The Use of Extracorporeal Shock Wave Lithotripsy (Eswl) in Solitary Kidney Our Experience

Additional endourologic procedures before ESWL remain controversial for patients with lithiasis in solitary kidneys. The authors report their experience on 31 patients treated with a Dornier MFL 5000 lithotriptor. They conclude that if there is no ureteral obstruction prior to ESWL, the majority of patients with stone size smaller than 20 mm do not need pre or post operation manipulation.

Prostate Cancer: Pathological Significance in 12 Cases Subjected to Radical Prostatectomy

We analysed 12 radical prostatectomy specimens of patients with T1c prostatic cancer in order to evaluate clinical, bioptical and pathological features. Of the tumours, 8/12 (67%) were locally advanced, with Gleason score of 6 or 7. The majority of our stage T1c tumours were significant and required radical treatment.

[Conservative therapy of renal parenchymal neoplasia]

We review our overall experience in 1375 patients, who underwent surgery for renal cell carcinoma in the Departments of Urology of Brescia and Bergamo from 1983 to 1996. 185 (13.4%) patients had nephron-sparing surgery: imperative procedure was performed in 74 cases, while an elective surgery was done in 111 patients. Three years minimal follow up was considered in order to evaluate the outcome of surgical treatment in 48 patients who underwent imperative nephron-sparing surgery and in 73 with an elective procedure. Disease specific survival was 80.8% in the first group and it was 97% in the latter.

[Conservative surgery of parenchymal renal carcinoma: urologic data from Lombardy]

We report the results of a questionnaire sent to various Urology departments in Lombardy about "Conservative Surgery in Renal Cell Carcinoma" which was the subject of discussion at the 50th meeting of the Lombardian Society of Urologist. 23 centres out of 34 i.e. 68% answered. 100% of the departments performed nephron sparing surgery, 91% in cases of imperative and elective indication and 9% only in imperative indication. 100% of the patients underwent preoperative staging with ultrasound and computer tomography. 48% treated in elective surgery only incidentally asintomatic discovered tumours, but 52% treated both incidentally and sintomatic ones. Elective surgery is suggested when the tumor has a diameter less than or up to 3 cm., from 3 to 5 cm., and more than 5 cm. in 48%, 48% and 4% of the urological departments respectively. 70% consider the importance of tumor location and do not perform partial nephrectomy when the tumor is intraparenchymal or in contact with the secretory tract. From a technical point of view 82% carried out partial nephrectomies while 18% carried out enucleation; 57% performed routinally frozen section on tumor bed and 61% do not performed lymphadenectomy. 83% believe in the multifocality problem. A macroscopic and microscopic haematuria does not condition the elective indication in 62% of the urology departments. The follow-up is carried out with ultrasonography alternated with CT in 78% of the departments and is continued for over 5 years in a likewise 52%. From 1990 to 1995, 3332 patients were surgically treated for renal cell carcinoma in 23 urology departments; 487 (14.6%) underwent nephron sparing surgery; 320 elective and 167 imperative indication. The local global relapse was 2.9% (14/487); 5.3% (9/167) in imperative group and 1.4% (5/320) in elective group. Conservative surgery in Lombardy will always try to have the golden standard treatment in the incidental, single renal cell carcinoma.

Management of ureteral calculi and DRG

Extracorporeal shock wave lithotripsy (ESWL) and ureterolithotripsy (ULT) have dramatically changed the management of ureteral calculi. Since the new financial policy of public hospitals is now operative, we tried to evaluate if the management of ureteral calculi is conditioned by technical availability and by the Diagnosis Related Group (DRG) payment system. Open surgery is still first-line treatment for renal calculi over 3 cm in diameter. ESWL is preferentially employed for the treatment of lumbar ureteral calculi, while ULT is preferred in distal ureteral stones. Non-analytical evaluation of costs in our Hospital showed that ESWL and ULT with an average of three days hospital stay were remunerative if DRG standards were applied. This was not the case if the same treatments were applied on a “day-hospital” basis or in one day of hospital stay. As far as therapeutical choice is concerned, in our and other urological divisions it was dictated by clinical and technical more than economic considerations.

Chemioterapia primaria e trattamento delle masse residue nei tumori germinali non seminomatosi del testicolo. La nostra esperienza

Thanks to the introduction of new chemotherapeutic agents, treatment of non-seminomatous germinal cell tumours (NSGCT) has dramatically improved during the last two decades. The association of chemotherapy and surgery has further increased the therapeutic success rate. The authors report their experience on this subject over the last ten years. Although the number of patients is relatively small and statistically insignificant, the results compare well with those of large centres dealing with this pathology.

Angiomiolipoma renale: Nostra esperienza in 14 casi sottoposti a terapia chirurgica

Renal angiomyolipoma (AML) is an uncommon hamartomatous benign tumour and may present in an isolated form or associated with tuberous sclerosis (Bourneville's disease). Since there is no specific symptomatology when dimensions are small or medium, discovery is often accidental and the tumour may sometimes grow to a considerable size. In the symptomatic forms or larger tumours, surgery may be indicated due to the risk of retroperitoneal hemorrhage, both spontaneous and secondary to lumbar trauma, however slight. As the tumour is benign, kidney-sparing surgery should be as conservative as possible. For this purpose, ultrasound and CT scan are considered essential for a differential diagnosis between AML and parenchymal renal masses. In our experience with 14 cases (12 women and 2 men; minimum age 31 years, maximum 62 years) of monolateral renal AML (10 right kidney AML and 4 left kidney AML) in patients not suffering from tuberous sclerosis, treated surgically between August 1988 and February 1997, the pre-operative ultrasound and CT scan gave a correct diagnosis in 7 cases, a suggestion of renal carcinoma in 5 cases while leaving doubts in 2 cases. The two methods of investigation therefore proved not to be error-free. Following instrumental diagnosis, 12 patients underwent enucleoresection of the tumour while the remaining two underwent extensive nephrectomy. The presence of hemorrhagic areas with AML was considered to be the frequent cause of pre-operative diagnostic error.

Low dose Pasteur bacillus Calmette-Guerin regimen in stage T1, grade 3 bladder cancer therapy

PURPOSE

We assessed the effectiveness of intravesical bacillus Calmette-Guerin (BCG) for high risk transitional cell carcinoma of the bladder.

MATERIALS AND METHODS

A total of 51 patients with stage T1, grade 3 disease was treated with weekly instillations of 75 mg. Pasteur strain BCG for 6 weeks after transurethral resection for bladder cancer. An additional induction course was given to patients with relapse. Tumor-free patients followed a maintenance course with monthly instillations for 12 months.

RESULTS

After the initial induction course 37 of 51 patients (72.5%) remained tumor-free. A second induction course was necessary in 13 patients. After 1 or 2 induction courses 44 of 51 patients (86.3%) were tumor-free. The maintenance course was administered to 44 patients, with 41 remaining tumor-free. After a median followup of 33 months (range 3 to 63) 28 patients (54.9%) were disease-free, 12 (23.5%) had recurrent tumors and 7 (13.7%) had progression. The risk of treatment failure was significantly greater for solid than papillary tumors (p = 0.0006), recurrent than primary tumors (p = 0.0052) and coexisting carcinoma in situ (p = 0.124) in multivariate analysis, and for early recurrence (p = 0.0001) in univariate analysis only. The drug was well tolerated with few side effects.

CONCLUSIONS

Our data suggest that this low dose Pasteur BCG regimen is effective in the treatment of high risk superficial bladder cancer. Some tumor characteristics, such as solid appearance, coexisting carcinoma in situ, history of superficial transitional cell carcinoma and early relapse after the initial induction course, seem to be negative prognostic factors.

[Conventional surgical treatment of penile tumors]

The surgical treatment of primary lesion in Carcinoma of the penis is the total excision of the carcinoma with tumor free margins. Distal preputial carcinomas without deep infiltration are often treated by extensive circumcision. Partial or total amputation of the penis is required by the location and the extent of the tumor. The evaluation and the treatment of the lymph nodes in penile cancer are still unclear.

[Precancerous lesions of the penis]

Premalignant penile lesions have been associated to squamous cancer, although the true incidence of progression of these entities to squamous cell carcinoma is unknown. These lesions may coexist with or may antecede the occurrence of carcinoma. For this reason close follow-up of the patient is necessary to detect early evidence of malignant degeneration.

The Margins

The gradual increase in indications for radical prostatectomy over these last few years has focussed attention on the issue of surgical margin positivity. In terms of prognosis, a positive surgical margin is comparable to lymph node positivity. The routine adoption of the most advanced anatomo-histological methods has increased our 17.5% of positive surgical margins to 30.2% despite surgical indication having become increasingly more rigid. In addition, more precise preoperative staging by echo-guided biopsy of the seminal vesicles and of periprostatic spaces, has allowed patients with positive lymph nodes to be reduced to just over 1%.

Surgical therapy and approaches

— In the field of upper urinary tract neoplasms there is a need to find a logical linear connection between staging and treatment with surgery performed according to the gravity of the neoplasm. The Authors consider the basic concepts of surgery, discussing the access route and best operation for each clinical situation plus the advantages and disadvantages. The case histories relating to 181 operated patients from the Treviso and Bergamo Units are reported, (141 total nephroureterectomies – of whom 14 with simultaneous cystectomy, 3 nephrectomies in high-risk patients, 6 pyelectomies or heminephrectomies, 19 segmental ureterectomies and 12 endourological procedures). Conservative therapy (rather than endourology) through segmental ureterectomy with removal of the bladder cuff and ureterocystoneostomy was preferred in neoplasms of the distal ureter. In fact, in these cases survival is in relation to the tumour stage and not the type of operation. Cases are reported where conservation of the renal emunctory necessitates conservative treatment. Results of radical therapy (80% of patients, justified by the high malignancy and multifocality of the neoplasms) showed recurrence in the bladder in 28%, contralaterally in 2% and a 5-year survival rate (according to Kaplan-Meyer) of 66%. With conservative treatment there was a high rate of local recurrences (33%) in the upper tract, but only 11 % after segmental ureterectomy for tumours of the pelvic ureter. In the Authors’ experience, total nephroureterectomy guarantees maximum extirpation whereas conservative surgery is the only form of treatment allowing complete tumour removal while maintaining, even if only partially, a renal emunctory.

[T1G3 transitional cell carcinoma of the bladder: our experience with 44 patients treated with intravesical BCG after TUR]

Forty-four patients affected by poorly differentiated (G3) superficial TCC invading lamina propria (stage T1) were treated with intravesical BCG. They underwent weekly instillations of 75 mg BCG for six week after trans-urethral resection (TUR) of bladder cancer. An additional induction course was given to patients who relapsed. A maintenance course with monthly instillations for twelve months followed in complete responder patients. After the first induction course, 34/44 patients (77.2%) showed complete response. In 10 patients a second induction course was necessary, with complete response in four. After one or two induction course, 38/44 patients (86.5%) showed complete response. The maintenance course was administered to 38 patients with 35/38 complete responses. After a median follow-up of 30 months, there were 29/44 (65.9%) disease free patients, 11/44 (25%) tumor recurrences and 4/44 (9%) tumor progressions. The drug has been well tolerated with few side effects. Our data suggest that intravescical BCG after TUR is effective in the treatment of high-risk superficial bladder cancer and we believe that it can be used a first approach in treating patients affected by T1G3 bladder cancer.

[Our current indications for radical prostatectomy]

Radical prostatectomy is the golden standard for localized prostate cancer. The identification of patients with intraprostatic disease who can be cured and will live long enough to benefit from a surgical therapy represents the primary goal of the authors. Target of this article is underlining the importance of an accurate preoperative staging through ultrasound-guided biopsy of seminal vesicles and periprostatic spaces. The positivity of the surgical margin after radical prostatectomy is also taken into account as it represents, according to the authors, an extremely important but often overlooked parameter.

[Surgical treatment of benign prostatic hypertrophy: what and when TURP vs adenomectomy]

Surgical treatment is the gold standard for Benign Prostatic Hyperplasia (BPH) therapy. At the present diagnostic approach allows better patient selection and treatment assignment. In this work we have studied retrospectively the outcome of 120 BHP patients who underwent trans urethral resection (TURP) and of 145 BPH patients underwent "open" prostatectomy. In all the patients surgical time, prostate weight, indwelling catheter standing, rest in bed, early and late complications were evaluated. Irritative symptoms occurred after TURP in 10% of the cases. The two therapeutical options are not comparable for they technically different. The choice between the two depends on the accurate patient characterization and selection.

Urologist: Clinical information system for urology

“Urologist” was developed to run a Department of Urology. A local area network (LAN), one server and five stations, connects the single functional units of the Department (O.R.; I.C.U.; wards; Spinal Unit and Patient services). A Patient Identification Card integrates both clinical and organisational data. A multidisciplinary group, consisting of medical and non-medical specialists, was necessary to develop this system.

[Nerve-sparing retroperitoneal lymph node dissection in patients with non-seminomatous testicular tumors at clinical stage 1]

Retroperitoneal lymph node dissection (RPLND) for low stage testicular cancer involves a low rate of dry ejaculation. The nerve-sparing technique avoids the damage of sympathetic fibers. 7 cases of non seminomatous testicular cancer have been treated by the Author. Through midline incision and intestinal derotation the vascular plane and the sympathetic fiber are identified before starting lymph node dissection. All the patients report physiological ejaculation; the post-operative follow-up is still short but at the present all patients are tumor free. In low stage testicular cancer nerve-sparing lymphadenectomy preserve physiological ejaculation and reducing surgical morbidity as well.

[What not to do when confronted with a iatrogenic lesion of the ureter]

Starting from their experience, the Authors report about steps to avoid in case of ureteral injury. They make a distinction between emergencies and planned surgery. In particular they underline that it is always advisable to confine surgery to transcutaneous or surgical nephrostomy when the experience in reconstructive surgery of upper urinary tract is limited. The Authors further suggest strict follow-up so as to avoid loosing functioning renal units due to a silent progression of an ureteral lesion. Ureteral reconstruction is the golden standard of an ureteral lesion repair; long term stenting has to be limited to the cases where a definitive surgery is not possible either for general conditions or for primary malignant disease. The discussion is integrated with pictures of several cases.

Surgical Treatment of Renal Cell Carcinoma with Vena Cava Or Cavo-Atrial Involvement. Our Experience

From January 1987 to September 1992, 290 patients were operated for renal cell carcinoma at the Department of Urology of Bergamo General Hospital. Among these, 22 had venous invasion, 13 of them with vena cava or cavo-atrial involvement. The Authors stress several technical details that they judge very helpful in the case of intrahepatic or supradiaphragmatic thrombi. Among them the routine use of transesophageal sonography, which gives precise details on the size, volume, and upper limit of the thrombus especially if floating. 4 patients were operated with the help of cardiopulmonary by-pass, circulatory arrest and profound hypothermia. The Authors stress the major advantages offered by this technique compared to simpler approaches like the control either of the supradiaphragmatic vena cava, or hepatic veins. Cardiopulmonary by-pass and circulatory arrest offers unsurpassed exposure of the IVC interior and allows easy and controlled extraction of the thrombus, previously the most difficult part of the procedure. Having no time limit imposed by liver ischemia (± 20 minutes), it also offers the possibility of resecting segments of caval wall and repairing it with patch grafts. Among 13 patients who underwent radical nephrectomy and intracaval thrombus removal, limited complications and no peri-operative mortalities are reported.

Urinary stress incontinence: A comparison between transvaginal procedures

— Transvaginal needle bladder neck suspension for stress urinary incontinence: personal experience. The Authors present their personal experience of 30 patients operated between 1988–1991 for stress urinary incontinence with transvaginal needle bladder neck suspension. 9 patients were treated with Gittes procedure, 14 with Raz and 7 with sling and minisling. Minimal post-operative complications, despite chronic urinary retentions, were observed. With a mean follow-up of 18 months (7–48) they report recurrence of incontinence respectively in 56%, 23% and 16% of the patients. With the significant rate of failure, even after repeated procedure, the Authors have drawn the conclusion that transvaginal needle-suspension should not be considered standard treatment of female S.U.I. They stress the need to carefully select patients. Females with major vaginal prolapse or significant rectocele are, from the authors' point of view, the best candidates for this kind of technique.