Diffuse lymphoid tissue associated with the human bulbourethral gland. An immunohistologic characterization.

This study investigates the presence and distribution of immunocompetent cells in bulbourethral glands obtained from four multiorgan transplant donors. Monoclonal antibodies reacting with B (Leu 12+) and T (Leu 4+) cells, suppressor-cytotoxic cells (Leu 2+), helper-inducer (Leu 3a+) and natural killer (Leu7+) phenotypes, monocyte-macrophages, (LeuM3+), and cells expressing interleukin-2 receptor and HLA-DR antigen were tested in all specimens using an indirect immunoperoxidase staining procedure. T lymphocytes were estimated to represent 10% of the mucosal cell population. Almost all intraepithelial lymphocytes were suppressor-cytotoxic (CD8+) cells. The results demonstrate the presence of a defined distribution of immunocompetent cells in these sex accessory glands. Their role in combatting infections or other chronic genitourinary diseases is still undefined.

Is there a role for adjuvant immunochemotherapy after radical nephrectomy in pT2-3N0M0 renal cell carcinoma?

Five-year overall survival after radical surgery in N0M0 renal cell carcinoma varies from 45-80% in pT2 to 35-50% in pT3 categories. In view of the alpha interferon and vinblastine combination which has shown some activity in advanced disease with increasing efficacy in limited metastatic invasion, we decided to explore the theoretical advantage of adjuvant chemo-immunotherapy in radically resected stage II, III renal cell carcinoma. A single-institution phase II study was undertaken to evaluate the efficacy and tolerability of alpha 2a-interferon (alpha 2a-INF) in combination with vinblastine in 30 patients with pT2-T3 N0M0 renal cell carcinoma (RCC). Thirty-two patients who received only radical nephrectomy and extended lymphadenectomy were analyzed and results were compared with the first group. Twenty-three of 30 (76.6%) patients in the first group are alive with no evidence of disease. The median follow-up for the 23 patients still alive was 67 months (range 60 to 72). Metastases were documented in 5 patients (16.6%) with a median interval to progression of 24 months. Four of them (13.6%) died of tumor. In the control group, 16 out of 32 patients (50%) are still alive, with a median follow-up for the patients still alive of 62 months (range 60 to 68). Fifteen patients developed distant metastases and 2 of them had a local recurrence. All of them (46.8%) died of tumor. Median progression interval was 24 months. After stratification by pathological grade, site, laterality and number of nodes found at lymphadenectomy there were no statistical differences in risk of progression or death in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Metastatic renal cell cancer treated with recombinant alpha 2a interferon and vinblastine.

42 patients with advanced renal cell carcinoma were treated with a combination therapy with interferon alpha 2a (mean dosage 16 x 10(6) U i.m. 3 times/week) and vinblastine (0.1 mg/Kg every 21 days). 12 patients (28.5%) had a positive response. Of them 1 presented a complete response (2.38%), 5 a partial response (11.9%) and 6 a stable disease (14.2%). No significant side effects were observed apart from the flu-like syndrome (all patients) and a moderate leukopenia (45.2%). The median duration of responses was 10+ months (range 3-37 months). At 4-year follow-up the median survival time was 16.0 months (range 4-37 months).

[Treatment of urinary infections with ticarcillin and clavulanic acid (Clavucar) by the intramuscular route]. / Trattamento delle infezioni urinarie con ticarcillina ed acido clavulanico (Clavucar) per via intramuscolare.

20 patients suffering from hospital-acquired UTI received intramuscularly ticarcillin 1 g and clavulanic acid 200 mg for 8 days. At the end of antimicrobial therapy 84.2% of the pts presented sterile urine. After 2 weeks 68.4% of the pts continued to have sterile urine. No significant side effects were registered. The results demonstrate that the association of ticarcillin with clavulanic acid can be considered a useful option in hospital acquired UTI.

[Antibiotic prophylaxis with netilmicin in patients undergoing cystoscopic study]. / Antibiotico-profilassi con netilmicina in pazienti sottoposti ad indagine cistoscopica.

Thirty adults of either sex, in several cases affected by severe urinary pathology, underwent check cystoscopy. An intramuscular injection of netilmicin 200 mg was administered one hour before the diagnostic procedure as antibiotic prophylaxis. Treated patients were controlled up to three months after cystoscopy, in order to verify the presence of urinary infections. Data obtained proved the efficacy of netilmicin in preventing postcystoscopy urinary infections in 87% of the cases. Safety was very good in all patients.

Antiandrogens: a summary review of pharmacodynamic properties and tolerability in prostate cancer therapy.

This article provides a summary of the pharmacodynamic properties of major antiandrogens as well as an extensive review of their tolerability. Presently there are two classes of androgen receptor antagonists: the so-called pure, non-steroidal antiandrogens which include flutamide, nilutamide and the more recent bicalutamide and the steroidal antiandrogens cyproterone acetate, megestrol acetate and WIN 49596. Although non steroidal and steroidal compounds have been found to be equally effective in the treatment of prostate cancer presently no studies comparing the use of steroidal or non steroidal antiandrogens with chemical or surgical castration have evaluated quality of life per se. The only advantage of cyproterone acetate on pure antiandrogens seems to be the low incidence of hot flushes; a commonly reported adverse effect of androgen ablative therapy. However, hepatotoxicity associated with long term daily doses of 300 mg daily and the unacceptably high incidence of cardiovascular side effects (10%) should restrict its use to patients who are intolerant of pure antiandrogen compound. In contrast to steroidal compound nonsteroidal compounds let sexual potency to be retained, which is an important consideration with respect to the quality of life of some patients and, at present, the main indication for monotherapy with the pure antiandrogens. As regard as pure antiandrogens clinically important adverse events including gastrointestinal events, particularly diarrhea and occasional disturbances of liver function related to flutamide treatment and antabuse effect, problems with light-dark adaptation and rare interstitial pneumonitis related to nilutamide indicates the bicalutamide, due to its better tolerability profile, together with its once-daily oral administration regimen, could be considered the antiandrogen of first choice in the treatment of prostatic cancer.

[Four corner bladder base and bladder neck suspension with intraosseous anchorage in the treatment of moderate cystocele]. / La sospensione della base e del collo vescicale ai quattro angoli con ancoraggio intraosseo per la correzione del cistocele moderato.

During the last 10 years the original Pereyra technique of needle bladder neck suspension has been object of more than 36 modifications with the goal to improve long term results and to enhance feasibility. It represents also a part of the so called four corner bladder and bladder neck suspension (anterior suspending sutures) which is at present a reliable and durable manner to manage mild to moderate cystocele; this procedure reestablishes safely and simply support to bladder base, bladder neck and urethra preventing the onset of a denovo stress urinary incontinence. Complications include post-operative pain which could represent a problem in about 16% of the patients: it has been related to the entrapment of the ileoinguinal nerve between prolene sutures and rectus fascia and may be responsible of a delay in the re-establishment of a normal voiding pattern due to the pain elicited during any rectus muscle contraction. We propose a refinement of this procedure which includes the osseous anchoring of the suspending suture through the Mitek G II anchor system. Reduction in postoperative pain and fast recovery of a normal voiding pattern soon after surgery seems to be the most important result of this modification. Osteitis pubis has not been noted. Any improvement in long term durability of the procedure has not yet been determined due to the short follow-up and limited series of cases and the need for subsequent long term follow-up.

Treatment results using a mixed fiber mesh in patients with grade IV cystocele.

PURPOSE: We determined the efficacy of a modification of the 4-corner bladder and bladder neck suspension procedure using mixed fiber mesh to correct grade IV cystocele. MATERIALS AND METHODS: We evaluated 15 women with a mean age of 67 years who had severe anterior vaginal wall prolapse, of whom 3 had concurrent enterorectocele. Previously 5 patients had undergone repair of anterior vaginal wall prolapse and 2 had undergone procedures for stress urinary incontinence. In 10 patients type II stress urinary incontinence was diagnosed with urethral hypermobility and abdominal leak point pressure greater than 90 cm. water. No patients with intrinsic sphincter deficiency were enrolled in the study. A mixed fiber mesh was positioned using a modification of the 4-corner bladder and bladder neck suspension technique. Patients with concurrent enterorectocele underwent simultaneous formal repair of the posterior descensus. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals. Mean followup was 23.4 months (range 18 to 39). Of the 15 women 13 were continent (dry) at followup. No recurrent cystocele was evident, except in 1 patient who presented with segmental posterior bladder prolapse. In 2 patients new onset enterorectocele developed 6 months after mesh implantation. CONCLUSIONS: Our study confirms that the addition of mesh to the classic 4-corner bladder base and neck suspension procedure effectively treats incontinence and cystocele. We recommend this method for cases in which traditional techniques have previously failed and when the quality of suspending tissue is poor or defective, as in connective tissue disease. However, the risk of worsening enterorectocele or its new onset must be considered.

Ureteroscopic removal of ureteral calculi in bilateral ureteral duplications.

Two rare cases of ureteroscopic removal of impacted ureteral calculi in patients with partial and complete ureteral duplication are described. The procedural steps and problems encountered are discussed. Successful ureteroscopic stone extraction was obtained in the 2 patients.

Effect of Casodex on sleep-related erections in patients with advanced prostate cancer.

Sleep-related erections in 5 patients with stage T3N0M0 prostate cancer treated with a new nonsteroidal antiandrogen, Casodex, were evaluated with continuous monitoring of penile tumescence and rigidity on multiple nights. Mean serum luteinizing hormone levels were 7.2 +/- 1.2 IU/l. before therapy and increased to 14 +/- 3.6 IU/l. after 6 months of therapy. Serum testosterone and estradiol levels also increased from a basal level of 5.05 +/- 1.9 ng./ml. and 102 +/- 18 pmol./l., respectively, to 8.04 +/- 1.32 ng./ml. and 175 +/- 20 pmol./l., respectively, after 6 months of therapy. No significant modifications in regard to number of nocturnal penile tumescence episodes, maximum penile circumference and total rigidity time were found before and after therapy. Only 1 patient reported a decrease in sexual drive and libido. All patients presented with stable disease (National Prostatic Cancer Treatment Group criteria) and an unmodified performance status (Eastern Cooperative Oncology Group) after 6 months. Pure antiandrogen therapy did not seem to interfere significantly with the erectile capability of men with prostate cancer.

Tension-free vaginal mesh repair for anterior vaginal wall prolapse.

OBJECTIVES: We determined the efficacy of the use of a tension free prolene mesh to correct a grade III anterior vaginal wall prolapse recurrence. METHODS: Twelve women (mean age 65.6 years) with stress urinary incontinence (SUI) (4 type II and 1 type III) and bladder prolapse entered the study. After vaginal incision a pretailored polypropylene mesh was fixed to its four angles by absorbable sutures to the urethropelvic ligaments and pubocervical fascia anteriorly and to the cardinal ligaments and pubocervical fascia posteriorly. When present, a posterior descensus was corrected during the same procedure. SUI was treated with the tension-free vaginal tape procedure (TVT) through a separate vaginal incision over the mid-urethra. RESULTS: All patients were available for postoperative pelvic examination at 3-month intervals, for a mean follow-up of 20.5 months (range 15-32). Nine patients were considered cured (no cystocele recurrence) while in 3 patients a grade 1 asymptomatic cystocele was present postoperatively (asymptomatic). No significant postoperative pain was reported by the patients. CONCLUSIONS: This study confirms that in patients with moderate cystocele a tension-free mesh to support bladder base and neck effectively treats the cystocele. It is particularly recommended in the treatment of previous failure with traditional techniques and when the quality of suspending tissue is poor or defective. A long-term study on a large number of patients is still warranted to confirm and validate its clinical use.

Polypropilene sling of the bulbar urethra for post-radical prostatectomy incontinence.

OBJECTIVE: We present details of a modification of the Stamey procedure using a polypropilene mesh to compress the corpus spongiosum of the bulbar urethra in the treatment of sphincteric incompetence following radical prostatectomy. MATERIALS AND METHODS: Between September 1999 and June 2000 nine patients 66-80 years old (mean age 74) with severe incontinence due to radical prostatectomy underwent the bulbourethral sling procedure with polypropilene (Prolene) mesh implant. After transperineal incision a 5cmx4cm rectangular prolene mesh was placed against the bulbar urethra and suspended by four prolene sutures transferred to a suprapubic incision through ligature carriers as in the four corner bladder and bladder neck suspension. If leakage recurred in the follow-up, a retightening procedure was performed in local anesthesia rescuing the prolene threads over a polypropilene mesh placed against the rectus fascia. Mean follow-up was 14 months (range 12-20). Continence status and post-void residual volume were evaluated after 1, 3 and 6 months post-operatively and successively every 3 months. RESULTS: At the present follow-up considering the results of the retightening procedure five out of nine patients were cured, two out of nine improved and two were unchanged. Five out of nine patients reported slight to mild perineal/genital discomfort which disappeared in four at three months post-operatively. No patients required mesh removal for complications. CONCLUSIONS: The male bulbourethral sling procedure using a polypropilene mesh is safe but further experience is needed to establish this procedure as plausible alternative for the treatment of post-radical prostatectomy urinary incontinence.

Intravesical instillation of beta-interferon in the treatment of bladder cancer.

A total of 36 patients with single superficial bladder cancer TNM stage Ta-T1/G2 was studied over a 24-month period before entering the study to evaluate the efficacy and tolerance of high doses of beta-interferon (beta-INF); 24 patients had a primary tumour (group 1) and 12 had had more than 3 recurrences (group 2). They received 8 intravesical doses of beta-INF, 50,000,000 IU in 50 ml sterile water, at weekly intervals, 15 days after transurethral resection of the bladder (TURB). Efficacy was estimated by simple recurrence rate and by the person-years method. The recurrence rate was 25% in group 1 with a mean follow-up of 21.6 months. Comparison with the recurrence rate of a historical control group treated only by TUR showed that there was a slight statistically significant difference. Group 2 had a recurrence rate of 100% in the period before beta-INF (follow-up 24 months) and 91% after INF administration (mean follow-up 20.5 months). Patients were questioned about side effects before and after each treatment; tolerance of the drug was excellent. The results suggest that beta-interferon could be safely used as a prophylactic agent against the recurrence of primary superficial bladder cancer. Its efficacy seems comparable to that obtained with other current chemoprophylactic agents.

Short term effects of flutamide administration on hypothalamic-pituitary-testicular axis in man.

The effect of short term administration of flutamide on the hypothalamic-pituitary-gonadal axis was studied in six patients with advanced prostate cancer (C2 stage). Flutamide significantly increased LH pulse frequency in all patients (p less than 0.05 by Wilcoxon's test). The FSH pulse analysis disclosed a similar pattern of LH. Plasma IC-T clearly increased following flutamide therapy; mean IC-T values were 2.67 +/- 0.47 ng./ml. and 4.67 +/- 0.62 ng./ml. before and after flutamide administration, respectively (p less than 0.05 by paired Student's t test). Our study demonstrates that flutamide acts in humans as a selective and specific antiandrogen compound.

Immunohistochemical detection of tissue-infiltrating lymphocytes in mild urothelial dysplasia.

The presence and distribution of immunocompetent cells in normal and dysplastic urothelium of the bladder were investigated in 3 patients. Using an indirect immunoperoxidase staining procedure, monoclonal antibodies reacting with B (Leu12+) and T (Leu4+) cells, cells of the suppressor/cytotoxic (Leu2a+), helper/inducer (Leu3a+) and natural killer (Leu7+) phenotypes, monocyte-macrophages (LeuM3+), and cells expressing interleukin-2 receptor and HLA-DR antigen (HLA-DR+) were tested in all specimens. The results confirmed the presence of a well ordered and compartmentalised distribution of immunocompetent cells in the normal mucosa far from dysplasia. There was an increased number of lymphocytes in the hyperplastic/dysplastic urothelium with associated Von Brunn's nests. Leu2a+ cells, HLA-DR expressing cells and monocyte-macrophages were present inside the epithelium, particularly within dysplasia and von Brunn's nests, but the Leu3a+/Leu2a+ ratio was not inverted (0.48 + 0.1 to 0.74 + 0.2). These findings reveal that in mild urothelial dysplasia with von Brunn's nests there is a spatial modification of the immunological barrier associated with the mucosa.

[Intravesical chemoprophylaxis with beta-interferon in superficial carcinoma of the bladder]. / Chemioprofilassi endovescicale con beta-interferone nel carcinoma superficiale della vescica.

24 patients with recurrent (group 1) or primary (group 2) bladder cancer (ta/t1 G2) were given 50.000.000 U.I. of beta interferon intravesically after TUR of the neoplasm. In group 1 recurrence rate (rr) was 100% in the period before INF and 83% after INF treatment (follow-up 15-24 months, median 19.8) (p = ns). In group 2 rr was 25% in a 24 months, median 19.8) (p = ns). In group 2 rr was 25% in a 24 months follow-up period; if compared to the rr of a historical control group treated by only a TUR (38.2%) there was a statistically significant difference (p less than 0.01). Tolerability of the drug was excellent.