Publications by authors named "Giovanni Motterle"

25 Publications

  • Page 1 of 1

Comparison of Multimodal Therapies and Outcomes Among Patients With High-Risk Prostate Cancer With Adverse Clinicopathologic Features.

JAMA Netw Open 2021 Jul 1;4(7):e2115312. Epub 2021 Jul 1.

Department of Urology, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland.

Importance: The optimal management strategy for high-risk prostate cancer and additional adverse clinicopathologic features remains unknown.

Objective: To compare clinical outcomes among patients with high-risk prostate cancer after definitive treatment.

Design, Setting, And Participants: This retrospective cohort study included patients with high-risk prostate cancer (as defined by the National Comprehensive Cancer Network [NCCN]) and at least 1 adverse clinicopathologic feature (defined as any primary Gleason pattern 5 on biopsy, clinical T3b-4 disease, ≥50% cores with biopsy results positive for prostate cancer, or NCCN ≥2 high-risk features) treated between 2000 and 2014 at 16 tertiary centers. Data were analyzed in November 2020.

Exposures: Radical prostatectomy (RP), external beam radiotherapy (EBRT) with androgen deprivation therapy (ADT), or EBRT plus brachytherapy boost (BT) with ADT. Guideline-concordant multimodal treatment was defined as RP with appropriate use of multimodal therapy (optimal RP), EBRT with at least 2 years of ADT (optimal EBRT), or EBRT with BT with at least 1 year ADT (optimal EBRT with BT).

Main Outcomes And Measures: The primary outcome was prostate cancer-specific mortality; distant metastasis was a secondary outcome. Differences were evaluated using inverse probability of treatment weight-adjusted Fine-Gray competing risk regression models.

Results: A total of 6004 men (median [interquartile range] age, 66.4 [60.9-71.8] years) with high-risk prostate cancer were analyzed, including 3175 patients (52.9%) who underwent RP, 1830 patients (30.5%) who underwent EBRT alone, and 999 patients (16.6%) who underwent EBRT with BT. Compared with RP, treatment with EBRT with BT (subdistribution hazard ratio [sHR] 0.78, [95% CI, 0.63-0.97]; P = .03) or with EBRT alone (sHR, 0.70 [95% CI, 0.53-0.92]; P = .01) was associated with significantly improved prostate cancer-specific mortality; there was no difference in prostate cancer-specific mortality between EBRT with BT and EBRT alone (sHR, 0.89 [95% CI, 0.67-1.18]; P = .43). No significant differences in prostate cancer-specific mortality were found across treatment cohorts among 2940 patients who received guideline-concordant multimodality treatment (eg, optimal EBRT alone vs optimal RP: sHR, 0.76 [95% CI, 0.52-1.09]; P = .14). However, treatment with EBRT alone or EBRT with BT was consistently associated with lower rates of distant metastasis compared with treatment with RP (eg, EBRT vs RP: sHR, 0.50 [95% CI, 0.44-0.58]; P < .001).

Conclusions And Relevance: These findings suggest that among patients with high-risk prostate cancer and additional unfavorable clinicopathologic features receiving guideline-concordant multimodal therapy, prostate cancer-specific mortality outcomes were equivalent among those treated with RP, EBRT, and EBRT with BT, although distant metastasis outcomes were more favorable among patients treated with EBRT and EBRT with BT. Optimal multimodality treatment is critical for improving outcomes in patients with high-risk prostate cancer.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.15312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251338PMC
July 2021

Multiparametric magnetic resonance imaging of the prostate underestimates tumour volume of small visible lesions.

BJU Int 2021 May 26. Epub 2021 May 26.

Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy.

Objective: To assess the relationship between the volume of the index lesion (IL) measured at multiparametric magnetic resonance imaging (mpMRI; MRIvol) and at radical prostatectomy (RPvol), stratifying it according to Prostate Imaging-Reporting and Data System (PI-RADS) score.

Patients And Methods: We identified 332 men with a positive mpMRI (single lesion with PI-RADS ≥3) who underwent systematic plus targeted biopsy and subsequent RP at two tertiary referral centres between 2013 and 2018. All mpMRIs were reviewed by experienced radiologists using PI-RADS scores. The study outcome was to assess the relationship between MRIvol (based on planimetry from MRI sequence best showing tumour) and RPvol (based on tumour involved area of each RP pathology slice). To achieve this endpoint, we performed a multivariable linear regression analysis (LRA) to predict RPvol using PI-RADS, prostate-specific antigen level, prostate volume, age, digital rectal examination, Gleason score at MRI-targeted biopsy, biopsy history and time from mpMRI to RP as covariates. Non-parametric locally estimated scatterplot smoothing (LOESS) function was used to graphically explore the relationship between MRIvol and RPvol, stratifying for PI-RADS score.

Results: Overall, 24%, 49% and 27% of men had visible PI-RADS 3, 4 and 5 lesions at mpMRI. The median (interquartile range [IQR]) MRIvol and RPvol were 0.67 (0.29-1.76) mL and 1.39 (0.58-4.23) mL. At LRA, MRIvol was significantly correlated with a RPvol underestimation (slope: 2.4, 95% confidence interval [CI] 0.1-46.3). The non-parametric LOESS analysis showed a non-linear relationship between MRIvol and RPvol. Significant underestimation was reported across all volumes with the highest differences between MRIvol and RPvol in the low volume range (<2 mL), where RPvol almost doubled MRIvol. A similar effect was observed across all PI-RADS scores subgroups.

Conclusions: In the present study, mpMRI significantly underestimated the exact volume of the IL, especially for small visible lesions, regardless of PI-RADS score. This should be considered when planning tailored focal therapy approaches often delivered to men with smaller prostatic lesions.
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http://dx.doi.org/10.1111/bju.15498DOI Listing
May 2021

Optimizing prostate-targeted biopsy schemes in men with multiple mpMRI visible lesions: should we target all suspicious areas? Results of a two institution series.

Prostate Cancer Prostatic Dis 2021 May 3. Epub 2021 May 3.

Department of Urology and Division of Experimental Oncology, URI, Urological Research Institute, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Background: To assess the diagnostic added value of sampling secondary lesions at prostate mpMRI (SL) in addition to index lesion (IL) in detecting significant prostate cancer (csPCa) when also systematic biopsy (SBx) is performed.

Methods: We relied on a cohort of 312 men with two suspicious lesions at prostate mpMRI who underwent subsequent targeted biopsy of each lesion (TBx) and concomitant SBx at two tertiary-referral centers between 2013 and 2019. The study outcome was the added value of targeting SL (i.e., the one with a lower PI-RADS score and/or the smaller size compared to IL) in the detection of csPCa. To this aim, we compared different biopsy strategies (SBx + overall TBx vs SBx + IL-targeted biopsy vs SBx + SL-targeted biopsy) and assessed whether SL features could be correlated with detection of csPCa at overall TBx in a multivariable logistic regression model (MVA).

Results: Overall, 44% of men had csPCa at TBx of all lesions while 39% and 23% of men had csPCa found in IL and SL, respectively. The rate of csPCa found at SBx, IL-TBx, and SL-TBx only was 5%, 6%, and 2%, respectively. The detection rate of csPCa for SBx + IL-TBx was 47%. The addition of SL-TBx increased csPCa detection by only 2% (p = 0.12). At MVA, neither PI-RADS of SL nor the number of cores targeting SL was associated with an increased detection of csPCa (all p > 0.3). Conversely, age (OR: 1.07), PSA (OR: 1.07), prostate volume (OR: 0.98), and PI-RADS of the IL (OR: 2.36) were independently associated with csPCa detection at TBx (all p < 0.01).

Conclusions: There is no significant benefit in terms of csPCa detection when an adequate SBx is performed in combination with IL-TBx in patients with multiple mpMRI lesions. In these men target biopsy of secondary lesions can be safely omitted.
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http://dx.doi.org/10.1038/s41391-021-00371-yDOI Listing
May 2021

Age and gleason score upgrading between prostate biopsy and radical prostatectomy: Is this still true in the multiparametric resonance imaging era?

Urol Oncol 2021 Apr 14. Epub 2021 Apr 14.

Division of Oncology/Unit of Urology, URI, IRCCS Ospedale San Raffaele, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.

Introduction: Several studies have invariably shown that the risk of Grade Group (GG) upgrading between biopsy and radical prostatectomy (RP) is higher in elderly men. Whether this is due to a real biological effect or to a diagnostic bias is still unknown. We hypothesized that the introduction of multiparametric magnetic resonance imaging (MRI) has improved the diagnostic accuracy of PCa detection in older men thus reducing the risk of GG upgrading at RP reported in the pre-MRI era.

Materials And Methods: We selected 424 men who received a systematic plus targeted biopsy for a positive MRI and subsequent RP at two referral centers between 2013 and 2019. Upgrading was defined as an increase in GG at final pathology as compared to biopsy. Multivariable logistic regressions tested the risk of upgrading over increasing age according to any upgrading definition and after stratifying definitions according to GG group and biopsy type. Non-parametric functions explored the relationship between age and upgrading rate.

Results: Median rate of upgrading was 17%. In multivariable models, while age was not associated with increased risk of GG upgrading (p=0.4). At non-parametric analyses, probability of upgrading slightly decreased with age, without reaching statistical significance. In subgroup analyses according to different upgrading definition and to biopsy type, age did not predict higher risk of upgrading regardless of outcome definitions (GG 1 to 2 P = 0.1; GG 2 to 3 P = 0.2; GG 3 to 4-5 P = 0.2) and in GG detected at TBx (OR 0.998, P = 0.8).

Conclusions: We showed that use of MRI has obliterated the association between older age and increased risk of upgrading mainly due to improved diagnostic approaches in this group of men. Therefore, it is likely that the effect of age and GG upgrading reported in previous studies in elderly men was due to misdiagnosis and lead-time bias in the pre-MRI era.
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http://dx.doi.org/10.1016/j.urolonc.2021.03.013DOI Listing
April 2021

Nomograms in Urologic Oncology: Lights and Shadows.

J Clin Med 2021 Mar 2;10(5). Epub 2021 Mar 2.

Urology Unit, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, 35128 Padua, Italy.

Decision-making in urologic oncology involves integrating multiple clinical data to provide an answer to the needs of a single patient. Although the practice of medicine has always been an "art" involving experience, clinical data, scientific evidence and judgment, the creation of specialties and subspecialties has multiplied the challenges faced every day by physicians. In the last decades, with the field of urologic oncology becoming more and more complex, there has been a rise in tools capable of compounding several pieces of information and supporting clinical judgment and experience when approaching a difficult decision. The vast majority of these tools provide a risk of a certain event based on various information integrated in a mathematical model. Specifically, most decision-making tools in the field of urologic focus on the preoperative or postoperative phase and provide a prognostic or predictive risk assessment based on the available clinical and pathological data. More recently, imaging and genomic features started to be incorporated in these models in order to improve their accuracy. Genomic classifiers, look-up tables, regression trees, risk-stratification tools and nomograms are all examples of this effort. Nomograms are by far the most frequently used in clinical practice, but are also among the most controversial of these tools. This critical, narrative review will focus on the use, diffusion and limitations of nomograms in the field of urologic oncology.
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http://dx.doi.org/10.3390/jcm10050980DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7957873PMC
March 2021

Transitional cell carcinoma recurrence impacting intestinal diversion after radical cystectomy. Oncologic outcomes of a rare site of recurrence.

Cent European J Urol 2020 9;73(4):445-456. Epub 2020 Dec 9.

Department of Urology, Mayo Clinic, Rochester, MN, USA.

Introduction: Transitional cell carcinoma recurrence within an intestinal urinary diversion (TCCUD) after radical cystectomy (RC) is a rare condition with unknown origin, prognosis and treatment. The aim of this study was to describe treatment options and oncologic outcomes of this understudied site of recurrence in a multi-institutional case series.

Material And Methods: TCCUD relapse cases after RC were investigated in a retrospective, multi-institutional study. Surgical approach and adjuvant chemotherapy were discussed. Early and late complications were described according to the Clavien-Dindo classification. Kaplan-Meier method was used to assess progression-free and cancer-specific survival.

Results: A total of 19 patients were selected. The most common presentation was gross hematuria. The median interval between RC and TCCUD was 51.2 months. Fifteen patients (78.9%) underwent surgical excision, and two underwent concomitant radical nephroureterectomy. In 12 (63.1%) cases the site of TCCUD was the uretero-ileal anastomosis. Tumor invading the muscularis of the intestinal diversion was described in 10 (52.6%) cases. Surgical complications occurred in 7/15 (46.6%) patients, of these two with Clavien-Dindo Grade III. Four patients (21.0%) underwent adjuvant chemotherapy and two (10.5%) both chemotherapy and radiation therapy. During follow-up 15 patients (78.9%) presented with other sites of recurrence, with lymph nodes (21.0%) and liver (15.7%) being the most common localizations. Recurrence free and overall survival rates were 36.8% and 15.8%, and 56.5% and 24.2%, respectively at 12 and 18 months.

Conclusions: Most patients with TCCUD have invasive disease and a substantial percentage experience upper tract cancer during their disease course. TCCUD is often the herald of advanced disease and systemic progression, with poor progression-free and overall survival rates.
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http://dx.doi.org/10.5173/ceju.2020.0168.R1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7848846PMC
December 2020

Spermatic Cord Sarcoma: A 20-Year Single-Institution Experience.

Front Surg 2020 17;7:566408. Epub 2020 Nov 17.

Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy.

Spermatic cord sarcomas represent a rare genitourinary malignancy with a challenging diagnostic and therapeutic pathway. Different histotypes have been described and prognostic factors remain poorly defined due to the paucity of data presented in literature. Retrospective chart review of 22 adult patients treated for spermatic cord sarcoma in a single institution in the last 20 years was performed. Clinicopathological characteristics of the tumors were collected with primary and subsequent treatment. Survival analysis was performed in order to identify prognostic factors of disease-specific survival. The median age at diagnosis was 68 years (58-78), the most common histotype was liposarcoma (14/22), and most patients (63.6%) were found to have positive surgical margins after surgery. The 5-year cancer specific survival was 91.3%. Grading ( = 0.480), histotype ( = 0.327), and type of intervention ( = 0.732) were not associated with survival. All patients dead of disease had positive surgical margins ( = 0.172). We report a good prognosis at 5 years. Wide radical resection remains the first and probably the most important step; thus, according also to literature, negative surgical margins should be aimed.
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http://dx.doi.org/10.3389/fsurg.2020.566408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705095PMC
November 2020

Spermatic Cord Sarcoma: A 20-Year Single-Institution Experience.

Front Surg 2020 17;7:566408. Epub 2020 Nov 17.

Surgical Oncology Unit, Veneto Institute of Oncology (IOV-IRCCS), Padua, Italy.

Spermatic cord sarcomas represent a rare genitourinary malignancy with a challenging diagnostic and therapeutic pathway. Different histotypes have been described and prognostic factors remain poorly defined due to the paucity of data presented in literature. Retrospective chart review of 22 adult patients treated for spermatic cord sarcoma in a single institution in the last 20 years was performed. Clinicopathological characteristics of the tumors were collected with primary and subsequent treatment. Survival analysis was performed in order to identify prognostic factors of disease-specific survival. The median age at diagnosis was 68 years (58-78), the most common histotype was liposarcoma (14/22), and most patients (63.6%) were found to have positive surgical margins after surgery. The 5-year cancer specific survival was 91.3%. Grading ( = 0.480), histotype ( = 0.327), and type of intervention ( = 0.732) were not associated with survival. All patients dead of disease had positive surgical margins ( = 0.172). We report a good prognosis at 5 years. Wide radical resection remains the first and probably the most important step; thus, according also to literature, negative surgical margins should be aimed.
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http://dx.doi.org/10.3389/fsurg.2020.566408DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7705095PMC
November 2020

A Rare Case of Prostate-Specific Antigen-Producing Metastatic Parotid Adenocarcinoma Developing Androgen Receptor Resistance.

Mayo Clin Proc Innov Qual Outcomes 2020 Oct 19;4(5):601-607. Epub 2020 Aug 19.

Division of Medical Oncology, Mayo Clinic, Rochester, MN.

A 62-year-old man presented with a rising serum concentration of prostate-specific antigen (PSA) to 53.3 ng/mL (to convert to μg/L, multiply by 1) and a PSA doubling time of 2.6 months. Computed tomography, fluorodeoxyglucose-positron emission tomography, and C-11 choline positron emission tomography demonstrated a parotid mass with innumerable lytic bone lesions and diffuse metastatic disease to the neck and mediastinal lymph nodes. Mediastinal lymph node biopsy revealed salivary ductal adenocarcinoma that produced PSA and demonstrated androgen receptor sensitivity. The patient had a prolonged clinical benefit to first- and second-line hormone therapy, and his PSA levels correlated with treatment response, development of hormone resistance, and progression. In summary, urologists, pathologists, and primary care providers should be aware that a rising PSA level in the setting of a head and neck mass in a patient without a history of prostate cancer does not constitute a diagnosis of metastatic prostate adenocarcinoma and that other primary tumors should be considered and a broader imaging and pathologic evaluation is indicated.
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http://dx.doi.org/10.1016/j.mayocpiqo.2020.05.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7557195PMC
October 2020

Urological Care and COVID-19: Looking Forward.

Front Oncol 2020 21;10:1313. Epub 2020 Jul 21.

Clinica Urologica, Department of Surgical and Oncological Sciences, University of Padua, Padua, Italy.

The recent COVID-19 pandemic represents a worldwide emergency and it is affecting healthcare at every level, including also urological care and especially oncologic patients. Recent epidemiological models show that, without effective treatment or vaccine, there will be a long-lasting phase of cohabitation with the virus. Current experts' opinions recommend performing only non-deferrable uro-oncological surgery and postponing other activities until the end of the emergency, with particular concerns regarding the safety laparoscopy. Veneto Region and Padua Province represent one of the first site of the pandemic spread of the virus outside China, thus we present our experience as a Urological Referral Center in applying a segregated-team work model of organization during the month of March 2020, with a stratified organization of activities, adequate screening and protection for patients and staff were adopted. Compared to the same period of last year even if a 19.5% reduction was experienced in overall surgical activity while maintaining a comparable proportion of oncologic robotic and laparoscopic surgery and guaranteeing care also for high priority non-oncological patients. No cases of COVID-19 infection were reported in staff members nor in patients and the number of surgical complications was comparable to that of last year. Therefore, in our opinion the recommended significant reduction in urological care, including surgical activities, is likely unrealistic in the long period with unknown effects affecting mostly oncological patients. Our experience introducing a segregated-team work model might represent a model for future planning.
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http://dx.doi.org/10.3389/fonc.2020.01313DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7386309PMC
July 2020

Adding carboplatin to chemotherapy regimens for metastatic castrate-resistant prostate cancer in postsecond generation hormone therapy setting: Impact on treatment response and survival outcomes.

Prostate 2020 10 31;80(14):1216-1222. Epub 2020 Jul 31.

Department of Urology, Mayo Clinic, Rochester, Minnesota.

Background: The clinical course in metastatic castrate-resistant prostate cancer (mCRPC) can be complicated when patients have disease progression after prior treatment with second generation hormone therapy (second HT), such as enzalutamide or abiraterone. Currently, limited data exist regarding the optimal choice of chemotherapy for mCRPC after failing second generation hormone therapy. We sought to evaluate three common chemotherapy regimens in this setting.

Methods: We retrospectively identified 150 mCRPC patients with disease progression on enzalutamide or abiraterone. Of these 150 patients, 92 patients were chemo-naïve while 58 patients had previously received docetaxel chemotherapy before being started on second HT. After failing second HT, 90 patients were assigned for docetaxel-alone (group A), 33 patients received carboplatin plus docetaxel (group B), while 27 patients received cabazitaxel-alone (Group C). A favorable response was defined by more than or equal to 50% reduction in prostate-specific antigen from the baseline level after a complete course of chemotherapy. Survival outcomes were assessed for 30-month overall survival.

Results: Patients in group (B) were 2.6 times as likely to have a favorable response compared to patients in group (A) (OR = 2.625, 95%CI: 1.15-5.99) and almost three times compared to patients in group (C) (OR = 2.975, 95%CI: 1.04-8.54) (P = .0442). 30-month overall survival was 70.7%, 38.9% and 30.3% for group (B), (A), and (C), respectively (P = .008). We report a Hazard Ratio of 3.1 (95% CI, 1.31-7.35; P = .0037) between patients in group (A) versus those in group (B) and a Hazard Ratio of 4.18 (95% CI, 1.58-11.06; P = .0037) between patients in group (C) compared to those in group (B) CONCLUSION: This data demonstrates improved response and overall survival in treatment-refractory mCRPC with a chemotherapy regimen of docetaxel plus carboplatin when compared to docetaxel alone or cabazitaxel alone. Further investigations are required.
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http://dx.doi.org/10.1002/pros.24048DOI Listing
October 2020

Minimally invasive urologic surgery is safe during COVID-19: experience from two high-volume centers in Italy.

J Robot Surg 2020 Dec 15;14(6):909-911. Epub 2020 Jun 15.

Urologic Clinic, "Santa Maria della Misericordia" Hospital, University of Udine, Udine, Italy.

Potential risks of COVID-19 spread during minimally invasive procedures caused several concerns among surgeons, despite the lack of high-level evidence. Urological robotic and laparoscopic surgery is performed in elective setting in almost all occasions, thus allowing adequate planning and stratification. Two high-volume urological centers in Italy performed 77 robotic and laparoscopic surgeries during the "lockdown" period and adopted various strategies to prevent contamination. First of all, all patients were tested negative with nasopharyngeal swab before the surgical intervention. Patients and personnel were provided adequate personal protective equipment and intraoperative strategies to prevent smoke formation and pneumoperitoneum spread were adopted. No patients nor staff members tested positive for COVID-19 during a 15-day follow-up period. In conclusion, minimally invasive urologic surgery can be safely performed during the pandemic period with adequate planning. We believe that renouncing the benefits of it would be counterproductive, especially in a scenario of long-lasting cohabitation with the virus.
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http://dx.doi.org/10.1007/s11701-020-01099-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7295143PMC
December 2020

The impact of COVID-19 pandemic on urological emergencies: a single-center experience.

World J Urol 2021 Jun 23;39(6):1985-1989. Epub 2020 May 23.

Clinica Urologica, Department of Surgical and Oncological Sciences, University of Padova, Via Giustiniani, 2, 35100, Padova, Italy.

Purpose: COVID-19 pandemic represents a novel challenge for healthcare systems, and it affects even the daily urological practice. Italy was the first country after China to experience a lock-down period. Our objective is to determine whether, during the COVID-19 period, there has been any modification in urological emergencies.

Methods: we retrospectively reviewed urgent urological consultations requested by the Emergency Department (ED) of Padua University Hospital in the 36-day period between February 22nd and March 30th, 2020 and compared them to the prior year cases within a similar time frame (February 24th to March 31st, 2019). Pediatric population (age < 15 years); surgical complications and traumas were excluded to avoid confounding from the reduction of activities during the lockdown. The number of daily consultations, the number of invasive procedures performed and admissions were evaluated, together with the predictors of admission were identified through multivariate logistic regression models.

Results: The final sample resulted in 107 consultations performed in 2020 and 266 in 2019. A higher number of daily consultations was performed during 2019 (7.33 vs 2.97, p < 0.001). Similarly, the number of daily-invasive procedures was higher in 2019 (p = 0.006), while there was no difference in the number of daily admissions (15 vs 12, p = 0.80). On multivariate analysis, the year (2020 vs 2019, OR 2.714, 95% CI 1.096-6.757, p = 0.0297) was a significant predictor of admission.

Conclusions: Urgent urology practice was affected during COVID-19 pandemic with a remarkable reduction in urgent urological consultations; furthermore, a higher risk of admissions was observed in 2020. The consequences of a potentially delayed diagnosis remain to be determined.
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http://dx.doi.org/10.1007/s00345-020-03264-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7245166PMC
June 2021

The multifaceted long-term effects of the COVID-19 pandemic on urology.

Nat Rev Urol 2020 07;17(7):365-367

Urology Clinic, Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.

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http://dx.doi.org/10.1038/s41585-020-0331-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201202PMC
July 2020

Prostate cancer: more effective use of underutilized postoperative radiation therapy.

Expert Rev Anticancer Ther 2020 04 17;20(4):241-249. Epub 2020 Mar 17.

Department of Urology, Mayo Clinic, Rochester, MN, USA.

: Adverse pathological features at radical prostatectomy such as extracapsular extension, seminal-vesicle involvement, positive surgical margins and/or lymph node invasion define a particular subgroup of patients that might benefit from additional treatment after surgery, in particular radiation therapy.: Post-prostatectomy radiation is intended as adjuvant, early-salvage or salvage depending on the timing and PSA levels at the treatment. After providing the most used definitions, the high-level evidence supporting adjuvant radiation is reviewed together with the limitations affecting its utilization. In recent years early-salvage radiation was hypothesized to be a non-inferior alternative based on good-quality retrospective data. Recently, preliminary results of ongoing trials provide additional evidence. In light of the need to identify patients that will truly benefit from adjuvant radiation, clinically based and molecular tools available for this purpose are reviewed.: In order to tailor treatment for the patient after radical prostatectomy, there is a need for a tool that could both improve the oncological outcomes and be cost-effective. To date, genomic testing provides the most promising results that will be reasonably improved in the coming years.
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http://dx.doi.org/10.1080/14737140.2020.1743183DOI Listing
April 2020

Neoadjuvant chemotherapy in bladder cancer: not a matter on how much but on who it is effective.

Transl Androl Urol 2019 Dec;8(Suppl 5):S480-S481

Department of Urology, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.21037/tau.2019.09.39DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989860PMC
December 2019

Salvage Radical Prostatectomy After Robot-assisted Laparoscopic Prostatectomy: Case Series.

Clin Genitourin Cancer 2020 04 16;18(2):e202-e207. Epub 2019 Oct 16.

Department of Urology, Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1016/j.clgc.2019.10.017DOI Listing
April 2020

The Role of Radical Prostatectomy and Lymph Node Dissection in Clinically Node Positive Patients.

Front Oncol 2019 10;9:1395. Epub 2019 Dec 10.

Department of Urology, Mayo Clinic, Rochester, MN, United States.

Patients diagnosed with clinically node-positive prostate cancer represent a population that has historically been thought to harbor systemic disease. Increasing evidence supports the role of local therapies in advanced disease, but few studies have focused on this particular population. In this review we discuss the limited role for conventional cross sectional imaging for accurate nodal staging and how molecular imaging, although early results are promising, is still far from widespread clinical utilization. To date, evidence regarding the role of radical prostatectomy and pelvic lymph node dissection in clinically node-positive disease comes from retrospective studies; overall surgery appears to be a reasonable option in selected patients, with improved oncological outcomes that could be attributed to both to its potential curative role in disease localized to the pelvis and to the improved staging to help guide subsequent multimodal treatment. The role of surgery in clinically node-positive disease needs higher-level evidence but meanwhile, radical prostatectomy with extended pelvic lymph-node dissection can be offered as a part of a multimodality approach with the patient.
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http://dx.doi.org/10.3389/fonc.2019.01395DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6914693PMC
December 2019

Tumor Seeding after Robot-Assisted Radical Prostatectomy: Literature Review and Experience from a Single Institution.

J Urol 2020 06 17;203(6):1141-1146. Epub 2020 Mar 17.

Department of Urology, Mayo Clinic, Rochester, Minnesota.

Purpose: Seeding of tumor cells is a rare complication of minimally invasive surgery. We reviewed and improved current knowledge of prostate cancer seeding.

Materials And Methods: A literature review was performed using MEDLINE®, Embase® and the Cochrane Library, including cases of peritoneal and port site seeding reported after minimally invasive prostatectomy. In addition, after institutionally approved chart review a descriptive summary of a single institution experience on the topic is provided.

Results: The data from 9 reported cases of port site metastases from prostate cancer in the world literature are summarized along with 3 additional cases from our experience. Similarly, 5 cases of peritoneal seeding are reviewed from the literature with the addition of 3 more cases from our institution. Good long-term outcomes are achievable with multimodality and individualized regimens, including seeding directed treatments.

Conclusions: Although no definitive recommendation can be made for treatment strategies for these patients, there is a need for awareness and further discussion of this atypical presentation.
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http://dx.doi.org/10.1097/JU.0000000000000701DOI Listing
June 2020

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review.

J Endourol 2020 02;34(2):113-120

Dipartimento di Scienze Oncologiche, Chirurgiche e Gastroenterologiche, UOC Urologia, Universita' degli Studi di Padova, Padova.

Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.
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http://dx.doi.org/10.1089/end.2019.0716DOI Listing
February 2020

Predicting Response to Neoadjuvant Chemotherapy in Bladder Cancer.

Eur Urol Focus 2020 07 8;6(4):642-649. Epub 2019 Nov 8.

Department of Urology, Mayo Clinic, Rochester, MN, USA. Electronic address:

Context: Neoadjuvant chemotherapy (NAC) is recommended prior to radical cystectomy in the setting of muscle-invasive bladder cancer. Despite a 5-10% survival benefit, some patients do not respond to NAC. Identification of the nonresponders could avoid side effects and delay in surgery.

Objective: The objective of this review is to summarize the latest evidence regarding predictors of NAC response.

Evidence Acquisition: MEDLINE, Embase, and the Cochrane Library databases were searched for published studies including clinical, pathological, molecular, and imaging tests or factors that can be applied before or during NAC to predict its results.

Evidence Synthesis: Patient characteristics and imaging techniques seem to have minimal utility to predict NAC response. Only advanced magnetic resonance imaging techniques seem to have a potential role. There is insufficient evidence to suggest a change in NAC paradigm for variant histology, whereas the most promising results come from molecular characterization of tumors.

Conclusions: No validated instrument currently exists to predict NAC response. While awaiting further evidence, no strong recommendation can be made toward a shift in paradigm.

Patient Summary: The most effective and aggressive treatment for muscle-invasive bladder cancer is radical cystectomy preceded by effective neoadjuvant chemotherapy. In this paper, we reviewed the current literature and published evidence to identify predictors of response to neoadjuvant chemotherapy for muscle-invasive bladder cancer. To date, no instrument exists to predict which patients will respond to neoadjuvant chemotherapy.
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http://dx.doi.org/10.1016/j.euf.2019.10.016DOI Listing
July 2020

Re: Evaluation of Cancer Specific Mortality with Surgery versus Radiation as Primary Therapy for Localized High Grade Prostate Cancer in Men Younger than 60 Years.

Eur Urol 2019 06 1;75(6):1035-1036. Epub 2019 Mar 1.

Department of Urology, Mayo Clinic, Rochester, MN, USA; Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Azienda Ospedaliera, Universitaria di Padova, Padova, Italy.

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http://dx.doi.org/10.1016/j.eururo.2019.02.025DOI Listing
June 2019

The Role of Lymph Node Dissection in the Treatment of Bladder Cancer.

Front Surg 2018 5;5:62. Epub 2018 Oct 5.

Clinica Urologica, Dipartimento di Scienze Chirurgiche, Oncologiche e Gastroenterologiche, Università degli Studi di Padova, Padova, Italy.

Lymph node dissection (LND; PLND: pelvic LND) is an essential component of radical cystectomy (RC) for bladder cancer (BC). However, the optimal anatomical extent of LND and its potential therapeutic role are still controversial: as we will explain, the extent of LND dissection is a predictor of survival and local recurrence but what is an adequate extension is still unclear. Moreover, there is large uncertainty about the role of surgery in patients with clinically-positive nodes. In this review we will provide a synthesis of the available evidence on this highly debated topic. Overall, the studies presented in this work support the idea that extended lymphadenectomy could provide optimal diagnostic and possibly therapeutic results in cN- patients. In cN+ patients, post chemotherapy surgery may be considered especially in subjects who have a good response to CHT, although definitive evidence is still needed. Finally, the final results of randomized trials are eagerly awaited to draw definitive conclusions of the role of PLND in BC.
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http://dx.doi.org/10.3389/fsurg.2018.00062DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6187970PMC
October 2018

Frailty and elderly in urology: Is there an impact on post-operative complications?

Cent European J Urol 2017 Jun 12;70(2):197-205. Epub 2017 Jun 12.

University of Padova, Department of Surgery, Oncology and Gastroenterology - Urology, Padova, Italy.

Introduction: Frailty used as predictive tool is still not carried out in daily practice, although many studies confirm the great clinical importance of the frailty syndrome in surgical outcomes. There is no standardized method of measuring the physiological reserves of older surgical patients. The aim of this study was to analyze a cohort of older urological patients according to various frailty indices, in order to evaluate whether they are predictors of post-operative complications after urological procedures.

Material And Methods: This is a prospective observational study on 78 consecutive older (≥70 years) patients, subjected to major urological (both endoscopic and 'open surgical') procedures. Frailty was defined according to the Edmonton Frail Scale. Several risk models and biochemical parameters were evaluated. Post-operative outcomes were surgical and medical complications, mortality and rehospitalisation within 3 months.

Results: An overall prevalence of frailty of 21.8% was found. Patients with complications were frailer than those without complications (univariate analysis), considering both total patients (p = 0.002) and endoscopic (p = 0.04) and 'open surgical' patients (p = 0.013). However, in multivariate analysis, a significant correlation was not found between all frailty indices tested and the risk of major complications. Limitation of the study: the small sample size (lack of statistical power), although this is a prospective study focused on older urological patients.

Conclusions: New urology-tailored pre-operative assessment tools may prove beneficial when calculating the risks/benefits of urological procedures, so that objective data can guide surgical decision- making and patient counselling. Further large clinical studies specifically focusing on elderly in urology will be needed.
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http://dx.doi.org/10.5173/ceju.2017.1321DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510344PMC
June 2017
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