==inizio objective==

To evaluate pathologic outcomes in patients affected by very low risk (VLR) and low risk (LR) prostate cancer and eligible for Active Surveillance.

==fine objective==

==inizio methodsresults==

We conducted a retrospective analysis in patients with low risk prostate cancer who underwent Laparoscopic Radical Prostatectomy (LRP) at our institution from 2005 to 2016. We identified patients with low risk (LR) PCa defined as cT1c-T2a, Gleason score <7, PSA ≤10 ng/ml and patients with very low risk (VLR) PCa as defined by Italian PRIAS (cT1c-T2a, Gleason score <7, PSA ≤10 ng/ml, PSAD ≤0,20 ng/ml/cc, ≤2 positive cores). Complete information on PSA, PSA density (PSAD), clinical stage, Gleason score, percentage of positive cores, number of nodes removed, and pathological outcomes were available. We evaluate GS upgrading (to primary pattern 4), non-organ confined disease and unfavorable disease (≥pT3, GS ≥4+3, pN1) in LR and VLR patients. Prognostic factors of unfavorable disease were analyzed by logistic regression analysis (SPSS 24). ==fine methodsresults== ==inizio results== We identified 103 patients with LR Prostate cancer. Of these, 58 patients have VLR cancer according with PRIAS criteria. Baseline characteristic of patients are described in table 1. There were no significant differences between LR and VLR patients. Pathological outcomes revealed upstaging in 9% and 1.7%, upgrading in 24.7% and 22.8% in LR and VLR patients, respectively. Unfavorable disease occurred in 28.2% and 22.4% of LR and VLR patients, respectively [table 2]. At multivariate analysis, PSAD was the only prognostic factor of unfavorable disease in LR patients [table 3]. ==fine results== ==inizio discussions== Active surveillance (AS) has emerged as a valid option for the conservative management of low risk prostate cancer (PCa). The D’Amico classification is commonly used criterion for identification of low risk patients. However upgrading and upstaging at radical prostatectomy occurred in 20-54% and 6-26% of patients, respectively. Therefore more restrictive criteria are adopted in several AS protocols. Italian arm (SIURO) of Prostate Cancer Research International Active Surveillance (PRIAS) inclusion criteria are stage cT1c/T2a, Gleason score <7, PSA ≤10 ng/ml, PSA density (PSAD) ≤0.20 ng/ml/cc, ≤ 2 positive cores. In our experience, a retrospective analysis on LR and VLR patients revelead no significant differences in terms of adverse pathology between LR and VLR patients (28.2 vs 22.4%). This results is probably due to clinical stage of LR patients (≤cT2a) and to percentage of positive cores. However this results seems to affirm need of mpMRI for more accurate selection of patients candidates for AS. ==fine discussions== ==inizio conclusion== In our experience, upstaging and upgrading at laparoscopic radical prostatectomy occurred in 9% and 25% of low risk patients and in 2% and 23% of very low risk patients. About a quarter of the patients presented unfavorable disease (non organ confined, primary Gleason 4). PSA density was the only prognostic factor of unfavorable disease. ==fine conclusion== ==inizio reference== Eur Urol 2016; 69: 576-81 Eur urol 2015; 68: 458-63 ==fine reference==

==inizio objective==

The prognosis of prostate cancer mainly depends on the presence or absence of metastatic spread . Prostate cancer usually metastasises to the bony skeleton, followed by Liver 19.8%, Lung 13.1%, Peritoneum 3.6%, Adrenal 3%, brain/dura 3%
Most cases present with localized disease and have good prognosis. However, advanced metastatic prostate cancer commonly metastasizes to regional lymph nodes and vertebral bones, but metastasis lateral cervical lymph nodes is rare.
Important to recognize rare presentations metastatic disease, to obtain the correct diagnosis.
There are only 2 published cases

==fine objective==

==inizio methodsresults==

CLG 76 years-old, cardiopathy post-IMA , treaty with anticoagulants and antihypertensive drugs ,psa 178 ng/ml, palpable lateral cervical lymph nodes (LLC). T ac total negative body except for 4 lymph nodes Lc . Therefore, the patient undergoes at the department of otolaryngology Taranto to resection of adenopathy. Histology was suggestive of positive adenocarcinomatoide infiltrated with immunohistochemical markers, (cytokines) CK8 and CK18. Therefore, the patient was sent to us for appropriate assessment. The patient after rectal examination, was performative a transrectal prostate biopsy, under local anesthesia
They are executed only 4 needles for no patient compliance and its upward pressure until 190/85 mm / HGG and 108 bpm

==fine methodsresults==

==inizio results==

The survey showed a clinical t2A, the biopsy Gleason 4 + 4 and 50 % of positive cores (those on the left). Scintigraphy t / B positive for secondarità 2 of radiopharmaceutical accumulation in the iliac crests
The patient, now has been put into bat ( bicalutamide + three-month Leuprorelina Acetato ) and if it evaluates the answer.

==fine results==

==inizio discussions==

Lymphnodes are commonly involved during the course of metastatic prostate cancer. Hypogastric and
obturator lymph nodes as the most common sites.
This case reported, wanted examineted a atypical prostate cancer metastases cases. The
awareness of the manifestations of prostate cancer metastases may enable accurate diagnosis,
staging and help in appropriate management of disease. direct us to the correct diagnosis markers such as cytokines , that we used in this case. Cytokines CK8, CK18, are useful screening markers for the recognition of epithelial differentiation.( 9)
PanCKC (CK8/CK18/CK19) representing
epithelial cells. CK18, are also positively expressed by lung adenocarcinoma,
colorectal cancer (CRC), and prostate cancer (10)
Finally, in the case of prostate cancer, we combined PSA, because in the clinical application, immunohistochemistry for PSA is commonly used for In the diagnosis of
prostate cancer (10).

==fine discussions==

==inizio conclusion==

Prostate cancer should be always considered in the differential diagnosis
of elderly men presenting with supraclavicular lymphadenopathy, hydroureteronephrosis
or later cervical lymphadenopathy even in the presence of a normal digital rectal. PSA immunohistochemical staining should be used in doubtful cases. Obviously, prevention has its importance.

==fine conclusion==

==inizio reference==

1. (Can Urol Assoc J. 2013 Mar-Apr; 7(3-4): E248–E250 Metastatic prostate cancer with malignant ascites: A case report and literature review
Ifeanyi Ani, MD,* Mark Costaldi, MD,† and Robert Abouassaly, MD*
2.AJR:199, August 2012 Anant H. Vinjamoori, Jyothi P. Jagannathan, Atul B. Shinagare, Mary-Ellen Taplin, William K. Oh, Annick D. Van den Abbeele, Nikhil H. Ramaiya
3.Arab Journal of Urology (2013) 11, 48–53 Ahmed Elabbady, Ahmed Fouad Kotb
4. Int J Surg Case Rep. 2016; 23: 177–181. A 76 year old male with an unusual presentation of merkel cell carcinoma
Joel C. Acab,a,⁎ Wade Kvatum,a and Chukwuma Ebob
5.Br J Radiol. 1999 Oct;72(862):933-41. Features of unusual metastases from prostate cancer. Long MA1, Husband JE.

6. World J Urol. 2015 Dec 22. [Epub ahead of print]
Update on histopathological evaluation of lymphadenectomy specimens from prostate cancer patients.
Conti A1, Santoni M2, Burattini L2, Scarpelli M3, Mazzucchelli R3, Galosi AB1, Cheng L4, Lopez-Beltran A5, Briganti A6, Montorsi F6, Montironi R
7.Can J Urol. 1994 Jul;1(3):55-9.
Unusual presentations of advanced prostate cancer.
Gulanikar A1, Lau P, Bell DG.
8.Semin Oncol. 1977 Mar;4(1):53-8.
Metastatic and histologic presentations in unknown primary cancer.
Nystrom JS, Weiner JM, Heffelfinger-Juttner J, Irwin LE, Bateman JR, Wolf RM
9. Arch Pathol Lab Med—Vol 132, March 2008 Undifferentiated Tumor, Immunohistochemistry—Bahrami et al 327
10. CANCER BIOLOGY & THERAPY 2016, VOL. 17, NO. 4, 430–438 Si-Hong Lua,b, Wen-Sy Tsaic, Ying-Hsu Changd, Teh-Ying Choue, See-Tong Pangd, Po-Hung Lind, Chun-Ming Tsaif, and
Ying-Chih Changa

==fine reference==

==inizio objective==

Active surveillance (AS) is a valid option for the treatment of low risk prostate cancer. Whether or not AS could be offered also to patients with intermediate risk prostate cancer is a debated issue. Some AS protocols included selected patients (older) with Gleason score 3+4. In our study we evaluated the risk of upgrading and upstaging and predictive factors of adverse disease in patients with favourable Gleason score 3+4 and identified prognostic factors.

==fine objective==

==inizio methodsresults==

From database of our institution, we identified patients with favourable GS 3+4 (PSA ≤10 ng/ml, cT1c-T2a) undergone a laparoscopic pelvic lymphadenectomy (LAD) and radical prostatectomy; data on age, BMI, PSA, PSAD, positive cores percentage, clinical stage, Gleason score, lymphadenectomy template, prostate volume, number of removed nodes were available. We correlated these variables with upstaging (≥pT3), upgrading (≥GS4+3) and adverse pathological outcomes (non-organ confined disease or ≥GS4+3 or pN1) by logistic regression analysis (SPSS 24).

==fine methodsresults==

==inizio results==

Baseline characteristics of the 82 patients with favourable Gleason score 3+4 PCa are reported in table 1. Surgical and pathological outcomes are reported in table 2. Upstaging to ≥pT3 occurred in 9.7% of patients; no variables were associated to upstaging (table 3). Upgrading occurred in 24.4% of patients; PSA was the only factor associated to upgrading [OR 2.12, p 0.04] (tables 4A and 4B). Adverse pathological outcomes (non organ confined disease or primary GS4 or pN1) occurred in 31.7% of patients; PSA correlated with adverse pathological outcomes [OR 2.87, p 0.01] (tables 5A and 5B). Downgrading occurred in about 5% of patients.

==fine results==

==inizio discussions==

Active surveillance (AS) is a valid option for the treatment of low risk prostate cancer. Whether or not AS could be offered also to patients with intermediate risk prostate cancer is a debated issue. Some AS protocols included selected patients (older) with Gleason score 3+4. NCCN guidelines have considered AS as option for patients with favourable intermediate risk PCa (GS3+4, PSA ≤10 ng/ml, positive cores <50%). We have evaluated rates of upstaging, upgrading and adverse pathology in favourable intermediate risk patients undergone to laparoscopic RP. Upstaging, upgrading and adverse pathology occurred in 9.7%, 24.4% and 31.7%, respectively. Among all variables considered, PSA was the only factor associated to upgrading and adverse pathology. ==fine discussions== ==inizio conclusion== In patients with favourable Gleason score 3+4, upstaging, upgrading and adverse pathological outcomes occurred in 10%, 24% and 32% of the patients. PSA was the only factor associated to upgrading and adverse pathological features. ==fine conclusion== ==inizio reference== Transl Androl Urol 2015; 4 (3): 342-54 Plos One 2014; 9 (9): Urol Oncol 2015; 33: 7121-9 ==fine reference==

==inizio objective==

To evaluate prognostic factors of nodal metastasis in patients affected by organ confined prostate cancer (PCa) who underwent laparoscopic radical prostatectomy (LPR).

==fine objective==

==inizio methodsresults==

From database of our institution, we identified patients undergone a laparoscopic pelvic lymphadenectomy (LAD) and radical prostatectomy; data on age, BMI, PSA, PSAD, positive cores percentage, clinical stage, Gleason score, lymphadenectomy template, prostate volume, number of removed nodes were available. We correlated these variables with pathological node metastasis by logistic regression analysis (SPSS 24).

==fine methodsresults==

==inizio results==

Data on 183 patients were analyzed. Baseline characteristics are reported in table 1. On univariate analysis, PSA, PSAD, prostate volume, biopsy Gleason score were associated with pN1. Surgical and pathological outcomes are reported in table 2. At univariate analysis, pathological stage, positive surgical margins and LAD template (obturator and external vs obturator, external hypogastric and common) correlated with pN1. At multivariate analysis, PSAD and superextended lymphadenectomy were associated with nodal metastasis.

==fine results==

==inizio discussions==

In our experience, nodal metastasis were present in 6.5% of patients despite a considerable average number of nodes removed. This results is probably due to a not high risk of nodal metastasis of our population. At multivariate analysis PSA density and lymphadenectomy template correlates with nodal metastasis. This evidence affirms need of an extended template during radical prostatectomy.

==fine discussions==

==inizio conclusion==

In our retrospective analysis, PSA density and superextended lymphadenectomy are prognostic factors of nodal metastasis.

==fine conclusion==

==inizio reference==

Tumori Journal 2016, DOI:10.5301/tj.5000546

Urologia 2015 DOI:10.5301/uro.5000139

==fine reference==

==inizio objective==

The transperitoneal approach remains the most accepted and popular approach in performing robot-assisted laparoscopic radical prostatectomy (RALP) associated with minimal perioperative morbidity and good functional and oncological outcomes (1). Choice of approach should be related on patient characteristics as well as surgeon preference (2). The aim of this paper was to report our initial experience in performing RALP without any assistance from a tutor.

==fine objective==

==inizio methodsresults==

From January to December 2016, 36 patients underwent a RALP to our Department of Urology. Of these, 17 patient underwent a RALP using an extraperitoneal approach (Group A) and 19 using a transperitoneal approach (Group B), with a progressive shift from the extraperitoneal to the transperitoneal access. In the first six months of the year only 3 out of 15 patients underwent a transperitoneal RALP. 12 out of 36 patients (33.3%) underwent a simultaneous pelvic lymphadenectomy. Of these, only 2 patients underwent a lymphadenedctomy with an extraperitoneal approach. The da Vinci Xi surgical robotic system was used in all the cases.
All procedures were performed by a single surgical team with a good experience in laparoscopic procedures.

==fine methodsresults==

==inizio results==

The mean operative time was 191,25±57,26 for Group A and 156,88±28,7 for Group B (p=0,0302).
The mean operative time for docking and for trocar positioning was 38,13±7,72 for Group A and 25,63±5,74 for Group B.
The mean blood losses were similar in the two groups (268,75±161,16 for Group A and 293,75±378,98 for Group B, p=0,8032). In one patient a shift from the extraperitoneal to the transperitoneal approach was needed. In 13 out of 17 patients a small hole in the peritoneum was made during the extraperitoneal approach. The rate of complications was similar in both groups. In the group A, one patient experience a gastric hemorrhage, one patient a leakage from the anastomosis, and one patients experience the dislocation of the urethral catheter because of a bladder anterior wall lesion that was repaired during the procedure.
In the group B, two patients experience a leakage from the anastomosis and one patient a rectal injury that was repaired during the procedure without postoperative sequelae.
The normalization of the intestinal canalization was slightly inferior for the group A but we have not reached the statistical significance (Group A= 2,63±0,72, Group B=3,25±1,19, p=0.0756). The time of dismissal from the hospital was similar in the two groups (Group A=4,94±1,95, Group B=4,69±1,20, p=0,6629)

==fine results==

==inizio discussions==

At the beginning of our learning curve in robotic procedures, without any assistance from a tutor, we were loath to the use of the fourth robotic arm. Despite this only four procedures were performed without the use of the fourth arm. The fourth arm was always placed on the left side of the abdomen (the same side of the bipolar forceps for the right-hander). Moreover, in the first three procedures we used to coagulate the prostatic pedicle with the Caiman instrument. After this first procedures we understood the utility of the fourth arms and we started the coagulation of the prostatic pedicles using the bipolar energy.
In our experience we assisted to a shift from the extraperitoneal to the transperitoneal approach. It is mainly related to the difficulty to introduce the trocar for the Air Seal system and for the bigger work spaces associated with the transperitoneal approach. Moreover in the last six months of the year, we started to perform a lot of “high risk group” radical prostatectomy with the robotic technology. As a consequence the need to perform an extensive lymphadenectomy lead to us to choose a transperitoneal approach.
In our experience we had a shorter operative time in the Group B despite the bigger number of lymphadenectomy performed in this group. It can be related to the use of an easier approach. Moreover in the last six months of the year, the surgical team was at a more advanced point in the learning curve for all steps of the robotic procedures. In conclusion, in the last five procedure in Group B, we used a V-Loc absorbable wound closure devices that helps the surgeon to perform a quicker anastomosis.

==fine discussions==

==inizio conclusion==

In our department less than 1% of laparoscopic radical prostatectomy were performed with the transperitoneal approach. The extraperitoneal approach to RALP was described as a good alternative to the transperitoneal approach with similar intraoperative, postoperative and functional outcomes (3). In our experience the transperitoneal approach is only related to a shorter operative time. In our opinion, surgeons should be familiar with both approaches in order to provide patients with the best care.

==fine conclusion==

==inizio reference==

1-Patel VR, Thaly R, Shah K.Robotic radical prostatectomy: outcomes of 500 cases. BJU Int. 2007 May;99(5):1109-12.

2- Capello SA, Boczko J, Patel HR, Joseph JV. Randomized comparison of extraperitoneal and transperitoneal access for robot-assisted radicalprostatectomy. J Endourol. 2007 Oct;21(10):1199-202.

3-Akand M, Erdogru T, Avci E, Ates M.Transperitoneal versus extraperitoneal robot-assisted laparoscopic radical prostatectomy: A prospective single surgeon randomized comparative study. Int J Urol. 2015 Oct;22(10):916-21.

==fine reference==

==inizio objective==

Prostate biopsy, the gold standard diagnostic procedure for prostate cancer diagnosis, is not free from complications, with a post biopsy prostatitis rate ranging between 1 and 5% [1].
In the recent years, especially in Europe, the incidence of bacterial strains like Escherichia coli, Klebsiella pneumoniae, Enterococci spp resistant to fluoroquinolones and cephalosporine is growing critically, leading to significative death and morbidity risk [2].
Fosfomicin, a bactericidal antibiotic produced by streptomycetes, shows a good activity against gram positive and gram negative bacteria [3] and seems to be an attractive alternative to quinolones based prophylactic regimen for prostate biopsies, due to the promising results of Cai et al [4].
The aim of our randomized study was to evaluate efficacy and safety of a prostate biopsy phrophylaxis protocol using two VS three fosfomicine dosis, with the aim to assess the optimal timing and dosage of this antibiotic.

==fine objective==

==inizio methodsresults==

229 patients undergoing transrectal ultrasound guided prostate biopsy were prospectively evaluated between April and December 2016 in a single italian center.
All the patients were evaluated with history, comorbidity evaluation with Charlson score, complete urological examination, PSA, urine exam and urinalysis, transrectal ultrasound.
The patients were, moreover, randomized to group A (fosfomicine 3 gr within 4 hours from the procedure and after 24 hours) and group B (fosfomicine 3 gr 12 hours before the procedure, within 4 hours from the procedure and after 24 hours).
About three weeks after the procedures the patients were evaluated in our outpatients clinic.

==fine methodsresults==

==inizio results==

229 patients were randomized to group A (n: 115) or group B (n:114); allocation was done by date of birth.
Mean age of the intire cohort was 65 years, whereas more represented Charlson comorbidity index was 0 (49%).
The 2 groups were comparable with respect to age, comorbidity, PSA value, prostate volume, operative time and urine culture results (p n.s.)
23 pts had a positive urine culture, and only one of those > 100.000 UFC; no one was resistant to fosfomicineand only of these (E. Coli plurisesnsible) pts was readmitted after the procedure.
3.4% (8/229) of our patients developed fever requiring a readmission after the procedure (6 in group A and 2 in group B, p n.s.).
Four of these patients presented respectively positive urineculture (only one positive for Enterobacter cloacae resistant to fosfomicine) and two presented a positive hemoculture (only one a Klebsiella pneumoniae resistant to fosfomicine).
None of the patients developed > grade II complications.

Table 1
Variable
Group A (n: 69)
Group B (n: 76)
Global
p
Age (yrs; mean + SD)
64.9 + 9.1
66.0 + 8.3
65.5 + 8.7
0.35
Charlson score (mean + SD)
0.6 + 0.9
0.7 + 1.2
0.7 + 1.1
0.30
PSA (mg/dl; mean + SD)
8.9 +12.6
12.4 + 42.1
10.6 + 31.1
0.4
Prostate volume (ml; mean + SD)
44.6 + 18.7
49.8 + 26.8
47.2 +23.2
0.1
Urine culture > 100.000 UFC
0
1
1

Operative time (min; mean + SD)
12.2 + 7.3
12.2 + 7.9
12.2 + 7.3
0.8
Complications (n) (only Clavien I and II)
11
6
17
0.31
Readmission (n)
6
2
8
0.28

==fine results==

==inizio discussions==

The low readmission rate of our cohort, treated with both doses of fosfomicine, shows that this prophylaxis is safe and effective.
Moreover, the two doses (2 VS 3 doses) show an overlapping efficacy.
Our study presents, moreover, possible limitations, as the single center, multisurgeon basis and the relatively low number of patients enrolled.

==fine discussions==

==inizio conclusion==

The low fever and prostatitis rate shows that fosfomicine prophylaxis is safe and efficacy; moreover, the two dosage seem to be overlapping in term of post operative outcomes.

==fine conclusion==

==inizio reference==

1 Linvert K.A., Kabalin J.N., Terris M.K. Bacteremia and bacteriuria after transrectal ultrasound guided prostate biopsy. J Urol. 2000;164:76–80..
2.Taylor S, Margolick J, Abughosh Z, et al.. Ciprofloxacin resistance in the faecal carriage of patients undergoing transrectal ultrasound guided prostate biopsy. BJU Int. 2013 May;111(6):946-53.
3. Hendlin D, Stapley EO, Jackson M, et al. Phosphonomycin, a new antibiotic produced by strains of streptomyces.Science. 1969 Oct 3;166(3901):122-3.
4. Cai T, Gallelli L, Cocci A, et al. Antimicrobial prophylaxis for transrectal ultrasound-guided prostate biopsy: fosfomycin trometamol, an attractive alternative. World J Urol. 2016 May 31. [Epub ahead of print]

==fine reference==