==inizio objective==

To present our initial experience and results of MRI-TRUS Fusion Guided Prostate Biopsy: our fist 100 cases experience and assess the role of contralateral lobe systematic biopsy in PIRADS-5 score

==fine objective==

==inizio methodsresults==

A number of 100 patients with clinical or biochemical suspicion for prostate cancer (PCa) were included. All patients harbored at least one PIRADS score ≥ 3 lesion and underwent MRI-TRUS fusion guided biopsy, as well as a concurrent systematic biopsy 12 samples.
Each patient sistematically perform urine cultures, red cells blood count, prothrombin time (PT) and activated partial thromboplastin time (APTT) before biopsy.
We used a rectal povidone-iodine preparation in addition to antimicrobial prophylaxis (fosfomycin trometamol e.g., 3 g before and 3 g 24–48 hrs. after biopsy)
Intra-rectal instillation of local anaesthesia with EMLA creame (lidocaine and prilocaine 2,5%+2,5%, 15 g ) is reserved for each patient.
For the assessment of pain, the VAS scale (1-10) was administered to all patients.
All biopsies were performed with a Philips Affinity 70 ultrasound and Fusion Percunav navigation system. At least 2 samples were taken for each target lesion and all samples were taken using TRUS longitudinal scans of the prostate.
Immediately after the biopsy procedure, pain assessment was achieved using Visual Analog Scale (VAS).

==fine methodsresults==

==inizio results==

The mean age of the patients was 66.2 years. The mean pre-biopsy PSA was 8.47 ng/dl.
The diagnosis rate of MRI-TRUS fusion guided biopsy was 42% for overall PCa and 29.4% for clinically significant (cs)PCa.
A higher PIRADS score was significantly associated with the presence of overall and csPCa.
MRI-TRUS fusion guided biopsy had a higher percentage of positive biopsy cores (51% vs 29%), higher likelihood of csPCa (OR 5.36, p=0.008) and upgrading (14.8%) in comparison with systematic biopsy but missed 6.7% csPCa.
Clinically significant prostate cancer detection rates (CDRs) for each PIRADS category were calculated: the CDR in patients with PIRADS categories 3, 4, and 5 was 18%, 40.7%, and 60.5%, respectively.
Moreover we also took 12 samples beyond the target, 6 of these on the contralateral lobe to the positive one on the magnetic resonance.
In our results the contralateral (compared to the target lesion) lobe systematic biopsy could have been avoided without losing the PCa diagnosis all patients with PIRADS score 5, both in initial and repeat biopsy setting. Anterior and transitional lesions were more likely to be diagnosed only by targeted cores.
According to our exsperience very low complications occurred with this technique. Sepsis occurred in one case following transrectal biopsy. UTI occurred in 2 cases (2%). Bleeding occurred in 10 cases (10%). The most common complication was AUR, which occurred in 12 cases (12%).
The VAS of patients was 1.31 ± 0.66.

==fine results==

==inizio discussions==

Transperineal and transrectal approaches to prostate biopsy are well-documented. Both methods are fraught with complications though, most times minor. The transrectal procedure proved to be safe with low complications rate and a good cancer detection rate.
According to the major systematic review and meta-analysis of randomised controlled trials TR approach1 was associated with more infectious complications, compared to TP prostate biopsy (21 TR and 11 TP; RR 2.18) while the percentage rates of urinary tract infections found by our study (2%) are very close to those found with the TP approach.

==fine discussions==

==inizio conclusion==

MRI-TRUS guided prostate biopsy improves the detection of PCa, but systematic biopsy is still essential. In selected cases (PIRADS 5), contralateral lobe systematic biopsy can safely be avoided without altering the patient’s oncological outcome in terms of percentage result to the Briganti score 2019.
Pre-biopsy mpMRI might reduce the number of biopsy sessions in patients with anterior and transitional lesions.
According to our initial experience, the MRI-TRUS fusion guided biopsy is effective in the diagnosis of prostate cancer, has a low percentage of complications and, last but not least, is well tolerated by the patient.

==fine conclusion==

==inizio reference==

1. Garcia C., et al. Does transperineal prostate biopsy reduce complications compared with transrectal
biopsy? a systematic review and meta-analysis of randomised controlled trials. J Urol, 2016. 195: e328

==fine reference==

==inizio objective==

To compare the imaging-based segment-wise intraprostatic cancer extension by means of 68Ga-PSMA PET and prostate 3Tesla mpMRI with whole-mount prostate histology

==fine objective==

==inizio methodsresults==

Fifty-two patients (age range: 48 – 74 years; median: 62 years) with biopsy-proven PCa (ISUP: 1 to 4; PSA range: 4,1-37,0ng/ml; biopsy T: T2a-T2c) were prospectively staged by 68Ga-PSMA PET and pelvic mpMRI within six weeks prior to radical prostatectomy. Both procedures were independently reported. Any focal 68Ga-PSMA-avid lesion was deemed positive for PCa on PET; PIRADS 4 and 5 lesions on mpMRI were considered indicative of PCa. A 12-segment prostate map was used to localize (monolateral versus bilateral PCa involvement) and to evaluate the categorical percentage of PCa-involved segments on 68Ga-PSMA PET, on MR T2-weighted imaging and on the whole-mount prostate specimens (i.e. PCa involvement <25% segments, 25-50% segments; 50-75% segments, >50% segments)

==fine methodsresults==

==inizio results==

Pelvic mpMRI identified PCa foci in 49 patients and correctly identified PCa bilaterality in 23 out of 49 patients and PCa monolaterality in 2 out of 3 patients; 68Ga-PSMA PET identified PCa foci in 47 patients and correctly identified PCa bilaterality in 16 out of 49 patients and PCa monolaterality in 1 out of 3 patients.

On a 12-prostate segment basis mpMRI-estimated PCa extension was concordant with definitive histology in 21 patients (n=13 with up to 25% PCa extension; n=5 with 25%-50% PCa extension, n=2 with 50%-75% PCa extension, n=1 over 75% PCa extension).
In 23 patients mpMRI-estimated PCa extension was smaller than on histology (mpMRI-based PCa segment involvement was 25% smaller than on histology in 19 patients and was 50% smaller than on histology in 4 patients). In 7 patients mpMRI-estimated PCa extension was 25% larger than on histology and 50% larger than on histology in 1 patient.

68Ga-PSMA PET-estimated PCa extension was concordant with definitive histology in 21 patients (n=12 with up to 25% PCa extension; n=7 with 25%-50% PCa extension, n=1 with 50%-75% PCa extension, n=1 over 75% PCa extension).
In 19 patients 68Ga-PSMA PET-estimated PCa extension was smaller than on histology (PET-based PCa segment involvement was 25% smaller than on histology in 15 patients and 50% smaller than on histology in 4 patients). In 9 patients 68Ga-PSMA PET PCa extension was 25% larger than on histology and was 50% larger than on histology in 3 patients.

On a 12-prostate segment basis mpMRI-estimated PCa extension was concordant with 68Ga-PSMA PET in 24 patients (n=17 with extension up to 25%; n=5 with 25%-50% extension, n=1 with 50%-75% extension, n=1 over 75% extension).
In 20 patients mpMRI-estimated PCa extension was smaller than on 68Ga-PSMA PET (mpMRI-based PCa segment involvement was 25% smaller than on PET in 16 patients and 50% smaller than on PET in 4 patients).
in 8 patients mpMRI-estimated PCa extension was 25% larger than on PSMA PET

==fine results==

==inizio discussions==

3T mpMRI and 68Ga-PSMA-PET detect a similar amount of PCa lesions in this intermediate- to high-risk cohort of PCa patients, 3T mpMRI being more accurate in identifying bilateral PCa. However, segment-wise, PCa extension on both procedures is concordant with pathology in less than a half of patients (40.4% of cases for both procedures). In a similar proportion of patients both procedures tend to underestimate true PCa extension, this being slightly more evident on 3T mpMRI (PCa underestimation in 44% of cases on 3T mpMRI and in 36.5% of cases on 68Ga-PSMA-PET). PCa extension overestimation was more frequently observed on 68Ga-PSMA-PET (23.1% versus 15.4% on 3T mpMRI). The percent of inter-imaging modality concordance was found to be 46%.

==fine discussions==

==inizio conclusion==

Segment-wise, both 3TmpMRI and 68Ga-PSMA-PET assessment of intraprostatic PCa tend to underestimate the true parenchymal extent of the disease, being concordant with histology in less than half of patients

==fine conclusion==

==inizio reference==

1) Sun C et Al. Comparison of T2-Weighted Imaging, DWI, and Dynamic Contrast-Enhanced MRI for Calculation of Prostate Cancer Index Lesion Volume: Correlation With Whole-Mount Pathology. AJR Am J Roentgenol 2019 Feb;212(2):351-356.doi: 10.2214/AJR.18.20147. Epub 2018 Dec 12.
2) Spohn S et Al. Intraindividual comparison between 68Ga-PSMA-PET/CT and mpMRI for intraprostatic tumor delineation in patients with primary prostate cancer: a retrospective analysis in 101 patients. European Journal of Nuclear Medicine and Molecular Imaging (2020) 47:2796–2803

==fine reference==

==inizio objective==

To identify staging 68Ga-PSMA PET and pelvic 3Tesla mpMRI imaging-based factors as well as clinical and pathological features associated with 2-year biochemical recurrence in patients with intermediate- to high-risk prostate cancer treated with radical prostatectomy ± adjuvant treatment

==fine objective==

==inizio methodsresults==

Twenty-six patients (age range: 48-72 years; median: 61 years) with biopsy-proven PCa (ISUP: 1 to 5; PSA range: 4,1-37ng/ml; biopsy T: T2a-T2c) were prospectively staged by means of 68Ga-PSMA PET and pelvic 3Tesla mpMRI within six weeks prior to radical prostatectomy. A 12-segment prostate map was used for tumor localization and quantitation on 68Ga-PSMA PET and pelvic 3Tesla mpMRI.
Post-surgical adjuvant treatment and follow up were offered as per clinical practice (minimum follow-up: 2 years).
Non-parametric statistics (Mann-Whitney test, Fisher’s Exact test with Yates’ correction) were used to identify imaging-based, clinical and pathological factors associated with 2-year biochemical recurrence, including: age, screening PSA, PSA density, percent of PCa involved cores (< 50% versus ≥ 50%), percent maximum core length (< 50% versus ≥ 50%), biopsy ISUP grade group (ISUP4-5 versus ISUP1-2-3), PCa SUVmax index (SUVmax ≤ 10 versus SUVmax > 10), degree of PCa-involvement according to 68Ga-PSMA PET (PCa involvement < 3 segments versus ≥ 3 segments), degree of PCa-involvement according to mpMRI (< 3 segments versus ≥ 3 segments), definitive ISUP grade group (ISUP4-5 versus ISUP1-2-3), pT stage (pT2 versus pT3) and R status (R0 versus R1). ==fine methodsresults== ==inizio results== Pelvic mpMRI identified PCa foci in 24 patients and correctly identified PCa extraprostatic extension in 5 out of 6 patients and seminal vesicle involvement in 2 out of 4 patients; 68Ga-PSMA PET identified PCa foci in 24 patients and correctly identified PCa extraprostatic extension in 4 out of 6 patients and seminal vesicle involvement in 3 out of 4 patients; 2-year biochemical relapse was more frequently observed in patients with more than 50% of biopsy cores involved (p: 0.0137) and in patients harboring PCa foci with 68Ga-PSMA SUVmax higher than 10 (p: 0.008). No statistically-significant difference was found between relapsed and non-relapsed patients in terms of age (p: 0.966), screening PSA (p: 0.936) and PSA density (p: 0.440), ISUP on biopsy (p: 0.863) and ISUP on pathology (p: 0.612), intraprostatic PCa extent on 68Ga-PSMA SMA PET (p: 0.340) and on mpMRI (p: 0.302), percent maximum core length (p: 0.198), pT status (p: 0.863), and R status (p: 0.809). ==fine results== ==inizio discussions== Imaging-based, clinical and pathological markers have different performance in predicting oncology outcomes. In this cohort of patients with intermediate- to high-risk prostate cancer staged by means of 68Ga-PSMA PET and pelvic mpMRI and treated with radical prostatectomy ± adjuvant treatments the percent of PCa involved cores and PCa 68Ga-PSMA SUVmax seems to hold prognostic potential in terms of 2-year biochemical recurrence -free survival ==fine discussions== ==inizio conclusion== In patients with intermediate- to high-risk prostate cancer treated with radical prostatectomy ± adjuvant treatments PCa involvement in less than 50% of biopsy cores and PCa 68Ga-PSMA SUVmax lower than 10 may hold predictive potential for 2-year biochemical recurrence-free survival. Further investigation in larger cohorts is needed to validate these preliminary results. ==fine conclusion== ==inizio reference== 1) Roberts MJ et Al. Primary tumour PSMA intensity is an independent prognostic biomarker for biochemical recurrence-free survival following radical prostatectomy. Eur J Nucl Med Mol Imaging. 2022 Jul;49(9):3289-3294. doi: 10.1007/s00259-022-05756-2. Epub 2022 Mar 17; 2) Wenzel M et Al. Assessment of the optimal number of positive biopsy cores to discriminate between cancer-specific mortality in high-risk versus very high-risk prostate cancer patients. Prostate. 2021 Oct;81(14):1055-1063. doi: 10.1002/pros.24202. Epub 2021 Jul 26. ==fine reference==

==inizio objective==

The prostatic urethra (PU) is conventionally resected during robot-assisted radical prostatectomy (RALP). Recent studies demonstrated the feasibility of the extended PU preservation (EPUP).
Our aim is to describe the histologic features of the PU.

==fine objective==

==inizio methodsresults==

The PU was evaluated in cystoprostatectomy and RALP specimens. Cases of PU infiltration by prostate cancer or distortion by benign hyperplastic nodules were excluded. The thickness of the chorion and the distance between basal membrane of the PU epithelium and prostate glands was measured. Prostate-specific antigen expression in the PU epithelium was evaluated with immunohistochemistry.

==fine methodsresults==

==inizio results==

Six specimens of PU were examined. Histologically, 3 layers of the PU were observed: 1) urothelium with basal membrane, 2) chorion 3) peri-urethral muscle tissue. The chorion measures between 0,2 to 0,4 millimeters. There is not a distinct urethral muscle layer but rather muscular fibers that originating by the prostatic stroma are distributed around the PU. This muscular tissue appears to be mainly represented in the basal and apical urethra but not in the middle urethra.
The mean distance between the chorion and the prostatic glands is 1.69 mm with a significant difference between base of the prostate, middle urethral portion and apex (2.2 vs 1.29 vs 1.34 mm respectively). PSA-expressing cells are abundant in the PU epithelium coexisting with urothelial cells.

==fine results==

==inizio discussions==

Urinary incontinence after radical prostatectomy is an adverse event that leads to significant di-stress. Reported continence rates at 12 months following RALP according to recent series range between 82.1 and 97% [8,9], depending on the definition of incontinence, severity, bother and the methodology to assess its magnitude [10].
More than long-term UC, early postoperative urinary incontinence still remains a challenge to be overcome with the highest rates of the urinary incontinence-associated bother noted in the first 2–6 mo after surgery [11-13]. Time to continence continues to be an issue of significant bother among men undergoing RALP [14].
Several techniques have been consequently developed in order to enhance continence recovery after RALP that can be summarized in three major categories: preservation and reinforcement [15]. The common denominator of these techniques is to maintain the intactness or to reply the functio-nality of the periprostatic anatomic structures [16].
Beside to the bladder neck preservation [4, 17], several studies support an association between the length of membranous urethra preserved and continence recovery [18–21]. A similar benefit for PUP has been suggested by retrospective series in which a portion of the apical prostatic urethra is spared during open RP [22-23] or RALP [24].
Concerning EPUP, the technique and outcomes have been presented in [6]. As described by the authors, EPUP was performed after releasing all prostatic tissue attachments other than the urethra. Following the incision and ligation of the dorsal venous complex the prostate base was retracted cranially and the outer fascial attachment between the membranous urethra and prostatic apex was divided coldly and circumferentially. Cranially oriented blunt dissection with periodic cold scissor division was performed to delineate the plane between the outer urethra skeletal muscle and prostatic apex. This plane was continued circumferentially. The inner urethral longitudinal smooth muscle layer was recognized by its longitudinally oriented muscle fibers after the outer skeletal muscle terminated within the prostate apex. After additional intraprostatic dissection, the surgical plane was transitioned deeper within the urethral muscle to decrease the likelihood of leaving prostatic tissue on the urethra. This approach thinned (“telescoped”) the urethra muscle as a longer segment was preserved. The dissection continued until: 1) the plane failed to develop easily; 2) the urethra muscle became too thin (e.g., reaching mucosa and/or tearing); or 3) the dissection reached the transected bladder neck (i.e., complete urethral spare).
All EPUP patients had undergone a preoperative multiparameter prostate MRI which showed no evidence of tumor involvement of the apical prostatic urethra.
With this technique, urethral sparing was carried to the prostate mid-gland or base in most cases, and two patients had preservation of the entire PU (transected bladder neck was reached). The median PUL preserved among EPUP patients was 4.0 cm (mean 3.9 cm; range 2.5–6.0 cm). In multivariable analyses that adjusted for potential confounders, an EPUP approach remained independently associated with earlier continence recovery. Within the EPUP patient subset, a longer PUL preserved was independently predictive of earlier continence recovery, suggesting that EPUP provides a functional benefit in terms of postoperative continence recovery.
In our study we evaluated the morphology of the PU. It can be easily summarized with the presence of a pseudo-stratified urothelial type epithelium sometimes mixed with epithelium with prostatic differentiation. The urethral epithelium of the prostate does not have a regular course: it may pre-sent pseudopapillary protrusions, areas of thickening and glandular ramifications that are combined to create a non-linear “tube”. In fact, at the midpoint between its distal end (the prostate apex) and the bladder neck, the posterior wall of the PU undergoes a sharp anterior kink, beyond which the entire proximal urethral segment pursues an altered course, with an angulation of about 35 degrees anterior to the course of the distal urethral segment [25-McNeal].
Below the basal lamina of the PU epithelium there is a thin lamina of loose connective tissue that is interposed between the epithelium itself and the fibromuscular stroma of the prostate (that itself hosts the prostate glands): this space can be defined as chorion or sub-epithelial tissue. The fibro-
muscular stroma does not arrange itself continuously around the chorion in a precise manner, main-taining a clear interface, but sometimes tends to “fray” within the sub-epithelial tissue, creating an ill-defined passage point. The thickness of the aforenementioned planes measure fractions of millimetres.
In the evaluated specimens an homogeneous distribution of the thickness of the chorion has been observed between base and apex of the prostate, ranging between 0,2-0,4 mm. The distance between basal membrane of the PU epithelium and prostatic glandular tissue showed a more variable distribution on average values, with greatest variability on the basal portions and with a progressively decreasing gradient of variability towards the apical ones. At the level of the pre-basal sections, the distance between the PU epithelium and the prostate glands ranged between <1mm-4mm while toward the prostate apex the distance between PU epithelium and glandular tissue is homogeneous between the specimens and in all cases ≤0.5mm. As a conclusion, the wide variability and narrowness of the distance between the PU and the glan-dular stroma together to the irregular distribution of the PUM does not probably allow for an effec-tive exclusion of the prostate glandular tissue from the peri-urethral resection margin. Furthermore, the results of the immunohistochemistry confirm the mixed phenotype of the urethral epithelial cells, most evident in the mid-apical sections. Similar to our results, Son DY et al. [26] observed three types of prostatic urethral glands: urethral mucosal, prostatic acinar, and mixed. The proximal segment of the prostatic urethra and the bladder neck consisted mostly of the urethral mucosal type, whereas the distal segment and apical margins consisted mostly of the prostatic acinar type. PSA was expressed in secretory cells in prostatic acinar and mixed types. These results indicate that PSA-expressing cells are abundant in all the segments of the PU till the apical margin and may be responsible for postoperative PSA persistence [27]. ==fine discussions== ==inizio conclusion== The exiguity of thickness of the PU chorion, the short distance from the glandular tissue and the coexistence of PSA-expressing cells of the PU epithelium raises important concerns about the oncologic safety of EPUP. ==fine conclusion== ==inizio reference== [1] Bill-Axelson A, Holmberg L, Ruutu M, Häggman M, Andersson SO, Bratell S, Spångberg A, Busch C, Nordling S, Garmo H, Palmgren J, Adami HO, Norlén BJ, Johansson JE; Scandinavian Prostate Cancer Group Study No. 4. Radical prostatectomy versus watchful waiting in early prostate cancer. [2] Bauer RM, Bastian PJ, Gozzi C, Stief CG. Postprostatectomy incontinence: all about diagnosis and management. Eur Urol. [3] Cambio AJ, Evans CP (2006) Minimising postoperative incontinence following radical prostatectomy: considerations and evidence. [4] Freire MP, Weinberg AC, Lei Y, Soukup JR, Lipsitz SR, Prasad SM, Korkes F, Lin T, Hu JC. Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol. [5] Hamada A, Razdan S, Etafy MH, Fagin R, Razdan S. Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique. J Endourol. [6] Nunez Bragayrac LA, Hussein AA, Attwood K, Pop E, James G, Osei J, Murekeysoni C, Kauffman EC. Feasibility and continence outcomes of extended prostatic urethral preservation during robot-assisted radical prostatectomy. Prostate Cancer Prostatic Dis. . [7] van der Kwast TH, Amin MB, Billis A, Epstein JI, Griffiths D, Humphrey PA, Montironi R, Wheeler TM, Srigley JR, Egevad L, Delahunt B; ISUP Prostate Cancer Group. International Society of Urological Pathology (ISUP) Consensus Conference on Handling and Staging of Radical Prostatectomy Specimens. Working group 2: T2 substaging and prostate cancer volume. [8]Coelho RF, Chauhan S, Palmer KJ, Rocco B, Patel MB, Patel VR (2009) Robotic-assisted radical prostatectomy: a review of current outcomes. BJU Int [9] Ficarra V, Novara G, Artibani W, Cestari A, Galfano A, Graefen M, Guazzoni G, Guillonneau B, Menon M, Montorsi F, Patel V, Rassweiler J, Van Poppel H (2009) Retropubic, laparoscopic, and robot-assisted radical prostatectomy: a systematic review and cumulative analysis of comparative studies. Eur Urol [10] Heesakkers J, Farag F, Bauer RM, Sandhu J, De Ridder D, Stenzl A (2017) Pathophysiology and contributing factors in postprostatectomy incontinence: a review. Eur Urol [11] Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, Lin X, Greenfield TK, Litwin MS, Saigal CS, Mahadevan A, Klein E, Kibel A, Pisters LL, Kuban D, Kaplan I, Wood D, Ciezki J, Shah N, Wei JT (2008) Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med [12] Prabhu V, Sivarajan G, Taksler GB, Laze J, Lepor H (2014) Long-term continence outcomes in men undergoing radical prostatectomy for clinically localized prostate cancer. Eur Urol [13] Donovan JL, Hamdy FC, Lane JA, Mason M, Metcalfe C, Walsh E, Blazeby JM, Peters TJ, Holding P, Bonnington S, Lennon T, Bradshaw L, Cooper D, Herbert P, Howson J, Jones A, Lyons N, Salter E, Thompson P, Tidball S, Blaikie J, Gray C, Bollina P, Catto J, Doble A, Doherty A, Gillatt D, Kockelbergh R, Kynaston H, Paul A, Powell P, Prescott S, Rosario DJ, Rowe E, Davis M, Turner EL, Martin RM, Neal DE, ProtecT Study Group* (2016) Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med [14] Barry MJ, Gallagher PM, Skinner JS, Fowler FJ Jr (2012) Adverse effects of robotic-assisted lap-aroscopic versus open retropubic radical prostatectomy among a nationwide random sample of medicare-age men. J Clin Oncol [15] Asimakopoulos AD, Topazio L, De Angelis M, Agrò EF, Pastore AL, Fuschi A, Annino F. Retzius-sparing versus standard robot-assisted radical prostatectomy: a prospective randomized comparison on immediate continence rates. Surg Endosc. [16] Asimakopoulos AD, Annino F, D'Orazio A, Pereira CF, Mugnier C, Hoepffner JL, Piechaud T, Gaston R. Complete periprostatic anatomy preservation during robot-assisted laparoscopic radical prostatectomy (RALP): the new pubovesical complex-sparing technique. Eur Urol. [17] Asimakopoulos AD, Mugnier C, Hoepffner JL, Piechaud T, Gaston R.Bladder neck preservation during minimally invasive radical prostatectomy: a standardised technique using a lateral approach. BJU Int. [18] von Bodman C, Matsushita K, Savage C, Matikainen MP, Eastham JA, Scardino PT, et al. Recov-ery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging. The Journal of urology. 2012;187(3):945–50. [19]. Hakimi AA, Faleck DM, Agalliu I, Rozenblit AM, Chernyak V, Ghavamian R. Preoperative and intraoperative measurements of urethral length as predictors of continence after robot-assisted radical prostatectomy. Journal of endourology / Endourological Society. 2011;25(6):1025–30. [20]. Mizutani Y, Uehara H, Fujisue Y, Takagi S, Nishida T, Inamoto T, et al.Urinary continence fol-lowing laparoscopic radical prostatectomy: Association with postoperative membranous urethral length measured using real-time intraoperative transrectal ultrasonography. Oncology letters. [21] Hammerer P HH. Urodynamic Evaluation of Changes in Urinary Control After Radical Retropubic Prostatectomy. J Urol. [22] Schlomm T, Heinzer H, Steuber T, Salomon G, Engel O, Michl U, et al.Full functional-length urethral sphincter preservation during radical prostatectomy. European urology. 2011;60(2):320–9. [23] van Randenborgh H, Paul R, Kubler H, Breul J, Hartung R. Improved urinary continence after radical retropubic prostatectomy with preparation of a long, partially intraprostatic portion of the membraneous urethra: an analysis of 1013 consecutive cases. Prostate cancer and prostatic dis-eases. 2004;7(3):253–7. [24] Hamada A, Razdan S, Etafy MH, Fagin R, Razdan S. Early return of continence in patients undergoing robot-assisted laparoscopic prostatectomy using modified maximal urethral length preservation technique. Journal of endourology / Endourological Society 2014;28(8):930–8. [25] mcneal [26] Son DY, Ro JY, Kang MJ, Jang WY, Cho YM. Histology and distribution of prostatic tissue on prostatic urethral margins: evaluation of radical prostatectomy specimens and implications on frozen section analysis. Ann Diagn Pathol. 2012 Apr;16(2):79-84. [27] Kohl SK, Balaji KC, Smith LM, Wilson NP, Johansson SL, Sterrett SP, Abrahams NA. Clinical significance of benign glands at surgical margins in robotic radical prostatectomy specimens. Urology. 2007 Jun;69(6):1112-6. [28] Ko YH, Kim TH, Song PH, Kim BH, Kim BS, Kim KH, Cho J; KYUS Group. Structural Variations of the Prostatic Urethra Within the Prostate Predict the Severities of Obstructive Symptoms: A Prospective Multicenter Observational Study. Urology. 2017 Jun;104:160-165. doi: 10.1016/j.urology.2017.03.014. Epub 2017 Mar 18. PMID: 28322900. [29] A. H. Wilson, M.D., M.R.C.S. The Prostate Gland: A Review of its Anatomy, Pathology, and Treatment- JAMA Revisited August 6, 2014 ==fine reference==

==inizio objective==

Fusion biopsy is currently a cornerstone in the diagnosis of prostate cancer. The technique works with a real-time 3-dimensional (3D) transrectal ultrasound (TRUS) imaging acquired and elastically fused with the mpMRI. However, both in the definition of the anatomical landmarks of the prostate both in targeting suspicious lesions, mistakes could be made. Aim of our study is compare the results, in terms of accuracy, between a center with a intraoperatrive dedicated radiologist and a center without a dedicated radiologist.

==fine objective==

==inizio methodsresults==

From December 2020 to December 2021, we have retrospectively collected all patient undergone fusion biopsy to our center(Group 1) where all procedure have been performed with an expert radiologist (>100 mpMRI). We have also collected the fusion biopsies performed in an other center(Group 2) where only the urologist is dedicated to prostate landmarking and in suspicious lesions targeting. A transrectal prostate biopsy was performed in both centers The following preoperative parameters were evaluated for each patient: age (y), PSA tot (ng/dl), Prostate Volume(cc), PIRADS index lesion ,Gleason score index Lesion, ISUP grade index lesion, Dmax Index lesion(mm), tot n° cores biopsied,n° cores target lesion, n° cores positive, n° cores positive/target lesion. Student T Test for unpaired samples was performed to assess inter-group mean statistical difference. We have also calculated the accuracy (%) of systematic prostate biopsy and fusion biopsy on the target lesion accuracy (%).We assumed p ≤0.05 as level of statistical significance.

==fine methodsresults==

==inizio results==

We enrolled in Group 1, 80 patients and in Group 2, 87 patients. Main groups characteristics are described in Tab 1. Among the parameters evaluated, we haven’t found any statistical difference in terms of age (66,9 ± 7,8 vs 66,0 ± 8,2, p=0.9), prostate volume (60,58 ± 28,48 vs 67,51±35,81 , p=0.65), Dmax index lesion 10,70 ± 5,59 vs 10,70 ± 5,41 p=0.95). The only statistical different parameter was the pre biopsy PSA tot 7,15 ± 2,43 vs 10,11 ± 3,36 ,p=0.045). Between the two groups (Group 1 vs Group 2) we assessed the following data’s: Tot n° cores biopsied 477 vs 1406, n° cores on target lesion 324 vs 398 n° tot positive cores 66 vs 128 n° tot positive cores on target lesion 36 vs 45. All positive results have been confirmed by the prostatectomy specimen histopathology. The systematic prostate biopsy accuracy was 13,8% vs 9,1% and fusion biopsy on the target lesion accuracy 11,1 % vs 11,3%.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

In this comparison study, we found that, in two homogeneous cohorts, the accuracy of the fusion biopsy for suspicious lesions was similar for the two groups examined. However, the accuracy for contextual standard biopsy is higher in the group with intraoperative assistance by the dedicated radiologist. This event would therefore seem related to a more accurate definition of prostate anatomy, although further multicentre prospective studies are needed.

==fine conclusion==

==inizio reference==

==fine reference==

==inizio objective==

Metastases account for most deaths due to malignancy [1], and the first site of metastases is usually the regional lymph nodes. Detection of lymph node invasion (LNI) is of major prognostic significance for many cancers [2, 3], especially for prostate and bladder cancers for which, at present, bilateral pelvic lymph node dissection (PLND) represents the most accurate and reliable staging procedure for the detection of LNI [4–7]. However, PLND is associated with increased operative time and is not devoid from severe complications. These limitations underscore the necessity of improving the identification of the primary lymph node pathway. In the last decade, optical imaging using near-infrared (NIR) fluorescence had emerged as a safe technique to visualize structures in real-time during surgery. Indocyanine green (ICG), an innocuous imaging dye, can be used for this scope [8]. In fact, it f luoresces bright green when viewed under NIR light (700–1000 nm). Currently, ICG NIR fluorescence-guided sentinel lymph node dissection (SLND) had emerged as a valid technique for the detection of regional LN for numerous tumors [8]. For urologic cancer, ICG NIR fluorescence-guided SLND is at its infancy but, recently, some authors reported that this technique is a promising complementary tool for lymphatic vessel visualization [9]. The goal of this series is to demonstrate that ICG real-time fluorescent lymphography is a safe and feasible technique that can be used to avoid or enable early recognition of damage to the deep lymphatic vessels. This technique could significantly reduce post-operative complications related to the lymphatic system during laparoscopic radical prostatectomy.

==fine objective==

==inizio methodsresults==

In five patients, for a diagnosis of cancer at prostatic biopsy, we intraoperatively performed ICG f uorescence-guided lymphography during laparoscopic radical prostatectomy with pelvic lymphadenectomy. ICG was injected in the prostatic tissue of the patient transrectally through ultrasound identification of the gland. A fine needle was used connected to a 10 cc syringe, taking care to aspirate before injecting the tracer in order to avoid blood vessels. A dedicated laparoscopic high-definition camera system, provided by Karl Storz, was used in our cases. This system allowed the surgeon to easily switch from White Light (WL) mode to ICG mode. For this reason, it was very simple to compare WL and ICG mode images. Furthermore, this technique is inexpensive, requiring only a small dose of ICG. Therefore, soon after ICG injection, the lymphatic vessels were identified in the pelvic cavity as fluorescent linear structures running side by side to the iliac vessels. Figure 1 shows the fluorescent lymph nodes in the obturator fossa. Then, using the “intensity map” function (also called “overlay function”), lymph nodes can be seen as white structures as this function uses WL (instead of blue light) and eliminates the colors, as shown in Fig. 2. Surgical dissection was therefore performed, avoiding iatrogenic damage to major lymphatic structures.

==fine methodsresults==

==inizio results==

On histological examination, the prostate gland was found to be affected by an acinar adenocarcinoma, with Gleason Score 7 (4+3) in three cases and Gleason Score 7 (3+4) in the remanent cases. On average twenty lymph nodes sent as obturators (divided per side) and 10 lymph nodes sent as external iliacs (divided per side) were free from metastases. The patients were discharged 5 days after surgery, and 6 months after surgery, they did not show any complications related to lymph node dissection.

==fine results==

==inizio discussions==

ICG has been used for decades in several medical applications such as retinal angiography, liver clearance tests (to measure hepatic function) and cardiac output monitoring [10]. Most recently, this technology has been used in different surgical fields, especially when a robotic approach is chosen. Our study is one of the very rare reports of applying ICG real-time fluorescent lymphography during laparoscopic radical prostatectomy. To our knowledge, there are no other reports in which this innovative technique is documented during laparoscopy in urology. However, our experience is preliminary and limited to a five cases but it can be the first step to develop a simple, easy and low-risk technique for lymphatic sparing surgery. Obviously, further large series are required to define surgery outcomes and lymphatic complication rate. Many different surgical procedures can damage the lymph nodes and lymph vessels, leading to serious complications such as lasting lymphorrhea, lymphocele and lymphedema. Lymphorrhea is a persistent lymph loss that can occur from surgical drain in cases of intraperitoneal or retroperitoneal procedures or from surgical wounds in cases of superficial site surgery [11]. Lymphocele is a lymph-filled collection without an epithelial lining, most commonly located in the retroperitoneal space. The incidence and frequency of this type of complication constitute a serious clinical problem, leading to impaired postoperative wound healing, wound infection and abscess formation; this scenario results in a prolonged hospital stay and increased cost of treatment. When lymph nodes have been removed or damaged during surgical procedures, lymph is not well drained from the affected area. So, when the lymph is overcollected, especially in the arms and legs, the result is the swelling that is characteristic of lymphedema. This condition makes the affected arm or leg particularly vulnerable to infections such as cellulitis and lymphangitis and, more rarely, to lymphangiosarcoma. Effective treatment of these complications can be challenging and time-consuming [12, 13]. All this is to be taken into serious consideration especially for patients with prostate cancer for whom iliac–obturator lymphadenectomy during radical prostatectomy represents the most accurate method of staging the disease from a lymph node point of view. We think that lymphatic vessel sparing and prompt recognition of lymphatic structure damage, during laparoscopic radical prostatectomy, could lead to a reduction in the post-surgical complications rate and, consequently, a reduced hospital stay.

==fine discussions==

==inizio conclusion==

In conclusion, although it is not necessary to perform fluorescence-enhanced surgery in all cases, we find the utilization of ICG-NIRF in lymph node dissection for prostate cancer useful. In effect, this technology in prostate cancer has a high detection rate, although its specificity to predict LN invasion remains poor. In our cases, the pathological examination did not demonstrate an involvement of the pelvic lymph nodes; however, the use of such an imaging system has allowed us to remove the main lymphatic networks involved in the drainage of the gland (thus ensuring an accurate staging of the disease), with the possibility at the same time to recognize any serious damage to the lymphatic vessels during dissection.

==fine conclusion==

==inizio reference==

1. Mehlen P, Puisieux A. Metastasis: a question of life or death. Nat Rev Cancer 2006;6:449–58.
2. Nguyen DX, Bos PD, Massagué J. Metastasis: from dis- semination to organ-specific colonization. Nat Rev Cancer 2009;9:274–84.
3. Pini G, Matin SF, Suardi N, Desai M, Gill I, Porter J, et al. Robot assisted lymphadenectomy in urology: pelvic, retroperi- toneal and inguinal. Minerva Urol Nefrol 2017;69:38–55.
4. Heidenreich A, Pfister D. Pelvic lymphadenectomy in clin- ically localised prostate cancer: counting lymph nodes or dissecting primary landing zones of the prostate? Eur Urol 2014;66:447–9.
5. Heidenreich A, Bastian PJ, Bellmunt J, Bolla M, Joniau S, van der Kwast T, et al. EAU guidelines on prostate cancer. Part 1: screening, diagnosis, and local treatment with curative intent-update 2013. Eur Urol 2014;65:124–37.
6. Witjes JA, Compérat E, Cowan NC, De Santis M, Gakis G, Lebret T, et al. EAU guidelines on muscle-invasive and
metastatic bladder cancer: summary of the 2013 guidelines.
Eur Urol 2014;65:778–92.
7. Mistretta FA, Boeri L, Grasso AA, Lo Russo V, Albo G, DE
Lorenzis E, Maggioni M, Palmisano F, Dell’orto P, Bosari S, Rocco B. Extended versus standard pelvic lymphadenec- tomy during robotassisted radical prostatectomy: the role of extended template as an independent predictor of lymph node invasion with comparable morbidity burden. Minerva Urol Nefrol 2017;69:475–85.
8. Polom K, Murawa D, Rho YS, Nowaczyk P, Hünerbein M, Murawa P. Current trends and emerging future of indo- cyanine green usage in surgery and oncology: a literature review. Cancer 2011;117:4812–22.
9. Alander JT, Kaartinen A, Laakso A, Pätilä T, Spillmann T, Tuchin VV, et al. A review of indocyanine green fluores- cent imaging in surgery. Int J Biomed Imaging 2012;2012: 940585.
10. Kamisaka K, Yatsuji Y, Yamada H, Kameda H. The bind- ing of indocyanine green and other organic anions to serum proteins in liver diseases. Clin Chim Acta 1974;53: 255e64.
11. Metcalf KS, Peel KR. Lymphocele. Ann R Coll Surg Engl 1993;75:387e92.
12. Mori N. Clinical and experimental studies on the so- called lymphocyst which develops after radical hysterec- tomy in cancer of the uterine cervix. J Jpn Obstet Gynecol Soc 1955;2:178e203.
13. White M, Mueller PR, Ferrucci JT, Butch RJ, Simeone JF, Neff CC, et al. Percutaneous drainage of postoperative abdomi- nal and pelvic lymphoceles. AJR Am J Roentgenol 1985;145: 1065e9.

==fine reference==

==inizio objective==

Prostate cancer (PCa) is a common cancer and the second cause of cancer-related mortality in men (1, 2). Nonetheless, PCa prevalence at the histological level is higher than the clinically detected disease rates. During autopsy studies, prostatic adenocarci-noma has been histologically detected in > 30% of men older than 50 years. These tumors are usually small and clinically indolent, with the ability to exist for several years before presenting any change, such as accelerated cell proliferation, tumor metastasis and clinical detection. More importantly, accumulating evidence has shown that, in patients affected by primary bladder cancer (BC) undergoing radical cystoprostatectomy (RCP), there is a higher incidence of PCa (3, 4). RCP specimens from patients affected by diseases other than PCa can be a random sample from the prostates of asymptomatic men, offering a unique opportunity to study the incidence and morphological features of these incidental prostatic tumors. In terms of randomness, this cohort shows similarities to that of the autopsy studies, but differs in the reported higher PCa incidence in men with BC (3, 4). According to the European Association of Urology guidelines, for patients affected by muscle-invasive bladder cancer (MIBC) or any high-risk, recurrent and non-invasive BC, the RCP procedure with bilateral pelvic lymphadenectomy and various types of urinary diversion is the gold standard of therapy (5). The standard RCP in men is based on the removal of the bladder along with prostate, seminal vesicles, a part of the vasa deferentia and distal ureter, including regional lymphadenectomy (in order to provide an effective local treatment of the disease), which can have a high incidence of sexual complications and urinary incontinence. Whereas alternative techniques can be considered in highly selected cases in which it is desired to preserve potency, fertility and urinary function. In the modern era of orthotopic bladder substitution after RCP for BC, sparing the entire prostate or a portion of it has become controversial in recent years. However, these techniques, in an effort to maintain sexual and urinary functions, have raised concerns regarding the oncological outcomes due to two potential risks: urothelial cancer local invasion of the prostate and a probable association with incidental PCa (6). PCa is complex: on one hand, numerous patients with PCa receive unnecessary treatment as their disease will never become clinically significant or result in death. On the other hand, some prostatic tumors require immediate treatment, which are known as clinically detected PCa. For this reason, incidentally identified PCas are divided in two groups: clinical significant and clinical insignificant. The aim of the present single-center retrospective study was to: i) assess incidence, histopathological features and clinical significance of incidentally identified prostatic tumors in RCP specimens obtained from patients affected by bladder cancer, but with clinically normal prostates; ii) examine patients’ age, pre-operative rectal examination findings and prostate specific antigen (PSA) values, in order to evaluate whether such features can help with the prediction and treatment of significant PCas; iii) establish whether prostate sparing-cystectomy could represent a feasible option for these patients.

==fine objective==

==inizio methodsresults==

The data of 303 male patients who underwent RCP with bilateral pelvic lym-phadenectomy and different urinary diversion for BC at our Department of Urology were retrospectively reviewed. Data from the pre-operative digital rectal exam (DRE) and PSA assays were analyzed in patients diagnosed with incidental PCa, for a total of 69/303 (22.7%) patients. Treatment and prognosis of muscle invasive bladder cancer (MIBC) are determined by tumor stage and grade. So, before any curative treatment, it is essential to evaluate the presence of distant metastases. For this reason, all patients enrolled in the current study underwent CT of the chest, abdomen and pelvis, as well as MRI of the abdomen and pelvis. This staging showed that none of the patients had distant metastases or neoplastic disease of the prostate. The selection criteria were as follows: i) no previous history of PCa; ii) no previous history of chemotherapy or radiotherapy; iii) no evidence of PCa in the imaging evaluation; and iv) age ≥ 40 years old. Routine pathological examination was performed as by routine on bio-specimens. Beyond evaluation of the bladder, it was considered i) the presence of PCa; the stage of any detected prostatic adenocarcinoma following the 2002 TNM classification (7) and its Gleason score according to the World Health Organization system (8) and ii) the surgical margin status (a positive surgical margin was recorded upon detection of tumor cells at the stained margin of the specimens). Prostate involvement in bladder cancer was also assessed. The intact RCP specimens were immersed in 10% buffered formalin solution. Then, the prostate in-cluding seminal vesicles and vas deferens, was cut out from bladder, weighed and stained with Indian Ink. Sectioning was performed by cutting at 5-mm interval sections transverse to the long axis, which were then embedded in paraffin for H&E staining and exami-nation. PCa was defined as clinically significant when any of the following criteria was met: Gleason Score ≥ 4, stage > pT3, extracapsular extension (ECE), lymph node metastasis (LNM) or positive surgical margins (SM).

==fine methodsresults==

==inizio results==

In order to undergo surgery, all patients enrolled in our study underwent DRE and MRI of the abdomen and pelvis to specifically evaluate the prostate both clinically and instrumentally. Both examinations did not reveal any prostate abnormalities such as to require a prostate biopsy. Of the 303 RCP specimens, incidental PCa was detected in 69 patients (22.7%), with a median age of 71.6 years (age range, 54-89 years). We performed orthotopic bladder substitution in 29 (42%) patients, ileal conduit procedure in 14 patients (20.2%) and ureterocutaneostomy in 26 patients (37.7%). Regarding bladder cancer features, all tumors were of high grade. In 69 patients with incidental PCa, 23 of these cancers (33.33%) were regarded clinically significant. In this group of patients, only seven (for a percentage equal to 10.1%) were affected by locally advanced prostate cancer on histopathological examination. From the retrospective analysis, moreover, these patients presented a bladder tumor which invaded the trigone and the bladder neck. For this reason, the differential diagnosis between primary prostate tumor and bladder infiltration of the prostate was very difficult. Patients were subdivided into three age groups based on the 33% and 66% age quantiles (< 70, between 70-75 and > 75 years of age) and then evaluated. For both TNM stage and Gleason score no significant difference in the mean value of the respective parameter between the three age categories was identified. In total, 46 (66.66%) of 69 patients presented a “non-aggressive” PCa. None of the pre-operative factors, namely PSA level and age, were predictive factors for non-aggressive PCa. Comparisons of the mean values and rank order for age and PSA level between the patients with aggressive PCa and the patients who had non-aggressive tumor by means of unpaired t-tests and Mann-Whitney U tests did not result in any significant difference.

==fine results==

==inizio discussions==

Incidental PCas identified in RCP samples, from patients who underwent BC surgery but had no preoperative evidence of prostatic disease, show histological and morphological features similar to those of latent tumors identified in several autopsies (9-11). According to the literature, the frequency variability of incidentally discovered PCa in cystoprostatectomy specimens is extremely high, ranging from 17%-70% (12, 13), owing to various factors. The first of these is the different definition of clinically significant cancer in published studies (14). Over the past two decades, the emerging concept of “insignificant” PCa has progressed to indicate low-grade, small-volume and organ-confined prostatic tumors that are likely slowly progressing, and these, although might not need urgent therapeutic treatment, are eligible for active surveillance (15). Currently, the pathological assessment of the lesion indicates further patient management (16). Generally, PCa is diagnosed as “insignificant” when: the disease has a Gleason score < 7 (without a Gleason pattern of 4 or 5); it is confined to the organ (stage pT2); and the tumor mass has a < 0.5 cm3 volume. Here, only tumor stage and grade could be taken into account to cancer aggressiveness as tumor volume was not available on the pathological report. Our results showed that 46 (66.66%) of the incidentally diagnosed PCas were considered as “non-aggressive” as they were organ-confined or with a Gleason score of < 7 (4+3). Then, an association between BC and PCa was suggested by several previous studies (17-21). However, the association between BC and PCa can be explained as a possible detection bias, associated with more detailed clinical assessment and thorough pathological examination. For example, once a diagnosis of BC has been made, a complete investigation of the entire genitourinary system is likely to occur (22, 23). In this regard, however, it is important to note that the prognosis of patients bearing both PCa and BC is not considered to be worse than the prognosis of patients bearing only one of these two cancer types; rather, it is the stage of BC that impacts the prognosis. The different detection rate of PCa in RCP specimens may be influenced by the thickness of the prostate histological slices, because pathologists might focus more to the bladder. Indeed, Kouriefs and colleagues (24) reasoned that the lower PCa incidence observed in their study (18%) was possibly caused by thick gland sections, indicating that thinner sectioning is recommended (< 10 mm). Consistently, Abbas et al. (25) found a 45% incidence rate using 2-3-mm-thick slices and Moutzouris et al. (26) a 27% of PCa using 5-mm slices. The current study used 5-mm slices and the observed 22.7% incidence rate of PCa supported the aforementioned hypothesis, indicating that thin tissue sectioning should be used to optimize cancer detection. Finally, genetic and environmental factors may influence the variability of the findings from different countries. In the present study, the majority of prostatic tumors were well differentiated. Our data are consistent with what reported in other studies in which most of detected tumors were not clinically significant, with only few patients requiring therapeutic treatment (25, 10, 11). The preservation of continence and erectile function, as well as guaranteeing excellent oncological results, remain the primary goals of the treatment of BC with RCP. Various techniques can help to preserve postoperative continence and erectile function, such as leaving the apex or the entire tissue of the prostate; however, the potential risk of not removing the synchronous PCa can be problematic. By contrast, the probability that patients undergoing RCP and have PCa will not die from prostatic disease is high. Determining whether patients are suitable for prostate-sparing surgery can be difficult. In this regard, the RCP findings obtained in a study by Moutzouris et al. (26) raise further concerns, showing apical involvement by PCa in the 31% of cases and the presence of multifocal PCa in the 31% of patients (26). Moutzouris et al. (26) claimed that apical involvement by PCa indicates the need of a complete prostate resection. Indeed, a patient within their cohort bearing PCa in the apex had recurrent prostatic disease in the urethro-ileal anastomosis of an orthotopic bladder substitute. Similarly, Revelo et al. (27) reported a 25% of patients with apical PCa, of which about 2/3 were clinically significant. They found apical involvement of the prostate with BC in 16% of patients. Overall, they suggested that prostatic apex preservation was a feasible method to improve continence, but it was associated with the risk of incomplete cancer resection. In the attempt to overcome this risk, Revelo et al. (27) suggested to perform a pre-operative prostate biopsy and freeze intraoperative sections. However, due to possible sampling error, a negative biopsy may not completely exclude apical involvement of PCa in subjects elected for apical sparing surgery. Hautmann et al. (28) performed sextant biopsies of the prostate upon removal of RCP specimens and detected through this method PCa in only 5% of cases, showing that that biopsy detection rate was 1 out of 9 tumors. Therefore, while sextant biopsies seem not adequate to exclude clinically significant PCa, the optimal prostatic biopsy procedure still needs to be defined. So, routine biopsy has a certain degree of uncertainty regarding the ability to identify clinically significant PCa with high sensitivity when attempting to select patients for prostate-sparing cystectomy. For a successful radical cancer removal it remains crucial not to leave PCa in the apical prostatic margin or residual tissue of PCa, which might be clinically significant. According to Pettus (29), only age was a predictive factor for PCa. However, the present data suggest that patients’ age was not a preoperative factor associated with a significant status of PCa. Likewise, the preoperative PSA level seems not significantly associated with the ability to incidentally discover PCa (15). In the present study, PSA values and DRE findings were available for all patients, but their results were not indicators for cancer. This finding suggests that preoperative PSA screening and DRE in RCP candidates provide no advantages in this setting, which was consistent with results of previous studies (25). ==fine discussions== ==inizio conclusion== The present study demonstrated that incidentally diagnosed PCa in specimens from RCP for BC was frequently found, resulting in a rate of ~23% of the current RCP spec-imens. As in other studies, also in the current report the majority of these prostatic tumors were not clinically significant, not requiring therapeutic treatment. This has increased the desire to preserve the continence and erectile function in patient undergoing RCP for bladder cancer; however, the risk of not removing the synchronous PCa shoudl be con-sidered. In effect, in our cohort, 33,3% of patients was affected by clinically significant prostate cancer. It was suggested that the differences in the incidence and behavior of prostatic disease were associated with the patient’s age. However, in this study, no preoperative predictive factors (patient’s age, PSA or DRE) were identified that were able to determine “non-aggressive” PCa status, resulting in the inabilty to adequately de-termine which patients can be safely selected for prostate-sparing surgery. So, the present results demonstrate the need for a careful and complete prostate removal during RCP. Nevertheless, since organ-sparing surgeries are widely performed in young population, due to the impossibility of predicting aggressive prostate cancer and considering the 33,3% of clinically significant prostate cancer in our cohort, these patients require close monitoring through lifelong PSA surveillance, particularly focusing on the possible re-lapse of PCa after RCP. Finally, in our study the technique for cutting the prostate at 5-mm interval sections trasverse to the long axis, allowing the detection of nearly 23% of PCA, supports the hypothesis that thin tissue sectioning should be used to optimize cancer detection (regardless of prostate volume which traditionally affects the number of biopsies to be taken). ==fine conclusion== ==inizio reference== 1. Devesa SS, Blot WJ, Stone BJ, Miller BA, Tarone RE, Franmeit Jr JF. Recent cancer trends in the United States. J Natl Cancer Inst 1995; 87: 175–82. 2. Wingo PA, Tong T, Bolden S. Cancer statistics 1995. CA Cancer J Clin 1995; 45: 8–30. 3. Winkler MH, Livni N, Mannion EM, Hrouda D, Christmas T. Charac- teristics of incidental prostatic adenocarcinoma in contemporary radical cystoprostatectomy specimens. BJU Int. 2007; 99: 554–8. 4. Konski A, Rubin P, Disantagnese PA, Mayer E, Keys H. Simultaneous presentation of adenocarcinoma of prostate and tran-sitional cell carci- noma of bladder. 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et al. Detection rate of histologically insignificant prostate cancer with systemic sextant biopsies and fine needle aspiration cytology. J Urol 2000; 163: 1734–8. 29. Pettus JA, Al-Ahmadie H, Barocas DA, et al. Risk assessment of prostatic pathology in patients undergoing radical cysto-prostatectomy. Eur Urol 2008; 53: 370–375. ==fine reference==