M. Fedelini1, M.P. Vitale2, G. Cartenì2, P. Fedelini1
1
AORN A. Cardarelli, U.O.S.C. Urologia (Napoli)
2
AORN A. Cardarelli, U.O.S.C. Oncologia Medica (Napoli)
Objective
Kidney cancer is one of the top ten most common cancers (1). Many renal masses remain asymptomatic until the late stages of
the disease (2). As a consequence more than 50% of kidney cancers are detected incidentally. Otherwise it can be detected in
an advanced stage when the patient reach an emergency department with a massive hemorrhage, flank pain, gross haematuria,
or general decadency (3). A multidisciplinary approach seems particularly useful for patients with malignancy of kidney (4).
PDTA is a path of diagnosis, therapy, follow up and research of patients (pts) with kidney cancer, based on a multidisciplinary
approach in order to have the highest quality of patient care.Our aim is to improve and make more easily accessible path to the
person facing the disease, and to improve patient satisfaction regarding the relationship with the hospital.
All patients who come to our hospital, with suspect or certain kidney cancer are evaluated in a specific multidisciplinary path.
Protocols of diagnosis, staging, surgical or medical treatment and follow-up are defined. Indicators of process and result have
been identified and will be periodically verified in order to evaluate the implementation of the path and the improvement of
patient care. The main indicators are summarized below:
t – median time between access to the hospital and starting medical treatment or
t surgery
t – hospitalization rate in emergency for suspected kidney cancer
t – ratio between number of pts who have suspended or interrupted drug therapy
t autonomously and number of pts treated
t – IP1: time between the date of the radiological findings of localized renal mass and
t surgery
t – IP2-IP3: time between the date of the radiological findings of metastatic disease
t and cytoreductive surgery or medical treatment
t – IR1-2: time to recurrence after radical or conservative surgery
t – IR3: % overall survival (OS)
t – IR4-IR5: % G3 or G4 toxicity (CTCAE=Common Terminology Criteria for Adverse Events)
t – IR6-IR7: time to disease progression during 1° or 2° line treatment
X
X
G. Simone1, M.C. Ferriero1, F. MInisola1, R. Papalia2, S. Guaglianone1, G. Tuderti1, L. Misuraca1, V. Pompeo1, R. Mastroianni2,
A.L. De Castro Abreu 3, M. Aron3, M. Desai3, I.. Gill3, M. Gallucci1
1
2
3
USC Institute of Urology and Departments of Urology Keck School of Medicine, University of Southern (Los Angeles)
Introduction & Objectives:
Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic
surgical procedures. We present perioperative outcomes of our first 10 cases of completely intracorporeal robot- assisted
radical nephrectomy with IVC level II and III tumor thrombectomy.
Material & Methods:
Ten patients underwent robot-assisted radical nephrectomy with IVC thrombectomy. The entire surgical procedure was
performed robotically. Baseline, peioperative and follow-up data were prospectively collected in an institutional review board
approved renal cancer database. Perioperative and oncologic outcomes were reported.
Results:
All procedures (right 5, left 5) were successfully completed, without any open conversion. Median tumor size was 8,55 cm
(range 3 to 13,5) and IVC thrombus length was 4,05 cm (range 1,7 to 6). Median operative time was 6 hours (range 3 to 8),
with a median IVC clamp time of 28 minutes (range 16 to 90). Median estimated blood loss was 650 cc (range 200 to 2000),
and hospital stay was 4 days (range 3-8). There were no intraoperative complications. Four patients underwent perioperative
transfusion (Clavien 2) and one patients underwent adrenalectomy due to a delayed bleeding on seventh postoperative day
(Clavien 3b). At a mean follow-up of 6.4 months, disease free survival rate was 80% and cancer specific survival rate was 100%.
Conclusions:
Our preliminary series supports feasibility and perioperative safety of completely intracorporeal robot-assisted radical
nephrectomy and IVC thrombectomy. Larger series and longer follow-up are needed to confirm these preliminary results.
10
11
t
t
t
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
– IR8: % of OS after starting of medical treatment
– IA1: % adherence to guidelines
– IA2: % pts evaluated by the multidisciplinary team
The degree of satisfaction of the patient is evaluated through a questionnaire and results will allow us to improve the path.
a
r
t
s
b
a
063463(*$"-5&$)/*26&*/$-".1-&44-"1"304$01*$1"35*"-/&1)3&$50.:
-1/
'033&/"-56.0634i8&+645/&&%"$&/5*.&5&3w
M. Fedelini1, F. Chiancone1, R. Giannella1, C. Meccariello1, L. Pucci1, P. Fedelini1
1
Objective
As time goes by, renal tumours surgery has had a trend towards parenchymal sparing and minimal invasive approach. It has
been always debated what are renal tumours who are fit and unfit for this kind of surgery. Most recent guidelines suggest as
limit for partial nephrectomy (PN) 7 cm of highest diameter of tumour (t1b tumours) (1). In any case the complications and
the outcomes of partial nephrectomy is associated with the treatment center’s learning curve and surgeon’s experience, and is
correlated with the anatomical features of each case (2). The aim of our study was to describe our technique in clampless LPN
analyzing the intraoperative and postoperative complications of patients who underwent this procedure at our institute and
X
X
Results
From November 2014 to December 2015, 94 patients were included in the path. The main results are:
t – Median age: 60 years old;
t – Median time between access to the hospital and starting medical treatment or
t surgery: 32 days and 48 days, respectively;
t – Rate of hospitalization in emergency for suspected kidney cancer: 56%;
t – Metastatic disease at the time of diagnosis: 22%;
t – Patients who underwent renal surgery as first therapeutic step: 13%;
t – Patients who underwent nephron-sparing surgery: 43%;
t – Patients who underwent radical surgery: 57%;
t – Ratio between number of patients who have suspended or interrupted drug therapy autonomously and number of
patients treated: 10/94.
It is still too early to collect data on recurrence and survival.
Discussions
In the last year we have experienced a growth in the number of patients who have reached our hospital for diagnosis and
treatment of kidney cancer of 15%. As a consequence, actually the median time between access to the hospital and starting
medical treatment or surgery was slightly higher than the previous year (30 days in September 2014 versus 32 days in December
2015 for medical treatment, 46 days in September 2014 versus 48 days in December 2015 for surgery). The rate of patients who
underwent hospitalization at our emergency department with the unique aim to achieve a diagnosis of kidney cancer was 95%
in the 2014. With a multidisciplinary approach to kidney cancer we have reduced this rate from 95% to 56%. In the future, our
aim will be to reduce the median time of access to medical and surgical cure also if we expect a progressive growth of patients
who will reach our hospital for the diagnosis and for the therapy of kidney cancer. Another target will be to reduce the rate of
patients who underwent hospitalization at our emergency department with the unique aim to achieve a diagnosis of kidney
cancer. Last but not least another target will be to reduce the number of patients who autonomously interrupt drug therapy
improving the monitoring of drug adverse events and providing more information to the patients about the management of
drug adverse events.
Conclusion
Our experience of creation of PDTA with the detection of indicators of process and result to monitor the path and a periodic
activity of clinical audit may become an important tool to ensure quality care. Overall, we have experienced a growth in the
number of patients who have reached our hospital and we have reduced the rate of patients who underwent hospitalization at
our emergency department with the unique aim to achieve a diagnosis of kidney cancer. In December 2014, we received the
certification of excellence IS0 9001-2008 for diagnosis, treatment and research of kidney cancer through a multidisciplinary
approach and in December 2015 the certification has been confirmed.
References
1- Ferlay J, Steliarova-Foucher E, Lortet-Tieulent J, Rosso S, Coebergh JW, Comber H, Forman D, Bray F. Cancer incidence and
mortality patterns in Europe: estimates for 40 countries in 2012. Eur J Cancer 2013 Apr;49(6):1374-403.
2- Novara G, Ficarra V, Antonelli A, Artibani W, Bertini R, Carini M, Cosciani Cunico S, Imbimbo C, Longo N, Martignoni
G, Martorana G, Minervini A, Mirone V,Montorsi F, Schiavina R, Simeone C, Serni S, Simonato A, Siracusano S, Volpe A,
Carmignani G. Validation of the 2009 TNM version in a large multi-institutional cohort of patients treated for renal cell
carcinoma: are further improvements needed? Eur Urol 2010 Oct;58(4):588-95.
3- Patard JJ, Leray E, Rodriguez A, Rioux-Leclercq N, Guillé F, Lobel B. Correlation between symptom graduation, tumor
characteristics and survival in renal cell carcinoma. Eur Urol 2003 Aug;44(2):226-32.
4- Pelikaan L, Vriesema JL, Brusse-Keizer MG, Cornel EB Value of a multidisciplinary team for patients with a urological
malignancy. Ned Tijdschr Geneeskd. 2015;159:A8590.
11
12
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
the feasibility of our technique.
From January 2005 to December 2015, 265 patients underwent clampless LPN for a renal tumour at our institution.
According to R.E.N.A.L (radius; exophytic/endophytic; nearness; anterior/posterior; location) NS (nephrometry scoring),
119 patients had low tumour complexity (score 4-6), 77 patients had moderate tumour complexity (score 7-9) and 69 patients
had high tumour complexity (score 10-12). Intraoperative and postoperative complications have been classified according
to standardized reporting systems such as the Satava (3) and the Clavien-Dindo system (4). In our technique we perform
a clampless LPN without isolation of the renal pedicle except where required by specific technical necessity like intrahilar
or perihilar tumors. A transperitoneal approach was used in all cases except for three cases (retroperitoneal approach). We
usually isolate the tumour and surrounding fat, with a small portion (about one centimeter) of healthy parenchyma around
its circumference, in order to control potential hemorrhages with transfixing parenchymal sutures. Usually we do not isolate
all surface of the kidney. During the enucleation, a cleavage plane between pseudocapsule and normal parenchyma is usually
created by monopolar scissors. Tumour is removed and hemostasis is controlled by using a bipolar dissector and “hem-o-lok®”
clips. Complete hemostasis is usually achieved by “floseal® hemostatic matrix” and “surgicel®”. We perform a sliding hem-o-lok
® clips absorbable suture when we need to achieve a better emosthasis and for kidney reconstruction. Finally Gerota’s fascia is
closed.
Results
Mean operating time was 116,8 minutes. Mean intraoperative blood loss was 220 millilitres (range 30-1200 millilitres).
Intraoperative blood transfusions were not necessary (according to intraoperative blood count analysis). Postoperative blood
transfusions were necessary in 8 out of 265 patients (3%). The mean length of hospital stay was 4,8 days (range 3-11 days).
Drains were removed at a mean time of 4,3 after surgery (range 3-7). All operations were performed laparoscopically without
conversion to open surgery. 6 out 265 patients (2,3%) experience intraoperative complications. 59 out of 265 patients (22,3%)
experienced postoperative complications. Table 1 shows in detail the intraoperative and the postoperative complications
according to Satava classification and Clavien-Dindo classification, respectively.
Discussions
The robotic technology seems to allow a safer and more precise excision of complex renal tumours, which are most commonly
removed using an open approach, with a technique that has a shorter learning curve and some technical advantages instead
of classical laparoscopy (5). Our present results indicate that LPN is feasible and safe in experienced hands compared to open
surgery also for high-surgical risk tumours when a robotic device is not avaible. Thompson RH et all. (2010) demonstrate
that “every minute counts” when the renal hilum is clamped and warm ischemia time (WIT) is a well-known predictor of
postoperative estimated glomerular filtration rate (eGFR) (6) . Based on this, it should be important to perform a clampless
partial nephrectomy. We usually start the procedure superficially with an enucleoresection of the tumour, but when we are
more deep the procedure becomes a simple enucleation, who has been previously described as a safe technique with oncologic
equivalence to standard partial nephrectomy (7). Postoperative complications rate was 22,3%. The rate is smaller (8,8%) if we
do not include Clavien-Dindo I grade complications. Despite this, estimated blood loss and overall postoperative complication
rate were similar to the previous series in which both clamped and clampless LPN are enrolled (8).
Conclusion
Current evidences suggest that the amount of residual functional parenchyma represents an important factor that impacts
postoperative renal function and that WIT is a well-known predictor of postoperative eGFR. As a consequence it is important
to perform a clampless partial nephrectomy removing the danger risk of sacrificing healthy parenchyma. Clampless LPN
without isolation of the pedicle is a feasible procedure for renal tumours with a low rate of intraoperative and postoperative
complications in high volume centers. Moreover clampless LPN is a feasible procedure for renal tumours of high surgical
complexity in high laparoscopic experience centers, when robotic devices are not available.
References
1- Simmons MN et all. Laparoscopic radical versus partial nephrectomy for tumors >4 cm: intermediate-term oncologic and
functional outcomes. Urology 2009 May;73(5):1077-82.
2-Porpiglia F et all. Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve
and tumour anatomical characteristics. BJU Int. 2013 Dec;112(8):1125-32. doi: 10.1111/bju.12317. Epub 2013 Aug 13.
3-Kazaryan AM et all. Morbidity assessment in surgery: refinement proposal based on a concept of perioperative adverse
events. ISRN Surg. 2013 May 16;2013:625093. doi: 10.1155/2013/625093. Print 2013.4- Clavien PA, Barkun J, de Oliveira
ML, Vauthey JN, Dindo D, Schulick RD, de Santibañes E, Pekolj J, Slankamenac K, Bassi C, Graf R, Vonlanthen R, Padbury
R,Cameron JL, Makuuchi M. The Clavien-Dindo classification of surgical complications: five-year experience. Ann Surg.
2009 Aug; 250 (2): 187-96.
5-Hanzly M et all. Learning curves for robot-assisted and laparoscopic partial nephrectomy. J Endourol. 2015 Mar;29(3):297303. doi: 10.1089/end.2014.0303. Epub 2014 Oct 21.
6- Thompson RH, et all. Every minute counts when the renal hilum is clamped during partial nephrectomy. Eur Urol. 2010
Sep;58(3):340-5. doi: 10.1016/j.eururo.2010.05.047. Epub 2010 Jun
7- Longo N, et all. Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes
based on a matched-pair comparison of 396 patients (RECORd project). Eur J Surg Oncol. 2014 Jun;40(6):762-8.
8-Choi JE et all. Comparison of perioperative outcomes between robotic and laparoscopic partial nephrectomy: a systematic
review and meta-analysis. Eur Urol. 2015 May;67(5):891-901. doi: 10.1016/j.eururo.2014.12.028. Epub 2015 Jan 6.
12
13
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
130(/045*$1"3".&5&340'3$$3&$633&/$&"'5&31"35*"-/&1)3&$50.:
3&46-54'30."4*/(-&$&/5&3:&"34'0--0861
a
r
t
s
b
a
30-& 0' )&.045"5*$ ."53*9 */ $0634& 0' 1"35*"- /&'3&$50.: 8& 45*--
/&&%46563&4
G.M. Badano1, E. Daglio1, A. Di Domenico1, E. Rikani1, L. Timossi1, C. Pezzica1, C. Introini1
1
Ospedale Evangelico Internazionale (Genova)
Objective
To evaluate the safety and efficacy due to use of only hemostatic matrix in course of laparoscopic partial nephrectomy.
From July 2013 to December 2014 36 patient underwent partial nephrectomy for small renal masses were recruited into the
study. Exclusion criteria were lesion major than 4 cm, completely endophytic lesion or lesion that infiltrate the urinary tract.
Median age of 58,5 years (37-71yr). 19 patient were male and 17 woman. The median size of the tumor were 2,8cm (1,9-3,5cm).
Left kidney were interested in 24 patients while in 12 patients the right one were interested. The tumor were localized at the
lower pole in 25 patients, 7 in the middle part and 4 in the upper pole,all the lesion were exophytic . All the patients undergone
laparoscopic partial nephrectomy with the palcement of two 10mm trocars and three 5mm trocars . All the procedures were
perferomed with anatomic zero ischemia and no preparation of renal vessels. The tumors were isolated and removed using
monopolar scissor and advaced bipolar forceps.Surgiflo were put immediatly after the tumor excision on the resection bed.
At the end of the procedures we perform a reconstruction of the posterior parietal peritoneum. Surgiflo is a topical thrombin
indicated as an aid to hemostasis whenever oozing blood and minor bleeding from capillaries and small venules is accessible
and control of bleeding by standard surgical techniques (such as suture, ligature or cautery) is ineffective or impractical.
Results
No patients required an intraoperatory open conversion. Intraoperatory blood loss were less then 100cc in 22 patients (61,1%)
100cc -200cc in 10 patients (31,2%) more than 200 cc in 4 cases (12,5%). All the surgical procedure were performed by the same
surgeon. The median operative time were 79 minutes (67-107min).3 patients required blood trasfusion No major complication
occurred. The median recovery was 3,2 days (2-5). 28 of the tumor were renal cell carcinoma (RCC) Grade 2 , 4 RCC Grade
3, 1 angiomyolipoma, 3 patients present a Bosniak type 3 lesion with cellular atypia.Surgical resection margins were negative
in 34 patient in 2 patients surgical margins were focal involved by the tumor. After at least 12 month no patient present local
recurrence or progression of the disease.
Discussions
Partial nefrectomy rappresent the gold standard therapy for kidney tumor with size lower than 4 cm . The use of suture the
X
X
M. Seveso1, G. Bozzini1, A. Mandressi1, S. Melegari1, O. De Francesco1, P. Bono1, M. Provenzano2, N. Buffi3, P. Casale3, G.
Lughezzani3, G. Guazzoni3, G. Taverna1
1
Humanitas Mater Domini (Castellanza)
2
Università Humanitas (Rozzano)
3
Clinica e Centro di Ricerca Humanitas (Rozzano)
Objective
Aim of this work is to evaluate clinical and pathological characteristics of RCC and prognostic effect of those variables on
tumor recurrence in patients treated with tumor enucleation for clinically intracapsular renal cell carcinomas (RCCs).
Methods and materials
Between 1995 and 2005 patients with single intracapsular RCC were scheduled for open partial nephrectomy. All clinical
and pathological data were recorded (ASA scale, blood loss, surgical time, BMI, tumor size, lesion site, warm ischemia time,
definitive histology, presence of infiltration, pT stage, grade, sarcomatoid features, microvascular invasion, intraparenchimal
necrosis). Local recurrence rate, progression-free survival (PFS), and cancer-specific survival were the main outcomes.
Statistical analyses included the Kaplan-Meier method, log-rank test, and univariate and multivariate Cox regression models.
Results
373 consectuive patients underwent open partial nephrectomy. Mean (median, range) follow-up was 183 months (182, 156–
234). 10.2% of the patients had III as a grade. 9.6% of the patients had positive surgical margins. 12.1% of the patients had
intralesional necrosis. The 15-year PFS rates for tumors was 37.5% with a not disease related mortality of 19.8%.
The multivariate Cox model showed tumor grading, presence of positive margins and of intraparenchimal necrosis to be the
significant independent predictors of disease related recurrence, whereas tumor size and other variables did not present a
significant increased risk in developing recurrence.
Conclusions
Even if tumor enucleation is an oncologically safe nephron-sparing surgical technique, recurrence should be suspected. Tumor
grading, positive margins and presence of intralesional necrosis are significant and independent predictors of tumor recurrence
in patients with clinically intracapsular RCCs scheduled for nephron-sparing surgery. The size of the tumor does not predict
the risk of recurrence.
13
14
X
X
a
r
t
s
b
a
Argomenti: cancro della vescica o alte vie urinarie
G. Canepa1, F. Campodonico1, S. Tamagno1, C. Introini2, M. Puntoni3
1
E.O. Ospedali Galliera, S.C. Urologia (Genova)
2
Ospedale Evangelico Internazionale, S.C. Urologia (Genova Voltri)
3
E.O. Ospedali Galliera, Direzione Scientifica e Biostatistica (Genova)
Objective
Management of non muscle invasive bladder cancer (NMIBC) after transurethral resection of bladder tumor generally consists
of surveillance and intravesical therapy (1). Particularly challenging is the treatment of patients who have not responded to
first-line intravesical bacillus Calmette-Guerin (BCG) or that have high-risk features. For such patients, radical cystectomy
remains a commonly recommended alternative treatment. High risk Non Muscle Invasive Bladder Cancer (HR-NMIBC),
as stated by EORTC, is an important challenge for urologist and oncologist to avoid tumor progression and to preserve the
bladder. The aim of the study is to evaluate the long-term experience on a treatment combining intravesical hyperthermia with
Mytomicin C (HT-MMC) delivered with the Synergo® device.
In a period between August 2004 and November 2015 a group of 146 patients (108 male and 38 female, mean age 68+/- 9 y.o.
Range 40 -84y.o.) affected by high risk NMIBC were recruited. All of them were treated with endovesical thermo-chemotherapy
MMC C 40mg (HT-MMC) performing more than 1600 treatment sessions using the Synergo® device. After an initial induction
of 4 weekly treatments with 2 x 40mg MMC, the efficacy was checked in tumor eradication by TUR B and cytology at week
6. Tumor-free patients continued with the maintenance therapy every 15 days with 3 sessions 2 x 40mg MMC, then every 21
days with 3 sessions 2 x 40mg MMC, and every 45 days with 3 sessions 2 x 40mg MMC and in parallel cystoscopy and urine
cytology every 3 months. The follow-up was conducted over an average period of 39.2months (Range 2.4 months – 7.9 years).
The majority of patients were at high-risk including G3 (64 – 44%), T1 (79 – 54%) and Cis (22 – 15%), high frequency of
recurrences (2,1 +/- 2,7 – Range 0-17 n° of recurrences before the first treatment). First aim of the study was the RecurrenceFree Survival (RFS) and disease progression for stage and grade (PFS), the secondary aim was the tolerability and adherence to
the proposed schedule of treatment.
Patients characterisrics N=146
Male 108 (74%)
Female 38 (26%)
Age (at the start of treatment)
mean (SD) 68 (9)
median (min-max) 70 (40-84)
Smoking habit*
Non smoker 47 (32%)
Smoker 98 (68%)
*(1 missing data)
Stage
Ta 45 (31%)
Cis 22 (15%)
T1 79 (54%)
Grade (Without Cis)
G1 13 (9%)
G2 47 (32%)
G3 64 (44%)
5&/ :&"34 &91&3*&/$& 8*5) */53"7&4*$"- 5)&3.0$)&.05)&3"1: ..$
.('03/0/.64$-&*/7"4*7&#-"%%&3$"/$&3)*()*/5&3.&%*"5&3*4,
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
ensecure hemostasis on bed resection is the most frequent tecnique used . Hemostasis control and collecting system suturing
are the most difficult parts during a laparoscopic procedure. For best outcomes with nephron sparing surgery, several tissue
sealants were developed to be associated with, or even replace sutures of the renal parenchyma . In this study we demostred
that the use of Surgiflo were safety and efficacy in all the patients undergone partial nefrectomy both intraoperatively that
postoperatively . No surgical procedure required emostatic suture to stop resection bed bleeding.
Conclusion
Laparoscopic partial nephrectomy is an effective surgical alternative in NSS in which the ultimate goal is to achieve the
“trifecta” of a negative cancer margin, minimal decrease in renal function and an absence of complication. The biological glue
is an important tool in laparoscopic partial nephrectomies. This data shows that during laparoscopic partial neprectomy for
small lesions in selected cases the use of Surgiflo is sufficient to ensure a good hemostasis and the non-use of sutures on the
renal parenchyma could ensure less damage to the parenchyma with a consequent improvement on renal function. Human
clinical trials with larger numbers are needed to confirm our results in patients with small renal tumors that could lead us to
better outcomes, by decreasing bleeding, when performing minimally invasive partial nephrectomy.
References
14
15
a
r
t
s
b
a
1. Lammers RJM, et al. The role of combined regimen with intravesical chemotherapy and hyperthermia in the management of non-muscle-invasive
bladder cancer: A systematic review. Eur Urol 2011; 60:81-93
2. Rahmi GE, et al. Intravesical bacillus Calmette-Guerin versus chemohyperthermia for high-risk non-muscle-invasive bladder cancer. Can Urol
Assoc J 2015;9 (5-6): E278-83
3. Fernandez-Gomez J, et al. Predicting nonmuscle invasive bladder cancer recurrence and progression in patients treated with bacillus CalmetteGuerin: the CUETO scoring model. J Urol 2009;182:2195-203
4. Babjuk M, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder: Update 2013. Eur Urol 2013; 64:639-53.
5. Shelley MD, et al. Intravescical therapy for superficial bladder cancer. A systematic review of randomised trials and meta-analyses. Cancer Treat Rev
2010;36:195-205
6. Brausi M, Oddens J, Silvester R et al. Side effects of Bacillus Calmette-Guerin (BCG) in the treatment of intermediate- and high-risk Ta, T1 papillary
carcinoma of the bladder: results of the EORTC genito-urinary cancers group randomised phase 3 study comparing one-third dose with full dose
and 1 year with 3 years of maintenance BCG. Eur Urol 2014;65:69-76
7. Malmstrom P-U, Sylvester RJ, et al. An individual patient data meta-analysis of the long-term outcome of randomised studies comparing intravesical
mitomycin C versus bacillus Calmentte-Guerin for non-muscle-invasive bladder cancer. Eur Urol 2009;56:247-56
8. Colombo R, et al. Long-term outcomes of a randomised controlled trial comparing thermochemotherapy with mitomycin C alone as adjuvant
treatment for non-muscle-invasive badder cancer (NMIBC). BJU Int 2011;107:912-8.
9. Moskovitz B, Halachmi S, Moskovitz M, et al. 10-year single-center experience of combined intravesical chemohyperthermia for non-muscle
invasive bladder cancer. Future Oncol 2012;8:1041-9
10. Sylvester RJ, et al. Predicting recurrence and progression in individual patients with stage TaT1 bladder cancer using EORTC risk tables: a combined
analysis of 2596 patients from seven EORTC trials. EurUrol 2006;49:466-5.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Results
After the first treatment of 4 weekly sessions of HT-MMC, only 11 patients (7.5%) were stopped for recurrences: 3 progressions
and 8 recurrences. At the end of each treatment 37/146 patients reported a recurrence and 14/146 patients presented a
progression. The RFS at 1, 2 and 5 years was 89.6%, 79.2 and 68.3 respectively. The PFS at 1, 2 and 5 years was 98%, 96.2 and
83.7 respectively. The number of treatment sessions for each patients were 10.4+/- 4.7 with a median of 11 sessions (Range
4-31). The time of exposure over 42°C was 37.4+/-7.4 mins. and the mean temperature was 42.0+/-0.8°C. The safety profile
showed mainly grade 1 and 2 side effects. Ten patients complained grade 3 side-effects, including 1 patient bladder spasms/
pain during treatment, 3 patients dysuria and 6 patients urgency after treatment.
Treatment (Synergo) characteristics: N=146
Number of treatments (per patient)
mean (sd) 10.4 (4.7)
median (min-max) 11 (4-31)
Time (minutes) over 42°C
mean (sd) 37.4 (7.4)
median (min-max) 38.6 (6.8-55)
Mean temperature (°C)
mean (sd) 42.0 (0.8)
median (min-max) 42.0 (38.2-45.9)
Power (Watt)
mean (sd) 18.7 (2.8)
median (min-max) 18.3 (10.9-26.8)
Discussions
We evaluated treatment efficacy and tolerability with intravesical HT-MMC in this retrospective cohort of high-risk NMIBC
patients. In the high-risk NMIBC the expected recurrence rate is 49% at 5 years (2, 3). In patients affected by high-risk urotelial
bladder tumour intravesical Bacillus Calmette-Guerin (BCG) is indicated (4). Intravesical BCG prevents 31% to 50% of tumour
recurrence, compared to TUR alone (5). The side-effect of BCG are remarkable, and treatment discontinuation rate of BCG for
toxicity is 7% to 19% (6). In a meta-analysis, 32% reduction in tumour recurrence for BCG maintenance compared to MMC
was found (7). MMC is considered a less effective alternative treatment for patients intolerant to BCG. Colombo and coll.
found out that HT-MMC is more effective than MMC alone (8). The 10-year disease-free survival rate for HT-MMC and MMC
alone was 53% and 15% respectively (8). So HT-MMC has shown to be an effective treatment for intermediate and high-risk
NMIBC with a good RFS especially in the first two years (9). In our retrospective HT-MMC treatments study the PFS was high
considering the percentage of high-risk patients. Tolerability was good without relevant systemic side-effects and most of the
patients demonstrated a complete adherence to the proposed schedule of treatment.
Conclusion
Endovesical thermo-chemotherapy MMC 40mg seems to be an effective treatment for NMI Bladder Cancer. Patients affected
by highly recurrent disease before chemo-hyperthermia have a lower recurrence free survival. Although the 5-year survival to
NMIBC is more than 90%, the survival period is not disease-free (10, 4). BCG intravesical is considered more effective than
chemotherapy for NMIBC, representing the first line approach in high-risk patients (4, 7). Due to side-effects and failure of
BCG, new chemotherapy agents and device-assisted instillation have been tested in high-risk patients (1). To enhance the
efficacy of MMC, a valid method for intravesical HT-MMC delivering was adopted in our department from 2004. We reported
our experience over a period of more than 10 years. The results of RFS and PFS are encouraging to maintain this kind of
protocol of treatment, although the high dosage of MMC used with ablative intent is well tolerated by a good percentage of
patients.
References
15
16
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
(451 .&5):-"5*0/ "/% 1305&*/ &913&44*0/ */ 13045"5& $"/$&3
%*"(/045*$*.1-*$"5*0/4
b
a
a
r
t
s
X
X
Argomenti: G. Roberta1, M. Fiori1, F. Martignano2, G. Gurioli2, S. Salvi2, D. Calistri2, M. Costantini3, T. Zenico1, U. De Giorgi4, F. Foca5, V.
Casadio2
1
Ospadale Morgagni-Pierantoni, U.O. Urologia (Forlì)
2
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Laboratorio di Bioscienze (Meldola)
3
Ospadale Morgagni-Pierantoni, U.O. Oncologia Medica (Forlì)
4
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Unità di Oncologia Medica (Meldola)
5
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Unità di Biostatistica e Sperimentazioni Cliniche
(Meldola)
Objective
GSTP1 belongs to the GSTs family, a group of enzymes involved in detoxification of exogenous substances and it also plays an
important role in cell cycle regulation [1].
GSTP1 plays an important role in the early process of cancerogenesis in prostate cancer (PCa) [2] and its methylation is present
in about 70-80% of PCa, while benign prostatic hyperplasias are normally hypomethylated [3].
Methylation often produces loss of gene expression and some literature data have shown a correlation between GSTP1 promoter
hypermethylation and reduction of expression in PCa [4] . However, these data still need to be confirmed.
Taking into account all the above considerations, GSTP1 expression could potentially represent a good histological marker in
substitution of or in addition to AMACR, p63 or cytokeratin [5-6], already in use in clinical practice, so as to improve PCa
detection when diagnosis is ambiguous due to the presence of cancer mimics such as PIN.
The aim of our study was to investigate GSTP1 gene methylation and its correlation with expression in cancer, preneoplastic
lesions and healthy tissues obtained by prostatectomy, to clarify its involvement in tumour development.
Fifty-six prostatectomies were recruited. We isolated DNA from cancer and healthy tissues previously selected by a pathologist.
DNA isolation was performed using QIAamp DNA FFPE Tissue Kit (Qiagen, Milan, Italy), according to the manufacturer’s
instructions.We investigated GSTP1 methylation status with methylation specific PCR (MS-PCR). Briefly, we converted DNA
with bisulphite and performed real-time PCR using SYBR-GREEN master mix (Biorad, Milan, Italy) and primers specific for
bisulphite-converted DNA. We tested the DNA quality by Actin B amplification.
We also manually performed immunohistochemistry by immunostaining tissue samples with a rabbit monoclonal antibody
anti GSTP1 (anti-GST3/GSTp, Abcam). Tissues were incubated with the antibody at a dilution of 1:500 for 60 minutes.
Results
Analysis of the PCa samples and the corresponding adjacent healthy prostatic tissue showed that GSTP1 is methylated in 51
tumor samples (91.1%) and in only 3 adjacent healthy tumor samples (5.4%).
All 56 prostatectomy samples analyzed showed GSTP1 expression in adjacent healthy tissue irrespective of methylation pattern.
All 51 (100.0%) cases methylated for GSTP1 in PCa tissue showed no expression. We observed an inverse association between
methylation and expression of GSTP1 in the overall case series with a p<0.001 (Fisher exact test).
GSTP1 is highly expressed in basal cell layer and lumen in benign glands while in prostatic intraepithelial neoplasia (PIN) it
stains only basal cell layer and PCa glands are completely negative.
The results obtained from GSTP1 expression analysis on prostatectomies were confirmed on 16 biopsies taken before surgery
(data not shown).
Discussions
GSTP1 promoter hypermethylation correlates with underexpression in malignant glands in almost every sample, whereas it is
strongly expressed in healthy tissues.
It is interesting to observe that, while GSTP1 hypermethylation often results in gene silencing in PCa tissue, the unmethylated
status for GSTP1 promoter with a loss of expression was observed in 3 cases of PCa. This suggests that GSTP1 suppression may
be due also to other regulation mechanisms.
GSTP1 appears to be methylated and silenced also in patients with low grade and low PSA values, suggesting that GSTP1
alterations (methylation or expression) may be considered as useful early diagnostic markers, so as to avoid unnecessary rebiopsies, as recently demonstrated by Zelic R et al [7].
We also performed immunohistochemistry on 16 prostate needle biopsies (data not shown) containing both low grade PCa
and PIN in order to understand whether GSTP1 staining could be helpful for the histological evaluation of core biopsies
for diagnostic purpose. Thanks to its capacity of staining in basal cell layer, we hypothesized that GSTP1 could be used to
discriminate benign prostatic hyperplasia and PIN (which maintains basal cell staining uniformity) from PCa (which lacks
a basal layer). Unfortunately, GSTP1 did not prove satisfactorily reliable due to its not always homogeneous staining in
morphologically normal glands that should be positive to GSTP1.
Conclusion
We demonstrated that gene methylation leads to underexpression of GSTP1. The progressive loss of GSTP1 expression from
healthy glands to PIN and to PCa glands underlines its involvement in early carcinogenesis; its behavior in the various stages
of tumor development is noteworthy and paves the way for further studies on larger case series.
We also confirmed that GSTP1 promoter methylation is an early epigenetic event related to PCa development. Methylation
analysis could be helpful to reveal PCa even in patients with low grade tumors and low PSA values, moreover expression
16
17
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
analysis further demonstrated that GSTP1 methylation leads to gene silencing in PCa tissues.
References
[1] E. Laborde, Glutathione transferases as mediators of signaling pathways involved in cell proliferation and cell death, Cell
death and differentiation 17 (2010), 1373-1380.
[2] M. Schnekenburger, T. Karius and M. Diederich, Regulation of epigenetic traits of the glutathione S-transferase P1 gene:
from detoxification toward cancer prevention and diagnosis, Frontiers in pharmacology 5 (2014), 170.
[3] D. Jiang, Y. Shen, D. Dai, et al. Meta-analyses of methylation markers for prostate cancer, Tumour biology : the journal of
the International Society for Oncodevelopmental Biology and Medicine 35 (2014), 10449-10455.
[4] W. Zhang, H. Jiao, X. Zhang, et al, Correlation between the expression of DNMT1, and GSTP1 and APC, and the methylation
status of GSTP1 and APC in association with their clinical significance in prostate cancer, Molecular medicine reports 12
(2015), 141-146.
[5] J.I. Epstein, L. Egevad, P.A. Humphrey, R. Montironi and Members of the ISUP Immunohistochemistry in Diagnostic
Urologic Pathology Group, Best practices recommendations in the application of immunohistochemistry in the prostate:
report from the International Society of Urologic Pathology consensus conference, The American Journal of Surgical
Pathology 38 (2014), e6-e19.
[6] V. Singh, V. Manu, A. Malik, V. Dutta, N.S. Mani and S. Patrikar, Diagnostic utility of p63 and alpha-methyl acyl Co A
racemase in resolving suspicious foci in prostatic needle biopsy and transurethral resection of prostate specimens, Journal
of cancer research and therapeutics 10 (2014), 686-692.
[7] R. Zelic, V. Fiano, D. Zugna, C. et al, Global Hypomethylation (LINE-1) and Gene-Specific Hypermethylation (GSTP1) on
Initial Negative Prostate Biopsy as Markers of Prostate Cancer on a Rebiopsy, Clinical cancer research : an official journal
of the American Association for Cancer Research (2015).
17
18
o
6
16:00
17:30
s
1
s
Mirò
0
e
2 ngr
Comunicazioni 2:
o
s
C
t
Calcoli e Prostata
I
I
c
I
a
X
r
X
t
s
22 maggio 2016
b
a
41*/"- "/&45)&4*" 4"
" 4"'& "/% '&"4*#-& "/&45)&5*$ .&5)0% '03
1&3$65"/&064/&1)30-*5)050.:1$/-
"/"-:4*40'063&91&3*&/$&
Argomenti: calcolosi
F. Chiancone1, D.. Di Lorenzo1, C. Meccariello1, M. Fedelini1, L. Pucci1, P. Fedelini1, L. De Rosa2, M. Ferraiuolo2
1
2
AORN A. Cardarelli, U.O.S.C. di Anestesia, TIPO e OTI (Napoli)
Objective
Percutaneous nephrolithotomy (PCNL), is widely used for the treatment of large kidney stones. It has been always debated
what is the best anesthetic method for PCNL.
General anesthesia (GA) is the most common anesthetic method applied in PCNL procedure (1). Despite this, GA can cause
pulmonary complications, drug side effects, and increased intraoperative hemorrhages (2),(3),(4). Consequently in many
hospitals there is a trend toward the use of spinal anesthesia (SA) for PCNL procedures, in an effort to decrease morbidity and
mortality(5), (6), (7), (8).
As time goes by, we have observed a progressive growth of the use of SA in recent years at our institution, in particular for
kidney stones with high surgical complexity as kidney stones in an horseshoe kidney or in pediatric patients.
The aim of this study is to investigate the effect of spinal anesthesia (SA) on the safety and efficiency of percutaneous
nephrolithotomy (PCNL).
From January 2010 to December 2015, 481 PCNL were performed at our department. All procedures were performed in a
prone position, except for 4 procedures that were performed in a supine position. 3 out of 481 patients underwent a GA for
contraindications to the SA. Spinal anesthesia with hyperbaric levobupivacaine 0.5% was performed in the sitting position
in all 478 patients. The anaesthetic dosage was based on anthropometric characteristics of patients and on American Society
of Anesthesiologists (ASA) Physical Status classification system. Spinal anesthesia was performed at the L2 – L3 or L3 – L4
interspace using a 25-gauge or 27-gauge Whitacre needle.
Results
Mean age of patients who underwent a SA was 48.7 years (range,14-75). Mean duration of the procedure was 58.0 minute
(range, 32-120). 8 of out 478 patients (1,7%) required blood transfusions. TUR (Trans Urethral Resection) Syndrome never
occurred. We use only sodium chloride solution during the PCNL. There were no important changes in sodium or potassium
concentration after the procedure in the others patients. No side effects related to SA occurred in all patients. In our experience
all patients showed excellent compliance with SA. We experienced that the common duration of hospitalization, operation, and
fluoroscopy of patients reduced over the years with the shift from a GA to a SA. The visual analogue scale (VAS) was inferior to
three in all patients after full resolution of the spinal block. Moreover no patients required analgesic drugs during the first two
hours after the procedures.
Discussions
Patient compliance has been critical for a successful access to calix. As the kidney moves with breathing, the voluntary control
of respiration can help the surgeon to perform an easier access to calix. Subarachnoid anesthesia allows continuous monitoring
of the state of consciousness, preventing the onset of a possible “reabsorption syndrome “ and allows a rapid identification of
16:00 - 17:30, Mirò - Comunicazioni 2 - Calcoli e Prostata
Moderatori: Maurizio Moroni
sala
18
19
a
r
t
s
b
a
063 &91&3*&/$& */ )&.033)"(*$ $0.1-*$"5*0/4 0' 1&3$65"/&064
/&1)30-*5)050.:5)&64&0')&.045"5*$"(&/54*/5)&*3."/"(&.&/5
C. Meccariello1, F. Chiancone1, M. Fedelini1, F. Monaco1, A. Oliva1, P. Fedelini1
1
Objective
According to the most recent guidelines, the percutaneous nephrolithotomy (PCNL) is the standard procedure for large renal
stones(1). Intraoperative and postoperative bleedings are common complications associated with PCNL(2).
Sometimes PCNL procedures have to be interrupted if a severe intraoperative hemorrhage occurs. Mild bleedings after PCNL
may be treated by brief clamping of the nephrostomy tube and adequate hydration. The superselective embolization of the
segmental renal artery may become necessary in the case of severe bleedings. When embolization fails, urgent open exploration
with an high probability of nephrectomy may become necessary. Sometimes a postoperatively bleeding may occurs at the time
of nephrostomic tube removal(3). Hemostatic agents are usually used for nephrostomy tract closure after tubeless PCNL(4) but
they are not described in scientific literature as devices usefull at the time of nephrostomic tube removal. The aim of this study
was to evaluate our series of haemorrhagic complications during PCNL procedures and to descrive our experience in the use
of the hemostatic agents at the time of nephrostomic tube removal.
From January 2010 to January 2015, 481 patients underwent a PCNL procedure at our department. 477 procedures were
performed in a prone position and 4 procedures were performed in a supine position. A standard access tract (24-30 Fr) was
used in 476 (99%) patients. The nephrostomy access was commonly achieved with the telescoping metal dilators of Alken. The
pneumatic balloon dilator (Nephromax®) was used in 52 patients (10,8%). Stone fragmentation was achieved with the use of
an ultrasonic device or a combined ultrasound/pneumatic lithotrite device. 16 out of 481 (3,3%) patients underwent a totally
tubeless PCNL and “FloSeal® Hemostatic Matrix” was used for nephrostomy tract closure in 7 procedures (43,8%). In the
standard procedures a 5-Fr-ureteral catheter was placed at the beginning of the procedure and a modified 20-Fr-Foley catheter
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
other complications like pleural lesions. Moreover the peripheral vasodilatation related to SA reduces the circulatory overload.
SA avoids complications related to GA (drug side effects, intraoperative risk of hemorrhage) and the rate of postoperative lung
infections above all in patients with lung diseases. SA provides a good analgesia during the first hours after surgery. SA showed
better efficacy in suppressing cortisol response as compared to the technique of GA. Based on metabolic, hormonal, and
hemodynamic responses, SA proved more effective than GA in suppressing stress response during elective surgical procedures
(9). SA reduce deep vein thrombosis risks by improving blood flow through the legs secondary to a sympathectomy-induced
vasodilatation. In addiction SA reduce the perioperative hypercoagulability that occurs as a result of the surgical stress response
(10).
Conclusion
SA is a safe and effective method for PCNL in high volume centers. In our experience no absolute surgical contraindications
were found. For example we usually perform a SA also in patients with renal abnormality like an horseshoe kidney. Only
anesthesiological contraindications can suggest to avoid a SA: anatomical disorders of the spine, bleeding disorders,
thrombocytopaenia or not collaborative patients. A limitation of this study is the small cohort of patients who underwent a
GA in the last years . As a consequence we can not compare the two technique in the same period but we can only refer to our
past experience.
References
1-Lingeman JE, Matlaga BR, Evan AP. In: Kavoussi LR, Novick AC, Partin AW, Peters CA, Wein AJ, editors. Campbell-Walsh
Urology. 9. Philadelphia: Saunders-Elsevier; 2007. pp. 1431–1507.
2- Modig J, Karlstrom G. Intra- and post-operative blood loss and haemodynamics in total hip replacement when performed
under lumbar epidural versus general anaesthesia. Eur J Anaesthesiol. 1987;4:345-355.
3- Scott NB, Kehlet H. Regional anaesthesia and surgical morbidity. Br J Surg. 1988;75:299-304.
4- Karacalar S, Bilen CY, Sarihasan B, Sarikaya S. Spinal-epidural anesthesia versus general anesthesia in the management of
percutaneous nephrolithotripsy. J Endourol. 2009;23:1591-1597.
5- Tangpaitoon T, Nisoog C, Lojanapiwat B. Efficacy and safety of percutaneous nephrolithotomy (PCNL): a prospective and
randomized study comparing regional epidural anesthesia with general anesthesia. Int Braz J Urol. 2012;38:504-511.
6- Kuzgunbay B, Turunc T, Akin S, Ergenoglu P, Aribogan A, Ozkardes H. Percutaneous nephrolithotomy under general versus
combined spinal-epidural anesthesia.J Endourol. 2009;23:1-5.
7- Mehrabi S, Shirazi KK. Results and complications of spinal anesthesia in percutaneous nephrolithotomy. Urol J. 2010;7:2225.
8- Singh V, Sinha RJ, Sankhwar SN, Malik A. A prospective randomized study comparing percutaneous nephrolithotomy under
combined spinal-epidural anesthesia with percutaneous nephrolithotomy under general anesthesia. Urol Int. 2011;87:1-6.
9- Milosavljevic SB, Pavlovic AP, Trpkovic SV, Ilić AN, Sekulic AD Influence of spinal and general anesthesia on the metabolic,
hormonal, and hemodynamic response in electivesurgical patients. Med Sci Monit. 2014 Oct 6;20:1833-40. doi: 10.12659/
MSM.890981.
10- Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip
replacement: a meta-analysis. Anesth Analg. 2006 Oct. 103(4):1018-25.
19
20
a
r
t
s
b
a
3&530(3"%& */53"3&/"- 463(&3: %&$3&"4*/( 0' 01&3"5*7& 5*.&4
"$$03%*/(505)&/6.#&30'130$&%63&4
S. Confalonieri1, S. Zambito1, A. Nordio1, F. Franzoso1
1
Ospedale Civile di Desio - ASST Monza, U.O. Urologia (Desio)
Objective
The technique RIRS (Retrograde Intra-Renal Surgery) in few years arose among other surgical techniques for the treatment of
renal stones, even the complex ones.
From literature we found comparative studies between RIRS and other techniques such as ESWL (External Shock Wave
Lithotripsy) and PCNL (PerCutaneous Lithotripsy), this one for the treatment of big stones; compared to ESWL, RIRS provides
higher stone-free rate and lower retreatment rate without increase in the incidence of complications. (1)
Although serious complications such as perioperative massive bleeding, urine leakage, bowel injury, hemothorax, and fistula
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
was placed at the end of the procedure as nephtrostomic tube.
Results
Severe intraoperative bleedings occurred in 13 patients (2,7%) and in 2 patients (0,4%) we had to interrupt the procedure.
Postoperative bleedings occurred in 39 patients (8,1%). 32 out of 39 bleedings (82,1%) were mild and were solved by
clamping of the nephrostomy tube and adequate hydration. 7 out of 39 bleedings (17,9%) were severe and the patients
underwent a diagnostic angiography. Of these, 5 patients underwent a superselective embolization of a vascular lesions or a
pseudoaneurysm (Image 1) and 2 patients experienced a spontaneous endogenous hemostasis during angiography, probably
due to a vasospasm(5). 8 out of 481 patients (1,7%) underwent blood transfusions for severe anemia. Postoperatively bleedings
at the time of nephrostomic tube removal occurred in 14 patients (2,9%). In 2 patients (14,3%) we have repositioned the
nephrostomic tube. In 1 patient (7,1%) haemostasis was achieved with the help of “TachoSil® Medicated Sponge” and in 11
patients (78,6%) with the help of “FloSeal® Hemostatic Matrix”.
Discussions
Most common risk factors for severe bleedings are described in scientific literature: upper caliceal puncture, solitary kidney,
staghorn stone, kidney inflammation, multiple punctures, angular movement in order to search distal caliceal stone and
inexperienced surgeon(6). Additional risk factors shown to increase the risk of bleeding during or after PCNL include diabetes
mellitus, prolonged operative time, utilization of a mature nephrostomy tract, concomitant surgical complications, modality of
access guidance (ultrasound versus fluoroscopic), and access tracts which traverse atrophic parenchima(7),(8). In our opinion
the right planning of the procedure and the surgeon experience can reduce the hemorrhagic complications during a PCNL. In
our series the intraoperative bleeding complication rate was very low and severe postoperative bleedings occurred only in 1,5%
of the patients. Moreover the blood transfusion rate was similar to the most important series in scientific literature(9).
Conclusion
PCNL is the standard procedure for large renal stones. PCNL is a feasible procedure with a low rate of intraoperative and
postoperative complications in high volume centers. Despite this, during the procedure, hemorrhagic complications can
occur, in particular in some categories of patients or when the procedure is particularly difficult. In our opinion, surgeon
experience and the right planning of the procedure can reduce the hemorrhagic complications during a PCNL. The “FloSeal®
Hemostatic Matrix”, commonly used for nephrostomy tract closure after tubeless PCNL, is an useful device in the management
of postoperative bleedings at the time of nephrostomic tube removal.
References
1- C. Türk , T. Knoll, A. Petrik, K. Sarica, A. Skolarikos, M. Straub, C. Seitz, Guidelines on Urolithiasis, 2015.
2- Seitz C, Desai M, Hacker A, Hakenberg OW, Liatsikos E, Nagele U, Tolley D. Incidence, prevention, and management of
complications following percutaneous nephrolitholapaxy. Eur Urol 2012 Jan;61(1):146-58
3- Ruoppolo M, Bellorofonte C, Dell’Acqua S, Zaatar C, Ferri PM, Tagliaferri A, Tombolini P.Complications of percutaneous
litholapaxy. Arch Ital Urol Nefrol Androl. 1990 Dec;62(4):399-410.
4-Yu C, Xu Z, Long W, Longfei L, Feng Z, Lin Q, Xiongbing Z, Hequn C. Hemostatic agents used for nephrostomy tract closure
after tubeless PCNL: a systematic review and meta-analysis. Urolithiasis. 2014 Oct;42(5):445-53. doi: 10.1007/s00240-0140687-7. Epub 2014 Jul 27.
5- Yuan KC, Wong YC, Lin BC, Kang SC, Liu EH, Hsu YP. Negative catheter angiography after vascular contrast extravasations
on computed tomography in blunt torso trauma: an experience review of a clinical dilemma. Scand J Trauma Resusc
Emerg Med. 2012;20(1):46.
6- El-Nahas AR, Shokeir AA, El-Assmy AM, Mohsen T, Shoma AM, Eraky I, El-Kenawy MR, El-Kappany HA. Postpercutaneous nephrolithotomy extensive hemorrhage: A study of risk factors. J Urol. 2007;177:576–9.
7-Wang Y, Jiang F, Wang Y, Hou Y, Zhang H, Chen Q, Xu N, Lu Z, Hu J, Lu J, Wang X, Hao Y, Wang C. Post-percutaneous
nephrolithotomy septic shock and severe hemorrhage: a study of risk factors. Urol Int 2012;88:307-10.
8-Kukreja R., Desai M., Patel S., Bapat S, Desai M. Factors affecting blood loss during percutaneous nephrolithotomy:
prospective study. J Endourol 2004;18:715-22.
9- Soucy F, Ko R, Duvdevani M, Nott L, Denstedt JD, Razvi H.. Percutaneous nephrolithotomy for staghorn calculi: a single
center’s experience over 15 years. J Endourol 2009;23:1669-73
20
21
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
are rare, increasing attention has been paid to the need for other minimally invasive surgical options to compensate for the
shortcomings of PCNL.
Up to now RIRS should be considered as standard therapy for stones < 2 cm (2), and for selected patients, RIRS may represent
an alternative theraphy to PCNL, with acceptable efficacy and low morbility (3).
Satisfactory outcomes can be achieved with multi-session RIRS in the treatment of 2-4 cm renal stones; RIRS can be used as an
alternative treatment to PCNL in selected cases with larger renal stones (4).
RIRS is a refined, gentle, precise, complex surgery and it takes extreme concentration and patience; it needs a dedicated
instrumentation and dedicated surgeons to give the best results.
Our study, retrospective and observational, has the target to compare operative times between surgeons of different experience,
to see if the endoscopical training is feasable in relatively short period.
We introduced RIRS since January 2014. Patients’ characteristics vary in number, location ad dimension of stones. The surgeons
dedicated to the Endourology are named as Surgeon A, B and C. We considered as data the operative times, independent from
the characteristic of stones and patients. We considered the RIRS procedurs from January 2014 up to December 2015: a total
number of 131 RIRS for a total amount of 98 renal units. We used Holmium laser (green) with fiber 270 micron. We treated 14
retreatment and 7 cases of three treatment to obtain the complete stone free. The surfaces of stones trated varies from 15 mm2
to 810 mm2. In 2014 we realized 50 procedures: 47 with Surgeon A and 3 with Surgeon B. Every procedures involves Surgeons
A and B contemporary. In 2015 we realized 81 RIRS divided as follows:
Surgeon A: 52 procedures
Surgeon B: 24 procedures (the last 15 alone)
Surgeon C: 5 procedures (with A as tutor, in 2015).
Results
Total medium surgical time about the whole 131 procedures during the biennium 2014-2015 was 48,1 minutes; Surgeon A 48,8
minutes, Surgeon B 43,8 minutes, Surgeon C 58,2 minutes.
Total medium surgical time stratified for years was of 49,8 minute in 2014 and 46,9 in 2015. Medium time stratified for each
surgeon is described as follows:
Surgeon A: in 2014 50,6 min in 2015 47,06 min
Surgeon B: in 2014 37,6 min in 2015 43,3 min
Surgeon C: in 2015 58,2 min
We evaluated the difference between medium time of A and B during the biennium: the difference was of 13 minutes in 2014
and of 3,76 minute in 2015.
Discussions
The increasing time of B in 2015 could be due to the progressive increasing in the complexity of the cases treated during the
training period. The procedures involded a more complex renal stones, with the higher surface treated of 810 mm2.
We reconsider the statistic with the evaluation Surgeon B medium time of the last 15 cases (which were performed without
tutor): medium time resulted 41,8 minutes.
As number os cases treated increas as we observed a more homogeneous medium time, which corresponds to a more confidence
with the procedure.
Surgeon B had a training also as second surgeon with surgeon A as trainer for 50 procedures.
Conclusion
We considered RIRS as first option for the treatment of renal stones. We consider it an involving therapeutichal approach
which will improve in the future due to the technical improvements of instrumentations. It is a refined technique and an
expertise surgeon is needed to preserve the precious instrumentation from rupture, to avoid kindey injuries and to optimized
surgical times.
As long as the surgeon practices, the surgical position becomes more ergonomic and the procedure easier.
A constant and progressive training allows the surgeon to learn the tecnique in a relatively short time, with the creation of self
sufficient surgeons in about 30 procedures.
References
1. Zheng C, Yang H, Luo J, Xiong B, Wang H, Jiang Q. Extracorporeal shock wave pithoptipsy versus retrograde intrarenal
surgery for treatment for renal stones1-2 cm: a meta-analysis. Urolithiasis 2015 Nov (6): 549-56,
2. De Sio S, Autorino R, Zargar H, Laydner H, Balsamo R, Torricelli FC, Di Palma C, Molina WR, Monga M, De Sio M.
Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and meta.analysis. Eur Urol Jan;
67(1): 125-37.
3. Bozkurt OF, Resorlu B, Yildiz Y, Can CE, Unsal A. Retrograde intrarenal surgery versus percutaneous nephrolithotomy in
the management of lower-pole renal stones with a diameteer of 15 to 20 mm. J Endourol 2011 Jul; 25(7): 1131-5.
4. Akman T, Binbay M, Ozgor F, Ugurlu M, Tekinarslan E, Kezer C, Aslan R, Muslumanoglu AY. Comparison of percutaneous
nephrolithotomy and retrograde flexible nephrlithotripsy for the management of 2-4 cm stones: a matched-pair analysis.
BJU Int. 2012 May; 109(9): 1384-9.
21
22
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
3&530(3"%&*/53"3&/"-463(&3:3*34
"/"-:4*40'$"4&4
b
a
a
r
t
s
X
X
F. Sommatino1, O. Maugeri1, F. Venzano1, C. Ambruosi1, G. Arena1
1
t ASO S. Croce e Carle (Cuneo)
Objective
Retrograde intrarenal surgery (RIRS) represents an intriguing technique that allows urologist to treat kidney stones. The
objectives of this study are to present our experience with RIRS and to report results and complications.
The outcomes of 200 consecutive patients who underwent RIRS with the indication of renal stone, between January 2013 and
January 2016, have been retrospectively analysed and recorded in an excel spreadsheet. Patients data include age, sex, relevant
medical history, stone side, location and size. The patients were evaluated with physical examination, routine blood culture,
x-ray kidney ureter and bladder (KUB), urinary ultrasonography (USG) and non contrasted computed tomography (CT). All
patients were operated in the standard lithotomy position, under general and spinal anesthesia. We always used ureteral access
sheath (UAS), where possible. RIRS was performed on patients with sterile urine cultures under antibiotic prophylaxis (second
generation intravenous cephalosporin). Ureterorenoscope was performed to exclude presence of any ureteral pathology
and dilate the ureter using semirigid ureterorenoscopy 7 Fr. Fluroscopy was always performed in all cases. A 7.2 Fr flexible
ureteroscope and a 272-micron laser fiber were used. The treatment consisted in stone fragmentation or dusting, performed
with holmium laser which was set at an energy level of 0.5–0.8 J and at a rate of 15–20 Hz. Continuous irrigation was used
to obtain and sustain a clear operative visual field. Fragments larger than 3 mm were removed using a 2.2 F zero-tipped
nitinol stone basket. At the end of the procedure a 4-6 Fr double J stent was placed. Stone free rates (SFR) of all patients were
evaluated after 1 month following the procedure using KUB and USG. Success was determined as stone-free status or presence
of residual fragments smaller 3 mm. Complications were classified according to the Clavien-Dindo Classification system.
Results
RIRS was performed on a total of 200 patients (male, n= 129; female, n= 71). The median age was 54 years (range 24-84). Stones
were located in the right (n= 78), left (n= 122) kidney; in particular stones were located in the lower (n= 137), middle (n=
44), and upper (n= 24) poles, renal pelvis (n= 76). The median stone diameter was 12,2 mm (5-30 mm). In 27 patients, access
sheath could not be advanced from distal to proximal ureteral, and the procedure was performed without access sheath. We
used: UAS 9,5 Fr (n=2), 10-12 Fr (n= 53), 11-13 Fr (n= 4), 12-14 (n= 78), 13-15 Fr (n= 36). None of the patients underwent
balloon dilatation. The median operative time was 72 minutes (18-140). 133 patients and 67 underwent spinal and general
anesthesia, respectively. Median hospitalization was 1,8 days (1-19). 29 patients (14%) underwent a second look and only one
patient underwent a third RIRS. The overall stone-free rates after procedures one and two were 85 % and 92 %, respectively.
None complication was observed during the operation. Post-operative complications were reported in 8 (4%) patients. 4
showed intolerance to the double J stent and or flank pain; one had a cerebrospinal fluid leak after spinal anaesthesia (Grade I
Clavien-Dindo). Two patients (1%), with infection were hospitalized to continue intravenous antibiotherapy (Grade II). In one
patient (0,5%) we observed a subcapsular renal haematoma (SRH) associated with pulmonary embolism, after two days from
the procedure (Grade IIIa). The latter received two units of packed red blood cells for low haematocrit level. Subsequently the
patient underwent in the first place angiography, which did not show any blood spill, and secondly to surgery for placement of
vena cava filter. At 6 months of follow-up, the SRH was resolved.
Discussions
Over the last 10 years, the retrograde intrarenal surgery has become an increasingly important option for the treatment of all
kidney stones [1]. Many authors emphasized ureteroscopy treatment of intrarenal calculi has a low complication rate, regardless
of calculus size and can be performed as an outpatient procedure [2]. In the literature, success rates have been indicated to range
between 65% and 92%. In our study SFR was 85% according to the literature. The operative time of RIRS ranged from 43,1 to
67,5 minutes [3]. In our study the median operative time was 72 minutes. Beneficial effects, and convenience of using recently
popularized access sheaths have been debated [4]. Access sheaths have been used to facilitate recurrent entries into, and exits
from renal collecting systems. In a study where effectiveness of these access sheaths was evaluated, its routine intraoperative
use during RIRS was recommended in that it decreases costs, and duration of operations, and causes minimal morbidity [5]. In
our study, we use access sheaths for nearly all of our patients. As to complications, the most frequently developed complication
following RIRS is infection as it can be observed in other urological interventions. We used the Clavien-Dindo Classification
system to standardize it [6]. Complications rates ranged from 0% to 25% where common complications of RIRS were fever
with prolonged antibiotic use (2%-28%) [7]. The potential infections should be treated with appropriate antibiotics. In our
study, since all patients received appropriate antibiotic prophylaxis, a serious infection was not encountered. Only 2 patients
had high fever at postoperative first day which was relieved with appropriate antibiotherapy (Grade II). In only one patient we
have a subcapsular renal haematoma in postoperative time. SRH is an unusual complication rarely described in the literature
and the incidence is about 0,4% [8]. Nowadays, the reason for this event is unclear. In our patient, there was no obvious trauma
to the pelvicalyceal system or renal parenchyma and operative procedure was uneventful. We think, according to Nuttall at al.
[9], the hematoma was probably caused by the change of intrapelvic pressure which induced the sudden expansion and rupture
of renal parenchyma and/ or capsular vessels.
Conclusion
According to the EAU guidelines, RIRS represents an alternative to percutaneous nephrolithotomy (PNL) in the treatment
of renal calculi up to 2 cm in diameter. Flexible ureteroscopy is an effective and safe treatment method for the active removal
of kidney stones and it is associated to a low rate of complications. A renal subcapsular hematoma was the only significant
22
23
a
r
t
s
b
a
"/"-:4*4 0' 3*4, 0' $0.1-*$"5*0/4 */ 1"5*&/54 6/%&38&/5 50 1$/- "/%
3*34
L. D’Arrigo1, N. Gill2, F. Savoca1, A. Costa1, A. Bonaccorsi1, E. Wit2, M. Pennisi1
1
Ospedale Cannizzaro, U.O. Urologia (Catania)
2
University of Groningen, Statistics and Probability Institute (Groningen)
Objective
The retrograde intrarenal surgery (RIRS) is as alternative to percutaneous lithopaxy (PCNL) in patients with renal stones
below 2 cm. Compared to PCNL, RIRS reduced incidence of postoperative complications but postoperative fever (POF) or
sepsi can be present in a high percentage of patients.
In this study patients underwent to RIRS o PCNL, in terms of stone free rate and complications, were compared.
The aims of our study is to find the predictive parameters of stone free rate and postoperative fever or sepsis between PCNL
and RIRS treatments, to identify better the patients who could benefit from these treatments and to evaluate the risk of POF or
sepsi in these patients.
A total of 177 medical records of single session patients were included. Among 177 patients, (62 in PCNL and 115 in RIRS
group). All patients were treated by two urologists having some experience of treating more than 50 cases in our hospital. We
recorded data and clinical parameters as age, gender, number of stones, location, stone diameter, volume, area, density and
operation time. Previous history of treatment and complications were also recorded. All patients were evaluated with blood
and urine analysis and those with urinary infection were treated five days before surgery with specific antibiotics, the others
with third generation cephalosporine or fluorchinolone preoperative prophylaxis.The percutaneous access was performed by
the urologist. The renal puncture was done under fluoroscopic and ultrasonography control. The telescopic dilation in prone
position was used under fluoroscopic control through the calix and when a supine procedure was done a pneumatic balloon
for dilation was used. A 24 F Amplatz sheath was positioned, and an ultrasonic or pneumatic lithotripter used for lithotripsy.
Nefroscope of 22 ch with continuous flow irrigation was used. A disconnectable nephrostomy tube of 16 or 18 ch was inserted
into the renal pelvis. The operative time was evaluated from the puncture to removal of Amplatz sheath. In RIRS treatment
a flexible URS 7.5 ch with holmium laser lithotripsy was used. After a urinary stent DJ was inserted and was removed within
two weeks. When the operation time was longer more than the 90 minutes, the RIRS procedure was stopped and a DJ was
inserted. Stone free status of patients was declared as stone free when a single stone is completely clear or a stone size < 4
mm on postoperative ultrasound and KUB after 3 month. The data analysis was performed using R 3.0.3 statistical software.
P-levels < 0.05 were considered significant.
Results
The stone free rate was higher in PCNL group. Stone diameter is an important predictor and significantly influence on stone
free rates in PCNL (p=0.018) as well RIRS (p=0.008). SFR of PCNL in terms of stone diameter for 2 cm and 4 cm were 98% and
85% and 81% and 24% for RIRS. However, until 2 cm of stone diameter RIRS also provides very good stone free rates (81%).
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
complication we recorded, which has been thoroughly studied and reported after ESWL; however, following ureteroscopy,
it is a far less common complication, rarely described in the literature. Although currently PNL remains the gold standard
treatment for large intrarenal stones, RIRS may allow decreased morbidity and hospital stay with a stone-free rate similar to
that of PNL. However PNL remains superior to flexible ureteroscopy in terms of the number of treatments required to clear a
stone.
References
1. Cindolo L, Castellan P, Scoffone CM et al Mortality and flexible ureteroscopy: analysis of six cases. World J Urol. 2016
Mar;34(3):305-10.
2. Elbir F, Başıbüyük İ, Topaktaş R, et al Flexible ureterorenoscopy results: Analysis of 279 cases. Turk J Urol. 2015 Sep;41(3):1138.
3. Breda A, Ogunyemi O, Leppert JT et al Flexible ureteroscopy and laser lithotripsy for multiple unilateral intrarenal stones.
Eur Urol. 2009 May;55(5):1190-6.
4. Kourambas J, Byrne RR, Preminger GM. Does a ureteral access sheath facilitate ureteroscopy? J Urol. 2001 Mar;165(3):78993.
5. Rapoport D, Perks AE, Teichman JM. Ureteral access sheath use and stenting in ureteroscopy: effect on unplanned emergency
room visits and cost. J Endourol. 2007 Sep;21(9):993-7.
6. Clavien PA, Barkun J, de Oliveira ML et al The Clavien-Dindo classification of surgical complications: five-year experience.
Ann Surg. 2009 Aug;250(2):187-96.
7. De S, Autorino R, Kim FJ et al. Percutaneous nephrolithotomy versus retrograde intrarenal surgery: a systematic review and
meta-analysis. Eur Urol 2015; 67:125-37.
8. Bai J, Li C, Wang S, et al Subcapsular renal haematoma after holmium:yttrium-aluminum-garnet laser ureterolithotripsy.
BJU Int. 2012 Apr;109(8):1230-4.
9. Nuttall MC , Abbaraju J , Dickinson IK et al. A review of studies reporting on complications of upper urinary tract stone
ablation using the holmium:YAG laser . Br J Med Surg Urol 2010 ; 3 : 151 – 9
23
24
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Incidence of postoperative POF and sepsi was respectively 14,8% and 17,7% in RIRS and PCNL group. The most predictive
factors for sepsis were age (p=0.011), gender (p=0.020), nefrostomy tube, and Double J and operation time (p=0.026) for
PCNL. The odds of women developing POF or sepsis after a PCNL intervention are 9.1 times higher than those of men. The
odds of women developing sepsis after a RIRS intervention are 2.4 times higher than those of men and the data was statistically
significant (p=0.011) and (p=0.026). Younger patients in both of the treatments had a higher risk, very high after PCNL, where
a steep decline at 35 yrs. and increased again after 65. A 20 years old patients of RIRS has 47% risk if she is female and 27% risk
if he is male, whereas in PCNL 20 years old patients 98% and 90% risk for females and males respectively. The highest risk for
both of the treatments was found for age group 20 to 35 years patient. In RIRS we also found two ureteral stenosis (Clavien
III B), one perirenal hematoma in a woman with hypotrophic kidney repeatedly treated in the past (Clavien III A). In PCNL
group a bleeding treated with endovascular embolization was also recorded. No blood transfusions were needed or others
complications were present and no patient needed to be admitted to intensive unit care in both groups.
Discussions
In our study, we found that patients age is one of the most important predictor factor that significantly increases the risk of
sepsis after RIRS and PCNL treatment. The odds of stone diameter 0.115 in PCNL treatment shows that with each additional
one cm increase in stone diameter, the stone free rates decreased by 10.9%, whereas the odds of RIRS 0.129 shows higher
decreasing percentage 12.1. Another thing we found that in PCNL treatment, stone free probability was significantly lower for
stone location middle calice (p=0.018), whereas stone free rates of all other stone locations (upper calice, middle calice and
renal pelvis) were comparatively higher.
Our finding shows that younger patients have great risk of developing sepsis and older peoples have very low risk. However,
we also investigated that after PCNL very older people 65 and over again slightly developing sepsis infection. Gutierrez [1] in
a recent study concludes that along with preoperative positive urine culture, younger age, preoperative nephrostomy, diabetes
and staghorn stones were predictive factors for post-operative fever among PCNL patients.
Sepsis has reported as one of important cause of mortality among patients particularly women after PCNL and Ureteroscopy,
a study by OKeeffe et al [2] reported that among 700 patients who treated by PCNL or endoscopic procedure for upper UTI
stones 9 of patients developed sepsis and all they were females , 7 of them died, therefore mortality rate 66% was reported in
that study among women. In our study, we found that post-PCNL was very high compared to RIRS among women patients
therefore, we will particularly focus on the risk factors that increses the post-PCNL sepsis risk among women patients. One
of the cross sectional study based on 217 PCNL patients reported in their study that the important predictors associated with
post-PCNL fever risk were female gender, use of nephrostomy tube and preoperative positive urine culture. They concluded
that higher fever among females might be due to the propensity of urinary tract infection [3].
In our present study we have found that during PCNL treatment, longer operation time is significantly associated (p=0.026)
with the probability of sepsis incidence. The probability of sepsis complications was relatively higher when the operation time
was longer than the 40 minutes and where higher sepsis rates were observed among women gender. Wang [4] reported the
result of their study that operation time longer than 90 minutes is strongly associated (p = 0.01) with the incidence of septic
shock and renal bleeding (0.017) based on 420 PCNL renal stone patients. One of the resent study published [5] concludes that,
the important risk factors related with postoperative sepsis risk in PCNL treatment are operation time, stone size and presence
of bacteriuria.
Conclusion
The risk of POF or sepsi after endourologic procedure for renal stones is high. Anyway if we compare patients underwent to
RIRS or PCNL the incidence is higher in PCNL group. The age, gender, presence of nefrostomy tube or double J and operation
time (only in PCNL group) can be considered favorable factors
Women and young patients develop postoperative fever more easily than older men.
The operative time hasn’t influenced the onset of sepsi in RIRS group. In PCNL group a longer operative time (more than 40
min) influence negatively onset of POF or sepsi. . Incidence of post-operative fever in RIRS is lower than PCNL group.
A correct preoperative evaluation of the patient, related risk factors, and analysis of urine are important. Adequate preoperative
antibiotic prophylaxis to prevent the development of infections and adverse events and onset of complications.
More studies are needed to explain the higher incidence of fever in younger female patients.
References
1) Gutierrez, J., Smith, A., Geavlete, P., Shah, H., Kural, A. R., de Sio, M., Sesmero, J. H. A., Hoznek, A., de la Rosette, J., Group,
C. P. S., et al. Urinary tract infections and post-operative fever in percutaneous nephrolithotomy. World journal of urology
31, 5 (2013), 1135–1140.
2) O’keeffe, N., Mortimer, A., Sambrook, P., and Rao, P. Severe sepsis following percutaneous or endoscopic procedures for
urinary tract stones. British journal of urology
72, 3 (1993), 277–283.
3) Aghdas, F. S., Akhavizadegan, H., Aryanpoor, A., Inanloo, H., and Karbakhsh, M. Fever after percutaneous nephrolithotomy:
contributing factors. Surgical infections 7, 4
(2006), 367–371.
4) Wang, Y., Jiang, F., Hou, Y., Zhang, H., Chen, Q., Xu, N., Lu, Z., Hu, J., Lu, J., Wang, X., et al. Post-percutaneous nephrolithotomy
septic shock and severe hemorrhage: a study of risk factors. Urologia internationalis 88, 3 (2012), 307–310.
5) Kreydin, E. I., and Eisner, B. H. Risk factors for sepsis after percutaneous renal stone surgery. Nature Reviews Urology 10,
10 (2013), 598–605.
24
25
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
5)6-*6. -"4&3 &/6$-&"5*0/ 0' 5)& 13045"5& 5)6-&1
7&3464 01&/
13045"5&$50.:01
'03-"3(&(-"/%4.0/5)4065$0.&
b
a
a
r
t
s
X
X
Argomenti: ipertrofia prostatica
G. Di Lauro1, G. Romeo2, A. Ruffo1, L. Romis1, S. Mordente1, M. Capece2, F. Iacono2
1
Ospedale Santa Maria delle Grazie (Pozzuoli)
2
Università “Federico II” di Napoli (Napoli)
Objective
Transurethral resection of the prostate (TURP) is the current standard operation for lower urinary tract symptoms due to
benign prostatic obstruction (BPO) in cases of prostates 30-80ml [1]. For larger glands, open simple prostatectomy (OP) is still
performed in many urological centers [2]. Transurethral holmium laser enucleation has been popularized over the last decade
as an effective alternative to OP [3].
Several types of laser systems are currently used in urological clinical practice for BPO treatment [4]. Among them, thulium
YAG (Tm-YAG) has gained attention over the last years, as it is suitable for many different transurethral surgical techniques,
including vaporization (ThuVAP), vaporesection (ThuVaRP), vapoenucleation of the prostate (ThuVEP), and bladder neck
incision and enucleation defined as ThuLEP [4]. ThuLEP employs the Tm:YAG laser for apical incision of the prostatic tissue
down to the surgical capsule. Then, the adenoma is enucleated bluntly with the sheath of the resectoscope, like using the
index finger in OP technique [5]. We previously published our initial experience with 148 patients, showing a significant
improvement in all outcome parameters [5].
The aim of our study was to compare in terms of efficacy and safety ThuLEP and OP for the treatment of BPO.
Patients with LUTS secondary to BPH treated at our center between March 2010 and July 2014 were deemed eligible for this
prospective single center study. Inclusion criteria were: prostate volume >80 ml, maximum urinary flow rate (Qmax) < 15 ml/
sec and IPSS >7. Patients with prostate cancer, neurogenic bladder dysfunction, and previous urinary tract surgery or previous
pelvic radiotherapy were excluded. There was no upper limit of prostate size. Patients were randomised in a 1.1 ratio with a
computer-generated table to ThuLEP (148 patients, group A) and to OP (148 patients, group B).
The time of catheterization was the primary endpoint of this study, as this translates into faster recovery and gained working
days. Given a mean catheterization time of 5.4 days for OP, based on in-house audit data as well as data from the literature [2],
and assuming 30% reduction in mean catheterization time for ThuLEP, as based on data reported in the meta-analysis by Bach
[6].
The catheter was removed when the urine was clear, and the patient was discharged from the hospital only after spontaneous
urinary voiding. The decision to remove the catheter was made by two co-investigators who were unaware of the surgical
modality used. Secondary outcomes were the operative time, hospital stay, blood loss (indirect measurement through
comparison of hemoglobin levels before and 24 hours postoperatively).
All patients were evaluated at baseline and after 12 months follow-up by digital rectal examination (DRE), trans rectal
ultrasonography, abdominal ultrasonography. International Prostate Symptoms Score (I-PSS) questionnaire was selfadministrated to patients. An International Index of Erectile Functions-5 questionnaire (IIEF-5), was administrated. PSA values
were evaluated. Uroflowmetry was performed. Moreover, the following pre and post-operative data were collected: hemoglobin
(g/dl), catheter time (days), hospitalization time (days). Every complication occurred during and after the operative procedure
was recorded.
Results
Patients mean age was 66.3±8.8yo. A better outcome for Group A was detected in terms of blood loss (1.27±0.88 sd VS Group B
3,23 g/dl ± 2,78 sd); mean days of Catheter removal (Group A 2,04 days ± 0,45 sd Vs Group B 6,33 days ± 2,42 sd); mean days
of Hospitalization (Group A 2,15 days ± 0,39 sd Vs Group B 6,54 days ± 1,93 sd).
Furthermore in the Group A there was a significant lower rate of complications then Group B. Bladder wall injury during
morcellation occurred in the 1.3% of group A patients, and in all cases bladder mucosa only was involved so the injured area
could be effectively coagulated with laser fiber at 40 W. Post-operative blood transfusion occurred in the 2.7% of patients.
Irritative symptoms, urge incontinence and/or dysuria, occurred in the 6,7% of patients and they lasted for a period of three
weeks maximum. Patients who underwent to OP develop as most important complication severe bleeding and 10,8% of them
needed blood transfusion. UTI occurred in 6,0% of patients; urinary incontinence (more then 1 pad per day) occurred in
the 3,3% of patients, they perform pelvic floor training for incontinence and all achieve social continence (1 pad/day). Clot
retention due to severe bleeding occurred in the 5,4%, these patients were treated with a bladder washing. At 12 months follow
up there were no statistical significant differences between two groups in terms of mean PSA volume (ng/ml) (Group A 0,93 Vs
Group B 0,85); mean Prostate Volume (ml) (Group A 13,76 Vs Group B 11,82); mean I-PSS (Group A 3,90 Vs Group B 4,20);
mean Qmax (ml/sec) (Group A 28,67 Vs Group B 27,87); mean PVR (ml) (Group A 12,89 Vs Group B 13,56); mean IIEF-5
score (Group A 20,3 Vs Group B 18,5).
Discussions
Here in we report the first study comparing ThuLEP to OP in patients with large prostate gland. Our data show that ThuLEP is
an effective and safe endoscopic surgical procedure in this patient population. OP has traditionally been the alternative option
to TURP for large prostate. Data in literature showed that this procedure is highly successful. In a recent series of 902 patients
who underwent OP for prostates of mean size of 96.3 ± 37.4 ml, the overall complication rate was 17.3%. The most relevant
complication was bleeding requiring transfusion in 7.5% of patients [2]. As far as ThuLEP was concerned, specific aspects were
emphasized as technically relevant. At this purpose, during the enucleation process a close contact between tip of laser fiber and
25
26
a
r
t
s
b
a
7. #274: GREEN LASER EXPERIENCE IN OBSTUCTIVE PATHOLOGY
Argomenti: cancro della prostata, ipertrofia prostatica
M. Schettini1, M. Stefanucci1, F. Attisani1, L. Mavilla1, F. Pisanti1, M. Casilio1
1
Casa di Cura Nuova Villa Claudia (Roma)
Objective
Demonstrate the efficiency, safety and simplicity in the execution of the prostate vaporization in a heterogeneous group of
patients by an inhomogeneous group of surgeons. The laser used is a Green laser beam at lithium triborate (180W maximum
power) used for the vaporization and coagulation of the prostate tissue (180W to 40W).
From July 2014 to January 2016, 158 Patients underwent 180-W XPS GreenLight vaporization (using a fiber MOXY©) for
the tratment of LUTS due to BPH by a team made up of five surgeons with different experience regarding TURP. Patients
were enrolled prospectively and preoperative, intraoperative and postoperative parameters were then reviewed retrospectively.
Were enrolled patients with obstructive disease caused by different prostate disease, particularly 155 patients were affected
by LUTS due to BPH and 3 patients were affected by prostate cancer. 3 Patients were also already undergoing TURP before
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
the prostatic capsule was carefully maintained. A rigorous enucleation plane was persistently created, using the resectoscope
that bluntly dissects the adenoma on its capsule thus clearly revealing the neat surface and distinctively observable fibres of the
capsule. Ultimately, the good visibility thus the low amount of blood loss, the clear identification with consequent coagulation
of all perforating vessels of the prostate capsule added to the safety of the morcellation stage.
ThuLEP compared with Open Prostatectomy showed a better clinical and statistically significant outcome in early postoperative. Peri and post-operative bleeding was drastically reduced and this fact is sustained from the lower drop of hemoglobin,
comparing ThuLEP and OP and from a mean g/dl of hemoglobin loss of 1,27 Vs 3,27 respectively. The low rate of bleeding
with ThuLEP is sustained also comparing the percentage of patients who needed blood transfusion 2,7% Vs 10,8 for ThuLEP
and OP respectively. The low rate of bleeding with ThuLEP showed really good ability in hemostasis, and this fact is relevant
especially for those patients who need surgery for BPH and who underwent also chronic antiplatelet or anticoagulant therapy
because the attitude of Thulium YAG, compared with other laser device, to offer maximum hemostats [5;6;7]. In our opinion,
although there are no data confirming this, those patients could go for ThuLEP without interrupting their therapy due to
reduce thrombosis risk. [8] Furthermore specific studies and international protocols are needed to confirm this.
Substantial advantaged of ThuLEP compared to OP concern also the days of catheterization (2,04 for Thulep Vs 6,33 for OP)
and the days of hospitalization (2,15 for ThuLEP Vs 6,54 for OP). The shorter postoperative recovery is one of main goal of all
newly surgical approaches, reducing biological costs like nosocomial infections, and reducing also economical costs.
Conclusion
It should be stressed that ThuLEP is prostate size independent procedure as the same as open prostatectomy for BPH, in fact we
treated patients with prostate size between 75 to 210 grams. Some studies showed that there is an increased risk of morbidity
when large volume of glands are treated [23], anyhow we did not find any correlation between prostate size and complications
rate in patients in Group A.
ThuLEP represents a safe and effective alternative to OP for the treatment of BPO. Minimal blood loss, short hospital stay,
short catheterization time, quick recovery, and possibility to treat patients under anticoagulantin therapy represent the main
advantages of this novel technique compared to OP.
References
1. Oelke M, Bachman A, Descazeaud A et al. EAU Guidelines on the treatment and follow-up of non-neurogenic male lower
urinary symptoms including benign prostatic obstruction. Eur Urol 2013; 64: 118 – 140
2. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients
with benign prostatic enlargement: results of a prospective multicenter study. J Urol 2007;177:1419–22.2.
3. Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater
than 100 grams: 5-year follow-up results of a randomised clinical trial. Eur Urol. 2008 Jan;53(1):160-6
4. Gravas S, Bachmann A, Reich O, Roehrborn CG, Gilling PJ, De La Rosette J. Critical review of lasers in benign prostatic
hyperplasia (BPH). BJU Int. 2011;107(7):1030-43
5. Iacono F, Prezioso D, Di Lauro G, et al. Efficacy and safety profile of a novel technique, ThuLEP (Thulium laser enucleation
of the prostate) for the treatment of benign prostate hypertrophy. Our experience on 148 patients. BMC Surg. 2012;12
Suppl 1:S214.
6. Bach T, Gross AJ, Herrmann TR, et al. Thulium: YAG 2 mum cw laser prostatectomy: where do we stand? World J Urol.
2010;28(2):163-8
7. Herrmann TR, Bach T, Imkamp F, et al. Thulium laser enucleation of the prostate (ThuLEP): transurethral anatomical
prostatectomy with laser support. Introduction of a novel technique for the treatment of benign prostatic obstruction.
World J Urol 2010; 28:45–51
8. Kyriazis I, Bach T, Gross AJ, Herrmann TR, et al. Anatomical enucleation of the prostate with Tm:YAG support (ThuLEP):
review of the literature on a novel surgical approach in the management of benign prostatic enlargement. World J Urol.
2015 Apr;33(4):525-30.
9. Van Melick HH, van Venrooij GE, Boon TA. Long-term follow-up after transurethral resection of the prostate, contact laser
prostatectomy, and electrovaporization. Urology 2003;62:1029–34.
26
27
a
r
t
s
b
a
)&."5041&3.*" "/% 9"/5)0(3"/6-0."5064 13045"5*5*4 "/ 6/646"-
0/4&50'"3"3&%*"(/04*4
A.L. Pastore1, G. Palleschi1, A. Ripoli1, D. Autieri1, Y. Al Salhi1, A. Leto1, G. Velotti1, V. Petrozza2, A. Carbone1
1
2
Objective
Granulomatous prostatitis is an unusual, non-specific inflammatory process of the prostate gland, characterized by the
presence of granuloma as the main histological feature. It is subclassified as: infectious granuloma, nonspecific granulomatous
prostatitis, post-biopsy granuloma, and systemic granulomatous prostatitis. Rare forms of granulomatous prostatitis include
sarcoidosis and xanthogranulomatous prostatitis. This form is histologically similar to granulomatous prostatitis, with the
prominence of foamy histiocytes, which constitute the xanthomatous component. Non-specific granulomatous prostatitis
and xanthogranulomatous prostatitis are likely caused by a blockage of prostatic ducts and stasis of gland secretions. The
resulting epithelial disruption leads to the escape of cellular debris, bacterial toxins, prostatic secretions, including corpora
amylacea, sperm and semen into the stroma, determining an intense localized inflammatory response. We present a case series
of xanthogranulomatous prostatitis in 5 patients that came to our clinic between 2008 and 2014. These patients have a history
of hematospermia, progressive lower urinary tract symptoms (LUTS), and increasing levels of serum prostate-specific antigen
(PSA).
All patients (mean age 56.8; range: 51–62) came for recurrent episodes of hematospermia (associated with fever in 3 patients),
which represented the onset symptom. All men suffered also from LUTS, characterized by urinary frequency, burning,
hesitancy, and nocturia. In all patients, a PSA elevation was observed (range: 4.8–6.7 ng/mL), with a normal ratio always
greater than 20% (range: 22–36%).3 Digital rectal examination (DRE) revealed an increase in the gland size and a change in
the consistency with an irregular surface in all cases. The palpatory findings (peripheral nodule of hard consistency) and the
serum PSA level (>4 ng/mL) also confirmed the use of antibiotic therapy and this lead us to suspect malignancy in all cases. As
such, the patients had an ultrasound-guided transperineal prostatic biopsy (12 cores) to exclude a malignant diagnosis.
Results
All patients were treated for LUTS with medical therapy (alpha-adrenergic blockers plus Serenoa repens), but none reported any
significant symptom improvement . For this reason all the subjects were evaluated by transrectal ultrasound examination (TRUS)
and urodynamics. TRUS showed a marked inhomogeneity of prostate tissue, with several hypoechoic and hypervascularized
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Greenlight vaporization. Enrollment patients were evaluated according to the following parameters: IPSS score, preoperative
and postoperative flow, post void residual, TRUS, PSA, prostate biopsy when necessary. The same parameters were evaluated
postoperatively. Also operative time, the energy delivered, the time to catheterization and adverse events were evaluated.
Results
The mean Patient age was 65 (range, 50-78); 81% of men were on an alpha-blocker preoperatively; mean (standard deviation;
SD) prostate volume by transrectal ultrasound was 55,1 ml (27,5); mean (SD) operative time was 24,36 minutes (6,03); mean
(SD) total laser kiloJoules used was 216,289 kJ (62,805); mean (SD) follow up time was 8,72 months (3,24); and mean (SD)
time of catherization was 18,1 hours (6,3). The 1-year decrease in mean (SD) IPSS-score was 22,3 (7,2)-8,4 (3,9). The maximal
urinary flow increased from 9,5 ml/s (2,3) to 27,5 (5,1). Patients postvoid residual improved from 119 mL (64) to 14 mL (11)
over a 1-year period. (P <.01 for all). Adverse effects occurred: 1 bladder neck sclerosis after 3 months, 2 urge incontinence
resolved with medical therapy, 1 unresolved hypocontractility bladder, 4 stress incontinence spontaneously resolved, 1 urinary
sepsis, 2 acute urinary retention resolved by temporary catheterization.
Discussions
The use of lasers in the treatment of BPH is now consolidated by time: they exploit different methods for the vaporization
or enucleation of the prostate tissue. The Greenlight Laser uses a green beam generated by an activated mixture of lithium
triborate with power up to 180W. The beam, having a wavelength of 532Hz, is selectively absorbed by hemoglobin resulting
in an immediate vaporization of the treated tissue. In particular, the selectivity of the beam allows not to cause deeper lesions
of 2 mm, thereby avoiding damage to deep tissue. The hemoglobin makes selectivity also because of the particular hemostasis
obtained during treatment. The action continues on prostate tissue makes possible the vaporization of about one gram of tissue
per minute every 10000J applied, whereby it is possible with this mode vaporize 10 grams of prostate in 10 minutes. The almost
complete absence of bleeding allows an accurate sculpture of the prostate bed. The treatment is effective, fast, safe.
Conclusion
The use of the Greenlight Laser 180W makes possible an effective treatment of obstructive BPH: it is possible to use the laser
energy for the vaporization of the prostate tissue and simultaneously for the anatomical incision of the tissue to be vaporized.
This solves the obstructive diseases related to prostate of different volumes. The efficacy and rapidity of the method allows
that with a vaporization minute can vaporize approximately 1 gram of prostatic tissue, delivering approximately 10,000 kJ,
because the processing time is proportional to the volume of the prostate. The technique is simple: in our experience the results
obtained from five different endoscopic surgeons with different experience are similar.
27
28
a
r
t
s
b
a
8"554 )0-&1 7&3464 8"554 )0-&1 " $0.1"3"5*7& .6-5*$&/53*$
456%:0/&''*$"$:"/%4"'&5:
Y. Hussein 1, A. Porreca2, A. Tesone3, D. Taglialatela1, R.. Milesi1, F. Ceresoli1, A. Del Rosso1, I. Vavassori1
1
Ospedale Treviglio-Caravaggio - ASST Bergamo Ovest, U.O.C. Urologia (Treviglio)
2
Policlinico Abano Terme - Presidio Ospedaliero Regione Veneto, U.O. Urologia (Abano Terme)
3
Ospedale Classificato Moriggia Pelascini, U.O. Urologia (Gravedona)
Objective
Holmium Laser Enucleation of the prostate (HoLEP) was introduce in 1998 by Peter Gilling with the traditional 3 lobes
technique. HoLEP technique diffusion is due to advantages such as the use of saline as irrigation fluid, less hemorrhagic risks
than TURP, and can treat any prostate size. The introduction of more powerful lasers has allowed to treat larger prostate volumes.
Holmium:yttrium-aluminum-garnet (Ho:YAG) lasers doubled their power since the HoLEP was introduced. Currently there
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
areas and calcifications along the peripheral surface of the adenoma, while pressure/flow studies showed the presence of a
severe bladder outlet obstruction (BOO). Therefore, all patients underwent transurethral bipolar endoscopic resection of the
prostate (TURP). During surgery, the prostate gland tissue appeared white-yellowish and presented no histiocytes significant
bleeding. After superficial resection, minimal pus came out from small, occasional abscess pockets. No intra- or postoperative
complications occurred. The mean catheterization time was 3 days; one patient had acute urinary retention 48 hours after
catheter removal due to inflammatory condition, revealed by DRE. PSA levels significantly decreased and were below 2
ng/mL in all patients. Urinary urgency and burning were the most represented urinary symptoms during the first 2 weeks
after surgery; 2 patients required additional antibiotic and anti-inflammatory medication. Histopathological examination of
resected prostatic tissue in all patients revealed xanthogranulomatous prostatitis with no evidence of malignancy. A nonspecific granulomatous inflammation was found, mainly consisting of plasma cells, lymphocytes, neutrophils, eosinophils,
multinucleated giant cells, and epithelioid cells that surrounded, distended or destroyed glandular lumens. The granulomas
were composed of multinucleated giant cells and “xanthogranulomatous cells” (diffusely in 4 cases, focally in the fifth).
Discussions
Xanthogthranulomatous prostatitis is an unusual benign inflammatory process of the prostate gland, first described by Tanner
and Mc Donald in 1943. It is a rare subtype of granulomatous prostatitis, sometimes associated with hyperlipidemia. The
etiology and pathogenesis are unclear, although some authors suggest a role of glandular ducts obstruction in its pathogenesis.
On average, patients usually present around age 60; the range can be from patients in their twenties to the very elderly.
The granulomatous prostatitis, and its rare variant xanthogranulomatous, are poorly defined clinically and features may include
irritative LUTS, frequency and burning, pyuria and hematuria sometimes combined with hematospermia. In 20% of cases,
granulomatous prostatitis presents with a triad of sudden-onset high fever, symptoms of prostatitis and a nodular painless
firm with a prostate enlargement, palpable on DRE. However, as our case series revealed, most patients suffer from a severe
BOO, which might exacerbate the chronic inflammatory condition of the prostate; this can help determine the xanthomatous
phenomenon inside the gland. According to this hypothesis, as expected, in our case series the complete symptoms relief was
achieved only through surgery. Hematospermia as the onset symptom has not been reported so far. Hemospermia has been
sporadically reported as an accompanying symptom in very few cases, but only in our case series it represented the uncommon
symptom of disease onset. In 40% of all cases reporting hematospermia, an infectious condition is revealed. Other etiologic
factors are inflammatory conditions, neoplasms and iatrogenic factors. After confirming the presence of hematospermia,
physicians should perform a clinical evaluation, including clinical history and physical examination with DRE.
A PSA level increase is often observed, with a reported rise to 150 ng/mL in 1 case. On rectal examination, the prostate
may be hard and nodular mimicking prostate carcinoma, which must be excluded. The transrectal ultrasound and magnetic
resonance image cannot distinguish this entity from prostatic malignancy, but generally the ultrasound shows hypoechoic
lesions. The final diagnosis can only be achieved by histopathological examination of the prostate. The histological feature of
xanthogranulomatous prostatitis is the presence of macrophages with foamy cytoplasm “xanthomatous cells” (CD68+) in the
mixed flogistic infiltrate with multi-nucleated giant cells.
Conclusion
In our case series, the hematospermia was always the onset symptom, which was accompanied by severe LUTS secondary
to BOO. The histopathologic findings after performing TRUS-guided transperineal biopsy only revealed a non-specific
inflammatory process of the peripheral gland. The patients were non-responsive to combined medical therapy, so TURP was
performed in all cases. To diagnose the xanthogranulomatous prostatitis, we highlight the importance of histological findings
obtained on the specimen of the transitional zone after performing TURP. In addition, the immunohistochemical examination,
such as CD68 and PSA, were crucial in getting a definitive diagnosis and in excluding the presence of carcinomatous foci that
may be suspected.
References
1. Lee HY, Kuo YT, Tsai SY, et al. Xanthogranulomatous prostatitis: a rare entity resembling prostate adenocarcinoma with
magnetic resonance image picture. Clin Imaging. 2012;36:858–60.
2. Rafique M, Yaqoob N. Xanthogranulomatous prostatitis: A mimic of carcinoma of prostate. World J Surg Oncol. 2006;4:30.
3. Razek AA, Elhanbly S, Eldeak A. Transrectal ultrasound in patients with hematospermia. J Ultrasound. 2010;13:28–33.
4. Uzoh CC, Uff JS, Okeke AA. Granulomatous prostatitis. BJU Int. 2007;99:510–2.
28
29
a
r
t
s
b
a
*."(& 26"-*5: &7"-6"5*0/ 0' " 46#.*--*.&5&3 41"$& 58&*()5&%
4&26&/$&*/13045"5&.6-5*1"3".&53*$.3*
Argomenti: E. Armando1, L. Capitolo1, F.. Cesarani1, A. Rocca1, F. Bardari2
1
Ospedale Cardinal Massaia (Asti)
2
Ospedale Mauriziano (Torino)
Objective
As mp-MRI is becoming an essential tool for detection and staging of prostate cancer, faster protocols are necessary for
increased requests of this examination. SPACE sequences are about 5 minutes faster than conventional T2 2D sequences
(2DT2) acquired in three planes.
The aim of this study is to evaluate image quality of a high-resolution SPACE in mp- MRI.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
is a lack in scientific literature of evidence in patients benefits and procedure’s outcome due to the increase in laser’s power up
to 120 W. This study compare the efficacy and safety between two Ho:YAG lasers, 120-W and 100-W, in perform HoLEP in
patients with lower urinary tract symptoms (LUTS) due to Benign Prostatic Hyperplasia (BPH).
A retrospective multicentric analysis of 120 patients with symptomatic BPH was carried out. Patients were enrolled in two
centers, in each center all HoLEP procedures were performed by a single experienced operator. Each center enrolled 60 patients,
in particular the first 30 consecutive patients undergone HoLEP with Ho:YAG laser 120-W (Lumenis Pulse 120H) and the last
30 patients undergone HoLEP with Ho:YAG laser 100-W (Lumenis VersaPulse 100W Holmium). All the HoLEP procedures
included in the study were performed with the traditional 3 lobes technique as described by Peter Gilling1. All surgical
instruments used during the HoLEP were the same for both groups except for the Ho:YAG laser tools. Patient demographics
data, peri-operative outcome and 3-months follow-up data were analyzed with the International Prostate Symptom Score
(IPSS), quality of life (QoL) score, maximum flow rate (Qmax), postvoid residual urine volume (PVR), and rates of perioperative complications
Results
Patients in each group showed no significant difference in pre operative parameters. Compared with the 100-W group, patients
in the 120-W group required significantly longer time for laser enucleation (p = 0.038). Mean peri-operative hemoglobin’s
decrease in the 120-W HoLEP group was similar to the 100-W group (P > 0.05). Early incidences of complications not differ
significantly between the two groups of 120 W HoLEP and 100-W HoLEP patients (P > 0.05). At 3 months follow-up, the
HoLEP performed with two different Ho:YAG laser compared, did not demonstrate a significant difference in IPSS, QoL score,
Qmax, or PVR (P > 0.05).
Discussions
Operative and laser times are longer in the 120W-Group, those differeces can be attributed to technical modifications in the
hemostatic phase; the need to apply the laser directly on the vessel to coagulate. In 100W-Group hemostasis is performed
using the same laser setting used during enucleation (2 Joule, 50 Hz), on the other hand in the 120W-Group enucleation is
performed using full power setting (2 Joule, 60 Hz) and hemostasis with a different setting (long pulse 2 Joule, 30 Hz) activated
using a dedicated second pedal. The reduction of the laser pulse frequency during the hemostasis and the presence of the
new double pedal are new aspects when using the 120 W-Ho:YAG laser to perform HoLEP. Particularly the new method of
laser application during hemostasis and use of the second pedal during hemostasis may have negatively affected the first 30
cases performed with the new 120 W-Ho:YAG laser given the need to change established habits of experienced operators with
HoLEP performed with 100W Ho:YAG lasers.
Conclusion
120 Watt HoLEP is safe and effective as HoLEP performed with 100 Watts Ho:YAG laser. In our study laser’s activation time
and HoLEP’s operating time are longer in HoLEPs performed with Ho: YAG laser 120 watts are longer than in the group of
HoLEP were performed with 100 watt Ho: YAG laser; more studies are needed to determine whether this is due to transition
from the Ho: YAG 100 Watts laser (Lumenis Holmium Versapulse 100W) to the new Ho: YAG laser 120 Watts (Lumenis Pulse
120H) or whether it is due to the laser settings used in the process of hemostasis.
References
1- GILLING, P. J., KENNETT, K., DAS, A. K., THOMPSON, D., & FRAUNDORFER, M. R. (1998). Holmium laser enucleation
of the prostate (HoLEP) combined with transurethral tissue morcellation: an update on the early clinical experience.
Journal of endourology, 12(5), 457-459.
2 – Gupta, N., KUMAR, R., Dogra, P. N., & Seth, A. (2006). Comparison of standard transurethral resection, transurethral
vapour resection and holmium laser enucleation of the prostate for managing benign prostatic hyperplasia of> 40 g. BJU
international, 97(1), 85-89.
3 – Elzayat, E. A., Habib, E. I., & Elhilali, M. M. (2005). Holmium laser enucleation of the prostate: a size-independent new
“gold standard”. Urology, 66(5), 108-113.
4 – Aho, T., & Gilling, P. (2008). Current techniques for laser prostatectomy-PVP and HoLEP. Archivos Españoles de Urología,
61(9), 1005.
5 – Barry M.J., et al. (1992) The American Urological Association symptom index for benign prostatic hyperplasia. The
Measurement Committee of the American Urological Association. J Urol,148(5): p. 1549-57
29
30
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
45 patients underwent mp-MRI in a 1.5-T scanner (Magnetom Avanto Fit) using a 16-minute protocol including a highresolution 3d T2 SPACE sequence (voxel size 0.7 x 0.7 x 1 mm). 28 patients examined with conventional 2D T2 sequences
were used as control group. Image quality was retrospectively assessed by two radiologists who traced regions of interest
(ROI) within healthy peripheral zone (PZ) and prostate cancer areas (PCa), identified at fusion biopsy, performed using Koelis
urostation. Mean signal intensity (MSI) and standard deviation (SD) values of each ROI were recorded; signal-noise ratio was
calculated as MSI/SD: relative tumour contrast as (PZ MSI- PCa MSI)/(PZ MSI). Statistical analyses were performed using
Student t test with Statistica 10 software
Results
There were no significant differences in prostate cancer Gleason scores between two groups. Mean signal intensity of both
healthy peripheral zone and prostate cancer was significantly lower using T2 SPACE than in conventional 2D T2 sequences
(320 ±81 vs 497 ±121, p< 0.001 and 81.9±24 vs 155,14±55, p< 0.001). However there was no difference in signal-noise ratio
in both healthy peripheral zone and prostate cancer (13.3± 7.26 vs 12.04± 4.77, p=0.41 and 7.02± 3.42 vs 7.63± 3.4, p=0.58).
Relative tumour contrast was higher in T2 SPACE than in conventional 2D T2 sequences (0.58 ± 0.11 vs 0.48 ± 0.11, p=0.008).
Discussions
T2 SPACE sequence has a good image quality in prostate peripheral zone; previous studies have tried 3D T2 sequences but
they never used so high resolution; despite smaller voxels, we showed a reliable signal-noise ratio and an optimal difference
in signal intensity between prostate cancer and healthy peripheral zone. Due to the small number of patients we haven’t yet
enough data for image quality assessment of T2 SPACE in the evaluation of transitional zone tumours. However we expect
an advantage of SPACE sequence over conventional 2D imaging because thinner slices should allow a better identification of
adenoma pseudocapsule that helps distinguishing benign adenomas form malignant tumours.
Conclusion
After the introduction of PIRADS v2, which has shortened dynamic contrast enhancement sequence to less than 3 minutes, it
is possibile to perform in about 13 minutes a complete mp-MRI protocol including also a T2 SPACE sequence and DWI with
calculated high b-value. Previous papers have already shown the utility of SPACE sequence in the assessment of extracapsular
extension of prostate cancer. Further advantages may come from better contouring of prostate and tumour lesions at prostate
base and apex due to less partial volume artifacts prior to biopsies or imaging guided therapies.
In the era of fusion biopsies and at dawn of focal therapy, faster acquisition of thinner slices may improve diagnostic utility of
mp-MRI and make it available for more patients
30
31
o
6
16:00
17:30
s
1
s
Goya
0
e
2 ngr
Video 1
o
s
C
t
Chirurgia no limits
I
I
c
I
a
X
r
X
t
22 maggio 2016
s
b
a
03$)*'6/*$6-&$50.*"-"1"304$01*$"1&34&.*/0."*/5&45*$0-0&$501*$0
1"3"7&4$*$"-&
Argomenti: cancro del pene del testicolo o tumori rari
R. Mastroianni1, R.. Papalia1, E.. Altobelli1, A.. Giacobbe2, D. Collura1, C. Falavolti1, E. Shehu1, E.. Luperto1, G. Muto1, M. Kurti1, G.
Muto1
1
Università Campus Bio-Medico (Roma)
2
Ospedale San Giovanni Bosco (Torino)
Abstract
Presentiamo il caso di un paziente monorchide di 45 anni, con storia di infertilità e pregressa esplorazione inguinale in età pediatrica
per sospetto testicolo ritenuto. Giunto alla nostra attenzione per riscontro occasionale di una massa paravescicale sinistra. Una RM
localizzava la lesione di 2 cm nello scavo pelvico, medialmente ai vasi iliaci esterni, da riferire in prima ipotesi a testicolo ritenuto.
Markers tumorali negativi. Nel video viene illustrato l’intervento di orchifuniculectomia sinistra laparoscopica del testicolo in sede
ectopica. L’esame istologico mostrato la presenza di un seminoma puro.
1-"45*$" 63&5&3"-& $0/ 3&*.1*"/50 30#05*$0 */ .&("63&5&3& %"
63&5&30$&-&
Argomenti: chirurgia ricostruttiva
A. Serao1, P. Vota1, F. Cortese1, D.. Tiranti1, P. Audino1, M. Ferraro1, A. Di Stasio1
1
ASO Alessandria SS. Antonio e Biagio e Cesare Arrigo (Alessandria)
Abstract
Il video mostra un intervento, eseguito in robotica, di plastica ureterale e rimodellamento in megauretere da ureterocele sinistro,con
reimpianto ureterale extravescicale con tecnica antireflusso. Il paziente di anni 22 aveva accusato da alcuni mesi coliche renali
recidivanti , non ravvicinate.Non riferiva infezioni urinarie nè episodi febbrili. La tac eseguita con mdc dimostrava la presenza di
un ureterocele sinistro con megauretere, a decorso tortuoso e idronefrosi omolaterale, con ritardo della fase escretoria.L’intervento
è stato condotto con tecnica robotica. Dopo un isolamento del tratto ureterale distale, a partire dall’incrocio con i vasi iliaci fino
alla vescica, l’uretere è stato distaccato dalla parete vescicale. E’ stato quindi eseguito un rimodellamento del tratto ureterale isolato
con plastica di riduzione del lume e successivamente un reimpianto con tecnica antireflusso extravescicale eseguendo un tunnel
sottomucoso. Il decorso post operatorio è stato regolare e senza complicanze. Alla rimozione del doppio J il paziente non ha accusato
sintomatologia urinaria ( pur praticando attività fisica agonistica). Il controllo tac a distanza di tre mesi ha evidenziato regolari
reperti.La tecnica robotica per la chirurgia ricostruttiva delle vie urinarie, tanto più in pazienti giovani, si dimostra altamente efficace
per la sua mininvasità e finezza operativa con risultati funzionali eccellenti.
30#05"44*45&%63&5&3"-3&*.1-"/5"5*0/8*5)/&0#-"%%&3#0"3*'-"1
G. Simone1, R.. Papalia2, G. Tuderti1, F. Minisola1, M.. Ferriero1, R. Mastroianni2, L. Misuraca1, S. Guaglianone1, G. Romeo1, G.. Muto2,
M. Gallucci1
1
2
16:00 - 17:30, Goya - video 1 - Chirurgia no limits
Moderatori: Franco Bergamaschi
sala
31
32
X
X
a
r
t
s
Y. Al Salhi1, G. Palleschi1, A.L. Pastore1, A. Leto1, A. Ripoli1, D. Autieri1, A. Fuschi1, G. Velotti1, S. Al Rawashdah1, A. Carbone1
1
Abstract
Horseshoe kidneys represent the most common renal fusion anomaly. Abnormal vasculature and the possibility of isthmusectomy
are the primary issues that require attention when surgery is considered. The present study describes the case of a pure transperitoneal
laparoscopic radical heminephrectomy for a large renal tumor in a horseshoe kidney. A solid renal tumor in the left moiety of
a horseshoe kidney was incidentally detected in a 35-years-old woman during a routine abdominal ultrasound. Computed
tomography (CT) identified a 7-cm enhancing mass supplied by three arteries in the left renal moiety, without any metastatic lesion.
The mobilization of the descending colon revealed the underlying kidney with a wide isthmus. The mobilization of the left side of
the horseshoe kidney extending to the isthmus was carried out. The tumor was identified in the infero-anterior section of the left
kidney. A 60-mm powered Echelon Flex Endopath Stapler was used for the division of the isthmus, while the renal arteries and veins
were secured with a 35-mm stapler. Operative time was 135 min with estimated blood loss<100 ml. No complications occured.The
patient was discharged on post-op day three. Pathology revealed a pT2N0M0 grade 3 ccRCC inflitrating the renal calices with free
surgical margins.
b
a
$-".1-&44-"1"304$01*$163&&/6$-&"5*0/*/15#3$$
L. Misuraca1, G.. Tuderti1, E. Santini1, M. Sampalmieri1, M. Guidotti1, E. Santagata1, M. Ciletti1, G. Franco1, C. De Dominicis1, C.
Leonardo1
1
Sapienza Università di Roma (Roma)
Abstract
We present a case of 65-year-old gentleman with a 6 cm posterior mass of the right kidney. A clampless laparoscopic enucleation was
planned. The colon was deflected medially and the ureter was isolated. The gonadal vein was transected and the renal hilum isolated.
A home-made tourniquet was placed around the two main arteries for an eventual clamping. The isolation was challenging due
to the hard and stuck renal fat. The kidney was completely isolated in order to reach the mass. The enucleation was started and
completed following the tumour capsule. A resection bed suture was placed with 2-0 monocryl. A sliding suture technique was done
for renal parenchyma with vicryl. At the end the renal capsule was closed and the kidney fixed to the abdominal wall. The operation
time was 110 minutes and the blood loss 300 millilitres. The final histopathological report showed a pT1b cromophobe RCC.
-"1"304$01*$/&1)3063&5&3&$50.:"/%$:45&$50.:
R. Sanseverino1, O.. Intilla1, U. Di Mauro1, T. Realfonso1, G. Molisso1, A. Pistone1, G. Napodano1
1
Ospedale Umberto I, U.O.C. Urologia (Nocera Inferiore)
Abstract
The video shows a case of a 70 years old male affected by muscle invasive bladder cancer with monolateral hydronephrosis. Patient
underwent a laparoscopic transperitoneal nephroureterectomy and cystectomy with monolateral ureterocutaneous anastomosis.
Isolation of renal vessels that are clamped with HemOlok. Isolation of kidney using Ligasure device. Isolation of ureter until bladder
insertion. Isolation of controlterl ureter that are clamped and cut. Pelvic lymphadenectomy using laparoclips. Posterior dissection of
bladder and resection of bladder pedicles with Ligasure. Isolation of seminal vessels and deferens that are cut. Haemostatic suture
of Santorini. Dissection of prostatic apex and section of distal urethra. Positioning of surgical specimen in endobag. Monolateral
ureterocutaneous anastomosis.
-"1"304$01*$."/"(&.&/50'3&/"-56.03*/")034&4)0&,*%/&:
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Abstract
We report a robot-assisted Boari-flap ureteral reimplantation in a 58yr old patient who previously underwent a robotic radical
cystectomy and intracorporeal orthotropic ileal neobladder. A 9-mo post-operative CT scan showed a 3 cm stricture of left distal
ureter with concomitant grade III hydronephrosis, treated with percutaneous nephrostomy. Patient position and port placement were
similar to Robotic radical cystectomy. The neobladder and a thin left distal ureter were easily identified. The ureter was identified
and sharply dissected before ending in a fibrotic tissue. The ureter was spatulated and passed through the mesosigma. Neobladder
was opened and a Boari flap prepared. A direct refluxing reimplantation was performed on a double J stent. The neobladder was
closed with running sutures and irrigated to confirm water tightness. A drain was left in place. Perioperative course was uneventful;
no urine leakage occurred; patient was discharged on third post-operative day. Double-j stent was removed after 3 weeks. A 6-mo
renal function assessment and a 1-yr postoperative CT-scan showed normal eGFR values and relief of ureteral obstruction. Robotassisted ureteral reimplantation in orthotropic neobladder is a safe, feasible and minimally invasive procedure. Neobladder Boari
flap is viable option to overcome ureter shortness.
32
33
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
4*.6-5"/&064 -"1"304$01*$ /&1)3063&5&3&$50.: "/% $:45&$50.: 063
&91&3*&/$&
a
r
t
s
b
a
&/6$-&";*0/& -"1"304$01*$" % %* 70-6.*/040 "/(*0.*0-*10." 3&/"-&
4*/*4530
A.B. Di Pasquale1, G. Romano1, G.. Ranieri1, R. De Domenico1, M. Prata2, L.. Di Clemente1
1
Ospedale San Salvatore, U.O.C. Urologia (L’Aquila)
2
Ospedale Civile, U.O. Urologia (Sora)
Abstract
Nel video mostreremo l’enucleazione laparoscopica di una angiomiolipoma gigante del rene sinistro. La paziente di 19 anni è
giunta alla nostra o osservazione con diagnosi ecografica di voluminosa massa del rene sinistro che causava idronefrosi. Dopo
posizionamento di stent ureterale doppio j, veniva eseguita la TC che permetteva di formulare la diagnosi di angiomiolipoma dell’ilo
renale sinistro di 6 cm di diametro. La mattina dell’intervento la paziente veniva sottoposta a tentativo di embolizzazione della massa
con spongostan. La manovra riusciva solo per la metà laterale della neoformazione, per impossibilità ad incannulare i vettori mediali.
L’intervento chirurgico di enucleazione renale sinistro è stato eseguito con tecnica laparoscopica 3D trans peritoneale. La voluminosa
neoformazione si sviluppava medialmente a rene ed uretere con compressione dell’uretere lombare, del giunto pieloureterale e del
bacinetto. L’isolamento della massa è iniziato dall’uretere lombare che decorreva posteriormente alla stessa. Dopo la lisi del giunto
pieloureterale e del bacinetto, abbiamo liberato i vasi dell’ilo renale, questi ultimi posti superiormente all’angiomiolipoma. È stato
alquanto problematico aggredire il seno pielico, dal momento che l’angiomiolipoma si insinuava tra i calici. Al controllo RMN,
eseguito 6 mesi dopo l’intervento laparoscopico la paziente è risultata libera da malattia in assenza di idronefrosi sinistra.
$)*363(*"&/%0630-0(*$"&453&."1&353"55".&/501"--*"5*70%*/&01-"4*"
%&--"-5"7*"&4$3&53*$&*/1";*&/5&"%"-503*4$)*0"/&45&4*0-0(*$0
S. Spatafora 1, S. Ricciardulli 1, R.. Napoli1, M.. Spagni1, V.. Domenico 1, G. Ruoppo1, F. Bergamaschi1
1
t
Arcispedale S. Maria Nuova, U.O Urologia (Reggio Emilia )
Abstract
Il video mostra come l’approccio percutaneo è utile nel trattamento di voluminose neoplasie delle alte vie urinarie in pazienti ad
altissimo rischio anestesiologico. Paziente di 91 anni, precedentemente sottoposto a nefroureterectomia sinistra per carcinoma
ureterale di alto grado e a successive TURBT per NMIBC di basso grado, giungeva alla nostra osservazione nel maggio 2015 per
macroematuria e grave anemizzazione. La UroTC evidenziava una neoformazione di 33×14 cm della pelvi renale dx; il paziente
veniva sottoposto infruttuosa ureterorenoscopia a scopo emostatico; in relazione all’alto rischio anestesiologico e alla necessità di
dialisi post-intervento non si procedeva a nefroureterectomia. Previo posizionamento di catetere ureterale, si eseguiva puntura ecoradioguidata del calice inferiore destro, dilatazione pneumatica e posizionamento di cannula di 30F attraverso la quale si introduceva
resettore 26F. Resezione e DTC della neoformazione; introduzione successiva di cistonefroscopio flessibile con esplorazione dei calici
superiori e medi e DTC con laser ad olmio di altre neoplasie. Il paziente veniva dimesso con nefrostomia a dimora, normalmente
mobilizzato, con risoluzione dell’ematuria, stabilizzazione dell’emoglobina e riduzione della creatininemia.Il trattamento percutaneo
è una possibile opzione terapeutica per il trattamento palliativo di voluminose neoplasie della alte vie urinarie in pazienti ad altissimo
rischio anestesiologico, con preservazione della loro qualità della vita.
X
X
B. Azizi1, W. Giannubilo1, C.A. Bravi1, C. Vecchioli1, M. Diambrini1, V. Ferrara1
1
Ospedale “Carlo Urbani” (Jesi)
Abstract
Patients with muscle-invasive bladder cancer and concomitant upper urinary tract tumors may be candidates for simultaneous
cystectomy and nephroureterectomy. Other clinical conditions such as dialysis-dependent end-stage renal disease and nonfunctioning kidney are also indications for simultaneous removal of the bladder and kidney. In the present video, we report our
laparoscopic experience with simultaneous laparoscopic radical cystectomy (LRC) and nephroureterectomy. Our surgical technique
was performed as follows through a trans-peritoneal approach. First surgical time was rapresented by nephroureterectomy. After
recognizing the ureter, the kidney was completely isolated from the perirenal fat and the ureter followed down to the intersection with
the iliac vessels. For subsequent cystectomy and bilateral lymph-node dissection, the patient was re-positioned in a supine position
and 2 more accesses (10- and 5-mm trocars) were placed in the iliac fossa. In this position we completed the ureter isolation without
dissecting it. Radical cystectomy was performed with a descending approach. . Bilateral iliac-obturator extended lymphadenectomy
and separate extraction of lymph-node specimens. The ureter was now identified and ejected from the corresponding side access.
Specimens were extracted through a 6-cm skin incision along the linea alba. Monolateral ureterocutaneostomy.
33
34
o
6
16:00
17:30
s
1
s
Velazquez
0
e
2 ngr
Poster digitali 1:
o
s
t
Male OncologyII C
c
I
a
X
r
X
t
s
22 maggio 2016
b
a
30-& 0' 1&/*-& %011-&3 64 */ 5)& 13&01&3"5*7& "44&44.&/5 0' 1&/*-&
426".064 $&-- $"3$*/0." 1"5*&/54 3&46-54 '30. " -"3(& 13041&$5*7&
.6-5*$&/5&3&6301&"/456%:
Argomenti: cancro del pene
G. Bozzini1, S. Melegari1, M. Seveso1, O. De Francesco1, P. Bono1, A. Mandressi1, M. Provenzano2, J. Romero Otero3, M.
Margreiter4, E. Garcia Cruz5, B. Osmolorskij6, P. Verze7, N. Pavan8, F. Sanguedolce9, N. Buffi10, G. Guazzoni10, G. Taverna1
1
2
3
Hospital Universitario 12 De Octubre (Madrid)
4
Vienna General Hospital (Vienna)
5
Hospital Clínic De Barcelona (Barcellona)
6
Lomonosov Hospital (Moscow)
7
Università Federico II (Napoli)
8
Università di Trieste (Trieste)
9
King’s College Hospital (London)
10
Università Humanitas, Clinica e Centro di Ricerca (Rozzano)
Objective: Aim of this study is to determine the role of Penile Doppler Ultrasound (PDU) compared to Magnetic Resonance
Imaging in preoperative diagnostic evaluation of patients with Penile Squamous Cell Carcinoma .
Materials and Methods: A prospective analysis on patients presenting with clinical diagnosis of penile squamous cell carcinoma
from 6 different European Hospitals between 2012 and 2014 was carried out. Each patient who had planned a organ sparing
approach underwent an MRI and PDU (while its report remained hidden and the surgical approach was driven by MRI and
frozen section examination -FSE-) both with an artificial erection with PGE1. Age, evidence of MRI or PDU corpora cavernosa
(CC) infiltration, FSE report, definitive pathological report and surgical approach used per patient were recorded. Accuracy,
Precision, Negative Predictive Value, Sensitivity and Specificity were calculated. Outcomes were statistically evaluated.
Results: 200 patients were enrolled in the study. The mean age of the patients was 67.35±15.45 (range 51-82). All of the patients were
treated surgically. Of the 200 patients, 135 (67.5%) underwent a corpora sparing approach while 65 had a partial penectomy
because of the frozen section outcome. About CC infiltration the definitive outcome confirmed the FSE. Penile Doppler US vs
MRI Accuracy was 96.5% vs 90.5%; Precision 92.6% vs 96%; Sensitivity 96.9% vs 73.8%, Specificity 96.2% vs 98.5%. Despite
Sensitivity (p<0.05) no statistical evidence was found between US and MRI.
Conclusions: Our multicentric study shows that a Penile Doppler US has a statistical similar outcome on detecting infiltration of
corpora cavernosa and could be used as a less expensive tool to drive surgical strategy in patient with a diagnosis of penile
Squamous Cell Carcinoma.
16:00 - 17:30, Velazquez-- Poster Digitali 1::Male Oncology
Moderatori: Michele Prencipe
sala
34
35
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
X
X
a
r
t
s
b
a
'&"4*#*-*5: 0' -"1"304$01*$ 1"35*"- /&1)3&$50.: 0' 1"5*&/54 13&7*064
6/%&3(0/&*14*-"5&3"-3&/"-130$&%63&4
M. Seveso1, S. Melegari1, G. Bozzini1, O. De Francesco1, P. Bono1, A. Mandressi1, G. Taverna1
1
Introduction: Previous ipsilateral renal surgery has been considered a relative contraindication for subsequent laparoscopic partial
nephrectomy (LPN) because of the likelihood of postoperative adhesions and distorted tissue planes making hilar control and
renal mobilization more difficult. We report perioperative outcome of 23 patients treated with LPN after previous ipsilateral
renal surgery.
Material & Methods: Out of the 251 patients undergone LPN from March 2005 and December 2015, at our Institution, 23 had
previous undergone ipsilateral open or percutaneous renal procedure. LPN registry and patients documents were analyzed to
obtain demographic data, preoperative surgical history, operative details and postoperative outcomes. Surgical technique: all
procedures were carried out through a 3-port trans-peritoneal approach.
Results: Mean patients’ age was 57,6 years ( range 41-78). 16 had previous undergone percutaneous surgery ( 9 PCNL, 5 biopsy), 7
open renal surgery ( 2 pyelolithotomy, 2 partial nephrectomy, 3 pyeloplasty). Mean time from previous surgery was 5.3 years.
LPN was successful in all patients. No open conversion or nephrectomy was needed. Mean tumor size was 2.1 cm ( range
1-4.5), estimated blood loss was 145 ml, surgical time was 183 minutes ( range 122-241), hospital stay was 3.1 days ( range
2-7). Histopathological examination confirmed renal cell carcinoma in 12 cases, papillary carcinoma in 5, oncocytoma in 4
and angiomyolipoma in 2. 1 patient required intra-operatory blood transfusion. There were 4 postoperative complications:
1 wound infection, 1 pancreatic leak and 2 urine leakage managed with temporary ureteral stenting. No patient experienced
metastatic disease but, in one case, a recurrent renal mass needed laparoscopic radical nephrectomy.
Conclusion: LPN after previous ipsilateral renal surgery is feasible, it is not associate to a significant increase in surgical time and
complication rate . However it can be technically challenging and adequate experience with LPN is necessary.
" $"4& 0' 91 53"/4-0$"5*0/ 3&/"- $"3$*/0." 8*5) 6/646"-
.031)0-0(*$'&"563&4
M. Addesso1, G. Napodano2, A. Campitelli2, A.. D’Antonio3, R. Sanseverino2
1
Ospedale Umberto I, U.O.C. Anatomia Patologica (Nocera Inferiore)
2
3
Ospedale San Giovanni di Dio e Ruggi d’Aragona, U.O.C. Anatomia Patologica (Salerno)
INTRODUCTION: Xp11-translocation renal carcinoma (Xp11-tRCC) and t(6;11)-tRCC are members of the microphthalmia-
Argomenti: cancro della prostata
G. Taverna1, L. Tidu2, F. Grizzi3, B. Stork4, M. Seveso1, G. Bozzini1, S. Melegari1, O. De Francesco1, P. Bono1, P. Sardella2, G.
Latorre2, G. Lughezzani5, N. Buffi3, G. Guazzoni3, A. Mandressi1
1
2
Ministero della Difesa, Centro Militare Veterinario dell’Esercito, CEMIVET (Grosseto)
3
Clinica e Centro di Ricerca Humanitas (Rozzano
4
West Shore Urology, Muskegon (Michigan)
5
Humanitas Clinical and Research Center (Rozzano)
Background: Cancer detection using sniffer dogs is a potential technology for clinical use and research. Here we evaluate the ability
of highly-trained dogs’ olfactory system to detect biochemical recurrence (BCR) in men undergone radical prostatectomy for
prostate cancer (PCa).
M&M: 114 consecutive men with clinical localized PCa undergone radical prostatectomy between November 2011 and May 2013
were investigated. For each patient urine and serum samples were collected before surgery, 45 days later and every six months
during follow-up (mean: 28 months; median: 28 months; range 19-37 months). Two dogs were trained to sit when they detected
PCa specific volatile organic compounds (VOCs) in the urine samples.
Results: Preoperatively, both dogs were able to detect PCa specific VOC’s in the urine samples of men with PCa with 100% accuracy.
45 days after surgery, 104 (91.2%) patients had a serum prostate-specific antigen (PSA) levels < 0.01 ng/ml, 6 (5,2%) patients
had a serum PSA levels >0.01 but < 0.2 ng/ml and 4 (3,5%) patients had a serum PSA > 1 ng/ml. 45 days after surgery, neither
dog detected prostate cancer specific VOC’s in the urine samples of the 104 men with a serum PSA level <0.01ng/ml. Both
dogs detected PCa specific VOC’s in samples collected from 2 out of 6 men with PSA levels >0.01ng/ml and <0.2ng/ml and
both dogs detected VOC’s in the samples each of the four men with PSA levels >1ng/ml (i.e. persistent disease). During the
successive follow up 9 of 110 patients (8.1%) had BCR. Both dogs were able to detect PCa VOC’s in the urine samples of 7 of
these 9 patients (77.7%).
Conclusions: Highly trained dogs can detect BCR in men who have previously undergone radical prostatectomy alone for PCa. Our
understanding of the use of the canine olfactory system in PCa detection continues to evolve.
)*()-:53"*/&% %0(4 0-'"$503: 4:45&. '03 %&5&$5*/( #*0$)&.*$"-
3&$633&/$&'0--08*/(3"%*$"-13045"5&$50.:
35
36
a
r
t
s
b
a
0/$0-0(*$"-065$0.&40'1"35*"-7&34643"%*$"-/&1)3&$50.:'03$5
/9$-&"3$&--3$$1301&/4*5:4$03&."5$)&%"/"-:4*4
G. Simone1, R. Papalia2, M. Ferriero1, G. Tuderti1, R. Mastroianni2, F. Minisola1, L. Misuraca1, M. Costantini1, S. Guaglianone1,
V. Pompeo1, G. Muto2, M. Gallucci1
1
2
Introduction: Few studies compared oncologic outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for renal
tumors larger than 7cm. In this study we compared oncologic outcomes of propensity score matched (PSM) cohorts of PN and
RN performed in patients with cT1-2-Nx renal tumors and pathologically confirmed pT1-pT3a-pNx clear cell (cc)- renal cell
carcinoma (RCC).
Material & Methods: The institutional review board approved prospective renal cancer database was queried for cT<3-cN0-cM0
and pT1a-pT3a-pNx cc-RCC. A 1:1 PSM analysis was used to minimize the potential biases of a retrospective analysis of data.
Kaplan-Meier method was performed to compare the oncologic outcomes of the PSM cohorts. Survival rates were computed
at 2, 5, and 10 yr after surgery and the log rank test applied to assess statistical significance between the two groups.
Results: Out of 1650 cases, 921 were cc-RCC and 666 patients met inclusion criteria, 232 of which treated with RN and 434 with
PN. A comparison of oncologic outcomes between PN and RN was performed. RN tumors were significantly larger (p<0.001),
with higher pT stage (p<0.001) and higher incidences of Fuhrman grade 3-4 (p=0.002). After applying the PSM, 155 RN
patients were matched with 155 PN cases. The two groups did not differ for all clinical and pathologic variables included in
the analysis (Table 1).
At Kaplan-Meier analysis PN and RN cohorts displayed comparable Metastasis Free Survival (5-yr 88,9% vs 89,9%, respectively,
p= 0.811), Local Recurrence Free Survival ( 5-yr 94,2% vs 95,9%, respectively, p = 0.283), Overall Survival (5-yr 94,5% vs
96,8%, respectively, p= 0.419), Cancer Specific Survival (5-yr 96% vs 98,6% respectively, p = 0.907) rates (Figure 1).
Conclusions: Our findings support oncologic equivalence of PN and RN also for patients with cc-RCC larger than 7 cm. Further
studies and larger cohorts are warranted to confirm our findings.
$0.1-&.&/5"3:7"-6&0'$0/53"45&/)"/$&%6-53"406/%$&64
*/
5)&%*"(/045*$"-(03*5).0'$0.1-&93&/"-$:454
G.C. Rocca1, E. Raimondi2, M.. Tilli2, S. Dallara2, C.. Ballista1, M.. Bernabei1, G. Benea2, M. Simone1
1
A.U.S.L. Ferrara, U.O. Urologia (Lagosanto)
2
Azienda Ospedaliera Universitaria di Ferrara, U.O. Radiologia (Ferrara)
Purpose: To assess the role of CEUS in the diagnostic algorithm of complex cysts, classified following the Bosniak system,
comared with CE-TC.
Methods and Materials: From March 2011 to September 2013 we selected 42 patients that underwent CE-CT after US
finding of complex renal cysts ( Bosniak > II F). All patients where also evaluated with CESU within a week. Two
indipendent radiologists analyzed results of both techniques. Therapeutic approach was planned based on the highest
grading CE-TC or CEUS.
Results: CE-CT images found 14 B-II, 8 B-IIF, 9 B-III, and 11 B-IV, while CEUS images found 12 B-II, 13 B-IIF, 6 B-III,
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
associated transcription factor (MiTF)t-RCCs. tRCC usually arises in young patients having typical microscopic features; Xp11
and t(6;11)-tRCC seem to be as indolent tumors with good prognosis. Conversely, Xp11-tRCC occurrence in adult patients is
extremely rare, more aggressive and needs surgical treatment.
MATERIALS AND METHODS: A 54 yrs woman with a painless left renal mass. A CT scan showed an heterogeneously enhanced
renal tumor; RENAL score was 9a . A laparoscopic partial nephrectomy was performed. A routinely immunohistochemical
panel (IHC) was applied. Because of the microscopic and IHC data, tRCC was considered and the following antibodies were
tested: TFE3, TFEB, Ksp-cadherin, and Melan-A.
RESULTS: The surgical sample showed a 47 mm large, non capsulated, tumor with a yellow-brownish appearance. Microscopically
the tumor showed a nested architecture; cells were large, well circumscribed and polygonal with clear and eosinophilic
cytoplasm; occasional hyaline globules were detected. Nuclei were vesicular with prominent nucleoli, mitoses were rare and
necrosis was not present. Lymphovascular invasion was observed in different areas of the tumor. Neither papillary structures,
pseudorosettes nor calcifications were present. A routinely immunohistochemical panel showed positivity for Pax-8 and focal
positivity for Cytokeratin-pan, negativite for CD10, Cytokeratin-7 e 20 e racemase. Antibodies sampling showed positivity for
TFE3, Ksp-cadherin, and Melan-A and negativity for TFE3, assessing the tumor as t(6;11)-tRCC. A subsequent, metaphase
, dual-color fluorescence in situ hybridization FISH confirmed the t(6;11)-translocation. The tumor was classified as stage
pT1bNX, Fuhrman grade 3.
CONCLUSIONS: In absence of typical morphological features the diagnosis of Xp11-tRCC may be missed. Attention should be
paid to the routine IHC profile that, in case of negativity of specific RCC markers, may suggest a t-RCC (either Xp11 or 6;11).
The adding of TFE3, TFEB, Ksp-cadherin and Melan-A can easily identify the specific sub-type.
36
37
a
r
t
s
1"35*"-/&1)3&$50.:"/%)&.033)"(*$$0.1-*$"5*0/43*4,'"$5034
b
a
5)& 580%*.&/4*0/"- /&07"4$6-"3 $0.1-&9*5: *4 4*(/*'*$"/5-:
)*()&3*//0/56.03"-13045"5&5*446&5)"/13045"5&$"/$&3
G. Taverna1, M. Seveso1, G. Bozzini1, A. Mandressi1, S. Melegari1, P. Bono1, O. De Francesco1, P. Colombo2, F. Grizzi3
1
2
3
Purpose: Prostate cancer is the most frequent cancer in men in Europe. A major focus in urologic research is the
identification of new diagnostic biomarkers with improved accuracy. Here, we evaluate the two-dimensional (2D) neovascular complexity in prostate tumoral and non-tumoral biopsy cores by means of a computer-aided image
analysis system, and assess any correlations between the results and some clinical and pathological parameters of
prostate carcinoma.
Materials and Methods: A total of 280 prostate biopsy sections from 70 patients were treated with CD34 antibodies and
digitized using an image analysis system that automatically estimates the surface fractal dimension as a “quantitator”
of the 2-D neovascular complexity of tumor vascular networks.
Results: Our study shows that biopsies without cancer have a significantly higher vascular surface fractal dimension as
compared to those tumoral. No correlations have been found between the vascular surface fractal dimension and
patient’s age, prostate-specific antigen (PSA) and free/total PSA ratios (f/t PSA) serum levels, pathological stage,
Gleason score, tumor volume, vascular invasion, capsular penetration, surgical margins, and biochemical recurrence.
Conclusions: Angiogenesis is a complex process, which involves multiple pathways that are dependent on the homeostatic
balance among several growth factors. Although the value of angiogenesis in prostate cancer is still controversial,
our findings suggest that prostate histology remains the reference tool for estimating the microvascularity, and that
the 2-D vascular fractal dimension represents a helpful geometrical index that might be included in the quantitative
analysis of prostatic tissue.
16:00 - 17:30, Velazquez-Poster Digitali 1::Male Oncology
X
X
M. Seveso1, G. Bozzini1, S. Melegari1, P. Bono1, O. De Francesco1, A. Mandressi1, G. Taverna1
1
Objectives: The most frequent complications of partial nephrectomy (PN) is hemorrhage that can lead to the need for
transfusion, embolization and reoperation raising morbidity, longer hospital stay and delay return to normal activities.
Aim of our study is to identify predictive factors of hemorrhage in the cohort of patients undergone PN in our Institute.
Materials and methods: 754 patients undergone PN (either open or laparoscopic or robotic) between March 2006 and
December 2014 were retrospectively analyzed. Patients with hemorrhagic complications (hematoma requiring
transfusion, postoperative decrease of hemoglobin> 3 g/dl, artery-venous fistula or false aneurysm) and without were
compared . Variables considered were gender, BMI, ASA score indications, surgical approach, RENAL nephrometry
score, estimated blood loss, anticoagulation/antithrombotic therapy, surgical time and hospital stay.
Results: Median age was 64 (36-78) years. The indication was imperative in 91 cases. Clinically significant postoperative
hemorrhage occurred in 98 patients (13%). Hematoma requiring transfusion occurred in 26 patients; Tc performed
in 13 patients with symptoms warranting a high degree of suspicion revealed pseudoaneurysms (5) or arteriovenous
fistula (8) needing angiographic intervention. 5 with unstable vital signs underwent surgical exploration. 54 case
required transfusion to stabilize the hemoglobin level. Age, ischemic time, BMI, tumor stage, RENAL nephrometry
score, operative method did not differ significantly between bleeding and nonbleeding groups; the only parameters to
differ was the anticoagulation/antithrombotic therapy and an operative blood loss ≥300 ml.
Conclusions: Despite the relatively low incidence of bleeding following PN, it remains one of the most serious complications.
Owing to significant disparities in the time of onset and presenting symptoms, great vigilance should be practiced for
timely identification and intervention. Patients with anticoagulation/antithrombotic therapy and operative blood loss
are at risk for hemorrhagic complications should be carefully monitored in the postoperative.
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
and 11 B-IV. CEUS upgraded CE-TC Bosniak grading from B-II to B-IIF in 2 cases, from B-IIF to B-III in 3 cases and
downgraded from B-III to B-IIF in 6 cases. Complete concordance between CEUS and CE-TC was observed in B-IV
graded cysts. All B-III and B-IV cysts ( 23/42) underwent surgery and pathological findings documented 4 benign
lesions and 19 malignant lesions. CE-TC overstimated only 1 malignant lesion resulting Minimal-fat angiomiolypoma
with no case of downstaging. All other patients were under imaging follow up, showing morpho-dimentional stability
at 2 years.
Conclusion: CEUS showed promising results evaluating renal complicated cysts, especially differentiating B-IIF from
B-III with better results than CE-CT; therefore CEUS should be considered in diagnostic algorithm of renal complex
cysts as a second step imaging tool after B-mode US to better screen lesions that will require CE-CT planning before
surgery.
37
38
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
G. Taverna1, G. Bozzini1, F. Grizzi2, M. Seveso1, S. Melegari1, A. Mandressi1, L. Balzarini2, F. Mrakic2, P. Bono1, O. De Francesco1,
N. Buffi2, G. Lughezzani2, M. Lazzeri2, G. Fiorini2, P. Casale2, G. Guazzoni2
1
2
Purpose: Aim of this work is to investigate prostate cancer (PC) detection rate, employing Endorectal Multiparametric 3-Tesla
Magnetic Resonance Imaging (MRI) driving subsequent Cognitive Systematic Prostatic Biopsy (CSPB) versus a homogenous
group of patients who did not undergo endorectal MRI.
Materials and Methods: A series of patients with a first negative biopsy were enrolled in the study. Patients were randomized into
two groups: Group A: patients underwent MRI and subsequent CSPB; Group B: patients that did not underwent MRI. Each
patient underwent a 13 cores sampling. Patients from Group A had 4 cores more for each MRI suspected lesion. The cancer
detection rate was calculated for each Group with regards to possible matches or mismatches between MRI evidence and
pathological reports.
Results: 200 consecutive patients were investigated. 50 out of 200 (25%) patients had a diagnosis of PC, 24 in Group A and 26 in
Group B. In Group A, 67 patients (67%) were positive for suspected lesions at the MRI. The mismatch between MRI findings
and the CSPB outcome was 61% with an MRI driven detection rate of 15%. Group B detection rate was 26% with no significant
differences versus Group A (p=NS). Patient discomfort was higher in Group A (82%). The accuracy of CSPB was 41% with
a positive predictive value of 22.3%. This rate is lower in High Grade Cancers (11.9%). The cost-effectiveness was higher in
Group A.
Conclusions: Prostate cancer detection rate does not improve by CSPB. The accuracy of CSPB was lower in High Grade PC, and a
higher cost was found with CSPB.
X
X
a
r
t
s
b
a
G. Taverna1, M. Seveso1, G. Bozzini1, A. Mandressi1, S. Melegari1, P. Bono1, O. De Francesco1, P. Colombo2, F. Grizzi3
1
2
3
Purpose: Aim of this study is to evaluate the two-dimensional vascularity in primary prostate tumoral and not-tumoral biopsies
by means of a computer-aided image analysis system and assess any correlations between the results and some clinical and
pathological parameters of prostate carcinoma.
Materials and Methods: A total of 680 whole prostate biopsy sections from 170 patients were treated with CD34 antibodies and
digitized using an image analysis system that automatically quantified the vascular surface. All the biopsies were obtained
from patients who underwent systematic biopsy sampling (Gleason score: 70 patients 3+3, 50 patients 3+4 and 50 ≥ 8) and
subsequent radical prostatectomy. Data were correlated with patient’s age, PSA and f/t ratio serum level, Gleason score,
pathological stage, and tumor volume.
Results: Our study shows that in all three groups analyzed biopsies without prostate cancer were more vascularized compared to
those tumoral. We found that the tumoral vascular surface did not decreased among low-, intermediate- and high-risk prostate
cancer. No correlations have been found between the vascular surface and patient’s age, PSA and f/t PSA ratio serum level,
pathological stage, Gleason score, tumor volume.
Conclusion: Angiogenesis is a complex dynamical process, which involves multiple pathways that are dependent on the homeostatic
balance between several growth factors. Although its significance in prostate cancer remains controversial, our findings suggest
that prostate biopsy is a valid reference tool for assessing the status of micro-vascularity, and further studies are necessary to
conclude whether angiogenesis is a canonic hallmark of prostate cancer.
%*"(/045*$ 1&3'03."/$& 0' .6-5*1"3".&53*$ .3* */ 13045"5& $"/$&3
1&3$03&"/"-:4*40'58013041&$5*7&6-53"406/%.3*'64*0/#*014:%"5"4&54
M.. Ferriero1, A. Giacobbe2, D. Collura2, R. Papalia3, S. Guaglianone1, G. Muto3, M. Gallucci1, G. Simone1
1
2
3
OBJECTIVES: The aim of this study was to evaluate the diagnostic performance of Mp-MRI using a per-core analysis of patients
who underwent a fusion prostate biopsy.
5)& .031)0.&53*$"- 7"4$6-"3 463'"$& *4 )*()&3 */ /0556.03"-
13045"5&#*014:5*446&5)"/13045"5&$"/$&3
&/%03&$5"- .6-5*1"3".&53*$ 5&4-" ."(/&5*$ 3&40/"/$& *."(*/(
"440$*"5&% 50 4:45&."5*$ $0(/*5*7& #*014*&4 %0 /05 */$3&"4& 13045"5&
$"/$&3%&5&$5*0/3"5&"3"/%0.*;&%13041&$5*7&53*"-
38
39
a
r
t
s
b
a
*.1"$50'26"-*5:0'13045"5&.1.3*0/5)&%&5&$5*0/3"5&0'5"3(&5&%
.1.3*64'64*0/#*014*&4
E. Altobelli1, R. Papalia1, A. Giacobbe2, D. Collura2, C.. Falavolti1, E. Shehu1, E. Luperto1, M. Kurti1, G. Muto1, R. Mastroianni1,
G. Muto1
1
t
2
t
Abstract
To evaluate the impact of the quality of prostate mpMRI on the detection rate of targeted mpMRI/US fusion biopsies
Between September 2015 and January 2016 a total of 83 patients underwent multiparametric MRI (mpMRI)/ ultrasound (US)
fusion biopsy at Campus Biomedico University of Rome. mpMRI where performed by an expert radiologists and radiologists
at the beginning of their prostate mpMRI experience.
Indication to mpMRI/US biopsy was established for pi-rads ≥3. Biopsy template was for 12 extended-cores protocol plus 2-3
targeted cores on the mpMRI target lesion. The UroStation™ (Koelis, France) and a V10 ultrasound system with an end-fire 3D
TRUS transducer were used for the fusion images procedure.
Median patients age was 65 (49-78) years old, median PSA level at biopsy was 4.3 (1.8-21) ng/mL. 76% (83 patients) underwent
at least 1 previous biopsy.
Prostate cancer was diagnosed in 44 patients (53%). Of these, 35 patients (80%) had a cancer positive biopsy with a positive
target, whereas 9 patients (20%) had a cancer positive biopsy with a negative target. G6 (3+3) was diagnosed in 24 patients
(55%), G7 (3+4) or (4+3) in 14 patients (32%), G8 (4+4) in 6 patients (13%). Men diagnosed with clinically significant cancer
were 20 (45%).
Of the 39 patients with a negative biopsy, 28 patients (72%) had an mpMRI performed by a naïve radiologist with probably an
over estimation of the pi-rads score.
mpMRI/US fusion biopsies improved the diagnosis of clinically significant prostate cancer optimizing the indications to
prostate biopsy. mpMRI quality is essential to reduce over indications to prostate biopsy and overdiagnosis of indolent cancers.
*.1"$50'-&"3/*/($637&0/5)&%&5&$5*0/3"5&0'5"3(&5&%.1.3*64
'64*0/#*014*&4
E.. Altobelli1, R.. Papalia1, A. Giacobbe2, D.. Collura2, C.. Falavolti1, E. Shehu1, E. Luperto1, M.. Kurti1, G. Muto1, R.. Mastroianni1,
G. Muto1
1
2
Abstract
To evaluate the difference in MRI fusion biopsy detection rate between an experienced center and a center at the beginning of
its learning curve.
Between September 2015 and January 2016 a total of 158 patients underwent multiparametric MRI (mpMRI)/ ultrasound
(US) fusion biopsy. 75 patients at a 1year experienced center (group A – San Giovanni Bosco, Turin) and 83 at a naïve center
(group B – Campus Biomedico, Rome).
Biopsy template was for both centers 12 extended-cores protocol plus 2-3 targeted cores on the mpMRI target lesion. The
UroStation™ (Koelis, France) and a V10 ultrasound system with an end-fire 3D TRUS transducer were used for the fusion
images procedure.
Median patient age was 65 (48-78) years old, median PSA level at biopsy was 4.5 (1.8-21) ng/mL. 75% (118 patients) underwent
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
METHODS: Data of 174 consecutive patients who underwent Mp-MRI/ultrasound fusion biopsy of prostate were prospectively
collected in two centres between October 2013 and September 2015. Sensitivity (Se), specificity (Sp), positive predictive value
(PPV), negative predictive value (NPV) and accuracy (Ac) of Mp-MRI were assessed on the base of a per core analysis of
histologic findings.
RESULTS: The 2 series were not homogeneous for number of suspicious foci at Mp-MRI, number of cores taken and number of
targeted cores taken (all p<0.001). Out of 174 patients, 111 had a PCa diagnosis (63.8%); 61 of them (54.6%) were Gleason
score (GS) 6. Overall, 3488 cores were taken: Se, Sp, PPV, NPV and Ac of Mp-MRI in the whole cohort were 47.1%, 85.5%,
45.9%, 86% and 77.5%, respectively. When restricting the analysis to GS >6, Se, Sp, PPV, NPV and Ac were 47.5%, 82.3%,
29.3%, 91.1% and 77.7%, respectively. In a per patient analysis, the detection rate of PIRADS scores 3,4 and 5 were 19.3%,
77.5% and 93.9%, respectively, while for GS>6 PCa detection rate of PIRADS scores 3,4 and 5 were 1.7%, 25% and 72.7%,
respectively. In a per core analysis, the PPV of PI-RADS scores 3,4 and 5 were 8.5%, 39.6% and 61.9%, respectively, while the
PPV of PI-RADS scores for GS>6 were 2.6%, 25.8% and 59.8%, respectively.
CONCLUSIONS: This study confirmed high PCa detection rates with fusion biopsy. A meticulous analysis of 3488 biopsy cores
taken showed a poor sensitivity and PPV of Mp-MRI, especially for GS >6 PCa. Despite the poor discrimination of PI-RADS
scores of 3 and 4, PIRADS scores 5 correctly identified PCa lesions with GS>6.
39
40
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
at least 1 previous biopsy.
Prostate cancer was diagnosed in 42 patients in group A (56%) and 44 patients in group B (53%). Of these, 34 patients (81%)
in group A and 35 patients (80%) in group B had a cancer positive biopsy with a positive target, whereas 8 patients (19%) in
group A and 9 patients (20%) in group B had a cancer positive biopsy with a negative target.
Our data suggest that learning curve does not impact detection rate outcomes of mpMRI/US fusion biopsies achieving good
detection rate. mpMRI/US fusion biopsies improved the diagnosis of clinically significant prostate cancer optimi.
X
X
a
r
t
s
b
a
-&:%*( $&-- 6-53"406/% '&"563&4 " 64&'6- 500- '03 " 1301&3
13&01&3"5*7&$06/4&--*/(
*OWJBUPEB‫ڀ‬HJPCP[!ZBIPPJU
G. Bozzini1, M. Seveso1, S. Melegari1, O. De Francesco1, P. Bono1, A. Mandressi1, G. Taverna1
1
Aim: The aim of this study is to clarify Leydig Cell Tumor (LCT) ultrasound features to distinguish between benign and malignant
intratesticular lesions. Actually there are no typical and described features to drive surgical approach.
Material & Method: From January 2007 to July 2014 we reviewed scrotal ultrasound images of all patients diagnosed with LCT, first
diagnosed at one of the participating centers and treated with conservative surgery (group A: 35). We create a random control
group (B: 35 patients), homogenous in term of age and presentation, different for definitive malignant histology. All images
were collected and we analyzed ultrasound lesion features in terms of length, homogeneity, shape, hypervascularization.
Collected data were analysed by an online regression (Student’s t-test, chi-square test, and logistic regression analysis).
Results: Patients’ mean age was 35,11 years ( 28 -45) in group A vs 33,89 years in B (22 -41). Patients presented with a palpable
nodule (12 in A, 34.28%; 29 in B 82,86% ) or a ultrasound diagnosed nodule (23 in A, 65.72% ; 6 in B 17.14% ). Mean
ultrasound size was 0.96 cm (0.25 – 1.8 cm) vs 1.57 cm (0.8- 3 cm). Both groups had hypervascularization of the lesions with
no significant differences. Group A had an homogenous ultrasound intralesional aspect, shape is defined with an elliptic or
spheroid mold while group B had dis-homogenous intralesional aspect with non-defined margins (p>0.05).
Conclusion: Ultrasound is a sensitive and accurate technique for the evaluation of testicular abnormalities, widely accepted as the
first-line imaging technique for testicular diseases. Although most focal lesions will be malignant requiring an orchiectomy,
recognition of the benign entity may be challenging. In a small lesion mainly not palpable the presence of a well-defined shape
with an homogenous intralesional ultrasound aspect do correlate with a LCT.
M. Ferriero1, G. Simone1, R. Papalia2, R.. Mastroianni2, F. Minisola1, S. Guaglianone1, M. Gallucci1
1
2
Abstract
INTRODUCTION AND OBJECTIVES: Robotic radical cystectomy (RRC) with intracorporeal urinary diversion (iUD) is
a technically demanding procedure with a high rate of perioperative complications. A recent consensus held in Pasadena
provided some benchmarks adapted to different levels of learning curve. In this study we assessed the role of learning curve in
predicting the achievement of these benchmarks.
METHODS: The first 100 consecutive patients who underwent RRC and iUD were selected for the analysis. Baseline demographics,
perioperative and follow up data were prospectively collected. The benchmarks considered for the analysis were overall
complication and high grade (Clavien 3-5) complication rates, operative time, transfusion rate and length of hospital stay. The
trends in incidence of these events was analyzed according to a tertile distribution (1-33 vs 34-67 vs 68-100). Student t and
chi-squared tests were used.
RESULTS: Out of 100 RRC, 81 patients received a Padua Ileal bladder (61 male and 20 female), while 19 patients received an ileal
conduit. In the whole series, perioperative complication rate, high grade complications and transfusion rate were 33.3%, 9.4%
and 7.2%, respectively. The case mix (neobladder/ileal conduit) did not change between the three groups. Complications, high
grade complications and transfusion rate significantly decreased after the first 67 cases (p<0.05) while operative time and
hospital stay remained stable for all cases. (Table 1)
CONCLUSIONS: Learning curve plays a key role in optimizing perioperative outcome of RRC with i-UD. Case mix in a tertiary
referral centre was not influenced by learning curve. Transfusion rate, overall complication and high grade complication rates
were significantly reduced after 67 cases.
-&"3/*/( $637& '03 30#05*$ 3"%*$"- $:45&$50.: 8*5) 505"-
*/53"$03103&"-63*/"3:%*7&34*0/"/"-:4*40'#&/$)."3,4'03463(&0/4
40
41
o
6
17:30
19:00
s
1
s
Goya
0
e
2 ngr
Comunicazioni 3:
o
s
C
t
Bersaglio Prostata
I
I
c
I
a
X
r
X
t
s
23 maggio 2016
sala
.35"3(&5&% 74 5364(6*%&% 13045"5& #*014: */ 1"5*&/54 8*5) )*() 14"
7"-6&4"3"/%0.*;&%$0/530--&%53*"Inviato da: [email protected]
A. Giacobbe1, F. Russo2, S. Mazzetti2, V. Giannini2, D. Collura1, E. Castelli1, G. Muto1, A. Pisacane3, A. Sapino3, D. Regge2, G.
Muto4
1
Ospedale San Giovanni Bosco, S.C. Urologia (Torino)
2
FPO-IRCCS, Direzione Radiodiagnostica (Candiolo)
3
FPO-IRCCS, Direzione Anatomia Patologica (Candiolo)
4
Objective
Most prostate biopsies are driven by prostate-specific antigen (PSA) testing. However, as the positive predictive value of PSA
has been significantly reduced over the last several years, more unnecessary prostate biopsies are performed annually on
millions of men worldwide [1]. Moreover, transrectal ultrasound (TRUS)-guided biopsy, which is the standard procedure for
prostate histological sampling, has a detection rate of about 40%, with a false negative rate of about 20% [2]. In this scenario
more accurate methods need to be found to detect significant prostate cancer (PCa) or rule out patients with elevated PSA
levels and insignificant lesions. In the last decade, with the aid of multiparametric magnetic resonance (mp-MR) imaging,
clinical relevant PCa foci could be better identified, sampled and treated than in the past. Hence more efforts are being made
to incorporate mp-MR imaging into routine prostate biopsy, including cognitive, fusion, and in-bore MR-guided techniques
[3]. Aim of this study is to compare PCa detection rate of in bore magnetic resonance (MR)-targeted biopsy with the detection
rate of TRUS-guided prostate biopsy in patients with high PSA values and at least one suspicious region identified by the
radiologist at mp-MR imaging.
The dataset of this study comprised 223 subjects referred for clinical suspicion of PCa who underwent mp-MR imaging. Of
these, 51 patients (23%, median age: 68.4 years, median PSA: 7.5 ng/ml) showed at least one suspicious lesion at mp-MR
imaging (median lesion diameter: 10 mm), with the characteristics of a clinically significant disease. Among these patients, 32
had at least one prior negative TRUS-guided biopsy (median of one session per patient, range 1-3). Then, they were randomly
divided into two groups balanced with respect to age, PSA value, lesion size and location. Group A included 26 patients who
underwent MR-targeted biopsy towards the MR findings. Two targeted cores were obtained from each lesion defined by the
radiologist. Group B included 25 patients who underwent a TRUS-guided biopsy with saturation scheme including at least
28 cores. Biopsy specimens were fixed in formalin and underwent pathologic evaluation to define PCa presence and Gleason
score.
Results
In group A, PCa was detected in 20 out of 26 (77%) cases, 6 of which were located in the transition zone. Five negative findings
in group A were located in the peripheral zone, and one was found in the transition zone. In group B we found 18 out of 25
(72%) PCa, 6 of which were in the transition zone. Six negative findings in group B were located in the peripheral zone, and one
in the transition zone. Detection rates between the two groups were not significantly different (p > 0.93). Results of pathologic
evaluation are reported in Table 1.
17:30 - 19:00 - Comunicazioni 3 - Bersaglio prostata
b
a
lunedì 23 maggio 2016
Moderatori: Richard Naspro
41
42
a
r
t
s
b
a
.3*6-53"406/%'64*0/ "/% 53"/43&$5"- 6-53"406/%(6*%&% 13045"5&
#*014: */ 1"5*&/54 8*5) 13*03 /&("5*7& #*014*&4 %*"(/045*$ "$$63"$: 0'
4*(/*'*$"/513045"5&$"/$&3%&5&$5*0/*/".6-5*$&/5&34&3*&4
A. Giacobbe1, R.. Papalia2, E. Altobelli2, L.. D’Urso1, A. Formiconi1, R. Rosso1, G.L. Muto2, D. Collura1, E. Castelli1, G. Muto2
1
2
Università Campus Bio-Medico, U.O.C. Urologia (Roma)
Objective
An extended Prostate Biopsy (10–12 cores) remains the standard for the initial diagnostic evaluation of a suspicious prostate1.
The rate of prostate cancer (PCa) detection for a first systematic transrectal ultrasound-guided biopsy (TRUS-GB) is typically
30–50%2. Nevertheless, clinically significant PCa can be missed even after several repeat TRUS-GB. This applies especially
to patients with anteriorly located tumors, which are frequently underdiagnosed by TRUS-GB3. Multiparametric MRI of the
prostate is able to detect clinically relevant CaP4. The ability to visualize some PCa on MRI has brought the opportunity to
use those images as targets for needle biopsy by incorporating (i.e. fusing) MRI into a needle-aiming or targeting method5.
The aim of the study was to evaluate the accuracy of targeted magnetic resonance imaging (MRI)-ultrasound fusion–guided
biopsy (FUS-GB) in the diagnosis of clinically significant prostate cancer (PCa) and to compare PCa detection between FUSGB alone and FUS-GB + TRUS-GB in patients with prion negative biopsies for cancer.
Between February 2014 and January 2016, we consecutively included in the study all men who underwent multiparametric
MRI and then MRI/US fusion biopsy with previous history of negative prostate biopsy and a PSA level of 4-20 ng/mL. Overall,
223 men were included in this study, enrolled in 3 centers: Dept of Urology Hospital San Giovanni Bosco of Turin – Clinica
Fornaca of Turin – Dept of Urology Campus Bio Medico of Rome. All men underwent a 12 extended-cores protocol plus 2-3
targeted cores on the multiparametric MRI (mpMRI) index lesion. The UroStation™ (Koelis, France) and a V10 ultrasound
system with an end-fire 3D TRUS transducer were used for the fusion images procedure.
Results
The mean patient age was 67 (48-77) years old, the mean PSA level at biopsy was 9.4 (2.3-20) ng/mL. pathologic report of
previous biopsies were : 145 BPH, 40 phlogosis, 12 PIN hg, 26 ASAP. 123/223 patients (55.1%) had positive biopsies with
Gleason score 3+3 in 63 patients (51%), Gleason score 3+4 or 4+3 in 48 patients (39%), Gleason score 4+4 in 12 patients (10%).
MRIdetected at least 1 suspicious area in 160 patients (72%), 2 or more suspicious area in 63 patients (28%). The median time
between MRI and biopsy was 30 days. The number of men diagnosed with clinically significant cancer was 36 (29%) with
TRUS-GB and 59 (48,3%) with FUS-GB.
Discussions
Three methods of MRI guidance are available for targeted prostate biopsy: cognitive fusion, ; direct MRI-guided biopsy,
performed within an MRI tube; and software coregistration of stored MRI with realtime ultrasound, using a fusion device6. In
FUS-GB, the operator images the prostate using ultrasound, as performed for the past several decades; while thus viewing the
prostate, the MRI of that prostate, which is performed beforehand and stored in the device, is fused with real-time ultrasound
using a digital overlay, allowing the target(s), previously delineated by a radiologist, to be brought into the aiming mechanism
of the ultrasound machine. our registration system uses an elastic (deformable) image registration that is performed with a 3D
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Discussions
The results obtained from a dataset of 51 patients suggest that introducing a mp-MR exam before scheduling a prostate biopsy
increases the detection rate of clinically significant PCa, whatever the biopsy technique used for sampling (MR targeted biopsy
or TRUS-guided biopsy). This study also has some limitations: first, this is a single center trial and results may not be as easily
reproduced as those of multicenter trials. Second, we included men without considering previous number of prostate biopsies
performed. At last, in the TRUS-guided arm, cognitive targeting could not be avoided, therefore PCa detection rate in arm B
may be overestimated.
Conclusion
In conclusion, this randomized controlled trial demonstrated that PCa detection rate of the MR-targeted and TRUS-guided are
not statistically different, provided that an additional mp-MR examination is performed before biopsy. The potential benefits
of mp-MR imaging are: i) accurate identification of significant cancer before biopsy, and ii) in positive cases it can localize the
lesions and assess their local extent. Therefore the introduction of a prostate mp-MR exam before taking a decision on whether
to perform biopsy may help to rule out subjects which would not benefit from further prostate sampling, and select patients
with clinically relevant PCa without delay a radical treatment.
References
[1] Zlotta AR and Robert KN. To Biopsy or Not to Biopsy – Thou Shall Think Twice. Eur Urol 2012; 61: 1115-7
[2] Schoots IG, Roobol MJ, Nieboer D, et al. Magnetic Resonance Imaging–targeted Biopsy May Enhance the Diagnostic
Accuracy of Significant Prostate Cancer Detection Compared to Standard Transrectal Ultrasound-guided Biopsy: A
Systematic Review and Meta-analysis. Eur Urol 2015; 68: 438-50
[3] Acar Ö, Esen T, Çolakoğlu B, et al. Multiparametric MRI guidance in first-time prostate biopsies: what is the real benefit?
Diagn Interv Radiol 2015; 21: 271-6
42
43
a
r
t
s
b
a
.3*64 '64*0/ *."(*/( '03 13*."3: %*"(/04*4 0' 13045"5*$ $"/$&3
#"4&-*/&#*014:0/461&$5&%"3&"45"3(&5&%8*5)'64*0/*."(*/(13&-*.*/"3:
&91&3*&/$&
E. Daglio1, G.M. Badano1, A. Di Domenico1, E. RIkani1, T. Montanaro1, G. Canepa2, F. Campodonico2, R. Sartoris3, L. Timossi1,
C. Introini1
1
2
E.O. Ospedali Galliera, S.C. Urologia (Genova)
3
IRCCS Azienda Ospedaliera Ospedale San Martino (Genova)
Objective
Aims of our study were to verify the success rate of Multiparametric Magnetic Resonance (mpMRI)-TRUS Fusion Imaging
guided targeted prostate biopsy in a primary baseline setting, and to compare the diagnostic performance of Fusion Imaging
guided biopsy with that of conventional 16-cores transrectal systematic conventional TRUS-guided biopsy. The primary
objective is to verify the success rate of baseline biopsy, performed for lesion targeted with MRI-US fusion imaging.
68 patients (mean age ± standard deviation (SD): 65 ± 16 y, range: 48–78 y) with clinical suspicion of prostate cancer (PCa)
(negative rectal examination and elevated PSA levels: 12.07 ± 4.71) underwent a mpMRI to detect nodular lesions. Exclusion
criteria were the inability to attend an MRI examination, controindications to MRI examination and uncorrectable coagulopathy.
The degree of PCa suspicion from mpMRI findings was classified according to the PI-RADS scoring system. We performed
mpMRI-TRUS Fusion Imaging guided biopsy on suspected areas, from 2- 4 cores were keep from any suspicious areas, and
16-cores systematic biopsies in the whole gland. mpMRI was performed with a 1,5 Tesla whole body scanner (GE Healthcare)
with a phased array coil. All biopsy procedures were performed in an operating room with a LOGIQ-E9 Ultrasound machine
with V-NAV fusion imaging system and two position sensors attached to the base of the probe.
Results
All the mpMRI examinations showed almost a suspected area by means of T2 weighted morphological sequences, DWI and/
or Perfusion dynamic imaging. All mpMRI detected lesions were not visible on conventional TRUS. Targeted biopsies were
performed on 82 nodules in 68 patients and the final histological diagnosis was: 36 adenocarcinoma, 1 ASAP, 1 HGPIN, 22
prostatic inflammation e 8 negative biopsies. 16-Core Systematic Biopsies were performed in the same 68 patients and the
final histological diagnosis in the whole gland was: 20 adenocarcinoma, 1 HGPIN, 20 prostatic inflammations, 27 negative
biopsies. The combination oft he two type of biopsies showed these histological results: 46 adenocarcinoma, 1 HGPIN, 1 ASAP,
8 prostatic inflammation and 12 negative biopsies.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
TRUS probe to acquire prostatic volume. Before each biopsy 3D TRUS acquisition is performed to calculate the deformation
of the prostate shape on MR images. Thus, it is not a real-time technique but the spatial accuracy of the system after image
registration was reported to be close to 1 mm. In our study, target biopsy with computerized MRI-TRUS image registration
significantly improved cancer detection over that of systematic transrectal ultrasound-guided biopsy.This improvement was
for both the clinically significant cancers that for clinically insignificant cancers. FUS-GB alone missed only 2 high grade
cancers detected by TRUS-GB.
Conclusion
In our experience, MRI–ultrasound fusion for lesion targeting is likely to result in fewer and more accurate prostate biopsies
than the current use of systematic biopsies with ultrasound guidance alone. MRI-ultrasound fusion–guided biopsy detected
more men with clinically significant PCa thansystematic transrectal ultrasound-guided biopsy. The limit of this method is that
it is indirect, involves use of an additional device and requires specialized operator training. The advantage is that it can be
performed within minutes in an outpatient clinic setting under local anaesthesia, using techniques familiar for several decades.
Results using a fusion device are very promising. Targeted biopsy has the potential to reduce overdiagnosis. Randomized
extended and saturation prostate biopsy have dominated the prostate biopsy scenario in the past, they are still the gold standard,
but probably they do not represent the future
References
1. Eichler K, Hempel S, Wilby J, et al. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer: a
systematic review. J Urol 2006 May;175(5):1605-12.
2. Cormio L, Scattoni V, Lorusso F, et al. Prostate cancer detection rates in different biopsy schemes. Which cores for which
patients? World J Urol 2014;32:341–6.
3. Komai Y, Numao N, Yoshida S, et al. High diagnostic ability of multiparametric magnetic resonance imaging to detect
anterior prostate cancer missed by transrectal 12-core biopsy. J Urol 2013; 190:867–73
4. Barentsz JO, Richenberg J, Clements R, et al. ESUR prostate MR guidelines 2012. Eur Radiol. 2012; 22:746–757. [PubMed:
22322308] . Current clinical guidelines for multiparametric prostate MRI.
5. Moore CM, Robertson NL, Arsanious N, et al. Image-guided prostate biopsy using magnetic resonance imaging-derived
targets: a systematic review. Eur Urol. 2012.
6. Leonard Marksa, Shelena Young, and Shyam Natarajan. MRI–ultrasound fusion for guidance of targeted prostate biopsy.
Current opinion Volume 23 _ Number 1 _ January 2013
43
44
a
r
t
s
b
a
7"-6& 0'‫ ڀ‬$0(/*5*7&‫ ڀ‬.3*5"3(&5&%‫ ڀ‬#*014:‫* ڀ‬/ )*55*/(‫ ڀ‬13045"5&‫ ڀ‬$"/$&3
104*5*7&3&(*0/40'*/5&3&45
A. Fandella1, S.. Guazzieri1, M. Gallo2, F.. Di Toma2
1
Casa di Cura Giovanni XXIII, U.O. Urologia (Monastier di Treviso )
2
Casa di Cura Giovanni XXIII, Unità di Scienza delle Immagini (Monastier di Treviso )
Objective
Introduction: In this series we aim to establish the added value of MR-cognitive guided biopsies (MRCGB) of tumor-suspicious
regions (TSR) on multimodality MRI of the prostate following negative transrectal ultrasound (TRUS)-guided biopsies (1-2).
Between November 2011 to November 2015 in 165 patients with a persistent suspicion of prostate cancer after negative TRUSguided biopsies (median: 3, range 1-7) a multimodality MRI (combination of T2-weighted, Dynamic Contrast Enhanced
(DCE-MR) and diffusion-weighted (DWI) MRI, with an endorectal coil of the prostate was performed. Lesions suspicious for
PCa on mp-MRI were classified according to Prostate Imaging-Reporting and Data System (PIRADS). In this class of patients
we decided to proxeed to immediate biopsy only in lesions classified as PIRADS >3. This details the successive steps of the
method (target detection, mp-MRI reporting, intermodality fusion, TRUS guidance to target, sampling simulation, sampling,
TRUS session reporting, and quality insurance), how to optimize each, and the global indications of mp-MRI-targeted biopsies
Consequently Cognitive transrectal biopsy (GTB) was performed.
Results
Median PSA before GTB was 12.0 (range 4.1-22.5). Digital rectal examination was not suspect for malignancy in 150/165
patients. In 105 of 165 patients (64%) GTB showed histological malignancy. for lesions suspicious for PCa on mp-MRI were
classified according to Prostate Imaging-Reporting and Data System (PIRADS). In this class of patients we decided to proxeed
to immediate biopsy only in lesions classified as PIRADS >3. Consequently Cognitive transrectal biopsy (CTB) was performed
3 cores in target plus 12 cores The biopsy Gleason score (GS) within this group was distributed as follows: 52% GS≤6, 33%
GS=7, 14% GS≥8. Out of 110 patients with a GS≤6 upon GTB, 70 had a PSA>10, 40 a positive (> 40) Prostate Health Index
analysis; GS 4+3=7 tumor was found in these radical prostatectomy (RP) specimen.
Discussions
Performing TB under TRUS guidance, with the visual help of the MRI images alone is called “Visual registration,” but is also
described as “cognitive registration” or “cognitive fusion” in the literature: the TRUS operator mentally relocates the target
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Discussions
The results confirm that Targeted biopsies have detection rates superior to systematic biopsies. This was especially true for
higher-grade disease. The higher-grade carcinoma is the disease which should be treated with radical surgeon so the importance
to perform accurate biopsies.The prostate is much larger than 16-Core in a systematic biopsy and it is widely accepted that
there are regions of the gland, including the central and anterior portions, that are commonly undersampled and in which
tumors cannot be detected on digital rectal examination. Targeted biopsies can be particularly useful in indicating to the
physician the importance in sampling these regions. There are studies which reported that anteriorly located cancerous lesions
were missed in up to 46% to 16-Core systematic biopsy.
Conclusion
Among men undergoing biopsy for suspected prostate cancer, targeted biopsy, compared with systematic ultrasound-guided
biopsy, was associated with increased detection of high-risk prostate cancer and decreased detection of low-risk prostate cancer.
MRI-TRUS Fusion Imaging seems to be a powerful tool for primary diagnosis of prostatic cancer and an important guidance
system for baseline biopsy on supected areas. The development of this technique could lead to the reduction of systematic
sampling of the prostate. Reducing the use of systematic biopsies with TRUS-guidance alone. This system MRI-TRUS Fusion
Imaging has the advantage of using a standard ultrasound scanner without the need to have a dedicated system for prostate
biopsies; in this way, costs are reduced and the learning curve is shortened.
References
1. European Association of Urology, Guidelines 2014
2. Eichler K, Hempel S, Wilby J, et al. Diagnostic value of systematic biopsy methods in the investigation of prostate cancer:
a systematic review. J Urol 2006 May;175(5):1605
3. Bratan F, Niaf E, Melodelima C, et al. Influence of imaging and histological factors on prostate cancer detection and
localisation on multiparametric MRI: a prospective study. Eur Radiol 2013 Jul;23(7):2019-29.
4. Kaplan I, Oldenburg NE, Meskell P, et al. Real time MRI-ultrasound image guided stereotactic prostate biopsy. Magn
Reson Imaging. 2002; 20:295–299.
5. Pinto PA, Chung PH, Rastinehad AR, et al. Magnetic resonance imaging/ultrasound fusion guided prostate biopsy improves
cancer detection following transrectal ultrasound biopsy and correlates with multiparametric magnetic resonance imaging.
J Urol. 2011; 186:1281–1285.
6. Barentsz J.O. et al. ESUR prostate MR guidelines 2012. Eur Radiol (2012) 22:746–757
7. Alonzi R, Padhani AR, Allen C (2007) Dynamic contrast enhanced MRI in prostate cancer. Eur J Radiol 63:335–350
8. Junker D, et al. Multiparametric Magnetic Resonance Imaging/ Transrectal Ultrasound Fusion Targeted Biopsy of the
Prostate: Preliminary Results of a Prospective Single-Centre Study . Urol Int 2015 10.1159
44
45
a
r
t
s
b
a
1301):-"$5*$4*/(-&%04&0'(&/5".*$*/"/%.&530/*%";0-*/1"5*&/54
6/%&3(0*/(53"/43&$5"-6-53"406/%(6*%&%13045"5&#*014:"13041&$5*7&
$-*/*$"-456%:
C. D’Elia1, E. Trenti1, G. Spoladore1, S.M. Palermo1, C. Ladurner1, P. Mian1, A. Pycha1
1
Ospedale Generale di Bolzano (Bolzano)
Objective
Prostate biopsy, conducted with aim to detect prostate cancer, is not free from complications, with a post biopsy prostatitis
rate ranging between 1 and 5% [1]; prostatitis is a frequent cause of hospitalization and can lead to urosepsis, a life threatening
condition. EAU Guidelines recommend antibiotic phrophylaxis with fluoroquinolones, that provide high bioavailability
and excellent penetration into the prostate tissue, preferring to ciprofloxacin ofloxacin [2]. The Global Prevalence Study of
Infections in Urology study documented how the transrectal approach is more prevalent among urologists (97%), as well as
quinolones are the most widely used prophylaxis (91%). However, especially at our latitudes, in recent years there has been
developed Escherichia coli strains resistant to fluoroquinolones. A recent study by Taylor et al, which evaluated 865 patients,
that underwent transrectal prostate biopsy at the Vancouver General Hospital, showed that 19% of the subjects presented
coliform strains resistant to ciprofloxacin, and the patients most at risk of developing these resistances were patients with
cardiac valve replacement history and who had used fluoroquinolones within the previous 3 months [3]. The aim of our study
was to evaluate efficacy and safety of a new phrophylaxis protocol using gentamicin 3 mg/kg in association with metronidazol
500 mg single shot in patients undergoing 20 cores transrectal ultrasound guided prostate biopsy in a single urologic center in
Italy.
A prosepective study was conducted between June and Decemeber 2016 in our center; we prospectively evaluated 136 patients
undergoing 20 core ultrasound prostate biopsy. The procedures were performed according to the indications of the EAU
Guidelines for prostate cancer detection or in adherence of a prostate cancer active surveillance protocol. The following pre
operative characteristics were registered and analyzed: age, comorbidities according to Chralson comorbidity index, serum
total PSA. Patients were pre operative evaluated with urinalysis and urin culture. Prior to ultrasound, a digital rectal exam was
conducted and prostate volume was extimated trough a rectal ultrasound. On the morning of the procedure, rectal enema was
performed, and antibiotic prophylaxis with gentamicin 3 mg/kg and metronidazol 500 mg was administered to all patients. All
the patients underwent a 20 cores transrectal ultrasound guided prostate biopsy and were discharged in the same day.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
detected on the prebiopsy mp-MRI, based on its zonal topography and on anatomical landmarks that may exist beside the
lesion (cyst, BPH nodule, calcification,…) Visual registration is easier if MRI data is available in a separate workstation beside
the ultrasound device, allowing the operator to review the MRI anatomy in T2-w sequences, relocate the target more precisely,
check anatomical landmarks, and perform distance measurements described above. If the physician performing the biopsies
did not interpret the MRI, he will also take benefit of a schematic interpretation report (3-5)
Conclusion
mMRI guided GTB of the prostate is an important addition to the diagnostic measures available in patients with repetitive
negative TRUS-guided prostate biopsies and a persistent suspicion of prostate cancer. The performance of MRGB in this series
is superior to the reported yield of repeat TRUS-guided biopsies or saturation biopsies in the literature. Overdiagnosis of
insignificant cancer using PIRADS > 3 it is no more a concern, in fact in our series biopsy GS indicates a strong suspicion of
significant prostate cancer in most cases (6).In comparison with other MRI-US fusion techniques Cognitive biopsy is easier to
learn, cheapest and simpler, making it compatible with daily office practice and a potential inclusion in the standard diagnostic
pathway of PCa.
References
1.Kurhanewicz J., Vigneron D., Carroll P., Coakley F. Multiparametric magnetic resonance imaging in prostate cancer: present
and future. Current Opinion in Urology. 2008;18(1):71–77. doi: 10.1097/MOU.0b013e3282f19d01. [PMC free article]
[PubMed] [Cross Ref]
2. Haffner J., Lemaitre L., Puech P., Haber G.-P., Leroy X., Jones J. S., Villers A. Role of magnetic resonance imaging before
initial biopsy: comparison of magnetic resonance imaging-targeted and systematic biopsy for significant prostate cancer
detection. BJU International. 2011;108(8, part 2):E171–E178. doi: 10.1111/j.1464-410X.2011.10112.x. [PubMed] [Cross
Ref]
3. Lemaitre L., Puech P., Poncelet E., Bouyé S., Leroy X., Biserte J., Villers A. Dynamic contrast-enhanced MRI of anterior
prostate cancer: morphometric assessment and correlation with radical prostatectomy findings. European Radiology.
2009;19(2):470–480. doi: 10.1007/s00330-008-1153-0. [PubMed] [Cross Ref]
4. Puech P., Potiron E., Lemaitre L., Leroy X., Haber G.-P., Crouzet S., Kamoi K., Villers A. Dynamic contrast-enhancedmagnetic resonance imaging evaluation of intraprostatic prostate cancer: correlation with radical prostatectomy specimens.
Urology. 2009;74(5):1094–1099. doi: 10.1016/j.urology.2009.04.102. [PubMed] [Cross Ref]
5. Villers A., Puech P., Mouton D., Leroy X., Ballereau C., Lemaitre L. Dynamic contrast enhanced, pelvic phased array magnetic
resonance imaging of localized prostate cancer for predicting tumor volume: correlation with radical prostatectomy
findings. The Journal of Urology. 2006;176(6):2432–2437.
6. Baris Turkbey, Peter L. Choyke PIRADS 2.0: what is new? Diagn Interv Radiol. 2015 September; 21(5): 382–384.
45
46
a
r
t
s
b
a
'0$"-53&"5.&/50'13045"5&$"/$&364*/('0$"-0/&%&7*$&13&-*.*/"3:
&91&3*&/$&
Argomenti: A. Rocca1, F. Bardari2
1
Ospedale Cardinal Massaia (Asti)
2
Ospedale Mauriziano (Torino)
Objective
Prostate cancer (CaP) may be detected on MRI. Fusion of MRI with ultrasound allows urologists to progress from blind,
systematic biopsies to biopsies, which are mapped, targeted and tracked. In the same way now we can treat focal prostate cancer
using high intensity focalized ultrasound (HIFU) with e new device We would like report our preliminary experience with
Focal one device
Focal One is a device designed for the focal therapy of Prostate Cancer integrating the ability to visualize, target, treat and
validate the focal treatment. Magnetic Resonnance Imaging (MRI) volumes are imported through the hospital’s network into
the device so that an elastic fusion can be done between the real time ultrasonography and the MRI where the regions to
treat have been previousy drawn, thus allowing to apply limited and targeted HIFU lesions. During the HIFU energy delivery
process, the operator sees a live ultrasound image of what is being treated and, if necessary, can readjust the treatment planning.
At the end of the treatment process, a Contrast-enhanced Ultrasound volume is acquired showing the de-vascularized areas. 19
patients with mono focal prostate cancer were treated from June 2015 and January 2016.HIFU treatment process was realized
with the Focal One device using a 6 mm safety margin around the tumor. Contrast enhanced MRI is performed within 30 day
after HIFU and Control biopsies with fusion technique (urostation Koelis) were performed only on suspected mri lesion.
Results
The mean age of patients was 65.8±5.5 years. The Clinical stage was T1c and The Gleason score was <_ 7 (3+4). Mean cancer
volume was 9 cc (6 to 15 cc) Time of Hospitalization 2 Days Time of catheterization 2 Days (1 Pz had catheter for 6 days doto
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Two weeks after the procedures the patients were evaluated in ou outpatients clinic, with the aim to communicate the
histological examination and to assess possible complications. Pre and post operative complication were recordered and
registerd according to Clavien Dindo classification.
Results
We prospectively evaluated 136 patients that received single shot prophylaxis with gentamicine 3mg/kg and metronidazol 500
mg; 98/136 (72%) received metronidazol ev, whereas 38 (28%) x os. Mean age of the cohort was 65.71 + 8.49 years, whereas
more represented Charlson comorbidity index was 0 (65%). Mean PSA was 11.32 + 19.00ng/ml and mean prostate volume was
42.91 + 20.99cc. 59% of the patients presented a negative rectal examination; mean operative time was 11.52 + 5.32min . Only
12 pts had a positive urine culture, and only one of this was resistant to quinolones; 10/53 rectal swabs was positive, with one
ESBL E. Coli resistant to quinolones. 22% of our patients developed fever or dysuria after the procedure; only 4/29 presented
a positive urinalysis, and none of these was quinolones resistants; moreover, 5 patients presented positive haemoculture, only
one resistant to quinolones. Due to the high incidence of fever and prostatitis, we evaluated the presence of complications
risk factors. The two groups, nevertheless, did not presented any differences regarding age (65.6 + 8.26 VS 63.67 + 9.23), CCI,
presence of positive urine culture or positive rectal swab ( all p > 0.05).
Discussions
In our cohort, the presence of fluoroquinolones resistant strains in urinary culture was lower than expected. Nevertheless,
22% of our patients developed fever or acute prostatitis after the procedure, documenting that a one shot prophylaxis with
gentamicine 3 mg/kg and metronidazol 500 mg is not a safe or effective pre operative prophylaxis. Our study presents, moreover,
possible limitations, as the single center design, the multisurgeon basis, the relatively low number of patients enrolled and
lack of randomization. Larger, randomized prospective trials are needed, with the aim to establish a safer and cost effective
prophylaxis for patients undergoing ultrasound guided rectal prostate biopsy.
Conclusion
In our cohort, the presence of fluoroquinolones resistant strains in urinary culture was lower than expected, whereas the post
procedure fever / prostatitis / readmission rate was significatively higher than in literature (22%; 29/136 patients). We did
not, find, moreover, any differences between the two groups of analyzed patients; our data suggest, therefore, that a one shot
prophylaxis with gentamicine 3 mg/kg and metronidazol 500 mg is not a safe or effective procedure for patients undergoing
transrectal ultrasound guided prostate biopsy. Due to the limitations of our study, larger randomized trials are needed, with the
aim to establish a cost effective prophylaxis.
References
1. Linvert K.A., Kabalin J.N., Terris M.K. Bacteremia and bacteriuria after transrectal ultrasound guided prostate biopsy. J Urol.
2000;164:76–80.
2. Aron M, Rajeev TP, Gupta NP. Antibiotic prophylaxis for transrectal needle biopsy of the prostate: a randomized controlled
study. BJU Int 2000 Apr:85(6):682-5.
3. Taylor S, Margolick J, Abughosh Z, Goldenberg SL, Lange D, Bowie WR, Bell R, Roscoe D, Machan L, Black P. Ciprofloxacin
resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int. 2013
May;111(6):946-53.
46
47
a
r
t
s
b
a
.6-5*%*4$*1-*/"3: "1130"$) */ ."/"(&.&/5 13045"5& $"/$&3 1"5*&/54 1"3." :&"3
&91&3*&/$&
Argomenti: L. Ruffini1, D. Gasparro2, P.. Losardo3, P. Bresciani4, R. Aloe5, M. Maggio6, F. Pilato7, M. Curti8, A. Balestrino9, U. Maestroni10
1
University Hospital, Unità di Medicina Nucleare (Parma)
2
University Hospital, Unità di Oncologia (Parma)
3
University Hospital, Unità di Radioterapia (Parma)
4
University Hospital, Unità di Radiologia (Parma)
5
University Hospital, Laboratorio di Biochimica (Parma)
6
University Hospital, Unità di Geriatria (Parma)
7
University Hospital, Unità di Anatomia Patologica (Parma)
8
Medico Medicina Generale, AUSL (Parma)
9
University Hospital, Direttore Sanitario (Parma)
10
University Hospital, Unità di Urologia (Parma)
Objective
Multidisciplinary team (MDT) can deliver high-quality care to patients with prostate cancer, also in a context of reducing
healthcare financial resources, and provide for a multi-layer, multiprofessional management of the disease. To assess impact of
the multidisciplinary team in prostate cancer management after diagnosis. To measure changes in imaging technology (MR,
PET) occupation before and after MDT activity starting. To evaluate patient and staff satisfaction about the mutidisciplinary
approach.
MDT activity was started in 2015 Jan with bi-monthly multidisciplinary meeting. The team discuss patients with high complexity
situation: low and high-risk pts, biochemical relapse, intermediate-risk for follow-up decision, follow up of curative treatment.
Clinical and diagnostic Units are involved in the MDT: oncology (2 members), radiotherapy (2), urology (3), nuclear medicine
(2), radiology (2), pathological anatomy (1), lab (1), aging specialist (1), general practitioners (2) Activity of the MDT is
recorded at each meeting by a meeting report and a patient record reporting group decision. An on-line archive is disposable
for all the participants and all the reports are stored in the archive. We analyzed all the reports and the records from the MDT
activity start to assess changes in management comparing individual statement and group decision, appropriateness criteria
to MR/PET facilities, enrollment for new treatment options. Moreover we evaluated patient and staff satisfaction by a scoring
system from 1(optimal management for patients and the best modality of care for the staff) to 4 (no change for both).
Results
MDT meeting number was 18 until Feb 2016 and 95 pts were discussed by the group, 50% proposed by the urologist, 25% by
the radiotherapist, 23% by the oncologist and 2% by the imaging specialist. In 11 cases MDT decision was surgery, in 32 RT,
in 12 W&S and in 27 hormonal therapy. In 4 cases restaging is ongoing, in 2 pathology review is ongoing, 2 were droppedout, 4 were driven to chemotherapy. 12 pts were enrolled in clinical trials with new medical treatment. 2 pts were recruited for
Radium-223 treatment for bone metastases. MDT decision changed initial statement in 30/95 pts: most of them from RT to
hormonal therapy, few patients from surgery to RT or hormonal therapy. Moreover, in 30 pts additional imaging modality was
decided to increase accuracy in disease staging (in 17 cases MR for local relapse or before repetition of mapping) and in 13 cases
choline-PET for disease burden and/or parenchimal incolvement before recruitment for Ra-223. In 7 pts multidisciplinary
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
anterior apicale lesion) The PSA value was < 10ng/ml and the mean Prostate Volume was 40±23 cc . A partial loss of potency
(IIEF <17) occurred in 1 patient an 1 patient had IUS because e anterior apical lesion. 2 patiens had a control fusion biopsy
because MRI suspect resulted negative At the moment alla Patients are cancer recurrence free
Discussions
The over treatments era is finished, the technologies (MRI multi parametric , fusion biopsy) let us to chose patients witch can
switch to Active surveillance ore active focal treatments without having to undergo to surgery as first therapy line.
Since the early 2000s, two systems have been marketed for this application, and other devices are currently in clinical trials.
HIFU treatment can be used either alone or in combination with (before- or after-) external beam radiotherapy (EBRT)
(before or after HIFU) and can be repeated multiple times. HIFU treatment is performed under real-time monitoring with
ultrasound or guided by MRI. Two indications are validated today: Primary care treatment and EBRT failure. The results of
HIFU for primary care treatment are similar to standard conformal EBRT, even though no randomized comparative studies
have been performed and no 10-year follow up data is yet available for HIFU. Salvage HIFU after EBRT failure is increasing
with oncological outcomes, similar to those achieved with surgery but with the advantage of fewer adverse effects.
Conclusion
HIFU is an evolving technology perfectly adapted for focal treatment. Thus, HIFU focal therapy is another pathway that must
be explored when considering the accuracy and reliability for PCa mapping techniques. HIFU would be particularly suited for
such a therapy since it is clear that HIFU outcomes and toxicity are relative to the volume of prostate treated. Focal One device
is able to achieve a complete destruction of small prostate cancer using an elastic magnetic resonance-ultrasound (MR-US)
registration system for tumor location and HIFU treatment planning. Otherwise HIFU is repeatable and no terapeutic choice
is precluded in the future Longer follow-up establish future considerations. Multicenter trials are desirable
47
48
a
r
t
s
b
a
$0.1"3*40/0'5805&.1-"5&40'-:.1)"%&/&$50.:*/1"5*&/54"''&$5&%
#:)*()3*4,13045"5&$"/$&3
Argomenti: R. Sanseverino1, G. Napodano1, U. Di Mauro1, O. Intilla1, G. Molisso1, A. Pistone1, T. Realfonso1
1
Objective
Pelvic lymph node dissection at the time of radical prostatectomy is currently the most reliable method for detecting lymph
node metastases in patients with prostate cancer (1-4). In high risk patients, extended lymphadenectomy is recommended, as it
increases the node-positive rate in localized prostate cancer. However, an increased risk of complications associated with ELND
has also been reported (5,6). We have compared two templates of pelvic lymphadenectomy in high risk patients undergone an
extraperitoneal or transperitoneal laparoscopic radical prostatectomy.
Two consecutive series of patients affected by high risk prostate cancer underwent laparoscopic radical prostatectomy. In group
1 (101 pts), the procedure was realized by a preperitoneal access with an extended lymphadenectomy including external iliac
and obturator nodes; in group 2 (25 pts), access was transperitoneal with a broader lymphadenectomy consisting of common
iliac, external iliac, hypogastric and obturator nodes. We have retrospectively compared perioperative outcomes in terms of
age, PSA, BMI, ASA score, clinical stage, bioptic Gleason, pathological stage, Pathological Gleason, operaitve time, number of
nodes removed, positive nodes, complications in the two groups of patients. Statistical analysis has been realized using SPSS
16.
Results
Data on 126 patients were analyzed. Baseline characteristics are reported in table 1. Mean age, PSA and BMI were 66.8 years,
11.7 ng/ml and 27.1, repsectively. of teh patients, 88.2% presented stage T2 and 11.8% stage T3. Preoperative data werebalanced
between two groups of patients except for biopsy Gleason score. Postoperative outcomes are listed in table 2: Group 2 patients
presented worse pathological stage (p0.01), longer operative time (246.1 vs 271.0 minutes, p0.005), more nodes removed (mean
31.6 vs 15.9, p<0.001) and more positive pathological nodes (28.0 vs 1.9%, p<0.001). Moreover, a wider lymphadenectomy
template was not associated to greater risk of complications or lymphocele (p0.3; p0.1).
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
visit was performed: in 3 cases to discuss wait&see strategy with the patient, in 2 cases to discuss RT and surgery options, in 2
cases to discuss chemioterapy/hormonal treatment. Twelve patients were submitted to the comprehensive geriatric assessment
(CGA:cognitive, physical and motor) before hormonal treatment for comorbidity, polipharmacy and disease burden. Pts
candidates to RT received choline-PET and/or MRI for planning both decided during the meeting.
Discussions
The establishment of a MDT appears as the core component in cancer care organisation, allowing improvement of the care
pathway for patients with Prostate Cancer disease avoiding multiple consultations, inappropriate treatments and/or use of
high-technology platform. However, conducting regular multidisciplinary team meetings requires significant investment of
time and finances. It is thus important to assess the empirical benefits of such practice. MDT meetings impact upon patient
assessment and management practices. However, there is little evidence indicating that MDT meetings result in improvements
in clinical outcomes and it appears hard to recruit in a randomized way discussed patients to assess it.
Conclusion
Patients satisfaction increases with MDT activity beacause of the multidisciplinary care inducing certainty and the synchronous
acitivity of different staff operators with no burden on the patient. Continuous interchange among different specialists and
care providers allows a holistic patient-centered care in which more attention is paid to quality of life, patients’ rights and
empowerment. The most suitable organisational structure for caring prostate cancer patients at all stages is offered combining
the skills of different specialists. Access to high-technology platform (MR, PET-CT, RT) and new treatment options is
simplified. Involvement of general practitioners allows a better patients home care, follow up management, and appropriate
use of diagnostic technology.
References
1. The impact of multidisciplinary team meetings on patient assessment, management and outcomes in oncology settings: A
systematic review of the literature. Brindha Pillay, Addie C. Wootten , Helen Crowe, Niall Corcoran, Ben Tran, Patrick
Bowden, Jane Crowe, Anthony J. Costello. Cancer Treatment Reviews 42 (2016) 56–72
2. Establishment of a new prostate cancer multidisciplinary clinic: Format and initial experience.Debasish Sundi, Jason E.
Cohen, Alexander P. Cole, Brian P. Neuman, John Cooper, Farzana A. Faisal, Ashley E. Ross and Edward M. Schaeffer.
Prostate 2015, 75(2): 191-9
3. Prostate Cancer Unit Initiative in Europe: A position paper by the European School of Oncology. Valdagni R, Van Poppel H,
Aitchison M, et al. Critical Reviews in Oncology/Hematology 95 (2015) 133–143
4. Using peer observers to assess the quality of cancer multidisciplinary team meetings: a qualitative proof of concept study.
Jenny Harris, James SA Green, Nick Sevdalis, Cath Taylor. Journal of Multidisciplinary Healthcare 2014:7: 355-363
5. Strategies to improve the efficiency and utility of multidisciplinary team meetings in urology cancer care: a survey study.
Benjamin W Lamb, Rozh T Jalil, Nick Sevdalis, Charles Vincent and James SA Green.. BMC Health Services Research
2014, 14:377
48
49
a
r
t
s
b
a
% 74 % -"1"304$01*$ 3"%*$"- 13045"5&$50.: 063 &91&3*&/$& */ 5)&
30#05*$&3"
F.. Chiancone1, M. Fedelini1, C. Meccariello1, L. Pucci1, A. Oliva1, D. Di Lorenzo1, P. Fedelini1
1
Objective
The robotic technology has a shorter learning curve and some technical advantages instead of classical laparoscopy (increased
number of degrees of freedom and three-dimensional visualization of the operative field) (1). A difficulty of laparoscopic surgery
involves converting two-dimensional (2D) images into three-dimensional 3D images and depth perception rearrangement. 3D
imaging may remove the need for depth perception rearrangement and therefore have clinical benefits (2) (3). The aim of this
study was to clarify if 3D images are really beneficial in the performance of laparoscopic radical prostatectomy compared with
2D imaging systems and to analyze oncological and functional outcomes at a short-term follow-up.
From January 2015 to November 2015, 92 patients underwent a laparoscopic extraperitoneal radical prostatectomy (LERP) at
our hospital. Oh these, 50 patients underwent a 3D-LERP (27 patients underwent an iliac/obturator lymph node dissection)
and 42 patients underwent a 2D-LERP (24 patients underwent an iliac/obturator lymph node dissection). We divided our
department surgeons into two subgroups according to the number of surgeries (less and more than 50 LERP). 41 out of
50 3D-LERP were performed by a surgeon with more than 50 LERP. 29 out of 42 2D-LERP were performed by a surgeon
with more than 50 LERP. 2D-HD Storz® system was used to perform 2D procedures and Einstein Vision® 3D system was
used to perform 3D procedures. We hypothesized that VUA (vesico-urethral anastomosis) was one of the most difficult and
challenging procedures. The primary outcome was the time of VUA. Secondary outcomes were operative time, blood loss,
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Discussions
LND in RP is considered to be of diagnostic value; however, its curative significance is unknown. The detection rate of nodes
metastasis may be increased by widening the dissection range, although the extent of the dissection remains controversial. In a
prospective study on extended and localized lymphadenectomy, Clark et al. observed no difference in the node-positive rate; in
addition, extended lymphadenectomy was associated with a higher complication rate (7). Several studies demonstrated the high
diagnostic accuracy of staging lymphadenectomy limited to the internal and external iliac and obturator fossa lymphonodes
(8,9). An autopsy study by Weingärtner et al (10) suggested that 20 nodes must be retrieved for an adequate lymphadenectomy.
Furthermore, retrospective studies revealed that number of positive nodes may affect survival. Some studies have suggested
that radical prostatectomy may be curative for patients with positive nodes prostate cancer. Sterinberg et al (11) followed 64
patients with positive nodes, of whom 83% and 68% remained free of detectable tumor at 60 and 80 months following radical
prostatectomy, respectively.
Conclusion
In high risk patients, extended lymphadenectomy is recommended, as it increases the node-positive rate in localized prostate
cancer. However, the extent of the dissection remains controversial. In our retrospective analysis, we have compared two
templates of pelvic lymphadenectomy in high risk patients undergone an extraperitoneal or transperitoneal laparoscopic
radical prostatectomy; a transperitoneal laparoscopic radical prostatectomy with an extended lymphadenectomy template
including obturator, external iliac, common iliac and hypogastric nodes allows to remove a greater number of nodes, to obtain
a more positive nodes without increasing risk of complications. Even though a prospective controlled study is required to
confirm our results, we suggest an extended lymphadenectomy in high risk prostate cancer patients.
References
1. Walsh PCet al. Cancer control and quality of life following anatomical radical retropubic prostatectomy: Results at 10 years.
J Urol 152: 1831, 1994.
2. . Catalona WJ et al. Cancer recurrence and survival rates after anatomic radical retropubic prostatectomy for prostate cancer:
Intermediate-term results. J Urol 160: 2428, 1998.
3. Gervasi LA et al. Prognostic significance of lymph nodal metastases in prostate cancer. J Urol 142: 332, 1989.
4. Hull GW et al. Cancer control with radical prostatectomy alone in 1,000 consecutive patients. J Urol 167: 528, 2002.
5. Withrow DR et al. Therapeutic value of lymph node dissection at radical prostatectomy: A population-based case-cohort
study. BJU Int 108: 209, 2011.
6. Schumacher MC et al. Good outcome for patients with few lymph node metastases after radical retropubic prostatectomy.
Eur Urol 54: 344, 2008.
7. Clark T et al Randomized prospective evaluation of extended versus limited lymph node dissection in patients with clinically
localized prostate cancer. J Urol 169: 145-147, discussion 147, 2003
8. Heidenreich A et al; European Association of Urology: EAU guidelines on prostate cancer. Eur Urol 53: 68, 2008.
9. Zincke H Extended experience with surgical treatment of stage D1 adenocarcinoma of prostate. Significant influences of
immediate adjuvant hormonal treatment (orchiectomy) on outcome. Urology 33 (Supp l): S27, 1989.
10. Weingärtner K et al. Anatomical basis for pelvic lymphadenectomy in prostate cancer: Results of an autopsy study and
implications for the clinic. J Urol 156: 1969, 1996.
11. Steinberg GD et al. Management of stage D1 adenocarcinoma of the prostate: The Johns Hopkins experience 1974 to 1987.
J Urol 144: 1425, 1990.
49
50
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
PSMs (post surgical margins) rate, recovery of continence according to the validated questionnaire Incontinence Quality
of Life (I-QoL) and the feasibility of basic tasks. The feasibility of basic tasks were measured by eight questionnaires using
7-point Likert scales. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical
significance was achieved if p-value was ≤0.05 (two-sides). Categorical data were compared using Pearson’s chi-squared test
(χ2).
Results
Mean time +/- SD of VUA using the van Velthoven technique (4) was 13.8+/-4.8 min using the 3D imaging system and
14.6+/-4.5 min using the 2D imaging system. No significant difference was observed (p=0.41). Mean time +/- SD of VUA
was statistically different in the subgroups of surgeons with less than 50 LERP (14.2+/-3.5 min vs 17.2+/-2.9 min, p=0,04)
but no significant difference was observed in the subgroups of surgeons with more than 50 LERP (13.2+/-2.8 vs 13.6+/-3.1
p=0.58). Mean total operative time +/- SD was 105,6 +/- 27,5 (50-190 min) using 3D imaging system and 106,4 +/- 36,1
(45-235 min) using 2D imaging system. No significant difference was observed (p=0.9043). The same trend was seen in the
subgroup of surgeon with more than 50 LERP (100.25+/-25.5 min vs 101.4+/-39,6 p=0,88) and in the subgroup of surgeon
with less than 50 LERP (115.68+/-20.1 vs 113.8+/-29.5, p=0,87). No significant differences were seen in mean blood loss
between the two groups (mean +/- SD 306,2 +/- 230 in the 3D-LERP group and 316.8 +/- 247.9 in the 2D-LERP group,
p=0.83). No conversion from the 3D to the 2D imaging system during LRP was observed. Feasibility of basic tasks, was
significantly better using the 3D imaging system in all questionnaires except for one (Table 1). No differences in PSMs were
seen (P=0.93). I-QoL questionnaires showed a significant quality of life improvement at the first month in the 3D-LERP
group (91,6+/-7) compared to the 2D-LERP group (81,2+/-5) (p =0). I-QoL questionnaires did not show a significant
quality of life improvement at the third month (93,5+/-5 vs 91,9 +/-6) (p =0.17). The overall continence rate did not reach a
statistically significant difference at 1 month follow-up (90% vs 88%), (P=0,77) and at 3 month follow-up after pelvic floor
rehabilitation (96% vs 94%), (P=0,51).
Discussions
Classical laparoscopic surgery is limited by a two-dimensional vision that does not allow perception of the operative field.
The lack of depth perception has repercussions both on the learning curve, and in the possibility for the surgeon to maneuver
the instruments with an accuracy comparable to that which would occur in the same “open” operation. In this study, we
demonstrate that the 3D imaging system do not decrease the time of VUA compared with the conventional 2D imaging
system except for surgeons who are at the beginning of their learning curve. The 3D imaging system do not decreased the
mean total operative time compared with the conventional 2D imaging system. No significant differences were seen in
mean blood loss between the two groups. Moreover PSMs rate was similar between the two groups. Meticulous handling
and tissue dissection obtained with the auxilium of the 3D view have allowed earlier continence recovery according to
I-QoL questionnaires. This could be mainly related to less trauma and greater sphincter- structures saving (5). Although
the trend is clearly favorable to the 3D-LERP group, the overall continence rate did not reach a statistically significant
difference at the first month and at the third month follow-up and I-QoL questionnaires did not show a significant quality
of life improvement at the third month follow-up after pelvic floor rehabilitation. The definition of continence was based
on a specific question appropriate to reflect the range of incontinence severity: “How many pads/day did you usually use
to control urine leakage during the last 4 weeks?”. We considered “dry” patients without any loss of urine (no pads/day) or
those who used a safety pad/day. There is no validated way to measure subjectively the feasibility of different tasks during
operation. Therefore, in this study, we measured surgeons’ subjective evaluation of surgical feasibility. In all questionnaires
but one, 3D was superior to 2D imaging. These results were the same as those reported for cholecistectomy (6).
Conclusion
In conclusion, performance time of VUA in LERP was not statistically different between 2D and 3D imaging except for
surgeon with a low experience in LERP. A positive trend for a better recovery of continence at 1 month follow-up was seen
in the 3D group. The 3D laparoscopy may be an intermediate step between the standard 2D laparoscopy and robot assisted
laparoscopy, allowing the combination of the low cost of the first with the 3D technology of the second. The experience
of surgeon may decrease the advantage of 3D imaging. Further studies are necessary to better comprehend the role of
3D-LERP in radical prostatectomy.
References
1- Ku JY, Ha HK.Learning curve of robot-assisted laparoscopic radical prostatectomy for a single experienced surgeon:
comparison with simultaneous laparoscopic radical prostatectomy. World J Mens Health. 2015 Apr;33(1):30-5. doi:
10.5534/wjmh.2015.33.1.30. Epub 2015 Apr 23.
2- Su LM, Vagvolgyi BP, Agarwal R, Reiley CE, Taylor RH, Hager GD Augmented reality during robot-assisted laparoscopic
partial nephrectomy: toward real-time 3D-CT to stereoscopic video registration. Urology,2009 73:896–900
3- Teber D, Guven S, Simpfendorfer T, Baumhauer M, Guven EO, Yencilek F et al. Augmented reality: a new tool to improve
surgical accuracy during laparoscopic partial nephrectomy? Preliminary in vitro and in vivo results. Eur Urol 2009
56:332–338
4-Van Velthoven RF, Ahlering TE, Peltier A, Skarecky DW, Clayman RV. Technique for laparoscopic running urethrovesical
anastomosis:the single knot method. Urology. 2003 Apr;61(4):699-702.
5- Schlomm T, Heinzer H, Steuber T, Salomon G, Engel O, Michl U, Haese A, Graefen M, Huland H. Full functional-length
urethral sphincter preservation during radical prostatectomy. Eur Urol. 2011;60:320–9.
6- Hanna GB, Shimi SM, Cuschieri A (1998) Randomised study of influence of two-dimensional versus threedimensional
imaging on performance of laparoscopic cholecystectomy. Lancet 351:248–251
50
51
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
("14." )#&%1&5$5 */ 5)& &7"-6"5*0/ 0' 5)& #*0$)&.*$"- 3&-"14& */
1"5*&/54 8*5) " )*4503: 0' 13045"5& $"/$&3 3"%*$"--: 53&"5&% 13&-*.*/"3:
3&46-54
17:30 - 19:00 - Comunicazioni
a
r
t
s
b
a
1. AIOM linee guida nel carcinoma della prostata 2012.
2. Hodolic M. Role of (18)F-choline PET/CT in evaluation of patients with prostate carcinoma. Radiol Oncol. 2011.
3. Bachmann LM et al. The role of 11C-choline and 18F-choline PET and PET/CT in prostate cancer: a systematic review and meta-analysis. Eur
Urol 2013.
4. Fanti S. et al. Role of 11C-choline PET/CT in the restaging of prostate cancer patients with biochemical relapse and negative results at bone
scintigraphy. Eur J Radiol 2012; Aug 81 (8).
5. Ali Afshar-Oromieh et al. Comparison of PET imaging with a 68 Galabelled PSMA ligand and 18F-choline based PET/CT for the diagnosis of
recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2014, 41:11-20.
6. Ali Afshar-Oromieh et al. The diagnostic value of PET/CT imaging with the 68Ga- labelled PSMA ligand HBED-CC in the diagnosis of recurrent
prostate cancer. Eur J Nucl Med Mol Imaging, 2015, 42: 197–209.
7. C.M. Zechmann et al. PET imaging with a 68 Ga labeled PSMA ligand for the diagnosis of prostate cancer: biodistribution in humans and first
evaluation of tumor lesions. Eur J Nucl Med Mol Imaging. 2013.
8. Benjamin T. Ristau. et al. the prostate specific membrane antigen: lessons and current clinical implications from 20 years of research. Urologic
Oncology: seminars and original investigations 2013.
9. Joseph R. Osborne et al. Prostate specific membrane antigen based imaging. . Urologic Oncology: seminars and original investigations 2012.
3 - Bersaglio prostata
X
X
P. Caroli1, R. Gunelli2, M. Fiori2, M. Celli1, L. Fantini1, M. Del Duca3, A. Moretti1, R. Galassi1, A. Romeo3, T. Zenico2, D.I. Valentina4, G.
Paganelli1, F. Matteucci1
1
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Medicina Nucleare Diagnostica (Meldola)
2
Ospedale Morgagni-Pierantoni, U.O. Urologia (Forlì)
3
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Unità di Radioterapia (Meldola)
4
IRST Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori IRCCS, Unità di Farmacia Oncologica (Meldola)
Objective
Prostate-specific membrane antigen (PSMA) is a membrane carboxypeptidase type II, widely over-expressed in prostate cancer cells.
Recently, an innovative 68Ga–labeled ligand have been designed to target membrane PSMA in diagnostic PET/CT. The aim of this
prospective study is to evaluate the added value of PET / CT with 68Ga-PSMA in identifying the source of PSA biochemical recurrence
in patients radically treated for prostate cancer and negative/equivocal conventional imaging such as, trans-rectal ultrasound, bone scan,
FCH PET / CT and CT / MRI.
Since December 2015, we have enrolled 13 patients with suspected biochemical recurrence of prostate cancer (Gleason Score: 7 to 9),
previously treated with either radical prostatectomy (RP) (9 patients), or external beam radiotherapy (RT) (3 patients) or brachytherapy
(BT) (1 patient). At enrollment all patients had a serum PSA value > 1.0 ng / ml (range 1,35-13,4 ng/ml), negative or equivocal
conventional imaging and had been off hormonal and radiation therapy for at least 6 months. 68Ga-HBED-CC-PSMA will be prepared
and according to national regulations, good radiopharmaceutical practices (GRP) as outlined in specific EANM guidelines, using a
product of Eazy synthesis module (Eckert and Zieckert , Germany). PET / CT, was performed from head to mid-thighs, 50 minutes after
intravenous administration through an indwelling catheter to avoid extravasation at a dosage of 100-200 MBq of 68Ga-PSMA. Patients
should not be fasting before scan and should void before scanning to reduce the background noise as well as the radiation dose to the
kidneys and bladder. 68Ga-PSMA PET / CT scans were performed on an integrated PET / CT system (Discovery LS camera, General
Electric Medical Systems, Waukesha, WI) in 2D acquisition mode for 3 minutes per bed position.
Results
68Ga-PSMA PET / CT was positive in 10 patients (72%), equivocal in 1 patient and negative in 2/11 patients. In particular, 8 patients
presented an intense radiotracer uptake at the prostate gland/bed (four patients submitted to RP and four patients underwent RT). One
patient showed nodal tracer uptake while one patient had radiotracer uptake in two lung nodules. In one patient 68Ga-PSMA PET / CT
showed equivocal uptake in some retroperitoneal nodes, whereas FCH PET/CT showed indeterminate uptake at the right clavicle. The
remaining two patients showed no localization of intense radiotracer uptake; both had been treated with PR and subsequently RT.
Discussions
A whole-body imaging technique detecting the source end extent of prostate recurrence in radically-treated patients experiencing
biochemical recurrence is essential to inform the selection of the most appropriate therapeutic strategy. Currently, Choline PET / CT is
used as gold standard in clinical practice, but suboptimal diagnostic accuracy has been reported in large cohorts, mainly due to a lack
of specificity. In order to overcome this drawback a novel tracer, 68Ga-PSMA, is currently being tested in the biochemical recurrence
scenario showing promising results both in terms of sensitivity and specificity. The preliminary experience at our Institution, among the
first in Italy to test this novel tracer, suggest similar excellent results.
Conclusion
Our preliminary data, awaiting clinical confirmation, suggest that PET/CT with the novel tracer 68Ga-PSMA is an effective tool allowing
the detection and the assessment of extent of biochemically-relapsing prostate cancer with negative or equivocal conventional imaging.
In our cohort of patients with a negative/equivocal 18F-Choline PET/CT , 68Ga-PSMA has proven particularly effective in detecting
prostate/prostate bed-confined recurrence over pelvic or extra-pelvic nodal disease. The confirmation of these early results will prompt
the validation of 68Ga-PSMA diagnostic accuracy over Choline PET/CT in a larger cohort of patients, with a potential gain in enabling
earlier recurrence detection and improving patient care management.
References
51
52
o
6
17:30
19:00
s
1
s
Dalì
0
e
2 ngr
Comunicazioni 4:
o
s
C
t
Andrologia
I
I
c
I
a
X
r
X
t
s
23 maggio 2016
sala
b
a
$033&-"5*0/ #&58&&/ 4&.*26"/5*5"5*7& 40/0&-"450(3"1): "/%
*..6/0)*450$)&.*453: */ 5)& &7"-6"5*0/ 0' 5&45*$6-"3 '0$"- ..
-&4*0/4
Argomenti: andrologia, cancro del pene del testicolo o tumori rari
A.L. Pastore1, G. Palleschi1, D. Autieri1, A. Fuschi1, A. Ripoli1, A. Leto1, Y. Al Salhi1, G. Velotti1, P. Maceroni2, V. Petrozza3, A.
Carbone1
1
2
CADI Istituto Radiologia (Latina)
3
Objective
Sonoelastography is a novel and promising imaging tool, which has been applied to breast, thyroid, and prostate tissues.
The aim of this study was to evaluate focal lesions of the testes with diameters of <10 mm using sonoelastography, B-mode
sonography (US), and colour Doppler ultrasonography (CDU). This study compared US, which is a widely used diagnostic
sonographic method, with semiquantitative sonoelastography, which is a new method for visualizing the elastic characteristics
of tissues, in the evaluation of testicular nodules with diameters of <10 mm. To explore the outcomes generated by this tool
in greater depth, we tested the relationship between the strain ratio data obtained using sonoelastography, and the vascular
indices (VI) that were determined from the immunohistochemical analysis of the testicular lesions.
Thirty patients who were referred to our outpatient clinics for varicocoeles, scrotal pain, scrotal enlargements, epididymitis,
palpable testicular nodules, or infertility, were prospectively enrolled into this study. Ultrasound evaluations had revealed that
27 subjects had focal testicular lesions with diameters of <10 mm and 3 subjects had 10-mm spherical non-homogeneous
testicular nodules. All lesions were evaluated using semiquantitative sonoelastography, and the patients underwent
orchifunicolectomies. The testicular lesions were examined histopathologically. The vascularization of the lesions and the
surrounding testicular parenchyma was evaluated by analysing the immunohistochemical distribution of the cluster of
differentiation 31 and by calculating the vascular indices (VI). Potential associations between the strain ratios (stiffness of the
lesions) and the VI were tested.
Results
Analyses of the strain fields obtained using the semiquantitative sonoelastography yielded different values for the masses and
the surrounding tissues, which led to significant increases in the strain ratios. Semiquantitative sonoelastography provided
data that supplemented those generated by US and CDU. Specifically, this tool demonstrated that the normal testicular
tissue and nodules had different elastographic patterns, with the latter showing stiffer sonoelastographic signals, particularly
at the perimeters of the masses, which was suggestive of pathological tissue, and has been described in previous reports.
Sonoelastography upheld all of the diagnoses that were suspected when the patients were physically examined, when the
serum markers were analysed, and after the patients had undergone US and CDU. Histopathological examinations confirmed
the neoplastic characteristics of these masses. A significant inverse correlation was determined between the sonoelastographic
17:30 - 19:00 - Comunicazioni 4 - Andrologia
Moderatori: Bruno Giammusso
52
53
a
r
t
s
b
a
&3&$5*-&%:4'6/$5*0/&%
*/1"5*&/548*5)3&$633&/5*4$)&.*$13*"1*4.
3*1
"/"-:4*40'3*4,'"$5034
Argomenti: andrologia
M. Carrino1, F. Chiancone1, L. Pucci1, G. Battaglia1, F. Maurizio1, F. Monaco1, P. Fedelini1
1
AORN A. Cardarelli, U.O.S.D. Andrologia (Napoli)
Objective
Erectile dysfunction (ED) is a common complication of priapism. ED can be irreversible if erectile tissue damage has occurred,
above all in case of priapism lasting longer than 24 hours (1). However ED was reported also in patients with RIP (recurrent
ischemic priapism) in which durations of priapism episodes are shorter (2). The basis of ED in RIP with briefer priapism duration
is unex-plained. In a previous retrospective evaluation of clinical outcomes associated with the use of phosphodiesterase type 5
inhibitors in a very small number of RIP patients, the rate of ED was higher in the group of patients with sick cell disease (SCD)
(3). The aim of this study was to evaluate the risk factors associated with EP in patients with RIP in our series.
We enrolled 78 patients with an history of RIP presenting to the urology and hematology department at our institution between
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
strain ratio and the VI (Pearson correlation coefficient, r, = - 0.93; p < 0.001).
Discussions
Testicular masses can be difficult to diagnose, particularly when they have a diameter of <1 cm and/or are not palpable.
Palpation provides subjective data, but physicians need instrumental support to make informed decisions about therapy when
the lesion is small. Evaluations using US combined with CDU are commonly used to characterize testicular lesions, but these
evaluations do not provide any information about the internal consistency of the masses. This information might help to
corroborate diagnostic assessments, especially when masses with small diameters are found incidentally. Sonoelastography
can be used to evaluate the mechanical elastic properties of soft tissues, which are determined by their macromolecules
and structural organization. This is the first report describing the use of semiquantitative sonoelastography to investigate
subcentimetre testicular masses, which could be promising potential targets for this new imaging technology. Indeed, the
information obtained through sonoelastography in this study has contributed to the diagnostic evaluation of testicular lesions,
because it has given an insight into their atypical compositions and it has emphasized the need for a high level of clinical
suspicion about malignancy in the context of subcentimetre testicular tumours. Our data concur with those from previously
reported studies and they ratify the potential role of sonoelastography in the evaluation of testicular nodules. In our study,
we sought to substantially reduce the subjectivity associated with evaluating the colour maps in real time by replacing the
classification system with a numerical parameter, that is, the strain ratio, which is not operator dependent, is reproducible,
and enables the elasticity of lesions to be given unique classifications. To ensure the objectivity of the assessment, we also
attempted to define a cut-off value that would differentiate between likely benign nodular lesions and likely malignant lesions,
and to add a numerical parameter that would help guide the next clinical step, for example, clinical monitoring with or without
treatment, or surgical excision. This was possible with the semiquantitative sonoelastography system, because it expresses the
deformation capacity of the structure under investigation relative to the normal (reference) tissue as an absolute value or as
a strain ratio. Therefore, semiquantitative sonoelastography represents a modification of the real-time method and enables
the off-line analysis of a nodule’s strain values by analysing variations in radiofrequencies using the raw data. The calculation
is performed by selecting an ROI within the nodular formation and a reference region in an area of normal parenchymal
elasticity. The result is an index of deformation (i.e. a strain index or a coefficient of elasticity) that can be compared with
the organ’s reference values, and that rises as the rigidity of the structure being examined increases. Using this method, the
coefficient of echogenicity can also be determined by comparing the echogenicity of the lesion with that of nearby normal
structures, while taking into account the absolute values of echogenicity expressed in the raw data.
Conclusion
The data generated by semiquantitative sonoelastography provide further evidence that the lesions discovered during the physical
examinations, US, and CDU were pathological, which prompted surgical treatment. Furthermore, the immunohistochemical
analysis undertaken in our study demonstrated a linear inverse correlation between the strain ratio values and the VI. It
could be postulated that this inverse correlation is an expression of the lesions’ diminished consistencies and greater
intralesional vascularity. This finding could be further interpreted as hypervascular tumours having lower levels of consistency
than hypovascular tumours. Hence, sonoelastography could quantify the magnitude of intralesional microcirculation or
neoangiogenesis, and substantiate the consistency of testicular masses. Together, these add important elements to diagnostic
and prognostic assessments. Given that the main limitation of the present study was the small number of patients, further
investigations with larger numbers of patients are required to corroborate these data and to support the use of semiquantitative
sonoelastography in the evaluation of testicular lesions.
References
1. Garra BS: Imaging and estimation of tissue elasticity by ultrasound. Ultrasound Q 2007, 23(4):255–268.
2. Goddi A, Sacchi A, Magistretti G, Almolla J, Salvadore M: Real-time tissue elastography for testicular lesion assessment. Eur
Radiol 2012, 22(4):721–730.
3. Magarelli N, Carducci C, Bucalo C, Filograna L, Rapisarda S, De Waure C, Dell’Atti C, Maccauro G, Leone A, Bonomo L:
Sonoelastography for qualitative and quantitative evaluation of superficial soft tissue lesions: a feasibility study. Eur Radiol
2014, 24(3):566–573.
53
54
a
r
t
s
b
a
"/ 6/'03&4&&/ 130#-&. %63*/( 1&/*-& 13045)&4*4 463(&3: 5)& ()045
'*#304*4
M. Carrino1, F. Chiancone1, L. Pucci1, G. Battaglia1, D. Mattace Raso1, F. Persico1, P. Fedelini1
1
Objective
Fibrosis in the corpora cavernosa, is usually related with well known anamnestic risk factors. Causes of corporal fibrosis
include complications from an infected implant such as explantation, priapism, penile trauma, Peyronie’s disease, and
prolonged use of an intracavernosal injection agent (1-2-3). Despite this, in our experience we have found significant fibrosis
in the corpora cavernosa of patients without any well know risk factors. The aim of our study was to investigate the causes of
significant penile fibrosis in our penile prosthesis implantation experience.
We enrolled 132 patients whose underwent a penile prosthesis implantation from January 2010 to December 2015. We
classified the patients according to the indication for the implantation and to the intraoperative discovery of significant
corpora cavernosa fibrosis. We classified the patients in two groups. In “group A” we enrolled 43 patients with high risk of
prevedible significant fibrosis and In “group b” we enrolled 89 patients with low risk of prevedible significant fibrosis. We
considered “significant fibrosis” if during the surgery we needed the help of additional straightening procedures like incision
or excision of the scar, multiple corporotomies with or without grafting, the use of the Rossello dilator, implant downsizing,
and transcorporeal resection (4). Arduos dilatation has not been considered as a paremeter of “significant fibrosis” because
it can be related to the surgeon experience. Categorical data were collected in a database and they were compared using
pearson’s chi-squared test (χ2).
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
January 2007 and January 2015. Erectile dysfunction was evaluated using priapism-specific IIEF and SHIM questionnaires.
We definied RIP as having >= 2 episodes of ischemic priapism within the past six months, with the majority (>75%) of
episodes lasting <5 hours. Almost all patients underwent phosphodiesterase type 5 inhibitors (PDE5i) therapy. The patients
who underwent surgical shunts, penile prostheses or androgen ablative therapy were excluded from the study. Categorical
data were collected in a database and they were compared using pearson’s chi-squared test (χ2).
Results
35 out of 78 patients (44,9%) with RIP had an history of SCD. Overall, 27 out of 35 patients (77,1%) were identified as having
mild or severe ED. 43 out of 78 patients (55,1%) with RIP had an idiopathic and drug-related etiologies. Overall, 21 out of the
43 (48,8%) patients were identified as having mild or severe ED. Patients with SCD had a significative higher rate of ED than
those without SCD (p=0,0106). SCD patients were also more likely to have ED than non-SCD patients among all patients
with episodes lasting <= 2 hours (p=0,0136) or those occurring weekly (p=0,0002).
Discussions
ED is a common complication of priapism but there is little evidence in scientific literature about its relationship with RIP.
In this study we confrimed RIP to be a risk factor for ED in particular for patient affected by SCD. Moreover the duration
of priapism episodes and episode frequency affected the patients with SCD more than the patients without SCD. Patients
with SCD may have an increased susceptibility to the reversible ischemic tissue injury associated with RIP episodes. It can
be related to a chronically decrease of nitric oxide (NO) biovailability (4), an aberration in NO regulatory signaling (5) and
an elevated oxidative stress resulting from reactive species generated chronically in SCD. Moreover these episodes can have a
cumulative effect in producing cavernosal damage independent of major episodes.
Conclusion
In our series we confirmed that ED is strongly associated with RIP, in particular in patients with SCD. The same strong
association is also seen in some subcategory of patients with SCD (episodes regularly lasting <=2 hours or occurring weekly)
compared to non-SCD. SCD is one of the most common etiology of RIP. As a consequence it is imperative to discover
early this dangerous condition, in order to prevent severe erectile dysfunction in this patients with a properly therapeutic
scheme. Despite of significant advancements in the understanting and in the management of priapism, identification of new
pathophysiologic mechanisms may suggest new strategy to treat and prevent SCD priapism-associated ED.
References
1-Broderick GA. Priapism and sickle-cell anemia: diagnosis and nonsurgical therapy. J Sex Med. 2012 Jan;9(1):88-103. doi:
10.1111/j.1743-6109.2011.02317.x. Epub 2011 Jun 23.
2-Emond AM, Holman R, Hayes RJ, Serjeant GR. Priapism and impotence in homozygous sickle cell disease. Arch Intern
Med. 1980 Nov;140(11):1434-7.
3-Burnett AL, Bivalacqua TJ, Champion HC, Musicki B. Feasibility of the use of phosphodiesterase type 5 inhibitors in a
pharmacologic prevention program for recurrent priapism. J Sex Med. 2006 Nov;3(6):1077-84
4- Akinsheye I, Klings ES Sickle cell anemia and vascular dysfunction: the nitric oxide connection. J Cell Physiol. 2010
Sep;224(3):620-5. doi: 10.1002/jcp.22195.
5- Bivalacqua TJ, Ross AE, Strong TD, Gebska MA, Musicki B, Champion HC, Burnett AL. Attenuated RhoA/Rho-kinase
signaling in penis of transgenic sickle cell mice. Urology. 2010 Aug;76(2):510.e7-12. doi: 10.1016/j.urology.2010.02.050.
Epub 2010 Jun 9.
54
55
a
r
t
s
b
a
3&$633&/5 *4$)&.*$ 13*"1*4. $-"44*'*$"5*0/ "/% ."/"(&.&/5 0' "
$0.1-&9$0/%*5*0/*/063&91&3*&/$&
M. Carrino1, F. Chiancone1, L. Pucci1, G. Battaglia1, A. Oliva1, D. Di Lorenzo1, P. Fedelini1
1
Objective
Priapism is a persistent penile erection that continues greater than four hours and can be not related to sexual stimulation.
Ischemic priapism is a nonsexual, persistent erection characterized by little or no cavernous blood flow and hypoxic, hypercarbic,
acidotic corporal blood gas. It is an urological emergency because it is associated with progressive fibrosis of the corpora
cavernosa and erectile dysfunction (1). Recurrent ischemic priapism (RIP) is a form of ischemic priapism characterized by
episodes of prolonged sleep-related erections (SRES) or transitory attacks of priapism. The aim of our study was to perform a
retrospective study of our series of RIP reporting our classification and our management.
We retrospectively analyzed 135 patients with a history of RIP presenting to the urology and hematology department at our
institution between January 2007 and May 2015. We usually classify our patients with RIP in three group: “prolunged sleeprelated erections (SRES) with spontaneous resolution” (group 1), “minor RIP: transitory attacks of priapism with conservative
management and resolution in two-five hours” (group 2), “major RIP: episodes of priapism with conservative management
and resolution after 5 hours” (group 3). In this study we describe our management strategy in prevention of RIP according to
some socio-demographic characteristics of the patients. We show the results of our series.
Results
72 out of 135 (53,3%) patients were enrolled in group 1, 35 out 135 (25,9%) patients were enrolled in group 2, 28 out 135
(20,7%) patients were enrolled in group 3. Finasteride has been used in 18 out of 135 (13,3%) patients. Only 8 out of 18
(44,4%) patients experienced zero episodes of priapism per month, another 3 (16,7%) experiencede 1-15 recurrences per
month, and the remainging men with over 15 priapic episodes. The mean age of this group of patients was 38,2 (range 3542). Ketoconazole has been used in 46 out of 135 (34%) patients. Prednisone was coadministered in all patients. 42 out of
46 (91,3%) patients experienced complete resolution of episodes of prolonged SRES. Moreover 33 patients (78,6%) did not
need to resume ketoconazole after the therapy was discontinued an average duration of 6 month. The mean age of this group
of patients was 23,4 (range 15-28). Phosphodiesterase type 5 inhibitors (PDE5i) has been used in 54 out of 135 patients. 35
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Results
In our series 47 out of 132 (35,6%) patients experienced significant fibrosis. 14 out of 43 patients (32,6%) were in group
A and 33 out 89 patiens (37,1%) in group B (p=0,6112). Table 1 shows in details anamnestic features of the patients who
underwent a penile prosthesis implantation and the rate of significant fibrosis. The most important rate (60%) of significant
fibrosis was found in the group of patients with an history of radical prostatectomy. Significant fibrosis was found in 31,8%
of diabetic patients, in 20% of patients with cardiovascular disease, in 44,4% of paraplegic patients, in 25% of patients with
Peyronie’s disease, in 22,2% of patients who underwent radiotherapy for prostate cancer, in 27,8% of patients with an history
of priapism, in 23% of patients with veno-occlusive dysfunction, in 20% of the patients who underwent a previous penile
prosthesis implantation and 5 patients had no clear causes of fibrosis.
Discussions
The primary pathophysiological event in the development of penile fibrosis is over-expression of plasminogen activator
inhibitor 1, TGF β1, and reactive oxygen species that lead to the increased activity of myofibroblasts and the elevated
production, deposition and accumulation of collagen (5). As expected, significant fibrosis was found frequently in priapism
and in patients affected by peyronie’s disease. Significant fibrosis was surprisingly found in a big rate of patients with venoocclusive disfunction, paraplegia and others no well know risk factors. 4 out of the 20 patients (20%) in the group of previous
radical prostatectomy underwent continuative therapy with intracavernosal injection agent. All these patients experienced
significant fibrosis. In more than a quarter of patients who are waiting for a penile prosthesis implantation without important
risk factor for significant fibrosis, addictional straightening procedures can be necessary to permorm a correct implantation.
Conclusion
In conclusion, during a penile prosthesis implantation procedure, we can found significant fibrosis in the corpora cavernosa
also in patients with no well know risk factors related to fibrosis. As a consequence it is imperative to have all needful surgical
instrumentary (like the Rossello dilator) in simple clinical cases too. Last but not least it is imperative to have a good property
of management of these complex cases. This preliminary study can suggest the use of a chronic preventive medical therapy
with phosphodiesterase-5 inhibitors or pentoxifylline in this new risk categories of patients who are waiting for a penile
prosthesis implantation.
References
1-Kabalin JN Corporeal fibrosis as a result of priapism prohibiting function of self-contained inflatable penile prosthesis.
Urology. 1994 Mar;43(3):401-3.
2-Wilson SK Reimplantation of inflatable penile prosthesis into scarred corporeal bodies. Int J Impot Res. 2003 Oct;15 Suppl
5:S125-8.
3- Bilgutay AN, Pastuszak AW. Peyronie’s disease: a review of etiology, diagnosis, and management. Curr Sex Health Rep. 2015
Jun 1;7(2):117-131.
55
56
a
r
t
s
b
a
&.#0-*;"5*0/ 0' 5)& %&&1 %034"- 7&*/ 64*/( "&5)09:4,-&30- */ 5)&
53&"5.&/50'&3&$5*-&%:4'6/$5*0/3&46-5*/('30.7&/064-&","(&"/"-:4*4
0'063&91&3*&/$&8*5)1"5*&/54
M. Carrino1, L. Pucci1, F. Chiancone1, G. Battaglia1, C. Meccariello1, D. Di Lorenzo1, P. Fedelini1
1
Objective
To evaluate the safety and efficacy of deep dorsal vein embolization using aethoxysklerol in the treatment of erectile dysfunction
resulting from venous leakage, in patients not responders to the maximum dosage of various phosphodiesterase type 5
inhibitors (PDE5i).
The study enrolled 171 consecutive (age 21-39 years old) patients from March 2006 to June 2015. International Index of Erectile
Function-Erectile Function Domain (IIEF-EF) questionnaire, medical history, physical examination, routine blood analysis,
hormonal analysis, penile dinamic doppler ultrasound with volumetric analysis of the penis were checked in all patients. Venus
leak was diagnosed by penile doppler and confirmed by dynamic infusion cavernosometry (DIC) using flow-to-maintain
(FTM) measurement as the defining parameter. Venous leak was diagnosed based upon a FTM value > 5 mL/minute. All
patients underwent CT cavernosography to study the site of venous leakage. After penile block with carbocaine, a short penile
dorsal midline incision was made at the corona of the glans penis. The superficial dorsal vein was ligated. The deep dorsal
vein was identified and isolated under the Buck´s fascia. The distal end was ligated with 3-0 Vicryl™ and circumflexed veins
were also ligated with 3-0 Vicryl™. The proximal end was catheterized with a 20 gauge steel needle after placing a tourniquet
at the root of the penis and 3 ml aethoxysklerol foam 3% was injected for venoablation. We do not use an air block technique
and Valsalva maneouvre. The patients were evaluated six months after surgery. Statistical analyses were conducted using SAS
version 9.3 software (SAS Institute, Inc., NC). Mean values with standard deviations (±SD) were computed and reported for all
items. Statistical significance was achieved if p-value was ≤0.05 (two-sides).
Results
The procedure did not cause any intraoperative complications. Postoperative minor hematomas occurred in 13 patients.
Painful erections lasting at least 3 months occurred in 21 patients. At 6-month follow-up 132 out of 171 patients (77,2%)
reported to have erections sufficient to permit vaginal penetration without the use of any drugs or additional devices. 23 out of
171 (13,45%) reported to have erections sufficient to permit vaginal penetration with the use of low dose of PDE5i. 16 out of
171 (9,4%) patients did not report any improvement. Preoperative IIEF-EF scores changed significantly at 6-month follow up
(9±6 vs 21±7; p<0,001). Volumetric analysis of the penis showed a significant increase (Pre-op: 122.63% ± 65.66% vs 6-month
post-op: 263.74% ± 90.20%; p<0,001) at 6-month follow up.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
out 54 (64,8%) patients had a sickle cell disease, 10 out 54 (18,5%) patients had thalassemia and 2 out 54 (3,7%) patients had
glucose-6-phosphate dehydrogenase deficiency. The other 7 patients (13%) had idiopathic priapism. 46 out 54 (85,2%) patients
alleviating (at least a 50% reduction in number and in severity of episodes) or solved (no more episodes) priapism at a mean
follow-up of six months. Self-administered intracavernosal injections (ICI) were used by 17 out of 135 (12,6%) patients.
Discussions
After the acute episode is resolved, with or without any invasive procedure, the preferred management strategy of RIP would
be prevention of future episodes. Current medical option for prevention of RIP are supported with level 3 or 4 evidence (2).
The therapeutic approach should be well tolerated, safe and effective (3). Our management strategy is usually related to some
socio-demographic characteristics of the patient. Antiandrogens are not recommended in young virile men. Ketoconazole
may be a potentially effective treatment for prepuberal men or those desidering fertility with testosterone monitoring and dose
tritation. PDE5i are usefull in men with idiopathic priapism and in priapism assoaciated with blood diseases, without affecting
normal erectile capacity. The costs of this therapy does not allow its widespread use. ICI was not used in order to prevent the
episodes of priapism but in order to treat episodes once they occur. It can be usefull in patients who are resilient to a selfinjection approach, with sporadic episodes of priapism and witouth significant cardiovascular disease.
Conclusion
Despite of a large number of therapy described in scientific literature for the prevention of future episodes in RIP, there is not a
therapy supported with an high evidence level (level 3 or 4 evidence). In our preliminary experience ketoconazole and PDE5i
are safe and useful in prevention of priapism episodes in patients affected by RIP. The other described therapies can be useful
only in specific categories of patients or in case of important contraindications to the use of PDE5i or ketoconazole. Despite
this a randomized multi-center study will be needed and our result should be followed-up in the future.
References
1-Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, Nehra A, Sharlip ID; American urological
association guideline on the management of priapism. J Urol. 2003 Oct;170(4 PT 1):1318-24.
2- Salonia A, Eardley I, Giuliano F, Hatzichristou D, Moncada I, Vardi Y, Wespes E, Hatzimouratidis K; European association
of urology guidelines on priapism. Eur Urol. 2014 Feb;65(2):480-9. DOI: 10.1016/J.EurUro.2013.11.008. Epub 2013 NOV
16.
3- Hoeh MP, Levine LA. Prevention of recurrent ischemic priapism with ketoconazole: evolution of a treatment protocol and
patient outcomes. J Sex Med. 2014 Jan;11(1):197-204. DOI: 10.1111/JSM.12359. Epub 2013 Nov 27.
56
57
a
r
t
s
b
a
630o"/%304&90-0(*$"-".#6-"503:$"3&*/"630-0(*$"-%&1"35.&/5
3&53041&$5*7&456%:0':&"34"$5*7*5:
Argomenti: M. Diambrini1, W. Giannubilo1, B. Azizi1, C. Vecchioli Scaldazza1, C. Bravi1, V. Ferrara1
1
Ospedale “Carlo Urbani”, U.O.C Urologia (Jesi)
Objective
The study highlights the change in ways of thinking in the field of uroandro- sexology either from the patient’s point of view
or from and the specialistic competence of the sex therapist.
Retrospective analysis of 26,993 uro-andro-sexological visits during 20 years activity, catchment area 40,000 people, conducted
by a single uroandrological clinical sexologist using a unique original dedicated data base.
Results
From 1995 to January 2016 , 26993 “urological” visits were evaluated. Annual average resulted 1,327 peaking in 2013 with
1,838 visits. 4215 of the total 26993 visits ( 15.6% ) showed sexological problems to a more careful analysis of the question
The 932 cases of declared erectile dysfunction (ED) showed an increase with the peak in the last three years with an annual
average of 164.6 versus 25.2 for the years 1995-2012. The 374 cases of premature ejaculation (PE) showed the same trend with
an annual average of visits in 2013-2105 estimated 66.6 versus 9.2 related to the years 1995-2012. ED was found to be 3.3% of
the total visits, but 22.1% of the 4215 sexological problems, PE 1.3% of the total visits but 8.8% on 4215 sexological problems,
mixed disorder ED and PE 168 equal to 0.6% of the total, but 3.9% of sexological problems
Moreover during the period
2014-January 2016, out of 2849 visits, a statistically significative increase of sexological problems was observed : 799 visits
corresponding to 28% versus 15,6 % of the global period 1995-2016 . Out of the 799 visits regarded sexual problems : ED and
PE were found in 44.3% and 17.8% respectively , 76 cases with mixed disturbance ED and PE (9.5% ) were observed; in the
other 226 visits : 100 relational disorders (12,5 % ) with 26 couples problems were found , 26 anxiety (3,2 %) , DE to subsequent
interviews in 66 cases (8,2 %) and disturbance of desire in 6 cases (0,7%.)
Discussions
Over the years, the phosphodiesterase inhibitors represented an epochal revolution in the approach to the quality of life. It
was born the concept of “Sexual Medicine”. On the other side analysing and understanding the real requests of the patient
is often a complex matter in a urological ambulatory care . This is due to the fact that the patient speaks about a presumed
urological problem, but in fact he is looking for specific anwsers to a sexological problem
Data were collected inside a
local district that is particularly significant for medical and sociological considerations as it covers a user base of around 40,000
people within a a unique Hospital with a single uroandro- sexological structure .
Conclusion
Data showed an increase of sexological requests but reading the real request of an urological patient requires minimal
sexological training and knowledge in order to manage the patient in an integrated manner , and to improve that”’empathy”
that is the basis of the “medical wellness”.
References
1. Male erectile dysfunction: integrating psychopharmacology and psychothrapy. E.F. Simopoulos, A.C. Trinidad Gen Hos
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Discussions
Nowadays PDE5i (inhibitors) are the first-line standard therapy in erectile dysfunction. The success rate of the therapy
with PDE5i is about 70%(1). Moreover this type of medication is notindicated in patients taking nitrates or with other
contraindication. DVO is one of the most common causes of vasculogenic erectile dysfunction. In the past, deep dorsal vein
ligation have been performed to correct DVO with a low succes rate (2), probably due to the opening-up of some collateral
veins. Embolization of the deep dorsal vein using aethoxysklerol has been previously described (3). Aeroblock techique in
Valsalva maneouvre seems to maintain the sclerosing agent at place and can lead to a sufficient sclerosing of the deep dorsal
vein network, including small veins. We perform a modified technique achieving results similar to others previously reported
series in literature (3).
Conclusion
DVO is one of the most common causes of vasculogenic erectile dysfunction above all in young patients. In our experience,
this technique was effective, minimally invasive, and cost-effective in young patients with veno-occlusive dysfunction. We do
not use an air block technique and Valsalva maneouvre. Despite this only 9,4% patients did not report any improvement after
this procedure. It can be an alternative procedure to the simple penile vein ligation and to the penile prosthesis implantation
after PDE5-inhibitor failure or in patients who cannot use this therapeutic option. Our study limitation is short follow-up
period and our result should be followed-up in the future.
References
1-Nam Cheol Park, Tae Nam Kim, Hyun Jun Park Treatment Strategy for Non-Responders to PDE5 Inhibitors-World J Mens
Health. 2013 April; 31(1): 31–35. Published online 2013 April 23. doi: 10.5534/wjmh.2013.31.1.31.
2-Henriet, JP. Value of sclerotherapy in the treatment of certain types of impotence caused by venous leakage. Phlebologie.
1987; 40:975-980.
3-Herwig R, Sansalone S. Venous leakage treatment revisited: pelvic venoablation using aethoxysclerol under air block
technique and Valsalva maneuver. Arch Ital Urol Androl. 2015 Mar 31;87(1):1-4. doi: 10.4081/aiua.2015.1.1.
57
58
2.
3.
4.
5)&$)*-%8*5)4."--(&/*5"-*"*/$*%&/$&"/%%*"(/045*$13050$0-
X
X
b
a
a
r
t
s
M.. Carrino1, F. Persico1, F. Chiancone1, C. Meccariello1, G. Battaglia1, L. Pucci1, P. Fedelini1
1
Objective
Abnormalities of the penis are infrequent, troublesome situations for both patients and urologists. Moreover a small penis
can provoke anxiety and depression in prepuberal patients’ parents (1). The incidence of real small genitalia is unknown (2).
In almost all cases who underwent an andrological consultation there was no real genital insufficiency, but only an excess of
expectations or an eunuchoid habitus, typical of the obese children. What is the correct strategy to reassure parents or require
a diagnosis of second level in order to identify endocrine or genetic damages that cause hypogenitalism? We report our series
and diagnostic flow chart used in cases of real micropenis.
From January 2008 to December 2015, 86 children (7-12 years) with suspected hypogenitalism underwent an andrological
consultation at our department. In all patients a physical examination with evaluation of scrotal contents and evaluation of
the stretched penile length was performed. Only patients with pathological length (according to Aaronson’s tables (3); 1994)
were admitted to the assessment of the second level. Our protocol includes the evaluation of FSH, LH, total testosterone (T),
prolactin, DHT (Dihydro-testosterone), and genetic study of androgen receptor to evaluate congenital or acquired disorders of
the hypothalamus, pituitary gland, gonads or an alpha reductase deficit or peripheral androgen insensitivity (4).
Results
73 patients had not real genitalia abnormalities. In 68 patients we documented an excess of expectations from parents, in 5
cases an eunuchoid habitus due to childhood obesity. Diagnosis of micropenis has been confirmed in 13 patients. Micropenis
can be defined as a penile length smaller than 2.5 standard deviations (SD) below the mean. 5 patients were diagnosed with
hypogonadotropic hypogonadism, 1 case with panhypopituitarism associated with consensual deficit of TSH, ACTH and GH,
2 cases with deficit of 5 alpha reductases, 2 cases with deficiency of androgen receptor. In 3 patients it was not possible to find
endocrine abnormalities and it has been hypothesized partial insensitivity of the genital skin to androgens.
Discussions
The reassuring attitude toward the parents worried about the size of genitals is justified in most cases, but this attitude must
be endorsed by an accurate assessment of the real stretched penile length. A meticulous physical examination could help
to identify the true cases of genital anomalies from the false ones. In pathological cases the diagnostic flow chart should be
properly completed. As a consequence we stretch the usefulness of a careful assessment of the T/DHT rate (normal value: 4.9
+ 2), that can be related with a deficit of 5-alpha reductase (5). 51 of the 86 patients were first-born child and the parents were
alarmed by the difference with the other sons.
Conclusion
Penile abnormalities have a varied etiology and require a flexible approach. An adequate physical examination may allow a
first assessment, useful to exclude cases of “false” small genitalia. In our series the majority of cases of “real” small genitalia are
due to micropenis, whose diagnosis is related on correct measurement. Congenital or acquired disorders of the HypothalamicPituitary-Gonadal axis are more rare instead. Endocrinological assessment helps in determining the etiology of small genitalia.
A careful assessment of the T/DHT rate is useful for evaluating a possible deficit of 5-alpha reductase in cases with unknown
etiology. Finally, an appropriate counseling with parents can reduce their anxiety and can improve the diagnosis and the
therapy of this rare pathology.
References
1 Suorsa KI , Mullins AJ. Characterizing Early Psychosocial Functioning of Parents of Children with Moderate to Severe Genital
Ambiguity due to Disorders of Sex Development. J Urol. 2015 Dec;194(6):1737-42. doi: 10.1016/j.juro.2015.06.104. Epub
2015 Jul 18.
2 Wang MH, Baskin LS. Endocrine disruptors, genital development, and hypospadias. J Androl. 2008 Sep-Oct;29(5):499-505.
doi: 10.2164/jandrol.108.004945. Epub 2008 May 22.
3 Aaronson IA. Micropenis: Medical and surgical implications. J Urol. 1994 Jul;152(1):4-14.
4 Hatipoğlu N, Kurtoğlu S. Micropenis: etiology, diagnosis and treatment approaches. J Clin Res Pediatr Endocrinol.
2013;5(4):217-23. doi: 10.4274/Jcrpe.1135.
5 Gad YZ, Nasr H, Mazen I, Salah N, el-Ridi R. 5 alpha-reductase deficiency in patients with micropenis. J Inherit Metab Dis.
1997 Mar;20(1):95-101.
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Psy xxx 2012
Biopsychosocial aspects of Prostate cancer . EJS Kunkel JR Bakker RE Myers, O Oyesanmi, LG Gomella Psychosomatics
2000; 41:85-94
Longitudinal effects of social support and adaptive coping on the emotional well-being of survivors of Localized Prostate
Cancer RES Zhou, FJ Penedo et al J Support Oncol 2010; 8 (5):196-201
Perceptions and opinions of men and women on a man’s sexual confidence and its relationship to ED: results of the
European Sexual Confidence Survey. San Martín C1, Simonelli C, Sønksen J, Schnetzler G, Patel S. Int J Impot Res. 2012
Nov-Dec;24(6):234-41. doi: 10.1038/ijir.2012.23. Epub 2012 Jun 21.
58
59
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
13&-*.*/"3:"/"-:4*40'5)&'*345$"4&4&/5&3&%*/5)&*5"-*"/3&(*453:
0'1&/*-&13045)&4*4463(&3:
b
a
a
r
t
s
X
X
E. Pescatori1, G. Franco2, E. Caraceni3, F. Colombo4, F. Dehò5, L. Utizi3
1
Hesperia Hospital (Modena)
2
Policlinico Umberto I (Roma)
3
ASUR Marche, Area Vasta 3 (Civitanova Marche)
4
Policlinico S. Orsola-Malpighi (Bologna)
5
Ospedale San Raffaele (Milano)
Objective
The penile prosthesis option presently suffers a paradox: despite being for the patient with severe ED the solution that scores the
highest in terms of satisfaction, the vast majority of patients that qualify for it do not have access to it. Several are the barriers
to the penile prosthesis solution: patients are not informed / misinformed about this option, costs of penile implants are
significant, no reliable figures on the dimensions of penile implant field are available. Two key interventions appear accordingly
needed: to produce reliable data on the phenomenon “penile implant surgery” at National level, and to correctly inform the
general population of the benefits and limits of the penile prosthesis option. For these purposes a prospective Registry for
penile implants and a Institutional informative website aimed to popularize the potentials of the penile prosthesis option to the
lay public have been launched on December 2014 by the Italian Society of Andrology (S.I.A.) (1).
The “INSIST-ED REGISTRY” (Italian Nationwide Systematic Inventarisation of Surgical Treatment for ED) is a prospective
Registry of penile prostheses (all brands, all models) open to all implanting surgeons operating in Italy. Registry surgeons agree
to provide anonimous patient, device, surgical procedure, outcomes, follow-up data, for both first and revision surgeries. The
impact of penile implants on recipients quality of life at 1 year f.u. is to be assessed by the QOLSPP questionnaire (2). S.I.A.
concurrently created an Institutional website (www.androprotesi.it) aimed to provide lay public with sound information on the
penile prosthesis option; only implanting surgeons adhering to the Registry and active on it are present in such website with a
personal page.
Results
As February 2016, 44 implanting surgeons joined the Registry, and 326 surgical procedures have been entered in the Registry
database. We report analysis of the first 300 consecutive cases entered in the Registry; they comprise: 252 (84%) new implants,
37 (12,3%) prosthesis substitutions, 10 (3,3%) device removal without substitution, 1 simple surgical revision. Geographic
distribution: 121 (40,3%) procedures were performed in North Italy, 115 (38,3%) in Centre Italy, 64 (21%) in South Italy. Chief
ED etiologies of the Registry cases were: 107 (35,6%) iatrogenic (radical pelvic surgery), 62 (20,6%) Peyronie’s cases, 31 (10,3%)
diabetes. The overall 289 implanted devices are represented by: 235 (81,3) three-component devices, 18 (6,2) two-component
devices, 36 (12,4%) non hydraulic devices. Surgical settings: 79% of all the performed procedures took place in public hospitals,
the remaining 21% in private settings. Waiting time from indication to surgery for new implants: 12 months in public hospitals,
1,4 months in private settings.
Discussions
Penile prosthetic surgery has potentials to become both: more acknowledged by the ED population, and more accessible.
This project moves in the direction to promote the realization of such potentials through the “INSIST-ED” Registry, and the
Institutional informative website www.androprotesi.it. Our Registry is the first experience of this kind in Europe. In the rest
of the world another Registry only is ongoing, in the U.S.A.: “PROPPER” (3), launched in 2011. It differs from our Registry in
the following aspects: it is a Company-devised study that evaluates only the devices produced by that Company, and with the
Company itself having direct access to data and planning their analysis. Conversely, in the “INSIST-ED” Registry the Scientific
Society S.I.A. has devised the study (opened to devices of all Companies), owns the database, and plans data analysis. We will
soon start collecting data on the impact of penile prostheses on recipients quality of life through the only validated tool for this
purpose: the QOLSPP (2).
Conclusion
The INSIST-ED Registry represents the first European experience of penile prosthesis Registry. The first data analysis at one
year since its start is providing for the first time objective data on the landscape of penile implantology in Italy. We hope that
such data will be instrumental also to negotiate with Health Authorities better policies for the penile implant surgery area (for
instance, more favourable reimbursements and more devices available in public hospitals). We also expect that our project
will induce a more appropriate request of access to the “penile prosthesis option” by the severe ED population, now correctly
informed by the Institutional website www.androprotesi.it .
References
1. Pescatori E, Franco G: Introducing the first Registry for penile implants: the INSIST-ED Registry (Italian Nationwide
Systematic Inventarisation of Surgical Treatment for ED). J Sex Med 2015;12(suppl 3):216–240 HP-06-005
2. Caraceni E, Utizi L: A questionnaire for the evaluation of quality of life after penile prosthesis implant: quality of life and
sexuality with penile prosthesis (QoLSPP): to what extent does the implant affect the patient’s life? JSM 2014; 11: 1005-12
3. Henry GD et al: The Who, How and What of Real-World Penile Implantation in 2015: The PROPPER Registry Baseline Data.
J Urol. 2016;195(2):427-33
59
60
o
6
17:30
19:00
s
1
s
Murillo
0
e
2 ngr
Video 2:
o
s
C
t
Su e giù per le vie
urinarie
I
I
c
I
a
X
r
X
t
s
23 maggio 2016
sala
b
a
1*&-0-*5050.*"%&453"-"1"304$01*$"
R. Mastroianni1, R. Papalia1, E.. Altobelli1, A. Giacobbe1, D. Collura2, C.. Falavolti1, E.. Shehu1, E. Luperto1, G.. Muto1, M. Kurti1,
G. Muto1
1
2
Abstract
Presentiamo il caso di una paziente di 71 anni sottoposta ad intervento di pielolitotomia destra laparoscopica per calcolosi pielica
di 3.5 cm.
Il video mostra l’incisione ampia della pelvi renale destra secondo Gil-Vernet e l’estrazione del calcolo in blocco.
70-6.*/040 $"-$0-0 %* $*45*/" */ .0/03&/& $)*363(*$0 $)*363(*"
3&530(3"%"*/53"3&/"-&3*34
O. Maugeri1, F.. Sommatino1, F. Venzano1, M. Mediago1, C. Dadone1, G. Arena1
1
Ospedale S. Croce e Carle (Cuneo)
Abstract
In questo video presentiamo la nostra gestione per via ureteroscopica retrograda in due look di voluminoso calcolo di cistina (3
cm) occupante il bacinetto in paziente monorene portatore di pielostomia per Insufficienza renale acuta. A pielostomia aperta
si eseguiva ureteroscopia semirigida lasertrissia ottenendo parziale polverizzazione e successiva completa frammentazione
del calcolo. Quindi si completava la lasertrissia con ureteroscopio flessibile su Guaina d’accesso ureterale e si procedeva ad
estrazione dei frammenti, collocando stent e destinando il paziente a second look. L’Rx addome e l’ecografia a 15 giorni
dalla procedura evidenziavano impilamento litiasico in uretere. Durante il second look a due mesi, dopo estrazione agevole
dei frammenti ureterali, il controllo ureterorenoscopico dimostrava completa bonifica del rene. Una TC a 15 giorni dalla
procedura evidenziava esclusivamente idronefrosi per stent migrato in uretere in assenza di litiasi renoureterale. Estratto lo
stent l’ecografia renale eseguita a 30 giorni di distanza dimostrava un rene senza idronefrosi e privo di calcoli residui. La
nefrolitotrissia percutanea resta il Gold standard di trattamento per calcoli superiori a 2 cm di diametro. Nei casi di necessità
valutando le caratteristiche intrinseche del calcolo e l’anatomia della via escretrice, la RIRS, in mani esperte, potrebbe comunque
essere una ragionevole opzione di trattamento.
17:30 - 19:00 - Video 2 - Su e giù per le vie urinarie
Moderatori: Gianfranco Deiana
60
61
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
6-53".*/*1&3$$0/-*5)"44*45$00,6/#60/$0.130.&44074.*$301&3$
a
r
t
s
30#05*$3*()5/&1)30-*5)050.:'03"45"()03/450/&
b
a
63&5301-"45*$" %* "/"450.04* %034"-& .6$0.6$04" i13&4&37*/(
410/(*046.w1*Ä".1-*".&/507&/53"-&$0/*//&450%*.6$04"#6$$"-&
E. Palminteri1, E. Berdondini2, G. Cucchiarale3, G. Milan3, F. Marson4, A. Gurioli4, L. Gatti5, G. Ferrari5
1
Centro di Chirurgia Uretrale-Genitale Arezzo - Humanitas Cellini Torino (Arezzo)
2
Centro di Chirurgia Uretrale-Genitale Arezzo- Humanitas Cellini Torino (Torino)
3
Humanitas Cellini, U.O. Urologia (Torino)
4
Clinica Urologica, Università di Torino (Torino)
5
Hesperia Hospital, U.O. Urologia (Modena)
Abstract
Descriviamo una nuova tecnica per il trattamento delle stenosi uretrali bulbari sub-obliterative tramite resezione di tessuto
uretrale cicatriziale con preservazione della spongiosa, anastomosi dorsale muco-mucosa e ampliamento ventrale con
innesto di mucosa buccale (MB). Dopo incisione cutanea perineale, l’uretra stenotica viene aperta ventralmente. Il piatto
uretrale appare molto ristretto: rimozione della mucosa cicatriziale ma senza sezionare a tutto spessore la spongiosa dorsale
che pertanto mantiene la continuità anatomica-vascolare. Mobilizzazione della mucosa uretrale dalla spongiosa per 1-2 cm
prossimalmente e distalmente alla zona di resezione. I due margini di mucosa mobilizzati vengono suturati dorsalmente a
ricostruire un neopiatto uretrale. Il neopiatto uretrale è ampliato ventralmente con innesto di MB (prelevato da guancia)
successivamente ricoperto dalla spongiosa preservata. Recentemente si sono sviluppate tecniche ricostruttive uretrali meno
aggressive e risparmiatrici dei tessuti. Nelle stenosi con piatto uretrale molto stretto, la nostra tecnica consente di rimuovere la
mucosa cicatriziale risparmiando la spongiosa circostante e ricreando un piatto uretrale da ampliare con un innesto di MB. La
tecnica consente di riparare stenosi molto strette evitando l’aggressività della sezione completa della spongiosa ed al contempo
rimuovendo la cicatrice che potrebbe essere causa di recidiva nelle uretroplastiche di ampliamento con innesti.
-"1"304$01*$#-"%%&3%*7&35*$6-&$50.:8*5)580"1130"$)&4
R. Sanseverino1, U. Di Mauro1, O.. Intilla1, G. Molisso1, T. Realfonso1, A. Pistone1, G. Napodano1
1
INTRODUCTION
The video shows two surgical laparoscopic approach to treat bladder diverticulum. In the first case, a 47 years old female
affected by a large posterolateral bladder diverticulum underwent an extravesical and transurethral approach; in the second
case, a 52 years old male underwent a laparoscopic tranvesical approach.
METHODS In the first case we perform a transurethral and extraperitoneal laparoscopic combined approach. After creating the
preperitoneal space by balloon trocar dissection, five trocars (2 x 5mm and 3 x 10mm port) are placed in hypogastrium.
Identification of the diverticulum is made easier by bladder filling and cystoscope lighting. Bladder diverticulum is completely
X
X
M. Ferriero1, G. Simone 1, R. Papalia2, R.. Mastroianni2, F.. Minisola1, S.. Guaglianone1, M.. Gallucci1
1
2
Abstract
The video shows a case of robotic right nephrolithotomy for a staghorn stone. With patient in extended flank position a five
trocar access and docking were performed. The right colon was deflected and Gerota’s fascia was opened. Renal parenchyma
was incised at the level of upper pole. The upper calix was opened and a 3 cm staghorn stone was secured in endobag. Irrigation
of pyelocaliceal system was performed; urinary tract and renal parenchyma were closed with a sliding clip technique. A drein
was left in place. Operative time was 110 minutes, blood loss was negligible. Postoperative course was uneventful. The patient
was discharged on 2nd postoperative day. A 6 mo x-Ray did not show recurrent stones.
C. Molinari1, C.. Anceschi1, C. Gulia1
1
Ospedale San Camillo, U.O.C. Urologia (Roma)
Abstract
Nel video mostriamo l’utilizzo del Lithassist COOK nell’Ultraminiperc, con dilatazione del tramite one-step a 12 Fr. Lithassist
è un device costituito da una cannula metallica con impugnatura ergonomica e due canali separati. Il primo permette
l’irrigazione-aspirazione controllata; il secondo consente l’introduzione di una fibra laser da 300 micron e della fibra ottica 3 Fr
VueOptic COOK. Oltre ad avere le stesse indicazioni della Microperc la tecnica risulta allo stesso modo agevole, rapida e con
costi assolutamente più contenuti.
61
62
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
isolated. An absorbable suture is passed around diverticulum neck; so it is clamped with suture and Hem-O-lock clip. Resection
of the diverticulum. Bladder is repaired with absorbable suture. In the second case, a extraperitoneal and tranvesical approach
is performed. Transurethral placing of ureteral catheter; bladder is opened; isolation and resection of diverticulum. Suture of
bladder wall with Vycril. Closure of bladder with absorbable suture.
RESULTS Mean operative time was 180 minutes. No complications were observed in both cases.
CONCLUSIONS Laparoscopic bladder diverticulectomy, both extravesical and transvesical technique, seems to be a safe and
feasible procedure.
X
X
a
r
t
s
b
a
1*&-01-"45*$" -"1"304$01*$" %&453" */ 1";*&/5& $0/ %011*0 %*453&550
*/$0.1-&50
C. Meccariello1, F. Chiancone1, G. Battaglia1, D. Mattace Raso1, D. Di Lorenzo1, M. Fedelini1, P. Fedelini1
1
Abstract
La duplicazione del sistema collettore e delle vie escretrici è una delle più comuni anomalie delle vie urinarie. L’anomalia si associa
spesso ad altre problematiche come la calcolosi renale, l’ureterocele, la stenosi del giunto pielo-ureterale ed il reflusso vescicoureterale. Il video mostra il caso di una donna di 33 anni affetta da stenosi della giunzione pielo-ureterale del distretto inferiore
in duplicità pielo ureterale incompleta destra. La paziente, affetta anche da duplicità pielo ureterale completa sinistra, era
stata sottoposta, due mesi prima della pieloplastica, a correzione endoscopica di ureterocele ed uretroscopia laser nel distretto
inferiore di sinistra. Con tecnica standard, dopo aver posizionato un caterino ureterale aperto in punta al di sotto della giunzione
pielo-ureterale, si procede in decubito laterale sinistro ad un miniaccesso open pararettale destro ed al posizionamento di trocar
di Hasson. Vengono posizionati quindi un trocar da 11 sottocostale e un trocar da 5 sovrailiaco sull’ascellare media. Dopo aver
identificato e resecato il giunto stenotico si procede ad anastomosi pielo-ureterale latero-laterale del distretto inferiore in vycril
5-0 su stent preposizionato. Il follow-up a 8 mesi mostra perfetta pervietà dell’anastomosi pielo-ureterale, dilatazione preesistente asintomatica della pelvi e buona funzionalità renale.
1*&-01-"45*$" .*/*-"1"304$01*$" ..
% 055*." "-5&3/"5*7"
'6/;*0/"-&&%&45&5*$""--"$)*363(*"30#05*$"
Argomenti: R. Nucciotti1, F.M. Costantini1, A. Bragaglia1, C. Brunettini1, R. Paolini1, V. Pizzuti1
1
Ospedale Misericordia (Grosseto)
Abstract
La miniaturizzazione degli strumenti permette di effettuare interventi complessi con piccole incisioni cutaee (3 mm). La
minilaparoscopia con colonna 3D è a nostro giudizio la più valida alternativa al single port ed un ottima alternativa alla
chirurgia robotica che necessita di accessi più ampi e di distanze tra trocars maggiori, cosa non sempre possibile soprattutto
nelle giovani ragazze. Il video mostra la tecnica, il funzionamento degli strumenti da 3 mm e il risultato estetico.
A. Gregori1, P. Rovellini1, R. Bonacina1, G. Caldera1, V.. Varca1, S.. Verrusio1, N. Visentin1
1
ASST Rhodense, Ospedale Guido Salvini (Garbagnate Milanese)
Abstract
Proponiamo la transposizione laparascopica di un uretere retrocavale in un giovane paziente di 18 anni giunto alla nostra
osservazione per un episodio di colica renale destra. La TAC addome mostrava idronefrosi destra di III° grado coinvolgente
il tratto prossimale dell’uretere, con decorso ureterale medializzato e in stretto rapporto con il margine anterolaterale della
vena cava, dati radiologici suggestivi per uretere retrocavale. Il video ha lo scopo di esporre la nostra tecnica di correzione
di un uretere retrocavale con approccio transiperitoneale con paziente disposto sul fianco sinistro a 70°, posizionando 5
trocar in emiaddome di destra di cui 3 da 3 mm ( 2 sull’ascellare media e 1 pararettale) e 2 due da 10 mm ( paraombelicale
per il laparoscopio e pararettale sottocostale per il passaggio dei punti dell’anastomosi ureterale). La miniaturizzazione degli
strumenti ( microlaparoscopia) oltre ad aver assicurato un ottimo risultato estetico ci ha permesso di mantenere una elevata
performance dell’atto operatorio, garantendo delle prese nettamente atraumatiche con alta precisione nel gesto chirurgico.
Tutto ciò ha consentito di eseguire minuziosamente sia la dissezione dell’uretere dal piano cavale che l’anastomosi ureterale
termino-terminale, ottenuta su stent ureterale JJ posizionato per via anterograda intracorporea con congruo rimodellamento
del lume ureterale .
63&5&3&3&530$"7"-&53"/4104*;*0/&-"1"304$01*$"$0/4536.&/5*%"
..
62
63
o
6
17:30
19:00
s
1
s
Mirò
0
e
2 ngr
Poster Digitali 2:
o
s
C
t
I grandi ClassiciIdell’Urologia
I
c
I
a
X
r
X
t
s
23 maggio 2016
Moderatori: Francesco Savoca
$)*363(*"3&530(3"%"*/53"3&/"-&3*34
74-*5053*44*"&953"$03103&"
48-
/&-53"55".&/50%&*$"-$0-*%&-$"-*$&*/'&3*03&
O. Maugeri1, F. Sommatino1, F. Venzano1, D. Bernardi1, M. Mediago1, G. Chiapello1, G. Arena1
1
Ospedale S. Croce e Carle (Cuneo)
Abstract
Scopo del nostro studio è eseguire una valutazione comparativa retrospettiva dei risultati di RIRS ed SWL su calcolosi singola
del calice inferiore sino a 2 cm di diametro
MATERIALI E METODI: La valutazione comparativa è stata ottenuta confrontando i risultati delle due procedure per un periodo
di 36 mesi (da Gennaio 2013 a Gennaio 2016). Lo stone free rate è stato definito per frammenti < a 3 mm di diametro con
valutazione ecografica. La raccolta dei dati con foglio Excel per le RIRS e ausilio di software dedicato (Computer Medical
Recording- C.M.R.) per le SWL.
RISULTATI: abbiamo analizzato un totale di 179 procedure (78 RIRS e 101 SWL). La dimensione media dei calcoli per SWL è
9,6 mm (range 5-20 mm), per RIRS 10,4 (5-20 mm). I trattamenti SWL eseguiti in regime ambulatoriale, mentre le RIRS in
ricovero ordinario con un tempo di degenza media di 1,67 giorni (1-4 g) e un tempo operatorio medio di 67 min (18-140 min);
53 eseguite in anestesia epidurale, 25 in generale. Lo stone free rate è significativamente migliore (p<0,001) per RIRS (78,87
% al I look e 90,09% al second look) rispetto a SWL (37,18% su un totale di 2 trattamenti). 4 pazienti (3,9%) del gruppo SWL
avevano subito ureteroscopia operativa per coliche ed idronefrosi (Clavien-Dindo IIIa), mentre del gruppo RIRS abbiamo
registrato 5 complicanze Clavien-Dindo I (6,4%) (4 coliche renali/intolleranza allo stent e 1 perdita di liquor da anestesia
epidurale)
MESSAGGIO CONCLUSIVO:i calcoli del calice inferiore sono di difficile e controversa gestione per la loro posizione declive
considerando anche le variabilità anatomiche, la dimensione e la durezza. Dall’analisi retrospettiva dei nostri dati si conferma
come il trattamento endoscopico retrogrado (RIRS), seppur gravato da maggiore invasività, dovrebbe essere il nuovo gold
standard di trattamento per la calcolosi del calice inferiore sintomatica.
-*5)"44*4576&015*$$00,*/5)&6-53".*/*1&3$"(00%."33*"(&
C. Molinari1, C. Anceschi1, M.. Governatori1, C. Gulia1
1
Ospedale San Camillo, U.O.C. Urologia (Roma)
OBJECTIVE: We want to demonstrate the powerful use of the device LITHASSIST COOK and fiber optic VUE COOK 3 Fr in
Ultraminiperc with one step dilation 12.0 Fr..
MATHERIALS AND METHODS:21 patients, aged between 14 and 67 years old, affected by ampullary stones with a diameter
of between 1.8 and 2.4 cm, were subjected to ultraminiperc, using, in one step, a sheath Amplatz 12.0 Fr In this has been
inserted Lithassist of Cook, a rigid device with control grip; it is used together with the holmium laser in the interventions of
percutaneous nephrolithotripsy. The device is equipped with a stainless steel cannula with two lumens. The flame of 5 French
17:30 - 19:00 - Poster Digitali
b
a
2 - I grandi Classici dell’Urologia
sala
63
64
a
r
t
s
X
X
Argomenti: incontinenza
1
Introduzione: Il grado di cura dell’incontinenza urinaria da urgenza o della sola urgenza minzionale è molto variabile nelle pazienti
trattate con sling TOT per incontinenza da sforzo. E’ nota anche la possibilità di insorgenza de novo di tale sintomatologia.
Ad oggi non sono ancora noti fattori predittivi del rischio di persistenza o insorgenza dell’ urgenza. Scopo di questo lavoro è
valutare nella nostra casistica i fattori di rischio di utilizzo degli antimuscarinici dopo sling TOT al follow up a lungo termine .
Materiali e metodi: Abbiamo valutato solo le pazienti sottoposte a sling TOT per incontinenza da sforzo con dati di follow up >5
anni. Sono state considerate le pazienti affette da incontinenza da urgenza o urgenza minzionale trattate con antimuscarinici.
La valutazione delle pazienti includeva: anamnesi, esame obiettivo, studio ecografico dell’apparato urinario con valutazione
del residuo post minzionale, prove urodinamiche ed urinocoltura. Sono stati considerati i possibili fattori di rischio come età,
peso, precedenti chirurgici, dati urodinamici, presenza di sintomatologia da urgenza preintervento, storia di infezione delle
vie urinarie.
Risultati: 128 pazienti sottoposte a sling TOT avevano un follow up di 5 anni. 61 (48%) lamentavano urgenza minzionale/urge
incontinence con necessità di terapia antimuscarinica. 38 presentavano una persistenza della sintomatologia versus 23 de novo.
I fattori di rischio sono risultati: età >60 anni (74% vs 31%) , utilizzo di antimuscarinici preintervento (46% vs 17%), massima
capacità cistometrica < 250 cc ( 64% vs 31%) e Pdet Q max > 30 cm/H2O (33,4% vs 21.8%).
Conclusioni: L’utilizzo degli antimuscarinici riguarda una percentuale elevata della pazienti con sling al follow up a lungo termine.
I fattori di rischio non sono modificabili con l’intervento. Le pazienti anziane e coloro che utilizzano preoperatoriamente
antimuscarinici sono a rischio di necessitarne anche postoperatoriamente.
b
a
4"5*4'"$5*0/ 3"5& */ 1"5*&/54 8)0 6/%&38&/5 505 4-*/( 1-"$&.&/5 "5
&"3-:"/%.&%*6.5&3.'0--0861
1
Aim: TOT sling placement is the gold standard procedure for female urinary stress incontinence (USI). Aim of this study is to
evaluate functional outcomes, complication rate and mainly patients’ satisfaction rate at 1 and 5 years.
Material & method: We evaluated 113 women undergone TOT sling placement with a minimum follow up of 5 years. Preoperative
evaluation included visit, cough test, International Consultation on Incontinence Questionnaire-Short Form and urodynamic
test. Post operatory evaluation (after 15 days, one month, 6 months, 12 months and every year) included Visual Analog Scale
(VAS) and pelvic examination. Micturition symptoms and complications were reported. A negative cough stress test, no need
of pads, auxiliary drug or surgical treatment were variables evaluated to consider a patient as healed.
Results:: Mean follow up was 63 months (60-71). Catheter was always removed on the first postoperative day, 102 (90.3%) patients
were discharged the same day, 2 had fever, 9 remained one day more having a US measured post voided residual >100 ml.
After one year 102 vs 78 at 5 years reported a VAS> 80% (p = 0.001). Subjective care rate decreased from 84% (1 year) to 62%
(5 years). After one year 96 reported no leakage, 91 at 5 years (p = 0.4). 3 asked for a new surgical procedure. According to
Clavien-Dindo scale complications were: Gr I 13.27%, Gr II 0.8%, Gr IIIa 6.19% , Gr IIIb 12.38%, no one intraoperative. 7 had
a “de novo” urinary incontinence; 30.1% reported urge urinary symptoms. Urge incontinence rate was 36.3% at 1 year vs 47.8%
at 5 years.
Conclusion: TOT sling placement is a feasible and safe procedure. Nevertheless medium term results point out a decrease in
patients’ satisfaction rate mainly for urge urinary incontinence related symptoms thus objective improvement has been
reported during follow up.
65*-*;;0%&(-*"/5*.64$"3*/*$**/1";*&/5*405501045&"104*;*0/".&/50
%*4-*/(505
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
allows the inclusion of fiber lasers and fiber-optic Vue Optic Cook 3 Fr diameter. The device allows the fiber laser block through
a Tuohy-Borst adapter thus allowing to maneuver the tip of the fiber with greater accuracy and control. The great channel,
connected to an independent source of suction, allows the intake of liquids, fragments of calculations and / or soft tissue. The
device is equipped with a trigger mechanism that allows the user to manually control the suction force in a continuous or
discontinuous way. Was inserted a 8 Fr nephrostomy at the end of the procedure. The mean operation time was 40 minutes.
RESULTS: All patients was stone free after the procedure. The nephrostomy was removed after 24 hours and the patients discharged
after 48 hours.
CONCLUSION: In our experience, LITHASSIST has proven a reliable and efficient device. The ergonomic handle and the ability
to adjust irrigation and aspiration makes it safe and reliable. The VueOptic 3 Fr avoids the problem of the weight of the camera
head. Finally, the costs are extremely competitive with those of microperc.
64
65
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
X
X
a
r
t
s
b
a
065$0.&4 "/% $0.1-*$"5*0/4 "'5&3 1)0504&-&$5*7& 13045"5&
7"103*;"5*0/ 171
8*5) (3&&/ -*()5 -"4&3 8 */ 1"5*&/54 8)0 )"7&
3&$&*7&%03"-"/5*$0"(6-"5*0/5)&3"1:"4*/(-&$&/5&3&91&3*&/$&
S. Ricciardulli1, R. Napoli1, M. Spagni1, F. Borgatti1, G. Ruoppo1, D. Viola1, S. Spatafora1, F. Bergamaschi1
1
Arcispedale S. Maria Nuova, U.O Urologia (Reggio Emilia)
Introduction: Patients on anticoagulant oral therapy are at high risk for bleeding after electro-cautery transurethral resection of the
prostate or open prostatectomy and they are often denied surgery for symptomatic benign prostatic hyperplasia. We explored
the outcomes and complications after photo-selective vaporization of the prostate in an anti-coagulated, high-risk cohort.
Materials and methods: This is a retrospective single center study. The patients, who received an anticoagulants oral therapy, entered
in the Group 1, the remaining in the Group 2. We evaluated Pre, Intra and Postoperative characteristics. Non parametric
Mann-Whitney U test was used to assess differences between groups.
Results: 60 patients entered in the Group 1 and 111 patients in the Group 2.The Group 1 presented an higher ASA score than Group
2 (2.4 vs. 2 p-value 0.011), lower IPSS score (20 vs. 22 p-value 0.009) and QoL score (3.5 vs. 3.8 p-value 0.023). The groups
presented similar results in surgery duration (47.3 vs. 47.9 minutes p-value 0.457), laser time (15.9 vs. 20 minutes p-value
0.057), energy delivered (13.7 vs. 16.9 kJ p-value 0.169). The 5% of patients in the Group 1 presented bleeding during surgery
with conversion to TURP. The 9% of patients in the Group 2(p-value 0.246) presented the same intraoperative complication.
The median hospital stay was 1,4 day in both groups (p-value 0.193) and the median catheter removal from surgery was 24.3
hours for the Group 1 and 23.2 for the Group 2 (p-value 0.326). According with the Clavien Dindo classification, the early
minor complication rate was 45% for the Group 1 and 36.9 % for the Group 2 and the major complication rate was 5% vs. 0.9%
(p-value 0.109). This study showed that the PVP 180-W is a safety procedure in the patients treated with an anticoagulants
oral therapy.
6/&91&$5&%."44*7&#-&&%*/(4*/630-0(:580$"4&3&10354
Argomenti: cancro del rene, cancro della prostata, ipertrofia prostatica
F. Chiancone1, M. Fedelini1, L. Pucci1, C. Meccariello1, M. Carrino1, P. Fedelini1
1
Abstract
We present two cases of unexpected massive bleedings in urological patients. A 75-year-old female was followed for a small
angiomyolipoma(AML) at our department. Her ultrasonography in November 2014 showed a small left renal AML(9mm).
In March 2015, she reached our emergency department with a typical Wunderlich’s syndrome. She underwent a computed
tomography(CT) scan that showed an actively bleeding small renal angiomyolipoma(28mm). She underwent a superselective
embolization of a segmental renal artery. Small, solitary AMLs(≤20mm) usually do not require a strict follow-up due to their
low probability of growth and of become symptomatic. Moreover, patients with AMLs that increased in size were significantly
younger. This case report shows an explosive small AML in an old female that has had a fast growth in 4 months and had its first
R. Giulianelli1, B.C. Gentile1, L.. Albanesi1, G. Mirabile1, P. Tariciotti1, G. Rizzo1
1
Nuova Villa Claudia (Roma)
Abstract
Between July 2011 to March 2012, 50 consecutive patients with symptomatic prostatic obstruction, were selected to undergo at
our initial experience with B-TUEP (1). All procedures were performed a single surgeon. Pre and postoperative investigation
protocols included PSA dosage, IPSS, IEFF-5, QOL, Uroflowmetry with post-voiding residual urinary volume (PVR), transrectal
ultrasonography assessing prostate volume (TRUS) and long-term complications of surgery. All treated patients completed the
36-months of follow-up. The group had similar baseline characteristics. The improvement was statistically significant for the
IPSS and Q(max) at 24 and 36 months vs the baseline values (P < 0.05). The mean (sd) IPSS decreased from 21 (±3.4) to 7.1
(±1.5) and 7.6 (±1.4) at 24 and 36 months, respectively. The mean Q(max)increased significantly from baseline values at 2 and
3 years, respectively, at 20.8 (±2.4) and 21.8 (±3.1) mL/s after B-TUEP which was statistically significantly better than baseline,
respectively (P < 0.05). Three patients (6%) had Adenoca of Prostate at 14, 20 and 36 months, respectively, and one patient had
a non muscle invasive bladder cancer. In the perioperative time, readmission was required for 6% of patients for hematuria,
and 6 months later, 2 (4%) of those patients developed bladder neck contracture treated with transurethral incision of the
prostate. Bulbar urethral strictures occurred in one patient (2%) , requiring internal optical urethrotomy. Erectile dysfunction
was reported by two (4%) after B-TUEP who were potent before surgery (P > 0.05). The retrograde ejaculation rates in patients
with erectile function were 100%, ( P < 0.05). In the B-TUEP groups, 45 patients (88,2%) were satisfied overall. Although early
results showed that B-TUEP was a good alternative technique among the minimally invasive methods for surgically managing
prostatic obstruction
5)& */5&3.&%*"5&5&3. 3&46-54 0' 53"/463&5)3"- &/6$-&"5*0/ 0' 5)&
13045"5&#56&1
64*/(#*10-"3&/&3(:"4*/(-&$&/53&&91&3*&/$&
65
66
a
r
t
s
X
X
S. Ricciardulli1, M. Spagni1, R. Napoli1, F. Borgatti1, G. Ruoppo1, D.. Viola1, S. Spatafora1, F. Bergamaschi1
1
Arcispedale S. Maria Nuova, U.O Urologia (Reggio Emilia)
Introduction: Photoselective vaporization of the prostate (PVP) with green light laser is a minimally invasive alternative that has
evolved since its introduction in 1998. Aim of this study was to assess safety and efficacy of PVP along the learning curve .
Materials and Methods: Population was divided into 3 groups: group 1 first 50 procedures, group 2 from 51th to 99th and group 3
over 100 procedures. Safety was evaluated by measuring the adverse events related to primary treatment. Efficacy was assessed
by improvements in uroflowmetry parameters, IPSS score and QoL score after a median follow up of 12 months.
Results: 171 patients entered in our study. Groups shown no differences in preoperative characteristics such as age (66 vs 67 vs 65 p
value 0.346), PSA (2.6 vs 3 vs 2.7 p value 0.468), prostate volume (51 vs 54 vs 52 p value 0.850) , IPSS score (21.7 vs 22.2 vs 21.1
pvalue 0.540), QoL score (3.8 vs 3.6 vs 3.6 p value 0.383) and Qmax (8.09 vs 8.2 vs 8.2 p value 0.887). The rate of conversion to
TURP was significantly higher in group 1 and 2 (10% vs 16% vs 1.4 % p value 0.0013). No differences were observed between
groups in early Clavien Dindo minor and major complications rate (p-value 0.805). The rate of re-interventions was higher in
Group 1 and 2 (2% vs 2.8% vs 0 % p-value 0.047). IPSS score, QoL score and maximum urinary flow rate were significantly
improved comparated to baseline at a median follow up of 12 months. Groups shown differences in median Qmax (pvalue
0.002 ), Qmax change (p value 0.008) and median QoL (p value 0.035).
Conclusion: Our study assessed tha a green light 180-W is a simple, safe, effective and reproducible technique with a short learning
curve.
b
a
7"10&/6$-&";*0/&%&--"13045"5"$0/-"4&35)6--*6.5)67&1
'0--08
61"-6/(05&3.*/&
A.. Giacobbe1, L. D’Urso1, A.. Formiconi1, R.. Rosso1, R. Papalia2, E. Altobelli2, G.L.. Muto2, D. Collura1, E. Castelli1, G. Muto2
1
2
Università Campus Bio-Medico, U.O.C. Urologia (Roma)
Abstract
Il laser Thullium consente di vaporizzare, vaporesecare e vapoenucleare il tessuto prostatico. Le caratteristiche fisiche del
laser Thullium ci aiutano a modulare il trattamento endoscopico dell’Adenomatosi prostatica, permettendo al chirurgo di
trattare volumi prostatici sempre maggiori, grazie anche all’elevato potere coagulativo. Presentiamo la Nostra esperienza
sulla vapoenucleazione prostatica (ThuVEP) in un Centro di alto volume, con follow up medio di 36 mesi L’enucleazione
dell’adenoma prostatico inizia dal lobo medio con laser Thullium settato a 90 watt per poi continuare ai lobi laterali. I lobi
enucleati, vengono spinti in vescica e successivamente morcellati. Il tessuto aspirato viene poi inviato per esame istologico.
Nel Nostro centro abbiamo eseguito 456 intervento di ThuVEP su pazienti di età media pari a 67 anni (51-84). Abbiamo
analizzato i nostri risultati dopo un follow up medio di 36 mesi. Preoperatoriamente il volume prostatico medio era 58 cc
(35-160), il flusso max medio 7,8 ml/sec (4-12), il residuo postminzionale medio 132 cc (43-253), il PSA medio 3,6 ng/ml (0,517,8), l’IPSS medio 22 (8-32), l’indice QoL medio 4 (1-6). A 36 mesi dall’intervento, il volume prostatico medio è risultato 24
cc (15-55), il flusso massimo medio 25 ml/sec (18-31), il residuo postminzionale medio 21 cc (0-39), il PSA medio 1,9 ng/ml
(0,2-6,1), l’IPSS medio 9 (2-12), l’indice QoL medio 1,7 (1-3): per tutti i suddetti parametri si è verificato un miglioramento
statisticamente significativo rispetto ai dati preoperatori (p < 0.001). Il tempo operatorio medio è stato di 69 minuti (40-110),
la durata media del cateterismo e della degenza è stata di 2,5 gg (2-4) e 4,2 gg (3-6) rispettivamente.Nella nostra esperienza la
vapoenucleazione dell’adenoma prostatico ha consentito di eseguire endoscopicamente, con perdite ematiche limitate e con
degenza media ridotta, interventi di disostruzione cervico-uretrale su prostate di medio-elevato volume.Tali dati confermano
l’efficacia dei risultati ottenuti già a breve termine
1)0504&-&$5*7&7"103*;"5*0/0'5)&13045"5&64*/(5)&(3&&/-*()5
8 4:45&. 3&53041&$5*7& 4*/(-& $&/5&3 456%: 0/ *.1"$5 0' -&"3/*/( $637&
0/4"'&5:"/%&''*$"$:
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
manifestation with a massive retroperitoneal haemorrhage. We can suggest that also small lesions should be followed closely.
A 66-year-old man underwent a TRUS-guided prostatic needle biopsy at another hospital. Laboratory values were all normal.
Seven hours after the biopsy, the patient reached our emergency department with severe diffuse abdominal pain, hypotension,
tachycardia, and confusional state. Hemoglobin was 6.1g/dl and two blood transfusions were performed immediately. He
underwent a CT that showed an active prostate bleeding and a giant retroperitoneal hematoma. Nevertheless the angiography
showed no more active contrast extravasation, without the need of embolization. Intraprostatic bleeding is very common in
patients undergoing TRUS-guided prostate biopsy, but it is usually bland, and spontaneously stops in a short time. We report
the second case in literature of a very large hematoma extending from the pelvis into the retroperitoneal space. Discrepant
results between CT and the following angiography can usually be found. It is possible that some vascular contrast extravasations
were venous bleedings or nonvascular contrast leakage. Another possibility is spontaneous endogenous hemostasis.
66
67
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
X
X
a
r
t
s
b
a
&70-6;*0/&%&--"4&/4*#*-*5"630"/%304&4460-0(*$"*/"//*456%*0
3&53041&55*70467*4*5&
M. Diambrini1, W.. Giannubilo1, B... Azizi1, C. Bravi1, C. Vecchioli Scaldazza1, V. Ferrara1
1
Ospedale “Carlo Urbani”, U.O.C Urologia (Jesi)
Abstract
Lo studio evidenzia il cambiamento nei modi di pensare di porsi di dialogare nel campo uro andrologico sessuologico dal
punto vista del paziente e della sensibilità dell urologo – andrologo sessuologo. Sono state valutate 26993 visite dal 1995 a
gennaio 2016 con una media annua di 1327 con picco nel 2013 con 1838 visite. Le disfunzioni erettili dichiarate (932) hanno
mostrano un costante incremento con picco negli ultimi 3 anni con una media annua di richieste di 164,6 contro 25,2 degli
anni 1995-2012. I 374 casi di eiaculazione precoce hanno mostrato lo stesso trend con una media annua di richieste nel 20132105 di 66,6 contro 9,2 degli anni 1995-2012. Le disfunzioni erettili sono state il 3,3 % delle visite totali, ma 22,1 % sui 4215
problemi sessuali , EP 1,3 % del totale visite ma 8,8 % sui problemi sessuali, disturbo misto DE e EP 168 pari a 0,6 % del totale
ma 3,9 % sui problemi sessuali. Per di più nel periodo 2014 – gennaio 2016 delle 2849 visite effettuate , 799 (28 %) hanno
lamentato problemi sessuali di cui DE 44,3 %, EP 17,8 % , 76 casi con disturbo misto DE e EP pari al 9,5 %. Gli altri 226 casi
mostravano 100 disturbi relazionali con 26 coinvolgimenti di coppia ,ansia 23, DE ai colloqui successivi in 66 casi , ansia mista
a DE in 3 e disturbo del desiderio in 6 casi . Nel corso degli anni i farmaci inibitori delle fosfodiesterasi hanno rappresentato
una rivoluzione epocale nel modo di affrontare la qualità della vita. Nasce il concetto di “Medicina Sessuale”. Il campione del
distretto di Osimo è particolarmente significativo in quanto copre un bacino utente di circa 40.000 persone offrendo una unica
struttura ospedaliera per tutti i servizi uroandrosessuologici. Ne risultano considerazioni mediche e sociologiche.
063453"5&(:*/5)&."/"(&.&/50'63&5)3"-453*$563&4
S. Guazzieri1, A. Fandella1
1
Casa di Cura Giovanni XXIII, U.O. Urologia (Monastier di Treviso)
Abstract: Stricture of male urethra are the most common cause of obstructed micturition in younger men and frequently recur after
initial endoscopic treatment, so secondmainly and also first line of treatment is switching to open surgery. We want show our
strategy tailored on patient age, length and place of the stricture and relative operating risk. So in 1995 we begin to use a laser
incision of the stricture at 6 o clock position of the urethra initially with a 980 nm diode laser and by 2013 with Ho:Yag 2100
nm of wavelegth.
Materials and Methods: 77 consecutive patients affected by urethra strictures (25-85 y.o., mean age 65). 69 (89,6%) with relapsing
stricture were treated between February 1995 and December 2015 in two different hospitals 1, but with the same procedure.
The fibrous and scar tissue was cut and vaporized usually at 6 o’clock position or towards 3,6 and 9 position in more scarred
cases. A laser urethral resectoscope 15,5 ch of new conception 2 was used. In the relapsed cases a protocol of autocalibration
was used .
Results: 72 / 77 (93,5%) patients were available for the follow up: 39 five years or more (group 1), 22 at three to five years (group 2)
and 11 treated with Holmium Yag laser more recently with almost 3 months of follow up (group 3).
L. Timossi1, E. RIkani1, G.M. Badano1, E. Daglio1, A. Di Domenico1, C. Pezzica1, C. Introini1
1
Abstract
Ureteral strictures (US) can be a recurrent chronic illness that leads to severe side effects and poor quality of life. Several options
to treat US exist, including repeated dilations, stents, minimally invasive reconstructive surgeries, and urinary diversion or
nephrectomy. Placement of an ureteral stent is a good minimally invasive option but has major limitations, such as stent
migration, mucosal in-growth, incrustations,and stent obstruction and the necessity of frequent replacement,we decide to
place this device cause seem that they can prevent all the risk related to double J stent placement. 5 patients whit a mean age of
71yr undergone to Allium placement in the last 9 months. All the patient presented a ureteral stricture due to ureteroenteric
anastomosis after urinary diversion for muscle invasive bladder cancer. All the patients had not recurrence of the desease from
at least 24 month. Previously the Allum placement the 5 patients undergone an anterograde placement of ureterale double
J stent.Preoperatory all the patient perform a CT scan of abdomen. The procedure approches in 3 cases were performed
anterograde and in 2 patients retrograde. Mean time of surgical procedures were 83 minutes (35-200min).The hospital stay
were 2 days in all the cases. After at least 3 month oh follow up no major complication occurred. We belive that this device
represent a good therapeutic options for patients with ureteral strictures, their cost is amortized as not to subject the patient to
additional maneuvers for a long period and the consequent lower consumption of the device in the long run.
63&5&3"- 453*$563&4 " -0/( 5&3. 53&"5.&/5 '03 " -*'&5*.& 130#-&.
063*/*5*"-&91&3*&/$&8*5)"--*6.634
67
68
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Conclusions: . At the third year of follow up more than two third (54/61 – 88%) had a peak flow equal or superior to 12 ml/sec..
With a narrow urethoscope (15,5 ch) and the laser beam we can make an incision at 6 o’clock position without significant
bleeding, opening very well the urethra and leavin a mucosa bridge for a anatomic repair. Autodialatation with a coated
generally 16 ch catheter is well accepted by the patients.
X
X
a
r
t
s
b
a
$0/5*/&/$&065$0.&4"'5&3#-"%%&3/&$,13&4&37"5*0/%63*/(
Argomenti: A. Nordio1, S. Zambito1, S. Confalonieri1, F. Franzoso1
1
t ASST Monza, Ospedale di Desio (Desio)
PURPOSE: Urinary incontinence is one of the major prostate cancer treatment-related morbidities. We review our laparoscopic
prostatectomy (LERP) experience, focusing on post-surgery continence rates.
MATERIAL AND METHODS: Two hundred consecutive patients were identified from a prospectively maintained LERP database.
A bladder neck sparing dissection was preferentially performed during extraperitoneal LERP. On postoperative day 5 or 6
(clinic logistics), the urethral catheter was removed following a trans-rettal ultrasound for exclude urine anastomosys leakage.
RESULTS: Median operative time was 170 minutes and estimated blood loss was 80 mL. Four (2%) patients required bladder neck
reconstruction, while 140 (85%) had bilateral, 20(10%) had unilateral and 10 (5%) did not undergo nerve sparing prostatectomy.
150 (75%) patients had negative surgical margins. Median hospitalization and urethral catheter duration were 6.0 days, both.
At six weeks, a median 1.0 pad per day usage was reported and mean QoL were significantly improved from baseline (p < 0.05).
Of the 170 patients having a minimum three-month follow-up, 150 (88.2%) achieved urinary continence without pads. Age,
QoL, prostate volume and prior TUR surgery independently had significant impact on early continence rate (p < 0.05).
CONCLUSION: A bladder neck sparing dissection allows for early return of urinary continence following LERP without
compromising cancer control.
Argomenti: P. Rovellini1, A.. Gregoro1, R. Bonacina1, G. Caldera1, V. Varca1, S. Verrusio1, N.. Visentin1
1
ASST Rhodense, Ospedale Guido Salvini (Garbagnate Milanese)
Abstract
L’ectopia ureterale viene definita come sbocco ureterale anomalo sito piu’ caudalmente rispetto al corner trigonale. Si conoscono
molteplici sedi di sbocco ectopico che nel sesso maschile sono sempre sopra sfinteriali potendo pero’ coinvolgere anche organi
che originano dal dotto mesonefrico come epididimi, vasi deferenti, vescicole seminali. Nel 80% dei casi gli ureteri ectopici
drenano il distretto superiore di un sistema escretore duplicato. Nella maggior parte dei casi la sede dello sbocco anomalo e’
l’ uretra prostatica, mentre in un terzo dei casi interessa le vescicole seminali con conseguente ureteroidronefrosi e perdita
dell’unita’funzionale.
CASE REPORT. Uomo di 59 anni, anamnesi urologica negativa ; a seguito di riscontro di proteinuria esegue ecografia
addominale che evidenzia plurime formazioni cistiche a carico del rene destro , assottigliamento del mantello corticale del
polo superiore e sospetta dilatazione del bacinetto renale ; in corrispondenza del scavo pelvico , a ridosso della vescica ,
riconoscibile formazione cistica di circa 50mm di dubbia interpretazione ( uretere dilatato? neoplasia ?). La successiva TAC
addome mostra un doppio sistema escretore destro con distretto superiore idronefrotico e funzionalmente escluso ( totale
assottiglimento della corticale) Il decorso ureterale e’ riconoscibile sino in regione pelvica retrovescicale dove appare confluire
in una massa rotondeggiante ipodensa di aspetto cistico pluriconcamerata riconosciuta come vescicola seminale destra
aumentata di volume. La cistoscopia in sedazione evidenzia un solo ostio ureterale a destra, regolare e normofunzionante,
con altrettanta regolarita’ morfologica ,del distretto ureterale inferiore alla ureteropielografia retrograda. A completamento
uno studio ecografico trans rettale conferma incremento volumetrico della vescicola seminale destra con aspetto cistico. I
dati clinici e strumentali depongono per ectopia ureterale superiore nella vescicole seminale omolaterale . In accordo con il
paziente si e’ proceduto a semplice follow-up osservazionale che attualmente risulta regolare con paziente libero da episodi
dolorosi e/o settici ( 18 mesi) .
4#0$$063&5&3"-&&$501*$07&4$*$0-"4&.*/"-&
*/%61-*$*5"%&--"7*"
&4$3&53*$&
68
69
o
6
08:30
10:00
s
1
s
Dalì
0
e
2 ngr
Comunicazioni 5:
o
s
C
t
Urologia funzionale
ed
altro
I
I
c
I
a
X
r
X
t
s
24 maggio 2016
Moderatori: Cristian Gozzi
b
a
Argomenti: M.S. Mangano1, C. Lamon1, A. De Gobbi1, F. Beniamin1, G. Cova1, G. Battistella2, L. Maccatrozzo1
1
Ospedale Ca’ Foncello, S. C. Urologia (Treviso)
2
Ospedale Ca’ Foncello, Servizio di Statistica ed Epidemiologia (Treviso)
Objective
Incidental prostate cancer (iPCa) is found in about 5% patients with lower urinary tract symptoms (LUTS). However, to
establish how to manage this pathological condition could be an interesting therapeutic hint to emphasize. The aim is to
evaluate clinical features in patients with iPCa underwent surgical or endoscopic treatment. Then we describe therapeutic
strategies implemented in our population.
We retrospectively analized 1002 consecutive patients affected by lower urinary tract symptoms (LUTS) and without prior
diagnosis of prostate cancer underwent surgical (227 prostatic retropubic adenomectomy) or endoscopic (775 trans urethral
resection of prostate) treatment between April, 2010 and December, 2015. The pathological stage and the cancer diagnosis of
all BPH specimens were reviewed by pathologists who were unaware of the clinical details. When iPCa was found, we collected
cTNM stages (T1a or T1b), clinical, pathological and biochemical patients’ data, as well as those regarding treatment, overall
survival and disease free survival. We used t-test (p<0.05) and Fisher test for statistical analysis.
Results
In 1002 patients with LUTS we performed 227 prostatic adenomectomy and 775 trans urethral resection of prostate (TURP).
In 60 patients (6%) iPCa: was found: in 30 cases it was cT1a and in the other 30 it was cT1b. In these two groups, comparing
the characteristics regarding age, prostate volume (determined by transrectal ultrasound), PSA density, weight of prostatic
adenoma removed and operative time, did not show statistically significant differences. PSA was significantly higher in cT1b
patients (p=0.03). 4 patients were lost at follow up; in the other 56 patients the mean time of follow up was 45 months. In 27
patients the clinical iPCa stage was T1a: 20 underwent to Watchful Waiting approach and 7 were treated by Active Surveillance
strategy. Of the 29 patients with cT1b, 15 (51.7%) underwent conservative treatment (Watchful Waiting or Active Surveillance
strategies), 4 patients (13.7%) radical prostatectomy, 6 (20.6%) radiotherapy, 4 (13.7%) androgen deprivation, mainly according
to comorbities and clinical conditions. Biochemical failure has occured in 4 patients (7%), of these 2 belonged to cT1a group
and 2 to cT1b. Only one patient died, for other causes.
Discussions
IPCa is still a clinical and pathological condition whose characteristics are not yet fully defined. TNM classification seems
to have a role in stratifying patients as for their management. This study has confirmed that the value of PSA is the only
statistically significant variable, like in the two groups of patients examined. The therapeutic strategies regarding the two
*/$*%&/5"-13045"5&$"/$&3."/"(&.&/5*/1"5*&/5453&"5&%'0363*/"3:
53"$54:.150.4
martedì 24 maggio 2016
08:30 - 10:00 - Comunicazioni 5 - Urologia funzionale ed altro
sala
69
70
b
a
a
r
t
s
-654$0.456%:o&7"-6"5*0/"/%."/"(&.&/50'-654"440$*"5&%50#1)
*/5)&$0/5&950'$0..0/$0.03#*%*5*&4
S. Spatafora1, R. Sanseverino2, C. Introini3, L. Simoni4, G. Conti5
1
Arcispedale S. Maria Nuova (Reggio Emilia)
2
Ospedale Umberto I (Nocera Inferiore)
3
4
Medineos Observational Research (Modena)
5
Ospedale S. Anna (Como)
Objective
Patients with Lower Urinary Tract Symptoms (LUTS) due to Benign Prostate Hypertrophy (BPH) frequently have comorbidities
related to the cardiovascular system such as arterial hypertension, diabetes, hyperlipidemia and metabolic syndrome (1 – 8). In
particular, BPH, causing nocturia- induced sleep disturbance, may have a possible impact on blood pressure variability during
night- time (1). Patients with BPH also frequently complain of depression (9, 10), osteoarthritis (11) chronic renal disease
(12), erectile dysfunction (2, 4, 7), and diabetes (13) and, finally they are frequently exposed to potentially hypotensive agents
such as PDE5-inhibitors (14,15,16). The pharmacological management of BPH with associated comorbidities is particularly
complex with risk of multiple interactions among the different types of treatments (7, 14, 17, 18) and an high likelihood of early
discontinuation of therapy; notwithstanding this, the impact of co-medications and comorbidities on therapeutic choice is still
to be ascertained (19). In general, the evaluation of comorbidities is considered highly relevant for the management of patients
with BPH (20).
1. Objective
The LUTS.COM (Evaluation and management of LUTS associated to BPH in the context of Common COMorbidities)
observational study was designed to assess the prevalence of significant comorbidities in male patients attending a visit for
LUTS associated with BPH at an outpatient clinical ward. Moreover, the study aims (i) to describe the medications administered
for comorbidities, (ii) to assess the patients’ quality of life patients by means of the nocturia-specific Quality-of-Life (N- QOL)
questionnaire administered during the visit, and (iii) to describe the patients’ adherence to the anti-BPH medications as
assessed by the Morisky 4-Item Self-Report Measure of Medication Adherence Scale (MMAS-4) (21, 22, 23), administered
during the visit, in patients under pharmacologic treatment
The LUTS.COM study is an Italian, observational, multicenter, cross-sectional study endorsed by AURO.it (Associazione
Urologi Ospedalieri). At the enrolment visit, retrospective data such as diagnostic tests, and urological parameters (i.e. plasma
levels of PSA, IPSS scores, Qmax, results of digital rectal examination or trans-rectal or suprapubic echographies) were collected
up to 3 months earlier; moreover, data regarding comorbidities and pharmacological treatments for significant comorbidities
and for LUTS were recorded. We focused on significant medical conditions such as arterial hypertension, known ischemic
heart disease, known cerebrovascular disease, known peripheral arterial disease of lower limbs, diabetes mellitus, osteoporosis,
major depressive disorder, chronic renal disorder, osteoarthritis, metabolic syndrome, and erectile dysfunction (as reported
by patients). The patients’ To be considered as evaluable for the LUTS.COM study, patients had to be aged >= 50 years and
present LUTS associated to BPH at enrolment as per clinical judgment. Patients who met the following exclusion criteria were
not considered as evaluable for the analyses: patients who received any investigational compound within 90 days prior to
inclusion; patients who were immediate family members, study site employee, or in dependent relationship with a study site
employee involved in the study; patients with known contra-indication to the medication prescribed for LUTS; patients who
present or refer a known overactive bladder syndrome or prostate cancer. quality of life was assessed by means of the N-QoL
questionnaire. The N-QoL questionnaire (24) specifically measures the effect of nocturia on quality of sleep and consists of
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
groups of patients (cT1a and cT1b) were different: conservative in cT1a group, or conservative vs. curative in T1b group,
depending on the stratification of clinical and pathological characteristics of patients. A longer follow-up could give us more
informations about “oncological end-points” and in particular concerning disease free survival and overall survival.
Conclusion
The population of Italy is aging, and thus interest in prostate cancer is increasing. It is becoming increasingly important to
establish appropriate treatment plans (including the choice of no treatment) that address factors related to patient quality of
life, patient age, life expectancy, performance status, availability of medical care, and patient education. In addition to clinical
stage (T1a vs. T1b), PSA value before and after disostructive approach represents the most informative variable for use in
clinical decisions. In our experience Watchful Waiting and Active Surveillance strategies represent the choice in cT1a iPCa,
while cT1b iPCa deserves to be treated or strictly followed-up.
References
1. Capitanio U. Contemporary management of patients with T1a and T1b prostate cancer. Curr Opin Urol. 2011 May;21(3):2526.
2. Jones JS, Follis HW, Johnson JR. Probability of finding T1a and T1b (incidental) prostate cancer during TURP has decreased
in the PSA era. Prostate Cancer Prostatic Dis. 2009;12(1):57-60.
3. Melchior S1, Hadaschik B, Thüroff S, Thomas C, Gillitzer R, Thüroff J. Outcome of radical prostatectomy for incidental
carcinoma of the prostate. BJU Int. 2009 Jun;103(11):1478-81.
70
71
a
r
t
s
b
a
X
X
1. Karatas OF, Bayrak O, Cimentepe E, Unal D. An insidious risk factor for cardiovascular disease: benign prostatic hyperplasia. Int J Cardiol.
2010 Oct 29;144(3):452. doi: 10.1016/j.ijcard.2009.03.099. Epub 2009 Apr 9. PubMed PMID: 19359054.
2. Roehrborn CG, Nuckolls JG, Wei JT, Steers W; BPH Registry and Patient Survey Steering Committee. The benign prostatic hyperplasia
registry and patient survey: study design, methods and patient baseline characteristics. BJU Int. 2007 Oct;100(4):813-9. PubMed PMID:
17822462.
3. Muzzonigro G. Tamsulosin in the treatment of LUTS/BPH: an Italian multicentre trial. Arch Ital Urol Androl. 2005 Mar;77(1):13-7.
PubMed PMID: 15906783.
4. Li MK, Garcia L, Patron N, Moh LC, Sundram M, Leungwattanakij S, Pripatnanont C, Cheng C, Chi-Wai M, Loi-Cheong N. An Asian
multinational prospective observational registry of patients with benign prostatic hyperplasia, with a focus on comorbidities, lower
urinary tract symptoms and sexual function. BJU Int. 2008 Jan;101(2):197-202. Epub 2007 Nov 13. PubMed PMID: 18005205. McVary
KT: BPH – epidemiology and comorbidities Am J Managed Care 2006, 12, 5 suppl.: S 122-8
5. Sarma AV, Kellogg Parsons J. Diabetes and benign prostatic hyperplasia: emerging clinical connections. Curr Urol Rep. 2009 Jul;10(4):26775. Review. PubMed PMID: 19570487.
6. Shah M, Butler M, Bramley T, Curtice TG, Fine S. Comparison of health care costs and co-morbidities between men diagnosed with
benign prostatic hyperplasia and cardiovascular disease (CVD) and men with CVD alone in a US commercial population. Curr Med
Res Opin. 2007 Feb;23(2):417-26. PubMed PMID: 17288695.
7. Hartung R, Matzkin H, Alcaraz A, Emberton M, Harving N, van Moorselaar J, Elhilali M, Vallancien G; ALF-ONE Study Group. Age,
comorbidity and hypertensive co-medication do not affect cardiovascular tolerability of 10 mg alfuzosin once daily. J Urol. 2006
Feb;175(2):624-8; discussion 628. PubMed PMID: 16407011.
8. Hartung R, Matzkin H, Alcaraz A, Emberton M, Harving N, van Moorselaar J, Elhilali M, Vallancien G; ALF-ONE Study Group. Age,
comorbidity and hypertensive co-medication do not affect cardiovascular tolerability of 10 mg alfuzosin once daily. J Urol. 2006
Feb;175(2):624-8; discussion 628. PubMed PMID: 16407011.
9. Quek KF, Low WY, Razack AH, Loh CS. The psychological effects of treatments for lower urinary tract symptoms. BJU Int. 2000
Oct;86(6):630-3. PubMed PMID: 11069367.
10. Rom M, Schatzl G, Swietek N, Rücklinger E, Kratzik C. Lower urinary tract symptoms and depression. BJU Int. 2012 Dec;110(11 Pt
C):E918-21. doi: 10.1111/j.1464410X.2012.11552.x. Epub 2012 Oct 26. PubMed PMID: 23107188.
11. Song HJ, Han MA, Kang HC, Park KS, Kim KS, Kim MK, Kang J, Park EO, Hyun MY, Kim CS. Impact of lower urinary tract symptoms
and depression on health-related quality of life in older adults. Int Neurourol J. 2012 Sep;16(3):132-8. doi: 10.5213/inj.2012.16.3.132.
Epub 2012 Sep 30. PubMed PMID: 23094219; PubMed
Central PMCID: PMC3469832.
12. Hong SK, Lee ST, Jeong SJ, Byun SS, Hong YK, Park DS, Hong JY, Son JH, Kim C,
Jang SH, Lee SE. Chronic kidney disease among men with lower urinary tract symptoms due to benign prostatic hyperplasia. BJU Int. 2010
May;105(10):1424-8. doi: 10.1111/j.1464-410X.2009.08975.x. Epub 2009 Oct 28. PubMed PMID: 19874305.
13. Fourcade RO, Lacoin F, Rouprêt M, Slama A, Le Fur C, Michel E, Sitbon A, Cotté FE. Outcomes and general health-related quality of life
among patients medically treated in general daily practice for lower urinary tract symptoms due to benign prostatic hyperplasia. World
J Urol. 2012 Jun;30(3):419-26. doi: 10.1007/s00345-011-0756-2. Epub 2011 Sep 3. PubMed PMID: 21892656; PubMed Central PMCID:
PMC3360843.
14. White WB, Moon T. Treatment of benign prostatic hyperplasia in hypertensive men. J Clin Hypertens (Greenwich). 2005 Apr;7(4):212-7.
Review. PubMed PMID: 15860960.
15. Nieminen T, Kööbi T, Tammela TL, Kähönen M. Hypotensive potential of sildenafil and tamsulosin during orthostasis. Clin Drug
Investig. 2006;26(11):667-71. PubMed PMID: 17163302.
16. Kloner RA. Pharmacology and drug interaction effects of the phosphodiesterase 5 inhibitors: focus on alpha-blocker interactions. Am J
Cardiol. 2005 Dec 26;96(12B):42M- 46M. Epub 2005 Dec 5. Review. PubMed PMID: 16387566.
17. Schulman CC. Lower urinary tract symptoms/benign prostatic hyperplasia: minimizing morbidity caused by treatment. Urology. 2003
Sep;62(3 Suppl 1):24-33. Review. PubMed PMID: 12957197.
18. O’Leary MP. Treatment and pharmacologic management of BPH in the context of common comorbidities. Am J Manag Care. 2006
Apr;12(5 Suppl):S129-40. Review. PubMed PMID: 16613527.
19. Verhamme KM, Dieleman JP, Bleumink GS, Bosch JL, Stricker BH, Sturkenboom MC. Treatment strategies, patterns of drug use
and treatment discontinuation in men with LUTS suggestive of benign prostatic hyperplasia: the Triumph project. Eur Urol. 2003
Nov;44(5):539-45. PubMed PMID: 14572751.
20. Djavan B, Margreiter M, Dianat SS. An algorithm for medical management in male lower urinary tract symptoms. Curr Opin Urol. 2011
Jan;21(1):5-12. doi: 10.1097/MOU.0b013e32834100ef. Review. PubMed PMID: 21045704.
21. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care.
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
12 items scored from 0 to 4 and one item regarding quality of life. Two sub-scales (sleep/energy and bother/concern) scores
and an overall score can be calculated. Higher scores mean better quality of life. Finally, patients’ adherence to the anti-BPH
therapies were evaluated by the MMAS-4. The MMAS-4 is a self-reported, medication-taking behavior scale and consists of
four questions about the way patients might experience drug errors or omissions. The MMAS-4 score is a nonadherence score
ranging from 0 to 4 (21, 22, 23); a higher score means higher adherence to therapy.
Results
Patients were consecutively enrolled from December 2014 to December 2015. The LUTS.COM study involved 29 Urology
Italian Centers that enrolled 807 male patients. Final statistical analyses are currently ongoing.
Discussions
Data are not available yet. Statistical analyses will be performed in order to respond to the study objectives.
Conclusion
The management of patients with LUTS due to BPH is strongly influenced by the frequent presence of multiple comorbidities,
and so, it is fundamental to have a clear idea of what is the distribution of comorbidities among these patients, in the Italian
context. This study will allow to describe comorbidities in Italian patients affected by LUTS suggestive of BPH.
References
71
72
Argomenti: E.. Altobelli1, R. Papalia1, A. Giacobbe2, D. Collura2, C.. Falavolti1, E. Shehu1, E.. Luperto1, M. Kurti1, R. Mastroianni1, G.. Muto1
1
2
Ospedale San Giovanni Bosco (Roma)
Objective
Primary malignant melanoma of the bladder is a very rare event; most commonly, malignant melanomas of the bladder are
metastatic lesions. 26 cases of primary melanoma of the bladder have been reported. We report a case of primary bladder
melanoma without involvement of other sites.
In January 2015, an 81-year-old man was admitted to our Geriatrics Unit for an episode of gross hematuria in the previous
month, in the absence of any symptoms. The medical history included hypertension, hypothyroidism treated with L-thyroxine,
peripheral arterial disease, and corneal transplantation at the age of 74. Urine cytology identified atypical cells, but analysis
was not diriment. The patient underwent cystoscopy, with evidence of three esophytic lesions on which multiple biopsies
were performed. Histology revealed groups of neoplastic cells with focal intracytoplasmatic melanin pigmentation.
Immunohistochemistry revealed positivity for HMB45, MART-1, and S-100. Thus, a diagnosis of bladder melanoma was
made. At a further cutaneous examination, two nevi were detected and surgically removed; both were dysplastic without any
sign of melanoma. A PET-CT did not reveal any further neoplastic localization. A gastrointestinal endoscopy was as well
negative. An ophthalmic exam with fundus oculi exam did not evidence retinal melanoma.
Results
The patient underwent total cystoprostatectomy with ureteroileal anastomosis. Anatomic and histological examination
showed two ulcerated lesions (2,5 cm and cm 1 in diameter respectively), involving the posterior wall. The lesions were totally
sampled embedded in paraffin and were cut at 3 μm thickness for standard histology and for immunohistochemical studies.
The lesions showed a proliferation of epithelioid-like cells, characterized by ample eosinophilic cytoplasm, nuclear irregularity
and pleomorphism, with conspicuous nucleolus, and arranged in solid nests. The neoplasia involved the mucosa, muscular
and adipose tissue of bladder’s wall. Pigment deposits were also present in the neoplastic tissue. Immunohistochemistry was
performed by the streptavidinbiotin method. The antibodies used were mouse monoclonal antibodies against HMB-45,
MART-1 and S100 protein, all from Dakocytomation, Denmark. Sections were incubated with LSAB2 (Dakocytomation).
3-3-Diaminobenzidine (DAB) was used for colour development and haematoxylin was used for counterstaining.
Immunohistochemical analysis evidenced positivity of neoplastic cells for HMB45, MART1 and, focally for S100 protein.
These findings confirmed the diagnosis of malignant melanoma. Also, a prostate cancer with a Gleason score of 7 (4+3) was
diagnosed. During the postoperative course, the patient experienced wound dehiscence, sepsis, and respiratory insufficiency.
In agreement with the patient and family, because of the patient’s age, and comorbidity, no further therapies were performed.
After 12 months, the patient is still alive and independent in the basic activities of daily living, apparently disease free.
Furthermore, the PSA is <0.01 ng/mL.
Discussions
Primary malignant melanoma is uncommon in the genitourinary tract, especially in the bladder. According to literature, age
at presentation of primary bladder melanoma ranges between 7 and 91 years (59 ± 17). The origin of malignant melanoma
in the bladder is still unclear. According to the ectopic theory, melanocytes would migrate from the neural crest through
the mesenchyme toward the skin and hair follicles, possibly stopping in ectopic locations, including a developing bladder.
Another hypothesis is that argyrophil urothelial cells are derived from urothelial stem cells with differentiation in the direction
of neoplastic melanocytes. In the absence of a clinical history of melanoma, other lesions with an infiltrative growth pattern
and similar cytomorphology may be considered. The possible list of differential diagnoses includes high grade urothelial
carcinoma, prostatic carcinoma in male, Mullerian carcinomas in female, lung carcinoma, breast carcinoma, and rare entities
like paraganglioma and sarcomatoid carcinoma.
Conclusion
There is no consensus opinion regarding the best treatment option in the management of primary malignant melanoma of
the urinary bladder, due to the paucity of cases so far reported. To date, the prognosis of primitive malignant melanoma is still
poor. Trials involving treatment options aimed at improving patient’s survival and quality of life are urgent. In this perspective,
our case report seems of special interest because our patient, though being frail and multimorbid, successfully underwent
major surgery and is free from release and in good clinical status after one year. In conclusion, this case report shows that
bladder melanoma, though distinctly rare, should be suspected at any age and might be amenable to a radical treatment even
in very old and frail patients
X
X
b
a
a
r
t
s
"/6/646"-$"64&0')&."563*"13*."3:#-"%%&3.&-"/0."*/"/0-%
."/
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
1986 Jan;24(1):67-74. PubMed PMID: 3945130.
22. Morisky DE, DiMatteo MR. Improving the measurement of self-reported medication nonadherence: response to authors. J Clin
Epidemiol. 2011 Mar;64(3):255-7; discussion 258-63. doi: 10.1016/j.jclinepi.2010.09.002. Epub 2010 Dec 8. PubMed PMID: 21144706;
PubMed Central PMCID: PMC3109729.
23. Morisky DE, Malotte CK, Choi P, Davidson P, Rigler S, Sugland B, Langer M. A patient education program to improve adherence rates
with antituberculosis drug regimens. Health Educ Q. 1990 Fall;17(3):253-67. PubMed PMID: 2228629.
24. Abraham L, Hareendran A, Mills IW, Martin ML, Abrams P, Drake MJ, MacDonagh RP, Noble JG. Development and validation of a
quality-of-life measure for men with nocturia. Urology. 2004 Mar;63(3):481-6. PubMed PMID: 15028442.
72
73
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
X
X
b
a
a
r
t
s
Argomenti: R. Nucciotti1, F.M. Costantini1
1
Objective
Abdominal sacrocohysteropexy is the gold standard treatment for pelvic organ prolapse (POP) and can be performed
laparoscopically. The demand for treatment of pelvic floor disorders has been projected to increase significantly in the
coming years, as Western countries are experiencing a rapid increase in the geriatric demographic. The prevalence of
pelvic organ prolapse (POP), defined as stage ≥2 prolapse using the Pelvic Organ Prolapse Quantification (POP-Q)
examination, was reported to be 37% in the general population and increased to 64.8% in an older population of
women with a mean age of 68 yr . . To evaluate the surgical outcome, complications and benefits of laparoscopic single
promonto-fixation for patients with pelvic prolapse.
POP surgery aims to restore physiologic anatomy as well as to preserve lower urinary tract, intestinal, and sexual
functions.We perform a posterior dissection down to the levator muscles and an anterior dissection down to the
trigone. a transperitoneal placement of a 100% polyester mesh on the anterior vaginal wall and a posterior mesh on the
levator ani muscle . The posterior mesh, “butterfly” shaped is sutured to the levator muscles, to the rectum above the
anorectal junction and to the uterosacral ligaments. The anterior mesh is sutured to the vagina and the isthmus/cervix
and attached to the promontory with a tension measured through a vaginal exam.
Results
A total of 243 patients were operated from 2005 to 2015. Their mean age was 63 (range 35–78), average follow-up
was 14.6 months, the mean operating time was 102 minutes. There were 2 conversions due to anesthetic or surgical
difficulties. Follow up was done by a postal questionnaire and physical examination at 6 months and then yearly.
96% were satisfied with the results of their operation and no patients complained of sexual dysfunction. There was
a 2% recurrence rate of prolapse, 0 vaginal erosions. Perioperative complications were one vaginal effraction . The
mean hospital stay was 3 days (2–5) . We observed no retraction of the mesh and no dyspareunia. With this type
of conformation of the posterior mesh we have significantly reduced the dischezia compared to double promontofixation.
Discussions
Laparoscopic promonto-fixation is feasible and highly effective technique that offers good long-term results with
complication rates similar to open surgery, with the added benefits of minimally invasive surgery We consider
unnecessary remove uterus and promontory attached of the posterior mesh, reducing the risk of erosion, constipation
and dischezia. De novo urgency was observed in 10 patients (10.5%) who had had previous high-grade cystocele
(five with concomitant prolapse of other compartments). The symptoms were treated with short-term anticholinergic
medications and always resolved in the first few weeks after surgery. Laparoscopic approach was developed to reduce
surgical invasiveness and was shown to achieve similar results compared with the open approach . However, the
procedure is technically challenging, particularly because of the need to perform intracorporeal sutures in a limited
space, and is characterised by relatively long operative times.
Conclusion
With this technique we performed a complete treatment for severe prolapse by a minimally invasive approach with a
low rate of recurrence at this point. Our technique of RASC with implant of polypropylene meshes is associated with
low morbidity and good long-term results in the treatment of all types of POP. High BMI and previous abdominal or
vaginal surgery, including previous treatments for POP, do not represent a contraindication for this surgical approach.
Our study is limited by its retrospective and noncomparative design. Furthermore, we relied only on the Baden-Walker
classification for assessment of POP without using the International Continence Society organ prolapse classification
and did not obtain information about QoL after surgery. We are also aware that the use of interviews before data analysis
rather than standardised questionnaires or mandatory follow-up examinations might have led to an underestimation
of symptoms or asymptomatic POP recurrences. Further prospective and comparative studies are needed to confirm
these findings.
References
-Medium-Term Anatomic and Functional Results of Laparoscopic Sacrocolpopexy Beyond the Learning Curve By:
Filip Claerhout, Dirk De Ridder, Jan Paul Roovers, Heidi Rommens, Federico … Issue: 6, Volume: 55, Pages: 1459
– 1468, Published: 2009
-Laparoscopic Sacral Colpopexy Approach for Genito-Urinary Prolapse: Experience with 363 Cases By: Francois Rozet,
Eric Mandron, Carlos Arroyo, Henry Andrews, Xavier Cathelineau, … Published: 2014
-A Review of the Current Status of Laparoscopic and Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse By:
Richard K. Lee, Alexandre Mottrie, Christopher K. Payne, David Waltregny Issue: 6, Volume: 65, Pages: 1128 –
1137, Published: 2014
-"1"304$01*$4"$30$0-101&9:'031&-7*$03("/130-"14&463(*$"-
5&$)/*26&"/%065$0.&4
73
74
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
X
X
b
a
a
r
t
s
C. Curatolo1, G. Masiello1, T. Turtur1, V. Verriello1, M. Altomare1
1
Ospedale Civile di Molfetta, U.O.C. Urologia (Molfetta)
Objective
Chronic pelvic pain syndrome (CPPS) is used to designate unexplained chronic pelvic pain in men. The management of
patients with chronic pelvic and perineal pain requires preliminary clinical analysis designed to identify correlated urological
and abdominal dysfunction. Physical evaluation is required to identify trigger points responsible for myofascial pain, pelvic
floor muscle tension, and lumbar-pelvic-hip instability. Physiotherapy is one of the first step therapy suggested in and must
be initiated early in the course of the disease by therapists trained in these techniques. These techniques can be supported by
use of several drugs. Palmitoylethanolamide (PEA) is an endogenous fatty acid amide, belonging to the class of nuclear factor
agonists. PEA has been demonstrated to bind to a receptor in the cell-nucleus (a nuclear receptor) and exerts a great variety
of biological functions related to chronic pain and inflammation. Aim of this study is to describe muscle examination in
patients with chronic pelvic and perineal pain and to determine the results that can be expected from physiotherapy and use
of palmitoylethanolamide.
In the study from January 2014 to April 2015 22 men (average age 37,8 – range 26-62) with Chronic Pelvic Pain Syndrome
(CP/CPPS) were selected and enrolled in this study. The pain was associated to irritative voiding symptoms in 12. Preliminary
clinical and instrumental evaluation was performed to exclude other pathologies. Physical evaluation was performed to identify
trigger points responsible for myofascial pain, pelvic floor muscle tension, and lumbar-pelvic-hip instability. In all patients we
administered palmitoylethanolamide, 1200 mg for 15 days and 600 mg for 75 days. Pelvic floor rehabilitation was performed
after 15 days of therapy and comprised repeated muscle contractions of the pelvic floor and biofeedback, twice a week for 6
weeks.
Results
All patients were evaluated with Vas pain score and SF 12 score for quality of life before and after therapy. Vas and SF 12 were
administrated at three and six months after therapy. We observed a significant decrease of Vas score and increase of SF 12 in
18 of 22 patients ( 81,8%). In 8 of the 12 patients with irritative voiding symptoms we observed significant improvements (66%
). These evaluations were confirmed by the dates at three and six months after therapy ( 16 and 14 of 22 patients). No adverse
reactions were recognized during administration of the drug.
Discussions
Pelvic pain is pain in the area of the pelvis. If the pain lasts for more than six months, it is deemed to be chronic pelvic
pain. It can affect both women and men. Chronic pelvic pain in men is often referred to as Chronic Prostatitis / Chronic
Pelvic Pain Syndrome (CP/CPPS). This pain is associated with irritative voiding symptoms and/or pain located in the groin,
genitalia, or perineum in the absence of pyuria and bacteriuria. The use of the term prostatodynia is not encouraged in
current practice. This term carries the negative historical connotation of being a “wastebasket” designation for a melange
of psychosomatic symptoms and suggests that the source of the patient’s symptoms invariably lies within the prostate gland
itself. Current research has provided evidence of numerous extraprostatic considerations, including neuropathic and other
systemic pathologies. There are no standard diagnostic tests; diagnosis is by exclusion of other disease entities. Multimodal
therapy is the most successful treatment option, and includes blockers, phytotherapy, and protocols aimed at quieting the
pelvic nerves through myofascial trigger point release with psychological re-training for anxiety control. Recently some
protocols have used Palmitoylethanolamide (PEA). It is an endogenous fatty acid amide, belonging to the class of nuclear
factor agonists. PEA, as an N-acylethanolamine, has physico-chemical properties comparable to anandamide, and while it is
not strictly an endocannabinoid, it is often studied in conjunction with anandamide because of their overlapping synthetic and
metabolic pathways. The signaling lipid PEA is known to activate intracellular, nuclear and membrane-associated receptors
and regulate many physiological functions related to the inflammatory cascade and chronic pain states. PEA’s mechanism of
action sometimes is described as Autacoid Local Injury Antagonism (acronym ALIA),and PEA under this nomenclature is an
ALIAmide. Since 1993, many papers have been published on the various effects of PEA on the mast cell. Mast cells are often
found in proximity to sensory nerve endings and their degranulation can enhance the nociceptive signal, the reason why
peripheral mast cells are considered to be pro-inflammatory and pro-nociceptive and in this work has been used successfully in
association with pelvic rehabilitation, in order to emphasize the role of the drug with the use of relaxing exercises understood
through biofeedback.
Conclusion
PEA’s activity is currently seen as a new inroad in the treatment of neuropathic pain and related disorders. PEA has been
explored in various clinical trials in a variety of pain states, for inflammatory and pain syndrome. From a clinical perspective
the most important and promising indications for PEA are linked to neuropathic and chronic pain states, such as diabetic
neuropathic pain, sciatic pain, CRPS, pelvic pain and entrapment neuropathic pain states. Although the limited number
of treated patients in this work Palmitoylethanolamide, in association with pelvic floor rehabilitation, seems to be a useful
alternative in the first step of treatment of chronic pelvic pain in men with or without voiding symptoms.
References
1. Treatment of the musculoskeletal component of chronic pelvic and perineal pain M Guerineau, J-J Labat, L Sibert, D
%FMBWJFSSF+3JHBVE/PWt1SPHSÒTFO6SPMPHJF
2. Pelvic Floor Muscle Examination in Female Chronic Pelvic Pain Colleen M Fitzgerald, Cynthia E Neville, Trudy Mallinson,
1&-7*$'-0033&)"#*-*5"5*0/*/$)30/*$1&-7*$1"*/4:/%30.&
74
75
3.
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
4V[BOOF"#BEJMMP$ISJTUJOB,)ZOFT'SBOL'5V+VOtćF+PVSOBMPGSFQSPEVDUJWFNFEJDJOF
&ďDBDZPG,FHFMFYFSDJTFTPOMPXFSCBDLQBJODPOUSPMJOQBUJFOUTPG$ZTUPDFMF5/BRBJTI'3J[WJ4"NCSFFO+BOt
Rawal Medical Journal
X
X
b
a
a
r
t
s
G. Palleschi1, A.L. Pastore1, Y. Al Salhi1, L. Riganelli2, D. Autieri1, A. Ripoli1, A. Leto1, G. Velotti1, S. Al Rawashdah1, A. Carbone1
1
2
“Sapienza” Università di Roma, Dipartimento di Ginecologia (Roma)
Objective
The number of surgeries as a treatment for female SUI has increased, and an alternative approach using a transobturator
passage of the tape has been developed; the midurethral slings (MUS) procedures has become increasingly popular. In
literature Few studies compared these two widespread techniques used for the management of SUI, and none, at the best of
our knowledge, evaluated before the sexual function after these procedures. Single-incision slings (SIS) have been developed
to reduce procedure-related discomfort without negatively affecting the benefit. Similar to the transobturator slings, the SIS
perforates the obturator internus muscle and the foramen obturatum but does not perforate the adductor muscles, resulting
in less postoperative pain. Thus, the aim of the study was to prospectively evaluate the effect of TVT-O vs. SIS procedures on
the sexual function and QoL in female patients with SUI by using the Female Sexual Function Index (FSFI) and International
Consultation on Incontinence Modular Questionnaire-Short Form (ICIQ-SF).
In total, 48 patients were included in the study and were divided into groups for treatment of SUI: 24 patients underwent
insertion of tension-free transobturator suburethral tape (TVT-O group) and 24 underwent insertion of transobturator singleincision mini-sling (SIS group). Patients were divided by a simple randomization (after a stratified randomization to control all
the baseline covariates between the two study arms) in the two treatment groups. Using a computer table generation of random
numbers: group 1 (n = 24 women) was treated with TVT-O to correct SUI, and group 2 (n = 24 women) was treated with
the SIS. Both groups were evaluated with the same questionnaires after 6 and 12 months of treatment to assess the impact of
continence on quality of life and the sexual function. The preoperative urodynamic assessment of the patients was performed
in accordance with the International Continence Society guidelines. Only sexual-active patients were enrolled in the study;
the participants who have had at least one sexual activity within three months prior to surgery were considered as being sexual
active. Before the surgery and at six months of follow-up (when the participants attended the Urogynecology outpatient clinic),
the participants were asked to complete the Italian versions of the FSFI questionnaires for the assessment of sexual function
and the ICIQ-SF questionnaires.
Results
Mean operative time was 23.5 mins (range: 13-26) in TVT-O group, and 22.5 mins (range: 12.8-25) in SIS group. No intra
and postoperative complications occurred. One patient of TVT-O group experienced a vaginal wall erosion (21 days after
surgery) and one of the SIS group reported a denovo outlet obstruction. No patients reported a denovo urgency incontinence
and/or overactive bladder. All women who had an active sexual life preoperatively reported sexual activity after procedures.
The mean time of postoperative sexual activity resumption was 36 days (range : 32-44 days). The 6 months postoperative
results indicated that the total FSFI scores increased from 23.96 ± 5.56 to 28.09 ± 3.34 for the TVT-O group and from 23.51 ±
3.78 to 27.42 ± 3.62 for the SIS group. Additionally, significant improvements were also found in all the domains considered
(sexual desire, sexual arousal, lubrication, orgasm, satisfaction and pain). No statistically significant differences were observed
between the two treatment groups. Furthermore, the mean postoperative ICIQ-SF scores were significantly lower than the
mean preoperative ICIQ-SF scores (an indicator of improvement of QoL). At the initial follow-up of 6 months 18/21 (85.7%)
and 17/21 (80.9%) patients after SIS and TVT-O groups respectively experienced a complete recovery of urinary continence.
At 12 months follow-up after surgery, 19 (90.4%) patients who successfully underwent the SIS procedure reported a complete
resolution of urinary incontinence while 2 (9.5%) reported an improvement in urinary incontinence. In the TVT-O group,
total recovery of urinary incontinence was observed in 18/21 (85.7%) of patients, and an improvement in the incontinence
was observed in 1/21 (4.1%) of patients who had showed negative results during the physical examination. In addition, one
vaginal wall erosion complication was observed in the TVT-O group, and one patient reported acute retention of urine in the
SIS group.
Discussions
To the best of our knowledge this is the first study to compare sexual function in patients affected by SUI submitted to SIS
versus TVT-O. Minimally invasive mid-urethral slings have become the standard surgical procedure for treatment of stress
urinary incontinence in women. The TVT-O procedure is an inside-out transobturator sling technique that is a modified
version of the TVT procedure. It has gained worldwide use because of its safety, simplicity, and effectiveness in treating SUI.
However, limited investigation exists on the effect of transobturator sling procedures, including TVT-O, on sexual function.
For avoiding the complications due to the blind needle passage through the retropubic space (TVT sling) or transobturator
&7"-6"5*0/0'4&96"-'6/$5*0/"/%26"-*5:0'-*'&*/80.&/53&"5&%'03
453&44 63*/"3: */$0/5*/&/$& 5&/4*0/'3&& 53"/40#563"503 46#63&5)3"-
5"1&744*/(-&*/$*4*0/4-*/(
75
76
a
r
t
s
b
a
-0/(5&3.&''*$"$:"/%3*4,'"$5034'03463(*$"-'"*-63&0'5750
T.. Realfonso1, G. Napodano1, G. Molisso1, U.. Di Mauro1, R.. Sanseverino1
1
Objective
The short-medium term outcomes after TVT-O are quite known in the literature. Less known are the long-term results. With
this retrospective study we wanted to examine the functional aspects, complications and the possible risk factors in the failure,
after the TVT-O placement in a long time.
Hundred twenty-five patients who had undergone a period of twelve years of TVT-O positioning operation for stress urinary
incontinence were evaluated retrospectively. One urogynecological team has performed all procedures. The patients had stress
urinary incontinence (SUI) and had undergone Urodynamics (UDS). They excluded women with a history of previous surgery
for incontinence or radical pelvic surgery and those with hyperactivity ‘detrusor overactivity (DO). They were considered
objectively cured patients who had no urinary leakage during cough stress test (CST). Subjective outcomes were assessed using
the Incontinence Questionnaire for Evaluating Female Lower Urinary Tract Symptoms (ICIQ-FLUTS). The quality of life was
measured with the King’s Health Questionnaire (KHQ). To identify risk factors for the failures of the procedure have been used
univariate and multivariate analyzes.
Results
The median follow-up was 102 months (range 72-144). 78.9% (98/125) of patients were objectively cured, while 80.4%
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
foramen (TOT sling), the new SIS systems were introduced. These slings aim to obtain the same suburethral support with less
invasivity by anchoring the two arms in the obturator fascia while avoiding the passage through the adductor muscles. In this
study no evidence of a significant difference in terms of continence rates between SIS (90.4%) and TVT-O (89.8%) groups was
observed. However, this lack of significant differences has to be carefully interpreted because of the study main limitations:
short term follow-up, and the small number of enrolled patients. Sentilhes et al. have found no significant differences after
surgery regarding the frequency and appreciation of sexual intercourse, extent of sexuality, and frequency of leakage during
intercourse. A review by Abdel-Fattah et al. reflected the primary suboptimal results of SIS with inferior patient-reported and
objective cure rates on the short-term follow-up and higher reoperation rates for SUI when compared with standard midurethral
tapes. In a multicentre prospective randomised trial in six UK centers, Mostafa and colleagues compared the postoperative
pain profile, peri-operative details, and short-term patient reported and objective success rates of single-incision mini-slings
(SIS) versus standard mid-urethral slings (TVT-O) in 137 women suffering from pure SUI. The adjustable single-incision sling
was associated with a significantly improved postoperative pain profile and earlier return to work when compared to standard
mid-urethral slings, with encouraging results in patient-reported and objective success rates at short-term follow-up. In our
study, both the sling systems provided high continence rates without major complications: 90.4% in SIS group and 89.8% in
TVT-O group with total continence or improvement support equality of data. A median follow-up period of 12 months is short
for the comparison of objective outcome measures to reveal the benefits of different sling systems. Thus, the limitations of the
study include the differences between pre- and postoperative results that were minimal, probably because of the small number
of sample size. Furthermore, sexual function is affected by multiple factors such as anatomy, traditional culture, education, and
psychological factors, and the FSFI questionnaire hardly reflects all the possible problems related to sexual function. It would
have been useful to have had a longer follow-up period to see whether sexual function changed over time.
Conclusion
The current evidence of pelvic floor surgery on sexual function is contradictory. Many studies dealing with the changes of
sexual function after incontinence surgery show varying results. SIS and the TVT-O procedures seem to be effective and safe
in the operative treatment of female SUI. Twelve-months of follow-up data showed comparable continence rates for SIS and
TVT-O without any severe side-effects or complications. The results also showed improved QoL after the surgery. In addition,
significant improvements in sexual function were also observed for both the TVT-O and SIS procedures. In our study, both the
sling systems are equally effective in improving continence and sexual function of female patients with SUI.
References
1. Abdel-Fattah M, Agur W, Abdel-All M et al (2012) Prospective multi-centre study of adjustable single-incision mini-sling
(Ajust°) in the management of stress urinary incontinence in women: 1-year follow-up study. BJU Int 109(6):880–886.
2. Pickens RB, Klein FA, Mobley JD 3rd, White WM (2011) Single-incision mid-urethral sling for treatment of female stress
urinary incontinence. Urology 77(2):321–324.
3. Elzevier HW, Putter H, Delaere KPJ, Venema PL, Lycklama à Nijeholt AAB, Pelger RCM. Female sexual function after
surgery for stress urinary incontinence: transobturator suburethral tape vs. tension-free vaginal tape obturator. J Sex Med
2008;5(2):400–6.
4. Sentilhes L, Berthier A, Caremel R, Loisel C, Marpeau L, Grise P (2008) Sexual function after transobturator tape procedure
for stress urinary incontinence. Urology 71:1074–1079
5. Mostafa A, Agur W, Abdel-All M, Guerrero K, Lim C, Allam M, Yousef M, N’Dow J, Abdel-fattah M. A multicentre
prospective randomised study of single-incision mini-sling (Ajust®) versus tension free vaginal tape-obturator (TVT-O™)
in the management of female stress urinary incontinence: pain profile and short-term outcomes. Eur J Obstet Gynecol
Reprod Biol. 2012;165(1):115-2.
76
77
a
r
t
s
b
a
#056-*/6. 509*/ '03 5)& 53&"5.&/5 0' 07&3"$5*7& #-"%%&3 " 4*/(-&
*/45*565&&91&3*&/$&
M. Carrino1, F. Chiancone1, F. Persico1, G. Battaglia1, R. Aponte1, L. Pucci1, P. Fedelini1
1
Objective
Overactive bladder syndrome (OAB) is a complex disease. It is associated with social embarrassment, depression and loss
of work productivity. It is usually treated with antimuscarinics drugs, even if antimuscarinics may be associated with side
effects that result in poor persistence and contribute to anticholinergic burden, particularly in those taking other medications
with anticholinergic properties. Recentely Mirabegron has been investigated as a potential alternative to antimuscarinics
(1),(2). Intravesical Botulinum injection is an effective treatment for overactive bladder in patients that are refractory to
antimuscarinics. Botulinum toxin significantly improves OAB symptoms and urodynamic parameters in patients with OAB
(3). The aim of this study is to evaluate our experience in the use of Botulinum toxin for OAB.
We conducted a retrospective analysis of patients treated with botulinum toxin for overactive bladder between June 2012
and January 2015 at our institution. A total of 70 patients were enrolled (45 women and 25 men). All patients enrolled in
this study had failed a 8 months treatment with 2 different oral pharmacological therapies. All patients also suffered of
urge incontinence. and used more than one pad/day. Patients with neurogenic detrusor overactivity and/or severe detrusor
underactivity were excluded from the study. Prior to the BoNT-A injections all patients underwent an uroflussimetry and an
urodynamic exam. We used onabotulinumtoxinA (BoNT-A). The injections were done cystoscopically by a single operator.
Average dose of BoNT-A was 100 units. The BoNT-A (total volume 10 mL) was administered as intradetrusor injections across
20 sites on the lateral and posterior bladder walls (sparing the trigone), and 0.5 ml (5 U) was injected at each site. We used
a rigid cystoscope. All patients took 1 injection. Clinical, urodynamic and QOL assessments were done at 1 and 12 months
after BoNT-A treatment. All patients underwent to an uroflussimetry and an urodynamic exam at 1 and 12 months after the
injection. Patient Global Impression of Improvement (PGI-I) score assessed patient quality of life pre- and postoperatively.
PGI-I scores were obtained at 1 and at 12 months after injections. A PGI-I score < 2 at 12 months after BoNT-A was defined
as a successful treatment. Statistical analyses were conducted using SAS version 9.3 software (SAS Institute, Inc., NC). Mean
values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value
was ≤0.05 (two-sides).
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
(100/125) are subjectively cured. A significant improvement was observed in all domains of the KHQ. De novo urgency rate
was 10% (12/125). The incidence of subjective and objective failures did not show statistically significant increases in relation
to the length of follow-up. The patients who had undergone a vaginal hysterectomy or with apical prolapse had a higher and
statistically significant risk of failure. The intraoperative complications were: perforation of the vaginal fornix in two patients,
bleeding stopped with intravaginal compression in two patients, pain lasting more than seven days in the thighs 15%. Transient
dyspareunia and less than one month in the 4%. No cases of vaginal erosion or bladder perforation.
Discussions
Several studies have confirmed the safety and short-term efficacy of the TVT-O. The procedure is technically simple, is associated
with a short learning curve, a short operating time and low morbidity. French registry data on 984 TVT-O procedures showed
a perioperative morbidity rate of 2.2% and a postoperative complication rate of 5.2%.4 The most common complication was
residual pain (2.7%). The other complications of paravesical hematoma, urinary retention, vaginal erosion, and reintervention
had an incidence of < 1%. These studies, along with several randomized trials, confirm that short-term and mediumterm
outcome results of the TVT-O are favorable and similar to the results of the retropubic TVT. Long-term outcome results of
the TVT-O procedure are scarce. Several recent studies have demonstrated that the incidence of perioperative and short-term
postoperative complications associated with the TVT-O procedure is low. In our study, no patient presented symptoms/signs
suggestive of vagina, bladder, or urethral erosion; neurologic complication; or persistent pain with 144 months follow-up.
Conclusion
An 21% rate of surgical failure was observed with median 102 months follow-up without significant increase over the duration
of follow-up. There are no recorded cases of women with symptoms/signs suggestive of vagina, bladder, or urethral erosion;
neurologic complication; or persistent pain with 144 months follow-up. De novo urgency rate was 10%. The positioning of
TVT-O is characterized by a high long-term effectiveness, determines a significant improvement on the quality of life of
patients and the relative technique has a high degree of safety. The vaginal hysterectomy and apical prolapse are significantly
associated with an increased risk of subjective and objective failures.
References
1. Collinet P, Ciofu C, Costa P, et al. The safety of the insideouttransobturator approach for transvaginal tape (TVT-O)
treatment in stress urinary incontinence: French registry data on 984 women. Int Urogynecol J 2008;19:711–715.
2. Waltregny D, Gaspar Y, Reul O, et al. TVT-O for the treatment of female stress urinary incontinence: Results of a prospective
study after a 3-year minimum follow-up. Eur Urol 2008;53:401–408
3. Liapis A, Bakas P, Creatsas G. Efficacy of inside-out transobturator vaginal tape (TVT-O) at 4 years follow-up. Eur J Obstet
Gynecol Reprod Biol 2010;148199–201.
77
78
a
r
t
s
b
a
30-& 0' /&6304"$3"- .0%6-"5*0/ '03 5)& 53&"5.&/5 0' 1&34*45&/5
1045 13045"5&$50.: 63*/"3: */$0/5*/&/$& "'5&3 53"/40#563"503: 4-*/(
*.1-"/5063&91&3*&/$&
A. Ceresoli1, A. Naselli1, S. Paparella1, P. Graziotti1
1
Ospedale San Giuseppe, Gruppo Multimedica (Milano)
Objective
Urinary incontinence following radical prostatectomy has yet a significant incidence, varying from 4% to 8% in modern
series, and impairs deeply quality of life [1]. The number of radical prostatectomies performed in 2010 in US was about
138000 (source Center for Disease Control and Prevention, http://www.cdc.gov/nchs/fastats/prostate.htm) and therefore
the number of patients involved is significant as well and can be estimated in 5500 to 11.000 de novo incontinent cases per
year. Incontinence is mainly a consequence of external sphincter weakness. However a concomitant urge component can be
present in at least a fifth of incontinent cases [2,3] and best assessed only after an appropriate “restitutio ad integrum” of the
sphincter function. Hence, the partial effect achieved after surgery for post prostatectomy incontinence could be due to a
failure and/or to the presence of minor or latent functional bladder dysfunction, which becomes dominant after the surgical
correction of the sphincter defect. After urodynamic evaluation assessing the presence of the bladder dysfunction, sacral
neuromodulation may be offered in order to improve continence and quality of life. Our report is intended to assess feasibility
of sacral neuromodulation for the treatment of the urge component of incontinence in this specific clinical scenario.
Our report is prospective case series without a control group or randomization.Internal review board approved our data analysis.
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Results
Mean age was of 44,2 years (range 24-56 years). The treatment with BoNT-A was successfully delivered in all 70 patients. There
were no injection related complications and only 5 out of 70 patients (7,1%) had mild hematuria. Treatment was generally well
tolerated. 5 out of 70 patients (7,1%) experienced postoperative uncomplicated UTI. 7 out of 70 (10%) patients (5 males and 2
females) had PVR urine volume >150 mL; 8 out of 70 (11,4%) patients (5 males and 3 females) had acute urinary retention after
treatment. Overall after 1 month 59 out of 70 patients (84,3%) had a significant improvement of global urinary symptomatology
and after 12 months 55 out of 70 patients (78,6%) had a significant improvement of global urinary symptomatology. Urgency
disappeared in 62 out of 70 patients (88,6%) of the patients and incontinence resolved in 59 out 70 patients (84,3%) within 1
or 2 weeks after BoNT-A injections. We considered “dry” patients without any loss of urine (no pads/day) or those who used
a safety pad/day. Mean maximal bladder capacity significantly increased from 248,06±47,1 to 310±58,5 milliliters (p=<0,05);
mean volume at first desire to void significantly increased from 155,3±4,6 to 196,1±41,5 milliliters (p<0,05).PGI-I scores were
available for 69out of 70 patients. Success rate was achieved in 51 out of 69 patients (73,9%).
Discussions
Clinical experiences with BoNT-A application for OAB are still scarce and controversial, and it differs in dose, dilution,
injection site, number of injections and rate. Most studies considered a low number of patients and there is a mixture of
idiopathic and neurogenic detrusor overactivity. Our study showed that a dose of 100 U BoNT-A could achieve beneficial
effects in a good percent of patients. We evaluated urodynamic (objective) and clinical (subjective) parameters. Urgency and
incontinence significantly decreased after BoNT-A in the majority of patients. All of these objective improvement are followed
by a significant impact on QOL, as based on PGI score. The side effect rate was low, and most common treatment-related
complication was UTI. A limitation of this study is a short follow-up period. As a consequence we can not indicate the reinjection rate.
Conclusion
In the most recent guidelines, it was stated that the best alterna¬tive among the minimally invasive treatment options in NDO
is BoNT-A (recommendation level A). The effectiveness of BoNT-A was supported by several randomized, placebo-controlled
studies, and there was no loss in effectiveness with repeated injections. In our experience intravesical BoNT-A is an effective
treatment for OAB in patients refractory to antimuscarinics. We recommended a dose of 100 UI administered as intradetrusor
injections across 20 sites using a rigid cystoscope. Treatment was generally well tolerated, and most common treatment-related
complications were UTI and urinary retention. We believe that it can be offered to the patients before other invasive therapeutic
options.
References
1-Sacco E, Bientinesi R, Bassi P, Currò D. Pharmacological methods for the preclinical assessment of therapeutics for OAB: an
up-to-date review. Int Urogynecol J. 2016 Feb 17. [Epub ahead of print]
2- Wagg A, Nitti VW, Kelleher C, Castro-Diaz D, Siddiqui E, Berner T Oral pharmacotherapy for overactive bladder in older
patients: mirabegron as a potential alternative to antimuscarinics. Curr Med Res Opin. 2016 Feb 17:1-18. [Epub ahead of
print]
3- Karsenty G, Denys P, Amarenco G, De Seze M, Gamé X, Haab F, Kerdraon J, Perrouin-Verbe B, Ruffion A, Saussine C, Soler
JM, Schurch B, Chartier-Kastler E.Botulinum toxin A (Botox) intradetrusor injections in adults with neurogenic detrusor
overactivity/neurogenic overactive bladder: a systematic literature review. Eur Urol. 2008 Feb;53(2):275-87. Epub 2007
Oct 16.
78
79
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
The study was conducted according to the Helsinki Declaration. From January 2010 to December 2011, 77 patients referred to
our center for post radical prostatectomy incontinence. Cases characterized by partial intrinsic sphincter deficiency (defined
as functional length less than 2 cm, retrograde leak point pressure test < 40 cm H2O, maximal urethral closure pressure < 45
cm H2O) and mild incontinence (24h pad test lower and upper limits respectively 20 and 500 mL, computed as 3 days mean)
underwent transobturatoy tensive perineal tape placement [4]. Twenty seven patients declared a partial or no improvement
and were submitted again to urodynamic evaluation. Twenty-five cases with a reduced bladder compliance (<10 mL/cm H2O)
or reporting a partial improvement after a trial with anticholinergic drugs were candidates to sacral neuromodulation. Twentytwo were implanted with sacral neuromodulator (InterStim – Medtronic) [5]. Before implantation patients signed a detailed
informed consent. Patients were followed up with interview, physical examination, ICIQ-SF questionnaires and pad test before
and post implantation, at 3 months and then yearly. The interview included a detailed continence assessment: number of
pads used, number of incontinence episodes, number of days affected by incontinence. Complete responders were dry cases,
not necessitating anymore of pads. Partial responders were defined as cases that more than halved the number of pads used
or reported a reduction of at least of 50% of incontinence episodes or days affected by incontinence. ICIQ-SF and pad test
findings pre and post implant were subjected to a Student’s T –test for paired samples for analysis of statistical significance.The
object of the analysis were the 2-year findings.. The test was two tailed for ICIQ-SF assessment and one tailed for the pad test.
Significance level was 0.05.
Results
Two patients died within 2 years after the implant, one for disease and one for unrelated causes whereas 18 had at least 2 year
follow up and were object of the report. Indications to implantation were bladder compliance < 10 cm H2O and improvement of
continence during the anticholinergic drugs trial in 4 cases (group 1), bladder compliance < 10 cm H2O without improvement
with drugs in 8 cases (group 2), bladder compliance >10 cm H2O and improvement with drugs in 6 cases (group 3). Median
age at prostatectomy was 72 (range 44 – 78), median number of years from prostatectomy to implant was 2 years (range 2 –
14). Two years after the implant, 4(22%) patients were completely continent (no pad), 4(22%) quasi-continent (1 pad), 5(28%)
improved of at least 50% (halved the number of pads) and five improved of at less than 50% or did not at all respect to pre
implant assessment. Concerning the number of incontinence episodes, 11 (61%) had a reduction greater than 50% whereas
the number of days affected by incontinence reduced more than 50% in 10 (56%) cases. Overall 13/18 patients (72%) had a
complete or partial response to the treatment and, most important, 10/18 (55%) declared to be satisfied and happy to have
decided to be treated. The pads’ number was reduced significantly from 4.4 ± 2.2 to 1.9 ± 1.6 (p<0.001). The ICIQ-SF score
decreased significantly from 16.3 ± 3 a 10.9 ± 4.5 (p<0.001). Data are summarized in table 1. Stratifying according to indication
of implantation, group 1 patients were more likely to respond than group 2 and 3 patients, with a rate of respectively 4/4, 5/8,
3/6. Interestingly all the complete responders belonged to group 1.
Discussions
Patients submitted to radical prostatectomy, irrespective of the technical approach, open, laparoscopic, robotic, may develop
permanent urinary incontinence [1] with similar rates [6], ranging from 4% to 8%. Considering the number of prostatectomy
performed every year, the number of patients affected by incontinence is significant. Data suggest that most are mainly stress
incontinence cases and only a minority, about 4%, is linked solely to overactive bladder [1]. However concomitant impaired
compliance and detrusor hypocontractility in stress incontinent cases have a significant incidence and are reported in up to
40% and 60% of patients respectively [1, 7, 8, 9]. Particularly urodynamic studies performed after radical prostatectomy in
incontinent patients, show that detrusor overactivity can be found in at least one fifth cases [2, 3, 10] and coexist with sphincter
weakness. The gold standard for the treatment of stress post prostatectomy incontinence is the artificial urinary sphincter
which is successful in about 80% of cases [11], however, in selected cases with mild incontinence, slings have comparable
results [12] and less complications [13,14]. Our cohort consisted of properly selected cases. Anastomotic stricture was excluded
by office cystoscopy, degree of incontinence was mild and urodynamic findings identified intrinsic sphincter deficiency.
However only an half recovered from incontinence. Our study focuses on cases not responding, totally or partially, to sling
placement. Given the significant incidence of bladder impaired compliance concomitant to stress incontinence, every patient
was resubmitted to urodinamic study. Sacral neuromodulation was offered to cases with a bladder compliance <10 mL/cm
H2O or clinical improvement of continence after a trial with anticholinergic drugs. Sacral neuromodulation was preferred to
tibial nerve stimulation simply because it does not imply repeated weekly office visits. Patients were prospectively followed up.
In all, 18 patients had a follow up lasting at least 2 years and were object of our study. Sacral neuromodulation may improve
continence by a wide range of mechanisms, related to the stimulation of sensitive and motor neural fibers of the ventral ramus
localized at the S3 level, as eloquently described in a paper from Chancellor and Chartier-Kastler [15]. Return to continence
in about half of patients shows effectiveness of sacral neuromodulation as treatment of urge incontinence also in this clinical
setting. Moreover, satisfaction rate, expressed by a direct and precise question to the patient was significantly high considering
the general dissatisfaction underlying post prostatectomy continence and a “failed” sling implant. The impression obtained
by interviewing the patients is substantiated by an objective and statistically significant improvement in ICIQ-SF score and
number of pads used. We reported ours results over a period of 2 years thus suggesting the achievements are likely to remain
definitive. Interestingly, even if not statistically significant, the patients who benefit most from the implant were those with
a bladder compliance < 10 cmH2O and who experienced a continence improvement after a trial with anticholinergic drugs.
Indeed failures should have probably an additional incontinence component beyond impaired bladder compliance linked to
the prostatectomy technique like a too short urethral stump or urethral fibrosis [16].
Conclusion
In this series of selected patients, the residual urinary incontinence was treated effectively with sacral neuromodulation when
the urodynamic evaluation, performed after the implant of the sling perineal bulb, showed a reduction in bladder compliance.
79
80
b
a
a
r
t
s
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
The 2-year follow up is not yet enough to consider definitively stable the results achieved even if it will likely remain unchanged.
Most important the procedure is safe, mini invasive and performed in local anesthesia. The procedure is feasible but further
studies are needed to validate the technique and its results. By the way our report should encourage centers specialized in male
incontinence treatment to perform dedicated clinical trials focusing on the population who is most likely to respond, namely
cases with a bladder compliance < 10 cmH2O and reporting an incontinence improvement after a trial with anticholinergic
drugs.
References
1) Hoyland K, et al. Post-radical prostatectomy incontinence. Rev Urol 2014;16:181-8.
2) Chung DE, et al. Detrusor underactivity is prevalent after radical prostatectomy. Can Urol Assoc J 2012;24:1-5.
3) Dubbelman Y, et al. Quantification of changes in detrusor function and pressure-flow parameters after radical prostatectomy.
Neurourol Urodyn 2012;31:637-41.
4) Ceresoli A, et al. New perineal tensive transobturator tape (T-TOT) for postprostatectomy urinary incontinence. Arch Ital
Urol Androl 2010;82:154-8.
5) Spinelli M, et al. New sacral neuromodulation lead for percutaneous implantation using local anesthesia. J Urol 2003;170:19057.
6) Gagnon LO, et al. Comparison of open and robotic-assisted prostatectomy. Can Urol Assoc J 2014;8:92-7.
7) Gomha MA, Boone TB. Voiding patterns in patients with post-prostatectomy incontinence. J Urol 2003;169:1766-1769
8) Porena M, et al. Voiding dysfunction after radical retropubic prostatectomy: more than external urethral sphincter deficiency.
Eur Urol 2007;52:38-45.
9) Giannantoni A, et al. Assessment of bladder and urethral sphincter function before and after radical prostatectomy. J Urol
2004;171:1563-1566.
10) Chao R, Mayo ME. Incontinence after radical prostatectomy. J Urol 1995;154:16-8.
11) James MH, McCammon KA. Artificial urinary sphincter for post-prostatectomy incontinence: a review. Int J Urol
2014;21:536-43.
12) Chung E,et al. Adjustable versus non-adjustable male sling for post-prostatectomy urinary incontinence. Neurourol
Urodyn 2015 Feb 14
13) Van Bruwaene S, et al. The use of sling versus sphincter in post-prostatectomy urinary incontinence. BJU Int 2015;116:33042
14) Hoy NY, Rourke KF. A retrospective comparison of transobturator male slings and the artificial urinary sphincter. Can
Urol Assoc J 2014;8:273-7
15) Chancellor MB, Chartier-Kastler EJ. Principles of sacral nerve stimulation (SNS) for the treatment of bladder and urethral
sphincter dysfunctions. Neuromodulation 2000;3:15–26
16) Paparel P, et al. Recovery of urinary continence after radical prostatectomy: association with urethral length and urethral
fibrosis. Eur Uro 2009;55:629-37
80
81
o
6
08:30
10:00
s
1
s
Goya
0
e
2 ngr
Video 3:
o
s
t
Tips and Tricks I C
I
c
I
a
X
r
X
t
s
24 maggio 2016
sala
/&'3&$50.*"3"%*$"-&4*/*453"-"1"304$01*$"*/1";*&/5&$0/"035"*/
4&%&3&530$"7"-&$0/4&(6&/5&"4$0-*04*."3$"5"
P.A. Mastrangelo1, T.. Masciandaro1, F. Di Giacomo1
1
I.R.C.C.S. CROB, U.O. Urologia (Rionero in Vulture)
Abstract
La scoliosi è un dismorfismo che implica la curvatura laterale della colonna e rotazione delle vertebre con conseguente
deformità. Presentiamo il video di nefrectomia radicale sinistra con approccio laparoscopico transperitoneale, per una massa
di 8 cm in sede mesorenale, con iniziale trombo in vena renale, in una donna con marcata scoliosi con concavità a sinistra. Si
esegue l’ accesso open in sede paraombelicale destra e si posizionano il trocar di Asson e 2 trocar operativi. Incisa la doccia
parietocolica sinistra ed isolata la fascia di Gerota dal colon discendente, si procede ad ampia e completa mobilizzazione di
milza e coda del pancreas che consente di scoprire la superficie anteriore della vena renale quasi per tutta la lunghezza. Viene
isolato il polo inferiore del rene e dopo aver repertato l’ uretere si si isola e si seziona la vena gonadica di sinistra. Si procede all’
isolamento dell’ ilo renale in un piano più mediale rispetto alla sede del convenzionale isolamento dal momento che la scoliosi
ha determinato la trasposizione dell’ aorta in sede retrocavale. L’ arteria renale viene chiusa con Hem-o-lok e la vena renale con
EndoGIA. Dopo aver sezionato il peduncolo si completa la nefrectomia con risparmio del surrene sinistro.
-*.1*&(0%&--".&.#3"/""./*05*$"/&--"13045"5&$50.*"3"%*$"-&
S. Guercio1, M. Mari1, F. Mangione1, R. Marco1, B. Maurizio1
1
Ospedale di Rivoli, S.C. Urologia (Rivoli)
Abstract
La membrana amniotica disidrata è stata utilizzata in corso di prostatectomia radicale robot-assistita allo scopo di migliorare
l’attività erettile. I risultati, riportati in Letteratura, sono molto interessanti e legati alle proprietà della membrana amniotica:
presenza di fattori di crescita, fattori anti-flogistici e anti-fibrotici. Gli Autori riportano la loro esperienza sull’uso della
membrana amniotica fresca in corso di prostatectomia radicale open “mini invasiva”.La membrana amniotica fresca, rispetto
alla disidrata, presenterebbe maggiore ricchezza in fattori di crescita e anti-fibrosi e, per la sua particolare consistenza è
applicabile sono con tecnica “open”. Nel video gli Autori mostrano i passaggi fondamentali della tecnica: Mini-incisione 8 cm
circa. Idroscollamento della fascia prostatica e preparazione dei fasci vascolo-nervosi con bisturi a getto d’ acqua ERBE-jet.
3 - Tips and Tricks
08:30 - 10:00 - Video
b
a
Moderatori: Massimo Capone
81
82
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
Preservazione dei bundles, collo vescicale e vescicole seminali. Applicazione, prima dell’anastomosi vescico-uretrale, sui bundles
vascolo-nervosi di patch di membrana amniotica fresca. Questa tecnica è indicata in pazienti selezionati per età (fino a 65 anni anni),
Gleason score (<4+3), PSA (<10 ng/ml), prelievi positivi (< 30%), sessualmente attivi. La membrana amniotica fresca, ottenuta
dalla placenta di parti cesarei elettivi, viene preparata e fornita dalla Fondazione Banca dei Tessuti di Treviso Onlus insiema alla
quale gli Autori intendono proporre uno studio multicentrico.
Argomenti: R. Nucciotti1, V. Pizzuti1, F. Viggiani1, F.M.. Costantini1
1
Abstract
I goals della prostatectomia radicale robotica in ordine decrescente di importanza sono: radicalità oncologica, preservazione
della continenza, recupero della funzione erettile. La continenza urinaria è fondamentale per la vita di relazione . In questo video
mettiamo in evidenza i presupposti per un buon recupero della continenza. Come incidere il collo vescicale, quando possibile
eseguire la neck sparing, preservazione del collare puboprostatico con o senza nerve sparing, incisione dell’uretra membranosa,
ricostruzione posteriore del rabdomiosfintere ed anastomosi vescicouretrale. Questi, a nostro giudizio, sono gli steps fondamentali
che se ben eseguiti permettono un ottimo recupero della continenza.
08:30 - 10:00 - Video
a
r
t
s
b
a
&/#-0$53"/463&5)3"-3&4&$5*0/0'#-"%%&356.038*5)0-*.164#6550/
"/07&-5&$/*26&
1
Abstract: The quality of transurethral resection of bladder tumor is able to determine patients prognosis, main limitation of standard
transurethral resection (TUR) of bladder cancer is fragmentation of the specimen, en bloc TURBT overcomes this problem. We
describe our “en bloc “ tecnique with button.
Tecnique: The bladder is filled to a medium capacity and the wall is incised using a Bottun loop (with a cutting current), starting
from apparently ‘normal’ mucosa surrounding the base and then extending throughout detrusor muscle. The muscular fibres are
sectioned cautiously from the periphery to the centre of the lesion base. After the lesion has been detached from the bladder, the
tumour is grasped by the loop and taken away from the bladder under direct vision. Each specimen is macroscopically orientated
and examined to assess its greatest dimension and the lateral circumferential margins. Staging is done in accordance with TNM
classification (2002 International Union Against Cancer/UICC) and grading by the WHO 2004 classification. Circumferential
lateral margins and bottom are resected with a classic loop.
Conclusion: In our preliminary experience en bloc bipolar button TURBT is a feasible and safe tecnique.
&/ #-0$ 53"/463&5)3"- 3&4&$5*0/ 0' #-"%%&3 56.03 8*5) $0--*/4 -001
063&91&3*&/$&
1
Abstract: The main limitation of standard transurethral resection (TUR) of bladder cancer is fragmentation of the speciment which may
impair the pathological analysis. The en bloc TURBT overcomes this problem.
Tecnique: Apart from the standard equipment (ESG 400 scalpels, , optical 0° for uretroscopy and 30° for TURBT), our technique
requires a 12° with Collins loop for en bloc TURBT. The bladder wall is incised around the lesion using a Collins loop (with a
cutting current), starting from ‘normal’ mucosa surrounding the base and then extending through the subepithelial connective
tissue and muscularis propria strata, inclining the loop to avoid any serious perforation. After the lesion has been detached from the
bladder, the tumour is grasped by the loop and taken out under vision. Each specimen is macroscopically orientated and examined
to assess its greatest dimension and the lateral circumferential margins. Staging is done in accordance with TNM classification
and grading by the WHO 2004 classification. Margins and bottom are resected with a classic loop and NBI assisted repeat TURBT
Conclusion: In our experience en bloc bipolar TURBT with Collins loop is a feasible and safe tecnique.
%*45"-$0310301-"45:5053&"5%*45"-1&/*-&13045)&4*4&95364*0/
Argomenti: andrologia, chirurgia ricostruttiva
M. Carrino1, F. Chiancone1, L. Pucci1, G. Battaglia1, D. Di Lorenzo1, P. Fedelini1
1
Abstract
Distal extrusion of cylinders is a potential complication of the penile prosthesis implantation. If the cylinders are not exposed
3 - Tips and Tricks
X
X
13045"5&$50.*"3"%*$"-&30#05*$"$0.&"44*$63"3&6/055*.03&$61&30
%&--"$0/5*/&/;"
82
83
&4*5* */&45&5*$* %* $*3$0/$*4*0/* 3&*5&3"5& $031030-*4* *.1*"/50 %*
1305&4*1&/*&/"".4&%*//&450$65"/&0
08:30 - 10:00 - Video
a
r
t
s
b
a
)0-&15*14"/%53*$,4/05+645'03#&(*//&34
Y. Hussein 1, I. Vavassori1
1
Ospedale “Treviglio-Caravaggio” - ASST Bergamo Ovest, U.O.C. Urologia (Treviglio)
Abstract
The aim of this video is to highlight some salient points in the execution technique of the HoLEP and some suggestions
intended to make the shortest learning curve.
5)6-*6.-"4&3&/6$-&"5*0/0'13045"5&5)6-&1
5&$/*$"01&3"5*7"
G. Di Lauro1, G. Romeo2, L. Romis1, S. Mordente1, A. Ruffo 1, M. Capece2, F. Iacono2
1
Ospedale Santa Maria delle Grazie (Pozzuoli)
2
Abstract
La ThuLEP prevede l’utilizzo di NaCl 0,9% per l’irrigazione, un resettore Storz a flusso continuo videocamera HD con ottica
12° gradi; laser Revolix™ 120W/200W con fibra di 550µm, un morcellatore Piranha Wolf. Il paziente è in posizione litotomica,
l’enucleazione inizia con il lobo medio e la prima incisione è fatta a ore 5’, partendo dal collo vescicale, previa identificazione
dei due osti ureterali, fino a raggiungere il veru-montanuum. L’incisione a questo punto è portata in profondità fino alla capsula
prostatica. Si continua con la stessa incisione ad ore 7’. A questo punto quando il lobo medio è separato dai lobi prostatici
lateralmente e dal veru-montanuum distalmente, inizia l’enucleazione per via smussa utilizzando il resettore, lungo la capsula
chirurgica come piano di clivaggio. Il laser a 40 W di potenza per coagulare i vasi trans-capsulari. I lobi laterali vengono
enucleati partendo distalmente con tre incisioni ad ore 12’ ad ore 4’ ed ore 8’, così da delimitare l’apice prostatico L’enucleazione
per via smussa avviene di nuovo lungo la capsula prostatica coagulando i piccoli vasi trans-capsulari. La morcellazione dei tre
lobi in vescica viene a questo punto eseguita e al termine un catetere tre vie Ch 20 viene posto in sede.
3 - Tips and Tricks
X
X
Argomenti: andrologia, chirurgia ricostruttiva
M. Carrino1, L. Pucci1, F. Chiancone1, C. Meccariello1, G. Battaglia1, A. Aveta1, P. Fedelini1
1
Abstract
Uomo di 59 anni, affetto da diabete mellito di tipo 2 dall’età di 38 anni, giunge alla nostra attenzione con esiti cicatriziali severi
come conseguenza di lichen scleroatrofico e tre circoncisioni effettuate all’età di 51, 54 e 58 anni. Il video mostra step by step la
procedura di corporolisi con contestuale impianto di protesi peniena AMS 700 ed innesto cutaneo. Dopo aver effettuato una
incisione coronale e rimosso la cicatrice delle precedenti circoncincisioni, si effettua una estesa corporolisi con deglowing del
pene. Viene successivamente impiantata la protesi tricomponente che viene lasciata parzialmente attiva. Dopo preparazione
accurata della cute della regione antero-mediale della coscia con olio di vasellina, si procede a prelievo di un’area cutanea
mediante dermatomo. Il patch viene fissato ai tessuti circostanti con suture in vicryl rapid 5-0 e l’attecchimento è facilitato dalla
deposizione sulla superficie peniena di una colla tissutale (ARTISS (TM), Baxter Healthcare Corp.). Viene infine effettuata
una medicazione compressiva. Dopo 60 giorni il paziente ha avuto il suo primo rapporto sessuale e a 12 mesi dall’intervento
chirurgico non sono riscontrabili esiti cicatriziali distrofici inestetici che avevano causato gravi disturbi funzionali e psicologici
al paziente.
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
to the exterior, and there is not infection, this complication can be solved with a surgical procedure called “distal corporoplasty”.
In this video we show the case of a patient who underwent a “SSDA subrini soft implant” penile prosthesis implantation for
vasculogenic erectile disfunction in January 2014 at another hospital. In March 2014 and July 2014 he underwent two failed
glandulopexy for distal cilinders extrusion at another hospital. After one year he reached our department with bilateral cylinder
extrusion and we performed a distal corporoplasty to correct this defect. A longitudinal corporotomy was made over the
cylinder on the anterior wall of the pseudocapsule. The cylinder was removed exposing the posterior wall of the pseudocapsule.
This wall was incised transversely and the plane of spongy tissue behind the pseudocapsule was opened to the distal end of the
corporal body with scissors and a new dilation was performed with brooks dilators. This procedure was performed bilaterally.
We implanted a tri-component penile prosthesis in this newly created tract. The old tract was not closed and the new prosthesis
was left partially inflated.
83
84
o
6
08:30 - 10:00
s
1
s
Mirò
0
e
2 ngr
Video 4:
o
s
C
t
Laparo e ri-Laparo
I
I
c
I
a
X
r
X
t
s
24 maggio 2016
sala
4 - Laparo e ri-Laparo
3*.0;*0/& -"1"304$01*$" %* 6/ 3"30 $"40 %* ."-"55*" %* $"45&-."/ "
-0$"-*;;";*0/&1"3"3&/"-&4*/*453"
S. Marinacci1, G. Palumbo1, P. Cantelmo1, A. Filoni1
1
Ospedale “Vito Fazzi”, U.O.C. Urologia (Lecce)
Abstract
Gli autori descrivono un “case report” di un paziente di 53 anni con massa perirenale sinistra diagnosticata nel 2010 con T.C.
addome e biopsia lapatotomica eseguita in altra sede con istologico di : “ Linfoma non hodgkin a piccole cellule di tipo B “ stadio
III A e trattato con cicli di cht. L’incremento volumetrico della massa , passata da 2.5 cm nel 2010 a 8.5 cm nel 2015 ha indotto
gli AA alla rimozione laparoscopica della massa , senza clampaggio del peduncolo vascolare renale. L’eame istologico definitivo è
stato di : “ Malattia di Castelman”, un raro amartona linfonodale benigno con prognosi decisamente differente.
4"-7"(&30#05*$3"%*$"-13045"5&$50.:8*5)1&-7*$-:.1)/0%&%*44&$5*0/
M. Ferriero1, G. Simone1, R. Papalia2, R. Mastroianni2, F.. Minisola1, S. Guaglianone1, M. Gallucci1
1
2
Abstract
The video shows a case of a salvage robotic radical prostatectomy with pelvic lymph node dissection for radiorecurrent prostate
cancer. A five trocar access and docking were performed. After divided some adesions, bilateral extended pelvic lymph node
dissection was performed. The Retzius space was developed and the endopelvic fascia bilaterally incised. After sealing Dorsal
Vein complex with Ligasure, urethral stamp was transected and the apex retrogradely dissected. Bladder neck was isolated and
sectioned. Denonvilliers fascia was opened and seminal vescicles were isolated. Bilateral extra fascial radical prostatectomy was
accomplished. A Van Velthoven anastomosis with posterior reconstruction was performed. Operative time was 132 minutes.
Blood loss was 300 ml. Patient was discharged on 3rd postoperative day.
&/6$-&03&4&;*0/&3&/"-&%&453"7*%&0-"1"304$01*$""1&%6/$0-0-*#&30
%*/&01-"4*"*/53"*-"3&
M. Fedelini1, C. Francesco1, G. Battaglia1, D.. Mattace Raso1, R. Giannella1, F. Monaco1, P. Fedelini1
1
Abstract
Il video mostra step by step il caso di una donna di 54 anni che presenta alla TC una neoformazione renale intrailare di circa 2,5
08:30 - 10:00 - Video
b
a
Moderatori: Mario Catanzaro
84
85
&/6$-&03&4&;*0/&3&/"-&30#05*$"$0/"64*-*0%*4*45&."%*'-603&4$&/;"
R. Falabella1, S. Lioi1, F. Ponti1, F. Abate1, A. Izzo1, A. Vita1
1
Azienda Ospedaliera San Carlo (Potenza)
Abstract
Il video mostra un caso di neoplasia renale polare superiore destra di 5 cm di diametro, parzialmente esofitica. Tale neoformazione
viene trattata con enucleoresezione renale robot assistita. Aperta la doccia parieto-colica, isolato il rene, si identifica ilo renale
costituito da due rami principali arteriosi. Si iniettano 2 cc di Infracianina e dopo circa 45 secondi, si utilizza il sistema di
fluorescenza Firefly del robot SI Da Vinci. Mediante questo sistema si identifica il ramo arterioso che irrora la neoplasia e ai clampa.
Si procede pertanto ad enucleoresezione della neoplasia. Sutura della breccia renale prima della midollare e successivamente della
corticale.
08:30 - 10:00 - Video
a
r
t
s
b
a
30#05 "44*45&% 3"%*$"- /&1)3&$50.: "/% */'&3*03 7&/" $"7"
5)30.#&$50.: 463(*$"- 5&$)/*26& 1&3*01&3"5*7& "/% &"3-: 0/$0-0(*$
065$0.&4
Argomenti: G. Simone1, M.C. Ferriero1, R. Papalia2, R. Mastroianni2, F. Minisola1, L. Misuraca1, G. Tuderti1, S. Guaglianone1, M. Costantini1,
V. Pompeo1, A.L. De Castro Abreu3, M. Aron3, M. Desai3, I. Gill3, M. Gallucci1
1
2
3
USC Institute of Urology and Departments of Urology, Keck School of Medicine, University of Southern, Department of Urology
(Los Angeles)
Abstract
Radical nephrectomy with Inferior vena cava (IVC) thrombectomy for renal cancer is one of the most challenging urologic
surgical procedures. We describe surgical technique and present perioperative and preliminary oncologic outcomes of our
first 10 cases of completely intracorporeal robot-assisted radical nephrectomy with IVC level II and III tumor thrombectomy.
Ten consecutive patients with renal tumor and IVC thrombus were treated. Baseline, perioperative and follow-up data were
collected in a prospectively maintained IRB approved database. Key steps of surgery include: a meticulous isolation of IVC; the
isolation and sealing of all lumbar and collateral vessels, a full monolateral retroperitoneal dissection for staging purpose and to
have a complete control of IVC; isolation of left renal vein, Tourniquet placement and infrarenal IVC control. IVC incision and
thrombectomy; cava suture with 3/0 visi-black monocryl; restoration of IVC flow; nephrectomy. This video shows a case of a
double IVC thrombectomy and reports perioperative and early oncologic outcomes of first 10 patients treated. All procedures
were successfully completed; open conversion was never necessary. Median EBL was 686 cc (range 200 to 2000), perioperative
transfusion rate was 40%. The 30-d and 90-d incidence of Clavien grade ≥3 complications was 10% and 10%, respectively.
*/%*"/"106$)30#05*$"*/53"$03103&"
Argomenti: G. Simone1, G. Romeo2, F. Minisola1, S. Guaglianone1, L.. Misuraca1, M. Ferriero1, A. Luis de Castro Abreu3, R. Papalia4, R.
Mastroianni4, V. Pompeo1, M. Aron3, M. Desai3, I. Gill3, G. Tuderti1, M. Gallucci1
1
2
3
USC Institute of Urology and Departments of Urology Keck School of Medicine, University of Southern, Department of Urology
(Los Angeles )
4
Campus Biomedico (Roma)
Abstract
Surgical steps: Robotic cystectomy and pelvic lymph node dissection (PLND) are performed with a 6-trocar access. Robot is
undocked and specimen extracted from the left lateral port. Both left side ports are closed and three additional ports are placed.
Table is rotated 45 degree to left and the robot is re-docked on right side. 12 cm of distal ileum and 30cm of right colon are isolated;
side to side stapled ileocolonic anastomosis is performed; colonic segment is detubularized along the antimesenteric tenia up to
3cm distal to the ileocecal valve and U folded. The medial aspect of the folded colon is sewn. Ureterocolonic anastomoses are
X
X
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
cm. In decubito laterale sinistro si procede ad un miniaccesso open pararettale destro ed al posizionamento di trocar di Hasson.
Vengono posizionati quindi un trocar da 11 sottocostale e un trocar da 5 sovrailiaco sull’ascellare media. Un quarto trocar da 5
verrà poi posizionato in regione epigastrica per il sollevamento del fegato. Dopo apertura del peritoneo parietale posteriore e della
fascia renale, si procede a completo isolamento del rene. Dopo isolamento del peduncolo, si identifica la neoplasia che è posta tra
l’arteria polare superiore e la vena renale principale. Dopo interruzione di un vaso arterioso afferente alla neoplasia con hem-olok, si procede ad enucleoresezione a peduncolo libero della stessa effettuando l’ emostasi del letto di resezione con coagulazione
bipolare ed hem-o-lok sui vasi maggiori. L’emostasi viene completata con l’apposizione di Floseal e Surgicel. La fascia renale viene
ricostruita con una “slinding suture”. Il decorso post-operatorio è stato regolare, l’esame istologico deponeva per un oncocitoma
ed ad un follow-up di 20 mesi non sono presenti recidive neoplastiche locali e a distanza.
85
86
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
performed on the posterior aspect of the pouch. Bilateral J stents are placed in ureters and secured to a 24-Fr hematuria catheter
inserted via the appendiceal orifice. After closing the lateral aspect of the pouch, a Foley catheter is inserted via the umbilical
port and through efferent ileal limb and placed into the colonic pouch. The efferent limb is tapered with a 60mm stapler on the
antimesenteric aspect. The ileocecal valve and the efferent limb are plicated to increase the outflow resistance. The efferent limb is
now extracted and the stoma created at the umbilical site.
G. Romano1, A.B.. Di Pasquale1, G. Ranieri1, R. De Domenico1, M.. Prata2, L. Di Clemente1
1
Ospedale San Salvatore, U.O.C. Urologia (L’Aquila)
2
Ospedale Santissima Trinità, U.O. Urologia (Sora)
Abstract
Descriviamo un caso di ascesso pelvico insorto dopo tre anni dal posizionamento di mesh in polipropilene per il trattamento
di un prolasso anteriore ed apicale. La paziente presentava clinicamente dolore pelvico ed una costante emissione di essudato
maleodorante da un piccolo tramite fistoloso vaginale. Lo studio preoperatorio ha compreso cistoscopia, RM della pelvi ed
ecografia transvaginale. La risoluzione di queste complicanze della chirurgia protesica impone spesso la rimozione, parziale o
totale della rete. Il tasso di complicanze di questi interventi, se affrontati con tecnica transvaginale, è alto, aggirandosi intorno al
40%. Il video descrive i passaggi dello scollamento della parete vaginale anteriore, ovviamente molto difficoltoso per la intensa
reazione fibrotica, dalla vescica, l’isolamento della rete e la sua exeresi totale comprese le quattro braccia di ancoraggio. Non si
sono avute complicanze nè intra né postoperatorie. Al controllo a tre mesi la Paziente era clinicamente guarita e senza recidiva del
prolasso.
08:30 - 10:00 - Video
a
r
t
s
b
a
3*1"3";*0/&30#05*$"%*'*450-"63&5&307"(*/"-&10453"%*05&3"1*$"
Argomenti: R.. Nucciotti1, V. Pizzuti1, F. Viggiani1, F.M. Costantini1, A. Bragaglia1
1
Abstract
L’urologo si trova spesso a dover riparare problematiche ureterali nelle giovani donne. E’ importante conoscere la diagnostica e le
scelte terapeutiche che si possono adottare. Il video mostra la riparazione mediante chirurgia robotica, di una fistola ureterovaginale
verificatasi a seguito di radioterapia per tumore della cervice uterina.
)0-.*0 -"4&3 53&"5.&/5 '03 #-"%%&3 /&$, $0/53"$563&4 #/$4
*/ 5)&
13045"5&$"/$&34637*703
A.. Fandella1, S. Guazzieri1, E. Guidoni1
1
Casa di Cura Giovanni XXIII, U.O. Urologia (Monastier di Treviso)
Abstract
Thera are many treatment for bladder neck contractures (BNCs) in the prostate cancer survivor.BNC rates have decreased
significantly in the last 2 decades, likely because of improvement in the surgical technique and increased utilization of laparoscopic
and robotic surgery, which may allow better visualization of the vesicourethral anastomosis. A number of therapeutic options are
available, however. In the event of BNC development, treatment should be structured minimizes the risk of urinary incontinence
The results of minimally invasive procedures such as urethral dilation and transurethral incision of the bladder neck may be not
sufficient to dominate this elusive confition. Significant factors associated with treatment failure were >10 pack/year smoking
history (P = .039) and ≥ 2 previous endoscopic BNC procedures (P = .03). A total of 21 patients with postprostatectomy bladder
neck contracture underwent treatment with Nd:YAG laser irradiation. A new 600-microns hemispherical optical quarz fiber
was used in contact technique to produce linear incisions in the scarred tissue. Overall success rate of 86% after 2 procedures.
Endoscopic application of laser energy in the contact mode enables the immediate vaporization and disintegration of the fibrous
area and secondary reepithelization of the bladder neck without scarring.
X
X
&9&3&4*1&37*"-"1"304$01*$"%*.&4)7"(*/"-&
86
87
o
6
08:30
10:00
s
1
s
Velasquez
0
e
2 ngr
Poster Digitali 3:
o
s
C
t
Oncologia per finire
I
I
c
I
a
X
r
X
t
s
24 maggio 2016
sala
)*()*/5&/4*5:'0$64&%6-53"406/%'0313045"5&$"/$&3*/1"5*&/58*5)
53"/41-"/5&%,*%/&:$"4&3&1035"/%-*5&3"563&3&7*&8
C. Maccagnano1, A. Paulesu1, A. D’Onofrio1, M. Corinti1, G. Conti1
1
ASST LARIANA (Como)
Abstract
High Intensity Focused Ultrasound (HIFU) is a curative option for the treatment of prostate cancer (PC) which has to be
considered in patients with life expectancy of over 5 years. In case of diagnosis of PC in subjects with transplant kidney,
HIFU can be a valid alternative to surgery, in order to preserve the renal function as much as possible, without the eventual
surgical complications. We found only one published spanish case report. A 71 years old man, affected by membranous
glomerulonephritis, was transplanted when he was 37 years old. After an acute reject and a period of haemodyalisis, the
patients was newly transplanted when he was 47 years old, with two subsequent episodes of acute reject, controlled with
immunosuppressors. When he was 69 years-old, the PSA level was 6.5 ng/mL. The digital rectal examination revealed a nodule
of about 1 cm in the right lobe. He was submitted to transrectal ultrasound prostate biopsy with transrectal approach. The
volume of the prostate was 18 ml, without evidence of suspicious nodules. The pathologist reported prostate adenocarcinoma
Gleason score 4 + 4 in 7/10 cores, bilaterally. We decided to treat PC with HIFU. The duration of the procedure was about 80
minutes. No sovrapubic catheter was placed. The patient was discharged after 48 hours, with trans-urethral catheter, which was
removed 10 days after HIFU. Additionally, he immediately started hormonal therapy with degarelix, firstly with the dosage of
160 mg and, successively, 80 mg once per month. The patient did not show any micturition problem. The renal function never
decreased. The last PSA, 12 months after the treatment was 0, and the patients stopped hormonal therapy. He is still on followup in our Centre.
-" 13045"5&$50.*" 3"%*$"-& */ %": 463(&3: $0.& -&70-6;*0/& %* 6/"
5&$/*$".*(-*03"-65*-*;;0%&--&3*4034&
Argomenti: S. Guercio1, F. Mangione1, M. Mari1, M.T. Carchedi1, L. Pezzano2, M. Bellina1
1
t Ospedale di Rivoli, S. C. Urologia (Rivoli)
2
t Direzione Sanitaria (Pinerolo)
Abstract
Introduzione:: In accordo con alcuni dati della letteratura internazionale, anche presso il nostro Centro è stata dimostrata la
fattibilità della prostatectomia radicale open in Day Surgery con notte in casi selezionati (AURO 2015). Scopo del lavoro è
08:30 - 10:00 - Poster Digitali 3 - Oncologia per finire
b
a
Moderatori: Gianluigi Taverna
87
88
X
X
a
r
t
s
b
a
Argomenti: C. Maccagnano1, A. Paulesu1, A. D’Onofrio1, M. Corinti1, G. Conti1
1
ASST LARIANA (Como)
INTRODUCTION: High Intensity Focuses Ultrasound (HIFU) of prostate can be considered as a curative treatment in patients
with local failure after brachytherapy (BT). Nevertheless, there are few published trials about this issue. We report two cases
of salvage HIFU after brachytherapy.
PATIENTS AND METHODS: Whole gland HIFU was administered following pathologic evidence of local recurrence after BT,
executed in another single Institution.
RESULTS: The first patient executed BT when he was 71 years old, because of an adenocarcinoma of the whole gland, Gleason
score 4 + 3; initial PSA was 3.8 ng/mL. Four years after BT, without hormonal therapy, the PSA raised until 4.2 ng/mL. Then
the patients was submitted to HIFU. No complications were reported after the procedure. The follow up was 48 months, and
the last PSA was 1.92 ng/mL, without any significant micturition complications. Complete erectyle dysfunction was described
by the patient but it was not simple to discriminate age component from the surgery. The second patient executed BT when
he was 58 years old, because of an adenocarcinoma of the whole gland, Gleason score 3 + 4; initial PSA was 4.2 ng/mL. Two
years after BT, without hormonal therapy, the PSA raised until 5.35 ng/mL. Then the patients was submitted to HIFU. No
complications were reported after the procedure. The follow up was 24 months, and the last PSA was 0.48 ng/mL. Comparing
to the first patient, this man reported low urinary flow and pollachyuria, with rare incontinence and urgency. The patients also
reported complete erectyle dysfunction. Both patients were not administered with hormonal therapy during follow-up and
they are still alive.
CONCLUSION: Salvage HIFU for locally recurrence after failed primary BT has promising results about disease control with a low
complication rate. Further studies are necessary to confirm these positive conclusions.
%0&4/#*$*4504$01:*/4.0,*/(1&01-&*.1307&5)&"#*-*5:50*%&/5*':
#-"%%&3-&4*0/4 13&-*.*/"3:&91&3*&/$&
Abstract
Recent reports have suggested that NBI cystoscopy is more effective than standard WLI cystoscopy for the detection of bladder
tumors. Cigarette smoking is the primary risk factor for bladder cancer The aim of this study was to evaluate, in the same
patient, smokers ot not-smokers, the probability to increase our ability to detect bladder cancer comparing the predictive
power NBI visible lesions cystoscopy versus white light visible lesions cystoscopy. The secondary objective was to evaluate how
the preoperative use of NBI cystoscopy can increase the ability to detect bladder lesions in higher smokers (> 20 cigarette/
die) vs fewer (< 20 cigarette/die) vs no-smokers. From June 2010 to April 2012, 797 consecutive patients, 423 male and 374
female, affected by suspected bladder cancer lesions, on the basis of the EAU Guideline 2010, were underwent to WL plus
NBI cystoscopy. The mean age was 67.7 yrs. (range 46-88). In our experience , 520 pts ( 65,2%) were smokers and 153 pts nosmokers . In the smokers group, 337 pts ( 64,8%) were higher (> 20 cigarette/die) than 183 pts (35,2%) fewer (< 20 cigarette/
die) smokers. This is the first study in the literature in a large patient’s cohort, in which the ability of NBI cystoscopy to increase
the ability to detect suspicious bladder lesions was compared with the use of WL cystoscopy alone in the same smokers or nosmokers patients. In smokers patients, the use of NBI cystoscopy, significantly increases by approximately 30% our predictive
power to identify lesions not visible with WL cystoscopy . In the others subgroups, fewer, no smokers and higher smokers
groups, we observed , following NBI cystoscopy, a significantly increased relative risk, approximately 35%, 30% and 25%,
respectively, to detect lesions not otherwise visible with the only WL cystoscopy.
1
4"-7"(&)*()*/5&/4*5:'0$64&%6-53"406/%'031"5*&/548*5)3&$633&/5
13045"5&$"/$&3"'5&3#3"$):5)&3"1:
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
valutare i possibili vantaggi economici derivanti dall’evoluzione della tecnica e dal migliore impiego delle risorse (Medici di
Medicina Generale ed ADI), che consentono la prosecuzione dell’assistenza del paziente a domicilio.
Materiali e metodi: utilizzando la metodologia ABC (Activity Based Costing) abbiamo eseguito una valutazione analitica dei costi
e dell’impiego delle risorse confrontando 3 diversi percorsi di cura per il trattamento del carcinoma prostatico localizzato:
prostatectomia radicale open con ricovero breve (4 giorni) prostatectomia radicale robot-assistita con ricovero breve (4 giorni)
prostatectomia radicale open in Day Surgery con notte L’analisi dei costi è stata eseguita con la collaborazione della S.C.
Programmazione e Controllo di Gestione dell’ASLTO3. I dati sui costi relativi alla tecnica robotica sono stati estrapolati dal
“Dossier dell’Emilia Romagna sul robot Da Vinci – 2008”e dal “Dossier del Nucleo tecnico HTA regionale della Sicilia con
supporto AGENASS sul Sistema Robotico da Vinci – 2013”.
Risultati:: L’analisi eseguita ha evidenziato, per quanto riguarda la prostatectomia radicale in Day Surgery con notte: una riduzione
dei costi rispetto a quelli standard di una prostatectomia radicale con ricovero breve; l’ importanza della sinergia OspedaleTerritorio; l’ impiego ottimale dei posti letto
Conclusioni: L’evoluzione della tecnica open consente, anche alla prostatectomia radicale, in casi selezionati, un’ ottimizzazione del
percorso di cura con attenzione ai costi.
88
89
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
/"3308 #"/% *."(*/( /#*
$:4504$01: "/% "44*45&% #*10-"3 563#5 "
13&-*.*/"3:&91&3*&/$&*/"4*/(-&$&/53&
a
r
t
s
b
a
%": .035"-*5: "'5&3 3"%*$"- $:45&$50.: '03 #-"%%&3 $"/$&3 %"5"
'30.".6-5*$&/5&3456%:
C.. D’Elia1, E. Comploj1, M.A. Cerruto2, S.M. Palermo1, E. Trenti1, W. Artibani2, A. Pycha1
1
2
AOUI Verona (Verona)
INTRODUCTION: Radical cystectomy (RC) represents gold standard treatment for muscle invasive bladder cancer (MIBC),
providing an excellent local control. Nevertheless, perioperative mortality ranges between 0,3 – 5,7%. The aim of our study was
to assess 90 day mortality and related risk factors in a cohort of patients that underwent RC for bladder cancer.
MATERIAL AND METHODS: Data regarding 475 patients that underwent RC and urinary diversion (ileal or sigmoid orthotopic
neobladder ora ileal/sigmoid conduit) at two italian Institution (Verona and Bolzano) from 2000 to 2015 were prosepctively
collected. Aziz nomogram was applied to the cohorts.
RESULTS Mean age at was 71.8 years and 81% of the patients were male. More represented ASA score was 2 (53%). At pathological
evaluation, 43.5% of the patients presented a locally advanced disease (VS 27.6% at clinical evaluation) and 24.3% confirmed
lymphnode involvment (VS 21.7%), showing a undifferential misclassification (Mc Nemar: 0,90). 90 days mortality was 5.2%
(n=25). Patients who died within 90 days underwent RC and ileal/sigmoid conduit; those patients were significatively older
(p < 0.0001) and with more advanced disease at pathological evaluation (p 0.03). No differences were found in BMI, gender,
center, ASA score, lymphnode metastasis, presence of CIS or metastasis. At logistic regression, patients with more clinical
advanced disease presents a OR of 1,5 in comparison with those with localized disease. Aziz nomogram was, moreover,
applied; evaluating the ROC curve of the cohort of patients of Verona, AUC was 0,77, whereas for the two centers AUC was
0,71. Hosmer Lemeshaw test was applied to the series,not showing a good calibration (0.07 VS 0.01).
CONCLUSIONS: We reported a 90 day mortality after RC of 5.2%. Only age, derivation and T stage resulted preoperative factors
predictive for 90 days mortality . Although with some limitations, Aziz nomogram represent the best predictive mortality tool.
$0.1-*$"5*0/4"'5&33"%*$"-$:45&$50.:*/&-%&3-:%*"#&5*$1"5*&/54
E. Altobelli1, R. Papalia1, A. Giacobbe2, D. Collura2, C. Falavolti1, E. Shehu1, E. Luperto1, M. Kurti1, G. Muto1, R. Mastroianni1,
G. Muto1
1
2
Abstract
To analyze the impact of diabetes on the perioperative complication rate of radical cystectomy in elderly patients. We
retrospectively evaluated the outcome of 576 radical cystectomies performed between October 2007 and June 2015. Of all
patients, 311 (54%) were ≥70-year-old (median age 73 year), of these 44 (8% of the whole cohort) were affected by diabetes.
Exclusion criteria were: type 1 diabetes, uncontrolled type 2 diabetes, history of coronary heart disease and uncontrolled
hypertension. According to these criteria, 12 patients were excluded from the study cohort. This group of 32 elderly diabetic
X
X
R. Giulianelli1, B.C. Gentile1, L. Albanesi1, G.. Mirabile1, P. Tariciotti1, G. Rizzo1
1
Abstract
The aim of this study was to evaluate, in the same patient before WL transurethral resection of bladder tumours , the possibility
to increase our ability to detect bladder cancer comparing the predictive power of lesion visible at NBI versus lesions lesions
visible white light cystoscopy. The secondary objective was to evaluate how the preoperative use of NBI cystoscopy can increase
the ability to detect bladder lesions in terms of status, multi-focality and dimensions after TURBT, as opposed to WL cystoscopy.
Between June 2010 and April 2012, 423 male and 374 female, affected by suspected bladder cancer lesions, , were underwent
to WL plus NBI cystoscopy and subsequently to WL Bipolar Gyrus PK TURBT. Mean age was 67.7 yrs. (range 46-88). All
patients underwent preoperative white light cystoscopy: topography with characterization of neoplasms and/or suspicious
lesions followed by a similar evaluation using NBI. Subsequently all the patients underwent by same surgeon to WLTURBT of
the previously identified lesions. All the removed tissue was sent separately for histological evaluation after mapping the areas
of resection on a topographic sheet. The use of NBI cystoscopy, significantly increases by approximately 30% our predictive
power to identify lesions not visible with WL cystoscopy, especially for unifocal lesions, those < 3 cm and recurrence lesions
. Following WLTURBT, status , dimensions and focalities are statistically significants (p<0,001) to detect bladder oncological
lesions following NBI cystoscopy than WL cystoscopy. This is the first study in the literature in a large patient’s cohort, in
which the ability of NBI cystoscopy to increase the ability to detect suspicious bladder lesions was compared with the use of
WL cystoscopy alone in the same patient. This study showed that NBI is an effective method for the identification of bladder
lesions and can be useful in supporting WL cystoscopy.
89
90
X
X
a
r
t
s
D.. Conconi 1, E. Sala 2, G.. Bovo 3, G.. Strada 4, P.. Viganò 4, A. Bentivegna 1
1
Università di Milano Bicocca, Dipartimento di Medicina e Chirurgia (Monza )
2
Ospedale San Gerardo, Laboratorio di Genetica Medica (Monza)
3
Ospedale san Gerardo, Unità Operativa di Patologia (Monza)
4
Ospedale Bassini ICP, Divisione di Urologia (Cinisello Balsamo)
Abstract
Bladder cancer is the ninth most common cancer worldwide. More than 90% of these tumors are transitional cell carcinomas
(TCC, also urothelial carcinoma) that are characterized by the presence of two distinct groups with different clinical and
prognostic features: non-muscle-invasive bladder cancers (NMIBCs) and muscle-invasive bladder cancers (MIBCs). Despite
progress in the study of tumors, treatment has not advanced significantly in recent years, with the absence of new therapeutic
targets. In particular, MIBCs still have an unfavorable outcome with a survival rate after 5 five years below 50% and common
progression to metastasis. In order to identify possible biomarkers for clinical application, we compared our array-CGH results
with those reported in literature for invasive bladder tumors and, in particular, we focused on the evaluation of copy number
alterations (CNAs) present in biopsies and retained in the corresponding cancer stem cell (CSC) subpopulations that should be
the main target of therapy. Our results showed that CCNE1, MYC, MDM2 and PPARG copy number gains were present both
in biopsies and in CSC subpopulations, making these interesting therapeutic targets. Surprisingly, HER2 copy number gains
are not retained in bladder CSCs, making the gene-targeted therapy less interesting than the others. These findings provide
valuable information to deeper study on bladder therapy, however the clinical importance of these results should be explored.
b
a
$033&-"5*0/ #&58&&/ )&9".*/0-&706-*/"5& 104*5*7*5: "/% '*4) */
)*450-0(*$"-/&("5*7&#-"%%&3#*014*&48*5)5)&%&7&-01&.&/50'5$$
D. D Andrea1, C. D Elia1, T. Martini2, C. Mian1, S.M. Palermo1, E. Comploj1, A. Pycha1
1
2
Ulm University Medical Center (Ulm)
INTRODUCTION: With the Photodynamic Diagnostic (PDD) bladder cancer detection has become more accurate. In this
procedure the false-positive detection rate has been reported between 12% and 60%. The aim of our study was to analyse
chromosomal patterns of false-positive lesions in the PDD and compared the FISH positive with the FISH negative biopsies,
with the aim to evaluate the development of a bladder TCC in the follow-up of these patients.
MATERIAL AND METHODS: We analyzed 48 patients, with suspected flat urothelial lesion on cistocopy or high grade cytology.
All patients received intravescical instillation of 80mg HAL (Hexvix) and all suspicious areas were biopsied. The chromosomal
pattern of all biopsies was analyzed with Fluorescence In Situ Hybridization (FISH, UroVysion).
RESULTS: 153 of 251 biopsies in 40 patients could be evaluated for FISH analysis. 45 biopsies in 22 patients were PDD positive
but negative in white light and histology (false-positive). 9 /22 patients showed chromosomal aberration in 26,7% of the falsepositive biopsies. All biopsies showed aneusomy of Locus 9p21 (p16), 17,8% also aneusomy of chromosome 3 and 15,5%
aneusomy of chromosome 7 and 17. 16/22 patients presentend false positive PDD biopsies and global negative hystologic
evaluation; mean follow up was 17 months. 56% patients did not showed disease recurrence and in all this patients except one
FISH was negative, whereas 55% (7/16) presented disease recurrence. 3/7 patients developed NMIBC and the two patients with
CIS recurrence presented a positive FISH. Moreover, 2 patients developed UUTUC and underwent nephroureterectomy; this
patients had negative FISH, but urinary FISH was positive, whereas the other two patients who underwent radical cystectomy
due to NMIBC reccurrence presented a positive FISH.
CONCLUSIONS: FISH and PDD may be able to discriminate patients with a higher risk of disease recurrence, aiming to create a
tailored follow up for every single patient.
64*/( $01: /6.#&3 "-5&3"5*0/4 50 *%&/5*': /&8 5)&3"1&65*$ 5"3(&54
'03#-"%%&3$"3$*/0."
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
patients (5% of the whole cohort) was compared with two matching groups. The first matching group included 32 elderly nondiabetic patients (5% of the whole cohort), the second matching group 25 younger diabetic patients (4% of the whole cohort)
aged ≤69 year (median age 63 year) without comorbidities. Fifty-seven patients (10%) suffered from type 2 diabetes mellitus,
41 were treated with oral antidiabetics and 16 required insulin. Perioperative complications were significantly more frequent in
the elderly diabetic group compared to the younger diabetic group: 31% versus 22% overall complication rate. One patient died
in the elderly diabetic group, no deaths were recorded in the younger cohort. Within the elderly group, the overall complication
rate was significantly higher in patients with diabetes (37%) than in patients without (26%). Multivariate logistic regression
analysis was used to identify that together with diabetes, age, ASA score and BMI were independent predictive factors for
perioperative complications. Elderly diabetic patients have a higher prevalence of postoperative complications after radical
cystectomy. Concomitant diabetes can affect surgical outcome after radical cystectomy in the elderly population, particularly
the frequency and severity of perioperative complications. Limits of the study are the retrospective analysis and the small
cohorts of patients. A prospective multicenter study will overcome these limits.
90
91
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
5)6-*6. -"4&3 &/#-0$, 3&4&$5*0/ 7&3464 563# " 45&1 ")&"% */ 5)&
."/"(&.&/50'#-"%%&3$"/$&3
a
r
t
s
b
a
4,*//*/(%&--"$65&%&-(-"/%&&3&463'"$*/($0/*//&4504055*-&%*
&1*%&3.*%&&41&3*&/;"*/*;*"-&
P.A.. Mastrangelo1, F. Di Giacomo1, T. Masciandaro1, G. Galdo2, D. Massariello2
1
I.R.C.C.S. CROB, U.O. Urologia (Rionero in Vulture)
2
I.R.C.C.S. CROB, U.O. Chirurgia Plastica (Rionero in Vulture)
Abstract
I carcinomi in situ del pene e le lesioni preneoplastiche del glande rappresentano una sfida nella ricerca di trattamenti
che conservino la funzione del pene senza compromettere il controllo oncologico. La terapia chirurgica è in alcuni casi
eccessivamente mutilante ed il ricorso all’ utilizzo di terapie esteticamente e funzionalmente più accettabili può essere
un’opzione. Trattamenti come la laserterapia, la chemioterapia topica, la radioterapia a fasci esterni o la brachiterapia, nel caso
del CIS o lesioni neoplastiche superficiali, presentano però fino al 30% di recidiva ed i pazienti necessitano di stretto e continuo
follow up. Presentiamo l’esperienza preliminare su 5 pazienti da noi trattati con skinning del glande e resurfacing con innesto
sottile di epidermide prelevato dalla coscia. Sono stati sottoposti ad intervento chirurgico 2 pazienti con CIS, 1 paziente con
carcinoma squamoso del glande con stadio pT1aG2, 1 paziente con Eritroplasia di Queyerat, ed un paziente con balanite di
Zoon. All’esame istologico sulla cute del glande asportata, ha confermato CIS nei 2 pazienti e balanite di Zoon in un paziente.
E’ stata riportata invece la presenza di CIS nel paziente con Eritroplasia di Queyerat ed l’ assenza di malattia nel paziente
con carcinoma squamoso pT1a. I margini chirurgici sono risultati negativi. In nessun caso si sono verificate complicanze
legate all`attecchimento dell`innesto. Possiamo concludere che questo tipo di chirurgia è sicuramente di semplice esecuzione e
facilmente riproducibile, a basso rischio di complicanze, con risultati oncologicamente superiori ai trattamenti non chirurgici,
e consente di ottenere risultati estetici e funzionali completamente soddisfacenti per il paziente.
13&%*$5034 0' */$*4*0/"- )&3/*" "'5&3 30#05*$ 3"%*$"- $:45&$50.:
8*5)*/53"$03103&"-63*/"3:%*7&34*0/
M.. Ferriero1, G. Simone1, R. Papalia2, R. Mastroianni2, F. Minisola1, S. Guaglianone1, M. Gallucci1
1
2
INTRODUCTION AND OBJECTIVES: Robotic radical cystectomy (RRC) with intracorporeal urinary diversion (iUD) provides
excellent clinical, functional and aesthetic outcomes, with decreased post-operative pain and quicker recovery. However these
benefits may be negated in patients who developed incisional hernia on the site of specimen extraction, especially in case of
severe complications such as obstruction and perforation. The aim of our study was to evaluate the incidence and potential
predictors of incisional hernia in patients who underwent RRC with iUD.
METHODS: From October 2012 to October 2015, 132 consecutive patients with cT2-4a/cN1-3/cM0 bladder cancer underwent
X
X
E.. Altobelli1, R. Papalia1, A. Giacobbe2, D.. Collura2, C.. Falavolti1, E. Shehu1, E.. Luperto1, M.. Kurti1, G. Muto1, R. Mastroianni1,
G. Muto1
1
2
Abstract
The purpose of the study was to evaluate and compare the outcomes of en-block Thulium laser resection in terms of: quality
of resection specimens, blood loss, catheterization time, and hospital stay. From April 2012 to September 2015, data of 120
patients with newly diagnosed bladder cancer were reviewed. Patients were divided in two groups of 60: group A was treated
with standard TURB while group B underwent en-block Thulium laser resection. A total 142 tumors were removed, 69 in
group A and 73 in group B. The mean tumor diameter was 2.02±1.68cm in Group A and 2.83±1.45cm in group B. Mean
operative time was 17.85±12.66 minutes for group A and 33.08±11.50 minutes for the group B. Of the 32 patients of group
A with tumors located in the lateral bladder walls, 18 (56,25%) encountered obturator reflex. No patients of group B showed
obturator reflex. In both groups there were no intraoperative or postoperative complications. In group A bladder postoperative
irrigation was necessary in all patients while it was not needed in group B. The average irrigation time was of 17.97±15.46
hours. Mean catheterization time was 37.4±16.9 hours for the patients belonging to group A while 17.9±8.71 hours for group
B (p<0.05). There were no statistical differences in terms of hospital stay and blood loss. The mean hospital stay was 3.07 ±
1.5 days for Group A and 3.37±1.22 days for group B (p=0.11). The average values of post-operative hb were 13,56±1,48g/dL
for group A and 13,61±1,46g/dL for group B (p=0.84). 37% of the specimens from the TURB group had encountered artifacts
from cautery while none were reported after laser resections. Laser en-bloc resection showed a better preservation of tumor
architecture ensuring greater accuracy in the diagnosis and staging. It was also associated to inferior catheterization time and
absence of obturator reflex.
91
92
X
X
a
r
t
s
b
a
M. Ferriero1, G. Simone1, R. Papalia2, R. Mastroianni2, S. Guaglianone1, F. Minisola1, M. Gallucci1
1
2
INTRODUCTION AND OBJECTIVES: Robotic radical cystectomy (RRC) with intracorporeal urinary diversion (iUD) is a
challenging procedure and currently robust results concerning feasibility and safety are required. In this study we evaluated
perioperative, functional and oncologic outcomes of our first 140 RRCs with iUD.
METHODS: From October 2012 to October 2015, 140 consecutive unselected patients with cT2-4a/cN1-3/cM0 bladder cancer
underwent RRC, extended lymphadenectomy and totally iUD. Baseline demographics, perioperative and follow up data were
prospectively collected. We reported perioperative, functional and oncological results. Kaplan- Meier analysis was used to
assess disease free survival (DFS) and cancer specific survival (CSS).
RESULTS: Out of 140 RRC, we selected 105 consecutive patients with a minimum 3-mo follow up. Eighty-five patients received a
Padua Ileal bladder (62 male and 23 female), while 20 patients received an ileal conduit. Median hospital-stay was 10 days (IQR
9 -14). Thirty-seven (35,2 %) patients experienced any kind of complications, while high grade (clavien 3-5) complication rate
was 9.5%. At a median follow-up of 10 months (IQR 6-15) day-time and night-time continence rate were 75.3% and 62.3%,
respectively. Ureteral and urethral anastomosis strictures occurred in 7.6% and 3.2% of patients, respectively. (Table 1) Two-yr
DFS rate was 84% in patients with organ confined disease (pT<3 N0). Patients with extra vesical disease (pT>2 N0) and those
with nodal metastasis had significantly worse DFS and CSS probabilities (log rank 0.041 and 0.013, respectively (Figure 1).
CONCLUSIONS: Preliminary experience with RRC and intracorporeal neobladder showed promising perioperative, functional
and oncological results.
1"3"5&45*$6-"3%&%*''&3&/5*"5&%-*104"3$0.""$"4&3&1035
C. Grassani1, M. Potenzoni1, A.M. Pieri1, N. Uliano1, R. Arnaudi1, D. Martens1, S.C. Destro Pastizzaro1, F. Cantoni1, A. Savino1,
A. Prati1
1
Ospedale di Vaio, U.O. Urologia (Fidenza)
Abstract
We present the case of a72years old male complaining right testicular pain risen from a few days.There were nohistories of local
trauma,infection,systemic syndrome.At physical examination a painful,non-tender right scrotal mass adherent to the right
epididymis was identified.The US revealed a nonhomogeneous lesion with a few thick septa,about 2,7cm of diameter close to
the head of the epididymis.All preoperative laboratory tests were normal.Surgical exploration revealed 3 multilobulated solid
masses arising from paratesticular region,encapsulated and attached to the deferent,gray-white at the cut surface with fibrous
septa.Removal of the above described nodules and of the deferent was performed with inguinal access.The testis was spared.
Microscopic examination of theHE-stained slides showed an high grade malignant mesechimal neoplasm,rich in spindle
cell and histiocyte-like cells,organized in small bundle and storiform patterns,with infiltrative borders.A few areas of well
differentiated adipocytic neoplasm were observed.The lesion was extensively himmunoreactive forMDM2 and CD4,negative
for Desmin,S100,CD34.Proliferative indexKi67 was about10-15%.The lesions were compleatly excised but they infiltrate the
deferent duct.The diagnosis was of a dedifferentiated liposarcoma.The patient was referred to a first level centre for sarcomas
where radical orchiectomy wth high ligation of the spermtic cord was performed.Until 4 months the patiens had no disease
recurrence or metastases.Dedifferentiated liposarcoma account10% of all liposarcoma.The spermatic cord liposarcoma is a
rare and frequently misdiagnosed entity.Due to low frequency treatment recommendations are based on small series.The
metastatic rate account about15-20% of the cases irrespective of histologic grade.These lesions often pose greater problems in
terms of local control.Mortality is more often related to uncontrolled local recurrence, and time to relapse to the extension of
5)3&&:3 &91&3*&/$& 8*5) 30#05*$ 3"%*$"- $:45&$50.: "/%
*/53"$03103&"- 63*/"3: %*7&34*0/ 1&3*01&3"5*7& '6/$5*0/"- "/%
0/$0-0(*$"-065$0.&4
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
RRC, extended lymphadenectomy and totally iUD. All women were excluded from the analysis because of vaginal extraction of
the specimen. Baseline demographics, perioperative and follow up data were prospectively collected. Age, UD, BMI, smoking,
diabetes, cardiovascular disease, neoadjuvant chemotherapy, hypoxia, transfusion rate, extraction site of the specimen (camera
port 2cm cranial to umbilicus vs 3-4cm prepubic incision), high grade complications and learning curve were included for
analysis. Univariable and multivariable cox regression analysis were performed to identify independent predictors of incisional
hernia.
RESULTS: Out of 132 RRC, 80 male patients were selected with a minimum 3 month follow up. Sixty-five patients received an
orthotopic neobladder, while 15 patients received an ileal conduit. At a median follow up of 10 months (IQR 5-15) 20 (25%)
patients experienced an incisional hernia. Fig. 1 Three cases required surgical repair. Age, learning curve and extraction
site were significant predictors of incisional hernia at univariable analysis (p= 0.037, p<0.001 and p=0.001, respectively).
At multivariable analysis, suvraumbilical extraction site of the specimen was the only independent predictor of developing
incisional hernia (p = 0.034; HR: 12.45 [95% CI, 1.13-137.5]).
CONCLUSIONS: A 3-4 cm prepubic incision significantly decreases the risk of incisional hernia after RRC with iUD.
92
93
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
the surgical resection.
The standard therapeutic approach has been radicalinguinal orchiectomy with wide local resection and negative microscopic
margins.Due to low responce of adiuvant therapy, surgery remains the only effective treatment.The goldstandard should be to
achive a complete resection with clean surgical margins.
"%6-54&9$03%56.030'5)&5&45*4"$"4&3&1035
b
a
a
r
t
s
X
X
C. Grassani1, M. Potenzoni1, N. Uliano1, A.M. Pieri1, F.. Cantoni1, R. Arnaudi1, A. Savino1, D. Martens1, S.C. Destro Pastizzaro1,
A. Prati1
1
Ospedale di Vaio, U.O. Urologia (Fidenza)
Abstract
We present the case of a80 years old male referred to our UrologyUnit complaining of right testicular pain from1 month.There
were no histories of local trauma,infection,systemic syndrome,no inguinal,cervical,supraclavicolar lymphoadenopathy and
gynecomastia.At physical examination,the right testis was slightly tender and painful.TheUS revealed an hypovascularized
intratesticuar nodule,2,7cm of maximum dimension.Preoperative exams were within the range.Radical inguinal orchiectomy
was performed.At the cut section,the testis was completely replacing by a yellowish,not tender extensively necrotic lesion.
Thehistopathological specimens showed an extensively necrotic neoplasm,constituted of medium size epitheliomorphic cells
with vesicular,macronucleolated nuclei and eosinophilic vacuolated cytoplasm,sometimes including lypidic vacuoles.The cells
were disposed in insular,trabecular and small nests pattern,infiltrating the testicular stroma,with numerous mitoses.In general
the neoplastic cells did not show a clear-cut differentiation into either Sertoli-Laydig cells or granulosa cells.These cells had a
positive immunohistochemical staining for CK pool,Calretinin,Alpha Inibin,CD99,Melan A,negative for EMA,OCT3/4,SALL
4,PAX8,WT1,TTF1,CEA.The findings were in keeping with a sex cord stromal tumor.The presence of necrosis,the high degree
of cytologic atypia,the infiltrative growing pattern and the high mytotic index are consistent with a malignant form.Surgical
margins were negative.Sex cord stromal tumors are rare tumors affecting predominantly children and young adults, in facts
they account about3% of all testicular tumors occurring in adults,though they account30% of testis tumors in children and
infants.The adult type is very rare and management is not completely understood and differs from the pediatric form by
presentation,histology evolution and treatment.Metastases has been reported most commonly to retroperitoneal lymph
nodes,but lung,liver and none metastases have also been noted.Approximately20% of cases are malignant.Retroperitoneal
dissection should be considered in case of metastatic disease or pathologic reports suggestive for malignancy,being the
metastatic disease poorly responsive to chemio and radio therapy.Follow up includes 6 months abdomen and chest CT scan.In
our case abdominal and chest CT at 6 months were completely negative for metastatic disease and local recurrence.
93
94
o
6
s
1
s
0
e
2 ngr
o
s
C
t
I
I
c
I
FINE
a
X
r
X
t
s
b
a
abstracts
XXIII
Congresso Nazionale
AURO
22-24 maggio • ROMA
2016
94

2016 XXIII Congresso

Transcript

Documenti analoghi

Concentration of elements in serum of patients affected by multiple

1storytelling - Cooperativa Ceramica d`Imola

Presentazione standard di PowerPoint

PULMONARY EMBOLISM

Pubblicazioni 2007 - LABORATORIO ANALISI E DIAGNOSTICA

Altre informazioni

VITA PARROCCHIALE / PARISH LIFE

abstracts

clinica e terapia - CG Edizioni Medico Scientifiche

from ahajournals.org

Analisi DUTASTERIDE