Abstract: Bone metabolic disruption that occurs in bone metastatic prostate cancer could lead to disturbances of calcium metabolism. The prognostic role of either hypocalcemia or hypercalcemia was assessed in a consecutive series of hormone-refractory bone metastatic prostate cancer patients. Serum calcium was measured in 192 patients. The presence of hypocalcemia and hypercalcemia was related with baseline biochemical and clinical characteristics and the role of these two calcium disturbances in predicting prognosis and adverse skeletal-related events (SREs) was assessed. As compared to normocalcemic patients, hypocalcemic patients (n=51) had higher tumor load in bone (P=0.005), higher plasma chromogranin A (CgA, P=0.01), serum alkaline phosphatase (P=0.01), urinary N-telopeptide (NTX, P=0.002) and lower hemoglobin values (P=0.01), while hypercalcemic patients (n=16) had higher plasma CgA (P=0.001) and serum lactate dehydrogenase values (P=0.001), higher bone pain (P=0.003) and a lower frequency of pure osteoblastic lesions (P=0.001). Hypercalcemia was significantly associated with poor prognosis: hazard ratio (HR), 1.9 (95% confidence Interval (CI) 1.2-3.3) and higher risk to develop SREs HR, 2.5 (95% CI 1.2-5.2, P=0.01), while hypocalcemia was not associated with poor prognosis. The prognostic role of hypercalcemia was maintained in multivariate analysis after adjusting for validated prognostic parameters: HR, 2.72 (95% CI 1.1-6.8, P=0.03). These data suggest that serum calcium levels should be taken into account in the clinical decision-making process of bone metastatic prostate cancer patients. Patients with asymptomatic hypercalcemia could benefit of a strict follow-up and an immediate bisphosphonate treatment. Further prospective clinical trials are needed to confirm this finding.
Abstract: PURPOSE: To describe our experience with laparoscopic transperitoneal vesico-vaginal fistula (VVF) repair and we review current literature. METHODS: Four patients with VVF underwent transperitoneal transvesical laparoscopic repair, with the same principles of open abdominal approach. We considered: operation time, complications, hospital stay, Foley catheter duration, and recurrence during the follow-up. RESULTS: Mean operative time was 103 minutes and no complications were recorded. Average length of hospital stay was 3 days, Foley catheter remained indwelling on an average of 8 days. All patients were cured, after a mean of 14.5 months no recurrence was recorded and no patient referred urinary symptoms. CONCLUSIONS: On the basis of our and literature data, we believe that laparoscopic VVF repair is feasible, safe and effective and it is a viable alternative to the traditional open procedure.
Abstract: OBJECTIVE: To evaluate, in a prospective randomized pilot study, the effectiveness and safety of tamsulosin, administered in patients with distal ureteric stones and who have already undergone an unsuccessful first cycle of medical expulsive therapy (MET). PATIENTS AND METHODS: We evaluated the effectiveness and safety of tamsulosin, administered as a further therapy, in patients previously unsuccessfully treated with combined expulsive 10-day therapy (tamsulosin + deflazacort) for distal ureteric stones. Ninety-one patients were enrolled and randomized into two groups, each receiving a different therapy for 10 days. Group A (46 patients) received a further cycle of tamsulosin (0.4 mg daily), and group B (45) did not. Age, gender, stone size, time to expulsion, number of acute episodes of colic during treatment and analgesic consumption were recorded. Patients who were not stone-free after the study period had ureteroscopy. The results were compared statistically using Student's t-, chi-square test and Fisher's exact test. RESULTS: The groups were comparable in age, gender and stone size (5.93 mm for group A and 6.03 mm for group B). The expulsion rate was significantly higher in group A (80%) than in group B (49%) (P < 0.01), whilst there were no differences between the groups in the number of colic episodes and analgesic use. There were no reported side-effects of medical therapy. CONCLUSIONS: A second cycle of 10 days of MET with tamsulosin in nonresponders to a 10-day first cycle of MET with tamsulosin and deflazacort is safe and effective, and therefore should be considered as an option in the management of uncomplicated distal ureteric stones.
Abstract: OBJECTIVES To evaluate, in a pilot prospective randomized trial, the safety, effectiveness and radiological recurrence of retroperitoneal renal cyst decortication compared with retroperitoneal decortication with wadding using perirenal pedicled fat tissue. PATIENTS AND METHODS From March 2004 to December 2007, 40 patients with simple renal cysts were enrolled and randomized; 22 (group A) had a simple retroperitoneal decortication (SRD) and 18 (group B) a decortication with wadding of the cyst using perirenal fat tissue (RDCW). The following variables were recorded: age, gender, side, size on ultrasonography/computed tomography (CT), location, operative duration, blood loss, complications, pathology, presence or absence of flank pain, hypertension, urinary tract compression or urinary infection. The primary endpoint of this trial was to evaluate and compare the efficacy of both treatments. Secondary endpoints were safety and pain, hypertension and the resolution of urinary tract obstruction. RESULTS In all, 40 cysts were treated; there were no bilateral cysts. The mean (sd) size on CT was 11.9 (1.84) cm in group A and 12.8 (1.25) cm in group B (P = 0.1). All the procedures were completed laparoscopically and no conversion was necessary. There were no intraoperative complications. The mean (range) hospital stay was 3.4 (3-6) days. There was no statistically significant difference between the groups for all variables assessed. There was a radiological recurrence in three patients (14%) in group A, but none in group B (all successful). CONCLUSION To be completely successful, with maximum safety and to prevent recurrences in the treatment of renal cysts, RCDW is recommended when a retroperitoneal approach is chosen, especially if the cyst is located anteriorly. When symptom relief is considered, RCDW duplicates the results obtained with SRD.
Abstract: BACKGROUND: Continence after laparoscopic radical prostatectomy is critical to patients and to surgeons. In this setting, the management of deep venous complex (DVC) without involvement of the sphincter fibres could be an important step of the procedure. OBJECTIVE: To evaluate the effects of a personal selective suture of the plexus (selective ligature of the deep venous complex [SLDVC]) on continence, blood loss, and surgical margin status during laparoscopic radical prostatectomy (LRP). DESIGN, SETTING, AND PARTICIPANTS: We planned a prospective randomised study. Sixty consecutive patients with clinically localised prostate cancer were involved in the study and were divided into two groups: group A (30 patients) underwent LRP with extraperitoneoscopic approach with standard management of DVC; group B (30 patients) underwent LRP with SLDVC. INTERVENTION: In group A, a standard ligature of DVC was performed (ligature and subsequent section); in group B, a selective ligature of DVC after its section was performed. MEASUREMENTS: Continence was evaluated during follow-up visits at catheter removal, and after 1, 3, 6, and 12 mo, perioperative variables and pathologic features of specimens were recorded. RESULTS AND LIMITATIONS: The two groups were comparable in terms of age, body mass index (BMI), prostate-specific antigen (PSA) values, and Gleason score at biopsy. No differences were found between the two groups in terms of operative times, blood loss, catheterisation time, and postoperative stay or histologic status. As far as continence rate is concerned, a significant difference was recorded between the groups (53% in group A vs 80% in group B) after 3 mo. CONCLUSIONS: This selective ligature of the DVC after its section can contribute to early recovery of continence. Our data suggest that SLDVC compromises neither the safety of the procedure nor its oncologic effectiveness.
Abstract: The role of percutaneous biopsy of renal masses has been traditionally limited by concerns about its safety, accuracy and sampling errors. The increasing incidence in the diagnosis of incidental small renal masses (SRMs), the development of conservative and minimally invasive treatments for low risk renal cell carcinomas (RCCs) and the discovery of novel targeted treatments for metastatic disease are now leading to wider indications for renal tumor biopsy. Percutaneous biopsy of renal tumors can be performed in an outpatient setting under ultrasound and/or CT guidance. 18 gauge needles loaded in an automatic biopsy gun are used to retrieve cores and 21 gauge needles to obtain FNA specimens through a 17 gauge coaxial cannula placed close to the tumor. A careful check of the quality of biopsies and aspirates is paramount to maximize the diagnostic yield of the procedure. With the development of new biopsy techniques the risk of tumor seeding appears negligible and significant bleeding is unusual and very rarely clinically significant. In centres with expertise, needle core biopsy with or without FNA can provide adequate specimens for an accurate diagnosis in over 90% of cases. Incidental SRMs are frequently detected in elderly patients and have a very heterogeneous biological behaviour At surgery up to one third have benign histologies and most of those that are malignant are low grade RCCs. Pretreatment percutaneous biopsy can significantly decrease the number of unnecessary surgeries for benign disease and assist the urologist in clinical decision making, especially for elderly and unfit patients who are possible candidates for active surveillance and/or minimally invasive ablative therapies. Finally, there is potential for stratifying initial therapy of metastatic RCC by histological subtype on needle biopsies.
Abstract: OBJECTIVES: To critically review the current scientific evidence about open partial nephrectomy (OPN) and laparoscopic partial nephrectomy (LPN) to define the current role of these techniques in the treatment of renal tumours. METHODS: PubMed and Medline were searched for reports about OPN and LPN that were published from 1990 to 2007 and the most relevant papers were reviewed. RESULTS: OPN is an established curative approach for the treatment of small renal tumours. LPN is challenging and the technique is still under development. The intermediate-term oncologic and functional outcomes of LPN are similar to those of OPN in experienced centres. However, the ischaemia time is longer in laparoscopy and a long learning curve is needed to decrease the risk of complications. In the first phase of a surgeon's experience with LPN, a careful case selection based on the tumour growth pattern is required. CONCLUSION: OPN is today the first treatment option for small renal tumours. LPN is technically challenging, but has been shown to achieve similar intermediate-term cancer cure and renal function results in centres with advanced laparoscopic expertise. Larger series with longer follow-up and prospective randomised studies are needed to confirm the safety and efficacy of LPN.
Abstract: OBJECTIVE: Laparoscopic partial nephrectomy (LPN) is a technique that is emerging as an attractive option for the treatment of renal tumors <or=4 cm. We retrospectively analyzed our experience with LPN to identify patient and tumor features that correlate with a higher risk of complications. MATERIAL AND METHODS: From January 2001 to May 2007, 90 patients underwent LPN at our institution for a clinically localized renal tumor. A retrospective chart review was carried out. Clinical and pathological information were collected for each patient, including patient age and body mass index, tumor size, location and pattern of growth (cortical vs. corticomedullar), surgical approach (transperitoneal vs. retroperitoneal), warm ischemia time, technique that was used to achieve hemostasis, maximum thickness of the margin of resection, and histology. Statistical analysis (chi-square test, Fisher exact test, Mann-Whitney U test, linear regression model) was performed to test the correlation between the above-mentioned variables and the occurrence of complications. RESULTS: Twenty-two patients (24.4%) had surgical and/or medical complications in our series. The only variable that was found to significantly correlate with a higher number of complications was a corticomedullar tumor growth pattern as opposed to a cortical growth pattern (p=0.02). CONCLUSIONS: LPN is an attractive alternative to open partial nephrectomy for the treatment of small renal tumors. On the basis of our experience, the selection of patients with cortical renal lesions seems to be required to reduce the risk of complications and therefore maximize the advantages of this minimally invasive but challenging procedure.
Abstract: Acute uncomplicated pyelonephritis (APN) is a complex clinical entity, which is defined differently based on clinical or imaging criteria. The aim of this study was to describe the clinical and radiological presentation of APN-upper urinary tract infection (UTI) cases observed between May 2005 and June 2006 and hospitalised in the Emergency Medicine ward of San Luigi Hospital, Orbassano, Turin, Italy. All patients underwent imaging scans and were differentiated on the basis of parenchymal involvement. Of around 45000 patient visits to the emergency room between May 2005 and June 2006, 23 patients were diagnosed as having uncomplicated upper UTI (all female, age 15-57 years). Renal parenchymal involvement was confirmed by imaging in 16 cases (69.6%). The imaging spectrum ranged from a small single lesion to large multiple defects; on admission, 2 cases had no pain and 2 had no fever; lower urinary tract symptoms were present in only 13 patients (7 with parenchymal involvement). All patients with parenchymal involvement had at least one sign of systemic inflammation-infection. Most patients (15) had taken antibiotics before hospitalisation; consequently, urine cultures were negative in 21 cases (14 cases with positive imaging (87.5%)). The data from patients with and without parenchymal involvement overlapped, the only difference being a higher prevalence of high CRP levels in cases with parenchymal involvement.
Abstract: OBJECTIVES: To describe and evaluate the safety and outcome of transperitoneal left laparoscopic pyeloplasty (TLLP) with a direct approach to the pelvi-ureteric junction (PUJ) through the mesentero-colic space, which avoids mobilization of the descending colon. PATIENTS AND METHODS: From March 2005 to June 2006, 18 consecutive patients underwent TLLP with direct access. For each patient age, gender, body mass index (BMI), hospital stay, skin-to-skin operative time, time from incision of the posterior peritoneum to dissection of the PUJ, blood loss, time to resumption of oral intake and complications were recorded. Statistical analysis was used to assess whether the body habitus (BMI <25 kg/m(2) or >25 kg/m(2)) affected the outcomes. RESULTS: There were no complications during or after surgery and no conversions to open surgery were needed. The mean (SD) time to resumption of oral intake was 1.36 (0.5) days. The mean hospital stay was 3.3 (0.67) days and the mean follow-up was 17.4 (4.7) months. There was no statistical difference between patients with BMI higher or lower than 25 kg/m(2) (P = 0.42). The success rate at 1 year after surgery was 100%. CONCLUSION: TLLP with direct access to the PUJ through the mesentero-colic space is a safe and effective technique. This approach should be considered for all patients with left primary PUJ obstruction who are eligible for a LP and especially for slim patients or patients with a large renal pelvis.
Abstract: Randomised prospective studies have shown that single-stage management of cholecysto-choledocholithiasis yields results equal or superior to sequential treatment, with a lower incidence of complications primarily associated with choledochotomy. We report the first case of transcystic Holmium:YAG laser lithotripsy using a flexible ureteroscope. The method was found to be a valuable aid in reducing the percentage of choledochotomies when calculi are too large to be retrieved from the common bile duct with normal graspers.
Abstract: Transitional cell carcinoma of the upper urinary tract (UUT-TCC) is relatively uncommon, accounting for 2-5% of all urothelial tumors. Its incidence appears to be increasing as a result of progress in imaging, endoscopy, and improved survival from bladder cancer. Renal pelvis tumors represent 10% of all renal cancers. Pyelic neoplasms occur at a rate twice to four times the incidence of tumors in the ureter, where the common site is the distal tract (about 70%). One third of UUT-TCC ore multifocal, and about 1% are simultaneous and bilateral. The introduction of lasers represented a big step in the diagnosis and endoscopic treatment of upper urinary tract tumors. A successful laser treatment is defined by the careful selection of the patients affected by urinary tract lesions. Usually, only patients affected by low grade and papillary lesion should be treated endoscopically with laser. Patients with high grade and invasive lesions should rather be submitted to surgical procedure. Actually, the urologist has a wide choice in laser technology (Holmium laser, Thulium laser). For a correct and safe treatment of ureteral and pyelic lesions with lasers it is mandatory to respect some technical advises. First of all, an adequate access for a good vision of ureter and renal pelvis is imperative. In fact, the urologist should always work in safety, with an optimal control of the instrumentation. Then, it is important to define the laser type and its energy level. The development in laser technology (i.e. small and flexible laser fibers) allows also a radical, safe and minimally invasive treatment of urothelial lesions using flexible ureteroscopes. Of course it is mandatory to evaluate the grade and stage of the tumors by means of the ureteroscopic biopsies: invasive tumors must be treated by immediate nephroureterectomy while the endoscopic treatment should be reserved to those patients with a solitary kidney, renal failure, bilateral tumors, severe comorbities or affected by a solitary tumors with <15 mm in diameter and of low-grade/stage.
Abstract: BACKGROUND: Percutaneous nephrolithotomy (PCNL), the gold standard for the management of large and/or complex urolithiasis, is conventionally performed with the patient in the prone position, which has several drawbacks. Of the various changes in patient positioning proposed over the years, the Galdakao-modified supine Valdivia (GMSV) position seems the most beneficial. It allows simultaneous performance of PCNL and retrograde ureteroscopy (ECIRS, Endoscopic Combined Intra-Renal Surgery) and has unquestionable anaesthesiological advantages. OBJECTIVE: To prospectively analyse the safety and efficacy of endoscopic combined intrarenal surgery (ECIRS) in GMSV position for the treatment of large and/or complex urolithiasis. DESIGN, SETTING, AND PARTICIPANTS: From April 2004 to December 2007, 127 consecutive patients who were followed in our department for large and/or complex urolithiasis were selected for surgery (American Society of Anesthesiologists [ASA] score 1-3, no active urinary tract infection [UTI], any body mass index [BMI]). INTERVENTION: All the patients underwent ECIRS in GMSV position. Technical choices about percutaneous access, endoscopic instruments and accessories, and postoperative renal and ureteral drainage are detailed. MEASUREMENTS: Patients' mean age plus or minus standard deviation (+/- SD) was 53.1 yr+/-14.2. Of the 127 patients, 5.5% had congenital renal abnormalities, 3.9% had solitary kidneys, and 60.6% were symptomatic for renal colics, haematuria, and recurrent UTI. Mean stone size+/-SD was 23.8mm+/-7.3 (range: 11-40); 33.8% of the calculi were calyceal, 33.1% were pelvic, 33.1% were multiple or staghorn, and 4.7% were also ureteral. RESULTS AND LIMITATIONS: Mean operative time+/-SD was 70min+/-28, including patient positioning. Stone-free rate was 81.9% after the first treatment and was 87.4% after a second early treatment using the same percutaneous access during the same hospital stay (mean+/-SD: 5.1 d+/-2.9). We registered overall complications at 38.6% with no splanchnic injuries or deaths and no perioperative anaesthesiological problems. CONCLUSIONS: ECIRS performed in GMSV position seems to be a safe, effective, and versatile procedure with a high one-step stone-free rate, unquestionable anaesthesiological advantages, and no additional procedure-related complications.
Abstract: PURPOSE: The prognostic accuracy of the current TNM 2002 staging system for locally advanced renal cell carcinoma has been questioned. To contribute to the development of a more accurate classification for this stage of disease we assessed the correlation between patterns of invasion in the pT3 category and outcomes in a large multi-institutional series. MATERIALS AND METHODS: Pathological data and clinical followup on 513 pT3 renal cell carcinoma cases treated with radical nephrectomy between 1983 and 2005 at 3 Italian academic centers were retrospectively reviewed. Cause specific survival rates were calculated with the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model. RESULTS: Estimated overall 5-year cause specific survival was 50.1% at a median followup of 61.5 months in survivors. The current TNM classification was not a significant outcome prognosticator. Patients with a tumor invading only the perirenal or sinus fat were at lowest risk for death from the disease. Patients at intermediate risk had tumors with invasion of the venous system alone. Simultaneous perirenal fat and sinus fat invasion or perirenal fat and vascular invasion as well as adrenal gland involvement characterized high risk tumors. Low risk tumors could be further divided into 2 groups with different outcomes based on a size cutoff of 7 cm. Our classification was a significant predictor of survival on multivariate analysis as well as M stage, N stage, Fuhrman grade and tumor size. CONCLUSIONS: We confirm that the prognostic usefulness of the current 2002 TNM system for pT3 renal cell carcinoma is limited. We have identified 4 groups of tumors with distinct patterns of invasion and significantly different survival probabilities in this category. Large prospective series are needed to validate these findings.
Abstract: OBJECTIVE: To assess changes in prostate cancer clinical and pathologic features by review of 15 years' experience with radical prostatectomy. STUDY DESIGN: A total of 596 consecutive patients who underwent open or laparoscopic radical prostatectomy (RP) between 1991 and 2006 were included. All had clinically localized prostate cancer. Surgical specimens were analyzed or blindly reviewed by a uropathologist, and whole-mount sections were prepared. Statistical analysis evaluated whether significant changes in clinical and pathologic variables occurred over time. RESULTS: Median prostate specific antigen (PSA) values at diagnosis significantly decreased over time. Definite stage migration was observed, with significant increase of organ-confined tumors. Incidence of seminal vesicle and lymph node involvement declined steadily. Median tumor volume decreased significantly over time (p<0.001). Incidence of nonsignificant cancers at RP increased significantly, reaching 25.6% in 2006. PSA value has progressively lost correlation with prostate cancer volume and today correlates only with prostate gland volume. CONCLUSION: Prostate cancer stage and volume at diagnosis have steadily decreased in the last 15 years, likely reflecting increasing use of PSA testing. In early prostate cancer, PSA level no longer correlates with tumor volume.
Abstract: PURPOSE: The aim of this prospective study was to evaluate the advantages or disadvantages of the use of fibrin glue and collagen fleece during laparoscopic partial nephrectomy. PATIENTS AND METHODS: Two groups of patients were studied. Group A (n = 24) received parenchymal suture, whereas Group B (n = 20) received parenchymal suture with fibrin glue and collagen fleece. The two groups were similar in baseline characteristics. We evaluated patient age, size of the lesion at CT, operative time, ischemia time, and sealant technique in relation to blood loss, hospital stay, and hemorrhagic complications. RESULTS: No significant difference was observed in perioperative parameters (P > 0.05). The mean size of lesion was 3.3 +/- 1.2 (range 1-8 cm) for group A and 3.0 +/- 1.3 (range 2-5 cm) for Group B. The mean operative time was 116 +/- 26.6 minutes (range 90-220 minutes) for group A and 130 +/- 23.5 minutes (range 90-210 minutes) for group B. The mean warm ischemia time was 28.8 +/- 5.7 minutes (range 18-60) minutes) and 35.6 +/- 6.2 minutes (range 20-52 minutes), respectively. The mean blood loss was 178 +/- 34.5 mL (range 50-400 ml) for group A and 219 +/- 44.6 mL (range 80-750 ml) for group B. The mean hospital stay was 5.9 +/- 1.2 days (range 5-8 days) for group A and 6.3 +/- 2.1 days (range 5-9 days) for group B. Four and two postoperative hemorrhage complications were observed in groups A and B, respectively. CONCLUSION: The use of fibrin glues and collagen fleece should be considered an adjuvant, as it does not present any substantial advantages, the suture being the key point in hemostasis control. We believe that in order to improve hemostasis, the efficacy of other types of sealants should be studied, as we were not convinced by those we used.
Abstract: OBJECTIVE: To evaluate renal damage and impairment of renal function 1 yr after laparoscopic partial nephrectomy (LPN) with warm ischemia >30 min. METHODS: From July 2004 to June 2005, 18 patients underwent LPN with warm ischemia time >30 min. Kidney damage markers (daily proteinuria and tubular enzymes) and renal function (serum creatinine, cystatin C, and creatinine clearances) were assessed on postoperative days 1 and 5 and at 12 mo. Glomerular filtration rate (GFR) was evaluated before surgery and at 3 mo. Renal scintigraphy was performed before the procedure, at 5 d and at 3 and 12 mo postoperatively. Statistical analysis was performed using the Student t test and logistic regression analysis. RESULTS: In terms of kidney damage and renal function markers, the statistical analysis demonstrated that at 1 yr there was complete return to the normal range and no statistical difference between the values at the various time points. The GFR was not significantly different before and 3 mo after surgery. In terms of scintigraphy of the operated kidney, the values were 48.35+/-3.82% (40-50%) before the procedure, 36.88+/-8.42 (16-50%) on postoperative day 5 (p=0.0001), 40.56+/-8.96 (20-50%) at 3 mo (p=0.003), and 42.8+/-7.2% (20-50%) 1 yr after surgery (p=0.001). CONCLUSION: Our results demonstrate that kidney damage occurs during LPN when warm ischemia is >30 min. This damage is only partially reversible and efforts should be made to keep warm ischemia within 30 min.
Abstract: BACKGROUND AND PURPOSE: Laparoscopic radical cystectomy is confined to centers where advanced laparoscopy is performed, and its role is not yet well clear. Our aim was to evaluate, through a prospective comparative study, the advantages of the laparoscopic compared with an open approach. PATIENTS AND METHODS: From November 2002 to December 2005, all the patients in our center who were found to have muscle-invasive bladder cancer without clinical evidence of lymph-node involvement and an American Society of Anesthesiologists (ASA) score <4 were included in a prospective nonrandomized study. Group A (N = 22) underwent open radical cystectomy, whereas group B (N = 20) underwent laparoscopy-assisted radical cystectomy. The two groups were demographically comparable. We evaluated the mean age, clinical stage, ASA score, operative time, blood loss, intraoperative complications and transfusions, type of diversion, time of catheterization, analgesic consumption, start of oral nutrition, rate of postoperative complications, length of hospital stay, pathologic diagnosis of the specimen, number of lymph nodes removed, and the oncologic outcome. RESULTS: No significant statistical difference was observed between the two groups in intraoperative and postoperative parameters except for analgesic consumption and the start of oral nutrition (P < 0.05). The mean operative time was 260 minutes (range 210-290 minutes) for group A and 284 minutes (range 260-305 minutes) for group B. The mean blood loss was 770 mL (range 450-870 mL) in group A and 520 mL (range 400-620 mL) in group B. The rate of autologous transfusion was 18% in group A and 10% in group B. Seventeen ileal diversions and five neobladder creations were performed in group A, whereas the Bricker diversion was used in 10 cases in group B, and a neobladder was chosen in the 10 other cases. CONCLUSION: Laparoscopy-assisted radical cystectomy is a safe procedure, like open surgery, but it offers the advantage of minimal invasiveness, represented by reduced analgesic consumption and early recovery of peristalsis with rapid oral nutrition.
Abstract: OBJECTIVE: Incidence of venous thromboembolism (VTE) and need for thromboprophylaxis in urologic surgery have received little attention since only one randomised study has addressed this issue in the last 20 yr. The present prospective observational study evaluated incidence and risk factors for clinically overt VTE in a wide spectrum of consecutive patients undergoing surgery for cancer and compared findings in urologic patients with those in patients undergoing general or gynaecologic surgery. METHODS: Patients having cancer surgery (general surgery, gynaecology, urology) were assessed for clinically overt VTE occurring up to 30+/-5 d after intervention or more if the hospital stay was longer. All suspected VTE events were evaluated by an external independent Adjudication Committee. RESULTS: A total of 2373 patients, 1238 (52%) undergoing general surgery, 685 (29%) urologic, and 450 (19%) gynaecologic surgery were evaluated. In urologic patients, most procedures (61%) were endoscopic, with bladder and prostate cancer being the most frequent tumours. In-hospital thromboprophylaxis was given to 71.7% of patients, whereas 32.5% received prophylaxis after discharge. The incidence of VTE in urologic patients was lower (0.87%) than that in general surgery and gynaecologic patients (2.8% and 2.0%, respectively). VTE consisted of three cases of nonfatal and three cases of fatal pulmonary embolism (PE). In four of the six cases, VTE occurred during prophylaxis. CONCLUSIONS: VTE still represents a severe complication and remains the most common cause of death after urologic cancer surgery. Efforts should be made to optimise prophylactic measures to further reduce such risk.
Abstract: Urachal carcinoma is a rare neoplasm treated with surgical resection. We report a case of adenocarcinoma of the urachus treated with a new surgical technique. In a 44-year-old man affected by urachal carcinoma we performed a combined endoscopic-laparoscopic surgical en bloc resection of the urachus and bladder dome. The procedure lasted 240 min, and no postoperative complications were recorded. The patient was discharged on fourth day and the catheter was removed on eighth day. Bladder capability resulted normal with no evident physical change. Multiple bladder biopsy and computed tomography scans at 6, 12 and 18 months proved negative.
Abstract: PURPOSE: We assessed chromogranin A as a tissue biomarker in prostate needle biopsies or as a plasma biomarker, a risk factor for hormone refractory prostate cancer. MATERIALS AND METHODS: A total of 211 patients with newly diagnosed prostate cancer treated with luteinizing hormone releasing hormone analogues constituted the study cohort. Univariate and multivariate Cox regression analyses were used to assess the predictive role of tissue and plasma chromogranin A expression. RESULTS: Chromogranin A expression in less than 30% or in 30% or more tumor cells was significantly associated with a shorter time to hormone refractory disease on univariate analysis (HR 2.0, 95% CI 1.3-3.1 and HR 6.0, 95% CI 2.7-12.9), or on multivariate analysis after adjusting for Gleason score, serum prostate specific antigen and disease stage (HR 1.7, 95% CI 1.0-2.8 and HR 3.9, 95% CI 1.7-9.0), respectively. Plasma chromogranin A measured at baseline (HR 3.0, 95% CI 1.8-5.2), and after 1 year (HR 5.8, 95% CI 3.1-10.1) and 2 years (HR 3.5, 95% CI 1.6-7.6), was predictive of hormone refractory risk confirming the tissue results. Plasma as well as tissue chromogranin A expression negatively correlated with overall survival. CONCLUSIONS: Chromogranin A expression in prostate cancer biopsies is an independent predictive factor of hormone refractory disease in patients with newly diagnosed prostate cancer on early androgen deprivation therapy. Plasma chromogranin A is also a reliable predictive marker and the predictive significance is maintained over time. These results deserve validation in another data set.
Abstract: OBJECTIVE: To compare OAB symptom outcomes following initial randomised treatment with solifenacin 5 mg or tolterodine ER 4 mg at the 4-week clinic-visit and again at 12 weeks for patients choosing to remain on this treatment dose from 4 weeks. METHODS: A prospective, double blind, double-dummy, two-arm, parallel-group, 12-week study (The STAR study) was conducted to compare the efficacy and safety of solifenacin 5/10 mg and tolterodine extended release (ER) 4 mg in OAB patients. RESULTS: At 4 weeks mean improvements in OAB symptoms, including urgency, frequency (primary variable), incontinence and nocturia, were larger in patients randomised to solifenacin 5 mg; with the difference for incontinence being statistically significant (mean reduction in incontinence episodes/24 hrs in the solifenacin group of -1.30 vs. -0.90 (p=0.0181); the mean result for solifenacin 5 mg amounted to a 44% additional improvement.) There was an associated significant reduction in pad use (reduced by -1.21 vs. -0.80; p=0.0089); the mean result for solifenacin 5 mg amounted to a 51% additional improvement over that of tolterodine ER 4 mg. For patients choosing to remain on these treatments improvements in favour of solifenacin were maintained at study end (12-weeks). Treatments were well tolerated. CONCLUSIONS: Within 4 weeks solifenacin 5mg was statistically significantly better than tolterodine ER 4 mg in improving incontinence and reducing incontinence pad use. Differences in efficacy in favour of solifenacin 5 mg were maintained from 4 weeks for the duration of the study for patients choosing to remain on their starting dose.
Abstract: OBJECTIVE: The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved). METHODS: All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively. RESULTS: A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1-35). The median number of LNs involved was 3 (range, 1-18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved (p = 0.02) and LN density >60% (p = 0.01). CONCLUSION: The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as < or =4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.
Abstract: SUMMARY BACKGROUND DATA: The epidemiology of venous thromboembolism (VTE) after cancer surgery is based on clinical trials on VTE prophylaxis that used venography to screen deep vein thrombosis (DVT). However, the clinical relevance of asymptomatic venography-detected DVT is unclear, and the population of these clinical trials is not necessarily representative of the overall cancer surgery population. OBJECTIVE: The aim of this study was to evaluate the incidence of clinically overt VTE in a wide spectrum of consecutive patients undergoing surgery for cancer and to identify risk factors for VTE. METHODS: @RISTOS was a prospective observational study in patients undergoing general, urologic, or gynecologic surgery. Patients were assessed for clinically overt VTE occurring up to 30 +/- 5 days after surgery or more if the hospital stay was longer than 35 days. All outcome events were evaluated by an independent Adjudication Committee. RESULTS: A total of 2373 patients were included in the study: 1238 (52%) undergoing general, 685 (29%) urologic, and 450 (19%) gynecologic surgery. In-hospital prophylaxis was given in 81.6% and postdischarge prophylaxis in 30.7% of the patients. Fifty patients (2.1%) were adjudicated as affected by clinically overt VTE (DVT, 0.42%; nonfatal pulmonary embolism, 0.88%; death 0.80%). The incidence of VTE was 2.83% in general surgery, 2.0% in gynecologic surgery, and 0.87% in urologic surgery. Forty percent of the events occurred later than 21 days from surgery. The overall death rate was 1.72%; in 46.3% of the cases, death was caused by VTE. In a multivariable analysis, 5 risk factors were identified: age above 60 years (2.63, 95% confidence interval, 1.21-5.71), previous VTE (5.98, 2.13-16.80), advanced cancer (2.68, 1.37-5.24), anesthesia lasting more than 2 hours (4.50, 1.06-19.04), and bed rest longer than 3 days (4.37, 2.45-7.78). CONCLUSIONS: VTE remains a common complication of cancer surgery, with a remarkable proportion of events occurring late after surgery. In patients undergoing cancer surgery, VTE is the most common cause of death at 30 days after surgery.
Abstract: OBJECTIVES: To evaluate the technical advantages of early ligature of the renal artery at the level of the Treitz ligament during left laparoscopic radical nephrectomy (LRN). MATERIAL AND METHODS: Twenty-six patients underwent LRN for organ-confined lesions. We grouped measured parameters (see Results) on the basis of the first 13 and last 13 patients, and compared both subgroups. All parameters were correlated to stage of disease (pT1 vs pT2-3). The Student t test was used for statistical analysis. RESULTS: The mean (range) for measured parameters are as follows: age: 56.5 +/- 11.6 (41-77) years; American Society of Anesthesiologists score: 2.4 +/- 1 (1-3); body mass index: 23.4 +/- 3.4 (21.1-33); lesion size at computed tomography: (6.2 +/- 2.4 (4-12) cm; operative skin to skin time: 130 +/- 20 (125-170) minutes; blood loss: 255 +/- 120 (100-800) ml; hospital stay: 6.5 +/- 2.0 (4-15) days; analgesic consumption (Tramadol 100 mg): 2.5 +/- 1 (2-4) vials; follow-up time: 30.5 +/- 5.6 (3-48) months. No intra-operative complications occurred. Pathologic analysis showed 12 pT1N0, five pT2N0, eight pT3aN0 and one pT3b N2 with mean lesion size of 6.2 +/- 1.6 (4-13) cm. Mean number of removed lymph nodes was 9.8 +/- 1.6 (7-17). No statistical difference was observed between the two subgroups (p > 0.05), and between pT1 and pT2-3 stage (p > 0.05) groups. CONCLUSIONS: Early ligature using direct access to the renal artery at the Treitz ligament permits the surgeon to follow the classic steps and principles of radical nephrectomy.
Abstract: OBJECTIVE: To demonstrate the safety of the Millin extraperitoneal laparoscopic adenomectomy by comparing the laparoscopic and open approaches. METHODS: From January 2003 to April 2005, patients, with indication of prostatic adenomectomy, were offered the chance to choose between 2 types of procedure: Millin adenomectomy with open or extraperitoneal laparoscopic approach. Forty patients were included in this prospective non-randomised study. The patients were divided into 2 Groups. Group A (20 patients) underwent extraperitoneal laparoscopic adenomectomy, while Group B (20 patients) was treated by open surgery. Pre-operative, peri-operative and post-operative parameters were evaluated. Group A was subdivided in two sub-groups (first ten and last ten) and peri-operative parameters were considered in order to determine the learning curve. RESULTS: In terms of pre-operative parameters considered, the 2 study groups are comparable (p>0.3). As far as peri and post-operative parameters are concerned: mean blood loss for Group A was 411.6+/-419 ml, for Group B 687.5+/-298.6 ml (p=0.004). For all the other parameters no significant statistical differences were recorded (p>0.4). Mean operative time was 107.2+/-34.9 min in Group A, and 95.5+/-22.5 min in Group B. Mean adenoma weight in Group A was: 69,5+/-21.5 g, in Group B: 88.1+/-43.8 g. Mean haemoglobin levels in Group A was: 11.2+/-1.8 g/dl, Group B: 11.6+/-1.2 (10-13.4) g/dl. Mean Analgesic consuming (Tramadol) during the post-operative stay was 385+/-36 mg in Group A, versus 430+/-108 mg in Group B. Mean catheterization time was 6.3+/-3.7 days in Group A, 5.6+/-1.1 days in Group B. The mean hospital stay was 7.8+/-4.1 days in Group A, and 7+/-1.6 days in Group B. One patient (5%) from Group A was re-operated for bleeding and clot retention, whilst in Group B patients did not present complications which required any further intervention. As far as peri-operative and post-operative parameters of the two sub-Groups A (first ten patients and last ten patients) are concerned, the statistical evaluation shows a significant difference only on operative time (p=0.01). The p-value for the other parameters was not significant (p>0.1). CONCLUSIONS: The extraperitoneal laparoscopic adenomectomy is a safe technique presenting results comparable to open surgery with the advantage of significantly lower peri-operative blood loss.
Abstract: OBJECTIVE: To validate the Italian version of two questionnaires for lower urinary tract symptoms (LUTS), i.e. the long (LF) and the short form (SF) of the International Consultation on Incontinence Questionnaire (ICIQ). METHODS: Two native Italian speakers and a native English speaker collaborated with clinical investigators through a multistep process to obtain a consensus version of the questionnaires. The resulting Italian versions were then pre-tested during a pilot study on 16 women for the LF and 10 for the SF. The final versions of the ICIQ-LF and ICIQ-SF were administered to two samples of consecutive female patients, aged > or = 18 years, who had been having LUTS for > or = 3 months, with respectively 82 and 50 women. Internal consistency and test-retest reliability were then assessed; to evaluate the latter, a subset of patients (25 for the ICIQ-LF and 42 for ICIQ-SF) was re-rated. To test the capacity of the questionnaires to discriminate women with or without LUTS (respectively cases and controls), a sample of healthy women was also enrolled and assessed. RESULTS: Both scales showed good psychometric properties overall. The correlation coefficient between ratings was > 0.75 in both questionnaires, and the discriminant power between cases and controls was confirmed for both scales. The ICIQ-SF showed good internal consistency for the total score (Cronbach's alpha 0.90). The sections of the ICIQ-LF 'impact of incontinence on everyday life', 'emotional aspects', 'urinary symptoms' and the degree of bother seemed to be internally consistent (Cronbach's alpha > 0.70); there was a weak relationship for items related to 'sexual matters' (Cronbach's alpha 0.38). CONCLUSION: The Italian version of both questionnaires is a valid and robust instrument which can now be used reliably both in daily practice and in clinical research.
Abstract: OBJECTIVES: To assess the clinical role of corticosteroids in the medical expulsive therapy of symptomatic distal ureteral stones. METHODS: Between January 2004 and September 2005, 114 patients with symptomatic distal ureteral stones with a >/=5mm diameter were enrolled in this prospective study and divided into four groups based on the urologist (of four) who treated them in the emergency unit. Group A (33 patients) received tamsulosin (0.4mg daily), group B (24 patients) received deflazacort (30mg daily), group C (33 patients) received both (0.4mg tamsulosin+30mg deflazacort daily), and control group D (24 patients) received only analgesics. The treatment duration was 10 d to prevent the side-effects of prolonged corticosteroid therapy. The end points were the expulsion rate, analgesic consumption, number of ureteroscopies, and safety. RESULTS: The groups were comparable in terms of age, sex, and stone location. The stone diameter was 5.96+/-0.33mm for group A, 5.83+/-0.4mm for group B, 5.88+/-0.23mm for group C, and 5.71+/-0.5mm (p>0.05) for group D. The rates of expulsion for the four groups were 60%, 37.5%, 84.8%, and 33.3%, respectively. There was a significant difference between group C and the other groups (p<0.001). The mean analgesic consumption was 42.5+/-0.4mg for group A, 50+/-0.3mg for group B, 27.3+/-0.5mg for group C, and 81+/-0.33mg for group D, with a significant difference between group C and the other groups (p<0.001). During the treatment period, only two cases of drug side-effects related to tamsulosin (without any drop-outs) were recorded. CONCLUSION: When the medical expulsive therapy for symptomatic distal ureteral stones is considered, the use of steroids (deflazacort) proves efficient only when administered together with alpha(1)-blockers (tamsulosin). In addition, tamsulosin used on its own as a medical expulsive therapy can be considered as an alternative treatment for those patients who are not suitable for steroid therapy, as it is generally efficient.
Abstract: OBJECTIVE: This article describes both the open and laparoscopic operative techniques of supra-ampullar cystectomy (SAC). METHODS: Both open (photographs and drawings) and laparoscopic (attached DVD) SAC are explained step by step. RESULTS: Between May 1984 and December 2005, 31 patients with bladder tumour underwent SAC with ileal orthotopic neobladder (2 Camey I, 26 Camey II, and 3 Y). Three patients underwent laparoscopy. Preoperatively, 26 patients had superficial high-risk transitional cell carcinoma (TCC). Median follow-up was 95.0 mo (range: 5-260 mo). The 10-yr cause-specific survival rate was 76.7%. Two patients had local recurrence. Potency was preserved in 28 patients (90.3%); 15 patients (48.3%) also maintained antegrade ejaculation, allowing procreation in 3 cases. In one patient the Camey I neobladder was converted into an ileal conduit (high postvoid residual, recurrent pyelonephritis). None of the remaining patients had daytime incontinence, eight had nightime urinary incontinence, and six performed intermittent self-catheterisation. CONCLUSION: SAC with detubularised ileal orthotopic neobladder allows preservation of sexual function and maintenance of urinary continence in most patients, without compromising oncologic outcome. The key element is the very strict and careful preoperative selection of the patients.
Abstract: OBJECTIVES: To analyze, in a consecutive study, the perioperative, postoperative, and functional results of the transperitoneal and extraperitoneal approaches for laparoscopic radical prostatectomy. METHODS: A total of 160 patients underwent radical prostatectomy and were subdivided into two groups. Group 1 underwent the transperitoneal approach and group 2, the extraperitoneal approach. The preoperative parameters, age, prostate-specific antigen level, biopsy Gleason score, American Society of Anesthesiologists class, body mass index, and clinical stage, were considered. The perioperative parameters evaluated were the operative time, blood loss, blood transfusion, hospital stay, catheterization time, complications, histopathologic findings, TNM stage, Gleason score, prostate and tumor volumes, and functional results. RESULTS: The patients in both groups had comparable preoperative data. No differences were observed between the two groups in the intraoperative data, except for the mean operative time (179 +/- 54.6 for group 1 versus 133.7 +/- 27 minutes for group 2). Also, no differences were observed between the two groups in terms of the postoperative data. The proportion of complications was 21.25% in group 1 and 22.5% in group 2. We recorded symptomatic lymphocele requiring treatment with a drain or reoperation in 8 patients (10%) in group 2 and 0% in group 1 (P <0.001) of all the patients who underwent lymphadenectomy. The rate of positive surgical margins was 25% for group 1 and 21.25% for group 2 (P = NS). For those with Stage pT2, the positive margin rate was 7.3% and 10% for groups 1 and 2, respectively. The recovery of continence at 3 months was faster in group 2 (75% of patients versus 50.9% in group 1; P <0.01). CONCLUSIONS: The extraperitoneal approach required less operative time and enabled faster recovery of continence and the transperitoneal approach prevented the formation of lymphocele.
Abstract: PURPOSE: To present a simple alternative technique to close the membranous urethra during laparoscopic radical cystectomy. PATIENTS AND METHODS: A series of 18 laparoscopy-assisted cystectomies were performed in our institute from November 2002 to May 2005. In order to prevent neoplastic-cell spillage, in 14 of these patients, the membranous urethra was closed with Hem-o-lok clips after careful dissection of the urethra and withdrawal of the bladder catheter. RESULTS: In all cases, one or two Hem-o-lok clips were easily, safely, and quickly positioned. The remaining length of the membranous urethra was sufficient for anastomosis with the neobladder if appropriate. In follow-up (mean 14 months), no local recurrence has been recorded. CONCLUSION: The closing of the membranous urethra with Hem-o-lok clips during laparoscopy-assisted cystectomy is in our experience a simple, fast, safe, and effective alternative that should be considered when laparoscopic radical cystectomy is performed.
Abstract: OBJECTIVES:To evaluate the morphological changes induced by a 3-month course of neoadjuvant bicalutamide 150 mg/day before radical prostatectomy (RP) on prostatic adenocarcinoma and high-grade prostatic intraepithelial neoplasia (HGPIN). PATIENTS AND METHODS: In all, 90 patients with cT1-T2 prostate cancer and HGPIN on prostatic biopsy were randomized to receive bicalutamide (150 mg/day for 3 months) before RP, or to have immediate surgery. Surgical specimens were assessed for the histopathological features of cancer, HGPIN and benign epithelium in a blinded manner. The volumes of prostate cancer and HGPIN were evaluated using a stereological (i.e. grid) method. RESULTS: Compared with the bicalutamide-treated group, the ratio of stroma to epithelium, evaluated by visual microscopic assessment in the normal epithelium of the three prostate zones, was significantly lower in the control group, at 2.27 (sd 1.13), than in the treated group, at 1.87 (sd 0.72) (P = 0.048). The mean (sd) tumour volume was significantly lower in the bicalutamide-treated than in the control group, at 0.914 (0.13) vs 1.47 (0.24) mL (P = 0.044). Similarly, the mean (sd) volume of HGPIN was significantly lower in the bicalutamide-treated than in the control group, at 0.34 (0.06) vs 0.62 (0.07) mL (P = 0.003). At RP, specimen Gleason scores in the bicalutamide-treated group were similar to those in the control group, and were no different from the biopsy Gleason scores. CONCLUSIONS: Involution and epithelial shrinkage of prostate cancer and HGPIN were evident after neoadjuvant treatment with bicalutamide 150 mg. There was no evidence of the emergence of higher-grade cancer after treatment.
Abstract: OBJECTIVES: The objective of this study was to validate the Italian version of the Urogenital Distress Inventory (UDI) in a sample of women with lower urinary tract symptoms (LUTS). METHODS: The linguistic validation of the questionnaire was performed through a multistep process: backward and forward translations coordinated by clinical investigators, followed by a pretest. The final version was administered to a larger sample of female patients, aged 18 years or older who had been having LUTS for at least 3 months, numbering 53 subjects. To evaluate test-retest reliability, patients were re-rated after 1 week. To test the questionnaire's capacity to discriminate women with or without LUTS (cases and controls, respectively), a sample of 53 healthy women was enrolled. A 72-h voiding diary was used as a gold standard and compared with the UDI. RESULTS: The correlation coefficient between ratings was >or=0.80, and the discriminant power between cases and controls was confirmed. The UDI showed good internal consistency for all domains, except irritative symptoms (total score's Cronbach alpha=0.86). Factor analytic structure revealed urinary incontinence to be opposite to the other urologic symptoms, with bed wetting being loaded separately. The average daily number of urgent micturitions was higher in patients who reported they "experience a strong feeling of urgency to empty bladder" in the UDI than those ones who did not (p<0.01). CONCLUSIONS: The Italian version of the UDI is a valid and robust instrument, which can now be used reliably in daily practice and clinical research.
Abstract: OBJECTIVES: To present a pilot study of laparoscopic unilateral sural nerve grafting during radical prostatectomy, with the aim of preserving sexual potency. PATIENTS AND METHODS: Because they had localized prostate cancer, 29 men had a laparoscopic radical prostatectomy with deliberate wide unilateral neurovascular bundle resection and preservation of the contralateral bundle. Fifteen men (group A) had an interposition sural nerve graft on the sectioned bundle, and 14 (group B) had laparoscopic radical prostatectomy with preservation of the unilateral bundle only. The men were also involved in a rehabilitation programme, and erectile function was evaluated after surgery, and at 3, 8, 12 and 18 months, using the five-item version of the International Index of Erectile Function (IIEF-5) questionnaire. RESULTS: The two groups had similar clinical characteristics (age, prostate-specific antigen level, body mass index, prostate volume, clinical stage, Gleason score before and after surgery, postoperative stage). The follow-up was complete for 12 men in group A and 10 in group B. Group A had significantly higher erectile function scores on the IIEF-5 at 12 and 18 months than immediately after surgery (P < 0.01), whereas in group B the improvement was not statistically significant. Overall, by 18 months after surgery five of 12 men in group A had achieved spontaneous unassisted erection or erection assisted with sildenafil, while three of 10 in group B achieved an erection assisted with sildenafil (not significant). CONCLUSIONS: These data suggests that laparoscopic sural nerve grafting during radical prostatectomy is feasible and safe; nevertheless we cannot conclude that sural nerve grafting is more effective than preserving the neurovascular bundle alone in retaining sexual potency. More research is required to validate the effectiveness of this technique.
Abstract: The presence of neuroendocrine (NE) differentiation in the context of predominantly exocrine prostate cancer may play a key role in androgen-independent tumor growth. The prognostic significance of plasma chromogranin A (CgA) was assessed in a series of consecutive prostate cancer patients with hormone-refractory disease. One hundred and eight patients with newly diagnosed hormone-refractory prostate cancer entered the study. Plasma CgA levels and other biochemical parameters, such as serum prostate specific antigen, serum alkaline phosphatase, serum lactate dehydrogenase, serum albumin and hemoglobin concentration, were measured at baseline (i.e. when hormone refractoriness occurred) and their prognostic role was evaluated together with patient performance status, Gleason score (at diagnosis of prostate cancer) and the presence of visceral metastases. Furthermore, plasma CgA was prospectively evaluated in 50 patients undergoing chemotherapy. At baseline, 45 patients (43.3%) showed elevated CgA values. Plasma CgA negatively correlated with survival, either in univariate analysis (P=0.008) or in multivariate analysis, after adjusting for previously mentioned prognostic parameters (P<0.05). In the patient subset undergoing chemotherapy, median CgA (range) values were 13.3 (3.0-141.0) U/l at baseline, 19.1 (3.0-486.0) U/l after 3 months, 20.8 (3.0-702.0) U/l after 6 months and 39.4 (3.0-414.0) U/l after 9 months (P<0.01). The corresponding supranormal rates were 17/50 (34%), 23/50 (46%), 26/50 (52%) and 34/50 (68%) respectively (P<0.005). Elevated plasma CgA levels are frequently observed in prostate cancer patients with hormone-refractory disease and correlate with poor prognosis. NE differentiation in hormone-refractory patients is a time-dependent phenomenon and is not influenced by conventional antineoplastic treatments.
Abstract: PURPOSE: We compared the status of the peritumoral parenchyma after open and laparoscopic nephron sparing surgery for renal cell carcinoma. MATERIALS AND METHODS: The records of 64 consecutive patients who underwent nephron sparing surgery for renal cell carcinoma of 4 cm or less were reviewed retrospectively. Patients in group 1 underwent open retroperitoneal surgery (1998 to 2000) and patients in group 2 underwent laparoscopic (transperitoneal or retro peritoneal) surgery (2001 to March 2004). A single pathologist was employed to analyze the specimens, and comparative analysis included examination of tumor size, weight, histological cell type, intraoperative histological biopsies and margin status. RESULTS: The 2 groups were comparable in terms of clinical data, and mean lesion size was 31.4 mm in group 1 and 32 mm in group 2. Positive margins were found in 1 of 30 patients in group 1 and in 1 of 34 in group 2 (p = 0.9). An analysis of margins was performed by taking measurements at the minimum and maximum points of the section. The minimum mean measurement was 2 mm in group 1 and 2.08 mm in group 2 (p = 0.75). The maximum mean measurement was 4.56 mm in group 1 and 5.2 mm in group 2 (p = 0.09). The difference between minimum and maximum margin thickness was 2.56 mm in group 1 and 3.16 mm in group 2 (p = 0.04). Mean followup for group 1 was 50 months (range 30 to 72) and 16 months (range 2 to 35) for group 2. One local recurrence was recorded in group 1 and treated with radical nephrectomy, while no recurrence was recorded in group 2. CONCLUSIONS: In this study we further confirmed the efficiency of resectioning lesions using laparoscopy. In our experience there is no difference between the 2 procedures in terms of efficient surgical margins. However, despite these encouraging results it is necessary to obtain more extensive followup data, which will allow us to be more specific in reporting on laparoscopic margin quality.
Abstract: PURPOSE: To describe and demonstrate the feasibility of early ligature of the renal artery using a direct access to the renal pedicle at the level of the Treitz ligament during left transperitoneal radical laparoscopic nephrectomy. MATERIALS AND METHODS: A total of 42 patient underwent left transperitoneal radical laparoscopic nephrectomies from February 2001 to July 2004. In the first consecutive 27 patients (Group A) we performed early ligature with the standard technique; in the last consecutive 15 patients (Group B) we attempted the early ligature with direct access to the renal artery at the level of the Treitz ligament. Comparative analysis was carried out between the two groups examining operative times, blood loss, intra and post operative complications, postoperative stay. RESULTS: No difference was noted in gender, age and size of the lesions (6.2 versus 6.25 cm respectively, p = 0.9) in the two groups. In 12/15 (80%) of Group B cases we successfully identified and ligated the renal artery at the level of the Treitz ligament. In the other 3 cases (20%) we were constrained to revert to the more common laparoscopic approach. Mean Operative times were 131' in group A versus 137' in group B (p = 0.15). The time required to find the renal artery at the level of Treitz ligament in group B was 16' (15'-30'). No differences were noted between the two groups in terms of blood loss (222 cc versus 268 ml, p = 0.4), intraoperative and postoperative complications (p = 0.6), postoperative stay (5 days in the two groups, p = 0.9). Mean follow-up was average 24 months (15-48) in Group A and average 7 months (3-12) in Group B. No complications and no recurrence of disease at CT evaluation were recorded neither in Group A nor in Group B. CONCLUSIONS: Radical laparoscopic left side nephrectomy with direct access to the renal artery at the level the Treitz ligament is technically feasible and safe and reproduces the classic principles of radical nephrectomy allowing to perform the procedure without any manipulation of the tumor.
Abstract: A group of 107 patients with lower urinary tract symptoms (LUTS) from benign prostatic enlargement (BPE) participated to the HOUSE Study (Home and Office Uroflowmetry Specific Evaluation). Patients received routine investigation, consisting of medical history taking, physical examination including digital rectal examination, prostate-specific antigen (PSA), assessment of symptoms listed both on the International Prostate Symptom Score and on ICS-male questionnaire. We examined the results of uroflowmetry evaluation in this population; data were analysed to observe if any circadian changes of parameters obtained with home uroflowmetry could be detected. We searched a correlation between Q(max), Q(ave) and ICS-benign prostatic hyperplasia symptom score: a significantly inverse correlation was found only for Q(max), confirming Q(max) as a reliable parameter to quantify subjective symptoms. When examining the multiple flow curves recorded in the same patient with home uroflowmetry, voided volume and flow time had usually higher values during night-time: the existence of circadian changes of uroflowmetry parameters in patients with LUTS from BPE was confirmed, and lower values of average and maximum flow rates during sleep hours were recorded in the same patient. In conclusion, when evaluating the natural history or treatment outcome of individual patients or group of patients in clinical trials for evaluation of BPE and LUTS, an assessment including multiple measurements may be useful and of value.
Abstract: BACKGROUND: Laparoscopy is widely accepted as the gold standard for adrenalectomy. Telementoring has been developed to reduce the complications associated with surgeon inexperience. We report our preliminary experience with laparoscopic telementored adrenalectomy. METHODS: From July 2002 to May 2003, eight laparoscopic telementored adrenalectomies were performed between two separate operating sites 430 km apart. Six of these procedures were monolateral laparoscopic adrenalectomies, and one was bilateral. All cases were performed by an expert open surgeon who was skilled in laparoscopic procedure but who had no experience in laparascopic adrenalectomy RESULTS: All the procedures were successfully performed in a telementored fashion. The mean operative times, blood loss, and postoperative morbidity results were comparable to those for standard laparoscopic adrenalectomies reported in the literature. CONCLUSIONS: This preliminary experience has demonstrated the feasibility of national telementoring. It is a viable method that can potentially add to surgical education and decrease the likelihood of complications due to inexperience with new techniques.
Abstract: We describe our technique of laparoscopic diverticulectomy under ultrasound (US) guidance after a transurethral resection of prostate (TURP) in the treatment of patients with benign prostatic hyperplasia and bladder diverticulum. A standard TURP is performed with an Iglesias resectoscope. A 12-Fr Foley catheter is positioned in the diverticulum and the catheter balloon is then inflated with 30 mL of water; then a Tiemann catheter is placed through the urethra into the bladder. A US probe is inserted through the 12 mm port placed in the right side by the surgeon, then laparoscopic transperitoneal bladder diverticulectomy is performed under US guidance. In our experience, the use of endolaparoscopic US makes identification and dissection of the diverticulum easy, safe and effective, even when the procedure has to be performed in disadvantageous anatomic conditions such as lateral-posterior diverticulum or post-TURP imbibition of pelvic tissue.
Abstract: PURPOSE: We compared two techniques of early ligature of the renal artery during transperitoneal laparoscopic radical nephrectomy: a standard technique and a direct approach to the artery. PATIENTS AND METHODS: Of 100 patients undergoing transperitoneal laparoscopic radical nephrectomy at our institution, in the last 70, we used early renal-artery ligature. Of these, the standard technique after exposure of the vascular pedicle was used in 45 patients (group A), and ligature with a direct access to the renal artery was attempted in 25 patients (group B). RESULTS: No statistical differences were noted between the two groups in terms of age, lesion size, operative time, estimated blood loss, or intraoperative and postoperative complications. There were no recurrences of disease by CT evaluation in either group during follow-up (range 1-46 months). CONCLUSIONS: Transperitoneal laparoscopic radical nephrectomy with direct access to renal artery for early ligature is technically difficult but feasible and safe.
Abstract: Factors predictive of skeletal-related events (SREs) in bone metastatic prostate cancer patients with hormone-refractory disease were investigated. We evaluated the frequency of SREs in 200 hormone-refractory patients consecutively observed at our Institution and followed until death or the last follow-up. Baseline parameters were evaluated in univariate and multivariate analysis as potential predictive factors of SREs. Skeletal-related events were observed in 86 patients (43.0%), 10 of which (5.0%) occurred before the onset of hormone-refractory disease. In univariate analysis, patient performance status (P=0.002), disease extent (DE) in bone (P=0.0001), bone pain (P=0.0001), serum alkaline phosphatase (P=0.0001) and urinary N-telopeptide of type one collagen (P=0.0001) directly correlated with a greater risk to develop SREs, whereas Gleason score at diagnosis, serum PSA, Hb, serum albumin, serum calcium, types of bone lesions and duration of androgen deprivation therapy did not. Both DE in bone (hazard ratio (HR): 1.16, 95% confidence interval (CI): 1.07-1.25, P=0.000) and pain score (HR: 1.13, 95% CI: 1.06-1.20, P=0.000) were independent variables predicting for the onset of SREs in multivariate analysis. In patients with heavy tumour load in bone and great bone pain, the percentage of SREs was almost twice as high as (26 vs 52%, P<0.02) and occurred significantly earlier (P=0.000) than SREs in patients with limited DE in bone and low pain. Bone pain and DE in bone independently predict the occurrence of SREs in bone metastatic prostate cancer patients with hormone-refractory disease. These findings could help physicians in tailoring the skeletal follow-up most appropriate to individual patients and may prove useful for stratifying patients enrolled in bisphosphonate clinical trials.
Abstract: Surprisingly perhaps for a tumor where there is such clear proof of a primary hormonal basis to its development, there is emerging evidence that all elements playing a key role in prostate cancer somehow affect the host immune system. This review turns the spotlight on some previously unsuspectable aspects, able to interact with the immune system in prostate cancer patients PSA, sex hormones, inflammatory infiltrates, cytokines, growth factors, neoformed blood vessels, neurotransmitters and neurotrophins, cigarette smoking, diet, therapeutic approaches. The concept of exploiting the immune system to combat cancer is not new, but only nowadays immunotherapy is a reality. Prostate cancer is an excellent target, involved in an increasing number of clinical immunotherapeutic trials. The main current purpose is to overcome the host immune tolerance of tumor cells. The most recent progresses in gene, monoclonal antibody and vaccine therapies are reported.
Abstract: The Prostatic Specific Antigen (PSA) is one of the best tumour markers currently available, and it is widely employed in the diagnosis and follow up of prostate cancer. Nevertheless, it is not specific for prostatic carcinoma, and an increase in its serum levels can also be related to benign prostatic hyperplasia, inflammation/infection or traumatic manoeuvres on the prostatic gland. Because of its well-known clinical features acute prostatitis does not require PSA evaluation for diagnosis, but other prostatitis (such as category IV NIH prostatitis) can be responsible of an increase in PSA levels without associated symptoms. Category IV prostatitis has a fairly high prevalence, affecting about one third of the adult males. Recently some studies have showed that approximately half of the patients with PSA levels in the grey zone and without symptoms of prostatitis undergo a decrease in PSA levels after a 2-4-week treatment with antibiotics. Thanks to this approach, 20-30% of the patients obtain PSA normalization and consequently avoid prostatic biopsies. In conclusion, the use of antibiotic treatment allows an increase in PSA specificity and a decrease in the number of unnecessary prostatic biopsies. The cost-benefit ratio of this approach has to be verified by means of prospective randomized trials.
Abstract: BACKGROUND: Epirubicin (EPX) has been found to be active in hormone-refractory prostate cancer (HRPC) patients. Prolonged EPX infusion has never been investigated in this patient subset. PATIENTS AND METHODS: A feasibility study was conducted in which EPX was administered in 21-day continuous infusion to 15 patients with HRPC. The EPX dose was 5 mg/m2 daily for 21 consecutive days (one course). One week was allowed before starting the next course. RESULTS: The patients received 1 to 6 courses (median 3). As a whole, the treatment was well tolerated. Nine patients did not develop any toxicity, while WHO grade 3 and 4 toxicities were recorded in 4 patients. Alopecia (WHO grade 1-2) was presented in 4 cases. Five patients attained >50% decrease in serum prostate-specific antigen (PSA). CONCLUSION: Prolonged EPX infusion is feasible and potentially active in the treatment of HRPC patients. Our data suggest caution in administering this treatment in patients bearing rheumatologic disease.
Abstract: OBJECTIVE: We describe the original surgical technique of supra-ampullar cystectomy associated with ileal neobladder, and present our results in terms of preservation of sexual potency, urinary continence and cancer control along twenty years of experience. MATERIALS AND METHODS: Twenty-eight consecutive patients with bladder tumor-27 transitional cell carcinomas (TCC) and 1 leiomyosarcoma-underwent supra-ampullar cystectomy with ileal orthotopic neobladder (2 Camey I and 26 Camey II) between May 1984 and June 1999. The median age of the patients was 51.0 years (range 23-65). Preoperatively 24 patients had superficial high-risk TCC. Involvement of prostatic urethra was excluded by means of preoperative endoscopic biopsies. The bladder, part of the prostate with the prostatic urethra and regional lymph nodes were removed, while the vas deferens with deferential ampullae, seminal vesicles, ejaculatory ducts and the peripheral portion of the prostate were maintained. Median followup was 90.5 months (range 10-228). RESULTS: Out of 28 patients 6 died of bladder cancer (all with metastases, 2 also with local recurrence); 4 out of the 22 patients who were free of disease at followup died of other causes. Potency was preserved in 26 patients (92.8%), reporting satisfactory sexual intercourses; 15 patients (53.5%) also maintained antegrade ejaculation allowing procreation in 3 cases. In one patient the orthotopic neobladder according to Camey I was converted into an ileal conduit because of the excessive capacity of the reservoir, high post-void residual and recurrent pyelonephritis. Of the remaining 27 patients 16 showed both daytime and nighttime urinary continence (average interval between micturitions = 3 hours), 6 were continent during the day and 5 performed self-intermittent catheterization. CONCLUSION: Supra-ampullar cystectomy with detubularized ileal orthotopic neobladder allows to preserve sexual function in nearly all the cases and to maintain urinary continence in most patients, without compromising oncological outcome. The indication must be restricted to highly selected cases, without potential risk of local recurrences and concomitant prostatic carcinoma.
Abstract: PURPOSE: In a retrospective nonrandomized study, we compared our experience with transurethral resection of the prostate (TURP) plus sequential laparoscopic bladder diverticulectomy with a series of combined open bladder diverticulectomies with transvesical prostatectomy. PATIENTS AND METHODS: We considered 12 consecutive patients (group A) having 16 diverticula who underwent sequential TURP and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group B) having 13 diverticula who underwent open bladder diverticulectomy and transvesical prostatectomy. We evaluated the size and position of the diverticulum, adenoma volume, operative time, postoperative hemoglobin variations, analgesia requirement, complications, postoperative hospital stay, and uroflowmetry results. RESULTS: No statistically significant differences existed between the groups in adenoma volume or diverticulum size or position. However, a significantly longer operative time was recorded in group A. The endolaparoscopic approach proved to be statistically superior to open surgery regarding blood loss, postoperative analgesia requirement, and hospital stay. No intraoperative complications were recorded. In addition, no statistically significant difference was found in uroflowmetry results. CONCLUSIONS: In our experience, the endolaparoscopic approach has proved to be safe, effective, and minimally invasive and therefore superior to transvesical prostatectomy and open bladder diverticulectomy. Its only disadvantage is the longer operative time.
Abstract: OBJECTIVES: To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses. METHODS: Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients. RESULTS: The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O. CONCLUSIONS: The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.
Abstract: PURPOSE: We evaluate and compare the effectiveness of 2 different medical therapies during watchful waiting in patients with lower ureteral stones. MATERIALS AND METHODS: A total of 86 patients with stones less than 1 cm located in the lower ureter (juxtavesical or intramural tract) were enrolled in the study and were randomly divided into 3 groups. Group 1 (30) and 2 (28) patients received daily oral treatment of 30 mg deflazacort, (maximum 10 days). In addition group 1 patients received 30 mg nifedipine slow-release (maximum 28 days) and group 2 received 1 daily oral therapy of 0.4 mg tamsulosin (maximum 28 days), Group 3 patients (28) were used as controls. Statistical analyses were performed using Student's test, ANOVA test, chi-square test and Fisher's exact test. RESULTS: The average stone size for groups 1 to 3 was 4.7, 5.42 and 5.35 mm, respectively, which was not statistically significant. Expulsion was observed in 24 of 30 patients in group 1 (80%), 24 of 28 in group 2 (85%) and 12 of 28 in group 3 (43%). The difference in groups 1 and 2 with respect to group 3 was significant. Average expulsion time for groups 1 to 3 was 9.3, 7.7 and 12 days, respectively. A statistically significant difference was noted between groups 2 and 3. Mean sodium diclofenac dosage per patient in groups 1 to 3 was 19.5, 26, and 105 mg, respectively. A statistical significant difference was observed between groups 1 and 2 with respect to group 3. CONCLUSIONS: Medical treatments with nifedipine and tamsulosin proved to be safe and effective as demonstrated by the increased stone expulsion rate and reduced need for analgesic therapy. Moreover medical therapy, particularly in regard to tamsulosin, reduced expulsion time.
Abstract: We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.
Abstract: OBJECTIVE: To evaluate the effect of levofloxacin (LVX) oral therapy on total serum prostate specific antigen (PSA) values in patients with histological prostatitis. MATERIALS AND METHODS: All consecutive outpatients with histological evidence of chronic prostatitis, total PSA > 4 ng/ml, normal DRE and urinalysis and treated once daily with LVX 500 mg per os for 20 days were retrospectively evaluated for total serum PSA reduction. A decrease of PSA value > 5% was considered correlated with the antibiotic therapy. RESULTS: A total of 26 outpatients were evaluated (median age = 65 years). Median total serum PSA concentrations, before and after LVX therapy, were 7.1 ng/ml (range 4.1-15 ng/ml) and 5.8 ng/ml (2-15 ng/ml), respectively (p= n.s). The median reduction of total PSA was 16.6% (range 5.7 - 63.6%). A statistically significant decrease of median total PSA was observed in 15 out of 26 patients (57.6%): 7.2 ng/ml and 4.2 ng/ml before and after LVX therapy, respectively (p=0.002); the marker normalized in 7 out of 15 patients (46.7%). In all the remaining patients prostate biopsy was repeated: prostate cancer (Pca) was detected in 1 out of 8 patients with significant reduction of total PSA and in 4 out of 11 patients with no significant marker decrease. The incidence of Pca in second prostate biopsies raised from 19% (5 cases out of 26) to 26% (5 cases out of 19). CONCLUSIONS: Treatment with LVX significantly reduced PSA values in over half of the patients with asymptomatic prostatitis, elevated total PSA and normal DRE and urinalysis. This approach could be applied in the ambulatory setting in order to increase the specificity of total PSA testing, reducing the number of negative, unnecessary, prostate biopsies.
Abstract: OBJECTIVES: The prognostic role of the invasion of the urinary collecting system (UCS) by renal cell carcinoma (RCC) has not attracted a notable amount of attention. The aim of this study was to investigate incidence and prognostic value of UCS involvement in RCC. MATERIAL AND METHODS: All pathological reports of radical nephrectomies performed in two centres of urology from November 1983 to December 1999 were reviewed in order to evaluate the invasion of the UCS (calices, renal pelvis, ureter). Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of UCS invasion. The stage was determined according to the TNM 6th edition. Overall and cause-specific survival rates were evaluated. Univariate and multivariate analyses were performed. RESULTS: The evaluable specimens were 671 from the 735 examined; in 64 cases it was not possible to ascertain or to exclude UCS involvement. Invasion of the UCS was found in 59 cases (8.8%). Median follow-up was 59.0 months (range 0-216). Tumours invading the UCS were usually symptomatic, with high nuclear grade and predominantly high stage. At univariate analysis the 5 year overall and cause-specific survival rates of tumours invading the UCS were significantly lower when compared to those without UCS invasion (42.8% versus 60.8% and 45.5% versus 64.7%, respectively). When groups were stratified, according to the pT category, the 5-year cause-specific survival rate was only significantly different for the pT2 category (33.3% versus 76.9%). At the multivariate analysis TNM staging, symptoms at diagnosis and tumour grade were the only independent prognostic factors. CONCLUSION: The invasion of the UCS by RCC is unusual, particularly in small tumours. UCS involvement does not represent an independent prognostic factor. However, in organ-confined tumours (i.e. pT2) UCS involvement has an influence on the prognosis and should be taken into account when planning adjuvant treatments and follow-up.
Abstract: OBJECTIVE: To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy. PATIENTS AND METHODS: The study included patients who underwent LA from 1995 to 2002, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structures, or solitary metastasis with well-controlled primary cancer. The variables evaluated were: size of the lesion, operative duration, estimated blood loss, intraoperative complications, local, port-site and intra-abdominal recurrence, distant metastasis, and survival time. RESULTS: Fourteen malignant adrenal lesions in 205 LAs (7%) were confirmed with histological diagnoses that showed a primary ACC in six and metastasis in another seven (in one there was bilateral metastasis). The mean (sd) size of the malignant lesions was 5.9 (2.8) cm. The 12 unilateral procedures required a mean operative duration of 164 (47) min; the bilateral procedure lasted 215 min. There was one conversion to open surgery caused by local infiltration, whereas there were no intraoperative complications. The mean follow-up was 30 months, during which three patients died, one from endoperitoneal and trocar port-site seeding. CONCLUSION: When the malignancy is confined to the adrenal gland, LA seems to be a feasible option if the principles of oncological surgery are respected. Nevertheless, further investigations are required to evaluate the appropriateness of this operation.
Abstract: The motor response to vasopressin, a neuropeptide promoting the reabsorption of water, was isometrically investigated in vitro in human renal calyces and pelvis in relation to possible modulation of urinary flow by these tubular structures. Kidneys were obtained from nine male patients who underwent nephrectomy for either renal or ureteral cancer. Minor calyces and pelvis were carefully removed. Strips (10 mm x 3 mm) were cut from infundibular region of minor calyces and from renal pelvis and placed in 10 ml organ bath for isometric tension recordings. Calyceal and pelvic smooth muscle strips exhibited spontaneous phasic contractions which occurred with regular frequency and amplitude. Vasopressin induced a dose-dependent [10(-10) to 10(-6) M] enhancement of basal tone (P <0.01) and a decrease of spontaneous contractions on isolated strips from minor calyces and pelvis. The effect of vasopressin was inhibited by prior administration of D(CH2)5Tyr(Me)2-Arg8-Vasopressin antagonist [10(-7) M]. The excitatory response to vasopressin was Tetrodotoxin [TTX]-resistant and was not affected by pre-treatment with phentolamine [10(-5) M], atropine [10(-5) M], and hexamethonium [10(-5) M]. After incubation of the specimens in Ca2+-free medium containing EGTA [0.5 mM] or after treatment with nifedipine [10(-5) M], both spontaneous and vasopressin-induced contractions [10(-10) to 10(-6) M] were completely inhibited in all specimens. Our results can be interpreted to imply that the tonic contractions induced by vasopressin facilitate the reabsorption of water by increasing the hydraulic resistance of the tubular structures below collecting ducts.
Abstract: OBJECTIVE: To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC). PATIENTS AND METHODS: We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1-4; group 2, 5-8; group 3, 9-12; group 4, 13-16; and group 5, >or= 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement. RESULTS: Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1-43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P < 0.01). The rate of pN+ was significantly higher in the patients with >or= 13 than in those with < 13 nodes examined (20.8% vs 10.2%; P < 0.001). For organ-confined and locally advanced tumours there was a statistically significant difference in the pN+ rate between patients with < 13 or >or= 13 nodes examined (3.4% vs 10.5%, and 19.7% vs. 32.2%, respectively). CONCLUSIONS: The proportion of tumours classified as pN+ increased with the number of lymph nodes examined. In RCC,> 12 lymph nodes need to be assessed for optimal staging.
Abstract: The incidence of prostate cancer is remarkably increased in the last decade. This dramatic epidemiological change can be primarily attributed to the widespread use of prostate specific antigen (PSA) as a diagnostic tool. Nowadays most of the prostate cancers are detected at an early stage and the age of the patients is decreased. This has led to a significantly increase in the number of prostate cancer patients treated by radical prostatectomy. Serum determination of PSA is the standard method to monitor the disease after radical surgery, while other tests can be required only when PSA is detectable. After radical prostatectomy the mean half-life of PSA is 1.5 days and it must become undetectable to consider a patient free of disease. A value greater than 0.4 ng/ml, with an increase in two determination, indicates a recurrence of the disease. PSA is an extremely sensitive marker. In fact, in patients who underwent radical prostatectomy, the presence of detectable serum PSA levels allows to detect tumor recurrence even before any other diagnostic investigation (radiological or scintigraphical) becomes able to document it ("serological" disease). Unfortunately, increasing serum PSA levels do not reveal whether a patient is affected by local relapse or by metastases, with obvious repercussion for the therapeutic choice. Clinical examination of the patient, together with random and echoguided biopsies of the vesico-urethral anastomosis, do not reveal all cases of local recurrence. Ongoing study are evaluating other diagnostic tools in the monitoring patients after radical prostatectomy, such as the serum chromogranin A, the reverse transcriptase-polymerase chain reaction for PSA and prostate specific membrane antigen (PSMA), the Positron Emission Tomography and the immunoscintigraphy with radiolabeled monoclonal antibody directed toward the PSMA.
Abstract: In this multicentre, double-blind study, patients with LUTS/BPH were randomised to 26 weeks with finasteride 5 mg once daily (n=204) or tamsulosin 0.4 mg once daily (n=199). Double-blind treatment was continued for another 26 weeks (total treatment duration: 1 y). The primary efficacy parameter was the difference in mean change in total Symptom Problem Index (SPI) from baseline to end point at week-26 in the intention-to-treat (ITT) and per protocol (PP) populations. Tamsulosin induced a greater improvement in total SPI (-5.2 points or -37%) compared to finasteride (-4.5 points or -31%) at week-26 (P=0.055 in ITT and P=0.032 in PP). Tamsulosin improved urinary symptoms (particularly the more bothersome storage symptoms) and flow more quickly than finasteride. The difference was statistically significant for the SPI from week-1 (reduction, respectively, -2.5 vs -1.8 points, P=0.043) to week-18 and for Qmax from week-1 (increase, respectively, 2.3 vs 0.7 ml/s, P=0.0007) to week-12. Both treatments were well tolerated with a comparable incidence of adverse events, including urinary retention.
Abstract: OBJECTIVES: To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones. METHODS: This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an "adjunctive" treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group. RESULTS: Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate (P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 (P = 0.02). CONCLUSIONS: The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.
Abstract: OBJECTIVES: To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS: A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results. RESULTS: A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters. CONCLUSIONS: Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.
Abstract: OBJECTIVES: To compare our experience with transurethral resection of the prostate and sequential laparoscopic bladder diverticulectomy with a previous series of combined open bladder diverticulectomy and transvesical prostatectomy. METHODS: We compared the data of 10 consecutive patients (group 1) who underwent sequential transurethral resection of the prostate and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group 2) who underwent traditional combined open bladder diverticulectomy and transvesical prostatectomy. The following parameters were considered: size and position of the diverticulum, transrectal ultrasound adenoma volume, operative time, postoperative hemoglobin variations, analgesic requirement, complications, postoperative hospital stay, and urinary flowmetry. RESULTS: No statistically significant differences existed between the two groups either for diverticulum size (6.8 versus 7.2 cm) or diverticula position. A significant difference was observed in the operative time (247 minutes for group 1 versus 136 minutes for group 2, P <0.0001), mean postoperative hemoglobin decrease (2.6 g/dL for group 1 and 3.9 g/dL for group 2, P = 0.001), analgesic requirement (1.3 ampoules of buprenorphine cloritrate for group 1 versus 1.8 ampoules for group 2, P = 0.45), and postoperative hospital stay (3 days for group 1 versus 9.6 days for group 2, P <0.0001). No statistically significant difference was recorded for control flowmetry. No intraoperative complications were recorded for the two groups. CONCLUSIONS: In our series, sequential transurethral resection of the prostate and transperitoneal laparoscopic diverticulectomy for large diverticula proved to be a safe, effective, and minimally invasive procedure, despite the longer operative times compared with transvesical prostatectomy and open bladder diverticulectomy.
Abstract: BACKGROUND: Increased osteolysis usually accompanies sclerotic bone metastases from prostate cancer. This provides a rationale for the use of bisphosphonates to treat bone pain and prevent skeletal complications. METHODS: The fasting urinary levels of calcium, hydroxyproline (OHPRO), pyridinolines (PYD), deoxypyridinolines (DPYD), collagen cross-linked N-telopeptide (NTX) and the serum values of calcium, total alkaline phosphatase and relevant bone isoenzyme, bone gla protein (BGP), carboxy-telopeptide of type I collagen (ICTP) and parathyroid hormone (PTH) were determined at baseline and on the 15th, 30th, 60th and 90th days after single-dose (90 mg) pamidronate administration in 35 consecutive prostate cancer patients with bone metastases. These biochemical indices and serum interleukin 6 (IL-6) were also measured after four days in the last consecutive 17 cases. RESULTS: PYD, DPYD and NTX showed a significant decrease lasting four weeks (p<0.01, <0.01 and <0.001, respectively). OHPRO and ICTP did not change significantly. The NTX decline was greater than that of PYD and DPYD (maximum percent decrease: -71.3, -23.1 and -28.2, respectively). Bone formation markers and serum calcium did not change significantly. Serum PTH showed a rapid initial increase followed by a slow decrease (p<0.001). DPYD and NTX patterns did not correlate with changes in bone pain. As observed in the last 17 cases, the maximum osteolysis inhibition after pamidronate occurred on the fourth day after drug infusion. Serum IL-6 levels showed a short-lived decrease preceded by a transient rise on the fourth day. CONCLUSIONS: Pamidronate is able to induce a decrease in bone resorption without significantly influencing bone formation. The maximum decrease in bone resorption occurs very early. NTX is the most sensitive bone resorption marker in bisphosphonate therapy monitoring. Changes in IL-6 but not bone resorption markers may be useful in the prediction of symptomatic response.
Abstract: Prostate cancer is a common disease among older men. Androgen suppression by either orchiectomy or administration of luteinising hormone-releasing hormone (LHRH) analogues is the mainstay of treatment. Since the use of prostate-specific antigen (PSA) serum testing has become widespread, however, the timing of endocrine therapy has expanded considerably to include patients with limited involvement of extraprostatic sites and patients presenting an isolated elevation of PSA after radical treatments. These patients are expected to be treated for a long time, since they have a rather low risk of disease progression and there is no recommended time limit for LHRH analogue therapy. The long-term adverse effects of androgen deprivation therapy, therefore, deserve more attention than they have received in the past. Osteoporosis represents a special concern for men with prostate cancer receiving androgen deprivation therapy. The rate of bone loss in these men seems to markedly exceed that associated with menopause in women, and fractures occur more frequently than in the healthy elderly male population. Serial bone mineral density (BMD) evaluation could allow the detection of patients with prostate cancer who are at greater risk of osteoporosis and adverse skeletal events after androgen deprivation therapy, such as patients already osteopenic or osteoporotic at baseline and men with rapid bone loss during treatment. BMD evaluated during treatment could also be a potential surrogate parameter of antiosteoporotic therapeutic efficacy. Treatment of bone loss induced by androgen deprivation comprises general prevention measures, antiosteoporotic drugs and the use of alternative endocrine therapies. Optimising lifestyle and diet is important, although it cannot completely prevent bone loss. Patients with nonsevere bone disease may benefit from calcium and vitamin D supplements. Men who are osteoporotic before androgen deprivation or men becoming osteoporotic during treatment and/or experiencing adverse skeletal events may also require bisphosphonates. The effectiveness of these drugs in preventing fractures has been shown in a single randomised study involving patients with osteoporosis, but it has not yet been established in a prostatic cancer population without bone metastases given androgen deprivation therapy. Different forms of endocrine therapy such as low-dose estrogens, antiandrogens and intermittent androgen ablation are under investigation. They could offer the advantage of avoiding (or limiting) treatment-related bone loss. In our opinion, however, the data available so far are not robust enough to recommend these alternative endocrine therapies instead of standard androgen deprivation in routine clinical practice.
Abstract: We examined the results of teaching pelvic floor muscle exercises (PME) on micturition parameters, urinary incontinence, post-micturition dribbling, and quality of life in patients after transurethral prostatectomy (TURP). Fifty-eight consecutive patients who were selected to undergo TURP for benign prostatic hyperplasia (BPH) were admitted into the study: 28 were randomly assigned to a control group (A), 30 formed the investigational group (B) during an initial visit conducted before surgery. In group B patients, perineal exercises were demonstrated in detail, and tested for their correct use via simultaneous rectal and abdominal examination. After the removal of the urethral catheter, these patients were instructed to perform pelvic floor muscle exercises at home and were evaluated before the exercises and at weekly intervals postoperatively. The American Urological Association Symptom Score improved significantly after TURP in both groups. The average quality of life score improved more significantly in group B after TURP, from 5.5 to 1.5 (P < 0.001). The grade of muscle contraction strength after 4 weeks of PME increased from 2.8 to 3.8 in group B (P < 0.01); it was unchanged in the group A. The number of patients with incontinence episodes and post-micturition dribbling was significantly lower in the group B at weeks 1, 2, and 3 (P < 0.01). Our results show that pelvic floor muscle re-education produces a quicker improvement of urinary symptoms and of quality of life in patients after TURP. Its early practice reduces urinary incontinence and post-micturition dribbling in the first postoperative weeks. The exercises are simple and easy to perform in the clinical setting and at home, and therefore should be recommended to all cooperative patients after TURP.
Abstract: Patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) complain about symptoms such as weak stream, dribbling, intermittency, frequency, nocturia and urgency. To effectively manage these symptoms, it is important to better understand the epidemiology and/or the bothersomeness of these symptoms, the impact of the symptoms on the patient's quality of life and life style, when and why patients seek medical advice and the subsequent management of LUTS/BPH in clinical practice. This paper gives an overview of these issues considering 3 recently conducted European surveys. Although voiding symptoms are more frequent in patients with LUTS/BPH, storage symptoms, such as frequency, urgency, nocturia and urge incontinence, seem to be more bothersome to the patients. LUTS seem to have a negative impact on the patient's quality of life and sexuality and to interfere strongly with daily life activities. With regard to sexuality, interference with the patient's overall sex life and erection problems is experienced as much more bothersome than ejaculation problems. After the initial symptoms, most patients postpone a visit to the physician and try to adjust their life style to self manage their symptoms. Eventually they seek medical advice because they are too much bothered by their LUTS. In Italy, medical therapy is the most frequently administered treatment option by urologists (57% of patients) followed by surgery (37% of patients). alpha(1)-Adrenoceptor antagonists are the predominant medical therapy prescribed (70% of all medically treated patients), particularly tamsulosin (35% of all medically treated patients). An interview with European urologists confirms that alpha(1)-adrenoceptor antagonists, especially newer uro-selective ones like tamsulosin, are a very appropriate initial treatment choice in the management of both voiding and storage LUTS.
Abstract: OBJECTIVE: Few epidemiological studies are available on Italian patients with lower urinary tract symptoms and their QoL. QUIBUS (QUality of life Investigated in BPH patients with Urinary Symptoms) is an observational longitudinal study aimed at evaluating symptoms and QoL in a large sample of Italian patients and investigating their correlation with demographic, social and clinical characteristics of BPH. PATIENTS AND METHODS: Patients with lower urinary tract symptoms and prostate enlargement suggestive of BPH (both old and new diagnosis) were enrolled between November 1998 and May 1999 in 31 Italian centers of urology. This longitudinal investigation consists of an enrollment visit, in which demographic, social and clinical aspects are recorded as baseline data, and a follow-up visit after 1 year of treatment freely assigned by the investigators. Symptoms and QoL are assessed by means of IPSS, ICS-BPH (at both visits) and SF-36 (only at the follow-up visit) questionnaires. RESULTS: 1,033 patients were enrolled. The follow-up visit is still under evaluation. In this series of papers the baseline results are presented and discussed in terms of (i) medical management, (ii) life-style, (iii) symptoms, bothersomeness and QoL, (iv) sexual function of a large and representative sample of Italian patients and (v) uroflowmetry.
Abstract: OBJECTIVE: We intended to ascertain the true role played by large-size prostatic glands with BPH in impeding ureteroscopy; since no such impediment was experienced by the authors, we then listed the most frequent obstacles to ureteroscopy, contrary to what is commonly reported in literature. MATERIALS AND METHODS: Endourological reports on a series of 2,147 diagnostic or therapeutic ureteroscopies were examined, together with the patients' clinical records. Male patients accounted for 1,288 cases. In 45 cases, the operators found the prostate so enlarged as to be worthy of note. In 9 of these cases, the procedure was performed bilaterally; thus, a total of 54 ureteroscopies was undertaken in patients with enlarged prostates or large median lobes. RESULTS: None of the surgical reports indicated that the ureteroscopic procedure was hindered by an enlarged prostate. On the other hand, the most frequent causes preventing ureteroscopy are, for both male and female patients, some types of tumor: uterine, ovarian, ureteral, bowel, bladder and prostate cancer, and inflammation. CONCLUSIONS: Benign prostatic hypertrophy (BPH) is not of itself an impediment to ureteroscopy when it is performed by an expert operator equipped with suitable instruments. On the other hand, tumours of the female reproductive system, as well as bladder and prostate tumours and serious inflammations and infections may make the procedure impossible or cause serious problems during its performance, at times requiring combined antegrade and retrograde maneuverings. At the root of this obstacle lies neoplastic or inflammatory infiltration and stiffening which attaches itself to the organs and hardens their connections. In the case of BPH, we do not find infiltration, but only a dislocation, which can be compensated by means of a few technical stratagems. Some interesting expedients in the incannulation of difficult meatuses were already suggested in 1914 by Heitz-Boyer and Marion.
Abstract: The contractile behaviour and effects of several autonomic drugs on the motor activity of human isolated ejaculatory ducts were investigated. Ejaculatory ducts exhibited spontaneous contractions characterised by an amplitude of 2.35 +/- 0.28 mN, a duration of 62. 9 +/- 3.72 s and a frequency of 0.64 +/- 0.014 waves min-1. Acetylcholine (10-5-10-4 m) induced a slight increase in basal tone and in the frequency of the contraction waves. These effects were suppressed by atropine (10-4 m). Noradrenaline (norepinephrine) increased the basal tone and frequency of spontaneous contractions in a dose-dependent manner. These responses were competitively inhibited by HEAT, a selective a1-adrenoceptor antagonist. These preliminary functional findings, indicating the presence of spontaneous motor activity of human ejaculatory ducts and its possible control by adrenergic agonists, suggests a physiological role for human ejaculatory duct in the propulsion of semen from the seminal vesicle towards the urethra.
Abstract: OBJECTIVE: To report on the experience obtained in the treatment of a series of 150 cases of ureteral stone disease by means of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser. METHODS: One hundred and fifty consecutive cases treated by means of Ho:YAG laser ureterolithotripsy have been reviewed in order to assess the results. In 81 cases the stones were located in the lower third, in 47 in the medium third, and in 22 cases in the upper third of the ureter. The laser was set at a power of 8-10 W and at a frequency of between 6 and 10 Hz. Thin ureteroscopes were selected, such as the 7-Fr Gautier or the new ultrathin 4.8-Fr Wolf instrument. In some cases other ureteroscopes were chosen. RESULTS: Lasertripsy was effective in every kind of stone, allowing fragmentation into portions measuring at most 4 mm (largest diameter) or disintegration. The clearance rate of the stones was 92.6% during the 30-day follow-up period. Calcium dihydrate stones were of course more easily broken than monohydrate ones. No damage to the ureter was observed following the vaporization which is produced by this kind of laser, since particular attention was paid to avoid any contact between the laser beam and the ureteral mucosa. In some instances ureteroscopic maneuvering provoked some slight lacerations. In a few cases accidental contact of the laser beam with the ureteral mucosa produced extremely small coagulations of no immediate or postoperative relevance. CONCLUSIONS: The Ho:YAG laser constitutes an effective instrument for the fragmentation of any kind of ureteral stone; it allows the use of thin or ultrathin instruments and, if manipulated with care, does not damage the ureteral mucosa or the ureteral wall.
Abstract: This article examines the technical modalities or ureteral catheterization. The authors also discuss unconventional modalities which, if used without prejudice, can sometimes constitute brilliant and economic solutions to complex problems which are often impossible to resolve otherwise. After a summary of the history of ureteral catheterization, the authors present the main indications for temporary ureteral catheterization: radiographic and fluoroscopic examination of the ureter; separate cytological harvesting; separate bacteriological harvesting; confirmation of the side of unilateral haematuria; preliminary temporary dilatation of the ureter to prepare it for ureteroscopy; temporary drainage of the excretory tract after endourological investigation. The authors also present particular situations may be observed temporary catheterization, or even permanent stenting, for example in the case of procedures in children, pregnant women and renal transplant recipients.
Abstract: This prospective study was carried out to evaluate the morbidity and complication rate of invasive urodynamics of the lower urinary tract after receiving oral antibiotic prophylactic treatment. A total of 105 patients, 55 men and 50 women, were included in the study and underwent pressure flow study (PFS) as part of the diagnostic assessment. Clinical diagnosis was prostatic obstruction from benign prostatic hyperplasia (BPH) in men and stress urinary incontinence or voiding dysfunction in women. Urine was screened for infection both before and after testing, and the incidence of urinary tract infections (UTI), dysuria, and other complications were assessed at 1-week follow-up to evaluate post-investigation morbidity. Dysuria of mild degree was experienced by 33% of patients, with no significant difference between male and female patients. Post-investigational UTI and fever were reported in 3.6% of men and 4% of women. Six patients had macroscopic hematuria of mild degree. No patient had urinary retention or severe complaints after the investigation and no patient required hospitalization. Post-void residual volume was higher in men with BPH obstruction compared to women; a significant difference between post-investigational UTI and residual volume could not be demonstrated (P = 0.8). We conclude that the objective morbidity rate of invasive urodynamic investigation is low. Mild dysuria is common, while severe complications, fever, and hematuria are seldom reported, and the risk of developing UTIs is low with antibiotic prophylaxis, with no significant difference between men and women. Neurourol. Urodynam. 18:647-652, 1999.
Abstract: We examined the urodynamics, particularly voiding dysfunction, in patients with a neobladder. Free uroflowmetry, pressure-flow study, and voiding cystourethrography were performed in 22 patients (mean age 65 years) at a mean of 21 months after ileal neobladder substitution. The results of free uroflowmetry were used to divide patients into two groups: the good voiders and the poor. Daytime continence was achieved in all patients, while 10 (45%) had nighttime continence. To void 250 ml urine the good voiders strained 2 +/- 1.5 times, and the poor voiders 6 +/- 5 times. The neobladder neck was at the most caudal portion of the reservoir in good voiders, and there was wide funneling. In the group with poor emptying ability, the outlet was not located at the most dependent position. The principal factors for ensuring good voiding function in neobladder patients are the ability to perform effective straining and the location of the neobladder neck.
Abstract: We studied the obstruction-relieving capabilities of transurethral electrovaporization of the prostate (TVP) in 32 symptomatic patients with benign prostatic hyperplasia (BPH). Urodynamic studies with pressure-flow analysis were performed before and 6 months after treatment. All 32 patients showed significant improvement of both subjective and objective obstruction parameters. There were few postoperative irritative symptoms and one patient required recatheterization. In conclusion, TVP is a promising modification of performing transurethral resection of the prostate, and it is indeed capable of relieving bladder outflow obstruction.
Abstract: OBJECTIVE: The aim of our study was to analyze the effect of gynecological dysfunction on voiding symptoms in women. METHODS: A modified AUA symptom index questionnaire was self-administered and an ambulatory home uroflowmetry was performed, using a specially designed home uroflowmetry apparatus for multiple flow measurements. Urinary symptoms and home uroflowmetry (Home Urodata TM System) were evaluated in 68 women: 34 patients with gynecological dysfunction, and 34 normal controls. A total of 156 urination episodes was recorded, with a mean of 5.4 measurements per patient. RESULTS: Symptom index showed lower values in the group of normal controls than in the group with gynecological dysfunction. Voided volume, peak flow rate and average flow rate were all significantly better in the group of normal controls than in the group with gynecological disorders; the most remarkable changes were observed in patients with genital prolapse and with large uterine fibroma. In both groups the total urine volume was lower between midnight and 8 a.m. (2460 ml), if compared with the total urine volume between 8 a.m. and 4 p.m. (3360 ml) and the total urine volume between 4 p.m. and midnight (3072 ml) (p < 0.05). CONCLUSIONS: Noninvasive home uroflowmetry combines the information of a typical flowchart with uroflow parameters and supplies the physician with multiple consecutive voiding episodes, minimizing the environmental artifacts of the study. In our experience it was found to be useful to evaluate urinary symptoms reported by 18/34 patients (52.9%) with gynecological dysfunction. It can help to select which patients require further urodynamic investigation to improve the diagnostic accuracy and choose the correct treatment.
Abstract: The ureteroscopic treatment of acute postoperative ureteral obstruction in a kidney transplant patient is presented. This approach was made possible by the use of thin instruments, which do not require predilation, and was chosen in place of antegrade nephrostomy or open surgical access. The concept that the ureteroscope must be adapted to the ureter and its characteristics and not vice versa is stressed. The increasingly widespread availability and use of thin and ultrathin ureteroscopes will ensure that this approach is likely to become the rule rather than the exception in the future.
Abstract: The lower urinary tract is affected by multiple sclerosis in many patients. We screened urologically and neurologically 120 patients with a confirmed diagnosis of multiple sclerosis. The mean age was 42 years (range 22 to 69 years). Urodynamic investigation as well as neuro-urophysiological investigations were performed in all patients. Renal ultrasound was used to study morphology, and excretory urogram (IVU) was used to assess renal function and the upper urinary tracts in 105 patients. Obstructive symptoms were found more commonly than irritative symptoms. The urinary symptoms were found to be related to disease duration and not to disability status. Urodynamic abnormalities were statistically significantly related to disease duration (X2 = 38.51; P = 0.0001), and to the disability status (X2 = 76.70; P = 0.0001). Few patients, only 3.3%, had upper urinary tract dilatation. With medical management, hydronephrosis disappeared in all of the patients and did not recur. A combination of oral pharmacological agents and clean intermittent catheterization was used in the majority of the patients. We conclude that lower urodynamic abnormalities can be present in every patient with multiple sclerosis, and appear to be related to disease duration and disability status, thus early treatment based upon urodynamic evaluation and close follow-up can reduce morbidity and improve the quality of life.
Abstract: We report on a 50-year-old woman first treated by us in 1990 for uroseptic fever. Urography showed occlusion of the terminal tract of the lower third of the left ureter. The patient was submitted to successful left ureteroneocystostomy (UNCS). Three months later, she had a relapse of uroseptic fever, and urography showed right ingravescent dilation and excellent functional activity of the left urinary tract. Right UNCS was performed. A further relapse on the right side was again treated with UNCS and psoas-hitch bladder, but both the dilation and the occlusion persisted. Considering the state of the patient, and in order to remove the right nephrostomy that had been applied in the meantime, and to reduce the state of inflammation in view of further surgery, it was decided to treat the right ureteral total stenosis with ureteroscopic resection through the ureter facilitated by an other luminous flexible ureteroscope inserted upstream via nephrostomy. This technique is based on concepts searching for stenotic ureteral zones in transplanted kidneys, with the help of an adequate luminous catheter. An X-ray follow-up 9 months later evidenced that the maneuver was totally successful.
Abstract: Interstitial cystitis is a chronic benign disease of the bladder that causes bothersome and debilitating symptoms and mainly affects women. Since interstitial cystitis (IC) might result from a defective glycosaminoglycan layer of the bladder epithelium, we conducted a trial of hyaluronic acid (HA), used intravesically, to test its activity in the treatment of this disease. A total of 10 patients with typical findings of IC were included. Following bladder catheterisation, the patients received a dose of 40 mg, weekly for 6 weeks, and then monthly. Response to therapy was evaluated by comparing the pre-treatment and post-treatment symptom scores and voiding diaries. There was a 30% positive response rate at week 6, which was maintained until week 24. No significant local or general side-effects were noted during the course of treatment. Although we recorded a low incidence of success in our group of patients, the results of our limited study were satisfactory in the group of responsive patients (30%), who had no relapses during the observation period of 6 months. The intravesical administration of HA was well tolerated in all cases.
Abstract: The 5-year follow-up of the implantation of a UroLume double urethral stent in 2 patients with recurrent, post-traumatic urethral strictures is presented. The double implantation for each patient was done by the long extension of the urethral lesion. Only 1 patient presented a single phosphatic concretion in the implantation area during the extended follow-up. Urinary flow rates remained absolutely normal. Sexual life was unaffected. This simple modification of the UroLume implantation may offer effective treatment for extended and recurrent posterior urethral strictures in young sexually active men, for almost 5 years without early or delayed complications of clinical relevance.
Abstract: PURPOSE: There is still excessive debate as to the preferred diagnostic and therapeutic approach to urolithiasis in pregnancy. We report our experience with 15 pregnant patients with renoureteral colic marked by pain not responsive to analgesia, dilatation and fever. We focused on the usefulness of ureteroscopy with thin instruments and ultrasound in the diagnosis and treatment of ureteral stone and ureteral colic during pregnancy. MATERIALS AND METHODS: Between 1990 and 1993 we performed ureteroscopy and ureterolithotripsy on 15 pregnant patients 16 to 30 years old. Gestation time ranged from 20 to 34 weeks. All patients underwent ureteroscopy with thin rigid 7.0F or 9.5F ureteroscopes without dilation of the ureteral meatus. The use of ionizing radiation was avoided before, during and after the procedures. A stone was extracted from the lower third of the ureter in 2 cases, displaced into the kidney from the middle third of the ureter in 3, and fragmented with the pulsed dye laser in 3, the holmium:YAG laser in 3 and the ballistic lithotriptor in 2. Finally absence of ureteral calculi was confirmed in 2 cases. A double pigtail ureteral catheter was placed via echographic guidance in 14 cases to monitor curling of the pigtail in the renal pelvis, while in 1 a cylindrical ureteral catheter was used. In 5 cases no anesthesia was necessary, while 10 required neuroleptic analgesia. RESULTS: There were no complications after the procedure. All pregnancies were full term. CONCLUSIONS: Rigid ureteroscopy may be performed on the entire urinary tract even during advanced pregnancy. Stones may be fragmented, extracted or displaced and double pigtail ureteral catheters may be applied with only sonographic guidance, at times without use of anesthesia. The use of small instruments, such as the Gautier ureteroscope, that do not require dilation or any particular manipulation of the ureteral meatus seems to be essential together with an accurate ureteroscopic technique. In this manner it is possible to diagnose and treat ureteral calculi during pregnancy without resorting to ionizing radiation but using only ultrasound monitoring and ureteroscopy.
Abstract: OBJECTIVE AND METHODS: We analyzed preoperative and postoperative urodynamic parameters in 26 patients who underwent transurethral prostatic resection with the aid of a computer program. The parameters URA, W and Wmax were evaluated: URA affords a monitoring of the removal of obstruction, while Wmax and W function monitor changes in detrusor contractility, which appear significant after prostatic resection in obstructed patients. RESULTS: Many patients had a fading contraction, that is detrusor contractility decreased during micturition: in most of them the removal of obstruction restored this pattern to normal. CONCLUSION: Evaluation of these parameters is recommended for preoperative assessment and postoperative follow-up.
Abstract: We report on a 16-year old patient with a neuropathic bladder secondary to Behçet's disease, which is an uncommon vasculitis usually involving venules. The genitourinary manifestations of this disease are discussed, a neuropathic bladder being a rare complication of the involvement of the nervous system. Urodynamic assessment is important when voiding dysfunction is present; three patients previously reported revealed a bladder function changing from normal detrusor to overactivity. Our patient showed early and severe involvement of the nervous system, and detrusor areflexia two years after the onset of the disease. Spontaneous voiding was restored two months after urological management (intermittent catheterization) was started.
Abstract: OBJECTIVES. The pediatric application of ureteroscopy was initially hindered by the size of the instruments and the fear of damaging the urethra and ureterovesical junction during endoscopic maneuvers. This review of our experience is focused on the usefulness of thin and ultrathin ureteroscopes such as the 7 F Gautier rigid ureteroscope with rod lens optics (Wolf) or the new, ultrathin 4.8 F Wolf ureteroscope, semirigid, fiberoptic, in conjunction with atraumatic sources of energy such as pulsed dye laser or ballistic lithotripter, for the treatment of ureteral stones in children. METHODS. Between 1989 and 1994, we performed ureteroscopy and ureterolithotripsy on 7 children less than 10 years old. There were 6 male patients and 1 female patient, with a mean age of 6 years (range, 3.5 to 10). We used the pulsed dye laser Pulsolith and the ballistic lithotripter Lithoclast, the Gautier (Wolf) rigid, rod lens ureteroscope (7 F), without the sheath or the blunt needle 4.8 F semirigid (Wolf), fiberoptic ureteroscope. In all cases a double pigtail ureteral catheter was left in situ. RESULTS. In all 7 cases, the treatment was successful without early or delayed complications. In particular, no case of vesicoureteral reflux was observed in any of the children during subsequent follow-ups. CONCLUSIONS. This article demonstrates the feasibility of ureteroscopy and ureterolithotripsy in children less than 10 years old with ureteral stones. We believe that because of the fragility of the ureter in the pediatric age group, ureteroscopic maneuvers should be performed and handled by experienced endourologists in well-equipped centers.
Abstract: Our study describes the results obtained in 44 patients with benign prostatic hyperplasia (BPH) who underwent transurethral microwave thermotherapy (TUMT) and their follow-up at 12 months. Prostatron, a prostatic TUMT device which comprised a microwave heat generator and a cooling system, was used at our centre. Forty-four out of the 60 patients given the treatment had a 12-month follow-up to be evaluated. The evaluation of subjective symptoms, according to the Boyarsky symptom score, demonstrated a significant rate of response (p < 0.0005). The analysis of pressure-flow recordings demonstrated a reduction of mean detrusor opening pressure (p < 0.0005), a reduction of detrusor pressure at maximum flow 12 months after treatment (p < 0.0005) and an improvement of mean values of maximum flow after treatment (p < 0.0005). This study shows that TUMT, though it cannot be considered an alternative to surgical or endoscopic therapy of BPH for severely obstructed patients, can produce improvement of both subjective and objective parameters of mild prostatic bladder outflow obstruction.
Abstract: The study included 18 men, submitted to urodynamic investigation 9-18 months after cystoprostatectomy for bladder cancer and bladder substitution with a detubularized ileal segment as described by Studer-Zingg. Sixteen patients were continent by day and 3 were incontinent during the night so as to require the use of a condom catheter. The residual urine was over 100 ml in 3 patients, while it was low or absent in the remainder. Micturition was performed by straining, and maximal flow rates were normal, although the pattern was intermittent. The incidence of nocturnal incontinence was 55.5%. Measurement of the urethral pressure profile revealed a shortened functional length, and low pressure was found in 3 patients, with a maximum urethral closure pressure < 45 cm H2O. During extramural ambulatory urodynamic monitoring, pressure values in the neobladder usually ranged below 20 cm H2O and exceeded 34 cm H2O in only 2 patients who complained of daytime and nocturnal incontinence. The urodynamic features of the neobladder in patients who underwent radical cystoprostatectomy and bladder replacement with a detubularized ileal segment indicate low pressure at high-level filling.
Abstract: 62 specimens of cystic fluid drawn back by ultrasound guided needle-aspiration in 37 males and 25 females were evaluated biochemical analysis including magnesium, calcium, phosphorus, chloride, uric acid, total protein, sugar, urea, creatinine, sodium, potassium, total cholesterol, AST, ALT, ALP, ACP, PAP, alpha-amilasys. In our study Cl, Na and sugar showed similar concentrations in the two fluids. Uric acid, and urea were more concentrated in the cystic fluid while Mg, Ca and total protein were more pronounced in the blood. The results obtained seem to indicate that simple renal cyst could originate from glomerular proximal tubulus part of the nephron as consequence of an obstructive cause.
Abstract: Pulsed dye laser lithotripsy represents nowadays a new approach to ureteral stones. 27 patients were treated with a pulsed dye laser unit (Pulsolith TM) at our department from november 1989 to january 1990. 21 had a single stone and the remaining a multiple ureteral lithiasis. The pulsed dye laser operated at a wave length of 504 nm, energy ranged between 90 and 160 mj with pulse of 1,5 ms. A 320 theta diameter quartz fiber with Helium Neon red laser (to visualize the top of the fiber) introduced in a rigid 9.5 ureteroscope (Wolf) was used during the procedure. Spinal, peridural or general anesthesia was done in all patients and the time of the procedure ranged between 8-150 minutes. Fiber was inserted in a 4 Ch ureteral catheter which provided easier manipulation of the fiber. Complete fragmentation was achieved in 88.9% of the patients, and combined manoeuvres were requested in another 3.7%. Failures were 7.4%. Minimal lesions of the ureter, due to ureteroscope advancement subsided spontaneously after placement of double F catheter. Pulsed dye laser lithotripsy seems to be a safe and useful procedure for treatment of impacted ureteral calculi and seems to offer low morbidity in respect of ultrasonic or electrohydraulic procedures especially when the stone location does not permit an ESWL approach.
Abstract: In this study we evaluated the effects induced by the administration of a natural oligomineral water "Funtana Piscamo" di San Leonardo di Siete Fuentes on patient with urinary stone disease. Urine from 30 stone formers attending our metabolic stone clinic were compared with freshly voided urine of 20 normal volunteers. A marked increase in urinary magnesium (p less than 0.001) and a change in the urinary Ca/Mg ratio (p less than 0.005) were the most striking features disclosed in patients with stone disease. This natural oligomineral water drawn from "Funtana Piscamu di San Leonardo di Siete Fuentes" seems to have a long-term efficacy in urinary stone prevention.
Abstract: 42 patients with advanced renal cell carcinoma were treated with a combination therapy with interferon alpha 2a (mean dosage 16 x 10(6) U i.m. 3 times/week) and vinblastine (0.1 mg/Kg every 21 days). 12 patients (28.5%) had a positive response. Of them 1 presented a complete response (2.38%), 5 a partial response (11.9%) and 6 a stable disease (14.2%). No significant side effects were observed apart from the flu-like syndrome (all patients) and a moderate leukopenia (45.2%). The median duration of responses was 10+ months (range 3-37 months). At 4-year follow-up the median survival time was 16.0 months (range 4-37 months).
Abstract: This study evaluates the sleep-related erections in 5 patients with locally advanced prostate cancer (T3NOMO) during 6 months treatment with Casodex by multinight continuous monitoring of penile tumescence and rigidity. Mean serum LH, Testosterone and Estradiol levels shown a no statistically significant increase at the six months control. We found no significant modifications in the number of NPT episodes, maximum penile circumference and rigidity time before and after therapy. Penile arterial flow and neurologic examination were also unmodified. All patients had a stable disease and unchanged performance status after 6 months. This pure antiandrogen in a men with prostate cancer does not seem to interfere with self reported libido and erectile capability.
Abstract: Several different medical strategies have been proposed for the treatment of advanced prostatic cancer: androgen withdrawal by surgical castration on indirect suppression of androgen production by estrogen or estrogen-like substances, antiandrogen compounds or LH-RH analogues. The Authors evaluated in detail tolerability and efficacy of a combination therapy of a LHRH analogue (Buserelin) and a pure antiandrogen (Nilutamide) in a group of 15 patients with advanced prostate cancer (stage D) followed over a period of six months.
Abstract: Erythrocyte, serum and urine ferritin concentrations were evaluated in 20 patients suffering from transitional cell carcinoma of the urinary bladder and in 20 healthy men. No clinical or biochemical signs of liver disorders, chronic inflammatory states or infections were present in both the patients and the controls. Our results showed no significant difference in the erythrocyte ferritin concentration in both groups. On the contrary there was a statistically significant difference in mean serum (p less than 0.05) and urine (p less than 0.01) ferritin concentration between the two groups. The mean serum ferritin concentration in the patients was 102.23 +/- 63.38 ng/ml while it was 258.41 + 250.68 ng/ml in normal subjects. The mean urine ferritin concentration was 6.30 +/- 5.35 ng/ml in normal subjects and 22.66 +/- 25.59 ng/ml in patients with bladder cancer. Our data seem to demonstrate that the assessment of the ferritin either in the serum or preferably, in the urine, could become an interesting tumoral marker for bladder cancer.
Abstract: Thirty adults of either sex, in several cases affected by severe urinary pathology, underwent check cystoscopy. An intramuscular injection of netilmicin 200 mg was administered one hour before the diagnostic procedure as antibiotic prophylaxis. Treated patients were controlled up to three months after cystoscopy, in order to verify the presence of urinary infections. Data obtained proved the efficacy of netilmicin in preventing postcystoscopy urinary infections in 87% of the cases. Safety was very good in all patients.
Abstract: In this work we have examined the results obtained from the chemical analysis of 1447 urinary stones. The data concerning the frequency are distinguished according to the sex. Then we examined the difference between frequency of pure and mixed calculi in a sample, analyzing the results obtained by a subdivision in two periods of five years each. Our data are compared with those obtained in other regions of our country.
Abstract: Cytogenetic study of 30 bladder carcinomas confirmed the heterogeneity and the complexity of the karyotypic picture in this type of tumor. Presence of numerical and/or structural chromosome aberrations was observed in all tumors. Clonal abnormalities were found in 19 cases. Chromosomes most frequently involved in changes were chromosome #1, #3 and #11(36.6%, 26.6%, and 20% of the cases respectively). Trisomy 7 and monosomy 9 were the sole abnormalities in one case each.
Abstract: The effect of short term administration of flutamide on the hypothalamic-pituitary-gonadal axis was studied in six patients with advanced prostate cancer (C2 stage). Flutamide significantly increased LH pulse frequency in all patients (p less than 0.05 by Wilcoxon's test). The FSH pulse analysis disclosed a similar pattern of LH. Plasma IC-T clearly increased following flutamide therapy; mean IC-T values were 2.67 +/- 0.47 ng./ml. and 4.67 +/- 0.62 ng./ml. before and after flutamide administration, respectively (p less than 0.05 by paired Student's t test). Our study demonstrates that flutamide acts in humans as a selective and specific antiandrogen compound.
Abstract: The effect of flutamide on basal and ACTH-stimulated plasma levels of adrenal androgens was investigated in 6 patients with untreated advanced prostate cancer, aged 52-75 yr. Flutamide was administered (250 mg three times daily) for 10 days; before and after treatment, a synthetic ACTH1-24 stimulation test (250 micrograms im, with blood sampling immediately before and 60 min after the stimulus) was performed. Basal plasma 17OH-pregnenolone (delta 5-17OHP), 170H-progesterone (delta 4-17OHP), androstenedione (A), dehydroepiandrosterone (DHEA) and its sulphate (DHEAS) were unchanged by flutamide treatment. In contrast, basal plasma testosterone (T) concentrations significantly increased (p less than 0.05). The response of cortisol delta 4-17OHP, delta 5-17OHP, A and DHEA to ACTH, as well as the ACTH-stimulated delta 5-17OHP/delta 4-17OHP, delta 5-17OHP/DHEA, delta 4-17OHP/A and DHEA/A ratios, were unchanged by flutamide treatment. These findings indicate that: a) Short-term flutamide administration enhances testicular steroidogenesis, via augmented LH pulse frequency; b) Adrenal steroidogenesis seems to be not affected by the drug, since ACTH-stimulated plasma levels of adrenal androgens and precursors/products ratios were unchanged.
Abstract: A multidisciplinary diagnostic approach to a case of bladder carcinoma in a 19-year-old male smoker is presented. The transitional cell carcinoma was submitted to conventional histological examination, flow cytometry and cytogenetic analysis. Serum and urine tumour markers were also investigated. The tumour was diploid, with an increased proliferative phase, and a chromosome marker was found. A net decrease in serum and urine ferritin concentrations was noted after transurethral resection of the neoplasm and its low malignancy was confirmed at follow-up.
Abstract: The presence of nonrandom chromosomal defects has been reported in a number of leukemias, lymphomas, and solid tumors. Primary karyotypic changes have been described in bladder carcinoma. We report the finding of chromosomal derivative markers 11 in three cases of bladder cancer. These markers were observed in all interpretable metaphases obtained by a direct method. The involvement of the short arm of chromosome 11 in the carcinogenetic process is discussed.
Abstract: In order to clarify the effects of androgen blockade on the hypothalamic-pituitary-testicular axis in man, four patients with advanced prostate cancer, not previously treated, were given oral flutamide, 250 mg three times daily for 9 days. Before, and 7, 8 and 9 days after starting flutamide treatment, on separate days, the following tests were performed: a gonadotrophin pulsatility study, with 20 min interval blood sampling for 12 h, a naloxone test and a GnRH test. Flutamide induced a significant increase in both LH and FSH pulse frequency, while pulse amplitudes and plasma integrated concentrations (IC) of LH and FSH were unaffected. Plasma integrated concentrations of testosterone and oestradiol rose significantly, while that of prolactin was unaffected. The increase in plasma LH concentration induced by naloxone injection was abolished by flutamide treatment. On the other hand, the small FSH response to naloxone was unaffected by flutamide treatment. Response to GnRH was unaffected by flutamide. These results suggest that flutamide exerts effective androgen blockade at the hypothalamic level, since, despite increased plasma testosterone concentrations, gonadotrophin pulse frequency increased and the LH response to naloxone was abolished.
Abstract: Sequential staining with Giemsa and quinacrine mustard on direct cytogenetic preparations was employed to characterize the karyotype of five bladder tumors of different stage and grade (TNM classification). The use of QFQ-banding allowed: the characterization of 2 euploid and 1 pseudodiploid cases, and the identification, in the two hyperdiploid cases, of a number of rearranged chromosomes otherwise morphologically indistinguishable from the normal ones. The importance of banding technique on direct cytogenetic preparations is stressed.
Abstract: Cytogenetic studies on bladder carcinomas from two patients were carried out on preparations obtained by a direct method. The chromosome mode was 49 and 55, respectively. Several karyotypic changes were found in the tumors. Moreover, the analysis of Q-banded chromosomes revealed the presence in both cases of a chromosome 11p+. These rearranged chromosomes showed a very similar banding pattern. The finding of a der(11) chromosome marker in two patients is intriguing, and suggests the possibility of nonrandom chromosome changes in bladder carcinoma, as already found in other kinds of tumors. The occurrence of chromosome #11 aberrations in tumors of the urinary tract is discussed in connection with the current theories on oncogenesis.
