[Partial elective nephrectomy]

INTRODUCTION

Partial nephrectomy is widely accepted as a therapeutic modality in renal cell carcinoma (RCC) in patients with single kidney, bilateral tumor or deteriorated renal function. Currently, long-term survival studies have consolidated partial nephrectomy as the treatment of choice for RCC in selected patients with normal contralateral kidney.

MATERIAL AND METHODS

Between July 1990 and January 2008, a total of 102 partial nephrectomy were performed on 100 patients with pre-operative ultrasonography diagnosis of renal carcinoma in 94 cases and complex renal cysts in 6 cases. The pre-operative ultrasonography size varied from 1.5 to 10 cm with an average of 4.85 cm.

RESULTS

Tumor size was correlated with the pathological stage, finding tumors in stage pT1 with sizes less than and greater than 4 cm in 74% and 64%, respectively, and in stage pT2 of 3.7% and 5.4%. Tumor size measured by pre-operative CT scan was compared with the definitive size of the pathology specimen in 93 cases (56<4 cm and 37>4 cm, according to the CT scan). We found high concordance, however in the larger tumors, there was a tendency of the CT scan to overestimate the size. A post-operative gamma scintigraphy with DMSA was performed in 40 patients. The values in the tumors <4 cm (21 patients) were 12-77% (average 43.3%). In tumors between 4 and 7 cm (17 patients), the values were 13.8-53.3% (average 37.6%) and in 2 cases of tumors >7 cm the post-operative DMSA showed 47.5 and 51%.

CONCLUSIONS

Partial nephrectomy is currently accepted as elective treatment in incidental kidney tumors less than 4 cm and it is indicated increasingly more frequently in larger tumors and of central localization. The finding of benign pathology in the anatomic-pathology specimen in up to 20% of the incidental renal tumors and low potential of malignancy of the possible satellite lesions in the remnant kidney also support nephron-sparing surgery in these tumors.

MRI in the diagnosis of testicular Leydig cell tumour

We report the appearance of three cases of Leydig cell tumours on MRI. This imaging method showed well-defined and peripheral intratesticular tumours displaying marked and homogeneous enhancement when contrast medium was used. This latter finding was only observed in Leydig cell tumours when they were compared in a series of 104 patients with different scrotal pathologies.

Renal smooth muscle tumor with features of lymphangioleiomyomatosis. Problems in histological diagnosis

A 44-year-old woman with left kidney tumor involving the perirenal and retroperitoneal lymph nodes is presented. Imaging findings including ultrasonography and computerized tomography showed renal and para-aortic masses and no features of lymphangioleiomyomatosis or angiomyolipoma were seen. The histopathological examination was considered as a renal smooth muscle tumor with features of lymphangioleiomyomatosis. Diagnosis considerations, particularly histopathological, immunohistochemical and hormonal studies are discussed and we comment the distinction of this case from the benign mesenchymal tumors.

T1 GIII bladder cancer. Management with transurethral resection only

OBJECTIVE

Transurethral resection (TUR) is the elective procedure in the treatment of superficial bladder tumor. The association of intravesical chemotherapy has no influence on survival and cause specific survival. This study was carried out to determine the evolution of T1 GIII bladder carcinoma treated with TUR only.

PATIENTS AND METHODS

We retrospectively reviewed the records of 42 consecutive patients with T1 GIII bladder carcinoma. Follow-up was available for 34 patients. No patient received either adjuvant or neoadjuvant therapy. All the patients were treated with TUR only and followed for a median of 40 months. They were followed by cystoscopy, urinary cytology and intravenous urography.

RESULTS

Forty-seven percent of patients had a solitary tumor while 53% had multiple tumors. Tumor recurrence occurred in 50% with a disease-free interval until the first relapse of 9.6 months. Progression of the primary tumor was observed in 23.5% of patients. The overall survival rate was 73.6% and the cancer-specific survival estimate was 88.2% at mean 36 months of follow-up.

CONCLUSIONS

T1 GIII bladder carcinoma may be treated initially with transurethral resection only with acceptable recurrence and progression rates. This would avoid costs and complications of the adjuvant/neoadjuvant therapies.

[Cushing syndrome caused by macronodular hyperplasia ACTH-independent]

Case report of a 49-year old male patient who presented with signs and symptoms in agreement with Cushing's Syndrome, the etiology of which was shown to be an ACTH-independent macronodular hyperplasia. In such cases, the therapeutical choice is bilateral adrenalectomy which was adopted by us using a posterior approach. The relevance of the clinical diagnosis and therapeutical aspects of this condition are reviewed.

[PSA levels and its relationship with digital examination, age, and score of prostatic symptoms]

Between November 1992 and March 1993 our Service conducted a campaign for early detection of prostate disease among the male population of Vigo. The study focused in the relationship of PSA with the age, rectal examination and prostate symptomatology score. In view of the results obtained it has been concluded that PSA levels increase gradually as a function of age, volume and prostate symptomatology score.

Adenomatoid tumor of intratesticular localization

The germinal cell tumor represents the most common malignancy of the testicular tissues. Benign testis tumors are exceptional, and in this situation organ preservation should be considered. The adenomatoid tumor is the most common paratesticular type with anatomic distribution limited to the epididymis, testicular membranes and rarely to the spermatic cord. Its intratesticular localization is very rare. We report here the clinical case of a 32-year-old man with a testicular tumor who came to our department with a 6-month growth of a testicular mass (normal alpha-fetoprotein and beta-HCG). The pathologic report revealed a solid and small tumor at the lower pole of the testicle with total intratesticular tumor growth (adenomatoid tumor of intratesticular localization). Because of its rarity, the clinical, diagnostic and therapeutic aspects and the possibilities of testicular preservation are discussed.

[Radical surgery of locally advanced prostatic cancer]

Retrospective study in 51 patient with locally advanced prostate cancer (34 pT3 and 17 N+) selected from 88 radical prostatectomies performed between February 1985 and December 1993. An evaluation is made of the clinical/pathological stage correlation and the effectiveness of the different diagnostic methods (61% of understaging). The possibility to rescue locally spread tumours is analyzed, 7/51 (13.72%) patients receiving pre-operative neoadjuvant hormonal therapy. Estimated survival at 8 years was 82.6% of all patients treated with radical surgery and, at the end of the study, the situation of 30/46 (65.2%) patients assessed by digital rectal examination, quality of life index, PSA follow-up, abdominal ultrasound and/or CT, bone scan and chest X-ray, was an estimated 8-year disease-free evolution. It is observed that radical surgery and the post-surgical hormonal approach permit good survival in locally advanced prostate cancer and that the use of a neoadjuvant hormonal approach permit good survival in locally advanced prostate cancer and that the use of a neoadjuvant hormonal approach allows in many cases the rescue of patients for radical surgery.

[Enzyme-induced masculinization]

Contribution of two cases of congenital adrenal hyperplasia by blockade in the 21-hydroxylase enzyme synthesis. Diagnosis was reached from the clinical signs and symptoms (virilization syndrome), and was confirmed by radiological and laboratory tests. Hormone treatment was done with hydrocortisone and fludrocortisone, but surgical correction of external genitalia was required to improve cosmetic appearance.

[Conn's syndrome]

Adrenal hypertension is an uncommon phenomenon. When seen in association with hypokalemia the existence of primary aldosteronism, the most frequent cause of which is an adenoma of the adrenal gland cortex, should be suspected. This paper contributes one case of primary aldosteronism treated by unilateral resection of the adrenal adenoma, with no surgical complications and good medium-term results.

[Acquired cystic renal disease. Association with hypernephroma]

Emergence of multiple bilateral renal cysts observed in patients undergoing periodic haemodialysis is 40%. The pathology, known as Acquired Cystic Renal Disease (A.C.R.D.) presents a high association to renal cancer. Two cases of A.C.R.D. and their association with hypernephroma, one resulting in secondary retroperitoneal haemorrhage and the other in intracystic haemorrhage, are presented. Forms and diagnosis are analyzed, insisting upon the need of monitoring the patients in haemodialysis from the point of view of tumour emergence.

[Adenocarcinoma in bladder. Apropos of a case]

Finding an adenocarcinoma at the vesicle suggests three possible diagnosis: Intestinal adenocarcinoma with vesical location. Adenocarcinoma of the urachus. Vesical primitive adenocarcinoma. Presentation of one case of intestinal adenocarcinoma, revealed by its mictional symptomatology, with the endoscopic appearance of being a single vesical tumour, later shown to be a vesical adenocarcinoma, on which extended surgery of the gut and partial surgery of the bladder was performed.

Bone biopsy in solitary lesions on bone scan in genitourinary malignancy

In the course of stagging for genitourinary malignancy, we identified 9 patients with asymptomatic bone lesions. Biopsies were taken in all cases. In 5 patients, biopsy revealed Paget's disease and, in 3 others, a solitary bone metastasis was confirmed, which demonstrates the utility of this method by avoiding unnecessary, high-risk surgical procedures. In 1 patient the biopsy was normal.

[Leydig's cell tumor with endocrine syndrome: presentation of a case and review of the literature]

We present a case of Leydig's cell tumour in a young adult, with endocrinal manifestation. The relative rarity of these neoplasias. The opposition of their clinical manifestations, virilizing in the child and feminizing in the adult. Its always benign evolution in infancy and its occasional malignity in the adult (20%) are commented on and reviewed.

Treatment of transitional cell carcinoma of the ureter: is the controversy justified?

Between 1938 and 1985, 73 patients with ureteral tumors underwent surgery at Puigvert Foundation (1 case with bilateral synchronous tumors). Sixty-three patients were males and 10 females. Ages ranged between 49 and 78 (mean of 62) years. Tumoral stages were: pTa 5 cases; pT1 56 cases; pT2 10 cases, and pT3 2 cases. Radical treatment was performed in 38 cases and conservative treatment in 35 cases. Follow-up ranged between 2 and 20 (mean of 7) years. The overall survival rate at 5 years was 100, 82 and 50% for stages pTa, pT1 and pT2-3, respectively (p less than 0.05). Analyzed together, the actuarial survival at 5 years was 90.3% with conservative surgery and 67.8% with radical surgery (p not significant). The survival by stages for the patients treated with radical surgery was: 100% in pTa; 69.6% in pT1, and 57.1% in pT2-3. For those treated conservatively, survival was 100% in pTa, 95.8% in pT1 and 33.3% in pT2. Thus patients presenting with infiltrating tumors should not be treated conservatively, while patients with superficial lesions had a similar evolution whether treated by conservative or radical surgery.

[Value of LDH in the diagnosis of pseudocystic renal cancer]

An asymptomatic case of cystic renal carcinoma is presented. The only diagnosis of certainty was given by a marked increase in L.D.H. levels in the fluid of the tumor after puncture. The pros and cons of imaging studies, and the relative lack of value of aspiration cytology when negative results are encountered are discussed. The pathological anatomical findings of the nephrectomy sample certified the diagnosis, showing the presence of a pseudocystic adenocarcinoma due to intratumor necrosis.

[Our experience in the treatment of superficial cancer of the bladder with BCG]

We report on our experience with 21 patients with superficial bladder cancer who were treated with intravesical BCG instillation. The BCG vaccine was effective in the treatment of carcinoma in situ. Tumor regression was achieved in 83.3% at 3 months, and 61.1% at 24 months. It is advisable to follow patients closely because of the possibility of tumor progression.

Correlation between tissular levels of prostatic acid phosphatase and prostate-specific antigen and hormonal response of metastatic prostatic cancer

A correlation between the serum levels of testosterone and the tissular intensity of prostatic acid phosphatase (PAP) and prostate-specific antigen (PSA) in normal prostates has been demonstrated. In prostatic cancer patients, we studied the correlation between the percentage of neoplastic cells secreting PAP and PSA and the response to androgen deprivation, and found no relationship between them. Therefore it is not possible to predict the response to hormone therapy through the grade of tissular PAP or PSA.

Value of radical cystectomy in bladder cancer with pelvic node involvement

Of the 241 patients with bladder cancer treated with cystectomy and urinary diversion between January, 1978, and May, 1985, pelvic lymphadenectomy was performed in 150. In 41 of the 150 patients, pelvic node involvement was shown in the pathology study (27%). The preoperative clinical stages showed bladder muscle invasion in all 41 cases. Node invasion was found in 16/77 cases with radiation therapy and in 25/73 cases without radiation therapy (p less than 0.05). Operative mortality was 3 cases (7.3%). Of the 38 patients who survived the operation, 35 (94%) died of cancer within an average of 8 months. Twenty-seven showed 1-3 pelvic nodes involved, 7 showed 4-6, and 4 patients had more than 6 nodes involved. These differences between survival rates are not statistically significant (p = 0.35). Two patients died of a disease not related to the tumor, and only 1 is alive 4 years after operation (2%).

Percutaneous transuretero-ureterostomy in situ

Endourological techniques allow one to postpone a second, planned intervention--urinary diversion to the intestine--in radical cystectomies with a high surgical risk. PTU consists in introducing one nephrostomy tube percutaneously through one kidney and replacing it by the definitive drainage tube during the surgical procedure after suturing both ureters together.

Place of cystectomy in superficial bladder cancer

Between January 1978 and June 1985, 44 patients underwent cystectomy for clinically diagnosed superficial bladder cancer. Operative mortality was 13.6%. Early and late complications were observed in 34 and 55% patients, respectively. Clinical understaging was seen in 23%, and stage reduction in 18% of the patients. Clinical staging was correct in 59% of the patients. The mean follow-up was 40 months (range, 24-84 months). Five patients presented local recurrence (13%) of the tumor and 10 patients showed distant metastases (26%). Urethral and upper urinary tract recurrences were observed in 7 and 4 patients, respectively. Fourteen patients (39%) died of cancer after a mean follow-up of 24 months. The actuarial 5-year survival was achieved by 77% of the patients with PTo-PTa-PTis and by 67% of the patients with PT1 (p, not significant).

Balanitis xerotica obliterans: surgical treatment

A case of BXO treated with complete surgical removal of the mucosal lesion and skin flap meatoplasty with excellent results 26th months later is reported.

Fiberendoscopy in the diagnosis of the pathology of the ileal conduit

The advantages of the exploration with flexible fiberendoscopy in the pathologies of the ileal conduit, as in hematuria, are commented. The method to be followed, as well as the results of the explorations in 2 patients are evaluated. This method has proved to be highly advantageous compared with the standard methods.

Nuclear magnetic resonance in advanced prostate cancer (stage D)

Nuclear Magnetic Resonance (NMR), a recently developed diagnostic method, has proved to be useful in the study of patients with prostatic disease. The authors report their experience with this technique in 10 cases of advanced prostate cancer (stage D) treated with LH-RH agonists (HOE 766-Buserelin). NMR provided information on the size of the prostate, the invasion of the vesical floor and seminal vesicles and the involvement of the pelvic and retroperitoneal nodes. It was also useful for ruling out metastases in the pelvis and spinal column, and showed an excellent correlation with the bone scan. In 2 untreated cases, NMR was sufficient by itself to diagnose metastatic prostate cancer. However, given the current lack of experience, it is not yet possible to draw conclusions concerning the superiority of this technique over other methods in the diagnosis and staging of prostatic carcinoma.

Fibrous polyp of the ureter

The most frequent ureteral tumors are transitional carcinoma. Benign neoplasms are uncommon. In this paper we present 6 cases of ureteral polyps, which represent 11.1% of all the tumors in our series of ureteral tumors. We have reviewed the possible etiopathogenesis and exposed the clinical characteristics. Secondary to the obstructive phenomenon and the radiologic signs, it is the tigroid appearance, the localization and the absence of total obstruction which allows the diagnostic suspicion. The treatment of choice is partial resection. Ureterostomy with peroperatory biopsy, in cases in which the malignancy is not yet established, is recommended in order to avoid unnecessary nephroureterectomies.