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Resumen Introduccion Se recomienda realizar una biopsia prostatica (PBx) de repeticion ante una sospecha persistente de cancer de prostata (PCa) o cuando se identifica proliferacion acinar atipica (ASAP), neoplasia intraepitelial de alto grado (HGPIN) extensa (≥ 3 zonas de biopsia) o HGPIN con celulas atipicas sospechosas de adenocarcinoma (PIN-ATYP). Actualmente se recomienda realizar una resonancia magnetica multiparametrica (mpMRI) y PBx guiada por mpMRI (MRI-TBx) en una PBx de repeticion. Nuestro objetivo fue analizar el valor actual para predecir el riesgo de PCa clinicamente significativo (csPCa) del hallazgo de ASAP, mHGPIN, PIN-ATYP y otros hallazgos histologicos. Metodos Se realizo un analisis retrospectivo de 377 PBx de repeticion. Se realizo MRI-TBx cuando la puntuacion PI-RADS fue ≥ 3 y PBX sistematicas de 12 cilindros guiadas por ecografia transrectal (TRUS) cuando fue ≤ 2. ASAP, HGPIN, HGPIN multifocal (mHGPIN), PIN-ATYP y otros 8 hallazgos histologicos fueron reportados prospectivamente en las PBx negativas. El csPCa fue definido como grado ISUP ≥ 2. Resultados La incidencia de ASAP, mHGPIN y PIN-ATYP fue 4,2%, 39,7% y 3,7% respectivamente, y la tasa de csPCa fue estadisticamente similar en los pacientes con estos hallazgos histologicos. Sin embargo, las tasas de csPCa con atrofia proliferativa inflamatoria (PIA) presente y ausente fueron 22,2% y 36,1%, respectivamente. La PIA fue el unico hallazgo histologico que predijo un menor riesgo de csPCa, con OR de 0,54 (IC 95%: 0,308-0,945, p = 0,031). La PIA fue, tambien, un factor predictor independiente en un modelo combinando variables clinicas y mpMRI, que obtuvo un area bajo la curva de 0,86 (95% IC: 0,83-0,90). Conclusiones La PIA resulto ser el unico hallazgo histologico predictor del riesgo de csPCa, y puede contribuir en un modelo predictivo; mHGPIN no fue predictor de riesgo de csPCa. La baja incidencia de ASAP (4,2%) y PIN-ATYP (3,7%) impidio que pudieramos obtener conclusiones sobre estas lesiones.

Background: Despite concomitant bladder and upper urinary tract cancers are present in 17% of cases, the simultaneous affection of the urethra, bladder, and both upper urinary tracts is extremely rare. Treatment decisions in this setting could be challenging because of the lack of evidence in the literature. Case Presentation: A 65-year-old Caucasian man with a history of nine low-grade (LG) and multifocal bladder tumor recurrences during the past 4 years is referred to our department with a newly diagnosed panurothelial carcinoma involving the bladder, urethra, and both upper urinary tracts. Because of the large and recurrent LG bladder tumor, the urethral involvement and the presence of bilateral pyelocaliceal tumors >4 cm the patient underwent a robot-assisted complete urinary tract extirpation (CUTE). Operating time was 360 minutes and blood loss 460 mL. No intraoperative complications were reported and blood transfusion was not required. The patient developed a surgical site infection in the glans that was solved with antibiotics without any other postoperative complication. He started renal replacement therapy and was discharged 6 days after the surgery. Pathologic analysis showed multifocal urothelial carcinomas; pTa LG involving the bladder and the prostatic-bulbar-membranous-penile urethra, pT3 high grade (HG) in right renal pelvis, pT1 HG in left renal pelvis, and pN0 in pelvic lymph node dissection. After a reasonable free-recurrence period of time the patient could be evaluated for a robot-assisted intracorporeal urinary diversion in preparation for a later renal transplantation. Conclusion: Robot-assisted CUTE could be a feasible and safe technique for selected patients with simultaneous panurothelial carcinoma. Further multicentric studies are warranted to determine the safety of this minimally invasive approach in patients with different comorbidities.

Background Repeat prostate biopsy (PBx) is recommended under persistent suspicion of prostate cancer (PCa) or in the face of the following findings: atypical small acinar proliferation (ASAP); extense (≥3 biopsy sites) high-grade prostatic intraepithelial neoplasia (HGPIN); or HGPIN with atypical glands; suspicious for adenocarcinoma (PIN-ATYP). Nowadays; multiparametric magnetic resonance imaging (mpMRI) and mpMRI targeted PBx (MRI-TBx) are recommended in repeat PBx. Our objective was to analyze the current value of ASAP; mHGPIN; PIN-ATYP and other histological findings to predict clinically significant PCa (csPCa) risk. Methods Retrospective analysis of 377 repeat PBxs. MRI-TBx was performed when Prostate Imaging-Reporting and Data System (PI-RADS) score >3 and 12-core transrectal ultrasound (TRUS) systematic PBx when ≤2. ASAP; HGPIN; mHGPIN; PIN-ATYP; and 8 other histological findings were prospectively reported in negative PBx. CsPCa was defined as ISUP group grade >2. Results Incidence of ASAP; multifocal HGPIN (mHGPIN) and PINATYP was 4.2%; 39.7% and 3.7% respectively; and csPCa rate was statistically similar among men with these histological findings. However; the rate of csPCa was 22.2% when proliferative inflammatory atrophy (PIA) was present; and 36.1% when it was not. PIA was the only histological finding which predicted lower risk of csPCa; with an OR of 0.54 (95%CI: 0.308−0.945; P = .031). In addition; PIA was an independent predictor of a model combining clinical variables and mpMRI which reached area under de ROC curve of 0.86 (95%CI: 0.83−0.90). Conclusion PIA emerged as the only predictive histological finding of csPCa risk and can contribute to a predictive model. mHGPIN failed to predict csPCa risk. The low incidence of ASAP (4.2%) and PIN-ATYP (3.7%) prevented us from drawing conclusions.

To analyze prostatic-specific antigen density (PSAD) according to the Prostate Imaging Reporting and Data System (PIRADSv.2) score, in order to determine how it should be used.This correlative series considered 952 men with prostatic-specific antigen3 ng/ml and/or abnormal digital rectal examination who were subjected to prostatic biopsy (PB) between 2016 and 2017. Of these men, 768 had no previous 5-α-reductase inhibitor use or history of prostate cancer (CaP) and had previously undergone 3-T multiparametric magnetic resonance imaging (mpMRI). In this sample, 549 men were biopsy-naïve and 219 had at least 1 previous negative PB. A 12-core transrectal ultrasound-guided PB was performed in all participants, as well as at least 2-core targeted biopsies of every detected lesion with a PIRADSv.2 score ≥3. Significant CaP (sCaP) was defined as an International Society of Uropathologist grade1 or tumor length4 mm.The overall CaP detection was 41.7%, with sCaP detected in 37.4%. sCaP was detected in 4.3% of PIRADSv.23, 21.5% of PIRADSv.2 =3, 56.6% of PIRADSv.2 =4, and 78.5% of PIRADSv.2 =5, (P0.001). Insignificant CaP detection ranged from 6.5% to 1.5% respectively (P = 0.099). PSAD was an independent predictor of sCaP (odds ratios 1.971, 95% confidence interval [1.633, 2.378], P0.001) and mpMRI (OR 3.179, 95%CI [2.593, 4.950], P0.001). Age (P = 0.013), family history of CaP (P = 0.021), and the type of PB (initial vs. repeated, P0.001) were also independent predictors of sCaP. PSAD was determined by PIRADSv.2 (P = 0.013) and the presence of sCaP (P0.001). PSAD increased with PIRADSv.2 score, even in men with CaP (P0.001) and slightly in men without CaP (P = 0.019). The area under the curve for mpMRI increased from 0.830 to 0.869 when PSAD was associated, (P0.001). The area under the curve of PSAD decreased from 0.727 in men with a PIRADSv.2 score3 to 0.706 in those with a score of 5.The efficacy of PSAD to detect sCaP decreases with PIRADSv.2. Predictors other than mpMRI and PSAD exist. Considering these conditions, independent predictors should be integrated in a nomogram and risk-calculator to personalize PB recommendation.