Publications by authors named "Roberto Mario Scarpa"

63 Publications

How Can the COVID-19 Pandemic Lead to Positive Changes in Urology Residency?

Front Surg 2020 24;7:563006. Epub 2020 Nov 24.

Department of Urology, IEO European Institute of Oncology IRCCS, Milan, Italy.

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.
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http://dx.doi.org/10.3389/fsurg.2020.563006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7732553PMC
November 2020

Telehealth in Urology: A Systematic Review of the Literature. How Much Can Telemedicine Be Useful During and After the COVID-19 Pandemic?

Eur Urol 2020 12 18;78(6):786-811. Epub 2020 Jun 18.

Department of Human and Pediatric Pathology "Gaetano Barresi", Urologic Section, University of Messina, Italy.

Context: Coronavirus disease 2019 (COVID-19) pandemic has caused increased interest in the application of telehealth to provide care without exposing patients and physicians to the risk of contagion. The urological literature on the topic is sparse.

Objective: To perform a systematic review of the literature and evaluate all the available studies on urological applications of telehealth.

Evidence Acquisition: After registration on PROSPERO, we searched PubMed and Scopus databases to collect any kind of studies evaluating any telehealth interventions in any urological conditions. The National Toxicology Program/Office of Health Assessment and Translation Risk of Bias Rating Tool for Human and Animal Studies was used to estimate the risk of bias. A narrative synthesis was performed.

Evidence Synthesis: We identified 45 studies (11 concerning prostate cancer [PCa], three hematuria management, six urinary stones, 14 urinary incontinence [UI], five urinary tract infections [UTIs], and six other conditions), including 12 randomized controlled trials. The available literature indicates that telemedicine has been implemented successfully in several common clinical scenarios, including the decision-making process following a diagnosis of nonmetastatic PCa, follow-up care of patients with localized PCa after curative treatments, initial diagnosis of hematuria, management diagnosis and follow-up care of uncomplicated urinary stones and uncomplicated UTIs, and initial evaluation, behavioral therapies, and pelvic floor muscle training in UI patients, as well as follow-up care after surgical treatments of stress urinary incontinence or pelvic organ prolapse. The methodological quality of most of the reports was good.

Conclusions: Telehealth has been implemented successfully in selected patients with PCa, UI, pelvic organ prolapse, uncomplicated urinary stones, and UTIs. Many urological conditions are suitable for telehealth, but more studies are needed on other highly prevalent urological malignant and benign conditions. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine. More robust data on long-term efficacy, safety, and health economics are necessary.

Patient Summary: The diffusion of coronavirus disease 2019 (COVID-19) infections has recently increased the interest in telehealth, which is the adoption of telecommunication to deliver any health care activity. The available literature indicates that telemedicine has been adopted successfully in selected patients with several common clinical urological conditions, including prostate cancer, uncomplicated urinary stones, uncomplicated urinary infections, urinary incontinence, or pelvic organ prolapse. Likely, the COVID-19 pandemic will give a significant boost to the use of telemedicine, but more robust data on long-term efficacy, safety, and costs are necessary.
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http://dx.doi.org/10.1016/j.eururo.2020.06.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7301090PMC
December 2020

Prioritising Urological Surgery in the COVID-19 Era: A Global Reflection on Guidelines.

Eur Urol Focus 2020 Sep 15;6(5):1104-1110. Epub 2020 Jun 15.

Department of Urology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey.

Background: Determining whether members follow guidelines, including guidelines prepared to help direct practice management during the coronavirus disease 2019 (COVID-19) pandemic, is an important goal for medical associations.

Objective: To determine whether practice of urologists is in line with guidelines for the management of common urological conditions during the COVID-19 pandemic produced by leading (inter)national urological associations.

Design, Setting, And Participants: Self-selected urologists completed a voluntary survey available online from March 27 to April 11, 2020 and distributed globally by the Société Internationale d'Urologie.

Outcome Measurements And Statistical Analysis: Responses to two survey questions on the (1) management of 14 common urological procedures and (2) priority scoring of 10 common urological procedures were evaluated by practice setting and geographical region using chi-square and one-way analysis of variance analyses, respectively.

Results And Limitations: There were 2494 respondents from 76 countries. Oncological conditions were prioritised over benign conditions, and benign conditions were deferred when feasible and safe. Oncological conditions with the greatest malignant potential were prioritised over less aggressive cancers. Respondents from Europe were least likely to postpone and most likely to prioritise conditions identified by guidelines as being of the highest priority. Respondents' priority scoring of urological procedures closely matched the priorities assigned by guidelines. The main limitation of this study is that respondents were self-selected, and access to the survey was limited by language and technology barriers.

Conclusions: Prioritisation and management of urological procedures during the COVID-19 pandemic are in line with current guidelines. The greatest agreement was reported in Europe. Observed differences may be related to limited resources in some settings.

Patient Summary: When deciding how best to treat patients during the coronavirus disease 2019 (COVID-19) pandemic, urologists are taking into account both expert recommendations and the availability of important local resources.
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http://dx.doi.org/10.1016/j.euf.2020.06.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7294295PMC
September 2020

Endourology (Lithiasis). Management, surgical considerations and follow-up of patients in the COVID-19 era.

Int Braz J Urol 2020 07;46(suppl.1):39-49

Department of Urology, Campus Biomédico, University of Rome, Rome, Italy.

Purpose: To provide recommendations on the endourological management of lithiasis in the scenario of the COVID-19 pandemic.

Materials And Methods: A non-systematic review in PubMed and the grey literature, as well as recommendations by a panel of stakeholders was made, regarding management, surgical considerations and follow-up of patients affected by lithiasis in the COVID-19 era.

Results: Under the current outbreak and COVID-19 pandemic scenario, patients affected by lithiasis should be prioritized into low, intermediate and high risk categories, to decide their delay and save resources, healthcare personnel, beds and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Delaying lithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may be useful in guiding these patients, reducing visits and unnecessary exposure.

Conclusions: categorization and prioritization of patients affected by lithiasis is crucial for management, surgical selection and follow-up. Protocols, measures and additional efforts should be carried out in the current situation of the COVID-19 pandemic.
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http://dx.doi.org/10.1590/S1677-5538.IBJU.2020.S105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719981PMC
July 2020

Accuracy of magnetic resonance imaging to identify pseudocapsule invasion in renal tumors.

World J Urol 2020 Feb 25;38(2):407-415. Epub 2019 Apr 25.

Department of Urology, Humanitas "Gardenigo" University, Turin, Italy.

Purpose: To evaluate accuracy of MRI in detecting renal tumor pseudocapsule (PC) invasion and to propose a classification based on imaging of PC status in patients with renal cell carcinoma.

Methods: From January 2017 to June 2018, 58 consecutive patients with localized renal cell carcinoma were prospectively enrolled. MRI was performed preoperatively and PC was classified, according to its features, as follows: MRI-Cap 0 (absence of PC), MRI-Cap 1 (presence of a clearly identifiable PC), MRI-Cap 2 (focally interrupted PC), and MRI-Cap 3 (clearly interrupted and infiltrated PC). A 3D image reconstruction showing MRI-Cap score was provided to both surgeon and pathologist to obtain complete preoperative evaluation and to compare imaging and pathology reports. All patients underwent laparoscopic partial nephrectomy. In surgical specimens, PC was classified according to the renal tumor capsule invasion scoring system (i-Cap).

Results: A concordance between MRI-Cap and i-Cap was found in 50/58 (86%) cases. ρ coefficient for each MRI-cap and iCap categories was: MRI-Cap 0: 0.89 (p < 0.0001), MRI-Cap1: 0.75 (p < 0.0001), MRI-Cap 2: 0.76 (p < 0.0001), and MRI-Cap3: 0.87 (p < 0.0001). Sensitivity, specificity, positive predictive value, negative predictive value, and AUC were: MRI-Cap 0: Se 97.87% Spec 83.3%, PPV 95.8%, NPV 90.9%, and AUC 90.9; MRI-Cap 1: Se 77% Spec 95.5%, PPV 83.3%, NPV 93.5%, and AUC 0.86; MRI-Cap 2- iCap 2: Se 88% Spec 90%, PPV 79%, NPV 95%, and AUC 0.89; MRI-Cap 3: Se 94% Spec 95%, PPV 88%, NPV 97%, and AUC 0.94.

Conclusions: MRI-Cap classification is accurate in evaluating renal tumor PC features. PC features can provide an imaging-guided landmark to figure out where a minimal margin could be preferable during nephron-sparing surgery.
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http://dx.doi.org/10.1007/s00345-019-02755-1DOI Listing
February 2020

Five-year Outcomes for a Prospective Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy.

Eur Urol Focus 2018 01 23;4(1):80-86. Epub 2016 Nov 23.

Division of Urology, San Luigi Gonzaga Hospital-Orbassano, University of Turin, Turin, Italy.

Background: The literature is lacking randomised controlled trials comparing robot-assisted (RARP) and laparoscopic (LRP) radical prostatectomy, especially for follow-up >1 yr.

Objective: To report 5-yr outcomes for our previously published prospective randomised study comparing RARP and LRP.

Design, Setting, And Participants: From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned to RARP or LRP.

Intervention: A single surgeon performed all interventions using the same transperitoneal anterograde technique.

Outcome Measurements And Statistical Analysis: Continence, potency, and serum prostate-specific antigen were assessed postoperatively at 1, 3, 6, and 12 mo, and then every 6 mo until 60 mo. At the end of the follow-up period, patients were administered questions 1 and 46 of the Expanded Prostate Cancer Index Composite questionnaire to assess their satisfaction with the intervention and general health status. A generalised estimating equations model was used to compare time series data for functional results, and Kaplan-Meier and Cox models were used to analyse oncologic outcomes.

Results And Limitations: The probability of achieving continence (odds ratio [OR] 2.47, p<0.021) and potency (OR 2.35, p<0.028) over time was more than doubled for the RARP compared to the LRP group. There was no difference between the two approaches in terms of patient survival. Pathologic Gleason score, positive surgical margins, and pT stage were associated with significantly higher biochemical recurrence in Cox multivariate models. Patient satisfaction with the intervention and their general health status was significantly higher in the RARP group.

Conclusions: Throughout the 5-yr follow-up, RARP yielded better functional results compared to LRP, without compromising oncologic outcomes.

Patient Summary: In this report we looked at 5-yr outcomes for a study comparing robot-assisted radical prostatectomy (RARP) and laparascopic radical prostatectomy for the treatment of prostate cancer. We found that continence and potency are better among patients treated with RARP, while oncologic results are comparable.
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http://dx.doi.org/10.1016/j.euf.2016.11.007DOI Listing
January 2018

Prostate health index and prostate cancer gene 3 score but not percent-free Prostate Specific Antigen have a predictive role in differentiating histological prostatitis from PCa and other nonneoplastic lesions (BPH and HG-PIN) at repeat biopsy.

Urol Oncol 2015 Oct 7;33(10):424.e17-23. Epub 2015 Jul 7.

Division of Urology, San Luigi Gonzaga Hospital and University of Torino, Orbassano, Italy.

Objective: To determine if prostate health index (PHI), prostate cancer antigen gene 3 (PCA3) score, and percentage of free prostate-specific antigen (%fPSA) may be used to differentiate asymptomatic acute and chronic prostatitis from prostate cancer (PCa), benign prostatic hyperplasia (BPH), and high-grade prostate intraepithelial neoplasia (HG-PIN) in patients with elevated PSA levels and negative findings on digital rectal examination at repeat biopsy (re-Bx).

Patients And Methods: In this prospective study, 252 patients were enrolled, undergoing PHI, PCA3 score, and %fPSA assessments before re-Bx. We used 3 multivariate logistic regression models to test the PHI, PCA3 score, and %fPSA as risk factors for prostatitis vs. PCa, vs. BPH, and vs. HG-PIN. All the analyses were performed for the whole patient cohort and for the "gray zone" of PSA (4-10ng/ml) cohort (171 individuals).

Results: Of the 252 patients, 43 (17.1%) had diagnosis of PCa. The median PHI was significantly different between men with a negative biopsy and those with a positive biopsy (34.9 vs. 48.1, P<0.001), as for the PCA3 score (24 vs. 54, P<0.001) and %fPSA (11.8% vs. 15.8%, P = 0.012). The net benefit of using PCA3 and PHI to differentiate prostatitis and PCa was moderate, although it extended to a good range of threshold probabilities (40%-100%), whereas that from using %fPSA was negligible: this pattern was reported for the whole population as for the "gray zone" PSA cohort.

Conclusion: In front of a good diagnostic performance of all the 3 biomarkers in distinguishing negative biopsy vs. positive biopsy, the clinical benefit of using the PCA3 score and PHI to estimate prostatitis vs. PCa was comparable. PHI was the only determinant for prostatitis vs. BPH, whereas no biomarkers could differentiate prostate inflammation from HG-PIN.
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http://dx.doi.org/10.1016/j.urolonc.2015.05.032DOI Listing
October 2015

Editorial comment.

Urology 2015 Apr;85(4):888-9

Department of Urology, University of Cagliari, Cagliari, Italy.

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http://dx.doi.org/10.1016/j.urology.2014.09.071DOI Listing
April 2015

Comparison of prostate cancer gene 3 score, prostate health index and percentage free prostate-specific antigen for differentiating histological inflammation from prostate cancer and other non-neoplastic alterations of the prostate at initial biopsy.

Anticancer Res 2014 Dec;34(12):7159-65

Division of Urology, San Luigi Gonzaga Hospital and University of Torino, Orbassano, Torino, Italy.

Aim: To determine if prostate cancer gene 3 (PCA3) score, Prostate Health Index (PHI), and percent free prostate-specific antigen (%fPSA) may be used to differentiate prostatitis from prostate cancer (PCa), benign prostatic hyperplasia (BPH) and high-grade prostate intraepithelial neoplasia (HG-PIN) in patients with elevated PSA and negative digital rectal examination (DRE).

Patients And Methods: in the present prospective study, 274 patients, undergoing PCA3 score, PHI and %fPSA assessments before initial biopsy, were enrolled. Three multivariate logistic regression models were used to test PCA3 score, PHI and %fPSA as risk factors for prostatitis vs. PCa, vs. BPH, and vs. HG-PIN. All the analyses were performed for the whole patient cohort and for the 'gray zone' of PSA (4-10 ng/ml) cohort (188 individuals).

Results: The determinants for prostatitis vs. PCa were PCA3 score, PHI and %fPSA (Odds Ratio [OR]=0.97, 0.96 and 0.94, respectively). Unit increase of PHI was the only risk factor for prostatitis vs. BPH (OR=1.06), and unit increase of PCA3 score for HG-PIN vs. prostatitis (OR=0.98). In the 'gray zone' PSA cohort, the determinants for prostatitis vs. PCa were PCA3 score, PHI and %fPSA (OR=0.96, 0.94 and 0.92, respectively), PCA3 score and PHI for prostatitis vs. BPH (OR=0.96 and 1.08, respectively), and PCA3 score for prostatitis vs. HG-PIN (OR=0.97).

Conclusion: The clinical benefit of using PCA3 score and PHI to estimate prostatitis vs. PCa was comparable; even %fPSA had good diagnostic performance, being a faster and cheaper marker. PHI was the only determinant for prostatitis vs. BPH, while PCA3 score for prostatitis vs. HG-PIN.
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December 2014

[Ureteroscopy: is it the best?].

Urologia 2014 Apr-Jun;81(2):99-107. Epub 2014 Jun 10.

Divisione di Urologia, Dipartimento di Oncologia, Ospedale San Luigi Gonzaga, Orbassano (TO) - Italy.

Over the last 40 years the treatment of urolithiasis passed from open surgical therapies to minimally invasive approaches. From the introduction of the first ureteroscopes in '80s many technological improvements allowed to reduce endourological instruments' size, ensuring in the meanwhile an increasingly high success rate in the resolution of the urolithiasis. The purpose of the study is to review the current role of the ureteroscopy(URS) in the treatment of urinary stones. A non-systematic review was performed considering the most recent Guidelines and results from Literature. The results confirm that, considering ureteral calculi, the stone-free rate (SFR) for URS is significantly higher than for ESWL in the treatment of distal ureteral stones <10 mm and >10 mm. Endoscopy has a first-line role also in the treatment of proximal ureteral stones >10 mm, together with ESWL. Retreatment rate and ancillary procedures are also lower in patients treated with URS, despite it is more invasive if compared with ESWL. Recent data are available in Literature about the treatment of nephrolithiasis with Retrograde Intra-Renal Surgery (RIRS). RIRS is the first-line treatment, together with ESWL, for stones <20 mm, and second choice for stones >20 mm. However, for large renal stones the role of RIRS is still being discussed. In conclusion, the majority of urinary stones can be treated by rigid or flexible URS. Further studies are required to clarify the role of endoscopy in the treatment of large stones, especially if compared to percutaneous approaches.
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http://dx.doi.org/10.5301/uro.5000076DOI Listing
September 2015

[Suture materials in urology].

Urologia 2013 Jul-Sep;80(3):179-87. Epub 2013 Sep 30.

AOU San Luigi Hospital, University of Turin, Orbassano, Torino - Italy.

Since ancient times, sutures have been a fundamental part of the surgeon's practice. Beside the vegetable and animal origin materials, in the last decades different refined synthetic materials have been introduced in the clinical practice. More recently, different devices, such as staplers and tissue sealers have been developed. Thus, more than ever, urologists are faced with a multitude of suture materials, and research of safe, effective materials and devices seems to be continuously growing. The introduction and widespread diffusion of laparoscopic and robotic surgery has further boosted this research. Given there is no single material that is ideal for all situations, the surgeon must choose the best material for each particular case.
The aim of this non-systematic review is to summarize the more innovative suture materials and devices and to describe the different surgical methods to utilize them both in general and in urologic surgery.
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http://dx.doi.org/10.5301/RU.2013.11503DOI Listing
April 2015

Editorial comment.

Urology 2013 Dec;82(6):1399

Università di Torino - A.O.U. San Luigi, Clinica Urologica, Orbassano (TO), Italy.

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http://dx.doi.org/10.1016/j.urology.2013.07.073DOI Listing
December 2013

Biopsy and radical prostatectomy pathological patterns influence Prostate cancer gene 3 (PCA3) score.

Anticancer Res 2013 Oct;33(10):4657-62

Division of Urology, Ospedale Gradenigo, Corso Regina Margherita 8, 10153, Torino, Italy.

Aim: To evaluate the relationship between Prostate cancer gene 3 (PCA3) score and prostate cancer as assessed by Gleason Score (GS) and pathological stage in a series of Italian patients, with elevated Prostate specific antigen (PSA) undergoing radical prostatectomy (RP).

Patients And Methods: A total of 222 patients underwent RP for clinically localized prostate cancer; total PSA, free-PSA (%fPSA) and PCA3 score were collected and the possible associations among PCA3 and histological grade/pathological stage at biopsy and RP were investigated.

Results: Median PCA3 scores by GS at radical prostatectomy were 51 vs. 67 (GS <7 vs. GS ≥ 7, p=0.007), while scores at the biopsy were 56 vs. 67 (GS <7 vs. GS ≥ 7, p=0.007), and in pT2 vs. pT3 patients they were 54 vs. 80 (p=0.001). Positive digital rectal examination (DRE) (odds ratio (OR)=5.47, p=0.026), pT3 pathological stage (OR=3.68, p=0.006) and PCA3 ≥ 35 (OR=2.04, p=0.030) were the main risk factors for the presence of an aggressive disease (GS ≥ 7 at RP).

Conclusion: PCA3 score could play an interesting role in predicting significant disease: positive DRE (OR=5.47, p=0.026), pT3 pathological stage (OR=3.68, p=0.006) and PCA3 ≥ 35 (OR=2.04, p=0.030) were the main independent risk factors for GS ≥ 7 at RP.
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October 2013

High-intensity focused ultrasound and cryotherapy as salvage treatment in local radio-recurrent prostate cancer.

Urol Int 2012 10;89(4):373-9. Epub 2012 Jul 10.

Department of Urology and Surgical Oncology, University of Western Ontario, London, ON, Canada.

Background: Salvage high-intensity focused ultrasound (HIFU) and cryotherapy (CRYO) have emerged as interesting alternatives in the treatment of local radio-recurrent prostate cancer. Currently, recommendations concerning the use of CRYO and HIFU in the salvage setting are still evolving.

Aim: The objective of this review was to analyze the results from studies on CRYO and HIFU as salvage treatment in local radio-recurrent prostate cancer.

Materials And Methods: A National Center for Biotechnology Information PubMed search (www.pubmed.gov) was conducted from 1993 to 2011 using medical subject headings 'High-Intensity Focused Ultrasound', 'Cryotherapy', 'Local Radio-Recurrent' and 'Prostate Cancer'.

Results: In the past years, there have been several published series demonstrating promising acceptable morbidity and oncological outcomes in the short term for HIFU and in the intermediate term for CRYO. The introduction of newer-generation devices and technical modifications has facilitated reduction of complications associated with the procedures. As with any salvage treatment, careful patient selection and subsequent follow-up are principal points.

Conclusions: HIFU and CRYO are promising salvage treatments in patients with local radio-recurrent prostate cancer. The risk of significant complications in the salvage setting is higher compared with primary therapy; therefore, the patients must be informed about the risk of complications and the modality of treatment. However, only further evaluation in formal prospective clinical trials will hopefully confirm their role in clinical practice.
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http://dx.doi.org/10.1159/000339616DOI Listing
May 2013

Prostate cancer gene 3 urine assay cutoff in diagnosis of prostate cancer: a validation study on an Italian patient population undergoing first and repeat biopsy.

Anal Quant Cytol Histol 2012 Apr;34(2):96-104

Department of Pathology, San Luigi Gonzaga Hospital and University of Turin, Orbassano.

Objective: To determine an optimal prostate cancer gene 3 (PCA3) cutoff in predicting prostate cancer in Italian patients undergoing first or repeat biopsy.

Study Design: In this observational multicenter study 1246 men with elevated prostate specific antigen (PSA) and negative digital rectal examination, with prostate biopsy after PCA3 assessment, were divided into two groups submitted to PCA3 testing before or after previous negative biopsies. Ideal PCA3 cutoff was identified using area under the curve of the receiver operating characteristic analysis. Various cutoff values were used to determine the best predictive score. Univariate and multivariate logistic regression models compared age, PSA, free-PSA, and PCA3 score to predict prostate cancer.

Results: PCA3 cutoff 39-50 had the highest accuracy in the repeat biopsy group in which cutoff of 39 could have avoided 51.9% negative repeat biopsies, eventually missing 7.8% of cancers (all low risk); cutoff of 50 would have prevented 56.5% of negative repeat biopsies, missing 29 tumors (10.3%), 5 potentially aggressive. The PCA3 test performed poorly in the first biopsy group.

Conclusion: We confirm the usefulness of PCA3 in Italian men with a previous negative biopsy. We achieved the best performance at a cutoff of 39. PCA3 did not perform better than PSA in non-biopsy-selected men.
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April 2012

Editorial comment.

Urology 2011 Dec;78(6):1378-9; author reply 1379

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http://dx.doi.org/10.1016/j.urology.2011.06.047DOI Listing
December 2011

Psychological distress in men with prostate cancer receiving adjuvant androgen-deprivation therapy.

Urol Oncol 2013 Apr 30;31(3):352-8. Epub 2011 Jul 30.

Medical Oncology, Department of Clinical and Biological Sciences, University of Torino, Italy.

Objectives: To compare the occurrence of depression, anxiety, self body image perception, sleep disturbances, and diminished quality of life in prostate cancer patients undergoing adjuvant androgen-deprivation therapy (ADT) as opposed to patients in follow-up alone.

Methods And Materials: Hospital Anxiety and Depression Scale, Pittsburgh Sleep Quality Index, Restless Legs Syndrome Study Group essential diagnostic criteria, Body Image Scale and Functional Assessment of Cancer Therapy Prostate were administered to consecutive prostate cancer patients who underwent radical prostatectomy or radiation therapy and are presently either under adjuvant ADT or included in a follow-up program.

Results: Of the 103 patients enrolled, 49 (47.6%) were receiving adjuvant ADT and 54 (52.4%) were not. Compared with the controls, the patients undergoing ADT showed higher levels of depression (P = 0.002), worse self body image perception (P = 0.001), worse quality of life (P = 0.0001) and worse sleep quality (P = 0.04). ADT was significantly associated with depression at multivariate analysis after adjustment for age, stage, Gleason score, as well as demographic and social variables (P = 0.001). Depression scores showed a strong inverse correlation with quality of life scores (P < 0.01).

Conclusions: Adjuvant ADT is associated with depression, worse quality of life, and altered self body image in prostate cancer patients.
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http://dx.doi.org/10.1016/j.urolonc.2011.02.005DOI Listing
April 2013

Surgical margin status of specimen and oncological outcomes after laparoscopic radical prostatectomy: experience after 400 procedures.

World J Urol 2012 Apr 23;30(2):245-50. Epub 2011 Jun 23.

Division of Urology, Department of Clinical and Biological Sciences, University of Turin, "San Luigi" Hospital, Regione Gonzole 10, 10043 Orbassano, Turin, Italy.

Purpose: To analyse the surgical margins status of prostatic glands, resected by laparoscopic radical prostatectomy (LRP) for prostate cancer, and to correlate it with biochemical free survival rate (BFSR).

Methods: Data were collected prospectively from 405 patients undergoing LRP from 2000 to 2009 at a single institution. Patients undergoing neoadjuvant and/or adjuvant therapy were excluded from the study. Three hundred patients matched all the criteria: 232 of these had negative surgical margins (NSM) and 68 positive surgical margins (PSM). The median follow-up was 62 months. PSM were classified based on the following: (a) the number of margins, monofocal and multifocal, (b) the location, apical or non-apical and (c) the extension, ≤2.8 mm or >2.8 mm. These data were then entered into a multivariate analysis.

Results: Overall BFSR rate was 67.6% in PSM group and 88.8% in NSM group (P < 0.001). We registered a HR of 3.78 in multivariate analysis (P < 0.001). In terms of the extension, BFSR in univariate survival analysis was 77.8% in ≤2.8 mm PSM and 38.9% in >2.8 mm PSM (P = 0.003), with a HR of 5.68 (P = 0.011) in multivariate analysis. BFSR was 59% for apical margins and 77% for non-apical margins (P = 0.038). In monofocal margins, BFSR was 73%, while 53% in multifocal (P = 0.014).

Conclusions: We recommend careful evaluation of patients with PSM following LRP, especially if they are more than 2.8 mm, and in these cases, adjuvant therapy should be considered after radical surgery.
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http://dx.doi.org/10.1007/s00345-011-0711-2DOI Listing
April 2012

Extraperitoneoscopic transcapsular adenomectomy: complications and functional results after at least 1 year of followup.

J Urol 2011 May 21;185(5):1668-73. Epub 2011 Mar 21.

S. C. D. U. Urologia Dipartimento di Scienze Cliniche e Biologiche, Facoltà di Medicina e Chirurgia San Luigi Gonzaga, Università degli Studi di Torino, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Orbassano, Italia.

Purpose: Laparoscopic simple prostatectomy has been proposed to treat large glands. To date groups have investigated the feasibility and perioperative results of laparoscopic simple prostatectomy but to our knowledge no study has focused on its complications and functional results at longer followup. We investigated complications and functional results in patients with a large prostate who were treated with laparoscopic simple prostatectomy and had at least 1 year of followup.

Material And Methods: From our prospectively maintained database we extracted data on 78 patients treated with laparoscopic simple prostatectomy at our institution who had at least 1 year of reported followup. Demographics, perioperative results, early and late complications, and functional results were evaluated. Followup was planned at 1, 3, 6 and 12 months, and every 6 months thereafter.

Results: Mean followup was 30 months. Grade III complications were recorded in 2 cases and late complications were reported in 4 (5%). Statistically significant differences were observed in the International Prostate Symptom Score, the International Prostate Symptom Score quality of life index and maximum urine flow when comparing preoperative and postoperative results. No significant differences were recorded in maximum urine flow or the International Prostate Symptom Score quality of life index during followup.

Conclusions: Results suggest that laparoscopic simple prostatectomy is safe and effective even after a significant period, as indicated by the low complication rate and positive, stable functional results found during followup. In our opinion laparoscopic simple prostatectomy can be offered to patients as a valid treatment option for a large prostate at advanced laparoscopic centers.
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http://dx.doi.org/10.1016/j.juro.2010.12.047DOI Listing
May 2011

Does tumour size really affect the safety of laparoscopic partial nephrectomy?

BJU Int 2011 Jul 2;108(2):268-73. Epub 2010 Nov 2.

SCDU Urologia, Dipartimento di Scienze Cliniche e Biologiche, Università degli Studi di Torino, Azienda Ospedaliera Universitaria San Luigi Gonzaga, Orbassano, Turin, Italy.

Objective: • To investigate the perioperative safety of laparoscopic partial nephrectomy (LPN) for large renal masses (>4 cm).

Patients And Methods: • After Institutional Review Board approval, data from 100 consecutive patients who had undergone transperitoneal or retroperitoneal LPN at our institution from January 2005 to June 2009 were obtained from our prospectively maintained database. • The patients were divided into two groups according to radiological tumour size: group A (67 patients) with tumours ≤4 cm and group B (33 patients) with tumours >4 cm. • Demographic, perioperative and pathological data were evaluated.

Results: • The two groups were comparable in terms of demographic data. Mean tumour size was 2.4 and 5 cm (P= 0.0001) for groups A and B, respectively. Group B tumours were more complex, as reflected by significantly more with a central location (P= 0.002), and by significantly more transperitoneal LPNs, pelvicalyceal repairs and longer warm ischaemia time (WIT; 19 vs 28 min). • Complications were recorded in nine group A patients (13.4%) and nine group B patients (27.2%) (P= 0.09). • There was no difference between preoperative and postoperative serum creatinine levels in either group, while a significant difference was found in postoperative estimated glomerular filtration rate between groups (P= 0.004). • The incidence of carcinoma was comparable between the two groups. • The incidence of positive surgical margins (PSMs) was 3.9% in group A, whereas no PSM was recorded in group B (P= 0.3).

Conclusions: • Laparoscopic partial nephrectomy for large tumours is feasible and has acceptable pathological results. However, the complication rate, in particular WIT, remains questionable. • Further studies are required to better clarify the role of LPN in the management of tumours of this size.
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http://dx.doi.org/10.1111/j.1464-410X.2010.09788.xDOI Listing
July 2011

Transvaginal natural orifice transluminal endoscopic surgery-assisted minilaparoscopic nephrectomy: a step towards scarless surgery.

Eur Urol 2011 Oct 8;60(4):862-6. Epub 2010 Oct 8.

Division of Urology, Department of Clinical and Biological Sciences, University of Turin San Luigi Hospital, Orbassano, Turin, Italy.

The feasibility of a transvaginal hybrid natural orifice transluminal endoscopic surgery (NOTES) nephrectomy has already been demonstrated using standard laparoscopic ports through the abdominal wall. We evaluated the feasibility of a transvaginal NOTES-assisted minilaparoscopic nephrectomy (mLN). The patient is positioned in a semilumbotomy position with legs separated to allow for vaginal access. A 3.5-mm port is placed at the umbilicus for a 30° laparoscope; two 3.5-mm ports are placed in the flank in the same location as for a standard transperitoneal nephrectomy; and a 12-mm port is placed through the vagina, perforating the vaginal wall. Kidney dissection is performed following the steps of a traditional nephrectomy. The renal pedicle is dissected and secured with Hem-o-Lok clips through the vaginal access port. The specimen is then extracted through an extended incision in the posterior wall of the vagina. We treated five patients. The average operative time was 120 min, blood loss was 160 ml, and no complications were recorded. Our initial experience suggests that transvaginal NOTES-assisted mLN is feasible and appears to be safe. It is simpler than a pure NOTES procedure and ensures excellent cosmetic results.
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http://dx.doi.org/10.1016/j.eururo.2010.09.038DOI Listing
October 2011

Endoscopic combined intrarenal surgery for high burden renal stones.

Arch Ital Urol Androl 2010 Mar;82(1):41-2

Department of Urology, San Luigi University Hospital, Orbassano, Torino, Italy.

"High burden stones" include single or multiple large calculi (altogether surface area > 300 mm 2, or largest diameter > 20 mm), and staghorn calculi (any branched stone occupying more than one portion of the renal collecting system, i.e. pelvis with one or more calyceal extensions). Since clinically threatening, their active removal is mandatory. All updated guidelines recommend four modalities as potential treatment for large/staghorn urolithiasis, including PNL monotherapy, ESWL monotherapy, combinations of PNL and ESWL, and open surgery. The technical enhancement and increasing spread of PNL, ESWL and ureteroscopy in the past twenty years has led to displacement of the surgical therapy of renoureteral calculi in the daily urological practice (nowadays 1-5.4% of cases in developed countries and in well-equipped, dedicated centres), but open or laparoscopic management of urolithiasis is still a viable option that should be considered in few, highly selected circumstances. Currently, PNL is the preferred first-line, minimally invasive treatment for complete one-step removal of high burden urolithiasis. It has been suggested that two or more access sites may be required for complete clearance, yet implying greater blood loss. The use of single-tract PNL with adjuvant procedures such as flexible ureteroscopy/nephroscopy may decrease the disadvantages of the multiple-tract PNL without compromising on stone-free rates. ECIRS (= endoscopic combined intrarenal surgery) is a new, versatile approach for the treatment of large and/or complex urolithiasis. Combining the anterograde and retrograde approach to the renal cavities, ECIRS allows the combined use of all the rigid and flexible endourological armamentarium, and optimal endovision percutaneous renal puncture, preliminary evaluation of renal stones features, negligible need of multiple percutaneous accesses, immediate treatment of concomitant ureteral calculi or ureteropyelic junction stenoses; final visual control of the stone-free status. ECIRS is usually performed in the Galdakao-modified supine Valdivia position, the only patient position supporting this comprehensive attitude of the urologist towards upper urinary tract pathologies. Optimal planning of a safe and effective ECIRS procedure also benefits from an accurate preliminary three-dimensional study by means of tomography urography of the pelvicalyceal anatomy (which is complex and often highly variable) and of the stone features (site, number, size).
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March 2010

The patient position for PNL: does it matter?

Arch Ital Urol Androl 2010 Mar;82(1):30-1

Department of Urology, San Luigi University Hospital, Orbassano, Torino, Italy.

Currently, PNL is the treatment of choice for large and/or otherwise complex urolithiasis. PNL was initially performed with the patient in a supine-oblique position, but later on the prone position became the conventional one for habit and handiness. The prone position provides a larger area for percutaneous renal access, a wider space for instrument manipulation, and a claimed lower risk of splanchnic injury. Nonetheless, it implies important anaesthesiological risks, including circulatory, haemodynamic, and ventilatory difficulties; need of several nurses to be present for intraoperative changes of the decubitus in case of simultaneous retrograde instrumentation of the ureter, implying evident risks related to pressure points; an increased radiological hazard to the urologist's hands; patient discomfort. To overcome these drawbacks, various safe and effective changes in patient positioning for PNL have been proposed over the years, including the reverse lithotomy position, the prone split-leg position, the lateral decubitus, the supine position, and the Galdakao-modified supine Valdivia (GMSV) position. Among these, the GMSV position is safe and effective, and seems profitable and ergonomic. It allows optimal cardiopulmonary control during general anaesthesia; an easy puncture of the kidney; a reduced risk of colonic injury; simultaneous antero-retrograde approach to the renal cavities (PNL and retrograde ureteroscopy = ECIRS, Endoscopic Combined IntraRenal Surgery), with no need of intraoperative repositioning of the anaesthetized patient, less need for nurses in the operating room, less occupational risk due to shifting of heavy loads, less risk of pressure injuries related to inaccurate repositioning, and reduced duration of the procedure; facilitated spontaneous evacuation of stone fragments; a comfortable sitting position and a restrained X-ray exposure of the hands for the urologist. But, first of all, GMSV position fully supports a new comprehensive attitude of the urologist towards a variety of upper urinary tract pathologies, facing them with a rich armamentarium of rigid and flexible endoscopes and a versatile antero-retrograde approach. Prone position may still be useful in case of important vertebral malformations, specifically hindering the supine position, or for simultaneous bilateral PNL, without having to move the patient intraoperatively, so is still present in the complementary techniques of a skilled endourologist.
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March 2010

Starting together: a focus group for the organization of a CKD outpatient care unit.

J Nephrol 2010 Nov-Dec;23(6):699-704

Unit of Nephrology, San Luigi University Hospital, University of Torino, Orbassano, Turin, Italy.

Introduction: The growing interest in patient empowerment in chronic diseases underlines the importance of assessing patients' opinions in planning healthcare strategies. Focus groups are flexible tools for investigating innovative aspects of care. The aim of the study was to use a focus group to define the main requirements for a chronic kidney disease (CKD) outpatient care unit.

Methods: The focus group met during the opening of a new CKD outpatient facility. It consisted of 12 patients with long-term experience of CKD, dialysis and transplantation; they had been followed previously by the senior physician, who moderated the discussion. The discussion was tape-recorded and the results were summarized and approved by all participants.

Results: The group made 10 major suggestions: 1. Therapeutic continuity in all disease phases, from pre-dialysis to transplantation; 2. Possibility to choose the reference physician; 3. Strict integration with the nursing activities; 4. Organizational flexibility, to adapt to the needs of daily life; 5. To be "fully" taken care of, with organizational support for blood tests, imaging and consultations; 6. Need for time with the reference physician in critical phases of the disease; 7. Identification of a network of consultants, in keeping with the need for continuity of care; 8. Educational sessions; 9. Meetings for critical discussion of organizational performances; 10. As a setting: a home for the disease and not a disease to take home.

Conclusion: Continuity of care and flexibility of organization, allowing time for education and discussion, are the quality requirements of our CKD patients.
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January 2011

Flexible pneumocystoscopy for double J stenting during laparoscopic and robot assisted pyeloplasty: our experience.

Int J Urol 2010 Feb;17(2):192-4

Division of Urology, Department of Clinical and Biological Sciences, University of Turin, San Luigi Hospital, Orbassano, Turin, Italy.

We present our results in terms of feasibility, safety and efficacy of flexible pneumocystoscopy during double J stenting in patients undergoing laparoscopic pyeloplasty (LP). The patient is placed on the flank at a 45 degrees angle. Laparoscopic pyeloplasty according to the Anderson-Hynes technique is carried out by transperitoneal access. After completing the running suture of the posterior wall of the uretero-pyelic anastomosis, the double J stent is placed in a retrograde manner with a pneumocystoscopy using flexible cystoscope. Thirty-six patients were prospectively evaluated; 28 of these were treated with standard LP and 8 with robot-assisted LP. Mean operative time was 124 min, whereas double J stenting time was 4.2 min (2-6). We observed one case of cranial migration of the stent, forcing us to repeat the procedure, which was completed without complications. No ancillary procedures or X-ray control were necessary. Retrograde double J stenting using flexible pneumocystoscopy during laparoscopic and robot assisted pyeloplasty is feasible, easy, safe and effective. The procedure can be completed without changing the patient's position and without the use of X-ray.
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http://dx.doi.org/10.1111/j.1442-2042.2009.02436.xDOI Listing
February 2010

Positron emission tomography as a tool for the 'tailored' management of retroperitoneal fibrosis: a nephro-urological experience.

Nephrol Dial Transplant 2010 Aug 15;25(8):2603-10. Epub 2010 Feb 15.

Urology and Nephrology, San Luigi Gonzaga University Hospital, Regione Gonzole 10, Orbassano Torino, Turin, Italy.

Background: Retroperitoneal fibrosis (RF) is a complex clinical entity characterized by a fibro-inflammatory reaction around the abdominal aorta and iliac arteries extended into the retroperitoneum. No biochemical marker correlates with the disease severity and progression, and imaging data fail to discriminate between fibrotic and florid lesions. Positron emission tomography (PET) was recently suggested as a promising tool to detect the disease.

Methods: We report on seven consecutive cases of RF managed by tailoring therapeutic interventions to the metabolic activity detected by PET. In 2006-09, seven patients with RF (five new diagnoses) were referred to the same nephro-urological facility. There were six males and one female aged 41-79. RF was associated with autoimmune diseases in three patients, with an aortic aneurysm in another three, and was 'idiopathic' in one. The diagnoses were made by imaging techniques [computed tomography (CT) or nuclear magnetic resonance (NMR)]; PET scan was performed in all patients in the same setting at referral and during follow-up.

Results: Patients were followed up with tailored interventions (medical therapy: tamoxifen, steroids, and immunosuppressors according to disease activity, side effects and tolerance). Six patients needed ureteral stenting for obstruction. PET imaging was used as a guide for the tapering of immunosuppressors and for stent removal. In this way, stents were safely removed when a negativization of disease activity was revealed by PET. Only one relapse was recorded over 163 months of follow-up (median 24 months) detected in time by PET.

Conclusion: PET is a promising tool for surveillance of disease activity and for planning the removal of ureteral stents in RF.
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http://dx.doi.org/10.1093/ndt/gfq051DOI Listing
August 2010

The prognostic role of immunohistochemical chromogranin a expression in prostate cancer patients is significantly modified by androgen-deprivation therapy.

Prostate 2010 May;70(7):718-26

Oncologia Medica, Dipartimento di Scienze Cliniche e Biologiche, Università di Torino, Torino, Italy.

Background: Several data suggest that neuroendocrine (NE) differentiation in prostate cancer is implicated in the development of resistance to androgen-deprivation therapy (ADT). This study was undertaken to assess the prognostic role of tissue chromogranin A (CgA) expression in patients addressed to ADT as opposed to those who did not.

Methods: Four hundred fourteen newly diagnosed prostate cancer patients, consecutively recruited in a single institution, entered the study. Two hundred fourteen patients received ADT early after diagnosis, 200 did not. Median follow-up was 85 months. CgA expression was evaluated immunohistochemically in prostate cancer needle biopsies.

Results: In multivariate analysis after adjusting for Gleason score, serum PSA, disease stage and local treatments, tissue CgA expression in overall cases was significantly associated with a shorter survival (P = 0.009) but failed to be associated with PSA progression (P = 0.10). Dividing patients according to whether they received immediate ADT or not, tissue CgA was associated with a shorter time to PSA progression in ADT-treated patients (hazard ratios (HR) 1.96, 95% confidence interval (CI): 1.37-2.81, P = 0.0001), but failed to be associated in those who did not (HR 0.87, 95% CI: 0.58-1.30, P = 0.49), interaction test P = 0.007. Conversely the survival effect of tissue CgA was not modified by ADT (interaction test, P = 0.41).

Conclusions: Tissue CgA expression, evaluated in prostate cancer needle biopsies at diagnosis, is an independent prognostic factor of survival in prostate cancer patients. The negative influence of NE differentiation on time to progression confined in ADT-treated patients suggests a role of NE differentiation in predicting endocrine resistance that deserves validation.
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http://dx.doi.org/10.1002/pros.21104DOI Listing
May 2010