Adherence to Mediterranean Diet, Dietary Salt Intake, and Susceptibility to Nephrolithiasis: A Case-Control Study.

Unhealthy dietary habits play a key role in the pathogenesis of nephrolithiasis (NL). The aims of this case-control study were to evaluate (i) the adherence to the Mediterranean Diet (MD) and the dietary salt intake in stone-forming patients (SF), (ii) the relationship occurring between MD adherence, salt intake and NL-related metabolic risk factors in SF, and (iii) the impact of combined high MD adherence and low salt intake on NL susceptibility. From 1 January 2018 to 31 December 2019, we recruited all SF consecutively referred to the Extracorporeal Shock Wave Lithotripsy (ESWL) center of Federico II University, and at least two control subjects without a personal history of NL, age-, sex-, and body mass index-matched to SF (NSF). All study participants were interviewed using the validated MEDI-LITE and MINISAL questionnaires. In an SF subgroup, the NL-related metabolic risk factors were also evaluated. SF showed a lower MD adherence and a higher salt intake compared with NSF. The NL susceptibility decreased by 36% [OR: 0.64 (0.59-0.70); p < 0.01] for each point of increase in MEDI-LITE score, while it increased by 13% [OR: 1.13 (1.03-1.25); p = 0.01] for each point of increase in MINISAL score. The SF prevalence was higher among subjects showing combined low MD adherence and high salt intake. In SF, the MEDI-LITE score directly correlated with 24 h-citraturia, whereas the MINISAL score directly correlated with urinary sodium and uric acid excretion. In conclusion, high MD adherence and low salt intake are associated with a reduced NL susceptibility, both separately and in combination.

Reliability of Multiparametric Magnetic Resonance Imaging in Patients with a Previous Negative Biopsy: Comparison with Biopsy-Naïve Patients in the Detection of Clinically Significant Prostate Cancer.

Background: Multiparametric magnetic resonance is an established imaging utilized in the diagnostic pathway of prostate cancer. The aim of this study is to evaluate the accuracy and reliability of multiparametric magnetic resonance imaging (mpMRI) in the detection of clinically significant prostate cancer, defined as Gleason Score ≥ 4 + 3 or a maximum cancer core length 6 mm or longer, in patients with a previous negative biopsy. Methods: The study was conducted as a retrospective observational study at the University of Naples "Federico II", Italy. Overall, 389 patients who underwent systematic and target prostate biopsy between January 2019 and July 2020 were involved and were divided into two groups: Group A, which included biopsy-naïve patients; Group B, which included re-biopsy patients. All mpMRI images were obtained using three Tesla instruments and were interpreted according to PIRADS (Prostate Imaging Reporting and Data System) version 2.0. Results: 327 patients were biopsy-naïve, while 62 belonged to the re-biopsy group. Both groups were comparable in terms of age, total PSA (prostate-specific antigen), and number of cores obtained at the biopsy. 2.2%, 8.8%, 36.1%, and 83.4% of, respectively, PIRADS 2, 3, 4, and 5 biopsy-naïve patients reported a clinically significant prostate cancer compared to 0%, 14.3%, 39%, and 66.6% of re-biopsy patients (p < 0.0001-p = 0.040). No difference was reported in terms of post-biopsy complications. Conclusions: mpMRI confirms its role as a reliable diagnostic tool prior to performing prostate biopsy in patients who underwent a previous negative biopsy, reporting a comparable detection rate of clinically significant prostate cancer.

Risk Factors for Testicular Cancer: Environment, Genes and Infections-Is It All?

The incidence of testicular cancer is steadily increasing over the past several decades in different developed countries. If on one side better diagnosis and treatment have shone a light on this disease, on the other side, differently from other malignant diseases, few risk factors have been identified. The reasons for the increase in testicular cancer are however unknown while risk factors are still poorly understood. Several studies have suggested that exposure to various factors in adolescence as well as in adulthood could be linked to the development of testicular cancer. Nevertheless, the role of environment, infections, and occupational exposure are undoubtedly associated with an increase or a decrease in this risk. The aim of this narrative review is to summarize the most recent evidence regarding the risk factors associated with testicular cancer, starting from the most commonly evaluated (cryptorchidism, family history, infections) to the newer identified and hypothesized risk factors.

The role of the general practictioner in the management of urinary calculi.

BACKGROUND: The prevalence of kidney stones tends to increase worldwide due to dietary and climate changes. Disease management involves a high consumption of healthcare system resources which can be reduced with primary prevention measures and prophylaxis of recurrences. In this field, collaboration between general practitioners (GPs) and hospitals is crucial. METHODS: a panel composed of general practitioners and academic and hospital clinicians expert in the treatment of urinary stones met with the aim of identifying the activities that require the participation of the GP in the management process of the kidney stone patient. RESULTS: Collaboration between GP and hospital was found crucial in the treatment of renal colic and its infectious complications, expulsive treatment of ureteral stones, chemolysis of uric acid stones, long-term follow-up after active treatment of urinary stones, prevention of recurrence and primary prevention in the general population. CONCLUSIONS: The role of the GP is crucial in the management and prevention of urinary stones. Community hospitals which are normally led by GPs in liaison with consultants and other health professional can have a role in assisting multidisciplinary working as extended primary care.

International Alliance of Urolithiasis (IAU) guidelines on the metabolic evaluation and medical management of urolithiasis.

The aim of this study was to construct the fourth in a series of guidelines on the treatment of urolithiasis by the International Alliance of Urolithiasis (IAU) that by providing a clinical framework for the metabolic evaluation, prevention, and follow-up of patients with urolithiasis based on the best available published literature. All recommendations were summarized following a systematic review and assessment of the literature in the PubMed database from January 1976 to June 2022. Each generated recommendation was graded using a modified GRADE methodology. Guideline recommendations were developed that addressed the following topics: initial evaluation, metabolic testing, dietary measures, medical management, and follow-up of recurrent stone formers. It was emphasized by the Panel that prevention of new stone formation is as important as the surgical removal of the stones. Although general preventive measures may be effective in reducing stone recurrence rates in some patients, specific medical and dietary management should be well considered and eventually applied in an individualized manner based on the outcomes of metabolic work-up, stone analysis and some certain patient related factors. A detailed follow-up of each case is essential depending on the metabolic activity of each individual patient.

Preoperative monocyte-to-lymphocyte ratio as a potential predictor of bladder cancer.

OBJECTIVES: The aim of this study was to investigate the role of preoperative Monocyte-to-Lymphocyte ratio (MLR) as a potential predictor of bladder cancer (BC). METHODS: Clinical data of patients who underwent TURBT at our institution between 2017 and 2021 were collected and retrospectively analysed. MLR was obtained from preoperative blood analyses performed within 1 month from hospital admission. The association of MLR with different clinic-pathological features obtained from histological reports was further analysed. Statistical analysis was performed using the Kruskal Wallis test for non-parametric variables, assuming p<0.05 as statistically significant. RESULTS: 510 patients were included in the study (81% males, 19% females), with a mean age of 71.66 ± 11.64 years. Mean MLR was higher in patients with any-type bladder cancer, reporting an MLR of 0.41 ± 0.11 compared to 0.38 ± 0.43 in patients without bladder cancer (p=0.043). In the subsequent comparison among low-grade and high-grade bladder cancer, MLR did not report statistically significant differences, with 0.29 ± 0.12 for low-grade BC and 0.51 ± 0.81 for high-grade BC (p=0.085). CONCLUSIONS: Our findings reported elevated preoperative MLR should be considered a potential biomarker predicting malignancy for bladder tumours. Furthermore, research are necessary to assess its role in discerning low-grade from high-grade patients.

Lower urinary tract symptoms and mental health during COVID-19 pandemic.

OBJECTIVE: Coronaviruses (CoVs) are a group of RNA viruses involved in several human diseases affecting respiratory, enteric, hepatic, and neurological systems. COVID-19 was identified in 2020 and was named SARS-CoV-2. To limit worldwide contagion, many countries instituted a lockdown, which conducted to disruption of routine life. In fact, pandemic was associated with several stresses among population, such as loss of employment, deaths of family members, friends, or colleagues, financial insecurity, and isolation. This led to long-lasting psychosocial effects as anxiety and depression, increasing the prevalence of stress and traumarelated disorders in the population. The aim of this study was to investigate the correlation between lower urinary tracts symptoms (LUTS) and stress/depressive symptoms during COVID-19 pandemic. MATERIALS AND METHODS: An anonymous cross-sectional webbased survey (comprehending anthropometric data, education level, occupation status, smoking and alcohol habits, current therapies, quarantine and COVID-19 infection status) was conducted from March to May 2020 in Italy. LUTS were examined through National Institute of Health-Chronic Prostatitis Symptom Index (NIH-CPSI) and Genitourinary Pain Index (GUPI). Hamilton Depression Rating Scale (HDRS) was utilized to evaluate depressive and anxiety symptoms. Non-parametric Kruskal-Wallis H Test was used for statistical analysis. RESULTS: A total of 356 out of 461 subjects fully completed the survey, with a response rate of 77.2%. Data showed that subjects involved in economic difficulties, quarantine measures or with increased HDRS reported a significative statistic worsened urinary symptoms (H(3) = 11.731, p = 0.008), quality of life, (H(3) = 10.301, p = 0.016), total NIH-CPSI/GUPI score (H(3) = 42.150, p = 0.000), and quality of life (H(3) = 48.638, p = 0.000). CONCLUSIONS: COVID-19 pandemic provoked several alterations in everyday life. Although general lockdown, quarantine and social distancing have been necessary to prevent virus spreading, this had long term effects on all population in terms of mental and physical health. NIH-CPSI and GUPI scores increased linearly with stress and anxiety levels measured at HDRS, confirming worse LUTS in subjects who suffered anxiety and stress from COVID-19 pandemic.

In-vitro and in-vivo new evidence for Flexor® Vue™ deflecting endoscopic system use: optimization of the stone free rate (SFR) after flexible ureteroscopy and Ho:YAG laser lithotripsy.

To test in-vitro and in-vivo the Flexor® Vue™ deflecting endoscopic system (FVDES) as a new technology able to improve the removal of residual intrarenal fragments.This is an observational prospective "proof of concept" study performed in patients with renal calculi treated with flexible ureteroscopy and Ho:YAG laser lithotripsy (f-URS) in Humanitas Research Hospital (Rozzano, Italy). We assessed feasibility, efficacy and safety of FVDES as an in-vivo tool for removing residual fragments after f-URS. The stone-free rate (SFR) at 30 days post-operatively was evaluated using CT. An in-vitro model was developed to evaluate the FVDES when used for this purpose.Eleven patients (M/F ratio: 7/4, mean age 63.5 ± 8.3) were treated. The stones were located in the lower calyces and the renal pelvis in 3 and 8 patients, respectively. Mean stone size was 18 ± 3.2 mm. The procedure with FVDES was feasible and effective in all the patients. Mean operative time was 82 ± 13.7 min and median hospitalization was of 1.5 days. The SFR after 90 days was 81% (9/11). We reported no relevant complications (Clavien-Dindo > 2); one patient had fever and was treated with antibiotics. The experimental in-vitro model demonstrated the efficacy of FVDES, allowing the removal of about 90% of fragments.Our study showed that FVDES is effective when used as a tool for retrieval of residual fragments at the end of f-URS. This technology could ensure a complete cleaning of the intrarenal collecting system and represent a safe alternative to basketing.

Osteoporosis is a Predictive Factor for Nephrolithiasis in an Adult Free-Living Caucasian Population From Southern Italy: A Longitudinal Retrospective Study Based on a General Practice Database.

Osteoporosis and nephrolithiasis are common multifactorial disorders with high incidence and prevalence in the adult population worldwide. Both are associated with high morbidity and mortality if not correctly diagnosed and accurately treated. Nephrolithiasis is considered a risk factor for reduced bone mineral density. Aim of this retrospective longitudinal study was to evaluate if osteoporosis is a predictive factor for the nephrolithiasis occurrence. Free-living subjects referring to "COMEGEN" general practitioners cooperative operating in Naples, Southern Italy. Twelve thousand seven hundred ninety-four Caucasian subjects (12,165 female) who performed bone mineral density by dual-energy X-ray absorptiometry and have a negative personal history for nephrolithiasis. Subjects aged less than 40 years or with signs or symptoms suggestive of secondary osteoporosis were excluded from the study. In a mean lapse of time of 19.5 months, 516 subjects had an incident episode of nephrolithiasis. Subjects with osteoporosis had an increased risk of nephrolithiasis than subjects without osteoporosis (Hazard Ratio = 1.33, 95% Confidence Interval 1.01-1.74, p = 0.04). Free-living adult subjects over the age of 40 with idiopathic osteoporosis have an increased risk of incident nephrolithiasis, suggesting the advisability of appropriate investigation and treatment of the metabolic alterations predisposing to nephrolithiasis in patients with osteoporosis. The study protocol was approved by the ASL Napoli 1 Ethical Committee, protocol number 0018508/2018.

Retrograde intra renal surgery versus percutaneous nephrolithotomy for renal stones >2 cm. A systematic review and meta-analysis.

INTRODUCTION: The recent advances in technology and miniaturization of endoscopic devices have permitted the use of retrograde intra renal surgery (RIRS) to treat large and complicated kidney stones as first line therapy in alternative to percutaneous nephrolithotomy (PCNL). Systematically review the efficacy and safety of RIRS for large renal stones over 2 cm versus the current gold standard, the percutaneous nephrolithotomy. EVIDENCE ACQUISITION: A large search was effected in PubMed, Cochrane Library, Embase, Ovid and Scopus regarding the treatment of renal stones over 2 cm with RIR S versus PCNL. Articles not in English and not regarding adult population were excluded. The retrieval time included a time span from 2000 to 2019. All clinical trials were further evaluated about quality and references. The eligible studies were included and analysed with RevMan 5.2 Software. EVIDENCE SYNTHESIS: Two randomized and nine non-randomized studies were included for a total of 1618 patients involved. Our meta-analysis showed no difference in SFR (RR =0.92, 95% CI : 0.86-0.99, P=0.03) and in mean operation time (WMD=6.34 min, 95% CI : -4.98 to 17.65, P=0.27) while shorter hospital stay was reported for RIR S (WMD=-2.15 days, 95% CI: -3.04 to -1.25, P≤0.00001). We reported moreover lower Hb drop (WMD=-0.83 g/dL, 95% CI: -1.20 to -0.45, P≤0.00001) and complications rate in favor of RIRS (RR=0.88, 95% CI: 0.71-1.09, P=0.23). CONCLUSIONS: RIRS is challenging PCNL for the treatment of large renal stones over 2cm, becoming a safe and effective alternative with a comparable stone free rate, lower complication rate and lower hospitalization time. It is, however, of the uttermost importance to share the treatment decision with the patient due to the possibility of requiring multiple RIR S session to completely clear larger stone burdens.

Stone residual fragments: A thorny problem.

Urolithiasis represents a widespread and common disorder among the world population, with a predicted increase in affected patients in the coming years. Treatment of renal and ureteral stones varies widely, and achieving true stone-free status in all patients is still difficult. Moreover, imaging used to assess residual fragments following procedure impacts the diagnosed stone-free rate percentage considerably. In particular, the use of computed tomography scans has led to a better evaluation of residual fragments as well as so-called clinically insignificant residual fragments, which in a considerable number of cases are, despite their definition, causes of adverse urological events, thus creating a thorny problem for both patients and urologists. Currently, there is no gold standard or validated protocol regarding the management, clearance and prevention of residual fragments. In this article, we review the current literature regarding residual fragments, clinically insignificant residual fragments and their natural history, reporting on diagnostic methods, incidence, complications and outcome with the use of less invasive procedures, taking into consideration viable treatment and management of patients affected.

Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.

OBJECTIVE: Diet interventions may reduce the risk of urinary stone formation and its recurrence, but there is no conclusive consensus in the literature regarding the effectiveness of dietary interventions and recommendations about specific diets for patients with urinary calculi. The aim of this study was to review the studies reporting the effects of different dietary interventions for the modification of urinary risk factors in patients with urinary stone disease. MATERIALS AND METHODS: A systematic search of the Pubmed database literature up to July 1, 2014 for studies on dietary treatment of urinary risk factors for urinary stone formation was conducted according to a methodology developed a priori. Studies were screened by titles and abstracts for eligibility. Data were extracted using a standardized form and the quality of evidence was assessed. RESULTS: Evidence from the selected studies were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as expert opinions. CONCLUSIONS: General measures: Each patient with nephrolithiasis should undertake appropriate evaluation according to the knowledge of the calculus composition. Regardless of the underlying cause of the stone disease, a mainstay of conservative management is the forced increase in fluid intake to achieve a daily urine output of 2 liters. HYPERCALCIURIA: Dietary calcium restriction is not recommended for stone formers with nephrolithiasis. Diets with a calcium content ≥ 1 g/day (and low protein-low sodium) could be protective against the risk of stone formation in hypercalciuric stone forming adults. Moderate dietary salt restriction is useful in limiting urinary calcium excretion and thus may be helpful for primary and secondary prevention of nephrolithiasis. A low-normal protein intake decrease calciuria and could be useful in stone prevention and preservation of bone mass. Omega-3 fatty acids and bran of different origin decreases calciuria, but their impact on the urinary stone risk profile is uncertain. Sports beverage do not affect the urinary stone risk profile. HYPEROXALURIA: A diet low in oxalate and/or a calcium intake normal to high (800-1200 mg/day for adults) reduce the urinary excretion of oxalate, conversely a diet rich in oxalates and/or a diet low in calcium increase urinary oxalate. A restriction in protein intake may reduce the urinary excretion of oxalate although a vegetarian diet may lead to an increase in urinary oxalate. Adding bran to a diet low in oxalate cancels its effect of reducing urinary oxalate. Conversely, the addition of supplements of fruit and vegetables to a mixed diet does not involve an increased excretion of oxalate in the urine. The intake of pyridoxine reduces the excretion of oxalate. HYPERURICOSURIA: In patients with renal calcium stones the decrease of the urinary excretion of uric acid after restriction of dietary protein and purine is suggested although not clearly demonstrated. HYPOCITRATURIA: The administration of alkaline-citrates salts is recommended for the medical treatment of renal stone-formers with hypocitraturia, although compliance to this treatment is limited by gastrointestinal side effects and costs. Increased intake of fruit and vegetables (excluding those with high oxalate content) increases citrate excretion and involves a significant protection against the risk of stone formation. Citrus (lemons, oranges, grapefruit, and lime) and non citrus fruits (melon) are natural sources of dietary citrate, and several studies have shown the potential of these fruits and/or their juices in raising urine citrate levels. CHILDREN: There are enought basis to advice an adequate fluid intake also in children. Moderate dietary salt restriction and implementation of potassium intake are useful in limiting urinary calcium excretion whereas dietary calcium restriction is not recommended for children with nephrolithiasis. It seems reasonable to advice a balanced consumption of fruit and vegetables and a low consumption of chocolate and cola according to general nutritional guidelines, although no studies have assessed in pediatric stone formers the effect of fruit and vegetables supplementation on urinary citrate and the effects of chocolate and cola restriction on urinary oxalate in pediatric stone formers. Despite the low level of scientific evidence, a low-protein (< 20 g/day) low-salt (< 2 g/day) diet with high hydration (> 3 liters/day) is strongly advised in children with cystinuria. ELDERLY: In older patients dietary counseling for renal stone prevention has to consider some particular aspects of aging. A restriction of sodium intake in association with a higher intake of potassium, magnesium and citrate is advisable in order to reduce urinary risk factors for stone formation but also to prevent the loss of bone mass and the incidence of hypertension, although more hemodynamic sensitivity to sodium intake and decreased renal function of the elderly have to be considered. A diet rich in calcium (1200 mg/day) is useful to maintain skeletal wellness and to prevent kidney stones although an higher supplementation could involve an increase of risk for both the formation of kidney stones and cardiovascular diseases. A lower content of animal protein in association to an higher intake of plant products decrease the acid load and the excretion of uric acid has no particular contraindications in the elderly patients, although overall nutritional status has to be preserved.

Urolithiasis in Italy: an epidemiological study.

OBJECTIVES: Worldwide the urolithiasis is the third most frequent urological disease affecting both males and females. In literature there are not recent Italian epidemiological data about stone disease. The objective of this study is the evaluation of current epidemiology of urolithiasis in Italy using the Health Search/CSD Longitudinal Patient Database (HS) database. MATERIAL AND METHODS: An observational, descriptive, retrospective trial was conducted. Inclusion criteria were: family physician- assisted Italian living population member of HS database within 31 December 2012, both genders, age over 17 years, at least two years of clinical history recorded from the beginning the trial. Data were collected by HS database and elaborated by its software Millewin®. RESULTS: In Italy prevalence of urolithiasis in 2012 was 4.14%, it was higher in males than in females (4.53% versus 3.78%) with a positive relation with increasing age. The highest prevalence rate of urolithiasis was reported in the region Campania (6.08%). The general incidence was 2.23 * 1000, with the highest incidence in the region Sicilia (3.15 * 1000). Incidence was higher in group age 65-74 years (3.18 * 1000). CONCLUSIONS: In Italy the incidence and prevalence of urolithiasis is increasing with particular distribution in relation to gender, age and regional position.

Evaluation of penile cavernosal artery intima-media thickness in patients with erectile dysfunction. A new parameter in the diagnosis of vascular erectile dysfunction. Our experience on 59 cases.

OBJECTIVE: A precise characterization of erectile dysfunction (ED) of vascular origin has not yet been achieved, although cavernous peak systolic velocity (PSV) is generally considered a major parameter. Nevertheless the penile dynamic color Doppler is invasive and linked to several complications. The intima-media thicknesses (IMT) of cavernosal artery would add to the predictive value of vasculogenic ED risk and outcomes. We also hypothesized the existence of a correlation between IMT cavernosal artery and IMT carotid arteries. This study seeks to evaluate these hypotheses with our experience, investigating the predictive accuracy of carotid and cavernosal Doppler ultrasound findings for discriminating patients with vasculogenic ED. MATERIAL AND METHODS: A total of 59 subjects (32 vasculogenic ED patients - group A - and 27 no vasculogenic ED patients - group B) were evaluated in our andrological center from September 2012 to June 2013 and enrolled in the study. All subjects underwent medical history, erectile function domain of the International Index of Erectile Function, physical examination, routine and sex hormone blood tests, and high resolution dynamic color Doppler ultrasound evaluation of carotid and penile districts and valuation of IMT in both districts. RESULTS: The values of cavernosal artery IMT in group A were higher than in group B (0,28 ± 0,06 mm vs 0,17 ± 0,07 mm). Even the values of carotid artery IMT in vasculogenic ED group were higher than in no vasculogenic ED group (0,74 ± 0,14 mm vs 0,59 ± 0,11 mm). The cavernosal IMT showed a moderate (r = 0.61) positive linear correlation (p < 0.001) with the carotid artery IMT. CONCLUSIONS: An increased cavernous IMT might predict ED of vascular origin with more accuracy than PSV and could be a sensitive predictor also for systemic atherosclerosis at an earlier phase.

Mannose-binding lectin genetic analysis: possible protective role of the HYPA haplotype in the development of recurrent urinary tract infections in men.

Factors related to bacterial virulence and/or to the host have been implicated in the pathogenesis of recurrent urinary tract infections (rUTI), but in most cases the cause is unknown. Mannose binding lectin (MBL) is an acute phase glycoprotein that exerts immunological functions by binding to the surface of a variety of pathogens. Some human gene variants reduce MBL activity thereby predisposing the host to bacterial and viral infections. The aim of this study was to investigate MBL2 gene variants in relation to rUTI risk. Six MBL gene variants and seven haplotypes were analyzed by PCR and direct sequencing in rUTI patients (n = 83) and in healthy subjects from southern Italy (n = 642). The frequencies of the L allele (-550) and the HYPA haplotype were higher in controls than in patients stratified according to sex (p < 0.05). Our data indicate that the HYPA haplotype in the MBL2 gene could be associated with a minor risk of developing rUTI in males.

Early versus delayed hormonal treatment in locally advanced or asymptomatic metastatic prostatic cancer patient dilemma.

INTRODUCTION: The objective of this work is to compare the effectiveness of hormonal treatment (luteinizing hormone-releasing hormone agonists and/or antiandrogens) as an early or as a deferred intervention for patients with locally advanced prostate cancer (LAPC) and/or asymptomatic metastasis. MATERIALS AND METHODS: Systematic review of trials published in 1950-2007. Sources included MEDLINE and bibliographies of retrieved articles. Eligible trials included adults with a history of LAPC who are not suitable for curative local treatment of prostate cancer. We retrieved 22 articles for detailed review, of which 8 met inclusion criteria. The Veterans Administration Cooperative Urological Research Group suggested that delaying hormonal therapy did not compromise overall survival and that many of the patients died of causes other than prostate cancer. In European Organisation for Research and Treatment of Cancer (EORTC) 30846 trial, the median survival for delayed endocrine treatment was 6.1 year, and for immediate treatment 7.6 year, the HR for survival on delayed versus immediate treatment was 1.23 (95 % CI 0.88-1.71), indicating a 23 % nonsignificant trend in favour of early treatment. In EORTC 30891, the immediate androgen deprivation resulted in a modest but statistically significant increase in overall survival. The protocol SAKK 08/88 showed the lack of any major advantage of immediate compared with deferred hormonal treatment regarding quality of life or overall survival. CONCLUSIONS: The early intervention with hormonal treatment for patients with LAPC provides important reductions in all-cause mortality, prostate cancer-specific mortality, overall progression, and distant progression compared with deferring their use until standard care has failed to halt the disease.

Presenting a case of a mucinous adenocarcinoma of an exstrophic bladder in an adult patient and a review of literature.

BACKGROUND: Bladder exstrophy occurs in approximately 1 in 35,000 live births and is associated with an increased incidence of bladder cancer. CASE PRESENTATION: A 55-year old male patient was diagnosed with a primary mucinous adenocarcinoma of an unreconstructed exstrophic bladder. Examination of the entire gastrointestinal tract shown there were not other primary cites. Immunohistochemistry confirmed the nature of the tumour. The patient underwent a radical cystoprostatectomy with en block bilateral pelvic lymphadenectomy, urinary diversion with a cutaneous ureterostomy and epidpadias repair. CONCLUSION: Adult bladder exstrophy and epispadia correction is a very rare practice in urology due the fact that this congenital disease is diagnosed and corrected in neonates. We advocate the radical surgical management, after exclusion of any primary malignant sites related to the gastrointestinal tract.