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Urothelial bladder cancer (UBC) represents a public health problem because of its elevated incidence and relapse rate. After prostate cancer, UBC is the most frequent malignancy of the urinary tract with a higher incidence in men and smokers. To date, there are no suitable biomarkers for an early diagnosis or detection of relapse/progression. In the attempt to improve diagnostic accuracy and to overcome the disadvantages of current diagnostic strategies, biomarkers found in easily accessible biofluids, such as blood or urine, represent a non-invasive and promising approach. The first aim of this study was the identification of reliable biomarkers of UBC risk starting with whole gene expression profile in white blood cells from 66 UBC cases and 70 controls. We observed a lower expression of MMP23B and its relative pseudogene MMP23A in UBC compared to controls (LogFC=-0.37, FDR adjusted p-value=0.02 and LogFC=-0.23, FDR adjusted p-value=0.03, respectively, adjusted for age, smoking, and batch). Thus, we investigated MMP23B protein levels both in plasma (49 controls and 53 UBC) and in urine (57 controls and 59 UBC) samples, to confirm gene expression observations. Unexpectedly, both western blot evidences and ELISA quantification showed increased MMP23B levels in UBC cases respect to controls, reaching a statistical significance in urine (mean UBC=1797.70pg/ml, mean controls=1075.73pg/ml, p-value=0.02). A positive trend of association of MMP23 levels was observed also for grade and risk. As the lack of correlation between mRNA and protein levels could be due to a post-transcriptional crosstalk mediated by microRNAs (miRNAs), we investigated the expression levels of miRNAs targeting MMP23B gene in urine of UBC patients and controls. We identified 5 differentially expressed miRNAs targeting MMP23B 3'UTR in UBC cases and controls. The present outcomes indicate a potential role of MMP23B as non-invasive UBC biomarkers. Moreover, we reported the first evidence of MMP23B secretion both in plasma and urine, suggesting a role of this poorly characterized metalloproteinase in UBC. Further analyses are needed to better elucidate the mechanism of regulation of MMP23B expression by miRNAs present in UBC urine. Citation Format: Barbara Pardini, Alessandra Allione, Clara Viberti, Giuliana Giribaldi, Stefano Turini, Cornelia Di Gaetano, Simonetta Guarrera, Francesca Cordero, Marco Oderda, Marco Allasia, Paolo Gontero, Carlotta Sacerdote, Alessio Naccarati, Paolo Vineis, Giuseppe Matullo. MMP23B expression and protein levels in blood and urine are associated with bladder cancer risk [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 1258.

Contains fulltext : 87719.pdf (Publisher’s version ) (Closed access) CONTEXT: Bacillus Calmette-Guerin (BCG) remains the most effective intravesical treatment for non-muscle-invasive bladder cancer (NMIBC), but the clinical development of BCG has been accompanied by controversy. Recent publications have called into question a number of aspects related to its use. OBJECTIVE: To review the current clinical role of BCG in NMIBC, focusing on efficacy and tolerability as primary objectives and on strategies to predict response and decrease toxicity as secondary objectives. EVIDENCE ACQUISITION: We performed a systematic literature search of published articles in PubMed, Embase, and the Cochrane Central Register of Controlled Trials databases for the period from 1976 to November 2008. The following "free text" combination was used in the first instance: "BCG and intravesical and bladder cancer." Further free text searches were performed by separately adding the following keywords to the combination "BCG and intravesical": survival, progression, recurrence, maintenance, dosing, toxicity, tolerability, side effects, prognostic factors. EVIDENCE SYNTHESIS: BCG is the most effective intravesical agent for preventing NMIBC recurrence, but its role in disease progression remains controversial. In intermediate-risk NMIBC, the superiority of BCG over chemotherapy is well established for disease recurrence but not for progression and needs to be balanced against higher toxicity. With regard to high-risk NMIBC, there is sufficient evidence to show that BCG is the most effective treatment of carcinoma in situ for ablation, disease-free interval, and progression, but the impact of BCG on the natural history of T1G3 tumors relies on a low level of evidence. Maintenance remains crucial for efficacy. The dose can be safely and effectively reduced to decrease its toxicity, which is slightly greater than chemotherapy. CONCLUSIONS: BCG should still be viewed as the most effective intravesical agent, but its role in the progression of papillary tumors needs to be clarified. BCG remains an alternative to intravesical chemotherapy in intermediate-risk NMIBC, and it is recommended as the standard of care for high-risk NMIBC. 01 maart 2010

This review aims to provide information about quality of life in elderly patients who have undergone radical cystectomy and bladder replacement for muscle-invasive bladder cancer, focusing on the best instruments for evaluation. Among patients over 75 years of age, bladder cancer is the fifth leading cause of death. Radical cystectomy is the standard treatment for muscle-invasive bladder cancer and it is also considered safe in the elderly population. Quality of life is an essential aspect following radical cystectomy and bladder replacement owing to its impact on patients’ satisfaction with body image and urinary, sexual and social functioning. Furthermore, the authors suggest that there are no significant differences between different methods of urinary diversion in the elderly.

We analyze patients with early progression after laparoscopic radical cystectomy in a large cohort by the ESUT (European Association of Urology Section of Uro-Technology). More specifically we focus on patients with favorable pathology (pT2 N0 R0 or less) who experienced an unexpected recurrence and analyze possible causes for such early recurrence, discussing the surgical technique including pneumoperitoneum.Since 2000 the ESUT has been constructing a large, multicenter, prospective database of patients undergoing laparoscopic radical cystectomy. All procedures were performed via a standard laparoscopic approach without robotic assistance. We specifically analyzed patients with favorable pathological characteristics, in particular pT2 N0 R0 or less, and evaluated those with progression despite these favorable characteristics. Univariate and multivariate logistic regression was performed to evaluate risk factors for early recurrence.A total of 627 patients were available for final analysis with a median followup of 46 months (mean 57). Of these patients 311 had favorable pathological characteristics of pT2 N0 R0 or less. During followup 27 (8.7%) patients experienced disease progression during the first 24 months. Surgical negligence was found in only 1 case. Most of these patients with early recurrence had progression to high tumor volume disseminated metastatic disease. On multivariate logistic regression tumor stage was the only factor significantly associated with early recurrence (p=0.027).We report early unexpected recurrences after laparoscopic radical cystectomy in nearly 5% of our entire cohort, all in patients with favorable pathological characteristics (pT2 N0 R0 or less). Pneumoperitoneum may have had a role in the development of these relapses. Specifically designed studies are necessary to investigate the possible role of pneumoperitoneum in urothelial cancer recurrence.

Objective: Targeted fusion biopsies have led to an improved prostate cancer (PCa) detection rate (CDR). Our aim was to assess if device-assisted fusion biopsies are superior to cognitive ones in terms of CDR. The association between multiparametric MRI parameters and PCa was also evaluated. Methods: We retrospectively enrolled 50 patients who underwent transrectal biopsy with elastic fusion (Koelis; group KB, n = 25) or cognitive approach (group CB, n = 25). Targeted biopsies were done on targets, while a variable number of random biopsies were performed depending on the clinical case. Results: The groups did not significantly differ in terms of age, prostate-specific antigen, prostate volume and previous biopsies. Mean number of random cores was significantly inferior in KB group (8.4 vs. 12.1) and mean number of targeted biopsies was significantly higher (3.6 vs. 2.6). CDR was higher in fusion biopsies (64 vs. 40%), with the gap becoming significant when considering CDR of MRI targets only (59 vs. 27%). The difference was marked for lesions ≤10 mm, where CDR was 52% in KB against 21% in CB group. Conclusions: According to our study, elastic fusion biopsies performed with Koelis achieve an increased per-patient and per-lesion CDR as compared to cognitive biopsies, especially in the case of lesions ≤10 mm.

Recurrent non muscle invasive bladder cancer (NMIBC) represents a therapeutic challenge, especially in the case of Bacillus Calmette Guerin (BCG)-failures. Chemohyperthermia (CHT) has been tested as adjuvant therapy in selected categories of patients with promising results. The aim of this systematic review is to explore the current role of CHT and its future perspectives. The review process was carried out following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. After the selection process, 30 articles were used in this review. Treatment with CHT is safe and quite well tolerated. CHT seems to be effective in low and intermediate risk bladder cancer. Moreover CHT could be offered to selected categories of high risk patients and BCG failures NMIBC. Further trials are needed in order to better identify the categories of patients which could benefit from this therapy and to standardise the right schedule of treatment.

Patients with neurogenic bladder are at increased risk of the development of lower urinary tract infection, bladder stones resulting from emptying disorders, and bladder neoplasms resulting from chronic stimulation after clean intermittent catheterization (CIC). In the present case report, a patient with neurogenic bladder who was initially diagnosed with a bladder stone was finally found to be affected by an osteoclast-like giant cell carcinoma of the bladder. This neoplasm has the unique characteristic of mimicking stones because of calcium deposits in the surface of the mass. In our opinion, it is advisable to perform an endoscopic diagnostic confirmation to rule out any oncologic disease before considering open surgery in patients with a similar clinical presentation.

According to the current guidelines, computed tomography (CT) and bone scintigraphy (BS) are optional in intermediate-risk and recommended in high-risk prostate cancer (PCa). We wonder whether it is time for these examinations to be dismissed, evaluating their staging accuracy in a large cohort of radical prostatectomy (RP) patients. To evaluate the ability of CT to predict lymph node involvement (LNI), we included 1091 patients treated with RP and pelvic lymph node dissection, previously staged with abdomino-pelvic CT. As for bone metastases, we included 1145 PCa patients deemed fit for surgery, previously staged with Tc-99m methylene diphosphonate planar BS. CT scan showed a sensitivity and specificity in predicting LNI of 8.8 and 98 %; subgroup analysis disclosed a significant association only for the high-risk subgroup of 334 patients (P 0.009) with a sensitivity of 11.8 % and positive predictive value (PPV) of 44.4 %. However, logistic multivariate regression analysis including preoperative risk factors excluded any additional predictive ability of CT even in the high-risk group (P 0.40). These data are confirmed by ROC curve analysis, showing a low AUC of 54 % for CT, compared with 69 % for Partin tables and 80 % for Briganti nomogram. BS showed some positivity in 74 cases, only four of whom progressed, while 49 patients with negative BS progressed during their follow-up, six of them immediately after surgery. According to our opinion, the role of CT and BS should be restricted to selected high-risk patients, while clinical predictive nomograms should be adopted for the surgical planning.

Renal transplant (RT) represents the treatment of choice for end-stage renal disease (ESRD) but harbours a wide range of possible complications and therapeutic challenges of urological competence. Dialysis years and clinical medical background of these patients are risk factors for sexual dysfunction and lower urinary tract symptoms (LUTS). On the contrary, RT itself may have a number of possible surgical complications such as ureteral stenosis and urinary leakage, while immunosuppressive treatment is a known risk factor for de-novo malignancies. The present review describes the main urologic problems of RT patients and their up-to-date treatment options according to the most recently available literature evidences.

To analyze postoperative complications after laparoscopic radical cystectomy (LRC) and evaluate its risk factors in a large prospective cohort built by the ESUT across European centers involved in minimally invasive urology in the last decade. Patients were prospectively enrolled, and data were retrospectively analyzed. Only oncologic cases were included. There were no formal contraindications for LRC: Also patients with locally advanced tumors (pT4a), serious comorbidities, and previous major abdominal surgery were enrolled. All procedures were performed via a standard laparoscopic approach, with no robotic assistance. Early and late postoperative complications were graded according to the modified Clavien–Dindo classification. Multivariate logistic regression was performed to explore possible risk factors for developing complications. A total of 548 patients were available for final analysis, of which 258 (47 %) experienced early complications during the first 90 days after LRC. Infectious, gastrointestinal, and genitourinary were, respectively, the most frequent systems involved. Postoperative ileus occurred in 51/548 (9.3 %) patients. A total of 65/548 (12 %) patients underwent surgical re-operation, and 10/548 (2 %) patients died in the early postoperative period. Increased BMI (p = 0.024), blood loss (p = 0.021), and neoadjuvant treatment (p = 0.016) were significantly associated with a greater overall risk of experiencing complications on multivariate logistic regression. Long-term complications were documented in 64/548 (12 %), and involved mainly stenosis of the uretero-ileal anastomosis or incisional hernias. In this multicenter, prospective, large database, LRC appears to be a safe but morbid procedure. Standardized complication reporting should be encouraged to evaluate objectively a surgical procedure and permit comparison across studies.

INTRODUCTION AND OBJECTIVES: Recently, Glu-NH-CONH-Lys-(Ahx)-[(68)Ga(HBED-CC)] as a novel 68Gallium-labelled ligand of the prostate-specific membrane antigen (68Ga-HBEDPSMA) has been introduced for the diagnostic evaluation of prostate cancer (PCa) patients. The aim of this study was to evaluate the accuracy of preoperative 68Ga-HBED-PSMA PET with the results of postoperative histological findings after radical prostatectomy (RP) and pelvine template lymph node (LN) dissection with regard to metastatic LN involvement. METHODS: 92 consecutive patients with intermediate to highrisk PCa patients were included. All patients received 68Ga-HBEDPSMA PET hybrid imaging prior to surgery. Pelvine template LN dissection was performed according to 8 predefined anatomical fields. In all patients LN involvement was evaluated in a blinded fashion according to a 5-point scale (1 1⁄4 metastatic; 2 1⁄4 probably metastatic; 3 1⁄4 equivocal; 4 1⁄4 probably benign; 5 1⁄4 benign) on a patientand field-based manner and correlated to postoperative histological analysis. RESULTS: Due to lacking PSMA expression of the primary tumor 4 patients were excluded from further analysis. In total, 20 patients showed metastatic LN. 68Ga-HBED-PSMA PET detected 15 out of 20 patients with histological proven metastatic LN (sensitivity: 75.0%) and correctly classified all 68 patients without histological evidence of LN metastases (specificity: 100%; accuracy 94.3%; PPV: 100%; NPV: 93.2%). 5 patients without evidence of metastatic LN on imaging showed only small metastases in single LN (3 patients with one positive LN, 2 patients with two LN). In total, 470 anatomical fields could be analysed (52 with LN metastases). Sensitivity, specificity, accuracy, PPV and NPV for the field-based analysis were calculated as 73.1%, 98.6%, 95.7%, 86.4% and 96.7%, respectively. CONCLUSIONS: 68Ga-HBED-PSMA PET hybrid imaging shows a high sensitivity as well as superb specificity and accuracy for lymph node staging in intermediate to high-risk PCa patients and might replace current standard imaging (sole MRI, CT or PET using FDG or choline-based tracers) in the future.

Antioxidants effectiveness in prostate cancer (PCa) chemoprevention has been severely questioned, especially after the recent results of the Selenium and Vitamin E Cancer Prevention Trial. We present the results of a double-blind randomized controlled trial (dbRCT) on the pharmacokinetic, clinical, and molecular activity of dietary supplements containing lycopene, selenium, and green tea catechins (GTCs) in men with multifocal high grade prostatic intraepithelial neoplasia (mHGPIN) and/or atypical small acinar proliferation (ASAP).From 2009 to 2014, we conducted a dbRCT including 60 patients with primary mHGPIN and/or ASAP receiving daily lycopene 35 mg, selenium 55 µg, and GTCs 600 mg, or placebo for 6 months. Pharmacokinetic analysis were performed with UV-Visible spectrophotometric assay under standard (SC) and accelerated (AC) conditions. Upon plasma lycopene concentrations falling within the expected range (1.2-90 mcg/l) and no side-effects of grade1, study proceeded to phase II (n = 50). After unblinding of results, eight men (4 per arm, 2 without and 2 with PCa, respectively) were randomly selected and totRNA extracted from "non-pathological" tissues. MicroRNA profiling was performed with the Agilent platform. Raw data processing used R-statistical language and linear models for microarray analysis.Samples were stable except for lycopene, showing significant degradation (SC = 56%, AC = 59%) and consequently stabilized under vacuum in a dark packaging. Mean plasmatic lycopene concentration was 1,45 ± 0,4 μM. At 6 months, 53 men underwent re-biopsy and 13 (24.5%) were diagnosed with PCa (supplementation n = 10, placebo n = 3 [P = 0.053]). At a mean 37 months follow-up, 3 additional PCa were found in the placebo group. No significant variations in PSA, IPSS, and PR25 questionnaires were observed. Stronger modulation of miRNAs was present on re-biopsy in the supplementation group compared to the placebo, including: (i) overexpression of miRNAs present in PCa versus non-cancer tissue; (ii) underexpression of miRNAs suppressing PCa proliferation; (iii) detection of 35 miRNAs in PCa patients versus disease-free men, including androgen-regulated miR-125b-5p and PTEN-targeting miR-92a-3p (both upregulated).Administration of high doses of lycopene, GTCs, and selenium in men harboring HGPIN and/or ASAP was associated with a higher incidence of PCa at re-biopsy and expression of microRNAs implicated in PCa progression at molecular analysis. The use of these supplements should be avoided.

Objective: To report the first case of robotic pudendal nerve (PN) decompression for bilateral PN entrapment (PNE). PN decompression is a safe and effective treatment for PNE and can be accomplished laparoscopically with a better exploration of the sacral roots and of the PN. Materials and Methods: We describe in detail all the steps of our surgery, performed on a 38-year-old female patient suffering from PNE. All the anatomic landmarks are clearly shown. Results: Our technique was successful, and the patient's postoperative course was uneventful. Six months after surgery, the pain had completely resolved, and the patient was drug-free. Conclusions: We showed the feasibility and effectiveness of robotic PN decompression, with surgical advantages that could potentially extend the indications of robot-assisted surgery.

Hematoceles are usually associated with a history of scrotal trauma, are usually painful and rarely have an idiopathic origin. We describe the peculiar case of a hematocele mistaken for a testicular cancer.

Introduction: We compared the postoperative sexual function of patients who underwent wide local excision (WLE) and glansectomy with urethral glanduloplasty for penile cancer.Methods: We retrospectively reviewed clinical data of 41 patients affected by superficial, localized penile cancer (≤cT2a) between 2006 and 2013. Patients with severe erectile dysfunction and not interested in resuming an active sexual life were selected for penile partial amputation. Patients with preoperative satisfying erectile function and concerned about the preservation of their sexual potency were scheduled for WLE (Group A) or glansectomy with urethral glanduloplasty (Group B). Sexual function was assessed with the International Index of Erectile Function (IIEF) questionnaire and the Sex Encounter Profile (SEP). At 1 year, patients were asked to complete the questionnaires again and were questioned about their genital sensibility and ejaculatory reflex persistence. Postoperative complications were reported according to the Clavien-Dindo classification. Statistical analysis was performed by two-tailed test: Student t-test and chi-square.Results: Among the 41 patients enrolled, 12 underwent WLE (29.2%), 23 glansectomy with urethral glanduloplasty (56%) and 6 with penile partial amputation (14.6%). A decrease in postoperative IIEF was recorded in both groups, but was statistically significant only in Group B (p = 0.003). As for the SEP, while no significant changes were recorded postoperatively in Group A, a marked reduction was reported for Group B, with a statistically significant decrease in the possibility of achieving penetrative intercourse (p = 0.006) and in the perceived satisfaction during sexual activity (p = 0.004).Conclusions: WLE lead to better sexual outcomes and less postoperative complications as compared to glansectomy with urethral glanduloplasty.

INTRODUCTION AND OBJECTIVES: Salvage lymph node dissection (sLND) has been proposed as a treatment option for management of prostate cancer nodal recurrence after primary treatment but a surgical template has not been identified yet. An extended template may be necessary for curative intents but at the cost of increased morbidity of the procedure. Aim of our multicentric study is to evaluate if positivity to presacral and common iliac nodes is a predictor of retroperitoneal involvement, finding an appropriate surgical template for sLND. METHODS: We retrospectively analyzed the data of 26 men who underwent sLND after diagnosis of pelvic nodal recurrence at PET/ CT scan and were previously treated with radical prostatectomy (n1⁄424), radiotherapy (n1⁄41) or brachitherapy (n1⁄41). All sLND included pelvic and retroperitoneal fields, irrespectively of PET results. Dissected nodes were stratified into 3 anatomical regions: A (internal iliac, obturatory, external iliac), B (presacral, common iliac), C (retroperitoneal). Chi square test was used on crosstabs; regression analysis was run. RESULTS: Twenty men (76.9%) had positive pelvic nodes at sLND: 15 (57.6%) in region A and 15 (57.6%) in region B. Retroperitoneal involvement was found in 10 (38.4%). Mean number of dissected and positive nodes was 19.1 and 3.1 in the pelvic region (10.1 and 1.9 in region A, 8.9 and 1.1 in region B) and 7.8 and 1.0 in the retroperitoneal region. Positivity in region AþB was associated with retroperitoneal involvement in 45% of cases, while the negative predictive value (NPV) was 83.3%. Table 1 shows the crosstabs of nodal positivity stratified by anatomical regions. According to multivariate analysis, no pelvic region significantly predicts retroperitoneal involvement. The predictive ability does not improve with the number of dissected and positive nodes. CONCLUSIONS: We were not able to find anatomical regions predictive of retroperitoneal involvement during sLND, probably due to the low number of patients enrolled. The high NPV of pelvic regions suggest that a threshold can be identified to select patients who need retroperitoneal LND. At the moment, an extended template including pelvic and retroperitoneal regions must be adopted to follow curative intents. Source of Funding: None

Bladder cancer (BC) is one of the leading causes of cancer-related death worldwide. BC is among the most expensive cancer per patient because it requires frequent surveillance and repeated treatments over many years. The identification of new biomarkers for early BC detection, recurrence/progression is urgently needed to both improve patient outcomes and decrease health care costs. MicroRNAs (miRNAs) are aberrantly expressed in many cancers, including BC, and may be isolated from various biological specimens, including urine. To investigate miRNA signatures in surrogate tissues may be a useful alternative to reduce invasiveness of biopsies, allowing repetitive samplings during follow-up and reducing health care costs for detection, monitoring of progression and treatment. We aim to identify specific miRNA signatures in urine samples from 66 BC male patients (10 muscle invasive BC (MIBC) and 56 non-muscle invasive BC (NMIBC)) and 48 healthy controls using a Next Generation Sequencing (NGS) approach able to accurately distinguish BC patients and predict disease outcome. The measurement of miRNA levels in urine could allow to measure the levels of promising biomarkers in one of the best and closest surrogate tissue for BC, since it is in direct contact with the tissue of tumor origin. A specific miRNA signatures that could distinguish the different types of BC patients from healthy controls was found in urine. For MIBC, a 18-miRNAs signature had over 80% predictive power (PP) to recognize patients from controls (data are under validation). For NMIBC we were able to stratify cases according to grade. In particular, 23 miRNAs resulted differentially expressed among G1-G2 cases and controls (5 of them had PP>0.70), while several miRNAs resulted differentially expressed among G3 patients and controls (a 10-miRNAs signature with PP>0.97). Interestingly, we found several differentially expressed miRNAs in common among cases and some miRNAs that were differentially expressed only in specific subcategories of BC cases. NGS data were also used to search for the most constant miRNAs in the set of samples to be used as reference genes in a validation step. Twenty-three miRNAs (21 target and 2 reference miRNAs) were validated by qPCR on 177 urine samples from 113 BC case and 64 controls . Interestingly, miRNAs differentially expressed among cases and controls were able to discriminate not only BC cases from controls, but also its subcategories. This data provide evidences of the possibility to use miRNAs specifically within the urine of patients with BC as diagnostic, prognostic and predictive biomarkers. Acknowledgements Work supported by Fondazione Umberto Veronesi (FUV) “Post-doctoral fellowship Year 2014, 2015 and 2016” (B.P. recipient), a FUV Grant 2013 (G.M. recipient), and by a HuGeF grant. Citation Format: Barbara Pardini, Francesca Cordero, Alessio Naccarati, Giulio Ferrero, Clara Viberti, Marco Oderda, Maddalena Arigoni, Raffaele Calogero, Carlotta Sacerdote, Paolo Gontero, Paolo Vineis, Giuseppe Matullo. Urine microRNA profiling in bladder cancer by next-generation sequencing [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 4431. doi:10.1158/1538-7445.AM2017-4431

Objective: To describe our technique of robotic rectovesical fistula (RVF) repair through the report of a case unique for its pathogenesis. RVF is a rare but devastating complication of prostatic surgery and can nowadays be managed with a minimally invasive approach. Patient and Methods: We describe in detail all the steps of our robotic RVF repair, performed on a 76-year-old man who developed RVF after radical prostatectomy. The RVF had been induced by tissue erosion due to Hem-o-lok® (Teleflex Medical, Research Triangle Park, NC) clips and had been unsuccessfully treated with an over-the-scope clip. Results: Our surgery was successful with an operative time of 70 minutes and an estimated blood loss of 150 mL. The postoperative course was uneventful, and the patient was discharged on postoperative Day 3. Conclusions: Our technique of robotic RVF repair was safe and effective. Care must be taken when considering new, endoscopic devices for the cure of RVF. A prospective study with a long follow-u...

Although many studies about penile prosthesis implantation (PPI) have been published so far, only a small amount of them take into account patients and partners outcome in terms of satisfaction and erotic function. The aim of this study is to explore the value of psycosexual counselling in and the sexual and erotic function of penile prosthesis recipients. Thirty patients and their partners were randomised into two groups. In arm A (case group) patients and their partners underwent a multistep psychosexual counselling before and after surgery. In arm B (control group) surgery was performed without the specific psychosexual counselling scheme. Specific questionnaires (International Index of Erectile Function (IIEF) and the Sexual Daydreaming Scale (SDS)) were administered before surgery and 12 months afterwards. Twenty-four months postoperatively patients were asked to complete the Global Assessment Questions (GAQ) and the Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS), while their partners were asked to answer to the EDITS partner's section. Between January 2009 and October 2011, we enrolled 30 patients undergoing PPI in our institution (15 in each arm). Twenty-four months postoperative follow-up is available for all of them. No significant differences between the two groups in terms of baseline questionnaires scores were observed. Mean IIEF score was significantly higher in case group (arm A 68.3, arm B 53.4, P-value

Contains fulltext : 153742.pdf (Publisher’s version ) (Closed access) BACKGROUND: The impact of prognostic factors in T1G3 non-muscle-invasive bladder cancer (BCa) patients is critical for proper treatment decision making. OBJECTIVE: To assess prognostic factors in patients who received bacillus Calmette-Guerin (BCG) as initial intravesical treatment of T1G3 tumors and to identify a subgroup of high-risk patients who should be considered for more aggressive treatment. DESIGN, SETTING, AND PARTICIPANTS: Individual patient data were collected for 2451 T1G3 patients from 23 centers who received BCG between 1990 and 2011. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Using Cox multivariable regression, the prognostic importance of several clinical variables was assessed for time to recurrence, progression, BCa-specific survival, and overall survival (OS). RESULTS AND LIMITATIONS: With a median follow-up of 5.2 yr, 465 patients (19%) progressed, 509 (21%) underwent cystectomy, and 221 (9%) died because of BCa. In multivariable analyses, the most important prognostic factors for progression were age, tumor size, and concomitant carcinoma in situ (CIS); the most important prognostic factors for BCa-specific survival and OS were age and tumor size. Patients were divided into four risk groups for progression according to the number of adverse factors among age >/= 70 yr, size >/= 3 cm, and presence of CIS. Progression rates at 10 yr ranged from 17% to 52%. BCa-specific death rates at 10 yr were 32% in patients >/= 70 yr with tumor size >/= 3 cm and 13% otherwise. CONCLUSIONS: T1G3 patients >/= 70 yr with tumors >/= 3 cm and concomitant CIS should be treated more aggressively because of the high risk of progression. PATIENT SUMMARY: Although the majority of T1G3 patients can be safely treated with intravesical bacillus Calmette-Guerin, there is a subgroup of T1G3 patients with age >/= 70 yr, tumor size >/= 3 cm, and concomitant CIS who have a high risk of progression and thus require aggressive treatment.

Background Dickoppf-1 (DKK-1) is a negative regulator of bone formation with tumorigenic potential. The up-regulation of DKK-1 is an early event in prostate cancer (PCa) development, thus we investigated its role as a marker in the diagnosis and prognosis of PCa. Methods We retrospectively enrolled 159 patients who underwent prostate biopsy, either for elevated PSA or suspect digital rectal examination, between 2003 and 2010. During the biopsy, one serum sample was collected from all patients; PSA and DKK-1 were measured by ELISA technique. Amongst the biopsy of 159 patients 75 were affected by PCa and 84 were not the mean period of follow-up for these patients was 5 years; a new biopsy was performed in case of PCa suspicion. Results PSA performed better than DKK-1 in detecting PCa (0.63 vs 0.51 respectively). Differently from PSA DKK-1 was significantly higher in patients who developed PCa during follow-up than in cancer-free ones, thus DKK-1 performed better than PSA in detecting these patients (0.67 vs 0.55). DKK-1 was significantly lower in patients with bone metastases, whereas PSA was not significantly different in patients with different outcomes. Conclusions DKK-1 might be predictive for patients negative at first biopsy who will develop PCa and in the prognosis of bone metastases. It performed worse than PSA in the early diagnosis of Pca.

Objectives: To compare the concordance of prostate cancer (PCa) laterality between the extended transperineal (TP) or transrectal (TR) prostate biopsy (BP) and radical prostatectomy (RP) specimens. To identify predictors of laterality agreement between BP and RP. Materials and Methods: Data from 533 consecutive patients with PCa (278 TP and 255 TR-diagnosed) treated with RP were analyzed. A 12-core technique was used for both TP and TR biopsies. Additional cores were obtained when necessary. Results: Overall, the percentage of agreement of PCa laterality between BP and RP was 60% (K = 0.27, p < 0.001). However, the RP confirmation of unilaterality at BP was obtained in just 33% of the cases. Considering the concordance on bilaterality as the “target” of our analysis, the sensitivity and specificity were 54.3% and 98.2%, respectively, with TP and 47.5% and 92.5%, respectively with TR. Focusing on patients with unilaterality at biopsy, none of the evaluated preoperative variables (biopsy technique, age, total positive biopsy cores, PSA, prostate volume, Gleason score on biopsy) were able to predict RP bilaterality in the multivariate analyses. Conclusions: Most of the patients with unilateral involvement at BP harbored bilateral PCa after RP. TR and TP biopsy showed no difference in their capacity to predict the concordance of tumor laterality at RP. None of the preoperative evaluated variables can predict the tumor laterality at RP. Using BP unilaterality to include patients in focal therapy (FT) protocols may hinder the oncologic efficacy of FT.

Objective To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches. Patients and Methods Between 2009 and 2012, 15 patients underwent laparoscopic (n = 11) or robot-assisted (n = 4) construction of vesicostomy by a single surgeon (D.R.): Mitrofanoff appendicovesicostomy (n = 11) or double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty. Indications for surgery included neurogenic bladder (n = 11) and urethral dysfunction (n = 4). The patients were evaluated postoperatively using cystography. Quality of life (QoL) was evaluated using an internally developed questionnaire. Results All surgeries were successfully completed with no conversions. Operating time was always

Introduction Primary extragonadal germ cell tumors (EGCT) are rare and it is still a matter of debate if they have to be considered as primary extragonadal issues or metastases from a primary testicular neoplasm. We describe two cases of the so-called burned-out seminoma, a primary testicular germ-cell tumor that spontaneously regressed after demonstration of retroperitoneal metastases. Cases Presentation Two patients (35 and 50 years old, respectively) presented with CT findings of retroperitoneal masses. In both cases physical examination of the testis was not suspicious, and only scrotal ultrasound (SUS) showed parenchymal alterations such as scarring, calcifications and nodular lesions. Left orchiectomy and chemotherapy were then performed in both cases. Currently, they are both free of disease. Conclusions Although primary germ cell tumors may be of retroperitoneal origin, the likelihood of metastasis from a testicular primary origin should always be carefully considered in order to avoid misdiagnosis and to apply the best treatment schedule for the patients. Therefore, a testicular ultrasonography is mandatory in patients presenting CT findings of retroperitoneal adenopathy, even if patients are completely asymptomatic and their physical examination appears normal.

Objective To report the feasibility of a novel robotic technique for intracorporeal construction of a double Yang-Monti ileal conduit with bladder augmentation in an adult patient. Methods The Yang-Monti procedure can be considered as an alternative to Mitrofanoff appendicovesicostomy when the appendix is not available or in obese patients. To date, the robotic approach has not been described. We have described all the steps of our surgery, performed on a 35-year-old obese patient with post-traumatic paraplegia and a neurogenic bladder. We focused on the technical tips and highlighted all the differences with the standard open technique. Results Our technique provided satisfactory results. No intraoperative complications occurred. The operative time was 250 minutes, and the intraoperative blood loss was 200 mL. The clinical course was uneventful. Conclusion We have shown that robotic intracorporeal realization of a double Yang-Monti ileal conduit with bladder augmentation is feasible, extending the potential indications of robot-assisted surgery. The evaluation of more cases is advised.

Medical conditions affecting the scrotum may present themselves with pain without any sign of swelling, with a painful swelling, or with a painless swollen scrotum. A sudden onset of a scrotal pain or swelling is defined as “acute ­scrotum” and can have a variety of causes. The diagnostic process is essential to rule out conditions that prompt urgent hospital referral. Among the causes of a painful and swollen scrotum, testicular torsion is the most feared one, as the likelihood of testicular salvage decreases as ischemia increases. Several conditions can mimic testicular torsion, such as torsion of testicular appendages, epididymitis, epididymo-orchitis, trauma, varicocele, inguinal hernia, and even systemic disease, like the rare Schonlein-Henoch purpura. Besides, several conditions can cause painless scrotal swelling. Among these, a testicular cancer must always be suspected when a firm mass is discovered within the testicular parenchyma. The aim of this chapter is to provide a practical flowchart to assist the physician in decision making among the most important scrotal diseases, guiding the choice between an urgent hospital referral and conservative management.

Objectives: To prospectively evaluate the prognostic utility of the traditional prognostic factors and molecular markers p53 and Ki-67 in a homogeneous series of patients with non-muscle-invasive bladder cancer (NMIBC) treated with Bacillus Calmette-Guérin (BCG). Patients and Methods: 192 intermediate- and high-risk NMIBC cases were enrolled. The variables in study were age, stage, grade, focality, tumour size, presence of associated carcinoma in situ, recurrence rate before BCG, maintenance for BCG, Ki-67 and p53. The endpoints considered were recurrence-free survival, progression-free survival, cancer-specific survival (CSS) and overall survival (OS). Results: T stage resulted in being associated with CSS, whereas age with OS. BCG maintenance was a significantly favourable independent predictor of OS, CSS, recurrence and progression. In univariate analysis, the labelling index of Ki-67 was significantly associated with OS, CSS and progression. Multivariate analysis, however, confirmed this association only for OS. On the contrary, the labelling index of p53 was a significant predictor of recurrence, both in uni- and multivariate analyses, but with a HR inferior to 1. Conclusions: Ki-67 was an independent predictor of survival. p53 overexpression showed a significant yet inverse correlation with recurrence, thus showing little clinical utility. Age, stage and maintenance were confirmed as independent predictors of BCG response.

Leiomyomata are benign neoplasms that are rarely encountered in the genitourinary tract outside the uterus. Pathological confirmation is always needed for definitive diagnosis, in order to rule out malignancies such as leiomyosarcoma. In cases of small leiomyomata, a surveillance strategy can be suggested, although the preferred approach is complete resection. Prognosis seems to be excellent, but available data are based on few, inconsistent series, as is often the case with rare neoplasms. This article presents long-term follow-up data from the most heterogeneous series, in terms of anatomical location, currently available.The present series of 33 genitourinary leiomyomata was retrieved after joining the "rare urogenital neoplasm" registry of two Italian regions. Two pathologists jointly reviewed all pathological slides and confirmed the diagnosis of leiomyoma.Sixteen cases were localized to the scrotum, eight to the bladder, five to the kidney, two to the prostate, one to the urethra and one to the penis. Mean patient age was 58.4 (range 32-80) years. Mean follow-up was 15.5 (range 2-20) years.In this highly heterogeneous series, the disease showed excellent long-term recurrence- and progression-free interval. The accuracy of pathological diagnosis, along with the indolent long-term course, make the role of active surveillance amenable for asymptomatic cases, particularly where surgery may result in overtreatment.

To present a series of 15 laparoscopic and robot-assisted Mitrofanoff and Yang-Monti vesicostomies in an adult population, and to assess the feasibility and safety of these minimally invasive approaches.Between 2009 and 2012, 15 patients underwent laparoscopic (n = 11) or robot-assisted (n = 4) construction of vesicostomy by a single surgeon (D.R.): Mitrofanoff appendicovesicostomy (n = 11) or double Yang-Monti ileal conduit (n = 4). Fourteen patients underwent concomitant augmentation enterocystoplasty. Indications for surgery included neurogenic bladder (n = 11) and urethral dysfunction (n = 4). The patients were evaluated postoperatively using cystography. Quality of life (QoL) was evaluated using an internally developed questionnaire.All surgeries were successfully completed with no conversions. Operating time was always5 h. The mean estimated blood loss was 150 mL and the mean follow-up was 22 months. Early postoperative complications included deep retrovesical abscess (n = 2) and upper urinary tract infections (n = 4), and one patient had peri-operative cardiac failure. Late postoperative complications included stomal stenosis (n = 2), persistent low-pressure bladder incontinence (n = 1) and recurrent infections (n = 1). Surgical excision of the conduit was necessary in one patient. Postoperatively, patients showed complete bladder emptying and no leak on follow-up cystography. According to our QoL questionnaire, 13/15 patients did not regret the surgery.While a longer follow-up is needed to assess the durability of our results, this series shows that the laparoscopic and robot-assisted approaches for the construction of continent urinary diversions are feasible and safe in an adult population.

Bladder cancer is the most common tumor of the urinary tract, with a worldwide incidence of 8.6 x 100000 in men and 2.6 x 100000 in women (1). The majority of patients (75-85%) present as non-muscle invasive bladder cancer (NMIBC); within this category the most represented stage is Ta (70%), followed by T1 (20%) and, less frequently, carcinoma in situ (CIS) (10%) (2). The diagnosis of NMIBC and, more generally, of bladder cancer, depends on urine cytology and endoscopic examination with histological evaluation of the resected tissue. Clearly, an optimal cystoscopy with accurate transurethral resection (TUR) is of great importance in order to improve the detection rate and to reduce the probability of recurrence and progression. Today the cystoscopy is routinely performed with the white light technique (WLC), the same of about 80 years ago (3). Several studies have demonstrated that an initial TUR with WLC can miss small papillary lesions and, particularly, flat lesions such as CIS. Moreover, recurrence rates of non-muscle invasive bladder cancer (NMIBC) are directly related to the possibility of achieving a complete resection: residual cancer is present in a large percentage of re-TUR, showing a not so good performance of resection with this method. For these reasons new methodologies have been investigated in order to improve the sensitivity and specificity of WLC, such as photodynamic diagnosis (PDD), narrow band imaging (NBI), optical coherence tomography (OCT) and CT virtual cystoscopy. Some of them have been well established and supported by consistent literature while others are still to be viewed as experimental. The purpose of this review is to investigate the state of the art of these new techniques.

Bladder cancer (BC) is the sixth most commonly diagnosed tumor worldwide. DNA repair capacity (DRC) refers to the ability of a cell to protect the integrity of the genome and DNA repair pathways have been implicated in BC risk. It has been observed that individuals with low DRC tend to accumulate more damage than those with a more efficient DRC. This inter-individual variability is modulated by the genetic background, as well as differential gene expression and epigenetic regulation. We aimed at studying the relationship between DRC and DNA damage (evaluated by H2AX phosphorylation and micronucleus assays) and BC risk and clinical outcome, integrating with gene expression and epigenetic profile data in 159 BC cases and 159 matched controls, enrolled in the Turin Bladder Cancer Study (TBCS). We investigated ã-H2AX phosphorylation levels and MN frequencies in cryopreserved peripheral blood mononuclear cells. We found significant differences in micronuclei and nuclear buds frequencies, with higher number of these damages in cases compared to controls (p = 0.0002 and p = 0.002 respectively). On the other hand, we observed a significant association between ã-H2AX basal levels and risk of disease recurrence/progression in both BC patients as a whole and the subgroup of non-muscle invasive BC (NMIBC) (for all BC HR 0.70, 95% CI 0.52-0.94, p = 0.02; for NMIBC HR 0.68, 95% CI 0.50-0.92, p = 0.01): this suggests a protective effect of DNA double strand breaks signalling in terms of preventing BC recurrence or progression. In order to evaluate the genetic and epigenetic role in modulation of DRC we performed whole genome methylation and gene expression analyses on the same BC cases and controls. Preliminary analyses on methylation levels did not show any significant difference between cases and controls. Two metalloproteinases (MMP23A and MMP23B) resulted significantly under-expressed in BC compared to healthy controls (logFC = -0.23, p = 0.01; logFC = -0.37, p = 0.007, respectively). Interestingly, the expression levels of these genes were also significantly correlated with the relative CpGs methylation. Further analyses focusing on the integration of whole genome data with DRC assays are ongoing to unravel new prognostic biomarkers of disease. Citation Format: Giuseppe Matullo, Clara Viberti, Barbara Pardini, Alessandra Allione, Simonetta Guarrera, Valentina Turinetto, Claudia Giachino, Giovanni Fiorito, Alessio Naccarati, Alessia Russo, Rossana Critelli, Paolo Destefanis, Marco Oderda, Paolo Gontero, Paolo Vineis, Carlotta Sacerdote. DNA repair capacity, chromosomal damage, methylation and gene expression levels in bladder cancer: An integrated analysis. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 778.

Bladder cancer (BC) is one of the leading causes of cancer-related death worldwide. Most BCs are non-muscle invasive (NMIBC), which generally have a good prognosis but frequently recur or progress to muscle invasion (MIBC) within 5 years. By contrast, MIBC has a poor prognosis and treatment requires a multidisciplinary approach with radical surgery, radiotherapy, and chemotherapy. BC is among the most expensive cancer per patient because it requires frequent surveillance and repeated treatments over many years. Reliable predictors of disease and progression for BC are lacking so developing novel noninvasive diagnostics is imperative to both improve patient outcomes and decrease health costs. MicroRNAs (miRNAs) are aberrantly expressed in many cancers, including BC, and may be isolated from various biological specimens, including plasma and urine. Next generation sequencing (NGS) technology provides novel information about miRNA expression and is likely to become the gold standard method for comprehensive miRNA analysis in cancer genomics. So far, only few studies investigated miRNA signatures in BC by NGS and only on tissues. To investigate miRNA signatures in surrogate tissues may be a useful alternative to reduce invasiveness of biopsies, allowing repetitive samplings during follow-up and reducing health care costs for detection, monitoring of progression and treatment. We aim to identify specific miRNA signatures in urine and plasma samples from 20 NMIBC, 20 MIBC patients and 40 healthy controls using a NGS approach able to accurately distinguish BC patients and predict disease outcome. The measurement of miRNA levels in both urine and plasma samples from the same patients will allow us to compare the levels of promising biomarkers in two surrogate tissues. Urine is the best and closest surrogate tissue for BC, since it is in direct contact with the tissue of tumor origin; while plasma is one of the best surrogate tissue for distant metastasis and advanced cancer detection. In plasma samples, 5 miRNAs were differentially expressed among cases and controls (miR-222, miR-146b, miR-126, miR221 upregulated and miR-5096 downregulated). However, after repetition of the analyses stratifying cases for NMIBC (the most represented group in BC cases), only 2 of the previously described miRNAs (miR-222 and miR-126) resulted dysregulated among NMIBC and controls. In urine, 31 miRNAs were differentially expressed among BC cases and controls (adjusted p-value ranging from 0.0007 to 0.05). On the other hand, 26 and 31 miRNAs resulted differentially expressed among NMIBC and controls and MIBC and controls, respectively (for NMIBC: adjusted p-value from 0.0009 to 0.04; for MIBC adjusted p-value from 7.2×10-9 to 0.04). Interestingly, miRNAs differentially expressed among cases and controls were able to discriminate not only BC cases from controls, but also NMIBC and MIBC. Citation Format: Barbara Pardini, Francesca Cordero, Alessandra Allione, Clara Viberti, Alessio Naccarati, Marco Oderda, Mirko Preto, Marco Allasia, Maddalena Arigoni, Federica Riccardo, Raffaele Calogero, Carlotta Sacerdote, Giuseppe Matullo. MicroRNA profiling by a next generation sequencing approach in urine and plasma samples: from genomics to diagnostics and prognostics of bladder cancer. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1061.

The management of non-muscle-invasive bladder cancer (NMIBC) in the elderly is complex and must be tailored to the individual needs and the physical capacity of this particular group of patients, taking into account the frailty status and life expectancy. On one hand, treatments that may be required might further stress an already vulnerable organism, carrying the risk of being more harmful to the patient than the disease itself. On the other hand, a surprisingly high cancer-specific mortality has been shown even in this old age group, which makes active treatment, and not only palliative approach, advised in fit categories. The issue of reduced efficacy of intravesical therapy, such as BCG, with advancing age further complicates the picture. More radical treatment such as early cystectomy has been shown to be feasible also in octogenarians, keeping in mind that the risk of intraoperative death or major complications becomes relevant in advanced age groups. In this respect, device-assisted administration of intravesical therapies will play an increasing role in the future. Unfortunately, up-to-date, no specific guidelines exist to guide the physician choosing the optimum management of these older patients, who too often end up receiving substandard care.

We report the case of a sacral neurinoma, which presented with mild hydronephrosis, due to compression of the right ureter, in a 71-yr old woman admitted to our hospital with recurrent urinary tract infections. CT and MRI detected a 4 x 4 cm mass pressing on the right ureter at the sacral level, in continuity with the second sacral foramen. Given this finding, the mass was thought to be of presumable neurogenic origin. In order to both reach a conclusive diagnosis and relieve the compression of the ureter, a laparoscopic resection of the mass was performed. Surgery was successful and the pathologic examination revealed a sacral Antoni A neurinoma. Neurinomas, also called Schwannomas, are uncommon benign nerve sheath tumors arising from Schwann cells. Their diagnosis can be extremely difficult due to their aspecific symptoms and the lack of pathognomonic characteristics on imaging exams. Therefore, histopathologic evaluation is essential in establishing the diagnosis. Surgical resection seems to be the best approach, both for diagnostic and therapeutic purposes.

Reduced cavernosal arterial inflow has been hypothesized to be the likely cause of erectile dysfunction after kidney transplants in recipients revascularized through end-to-end anastomosis to the internal iliac artery, suggesting that end-to-side anastomosis at the external iliac artery is preferable. The aim of this study was to prospectively evaluate the effect of the use of the external iliac artery on erectile function, hormone profiles and penile blood flow by evaluating changes in penile colour Doppler ultrasound parameters in a consecutive series of 22 recipients before and after end-to-side external iliac artery transplantation. The mean International Index of Erectile Function-Erectile Function (IIEF-EF) domain score decreased significantly 3 months after transplant (18.09±6.33 vs. 22.50±7.09, P=0.01). The reduction in peak systolic velocity (PSV) was significant for the cavernous artery homolateral to the side of transplant (42.60±18.77 vs. 52.01±19.91, P=0.01). The mean postoperative end diastolic velocity (EDV) did not differ significantly from the preoperative value (P=0.74). No statistical differences were found in the serum levels of testosterone or prolactin. Kidney grafts anastomosed at the external iliac artery produced significant (P=0.01) reductions in arterial inflow at the homolateral cavernosal artery that remained above the normal threshold. Whether these haemodynamic changes can explain the worsening of postoperative erectile function remains to be proven.

A ganglioneuroma (GN) is the rarest and most benign of the neuroblastic tumors and originates from neural crest cells wherever sympathetic nervous tissue exists, such as in the retroperitoneum and adrenal gland. The diagnosis can be very challenging, given the rarity and asymptomatic presentation of this neoplasia, and can be achieved only by means of histological evaluation. Although benign, a few cases of metastatic GNs have been reported in the literature. The prognosis, however, seems to be excellent after surgical resection. We describe a rare case of multifocal retroperitoneal GN, diagnosed incidentally in a 46-year-old woman, with para-aortic and adrenal localizations. After intraoperative pathological diagnosis was made, complete excision of all the visible masses was performed. The postoperative period was uneventful and she was recurrence free 3 months after surgery. To our knowledge, this is the first case report of a multifocal retroperitoneal GN. Among the broad differential diagnoses of adrenal incidentalomas, an adrenal location of neuroblastic tumors should not be forgotten.

Introduction: Adherence to international guidelines is viewed as a prerequisite for optimal medical care delivery. Previously reported surveys for non-muscle-invasive bladder cancer (NMIBC) employed mailed questionnaires to urologists or patients resulting in conflicting degrees of agreement with existing guidelines. In the current study, contemporary information on the management of NMIBC was generated from a sample of Italian centers. Patients and Methods: Eight Italian referral centers for the treatment of NMIBC were asked to collect information relative to all consecutive patients with a histology-proven NMIBC undergoing a transurethral resection from January 1 to March 31, 2009. The primary study objective was to verify the level of adherence of disease management with European guidelines. Results: 344 patients resulted in being evaluable. 49.2% of high-risk patients underwent a repeat transurethral resection. Bacillus Calmette-Guérin was employed in 35% of cases, while chemotherapy was in 22%. An early single regimen was adopted in 136 patients and only in 1 out of 3 low-risk patients. High-risk NMIBC received bacillus Calmette-Guérin and chemotherapy as first-line therapy in 66 and 12.5% respectively. After 3 months, cystoscopy had been reported for 82.5% of patients with a recurrence rate of 13%. Conclusion: Adherence of Italian Institutions to EAU guidelines was optimal when reporting baseline variables. Significant degrees of discrepancy emerged in treatment choices.

What's known on the subject? and What does the study add? Penile lengthening methods remain a controversial issue. Surgical procedures of "lengthening phalloplasty" are characterized by poorly defined indications and an unacceptably high rate of complications, as recently outlined by a literature review, while non-surgical techniques are largely popularized by the media but often lack scientific evidence. In the literature we found only ten articles/abstracts of studies pertaining to the topic of our review. With our review, we aimed to explore whether non-surgical methods of penile lengthening may have some scientific background. We focused specifically on penile extenders, which among conservative methods are those whose efficacy is supported by some scientific evidence. It seems that penile traction devices should be proposed as the first-line treatment option for patients seeking a penile lengthening procedure. Penile size is a matter of great interest among men who are affected by 'short penis syndrome' or just believe themselves to have a small penis, even though the dimensions of the organ fall within the normal range. Surgical procedures of 'lengthening phalloplasty' lack standardized indications and carry a high risk of complications. Several non-invasive methods of penile lengthening have been described, such as vacuum devices, penile traction devices and penoscrotal rings; even 'physical exercises' have been popularized through the media. Most of these techniques, however, are not supported by any scientific evidence. We briefly analyse the efficacy and scientific background of such non-surgical methods of penile lengthening. It seems that penile extenders represent the only evidence-based technique of penile elongation. Results achieved do not seem to be inferior to surgery, making these traction devices an ideal first-line treatment option for patients seeking a penile lengthening procedure.

Objective: Neuroendocrine bladder tumours are rare entities known for their aggressive behaviour. The aim of this study was to retrospectively evaluate the outcome of a contemporary series of 14 consecutive bladder neuroendocrine neoplasms observed at 2 institutional hospitals. Materials and Methods: The charts of patients with a pathological diagnosis of neuroendocrine bladder tumours observed at 2 institutions in the last 5 years were reviewed. Fourteen cases were retrieved. The main endpoint was to evaluate the pathological features and the cancer-specific survival (CSS) of the cohort. Subanalysis of survival based on the type of treatment received was attempted. Results: Mean age was 70.2 years. The rate of metastatic disease at diagnosis was 57.1%. Mean follow-up was 13.7 months (95% CI 5.1–22.3). The 6-month CSS rate was 57.1%, while the 2-year CSS rate was 21.4%. CSS and overall survival rates overlapped. The median survival for the cohort was 7 months. There was no statistically significant difference in survival between patients who underwent surgery and those who did not. Conclusion: Neuroendocrine bladder tumours remain a disease with an extremely unfavourable prognosis. The impact of radical surgery on survival remains questionable. Patients harbouring this rare bladder cancer should be referred for trials assessing neoadjuvant and adjuvant systemic treatment strategies.

Nowadays, ultrasound-guided percutaneous kidney biopsy (PKB) is the gold standard for renal biopsies. Nevertheless, PKB is still contraindicated by conditions such as bleeding diatheses, severe obesity, solitary kidney, uncontrolled hypertension, and previous failed attempts at PKB. In these cases, the laparoscopic approach may offer a valid and mini-invasive alternative to open biopsy. We describe our technique and report indications and outcomes of a consecutive series of retroperitoneal laparoscopic kidney biopsies (LKB).In a retrospective review of patients who underwent LKB, we examined indications, outcomes, and complications, stratified according to the Clavien classification.In all, 40 patients underwent LKB between 2001 and 2010 (mean age 58.85 years, SD 10.87). Mean serum creatinine at surgery was 3.02 mg/dL. Indications for LKB included coagulopathy (30%), polycystic kidney or multiple renal cysts (30%), solitary kidney (12.5%), and morbid obesity (10%). All the biopsies were performed with a Trucut needle. All the procedures were successful and led to pathological diagnosis. The most common pathological findings were glomerulonephritis (47.5%) and glomerulosclerosis (27.5%). All biopsies were performed in less than 1 hour. Only three complications (7.5%) were reported: two grade I and one grade IIIa according to Clavien classification. In three selected cases, we used a particular "ready-to-laparo" open surgical technique, which allowed to view a part of kidney parenchima through the 10-mm incision made for the Hasson trocar sufficient for Trucut biopsies and hemostasis under direct vision.This study shows that LKB is a safe, effective, and minimally invasive procedure that allows direct control of hemostasis and lower risks of postoperative morbidity compared with open biopsy. When PKB is contraindicated, LKB should be the first-choice alternative.

Primary and secondary artery-ureteral fistulas are a rare condition. In this case report we describe a case of misunderstood iliac artery-ureteral fistula, with negative radiological preoperative imaging, which occurred in a man as late complication of ureterocutaneostomy.