Randomized Comparison of Goserelin Acetate versus Mitomycin C plus Goserelin Acetate in Previously Untreated Prostate Cancer Patients with Bone Metastases

In a prospective trial conducted by the Gruppo Onco Urologico Piemontese, newly diagnosed prostate cancer patients with bone metastases were randomized to receive goserelin (3.6 mg subcutaneously every 4 weeks) or goserelin plus mitomycin at 14 mg/m2 i.v. every 6 weeks. Treatment was planned to be continued until progression. The study was interrupted because of inadequate accrual rate when 63 patients had been recruited. A long-term follow-up (median, 47 months), performed to counterbalance the limited number of patients included, revealed no difference in time to progression and overall survival between the study treatments. However, 56.5% of assessable patients allocated to the chemotherapy arm presented a ≥90% reduction of prostate-specific antigen levels compared with 36.3% in the goserelin group, and previously elevated levels normalized in 73.9% versus 45.4%. Non-progressing patients received 5-7 cycles of mitomycin C with acceptable toxicity, but the cytotoxic treatment was interrupted early in all cases within the first year due to cumulative myelotoxicity. In conclusion, the results, although inconclusive, fail to support a clear advantage in terms of cost/benefit of chemotherapy plus hormone therapy over hormone treatment alone in advanced prostate cancer with bone involvement.

Proposal of an improved prognostic classification for pT3 renal cell carcinoma

PURPOSE

The prognostic accuracy of the current TNM 2002 staging system for locally advanced renal cell carcinoma has been questioned. To contribute to the development of a more accurate classification for this stage of disease we assessed the correlation between patterns of invasion in the pT3 category and outcomes in a large multi-institutional series.

MATERIALS AND METHODS

Pathological data and clinical followup on 513 pT3 renal cell carcinoma cases treated with radical nephrectomy between 1983 and 2005 at 3 Italian academic centers were retrospectively reviewed. Cause specific survival rates were calculated with the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model.

RESULTS

Estimated overall 5-year cause specific survival was 50.1% at a median followup of 61.5 months in survivors. The current TNM classification was not a significant outcome prognosticator. Patients with a tumor invading only the perirenal or sinus fat were at lowest risk for death from the disease. Patients at intermediate risk had tumors with invasion of the venous system alone. Simultaneous perirenal fat and sinus fat invasion or perirenal fat and vascular invasion as well as adrenal gland involvement characterized high risk tumors. Low risk tumors could be further divided into 2 groups with different outcomes based on a size cutoff of 7 cm. Our classification was a significant predictor of survival on multivariate analysis as well as M stage, N stage, Fuhrman grade and tumor size.

CONCLUSIONS

We confirm that the prognostic usefulness of the current 2002 TNM system for pT3 renal cell carcinoma is limited. We have identified 4 groups of tumors with distinct patterns of invasion and significantly different survival probabilities in this category. Large prospective series are needed to validate these findings.

Reassessing the Current TNM Lymph Node Staging for Renal Cell Carcinoma

OBJECTIVE

The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved).

METHODS

All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively.

RESULTS

A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1-35). The median number of LNs involved was 3 (range, 1-18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved (p = 0.02) and LN density >60% (p = 0.01).

CONCLUSION

The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as < or =4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.

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

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

Prognostic value of the involvement of the urinary collecting system in renal cell carcinoma

OBJECTIVES

The prognostic role of the invasion of the urinary collecting system (UCS) by renal cell carcinoma (RCC) has not attracted a notable amount of attention. The aim of this study was to investigate incidence and prognostic value of UCS involvement in RCC.

MATERIAL AND METHODS

All pathological reports of radical nephrectomies performed in two centres of urology from November 1983 to December 1999 were reviewed in order to evaluate the invasion of the UCS (calices, renal pelvis, ureter). Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of UCS invasion. The stage was determined according to the TNM 6th edition. Overall and cause-specific survival rates were evaluated. Univariate and multivariate analyses were performed.

RESULTS

The evaluable specimens were 671 from the 735 examined; in 64 cases it was not possible to ascertain or to exclude UCS involvement. Invasion of the UCS was found in 59 cases (8.8%). Median follow-up was 59.0 months (range 0-216). Tumours invading the UCS were usually symptomatic, with high nuclear grade and predominantly high stage. At univariate analysis the 5 year overall and cause-specific survival rates of tumours invading the UCS were significantly lower when compared to those without UCS invasion (42.8% versus 60.8% and 45.5% versus 64.7%, respectively). When groups were stratified, according to the pT category, the 5-year cause-specific survival rate was only significantly different for the pT2 category (33.3% versus 76.9%). At the multivariate analysis TNM staging, symptoms at diagnosis and tumour grade were the only independent prognostic factors.

CONCLUSION

The invasion of the UCS by RCC is unusual, particularly in small tumours. UCS involvement does not represent an independent prognostic factor. However, in organ-confined tumours (i.e. pT2) UCS involvement has an influence on the prognosis and should be taken into account when planning adjuvant treatments and follow-up.

The number of lymph nodes examined and staging accuracy in renal cell carcinoma

OBJECTIVE

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

PATIENTS AND METHODS

We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1-4; group 2, 5-8; group 3, 9-12; group 4, 13-16; and group 5, >or= 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement.

RESULTS

Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1-43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P < 0.01). The rate of pN+ was significantly higher in the patients with >or= 13 than in those with < 13 nodes examined (20.8% vs 10.2%; P < 0.001). For organ-confined and locally advanced tumours there was a statistically significant difference in the pN+ rate between patients with < 13 or >or= 13 nodes examined (3.4% vs 10.5%, and 19.7% vs. 32.2%, respectively).

CONCLUSIONS

The proportion of tumours classified as pN+ increased with the number of lymph nodes examined. In RCC,> 12 lymph nodes need to be assessed for optimal staging.

Symptoms, bothersomeness and quality of life in patients with LUTS suggestive of BPH

The QUIBUS study is the largest investigation ever performed in Italy with an extensive use of the ICS-BPH questionnaire. The internal consistency of each of its three domains was high for ICS-Male (Cronbach's alpha = 0.83 and 0.89 for symptoms and bother, respectively) and lower for ICS-Sex (Cronbach's alpha = 0.63 and 0.75, see a following paper of this issue) and ICS-QoL (Cronbach's alpha = 0.53), as previously reported in the validation study of this tool. Voiding symptoms were more frequently reported, with reduced urinary stream, terminal dribble and incomplete bladder emptying as the most frequently represented. The first storage symptom in the ranking by frequency was 'rush to toilet' (70% of the population), in 7th position; however, the relevant bother was among the highest reported. Items related to urinary incontinence appeared, when present, highly bothersome (87-92% of patients), even though exhibited by a minority of the population (5-34%). The mean (+/-SD) IPSS, calculated on 970 patients, was 15 (+/-7). Two major discrepancies were found in the comparison between IPSS and ICS-Male. First, terminal dribble, which is not considered in the IPSS, is often reported in the ICS-Male. Second, some storage symptoms (nocturia and day-time frequency) are less frequently reported in the ICS-Male than in the IPSS, while being, in general, highly bothersome. As regards QoL, 95% of subjects declared that they would not be completely happy to spend the rest of their life with their actual symptoms (ICS-QoL item 33) and 79% that BPH influences their life from 'a little' to 'a lot' (ICS-QoL item 30). The mean (+/-SD) IPSS-QoL single question score was 3.0 +/- 1.4 (n = 970), and the frequency distribution of scores was equivalent to the one detected by the corresponding question of ICS-QoL (item 33). SF-36, a disease-independent questionnaire about QoL, after a 1-year follow-up is expected to clarify which among the IPSS and ICS-BPH items better describe the impact of BPH on QoL.

Long-term results of Burch colposuspension and anterior colpoperineorraphy in the treatment of stress urinary incontinence and cystocele

OBJECTIVE

Female urinary incontinence and bladder prolapse are very common conditions whose treatment is not standardized. The aim of this study was to evaluate retrospectively the long-term results of Burch colposuspension and anterior colpoperineorrhaphy in the treatment of stress urinary incontinence (SUI) and cystocele, respectively.

MATERIALS AND METHODS

We reviewed 36 female patients with a mean follow-up of 53 months. Mean patient age at time of surgery was 57.3 +/- 9.6 years (range 37-76). All patients were submitted to urodynamic investigation. Anterior colpoperineorrhaphy was performed in 18 cases (13 with cystocele, one with SUI and four with both). Burch colposuspension was performed in 14 cases (six with SUI and eight with both cystocele and SUI). The association of the two surgical procedures was used in four cases with both cystocele and SUI.

RESULTS

Satisfactory results, such as disappearance of SUI with Burch colposuspension and cystocele with colpoperineorrhaphy, were obtained in the 88.8% and 85.8% of the cases, respectively. These results are even more excellent considering that 22.5% of the patients failed previous surgery. We observed no significant complications.

CONCLUSIONS

The high percentage of long-term success confirms that anterior colpoperineorrhaphy and Burch colposuspension are two effective therapeutic choices for cystocele and SUI, respectively. The new mini-invasive techniques have to be compare with these traditional surgical treatments which efficacy is consolidated.

Iatrogenic ejaculation disorders and their prevention

Ejaculation is mediated by sympathetic fibers originating from the D10-L2 medullar center. These nerves rise from the lumbar ganglia of the paravertebral sympathetic trunk and travel posteriorly to the vena cava and then to the interaortocaval space, on the right side, and laterally to the aorta, on the left side. They are the principal constituents of the superior hypogastric plexus. Many surgical operations can cause an ejaculation disorder, but the most important is retroperitoneal lymphadenectomy (RL) for testis cancer, because it involves young patients and it has been the subject of important researches in order to perform lymph node dissection without ejaculation loss (unilateral lymphadenectomy and nerve sparing lymphadenectomy). Our experience concerns 41 patients who underwent RL for testis cancer from 1983 to 1998. Survival rate was 95.2% (mean follow up 64 months). RL was performed bilaterally in 14 patients. Two of them died of metastases within 2 years after the operation. Ejaculation was maintained in only 4 of the 12 surviving patients (33%). All the 17 patients (100%) underwent right monolateral RL and 7 of the 10 (70%) underwent left monolateral RL preserved ejaculation. The anatomosurgical concepts of the RL sparing the ejaculation can be adopted in other retroperitoneal surgical operations that can produce ejaculation disorders, such as wide lymphadenectomy for renal cell carcinoma or tumors of the upper urinary tract, exeresis of pre- aortic tumors, exeresis or disjunction of horseshoe kidney and aorto-iliac revascularization. Surgical therapy of benign prostatic hyperplasia (BPH) (open surgery or transurethral prostatic resection) is associated with retrograde ejaculation in nearly 100% of cases. The mechanism of the dysfunction is clear, if following the procedure the bladder neck remains opened. Loss of ejaculation is reported in variable percentage after the newer endoscopic techniques for the treatment of BPH. Transurethral needle ablation (TUNA) seems to have the lower risk of retrograde ejaculation. Retrograde ejaculation can also be related to a traumatic injury of the posterior urethra, because of the trauma itself or the therapy. Finally, the ejaculation disorder can be produced by several drugs that block, as a main or secondary effect, the alpha-adrenoreceptors or act at the central level. This side effect has to be kept in mind when these drugs are used in young or sexually active patients.

Vesical telangiectasias as a cause of macroscopic hematuria in systemic sclerosis

A 36-year-old female with diffuse cutaneous systemic sclerosis (dcSSc) developed macrohematuria due to vesical telangiectasias that was responsive to diathermocoagulation of the vasal lesions. This is the first report of a patient with dcSSc and vesical telangiectasias leading to severe macrohematuria that was successfully treated with diathermocoagulation.

[Retroperitoneal lymphadenectomy for testicular cancer and genito-sexual conditions: retrospective study]

OBJECTIVES

The aim of this study was to evaluate retrospectively the preservation of fertility in a number of patients with testis or funicle tumour treated with retroperitoneal lymph node dissection (RPLND).

MATERIAL AND METHODS

Between 1983 and 1998, 41 patients with testis or funicle cancer (mean age 29 years, range 18-58) underwent RPLND at our institution. Clinical staging included abdominal CT scan, chest X-rays and serum tumour markers (alpha FP, beta HCG, LDH). RPLND was performed bilaterally in 14 patients and unilaterally in 13 patients (6 right and 7 left). The nerve sparing technique was used in 14 cases. Ejaculation was evaluated in 39 patients (2 patients died of metastases before the study). Mean follow up was 64 months (range 5-182). Semen was available for 21 patients before RPLND and for 19 patients after RPLND. The "t Student" test was used to compare the semen parameters before and after surgery.

RESULTS

Bilateral RPLND caused loss of ejaculation in 67% of the patients (8/12). Unilateral right and left RPLND allowed to maintain ejaculation in 100% (6/6) and 57% (4/7) of cases respectively. Nerve sparing procedure preserved ejaculation in 100% of the patients (14/14). After RPLND, both mean total sperm count and mean motility rate were not significantly changed (143 +/- 124 x 10(6) vs 128.2 +/- 72 x 10(6) p > 0.05; 40.7 +/- 17.6 vs 48 +/- 15.5%, p > 0.05). The survival rate of the patients treated with RPLND was 95%. None of the patients treated with unilateral (en bloc or nerve sparing) RPLND had relapse.

CONCLUSION

The evolution of surgical technique has notably reduced the andrological complications of the RPLND without affecting the oncological results.

[Preservation of potency by supra-ampullar cystectomy in patients with bladder neoplasms]

Between May 1984 and November 1998 a total of 27 consecutive patients with bladder tumor (26 transitional cell carcinomas and 1 leiomyosarcoma) underwent supra-ampullar cystectomy and ileal orthotopic neobladder (2 Camey I and 25 Camey II). Mean patients age was 51.1 years (range 23-65). Pre-operatively 22 patients had superficial bladder carcinoma. An involvement of prostatic urethra was excluded by biopsy. The bladder, part of the prostate with prostatic urethra and regional lymph nodes were removed while was deferens, deferential ampullae, seminal vesicles, ejaculatory ducts and peripheral portion of the prostate were saved. Mean follow-up was 56.5 months (range 4-178). One patient was lost to follow-up at 60 months. Of the 27 patients 6 died of bladder cancer (1 with local relapse, 1 with local and distant recurrence and 5 with metastases) and the remaining 21 had neither local nor distant relapse. Four patients died of other causes. Potency was preserved in 25 patients (92.5%) who reported satisfactory sexual intercourse. Sixteen patients (59.2%) also maintained ejaculation allowing procreation in two of them. Supra-ampullar cystectomy provides good results in term of quality of life allowing to preserve sexual function in nearly all the cases without compromise the control of the neoplastic disease. The indication must be restricted to bladder cancer without risk of local recurrence and concomitant prostatic carcinoma.

Sonographic appearance of aggressive angiomyxoma of the bladder

Aggressive angiomyxoma is a rare, benign but locally aggressive mesenchymal neoplasm. We report the sonographic findings in a case of histologically proven aggressive angiomyxoma of the bladder. Sonography revealed a solid polypoid mass 2 cm in diameter with sharply demarcated borders, a heterogeneous echotexture, and a slightly hyperechoic rim.

[The therapy of metastatic renal carcinoma]

Nowadays, renal cell carcinomas (RCC) are mostly detected incidentally, following abdominal ultrasound performed for non-urological complaints. These asymptomatic tumors are often small and with low stage. However, about 25% of the RCC are still detected in advanced stage, with synchronous metastasis. Since few years ago, there was no effective treatment for the advanced RCC that shows resistance to the traditional systemic chemotherapy and radiotherapy. Today, two different treatments, either alone or in association, have provided interesting results in these setting, mostly in term of stabilization of the disease. Continuous systemic chronobiological chemotherapy with Floxuridine and immunotherapy with recombinant Interleukin-2 administered intravenously or subcutaneously, represent the treatment of choice of advanced RCC. Both treatment are well tolerated by the patients (except the intravenous Interleukin-2) and do not preclude radical nephrectomy. This paper reports a review of recent literature and the results of the authors' experience.

Management of renal angiomyolipoma: a report of 53 cases

OBJECTIVE

To evaluate the clinical, therapeutic and prognostic aspects of renal angiomyolipoma (AML) in patients either monitored by clinical and radiological follow-up or treated by surgical therapy.

PATIENTS AND METHODS

Fifty-three patients with renal AML were divided in two groups; 33 patients in group 1 were monitored by annual clinical and ultrasonographic follow-up and 20 in group 2 were treated with surgical therapy. Two patients had tuberous sclerosis (TS) with synchronous bilateral and multiple lesions. Apart from the patients with TS, there were 38 lesions in group 1 and 25 in group 2. The mean (range) follow-up of group 1 was 60.2 (12-164) months.

RESULTS

In group 1, the diagnosis was most often incidental, after ultrasonography performed for symptoms unrelated to AML. In group 2, the suspicion of a malignant renal lesion, and spontaneous tumour rupture with bleeding and perirenal haematoma, were the main indications for surgical treatment. The mean lesion diameter was significantly greater in group 2 (5.4 cm) and in symptomatic patients (8.1 cm). In group 1, 92% of renal AMLs showed no radiographic changes, serious complications or new renal or extrarenal lesions during the follow-up. Only three lesions grew, after 22, 85 and 164 months, respectively. Of the 20 patients in group 2, 14 underwent conservative surgery.

CONCLUSION

Small (<4 cm) isolated AMLs, detected incidentally, showed a low risk of developing during long-term follow-up. Such patients may be followed conservatively by ultrasonography every 2 years. Spontaneous perinephric haemorrhage is related to the size of the lesion. When surgery is indicated (by symptoms or diagnostic doubt), a conservative procedure can be performed in most of cases.

Major surgery (radical cystectomy with urethrectomy) in a patient with von Willebrand's disease type I. Reliability and limits of hemocoagulative tests

Patients with bleeding disorders frequently need medical or surgical care. The case is reported of a man with von Willebrand's disease type I undergoing radical cystectomy with urethrectomy for multicentric bladder cancer with neoplastic involvement of prostatic urethra, who developed serious bleeding complications which can not be predicted with conventional coagulation in laboratory. The use of the thromboelastograph (TEG) in the critical postoperative period was decisive. The tracing alterations allowed to assess the clotting disorder, constantly counterbalancing the baseline deficit and the blood loss.

Aetiopathogenesis and treatment of idiopathic retroperitoneal fibrosis

Idiopathic retroperitoneal fibrosis (IRF) is a rare urological disease, for which many pathogenic theories have been proposed. The authors report a series of 13 cases of IRF in order to evaluate the clinical, diagnostic, laboratory, therapeutic and prognostic aspects. They also report a rare case (the ninth case reported in the literature) of multifocal fibrosclerosis. A possible genetic predisposition was studied by testing for the presence of immunophenotype HLA-B27; this test was positive in 44% of cases. A study of the immunological profile and lymphocyte populations revealed the typical features of chronic immune disease. Experience with medical and surgical treatment is reported, comparing various procedures: ureterolysis followed by application of a vascularized omental flap over the ureter (without subsequent corticosteroid therapy) gave the best results, with complete resolution of the symptoms and long-term successful alleviation of ureteric obstruction in 100% of patients, with a mean follow-up of 58 months.

Surgical and endoscopic therapy

Despite the efficacy of new chemotherapy regimens, the medical treatment of genitourinary tubercolosis leads to recovery without sequelae in only 17–47% of cases. Open or endoscopic surgery therefore maintains an important role in treatment of the disease. Eighty years ago nephrectomy was the treatment of choice of renal tubercolosis. Nowadays some authors limit nephrectomy to patients with intractable pain, uncontrollable secondary infections, life-threatening hematuria, uncontrollable hypertension or resistance of the mycobacterium to medical therapy. We believe nephrectomy should be performed in cases of extensive renal damage, with or without complete functional loss, and in any case should be associated with exeresis of the whole ureter. In the presence of localised lesions, such as infundibular scarring with closed-off calyx, we generally perform a calycectomy in order to avoid a relapse of the disease and other possible complications. Also in these cases, however, surgery is controversial. Another aspect under debate concerns the association between chemotherapy and steroids. These stenoses, often involving the ureter, can be treated endoscopically (placement of ureteral stent, balloon dilatation, ureterotomy) or surgically (pyeloplasty, ureteral reimplantation, ileal ureter replacement, renal auto-transplantation). A serious consequence of urogenital tuberculosis is the loss of bladder capacity. This condition may be effectively treated with cytoplasty using an intestinal segment. In conclusion, conservative or radical surgery is still necessary to treat many cases of urogenital tubercolosis.

Coexistence of orbital and retroperitoneal involvement in multifocal fibrosclerosis: case report

OBJECTIVE

To report a rare case of multifocal fibrosclerosis involving the retrobulbar tissue and the retroperitoneum.

METHODS

A 59-year-old man presented with bilateral exophthalmos, more serious in the right eye. Right orbital biopsy showed fibrous tissue with inflammatory cells. After the failure of the radiation therapy, a right orbital exenteration was required. Radiological examinations demonstrated a retroperitoneal mass involving the perirenal fat, the aorta, the presacral and the perivesical tissue. Renal function impaired. A left inferior calycoureterostomy and a surgically placement of a right JJ stent were performed. Histological examination of the retroperitoneal biopsies revealed fibrous connective tissue.

RESULTS

After 9 years of follow up, there was no change in left visual or renal function (last creatinine: 1.3 mg/dl), and no symptoms or signs of recurrences.

CONCLUSION

This case is the ninth to document the association of orbital pseudotumor and retroperitoneal fibrosis. It is important that both the ophthalmologist and the urologist are aware of the existence of this association, so that suitable treatment can be initiated without delay.

Chemotherapy with FUDR in the management of metastatic renal cell carcinoma

SUMMARY

Metastatic renal cell carcinoma has a poor prognosis, requiring systemic therapy, in addition to radical nephrectomy. Since August 1989, 50 patients were treated with continuous, systemic, chronobiological infusion of FUDR (floxuridine) at our Institution. We reported 11.7% of objective responses, a long period of stable disease and low toxicity. We also compared our actuarial survival with the results obtained with recombinant IL-2 treatment.

Sex steroids modulate NADPH-diaphorase expression in the postnatal adrenal neurons of the rat

The rat adrenal gland contains nitric oxide-producing ganglion cells, contributing to its innervation. In a previous study postnatal number and morphology of these adrenal neurons were analyzed by NADPH-diaphorase histochemistry in the two sexes. A transient sex-related difference in the number of NADPH-diaphorase positive neurons per adrenal gland was found at postnatal day 10, when the number of stained neurons in males was nearly twice that found in females. In the present work we studied the effects of perinatal hormonal manipulation on the number of adrenal NADPH-diaphorase-positive neurons during the second postnatal week. The number of labeled adrenal neurons at postnatal day 10 was higher in females receiving perinatal androgen treatment than in control untreated females, and was similar to that of control untreated males. In contrast, in males that underwent perinatal deprivation of testosterone the number of labeled adrenal neurons was lower than in control males, and similar to that of control females. These differences were found in both the adrenal cortex and medulla. In males and in testosterone-treated females there was a higher proportion of stained multipolar neurons than in females and in androgen-deprived males. No intergroup differences were found in the size of stained neurons. Thus, we demonstrated that the postnatal difference in the number of NADPH-diaphorase-positive adrenal neurons in the two sexes is related to the epigenetic action of gonadal hormones during perinatal maturation.

Conservative surgery for renal cell carcinoma

Conservative surgery was initially limited to patients with localized RCC present bilaterally or in a solitary kidney, in whom radical nephrectomy would necessitate immediate renal replacement therapy. Today, the widespread use of abdominal ultrasound as screening modality in patients with nonspecific or unrelated symptoms allows the detection of renal parenchymal tumors rarely seen before: asymptomatic, small and unilateral neoplasms, often surrounded by a thick and complete pseudocapsule. Global renal function and contralateral kidney are usually normal and the patients show good performance status. For these reasons and because of the generally good results of the first experiences, several authors advocate conservative surgery as an elective indication. Recently, some studies have reported promising results with this approach. On the other hand, some controversial issues persist (multifocality of RCC, low risk of local relapse and renal failure after radical surgery, low incidence of tumor in the contralateral kidney) reducing the opportunity to perform nephron-sparing surgery when the contralateral kidney is normal. In the present study, we report our experience of nephron-sparing surgery for RCC and we review the current and international opinion concerning this treatment.

[Obstructive azoospermia and malformations of seminal tract]

About 10% of the cases of male infertility is represented by the obstruction of the seminal tract, which may be congenital or secondary to inflammatory events or surgery. The most frequent obstructive malformation of the seminal tract is the bilateral agenesia of the vas deferens. Such malformation is typical of the cystic fibrosis (CF), an autosomal recessive disorder determining chronic respiratory infections with bronchiectasia, and pancreatic failure. Recently the defective gene responsible for CF has been identified on the long arm of the chromosome 7. Congenital bilateral absence of the vas deferens (CBAVD) may be present in otherwise healthy males without clinical evidence of CF. Genetics studies demonstrated that most CBAVD display at least one detectable CF mutation, therefore this disease can be considered as an incomplete clinical form of CF. With the realization that a man with CBAVD may have CF, albeit a genital form, considerable care is required not only to document his specific mutations, but also to test his partner for CF mutations to evaluate the risk that their child would have CF. The association of chronic suppurating respiratory disease with obstructive azoospermia characterizes also the Young's syndrome. In this disease the obstruction could possibly be the result of defective epididymal sperm transport, related to an abnormality in the mucus. Despite some clinical common aspects, CF and Young's syndrome are two distinct entity. In fact, no CF mutations have been demonstrated in Young's syndrome. Congenital obstructive abnormalities of the vas deferens and epididymis are often associate to cryptorchidism (36-68% of the cases) and to patent processus vaginalis. The degree of testicular retention and processus vaginalis closure correlates well with the incidence of associated epididymal defects. Rare causes of congenital obstructive azoospermia are represent by the cyst of Müllerian or Wolffian origin. An obstruction to the progression of the sperm along the seminal tract can also be present in complex malformations, such as pseudohermaphroditism in which the infertility has a multifactorial etiology.

Quality of life in prostate cancer patients

INTRODUCTION

Quality of life (QL) assessment should be an essential part of clinical practice and should also be included in every clinical trial of prostate cancer. The term QL describes a person's overall well-being comprising not only physical functioning but also psychological and social dimensions. It is important to remember that QL can be affected by the disease as well as by the therapeutic treatment adopted.

OBJECTIVES

To measure the impact on QL in 161 patients treated by radical prostatectomy performed from January 1980 to June 1995. To describe the QL results from a national epidemiological study on prostate cancer, and to review the assessment of QL in this setting.

CONCLUSIONS

We found radical prostatectomy to have minimal overall impact on QL in patients informed of, and involved with all therapeutic decisions. Maintenance of sexual activity was considered to be of less importance than the attempt to cure the disease. The best method of assessment remains unclear but, minimally, a general questionnaire supplemented by specific questions on urinary-sexual symptoms should be administered at follow-up.

Fournier's gangrene: Clinical and therapeutical remarks on 5 new cases and review of the literature

Fournier's gangrene is an uncommon disease. It is characterised by superficial cellulitis involving the external genitalia, with a quick necrotic evolution. The origin of infection is often unclear. Generally the disease has a good prognosis, without systemic toxicity or compromising the patient's life. Many cases of Fournier's gangrene with bad prognosis, sepsis, have been described, however, in literature. In these cases the infection propagates from the colorectum, the periurethral glands or the urethra. We believe that these cases must be described as urinous phlegmon which unlike Fournier's gangrene, is a deep cellulitis. The 5 cases that we report, confirm our opinion.

REICAP: prospective epidemiologic study of prostate cancer in Italy. Preliminary results. Ricerca Epidemiologica Italiana sul Carcinoma Prostatico

OBJECTIVES

Prostatic carcinoma is a common disease of aging male subjects. Owing to structural population changes, its incidence is increasing, making it a major social problem. Epidemiological studies are useful but often do not fully rely on clinical data. The purpose of the present study was to investigate characteristics of prostatic carcinoma from both a clinical and epidemiological point of view.

METHODS

A multiphased clinicoepidemiological study was initiated in Italy, involving 26 urological centers operating in districts where national tumor registries are active. Demographic and clinical data on stage, pathology, prostate-specific antigen (PSA), and first-line treatment of 819 patients recruited during the prospective 1-year clinical phase of the study were examined.

RESULTS

The study showed that most patients with prostate carcinoma were symptomatic, that incidental cases were 10% and distant metastases were present at first observation in 15.3% of patients. PSA within the normal range was found in about 60% of incidental cases and in about a third of stage B cases. Most patients were treated with hormonal therapy. Radical surgery showed a limited incidence of capsular involvement and lymph node metastases.

CONCLUSIONS

These preliminary data show that in Italy, prostate carcinoma is diagnosed mainly when symptoms are present and that in 53% of cases the disease is locally advanced or disseminated. Treatment appears quite homogeneous for advanced cases but controversies exist for stage A1 (19% treated with hormones, 23% with radical surgery and 52% with watchful waiting), for stage A2 (52% treated with hormones, 23% with watchful waiting), and for stage B (58% of B2 treated with hormones against 27% only treated with radical prostatectomy). A special analysis is planned to investigate the cause of the low incidence of capsular invasions and D1 in operated cases.

Osteogenic sarcoma of the urinary tract. personal experience

Osteosarcoma is one of the most frequent bone tumours in paediatric age. It has a strong tendency to metastatic spread. Secondary involvement of the kidney with clinical evidence is a rare event (6 cases have been reported in literature). Primary osteogenic sarcoma of the urinary tract is also very unusual (20 cases of primary renal osteosarcoma have been reported until now). To our knowledge primary ureteral osteosarcoma has never been described. We present here one case of symptomatic kidney metastasis of osteosarcoma in a 20-year-old female patient and the first case of primary osteosarcoma of the ureter in an 81-year-old male patient.

Frozen section accuracy in the lymph node staging of prostatic carcinoma

— We investigated the accuracy of frozen sections in the detection of pelvic lymph node metastases in prostatic carcinoma. A group of 77 patients with clinical stage B or C prostatic cancer underwent staging pelvic lymphadenectomy followed by radical prostatectomy in 71 cases. Frozen section examination was performed in 46 cases because of the presence of suspicious lymph nodes. The accuracy of frozen section was 95.5% with 5.4% false negative results. Out of 24 patients with lymph node metastases confirmed by paraffin sections, 20 had frozen sections: 9 positive for cancer, 2 false negatives and 9 true negatives. Of the 31 patients from whom frozen sections were not obtained, 4 were found to have lymph node metastases on paraffin sections. In these 4 cases and in the presence of true negative frozen sections, nodal disease was minimal in 75% of patients. The results suggest that frozen sections are a useful tool to detect lymph node metastases. The accuracy depends on the experience of the histopathologist and the volume of the metastases.

Complications of Bacillus Calmette-Guerin immunotherapy in superficial bladder cancer

— Intravesical immunotherapy with BCG has become a standard treatment of superficial recurrent transitional cell carcinoma and in-situ bladder carcinoma. Studies on the mechanism of action have demonstrated the role of T lymphocytes. Moreover clinical and experimental results suggest a role by cytochines and delayed type hypersensitivity. BCG, while effective in the treatment of bladder cancer, has a defined morbidity that can be ascribed to the fact that it consists of viable bacterial cells. We evaluated the complications and side effects of this therapy in 71 patients who had received intravesical BCG (Pasteur strain BCG was instilled weekly for 6 weeks, fortnightly for three months and monthly for 12 months at a dose of 75 mg). Our findings showed the following complications: cystitis (63.3%), hematuria (28.1%), fever (7%), two cases of pruritus (2.8%), one case of hepatitis with persistent fever. Granulomatous prostatitis was noted in four cases (5.6%), a higher incidence than reported in literature, but it is a localized and self-limiting process that does not require specific therapy. In conclusion, the treatment with intravesical BCG has a significant morbidity, but the rate of complications is low and most need no treatment.

Immunological aspects of urethral stenosis. Involvement of the S100 protein-positive dendritic cells

— Within the superficial layers of healthy skin and of some mucosae there is a Population of accessory cells of the immune system, able to interact with T helper lymphocytes. Such cells, called tissular dendritic cells (DCs), increase their density and display different morphological features in a variety of immunologically-mediated dermatological disorders. In the present work we investigated DCs within the various urethral segments, both in normal conditions and in urethral stenosis. The specimens, obtained from urethrectomies and urethroplasties with end-to-end anastomosis, were stained with anti-S100 protein antibody and immunofluorescence techniques. We demonstrated an increasing density of S100 protein-positive epithelial DCs from the Prostatic urethra to the glandular one, where DCs were also larger and richer in dendritic Processes. In urethral stenosis the intraepithelial infiltrate of ramified DCs was much denser than any other control. We therefore hypothesize a role for the immune system in the development and maintenance of urethral stenoses, where, as already demonstrated for other types of pathological scarring, morphological changes of DCs serve as clues to their functional activation.

Clinical Usefulness of Prostate Specific Antigen and Prostate Specific Antigen Density to Distinguish Benign from Malignant Prostate Diseases

The possibility of distinguishing prostate cancer from BPH with the prostate specific antigen (PSA) determination is particularly poor when PSA levels are between 4.1 and 10 ng/ml. In these cases the quotient of serum PSA and prostate volume, defined as prostate specific antigen density (PSAD), seems to enhance the accuracy of PSA alone. In this study we evaluated retrospectively the preoperative PSA levels in 139 patients with BPH and in 26 patients with prostate cancer who underwent surgical treatment at our Department. We calculated the prostate volume with the following formula: length x width x depth x 0.52. The three dimensions were obtained from the surgical specimen in the patients with prostate cancer and using transrectal ultrasound in the cases of BPH. In patients with a serum PSA level of 4.1 to 10 ng/ml, PSA alone was not able to distinguish benign from malignant prostate disease; the PSAD values, on the contrary, provided a statistically significant (p < 0.003) stratification between BPH and prostate cancer (mean PSAD of 0.0088 and 0.191 respectively). Only 6% of patients with BPH had a PSAD greater than 0.15 compared to 76% of patients with prostate cancer. These results suggest the usefulness of PSAD in predicting the presence of prostate cancer in patients with intermediate levels of serum PSA.

Pelvic lymphadenectomy: Anatomic considerations

The real significance of pelvic lymphadenectomy, cure or staging, is still unknown. The morbility of this procedure is surely proportional to the extension of lymph node ablation. Bleeding, intraoperative lesions of nervous structure (lumbo-sacral trunk) post-operative lymphocele, but also lesion of the inferior hypogastric plexus and pelvic branches are more frequent in the case of extended (all the hypogastric and pre-sacral lymph nodes) than limited procedures. Therefore pelvic lymphadenectomy in the case of urologic malignancy is obviously incomplete. Nevertheless the incidence of recurrences in the remaining lymphatic structure is neither high nor clinically significant an therefore the indication for limited procedures is reinforced.

Round Table: “Comparison between laparoscopy-surgery in pelvic lymphadenectomy” - Introduction

Pelvic lymphadenectomy is a staging procedure for most urologists. It is therefore limited to the lymph nodes that can be approached in the easiest and least dangerous way. The dissection generally removes the lymph nodes situated below the bifurcation of the common iliac arteries; lymphatic drainage from bladder and prostate is also directed to pre-sacral nodes. As the main aim of lymphadenectomy is staging with minimal discomfort for the patient, the laparoscopic technique is clearly the most well-suited for this purpose. In the round table we will discuss the main features of “open” and laparoscopic lymph node dissection.

Utility and limits of serum prostate specific antigen determinations in prostatic cancer staging in view of surgical treatment

We investigated the clinical value of serum prostate specific antigen in 35 patients with apparently localized prostate cancer who underwent retropubic radical prostatectomy at our Department. In this series preoperative prostate specific antigen levels tended to increase with the increasing severity of pathological stage. The positive and negative predictive values were 68.1% and 63.6% respectively, accuracy was 66.6%. In the case of lymph node involvment, PSA values were lower than 10 nanog./ml in 20% of cases. Prostate specific antigen values not useful to predict preoperatively the final pathological stage of the prostate cancer because of the wide range of values among patients within each stage.

[Surgical interventions and andrological complications]

Several abdomino-Pelvic surgical procedures can cause ejaculatory failure or impotence. Retroperitoneal lymph node dissection for testis cancer is followed by loss of ejaculation if bilateral. In low stage cancers, monolateral procedure is associated with maintenance of ejaculation in most patients. Evaluation of seminal fluid before surgery is essential for cryopreservation and artificial insemination erectile impotence is consequent to section of "nervi erigentes" in pelvic surgery for cancer. Careful anatomic dissection can spare these nerves but oncologic radicality should be always kept in mind.

Aztreonam monotherapy as prophylaxis in transurethral resection of the prostate: a multicenter study

The efficacy and safety of aztreonam in the prophylaxis of urinary tract infection following transurethral resection of the prostate (TURP) in patients with preoperatively sterile urine were studied in a multicenter trial including 300 patients at six Italian urology centers. The present report describes the first 192 patients enrolled in the protocol. Aztreonam or placebo was administered to each patient in three doses, which were given at the induction of anesthesia and 8 and 16 hours later. The development of bacteriuria was monitored by cultures of urine obtained before surgery, 3 days later, at removal of the bladder catheter, at discharge from the hospital, and at a follow-up visit 39-46 days after surgery. A febrile peak was observed for 6% of aztreonam-treated patients and for 20.9% of the placebo group (P less than .005), while bacteriuria was reported in 17.9% and 59.3% of these groups, respectively (P less than .001). From our data, TURP appears to be a clean-contaminated procedure requiring antibiotic prophylaxis, and aztreonam appears to reduce significantly the incidence of postoperative bacteriuria after this surgical procedure.

[A case of pheochromocytoma with atypical clinical presentation]

A case of pheochromocytoma that had undergone coronary arteriography because it stimulated coronary heart disease is presented. The correct diagnosis was suspected while checking the signs and symptoms during an episode of pulmonary edema and was definitely proved by computed tomography and scintigraphy with I 131 metaiodobenzylguanidine. The authors stress the importance of these new non invasive procedures in the diagnosis of site and nature of this disease.

[Blood and urinary values of CEA and CA 19-9 in patients with bladder carcinoma]

Carcinoembryonic antigen (CEA) and Ca 19-9 levels in urine and serum from 46 patients with bladder cancer in varying stages have been evaluated. All samples of urine were obtained germ-free and without bacterial infection in the bladder. The sensitivity of CEA monoclonal antibody is 60.8% and specificity is 80%. Ca 19-9 test has higher sensitivity (74%) and the same specificity. Correlation between staging, grading and CEA or Ca 19-9 values were also evaluated.