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Von Hippel-Lindau disease predisposes to develop renal cell carcinoma (RCC). Treatment is frequently challenging due to presence of bilateral tumors and high risk of recurrence. We present the case of a VHL-patient with bilateral recurrence of clear-cell RCC after bilateral partial nephrectomy and autotransplantation on one side. Recurrence on the transplanted kidney was treated with repeat partial nephrectomy with good oncological and functional outcomes. This approach is feasible in centres with wide experience in partial nephrectomy and renal transplantation when minimally invasive tumor ablation is not indicated.

INTRODUCTION AND OBJECTIVES:According to the d’Amico classification, high-risk prostate cancer (PCa)disease is defined as either preoperative PSA>20ng/ml, clinical tumor stage (cT) ≥T2c or biopsy...

Introduction: The aim of the study was to identify the appropriate level of Charlson comorbidity index (CCI) in older patients (>70 years) with high-risk prostate cancer (PCa) to achieve survival benefit following radical prostatectomy (RP). Methods: We retrospectively analyzed 1008 older patients (>70 years) who underwent RP with pelvic lymph node dissection for high-risk prostate cancer (preoperative prostate-specific antigen >20 ng/mL or clinical stage ≥T2c or Gleason ≥8) from 14 tertiary institutions between 1988 and 2014. The study population was further grouped into CCIÂ

OBJECTIVES: To assess the predictive accuracy and the clinical value of a recent nomogram predicting cancer-specific mortality-free survival after surgery in pN1 prostate cancer patients through an external validation. METHODS: We evaluated 518 prostate cancer patients treated with radical prostatectomy and pelvic lymph node dissection with evidence of nodal metastases at final pathology, at 10 tertiary centers. External validation was carried out using regression coefficients of the previously published nomogram. The performance characteristics of the model were assessed by quantifying predictive accuracy, according to the area under the curve in the receiver operating characteristic curve and model calibration. Furthermore, we systematically analyzed the specificity, sensitivity, positive predictive value and negative predictive value for each nomogram-derived probability cut-off. Finally, we implemented decision curve analysis, in order to quantify the nomogram's clinical value in routine practice. RESULTS: External validation showed inferior predictive accuracy as referred to in the internal validation (65.8% vs 83.3%, respectively). The discrimination (area under the curve) of the multivariable model was 66.7% (95% CI 60.1-73.0%) by testing with receiver operating characteristic curve analysis. The calibration plot showed an overestimation throughout the range of predicted cancer-specific mortality-free survival rates probabilities. However, in decision curve analysis, the nomogram's use showed a net benefit when compared with the scenarios of treating all patients or none. CONCLUSIONS: In an external setting, the nomogram showed inferior predictive accuracy and suboptimal calibration characteristics as compared to that reported in the original population. However, decision curve analysis showed a clinical net benefit, suggesting a clinical implication to correctly manage pN1 prostate cancer patients after surgery.

To assess the outcomes of patients treated with postoperative RT in relation to the possible prognostic factors.Postoperative radiotherapy (RT) has been proved to reduce the risk of biochemical recurrence in high-risk prostate cancer patients. Baseline prostate specific antigen (PSA), pathological Gleason score (GS), positive surgical margins, nodal status and seminal vesicle invasion are independent predictors of biochemical relapse.The clinical records of 282 patients who underwent postoperative RT were retrospectively reviewed. The prognostic value of postoperative PSA, preoperative risk class, nodal status, pathological GS, margins status, and administration of hormonal therapy (HT) was analyzed.Postoperative RT was delivered with a median dose to the prostatic fossa of 66 Gy (range 50-72) in 1.8-2 Gy/fraction. Median follow-up was 23.1 months (range 6-119). Five-year actuarial biochemical disease-free survival (bDFS) and overall survival rates were 76% and 95%, respectively. Higher bDFS was found for patients with postoperative PSA0.02 ng/ml (p = 0.03), low preoperative risk class (p = 0.01), pN0 (p = 0.003), GS 4-6 (p = 0.0006), no androgen deprivation therapy (p = 0.02), and irrespective of surgical margin status (p = 0.10). Multivariate analysis showed that postoperative PSA and Gleason score had a significant impact on bDFS (p = 0.039 and p = 0.05, respectively).Postoperative RT with a dose of 66 Gy offers an acceptable toxicity and an optimal disease control after radical prostatectomy in patients with different risk features. A postoperative PSA0.02 ng/ml could be considered as a prognostic factor and a tool to select patients at risk for progression.

Primary extratesticular seminomas exceptionally occur in the epididymis or in the paratesticular region/spermatic cord. Some old papers included poor histological description or insufficient photographic documentation, reducing the number of faithful cases: an up-to-date systematic review is lacking. We report the 4th primary seminoma of the paratesticular region/spermatic cord in a 35-year-old man, including the first echographic description. We provide review of the literature and etiopathogenetic discussion. Ultrasound examination showed a right paratesticular, solid, heterogeneous mass (iso-hypoechoic with hyperechoic striae; peri- and intra-lesional vascular signals) with no testicular involvement: the paratesticular origin was confirmed by pathological examination. Despite careful gross examination and extensive sampling, the 6.5-cm extratesticular tumor revealed only one microscopic focus with minimal invasion (

Background:Several randomized controlled trials assessed the outcomes of patients treated with neoadjuvant hormonal therapy (NHT) before radical prostatectomy (RP). The majority of them included mainly low and intermediate risk prostate cancer (PCa) without specifically assessing PCa-related death (PCRD). Thus, there is a lack of knowledge regarding a possible effect of NHT on PCRD in the high-risk PCa population. We aimed to analyze the effect of NHT on PCRD in a multicenter high-risk PCa population treated with RP, using a propensity-score adjustment.Methods:This is a retrospective multi-institutional study including patients with high-risk PCa defined as: clinical stage T3-4, PSA >20 ng ml â '1 or biopsy Gleason score 8-10. We compared PCRD between RP and NHT+RP using competing risks analysis. Correction for group differences was performed by propensity-score adjustment.Results:After application of the inclusion/exclusion criteria, 1573 patients remained for analysis; 1170 patients received RP and 403 NHT+RP. Median follow-up was 56 months (interquartile range 29-88). Eighty-six patients died of PCa and 106 of other causes. NHT decreased the risk of PCRD (hazard ratio (HR) 0.5; 95% confidence interval (CI) 0.32-0.80; P=0.0014). An interaction effect between NHT and radiotherapy (RT) was observed (HR 0.3; 95% CI 0.21-0.43; P

Background: Accurate prediction of survival after radical prostatectomy (RP) is important for making decisions regarding multimodal therapies. There is a lack of tools to predict prostate cancer-related death (PCRD) in patients with high-risk features. Objective: To develop and validate a prognostic model that predicts PCRD combining pathologic features and using competing-risks analysis. Design, setting, and participants: This was a retrospective multi-institutional observational cohort study of 5876 patients affected by high-risk prostate cancer. Patients were treated using RP and pelvic lymph node dissection (PLND) in a multimodal setting, with median follow-up of 49 mo. Outcome measurements and statistical analysis: For PCRD prediction, a multivariate model with correction for competing risks was constructed to evaluate pathologic high-risk features (pT3b-4, Gleason score ≥8, and pN1) as predictors of mortality. All possible associations of the predictors were combined, and then subgroups with similar risk of PCRD were collapsed to obtain a simplified model encoding subgroups with significantly differing risk. Eightfold cross-validation of the model was performed. Results and limitations: After applying exclusion criteria, 2823 subjects were identified. pT3b-4, Gleason score ≥8, and pN1 were all independent predictors of PCRD. The simplified model included the following prognostic groups: good prognosis, pN0 with 0-1 additional predictors; intermediate prognosis, pN1 with 0-1 additional predictors; poor prognosis, any pN with two additional predictors. The cross-validation yielded excellent median model accuracy of 88%. The retrospective design and the short follow-up could limit our findings. Conclusions: We developed and validated a novel and easy-to-use prognostic instrument to predict PCRD after RP + PLND. This model may allow clinicians to correctly counsel patients regarding the intensity of follow-up and to tailor adjuvant treatments. Patient summary: Prediction of mortality after primary surgery for prostate cancer is important for subsequent treatment plans. We present an accurate postoperative model to predict cancer mortality after radical prostatectomy for high-risk prostate cancer. The EMPaCT classifier can accurately predict the survival of patients with high-risk prostate cancer. The EMPaCT classifier can become a novel standard to support decision-making in the multimodal setting.

Purpose A sentinel lymph node (SNL) is the primary landing zone of cancer cells that spreads through the lymphatic vessels. The rational of the detection of sentinel node (SLN) during radical prostatectomy (RP) for prostate cancer (PCa) is the removal of the first nodal stations to provide a restriction of the template of node dissection. A review of the outcomes of SNL detection during RP for PCa was performed. Materials and methods A systematic review of the literature was conducted, searching on PubMed and Web of Science, using the following keywords: lymph node dissection, prostatic neoplasm, sentinel node. Results Twenty articles were selected and analyzed including over 2000 PCa patients. Although promising and technically feasible, many points remain to be clarified before clinical application can be recommended. Conclusions The technique of SNL detection is feasible and provides a higher sensitivity and detection rate than standard lymphadenectomy, especially for organ-confined tumors. Larger series and long-term follow-up data are mandatory to assess the oncologic effectiveness of the detection of SNL for PCa.

Objective In patients with a long life expectancy with high-risk (HR) prostate cancer (PCa), the chance to die from PCa is not negligible and may change significantly according to the time elapsed from surgery. The aim of this study was to evaluate long-term survival patterns in young patients treated with radical prostatectomy (RP) for HRPCa. Materials and methods Within a multiinstitutional cohort, 600 young patients (≤59 years) treated with RP between 1987 and 2012 for HRPCa (defined as at least one of the following adverse characteristics: prostate specific antigen>20, cT3 or higher, biopsy Gleason sum 8–10) were identified. Smoothed cumulative incidence plot was performed to assess cancer-specific mortality (CSM) and other cause mortality (OCM) rates at 10, 15, and 20 years after RP. The same analyses were performed to assess the 5-year probability of CSM and OCM in patients who survived 5, 10, and 15 years after RP. A multivariable competing risk regression model was fitted to identify predictors of CSM and OCM. Results The 10-, 15- and 20-year CSM and OCM rates were 11.6% and 5.5% vs. 15.5% and 13.5% vs. 18.4% and 19.3%, respectively. The 5-year probability of CSM and OCM rates among patients who survived at 5, 10, and 15 years after RP, were 6.4% and 2.7% vs. 4.6% and 9.6% vs. 4.2% and 8.2%, respectively. Year of surgery, pathological stage and Gleason score, surgical margin status and lymph node invasion were the major determinants of CSM (all P ≤0.03). Conversely, none of the covariates was significantly associated with OCM (all P ≥ 0.09). Conclusions Very long-term cancer control in young high-risk patients after RP is highly satisfactory. The probability of dying from PCa in young patients is the leading cause of death during the first 10 years of survivorship after RP. Thereafter, mortality not related to PCa became the main cause of death. Consequently, surgery should be consider among young patients with high-risk disease and strict PCa follow-up should enforce during the first 10 years of survivorship after RP.

Objectives: To investigate cancer-specific mortality and other-cause mortality in prostate cancer patients with nodal metastases. Methods: The study included 411 patients treated with radical prostatectomy and pelvic lymph node dissection for prostate cancer with lymph node metastases at 10 tertiary care centers between 1995 and 2014. Kaplan–Meier analyses were used to assess cancer-specific mortality-free survival rates at 8 years' follow up in the overall population, and after stratifying patients according to clinical and pathological parameters. Uni- and multivariable competing risk Cox regression analyses were used to assess cancer-specific mortality and other-cause mortality. Finally, cumulative-incidence plots were generated for cancer-specific mortality and other-cause mortality after stratifying patients according to the number of positive lymph nodes and the median age at surgery, according to the competing risks method. Results: Men with prostate-specific antigen ≤40 ng/mL and those with one to three positive lymph nodes showed higher cancer-specific mortality-free survival estimates as compared with their counterparts with prostate-specific antigen >40 ng/mL and >3 metastatic lymph nodes, respectively (all P < 0.001). At multivariable Cox regression analyses, preoperative prostate-specific antigen >40 ng/mL, >3 lymph node metastases and pathological Gleason score 8–10 were all independent predictors of cancer-specific mortality (all P-values ≤0.001). On competing risk analysis, when patients were stratified according to the number of positive lymph nodes (namely, ≤3 vs >3), the 8-year cancer-specific mortality rates were 27.4% versus 44.8% for patients aged 3 positive lymph nodes, the overall mortality rate is completely related to prostate cancer in young patients.

Background: The current role of radical prostatectomy (RP) in patients with high-risk disease remains controversial. Objective: To identify which high-risk prostate cancer (PCa) patients might have favorable pathologic outcomes when surgically treated. Design, setting, and participants: We evaluated 1366 patients with high-risk PCa (ie, at least one of the following risk factors: prostate-specific antigen [PSA] > 20 ng/ml, cT3, biopsy Gleason 8-10) treated with RP and pelvic lymph node dissection (PLND) at eight European centers between 1987 and 2009. A favorable pathologic outcome was defined as specimen-confined (SC) disease-namely, pT2-pT3a, node negative PCa with negative surgical margins. Intervention: All patients underwent radical retropubic prostatectomy and PLND. Measurements: Univariable and multivariable logistic regression models tested the association between predictors and SC disease. A logistic regression coefficient-based nomogram was developed and internally validated using 200 bootstrap resamples. The Kaplan-Meier method was used to depict biochemical recurrence (BCR) and cancer-specific survival (CSS) rates. Results and limitations: Overall, 505 of 1366 patients (37%) had SC disease at RP. All preoperative variables (ie, age and PSA at surgery, clinical stage, and biopsy Gleason sum) were independent predictors of SC PCa at RP (all p

Intraoperative electron beam radiotherapy (IOERT) for prostate cancer (PC) is a radiotherapeutic technique, giving high doses of radiation during radical prostatectomy (RP). This paper presents the published treatment approaches for intraoperative radiotherapy analyzing functional outcome, morbidity, and oncological outcome in patients with clinical intermediate-high-risk prostate cancer. A systematic review of the literature was performed, searching PubMed and Web of Science. A “free text” protocol using the term intraoperative radiotherapy and prostate cancer was applied. Ten records were retrieved and analyzed including more than 150 prostate cancer patients treated with IOERT. IOERT represents a feasible technique with acceptable surgical time and minimal toxicity. A greater number of cases and longer follow-up time are needed in order to assess the long-term side effects and oncological outcome.

• To assess the feasibility of radical prostatectomy (RP) in a series of patients with prostate cancer with very high prostate-specific antigen (PSA) levels by comparing the clinical outcomes of different PSA thresholds (20.1-50 ng/mL, 50.1-100 ng/mL and >100 ng/mL, respectively).

Objectives To determine the chemical composition of pure and mixed urinary calculi by multislice helical computed tomography (CT) in an in-vitro setting. CT is becoming the preferred radiologic examination in diagnosis and management of calculus disease. The management of calculus disease can be facilitated by ascertaining stone composition. Recent in-vitro studies have suggested that CT can be used to predict the composition of urinary stones on the basis of differences in radiodensity (measured in Hounsfield units, HU) supporting the clinician in selecting the more opportune therapeutic strategy. Aim of our study is to compare the radiodensity and chemical composition of urinary stones with the purpose of identifying the cut-off value of HU with high specificity. Materials e Methods A total of 76 patients with urinary stones, candidate to treatment, were assessed in a multislice helical scanner within an air-filled environment (Ge Healthcare light Speed, 120 KV; 150–250 mA 1.5 pitch thick speed 2.5; interval 2.5) differentiating dimensions and radiodensity. The chemical compositions of urinary stones were assessed on the basis of the differences in densities measured in Hounsfield units. Chemical analysis of stone has been done, using colorimetrical kit Ecoline (DiaSys Diagnostic System GmbH, Germany) validated versus IR Spectrometry. HU density values are expressed as median and interquantile range (IQR). Statistic analysis has been done using SPSS 15.0 (SPSS Inc., Chicago, IL, USA). Results The stones were assigned to seven different groups according to the chemical composition: calcium oxalate in 57%, calcium oxalate and phosphate in 16%, calcium urate-oxalate 12%, uric acid in 5%, struvite and calcium phosphate in 4%, struvite and calcium oxalate in 5%, cystine in 1%. Uric acid stone density (Ur+Ur/Ox-Ca, n=13; HU 487, IQR 352 - 594) was significantly lower than both Ox-Ca pure (n=44; HU 639, IQR 460 -942) (Bonferroni correction p=0012) and phosphate (Ox / P-Ca+struvite, n=19; HU 801, IQR 502 -1205) (Bonferroni correction p=0006), while no difference was evident between oxalate and phosphate stones. Areas under ROC curve for uric acid stone identification (toward phosphate and oxalate) or for phosphate stone identification (toward uric acid and oxalate) were respectively 0.73 (95%IC 0.59–0.87) and 0.62 (95%IC 0.46–0.79). Cut-off values of 352 HU (first quartile uric distribution) and 1205 HU (third quartile phosphates distribution) allow to identify a specificity of 91% and 96%, respectively, for uric acid or phosphates stones. Conclusions Although our data underline an association between radiodensity and chemical composition, confirming literature, the big overlap of distributions of HU values limits clinical application. It is possible to identify specific HU cut-off values for uric acid and phosphates stone, however it is necessary to verify these results in a larger sample. The spiral TC is useful to study the chemical composition of the urinary stone, but a larger sample is necessary to calculate more accurate radiodensity cut-off values.

Objectives Previous prospective studies of the surgical treatment of locally advanced prostate cancer have enrolled patients selected on the basis of a limited T3 disease extension. The aim of the present study was to assess the feasibility and the oncologic outcome of radical prostatectomy administered to a consecutive unselected series of advanced, non-bone metastatic prostate cancers. Methods Between March 1998 and February 2003 radical prostatectomy was offered at our institution to any patient diagnosed with prostate cancer with no sign of extranodal metastatic disease. Data on morbidity and survival for 51 clinically advanced cases (any T ≥3, N0–N1, or any N1 or M1a disease according to the TNM 2002 classification system) operated on by a single expert surgeon were compared with a series of 152 radical prostatectomies performed during the same period by the same operator for clinically organ-confined disease. Adjuvant treatment was administered according to current guidelines. Results The two groups did not differ significantly in surgical morbidity except for blood transfusion, operative time, and lymphoceles, which showed a higher rate in patients with advanced disease. The Kaplan-Meier estimate of overall survival and prostate cancer–specific survival at 7 yr were 76.69% and 90.2% in the advanced disease group and 88.4% and 99.3% in the organ-confined disease group, respectively. Conclusions Even in the scenario of extensive surgical indications up to M1a disease, radical prostatectomy proved to be technically feasible and to have an acceptable morbidity rate compared with organ-confined disease. Our initial survival data strengthen the role for surgery as an essential part in the multimodal approach to treating advanced prostate cancer.

BACKGROUND No data exist on the patterns of biochemical recurrence (BCR) and their effect on survival in patients with high-risk prostate cancer (PCa) treated with surgery. The aim of our investigation was to evaluate the natural history of PCa in patients treated with radical prostatectomy (RP) alone. MATERIALS AND METHODS Overall, 2,065 patients with high-risk PCa treated with RP at 7 tertiary referral centers between 1991 and 2011 were identified. First, we calculated the probability of experiencing BCR after surgery. Particularly, we relied on conditional survival estimates for BCR after RP. Competing-risks regression analyses were then used to evaluate the effect of time to BCR on the risk of cancer-specific mortality (CSM). RESULTS Median follow-up was 70 months. Overall, the 5-year BCR-free survival rate was 55.2%. Given the BCR-free survivorship at 1, 2, 3, 4, and 5 years, the BCR-free survival rates improved by+7.6%,+4.1%,+4.8%,+3.2%, and+3.7%, respectively. Overall, the 10-year CSM rate was 14.8%. When patients were stratified according to time to BCR, patients experiencing BCR within 36 months from surgery had higher 10-year CSM rates compared with those experiencing late BCR (19.1% vs. 4.4%; P

Objectives To compare the intraoperative results of inguinal versus subinguinal varicocelectomy using magnifying loupe, in terms of vein ligation and arterial preservation, recurrence rate, and patient tolerability. Methods Ninety-nine patients were randomized to undergo a varicocele repair with an inguinal or a subinguinal approach under local anesthesia. Data concerning the number of veins ligated and arterial preservation were recorded during each procedure. The amount of intraoperative and postoperative pain was assessed by means of visual analogue scale (VAS) scores. The recurrence rate was documented by color Doppler ultrasound examination. Results The average number of ligated veins was 5.6 with a subinguinal dissection and 4.4 with the inguinal approach. Inadvertent injury of the spermatic artery occurred in 6 of 47 subinguinal and 3 of 50 inguinal dissections; the artery could not be identified during 2 subinguinal and 1 inguinal dissection. Recurrent varicocele was detected in 8% and 14.9% of patients after an inguinal and a subinguinal approach, respectively. The intraoperative VAS score was significantly higher in the inguinal than in the subinguinal patients ( P = 0.008). Conclusions In our hands, the inguinal approach to the spermatic cord showed a trend toward an easier preservation of the artery and a reduced incidence of persistent pathologic vein reflux. The subinguinal approach had a lower degree of intraoperative pain. On the whole, an inguinal repair might be preferable when magnifying loupe are used for varicocelectomy.

INTRODUCTION AND OBJECTIVES: Laparoscopic renal cryoablation [LRC] is an effective minimally invasive treatment option for small renal masses [SRMs], but evidences regarding long-term oncologic safety are still lacking. The aim of this study is to evaluate the longterm oncological outcomes of LCR in patients with at least one SRM. METHODS: The study design is an observational, retrospective analysis of prospectively collected data of 189 consecutive patients who underwent LRC between 2000 and 2013. Overall, 214 cT1a contrast enhanced SRMs were diagnosed on CT or MRI scan and subsequently treated with LRC. Surgery consisted of transperitoneal or retroperitoneal access to the renal cavity, kidney mobilization, laparoscopic ultrasound evaluation, ultrasound-guided biopsy of the lesion, puncture of the SRM with the cryoprobes and double freeze-thaw cycle extending the ice ball approximately 1 cm beyond the tumor edge. Patients were evaluated on post-operative day 1 with MRI to assess the treatment efficacy: residual disease was defined as persistent enhancing tissue in the treated area. Follow-up was determined using serial MRI at 1, 6, 12, 24, 36, 48, 60, 72 and 120 months. Local recurrence after LRC was defined as the presence of an enhancing nodule in the treated area increasing in size. The outcome of the study was to evaluate the 5 years disease free survival, cancer specific survival and overall survival. RESULTS: Mean follow up was 55.6 months (range 1-156). Mean patient age was 63.42 (range 25 88). Median tumor size was 21 mm (range 7 40). The mean ice-ball diameter after surgery was 44.8 mm (range 18 80), and it decreased over time: MRI showed a mean iceball diameter of 35.0, 23.3, 18.5, 13.5, 11.7, 9.5, 6.4, 5.8 and 2.4 mm at 1, 6, 12, 24, 36, 48, 60, 72 and 120 months, respectively (p

The aim was to analyze the prognostic role of preoperative chromogranin A CgA) as a marker of poor prognosis and recurrence after radical prostatectomy (RP) and to find a correlation with the other well known prognostic variables.This study comprises 306 patients with prostate cancer prospectively recruited who underwent RP from between 2000 and 2005. A blood sample for the determination of serum preoperative CgA value was obtained in all cases. Spearman correlation test was used to compare CgA to other variables, Kruskal-Wallis test to analyze CgA differences amongor = 3 groups (PSA, GS, Stage), Mann-Whitney test for 2 grouping variables. Survival analysis was estimated by Kaplan-Meier method, log-rank test to estimate differences among the analyzed variables.Median CgA level was 68 ng/ml. Correlation between age and CgA levels was positive and statistically significant (p0.001). Patient were divided in 2 groups based on median age.The difference was statistically significant (p = 0.002). Comparison of CgA among patients grouped according to other variables and patient stratified on normal (123 ng/ml) and cut-off value (68 ng/ml) of CgA did not achieve significant risk stratification.Studies on a possible prognostic role of CgA have provided conflicting results. In our series we found a significant positive correlation between CgA and age, but no significant statistical correlation with other available variables analyzed.