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Objective: we present our 7-years’ experience with fiducial gold markers inserted before Image-Guided Radiotherapy (IGRT) focusing on our echo-guided technique reporting early and late complications. Material and methods: 78 prostate cancer (PCA) patients who underwent fiducial markers placement for adaptive IGRT (period 2007-2014) were selected. Mean patient age was 75 years (range 60-81), mean PSA 7.8 ng/ml (range 3.1-10), clinical stage < T3, mean Gleason Score 6.4 (range 6-7). We recorded early and late complications. Maximum distance between the Clinical Target Volume (CTV) and Planning Target Volume (PTV) was assessed for each direction and the mean PTV reduction was estimated. Results: we describe in details our echo-guided technique of intraprostatic gold fiducial markers insertion prior to adaptative IGRT. We report rare early toxicity (5-7% grade 1-2), a mean PTV reduction of 37% and a very low late toxicity (only 3.4% bladder G3 and 8% rectal G2 side effects). Conclusion: Our technique of fiducial gold markers implantation for adaptative IGRT is safe and well-tolerated and it resulted helpful to reduce CTV-PTV margin in all cases; the effects on clinical practice seem significant in terms of late toxicity but further investigations are needed with longer follow-up.

To evaluate the role of intrarectal EMLA, a new topical anesthetic cream, and lidocaine gel as local anesthesia during transrectal prostate biopsy and to observe whether gel temperature can improve pain control.A series of 210 consecutive patients were randomized. Group 1 (N = 60) underwent intrarectal instillation of EMLA cream, group 2 (N = 50) 2.5% lidocaine gel, group 3 (N = 40) placebo, and group 4 (N = 60) no treatment. Patients in groups 2 and 3 were subdivided into subgroups according to instillation of warm or cooled gel. Pain control was assessed by a 10-point visual analog scale.The median pain scores were 2.6 in group 1, 3.8 in group 2, 3.9 in group 3, and 3.6 in group 4. In 16 patients (7.6%), the procedure was suspended because of pain: none group 1, 6.0% in group 2, 10% in group 3, and 15% ing group 4. The temperature of the lidocaine gel did not affect tolerability.Intrarectal instillation of EMLA cream is a simple, safe, and effective method of local anesthesia during transrectal prostate biopsy, superior to lidocaine gel, placebo, and no treatment.

Topical and systemic therapeutic agents and treatment modalities, such as thiotepa and mitomycin C, cyclophosphamide, bacillus Calmette-Guerin, radiation therapy, photodynamic and laser therapy, and gene therapy, produce a host of changes in the bladder, some of them mimicking cancer. Pathologists must be aware that following these types of treatment, the clinical utility of urinary cytology is reduced.

Genetic studies have provided remarkable clues to the causes of prostate cancer (PCa). For example, in addition to the expected role of androgens in facilitating the development of PCa, the possibility that infections might lead to prostate cancer has been raised with the identification of RNASEL and MSR1 as familial prostate cancer genes; that insight will profoundly affect future studies and may ultimately lead to new approaches to the prevention of prostate cancer. The identification of key molecular alterations in prostate cancer cells implicates carcinogen defenses, including GSTP1, growth factor signaling pathways (such as NKX3.1, PTEN and p27) and androgens as critical determinants of the phenotype of PCa cells and defines specific targets for detection, diagnosis and treatment of PCa.

To evaluate the effect of neoadjuvant androgen deprivation therapy (NADT) on the cellular proliferative activity in primary prostate cancer and lymph node metastases using proliferating cell nuclear antigen (PCNA) immunostaining.Metastatic pelvic lymph nodes and tumoral prostatic tissue were obtained from 21 patients after radical prostatectomy and pelvic lymphadenectomy. Sixteen patients received NADT for 3 months prior to surgery; five patients did not and were evaluated as a control group. Histopathologic analysis was performed using PCNA immunostaining. and histopathologic findings of primary tumors and lymph node metastases after NADT were reported. Clinical follow-up was performed for a mean of 43.7 months.Evaluation of PCNA immunostaining of lymph node metastases in the 16 treated patients revealed a mean positivity for metastatic tumor of 4.5% (SD 3.1%); the corresponding value for the five patients who were not treated with NADT was 19.6% (SD 0.94%) (p0.05). In four of the treated cases the proliferative activity in the lymph node metastases was greater than that in the other 12 (9.3% and 3.0%, respectively) and no histopathologic regressive changes were observed in these four cases. The residual tumoral proliferative activity in lymph nodes was greater than that in primary tumors (4.5% and 1.3%, respectively).This study shows that the nodal metastases were responsive to hormonal therapy, as assessed by PCNA staining, although a greater residual proliferative activity was observed after NADT in lymph node metastases in comparison with the primary prostatic tumor. This can be attributed to a metastatic phenotype less responsive to hormonal therapy compared to the primary tumor.

We have assessed 24 patients consecutively treated with cryosurgery and chosen according to the guidelines of the European Study Group of Urologic Cryosurgeons. Of the 24 patients (average age about 70, range 61-79), all were not considered candidates for radical prostatectomy, 9 (37%) were clinical stage cT2 N0M0, 15 (63%) cT3 N0M0 who had not received any prior treatment, except 1 patient (61 years old) who was treated with TCT and successive recurrence of the disease (cT2). Of the 24 chosen patients, 13 (55%) were over the age of 71, 11 (45%) had important factors of co-morbidity and an elevated risk of surgery (ASA 3). The average PSA was of 19.3 ng/ml (range 2.2-61). Gleason score was 2-5 in 9 cases, 6-7 in 14 and 8-10 in 1 case. In the follow-up, we evaluated serum PSA every 3 months and transrectal ultrasound and the echoguided prostatic biopsies at 6, 12 and 24 months. Post-operative complications included: ecchymosis and edema of external genitals (16/24), fever38 degrees C (1/24), sloughing syndrome (6/24), urinary tract infections (10/24) acute urine retention (1/24). In 2 cases, 6 months after treatment, a transrectal resection was carried out. After a follow-up at 6 months, the PSA was 0.4 ng/ml (range 0.1-0.9), in 1 case. In positive core biopsy out of 6 showed neoplastic cells with fibrous tissue; the patient had a PSA of 0.58 ng/ml. At 12 months there were 11 assessable patients. The average PSA was 0.3 ng/ml (range 0.1-0.9). At 24 months there were 4 assessable patients, 1 of 4 showed serum PSA level of 4 ng/ml and cancer in apical biopsy. Erectile dysfunction was assessed on 8 patients affective before surgery: 1 referred to sufficient erections at penetration (1/8, 12.5%). After removal of the catheter, 4 of the 20 patients suffered stress and urge incontinence with the use of 1 pad a day. In 1 case, 18 months from surgery, slight stress incontinence was found (1 pad/day). Cryoablation is an efficient method and is given to slight post-operative morbidity and no intra-operative mortality, also in patients with high risk for open surgery. Indications may be found in patients with the following conditions: older than 72 years, severe co-morbidity and high risk for surgery, neoplasia at high risk of progression, and disease recurrence after radiotherapy. Our case history is at the moment encouraging and a larger number of cases as well as longer follow-up are needed.

Cryosurgery of prostate is a minimally invasive treatment for localized cancer. Imaging techniques (transrectal ultrasound (TRUS) or magnetic resonance) have been proposed to evaluate tumor persistence/recurrence after cryosurgical treatment other than serum PSA and prostate biopsies. Actually, criteria to identify cancer after cryosurgical ablation are not well assessed. Aim of this study is to evaluate the clinical significance and role of TRUS in detecting tumor within the former prostate gland after cryoablation. We evaluated ultrasound (US) features and imaging, serum PSA and biopsies in 20 patients treated by cryosurgery at our Hospital with a mean follow-up of 18 months. Twenty patients (mean age 70 years, PSA 25.9 ng/ml, clinical stage: 10 T2 N0M0 and 10 T3 N0M0) were followed up for a mean of 16 months. Ultrasound findings (gland volume, capsule, hypoechoic area, post-voided urine volume, seminal vesicles) were correlated to PSA levels (every 3 months) and prostate biopsies (6, 12 and 24 months). All cases were evaluated by the same ultrasound scanner (Eidos, Hitachi-5-6.5 MHz) and by two operators. Prostate capsule was interrupted by hypo-hyperechoic areas in all cases. Transition zone was no more recognizable. Ultrasound findings showed in all cases hypoechoic areas, but US did not identified tumor recurrence in 2 patients. During follow-up, PSA below 0.5 ng/ml was recorded in 75% of cases. We detected tumor in 2 cases, respectively 12 and 18 months after cryosurgery: in the first case few residual cancer cells within fibrous tissue were found in 1 out of 6 biopsies at 6 months (PSA 0.58 ng/ml), in the second one, tumor with viable normal prostatic glands was found in one biopsy of the apex at 18 months (PSA 4.0 ng/ml). TRUS showed several anaechoic foci with necrotic tissue and coalescence of liquid areas in 2 patients (one developed acute urinary retention). Actually, serum PSA is the best marker in order to detect clinically significant tumor after cryosurgery. Hypoechoic areas and capsule interruptions observed by ultrasound imaging of prostate gland after cryosurgery are not correlated with tumor recurrence or tumor persistence. TRUS is only indicated for ultrasound-guided biopsies during follow-up and to confirm urologic complications.

To evaluate urinary NMP22 dosage as a marker of urothelial tumours, we have selected a group of 90 patients (85 males and 5 females, mean age 66 years) with clinical suspicion of transitional cell carcinoma (TCC), with microscopic or macroscopic hematuria, flank pain, urographic abnormalities and dysuria. All the patients have been evaluated by urinary cytology, renal and bladder ultrasound, cystoscopy. When a bladder tumour has been detected, bladder biopsies and, when required, I.V.P., CT or retrograde pyelography have been performed. A urine sample has been collected between midnight and noon; all samples from patients who were undergoing invasive procedures such as cystoscopy, were collected before or at least 5 days after the procedure. The test has been performed according to ELISA NMP22 (Matritech) technique; the test is specific for the nuclear matrix protein/nuclear mitotic apparatus protein expressed by cancer cells. When performing the test, 30 patients presented macroscopic hematuria. 22 patients resulted to have benign urinary tract conditions, 65 patients had TCC and 3 patients had a final evaluation suspicious for TCC. The NMP22 values were respectively 7.1 +/- 4.7 U/ml, 21.9 +/- 21.0 U/ml and 16 +/- 8.0 U/ml. From our study the sensitivity of the test is 67% (with a threshold value of 10 U/ml) and 55% (with a threshold value of 20 U/ml), while the urinary cytology resulted to have a sensitivity of 26% (p0.05). The sensitivity of the test in relation to staging was as follow: Tis 66% with a mean NMP22 value of 23.3 U/ml, Ta 26% with a mean NMP22 value of 13.2 U/ml, T1 100% with a mean NMP22 value of 40 U/ml, T2 73% with a mean NMP22 value of 36.4 U/ml. The specificity of the test was 100% with a threshold value of 20 U/ml. When considering a threshold value of 10 U/ml, the NMP22 test has a sensitivity higher than cytology, especially in low stage TCC. Macroscopic hematuria does not affect its sensitivity; the diagnostic efficacy of the test is not increased by the association of urinary cytology. It has an important role in the diagnosis of residual disease after TURB and in the follow-up evaluation of bladder cancer patients, since its dosage is not influenced by inflammatory conditions of the mucosa. We believe therefore that NMP22 is useful in clinical practice.

Although transurethral resection of the prostate (TURP) is the gold standard for treatment of BPH, a new, minimally invasive technique, called Interstitial Laser Coagulation (ILC), introduced by Muschter and Hofstetter, has been developed to treat BPH. ILC is base on the coagulation of prostatic tissue by means of diffused laser light using a diode laser system with a temperature feed-back (Indigo Medical 830e TM). We report our results in treating 20 patients with BPH and Bladder Outlet Obstruction (BOO), after a mean follow-up of 7 months. To define the indication for treatment and to monitor the success, urinary flow-rate (Omax), I-PSS symptoms score, residual urinary volume and prostate volume determined by ultrasound were recorded before treatment and after 3, 6, 12 months. Transurethrally, under spinal or regional anaesthesia, 2 or 3 insertions of the laser fibre in each prostatic lobe were performed beginning at the apex directly proximal to the bladder neck, made at 1 cm intervals, using a modified model Olympus cystoscope. After 6 months, Qmax increased from 6, 7 ml/sec to 11, 3 ml/sec; I-PSS score decreased from 18 to 8; residual urinary volume from 130 ml to 40 ml, prostate volume decreased from 60 to 48 ml. In selected cases, urodynamic evaluation was performed before and after treatment. Urodynamic findings were classified according Shafer diagram to grade B.O.O.: the score was 4 before treatment and 2 after 6 months. We observed UTI in 3 cases, retrograde ejaculation and acute urinary retention in 1 case, transitory irritative and obstructive syndrome in 8 cases after treatment. ILC is a simple, safe and effective treatment for BPH with significant improvements in both objective and subjective parameters. It is cheaper than others mini-invasive therapies and is able to treat any prostate volume, saving urethra and sexual function.

The use of topical local anesthetics in the form of creams, gel or spray is the oldest method of retarding ejaculation. However, several studies have suggested that phosphodiesterase type 5 inhibitors (5-PDEiS) show a potential therapeutic use in the treatment of premature ejaculation (PE). The aim of this study was to compare the efficacy and tolerability of tadalafil-only, tadalafil plus local anesthetic spray (lidocaine), and topical lidocaine spray-only before intercourse on the intravaginal ejaculatory latency time (IELT) of patients with lifelong PE.The study included 78 men in stable heterosexual, monogamous relationships (of ≥3 months) who were diagnosed with lifelong PE. The patients were divided into three groups: G1: 25 patients who received lidocaine spray 10 g/100 ml at 5 min before intercourse; G2: 27 patients who received tadalafil 5 mg once daily; G3: 26 patients who treated with tadalafil once daily plus lidocaine spray before planned sexual activity. The treatments were continued for up to three months in all groups. Moreover, the quality of their sexual attempts was rated on a 5-point scale. Follow-up was made at 1-month and 3-month.Not statistically significant differences emerged between the three groups at baseline. Mean ejaculatory latency time at the 3-month follow-up in G1, G2 and G3 was 3.7±1.3, 3.4±1.5, 5.6±1.7 (p0.001). Mean satisfaction score was at the 3-month follow-up in G1: 2.8±1.4, in G2: 2.9±1.8, and G3: 3.7±1.5 (p0.002). None of the patients withdrew from the study because of these adverse events.This study demonstrates that tadalafil used daily has a role on treatment in lifelong PE. This action is valid when combined strategically to the synergistic action of lidocaine spray applied before intercourse increasing significantly the mean IELT.

A series of 48 patients with hydronephrosis (mean age 31 yrs.) underwent on Anderson-Hynes pyeloplasty. Assessment was carried out in 30 pts. after a mean observation time of 90 months, with a minimum 5 years follow-up. Clinical examination, laboratory investigations, renal ultrasonography, urography and renal scan were performed pre-operatively and at follow-up. There was one patient with evidence of stenosis in the ureteropelvic junction; one patient developed urinary leakage post-operatively and required surgical correction. All patients had symptoms pre-operatively and no one had symptoms post-operatively. Four patients had calcolosis associated, postoperatively all pts. were stone free; four years later one patient developed litiasis. We observed that the results of surgical intervention in hydronephrosis are excellent especially in patients aged less than 30 years.

The aim of this study is to identify and evaluate a scheme of graphic representation of the prostate, that allows the reconstruction of cancer diffusion based on ultrasound findings and on histological biopsy findings. A graphical representation of the prostate using transversal and longitudinal sections is represented by the US-operator, who write severy single performed biopsies (site, directions, and angle) and draws the US relieves. Biopsy specimens are separately prepared on a paper-support and marked at one extremity with china ink. The histopathological examination on every single specimen allows to identify the tumor extent, Gleason grading and the percentage occupied by the neoplasia. Were performed 50 transrectal echo-guided mapping biopsies. Comparing biopsy results with the pathological analysis on 13 whole-mount radical prostatectomy: pathological stage was predicted in 6 of 7 cases, Gleason grading was predicted in 85% of cases. In 5 cases in which the core biopsy histological analysis showed only atypical glands suspicious for cancer it has been possible to repeat new biopsies in the same site of the gland. Tumor was this time diagnosed in 3 of 5 cases (60%). The proposed approach can be useful to reduce variables linked to operator, technique, and single clinical situation, but it needs an employment on a higher number of cases and a verification on more surgical specimens. The scheme proposed has been of easy complication and immediate interpretation by clinicians and pathologists.

Prostate needle biopsy can give important clinical information on tumor extension and grading, useful prognostic parameters for the therapeutic choice and prognostic definition. Currently about the 25% of positive biopsies for carcinoma contain only small foci of cancer that makes histopathological evaluation often the difficult and less reliable. We reviewed the literature about different methods to perform needle biopsies and methods to improve histologic yield of prostatic biopsies in order to obtain more histopathological information on the specimens to improve diagnostic accuracy on core biopsy. We report our initial experience using the preembedding methods proposed by Rogatsch. The best method to perform a prostate biopsy includes the use of using 18-gauges needles, single specimen identification and subsequent orientation of every bioptic fragment by inking its proximal end. We performed the preembedding technique of the fragments, proposed by Rogatsch et al., stretching the fragment between two nylon meshes enclosed in a tissue cassette in formalin. The full length of the biopsy is within the section plane. This technique partially modified in our preliminary experience with the employment of two sponges containing 10% buffered formalin placed in a tissue cassette (2.8 x 3.3 cm). This "sandwich" technique has furnished evident advantages for the pathologist, optimizing the visible area for section plane in comparison to that obtainable from free floating core biopsies. In conclusion, routinely application of the preembedding prostatic core biopsies could improve the accuracy of the histopathological examination and therefore provide more reliable data on tumor extension and grade.

The human penis is a superficial organ ideally suited to ultrasound imaging. Penile ultrasound should be performed using high-frequency, linear probe. Ultrasound allows to evaluate the corpora cavernosa, the corpus spongiosum, the fascial layers, the septum, and the vascular structures. The external portion of the penis can be examined through a dorsal, a ventral, or a lateral approach. The non-external portions of the corpora cavernosa and the proximal bulbous urethra are best examined through a transperineal approach. The sonographic appearance of various structures varies according to the degree of rigidity.

In the clinical practice, there is an increasing incidence of small, non-palpable testicular lesions identified with an ultrasonographic investigation performed for other purposes. Many of these lesions are benign tumours or non-neoplastic conditions. In this context, the old axiom that every testicular mass should be considered a malignant tumour and the testis must be removed is no longer valid. Lesions can either undergo active surveillance or testis-sparing surgery, which allows maximal preservation of testicular parenchyma and its vasculature. To provide for the possibility of testis-sparing surgery for non-palpable nodules, precise intraoperative ultrasonographic localisation of the lesion is necessary. Our technique includes ultrasonographic localisation of the nodule within the exposed testicle and placement of a localising needle while the patient is on the operating table.