On-clamp versus off-clamp partial nephrectomy: Propensity score-matched comparison of long-term functional outcomes.

OBJECTIVES: To compare long-term functional outcomes of off-clamp or on-clamp partial nephrectomy patients of two high-volume centers with cT1-2/N0 M0 renal tumors and baseline estimated glomerular filtration rate >60 mL/min. METHODS: A 3:1 propensity score-matched analysis was used to select two homogeneous cohorts to compare off-clamp versus on-clamp partial nephrectomy. Joinpoint regression analysis was used to compare the 2-8-year probabilities of estimated glomerular filtration rate modifications in both selected cohorts. The Kaplan-Meier method assessed the risk of developing a stage ≥3b chronic kidney disease during follow up. Multivariable analyses aimed to identify predictors of renal function deterioration. Perioperative complications and oncological outcomes were compared. RESULTS: Overall, 1073 patients were included (588 on-clamp and 485 off-clamp). After applying the propensity score-matched analysis, the two cohorts of 157 on-clamp and 472 off-clamp patients did not differ for all covariates, except for warm ischemia time and last estimated glomerular filtration rate. At joinpoint analysis, the off-clamp group showed higher probabilities of maintaining an unmodified estimated glomerular filtration rate (P = 0.02). The probability of developing a stage ≥3b chronic kidney disease was significantly higher (P < 0.001) in the on-clamp cohort. At multivariable analysis, estimated glomerular filtration rate at discharge and off-clamp approach were independent predictors of improved functional outcomes. Perioperative complications were comparable among the two cohorts (P = 0.67). There were not any statistically significant differences in terms of cancer-specific survival (P = 0.26) and overall survival (P = 0.18). CONCLUSIONS: Off-clamp partial nephrectomy seems to offer a higher probability of maintaining 100% estimated glomerular filtration rate after surgery. In our cohort, patients undergoing on-clamp partial nephrectomy presented a 7.3-fold increased risk of developing a severe chronic kidney disease during follow up.

Purely off-clamp robotic partial nephrectomy: Preliminary 3-year oncological and functional outcomes.

OBJECTIVES: To describe our surgical technique and to report perioperative, 3-year oncological and functional outcomes of a single-center series of purely off-clamp robotic partial nephrectomy. METHODS: A prospective renal cancer institutional database was queried, and data of consecutive patients treated with purely off-clamp robotic partial nephrectomy between 2010 and 2015 in a high-volume center were collected. Perioperative complications, and 3-year oncological and functional outcomes were assessed. Univariable and multivariable analyses were carried out to identify independent predictors of renal function deterioration. RESULTS: Out of 308 patients treated, 41 (13.3%) experienced perioperative complications, 2.9% of which were Clavien grade ≥3. The 3-year local recurrence-free survival and renal cell carcinoma-specific survival rates were 99.5% and 97.9%, respectively. No patient with preoperative chronic kidney disease stage ≤3B developed severe renal function deterioration (chronic kidney disease stage 4) at 1-year follow up. At multivariable analysis, preoperative estimated glomerular filtration rate (P = 0.005) was the only independent predictor of a new-onset chronic kidney disease stage ≥3 in patients with preoperative chronic kidney disease stages 1 or 2. CONCLUSIONS: Off-clamp robotic partial nephrectomy is a safe surgical approach in tertiary referral centers, with adequate oncological outcomes and negligible impact on renal function.

Robotic Intracorporeal Continent Cutaneous Diversion.

PURPOSE: Robotic intracorporeal urinary diversion has mostly been done for ileal conduit or orthotopic neobladder diversion. We present what is to our knowledge the initial series, detailed technique and outcomes of the robotic intracorporeal Indiana pouch with a minimum 1-year followup. MATERIALS AND METHODS: Ten patients underwent robotic radical cystectomy, pelvic lymphadenectomy and intracorporeal Indiana pouch urinary diversion for cancer in 9 and benign disease in 1. Data were collected prospectively. Baseline demographics, pathology data, and 1-year complication rates and functional outcomes were assessed. RESULTS: All 10 cases were successfully completed intracorporeally without open conversion. Median total operative time was 6 hours, including 3.5 hours for pouch creation. Median blood loss was 200 cc and median hospital stay was 10 days. Four Clavien grade 1-2 and 3 Clavien 3-5 complications occurred. None of the patients had a bowel leak. One noncompliant patient requested undiversion to an ileal conduit. The remaining 9 patients successfully catheterized the ileal channel and were completely continent at the last followup at a median of 13.7 months (range 12.3 to 15.2). Study limitations include small sample size and short followup. CONCLUSIONS: We present what is to our knowledge the initial series of robotic completely intracorporeal Indiana pouch diversion. Early perioperative data indicate acceptable operative efficiency and complication rates. Longer followup is required to assess the functional outcomes of this less commonly performed diversion.

Oncological outcomes of minimally invasive partial versus minimally invasive radical nephrectomy for cT1-2/N0/M0 clear cell renal cell carcinoma: a propensity score-matched analysis.

PURPOSE: To compare the oncologic outcomes of partial nephrectomy (PN) and radical nephrectomy (RN) for cT1-2/N0 renal tumors and pathologically confirmed pT1-pT3a-pNx clear cell (cc)-renal cell carcinoma (RCC). Few studies compared the oncologic outcomes of PN and RN for renal tumors >7 cm. METHODS: A prospective "renal cancer" database was queried for cT<3-cN0-cM0 and pT1a-pT3a-pNx cc-RCC. Out of 1650 cases treated between 2001 and 2013, 921 were cc-RCC and 666 met inclusion criteria, 232 of which treated with minimally invasive RN and 434 with MIPN. A 1:1 propensity score-matched (PSM) analysis was employed to minimize the selection bias of non-random assignment of patients to PN as opposed to RN. Kaplan-Meier method was used to compare the oncologic outcomes of the PSM cohorts. Survival rates were computed at 2, 5, and 10 years after surgery, and the log-rank test was applied to assess statistical significance between the two PSM groups. RESULTS: RN tumors were significantly larger (p < 0.001), with higher pT stages (p < 0.001), higher Fuhrman grades (p = 0.002) and a more frequent sarcomatoid differentiation (p = 0.04). After applying the PSM analysis, the two cohorts of 155 RN and 155 PN cases did not differ for all clinical and pathologic covariates (all p ≥ 0.32). PN and RN cohorts displayed comparable 5-year metastasis-free survival (88.9 vs 89.9 %, p = 0.811), local recurrence-free survival (94.2 vs 95.9 %, p = 0.283), overall survival (94.5 vs 96.8 %, p = 0.419) and cancer-specific survival (96 vs 98.6 %, p = 0.907) rates. CONCLUSIONS: PN and RN for patients with cc-RCC larger than 7 cm provided equivalent oncologic outcomes. Safety and reproducibility of our findings should be further investigated in larger multicentric cohorts.

Thulium laser supported nephron sparing surgery for renal cell carcinoma.

PURPOSE: We analyze the feasibility, advantages and results of the use of a thulium laser in nephron sparing surgery for renal cell carcinoma. MATERIALS AND METHODS: In this single center prospective study 10 consecutive high risk patients underwent open or laparoscopic thulium laser assisted enucleation for small peripheral renal cell carcinoma at our department. We used a 2.0 µm continuous or pulsed thulium laser. This diode pumped solid state laser emits a wavelength of 2,013 nm in the infrared spectrum and penetrates tissue to a depth of 0.5 mm. RESULTS: The entire tumor enucleation was performed using the frontal thulium laser fiber. In all cases the thulium laser produced a smooth incision of the renal parenchyma and a safe delineation of the plane between the tumor and the surrounding tissue. In addition, in the off clamp procedures bleeding was limited during the dissection and did not interfere with the definition of the surgical plane. Median surgical time from the beginning of the laser assisted tumor dissection to the end, after verification of bleeding control on the cut surface, was 15 minutes (range 12 to 20). No significant (less than 40 cc) blood loss occurred during the laser assisted tumor dissection. All cases were clear cell renal cell carcinoma and no positive surgical margins were found. In all cases postoperative management was uncomplicated without evidence of hemorrhage. CONCLUSIONS: In our prospective preliminary experience, thulium laser assisted enucleation for renal cell carcinoma is a feasible, safe and effective procedure.

Use of multiparametric MR with neurovascular bundle evaluation to optimize the oncological and functional management of patients considered for nerve-sparing radical prostatectomy.

INTRODUCTION: To obtain the best results with radical prostatectomy, either from an oncological or a functional point of view, a correct selection of cases and planning of surgery are crucial. Multiparametric magnetic resonance imaging (MRI) promises to make it a successful imaging tool for improving many aspects of prostate cancer management. AIM: The aim of this study is to evaluate whether a modern multiparametric MRI can help either to better select prostate cancer cases for a nerve-sparing radical prostatectomy or to improve the functional evaluation related to neurovascular bundles preservation. MAIN OUTCOME MEASURES: The effect of preoperative MRI on neurovascular bundle management was examined for the frequency and the appropriateness of changes of the surgical plane on the basis of MRI indications. METHODS: In a prospective study, 125 consecutive patients with biopsy proven prostate cancer who were scheduled to undergo bilateral nerve-sparing surgery. All patients included into the study were submitted to a preoperative multiparametric MRI. On the basis of MRI evaluation, patients were divided into two groups. Patients in group A were then submitted to a bilateral nerve-sparing (NS) radical prostatectomy (RP), whereas patients in group B were submitted to unilateral NS or non-NS RP. RESULTS: In group A, the confirmation from the MRI study to perform a bilateral NS procedure was appropriate in 70 of 73 cases (95.9%), whereas in group B, the surgical plan was appropriate in 28 of 32 cases (87.5%). On the contrary, MRI findings suggested a change in the initial surgical plan (group B) for 32 of 105 cases (30.5%). Of these 32 cases in group B, MRI suggested to perform a unilateral NS procedure in 21 of 32 cases (65.6%) and a non-NS procedure in 11 of 32 cases (34.4%). CONCLUSIONS: Multiparametric MRI analysis can significantly improve the standard selection and management of prostate carcinoma cases considered for an NS RP.

Wunderlich syndrome, an unexpected urological complication in a patient with coronavirus disease 2019 (COVID-19): A case report.

We describe the first case of Wunderlich syndrome as a hemorrhagic complication in a patient with severe acute respiratory syndrome coronavirus 2 infection and acute respiratory distress syndrome. The possible underlying pathophysiological mechanisms have been extensively discussed. Emergency management included selective angioembolization of the upper polar arterial branches of the left kidney and discontinuation of thromboprophylaxis. The patient was discharged after 18 days. No other localizations or local recurrence of bleeding occurred during the hospitalization. Our report suggests a broad spectrum of clinical manifestations in patients with coronavirus disease 2019. As observed in our clinical case, in addition to thrombotic complications, bleeding is a significant cause of morbidity in coronavirus disease 2019 patients. Further studies should determine whether these urological bleeding sequelae are a direct manifestation of the infection or an indirect effect of thromboprophylaxis.

Urethra and Ejaculation Preserving Robot-assisted Simple Prostatectomy: Near-infrared Fluorescence Imaging-guided Madigan Technique.

BACKGROUND: With the increasing adoption of novel technologies and anatomical techniques, surgical management of benign prostatic hyperplasia (BPH) provides significant benefits in terms of obstruction relief, early urethral catheter removal, and faster return to daily activities. However, the main pitfall of BPH surgery in sexually active men remains ejaculatory dysfunction (EjD), which permanently affects quality of life. OBJECTIVE: To detail a novel technique for marking the intraprostatic urethra through a retrograde injection of indocyanine green to enhance selective dissection of prostatic lobes during urethra-sparing robot-assisted simple prostatectomy (US-RASP) with the use of near-infrared fluorescence imaging (NIFI). DESIGN, SETTING, AND PARTICIPANTS: Between January and September 2017, 12 consecutive male patients, who had BPH, were sexually active, and were motivated to preserve ejaculatory function, underwent US-RASP. SURGICAL PROCEDURE: US-RASP with NIFI to enhance the identification and preservation of the prostatic urethra. MEASUREMENTS: Clinical data were prospectively collected in our institutional RASP dataset. Perioperative and functional outcomes of US-RASP were both graded, and assessed according to Clavien grading system and validated questionnaires postoperatively (International Prostate Symptom Score [IPSS]; Male Sexual Health Questionnaire on EjD [MSHQ-EjD] Short Form) at 3 and 12mo. RESULTS AND LIMITATIONS: Median preoperative prostate size was 102cc (interquartile range [IQR] 88-115). Median operative time was 150min (IQR 145-170). Median estimated blood loss was 250 (IQR 200-350). Continuous bladder irrigation was avoided in 83.4% of patients. Median time to catheter removal was 7d (IQR 7-7) with a median hospital stay of 3d (IQR 2-3). At 1-yr follow-up, median IPSS score, International Index of Erectile Function score, and MSHQ-EjD Short Form score were 5 (IQR 4-8), 26 (IQR 26-28), and 12 (IQR 1-14), respectively. Satisfactory anterograde ejaculation was reported in eight patients (66%). CONCLUSIONS: We described a novel NIFI-guided technique to perform US-RASP. This technique showed promising early functional results, suggesting a significant role of intraprostatic urethral integrity for the preservation of ejaculatory function. PATIENT SUMMARY: We developed a novel robotic technique to perform simple prostatectomy with integral preservation of the prostatic urethra. This technique provided a high rate of ejaculatory function preservation.

Transnephrostomic Indocyanine Green-Guided Robotic Ureteral Reimplantation for Benign Ureteroileal Strictures After Robotic Cystectomy and Intracorporeal Neobladder: Step-By-Step Surgical Technique, Perioperative and Functional Outcomes.

Objectives: To describe our surgical technique of robotic ureteroileal reimplantation (RUIR) for ureteroileal anastomosis strictures with the use of near-infrared fluorescence imaging (NIFI) after transnephrostomic antegrade injection of indocyanine green in patients previously treated with robot-assisted radical cystectomy and intracorporeal orthotopic neobladder. Materials and Methods: From March 2015 to December 2017, 10 consecutive patients underwent RUIR in our tertiary referral center. All patients previously underwent percutaneous nephrostomy and at least one antegrade stenting and stricture dilatation attempt. Clinical data were prospectively collected into our institutional dataset. Both perioperative and functional outcomes were assessed. Results: Median time from robotic cystectomy to ureteroileal anastomosis strictures diagnosis was 5 months (interquartile range [IQR] 2-6). Median stricture length was 1.5 cm (IQR 1-2). Median operative time was 140 minutes (IQR 81-155), and median length of stay was 5 days (IQR 3-9). Two patients experienced Clavien grade 2 complications (urinary tract infection requiring antibiotics and blood transfusion, respectively). One patient underwent ileum resection and anastomosis due to bowel perforation (Clavien IIIb). At a median follow-up of 19 months (IQR 14-39), one patient developed a stricture recurrence. No patient developed worsening of renal function (newly onset chronic kidney disease stage 3b-4). Conclusions: Robotic reimplantation for ureteroileal anastomosis strictures is a safe and highly effective procedure, with a high success rate and excellent perioperative and functional outcomes. NIFI provides an easy guide to identify and progressively dissect the ureter.

"Ride the Green Light": Indocyanine Green-marked Off-clamp Robotic Partial Nephrectomy for Totally Endophytic Renal Masses.

BACKGROUND: Complexity of robot-assisted partial nephrectomy (RAPN) mostly depends on tumor size and location. Totally endophytic renal masses represent a surgical challenge in terms of both intraoperative identification and anatomical dissection. OBJECTIVE: To detail a novel technique for marking preoperatively endophytic renal tumors with transarterial superselective intrarenal mass delivery of indocyanine green (ICG)-lipiodol mixture, in order to enhance surgical margins control during purely off-clamp (OC) RAPN with the use of near-infrared fluorescence imaging. DESIGN, SETTING, AND PARTICIPANTS: Between June and July 2017, 10 consecutive patients with totally endophytic renal masses underwent preoperative ICG tumor marking immediately followed by RAPN. SURGICAL PROCEDURE: Preoperative superselective transarterial delivery of a lipiodol-ICG mixture (1:2 volume ratio) into tertiary-order arterial branches feeding the renal mass prior to transperitoneal OC-RAPN. MEASUREMENTS: Clinical data were prospectively collected in our institutional RAPN dataset. Perioperative, pathological, and functional outcomes of RAPN were assessed. RESULTS AND LIMITATIONS: Median tumor size was 3cm (interquartile range 2.3-3.8). The median PADUA score was 10 (9-11). Angiographic procedure was successful in all patients. Median operative time was 75min (65-85); median estimated blood loss was 250ml (200-350). No conversion to on-clamp PN or radical nephrectomy was needed. All patients had uneventful perioperative course; median hospital stay was 3 d (2-3). At discharge, median hemoglobin (Hgb) and percent estimated glomerular filtration rate (eGFR) drop were 3.3g/dl (2.1-3.3) and 11% (10-20%), respectively. Surgical margins were negative in all cases. One-year median ipsilateral renal volume and 1-yr eGFR percent decreases were 11.7% (6-20.9%) and 12.2% (5.3-13.7%), respectively. CONCLUSIONS: We described a novel technique to simplify challenging RAPN based on ICG superselective transarterial tumor marking. Key benefits include quick intraoperative identification of the mass with improved visualization and real-time control of resection margins. PATIENT SUMMARY: Robot-assisted partial nephrectomy (RAPN) for totally endophytic renal masses is a technically demanding surgical procedure, sometimes requiring radical nephrectomy. This novel technique significantly simplified surgical complexity in our Institution. Further studies with larger cohorts are warranted to confirm whether this technique provides relevant intraoperative and functional advantages.

Robot-assisted Partial Adrenalectomy for the Treatment of Conn's Syndrome: Surgical Technique, and Perioperative and Functional Outcomes.

BACKGROUND: In the era of minimally invasive surgery, partial adrenalectomy has certainly been underused. We aimed to report surgical technique and perioperative, pathologic, and early functional outcomes of a two-center robot-assisted partial adrenalectomy (RAPA) series. OBJECTIVE: To detail surgical technique of RAPA for unilateral aldosterone-producing adenoma (UAPA), and to report perioperative and 1-yr functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: Data of 10 consecutive patients who underwent RAPA for UAPA at two centers from June 2014 to April 2017 were prospectively collected and reported. SURGICAL PROCEDURE: RAPA was performed using a standardized technique with the da Vinci Si in a three-arm configuration. MEASUREMENTS: Baseline and perioperative data were reported. One-year functional outcomes were assessed according to primary aldosteronism surgery outcome guidelines. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS: All cases were completed robotically. Median nodule size was 18mm (interquartile range [IQR] 16-20). Intraoperative blood loss was negligible. A single (10%) postoperative Clavien grade 2 complication occurred. Median hospital stay was 3 d (IQR 2-3). Patients became normotensive immediately after surgery (median pre- and postoperative blood pressure: 150/90 and 120/70mmHg, respectively). At both 3-mo and 1-yr functional evaluation, all patients achieved biochemical success (aldosterone level, plasmatic renin activity, and aldosterone-renin ratio within normal range). Complete clinical success was achieved in nine patients, but one required low-dose amlodipine at 6-mo evaluation. At a median follow-up of 30.5 mo (IQR 19-42), neither symptoms nor imaging recurrence was observed. CONCLUSIONS: We demonstrated feasibility and safety of RAPA for UAPA; this technique had very low risk of complications and excellent functional results. Increased availability of robotic platform and increasing robotic skills among urologists make RAPA a treatment option with potential for widespread use in urologic community. PATIENT SUMMARY: Robot-assisted partial adrenalectomy is a safe, feasible, and minimally invasive surgical approach. Promising perioperative and functional outcomes suggest an increasing adoption of this technique in the near future.

Metachronous Isolated Splenic Metastasis in a Young Patient With Renal Cell Carcinoma: Case Report and Literature Review.

Splenic metastasis is uncommon and is usually associated with widespread disease.1,2 Isolated splenic metastases from renal cancer are also rarer and are often an incidental finding. This eventuality may turn into a dangerous scenario due to a spontaneous splenic rupture leading to sudden death.2,3 At the best of our knowledge, only few cases of metastasis from renal cell carcinoma (RCC) have been documented in the literature.4-11 We hereby present a literature review of these cases and report a case of isolated splenic metastasis in a young man on active follow-up for a clear cell RCC clear cell Renal Cell Carcinoma (ccRCC).

Robotic Intracorporeal Padua Ileal Bladder: Surgical Technique, Perioperative, Oncologic and Functional Outcomes.

BACKGROUND: Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder reconstruction is a challenging procedure. The need for surgical skills and the long operative times have led to concern about its reproducibility. OBJECTIVE: To illustrate our technique for RARC and totally intracorporeal orthotopic Padua ileal bladder. DESIGN, SETTING, AND PARTICIPANTS: From August 2012 to February 2014, 45 patients underwent this technique at a single tertiary referral centre. SURGICAL PROCEDURE: RARC, extended pelvic lymph node dissection, and intracorporeal partly stapled neobladder. Surgical steps are demonstrated in the accompanying video. MEASUREMENTS: Demographics, clinical, and pathological data were collected. Perioperative, 2-yr oncologic and 2-yr functional outcomes were reported. RESULTS AND LIMITATIONS: Intraoperative transfusion or conversion to open surgery was not necessary in any case and intracorporeal neobladder was successfully performed in all 45 patients. Median operative time was 305min (interquartile range [IQR]: 282-345). Median estimated blood loss was 210ml (IQR: 50-250). Median hospital stay was 9 d (IQR: 7-12). The overall incidence of perioperative, 30-d and 180-d complications were 44.4%, 57.8%, and 77.8%, respectively, while severe complications occurred in17.8%, 17.8%, and 35.5%, respectively. Two-yr daytime and night-time continence rates were 73.3% and 55.5%, respectively. Two-yr disease free survival, cancer specific survival, and overall survival rates were 72.5%, 82.3%, and 82.4%, respectively. The small sample size and high caseload of the centre might affect the reproducibility of these results. CONCLUSIONS: Our experience supports the feasibility of totally intracorporeal neobladder following RARC. Operative times and perioperative complication rates are likely to be reduced with increasing experience. PATIENT SUMMARY: We report the outcomes of our first 45 consecutive patients who underwent robot-assisted radical cystectomy with intracorporeal neobladders. Perioperative, oncologic, and functional outcomes support this technique as a feasible and safe surgical option in tertiary referral centres.

Perioperative and mid-term oncologic outcomes of robotic assisted radical cystectomy with totally intracorporeal neobladder: Results of a propensity score matched comparison with open cohort from a single-centre series.

AIM: In this study, we compared perioperative and oncologic outcomes of patients treated with either open or robot-assisted radical cystectomy and intracorporeal neobladder at a tertiary care center. METHODS: The institutional prospective bladder cancer database was queried for "cystectomy with curative intent" and "neobladder". All patients underwent robot-assisted radical cystectomy and intracorporeal neobladder or open radical cystectomy and orthotopic neobladder for high-grade non-muscle invasive bladder cancer or muscle invasive bladder cancer with a follow-up length ≥2 years were included. A 1:1 propensity score matching analysis was used. Kaplan-Meier method was performed to compare oncologic outcomes of selected cohorts. Survival rates were computed at 1,2,3 and 4 years after surgery and the log rank test was applied to assess statistical significance between the matched groups. RESULTS: Overall, 363 patients (299 open and 64 robotic) were included. Open radical cystectomy patients were more frequently male (p = 0.08), with higher pT stages (p = 0.003), lower incidence of urothelial histologies (p = 0.05) and lesser adoption of neoadjuvant chemotherapy (<0.001). After applying the propensity score matching, 64 robot-assisted radical cystectomy patients were matched with 46 open radical cystectomy cases (all p ≥ 0.22). Open cohort showed a higher rate of perioperative overall complications (91.3% vs 42.2%, p 0.001). At Kaplan-Meier analysis robotic and open cohorts displayed comparable disease-free survival (log-rank p = 0.746), cancer-specific survival (p = 0.753) and overall-survival rates (p = 0.909). CONCLUSIONS: Robot-assisted radical cystectomy and intracorporeal neobladder provides comparable oncologic outcomes of open radical cystectomy and orthotopic neobladder at intermediate term survival analysis.

Mineral metabolism abnormalities in patients with prostate cancer: a systematic case controlled study.

PURPOSE: Prostate cancer is the most common tumor in men. To the best of our knowledge a systematic assessment of bone and mineral abnormalities has not been performed in prostatic cancer patients consecutively enrolled. METHODS: This study was therefore carried out to investigate changes of skeletal and mineral metabolism in patients with prostate cancer (n = 69). A population of patients with cancer of various origin was also investigated as a control group (n = 53), since a comparison with non-prostate cancer patients has not been previously reported. RESULTS: In the prostatic cancer group, one patient had extremely high values of C-terminal Fibroblast Growth Factor 23, low values of tubular reabsorption of phosphate and very high values of bone alkaline phosphatase, suggesting the diagnosis of oncogenic osteomalacia. We found nine patients with primary hyperparathyroidism in the group of prostate cancer vs. only one in cancer patients group (p < 0.026). We stratified the population on the basis of Gleason score, prostate specific antigen and hormonal therapy. Using a generalized linear model with a logit link to predict the probability of developing primary hyperparathyroidism, only Gleason score, C-terminal fibroblast growth factor 23 and hormonal therapy had a significant effect (p < 0.05). Controlling for other covariates, a rise in fibroblast growth factor 23 increases the odds of developing primary hyperparathyroidism by 2% (p = 0.017), while patients with higher values of Gleason score have a much greater probability of developing primary hyperparathyroidism (log-odds = 3.6, p < 0.01). The probability decreases with higher values of Gleason score while on hormonal therapy; a further decrease was observed in patients on hormonal treatment and lower values of GS. Finally, lower grade of Gleason score without hormonal therapy have a significant protective factor (p < 0.01) decreasing the odds of developing primary hyperparathyroidism by 8%. CONCLUSION: We showed a remarkable prevalence of primary hyperparathyroidism in men with prostate cancer; the multivariate analysis demonstrates that higher aggressiveness of prostate cancer, as determined by Gleason score, is a significant predictor of increased risk of developing primary hyperparathyroidism.

Supernumerary kidney laparoscopically treated.

Congenital anomalies of the kidney and urinary tract are part of a family of diseases with different anatomical origins. Duplicated collecting systems can be defined as a renal unit containing 2 pyelocalyceal systems associated with a single ureter or with double ureters. The supernumerary kidney is a definitive accessory organ with its own collecting system, blood supply, and distinct encapsulated parenchima. The true incidence of supernumerary kidney remains unknown, but most cases are in males, are unilateral and on the left side. We present a case of an adult woman with a hypoplastic supernumerary kidney with a complete ureteral duplication and an ectopic junction. The case has been laparoscopically treated. We demonstrate that a laparoscopic nephro-ureterectomy is feasible and that the management of the complication (urinoma and fistula) can be managed conservatively.

[Role of neuroendocrine cells in prostate cancer progression]. / Ruolo delle cellule neuroendocrine nella progressionedel carcinoma prostatico.

Neuroendocrine (NE) cells represent the third epithelial cell type on normal prostatic tissue (in addition to basal and secretory cells). They are localized in all regions of the human prostate at birth but rapidly decrease in the peripheral prostate after birth, and then reappear at puberty. After puberty, their number seems to increase until an apparently optimum level is reached, which persists between the age of 25 and 54. NE cells were defined by Pearse as APUD to refer to chemical characteristics of amine precursor uptake and decarboxylation, common to the cells of this system. The most predominant product of prostatic NE cells is Chromogranin A, but they also produce serotonin, CgB, secretogranin or CgC, thyroid-stimulating hormone-like peptide, calcitonin, katacalcin, PTHrP and a-human chorionic gonadotropin-like peptide. NE cells in normal and neoplastic prostates are devoid of androgen receptors, but they express epidermal growth factor (EGF) receptor and c-erbB-2. For these reason NE cells are androgen-insensitive. The NE component of prostate adenocarcinoma is resistant to hormone therapy; some studies showed that the number of NE tumor cells and CgA serum levels increase with the recovery of human prostate tumor from hormonal therapy. Currently there are no clinical data available to support an active role of radiotherapy in NE differentiation.

[Current diagnostic procedure on neuroendocrine differentiation of prostate cancer]. / Attuale iter diagnostico sulla differenziazione neuroendocrina del carcinoma prostatico.

Chromogranin A (CgA) is considered as a major specific neuroendocrine tumor marker. It belongs to the secretogranin family, which is present in the gastrointestinal tract, respiratory system, endocrine glands and in a group of endocrine cells such us pancreas and thyroid. Serum levels of CgA could reflect the neuroendocrine activity and could be used when evaluating advance prostate carcinoma. Moreover, there are also several factors that may increase the serum level of CgA: treatment with proton-pump inhibitors or H2-receptor blockers, chronic atrophic gastritis, rheumatoid arthritis, liver and renal failure. Another method to evaluate NE differentiation is scintigraphy with the 111In-labeled somatostatin analogue (DTPA-D-Phe)-octrotide, (Octreoscan). This method takes advantage of the overexpression of type II somatostatin receptors on the cell surface of NE tumors. With this technique the presence of NE differentiation can be detected both at the primary (prostate) and the metastatic sites. A more specific system to detect NE cell activity is obtained by analyzing CgA gene expression in prostate tissue by a semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR).

[Neuroendocrine target therapies for prostate cancer]. / "Neuroendocrine target therapies" per il carcinoma prostatico.

It is important to determine whether an increase in Chromogranin A levels and neuroendocrine (NE) cell activation are associated with progression towards on hormone-independent prostate-cancer. We proposed a combination of estrogens and somatostatin analogues as therapy of NE activation in hormone-independent prostate cancer. The combined therapy with ethinyl estradiol and lanreotide offered objective and symptomatic responses in patients with limited treatment options and refractoriness to conventional hormonal therapy strategies; in particular, it offered a median overall survival that was superior to the 10-month median survival in patients with hormone refractory disease. This combined therapy also sustains the new concept in cancer treatment in which therapies may target not only cancer cells but also its microenvironment, which can yield protection against apoptosis.