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Purpose We developed a prognostic nomogram for patients with high grade urothelial carcinoma of the upper urinary tract after extirpative surgery. Materials and Methods Clinical data were available for 2,926 patients diagnosed with high grade urothelial carcinoma of the upper urinary tract who underwent extirpative surgery. Cox proportional hazard regression models identified independent prognosticators of relapse in the development cohort (838). A backward step-down selection process was applied to achieve the most informative nomogram with the least number of variables. The L2-regularized logistic regression was applied to generate the novel nomogram. Harrell's concordance indices were calculated to estimate the discriminative accuracy of the model. Internal validation processes were performed using bootstrapping, random sampling, tenfold cross-validation, LOOCV, Brier score, information score and F1 score. External validation was performed on an external cohort (2,088). Decision tree analysis was used to develop a risk classification model. Kaplan-Meier curves were applied to estimate the relapse rate for each category. Results Overall 35.3% and 30.7% of patients experienced relapse in the development and external validation cohort. The final nomogram included age, pT stage, pN stage and architecture. It achieved a discriminative accuracy of 0.71 and 0.76, and the AUC was 0.78 and 0.77 in the development and external validation cohort, respectively. Rigorous testing showed constant results. The 5-year relapse-free survival rates were 88.6%, 68.1%, 40.2% and 12.5% for the patients with low risk, intermediate risk, high risk and very high risk disease, respectively. Conclusions The current nomogram, consisting of only 4 variables, shows high prognostic accuracy and risk stratification for patients with high grade urothelial carcinoma of the upper urinary tract following extirpative surgery, thereby adding meaningful information for clinical decision making.

Aims: The Pros-IT CNR project aims to monitor a sample of Italian males ≥18years of age who have been diagnosed in the participating centers with incident prostate cancer, by analyzing their clinical features, treatment protocols and outcome results in relation to quality of life. Methods: Pros-IT CNR is an observational, prospective, multicenter study. The National Research Council (CNR), Neuroscience Institute, Aging Branch (Padua) is the promoting center. Ninety-seven Italian centers located throughout Italy were involved. The field study began in September 1, 2014. Subjects eligible were diagnosed with biopsy-verified prostate cancer, naïve. A sample size of 1500 patients was contemplated. A baseline assessment including anamnestic data, clinical history, risk factors, the initial diagnosis, cancer staging information and quality of life (Italian UCLA Prostate Cancer Index; SF-12 Scale) was completed. Six months after the initial diagnosis, a second assessment evaluating the patient’s health status, the treatment carried out, and the quality of life will be made. A third assessment, evaluating the treatment follow-up and the quality of life, will be made 12months after the initial diagnosis. The 4th, 5th, 6th and 7th assessments, similar to the third, will be completed 24, 36, 48 and 60months after the initial diagnosis, respectively, and will include also a Food Frequency Questionnaire and the Physical Activity Scale for the Elderly. Discussion: The study will provide information on patients’ quality of life and its variations over time in relation to the treatments received for the prostate cancer.

Background: The Aim of This Study Was to Evaluate Intra- and Perioperative Outcomes of a Single High Volume Open Radical Prostatectomy (Orp) Surgeon, During His Learning Curve Period for Robot-Assisted Radical Prostatectomy (Rarp) and Extended Pelvic Lymph Node Dissection (Eplnd). Methods: The Study Included 264 Intermediate-High Risk Prostate Cancer Patients, Treated By Orp + Eplnd or Rarp + Eplnd, Prospectively Collected. Descriptive Statistics Compared Clinical and Pathological Variables Between Groups. Bivariate (Pearson) Correlation Analysis Assessed The Relationship Between The Number of Lymph Node (Ln) Removed, Positive Surgical Margins (Psm), Surgical Time and The Number of Procedures Performed Per Group. Results: Pt Stage and Gleason Score (Gs) Were Lower In Rarp Than In Orp Group (Both P=0.04), While Psm Were More Frequent In The Rarp Group (40% Vs. 25%; P=0.02). However, Psm Decreased With The Increase of Rarp ProCedures. The Number of Lns Removed Was 25 and 22, In Rarp and Orp Group (P=0.03). However, Ln+ Rate Did Not Differ Between Groups (11% Vs. 16%; P=0.216). In The Rarp Group, Overall Surgical Time and Eplnd Time Decreased With The Increase of Surgical Procedures (All P

Objectives: To evaluate the frequency and distribution of pelvic nodes metastases, in intermediate-high risk prostate cancer (PCa) patients (pts), who underwent open radical prostatectomy (ORP) and superextended pelvic lymph node dissection (sePLND). Patients and Methods: We retrospectively evaluated 630 consecutive pts with clinically localized, intermediate-high risk PCa, treated with ORP and sePLND from 2009 to 2016 at a single institution. The sePLND always removed all nodal/fibro-fatty tissue of the internal iliac, external iliac, obturator, common iliac, and presacral regions. Results: Positive lymph nodes (LN+) were found in 133 pts (21.1%). The median number of removed nodes and LN+ was 25 and 1, respectively. LN+ were found in 64 (48.1%), 58 (43.6%), 53 (39.8%), 16 (12%), and 20 (15%) pts and were present as a single site in 27 (20.3%), 22 (16.5%), 20 (15%), 0, and 6 (4.5%) cases in the internal iliac, external iliac, obturator, common iliac, and presacral chain, respectively. An ePLND would have correctly staged 127 (95%) pts but removed all LN+ in only 97 (73%) pts. Presacral nodes harbored LN+ in 20 patients. Among them, 18 were high-risk patients. Moreover, all but 1 pts with common iliac LN+ were in high risk group. Conclusions: These results suggest that removal of presacral and common iliac nodes could be omitted in intermediate risk pts. However, a PLND limited to external iliac, obturator, and internal iliac region may be adequate for nodal staging purpose, but not enough accurate if we aim to remove all possible site of LN+ in high risk pts.

Background The role of lymph node dissection (LND) in renal cell carcinoma (RCC) is still under debate. We aimed to assess the utilization rates of LND over time in Europe. Methods A multi-institutional database of 13,581 RCC patients who underwent radical nephrectomy (RN) or nephron sparing surgery (NSS) between 1988 and 2014 was created within an European consortium. We analysed temporal trends in the frequency of LND by using Joinpoint regression. Logistic regression models were used to identify predictors of LND. Results Overall, 5114 patients (42.7%) underwent LND. Lymph node invasion was recorded in 566 cases (11% of LND patients) which represents 4.7% of the whole study cohort. A gradual decline in the use of LND started in the 1990s. After 2008 LND decreased significantly by 21.5% per year (95%CI −33.3 to −7.5, p < 0.01) until 2011 and stabilized thereafter (Annual Percentage Change 4.9%, 95%CI −3.4 to 13.8, p = 0.2). At multivariable analyses, patient age (OR 0.98, p < 0.0001), type of surgery (RN vs. NSS: OR 5.46, p < 0.0001), surgical approach (open vs. minimally invasive: OR 1.75, p < 0.0001), T stage (T2 vs. T1: OR 1.57; T3-4 vs. T1: OR 1.44, p < 0.0001), clinical tumour size (OR 1.14, p < 0.0001), and year of surgery (OR 0.95, p < 0.0001) were associated with higher probability of LND at nephrectomy. Conclusions A trend towards lower LND was observed over time for RCC patients who underwent RN or NSS. LND is more frequently performed in younger patients, locally advanced diseases and in case of open surgery.

Purpose: To report the outcomes of patients with pathologic T4 UTUC and investigate the potential impact of peri-operative chemotherapy combined with radical nephroureterectomy (RNU) and regional lymph node dissection (LND) on oncologic outcomes. Materials and Methods: Patients with pathologic T4 UTUC were identified from the cohort of 1464 patients treated with RNU at 13 academic centers between 1987 and 2007. Oncologic outcomes were stratified according to utilization of perioperative systemic chemotherapy and regional LND as an adjunct to RNU. Results: The study included 69 patients, 42 males (61%) with median age 73 (range 43-98). Median follow-up was 17 months (range: 6-88). Lymphovascular invasion was found in 47 (68%) and regional lymph node metastases were found in 31 (45%). Peri-operative chemotherapy was utilized in 29 (42%) patients. Patients treated with peri-operative chemotherapy and RNU with LND demonstrated superior oncologic outcomes compared to those not treated by chemotherapy and/or LND during RNU (3Y-DFS: 35% vs. 10%; P = 0.02 and 3Y-CSS: 28% vs. 14%; P = 0.08). In multivariate Cox regression analysis, administration of peri-operative chemotherapy and utilization of LND during RNU was associated with lower probability of recurrence (HR: 0.4, P = 0.01), and cancer specific mortality (HR: 0.5, P = 0.06). Conclusions: Pathological T4 UTUC is associated with poor prognosis. Peri-operative chemotherapy combined with aggressive surgery, including lymph node dissection, may improve oncological outcomes. Our findings support the use of aggressive multimodal treatment in patients with advanced UTUC.

"Background: To our knowledge, the impact of venous tumour thrombus (VTT) consistency in patients affected by renal cell carcinoma (RCC) has never been addressed. Objective: To analyse the effect of VTT consistency on cancer-specific survival (CSS). Design, setting, and participants: We retrospectively analysed 174 consecutive patients with RCC and renal vein or inferior vena cava (IVC) VTT who underwent surgical treatment between 1989 and 2007 at our institute. Intervention: All patients underwent radical nephrectomy and thrombectomy. Measurements: Pathologic specimens were reviewed by a single uropathologist. In addition to traditional pathologic features, the morphologic aspect of the tumour thrombus was evaluated to distinguish solid from friable patterns. The prognostic role of thrombus consistency (solid vs friable) on CSS was assessed by means of Cox regression models. Results and limitations: The VTT was solid in 107 patients (61.5%) and friable in 67 patients (38.5%). The presence of a friable VTT increased the risk of having synchronous nodal or distant metastases, higher tumour grade, higher pathologic stage, and simultaneous perinephric fat invasion (all p < 0.05). The median follow-up was 24 mo. The median CSS was 33 mo; the median CSS was 8 mo in patients with a friable VTT and 55 mo in patients with a solid VTT (p < 0.001). On multivariable analyses, the presence of a friable VTT was an independent predictor of CSS (p = 0.02). The power of our conclusion may be somewhat limited by the relatively small study population and the retrospective nature of the study. Conclusions: In patients with RCC and VTT, the presence of a friable thrombus is an independent predictor of CSS. If our finding is confirmed by further studies, the consistency of the tumour thrombus should be introduced into routine pathologic reports to provide better patient risk stratification. (C) 2011 European Association of Urology. Published by Elsevier B. V. All rights reserved."

We investigated whether a history of endoscopic tumor ablation impacts oncologic outcomes after radical nephroureterectomy (RNU) for upper urinary tract urothelial carcinoma (UTUC). Using a multi-institutional database that contained patients who were treated with RNU, oncologic outcomes were assessed according to history of ureteroscopic tumor ablation. Disease-free survival (DFS) and cancer-specific survival (CSS) were estimated using the Kaplan-Meier survival analysis. Multivariate Cox regression analyses were performed to determine independent predictors of disease recurrence and cancer-specific mortality after RNU. The study included 1268 patients, 853 men and 415 women, with a mean age of 67.5 years (range 32-94 y) and 52.8 months median follow-up after RNU. A total of 175 (13%) patients underwent RNU after endoscopic tumor ablation and 1093 (87%) patients underwent RNU without a history of endoscopic ablation. The 5-year DFS and CSS rates were 72% and 77% in those with a history of tumor ablation vs 69% and 73% in those without a history of ablation (P = 0.171 and P = 0.365, respectively). In multivariate Cox regression analysis, history of ablation therapy was not associated with disease recurrence or cancer-specific mortality (hazard ratio [HR]: 0.79, P = 0.185 and HR: 0.7, P = 0.078, respectively). Our collaborative international efforts suggest that in selected patients, endoscopic tumor ablation does not adversely affect the recurrence and survival after subsequent RNU for UTUC. Our data support the continued role of ureteroscopic ablation of UTUC in appropriately selected patients.

Background: A new edition of the TNM was recently released that includes modifications for the staging system of kidney cancers. Specifically, T2 cancers were subclassified into T2a and T2b ( 10 cm), tumors with renal vein involvement or perinephric fat involvement were classified as T3a cancers, and those with adrenal involvement were classified as T4 cancers. Objective: Our aim was to validate the recently released edition of the TNM staging system for primary tumor classification in kidney cancer. Design, setting, and participants: Our multicenter retrospective study consisted of 5339 patients treated in 16 academic Italian centers. Intervention: Patients underwent either radical or partial nephrectomy. Measurements: Univariable and multivariable Cox regression models addressed cancer-specific survival (CSS) after surgery. Results and limitations: In the study, 1897 patients (35.5%) were classified as pT1a, 1453 (27%) as pT1b, 437 (8%) as pT2a, 153 (3%) as pT2b, 1059 (20%) as pT3a, 117 (2%) as pT3b, 26 (0.5%) as pT3c, and 197 (4%) as pT4. At a median follow-up of 42 mo, 786 (15%) had died of disease. In univariable analysis, patients with pT2b and pT3a tumors had similar CSS, as did patients with pT3c and pT4 tumors. Moreover, both pT3a and pT3b stages included patients with heterogeneous outcomes. In multivariable analysis, the novel classification of the primary tumor was a powerful independent predictor of CSS (p for trend < 0.0001). However, the substratification of pT1 tumors did not retain an independent predictive role. The major limitations of the study are retrospective design, lack of central pathologic review, and the small number of patients included in some substages. Conclusions: The recently released seventh edition of the primary tumor staging system for kidney tumors is a powerful predictor of CSS. However, some of the substages identified by the classification have overlapping prognoses, and other substages include patients with heterogeneous outcomes. The few modifications included in this edition may have not resolved the most critical issues in the previous version. (C) 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Objectives: Recent data support the sextant TRUS guided biopsy scheme of the prostate and TRUS prostatic lesion-guided biopsies are inadequate to detect all clinically important cancers. Consequently, different types of schemes with more than six biopsies have recently been proposed. The type of scheme and the number of biopsies needed to optimize the detection rate of prostate cancer is still a somewhat controversial issue. In order to draw attention to the most interesting issues and controversies involving needle biopsies, we describe not only the most common methods used but also some of the new schemes proposed in literature. Methods: Literature on prostate biopsy was reviewed and a selection of articles made. Keywords used for the Medline search included: prostate cancer, biopsy, transrectal ultrasound and diagnosis. Results: Over the last few years, an increasing number of investigators have modified the standard sextant biopsy scheme, increasing the number and areas of the prostate sampled, especially biopsies taken more laterally or in the anterior horn or medially towards the apex of the prostate. Cancer yield does not appear to be related solely to the number of biopsies but also to the regions of the prostate sampled. Conclusions: In the current PSA eras prostatic biopsies only performed at lesions detected by TRUS are obsolete. Sextant and lesion-directed biopsies maximizes detection rate using the lowest possible number of biopsy cores if hypoechoic lesions are clearly visible. In the case of a negative TRUS and/or digital rectal examination, the ideal number of cores and prostate areas requiring sampling is still not defined, but the use of 10 or 12 multiple biopsies is becoming routine in many centers. In the future, biopsy techniques will probably be individualized for each patient according to TRUS findings, prostatic volume and PSA levels. (C) 2002 Elsevier Science B.V. All rights reserved.

Study Type--Diagnostic (case series). Level of Evidence 4. What's known on the subject? And what does the study add? Multifocality, age, PSA values, and biopsy protocols regarding the predictive value of high grade PIN have been discussed extensively in the literature. Our study developed for the first time a predictive nomogram that could be helpful for patient counselling and to guide the urologist to perform rPBX after an initial diagnosis of isolated HGPIN.• To evaluate factors that may predict prostate cancer (PCa) detection after the initial diagnosis of high-grade prostatic intra-epithelial neoplasia (HGPIN) on prostate biopsy (PBx) with six to 24 random cores.• We retrospectively evaluated 262 patients submitted from 1998 to 2007 to prostate re-biopsy (rPBx) after an initial HGPIN diagnosis in tertiary academic centres. • HGPIN diagnosis was obtained on initial systematic PBx with six to 24 random cores. • All patients were re-biopsied with a 'saturation' rPBx with 20-26 cores, with a median time to rPBx of 12 months. • All slides were reviewed by expert uropathologists.• Plurifocal HGPIN (pHGPIN) was found in 115 patients and monofocal HGPIN (mHGPIN) was found in 147 patients. • In total, 108 and 154 patients, respectively, were submitted to12-core initial PBx and ≤12-core initial PBx. • Overall PCa detection at rPBx was 31.7%. PSA level (7.7 vs 6.6 ng/mL; P= 0.031) and age (68 vs 64 years; P= 0.001) were significantly higher in patients with PCa at rPBx. • PCa detection was significantly higher in patients with a ≤12-core initial PBx than in those with a12-core initial PBx (37.6% vs 23.1%; P= 0.01), as well as in patients with pHGPIN than in those with mHGPIN (40% vs 25.1%; P= 0.013). • At multivariable analysis, PSA level (P= 0.041; hazards ratio, HR, 1.08), age (P0.001; HR, 1.09), pHGPIN (P= 0.031; HR, 1.97) and ≤12-core initial PBx (P= 0.012; HR, 1.95) were independent predictors of PCa detection. • A nomogram including these four variables achieved 72% accuracy for predicting PCa detection after an initial HGPIN diagnosis.• PCa detection on saturation rPBx after an initial diagnosis of HGPIN is significantly higher in patients with a ≤12-core initial PBx than those with a12-core initial PBx and in patients with pHGPIN than in those with mHGPIN. • We developed a simple prognostic tool for the prediction of PCa detection in patients with initial HGPIN diagnosis who were undergoing saturation rPBx.

What's known on the subject? and What does the study add? Tumour stage is a powerful predictor of clinical outcomes and the most important factor driving clinical decision-making after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC). It has been suggested that renal pelvic pT3 subclassification into microscopic infiltration of the renal parenchyma (pT3a) versus macroscopic infiltration or invasion of peripelvic adipose tissue (pT3b) has strong prognostic value. This is an external validation study of the prognostic value of pT3 subclassification of renal pelvic UTUC in a large international cohort of patients treated with RNU. pT3b UTUC is associated with features of aggressive tumour biology, disease recurrence and cancer-specific mortality. However, pT3 subclassification is not an independent predictor of clinical outcomes.To externally validate the prognostic value of subclassification of pT3 renal pelvic upper tract urothelial carcinoma (UTUC) in a large international cohort of patients treated with radical nephroureterectomy (RNU).The RNU specimens with pT3 UTUC of the renal pelvis from 284 patients at 11 centres located in Asia, North America and Europe were retrospectively evaluated. All specimens were reviewed by genitourinary pathologists at each institution. Tumours were categorized as pT3a (microscopic infiltration of the renal parenchyma) or pT3b (macroscopic infiltration of the renal parenchyma and/or infiltration of peripelvic adipose tissue).Overall, 148 (52%) tumours were classified as pT3a and 136 (48%) as pT3b. Patients with pT3b disease were more likely to have high-grade tumours and sessile tumour architecture (all P ≤ 0.02). Patients with pT3b tumours were at increased risk of disease recurrence (5-year estimates: 55% versus 42%, P = 0.012) and cancer-specific mortality (CSM) (5-year estimates: 48% versus 40%, P = 0.04). Lymph node status, tumour architecture and tumour grade were independently associated with disease recurrence, whereas lymph node status, tumour architecture and lymphovascular invasion were independently associated with CSM. Subclassification of pT3 tumours was not associated with recurrence or CSM in multivariable analyses.Patients with pT3b UTUC were more likely to have tumours with aggressive pathological features and were at higher risk of disease recurrence and CSM after RNU compared with patients with pT3a disease. However, the pT3 subclassification did not remain an independent predictor of disease recurrence or CSM after controlling for tumour grade, lymph node status, tumour architecture and lymphovascular invasion.

Objectives: To evaluate factors that may predict prostate cancer (PCa) detection after initial diagnosis of high-grade prostatic intraepithelial neoplasia (HGPIN) on 6-24 cores prostatic biopsies (PBx). Material and Methods: We retrospectively evaluated 193 patients submitted from 1998 to 2007 to prostate re-biopsy after initial HGPIN diagnosis in three urologic departments. HGPIN diagnosis was obtained on initial systematic PBx with 6 to 24 random cores. All patients were re-biopsied with a "saturation" PBx with 18-26 cores with a median time to re-biopsy of 12 months. All slides were reviewed by expert uro-pathologists. Results: Plurifocal HGPIN (pHGPIN) was found in 103 patients and monofocal HGPIN (mHGPIN) in 90. Seventy-two and 121 patients were submitted to > 12-core initial biopsy and ≤ 12-core, respectively. Overall PCa detection at re-biopsy was 28.4%. PSA (6.7 vs 8.5 ng/ml; p = 0.029) and age (64 vs 68 years; p = 0.005) were significantly higher in patients with PCa at re-biopsy. PCa detection was significantly higher in patients who underwent a ≤ 12-core initial PBx than in those with > 12-core (35.5% vs 16.8%; p = 0.03), and in patients with pHGPIN than in those with mHGPIN (34.9% vs 21%; p = 0.035). At multivariable analysis, PSA value (p = 0.007; HR:1.18), prostate volume (p = 0.01; HR:0.966), age (p < 0.001; HR:1.15), pHGPIN (p = 0.003; HR:2.97) and ≤12-core initial biopsy (p = 0.012; HR:3.62) were independent predictors of PC detection. We further analysed the 2 groups of patients submitted to ≤ 12-core and > 12-core initial PBx. Plurifocal HGPIN and older age at biopsy were independent predictors in patients with ≤ 12-core initial PBx. On the contrary, in patients with > 12-core initial biopsy, higher PSA values and lower prostate volume were independent predictors of PC detection. Conclusions: PCa detection on saturation re-biopsy after initial diagnosis of HGPIN is significantly higher in patients submitted to ≤ 12-core than those submitted to > 12-core initial PBx. In patients with ≤ 12-core initial biopsy pHGPIN and older age were predictors of PCa detection at re-biopsy. In patients with > 12-core initial biopsy, higher PSA values and lower prostate volume was associated to an increased risk of PCa detection at re-biopsy

"OBJECTIVE To test the hypothesis that there is no significant difference in the rate of prostate cancer (PCa) detection rate between the transrectal and transperineal approach in men undergoing a saturation (24-core) prostate rebiopsy. METHODS We evaluated 472 consecutive men who underwent a 24-core prostate rebiopsy at 2 tertiary referral centers. Of these, 70% (332) underwent a transrectal biopsy, and 30% (140) underwent a transperineal biopsy. Propensity score was used to match 280 patients with homogeneous characteristics; those represented the final study cohort. Univariable and multivariable logistic regression analyses were used to address the relationship between biopsy approach and PCa detection rate. Covariates consisted of age at biopsy, prostate-specific antigen, total prostate volume, digital rectal examination findings, histologic findings on previous biopsy, and the number of previous negative biopsy sets. RESULTS Overall, PCa detection rate was 28.6%. There was no statistically significant difference in PCa detection rate between the transrectal and transperineal approach (31.4% vs 25.7%, respectively; P = .3). The type of approach was not an independent predictor of PCa detection rate at multivariable analyses (odds ratio = 0.61, P = .1). CONCLUSIONS Transrectal and transperineal prostate saturation biopsies have a similar PCa detection rate in men undergoing a saturation rebiopsy. Both approaches can be offered to men undergoing a prostate rebiopsy without undermining the rate of PCa detection. UROLOGY 77: 921-926, 2011. (C) 2011 Elsevier Inc. All rights reserved."

Purpose: To determine the clinical benefit of high-dose early adjuvant radiotherapy (EART) in high-risk prostate cancer (hrCaP) patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy. Patients and Methods: The clinical outcome of 334 hrCaP (pT34 and/or positive resection margins) node-negative patients submitted to radical retropubic prostatectomy plus pelvic lymphadenectomy before 2004 was analyzed according to the EART dose delivered to the prostatic bed, = 70.2 Gy (median 70.2 Gy, n = 181). Results: The two groups were comparable except for a significant difference in terms of median follow-up (10 vs. 7 years, respectively) owing to the gradual increase of EART doses over time. Nevertheless, median time to prostate-specific antigen (PSA) failure was almost identical, 38 and 36 months, respectively. At univariate analysis, both 5-year biochemical relapse-free survival (bRFS) and disease-free survival (DFS) were significantly higher (83 % vs. 71 % [p = 0.001] and 94 % vs. 88 % [p = 0.005], respectively) in the HD group. Multivariate analysis confirmed EART dose >= 70 Gy to be independently related to both bRFS (hazard ratio 2.5, p = 0.04) and DFS (hazard ratio 3.6, p = 0.004). Similar results were obtained after the exclusion of patients receiving any androgen deprivation. After grouping the hormone-naive patients by postoperative PSA level the statistically significant impact of high-dose EART on both 5-year bRFS and DFS was maintained only for those with undetectable values, possibly owing to micrometastatic disease outside the irradiated area in case of detectable postoperative PSA values. Conclusion: This series provides strong support for the use of EART doses >= 70 Gy after radical retropubic prostatectomy in hrCaP patients with undetectable postoperative PSA levels. (C) 2009 Elsevier Inc.

Purpose: According to the 2002 American Joint Committee on Cancer TNM classification, perinephric and renal sinus fat invasion are classified as pT3a renal cell carcinoma. However, only a few studies have assessed the impact of sinus fat invasion on patient survival and with controversial results. We analyzed the impact of sinus fat invasion on cancer specific survival in a cohort of patients with pT3a clear cell renal cell carcinoma. Materials and Methods: We retrospectively analyzed data on 115 consecutive patients treated with open radical nephrectomy for unilateral, sporadic pT3a clear cell renal cell carcinoma at our department from 1989 to 2006. All pathological specimens were rereviewed by a single uropathologist. The prognostic role of sinus fat invasion in cancer specific survival was assessed by Cox proportional hazards regression models. Results: Ten patients had direct ipsilateral adrenal invasion and were excluded from analysis. A total of 105 patients with clear cell renal cell carcinoma were evaluated. Median followup was 38 months. In the overall population sinus fat invasion did not reach independent predictive status in terms of cancer specific survival on multivariate Cox regression analysis after adjusting for age, performance status, tumor dimension, tumor grade, synchronous metastases, nodal involvement, sarcomatoid differentiation and coagulative necrosis. In the subset of patients with pNx/pN0 M0 (83) the actuarial 5-year cancer specific survival was 71.9% and 45.5% for those with perinephric fat invasion only and sinus fat invasion, respectively (p = 0.025). Sinus fat invasion achieved an independent predictive role on multivariable Cox regression analysis (p = 0.048, HR 2.06). Conclusions: Sinus fat invasion in clear cell renal cell carcinoma significantly affects cancer specific survival in patients without nodal or distant metastases. However, sinus fat invasion is not associated with worse cancer specific survival in cases of metastatic disease.

Objectives To analyze the prognostic role of lymphadenectomy (LND) in patients with muscle-invasive transitional cell carcinoma (TCC) of the upper urinary tract (UUT) managed with radical surgery. Methods From 1986 to 2003, 132 consecutive patients with muscle-invasive TCC of the UUT underwent radical surgery. LND was performed in 95 cases. Patients were stratified according to the presence of LND and lymph node (LN) status. Univariable and multivariable Cox regression models determined the effect of age, pT, grade, nodal status (pN), number of LNs removed, year of surgery, and postoperative chemotherapy on disease-free survival (DFS) and cancer-specific survival (CSS) in the overall population and in patients who underwent LND. Results The actuarial 5-yr CSS in pNx patients was significantly worse than in pN0 patients (48% vs. 73%, p = 0.001) and comparable to pN+ outcome (48% vs. 39%, p = 0.476). In the entire population, multivariable Cox regression analyses indicated that pT and pN status were independent predictors of DFS (p = 0.04, hazard ratio [HR] = 1.82 and p < 0.01, HR = 1.34, respectively) and CSS (p < 0.01, HR = 2.42 and p = 0.04, HR = 1.32, respectively). In patients who underwent LND, the number of LNs removed was an independent predictor of DFS (p = 0.03, HR = 0.928) and of CSS (p = 0.007, HR = 0.903). The extent of LND again resulted in an independent predictor either of DFS or CSS (p = 0.04, HR = 0.904 and p = 0.01, HR = 0.867, respectively) in the subgroup of pN0 patients. Conclusions LND emerged as a strong independent predictor of DFS and CSS in patients surgically managed for a muscle-invasive TCC of the UUT.

A 40-year-old woman in the twenty-fifth week of pregnancy presented with a gross retroperitoneal mass. At the end of the pregnancy, the patient was submitted to surgery, and the gross infiltration of the inferior vena cava wall required the resection of the vena cava with its prosthetic substitution. The histopathological examination demonstrated the presence of a leiomyosarcoma of the inferior vena cava. An electronic video supplement showing the most important intraoperative passages is available online at doi:10.1016/j.eururo.2008.06.074. (C) 2008 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Objectives Radical nephrocapsulectomy and cavoatrial thrombectomy with median sternotomy and abdominal access, using extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA), has become the gold standard treatment for renal cell carcinoma (RCC) with neoplastic thrombosis of the suprahepatic and intrapericardial inferior vena cava (IVC) and right atrium (RA). Any modification of surgical techniques should be compared with this therapeutic strategy. Methods In our quest to identify a minimally invasive approach and to apply available technology to ensure patient safety, even in cases of RCC with suprahepatic IVC and RA thrombosis, we identified a therapeutic approach that foresees en bloc radical nephrocapsulectomy, with ECC and DHCA in right anterior minithoracotomy. Furthermore, to make surgery even safer, we made some modifications and used auxiliary maneuvers. We present the case of a 39-year-old man with a neoplasm that involved the right kidney and suprahepatic IVC thrombosis, undergoing radical nephrocapsulectomy and thrombectomy with ECC and DHCA in right anterior minithoracotomy. Conclusions Radical nephrocapsulectomy and thrombectomy of the suprahepatic and intrapericardial IVC and/or of the RA with ECC and DHCA in right anterior minithoracotomy for RCC is a valid minimally invasive alternative to standard surgical techniques. Compared with standard median sternotomy access, right anterior minithoracotomy allows a more rapid functional recovery, a reduction in risk of infection of the wound, and a reduction in pain during postoperative convalescence, and has considerable esthetic advantages, without limiting surgical therapeutic chances, regardless of the cranial extension of the thrombus.

Objectives: To prospectively evaluate the accuracy of integrated [C-11]choline-PET/CT in the diagnosis of lymph-node recurrence in prostate cancer patients with biochemical failure after surgery. Methods: Since October 2002, 25 patients with biochemical recurrence (median PSA: 1.98 ng/ml), based on evidence of lymph-node metastases on [C-11]cholinePET/CT scan (21 cases) or conventional imaging (4 cases), were scheduled for either bilateral pelvic (12 cases) or both pelvic and retroperitoneal lymph-node dissection (13 patients). Results: Sixty-three nodal sites were evaluated histologically. The mean number of nodes removed and positive nodes were 21.92 +/- 16.91 (range: 4-74) and 8.84 +/- 9.65 (range: 1-31), respectively. Of the four patients with negative [C-11]choline-PET/CT and positive magnetic resonance, none had nodal metastases. Nineteen of the 21 patients (90%) with positive [C-11]choline-PET/CT had nodal metastases of prostate adenocarcinoma at histologic evaluation. A lesion-based analysis showed that [C-11]choline-PET/CT sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 64%, 90%, 86%, 72%, and 77%, respectively. The mean maximum diameter of true positive metastases was larger than false-negative ones (15.0 vs. 6.3 mm; p = 0.0004). Conclusions: [C-11]Choline-PET/CT is an accurate diagnostic tool for the detection of lymph-node metastases of recurrent prostate cancer. The low negative predictive value seems to depend on the limited capability of [C-11]choline-PET/CT to detect microscopic lesions. The high positive predictive value, even with low PSA values, provides a basis for further treatment decisions. (C) 2007 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Background and purpose: To investigate the usefulness of vesicourethral anastomotic biopsy (VUBx) in patients who are candidates for salvage radiotherapy (SalvRT) after radical prostatectomy (RRP). Material and methods: From 1992 to 2001, 98 patients with a PSA failure (PSAf) after RRP underwent SalvRT to the prostatic bed (median dose 70 Gy). In 50/98 patients the VUBx was positive, in 26 negative; 22 patients underwent salvRT without a prior VUBx. The prognostic impact on biochemical disease-free survival (bNEDs) of histologic confirmation of the local failure was evaluated retrospectively. Results: In the 40 patients with pre-RT PSA

Objectives: To assess the baseline erectile function (EF) of patients with clinically localized prostate cancer (pCa), who are candidates for a bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP) to (a) objectively rate the preoperative self-reported subjective patient's EF and (b) investigate possible correlations between preoperative EF and demographic data and comorbidities. Materials and methods: Two-hundred-thirty-four patients, who verbally self-reported they were preoperatively fully potent and strongly motivated to maintain postoperative EF, underwent a BNSRRP. A comprehensive medical and sexual history was obtained on hospital admission the day prior to surgery. Subjectively reported potency rate was compared with the scores of the International Index of Erectile Function (IIEF). Results: The EF domain of the IIEF showed a baseline normal EF in only 43% of the subjects. In contrast, 13% had a mild erectile dysfunction (ED), 8% had a mild to moderate ED, 8% complained of a moderate ED, and as many as 28% reported severe EF impairment. Interestingly, 38% of the patients with severe ED did not attempt any intercourse during the last 4 weeks prior to surgery. Conclusions: A significant proportion of patients with clinically localized pCa and self-reported total potency already had suffered from ED preoperatively. Incorrect timing of questionnaires administration, the potential influence of preoperative patient's psychological distress, and the implication of the patient's partner's psychological and sexual health may be contributing factors to the contradictory finding. The preoperative use of validated questionnaire may help to identify patients who can actually expect to regain potency following a BNSRRP. (c) 2006 Published by Elsevier B.V. on behalf of European Association of Urology.

We present the case of a 44-year old man, presenting with acute left flank pain and gross haematuria, affected by bilateral renal mass and massive para-aortic and mediastinic lymphadenopathy, highly suspicious for metastatic renal cancer. (c) 2005 Elsevier B.V. All rights reserved.

Androgen ablation or blockade of androgen action through the androgen receptor (AR) has been the cornerstone of treatment of advanced prostate cancer. The relative merits of monotherapy or combined androgen blockade (CAB) are still the subject of debate. Each treatment strategy/hormonal agent has favourable and unfavourable effects. Patients with advanced prostate cancer will clearly benefit androgen deprivation-based treatment for palliating their symptoms and for improving their quality of life (QOL). However, whether these therapies prolong survival when administered before there are symptoms caused by disease progression remains controversial. Data from multiple recent studies indicate that an earlier treatment in patient's disease course likely leads to better outcome, but it is not easy to predict the best timing of hormonal therapy for asymptomatic advanced disease. For the purpose of delaying the onset of androgen-independent growth of prostate cancer, different regimen of intermittent androgen blockade (IAB) have been applied to patients. The use of IAB is increasing but, despite theoretical advantages in terms of patient QOL, clinical studies have yet to prove superiority over continuous therapy. The role of androgen deprivation in combination with surgery or radiotherapy has been also evaluated. While neoadjuvant hormonal therapy (NHT) can significantly decrease the incidence of positive margins at the time of radical prostatectomy (RP), 3 months of treatment is not long enough to have any significant effect on biochemical recurrence rates. The results of studies investigating longer courses (8 months) of NHT are awaited. High-risk patients should be considered for early adjuvant hormonal therapy (AHT) after surgery, as they may be most likely to benefit. The rationale for the use of NHT in combination with radiotherapy is that it reduces tumour volume and therefore the amount of radiation therapy that is needed to treat the tumour. It has been found that 3-4 months of hormonal treatment reduces prostate volume by 25-50%. Interme-diate-risk patients treated with NHT and concomitant hormonal therapy have been found to have a 94% freedom for biochemical failure after 4 years, suggesting that this group is the ideal patient population to receive short-term hormonal therapy in combination with brachytherapy. Several studies suggested the current consensus that patients with clinically localized or locally advanced high-grade tumours benefit from definitive radiation therapy and long-term AHT. The current treatment for advanced prostate cancer remains essentially palliative. However, an increased understanding of the heterogeneous nature of the disease, the mechanisms that lead to hormone-refractory prostate cancer (HRPC) has identified novel therapeutic targets and led to the development of selective new therapies, that may help to prolong survival and maintain QOL for patients with HRPC.

In the long-term there is biochemical evidence of recurrent prostate carcinoma in approximate to 40% of patients after radical prostatectomy (RP). Detecting the site of recurrence (local vs distant) is critical for defining the optimum treatment. Pathological and clinical variables, e.g. Gleason score, involvement of seminal vesicles or lymph nodes, margin status at surgery, and especially the timing and pattern of prostate-specific antigen (PSA) recurrence, may help to predict the site of relapse. Transrectal ultrasonography (TRUS) of the prostatic fossa in association with TRUS-guided needle biopsy is considered more sensitive than a digital rectal examination for detecting local recurrence, especially if PSA levels are low. Although it cannot detect minimal tumour mass at very low PSA levels (

Objectives. To evaluate factors predicting cancer detection by extended repeat prostate biopsies in patients with an initial, isolated, monofocal or plurifocal, high-grade prostatic intraepithelial neoplasia (HGPIN) diagnosis. Methods. From 1995 to 2002, after a first set of 10 to 12 systematic biopsy cores, 47 patients with an initial HGPIN diagnosis underwent repeat biopsy using the same technique (mean repeat biopsy cores 11.5) after a median follow-up of 11.4 months (range 3 to 24). Results. Cancer was detected at the second biopsy in 21 patients (44.6%). Cancer detection was significantly greater in patients with plurifocal HGPIN than in those with monofocal HGPIN (70% vs. 10%, respectively; P < 0.005) and in patients who underwent repeat biopsy more than 6 months after the first biopsy set (65%) compared with patients who underwent repeat biopsy within 6 months (25%; P < 0.01; mean follow-up 15.5 and 3.8 months, respectively). Multivariate analysis showed that prostate-specific antigen, prostate-specific antigen density, digital rectal examination, and transrectal ultrasound findings were not statistically significant predictors of prostate cancer, and HGPIN multifocality and interval between biopsies (more than a 6-month follow-up interval) were independent prognostic factors (odds ratio 4.65 and 2.65, respectively). After radical prostatectomy (14 patients), no statistically significant differences were found in the pathologic stage between patient groups stratified by repeat biopsy interval (within or after 6 months). Conclusions. After a 10 to 12-core biopsy, patients with initial, isolated monofocal or plurifocal HGPIN diagnoses had an overall cancer detection rate of 45% on repeat extended biopsies. Plurifocal HGPIN on the first biopsy set was the strongest independent predictive factor in cancer detection. A 12 to 18-month interval before repeat biopsy could permit a significantly greater cancer detection rate, with no apparent likelihood of clinical cancer progression. (C) 2004 Elsevier Inc.

Purpose: To evaluate the clinical benefit deriving from early (within 6 months) radiotherapy (ERT) after pelvic lymphadenectomy and radical retropubic prostatectomy for localized/locally advanced adenocarcinoma of the prostate in a single-institution series. Methods and Materials: We retrospectively analyzed 415 patients who underwent pelvic lymphadenectomy and radical retropubic prostatectomy between 1986 and 1998 for pT2b-pT4, pN0-pN1 prostate carcinoma. Of the 415 patients, 237 underwent ERT for adverse pathologic findings and 178 patients did not receive RT or underwent salvage RT less than or equal to6 months (salvage or no RT [SNRT]). Results: After a median follow-up of 62 months, the 8-year actuarial freedom from biochemical, local and systemic failure, and cause-specific survival rate was 69% vs. 31% (p

Introduction: The aim of this study is to verify the predictive role of transrectal ultrasound (TRUS) of prostatic fossa, digital rectal examination (DRE), prostate specific antigen (PSA) and pathological stage after radical prostectomy in the detection of a prostate tumor recurrence at the level of the vesico-urethral anastomosis by means of multiple TRUS biopsies (6-8 cores). Material and Methods: From October 1997, following a radical prostatectomy, 119 consecutive patients (median age: 67.9 years) with a PSA greater than or equal to 0.2 ng/ml (median PSA: 0.9 ng/ml) underwent DRE and TRUS examinations with a 5.0-7.5 MHz variable frequency end-fire probe (Hitachi Medical System) and an EUB-525 machine. All patients received six TRUS-guided biopsies of the vesico-urethral anastomosis, and 1-2 additional biopsies directed to hypoechoic or suspicious areas, if detected by TRUS. Results: Biopsies revealed recurrent carcinoma in 50% of patients (60/119). TRUS proved more sensitive than DRE (75% vs. 50%; p = 0.01) and, conversely, DRE proved more specific than a TRUS (85% vs. 66%; P = 0.03). Cancer was detected in 45% of the 34 patients with a PSA less than or equal to 0.5 ng/ml. In the group of patients with a PSA greater than or equal to 2.0 ng/ml (24 patients), TRUS was able to detect every biopsy-proven local recurrence lesion (sensitivity: 100%). Conversely, all patients with a PSA greater than or equal to 2.0 ng/ml and a negative TRUS had a negative biopsy (negative predictive value: 100%). In a multi-variable logistical analysis, the most predictive parameters determining a positive biopsy rate among those values studied (PSA, DRE, TRUS, positive surgical margins, pathological stage and time to PSA elevation) were TRUS and DRE findings (p = 0.003, with an odds ratio of 4.6 and p = 0.02, with an odds ratio of 4.1, respectively). Conclusion: TRUS and TRUS biopsies utilizing 6-8 cores are efficient tools in the detection of local recurrence after a radical prostatectomy, even with a PSA less than or equal to 0.5 ng/ml. A combination of TRUS and DRE findings seems to predict biopsy results best. In case of a PSA greater than or equal to 2.0 ng/ml and a negative TRUS, a biopsy of the vesico-urethral anastomosis could be avoided since the negative predictive value is 100%. Cancer recurrence detection seems to be predicted by TRUS and DRE findings, but not by PSA levels, pathological stage, status of the surgical margins or time to PSA elevation. (C) 2003 Elsevier B.V. All rights reserved.

Purpose: Radical cystectomy is advocated for high risk patients with superficial bladder cancer. To preserve complete urinary continence, normal sexual function and fertility in young patients, we developed an innovative technique based on nerve and seminal sparing radical cystectomy. Materials and Methods: Radical cystectomy was recommended for 8 patients with superficial bladder cancer that was not conservatively manageable. Average patient age was 44 years (range 36 to 48), and all patients were extremely anxious to maintain potency and fertility. The surgical procedure consisted of transurethral resection of the prostate, pelvic iliac lymph node dissection and extraperitoneal radical cystectomy performed while preserving the vas deferens seminal vesicles and neurovascular bundles. Urinary diversion was accomplished with a W-shaped ileal reservoir anastomosed to the prostatic capsule. Results: Patients were generally discharged from the hospital 15 days after surgery, and postoperative morbidity was limited. Daytime and nighttime continence was immediate and complete after catheter removal. Normal erectile function was clinically documented in all patients while fertility potential with semen retrieval via urine was recorded in 7. The quality of life, as reported by the patients, was highly satisfactory at 18-month followup. Conclusions: The surgical approach we describe should be considered in young men with clinical, superficial bladder tumors refractory to conservative treatment who wish to maintain potency and fertility, and to guarantee as good a quality of life as possible. To ensure oncological success scrupulous patient selection is a primary step of this procedure.