==inizio objective==

Robot assisted laparoscopic radical prostatectomy (RALP) spread in the last decade as a minimally invasive alternative to open radical prostatectomy for men with localized prostate cancer. It is associated with excellent surgical, functional and oncological results with less postoperative pain and shorter convalescence. Anyway, the development of an incisional hernia (IH), may negate known benefits as it can lead not only to bothersome symptoms but also to severe complications, such as bowel obstruction, strangulation and perforation. Port-site or extraction site hernias, whose incidence rate is underdiagnosed, have become more commonly after minimally invasive surgery; but IH rate after robot-assisted radical prostatectomy has not been well characterized.
This study aimed to evaluate the impact of extraction-site location (vertical supra-umbilical incision versus an off-midline incision) on incisional hernia rates in robotic prostatectomy.

==fine objective==

==inizio methodsresults==

We included in the study 800 patients undergone RALP, 400 with a supra-umbilical incision for specimen extraction and 400 with off-midline incision. All were followed up for at least 3 years. The main study end point was IH occurrence at the extraction site (midline versus off-midline).

==fine methodsresults==

==inizio results==

IH rate for the entire series was 4.75 %., in particular 5% for the midline group and 4.5 % for the off-midline group. The hernias were diagnosed at a mean of 20,2 and 18.2 months after surgery, respectively in the two groups. There was no statistically significant differences in baseline characteristics; anyway larger prostate weight, wound infection and history of prior cholecystectomy were associated with higher proportion of IH.

==fine results==

==inizio discussions==

The occurrence of IH remains underreported, problematic to patients, and a concern because it is a complication often requiring surgical revision, with a reported failure rate of 45%. Another very concerning aspect of IHs is that their incidence increases with time and appears to be largest under reported in RALP series. Mudge and Hughes demonstrated that 35% of all IHs occur after 3 years in a study that followed patients prospectively over 10 years [1]. The IH rate after RALP has been poorly defined, with a range of 0-8 %. Patel et al. had a rate of 0,2% with average follow-up of 24 months [2]. In another series of more than 600 RALP by Blatt et al, the incisional/inguinal hernia rate was 1.9% at 4 months of follow up [3]. Many factors lead to the formation of port-site hernias: mechanical factors as trocar type and size, site of specimen extraction and wound extension or stretching for organ retrial, and perioperative factors as trocars direction, wound infection, operative time, use of drain and port location, post-operatory persistent cough [4, 5]. Pre-existing disease like diabetes mellitus, connective diseases, obesity, malnutrition, smoking, umbilical defects are considered as risk factors.
Obviously an improper closure of fascial defect is the single most important factor related to HI, which more often occurs in obese patients because of it is difficult to find the fascia and the intra-abdominal pressure is higher as well [6].
Recently , it has been reported that a transverse incision at the midline trocar site decreased the incidence of IH from 5,3% to 0,6%; as the increased risk of herniation through the midline incision may be because of the lack of muscular abdominal wall layers. Specimen extraction site has been shown to play an important role in IH development and may account for the major differences in the reported hernia rates [7]. Singh et al found a significant differences when the midline was used as the extraction site compared to off midline, 17,6% vs 0% respectively in patients undergone laparoscopic colorectal surgery [8].Some authors have reported a lower incidence of hernias with the use of a para-median incision and no bladed trocars which have a conical tip [9].
The linea alba, including the umbilicus, lacks the muscle support in spontaneously fascial closure due to the lack of rectus muscle; it is possible that midline incisions through the avascular linea alba are put on tension by abdominal wall contraction directed away from the incision. This might result in tension-induced ischemia on the closure line and thus impairs wound healing, whereas paramedian incisions have been shown in animal studies to be supported by muscle re-opposition after blunt trocars were used [10].
In conclusion, the incidence of IH after RALP is likely under reported in prior studies.

==fine discussions==

==inizio conclusion==

Extraction site hernias are a rare but a potentially serious complication following RALP.
In our series, the midline extraction doesn’t result in a significantly higher IH rate in comparison with the off-midline extraction site.

==fine conclusion==

==inizio reference==

1. Mudge M, Hughes L.E.
Incisional hernia: a 10 year prospective study of incidence and attitude
Bratislava Journal of Surgery, 72,no 1,70-71, 1985

2.Patel V.R, Siraman A.
Current status of robot-assisted radical prostatectomy: progress is inevitable
Oncology, vol 26,pp616-619, 2012

3. Blatt AM,Fadahunsi A, Ahn C et al.
Surgical complications related to robotic prostatectomy; prospective analysis
J Urol 2009; 181:353

4. Fuller A, Fernandez A, Pautler S.
Incisional Hernia after robot-assisted radical prostatectomy-predisposing factors in a prospective cohort of 250 cases.
Journal of endourology ,Vol 25, 6, 1021-1024

5. Ho J,Pigazzi A.
Laparoscopic repair of extraction site ventral hernia after robotic prostatectomy: institutional experience with 42 consecutive cases
Hernia (2011) 15: 673-676

6. Shaft A,Ahmaieh K,Shah A,Garvey E.M, Harold K.L.
Incidence and outcomes of ventral hernia repair after robotic retropubic prostatectomy: a
retrospective cohort of 570 consecutive cases.
International Journal of surgery (2017) 38: 74-77

7. Navaratnam AV, Ariyaratnam R, Smart NJ, Parker M, Motson RW, Arulampala TH
Incisional hernia rate after laparoscopic colorectal resection is reduced with standardisation of specimen extraction
Ann R Coll Surgery Engl 2015; 2015, 97: 17-21

8. Singh R, Omicicioli A, Hegge S, McKinley C.
Does the extraction-site location in laparoscopic colorectal surgery have an impact on incisional hernia rates?
Surg Endosc (2008) 22:2596-2600

9. Belice C, Stocchi L, Costedio M, Gorgun E, Kessler H.
Impact of the specific extraction site location on the risk of incisional hernia after laparoscopic colorectal resection
Dis Colon Rectus 206; 743-750

10. Beck S, Skarecky D,Osann K, Juarez R, Ahlering T
Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on
incisional hernias and cosmesis.
Urology 2011, september; 78 (3):586-590

==fine reference==

==inizio objective==

Prostate-specific membrane antigen (PSMA) is a membrane carboxypeptidase type II, widely over-expressed in prostate cancer cells. Recently, an innovative 68Ga–labeled ligand have been designed to target membrane PSMA in diagnostic PET/CT (1).
We report two years experience with 68Ga‐Prostate Specific Membrane Antigen (PSMA) PET/CT for detecting prostate cancer (PCa) disease in patients with biochemical recurrence (BCR) after primary radical treatment.

==fine objective==

==inizio methodsresults==

This prospective single-center trial was approved by the Local Ethical Committee (Protocol Code: IRST185.02; Eudract: 2015-003397-33). Inclusion criteria: proven PCa, radical therapy (surgery and/or radiotherapy with/without ADT) with curative intent, proven BCR (PSA increasing). 68Ga-PSMA PET/CT scans, performed from mid thighs to top of skull 60 minutes after intravenous injection of 150±50 MBq of 68Ga-PSMA were interpreted by two nuclear medicine experts physicians.
68Ga-PSMA PET / CT scans were performed on an integrated PET / CT system (Biograph mCT Flow® Siemens Healthineers, Germania) in 3D Flow acquisition (0,7 mm / sec).
Results were correlated to PSA at the time of the scan (trigger), staging PSA (iPSA), PSA doubling time (PSAdt), Gleason Score (GS), Tumor Stage (T, N), tumor residual after surgery (R+), time from primary therapy to BCR (TTR) and age. When available, 68Ga-PSMA PET/CT were compared to negative 18F-choline PET/CT routinely performed within 28 days (2,3).

==fine methodsresults==

==inizio results==

From November 2015 to October 2017, Three hundred fourteen PCa patients with BCR were enrolled in this study (mean age=69 years old; median trigger PSA 0.83 ng/mL). 68Ga‐PSMA resulted positive, detecting at least one site of suspected PCa lesion, in 197 (62.7%) patients. On a patient-based analysis, local lesions limited to the pelvis (prostate/prostate bed and/or pelvic LNs) were detected in 117/197 patients (59.4%). At least one distant lesion (distant LNs, bone, other organs; separately or combined with local lesions) was detected in 80/197 patients (40.6%). Trigger PSA and iPSA were higher in PET positive vs. PET negative patients (respectively p<0.0001 and p<0.007). Eighty-eight negative Choline PET/CT resulted positive in 59 (67%) patients. ==fine results== ==inizio discussions== A whole-body imaging technique detecting the source end extent of prostate recurrence in radically-treated patients experiencing biochemical recurrence is essential to inform the selection of the most appropriate therapeutic strategy. Currently, Choline PET / CT is used as gold standard in clinical practice, but suboptimal diagnostic accuracy has been reported in large cohorts, mainly due to a lack of specificity (4). In order to overcome this drawback a novel tracer, 68Ga-PSMA, is currently being tested in the biochemical recurrence scenario showing promising results both in terms of sensitivity and specificity (5,6). The two years experience data at our Institution, among the first in Italy to test this novel tracer, suggest similar excellent results. A major limitation of these imaging techique (Choline PET/CT and 68Ga-PSMA PET/CT) is the lack of histopathologic proof in most patients. ==fine discussions== ==inizio conclusion== This prospective trial confirms the importance of 68Ga‐PSMA PET/CT in restaging PCa with BCR, its superiority compared to Choline PET/CT and safety (5,6). Higher trigger PSA is associated with higher detection rate. ==fine conclusion== ==inizio reference== 1. C.M. Zechmann et al. PET imaging with a 68 Ga labeled PSMA ligand for the diagnosis of prostate cancer: biodistribution in humans and first evaluation of tumor lesions. Eur J Nucl Med Mol Imaging. 2013. 2. Hodolic M. Role of (18)F-choline PET/CT in evaluation of patients with prostate carcinoma. Radiol Oncol. 2011. 3. Bachmann LM et al. The role of 11C-choline and 18F-choline PET and PET/CT in prostate cancer: a systematic review and meta-analysis. Eur Urol 2013. 4. Fanti S. et al. Role of 11C-choline PET/CT in the restaging of prostate cancer patients with biochemical relapse and negative results at bone scintigraphy. Eur J Radiol 2012; Aug 81 (8). 5. Ali Afshar-Oromieh et al. Comparison of PET imaging with a 68 Galabelled PSMA ligand and 18F-choline based PET/CT for the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging. 2014, 41:11-20. 6. Ali Afshar-Oromieh et al. The diagnostic value of PET/CT imaging with the 68Ga- labelled PSMA ligand HBED-CC in the diagnosis of recurrent prostate cancer. Eur J Nucl Med Mol Imaging, 2015, 42: 197–209. ==fine reference==

==inizio objective==

To assess the safety and the oncological and functional efficacy of a prospective series of extraperitoneal laparoscopic radical prostatectomy (ELRP), to suggest the validity of laparoscopic technique in oncological control and preservation of continence and sexual function, based on data from experience in a single urological center. Our report describes one institution’s experience and the analysis confirms that the efficiency of laparoscopic radical prostatectomy is no longer in question; indeed, the authors report data on the short-term oncologic efficacy.

==fine objective==

==inizio methodsresults==

Over one year, 80 patients underwent to a videolaparoscopic radical prostatectomy for prostate cancer. All the procedures were carried out by the same operator. An extraperitoneal technique (ELRP) was used in 72 patients, a transperitoneal descending technique in 2 patients, due to previous abdominal surgery. Pelvic lymph node dissection (PLND) was carried out only in selected case (12 patients) belonging to intermediate/high risk group (2-4) according to Grade Group classification (Pierorazio et al).

==fine methodsresults==

==inizio results==

There were no conversions to open surgery. The mean (SD) operative duration was 127 (28,1) min (range 60-195 mL) , the blood loss was 381 (276,62) mL, the hospital stay was 7.1 (2.0) days, and the duration of catheterisation 6.1 (1.5) days. Collectively, 26,25% (21/80) of patients had positive surgical margins. Mean PSA nadir at one month was 0,075 ng/ml.

==fine results==

==inizio discussions==

With the advent of robotic surgery, it seemed that laparoscopic technique was set aside and overcome, but several considerations should be made in favor of laparoscopy, especially as far as its economic and clinical benefits are concerned. First, the robotic procedure is expensive. Leonardo da Vinci devices are only available in some centers, so the waiting list for intervention is in many cases too much long. Secondly, the alternatives to robotics are open surgery and laparoscopy. Open surgery is now an unsafe technique, especially if there are difficulties in some cases of accurate control of the haemostasis and to allow nerve sparing approach, when required. In these terms the benefit of laparoscopy is in the best vision and vascular and nervous control.

==fine discussions==

==inizio conclusion==

Laparoscopic technique is technically safe and not to much difficult nor impracticable, however with a longer learning curve than the open and robotic techniques. The benefits are to be found in terms of short-term oncological outcomes as well as continence and sexual power in patients undergoing NS technique. We highlight the feasibility of the technique and the benefits of cost reduction

==fine conclusion==

==inizio reference==

1: Goonewardene SS, Cahill D. Laparoscopic radical prostatectomy: continence and
oncological outcomes in 268 cases. J Robot Surg. 2015 Sep;9(3):267. doi:
10.1007/s11701-015-0525-0. Epub 2015 Jul 26. PubMed PMID: 26531209.

2: Good DW, Stewart GD, Laird A, Stolzenburg JU, Cahill D, McNeill SA. A Critical
Analysis of the Learning Curve and Postlearning Curve Outcomes of Two Experience-
and Volume-Matched Surgeons for Laparoscopic and Robot-Assisted Radical
Prostatectomy. J Endourol. 2015 Aug;29(8):939-47. doi: 10.1089/end.2014.0810.
Epub 2015 Feb 25. PubMed PMID: 25630790.

3: De Carlo F, Celestino F, Verri C, Masedu F, Liberati E, Di Stasi SM.
Retropubic, laparoscopic, and robot-assisted radical prostatectomy: surgical,
oncological, and functional outcomes: a systematic review. Urol Int.
2014;93(4):373-83. doi: 10.1159/000366008. Epub 2014 Sep 23. Review. PubMed PMID:
25277444.

4: Manferrari F, Brunocilla E, Baccos A, Bertaccini A, Garofalo M, Borghesi M,
Schiavina R, Martorana G. Laparoscopic radical prostatectomy: 10 years of
experience at a single institution. Anticancer Res. 2014 May;34(5):2443-8. PubMed
PMID: 24778058.

5: Close A, Robertson C, Rushton S, Shirley M, Vale L, Ramsay C, Pickard R.
Comparative cost-effectiveness of robot-assisted and standard laparoscopic
prostatectomy as alternatives to open radical prostatectomy for treatment of men
with localised prostate cancer: a health technology assessment from the
perspective of the UK National Health Service. Eur Urol. 2013 Sep;64(3):361-9.
doi: 10.1016/j.eururo.2013.02.040. Epub 2013 Mar 7. PubMed PMID: 23498062.

6: Si-Tu J, Lu MH, Li LY, Sun QP, Zhou XF, Qiu JG, Gao X. Prospective evaluation
of pentafecta outcomes at 5 years after laparoscopic radical prostatectomy:
results of 170 patients at a single center. Neoplasma. 2013;60(3):309-14. doi:
10.4149/neo_2013_041. PubMed PMID: 23374001.

7: Lim SK, Kim KH, Shin TY, Rha KH. Current status of robot-assisted laparoscopic
radical prostatectomy: how does it compare with other surgical approaches? Int J
Urol. 2013 Mar;20(3):271-84. doi: 10.1111/j.1442-2042.2012.03193.x. Epub 2012 Oct
29. Review. PubMed PMID: 23106163.

8: Pierorazio PM, Walsh PC, Partin AW, Epstein JI. Prognostic Gleason grade
grouping: data based on the modified Gleason scoring system. BJU Int. 2013
May;111(5):753-60. doi: 10.1111/j.1464-410X.2012.11611.x. Epub 2013 Mar 6. PubMed
PMID: 23464824; PubMed Central PMCID: PMC3978145.

==fine reference==

==inizio objective==

The wide diffusion of multiparametric magnetic resonance imaging (MRI) has dramatically modified the scenario of prostate cancer (PCa) diagnosis. The detection rate of MRI-ultrasound (US) fusion biopsy increased as well as the need for an extended prostate biopsy sampling with saturation biopsy decreased. The aim of this study was to develop, to calibrate and to externally validate a nomogram to predict the probability of detecting a clinically significant prostate cancer.

==fine objective==

==inizio methodsresults==

Prospectively collected data from 3 european tertiary referral center series of 478 consecutive patients who underwent MRI-US fusion biopsy using the UroStation™ (Koelis, France) were used to build the nomogram. External validation was performed in 406 patients from a US tertiary referral center. The Mann–Whitney U test and the Chi-square tests were used to evaluate differences in continuous and categorical variables, respectively. A logistic regression model is created to identify predictors of PCa diagnosis with MRI-US fusion biopsy. Predictive accuracy was quantified using the concordance index (CI). Internal validation with 200 bootstrap resampling and calibration plots were generated to explore nomogram performance.

==fine methodsresults==

==inizio results==

The development and validation cohorts were homogeneous for age (66.3 vs 66 yrs, p=0.57]), PSA levels (9.4 vs 8.8 ng/Ml, p=0.71] and PCa detection rates (57.4 vs 56.7%, p=0.81). Age, PSA serum levels, PIRADS score at MRI report, number of targeted and number of systematic cores taken were included in the model (Figure 1a). The nomogram showed high predictive accuracy (CI 0.82) and was well calibrated (Figure 1b). In the validation cohort the predictive accuracy was 0.77. Limitations include the need for a pre-biopsy mp-MRI and consequent fusion biopsy to reproduce findings.

==fine results==

==inizio discussions==

The wide diffusion of multiparametric magnetic resonance imaging (MRI) has dramatically modified the scenario of prostate cancer (PCa) diagnosis. The detection rate of MRI-ultrasound (US) fusion biopsy increased as well as the need for an extended prostate biopsy sampling with saturation biopsy decreased [1]. Our nomogram provides a high accuracy in predicting the probability of PCa diagnosis with MRI-US fusion biopsy. This is an easy to use clinical tool that physicians may use for patients counseling purposes.

==fine discussions==

==inizio conclusion==

This nomogram provides a high accuracy in predicting the probability of PCa diagnosis with MRI-US fusion biopsy. This is an easy to use clinical tool that physicians may use for patients counseling purposes.

==fine conclusion==

==inizio reference==

1. Magnetic resonance imaging for localization of prostate cancer in the setting of biochemical recurrence.
Panebianco V, Barchetti F, Grompone MD, Colarieti A, Salvo V, Cardone G, Catalano C.
Urol Oncol. 2016 Jul;34(7):303-10. doi: 10.1016/j.urolonc.2016.01.004. Epub 2016 Mar 21. Review.

==fine reference==

==inizio objective==

The aim of this study is to create, calibrate and externally validate a nomogram to predict the probability of detecting clinically significant prostate cancer (CSPCa) on magnetic resonance imaging–transrectal ultrasound (MRI/TRUS) fusion guided prostate biopsy (PBx).

==fine objective==

==inizio methodsresults==

We identified 884 consecutive patients from prospectively maintained IRB-approved PBx databases of 4 tertiary referral centers. All patients underwent MRI/TRUS fusion PBx, targeting suspicious lesions followed by 12-core systematic PBx, using the UroStation™ (Koelis, France), from 2013 to 2016. Patients were included if they underwent pre-PBx multi-parametric MRI (3T; DWI, T2W, DCE) that showed PIRADS score ≥ 3. Exclusion criteria were a negative MRI (PIRADS < 3) or patients with any prior treatment for PCa. The MRIs were evaluated and reported, by experienced radiologists, using Prostate Imaging – Reporting and Data System (PIRADS V2). Data from 478 consecutive patients from 3 European centers were used to create the nomogram. External validation was performed using data of 406 patients from a single center from USA. CSPCa was defined as Gleason > 3+4. The Mann–Whitney U test and the Chi-square tests were used to evaluate differences in continuous and categorical variables, respectively. A logistic regression model was created to identify predictors for CSPCa. Predictive accuracy was quantified using the concordance index (CI). Internal validation with 200 bootstrap resampling and calibration plots were generated to explore nomogram performance.

==fine methodsresults==

==inizio results==

The development and validation cohorts were homogeneous for age (66.3 vs 66 yrs, p=0.57]), PSA (9.4 vs 8.8 ng/mL, p=0.71] and overall PCa detection rates (57.4 vs 56.7%, p=0.81). Age, PSA, PIRADS score, number of targeted and number of systematic cores taken were included in the model (Figure 1a). The nomogram showed high predictive accuracy (CI 0.81) and was well calibrated (Figure 1b). In the validation cohort the predictive accuracy was 0.80. Limitations include the need for a pre-biopsy mp-MRI and consequent fusion biopsy to reproduce findings.

==fine results==

==inizio discussions==

The aim of this study is to create, calibrate and externally validate a nomogram to predict the probability of detecting clinically significant prostate cancer (CSPCa) on magnetic resonance imaging–transrectal ultrasound (MRI/TRUS) fusion guided prostate biopsy (PBx) [1]. A nomogram that provides a high accuracy in predicting the probability of diagnosing clinically significant PCa with MRI/TRUS fusion biopsy is created and validated. The simplicity of this nomogram makes it a useful clinical tool for both patients and physicians.

==fine discussions==

==inizio conclusion==

A nomogram that provides a high accuracy in predicting the probability of diagnosing clinically significant PCa with MRI/TRUS fusion biopsy is created and validated. The simplicity of this nomogram makes it a useful clinical tool for both patients and physicians

==fine conclusion==

==inizio reference==

1.Magnetic resonance imaging for localization of prostate cancer in the setting of biochemical recurrence.
Panebianco V, Barchetti F, Grompone MD, Colarieti A, Salvo V, Cardone G, Catalano C.
Urol Oncol. 2016 Jul;34(7):303-10. doi: 10.1016/j.urolonc.2016.01.004. Epub 2016 Mar 21. Review.

==fine reference==

==inizio objective==

Several studies report that [-2]proPSA, expressed as percentage of free PSA (fPSA) or in the Phi algorithm {[-2]proPSA/(fPSA×totalPSA)1/2}, outperforms total PSA (tPSA) and fPSA ratio for the diagnosis of prostate cancer (PCa). Nonetheless, although preanalytical variables are expected to affect its levels, the stability of [-2]proPSA has not been thoroughly evaluated. Our study was designed to investigate the stability of [-2]proPSA, fPSA and tPSA in whole blood after short term sample storage (by mimicking the time that may realistically elapse between sampling and centrifugation in the routine of clinical laboratories) in serum and plasma tubes.

==fine objective==

==inizio methodsresults==

Blood was drawn from 26 patients (pts) referred for prostate biopsy (Age: 47-79, median 66; tPSA from 2.34 to 12.77 ng/mL) and separated in polyethylene tubes as follows: 3 tubes for serum and 3 tubes for K2EDTA plasma. The samples were centrifuged after being stored at room temperature for 1, 3 and 5 h from collection. TPSA, fPSA, and [-2]proPSA were assayed with chemiluminescent immunoassays.

==fine methodsresults==

==inizio results==

TPSA did not show significant variations at the different time points from centrifugation in serum or plasma tubes; fPSA was stable in plasma whereas it significantly decreased in serum (mean percentage of variation: -2.89% after 3 h and -5.98% after 5 h); [-2]proPSA was stable in plasma but it showed a significant and progressive increase in serum (+4.92% after 3 h and +12.46% after 5 h); Phi values were stable in plasma whereas they increased significantly in serum (+8.08% after 3 h and +18.62% after 5 h). TPSA, fPSA and [-2]proPSA were higher in plasma than in serum at any time point examined (1h, 3h or 5h).

==fine results==

==inizio discussions==

We confirmed that fPSA and [-2]proPSA are subject to loss of stability over time, showing variations superior to the inherent imprecision of the methods when whole blood collected in serum tubes remained at room temperature up to 5 h before centrifugation. Conversely, the presence of EDTA as anticoagulant in the blood collection tubes prevented spurious in vitro modifications of both markers. Our study indicates the need to adopt stringent preanalytical operating procedures for the determination of different PSA isoforms for clinical use and the need to evaluate with caution the fPSA and Phi values when the whole blood short-term storage protocol before centrifugation is unknown.

==fine discussions==

==inizio conclusion==

Our study indicates the need to adopt stringent preanalytical operating procedures for the determination of different PSA isoforms for clinical use and the need to evaluate with caution the fPSA and Phi values when the whole blood short-term storage protocol before centrifugation is unknown.

==fine conclusion==

==inizio reference==

==fine reference==

==inizio objective==

During the last decades, many technical improvements have
been introduced, in order to preserve postoperative functional results
after radical prostatectomy; nevertheless, postoperative stress urinary
incontinence remains  a major complication, largely affecting patients
quality of life.
Aim of this study was to evaluate immediate postoperative results of a
new technique of intraoperative urethral suspension, whose tension can
be adjusted postoperatively.

==fine objective==

==inizio methodsresults==

From June 2017 to October 2017, 30 patients
underwent to open radical retropubic prostatectomy with nerve and bladder neck
sparing technique for localized prostate cancer.
15 patients received a standard procedure (group 1); on 15 patients we
performed a new technique for adjustable urethral suspension (group 2).
Our standard technique for the urethrovesical anastomosis includes
an interrupted suture with 3 stitches on both sides (towards 11, 9, 7
on the left, and toward 1, 3, 5 on the right), and a running suture on
the posterior urethral plate (which is tied to the suture towards 7 on
the left, and to the suture towards 5 on the right).
According to the new technique, the threads of the sutures towards 7
and 5, are put together with a prolene sling (1 x 10 cm), which is
brought outside the suprapubic skin on both sides.
Tension on both threads is then modulated at 24 and 48 hours
postoperatively, according to patient’s continence and using a stress test .
For each group, we evaluated number of pads per day and Internetional
Consultation on Incontinence Questionnaire (ICIQ) score at 24 and 48
hours and at 7 days postoperatively.
Continence was defined as the need of 0-1 pad per day.

==fine methodsresults==

==inizio results==

Results: At 24 hours, 3 patients (20%) in group 2 were continent, Vs. 1
patients in group 1 (6%); at 48 hours, 8 (53%) Vs. 3 (20%); at 7days,
11 pts (73%) Vs.6 pts (40%) were continent.
No complications related to the new technique were recorded.

==fine results==

==inizio discussions==

Although our limited series of patients, and with a low follow-up
period, our results showed better early continence results after
traction on urethral suspensions at 24 and 48 hours postoperatively,
compared to patients who received a standard urethrovesical anastomosis
technique. In our study we didn’t have complications related to the new technique of urethrovesical anastomosis: no urinary retention, anastomosis leak or perineal pain was observed.

==fine discussions==

==inizio conclusion==

We showed that postprostatectomy incontinence can be improved using a new technique for vesicourethral anastomosis that can be modulated postoperatively repositioning membranous urethra in the retropubic space. This could significantly improve the quality of life of patients after radical prostatectomy.

==fine conclusion==

==inizio reference==

The “ventral urethral elevation plus’ sling: a novel approach to treating stress urinary incontinence in men. Craig V. Comiter and Eugene Y. Rhee, BJU International (2007) 101: 187-191

Advanced Recostruction of vesicourethral Support (ARVUS) during Robot-assisted Radical prostatectomy: one year functional outcomes in a two-group Randomised controlled trial
Vladimir Student Jr et al, Eur Urol (2017)71:822-830

==fine reference==

==inizio objective==

The ligation of the dorsal vascular complex (DVC) during robot-assisted radical prostatectomy (RARP) can be sometimes avoided by using an accurate bipolar coagulation of the veins. The aim of this study is to compare outcomes of RARP with ligation versus bipolar coagulation of the DVC in a single-institution retrospective analysis.

==fine objective==

==inizio methodsresults==

Between January 2016 and January 2017, 48 RARP were performed at our institution. RARP was performed according to the Patel technique, by one single experienced robotic surgical team (1).
The veins of the DVC were closed by using an accurate bipolar coagulation or was ligated with a Vicryl-0® continuous suture. Patients’ characteristics and data are recorded in a prospective maintained database and retrospectively analysed. The primary endpoint is estimated blood loss (EBL) during prostatectomy. Secondary endpoints are: operative time, transfusion rate, hospitalisation, positive surgical margins (PSMs) in general and apical PSMs in particular and 1-month PSA and continence (defined as the use of 0 pad or 1 security pad per day). Means and standard deviation were reported for continuously coded variables. Statistical analyses were performed using SPSS version 20.0 (IBM, Armonk, NY, USA), considering a statistical significance at P < 0.05. ==fine methodsresults== ==inizio results== Of the total 48 patients, 22 had suture ligation (Group 1) and 26 had bipolar coagulation (Group 2) of the DVC. The two groups had comparable preoperative features and no statistically significant differences were found in term of primary and secondary endpoints. The mean age was 62.55±6.13 years for Group 1 and 63.12±5.85 years for Group 2 (p=0.7436). The mean opeative time was 161.05±24.13 minutes for Group 1 and 153.39±24.7 minutes for Group 2 (p=0.2849). The mean bloos loss was 112.73±76.17 mL for Group 1 and 108.46±86.8 for Group 2 (p=0.8583). The mean days of hospitalisation were 4.14±0.77 for Group 1 and 4.12±0.86 for Group 2 (p=0.9333). The mean value of PSA at 1-month follow-up was 0.06±0.07 ng/ml for Group 1 and 0.06±0.06 ng/ml for Group 2. No patients received blood transfusions in both two groups. No differences were seen in PSM (p=0.8642). In particular, no differences were seen in Apical PSM (p=0.5112). At 1-month follow-up 54.55% of the patients were continent (0-1 security pad) in the Group 1 and 53.85% of the patients were continent in the Group 2 (p=0.9614). 13.64% of the patients used more than 1 pad/die in the Group 1, and 11.54% in the Group 2 (0.8267) . ==fine results== ==inizio discussions== Theoretically, an accurate and selective bipolar coagulation of the DVC could be associated to greater blood loss but, on the other side, to a low rate of PSM and an early recovery of continence due to a minor damage of the rabdosphincter fibres avoiding the suture (2). Obviously, we do not intend to claim that the selective bipolar coagulation is the best way to manage the venous complex, but we highlight the fact that it can be an interesting alternative to the classical dorsal vascular plexus suture. ==fine discussions== ==inizio conclusion== Our preliminary results show that the bipolar coagulation of the DVC during RALP is not detrimental on surgical morbidity or oncological safety and no differences in functional outcome are evident at a short term follow-up between the two techniques. ==fine conclusion== ==inizio reference== 1-Woldu SL, Patel T, Shapiro EY, Bergman AM, Badani KK. Outcomes with delayed dorsal vein complex ligation during robotic assisted laparoscopic prostatectomy. Can J Urol. 2013 Dec;20(6):7079-83. 2-Ficarra V, Novara G, Rosen RC, Artibani W, Carroll PR, Costello A, Menon M, Montorsi F, Patel VR, Stolzenburg JU, Van der Poel H, Wilson TG, Zattoni F, Mottrie A.Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy. Eur Urol. 2012 Sep;62(3):405-17. doi: 10.1016/j.eururo.2012.05.045. Epub 2012 Jun 1. ==fine reference==

==inizio objective==

Prostate cancer is the second most prevalent cancer in men globally. It is now accepted that angiogenesis is a complex phenomenon accompanying the development, progression, and metastasis of tumors of unrelated histological origin. Here we introduce the Hurst index to investigate the two-dimensional (2-D) geometrical complexity of the tumor vascular network in biopsy specimens to comprehend whether non-tumoral biopsy cores might be helpful to select patients with hidden prostate cancer.

==fine objective==

==inizio methodsresults==

1984 biopsy cores sampled from a total of 316 patients were analyzed. Patients were categorized in two main groups: a) Prostate Cancer Group, which includes 140 patients with first positive biopsies for prostate cancer and 60 patients negative for prostate cancer at first biopsy and positive at re-biopsy, and b) Control Group, which includes 60 patients negative for prostate cancer at the first, second and third biopsy, and 56 patients with benign prostatic hyperplasia (BPH) following transurethral resection of the prostate (TURP). Two-micrometer thick sections were cut and processed for immunohistochemistry with primary antibodies raised against CD34 (Dako, Milan, Italy). This was followed by 30 min incubation with the Envision system (Dako). 3,3’-Diaminobenzidine tetrahydrochloride was used as a chromogen to yield brown reaction products. The histological sections were digitized using a computer-aided image analysis system that automatically selected the immunopositive vessels on the basis of RGB color segmentation and calculated the Hurst index by applying the formula:
H = E+1-D, where the Euclidean dimension E is equal to 1 and D represents the 2-D vascular surface fractal dimension. All of the data were analyzed using Statistica software (StatSoft, Inc., Tulsa, OK, USA) and GraphPad Prism 5 (San Diego, California, USA). P-values of ≤ 0.05 were considered to be statistically significant.

==fine methodsresults==

==inizio results==

A low Hurst index values in negative core biopsies suggest a higher probability of hidden prostate cancer. We found that Hurst index values in the non-tumoral biopsy below 0.20 suggest that the risk to have hiding prostate cancer is high. In contrast, Hurst indexes in the non-tumoral biopsy upper than 0.35 suggests that the risk to have misunderstood and contemporary prostate cancer is low.

==fine results==

==inizio discussions==

Scientific knowledge develops through the evolution of new concepts, and this process is usually driven by new methodologies that provide previously unavailable observation. The potential broad applicability of the Fractal geometry makes it possible to explore the range of the morphological variability of neovasculature that can be produced in nature, thus increasing its diagnostic importance in cancer research Prostate histology may remain the reference method for assessing the status of neovascularity, but there are still several open questions, including whether angiogenesis is a canonic hallmark of PC, and the absence of a powerful method of quantifying the reversal of neovascularity.

==fine discussions==

==inizio conclusion==

This study first shows that vascular Hurst index in non-tumoral biopsies might represent a low-cost adjunctive histopathological predictive value of prostate cancer. The proposed computer-aided analysis is cheap and might be introduced in combination with actual histopathological procedures to support the clinical practice. In addition, the present study first introduces the concept that also the non-tumoral biopsy tissue might have an informative content on the presence of a contemporary cancer.

==fine conclusion==

==inizio reference==

Taverna G, Grizzi F, Colombo P, Graziotti P. Is angiogenesis a hallmark of prostate cancer? Frontiers in oncology. 2013;3:15.

==fine reference==