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Indocyanine green guided urethra-sparing robot assisted Millin’s prostatectomy

==inizio abstract==

INTRODUCTION: Millin’s prostatectomy is an established surgical option for large benign prostatic hyperplasia (BPH). The main pitfalls of surgical options remain the retrograde ejaculation, to date considered an intrinsic side effect of surgery.
METHODS: In this video we first report surgical steps of a robot assisted Millin’s prostatectomy with complete preservation of prostatic urethra in order to preserve antegrade ejaculation.
The first step was a retrograde injection of 10 mL of indocyanine green through the urethral catheter placed at navicular fossa.
Near infrared fluorescence (NIRF) imaging was used when dissection moved towards the median aspect of the lobe in order to improve visualization of the bladder neck and of the urethra, to avoid any unintended violation of urinary tract.
RESULTS: Operative time was 115 minutes. Estimated blood loss was 100 mL. Continuous bladder irrigation was not necessary. Urethral catheter was removed on third postoperative day. Patients was discharged on 4th postoperative day.
On final pathology, 75 grams of benign hyperplastic tissue were confirmed.
At 1 month evaluation, IPSS score decreased from 22 to 8, and patient reported a satisfying antegrade ejaculation.
CONCLUSIONS: We first described a NIRF imaging guided technique to perform robot assisted urethra sparing Millin’s prostatectomy with preservation of ejaculatory function.

==fine abstract==

Atypical Adenomatous Hyperplasia (AAH) of the prostate in a case report with previuos diagnosis of ASAP (Atypical Small Acinar Proliferation): a review of the literature

==inizio objective==

Case report of Atypical Adenomatous Hyperplasia and review of literature.

==fine objective==

==inizio methodsresults==

A 61-year old man performs periodic checks of PSA (prostate-specific antigen) with elevated level of 4.02 ng/mL and Ratio 18% (PSA free/PSA total). He doesn’t present with symtoms of urinary obstruction. The first prostate biopsy showed glandular atypia on lateral right and intermediate left side, with negative immunoreaction for anti-cytokeratin 34betaE12. The second biopsy showed evidence of ASAP on the left apex, with negative immunoreaction for anti-cytokeratin 34betaE12. The third biopsy is negative for atypical or cancerous lesions. After the three biopsies the patient perfoms an abdominal NMR (Nuclear Magnetic Resonance), that is negative for neoplasms and it doesn’t show disomogeneity of prostatic parenchyma. So he performs a saturation biopsy with 32 specimens. At that time the level of PSA is 4.12 ng/mL and Ratio 17%. The results of saturation biopsy shows evidence of Atypical Adenomatous Hyperplasia (AAH) on left lateral side, with immnureaction slowly positive for AMACR (alphamethylacyl-coenzyme A-racemase) and patchy immunostaining high-molecular-weight cytokeratin 34betaE12. This case is a review of the literature about the AAH and highlights the differences with low grade adenocarcinoma or precancerous lesions like PIN (prostatic intraepithelial neoplasia) or ASAP.

==fine methodsresults==

==inizio results==

A 61 year-old male man performs periodic checks of PSA with elevated level of 4.02 ng/mL and Ratio 18%. He doesn’t present with symptoms of urinary obstruction. Digital rectal examination reveals a large prostate (estimated volume doubled) without nodules suggestive of malignancy. Some needle biopsies are performed.
The first biopsy showed glandular atypia on lateral right and intermediate left side. The specimens show lymphogranulocyte inflammation with lymphoid aggregates; in one of these, there is a glandular microaggregate with nuclear atypia, and negative immunoreaction for anti-cytokeratin 34betaE12. It’s no possible to make sure of diagnosis so the patient will repeat the prostate biopsy after 6 months, with new dosage of PSA
Before the second biopsy the presentation clinical and the dosage of PSA are stable (4.1 ng/Ml). The second biopsy showed specimens of the left apex with limphocyte inflammation with typical cytological and architectural atypia as a ASAP, and negative immunoreaction for anti-cytokeratin 34betaE12. European and American guidelines suggest repeating prostate biopsy within 6 months.
Before the third biopsy the presentation clinical and the dosage of PSA are stable (3.8 ng/Ml). The third biopsy, examining 12 specimens, is negative for atypical or cancerous lesions.
After 2 months from the last biopsy the patient performs an abdominal NMR, that is negative for neoplasms and it doesn’t show disomogeneity of prostatic parenchyma.
After 6 months from the last biopsy the patient performs a saturation biopsy with 32 specimens. The clinical feauteres and the dosage of PSA are stable (4.12 ng/Ml and Ratio 17%). The specimens show evidence of atypical adenomatous hyperplasia on left lateral side, with slowly positive for AMACR (alphamethylacyl-coenzyme A-racemase) and patchy immunostaining high-molecular-weight cytokeratin 34betaE12Discussion
AAH is a pseudoneoplastic lesion that can mimic the prostate adenocarcinoma. AAH is usually an incidental finding in TURP (transurethral resection of prostate) or found in the transition zone in a prostate biopsy [1]. The case reports that AAH is found on left lateral side, with a suspect glandular atypia in the first biopsy on lateral right and intermediate left side, and with ASAP in the second biopsy on the left apex.
The specimes were examined always in the same lab.
In literature, AAH is rare finding, reaching only 2% of transurethral resection of the prostate specimens and < 1% of core biopsy specimens. [6] Typically, they are lined by cuboidal to short columnar cells. Also, the glands will be densely packed, stay well separated, and show no evidence of fusion. The luminal borders will be serrated and irregular. The lumens of glands/acini will often be empty but can contain corpora amylacea and crystalloids in 24% of biopsies. [5] ==fine results== ==inizio discussions== AAH is frequently multifocal, and in 84% of cases has been associated with nodular hyperplasia. It can be difficult to distinguish AAH from low-grade prostatic adenocarcinoma because both can be observed in the transition zone and can show intraluminal crystalloids and mitotic figures. The crucial feature of all AAH cases is a fragmented basal cell layer, which can be demonstrated by patchy immunostaining for high-molecular-weight cytokeratin 34betaE12 or p63. [8] Today no evidence is available indicating the progression of AAH into prostatic intraepithelial neoplasia (PIN). [4] A similar histological pattern can be the partial atrophy. It can be mistaken for cancer because of the AMACR, which is found in 69.1% of such cases. AMACR is found by staining with cytokeratin 34betaE12/p63, which will be negative in 31.4% Tipcally it’s found on peripheral side of the gland and the differential diagnosis with AAH, even if, as in the AAH, today no evidence is available indicating progression into PIN [6] ==fine discussions== ==inizio conclusion== AAH is a rare histologic finding of the prostatic biopies. There are some typical findings of immunohistochemistry to distinguish a ASAP/PIN from AAH or low grade adenocarcinoma or partial atrophy, but It need experience from the pathologist. The indications to repeat biopsy are: rising and/or persistently elevated PSA suspicious DRE, 5-30% cancer risk atypical small acinar proliferation (i.e., atypical glands suspicious for cancer), 40% risk; extensive (multiple biopsy sites, i.e., > 3) high-grade prostatic intraepithelial neoplasia (HGPIN), ~30% risk
a few atypical glands immediately adjacent to high-grade prostatic intraepithelial neoplasia (i.e., PINATYP), ~50% risk
intraductal carcinoma as a solitary finding, > 90% risk of associated high-grade prostate carcinoma
positive multiparametric magnetic resonance
European Guidelines don’t specify the way of follow-up of AAH, but some studies say the patients have to continue the controls like in benign lesions (once a year).
Our team, considering the previous diagnosis of ASAP, although there is no evidence of progression into cancerous lesion either of correlation between ASAP and AAH, has decided to continue the follow-up as a ASAP or PIN, respectively a dosage of PSA and prostatic rebiopsy every 4 or 6 months .
Alternately, it’s useful to repeat the dosage of PSA every 4 or 6 months and the pelvic multiparametric RMN.

==fine conclusion==

==inizio reference==

[1] J. T. Kwak, S. M. Hewitt, S. Sinha, and R. Bhargava, “Multimodal microscopy for automated histologic analysis of prostate cancer,” BMC Cancer, vol. 11, article 62, 2011
[2] Montironi R, Mazzucchelli R, Lopez-Beltran A, Cheng L, Scarpelli M. Mechanisms of disease: high-grade prostatic intraepithelial neoplasia and other proposed preneoplastic lesions in the prostate. Nat Clin Pract Urol. 2007;4:321–32
[3] Stamatiou K, Alevizos A, Natzar M, Mihas C, Mariolis A, Michalodimitrakis E, Sofras F. Associations among benign prostate hypertrophy, atypical adenomatous hyperplasia and latent carcinoma of the prostate. Asian J Androl. 2007;9:229–33;
[4] Montironi R, Mazzucchelli R, Lopez-Beltran A, Cheng L, Scarpelli M. Mechanisms of disease: high-grade prostatic intraepithelial neoplasia and other proposed preneoplastic lesions in the prostate. Nat Clin Pract Urol. 2007;4:321–32.
[5] [Lopez-Beltran A, Qian J, Montironi R, Luque RJ, Bostwick DG. Atypical adenomatous hyperplasia (adenosis) of the prostate: DNA ploidy analysis and immunophenotype. Int J Surg Pathol. 2005;13:167–73.
[6] Postma R, Schröder FH, van der Kwast TH (2005) Atrophy in prostate needle biopsy cores and its relationship to prostate cancer incidence in screened men. Urology 65:745–749
[7]  Rekhi B, Jaswal TS, Arora B. Premalignant lesions of prostate and their association with nodular hyperplasia and carcinoma prostate. Indian J Cancer. 2004;41:60–5
[8] Rekhi B, Jaswal TS, Arora B. Premalignant lesions of prostate and their association with nodular hyperplasia and carcinoma prostate. Indian J Cancer. 2004;41:60–5.
[9] Anim JT, Ebrahim BH, Sathar SA. Benign disorders of the prostate: A histopathological study. Ann Saudi Med. 1998;18:22–7;
[10] Bostwick DG, Qian J. Atipical adenomatous hyperplasia of the prostate. Am J Surg Pathol.1995;19:506–18;

==fine reference==

30-Watt Thulium vapoenucleation of the prostate (THUVEP): Low energy and better functional outcomes

==inizio objective==

Thulium laser vapo-enucleation of the prostate (THUVEP) is the lastest of minimally invasive therapies available for the surgical treatment of lower urinary tract symptoms secondary to benign prostate obstruction (BPO)[1-2-3]. Modern laser therapy for BPO has advantages over TURP including decreased blood loss and minimal serum electrolyte changes resulting in fewer cardiovascular complications, decreased catheter time, shorter hospital stay and the ability to treat patients on anticoagulation [4-5]. Thulium laser performs excellent haemostasis and coagulation, presents effective resection and vaporization of prostate tissue [5]. In some cases THUVEP can cause irritative urinary symptoms [6]. It may be caused by the laser energy on the urethral sphincter The aim of this study is to compare irritative urinary symptoms in patients with BPO undergone 70 or 30 watt THUVEP.

==fine objective==

==inizio methodsresults==

We retrospectively studied 106 patients with BPO from September 2015 to December 2016. All patients were aged 45 to 78 years and divided into 2 groups. Group 1 (n=53) underwent 70-Watt Thuvep and group 2 (n=53) 30-Watt Thuvep. Groups were similar for PSA range (0,5-3,5 ng/ml), prostate volume (42-150 g), preoperative urinary flow (5-10,2 ml/s) and post void residual volume (PVR) (35-68 ml). Patients were evaluated at 1, 3 and 6 months postoperative with International Prostate Symptom Score (IPSS), Overactive Bladder questionnaire short form (OAB-q SF) and International index of erectile function (IIEF).

==fine methodsresults==

==inizio results==

Mean operative time was 52 (IQR 42-73) min vs 70 (53-101) min in group 1 and 2, respectively. Mean laser time was 19 (13-35) min vs 32 (21-52) min. The rate of intraoperative prostate capsule perforation was less using 30-Watt than using 70-Watt Thuvep. Postoperative bleeding was less in 30-Watt Thuvep group. No differences in IPSS score and IIEF score were observed between the groups. After 1 month from treatment we found significative differences between group 1 and 2 in OAB-q symptom bother (24.43 ± 8.03 vs. 15.61 ± 4.25) and health-related QoL (51.07 ± 8.99 vs. 26.01 ± 5.26) scores (P < .0001 for all). No significative difference were observed in OAB-q SF score between the groups after 6-months from treatment. We found that none of the patients required re-operation for recurrent BPO. ==fine results== ==inizio discussions== Laser enucleation techniques such as THUVEP have emerged over the last 10 years as viable treatment options for BPH based on evidence from prospective clinical trials [1 - 4 - 5]. The thulium laser is a new technology with several potential advantages over others lasers for the treatment of BPH such as favorable hemostatic properties, a relatively shallow depth of thermal damage [7] and the ability to perform hybrid procedures utilizing both vaporization and resection properties of the laser [8, 9]. A systematic literature review was performed to identify articles that reported data on the use of low voltage THUVEP. There are no articles speaking about this. Our early experience suggested 30 Watt ThuVEP is safe and effective and is better than high voltage THUVEP concerning irritative urinary symptoms, despite a longer operative time. ==fine discussions== ==inizio conclusion== 30-watt Thuvep is a safe and effective treatment for BPO. Patients undergone 30 Watt Thuvep had a better score in OAB-q SF. Using lower energy we found a significant difference in filling urinary symptoms in the first month after surgery. ==fine conclusion== ==inizio reference== 1. Xia SJ, Zhuo J, Sun XW, Han BM, Shao Y, et al. Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol. 2008;53:382–9. 2. Herrmann TR, Bach T, Imkamp F, Georgiou A, Burchardt M, Oelke M. Gross AJ Thulium laser enucleation of the prostate (ThuLEP): transurethral anatomical prostatectomy with laser support. Introduction of a novel technique for the treatment of benign prostatic obstruction. World J Urol. 2010;28(1):45–51. 3. Fried NM. Therapeutic applications of lasers in urology: an update. Expert Rev Med Devices. 2006;3(1):81–94. 4. Mebust WK, Holtgrewe HL, Cockett AT, Peters PC. Writing Committee, the American Urological Association. Transurethral prostatectomy: immediate and postoperative complications. Cooperative study of 13 participating institutions evaluating 3,885 patients. J Urol. 1989;141:243–247. J Urol. 2002;167:5-9. 5. Aho TF, Gilling PJ. Laser therapy for benign prostatic hyperplasia: a review of recent developments. Curr Opin Urol. 2003;13:39–44. 6. Netsch C, Becker B, Tiburtius C, Moritz C, Becci AV, Herrmann TRW, Gross AJ. A prospective, randomized trial comparing thulium vapoenucleation with holmium laser enucleation of the prostate for the treatment of symptomatic benign prostatic obstruction: perioperative safety and efficacy. World J Urol. 2017 Dec;35(12):1913-1921. 7. Wendt-Nordahl G, Huckele S, Honeck P, Alken P, Knoll T, Michel MS, et al. Systematic evaluation of a recently introduced 2-microm continuous-wave thulium laser for vaporesection of the prostate. J Endourol. 2008;22:1041–1045. 8. Xia SJ, Zhuo J, Sun XW, Han BM, Shao Y, Zhang YN. Thulium laser versus standard transurethral resection of the prostate: a randomized prospective trial. Eur Urol. 2008;53:382–389. 9. Bach T, Herrmann TR, Ganzer R, Burchardt M, Gross AJ. RevoLix vaporesection of the prostate: initial results of 54 patients with a 1-year follow-up. World J Urol. 2007;25:257–262. 10. Ahyai SA, Gilling P, Kaplan SA, Kuntz RM, Madersbacher S, et al. Meta-analysis of functional outcomes and complications following transurethral procedures for lower urinary tract symptoms resulting from benign prostatic enlargement. Eur Urol. 2010;58:384–97. ==fine reference==