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Aim: The upgrading or staging in men with prostate cancer (PCA) undergoing active surveillance (AS), defined as Gleason score (GS) ≥ 3+4 or more than 2 area with cancer, was investigated in our experience using the software-based fusion biopsy (FB). Methods: We selected from our database, composed of 620 biopsies, only men on AS according to criteria of John Hopkins Protocol (T1c, < 3 positive cores, GS = 3+3 = 6). Monitoring consisted of PSA measurement every 3 months, a clinical examination every 6 months, confirmatory FB within 6 months and then annual FB in all men. The suspicious MRI lesions were scored according to the Prostate Imaging Reporting and Data System (PI-RADS) classification version 2. FB were performed with a transrectal elastic free-hand fusion platform. The overall and clinically significant cancer detection rate was reported. Secondary, the diagnostic role of systematic biopsies was evaluated. Results: We selected 56 patients on AS with mean age 67.4 years, mean PSA 6.7 ng/ml and at least one follow-up MRI-US fusion biopsy (10 had 2 or 3 follow-up biopsies). Lesions detected by MRI were: PIRADS-2 in 5, PIRADS-3 in 28, PIRADS-4 in 18 pts and PIRADS-5 in 5 patients. In each MRI lesion, FB with 2.1 ± 1.1 cores were taken with a mean total cores of 13 ± 2.4 including the systematic cores. The overall cancer detection rate was 71% (40/56): 62% (25/40) in target core and 28% (15/40) in systematic core. The overall significant cancer detection rate was 46% (26/56): 69% (18/26) in target vs 31% (8/26) in random cores. Conclusions: The incidence of clinical significant cancer was 46% in men starting active surveillance, but it was more than doubled using MRI/US Target Biopsy 69% (18/26) rather than random cores (31%, 8/26). However, 1/3 of disease upgrades would have been missed if only the targeted biopsies were performed. Based on our experience, MRI/US fusion target biopsy must be associated to systematic biopsies to improve detection of significant cancer, reducing the risks of misclassification.

Reasons why significant prostate cancer is still missed in early stage were investigated at the 22nd National SIEUN (Italian Society of integrated diagnostic in Urology, Andrology, Nephrology) congress took place from 30th November to 1st December 2020, in virtual modality. Even if multiparametric magnetic resonance (MR) has been introduced in the clinical practice several, limitations are emerging in patient with regular digital rectal examination (DRE) and serum prostate specific antigen (PSA) levels approaching the normal limits. The present paper summarizes highlights observed in those cases where significant prostate cancer may be missed by PSA or imaging and DRE. The issue of multidisciplinary interest had been subdivided and deepened under four main topics: biochemical, clinical, pathological and radiological point of view with a focus on PI-RADS 3 lesions.

Aim: The objective of this study is to present our initial experience with magnetic resonance imaging/ultrasound (MRI/US) fusion biopsy using the Koelis Trinity device after the first consecutive 59 patients. Materials and methods: 59 consecutive patients with suspected prostate cancer (PCA) underwent prostate biopsy using Trinity Koelis® (Koelis, Grenoble, France). We divided the patients into 2 groups: patients with a previous negative mapping underwent to a MRI/US fusion re-biopsy (Group A); and biopsy-naïve patients who underwent to a first stereotactic 3-D mapping of the prostate (Group B). Group A (22 patients):mean age 64 years (CI 48-73), mean PSA = 7.7 ng/ml (CI 4.2- 9.9); mean prostate volume 55 ml(CI 45-82), Digital Rectal Examination (DRE) positive in 2/22, number of lesions detected by MRI 1.4, mean cores from each MRI target lesion 3 (CI 2-5), mean total cores 15 ( CI 12-19). Group B (37 patients): mean age 66 years (CI 49-77), mean PSA= 4.7 (3.2- 7.9); mean prostate volume 45 ml (33-67), DRE positive in 5/37, mean total cores 14 ( CI 10-16) Results: In Group A 10/22 patients were positive for PCA (overall detection rate of 45.5%): 6 PCA were detected by target biopsy and 4 cancer by random biopsy. Significant prostate cancer (defined as the presence of Gleason pattern 4) was detected in 4/10 patients (Significant PCA detection rate of 40%) and all significant PCA were detected by MRI target biopsy. All PCA detected by random biopsy had Gleason score 3 + 3 = 6. In Group B (biopsy naïve patients) 14/37 patients were positive for PCA (overall detection rate of 37.8%), Significant prostate cancer was detected in 5/14 patients (Significant PCA detection rate of 35,7%). No significant side effects were recorded. Conclusions: Our overall detection rate was 45.5% and 37.8% in Group A (patients with previous negative biopsy and persistent suspicion of PCA) and in Group B (biopsy naïve patients) respectively; clinical significant PCA detection rate was respectively 40% and 35.7%. These results are similar to current literature and promising for the future. We believe that using platforms of co-registered MRI/US fusion biopsy can potentially improve risk stratification and reduces understaging, undergrading and the need for repeat biopsies in biopsy naïve patients (using a stereotactic first mapping) and in patients with previous negative biopsy and persistent suspicion of PCA ( using a second MRI/US fusion biopsy).

Objective: To evaluate the main factors which influence understaging in patients with T1G3 non-muscle invasive bladder cancer (NMIBC). Materials and methods: 109 patients with T1/G3 underwent transurethral resection of bladder tumor (TURBT) and then radical cystectomy (RC) with pelvic lymph nodes dissection. A number of variables were considered when evaluating the detection of understaging. We considered the patients age and gender, as well as the size, number, location and morphology of their tumor. We also considered coexistence of bladder carcinoma in situ (CIS), microscopic vascular invasion and deep lamina propria invasion. The level of experience of the surgeon was also analyzed. Results: in RC samples muscle invasion, that is understaging, was detected in 74 (67.9%) patients, while 35 (32.1%) patients were appropriately staged. In these cohort of patients with high grade tumors, understaging was associated with deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor; age, gender, tumor morphology, CIS associated, and experience of urological surgeon were not associated with clinical understaging. Conclusions: in our study, evaluating patients with high grade NMIBC at first TURBT, we identified some risk factors that need to be considered and that are able to increase the risk of understaging: deep lamina propria and microscopic vascular invasion, multiple tumors, tumor size > 6 cm, tumor location (trigone and dome), presence of residual tumor. When these risk factors are present, performing an early cystectomy, and not a re-TURBT, could lower the risk of worse pathological finding due to rapid disease progression of the high grade tumors, and can prolong survival.

Aim: The objective of the present study is to evaluate the diagnostic accuracy of hexylaminolevulinate (HAL) blue light cystoscopy compared with standard white light cystoscopy (WLC) in daily practice. Materials and methods: An observational, comparative, controlled (within patient) study was carried out at our Center. 61 consecutive patients with suspected or confirmed bladder cancer were recruited for the study from January 2008 until January 2015. Patients with suspected bladder cancer (positive cytology with negative WLC) or history of previous high-grade NMIBC or CIS were included in the study. Biopsies/resection of each positive lesion/suspicious areas were always taken after the bladder was inspected under WLC and BLC. Diagnoses of bladder tumor or CIS were considered as positive results, and the presence of normal urothelium in the biopsy specimen as negative result. Results: 61 BLC were performed. 15/61 (24.5%) with suspected initial diagnosis of NMIBC and 46/61 (75.5%) with a history of high-risk non-muscle invasive bladder cancer (NMIBC). We performed a total of 173 biopsies/TURBT of suspicious areas: 129 positive only to the BLC and 44 both positive to WLC and BLC. 84/173 biopsies/TURBT were positive for cancer. All 84 NMIBC were positive to the BLC, while 35/84 were positive to the WLC with a sensitivity of BLC and WLC respectively of 100% and 41.7%. Sensitivity of WLC for highgrade NMIBC and CIS was 34.1% and 39% respectively while sensitivity of BLC for high-grade NMIBC and CIS was 100%. The specificity of the WLC was 79.9% compared to 48.5% of the BLC. The positive predictive value of BLC and WLC were respectively 48% (95% CI: 0.447-0.523) and 79% (95% CI: 0.856-0.734). Conclusions: Our data confirm those reported in the literature: BLC increases the detection rate of NMIBC particularly in high risk patients (history of CIS or high grade). BLC is a powerful diagnostic tool in the diagnosis of bladder cancer if malignancy is suspected (positive urine cytology) and if conventional WLC is negative.

The incidence of prostate cancer (PCA) was evaluated in 155 patients with isolated Atypical Small Acinar Proliferation (ASAP) found on initial prostate biopsy, after a medium-term follow-up (40 months) with at least one re-biopsy. Clinical and histological data were analysed. Cancer was detected in 81 of 155 (52.3%). The cancer detection rate was 71.6%, 91.3%, 97.5%, 100% at the 1st re-biopsy, 2nd, 3rd, and 4th rebiopsy respectively. At the uni- and multivariate analyses, prostate volume (≤ 30 cc), transition zone volume (≤ 10 cc), small core length at the initial biopsy (≤ 10 mm) and few number of cores at initial biopsy (≤ 8) are predictive of cancer. Furthermore, tumour characteristics on the whole surgical specimens was assessed in 30 men: 13 of 30 (43 %) had clinically relevant cancer (volume > 0.5 ml or/and Gleason score ≥ 7, or pT3). Most of relevant cancers were detected in the distal apex, anterior gland and midline. These anatomical sites could be under-sampled at the initial biopsy using the transrectal approach. Our data suggest that follow-up biopsy is recommended in all cases of isolated ASAP detected after biopsy using endfire transrectal probe. The re-biopsy strategy should increase the number of cores (or a saturation biopsy), focusing on area of ASAP in the initial biopsy, but also including the under-sampled areas (anterior gland, distal apex and midline) to detect clinically relevant cancers.

Objective: we present our 7-years’ experience with fiducial gold markers inserted before Image-Guided Radiotherapy (IGRT) focusing on our echo-guided technique reporting early and late complications. Material and methods: 78 prostate cancer (PCA) patients who underwent fiducial markers placement for adaptive IGRT (period 2007-2014) were selected. Mean patient age was 75 years (range 60-81), mean PSA 7.8 ng/ml (range 3.1-10), clinical stage < T3, mean Gleason Score 6.4 (range 6-7). We recorded early and late complications. Maximum distance between the Clinical Target Volume (CTV) and Planning Target Volume (PTV) was assessed for each direction and the mean PTV reduction was estimated. Results: we describe in details our echo-guided technique of intraprostatic gold fiducial markers insertion prior to adaptative IGRT. We report rare early toxicity (5-7% grade 1-2), a mean PTV reduction of 37% and a very low late toxicity (only 3.4% bladder G3 and 8% rectal G2 side effects). Conclusion: Our technique of fiducial gold markers implantation for adaptative IGRT is safe and well-tolerated and it resulted helpful to reduce CTV-PTV margin in all cases; the effects on clinical practice seem significant in terms of late toxicity but further investigations are needed with longer follow-up.

Objectives: To evaluate the improvement of Lower Urinary Tract Symptoms (LUTS) and Erectile Function (EF) evaluated before and after Open Simple Prostatectomy, focusing on which patients this procedure allows better outcomes in term of sexual activity. Material and methods: 50 men with large size benign prostatic hyperplasia (BHP) greater than 80 gr were prospectively evaluated before and 6 months after Open Simple Prostatectomy (Freyer procedure) between October 2012 to September 2013. Patients had a pre-operative transrectal ultrasound (TRUS) for volume evaluation and filled pre and post operative questionnaires for International Prostate Symptom Score (IPSS) and International Index of Erectile Function (IIEF-5) score. Results: Mean patients age was 71 years (D.S. 3,5), mean prostate volume results 103 ml (D.S. 23,7); regarding LUTS and EF, mean improvement of IPSS score was 15,3 (D.S. 4) and mean increase of IIEF-5 score was 3,4 (D.S.3). This study highlights a correlation between patients’ age and increase of IIEF-5 score; no correlation with prostate size was found. Conclusion: According to the EAU Guidelines 2014, large size BPH (over 80-100 mL) with LUTS refractory to medical management continue to have open prostatectomy as the treatment of choice. In our experience we found not only an reduction of LUTS after the procedure but also an improvement of erectile function; this improvement was related with patient’s age.

Objectives: To establish whether repeated trans-rectal ultrasound-guided Prostate Needle Biopsies (PNBx) performed in men with diagnosis of Small Acinar Atypical Proliferation (ASAP) predispose these subjects to Erectile Dysfunction (ED) and to evaluate if EcoColorDoppler (ECD) can help to reduce this side effect. Materials and methods: We performed a retrospective study regarding 190 men with diagnosis of ASAP detected between January 2001 and December 2011, who underwent to repeated prostate needle biopsies (PNBx). These patients were investigated about Erectile Function (EF) and Lower Urinary tract Symptoms (LUTS) using International Index of Erectile Function (IIEF-5) and International Prostate Symptom Score (IPSS) questionnaires before the first PNBx and 3 months after each other one. In particular, among the 89 men without ED before first PNBx, we compared IIEF-5 score between 64 patients who underwent to standard PNBx and 25 patients submitted to a PNBx done with in addition ECD ultrasound imaging. Results: Mean patient age was 65 years (SD 7.7); mean follow-up was 3.2 years (SD 1.8) and the mean number of re-biopsies completed was 2 (SD 1.5). Among the 143 men considered, only 89 resulted with a normal EF (IIEF-5 score > 21): in this group incidence of ED (IIEF-5 score < 21) among patients who underwent to standard PNBx was 4/64 (6.25%) while in patients submitted to a PNBx with ECD was 1/25 (4%). A greater decrease of EF was observed in patients undergone to 3 or more biopsies; no relationship between IPSS score and re-PNBx was identified. Conclusion: Repeated PNBx done in patients with diagnosis of ASAP appear to get worse EF; number of biopsies seems to increase the risk of ED. Use of ECD in transrectal ultrasound- guided PNBx may have a role to avoid neurovascular bundles (NVBs) and preserve EF; anyway further studies are highly recommended to validate this hypothesis.

Aim: We evaluated the effectiveness of tamsulosin monotherapy versus tamsulosin plus sildenafil combination therapy on erectile dysfunction (ED) in young patients with type III chronic prostatitis and ED by using symptom score scales. Materials and methods: 44 male patients were divided into 2 groups: the first group (20 patients) was treated with tamsulosin 0,4 mg monotherapy and the second one 24 patients) was treated with tamsulosin 0,4 mg plus sildenafil 50 mg combination therapy. “International Prostate Symptom Score” (IPSS), “National Institute of Health Chronic Prostatitis Symptom Index” (NIH-CPSI) and “International Index of Erectile Function” (IIEF-5) were inves- tigated in each group of patients, and scores calculated during the first medical examination. Both groups were treated with tamsulosin once daily for 60 days, while sildenafil 50 mg was given on demand (at least 2 times per week) for 60 days. During the second medical examination IPSS, NIH-CPSI and IIEF-5 scores were analyzed once more. Afterwards, the alterations of scores among medical examinations in each group and between both groups were statistically compared. Results: The age average of the 44 cases included was 32.04 ± 3.15 years. Both groups present a statistically significant decrease, between the first and the second medical examination, in IPSS, NIH-CPSI scores and statistically significant increase in IIEF-5 score. In addition, there is no sta- tistically significant difference, in all scores, between mono and combination therapy. Conclusions: tamsulosin monotherapy, as well as a combination therapy (tamsulosin plus silde-nafil) has an improving effect on symptoms and on ED in patients with type III prostatitis. In the near future alpha-blockers monotherapy could be used in the treatment of chronic prostatitis and ED cases instead of phosphodiesterase type 5 (PDE-5) inhibitors combination therapy.

Objective: To quantify how many men with normal semen according to WHO (WHO - World Health Organization) 1999 criteria, should be considered with abnormal semen according to 2010 criteria and vice versa; to study which parameter of volume, concentration, motility and morphology is the most responsible of this change. Materials and methods: We studied, using WHO 1999 parameters, 529 consecutive semen samples from 427 men, collected in our Department from January 2008 to December 2009, then we re-evaluated those results using WHO 2010 parameters; we also studied each parameter to understand how changed the classification from normal (defined normal by all parameters) to abnormal (defined abnormal by at least one parameter) using the two WHO criteria. Results: 3 men (0.56%) were azoospermic. Among the remaining 526 samples, 199 (37.83%) were considered normal and 246 (46.76%) abnormal both according to WHO 1999 and WHO 2010 criteria; we found that none of the samples classified normal according to the previous criteria was classified abnormal according the more recent criteria, while 82 (15.58%) evaluated as abnormal according 1999 criteria changed to normal according 2010 criteria. The concordance between 1999 and 2010 evaluation was 84.44%. Conclusions: In this study we noted that the changes from WHO 1999 to WHO 2010 criteria did not modify the interpretation of semen quality, because comparing the two classifications we demonstrated that there is a substantial agreement, considering the three parameters (count, motility and morphology) all together, and also considering each single parameter. Anyhow, almost 16% of the patients considered infertile according to the old criteria, should be evaluated normal by the new classification and they should not need any treatment for infertility.

Background: Testicular microlithiasis (MT) is an uncommon sonographic finding (prevalence in the literature: 0.7 to 6%). Several studies have highlighted its possible correlation with an increased risk of testicular cancer, but few studies have investigated its possible link with dyspermia. Objectives: The aim of our study was to investigate in our series the number of patients with microlithiasis, diagnosed by ultrasound, and compare the quality of their sperm with that of patients in a control group with normal testicular ultrasound exam. Materials and methods: We performed 277 consecutive testicular ultrasound examinations from January 2012 to July 2012. Among all these, we selected 86 patients that showed no pathological elements at echography and 11 patients affected by MT, to one or both testicles. Each patient was also submitted to a short-term semen analysis using the WHO2010 parameters for sperm evaluation. Results: Among 11 patients with MT, 7 (63.63%) were dyspermic and 4 (36.36%) were normospermic. Among the 86 patients with normal testicular ultrasound 51 (59.3%) were dyspermic, 4 (4.65%) were azoospermic, while the remaining 31 (36.05%) were normospermic. Comparing the results of the two groups we obtained an odds ratio of 0.99 (95% CI: 0.27 to 3.64, p: 0.98). Conclusions: This study, although preliminary, with a low number of partecipants, shows that sperm quality is not affected by the presence of testicular microlithiasis, because the results of spermiograms are almost comparable between the two groups.

Introduction: We describe a rare tumor arising from the prostate gland: Perivascular Epithelioid Cells tumor (PEC-ome). A 54-years old was treated for acute urinary retention with alpha-blockers at presentation due to benign prostate enlargement (65 cc) with asymmetric middle lobe and regular PSA (0.92 ng/ml). After 5 months, patient developed a second acute urinary retention episode and nodules in the left lung; he was treated with transurethral resection of the prostate and left lobectomy. Results: Histological examination of prostate and lung tissue gave the same diagnosis: leiomyosarcoma with atypical morphological features and patient was observed for 4 months. Considering the uncommon diagnosis, pathological review by the uro-pathologist at our Hospital was done. Additional immunohistochemistry was done and both tumors showed similar and typical features of metastatic PEC-ome (T1b N0 M1). Therefore a new staging showed local and distant progression with prostatic mass and small lung metastasis. Three cycles of Gemcitabine and Pazopanib were administered, but 2 months later a new urinary retention occurred, despite chemotherapy. Patient referred to our Hospital for salvage pelvic surgery with lymph node dissection. Final pathological diagnosis was PECome of the prostate stage pT4 pN0 R0 M1. Conclusions: PEC-ome is a rare but rapidly invasive mesothelial tumor with early metastatic potential. When this tumors originates from the fibromuscular stroma of the prostate it mimics benign prostatic enlargement and causes LUTS. Expert pathology aided by immunoisthochemistry is the cornerstone of diagnosis. There are no pathognomonic imaging on ultrasound or symptoms suggesting the presence of PECome in early stage. A multidisciplinary approach is necessary and radical surgery should be done to treat this aggressive cancer.

We present a rare case of primary lymphoblastic B-cell lymphoma of the testis focusing on ultrasonographic and pathological features and clinical implications. Pathological examination revealed primary testicular lymphoblastic B-cell lymphoma which was treated with adjuvant chemotherapy, including rachicentesis with administration of chemotherapy and with radiotherapy of contralateral testis. Primary testicular lymphoblastic B cell lymphoma is an aggressive disease and it is necessary a multimodal therapy (surgery, chemotherapy and radiotherapy) to prevent metastasis.