Proposal for a "European Scoring System for Laparoscopic Operations in Urology"

PURPOSE

To propose a scoring system of difficulties for the most currently performed laparoscopic procedures in urology.

MATERIALS AND METHODS

Each current laparoscopic procedure has been evaluated according to three different criteria: technical difficulty, operative risk and the attention required. Each criterion is scored from 1 (minimal impact of the criteria) to 7 (maximal impact of the criteria). The sum of the 3 criteria is used to classify each operation according to an increasing level of global difficulty, classified into 6 levels: easy (E: sum of criteria between 3 and 5), slightly difficult (SD: sum of criteria between 6 and 8), fairly difficult (FD: sum of criteria between 9 and 11), difficult (D: sum of criteria between 12 and 14), very difficult (VD: sum of criteria between 15 and 17), extremely difficult (ED: sum of criteria greater than 18).

RESULTS

Procedures currently performed by laparoscopy have been selected for evaluation according to the above criteria, and retrospectively validated by European experts in laparoscopic urology according to their experience and the international literature.

CONCLUSION

This proposal of a scoring scale system is a basis for discussion, teaching and learning of urological laparoscopy. By necessity, this scale is evolving and will be regularly reconsidered and updated every 5 years.

Transurethral electrovaporization of the prostate vs. transurethral resection. Results of a multicentric, randomized clinical study on 150 patients

AIM OF THE STUDY

To evaluate clinical, urodynamic efficacy and safety of TURP and TVP in patients with symptoms due to obstructive benign prostatic hypertrophy with a prospective multicentric randomized study.

MATERIALS AND METHODS

150 patients with BPH, urodynamically obstructed, were randomized to receive TURP or TVP. At the end of the recruitment phase, 80 patients underwent TURP and 70 patients underwent TVP. Patients were clinically evaluated by the I-PSS score at months 0, 1, 3, 6 and 12. Preoperative evaluation included complete blood routine examination, PSA, transrectal ultrasound and pressure/flow studies. Pressure/flow studies were also performed after 3 months.

RESULTS

There was no statistical difference between groups in any of the preoperative parameters. All patients were considered urodynamically obstructed at preoperative pressure studies. As for catheter days and hospitalization days, statistical differences between TVP and TURP were found; catheter days were 2.71 days (SE 0.12) in the TURP group vs. 1.9 (SE 0.24) in the TVP group (p < 0.000). Hospitalization was 4.7 days (SE 0.22) after TURP and 3.9 days (SE 0.24) after TVP (p < 0.000). Mean preoperative I-PSS score was 18.84 and 18.19 in the TVP and TURP groups, respectively. At 3, 6 and 12 months, IPSS was 5.52 and 5.50, 3.77 and 4.94, 3.52 and 4.04 for TURP and TVP, respectively. Mean preoperative peak flow rate (PFR) was 8.78 and 7.26 ml/s for TURP and TVP, respectively; after 3, 6 and 12 months, PFR was 19.21 and 18.8, 20.77 and 20.13, 20.30 and 20.31 ml/s, respectively. After 3 months, 6 patients in the TURP group (7.5%) and 7 patients in the TVP group (10%) were borderline obstructed. 1 patient in the TVP group (1.4%) was still obstructed and underwent TURP. As for complications, 4 patients (5.7%) in the TVP group had stress urinary incontinence after 12 months vs. 1 (1.25%) in the TURP group.

DISCUSSION

The present study clearly demonstrates that TVP is as effective as TURP in relieving urinary obstruction due to BPH, it offers some advantages in terms of catheterization and hospital stay, but at the price of a higher incidence of postoperative urine incontinence. Technical improvements might solve this problem in the future, perhaps combining TVP with TURP of the apical tissue.

[Urologic laparoscopy in day hospital]

Thanks to the less invasiveness that is the limitation of the surgical trauma, the utilization of laparoscopic techniques for managing a wide range of urological disorders has vastly expanded over the past five years. The advantages of less postoperative pain, shorter convalescence and decreased analgesic use collide with the high costs and the necessity of a proper training. Few cases are reported in the literature about urological laparoscopic procedures performed on an outpatient basis. This is due to the requirement of the general anesthesia in most cases with prolonged operative and anesthesiological times. Urological laparoscopic procedures are applicable on an outpatient basis only if the length of the surgery is less than two hours and the patients are able to collaborate and without concurrent medical problems. Therefore we think that the urological laparoscopic diagnostic procedures feasible on an outpatient basis could be: pelvic lymphadenectomy, identification of intra-abdominal testis and intersex, renal biopsy. Varicocelectomy, intra-abdominal orchiectomy, renal cyst resection, pelvic lymphocelectomy and bladder neck suspension can be performed as same-day surgery. We emphasize that the appropriate patient selection is critical: the ability of the patient and his family to care for the patient at home following surgery is of paramount importance in the decision to proceed with outpatient surgery. The availability of appropriately trained and experienced doctors and nurses are crucial for the potential postoperative complications.

Long-term results of intrarenal surgery for branched calculi: is such surgery still valid?

OBJECTIVE

To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy.

PATIENTS AND METHODS

Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex surgery for large stones, requiring opening of the renal pelvis and a transparenchymal approach to the calices; 47 renal units were operated in 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abdominal plain X-ray (44 patients), intravenous urography (42) and isotopic renography with renal scintigraphy (five). Renal lithiasis was categorized and all patients underwent extended pyelolithotomy with a transparenchymal approach, achieved by partial nephrectomy (six patients), radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segmentotomy and reconstruction (2); 16 operations were performed under ischaemia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (42), IVU (34), isotopic renography (eight), renal ultrasonography (eight) and blood pressure measurement (44). The mean follow-up was 14.8 years.

RESULTS

The major postoperative complications were; residual stones (six patients), fistula with ureteric stenosis (one, with a permanent nephrostomy), toxic temporary hepatic failure (one), femoral arterial embolism (one, resolved using a Fogarty catheter) and recurrent large stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 patients had recurrent stones and two underwent dialysis. In October 1996, the renal function of 47 renal units was stable or normal in 36 (77%), reduced in seven (15%) and lost in four (8%); 24 patients were hypertensive (12 preoperatively), nine have urinary tract infection, three are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units.

CONCLUSIONS

Intrarenal surgery, conducted using modern anatomical guidelines, was an effective treatment for renal branched stones. The long-term results are satisfactory after appropriate correction of the urinary tract, with the consequent prevention of stasis and chronic infection. The definitive comparison between surgical and combined endoscopic/extracorporeal methods will only become clear when there is a comparable follow-up. Currently, surgery remains preferable in patients with giant calculi, a small pelvis and prevalent calyceal development.

Variation in nocturnal urinary excretion of melatonin in a group of patients older than 55 years suffering from urogenital tract disorders

Melatonin (MLT) is directly or indirectly related to cell growth (both of normal and neoplastic cells), to the immune system stimulation and to the endocrine system modulation. This controlled study was carried out to evaluate urinary excretion of MLT in patients suffering from urogenital tract disorders. Eighty-one patients affected by urogenital disorders were divided in two groups (neoplastic and non-neoplastic) and urinary excretion of MLT was evaluated. Mean diurnal (from 8 a.m. to p.m.) urinary excretion of MLT was 4.97 + 6.08 pg/12 h in non-oncologic patients and 4.82 + 6.21 pg/12 h in oncologic patients (p = 0.50). Mean nocturnal (from 8 p.m. at 8 a.m.) urinary excretion of MLT was 11.97 + 9.34 pg/12 h in non-oncologic patients while in oncologic patients it was 7.86 + 8.95 pg/12 h. Statistically significant variation in nocturnal urinary excretion of melatonin was observed in oncologic patients (p = 0.022) versus non oncologic patients.

[Conservative therapy in renal carcinoma: follow-up]

Due to the increasing use of sophisticated imaging techniques, up to 30% of diagnosed renal cell carcinoma (RCC) are asymptomatic and diagnosed incidentally. Getting the cue from our personal survey of conservative renal surgery for renal cell carcinoma with a cancer specific survival of 95.5% after a mean follow up of 32.7 months, a review of the literature is illustrated: numerous studies have documented the technical success rate with this approach as well as long term disease free survival, comparable to that obtained by radical nephrectomy, in patients with unilateral, small, low stage tumors and normal opposite kidney. Patient selection is of extreme importance in case of partial resection in the presence of a normal contralateral kidney. The tumor must be < 3-4 cm, solitary, well delineated on CT, without invasion of the perinephric far or pyelocaliceal system (T1 and T2), easily resectable with at least 1 cm of healthy parenchyma. Only well informed patients who agree on a careful follow up after surgery can be candidates for kidney sparing surgery. In case of imperative surgery the follow up must be strict and personified for every single patient. Those patients who underwent a partial nephrectomy in presence of a normal contralateral kidney should be monitored with a conventional follow up monitored in order to detect an eventual local recurrence: 12 monthly ultrasonography and contrast enhanced CT scan alternately every 6 months for the first five years after surgery and then lifelong once a year by echography and/or CT scan.

[100 orthotopic neobladders in men after cystectomy: a 5-year experience]

Urethral bladder substitution is traditionally suggested to good prognosis cystectomized patients. In our series this diversion was chosen for all but the salvage cystectomized men. Between the 1st of February 1991 and the 30th of April 1996, one hundred consecutive men underwent lower urinary tract reconstruction after radical cystoprostatectomy for bladder cancer. An orthotopic ileal neobladder was constructed (in 84 cases according to Kock's technique and in 16 to Studer's technique). Total early complication rate was 29% (29/100), including one perioperative death due to sepsis (mortality rate 1%). 13 patients required surgery (6 retroperitoneal hematomas, 2 wound dehiscences, 1 urinary fistula, 1 lymphocele, 1 rectal-neobladder fistula, 1 rectal-cutaneous fistula, 1 necrosis of the terminal ureter). The late complication rate was 19% (19/100); in 8 cases reparative surgery was required (1 mechanical ileus, 2 bladder neck stenoses, 3 stenoses of the ureteral anastomosis, 2 laparoceles). Four patients were lost at the follow-up; out of the 96 remaining patients only 85 were evaluable for continence: continence during the day was achieved in a period between there to six months in 78 patients (91.7%); night continence was achieved with planned awakenings in 60 patients (70.5%). Eight patients recovered potency, another 7 had successful intercourses after PGE1 intracavernous injection. Renal function based on creatinine value was mildly impaired in 5/78 evaluable patients (6.4%) (peak creatinine 2.8 mg%). In 29 patients tumour progression was observed (29%): 9 pelvic and 20 metastatic. Among the latter 2 urethral recurrences were observed (2%). Twenty-four patients died for metastatic cancer, one for primitive lung cancer, one patient for postoperative septic shock. Adjuvant chemotherapy was administered in 11 patients without complication with an indwelling catheter in the neobladder to avoid drug reabsorption. Four patients showed complete response (2 are alive after a mean of 12 months), 6 were non responders and 1 had a partial response. In our series the ileal neobladder is a feasible method of urinary diversion when urethral cancer involvement is ruled out. Early and late complications are proportionally decreasing with experience and overall continence is satisfactory. The fate of the neobladder depends on both the technique and patient's compliance. Only educated patients can cope successfully with neobladder diversion without major complications. All the patients operated for non salvage cystectomy deserve to be diverted with a continent urethral bladder substitution.

Is laparoscopy a worthy method to treat varicocele? Comparison between 160 cases of two-port laparoscopic and 120 cases of open inguinal spermatic vein ligation

Because it is still a puzzling debate whether ligation of a unilateral varicose spermatic vein is worth performing by laparoscopy, even with the two-port technique, we conducted a study in which 280 patients with palpable left varicoceles were treated with spermatic vein ligation either by open surgery (120 patients) or by laparoscopy (160 patients). The inclusion criteria were the same for each group, and the two groups were homogeneous in preoperative clinical features and patient characteristics. The clinical outcomes were compared 6 months after surgery, and the costs of each treatment were analyzed. The procedures showed the same effectiveness and intraoperative safety. Open surgery scored a shorter operating time, whereas hospitalization was significantly shorter in the laparoscopic group. Postoperative complications occurred more frequently in the open surgery than in the laparoscopic group (7.5% and 0.6%, respectively). Of the patients treated, 197 were eligible for seminal analysis: 82 and 115 in the open surgery and laparoscopic groups, respectively. Significant improvement in seminal analysis was recorded in both groups, whereas no difference was found between the groups. Laparoscopy costs about 60% more than open surgery. It can thus be concluded that laparoscopy is not a worthy method to treat unilateral varicocele.

Incidental Prostatic Carcinoma

Incidental carcinoma of the prostate is defined as an incidentally detected cancer without any clinical manifestation, i.e. latent. Clinically, it is diagnosed mostly by TUR and is staged as T1a and T1b according to the TNM classification. There is clinical understaging, however, of up to 27% for T1a and 68% for T1b. Although the subdivision seems justifiable on the basis of the progression rates (8% and 63% respectively), it is not a useful indicator of the natural history of the incidental carcinoma. Pathological staging of TUR specimens is far from standardized, with regard to both the different sampling methods and the commonly-used classifications. Since the T1 staging system is based more on how the cancer is identified than on classifying its pathology, different methods should be used for a full clinical understanding of an incidental carcinoma. Distinguishing cancers as clinically important or not allows a better prognostic indication compared to the staging systems, which can still not be considered as precise indicators of whether to treat the cancer or wait and see. Unfortunately the true prognostic factors cannot be directly deduced from the currently used sampling methods of TUR specimens. A complete diagnostic assessment should be carried out after initial diagnosis of incidental prostatic cancer in order to appreciate its clinical importance. Basically both revision of the material by the pathologist and further clinical investigation are useful. Lastly, the need for close co-operation between urologists and pathologists should be stressed.

[T1G3 of the bladder: our experience]

From June 1991 to June 1995 we treated 20 patients affected by T1 G3 TCC of the bladder, 18 men and 2 women, with a mean age of 65.1 years (46-71). In 11 patients the disease was monofocal, with diameter of the tumor under 3.5 cms; in 5 patients monofocal with diameter of the tumor over 3.5 cms; in 1 patient multifocal and in 3 patients complex (mono or multifocal associated with CIS). The 11 patients with monofocal disease under 3.5 cms were treated with TUR-B, the other 9 (all males) were submitted to radical cystectomy with OINB diversion as first choice treatment. The mean follow up (all patients) was 3.2 years (6 months-14 years). Out of the patients of the former group only 3 did not show any relapse, the other 8 showed multiple relapses or metachronous tumors: 5 were treated with TUR-B+BCG, 3 were cystectomized. The patients submitted to cystectomy as first choice treatment did not show any progression of the disease after a mean follow-up of 19.8 months.

I presupposti di una comunicazione scientifica: “Come si archiviano i dati clinici”: Premises for a scientific report: “How to file the clinical data”

Clinical data are filed to be retrieved whenever they are needed. They must comply with the following requisites: give access to all information regarding the matter of the study, be easy to record, be easy and quick to recover and offer the possibility of correct, easy analysis of the actual data. To identify the clinical data filing methods, it is necessary to identify the purpose for which the data are filed, what must be filed and the media available. The reasons are: to keep a record of patient data for clinical purposes; as a diagnostic and therapeutical reference for the medical examiner, and to recover data for a clinical review for scientific purposes. Depending on the purpose the collection of data should be organised by choosing both the type of data to be filed and exactly what should be filed from a data record. Records may be classified into 4 main types: numerical, logical, imaginal, descriptive: it should be borne in mind that a descriptive and/or statistical analysis is impossible when data filed are not digital or logical records. There are basically two means of filing: on paper and on a magnetic medium. Paperwork requires a copy of data and different filing methods depending on its future use, while direct filing of data on a magnetic medium by computer enables work to be optimised: just one recording/filing of data serves for any future purpose. Filing on a magnetic medium is good training for the work optimization because the collection of data must be organized in advance. This method offers excellent results and certainty, plus saving of time and resources. Filing on a magnetic medium is therefore the ideal method for organizing both clinical and scientific work.

[Alpha blockers, TUS-P and TUR-P in the treatment of benign prostatic hypertrophy. A comparison using multivariate statistical analysis]

To evaluate the effectiveness of Alpha-blockers, TUI-P and TUR-P in the treatment of obstruction due to BPH, 50 patients, never before treated, were considered. Fifteen were treated with alfuzosin chlorhydrate 7.5 mg/day for four months, 15 were submitted to TUI-P and 20 to TUR-P. In all patients linear purr was carried out before treatment and was repeated from 60 to 90 days after intervention in surgical patients and during the fourth month of treatment in patients treated with alfuzosin. The data obtained were analyzed with the T-test both for dependent and independent samples. The results show that Alpha-blocker contain an increase in maximal flow, without decreasing bladder voiding pressures. On the contrary TUI-P and TUR-P, besides the increase in maximal flow obtain a significant reduction of bladder pressures. The conclusions are the following: maximal flow alone is not a sufficient parameter to evaluate the work of the bladder, the entity of the obstruction and the effectiveness of the therapy. The treatment with Alpha-blockers is unable to reduce the obstruction due to BPH. TUI-P and TUR-P realize an effective deobstruction. Under the same deobstructing effect TUR-P assures a better voiding performance by obtaining higher flow values.

[Physiopathology of BPH obstruction]

The underlying BPH related mechanisms of outlet obstruction are outlined (modification of the shape of the bladder neck, failure of funnel formation, geometric variations of the urethra, alpha 1 adrenoceptors mediated sympathetic hyperactivity at the level of the lower genito-urinary tract). Bladder voiding dysfunction in response to prostate obstruction is also discussed and correlated to ultrastructural patterns and clinical symptoms. Finally, a pathogenetic mechanism for detrusor overactivity in obstructed bladder is suggested.

Retroperitoneoscopy

From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.

[Familial multiple bilateral carcinoma of the kidney: clinical strategy and surgical approach]

A case of familiar bilateral multicentric RCC in a young woman is an ideal model to evaluate preoperative and intraoperative diagnostic and surgical tools in order to achieve two distinct goals: the oncologic radicalness and the renal function preserved. Radical bilateral nephrectomy, the renal hypothermia by perfusion of both kidneys, the bench high resolution sonography of parenchyma, the choose of one kidney suitable for conservative surgery, the resection of suspect lesions with intraoperative pathology, the reconstructive bench surgery, the autotransplantation, are the steps accurately performed with particular concern to eradication of all the tumoral lesions present in the kidneys. The results confirm that renal function has been preserved with this method. Radicalness should be appointed by a longlasting follow up. However, as it is discussed, conservative surgery, when accurately performed can give results not different from radical demolitive surgery. In this paper tools to improve diagnostic and therapeutic methods are described in order to increase the diagnostic accuracy and the therapeutic efficacy. The possibility that this multiple RCC can be a part of the abnormalities occurring in the Von Hippel-Lindau syndrome does not change the surgical approach, being the RCC the worst prognostic factor of the syndrome.

[Retroextraperitoneal laparoscopic nephrectomy]

The authors describe a new technique of laparoscopic nephrectomy; the retroextraperitoneal approach has been successfully performed in 4 patients with the following indications: 2 non functioning hydronephrotic kidneys, 2 atrophic chronic pyelonephritic kidneys. The patient was put in a proneoblique position after the retrograde placement of a ureteral catheter up to the renal pelvis, through which the contrast medium was injected. The Veress needle is inserted under fluoroscopic guidance into the perirenal fatty space which was insufflated with CO2. One 12 mm and three 10 mm Trocars were inserted into the cavity created by gas in the trapezoid area whose boundaries are: the 12th rib, the iliac crest, the posterior axillary line and the sacrospinalis muscle. The kidney was progressively dissected free with the traditional laparoscopic instruments (forceps and scissors). The artery has always been closed with clips. In two patients the vein has been stapled and cut with EndoGIA. After the section of the clipped ureter the kidney was removed en block by pulling it out through the 20 mm Kleiber Trocar in two cases and in the other two cases by extending to a length of 4 cm the port of one Trocar. The average total operating time was 4.35 hours and blood loss < 200 cc. The patients were all discharged on the fourth postoperative day. The advantages of the retroextraperitoneal approach with respect to open surgery are synthetically the following: a less traumatic and a more accurate dissection almost always bloodless; a shorter hospitalization period; an almost painless postoperative course.(ABSTRACT TRUNCATED AT 250 WORDS)

[Ligation of the internal spermatic vein through 2 laparoscopic ports]

Thirty-three two port laparoscopic internal spermatic vein ligations have been performed in 31 patients in our Department. The procedure carried out through two 10 mm ports in a mean time of 25 minutes decreases both the invasivity of intervention and the costs when reusable instruments are used. The technique is feasible with an operative laparoscope (working channel diameter 4 mm) through which a grasp can be maneuvered. The two port procedure is as safe as the three port procedures. Preliminary follow up indicated only one recurrence of varicocele (4%). Out of the 19 patients treated for male subfertility who have at least a 6 month follow up, eleven reported an improvement in seminal quality. All the patients but one were discharged on the first postoperative day. Laparoscopic internal spermatic vein ligation provides a real alternative to different surgical techniques decreasing postoperative pain and shortening period of convalescence with immediate return to full activity. The advantages of laparoscopic internal spermatic vein ligation are increased with the two port procedure.

[Adjuvant interferon alpha in renal carcinoma with a high risk of recurrence. Multicenter pilot study]

Twenty-eight consecutive patients submitted to radical nephrectomy for Robson's stage II-III renal cell carcinoma underwent adjuvant recombinant a-2b interferon, 5 MUI s.c. 3 times a week, for 6 consecutive months. Home-feasibility of this therapy resulted easy. The most frequent acute (flu-like syndrome) and late (myalgia, fatigue, anorexia) side effects did not affect normal daily life of patients. Eight (28.5%) patients had WHO grade < or = 2 biochemical and hematological toxicity, that normalized after a reduction or a temporarily suspension of therapy. Twenty-seven patients were evaluable for response. Out of these, 7 (26%) relapsed after a 16 months median follow-up.

Round Table: “Urinary diversion” - Prevention of complications

— The Authors take into consideration the different techniques of urinary diversion; in the light of their findings, they reviewed the most important complications following urinary diversion and the possibilities of their prevention.

Long-term followup after extracorporeal shock wave lithotripsy treatment of kidney stones in solitary kidneys

A total of 64 treatments by the Dornier HM3 lithotriptor was performed on 52 solitary kidneys with stones. A slight increase but no significant variations in serum creatinine was noted in 15 patients without obstruction just after treatment (p greater than 0.05). No significant increases in serum creatinine were found even at the short-term, mid-term and long-term followup. After 12 to 56 months hypertension developed in only 1 previously normotensive patient. Of 37 patients at mid-term followup (12 to 24 months) 62% were stone-free, 24% had passable fragments, 8% had recurrent stones and 5% had regrowth of the residual fragments. At long-term followup (24 to 56 months) 50% of 26 patients were stone-free, 19% had dust or passable fragments, 19% had recurrences and 11% had regrowth of the residual fragments. The demonstrated effectiveness, small number of complications at the short-term followup, lack of sequelae at the long-term followup and relatively small number of recurrences confirm that extracorporeal lithotripsy is not only effective but also safe. It can be proposed as the treatment of first choice even when the stone is in a single remaining kidney.

[Recurrence of lithiasis after extracorporeal lithotripsy, percutaneous surgery, and open surgery for calculi of the upper urinary tract]

The safety and short-term effectiveness of percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL) have already been well established. However, long-term follow-up studies are essential to prove that the recurrence rate after PCNL and/or ESWL is equal or even better than that of surgery. We reviewed 57 patients treated with ESWL monotherapy, 45 patients treated by PCNL (or by PCNL combined with ESWL for complete staghorn stones) and 59 patients treated by open surgery who all had at least three years of follow-up. The overall recurrence rate for ESWL was 37% for PCNL and for open surgery 39%. ESWL, PCNL and open surgery all showed a higher rate of recurrence and persistent bacteriuria when associated with residual stones. Therefore every effort should be made to remove residual fragments following stone treatment. We conclude that because of its efficacy and low morbidity ESWL should be the treatment of choice for most of renal calculi. Complete staghorn calculi are best treated with open surgery because the complete elimination of all calculous material and the eradication of infection are achieved at a higher rate than by PCNL and ESWL.

A randomized trial of flutamide alone versus orchidectomy and flutamide in the management of advanced prostatic cancer

We included in a controlled study 38 consecutive patients aged up to 75 with newly diagnosed cancer of the prostate suitable for hormonal treatment (stage C-D). Patients were randomized to receive either flutamide and orchidectomy or flutamide alone. After 4 years the survival rate for the orchidectomy plus flutamide group (53%) appears to be better than for the group with flutamide alone (40%).

Urinary excretion of citrate, glycosaminoglycans, magnesium and zinc in relation to age and sex in normal subjects and in patients who form calcium stones

One hundred and ninety-seven healthy subjects and 104 patients with idiopathic calcium stone disease had their urinary excretion of citrate, glycosaminoglycans, magnesium, and zinc measured and the results correlated with sex and age. In normal subjects the daily excretion of citrate, magnesium, and zinc increased with age to a maximum during the fifth decade and remained relatively constant until the eighth decade when they decreased. The daily excretion of magnesium and zinc were higher in men than in women, which was attributed to the higher body weights of the men. The urinary excretion of citrate, magnesium, and zinc related to creatinine remained relatively constant with age in adult life; analyses of magnesium and zinc excretion rates divided by urine creatinine did not distinguish men from women. There was no significant difference between men and women for citrate excretion in 24 hour urine, but the citrate:creatinine ratio was significantly higher in women than men. The higher citrate excretion in women may explain the lower incidence of calcium stones in women. The highest glycosaminoglycan excretion rates were seen during the first two decades which is why children and teenagers are less prone to develop calcium stones in spite of high urinary calcium concentrations. Urinary citrate and magnesium excretion were lower, and glycosaminoglycan and zinc excretion were higher, in stone formers than in controls. It seems that a decreased excretion of citrate and magnesium together with an increased excretion of calcium, may contribute to the formation of calcium stones. The role of urinary glycosaminoglycans and zinc in the formation of calcium stones remains uncertain.

[Interleukin immunotherapy of progression]

IL-2 is a lymphokine which as variety of in vivo immunomodulatory effects. The administration of IL-2 can mediate enhancement of cellular immune response, induction of lymphocyte proliferation and production of cytokines. The availability of large quantities of recombinant IL-2 has enabled investigator to examine its therapeutic potential, with of without lymphokine-activated killer cell, in the treatment of metastatic renal cancer. Several studies have documented the ability of IL-2 administration to cause durable tumor regression in a good percentage of patients. Otherwise there were a number of problems which had to be resolved. First, the high-dose bolus or low-dose continuous infusion? Indeed, administration by the intravenous or subcutaneous routes? Last but non least, what is the place of lymphokine-activated Killer cells? Toxicity of therapy is dose related and is mediated by a vascular capillary leak syndrome, lymphocytic infiltration and the release of cytokines secreted in response to IL-2 administration. The side effects are completely reversible upon cessation of therapy. The patients undoubtedly require much more careful monitoring than with standard oncological treatments but rapid recovery of the preexisting conditions before therapy suspension must certainly be stressed.

[Adjuvant chemotherapy]

The authors treated 10 advanced renal cell carcinoma with circadian venous continuous infusion of 5-Fluoro 2-Deoxyuridine (FUDR). The drug was delivered by Medtronic Synchromed implantable pump in 14-day cycles alternating with 14-day intervals of physiologic saline infusion. Of the patient observed for at least 8 months (range: 8-32, median: 22.1) 1 showed progression. Circadian continuous central venous infusion of FUDR is minimally toxic. The FUDR can be delivered safely and conveniently in this way for long spans. This therapy is administrated in on entirely out patient setting, and associated with a normal quality of life.

The influence of diet on urinary risk factors for stones in healthy subjects and idiopathic renal calcium stone formers

The daily intake of 103 recurrent idiopathic calcium stone formers and 146 controls was assessed by means of a computer-assisted 24-h dietary record. Timed 24-h urine samples were collected over the same period to assess the relationship between dietary intake of nutrients and urinary risk factors for calcium stones. After standardisation for sex, age and social status a total of 128 subjects underwent final statistical analysis; 64 renal stone formers and 64 controls. Significant increases in the consumption of animal and vegetable protein and purine were identified as the nutritional factors that distinguished renal stone formers from controls. As expected, the daily urinary excretion of calcium and oxalate was higher and the daily urinary excretion of citrate was lower in stone formers than in controls. No difference with respect to daily urinary uric acid excretion was recorded. Daily urinary excretion of calcium was correlated to dietary protein intake while daily urinary oxalate was correlated to dietary vitamin C intake. It was concluded that renal stone formers could be predisposed to stones because of their dietary patterns. A link between the protein content of the diet and urinary calcium was confirmed, but dietary animal protein had a minimal effect on oxalate excretion.

Secretory immunoglobulin A and inhibitory activity of bacterial adherence to epithelial cells in urine from patients with urinary tract infections

To assess the role of local immune response against bacterial invasion of the urinary tract we studied 168 patients with bacteriuria. Urinary secretory immunoglobulins A (sIgA) were measured using radial immunodiffusion or enzyme-linked immunosorbent assay (ELISA). In particular, ELISA is a very suitable assay for measuring the low levels of sIgA in urine. Furthermore, we used a quantitative in vitro adherence assay to investigate the attachment of Escherichia coli to human uroepithelial cells after incubation in urine from patients with urinary tract infection. Urine from patients with ileocystoplasty was significantly more potent in inhibiting bacterial adherence than was urine from other groups of patients with urinary tract infection. The presence of high urinary sIgA may help explain the increased antiadherence activity of urine in patients with ileocystoplasty. Mean urinary sIgA in patients with upper urinary tract infection was higher than in patients with uncomplicated infection in the lower urinary tract. Alterations in mucosal immune functions may account for the propensity toward bacterial colonization in women prone to uncomplicated urinary tract infection.

Urinary NAG excretion after anesthesia-free extracorporeal lithotripsy of renal stones: a marker of early tubular damage

Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biological side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lithotripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments.

[Neoadjuvant chemotherapy using methotrexate and cisplatin in locally advanced urothelial cancer of the bladder]

Thirty-one consecutive patients with clinically and histologically documented urothelial cancer of the urinary bladder of category T3-T4a, N0, M0 underwent a trial of neoadjuvant chemotherapy before radical cystectomy. All patients received 2 courses of methotrexate 300 mg/m2 day 1 followed by folinic acid rescue days 2 and 3 and cisplatin 100 mg/m2 day 4, q. 3 weeks. Only responders were to receive 2 further courses of chemotherapy. The protocol was violated in 5 cases and all did poorly. Of the remaining 26 patients, 19 (73%) had a partial or complete remission to neoadjuvant chemotherapy. The actuarial disease-free survival was very encouraging at 18 months (87% for responders versus 43% for the 7 non responders), but at 30 months the difference became minimal (60% versus 43%). Furthermore, all 3 responders who had refused radical cystectomy relapsed locally. Postoperative randomized trials are necessary to prove the advantage of neoadjuvant therapy with a long term survival and bladder preservation.

[Neoadjuvant chemotherapy of locally advanced tumors of the bladder: introduction]

The locally advanced bladder cancer cannot be cured only with cystectomy: in this case the surgery has a palliative meaning and do not relieve the patient from the disease. Adjuvant or neoadjuvant treatments have been proposed to transform a palliative treatment in a curative method. Mainly radiotherapy and chemotherapy have been performed to achieve this goal. In fact radiotherapy failed to cure the locally advanced bladder cancer but in increasing survival in T3 cystectomized patients. So far chemotherapy with MP and M-VAC regimens demonstrated a good efficacy in achieving an early response rate in advanced diseases. In many urological centers chemotherapy has been carried out before cystectomy in order to have a pathological control of the response when cystectomy had been performed, and to verify an hypothetical increase in survival rates. The experiences among a group of urologists in Lombardy are reported in this issue. The preliminary results and the problems arisen in treating such patients and in following up both the cured and the relapsing patients are reported in short papers. The clinical problems are further discussed in the final panel discussion.

[A new classification of reno-ureteral lithiasis]

The Authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p, s, m, i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters "l, i, p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract; "+" and "-" indicate the presence or absence of dilatation, the small letters "e, i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3, refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.

[An overview of extracorporeal lithotriptors in current clinical use: technical notes]

ASWL ten years ago opened a new era for kidney stone treatment and recently it's showing a new therapeutical approach to biliary stones. Dornier HM3 is since 1983 the first lithotripter with a wide clinical employment. Actually we know about twenty extracorporeal lithotripter in clinical use. Our review try to classify old and new extracorporeal lithotripsy devices looking at technical aspects and lithotripsy center organization.

[Enoxacin in the treatment of bacterial prostato-cystitis]

Thirty-three patients suffering from acute, subacute or chronic prostatovesiculitis were admitted to an open, non comparative trial. Enoxacin was administered at the daily dosage of 400 mg every 12 hours for 10 days starting from the enrollment. A second cycle of treatment was performed if cure was not obtained with the first cycle. Treatment efficacy was established by assessing patient symptoms related to the infection, such as pollakiuria and dysuria, consistency and volume of prostate and spermatic vesicles (evaluated by rectal examination and transrectal ultra-sonography); bacterioscopical and bacteriological evaluations of prostate/vesicles secretion with sensitivity testing were also carried out. All observations were collected at baseline, 5 and 30 days after the end of the first cycle and 5 days after the end of the 2nd cycle of treatment. After the first cycle of treatment, cure was obtained in 22 subjects (67%) and clinical improvement in 24 (73%). All but one patients still infected at the end of the first treatment period, showed improvement (5; 45.5%) or cure (6; 54.5%). The end of the second cycle None of the 22 patients cured with one cycle of treatment relapsed within 30 days after the end of treatment, confirming they really achieved cure. Side effects were observed only in 1 case (mild vertigo); no drop outs were observed. These results suggest that enoxacin may be successfully used in the treatment of prostato-vesiculitis.