Laparoscopic radical prostatectomy: a marketing or surgical strategy?

The aim of the present review is to compare the advantages and the disadvantages of radical perineal, retropubic and laparoscopic prostatectomy with a close look at the laparoscopic procedure, an operation which has gained much attention in the urological world over the last 3 years. Also reviewed are the motivations, in terms of real advantages for the patient and the needs of the urological 'market', that push the urologist towards using the laparoscopic technique instead of the radical retropubic or radical perineal prostatectomy.

Extracorporeal shock wave lithotripsy in ureteral and kidney malformations.

INTRODUCTION: Extracorporeal shock wave lithotripsy (SWL) has long been accepted worldwide in the treatment of kidney stone disease. Upper ureter calculi in ureteral and kidney malformations are rather frequent (10-25%). The aims of this retrospective study were to determine whether malformations might impair fragment expulsion. MATERIAL AND METHODS: From 1986 to 1995, 203 patients with ureteral and kidney malformations were treated and followed up for a minimum of 1 year to a maximum of 9 years. Malformations included: ureteropelvic junction stenosis, horseshoe kidney, renal malrotation, renal ectopia, duplicated ureter, nonobstructive megaureter, medullary sponge kidney and caliceal diverticula. As pretreatment workup, all patients underwent conventional studies prior to SWL treatment: X-rays, renal ultrasound, intravenous pyelography, routine blood tests and urinalysis. All examinations were repeated at regular intervals for the first 6 months. Patients with metabolic disorders were excluded from the study. We also excluded patients with a follow-up of under 1 year. We considered three groups of patients: (1) stone-free patients at plain X-rays and ultrasound; (2) >90% elimination, i.e. stone-free patients at plain X-rays and positive at ultrasound; (3) patients with residual fragments at plain X-rays and ultrasound. RESULTS: 96 (55%) patients were in group 1 (stone free), 40 (19%) were in group 2 (>90% elimination) and 67 (26%) were in group 3 (residual). Residual stones were more frequent in patients with medullary sponge kidney (82%). In patients with renal ectopia the residual stone rate accounted for only 13% of cases. CONCLUSIONS: There is evidence that SWL should always be offered to patients with ureteral and kidney malformations. These patients should however be considered at high risk for recurrences and so they need to be carefully followed up.

High levels of transforming growth factor-alpha (TGF-alpha) mRNA may predict local relapses in early stage urinary bladder cancer.

Elevated expression of transforming growth factor-alpha (TGF-alpha) gene has been previously reported in some types of human neoplasms, but its role in the pathogenesis of bladder cancer has still not been investigated. In the present study, we analysed 28 samples of early stage bladder tumours for the presence of TGF-alpha mRNA using reverse transcription-polymerase chain reaction (RT-PCR). We detected TGF-alpha mRNA in 71% (20/28) of these samples. When we related the expression levels of TGF-alpha with local relapses of patients during a follow-up of 2 years, we found that a high TGF-alpha expression level in bladder cancer was significantly associated with local relapses in patients with early stage tumours. The appearance of early relapses in tumours with high TGF-alpha expression levels may suggest the existence of an additional marker in the prediction of local relapses in patients with superficial disease.

Variable levels of bcl-2, bcl-x and bax mRNA in bladder cancer progression.

We investigated the expression of the anti-apoptotic genes bcl-2 and bcl-X and the pro-apoptotic gene bax in bladder tumors and normal samples from urinary bladder, using RT-PCR analysis. Bcl-2 mRNA was not detected in any of the normal samples, while it was found expressed in 66% of the low stage tumors and in 100% of the high stage tumors. Bax expression had an inverse progress, being present in 62% of the normal tissues examined, in 16% of the low stage tumors and in 14% of the high stage. Bcl-X gene expression was quite variable among all samples (37% in normal tissues, 50% in the low stage tumors and 14% in the high stage). bcl-X mRNA was only found in the isoform bcl-XL, with anti-apoptotic functions, whereas no sample expressed the isoform bcl-XS, which is known to suppress bcl-2 functions. Most samples expressing bcl-2 did not express bcl-X, and vice versa. These results, besides confirming the potential role of these genes in the pathogenesis of low stage bladder cancer strengthen the hypothesis concerning their possible interaction in the progression of disease.

Management of hemorrhage after percutaneous renal surgery.

Percutaneous renal surgery is routine therapy for a number of renal pathologies. It is a technique not without complications, often serious ones, of which the worst is bleeding. We reviewed our experience of the incidence, etiology, and management of this serious complication to determine a protocol of treatment that will minimize the consequences. Between 1984 and 1996, we carried out 976 percutaneous operations for reno-calix stones, pyeloureteral junction stenosis, neoplasia of the renal pelvis, diagnosis, and ureteral prostheses. In all cases, the percutaneous access was achieved through a lower calix in the posterior axillary line with the patient in a prone position. The lithotripsy was performed with ultrasound and balistic energy lithotripters. Antegrade endopyelotomy was performed according to our technique. At the end of the procedure, a nephrostomy tube was positioned, 24F for lithotripsy and 16F for endopyelotomy. The nephrostomy tube was removed after 24 to 48 hours. In this series, 146 patients (15%) presented significant perioperative bleeding. In 97 cases (10%), this complication was resolved with the repositioning of the nephrostomy tube, bedrest in a supine position, and observation, whereas in 49 cases (5%), clamping of the nephrostomy tube for 24 hours was necessary. In 56 patients (5.7%), two blood transfusions were necessary, and three patients (0.3%) had bleeding 10, 12, and 20 days after the operation, which was resolved by embolization of the lacerated vessel.

Ureteral occlusion prosthesis.

Although temporary or definitive complete ureteral occlusion is rarely needed, there is a considerable number of reports introducing different devices to achieve this goal, most of which can be inserted with minimally invasive procedures. Easy placement is considered of paramount importance, as the candidates are very often in bad general condition as a result of previous surgery, radiotherapy, or other palliative treatments for cancer. A device that can be inserted and removed percutaneously is presented herein. It can be employed in cases of ureteral fistulas resulting from radiotherapy and ureterosigmoidostomy with good results. The technique is simple and not time consuming.

Bcl-2/bax mRNA expression ratio as prognostic factor in low-grade urinary bladder cancer.

Apoptotic cell death represents an important mechanism for the precise regulation of cell numbers, and a defence mechanism against tumoral cell. bcl-2 and bax genes are known to be involved in the control of apoptotic pathways; in particular, the ratio between bcl-2 and bax represents a cell rheostat that is able to predict a cell's response toward life or death to an apoptotic stimulus. In the present study we investigated the role of bcl-2 and bax gene expression in a panel of 37 low-grade tumours of the urinary bladder, and correlated the expression of these genes to the prognosis of patients in a follow-up of more than one year. We found that levels of bax expression higher than bcl-2 in bladder tumours well correlates to a better outcome for patients. Early relapses are much more frequently observed in those patients whose tumours express more bcl-2 than bax mRNA. We conclude that the bcl-2/bax expression ratio may be considered as a marker for disease progression in low grade bladder tumours, independently of clinical staging and histological grading.

[Anterograde transpelvic endopyelotomy]. / Endopielotomia transpielica anterograda.

The Authors describe their own technique of antegrade endopyelotomy for cases of primary ureteropelvic junction obstruction. After percutaneous access has been gained via the lower calix, the technique involves making a wide opening of the renal pelvis and exploring the peripelvic space in front of a 3 to 4 cm long section of the ureter. The aim is to carry out the operation with an unrestricted view and without the need for a large calibre stent, in order to perform endopyelotomy in pediatric patients or in the presence of anomalous vessels. The follow-up demonstrates good results in 80% of 46 patients aged 5 to 62 years. The Authors think that antegrade transpelvic endopyelotomy is an endourologic operation with results and feasibility similar to those reported for open surgery.

Transurethral electrovaporization of the prostate with the Vaportrode VE-B. Preliminary results.

UNLABELLED: Transurethral resection of the prostate (TURP) is still considered the 'gold standard' in the treatment of benign prostatic hyperplasia (BPH). However, it is possible to replace this technique in particular situations (advanced age, serious cardiovascular, respiratory and metabolic disorders). OBJECTIVE: The aim of this study is to propose an alternative treatment to TURP with a minimal invasiveness, rapid discharge of the patient and lower costs achieving the same results as TURP. We have used electrovaporization of the prostatic tissue to investigate the outcome of electrovaporization in the treatment of patients with BPH. METHODS: A grooved rolling electrode with a large surface contact was used (Vaportrode VE-B; Circon Acmi, USA), mounted on a common resectoscope connected to a normal high-frequency discharge unit. This concentration of high energy produces an area of high current density at the point of contact with the prostatic tissue and a consequent thermal reaction which causes the tissue temperature to rise rapidly until vaporization. In the period ranging from January 1995 to June 1995, 35 patients with BPH were treated. RESULTS: The average maximal flow increased from 9.8 +/- 3.18 to 13.6 +/- 5.9 ml/s at 2 days and to 20.74 +/- 9.8 ml/s at 28 days (p < or = 0.01); the average symptom score decreased from 18.17 +/- 4.5 to 10.4 +/- 3.3, 28 days after surgery with an average improvement of 52% (p < or = 0.01). Voiding pressure at 28 days was 22.9 +/- 2 cm H2O (p < or = 0.01). Sixteen patients were obstructed preoperatively while 19 patients were unobstructed postoperatively and 3 were equivocal as shown in the Abrams-Griffiths nomogram. Postvoiding residual urine was 0 ml at the follow-up at 2 and 28 days. The average reduction in weight of the prostatic adenoma, measured with transrectal ultrasound and the ellipsoid formula, was 84% (range 50-90%). CONCLUSION: We think that this technique represents an interesting alternative in the treatment of symptomatic BPH.