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Background: Bladder cancer is the ninth most common type of cancer worldwide. In the past, radical cystectomy via open surgery has been considered the gold-standard treatment for muscle invasive bladder cancer. However, in recent years there has been a progressive increase in the use of robot-assisted laparoscopic radical cystectomy. The aim of the current project is to investigate the surgical, oncological, and functional outcomes of patients with bladder cancer who undergo radical cystectomy comparing three different surgical techniques (robotic-assisted, laparoscopic, and open surgery). Pre-, peri- and post-operative factors will be examined, and participants will be followed for a period of up to 24 months to identify risks of mortality, oncological outcomes, hospital readmission, sexual performance, and continence., Methods: We describe a protocol for an observational, prospective, multicenter, cohort study to assess patients affected by bladder neoplasms undergoing radical cystectomy and urinary diversion. The Italian Radical Cystectomy Registry is an electronic registry to prospectively collect the data of patients undergoing radical cystectomy conducted with any technique (open, laparoscopic, robotic-assisted). Twenty-eight urology departments across Italy will provide data for the study, with the recruitment phase between 1st January 2017-31st October 2020. Information is collected from the patients at the moment of surgical intervention and during follow-up (3, 6, 12, and 24 months after radical cystectomy). Peri-operative variables include surgery time, type of urinary diversion, conversion to open surgery, bleeding, nerve sparing and lymphadenectomy. Follow-up data collection includes histological information (e.g., post-op staging, grading, and tumor histology), short- and long-term outcomes (e.g., mortality, post-op complications, hospital readmission, sexual potency, continence etc)., Discussion: The current protocol aims to contribute additional data to the field concerning the short- and long-term outcomes of three different radical cystectomy surgical techniques for patients with bladder cancer, including open, laparoscopic, and robot-assisted. This is a comparative-effectiveness trial that takes into account a complex range of factors and decision making by both physicians and patients that affect their choice of surgical technique., Trial Registration: ClinicalTrials.gov , NCT04228198 . Registered 14th January 2020- Retrospectively registered.

Background: The impact of neobladder and urostomy on bladder cancer patient's health-related quality of life (HR-QoL) is controversial and many issues currently remain under-investigated. Initial studies pointed out that the emotional responses of caregivers might be ' contagious ', influencing emotional reactions in bladder cancer patients undergoing radical cystectomy., Methods: Three hundred and eighty-two bladder cancer patients (aged M = 67.29 years; SD = 9.23) (16.9% (65) were female and 82.9% (319) were male) and their caregivers were enrolled. Data were collected prospectively: at T0 (1 month before the surgery), at T1 (2 weeks after the surgery, at patient discharge from the hospital) and at T2 (6-month follow-up). At each time point (T0, T1 and T2), a set of questionnaires (EORT QLQ-C30 and emotion thermometer) were given to patients and their caregivers., Results: All patients reported a general improvement in the HR-QoL and global health status/QoL from T0 to T2 ( p < 0.001). No significant differences were observed between neobladder and urostomy. At T0, the emotional thermometer total scoring in caregivers was positive in relation to HR-QoL ( p < 0.001) and negative in relation to the patient's perception of QoL ( p < 0.001) and global health (p < 0.001). Similar trends were observed at T1 and T2., Conclusions: These results suggest that patients and their caregiver's emotional reactions to cancer are deep-rooted and strongly interconnected, and they provide innovative insights for the clinical management of bladder cancer patients., Competing Interests: The authors declare no conflicts of interest., (© the authors; licensee ecancermedicalscience.)

Synchronous cancers should be first evaluated at high-volume referral oncological centers. Multidisciplinary evaluation, as the first step of multimodal treatment strategy, is also a way to select candidates fit for surgical resections. Concurrent minimally invasive approaches are a safe and effective option that may result in long-term control of the disease. Robot-assisted surgery allows obtaining the oncological radicality with lower invasiveness for the patient, thus retaining greater surgical aggressiveness even in high-risk patients. The reports of successful synchronous robot-assisted pulmonary and urologic resections for cancer in frail elderly subjects are described here.

Introduction: Double-J ureteral stents are subject to encrustation. Studies have shown that the encrustation onset is linked with indwelling time. In prevention, it is admitted that the Double-J stent indwelt for medium or long term should be replaced periodically. However, in the absence of guidelines, indwelling durations vary with centers' habits, stent indication, and stent materials. Our target was to evaluate the actual ureteral stent medium-/long-term indwelling times and related encrustation rates perceived by urologists in daily practice. Methods: An observational retrospective study was performed over six European centers. All data of all consecutive removed stents of the same material implanted for more than 2 months within a same 2-year referred period were collected. Three stent types of various materials, with/without coating, were evaluated. Encrustation rates were analyzed according to indwelling times and stent indication. Results: Four hundred seventy-three stents were recorded with indwelling times between 60 and 679 days. An unexpected number of long-term indwelling times were noticed: globally one-third more than 6 months, and 9% more than 1 year. In case of malignant indication, these rates were, respectively, 44% and 17%. For nonstone indication, clinically significant encrustation rates stayed extremely low before 4 months (1.3%) and quite low before 6 months (5.2%), increasing with time to reach around 10% in the long term. However, as expected, the rate was higher for stone indication with a marked increase after 4 months (8% before 4 months, nearly 17% after). Conclusion: Our data confirm a higher encrustation risk for stone patients. Long indwelling times in nonstone patients beyond 6 months or even 12 months appear to be still requested and relatively well supported in usual practice by this population.

Introduction: Radical cystectomy (RC) is the gold standard treatment for patients with muscle-invasive or refractory non-muscle invasive bladder cancer. It is estimated that approximately 64% and 13% of RC patients experience any complication and major complications, respectively. Specialized immunonutrition (SIM) aims to reduce the rates of complications after RC. We reported surgical complication rates in RC patients who received (SIM group) versus who did not receive (no-SIM group) perioperative SIM. Moreover, we investigated factors associated with complications after RC., Material and Methods: This is a retrospective cohort study of 52 patients who underwent RC between April 2016 and December 2017. Overall, 26 (50%) patients received perioperative SIM. We recorded age, gender, Charlson Comorbidity Index (CCI), body mass index (BMI), Malnutrition Universal Screening Tool (MUST) score, unintentional weight loss (UWL), SIM drinks consume, surgical approach, urinary diversion, neoadjuvant chemotherapy (NAC), use of total parenteral nutrition (TPN), final pathology, length of stay (LOS), and complications., Results: SIM was associated with higher rates of documented infections ( P  = .03). Conversely, post-operative ileus was associated with higher rates of overall infections ( P  = .03). Median LOS was comparable within the 2 groups. Overall, 4 (15.38%) versus 0 (0%) patients in SIM versus no-SIM group were readmitted to hospital ( P  = .03). Age, CCI, NAC, and TPN were not associated with complication rates., Conclusions: SIM is not associated with lower rates of post-operative complications in RC candidates. Moreover, higher rates of documented infections were observed in the SIM group. Patients with post-operative ileus experienced more infections. Age, CCI, NAC, and TPN were not predictive of complications.

Objective: The objective of the study is to test the effect of age on cancer-specific mortality (CSM) in patients with urothelial carcinoma of the urinary bladder (UCUB), across all disease stages., Materials and Methods: Within the Surveillance, Epidemiology, and End Results (SEER) registry (2004-2016), we identified 207,714 patients. Age was categorized as: below 60 versus 60 to 69 versus 70 to 79 versus 80 years and above. Multivariable competing-risks regression (CRR) models were used according to disease stage (low-risk nonmuscle invasive: TaN0M0 low grade, high-risk nonmuscle invasive: Ta high grade or Tis-1N0M0, muscle invasive: T2-3N0M0, regional: T4N0M0/TanyN1-3M0, and metastatic: TanyNanyM1)., Results: Overall, 33,970 (16.4%) versus 52,173 (25.1%) versus 64,537 (31.1%) versus 57,034 (27.4%) patients were below 60 versus 60 to 69 versus 70 to 79 versus 80 years and above, respectively. In multivariable CRR models that focused on low-risk nonmuscle invasive UCUB, advanced age was associated with higher CSM rates (hazard ratio [HR]: 7.04 in patients aged 80 y and above, relative to below 60 y; P<0.001). Moreover, advanced age was also associated with higher CSM rates in high-risk nonmuscle invasive UCUB (HR: 2.77 in patients aged 80 y and above, relative to below 60 y; P<0.001) and in muscle invasive UCUB patients (HR: 1.38 in patients aged 80 y and above, relative to below 60 y; P<0.001). Conversely, lower CSM rates with advanced age were observed in multivariable CRR that focused on regional (HR: 0.91 for patients aged 80 y and above, relative to below 60 y; P=0.02) or metastatic UCUB (HR: 0.75 for patients aged 80 y and above, relative to below 60 y; P<0.001)., Conclusions: The direction and the magnitude of the association between advanced age and CSM in UCUB patients changes according to tumor stage. In low-risk nonmuscle invasive, high-risk nonmuscle invasive, and muscle invasive UCUB, more advanced age is associated with higher CSM rates. Conversely, in regional and metastatic UCUB patients, more advanced age is associated with lower CSM rates., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Objectives: To test international society of urological pathology grade group (ISUP GG) concordance rates between multiparametric magnetic resonance imaging (mpMRI) targeted biopsies (TB) vs. standard systematic biopsies (SB) and radical prostatectomy (RP) specimens, in biopsy naïve patients., Materials and Methods: This retrospective single center study included 80 vs. 500 biopsy naïve patients diagnosed with TB vs. SB and treated with RP between 2015 and 2018. First, we compared ISUP GG concordance rates and the percentages of undetected clinically significant prostate cancer (csPCa: ISUP GG  ≥ 3), between TB vs. SB and RP. Second, multivariable logistic regression models tested predictors of concordance rates before and after 1:3 propensity score (PS) matching. Third, among TB patients, univariable logistic regression models tested variables associated with ISUP GG concordance at RP., Results: Overall, ISUP GG concordance rates were, respectively, 55 vs. 41.4% for TB vs. SB (P = 0.02). However, no differences in concordance rates were observed in patients with biopsy ISUP GG1 (31 vs. 33.9% for TB vs. SB; P = 0.8). Moreover, 15 vs. 18.8% csPCa were missed by TB vs. SB, respectively (P = 0.4). In multivariable logistic regression models, TB were associated with higher concordance rates before (odds ratio [OR]: 1.13; P = 0.04) and after 1:3 PS matching (OR: 1.15; P 0.03), compared to SB. In TB patients, age (OR: 0.98; P = 0.04), maximum cancer core involvement (MCCI; OR: 1.02; P = 0.02) and maximum cancer core length (MCCL; OR: 1.01; P = 0.07) were associated with ISUP GG concordance. Moreover, a trend for lower concordance rates was observed with higher PSA-D (OR: 0.77; P = 0.1). Finally, intermediate lesion location at mpMRI was associated with lowest concordance rates (44%)., Conclusion: In biopsy naïve patients treated with RP, TB achieved higher rates of ISUP GG concordance, but same percentages of csPCa missed, compared to SB. Moreover, only patients with ISUP GG ≥2, but not patients with ISUP GG1, exhibited higher concordance rates. Finally, age, MCCI, MCCL, PSA-D, and lesion location were associated with concordance between TB and RP., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Multiparametric magnetic resonance imaging (mpMRI) and targeted biopsy have become an integral part of the diagnosis of prostate cancer (PCa), as recommended by the European Association of Urology Guidelines. The aim of the current study was to evaluate the performance of MRI and MRI-transrectal ultrasound (TRUS) fusion prostate biopsy as first biopsy setting in a tertiary center., Methods: A cohort of 300 patients was included in the current analysis. All patients presented with clinical or biochemical suspicion of PCa and harbored at least one suspect lesion on mpMRI. MRI-TRUS fusion prostate biopsy, followed by 12 core systematic prostate biopsy were performed by the same operator using a rigid registration system., Results: The mean age of the patients was 64 years (IQR: 58-68.5 years) and the mean PSA was 6.35 ng/mL (IQR: 4.84-9.46 ng/mL). Overall cancer and csPCa diagnosis rates were 47% and 40.66%. Overall PCa/csPCa detection rates were 20.4%/11.1%, 52%/45% and 68.5%/66.7% for PI-RADS lesions 3, 4 and 5 (P<0.001/P<0.0001). Larger lesion diameter and lesion volume were associated with PCa diagnosis (P=0.006 and P=0.001, respectively). MRI-TRUS fusion biopsy missed PCa diagnosis in 37 cases (of whom 48.6% ISUP 1) in comparison with 9 patients missed by systematic biopsy (of whom 11.1% ISUP 1). In terms of csPCa, systematic biopsy missed 77.7% of the tumors located in the anterior and transitional areas. The rate of csPCa was highest when targeted biopsy was associated with systematic biopsy: 86.52% vs. 68.79% for targeted biopsy vs. 80.14% for systematic biopsy, P=0.0004. In 60.6% of cases, systematic biopsy was positive for PCa at the same site as the targeted lesion. Of these patients, eight harbored csPCa and were diagnosed exclusively on systematic biopsy., Conclusions: MRI-TRUS fusion prostate biopsy improves the diagnosis of csPCa. The main advantage of an MRI-guided approach is the diagnosis of anterior and transitional area tumors. The best results in terms of csPCa diagnosis are obtained by the combination of MRI-TRUS fusion with systematic biopsy. The systematic biopsy performed during MRI-targeted biopsy could have an important role in overcoming errors of MRI-TRUS fusion systems., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau-20-1001). The authors have no conflicts of interest to declare, (2020 Translational Andrology and Urology. All rights reserved.)

The COVID-19 outbreak, in a few weeks, overloaded Italian hospitals, and the majority of medical procedures were postponed. During the pandemic, with hospital reorganization, clinical and learning activities performed by residents suffered a forced remodulation. The objective of this study is to investigate how urology training in Italy has been affected during the COVID-19 era. In this multi-academic study, we compared residents' training during the highest outbreak level with their previous activity. Overall 387 (67.1%) of the 577 Italian Urology residents participated in a 72-h anonymous online survey with 36 items sent via email. The main outcomes were clinical/surgical activities, social distancing, distance learning, and telemedicine. Clinical and learning activity was significantly reduced for the overall group, and after categorizing residents as those working only in COVID hospitals, both "junior" and "senior" residents, and those working in any of three geographical areas created (Italian regions were clustered in three major zones according to the prevalence of COVID-19). A significant decrease in outpatient activity, invasive diagnostic procedures, and endoscopic and major surgeries was reported. Through multivariate analysis, the specific year of residency has been found to be an independent predictor for all response modification. Being in zone 3 and zone 2 and having "senior" resident status were independent predictors associated with a lower reduction of the clinical and learning activity. Working in a COVID hospital and having "senior" resident status were independent predictors associated with higher reduction of the outpatient activity. Working in zone 3 and having "senior" resident status were independent predictors of lower and higher outpatient surgical activity, respectively. Working in a COVID hospital was an independent predictor associated with robotic surgical activity. The majority of residents reported that distance teaching and multidisciplinary virtual meetings are still not used, and 44.8% reported that their relationships with colleagues decreased. The COVID-19 pandemic presents an unprecedented challenge, including changes in the training and education of urology residents. The COVID era can offer an opportunity to balance and implement innovative solutions that can bridge the educational gap and can be part of future urology training., (Copyright © 2020 Busetto, Del Giudice, Mari, Sperduti, Longo, Antonelli, Cerruto, Costantini, Carini, Minervini, Rocco, Artibani, Porreca, Porpiglia, Damiano, De Sio, Arcaniolo, Cimino, Russo, Lucarelli, Di Tonno, Gontero, Soria, Trombetta, Liguori, Scarpa, Papalia, Terrone, Borghesi, Verze, Madonia, De Lisa, Bove, Guazzoni, Lughezzani, Racioppi, Di Gianfrancesco, Brunocilla, Schiavina, Simeone, Veccia, Montorsi, Briganti, Dal Moro, Pavone, Serretta, Di Stasi, Galosi, Schips, Marchioni, Montanari, Carrieri, Cormio, Greco, Musi, Maggi, Conti, Tubaro, De Berardinis, Sciarra, Gallucci, Mirone, de Cobelli and Ferro.)

Purpose: To test the effect of tumor location (urachal vs. non-urachal) on cancer-specific mortality (CSM) in patients with adenocarcinoma of the urinary bladder (ADKUB)., Materials and Methods: Within the Surveillance, Epidemiology, and End Results registry (2004-2016), we identified patients with non-metastatic (≤ T4N0M0) ADKUB. Stratification was made according to tumor location: urachal vs. non-urachal ADKUB. Kaplan-Meier plots and multivariable Cox regression models were fitted before and after 1:3 propensity score (PS) matching and separate Cox regression models were refitted before and after inverse probability of treatment weighting (IPTW)., Results: Of 1681 patients, 226 (13.5%) vs. 1455 (86.5%) harboured urachal vs. non-urachal ADKUB, respectively. Five-year cancer-specific survival (CSS) rates were, respectively, 75 vs. 67% for urachal vs. non-urachal ADKUB (p = 0.001). In subgroup analyses of ≤ T2N0M0 patients, 5-year CSS rates were, respectively, 84 vs. 73% for urachal vs. non-urachal ADKUB (p = 0.006). In subgroup analyses of T3-4N0M0 patients, 5-year CSS rates were, respectively, 68 vs. 49% for urachal vs. non-urachal ADKUB (p < 0.001). In multivariable Cox regression models, urachal ADKUB was associated with lower CSM rates (HR 0.6; p = 0.01). Virtually, the same findings were recorded after 1:3 PS matching (HR 0.6; p = 0.009) as well as when Cox regression models were refitted after IPTW (HR 0.7; p = 0.01)., Conclusion: The distinction between urachal vs. non-urachal ADKUB indicates better prognosis when the origin of the tumor is urachal, regardless of methodological approach used for the comparison.

Objective: To evaluate the clinical and pathological implications of Prostate Cancer (PCa) patients with a Prostate Imaging - Reporting and Data System (PI-RADS) 3 lesion at multi parametric magnetic resonance imaging (mpMRI)., Methods: We included 356 patients with a PI-RADS score 3 lesion at mpMRI who underwent prostate biopsy for a suspect of PCa at a single tertiary high-volume centre between 2013 and 2016.We developed Uni- (UVA) and multi variable (MVA) logistic regression analyses assessing the predictors of three endpoints: 1) diagnosis of PCa, 2) active surveillance (AS) criteria and 3) clinically significant (CS) PCa at final pathology., Results: PCa was diagnosed in 285 patients (80%), out of these 154 (56%) were eligible for AS according to Prostate Cancer Research International Active Surveillance (PRIAS) criteria. Over the 228 (64%) patients who underwent surgery, 93 (40.8%) had a CS disease at final pathology. Hundred and ninety-three (84.6%) had a pT2 disease and 35 (15.4%) had a pT3 disease. The size of the main lesion, age, PSA and prostate volume efficiently predicted PCa at MVA (all p  < 0.05). None of our predictors were significantly associated with AS characteristics. Over those patients who underwent surgery, the biopsy Gleason Score ( p  = 0.007) efficiently predicted a CS PCa at final pathology., Conclusions: mpMRI-detected PI-RADS 3 lesions should be sent to a prostate biopsy if other clinical parameters suggest the presence of a PCa. In case of diagnosis of a PCa, patients should undergo confirmatory biopsy before being included in AS protocols to avoid underestimation of a CS disease.

Objectives: To test the effect of systemic chemotherapy on cancer-specific mortality (CSM) in patients with adenocarcinoma of the urinary bladder (ADKUB)., Materials and Methods: Within the Surveillance, Epidemiology, and End Results registry (2004 to 2016), we identified patients with localized (T2-3N0M0), regional (T4N0M0/TanyN1-3M0), and metastatic (TanyNanyM1) ADKUB. Temporal trends, Kaplan-Meier plots, and multivariable Cox regression models were used before and after 1:1 propensity score matching and inverse probability of treatment weighting., Results: Of 1537 patients with ADKUB, 834 (54.0%), 363 (23.5%), and 340 (22.5%) harbored localized, regional, and metastatic disease, respectively. The rates of chemotherapy use increased in localized (estimated annual percentage change [EAPC]: +2.7%; P=0.03) and regional ADKUB (EAPC: +2.4%; P=0.04). Conversely, chemotherapy rates remained stable in metastatic patients (EAPC: +1.6%; P=0.4). In multivariable Cox regression models, chemotherapy use was associated with lower CSM in metastatic ADKUB (hazard ratio [HR]: 0.5; P=0.003), but not in either localized (HR: 0.8; P=0.2) or in regional ADKUB (HR: 1.0; P=0.9). In metastatic ADKUB, the benefit of chemotherapy on CSM persisted after 1:1 propensity score matching (HR: 0.6; P=0.002) and after inverse probability of treatment weighting (HR: 0.4; P<0.001)., Conclusions: Chemotherapy improves survival in metastatic ADKUB. However, only one out of 2 such patients benefit from chemotherapy. In consequence, greater emphasis on chemotherapy use may be warranted in these patients. Conversely, no benefit was identified in localized or regional ADKUB.

Background: The objective of this study was to test the effect of chemotherapy and/or radical cystectomy (RC) and/or radiotherapy (RT) on survival of patients with non-metastatic small-cell carcinoma of the urinary bladder (SCCUB)., Materials and Methods: Within the Surveillance, Epidemiology, and End Results registry (2001-2016), we identified patients with non-metastatic (T1-4, N0, M0) SCCUB. Treatment was defined as: chemotherapy alone, chemotherapy + RC, and chemotherapy + RT. Temporal trends, cumulative incidence plots, and multivariable competing risks regression models were used., Results: Of 595 patients with SCCUB, 230 (38.5%), 159 (27%), and 206 (34.5%) were treated with chemotherapy alone, chemotherapy + RC, and chemotherapy + RT, respectively. The rates of chemotherapy + RC increased (estimated annual percentage changes [EAPC], +5.9%; P = .002). Conversely, chemotherapy alone (EAPC, -1.7%; P = .1) and chemotherapy + RT rates decreased (EAPC: -2.2%; P = .08). Overall, 5-year cancer-specific mortality (CSM) rates were 44%, 29%, and 40% for patients treated with chemotherapy alone, chemotherapy + RC, and chemotherapy + RT, respectively (P = .004). Relative to chemotherapy alone, patients treated with chemotherapy + RC experienced lower CSM (hazard ratio, 0.5; P < .001). Conversely, patients treated with chemotherapy + RT did not exhibit any CSM benefit (hazard ratio, 0.8; P = .2), when compared with chemotherapy alone., Conclusion: In contemporary patients with SCCUB with non-metastatic disease, the rates of chemotherapy + RC are increasing. Conversely, the rates of combined chemotherapy with RT and chemotherapy alone are decreasing. These patterns of treatment are in agreement with better cancer control in patients with SCCUB. In consequence, until more robust data become available, the combination of chemotherapy and RC should represent the recommended treatment strategy., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We aimed to assess the incidence of prosthesis-related complications in patients who received a testicular prosthesis at the time of radical orchiectomy for testicular cancer and were then treated with chemotherapy (ChT) or radiotherapy (RT). We reviewed the records of the patients who underwent radical orchiectomy at our Institute since 1999; we also retrieved data from patients who underwent surgery elsewhere and then received ChT or RT at our Institution since 1999. We used the chi-square test to evaluate differences in the incidence of prosthesis-related complications between the groups. We retrieved the records of 587 patients; 393 had a testicular prosthesis implanted. Median follow-up was 57.7 months. One hundred thirty-eight patients (35.11%) received ChT, 129 RT (38.82%) and 10 (2.55%) both ChT and RT; of them, 6 (4.34%), 8 (6.20%) and 0 reported problems respectively. Seven (6.03%) of the 116 patients (29.52%) who had no further treatment had complications. The incidence of complications was not significantly different between patients who had no further treatment versus patients who underwent ChT (p = .75) or RT (p = .83). Testicular prosthesis insertion at the time of radical orchiectomy is safe even in patients subsequently undergoing ChT or RT., (© 2020 Blackwell Verlag GmbH.)

Objectives: To develop a novel nomogram to identify candidates for active surveillance (AS) that combines clinical, biopsy and multiparametric magnetic resonance imaging (mpMRI) findings; and to compare its predictive accuracy to, respectively: (i) Prostate Cancer Research International: Active Surveillance (PRIAS) criteria, (ii) Johns Hopkins (JH) criteria, (iii) European Association of Urology (EAU) low-risk classification, and (iv) EAU low-risk or low-volume with International Society of Urological Pathology (ISUP) Grade Group (GG) 2 classification., Patients and Methods: We selected 1837 patients with ISUP GG1 or GG2 prostate cancer (PCa), treated with radical prostatectomy (RP) between 2012 and 2018. The outcome of interest was the presence of unfavourable disease (i.e., clinically significant PCa [csPCa]) at RP, defined as: ISUP GG ≥ 3 and/or pathological T stage (pT) ≥3a and/or pathological N stage (pN) 1. First, logistic regression models including PRIAS, JH, EAU low-risk, and EAU low-risk or low-volume ISUP GG2 binary classifications (not eligible vs eligible) were used. Second, a multivariable logistic regression model including age, prostate-specific antigen density (PSA-D), ISUP GG, and the percentage of positive cores (Model 1) was fitted. Third, Prostate Imaging-Reporting and Data System (PI-RADS) score (Model 2), extracapsular extension (ECE) score (Model 3) and PI-RADS + ECE score (Model 4) were added to Model 1. Only variables associated with higher csPCa rates in Model 4 were retained in the final simplified Model 5. The area under the receiver operating characteristic curve (AUC), calibration plots and decision curve analyses were used., Results: Of the 1837 patients, 775 (42.2%) had csPCa at RP. Overall, 837 (47.5%), 986 (53.7%), 348 (18.9%), and 209 (11.4%) patients were eligible for AS according to, respectively, the EAU low-risk, EAU low-risk or low-volume ISUP GG2, PRIAS, and JH criteria. The proportion of csPCa amongst the EAU low-risk, EAU low-risk or low-volume ISUP GG2, PRIAS and JH candidates was, respectively 28.5%, 29.3%, 25.6% and 17.2%. Model 4 and Model 5 (in which only PSA-D, ISUP GG, PI-RADS and ECE score were retained) had a greater AUC (0.84), compared to the four proposed AS criteria (all P < 0.001). The adoption of a 25% nomogram threshold increased the proportion of AS-eligible patients from 18.9% (PRIAS) and 11.4% (JH) to 44.4%. Moreover, the same 25% nomogram threshold resulted in significantly lower estimated risks of csPCa (11.3%), compared to PRIAS (Δ: -14.3%), JH (Δ: -5.9%), EAU low-risk (Δ: -17.2%), and EAU low-risk or low-volume ISUP GG2 classifications (Δ: -18.0%)., Conclusion: The novel nomogram combining clinical, biopsy and mpMRI findings was able to increase by ~25% and 35% the absolute frequency of patients suitable for AS, compared to, respectively, the PRIAS or JH criteria. Moreover, this nomogram significantly reduced the estimated frequency of csPCa that would be recommended for AS compared to, respectively, the PRIAS, JH, EAU low-risk, and EAU low-risk or low-volume ISUP GG2 classifications., (© 2020 The Authors BJU International © 2020 BJU International Published by John Wiley & Sons Ltd.)

The recent exponential increase in the number of COVID-19 patients in Italy led to the adoption of specific extraordinary measures, such as the need to convey treatment of all non-deferrable cancer patients to specialized centres (hubs). We reported a comprehensive summary of guidelines to create and run an oncologic hub during the COVID-19 pandemic. Oncologic hubs must fulfil some specific requirements such as a high experience in oncologic patient treatment, strict strategies applied to remain a "COVID-19-free" centre, and the creation of a dedicated multidisciplinary "hub team". Cancer treatment of patients who belong to external centres, namely spoke centres, could be organized in different pathways according to the grade of involvement and/or availability of the medical team of the spoke centre. Moreover, dedicated areas should be created for the management and treatment of patients who developed COVID-19 symptoms after hospitalization (i.e., dedicated wards, operation rooms and intensive care beds). Lastly, hospital staff must be highly trained for both preventing COVID-19 contagion and treating patients who develop the infection. We provided a simplified, but complete and easily applicable guide. We believe that this guide could help those clinicians who have to treat oncologic patients during the COVID-19 pandemic.

Objective: To test the association between metabolic syndrome (MetS) and its components (high blood pressure, body mass index [BMI]  ≥ 30, altered fasting glucose, low high-density lipoprotein cholesterol and high triglycerides) on perioperative outcomes after partial nephrectomy (PN)., Methods: Within the National Inpatient Sample database (2000-2015) we identified all PN patients. First, temporal trends of MetS were reported. Second, the effect of MetS components was tested in multivariable logistic regression models predicting overall and specific perioperative complications. Third, we tested for dose-response from the concomitant effect of multiple MetS components. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics., Results: Of 25,875 patients: (1) 59.3% had high blood pressure, (2) 14.7% had BMI  ≥ 30, (3) 21.7% had altered fasting glucose, (4) 20.2% had high triglycerides, and (5) <0.01% had low high-density lipoprotein cholesterol. One vs 2 vs 3 vs 4 MetS components were recorded in 34.9% vs 22.9% vs 8.9% vs 2.2% patients. Of all, 11.1% exhibited  ≥ 3 components and qualified for MetS. The rates of MetS increased over time (estimated annual percentage changes: +12.0%;P <.001). The 4 tested MetS components (high blood pressure, BMI  ≥ 30, altered fasting glucose, and high triglycerides) achieved independent predictor status in multivariable models predicting overall, cardiac, miscellaneous medical, vascular, and respiratory complications, as well as transfusions. Moreover, a statistically significant dose-response was confirmed for the same endpoints., Conclusion: MetS and its components consistently and strongly predict perioperative complications after PN. Moreover, the strength of the effect was directly proportional to the number of MetS components exhibited by each individual patient, even if formal MetS diagnosis of  ≥ 3 components has not been met., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Bleomycin, etoposide, and cisplatin (BEP) is the most common and successful chemotherapy regimen for germ-cell tumor (GCT) patients, accompanied by a bleomycin-induced dose-dependent lung toxicity in certain patients. In an attempt to reduce bleomycin-toxicity, we developed a modified-BEP (mBEP) regimen., Materials and Methods: Between August 2008 and February 2018, 182 unselected mainly testicular GCT patients (39 with adjuvant purpose and 143 with curative purpose) received a tri-weekly 5-day hospitalization schedule with bleomycin 15 U intravenous (IV) push on day 1 and 10 U IV continuous infusion over 12 hours on days 1 to 3, cisplatin 20 mg/m IV, and etoposide 100 mg/m IV on days 1 to 5. Pulmonary toxicity was assessed through chest computed tomography scan and clinical monitoring., Results: Median number of mBEP cycles was 3 (range: 1 to 4). In the curative setting, according to the International Germ Cell Cancer Collaborative Group (IGCCCG) prognostic system, 112, 21, and 9 patients had good-risk, intermediate-risk, and poor-risk class, respectively; 66 (46%) patients had complete response (CR), 67 (47%) had partial response (52 of whom became CR afterwards), 6 (4%) had stable disease (that in 3 became CR afterwards), 3 (2%) progressed, and 1 (1%) died of brain stroke. At a median follow-up of 2.67 years (interquartile range: 1.23-5.00 y), 1 and 5-year overall survival and progression-free survival were 99% and 95%, and 90% and 88%, respectively. In the entire patient population, there was grade 3/4 neutropenia in 92 patients (51%), febrile neutropenia in 11 patients (6%), grade 1/2 nausea in 74 patients (41%), and no death due to pulmonary toxicity., Conclusion: In GCT patients, our mBEP-schedule would suggest an effective treatment modality without suffering meaningful pulmonary toxicity.

Background: The use of organ sparing strategies to treat penile cancer (PC) is currently supported by evidence that has indicated the safety, efficacy and benefit of this surgery. However, radical penectomy still represents up to 15-20% of primary tumor treatments in PC patients. The aim of the study was to evaluate efficacy in terms of overall survival (OS) and disease-free survival (DFS) of radical penectomy in PC patients., Methods: Data from a retrospective multicenter study (PEnile Cancer ADherence study, PECAD Study) on PC patients treated at 13 European and American urological centers (Hospital "Sant'Andrea", Sapienza University, Roma, Italy; "G.D'Annunzio" University, Chieti and ASL 2 Abruzzo, Hospital "S. Pio da Pietrelcina", Vasto, Italy; Department of Genitourinary Oncology, Moffitt Cancer Center, Tampa, FL, USA; Hospital of Budapest, Hungary; Department of Emergency and Organ Transplantation, Urology and Andrology Unit II, University of Bari, Italy; Hospital "Spedali Civili", Brescia, Italy; Istituto Europeo di Oncologia, University of Milan, Milan, Italy; University of Modena & Reggio Emilia, Modena, Italy; Hospital Universitario La Paz, Madrid, Spain; Ceara Cancer Institute, Fortaleza, Brazil; Virginia Commonwealth University, Richmond, VA, USA; Aristotle University of Thessaloniki, Thessaloniki, Greece; Maria Skłodowska-Curie Memorial Cancer Center, Warsaw, Poland) between 2010 and 2016 were used. Medical records of patients who specifically underwent radical penectomy were reviewed to identify main clinical and pathological variables. Kaplan-Meier method was used to estimate 1- and 5-year OS and DFS., Results: Of the entire cohort of 425 patients, 72 patients (16.9%) treated with radical penectomy were extracted and were considered for the analysis. The median age was 64.5 (IQR, 57.5-73.2) years. Of all, 41 (56.9%) patients had pT3/pT4 and 31 (43.1%) pT1/pT2. Moreover, 36 (50.0%) were classified as pN1-3 and 5 (6.9%) M1. Furthermore, 61 (84.7%) had a high grade (G2-G3) with 6 (8.3%) positive surgical margins. The 1- and 5-year OS rates were respectively 73.3% and 59.9%, while the 1- and 5-year DFS rates were respectively 67.3% and 35.1%., Conclusions: PC is an aggressive cancer particularly in more advanced stage. Overall, more than a third of patients do not survive at 5 years and more than 60% report a disease recurrence, despite the use of a radical treatment., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/tau.2020.04.04). The authors have no conflicts of interest to declare., (2020 Translational Andrology and Urology. All rights reserved.)

Image-guided thermal ablations are increasingly applied in the treatment of renal cancers, under the guidance of ultrasound (US) or computed tomography (CT). Sometimes, multiple ablations are needed. The aim of the present study was to evaluate the long-term results in patients with renal mass treated with radiofrequency ablation (RFA) with both US and CT, with a focus on the multiple ablations rate. 149 patients (median age 67 years) underwent RFA from January 2008 to June 2015. Median tumor diameter was 25 mm (IQR 17-32 mm). Median follow-up was 54 months (IQR 44-68). 27 (18.1%) patients received multiple successful ablations, due to incomplete ablation (10 patients), local tumor progression (8 patients), distant tumor progression (4 patients) or multiple tumor foci (5 patients), with a primary and secondary technical efficacy of 100%. Complications occurred in 13 (8.7%) patients (6 grade A, 5 grade C, 2 grade D). 24 patients died during follow-up, all for causes unrelated to renal cancer. In conclusion, thermal ablations with the guidance of US and CT are safe and effective in the treatment of renal tumors in the long-term period, with a low rate of patients requiring multiple treatments over the course of their disease.

Background: To test contemporary rates and predictors of open conversion at minimally invasive (laparoscopic or robotic) radical prostatectomy (MIRP). Materials and Methods: Within the National Inpatient Sample database (2008-2015), we identified all MIRP patients and patients who underwent open conversion at MIRP. First, estimated annual percentage changes (EAPCs) tested temporal trends of open conversion. Second, multivariable logistic regression models predicted open conversion at MIRP. All models were weighted and adjusted for clustering, as well as all available patient and hospital characteristics. Results: Of 57,078 MIRP patients, 368 (0.6%) underwent open conversion. The rates of open conversion decreased over time (from 1.80% to 0.38%; EAPC: -26.0%; p  = 0.003). In multivariable logistic regression models predicting open conversion, patient obesity (odds ratio [OR]: 2.10; p  < 0.001), frailty (OR: 1.45; p  = 0.005), and Charlson comorbidity index (CCI) ≥2 (OR: 1.57; p  = 0.03) achieved independent predictor status. Moreover, compared with high-volume hospitals, medium-volume (OR: 2.03; p  < 0.001) and low-volume hospitals (OR: 3.86; p  < 0.001) were associated with higher rates of open conversion. Last but not least, when the interaction between the number of patient risk factors (obesity and/or frailty and/or CCI ≥2) and hospital volume was tested, a dose-response effect was observed. Specifically, the rates of open conversion ranged from 0.3% (patients with zero risk factors treated at high-volume hospitals) to 2.2% (patients with two to three risk factors treated at low-volume hospitals). Conclusion: Overall contemporary (2008-2015) rate of open conversion at MIRP was 0.6% and it was strongly associated with patient obesity, frailty, CCI ≥2, and hospital surgical volume. In consequence, these parameters should be taken into account during preoperative patients counseling, as well as in clinical and administrative decision making.

Objectives: The aim of this multicenter study was to investigate the prognostic role of type 2 diabetes mellitus (T2DM) comorbidity in a large multi-institutional cohort of patients with primary T1HG/G3 non-muscle-invasive bladder cancer (NMIBC) treated with transurethral resection of the bladder (TURB)., Materials and Methods: A total of 1,172 patients with primary T1 HG/G3 who had NMIBC on re-TURB and who received adjuvant intravesical bacillus Calmette-Guérin therapy with maintenance were included. Endpoints were recurrence-free survival and progression-free survival., Results: A total of 231 (19.7%) of patients had T2DM prior to TURB. Five-year recurrence-free survival estimates were 12.5% in patients with T2DM compared to 36% in patients without T2DM, P < 0.0001. Five-year PFS estimates were 60.5% in patients with T2DM compared to 70.2% in patients without T2DM, P = 0.003. T2DM was independently associated with disease recurrence (hazard ratio = 1.41; 95% confidence interval = 1.20-1.66, P < 0.001) and progression (hazard ratio = 1.27; 95% confidence interval = 0.99-1.63, P < 0.001), after adjusting for other known predictive factors such as tumor size, multifocality, T1G3 on re-TURB, body mass index, lymphovascular invasion, and neutrophil-to-lymphocytes ratio., Conclusions: Given the potential implications for management, prospective validation of this finding along with translational studies designed to investigate the underlying biology of such an association are warranted., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To test the effect of stage and grade migration on cancer specific mortality (CSM) in renal cell carcinoma (RCC) patients, according to clear cell (ccRCC) vs. non-ccRCC histology., Methods and Materials: Within the Surveillance, Epidemiology, and End Results registry (2004-2015), we identified patients with ccRCC and non-ccRCC (papillary [papRCC], chromophobe [chRCC], sarcomatoid [sarcRCC], and collecting duct [cdRCC]). Two consecutive time groups were considered - historical (2004-2009) and contemporary era (2010-2015). Temporal trends of tumor characteristics were evaluated. Cumulative incidence plots and multivariable competing risks regression models tested the effect of year groups on CSM., Results: Overall, 24,746 and 73,228 patients with non-ccRCC and ccRCC were evaluated. Of those, 42% and 58% were recorded in historical and contemporary era. Time trend analyses showed (1) tumor size decreased for non-ccRCC (estimated annual percent changes [EAPC]: -1.1%; P <0.01) and for ccRCC (EAPC: -1.0%; P <0.01), (2) rates of G3/G4 decreased for non-ccRCC (EAPC: -0.7%; P = 0.03), but increased for ccRCC (EAPC: +1.1; P <0.01), 3) rates of node positive disease decreased for non-ccRCC (EAPC:-3.1%; P = 0.02), but were stable for ccRCC (EAPC: +0.4; P =0.5), (4) rates of metastatic disease at diagnosis decreased for non-ccRCC (EAPC: -3.2%; P <0.01), but were stable for ccRCC (EAPC: -0.6%; P = 0.1), (5) among non-ccRCC, the percentage of papRCC increased (EAPC:+1%; P <0.01), while the percentage of sarcRCC (EAPC: -7%; P <0.01) and cdRCC (EAPC: -11.2%; P <0.01) decreased. Finally, in multivariable CRR models, lower CSM was recorded for contemporary non-ccRCC (HR: 0.7; P <0.001) and ccRCC (HR: 0.8; P <0.001) patients., Conclusion: Our findings illustrate a favorable stage and grade migration and improved cancer-specific mortality in contemporary non-ccRCC. Additionally, despite absence of meaningful stage migration in ccRCC, improved cancer-specific mortality in contemporary patients was also recorded. In consequence, a 2-tiered process appears to be operational in non-ccRCC vs. a 1-tiered phenomenon in ccRCC., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: To analyze contemporary multimodality treatment rates, defined as radical cystectomy plus chemotherapy and/or radiotherapy, for pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients. Additionally, we tested for the effect of multimodality treatment versus radical cystectomy alone on cancer-specific mortality., Methods: Within the Surveillance, Epidemiology and End Results database (2004-2015), 887 pT2-3 any N-stage M0 non-urothelial carcinoma of urinary bladder patients treated with radical cystectomy were identified. Kaplan-Meier plots, and univariable and multivariable Cox regression analyses focused on cancer-specific mortality rates., Results: Squamous cell carcinoma was recorded in 499 (56.3%) patients, neuroendocrine carcinoma in 246 (27.7%) and adenocarcinoma in 142 (16.0%). The highest proportion of multimodality treatment patients was recorded in neuroendocrine carcinoma (69.1%), relative to adenocarcinoma (34.5%) and squamous cell carcinoma (26.4%). A statistically significant annual increase was recorded in multimodality treatment rates in neuroendocrine carcinoma patients (46.7-74.2%, P < 0.01), but not in adenocarcinoma or squamous cell carcinoma patients. The 5-year cancer-specific mortality rate in neuroendocrine carcinoma patients was significantly lower after multimodality treatment versus radical cystectomy alone (37.0% vs 51.5%; P < 0.01), but no statistically significant differences were recorded in both adenocarcinoma (46.1% vs 35.5%; P = 0.8) and squamous cell carcinoma (41.4% vs 31.1%; P = 0.8) patients. In multivariable analyses, for neuroendocrine carcinoma patients, multimodality treatment was an independent predictor of a lower cancer-specific mortality rate (hazard ratio 0.58, P = 0.03)., Conclusions: Multimodality treatment has been increasingly used during the study period in neuroendocrine carcinoma patients, and it has translated into a cancer-specific mortality benefit. This is not the case for other non-urothelial carcinoma of urinary bladder patients, such as adenocarcinoma or squamous cell carcinoma., (© 2020 The Japanese Urological Association.)

Background: The present study tested cancer-specific (CSM) and overall mortality (OM) after partial cystectomy (PC) for variant histology bladder cancer (non-urothelial carcinoma of the urinary bladder UCUB), relative to UCUB and relative to radical cystectomy (RC)., Materials and Methods: Within the Surveillance, Epidemiology, and End Results registry (2001-2016), we identified patients with stage T1-T2N0M0 non-UCUB and UCUB who had undergone PC or RC. Non-UCUB included adenocarcinoma, squamous carcinoma, neuroendocrine carcinoma, and other histologic subtypes. First, CSM and OM after PC were compared between the non-UCUB and UCUB groups. Second, CSM and OM after PC were compared with RC in the non-UCUB group. Kaplan Meier plots and multivariable Cox regression models were used before and after inverse probability of treatment weighting., Results: Overall, 248 patients (16.3%) treated with PC had had non-UCUB. Of the 248 cases, 115 (46.5%), 50 (20%), 34 (14%), and 49 (19.5%) were adenocarcinoma, squamous carcinoma, neuroendocrine carcinoma, and other histologic subtypes, respectively. The comparison between PC in the non-UCUB and PC in the UCUB group showed higher CSM (hazard ratio, 1.4; P = .03) but the same OM rates (hazard ratio, 1.1; P = .7) in the non-UCUB group. The comparison between PC and RC for the non-UCUB group showed no CSM or OM differences., Conclusions: PC for non-UCUB was associated with higher CSM compared with PC for UCUB. However, PC instead of RC for select patients with non-UCUB appears not to undermine cancer-control outcomes. Thus, the excess CSM is probably unrelated to cystectomy type but could originate from differences in the tumor biology. These results could act as hypothesis generating for the design of future trials., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: The impact of resection technique on partial nephrectomy outcomes is controversial. The aim of this study was to evaluate the pattern of resection techniques during partial nephrectomy and the impact on perioperative outcomes, acute kidney injury, positive surgical margins and the achievement of the Trifecta (negative surgical margins, no perioperative Clavien-Dindo grade 2 or greater surgical complications and no postoperative acute kidney injury)., Materials and Methods: We prospectively collected data on consecutive patients with cT1-2N0M0 renal masses treated with partial nephrectomy at a total of 16 referral centers from September 2014 to March 2015. After partial nephrectomy the resection technique was classified by the surgeon as enucleation, enucleoresection or resection according to the SIB (Surface-Intermediate-Base) margin scores 0 to 2, 3 or 4 and 5, respectively. Multivariable logistic regression analysis was done to evaluate the potential impact of the resection technique on postoperative surgical complications, positive surgical margins, acute kidney injury and Trifecta achievement., Results: Overall 507 patients were included in analysis. The resection technique was classified as enucleation in 266 patients (52%), enucleoresection in 150 (30%) and resection in 91 (18%). The resection technique (enucleoresection vs enucleation and resection) was the only significant predictor of positive surgical margins. Tumor complexity, surgical approach (open and laparoscopic vs robotic) and resection technique (enucleoresection vs enucleation) were significant predictors of Clavien-Dindo grade 2 or greater surgical complications. The surgical approach (open and laparoscopic vs robotic), the resection technique (enucleoresection vs enucleation) and warm ischemia time were significantly associated with postoperative acute kidney injury and Trifecta achievement., Conclusions: Resection techniques significantly impact surgical complications, early functional outcomes and positive surgical margins after partial nephrectomy of localized renal masses.

Purpose: To test the conditional survival that examined the effect of event-free survival on cancer-specific mortality after primary tumour excision (PTE) in patients with squamous cell carcinoma of the penis (SCCP)., Materials and Methods: Within the SEER database (1998-2015), 2282 stage I-III SCCP patients were identified. Conditional survival estimates were used to calculate cancer-specific mortality (CSM) after event-free survival intervals of 1, 2, 3, and 5 years. Multivariable Cox regression models predicted CSM according to event-free survival., Results: After PTE, 5-year CSM-free rate was 78.0% and increased to 84.6%, 88.1%, 92.0%, and 94.2% in patients who survived ≥ 1, ≥ 2, ≥ 3, and ≥ 5 years. After stratification according to tumour characteristics, 5-year CSM-free rates increased from 85.9 to 95.4%, 79.0 to 97.1%, 78.9 to 90.0%, and from 54.5 to 86.0% in those survived ≥ 5 years, respectively, in T1N0, T2N0, T3N0, and N1-2 patients. In multivariable analyses, T2N0 [hazard ratio (HR) 1.68; p value < 0.001], T3N0 (HR 1.94; p value 0.001), and N1-2 (HR 6.61; p value < 0.001) were independent predictors of higher CSM rate at baseline, relative to T1N0. A decrease in all HRs was assessed over time in patients who survived. Attrition due to CSM was highest in N1-2 cohort and lowest in T1N0., Conclusions: Conditional survival models showed a direct relationship between event-free survival duration and subsequent CSM in SCCP patients. Even patients with non-organ-confined disease may achieve survival probabilities similar to those with organ-confined disease after at least 5 years of event-free survival since PTE.

Purpose: To test the association between African-American race and overall mortality (OM) rates in patients with metastatic renal cell carcinoma (mRCC)., Methods: Within the Surveillance, Epidemiology, and End Results registry (2006-2015), we identified patients with clear cell (ccmRCC) and non-clear cell mRCC (non-ccmRCC). African-Americans, Caucasians, and Hispanics were identified. Stratification was made according to histology and treatments: (1) no treatment, (2) systemic therapy (ST), (3) cytoreductive nephrectomy (CNT), (4) CNT + ST. Kaplan-Meier plots and multivariable Cox regression analyses were used., Results: Of ccmRCC patients, 410 (7%), 4353 (75%), and 1005 (17%) were African-American, Caucasian, and Hispanic, respectively. Of non-ccmRCC patients, 183 (25%), 479 (65%), and 77 (10%) were African-American, Caucasian, and Hispanic, respectively. In ccmRCC, African-Americans were associated with higher OM rates (HR 1.20; 95% CI 1.05-1.37). Conversely, in non-ccmRCC, African-Americans were associated with lower OM rates (HR 0.75; 95% CI 0.59-0.97)., Conclusion: African-American race is associated with prolonged survival in non-ccmRCC, but it is also associated with lower survival rates in ccmRCC. The exception to these observations consisted of patients treated with combination of CNT + ST for either ccmRCC or non-ccmRCC.

Background: To understand the value of multiparametric magnetic resonance imaging (mpMRI) and targeted biopsies at recruitment on active surveillance (AS) outcomes., Materials and Methods: This retrospective single-center study enrolled two cohorts of 206 and 310 patients in AS. The latter group was submitted to mpMRI and targeted biopsies at recruitment. Kaplan-meier curves quantified progression-free survival (PFS) and Bioptic-PFS (B-PFS: no upgrading or >3 positive cores) in the two cohorts. Cox-regression analyses tested independent predictors of PFS and B-PFS. In patients submitted to radical prostatectomy (RP) after AS, significant cancer (csPCa) was defined as: GS ≥ 4 + 3 and/or pT ≥ 3a and/or pN+ . Logistic-regression analyses predicted csPCa at RP., Results and Limitations: Median time follow-up and median time of persistence in AS were 46 (24-70) and 36 (23-58) months, respectively. Patients submitted to mpMRI at AS begin, showed greater PFS at 1- (98% vs. 91%), 3- (80% vs. 57%), and 5-years (70% vs. 35%) follow-up, respectively (all p < 0.01). At Cox-regression analysis only confirmatory mpMRI± targeted biopsy (HR: 0.3; 95% CI 0.2-0.5; p < 0.01) at AS begin was an independent predictor of PFS. Globally, 50 (16%) vs. 128 (62%) and 26 (8.5%) vs. 64 (31%) [all p < 0.01] men in the two groups experienced any-cause and bioptic AS discontinuation, respectively. Patients submitted to confirmatory mpMRI experienced greater 1-(98% vs. 93%), 3-(90% vs. 75%), and 5-years (83% vs. 56%) B-PFS, respectively (all p < 0.01). At Cox-regression analysis, mpMRI±-targeted biopsy at AS begin was associated with B-PFS (HR: 0.3; 95% CI 0.2-0.6; p < 0.01). No differences were recorded in csPCa rates between the two groups (22% vs. 28%; p = 0.47). Limitations of the study are the single-center retrospective nature and the absence of long-term follow-up., Conclusions: Confirmatory mpMRI±-targeted biopsies are associated with higher PFS and B-PFS during AS. However, a non-negligible percentage of patients experience csPCa after switching to active treatment.

Background: Widespread use of prostate specific antigen (PSA) in screening procedures allowed early identification of an increasing number of prostate cancers (PCas), mainly including indolent cancer. Availability of different therapeutic strategies which have a very different impact on the patient's quality of life suggested a strong need for tools able to identify clinically significant cancer at diagnosis. Multi-parametric magnetic resonance showed very good performance in pre-biopsy diagnosis. However, it is an expensive tool and requires an experienced radiologist. In this context, a simple blood-based test is worth investigating. In this context, researchers focused their attention on the development of a laboratory test able to minimize overdiagnosis without losing the identification of aggressive tumors., Results: Recent literature data on PCa biomarkers revealed a clear tendency towards the use of panels of biomarkers or a combination of biomarkers and clinical variables. Phi, the 4Kscore, and Stockholm3 as circulating biomarkers and the Mi-prostate score, Exo DX Prostate, and Select MD-X as urinary biomarker-based tests have been developed. In this scenario, phi is worthy of attention as a noninvasive test significantly associated with aggressive PCa., Conclusions: Literature data showed that phi had good diagnostic performance to identify clinically significant (cs) PCa, suggesting that it could be a useful tool for personalized treatment decision-making. In this review, phi potentialities, limitations, and comparisons with other blood- and urinary-based tests were explored., Competing Interests: The authors declare no conflict of interest.

Background: The new severe acute respiratory syndrome virus (SARS-CoV-2) outbreak is a huge health, social and economic issue and has been declared a pandemic by the World Health Organization. Bladder cancer, on the contrary, is a well-known disease burdened by a high rate of affected patients and risk of recurrence, progression and death., Summary: The coronavirus disease (COVID-19 or 2019-nCoV) often involves mild clinical symptoms but in some cases, it can lead to pneumonia with acute respiratory distress syndrome and multiorgan dysfunction. Factors associated with developing a more severe disease are increased age, obesity, smoking and chronic underlying comorbidities (including diabetes mellitus). High-risk non-muscle-invasive bladder cancer (NMIBC) progression and worse prognosis are also characterized by a higher incidence in patients with risk factors similar to COVID-19. Immune system response and inflammation have been found as a common hallmark of both diseases. Most severe cases of COVID-19 and high-risk NMIBC patients at higher recurrence and progression risk are characterized by innate and adaptive immune activation followed by inflammation and cytokine/chemokine storm (interleukin [IL]-2, IL-6, IL-8). Alterations in neutrophils, lymphocytes and platelets accompany the systemic inflammatory response to cancer and infections. Neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio for example have been recognized as factors related to poor prognosis for many solid tumors, including bladder cancer, and their role has been found important even for the prognosis of SARS-CoV-2 infection. Key Messages: All these mechanisms should be further analyzed in order to find new therapeutic agents and new strategies to block infection and cancer progression. Further than commonly used therapies, controlling cytokine production and inflammatory response is a promising field., (© 2020 S. Karger AG, Basel.)

Background: Basophils, eosinophils and monocytes may be involved in BCG-induced immune responses and be associated with outcomes of bladder cancer patients receiving intravesical BCG. Our objective was to explore the association of baseline counts of basophils, eosinophils and monocytes with outcomes of patients with high-grade T1 bladder cancer receiving a standard course of intravesical BCG., Methods: We retrospectively reviewed medical records of patients with primary T1 HG/G3 bladder cancer. After re-TURBT, patients were treated with a 6-week course of intravesical BCG induction followed by intravesical BCG every week for 3 weeks given at 3, 6, 12, 18, 24, 30 and 36 months from initiation of therapy The analysis of potential risk factors for recurrence, muscle invasion and cancer-specific and overall survival was performed using univariable Cox regression models. Those factors that presented, at univariate analysis, an association with the event at a liberal p < 0.1, have been selected for the development of a multivariable model., Results: A total of 1045 patients with primary T1 HG/G3 were included. A total of 678 (64.9%) recurrences, 303 (29.0%) progressions and 150 (14.3%) deaths were observed during follow-up. Multivariate analysis showed that logarithmic transformation of basophils count was associated with a 30% increment in the hazard of recurrence per unit increase of logarithmic basophils count (HR 1.30; 95% confidence interval 1.09-1.54; p = 0.0026). Basophil count modeled by quartiles was also significantly associated with time to recurrence [second vs. lower quartile HR 1.42 (1.12-1.79); p = 0.003, third vs. lower quartile HR 1.26 (1.01-1.57); p = 0.041; upper vs. lower quartile HR 1.36 (1.1-1.68); p = 0.005]. The limitations of a retrospective study are applicable., Conclusion: Baseline basophil count may predict recurrence in BCG-treated HG/G3 T1 bladder cancer patients. External validation is warranted.

Penile shortening after inflatable penile prosthesis for erectile dysfunction is a common postoperative patient complaint and can reduce overall satisfaction with the procedure. In this prospective study we report our results regarding penile dimensions and patient satisfaction outcomes after 1 year of follow-up from AMS™LGX700® penile prosthesis implant with 6 months of vacuum erectile device therapy. Seventy-four selected patients with medically refractory erectile dysfunction underwent AMS™ LGX 700® IPP placement. Postoperatively, patients were assigned vacuum device therapy for 5 min twice daily. Follow-up continued for 1 year after surgery. Dimensional and functional results were assessed. Baseline median preoperative stretched penile length and girth were 14 cm (range 10-17) and 9 cm (range 7-12), respectively. At the end of the study penile median dimensional outcomes were 17 cm (range 13-23) for length and 11 cm (range 10-13) for girth while a median number of 24 pumps (range 18-29) to fully inflate the device was seen. Baseline median International Index of Erectile Function (IIEF-5) score was 9 (range 5-11), at 6 months 20 (range 18-26) and at 1 year was 25 (range 20-27) (p < 0.0001). Median Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) score at the end of the follow-up was 74 (range 66-78). Our postoperative rehabilitation program is feasible and should be recommended after prothesis surgery in order to increase overall satisfaction with the procedure. Penile postoperative dimensional outcomes were statistically significant improved and complications were negligible.

Purpose: To compare clinical outcomes and toxicities of 2 radiation therapy (RT) schemes for localized prostate cancer (PCa): extreme hypofractionation (EH; fractions of 6.5-7 Gy to a total dose of 32.5-35 Gy) and the moderate hypofractionation (MH; 26 fractions of 2.7 Gy to a total dose of 70.2 Gy). A propensity score method was used to compare the EH-RT and MH-RT groups., Methods and Materials: Our analysis included a total of 421 patients divided in 2 groups: 227 treated with MH-RT and 194 treated with EH-RT (43 and 30 months median follow-up, respectively). Propensity matching created comparable cohorts. Statistical evaluations were performed on the whole cohort, stratifying the analyses by risk strata factors identified with the propensity scores, and on a subgroup of patients matched by propensity score. Multivariate proportional hazard Cox models were used to compare the 2 groups, mainly for gastrointestinal and genitourinary toxicity and secondarily for clinical progression-free survival, biochemical progression-free survival, and overall survival., Results: Considering the whole population, acute genitourinary and gastrointestinal greater than grade 1 was significantly more frequent in the whole MH-RT group (P < .001 and P < .002, respectively). A borderline significantly greater late genitourinary was confirmed with the multivariate analysis (P = .07). Concerning tumor outcome, no statistically significant differences were observed. After propensity score matching, 226 patients were included in the analysis. The 2 obtained propensity score matched groups did not differ for any of the clinical and pathologic variables considered for the analysis, resulting in well-balanced cohorts. The results obtained on the whole population were confirmed in the matched groups., Conclusions: EH-RT yields a decreased risk of acute or late toxicities compared with MH-RT, and oncologic outcomes were comparable. Our data indicate that EH-RT might be considered as a treatment modality of choice for select patients with PCa., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Aims of this study were to assess sexual recovery after robotic-assisted radical prostatectomy (RARP) and to build a nomogram predicting 1-year sexual function. From May 2015 to July 2016, all patients eligible for RARP at our institution were invited to enter the study. The Expanded Prostate cancer Index Composite (EPIC) questionnaire was administered pre-operatively, then at 45 days, and at 3, 6, 9, and 12 months post-operatively. According to sexual function scores, patients were divided into four classes. Multivariate analysis was used to investigate the influence of patient- and disease-related features on sexual recovery. A total of 643 patients were included. Age was associated with baseline potency (p < .0001). Bioptic Gleason score (GS; p = .0002), American Society of Anesthesiologists (ASA) score ( = .002ASA Physical Status Classification System ) and Charlson Comorbidity Index (CCI; p = .02) were negatively associated with potency. Baseline sexual function was associated with potency recovery. A nomogram resulted from fitting a proportional odds logistic model for ordinal outcomes, with 1-year sexual function as a dependent variable and baseline sexual potency, age, body mass index (BMI), clinical stage, biopsy GS, initial prostate-specific antigen (iPSA), ASA score, and CCI as predictors. After further validation, this nomogram could be a useful tool for the pre-operative counselling., (© 2019 Blackwell Verlag GmbH.)

Objectives: To evaluate whether low PI-RADS v2 assessment categories are effective at excluding extraprostatic extension (EPE) of prostate cancer (≥pT3a PCa)., Methods: The local institutional ethics committee approved this retrospective analysis of 301 consecutive PCa patients. Patients were classified as low- or intermediate/high-risk based on clinical parameters and underwent pre-surgical multiparametric magnetic resonance imaging. A PI-RADS v2 assessment category and ESUR EPE score were assigned for each lesion by two readers working in consensus. Histopathologic analysis of the whole-mount radical prostatectomy specimen was the reference standard. Univariate and multivariate analyses were performed to evaluate the association of PI-RADS v2 assessment category with final histology ≥pT3a PCa., Results: For a PI-RADS v2 assessment category threshold of 3, the overall performance for ruling out (sensitivity, negative predictive value, negative likelihood ratio) ≥pT3a PCa was 99%/98%/0.04 and was similar in both the low-risk (96%/97%/0.12; N = 137) and the intermediate/high-risk groups (100%/100%/0.0; N = 164). In univariate analysis, all clinical and tumor characteristics except age were significantly associated with ≥pT3a PCa. In multivariate analysis, PI-RADS v2 assessment categories ≤ 3 had a protective effect relative to categories 4 and 5. The inclusion of ESUR EPE score improved the AUC of ≥pT3a PCa prediction (from 0.73 to 0.86, p = 0.04 in the overall cohort). The impact of PI-RADS v2 assessment category is reflected in a nomogram derived on the basis of our cohort., Conclusions: In our cohort, low PI-RADS v2 assessment categories of 3 or less confidently ruled out the presence of ≥pT3a PCa irrespective of clinical risk group., Key Points: • Our analysis of 301 mp-MRI and RARP specimens showed that the addition of PI-RADS v2 assessment categories to clinical parameters improves the exclusion of ≥pT3a (extraprostatic) prostate cancer. • PI-RADS v2 assessment categories of 1 to 3 are useful for excluding ≥pT3a prostate cancer with a NPV of 98%; such patients can be considered as candidates for less invasive approaches. • The ability to exclude ≥pT3a prostate cancer may improve confidence in choosing nerve-sparing surgery or in avoiding pelvic nodal dissections, and similarly for patients undergoing radiotherapy, in adopting short-course adjuvant hormonal therapy or foregoing prophylactic nodal irradiation.

Background: Prostate cancer (PCa) is the second most common cancer among men. New imaging-modalities have increased the diagnosed patients with limited number of metastasis after primary curative therapy, introducing so-called oligometastatic state. Stereotactic body radiotherapy (SBRT) is emerging as a low-toxicity treatment to erase PCa localizations and postpone androgen deprivation therapy (ADT). A deeper understanding of the predictive role of biomarkers is desirable for a targeted treatment selection and surveillance programs. The aims of the RADIOSA trial are: 1. Compare SBRT +/- ADT for oligorecurrent-castration-sensitive PCa (OCS-PCa) in terms of efficacy, toxicity and Quality of Life (QoL). 2. Develop biology/imaging based prognostic tool that allows identifying OCS-PCa subclasses., Methods: This is a randomized phase II clinical trial, recruiting 160 OCS-PCa in 3 years, with progression-free survival (PFS) as primary endpoint. Three tasks will be developed: 1. Randomized clinical study (3 years for accrual and 2 years for follow-up and data analysis); 2. Imaging study, including imaging registration and METastasis Reporting and Data System (MET-RADS) criteria; 3. Pre-clinical study, development of a biobank of blood samples for the analysis of neutrophil-to-lymphocyte ratio and preparatory for a subsequent miRNA profiling. We aim to determine which arm is justified for testing in a subsequent Phase III trial. A decision-tree algorithm, based on prognosis, biological phenotype and imaging profile, will be developed., Discussion: Recruiting will start in July 2019. SBRT will allow obtaining excellent PFS, local control, QoL and low toxicity. In SBRT arm, ADT deferral will allow for a drug-holiday, delaying the detrimental impact on QoL. A sufficient number of blood samples will be collected to perform biological patient profiling. A stratification tool will be established with an analysis of morphological and functional imaging, based on the use of MET-RADS criteria. So, in conclusion, RADIOSA aims to define the optimal management of bone/nodal PCa relapses in a SBRT regimen. This study will increase our knowledge on low-burden metastatic PCa in the era of high precision and high technology personalized medicine, offering highly effective therapy in terms of clinical outcome and cost-effectiveness., Trial Registration: The RADIOSA study was prospectively registered at clinicaltrials.gov ( NCT03940235 , May 2019).

Introduction: We analyzed adherence rates to contemporary guidelines regarding inguinal lymph node dissection (ILND) for squamous cell carcinoma of the penis, as well as ILND association with cancer specific mortality (CSM), and complication rates., Materials and Methods: Within the Surveillance, Epidemiology, and End Results and the National Inpatient Sample databases, 943 and 317 nonmetastatic penile cancer patients (1998-2015) were respectively identified. Multivariable analyses focused on ILND rates, CSM, and complication rates. Inverse probability of treatment weighting adjustment was used in CSM analyses., Results: Within the Surveillance, Epidemiology, and End Results database, ILND was performed in 233 (24.7%) patients. ILND rates did not vary over time (P = 0.2). In the overall cohort (n = 943), ILND was an independent predictor of lower CSM (hazards ratio [HR]: 0.42; P < 0.001). In Multivariable CSM analyses stratified according to N-stage, ILND was associated with lower CSM in N1 (HR: 0.25; P < 0.001) and N2-3 (HR: 0.42; P = 0.01), but not in N0 patients. Within the National Inpatient Sample database, presence of LN invasion (LNI) was associated with longer hospitalization (odds ratio: 1.27, P = 0.01), but not with higher complications or in-hospital mortality., Conclusions: The adherence to guidelines for ILND was low (24.7%), and did not change over time. Nonetheless, a CSM benefit related to ILND was observed in N1, N2, and N3 patients. Complication rates and in-hospital mortality did not differ according to LNI. However, hospital stay may be longer in LNI patients. Finally, it should be noted that lack of distinction between clinical and pathological N-stage represents an important limitation., (Copyright © 2019 Elsevier Inc. All rights reserved.)

We performed a systematic review of studies evaluating the impact of surgery for lower urinary tract symptoms suggestive of benign prostate enlargement (LUTS/BPE) on both erectile and ejaculatory functions. In June 2018, we searched for randomized controlled trials (RCTs) published between 1998 and 2018 in which both functions were assessed using questionnaires. Overall, 15 studies were identified. Pre-operatively, mean International Index of Erectile Function -5 (IIEF-5) and mean IIEF-Erectile Function (EF) scores ranged from 13.3 to 20.8, and from 13.7 to 22.3, respectively. At follow-up evaluations, mean IIEF-5 and mean IIEF-EF scores did not significantly vary (13.4 to 20.7 and 14.4 to 24.3, respectively). Mean baseline Male Sexual Health Questionnaire- Ejaculatory Disease function score at baseline and follow-up evaluations ranged from 8.7 to 10.6, and from 4.9 to 11.9, respectively. Ejaculatory function significantly worsened in three studies after transurethral resection of the prostate and significantly improved in 2 studies after prostate urethral lift implant. In conclusions, available RCTs evaluating both erectile and ejaculatory functions after surgical procedures for LUTS/BPE fail to demonstrate significant variations in terms of erectile function scores while providing significant variations of ejaculatory function scores that are heterogeneous depending on the procedure adopted.

Background: We tested contemporary surveillance and active treatment (AT) that included chemotherapy (CHT) and radiotherapy (RT) rates for stage I testicular seminoma patients, as well as cancer-specific mortality (CSM) and other-cause mortality (OCM) rates., Patients and Methods: Within the Surveillance, Epidemiology, and End Results database (1988-2015) we identified 11,206 stage I testicular seminoma patients. Surveillance versus CHT versus RT use rates were investigated using estimated annual percentage change (EAPC) analyses. After propensity score (PS) matching, cumulative incidence plots and multivariable competing risks regression models (MCRRMs) tested for CSM and OCM., Results: Of all 11,206 patients, 4434 (40%), 918 (8%), and 5854 (52%), respectively, underwent surveillance, CHT, or RT after initial orchiectomy. Surveillance (EAPC: 7.5%; P < .001) and CHT (EAPC: 13.5%; P < .001) rates increased over time, whereas RT rates decreased (EAPC: -3.8%; P < .001). After PS matching, in MCRRMs surveillance was an independent predictor of CSM, relative to AT (hazard ratio [HR], 2.59; P = .04). Conversely, surveillance versus AT did not affect OCM (HR, 1.52; P = .051). All other analyses that focused on CSM and OCM, namely surveillance versus RT, surveillance versus CHT, and RT versus CHT resulted in nonsignificant differences (all P > .5)., Conclusion: Surveillance and CHT use in stage I testicular seminoma rates increased, whereas RT rate decreased over time. A protective effect of AT defined as either RT or CHT was identified on CSM, relative to surveillance. This protective effect was not described for OCM. No differences in survival were recorded, when individual management strategies (surveillance vs. RT vs. CHT) were compared with each other., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Introduction: We aimed to evaluate adherence to the EAU guidelines (GL) on penile cancer (PC) with regard to primary surgical treatment and management of lymph nodes and to estimate the influence of adherence to GL on clinical outcome., Materials and Methods: This is a retrospective multicenter study (PEnile Cancer ADherence study, PECAD Study) on PC patients treated at 12 European and American centers between 2010 and 2016. Adherence to the EAU GL on the surgical management of the primary penile tumor and lymphadenectomy was evaluated. Descriptive analyses were performed, and survival curves were estimated., Results: Data on 425 patients were considered for the analysis. The EAU GL on surgical treatment of the primary tumor and lymphadenectomy were respected in 74.8% and 73.7% of cases, respectively. Survival analysis showed that adherence to the GL on primary penile surgery was significantly associated with a good overall survival [adjusted HR 0.40 (95% CI 0.20-0.83, p value = 0.014)]. Also, the adherence to the GL on lymphadenectomy was statistically significantly associated with overall survival [adjusted HR 0.48 (95% CI 0.24-0.96, p value = 0.038)]. Limited follow-up and retrospective design represent limitations of this study., Conclusions: Our findings suggest that there is a good adherence to the EAU GL on PC. However, this should be further reinforced, endorsed and encouraged as it might translate into better clinical outcomes for PC patients.

Background: Nowadays, there is a debate about which surgical treatment should be best for clinical T1 renal tumors. If the oncological outcomes are considered, there are many open and laparoscopic series published. As far as robotic series are concerned, only a few of them report 5-yr oncological outcomes., Objective: The aim of this study was to analyze robot-assisted partial nephrectomy (RAPN) midterm oncological outcomes achieved in a tertiary robotic reference center., Design, Setting, and Participants: Between April 2009 and September 2013, 123 consecutive patients with clinical T1-stage renal masses underwent RAPN in our tertiary cancer center. Inclusion criteria were as follows: pathologically confirmed renal cell carcinomas (RCCs) and follow-up for >12 mo. Eighteen patients were excluded due to follow-up of <12 mo and 15 due to benign final pathology. Median follow-up was 59 mo (interquartile range 44-73 mo). Patients were followed according to guideline recommendations and institutional protocol., Outcome Measurements and Statistical Analysis: Outcomes were measured by time to disease progression, overall survival, or time to cancer-specific death. Kaplan-Meier method was used to estimate survival; log-rank tests were applied for pair-wise comparison of survival., Results and Limitations: From the 90 patients included, 66 (73.3%) had T1a, 12 (13.3%) T1b, three (3.3%) T2a, and nine (10%) T3a tumors. Predominant histological type was clear cell carcinoma: 67 (74.5%). Fuhrmann grade 1 and 2 was found in 73.3% of all malignant tumors. Two patients (2.2%) had positive surgical margins, and complication rate was 17.8%. Relapse rate was 7.7%, including two cases (2.2%) of local recurrences and five (5.5%) distant metastasis. Five-year disease-free survival was 90.9%, 5-yr cancer-specific survival was 97.5%, and 5-yr overall survival was 95.1%., Conclusions: Midterm oncological outcomes after RAPN for localized RCCs (predominantly T1a tumors of low anatomic complexity) were shown to be good, adding significant evidence to support the oncological efficacy and safety of RAPN for the treatment of this type of tumors., Patient Summary: Robot-assisted partial nephrectomy seems to be the most promising minimally invasive approach in the treatment of renal masses suitable for organ-sparing surgery as midterm (5 yr) oncological outcomes are excellent., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Background: Cancer-related fatigue (CRF) is a complex condition that is reported in > 50% of cancer patients. In men with castration-resistant prostate cancer (CRPC), CRF was reported in 12-21% of patients. Approved systemic therapy against CRPC is commonly administered in combination with androgen-deprivation treatment (ADT) and, in some cases, with daily, low-dose corticosteroids. Importantly, the use of low-dose corticosteroids is associated with multiple negative effects, including reduced muscle mass. On these grounds, we hypothesized that the chronic use of corticosteroids may increase the incidence of fatigue in patients with prostate cancer., Methods: We reviewed all randomized trials published during the last 15 years conducted in patients with prostate cancer receiving systemic treatment and we performed a sub-group analysis to gather insights regarding the potential differences in the incidence of fatigue in patients receiving vs. not receiving daily corticosteroids as part of their systemic anti-neoplastic regimen., Results: Overall, 22,734 men enrolled in prospective randomized phase II and III trials were evaluable for fatigue. Estimated pooled incidence of grade 1-2 fatigue was 30.89% (95% CI = 25.34-36.74), while estimated pooled incidence of grade 3-4 fatigue was reported in 3.90% (95% CI = 2.91-5.02). Sub-group analysis showed that grade 3-4 fatigue was approximately double in patients who received daily corticosteroids as part of their anti-neoplastic treatment (5.58; 95% CI = 4.33-6.98) vs. those who did not (2.67%; 95% CI = 1.53-4.11)., Conclusion: Our findings highlight the need for ad hoc-designed prospective clinical trials to investigate whether the benefits associated with low-dose, daily corticosteroids outweigh the risks associated with corticosteroid-related adverse events such as fatigue.

Purpose: To understand the multiparametric magnetic resonance imaging (mpMRI) interreader agreement between radiologists of peripheral and academic centers and the possibility to avoid prostate biopsies according to magnetic resonance imaging second opinion., Patients and Methods: This prospective observational study enrolled 266 patients submitted to mpMRI at nonacademic centers for cancer detection or at active surveillance begin. Images obtained were reviewed by 2 unblinded radiologists with 8 and 5 years' experience on mpMRI, respectively. We recorded Prostate Imaging Reporting and Data System (PI-RADS) v2 categories and management strategy changes after mpMRI rereadings. Interreader agreement was assessed by the Cohen kappa. For mpMRI second opinion, positive predictive value and negative predictive value were calculated., Results: In the original readings, no lesions (ie, PI-RADS < 2) were observed in 17 cases (6.5%). Reported index lesion (IL) PI-RADS category was 2 in 23 (8.5%), 3 in 85 (32%), 4 in 98 (37%), and 5 in 13 (5%) men, respectively. It is noteworthy that in 30 examinations (11%), an IL was recognized by radiologists, but a suspicious score was not assigned. According to first reading of mpMRI, initial clinical strategy included performing a targeted (226; 85%) or a systematic biopsy (8; 3%), scheduling the patient to an active surveillance program without repeat biopsy (10; 4%), or monitoring prostate-specific antigen without prostate sampling (22; 8%). The mpMRI rereads did not change IL PI-RADS category in 91 cases (38.5%), although in 20 (8.5%) and 125 (53%) IL PI-RADS was upgraded or downgraded, respectively (κ = 0.23). The clinical management changed in 113 patients (48%) (κ = 0.2). Overall, 102 targeted biopsies (51%) were avoided and 72 men (34.5%) were not submitted to biopsy after mpMRI second opinion. Positive predictive value and negative predictive value of the mpMRI rereading were 58% and 91%, respectively. Major limitations of the study are limited-time follow-up and the lack of a standard of reference for some men, who were not submitted to biopsy according to mpMRI second opinion., Conclusion: There is an important level of discordance between mpMRI reports. According to imaging second opinion, roughly half of targeted biopsies could be avoidable and 34.5% of men could skipped prostate sampling. Prospective randomized trials are needed to confirm our findings., (Copyright © 2018 Elsevier Inc. All rights reserved.)

The aim is to present the technical feasibility and efficacy of multiple re-irradiation (re-EBRT) for local recurrence of prostate cancer (PCa) using retrospective analysis of an updated series of patients who received ablative re-EBRT with stereotactic image-guided technique for isolated local recurrence of PCa. Eight patients received three RT courses (2 re-RTs); of those 2 received 4 RT courses (3 re-RTs). Local relapse in the prostate was assessed by multiparametric magnetic resonance and/ or choline positron emission tomography. Before treatment planning, all patients had been evaluated for late toxicity from previous RT according to RTOG/EORTC. Biochemical control was assessed according to Phoenix definition. Mean age at the third RT course was 68 (standard deviation, SD: 7.2); all patients had a good performance status. At diagnosis, four cases were classified as high risk PCa, three as intermediate and one as low per NCCN 2017. Biochemical progression free interval after first and second RT-course were 74 (IQR: 59.3-133.6) months and 33 (IQR: 20.8-53.1) months, respectively. Biochemical and radiological response was registered in all patients. At present, seven out of eight patients are disease free. Overall toxicity profile was good; no severe acute or late genitourinary or gastrointestinal events were recorded. Multiple RT courses with high precision technology and image guidance can be proposed as a possible salvage therapy for locally recurrent, low-burden PCa recurrence in adequately selected patients. Deeper understanding of radiobiological effects of hypofractionation and larger series of patients are warranted to fully evaluate the applicability of multiple RT courses in the setting of locally recurrent PCa.

Background: To date, few series on robot-assisted radical prostatectomy (RARP) in kidney transplant recipients (KTRs) have been published., Purpose: To report the experience of two referral centers adopting two different RARP approaches in KTRs. Surgical, oncological and functional results were primary outcomes evaluated in the study., Material and Methods: We retrospectively analyzed data from 9 KTRs who underwent transperitoneal RARP or Retzius-sparing RARP for PCa from October 2012 to April 2016. Data were reported as median and interquartile range (IQR). Pre- and postoperative outcomes were compared by non-parametric Wilcoxon signed-rank test. Significant differences were accepted when p ≤ 0.05. Overall survival was assessed using Kaplan-Meier method., Results: Four KTRs underwent a T-RARP and 5 a RS-RARP. Patient median age was 60 (56-63) years. Charlson comorbidity index was 6 (5-6). Preoperative median PSA was 5.6 (5-15) ng / mL. Preoperative Gleason score (GS) was 6 in 5 patients, 7 (3 + 4) in 3, and 8 (4 + 4) in one. Pre- and postoperative creatinine were 1.17 (1.1; 1.4) and 1.3 (1.07; 1.57) mg / dL (p = 0.237), while eGFR was 66 (60-82) and 62 (54-81) mL / min / 1.73m2 (p = 0.553), respectively. One (11.1%) Clavien-Dindo grade II complication occurred. Two extended template lymphadenectomies were performed, both with nodal invasion. These two patients experienced a biochemical recurrence and were subjected to RT. Two patients (22.2%) had PSMs. Median follow-up was 42 months. Seven patients (77.8%) were continent, 5 (55.6%) were potent. Two (22.2%) patients died during follow-up for oncologic unrelated causes., Conclusions: Our series suggests that both RARP approaches are safe and feasible techniques in KTRs for PCa., Competing Interests: None declared, (Copyright® by the International Brazilian Journal of Urology.)