Denial and oncological pathology: Case report of a massive testicular cancer

LITERATURE

The cancer of testicles represents 1% of male neoplasms and 5% of urological malignant neoplasm. Its incidence has been growing in Western societies. Cancer of testicles usually presents as an increase of consistence in one testicles and absence of pain, as a casual ultrasound scan finding, or it could be highlighted by a scrotal injury. The surgical treatment is either radical orchiectomy or radical orchiectomy plus retroperitoneal lymph node dissection.

CASE PRESENTATION

The case presented concerns a 48-year-old male with a history of left testicular trauma and subsequent hypotrophy. Over the next 4 years, the patient developed a testicle size increase up to 15 cm in diameter. At diagnosis, he had retroperitoneal lymphadenopathy. The patient was, after surgery, referred to the oncology department.

CONCLUSION

The awareness of the male population respect to testicular cancer and its screening methods (e.g. self-examination) is essential to make the diagnosis at an early stage. It is also essential to psychologically support patients undergoing surgical and/or pharmacological therapy due to risk of determining anxiety or depression compared to the whole population.

Recent Applications of the Sentinel Lymph Node Concept: Preliminary Experience in Prostate Cancer

Aims and Background

Following the widespread use of radioguided surgery (RGS) in melanoma and breast cancer, we applied this new surgical strategy to prostate cancer (PC). The aims of this study were 1) to evaluate the accuracy of RGS in the detection of prostatic sentinel lymph nodes (SLN), and 2) to verify if pelvic lymphadenectomy (LAD) is an accurate means to detect solitary micrometastases.

Study design

We investigated 48 patients with PC confirmed by transrectal biopsy who underwent radical prostatectomy and bilateral LAD. A dose of 99mTc-labeled nanocolloid particles was injected into the prostate after needle positioning by ultrasonography. Serial imaging was obtained with a gamma camera, identifying 1) the first radioactive lymph node (sentinel lymph node, SLN); 2) other radioactive lymph nodes, and 3) non-active lymph nodes.

Results

Forty-three SLNs were identified in 48 patients. Twenty SLNs were located at unusual sites with respect to the extent of conventional LAD. Five SLNs were positive for micrometastases and two of these were located outside the usual LAD area. No micrometastases were found in any of the remaining lymph nodes (active and non-active).

Conclusions

These preliminary results are in agreement with the few previous scientific contributions available on this topic and indicate that it is possible to reduce the extent and duration of surgery and necessary to reevaluate the conventional sites of lymphatic drainage.

Bladder Cancer and Cigarette Smoking in Males: A Case-Control Study

Cigarette consumption was compared between 355 males with cancer of the lower urinary tract and 276 male hospital controls. Both duration of smoking and average daily consumption of cigarettes showed a dose-response relationship with risks of developing bladder cancer. Quitting smoking seems to have a protective role, whereas higher relative risks are associated with an early age at start of smoking. The use of a filter seems to have a weak protective effect.

Batson's Paravertebral Venous Plexus and Single Vertebral Metastases from Renal cell Carcinoma

Objectives

The presence of a single site bone metastasis in patients with renal cell carcinoma (RCC) is a rare clinical event. We report a single case of RCC with solitary vertebral metastasis and review of literature about renal tumor spreading in order to understand the anatomic explanation for this peculiar clinical case.

Methods

We have considered the single case and reviewed current and past literature to describe the anatomic and functional background of this clinical situation.

Results

There are rare cases of single vertebral metastasis from RCC and these are characterized from a contemporary neoplastic thrombus. The neoplastic thrombus could justify the tumoral back-flow into the paravertebral anasthomoses and so into vertebral venous sinusoids. The rich anasthomotic system that surrounds kidneys and the experimental evidence of anasthomotic links among perirenal Lejars venous system and paravertebral Batson's venous system could explain these clinical evidences.

Conclusion

Enrolment of para-vertebral Batson's venous system could have a major role in the RCC vertebral metastatic diffusion.

The Role of Non-Invasive Urodynamics in Bladder Outlet Obstruction Diagnosis in Male Patients

Purpose

Many Methods have been suggested to assess bladder outlet obstruction, as defined by the gold standard of pressure flow studies. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by non-invasive means was performed in order to compare those methods to invasive urodynamics in terms of sensitivity and specificity.

Materials and Methods

A MEDLINE search was done of the published literature covering from December 2003 on non-invasive methods, including only single measures to diagnose bladder outlet obstruction. We performed a comparison between all methods in terms of sensitivity and specificity for each test. For many techniques these values were calculated directly from the data presented in the article.

Results

There has been applied many methods to diagnose bladder outlet obstruction. Those methods were divided into uroflowmetry condom-catheter method, penile cuff method and Doppler ultrasonography urodynamics. Each method has been described and discussed in terms of its role in adding information to the diagnostic work-up for bladder outlet obstruction.

Conclusions

Pressure flow studies still remain the gold standard for assessing bladder outlet obstruction. However non-invasive urodynamics is a promising branch. Probably the most reliable information is given by the association of numerous methods together.

[Batson's paravertebral venous plexus and single vertebral metastases from renal cell carcinoma]

OBJECTIVES

The presence of a single site bone metastasis in patients with renal cell carcinoma (RCC) is a rare clinical event. We report a single case of RCC with solitary vertebral metastasis and review of literature about renal tumor spreading in order to understand the anatomic explanation for this peculiar clinical case.

METHODS

We have considered the single case and reviewed current and past literature to describe the anatomic and functional background of this clinical situation.

RESULTS

There are rare cases of single vertebral metastasis from RCC and these are characterized from a contemporary neoplastic thrombus. The neoplastic thrombus could justify the tumoral back-flow into the paravertebral anasthomoses and so into vertebral venous sinusoids. The rich anasthomotic system that surrounds kidneys and the experimental evidence of anasthomotic links among perirenal Lejars venous system and paravertebral Batson's venous system could explain these clinical evidences.

CONCLUSION

Enrolment of para-vertebral Batson's venous system could have a major role in the RCC vertebral metastatic diffusion.

[The role of non-invasive urodynamics in bladder outlet obstruction diagnosis in male patients]

PURPOSE

Many methods have been suggested to assess bladder outlet obstruction, as defined by the gold standard of pressure flow studies. A comprehensive review of the literature on the different methods used to diagnose bladder outlet obstruction by non-invasive means was performed in order to compare those methods to invasive urodynamics in terms of sensitivity and specificity.

MATERIALS AND METHODS

A MEDLINE search was done of the published literature covering from December 2003 on non-invasive methods, including only single measures to diagnose bladder outlet obstruction. We performed a comparison between all methods in terms of sensitivity and specificity for each test. For many techniques these values were calculated directly from the data presented in the article.

RESULTS

There has been applied many methods to diagnose bladder outlet obstruction. Those methods were divided into uroflowmetry, condom-catheter method, penile cuff method and Doppler ultrasonography urodynamics. Each method has been described and discussed in terms of its role in adding information to the diagnostic work-up for bladder outlet obstruction.

CONCLUSIONS

Pressure flow studies still remain the gold standard for assessing bladder outlet obstruction. However non-invasive urodynamics is a promising branch. Probably the most reliable information is given by the association of numerous methods together.

Andrological and hormonal findings in subjects with ductus deferens agenesia

The aim of our study has been the complete andrological and endocrinological evaluation of seven cases of bilateral ductus deferens agenesia. In all cases testicular biopsy demonstrated a normal spermatogenesis. Urographic examination showed, in four cases, the existence of congenital anomalies of the urinary tract. The presence of spermioagglutinating and spermimmobilizing antibodies in blood and in seminal plasma was excluded in all cases. Basal and stimulated levels of FSH, LH, PRL and testosterone were within normal limits. Surgical exploration of seminal tracts and bilateral collection of sperm at the caudal portion of the epididymis appear to be mandatory in order to select the cases for surgical therapeutic approach.

Proposal of an improved prognostic classification for pT3 renal cell carcinoma

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.

Actual experience and future development of gemcitabine in superficial bladder cancer

Gemcitabine has a molecular weight of 299 D, lower than that of commonly-used intravesical chemotherapeutic agents such as mitomycin C (389 D) and doxorubicin (589 D). This may enable gemcitabine to penetrate the bladder mucosa with beneficial effects in the treatment of early invasive bladder cancer (T1 disease). At the same time the molecular weight is high enough to prevent significant systemic absorption in an intact bladder. Based on the results of phase I studies, it appears that the 2000 mg dose of gemcitabine in 50/100 ml normal saline when administered intravesically for up to 2 h once a week for 6 weeks has unremarkable systemic and local side effects and therefore should be considered the most convenient schedule. The currently available phase II studies have assessed the activity of intravesical gemcitabine on a marker lesion in intermediate risk superficial bladder cancers (SBC), showing complete responses in up to 56% of cases. Few attempts have been made to test the activity of intravesical gemcitabine in high risk SBC achieving unexpected complete responses in BCG refractory CIS. Gemcitabine seems to have fulfilled the requirements to be a promising new candidate for standard intravesical therapy in SBC so far. Further phase II trials exploring the activity of gemcitabine on highly-recurrent intermediate risk or high risk SBC would provide additional information to foresee its efficacy in clinical practice and thus constitute the framework for large comparative phase III trials.

Fatal Hemorrhage during Nephrolithotomy in a Patient with Unknown Vascular Ehlers-Danlos Syndrome Type IV

Ehlers-Danlos syndrome type IV (vascular EDS), is a life-threatening inherited connective tissue disorder resulting from mutations in the COL3A1 gene coding for type III procollagen. Vascular EDS causes severe fragility of connective tissues. We report a case of a 26-year-old male with bilateral staghorn renal calculi, the patient underwent a left nephrolithotomy, during the suspension of the renal artery incredibly, it was lacerated by the vessel loop, without any actraction. Subsequently, all hemostatic attempts, although gentle, resulted in important and catastrophic aortic and caval injures; the patient died due to an uncontrollable abdominal and thoracic hemorrhage. The early diagnosis of the vascular EDS is difficult if there are no known cases. Every surgical procedure in patients with Enlers-Danlos syndrome has a high risk of fatal vascular injuries.

Adjustable Continence Therapy for Female Sui

Since December 1999 a new adjustable device for female stress urinary incontinence called the ACT (Adjustable Continence Therapy) has been used in a multicentre study. The two year follow-up of the Italian multicentre study is presented.

Material & Methods

A group of 37 female patients, affected by SUI was evaluated before and after the positioning of the ACT with physical examination, urodynamic study and quality of life questionnaires (I-QOL) Mean age was 58,5 (range 21.9 – 84.6). 59% (22/37) had type II SUI while 42% (15/37) had type III SUI. 57% (21/37) had had prior urogenital surgery. The ACT device consists of an adjustable silicon balloon, a subcutaneously positioned titanium port and a two lumen tube in between. The devices are positioned via a percutaneous perineal approach, using either local or regional anaesthesia. A 2 cm skin incision is made on each labia majora and through these incisions a delivery trocar is directed toward the bladder neck. The trocar is manoeuvred into the desired position using tactile guidance and an image intensifier (III). Each ACT device is then inserted via the delivery tool. Each balloon is positioned lateral to the bladder neck, proximal to the vesico-vaginal space, below the endopelvic fascia. Each balloon is then filled with one to two millilitres of the isotonic contrast/sterile water mixture with X rays confirmation of the correct location. The injection ports attached to each balloon are then positioned subcutaneously in each labia majora; the balloons are subsequently adjusted, if this is required.

Results

15 patients reached 24 months of follow-up. 46% of them were dry at physical examination and wear no pads. Additional 26% were significantly improved. This group of patients had to wear 1 pad/daily. 56% of the patients required one adjustment to achieve continence, 10% two adjustments, 10% three adjustments 24% need no adjustments. No cases of urinary retention were reported out of 37 cases. One patient had a transient dyspareunia.

Conclusions

70 % of our patients where dry or substantially improved and the patients quality of life increases significantly, this results includes mainly the patient with sever intrinsic sphincter deficiency and failed previous incontinence surgery. The ability to post-operatively adjust the ACT permits to reach the appropriate volume to each patient. However a longer follow up and a bigger number of procedures are required for definitive conclusions.

ProACT: A New Surgical Therapy for the Male Sui

The incidence of reported male stress urinary incontinence (SUI) status prostate surgery varies widely between 2–40%. While the artificial urinary sphincter (AUS) reports good long-term efficacy, this procedure is associated with a high rate of reoperation. The aim of this study was to assess the results at 1 year of follow up of a new minimally invasive surgical technique called Pro ACT (Adjustable Continence Therapy).

Material & Methods

The ProACT is a new implant for post-prostatectomy incontinence. A balloon, a port and a tube of connection are the components of the Pro ACT. It is percutaneously implanted and is postoperatively adjustable. From September 2000 to December 2003 16 males underwent to the procedure. The mean age was 56.5 years (range 29–83). The SUI was due in 13 cases to radical retropubic prostatectomy, in one case to TURP, in one case to open prostatectomy for benign prostatic hypertrophy and one case to congenital incontinence associated with epispadia. The urodynamic exam revealed SUI due to intrinsic sphincteric deficiency in all patients. Efficacy was assessed by change in use of average number of pads used daily, and overall impression

Results

The average number of adjustments after the surgery was 1.6. The average number of pads used decreased from a mean 5.11 at baseline to 1.62 at 12 months. Overall 42.8% of the patients are now completely dry. 28% are improved and 30% are either not improved or only slightly improved. In three of these patients the adjustments are still on going. The only post-operative complication was a migration of both the balloons into the bladder in one patient, which necessitated the removal of both devices as a minor procedure under local anesthetic.

Conclusions

The ProACT is a new surgical therapy for the male SUI. This technique is easy, quick to learn and associated with a low rate of complications and a satisfactory rate of success. 70% patients were dry or improved at 1-year follow up. The device is well accepted from the patients because it doesn't require any manual skill to operate implanted components. Complications are easily managed because of the possibility to remove the Pro ACTs implants completely, or by simply deflating the balloons via percutaneous injection.

Complications of Irrigations Solutions during Transurethral Resection of the Prostate in Spinal Anesthesia

Perspective study in order to estimate the incidence of TURP-Syndrome, in spinal anesthesia (SA) with volemic expansion with sodium chloride solution 0.9 % vs 3%.

Materials and Methods

Two groups (gr) of patients (pt) A (n=20) and B (n=20) in SA have received like respective 500 ml of NaCl 0.9% and 250 ml. of NaCl 3%. The bladder was irrigated with a solution containing 1.5% glycine (1). We estimated: weight of prostate adenoma and weight of removed tessue, Sodium (Na) preop - intraop - postop. and after 24 hours, Ammonium (NH4+) pre - postop, volumes (V) of dropped solutions, V of dropped glycine (gl), operation time, core body temperature intraop and postop, mental state intra and postop., osmolarity.

Results

We found no significant difference in weight of adenoma and removed tessue. We have not observed any differences in the V of infusive solutions in the periop. We have not observed any difference in the values of Na preop. and postop, in those of NH4+ preop and postop, in operation time and in the V of gl. During procedure 5 pz. (S group) showed: visual disturbances, mental confusion (TURP-Syndrome) and hypertention (2). No pz. have any Na and NH4+ intraop.values altered. Time of TURP appeared bigger in non symptomatic patients (69 mn gr S. vs 48.43 gr.A and 47.26 gr. B). The V of instilled gl. has appeared meaningfully more elevated in gr. S (21.4 / vs 12 in gr.A and 12.31 in gr. B). The Na and NH4+ postop., Na after 24 hours and core body temperature have turned out statistically omogenee in all pt. In the 5 symptomatic pt the osmolarity values entered in normality ranges and they did not show differences between the groups considered.

Conclusions

We have not noticed any differences in using of the NaCl solution 0.9% versus NaCl 3% like volemic prefilling; the symptomatic patients have endured one longer procedure and greater amount of irrigating solution; their values of Na and NH4+ were in the limits of the normality; for this reasons perhaps the cause of symptoms in our patients would be searched in direct toxicity of glycine as inhibitory neurotrasmitter in CNS.

Clinical efficacy of Apomorphine SL in erectile dysfunction of diabetic men

Although subgroup analyses from large randomised premarketing studies have shown that Apomorphine SL enhances the percentage of erections firm enough for sexual intercourse in diabetic men, the clinical role of the drug in this patient population remains to be elucidated. The aim of the present study was to assess the efficacy of Apomorphine SL in diabetic males with erectile dysfunction (ED) and to identify factors predicting those who may benefit from the treatment. A total of 130 diabetic patients were randomised to receive either four tablets of 3 mg Apomorphine or a matching placebo. Assessments of efficacy comprised the erectile function (EF) domain of the International Index of Erectile Function (IIEF) and the one-item global efficacy question (GEQ). Patients with both a positive response to the GEQ and an improvement of at least 5 points in the EF domain of the IIEF were considered responders and subanalysed by several parameters indicative of the severity of both ED and diabetes. Response rate was 17% after placebo and 22% after Apomorphine SL. The EF domain of the IIEF and both questions 3 and 4 scores did not significantly improve in either of the two arms over the baseline. A younger age and a lower Hb1Ac were significantly linked to the status of responder in the Apomorphine arm. Apomorphine SL failed to show a statistically significant benefit over a placebo, but 22% of patients had a clinically significant erectile response. These figures seem to suggest that the drug has a limited use for ED diabetic patients.

Evaluation of minimally invasive analysis system for cough leak point pressure measurement

PURPOSE

Leak point pressure (LPP) measurement has become standard in the diagnosis of stress urinary incontinence. Leak point pressure is determined by increasing abdominal pressure, which can be done with a Valsalva maneuver or coughing, that is Valsalva LPP and cough LPP (CLPP). It may be influenced by catheter size, bladder volume and interobserver variability. A new, computerized LPP measuring technique for routine use in daily urodynamic practice was tested at a female unit urodynamic practice to evaluate female urinary incontinence.

MATERIALS AND METHODS

A total of 28 female patients with a mean age of 54.07 years (range 23 to 82) and urinary incontinence underwent a new, minimally invasive measurement of the cough leak point. Measurements are made with the patient standing and repeated 3 times per patient. Additionally, parameters of the corresponding leak were recorded simultaneously. All patients underwent new CLPP measurement and a standard, complete urodynamic investigation, including filling cystometry with abdominal LPP and urethral pressure profile at rest. Statistical evaluation was done by linear regression analysis and the correlation coefficients among CLPP, age, standard abdominal LPP and maximum urethral pressure, and among the 3 measurements for each patient.

RESULTS

: The assignment of leakage to the pressure signal presented no problem. All CLPP data were reproducible in the 3 repeated measurements per patient. No correlation was seen between CLPP and abdominal LPP or the urethral pressure profile.

CONCLUSIONS

The study confirm that the CLPP is a practicable, consistent and minimally invasive method in routine use. Clinical use is easy and reproducible, and only 1 catheter is required for measurement.

Morbility and Outcomes of Radical Prostatectomy in Patients with Clinically Advanced Prostatic Cancer

In this study we have reviewed patients with prostate cancer clinically advanced at the diagnosis, and subjected at radical prostatectomy, to evaluate the morbility, mortality, and results of the surgery. We have subjected 38 patients with sure clinically advanced disease to radical prostectomy (PSA average 80 ng/mL). An ureteral injury and no rectal lesion have been observed. The rate of urinary incontinence have not been increased in comparison with the literature data, while more frequently are been developed stenosis of bladder neck (26%).

At 2 years the 15% of the patients is disease free survival. Our opinion is that radical prostectomy in patients with locally advanced prostate cancer is feasible and the rate of the complications is acceptable.

Predictive Factors of Prostate Cancer in Patients Subjected a Prostatic Re-Biopsy, with Psa in the Grey Zone

In this study we have tried to define which are the most useful predictive factors in the diagnosis of the prostate cancer in patients with first negative biopsy and with PSA in the grey zone. We have therefore analysed 123 patients subjected at re-biopsy: in 25 patients (20%) it is been diagnosed a prostate cancer at the second biopsy, while in 98% (80%) also the second biopsy was negative.

The PSA ratio and the PSA density of the transitional zone have demonstrated having the highest sensitiveness in finding patients with cancer at the re-biopsy (92% and 88%) in comparison with the ER and the TRUS (20% and 32%). Moreover the PSA DTZ let spare the 41% of the re-biopsy that will result negatives.

Y-neobladder: an easy, fast, and reliable procedure

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.

[Voiding ultrasonographic cystourethrography]

Transvaginal ultrasonography examines the bladder base, the urethral anatomy and the relationship between these structures. This procedure particularly evaluates the striated sphincter and periutrehral structures, during micturition attention is focused on elasticity of urethral walls, deviation of urethral axis, the presence of fibrotic rings, fibrosis extending to the whole urethra and on urethral diverticuli. At che present, the literature available does not provide certain diagnostical criteria for the identification of female vaiding disorders. The high number of proposed therapeutical solutions indicate that the solution to this problem is yet to be found.

[Does PSA density of the transition zone represent a useful parameter in the diagnosis of prostate carcinoma?]

Prostate specific antigen (PSA) has unequivocally proved its clinical usefulness ad a serum marker for prostate cancer. In order to enhance the specificity of serum PSA, several diagnostic parameters have been employed including PSA density of transition zone (TZ). The authors report their experience on the efficacy of PSA density TZ with level of PSA < 4 ng/ml, between 4-10 ng/ml, > 10 ng/ml, in the diagnostic of prostate cancer. The PSA density of TZ resulted uscless for PSA levels < 4 ng/ml, but improved the diagnostic specificity associated to PSA serum in the PSA levels ranging between 4-10 ng/ml and > 10 ng/ml.

[Clinical response and survival in metastatic renal carcinoma during subcutaneous administration of interleukin-2 alone. Subcutaneous Il-2 in renal carcinoma]

Several clinical studies have demonstrated the efficacy of subcutaneous immunotherapy with Il-2 alone in metastatic renal cell carcinoma (RCC). In an attempt to better define the clinical parameters which may predict the efficacy of treatment, the present study shows the results obtained with subcutaneous Il-2 alone in 91 evaluable metastatic RCC patients. IL-2 was injected subcutaneously at 3 million IU twice/day for 5 days/week for 6 weeks, corresponding to one immunotherapeutic cycle. In nonprogressing patients, a second cycle was given after 28-day rest period. A complete response (CR) was achieved in 2/91 patients. Moreover, 19/91 patients had a partial response (PR). Therefore, objective response (OR) rate was 21/91 (23%) patients. Stable disease (SD) was achieved in 41 patients, while the remaining 29 patients had a progressive disease (PD). OR rate was significantly higher in patients with a long disease-free survival than in patients with synchronous metastases, in nephrectomized patients than in the non-nephrectomized ones, and in patients with high than in those with low PS. The survival obtained in patients with CR or PA was significantly longer with respect to that found in patients with SD or PD. The toxicity was substantially low in all patients. This study confirms that the subcutaneous immunotherapy with IL-2 alone is an effective and well tolerated therapy of metastatic RCC.

[Preoperative subcutaneous immunotherapy with interleukin-2 in renal carcinoma with synchronous metastasis: randomized clinico-biological study. Preoperative use of Il-2 in renal carcinoma]

Despite the efficacy of IL-2 in the treatment of metastatic renal cell carcinoma (RCC), the prognosis of patients with synchronous metastases still remains poor. Nephrectomy itself, as well as other surgical operations, may further suppress the antitumor immune response. Previous studies suggested that the preoperative injection of IL-2 may neutralize surgery-induced lymphocytopenia in advanced colon cancer. On this basis, a pilot randomized study was performed in an attempt to evaluate the effects of a preoperative administration of IL-2 on postoperative lymphocyte numbers and on the survival in advanced RVV patients with more than 3 synchronous metastases. The study included 20 consecutive patients, who were randomized to receive nephrectomy alone or nephrectomy plus preoperative subcutaneous immunotherapy with IL-2 (18 million IU/day for 3 days). Then, all patients underwent postoperative immunotherapy with IL-2 (6 million IU/day for 5 days/week for 6 weeks). Surgery-induced lymphocytopenia was completely abolished by IL-2 preoperative injection. The frequency of postoperative complications was significantly higher in controls than in patients preoperatively treated with IL-2. On the contrary, significant differences between control and patients preoperatively treated with IL-2 were observed neither in the clinical response to IL-2 immunotherapy, nor in the percent of 1-year survival. The results of this preliminary pilot study would suggest that IL-2 preoperative immunotherapy may neutralize surgery-induced lymphocytopenia and reduce the postoperative complications in RCC patients with synchronous metastases, without, however, influencing their prognosis in terms of survival time.

[Orthotopic ileal neobladders in men and women: techniques and comparison]

PURPOSE

evaluation of results and complications of ileal orthotopic neobladders in men and women with transitional cell carcinoma.

MATERIALS AND METHODS

between 12-89 and 12-95 we performed 146 radical cystectomy for bladder neoplasm, in 32 patients we can perform ileal orthotopic neobladder, 29 were male and 3 were female. Oncologic indications to this kind of operation were: clinical stage T2, T3a, T3b, T1G3 multicentric and or recurrence, absence of metastasis absence of nodal metastasis, negativity of urethral biopsy. General contraindications were urethral stenosis and incontinence. Oncological contraindications, in woman, were bladder neck neoplasm or urethral neoplasm. In 4 patients we use Camey II technique, in 19 pts we performed the paduan ileal neobladder, in 9 pts we use Hautmann technique. 7 patients performed neoadjuvant chemotherapy with 4 circles of MVAC, 4 pts underwent adjuvant chemotherapy, and 2 pts salvage chemotherapy. In woman we take care during cystectomy to dissect cardinal ligament very close to cervix uteri, to resect the uterosacral ligament far to the sacrum. We did not dissect under the ureter and we cut the urethra 0.5-1 cm far from the bladder neck.

RESULTS

follow up was between 6 and 66 months. 24 patients are now alive and disease free, 2 patients are alive with disease progression, 1 have a pelvic recurrence and 1 have pulmonary recurrence. 4 pts died for disease progression and 2 for non oncological cause, quality of life was considered as regard to continence and sexual activity. 1 pts was completely incontinent and 1 pts has nocturnal incontinence with a daily micturation every 1 hour. We can evaluate only 18 patients for sexual activity and 4 reported normal erection.

COMPLICATIONS

in three cases we had to reoperate for early complications due to mechanical bowel obstruction, ileocutaneous fistula and wound dehiscence. In three cases we had the formation of stones, in two patients ureteroileal stenosis, in two cases urethro-ileal stenosis and 1 reflux from the neobladder. Orthotopic ileal neobladder allows a very good quality of life and is the first choice derivation after radical cystectomy.

[Radical prostatectomy: comparison of technics]

From 1989 until today 46 patients aged 44-75 years underwent a radical prostatectomy two of whom transperineal and another 44 patients underwent a retropubical prostatectomy (twenty of whom with the nerve sparing technique). Based on our experience, the clinical stages that benefit from a radical prostatectomy as are as followed: T1b, T1c, T2a, T2b; T2c, in patients who present a good A.S.A., a remaining life-span of ten years is expected. Our preference, regarding the best access was clearly the traditional retropubical which allowed us on a preliminary bases a bilateral iliaco-otturatorial lymphoadenectomy with extemporaneus histological exams. Based on our experience we do not see an indication for a radical surgical intervention in the following with: P.S.A. higher than 60 ng./ml in patients with a clinical stage C. Positive abdominal-pelvical computer tomography for macrometastical lymph nodes. Positive bone scintigraphy. Patients over the age of 75 years.

Neurogenic urinary dysfunction in AIDS patients

From May 1992 to December 1993 (17 months), 18 patients with AIDS, 15 male and 3 female, age range from 25 to 50, were found to have severe voiding disorders related to neurogenic bladder dysfunction. All patients underwent neurologic, urologic and immunologic evaluation and were staged as AIDS-IVB. The neurological evaluation demonstrated: cryptococcal abscess of the brain in 1 patient, progressive and diffuse leukoencephalopathy in 3 patients, AIDS Dementia Complex in 3 patients and no neurologic abnormalities in 11 patients. The urodynamic tests demonstrated: detrusor areflexia in 5 patients, detrusor hyperreflexia with external sphincter dyssynergia in 5 patients, detrusor hyperreflexia with external sphincter dyssynergia and vesico-ureferai reflux in 1 patient, detrusor hyperreflexia without dyssynergia in 7 patients.

Trattamento con laser infrarosso endouretrale delle prostatiti croniche abatteriche riacutizzate

The Authors present a new infrared laser device with endourethral atraumatic optic fiber capable of effectively treating patients with newly acute chronic prostatitis. Cost-benefit ratio is excellent and the method is minimally invasive.

Le basi anatomiche della prevenzione dei danni neurogeni in corso di chirurgia radicale pelvica nella donna

Radical pelvic surgery in women is considerably handicapped by serious neurogenic complications, commonly due to lesions in the inferior hypogastric plexus or its branches, which cannot be easily identified in the female pelvic cavity. The pelvic cavities of 42 adult female cadavers were studied and the relations between the nervous structures and the cardinal and utero-sacral ligaments were analysed. The possibility of identifying and recognising in vivo anatomical findings of the pelvic plexus is the fulcrum of nerve sparing pelvic surgery.

[Involvement of the urogenital system in HIV virus infection]

Despite the genitourinary system is prone to infections by the Human Virus of Immunodeficiency, so far poor interest has been focused on urological manifestations of AIDS. We thoroughly reviewed the Literature and examined the different patterns of HIV infections on the kidneys, the prostate and the testes. An extensive description is given.

[Transvaginal echocystourethrography]

The anatomo-physiologic appearances of female urination obtained with a new ultrasonographic technique is illustrated. The technique is performed using an intravisceral linear probe positioned in the vagina and a special chair which allows the urination in physiological position; at the same time the urination is videorecorded. The results, compared with X-Ray cystourethrography, enabled us to show the normal aspects (both dynamic and morphologic) and several pathologic aspects. Basing upon the direction of the urethra, it is possible to establish the change of the position of the floor and the neck bladder, which are often responsible of stress incontinence. The Authors stress the relative simplicity and noninvasiveness of the echographic technique. X-Ray radiation aren't used: this test is particularly advisable to study the urination disease of women in fertile-age.

[Bladder leiomyoma. Presentation of a case]

After a brief review of the literature a case of leiomyoma of the bladder accidentally identified during endoscopy for prostatic adenomatosis is presented.