Phase II Study with Lonidamine in the Treatment of Hormone-Refractory Prostatic Cancer Patients

Twenty-one patients with metastatic prostate cancer who had become refractory to hormonal therapies received lonidamine (150 mg tid and 600 mg daily dose in 17 and 4 patients, respectively). In all but 4 patients, treatment was continued until disease progression or the development of severe toxicity. Toxicity was minimal and reversible (score 1 or 2) and included myalgia (8 cases), arthralgia (6 cases), gastrointestinal toxicity (11 cases), fatigue (14 cases) and testicular pain (9 cases). The response was evaluated after at least one month of therapy with lonidamine, according to NPCP-USA recommendations. Of 21 patients who entered the study, only 15 were evaluable for response; 2 died (1 for severe toxicity and 1 for drug-unrelated reasons). No objective response was obtained in the series. In fact, only 6 patients achieved stable disease and 9 progressed. Median survival time from the beginning of treatment was no longer than that of patients in a similar condition who were treated with standard palliative maneuvers. We conclude that this therapeutic approach with lonidamine is not active in hormone-refractory prostatic cancer patients with distant metastasis.

Preservation of the internal vesical sphincter and proximal urethra during retropubic radical prostatectomy may improve earlier recovery of continence in selected patients

OBJECTIVES

To evaluate the influence of preservation of the muscular internal sphincter and proximal urethra on continence recovery after radical prostatectomy (RP).

MATERIAL AND METHODS

Fifty-five consecutive patients with organ confined prostate cancer were submitted to RP with the preservation of muscular internal sphincter and the proximal urethra (group 1) and compared to 55 patients submitted to standard procedure (group 2). Continence rates were assessed using a self-administrated questionnaire at 3, 7, 30 days and 3, 12 months after removal of the catheter.

RESULTS

Group 1 had a faster recovery of continence than group 2 at 3 days (50.9% vs. 25.5%; P=.005), at 7 days (78.2% vs. 58.2%; P=.020), at 30 days (80.0% vs. 61.8%; P=.029) and at 3 months (81.8% vs. 61.8%; P=.017); there were no statistically difference in terms of continence at 12 months among the two groups. Multivariate logistic regression analysis of continence showed that surgical technique was significantly associated with earlier time to continence at 3 and 7 days. The two groups had no significant differences in terms of surgical margins.

CONCLUSIONS

Our modified technique of RP with preservation of smooth muscular internal sphincter as well as of the proximal urethra during bladder neck dissection resulted in significant increased early urinary continence at 3, 7, 30 days and 3 months after catheter removal. The technique does not increase the rate of positive margins and the duration of the procedure.

Warm ischemia time and postoperative complications after partial nephrectomy for renal cell carcinoma

OBJECTIVE

To evaluate the correlations between PADUA and RENAL scores, WIT and postoperative complications in a cohort of patients who underwent elective open or minimally invasive nephron sparing surgery for renal cell carcinoma.

MATERIAL AND METHODS

We analyzed 96 consecutive patients who underwent partial nephrectomy for renal cell carcinoma between 2004 and 2013 at our Institution. The Spearman test was used to compare categorical variables. For all statistical analyses, a two-sided P < .05 was considered statistically significant.

RESULTS

The median (IQR) PADUA score was 7 (7-8) and the median (IQR) RENAL score was 7 (6-8). The median (IQR) warm ischemia time was 14 min (8-20). Low grade and high grade postoperative complications were found in 27 (28.1%) and 6 (6.3%) patients, respectively. PADUA risk group categories significantly correlated with WIT > 20 minutes and high grade postoperative complications, respectively (P = .04), regardless of the surgical approach. RENAL risk group categories significantly predicted longer hilar clamping time in our cohort (P = .04), but no statistically significant correlations with high grade postoperative complications were found.

CONCLUSIONS

In our retrospective series nephrometric scores demonstrated to significantly predict longer warm ischemia time and higher postoperative complications, especially in those patients with more challenging and complex renal tumors. Therefore, when planning to perform partial nephrectomy, urologists should widely use these comprehensive tools.

The dilemma of localizing disease relapse after radical treatment for prostate cancer: which is the value of the actual imaging techniques?

Only few patients with PSA relapse after radical treatment will show clinically detectable disease. Although the natural history of recurrent prostate cancer is often one of the slowly progressing diseases, in some men it can be rapid and may need a salvage treatment. In general, time to PSA relapse, PSA velocity and PSA doubling time are useful in patient assesment. In patients with PCa disease relapse after primary therapy, salvage treatment for a local recurrence should only be offered to patients with little risk of already having metastases. In these patients a systemic imaging negative for metastases is mandatory, a positive biopsy is not always necessary before radiotherapy, but is mandatory before salvage prostatectomy. In patients with a high risk of distant metastases and suitable for systemic salvage therapy, a positive lesion must be obviously visualized with one of the currently available imaging techniques. Transrectal ultrasound has low accuracy in the detection of the recurrence. Multiparametric Magnetic Resonance Imaging may have a role in the early phase of PSA relapse. Conventional imaging, such as bone scan and CT, are not suggested in the initial phase of BCR. Today, it has been reported that PET/CT allows changing the therapeutic strategy (from palliative to curative treatment and vice-versa) in about 20% of cases. In recent years, the new radiotracer 18F-FACBC has been proposed as a possible alternative radiopharmaceutical to detect PCa relapse. The aim of the present paper is to evaluate the management of patients with BCR after radical treatment of PCa from the urologist point of view.

Simple enucleation versus standard partial nephrectomy for clinical T1 renal masses: perioperative outcomes based on a matched-pair comparison of 396 patients (RECORd project)

OBJECTIVES

To compare simple enucleation (SE) and standard partial nephrectomy (SPN) in terms of surgical results in a multicenter dataset (RECORd Project).

MATERIALS AND METHODS

patients treated with nephron sparing surgery (NSS) for clinical T1 renal tumors between January 2009 and January 2011 were evaluated. Overall, 198 patients who underwent SE were retrospectively matched to 198 patients who underwent SPN. The SPN and SE groups were compared regarding intraoperative, early post-operative and pathologic outcome variables. Multivariable analysis was applied to analyze predictors of positive surgical margin (PSM) status.

RESULTS

SE was associated with similar WIT (18 vs 17.8 min), lower intraoperative blood loss (177 vs 221 cc, p = 0.02) and shorter operative time (121 vs 147 min; p < 0.0001). Surgical approach (laparoscopic vs. open), tumor size and type of indication (elective/relative vs absolute) were associated with WIT >20 min. The incidence of PSM was significantly lower in patients treated with SE (1.4% vs 6.9%; p = 0.02). At multivariable analysis, PSM was related to the surgical technique, with a 4.7-fold increased risk of PSM for SPN compared to SE. The incidence of overall, medical and surgical complications was similar between SE and SPN.

CONCLUSIONS

Type of NSS technique (SE vs SPN) adopted has a negligible impact on WIT and postoperative morbidity but SE seems protective against PSM occurrence.

Active surveillance for small renal masses diagnosed in elderly or comorbid patients: looking for the best treatment strategy

INTRODUCTION

Aim of this study is to provide our results after long-term active surveillance (AS) protocol for small renal masses (SRMs), and to report the outcomes of patients who remained in AS compared to those who underwent delayed surgical intervention.

PATIENTS AND METHODS

We retrospectively reviewed our database of 58 patients diagnosed with 60 contrast enhancing SRMs suspicious for renal cell carcinoma (RCC). All patients had clinical and radiological follow-up every 6 months. We evaluated the differences between patients who remained on AS and those who underwent surgical delayed intervention.

RESULTS

The mean age was 75 years, the mean follow-up was 88.5 months. The median initial tumor size at presentation was 2.6cm, and the median estimated tumor volume was 8.7cm(3). The median linear growth rate of the cohort was 0.7cm/year, and the median volumetric growth rate was 8.8 cm(3)/year. Death for metastatic disease occurred in 2 patients (3.4%). No correlation was found between initial tumor size and size growth rate. The mean linear and volumetric growth rates of the group of patients who underwent surgery was higher than in those who remained on surveillance (1.9 vs. 0.4cm/year and 16.1 vs. 4.6 cm(3)/year, respectively; P<.001).

CONCLUSIONS

Most of SRMs demonstrate to have an indolent course and low metastatic potential. Malignant disease could have faster linear and volumetric growth rates, thus suggesting the need for a delayed surgical intervention. In properly selected patients with low life-expectancy, AS could be a reasonable option in the management of SRMs.

Diagnostic imaging work-up for disease relapse after radical treatment for prostate cancer: how to differentiate local from systemic disease? The urologist point of view

About 40% of all patients undergoing radical treatment for localized prostate cancer (PCa) develop biochemical relapse (BCR) during lifetime but only 10-20% of them will show clinically detectable recurrences. Prostatic bed, pelvic or retroperitoneal lymph nodes (LN) and bones (especially the spine) are the sites where we must focus our attention in the early phase of PSA relapse. Time to PSA relapse, PSA kinetics, pathological Gleason score and pathological stage are the main factors related to the likelihood of local vs. distant relapse. Before an extensive diagnostic work-up in patients with BCR, is mandatory to understand if there is a therapeutic consequence or not for the patient. Current imaging techniques have some potential but many limits are yet encountered in the diagnosis of disease relapse. Transrectal ultrasound (TRUS) and Multiparametric Magnetic Resonance Imaging (MRI) have low accuracy in the detection of the recurrence. Today, Choline PET/CT may visualize the site of recurrence earlier, with better accuracy than conventional imaging, in a single step and even in the presence of low PSA level. In recent years, the new radiotracer (18)F-FACBC has been proposed as a possible alternative radiopharmaceutical to detect PCa relapse. From a clinical point of view, first clinical studies showed very promising and reproducible results with an improvement in sensitivity is about 20-25% with respect to Choline PET/CT, rendering the FACBC the possible radiotracer of the future for PCa. In conclusion, many improvements have been recently achieved in imaging techniques for PCa restaging, essentially in Nuclear Medicine and MRI, but negative results remain in many cases. Low sensitivity, costs, availability of technologies and confirmation of the results remain the major limitations in most cases.

Can side-specific biopsy findings predict the side of nodal metastasis in clinically localized prostate cancer? Results from a multicenter prospective survey

BACKGROUND

To evaluate the correlation between the side of positive biopsy (Bx) and the risk of lymph-node metastases (LNMs) on each side and to quantify the risk of contralateral LNMs in patients with unilateral positive biopsy.

METHODS

We analyzed the outcomes of 1599 patients with complete data regarding the sides of positive Bx and LN (lymph-node). By dividing each prostate into two separate sides, we assessed the accuracy of the side-specific Bx details in determining the side of positive nodes; the area under the receiver-operating characteristic (ROC) (AUCs) was used. For patients with unilateral positive Bx, we assessed the risk of homolateral and contralateral LNMs according to the number of total Bx taken and the preoperative risk of LN invasion.

RESULTS

Considering the 3198 prostate sides, there was a strict correlation between the side of positive Bx and the side of LNMs. The ratio of positive/total Bx was more informative than the number of positive core. The AUC for ipsilateral LNMs was significantly higher than that for contralateral LNMs (P = 0.039). In the 805 patients with unilateral positive Bx, the percentage of contralateral LNMs was >30% even considering a more meticulous biopsy scheme and increased in the patients at a higher clinical risk for LN invasion.

CONCLUSION

PCa preferentially metastasizes to ipsilateral LNs but >30% of contralateral LNMs are present. A unilateral LN dissection that is limited to the tumor-bearing side of the gland should not be recommended because of the substantial risk of missing contralateral metastases.

A new preperitoneal technique for the repair of inguinal hernia during prostatic surgery: first 153 procedures

PURPOSE

We describe a new preperitoneal technique that makes use of a plug fixed with a single percutaneous suture to cover the hernial defect during prostatic surgery.

METHODS

One hundred and twenty-seven patients with unilateral or bilateral inguinal hernia underwent preperitoneal prosthetic hernioplasty during pelvic surgery for benign or malignant prostatic pathologies. These procedures (153 hernioplasties in total) were performed by the same urologist using the new technique described.

RESULTS

There was only one recurrence (0.6%) reported by patients undergoing preperitoneal inguinal hernioplasty with our new technique. No patients had other complications like infections, fistula, painful scrotum, or hematoma.

CONCLUSIONS

The new technique, described by us, is easily performed, and it does not require a long execution time. It provides minimum tension on the surrounding tissues and it can be performed safely and without important complications like recurrence, infection, and chronic pain.

Positron-emission tomography in imaging and staging prostate cancer

With increasing application of positron-emission tomography (PET) imaging, familiarity with the applications of PET in genitourinary oncology, especially prostate-cancer (PCa) imaging, becomes important. PET studies provide functional information using radiolabeled tracers, with fluoro-dexoxy-glucose (FDG) being the most commonly used. Nevertheless FDG has limitations for evaluation of PCa patients and therefore alternative tracers are being investigated. To date, the best results have been obtained with 11C-choline and 11C-acetate PET, which seem to demonstrate similar values in this field. We review the current role of PET in PCa patients based on data published in the literature as well as our own experience. Most studies of PET imaging of PCa address three goals: a) detecting primary PCa; b) staging PCa; and c) assessing PCa recurrence. From available results, routine clinical use of 11C-choline PET cannot be recommended for detecting and staging primary PCa. At present, the only clinical indication for imaging PCa with 11C-choline-PET is evaluation of suspected recurrence after treatment.

11C-choline positron emission tomography/computerized tomography for tumor localization of primary prostate cancer in comparison with 12-core biopsy

PURPOSE

(11)C-choline positron emission tomography is an innovative imaging technique for prostate cancer. We assessed the sensitivity of positron emission tomography used together with computerized tomography for intraprostatic localization of primary prostate cancer on a nodule-by-nodule basis, and compared its performance with 12-core transrectal biopsy.

MATERIALS AND METHODS

In 43 patients with known prostate cancer who had received positron emission tomography/computerized tomography before initial biopsy, we assessed sensitivity of positron emission tomography/computerized tomography for localization of nodules 5 mm or greater (those theoretically large enough for visualization) using radical prostatectomy histopathology as the reference standard. Comparison with transrectal ultrasound guided biopsy was based on sextant assessment of all cancer foci following sextant-by-sextant matching and reconstruction. Sensitivity/specificity of positron emission tomography/computerized tomography and magnetic resonance imaging for prediction of extraprostatic extension was also assessed.

RESULTS

Positron emission tomography/computerized tomography showed 83% sensitivity for localization of nodules 5 mm or greater. At logistic regression analysis only nodule size appeared to influence sensitivity. At sextant assessment positron emission tomography/computerized tomography had slightly better sensitivity than transrectal ultrasound guided biopsy (66% vs 61%, p = 0.434) but was less specific (84% vs 97%, p = 0.008). For assessment of extraprostatic extension, sensitivity of PET/CT was low in comparison with magnetic resonance imaging (22% vs 63%, p <0.001).

CONCLUSIONS

Positron emission tomography/computerized tomography has good sensitivity for intraprostatic localization of primary prostate cancer nodules 5 mm or greater. Positron emission tomography/computerized tomography and transrectal ultrasound guided biopsy show similar sensitivity for localization of any cancer focus. Positron emission tomography/computerized tomography does not seem to have any role in extraprostatic extension detection. Studies of diagnostic accuracy (as opposed to tumor localization) are needed in patients with suspected prostate cancer to see whether positron emission tomography/computerized tomography could have a role in not selected patients.

Acceptability of an injectable male contraceptive regimen of norethisterone enanthate and testosterone undecanoate for men

BACKGROUND

We assessed attitudes towards and acceptability of male hormonal contraception among volunteers participating in a clinical trial of a prototype regimen, consisting of progestin and testosterone injections.

METHODS

After completing screening, eligible men were randomly assigned to the no-treatment group (n = 40) or to receive injections of norethisterone enanthate and testosterone undecanoate or placebo at different intervals (n = 50) according to a blocked randomization list. They underwent self-administered questionnaires.

RESULTS

The average age of the participants was approximately 28 years; most were involved in a stable relationship and had no children. Ninety-two percentage of the respondents thought that men and women should share responsibility for contraception and 75% said they would try a hormonal contraceptive if available. At the end of the treatment phase, 66% of the participants said that they would use such a method, and most rated its acceptability very highly; none reported it to be unacceptable. The injections themselves were indicated as the biggest disadvantage. No significant changes in sexual function or mood states were detected among the men who underwent hormone injections.

CONCLUSIONS

The contraceptive tested in this study was well accepted by the participants over the course of 1 year.

Apoptosis-related gene expression in benign prostatic hyperplasia and prostate carcinoma

BACKGROUND

The aim of this study was to examine the expressions of the bcl-2, bax, fas and c-myc apoptosis-related genes in benign prostatic hyperplasia (BPH) and prostate carcinoma (CaP) to determine whether significant differences exist within each disease and between the two groups of patients. The correlation between gene expression and tumour diameter, stage, Gleason score and serum PSA was also investigated.

PATIENTS AND METHODS

Tissue specimens from 51 cases of BPH and 27 cases of CaP were examined for bcl-2, bax, fas and c-myc expression by reverse transcriptase-PCR (RT-PCR).

RESULTS

In BPH, bcl-2 and bax gave the weakest signals (p < 0.001). In CaP, bcl-2 was the least expressed gene (p < 0.001). In both patient groups, fas and c-myc were the most highly expressed genes (p < 0.05). Both bcl-2 and bax were expressed at higher levels in CaP than in BPH (p < 0.02). The bcl-2/bax ratio was lower in CaP than in BPH (p < 0.001). Bcl-2 was more highly expressed in high Gleason grade (> 7) tumours (p < 0.05). In the BPH group, bax showed a positive relationship with fas (p < 0.01), while the bcl-2 level inversely correlated with that of c-myc (p < 0.05).

CONCLUSION

Our data showed that all the apoptosis-related genes were expressed in both BPH and CaP. The stronger expression of bax and the lower bcl-2/bax ratio observed in CaP may suggest a pro-apoptotic stimulus, while the higher bcl-2 levels appear to counterbalance the tendency to cell death.

Norethisterone enanthate plus testosterone undecanoate for male contraception: effects of various injection intervals on spermatogenesis, reproductive hormones, testis, and prostate

The goal of this study was to find the most favorable injection interval of norethisterone enanthate (NETE) plus testosterone undecanoate (TU) in terms of gonadotropin, sperm suppression, and prostatic effects. Fifty normal men were randomly assigned to receive NETE 200 mg plus TU 1000 mg every 8 wk (n = 10), every 12 wk (n = 10), every 6 wk for 12 wk and then every 12 wk (n = 10), and every 6 wk for 12 wk and thereafter TU 1000 mg plus placebo every 12 wk (n = 10), and placebo plus placebo every 6 wk for 12 wk and then every 12 wk (n = 10) for 48 wk. Semen analyses, blood drawings, physical examinations, and prostate ultrasounds were performed throughout the study. Of the men in the 8-wk injection group, 90% (nine of 10) achieved azoospermia, compared with 37.5% (three of eight) in the 12-wk injection group (P = 0.019). TU plus placebo injected every 12 wk did not maintain sperm suppression. Prostate volumes did not change significantly in either group. In conclusion, these data suggest that the combined administration of NETE and TU at 8-wk intervals represents an effective hormonal contraceptive regimen.

Evaluation of tamoxifen and anastrozole in the prevention of gynecomastia and breast pain induced by bicalutamide monotherapy of prostate cancer

PURPOSE

To determine whether tamoxifen or anastrozole prevents gynecomastia and breast pain caused by bicalutamide (150 mg) without compromising efficacy, safety, or sexual functioning.

PATIENTS AND METHODS

A double-blind, placebo-controlled trial was performed in patients with localized, locally advanced, or biochemically recurrent prostate cancer. Patients (N = 114) were randomly assigned to either bicalutamide (150 mg/d) plus placebo or in combination with tamoxifen (20 mg/d) or anastrozole (1 mg/d) for 48 weeks. Gynecomastia, breast pain, prostate-specific antigen (PSA), sexual functioning, and serum levels of hormones were assessed.

RESULTS

Gynecomastia developed in 73% of patients in the bicalutamide group, 10% of patients in the bicalutamide-tamoxifen group, and 51% of patients in the bicalutamide-anastrozole group (P < .001); breast pain developed in 39%, 6%, and 27% of patients, respectively (P = .006). Baseline PSA level decreased by > or = 50% in 97%, 97%, and 83% of patients in the bicalutamide, bicalutamide-tamoxifen, and bicalutamide-anastrozole groups, respectively (P = .07); and adverse events were reported in 37%, 35%, and 69% of patients, respectively (P = .004). There were no major differences among treatments in sexual functioning parameters from baseline to month 6. Elevated testosterone levels occurred in each group; however, free testosterone levels remained unchanged in the bicalutamide-tamoxifen group because of increased sex hormone-binding globulin levels.

CONCLUSION

Anastrozole did not significantly reduce the incidence of bicalutamide-induced gynecomastia and breast pain. In contrast, tamoxifen was effective, without increasing adverse events, at least in the short-term follow-up. These data support the need for a larger study to determine any effect on mortality.

Renal and Lymph-Node Inflammatory Pseudotumor

Inflammatory pseudotumor (IP) is a benign uncommon tumour with uncertainly aetiology. Aetiology may be an inflammatory process due to small traumas, surgery, or malignancy. Some studies showed that patients affected by IP were also affected by wide vasculities and genetics abnormalities, strengthening the hypothesis of an aetiology of this disease from an autoimmune pathology or a true tumour respectively. The bladder localization is the most frequently localisation in the genital-urinary apparatus, while the kidney localization is very uncommon. The IP consist of inflammatory and myofibroblastic cells.

Material and Methods

A 69 years old affected with inhomogeneous mass in the right kidney of about 8 cm, calcify lymph-node of the mesentery of about 28 mm.

Results

The patient was undergone to right nephrectomy and removal of mesenteric lymph-node. Histological issue showed a renal cells carcinoma G2 associated to IP. Mesenteric lymph-node with ossification and associated to IP.

Conclusions

This case is interesting for the simultaneous finding of the IP placed to right kidney and mesenteric lymph-node. Similar wide IP have already described in other studies like true tumour with more biological aggressivity. The differential diagnosis of IP with other neoformations is still difficult. We consider an optimal indication to perform a radical surgery therapy in any case, because IP may be associated with a malignancy and because sometime IP may increases progressively its aggressiveness. The histological diagnosis achieved by bioptical sample may be risky because biopsy cannot exclude all doubt about the existence of a mixed neoformations with IP and malignancy like our case.

Rehabilitation Therapy and Urinary Incontinence Post Radical Prostatectomy

Urinary incontinence rates after radical retropubic prostatectomy vary widely among the different series and depending on the different scoring systems, from 2–10% up to 87%. Rehabilitation therapy is the safest and simplest treatment available so far, although a wide consensus on the efficacy of its results is still lacking.

In our experience, treating post radical prostatectomy incontinent patients with rehabilitation therapy has been safe, reproducible and without side effects; nevertheless, our results suggest its use only in mild to moderate cases of post radical prostatectomy urinary incontinence.

Expression of 60-kD heat shock protein increases during carcinogenesis in the uterine exocervix

OBJECTIVES

The aim of the present study was to determine the presence and expression of the 60-kD heat shock protein (HSP60) in the dysplasia-carcinoma sequence in the uterine exocervix and to evaluate its diagnostic and prognostic significance.

METHODS AND RESULTS

We performed Western blot and immunohistochemical analyses on biopsies from 40 cases, consisting of 10 normal exocervical biopsies, 10 low-grade squamous intraepithelial lesions (L-SIL), 10 high-grade squamous intraepithelial lesions (H-SIL) and 10 cancerous exocervices (G2 grade). The immunohistochemical results were quantified by computer-assisted image analysis. Western blot analysis showed that HSP60 was undetectable in normal tissues and that there was a gradual increase of protein expression from L-SIL to carcinoma. Immunostaining for HSP60 was negative in normal tissue and positive in basal and parabasal layers of L-SIL epithelium; H-SIL were markedly stained in all layers of epithelium, and carcinomas showed an even stronger positivity. The increasing expression correlated with the malignancy grade. Finally, koilocytes were mostly negative in L-SIL and positive in H-SIL.

CONCLUSIONS

The increasing degree of expression of HSP60 from L-SIL to carcinoma and the different intraepithelial distribution between L-SIL and H-SIL could be used as a new diagnostic tool. Moreover, HSP60 could have a role in cervical carcinogenesis.

An endoscopic approach to the management of surgical bile duct injuries: nine years' experience

BACKGROUND

The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial.

AIM

The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily.

PATIENTS AND METHODS

A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak).

RESULTS

The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure.

CONCLUSIONS

Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.

Prostaglandin E(1)-based vasoactive cocktails in erectile dysfunction: how environmental conditions affect PGE(1) efficacy

INTRODUCTION

The chemical stability of prostaglandin E(1) (PGE(1)) in physiological solution has been studied in different environmental conditions. However, very little data exist regarding the PGE(1) stability and the consequent breakdown products in PGE(1)-based vasoactive cocktails under different environmental conditions.

OBJECTIVE

To evaluate the loss of the therapeutic efficacy of PGE(1) either alone or in combination with other vasoactive substances under different storage conditions.

MATERIALS AND METHODS

Utilizing high performance liquid chromatography the PGE(1) content was evaluated alone and in association with papaverine and papaverine plus phentolamine at temperatures of 2-8 and at 20 degrees C, and after 15, 30, 60, 90 and 120 days of storage using multivariate statistical analysis of variance.

RESULTS

We found that the time of storage significantly affects PGE(1) activity. Furthermore, both the storage temperature and cocktail composition had a significant effect on PGE(1) stability. The chromatographic studies did not disclose the presence of the principal degradation products of PGE(1) (PGA(1), PGB(1)). The presence of papaverine and temperature of 20 degrees C have the greatest effect on the degradation of PGE(1 )during the first 30 days of storage.

DISCUSSION

Temperature and time are prevalent factors determining the slow and progressive deterioration curve of PGE(1) after 30 days of storage. None of the environmental conditions evaluated was so drastic to determine the presence of PGA(1) and PGB(1).

CONCLUSION

For clinical use, one should note that PGE(1) maintains 50-80% of its efficacy for about 1 month even if stored at room temperature (20 degrees C) and/or combined with papaverine.

Telomerase activity in touch-imprint cell preparations from fresh prostate needle biopsy specimens

OBJECTIVE

To evaluate whether it is possible to detect telomerase activity in cells exfoliated from prostate biopsies immediately before fixation.

METHODS

A total of 115 transrectal biopsies of prostate tissue from 49 patients were touch-imprinted on an RNase-free microscope slide and then fixed. Touch imprints were immediately frozen and used to extract telomerase. Telomerase activity was determined by a telomeric repeat amplification protocol (TRAP) using a PCR-ELISA method. Inflammation and epithelial cells in each biopsy were quantitated by image cytometry.

RESULTS

A total of 90/115 extracts had a proteic content suitable for analysis. Telomerase activity was detected in 18/26 (70%) carcinomas, 2/9 (22%) low-grade prostatic intraepithelial neoplasia (PIN) lesions, and 1/3 (33%) high-grade PIN lesions. In 4 of 7 patients with telomerase-positive tumors, telomerase activity was also found in a distant site devoid of morphologically detectable cancer cells. Telomerase activity was detected in touch imprints from fragments with less than 1 mm(2) of epithelial tissue, and was not associated with the extent of inflammation.

CONCLUSIONS

From the technical stand point, the touch-imprint method may provide a useful adjunct for telomerase detection in prostate biopsies. With this procedure the bioptic fragment is left intact for histological examination. Diagnostically, the presence of telomerase activity in sites distant from the original tumor might suggest the presence of tumor cells that are morphologically undetectable.

Factor V Leiden and prothrombin gene mutation in inflammatory bowel disease in a Mediterranean area

BACKGROUND

Thromboembolism has been reported to be associated with inflammatory bowel disease.

AIM

To evaluate the association of factor V Leiden and prothrombin gene mutation with inflammatory bowel disease in a population of patients with thromboembolic events and inflammatory bowel disease and in a control population of patients with inflammatory bowel disease without thromboembolic events.

PATIENTS AND METHODS

A series of 18 patients with inflammatory bowel disease and a history of arterial or venous thrombosis and 45 patients with inflammatory bowel disease without thromboembolic events were evaluated for the presence of factor V Leiden and prothrombin gene mutation. Frequency of gene mutation was compared with its occurrence in 100 healthy controls.

RESULTS

One patient with inflammatory bowel disease without thromboembolic events was heterozygous for factor V Leiden mutation. whereas no patient with a thromboembolic event had factor V Leiden mutation. No patients (either cases or controls) had prothrombin gene mutation. In the healthy population the frequency of factor V Leiden and prothrombin mutation was 5% and 2%, respectively.

CONCLUSIONS

Data emerging from the present study do not support any role of factor V Leiden and prothrombin gene mutation as the cause of thromboembolism in inflammatory bowel disease.

[Treatment with chimeric monoclonal antitumor necrosis factor (infliximab) of patients with active steroid-dependent/resistant Crohn's disease and fistulas]

30 patients--13 with active steroid-dependent/resistant Crohn's disease (CD), 8 with active steroid-dependent/resistant disease complicated by fistulas and 9 with fistulas only (perianal or abdominal)--were treated with infliximab. "Clinical response or remission" were defined as the reduction by 70 or more points or below 150 points of the CDAI score, respectively. As regards fistulas, "response" was defined as the reduction of 50 percent or more from baseline in the number of draining fistulas or of the quantity of drainage, "remission" as their closure. At 8 weeks 13/21 (61.9%) patients treated for active disease went on remission and 6/21 (28.5%) had a clinical response; 6/17 (35.2%) patients treated for fistulas went on remission and 8/17 (47%) had a response, while 3/17 (17.6%) didn't have any response. At 24 weeks, 9/12 (75%) patients treated for active disease and 13/16 (81.25%) treated for fistulas had a recurrence in a median time of 18.3 weeks (range, 1-36 weeks) after the first infusion.

Solitary fibrous tumour of the urinary bladder with expression of bcl-2, CD34, and insulin-like growth factor type II

We describe a solitary fibrous tumour of the urinary bladder wall removed from a 50-year-old man with a history of pelvic pain, dysuria, and urinary bleeding. Anamnesis revealed a weight increase during the preceding 3 months, but no apparent episodes of biochemical hypoglycaemia or hormonal abnormalities. The patient is alive and well 18 months after surgery. Pathological examination revealed a 6.5-cm well-circumscribed nodular mass composed of uniform spindle cells arranged in bundles and fascicles with varying amounts of collagen and a typical haemangiopericytoma-like vascular pattern. The tumour cells were positive for bcl-2, CD34, and vimentin and ultrastructurally showed mesenchymal-myofibroblastic traits. These cells produced insulin-like growth factor type II mRNA as demonstrated by non-isotopic in situ hybridization. This rare case with a solitary fibrous tumor suggests that insulin-like growth factor type II could join CD34 and bcl-2 as markers for postoperative differential diagnosis.

The future of urology in Europe: an overview from the European association of urology

INTRODUCTION

In order to be able to influence and monitor future developments for urologists, strategies should be promoted in advance to guarantee the future of the speciality and to accommodate the inevitable changes. Faced with this challenge, the EAU, through its Strategy Planning Office (SPO), has prepared a document which is offered, here, in abbreviated form, to the European and international urological communities for general consideration.

MATERIAL AND METHODS

A group of subjects, related to the domains and internal consistency of urology as a speciality, were selected and discussed among the members of the SPO and later submitted to open consultation among distinguished members of the urological community. The topics selected for discussion included: what is urology; urology in the university; sub-specialization in urology; training in urology; does kidney transplantation belong to urology, and others.

RESULTS

It is shown that urology is going through an exciting and hazardous transition period. Urology has conflicting problems in its traditional domains due to changes in health care policy, and internal identification problems due to its permanent expansion and sub-specialization options. Weaker points are its relation with primary care medicine (shared care options), the presence and role of urology in institutions such as the university, department of surgery, children's hospitals, administration, etc.; the desegregating effect of the sub-specialities; the increasing encroachment of other specialities, and the increasing outpatient effect of technological progress.

CONCLUSION

An action plan is proposed to confront these changes without loosing manpower, internal consistency or social image and improving patient care quality, excellence of training and scientific progress.

[The future of urology in Europe: a perspective from the European Urology Association]

INTRODUCTION

In order to be able to influence and monitor future developments for urologists, strategies should be promoted in advance to guarantee the future of the speciality and to accommodate the inevitable changes. Faced with this challenge, the EAU, through its Strategy Planning Office (SPO), has prepared a document which is offered, here, in abbreviated form, to the European and international urological communities for general consideration.

MATERIAL AND METHODS

A group of subjects, related to the domains and internal consistency of urology as a speciality, were selected and discussed among the members of the SPO and later submitted to open consultation among distinguished members of the urological community. The topics selected for discussion included: what is urology; urology in the university; sub-specialization in urology; training in urology; does kidney transplantation belong to urology, and others.

RESULTS

It is shown that urology is going through an exciting and hazardous transition period. Urology has conflicting problems in its traditional domains due to changes in health care policy, and internal identification problems due to its permanent expansion and sub-specialization options. Weaker points are its relation with primary care medicine (shared care options), the presence and role of urology in institutions such as the university, department of surgery, children's hospitals, administration, etc.; the desegregating effect of the sub-specialities; the increasing encroachment of other specialities, and the increasing outpatient effect of technological progress.

CONCLUSIONS

An action plan is proposed to confront these changes without losing manpower, internal consistency or social image and improving patient care quality, excellence of training and scientific progress.

Prevalence of cytomegalovirus infection in severe refractory ulcerative and Crohn's colitis

OBJECTIVES

Cytomegalovirus infection has been reported as a cause of refractory inflammatory bowel disease, but no data are available on its prevalence in severe colitis. The aim of this study was to evaluate the prevalence and outcome of cytomegalovirus infection in a consecutive series of patients with severe steroid refractory colitis admitted to our department from 1997 to 1999.

METHODS

Among 62 patients with severe colitis, 55 with ulcerative colitis and seven with Crohn's disease, 19 (30%) were resistant to intravenous steroids and bowel rest. In all of them, rectal biopsies were examined for cytomegalovirus (the flexible proctoscopy being performed without air insufflation and limited to the first 10 cm). Buffy coat preparation on leukocytes was also performed to detect systemic infection. If cytomegalovirus was not detected, cyclosporine was started.

RESULTS

In seven (five with ulcerative colitis and two with Crohn's disease) out of 19 (36%) patients with refractory disease, cytomegalovirus was diagnosed in the rectal specimens as well as by buffy coat preparation. Five patients went into remission after antiviral treatment (three with ganciclovir and two with foscarnet). One patient did not respond and was operated on. In one patient, cytomegalovirus was found in the surgical specimen.

CONCLUSIONS

Cytomegalovirus infection is a frequent cause of severe refractory colitis. Rectal biopsy should always be performed in severe steroid-resistant colitis.

Italian urological manpower: employment prospects and future scenarios. A panorama of employment opportunities for young urologists

INTRODUCTION

Italy delayed limiting access to the Faculty of Medicine and the reform of schools of specialization was not accompanied by programming the number of scholarships, so employment expectations are often disappointing. The aim of this study is to analyze the employment prospects of specialists in urology through the development of possible scenarios for the 5-year period 2000-2004.

MATERIALS AND METHODS

We recorded data received from Italian Schools of Specialization in Urology on specialists in the 5-year period 1994-1998. We also tried to obtain a picture of the national distribution of urologists and urological units. Statistical processing was done with SPSS for Windows 5.0.

RESULTS

In the last 5 years, 501 urologists were licensed at an average age of 37 years; 535 urological units exist; 2,332 doctors practice urology (2,235 males and 97 females) for a ratio of 1 urologist to 24,500 inhabitants. By comparing the 'entrance' forecast with the potential 'exit', we can hypothesize an annual excess of 80 units. There is no significant correlation between the number of urologists in each structure and the number of inhabitants for each urologist.

CONCLUSIONS

The present government programme does not take into account continual changes in employment and many other variables when defining the actual need for specialists. For valid predictions, the data we obtain must be updated for at least 5 years.

Serum prostate-specific antigen in pancreatic disease

BACKGROUND

Prostate-specific antigen has been considered a specific and sensitive marker of prostate cancer. In recent years, it has been reported that prostate-specific antigen may also be found in pancreatic tissue; however, very little evidence of serum levels of this protein in pancreatic disease has been forthcoming.

AIMS

To explore the possibility that pancreatic diseases may influence both total and free serum prostate-specific antigen.

PATIENTS AND METHODS

A total of 72 females were studied: 44 patients with acute pancreatitis: 6 with chronic pancreatitis: 12 with pancreatic carcinoma and 10 healthy volunteers. Total and free serum prostate-specific antigen were measured using commercial kits.

RESULTS

In patients with acute pancreatitis, total and free serum prostate-specific antigen were detectable in two out of the 44 patients (5%). In patients with chronic pancreatitis, total and free serum prostate-specific antigen were undetectable, whereas 4 out of the 12 patients (33%) with pancreatic carcinoma had detectable serum levels of total and free prostate-specific antigen.

CONCLUSIONS

Female patients with acute pancreatitis and especially those with pancreatic cancer may have detectable serum levels of total and free prostate-specific antigen. Further studies are necessary to understand why these molecules are elevated in patients with pancreatic diseases, thus affecting the specificity of prostate-specific antigen determination as a prostate tumour marker.

Epidemiology of inflammatory bowel disease in Italy

The incidence of inflammatory bowel diseases is similar throughout Italy. Two prospective multicentre studies in the same period have shown an incidence very similar to Northern Europe. The incidence of ulcerative colitis ranged from 3.4 to 10.5. The incidence of Crohn's disease ranged from 1.9 to 6.6. The time trends seem to indicate an increase in both diseases. The need to set up General Registries of disease is underlined. The clinical behaviour and the diagnostic approach are homogeneous throughout the country. Compared to Northern Europe, surgery was less common in ulcerative colitis. Among the risk factors, familial occurrence has been shown to have the same prevalence as in Northern Europe suggesting a common genetic background. Studies on other risk factors are warranted considering the lack of data. Data on mortality show that there is a decrease in deaths in ulcerative colitis and a slight increase in mortality for Crohn's disease in the first few years after diagnosis. A retrospective study on costs has shown a greater economic burden from ulcerative colitis, however, new multicentre prospective studies are necessary.

The long-term course of chronic hepatitis B

The aim of this study was to assess the long-term outcome in hepatitis B virus (HBV)-infected patients according to HBV, hepatitis C virus (HCV), and hepatitis D virus (HDV) replication, focusing on survival, liver failure, and hepatocellular carcinoma (HCC). A cohort of 302 hepatitis B surface antigen (HBsAg)-positive subjects (mean age, 34 +/- 15.3 years; male/female 214/88; 39 subjects under 14 years) with biopsy-proven chronic hepatitis (86 with cirrhosis) was prospectively assessed, with a median follow-up of 94 +/- 37.6 months. One hundred nine patients received interferon alfa (IFN). At baseline, 86 subjects (28.5%) were hepatitis B e antigen (HBeAg)-positive (wild-type HBV), 80 (26.5%) were HBeAg-negative, HBV-DNA-positive, 76 (25.2%) had HDV infection, 43 (14.2%) had dual HBV/HCV infection, and 17 (5.6%) were negative for HBV-DNA, anti-HCV, and anti-HDV. During follow-up, decompensation of disease occurred in 46 subjects: 8 developed HCC, 36 developed ascites, and 2 developed jaundice. Five patients underwent transplantation. Thirty-five subjects died: 33 of hepatic and 2 of nonhepatic causes. Overall mortality was 5.2-fold that of the general population (95% CI: 3.6-7.3; 35 deaths observed, 6.7 expected; P <.0001). By Cox regression analysis, survival was independently predicted by young age, absence of cirrhosis at baseline, and sustained normalization of aminotransferases during follow-up. Survival without decompensation was independently predicted by the same factors and by IFN treatment. Chronic hepatitis B infection increases mortality in comparison with the general population in our area regardless of specific virological profiles at presentation. Presence of cirrhosis and persistent necroinflammation markedly increase the risk of death.

Vasoactive cocktails for erectile dysfunction: chemical stability of PGE1, papaverine and phentolamine

PURPOSE

Vasoactive cocktails are widely used in diagnosing and treating erectile dysfunction, especially in poor responders to prostaglandin E1 (PGE1). However, very little information as to their chemical interactions and stability is available, despite the huge amount of published work regarding their clinical efficacy. Obviously, medical and legal problems are involved.

MATERIALS AND METHODS

We analyzed four kinds of vasoactive cocktails, composed of papaverine, phentolamine and PGE1 in different combinations, using High Performance Liquid Chromatography analysis after 5 to 60 days of storage at temperatures between 2 and 8C. SPSS MANOVA analysis and a t-test for paired samples were used for statistical purposes.

RESULTS

Papaverine and phentolamine concentrations showed no significant variations during the 2 month study, ranging from a minimum of 96.75+/-1.20 to a maximum of 103.00+/-0.20% of the starting values. In the same period, PGE1 showed an accelerated degradation profile, reaching concentration values, after 60 days, of 76.00+/-2.28% and 70.20+/-2.02% when added to phentolamine or papaverine respectively and 70.00+/-2.40% with both.

CONCLUSIONS

Papaverine and phentolamine are characterized by chemical stability when blended together or with PGE1. Papaverine and/or phentolamine increase the naturally occurring degradation of PGE1 in physiological solution. This effect is most evident in the first 10 days. Papaverine has the greatest deteriorating effect on PGE1. A safe and proper use of these cocktails should take into account the variations of PGE1 concentration.