Dioxoiodane Compounds as Versatile Sources for Iodine(I) Chemistry.

The general synthesis, isolation and characterization of electrophilic iodine reagents of the general formula R4 N[I(O2 CAr)2 ] is reported. These compounds are air- and moisture-stable iodine(I) reagents, which were characterized including X-ray analysis. They represent conceptually new iodine(I) reagents with anions as stabilizers. These compounds display the expected performance as electrophilic reagents upon interaction with electron-rich substrates. The performance of these compounds in a total of 47 different reactions of vicinal iodooxygenation of alkenes is studied and some key features on the reagents are revealed.

Corporoplasty by plication: out patient surgery for the correction of penile curvature.

OBJECTIVE: Corporoplasty using plication of the albuginea is a simple technique but considered by many Authors at high risk for recurrence in respect to other corrective techniques using excision of the albuginea tunica. The aim of this study was to assess long-term functional and cosmetic results of this approach done in an outpatient environment. MATERIAL AND METHODS: From January 1997 to December 2008 we submitted 217 patients presenting induratio penis plastica (183) or congenital curvature (34) to corporoplasty with albuginea plication. All patients were assessed preoperatively with history, physical examination and photographic documention of the erectile penis. These patients, all with vaginal penetration problems, were submitted to corporoplication with 2-4 sutures 2/0 (polyglycolic) contralateral to the curvature, using local anaesthesia on outpatient basis. Follow-up included functional and cosmetic results, eventual complications and level of patient satisfaction. RESULTS: Median follow-up of our study was 44 months (range 2-58). Complete correction of curvature was achieved in 206 patients (95%) whereas 87% reported good erectile function (IIEF-5 > 21). 145 patients (67%) reported penis shortening and 41% complained of palpating the sutures. Two patients required reoperation for recurring curvature. No perioperative complications or altered sensitivity of the glans were reported. CONCLUSIONS: Simple plication of the corpora cavernosa can be done on an outpatient basis using local anaesthesia with optimal functional and cosmetic results. The success of this minimally invasive approach makes it a valid alternative to standard excision of the tunica albuginea procedure. Detailed preoperative information concerning procedure expectations and treatment course are extremely important in obtaining complete functional and cosmetic patient satisfaction.

Percutaneous nephrolithotomy: tubeless or not tubeless?

The objective of this study is to evaluate the safety and outcomes of tubeless PCNL in comparison with standard PCNL. Since June 2002, we have performed 99 tubeless PCNL. Tubeless technique involves antegrade placement of a 6Fr double-J stent without nephrostomy tube at the end of the procedure. This series has been compared with a total of 110 patients in which revision of operative reports ruled out the presence of intraoperative conditions necessary to candidate a patient to tubeless procedure but standard PCNL was performed because prior to its introduction or because of surgeon's attitude afterward. Mean stone burden was 5.4 for standard group and 4.9 cm(2) for tubeless group, respectively. Mean BMI was 24.1 in the first group and 23.6 in the second one. In this retrospective study, complications rate, postoperative pain, length of hospitalization and convalescence were evaluated by chart review. Hematocrit drop did not differ significantly between tubeless PCNL and standard PCNL (5.5 vs. 5.9%). Conversely, there was statistically significant difference between tubeless and standard PCNL in terms of the amount of analgesics (49.5 vs. 84.2 mg), immediate postoperative patients' discomfort, hospitalization (2.2 vs. 5.3 days) and time to resume normal activities (11.0 vs. 16.5 days). In conclusion, in our series, tubeless approach did not determine increase in complication rate. Conversely, tubeless PCNL reduced analgesics' requirement, patients' discomfort, hospitalization and time to recovery. As such, at our institution, tubeless PCNL has become routine procedure that actually is feasible in almost two-third of renal calculi suitable for percutaneous treatment.

PSA repeatedly fluctuating levels are reassuring enough to avoid biopsy?

INTRODUCTION: Prostate-specific antigen (PSA) levels can show wide fluctuations when repeatedly measured. Here we investigatewd if: (a) biopsy timing influences the prostate cancer (PC) detection rate in patients with fluctuating PSA (flu-PSA) in comparison with patients with steadily increasing PSA (si-PSA); (b) PSA slope estimated in patients with flu-PSA predicts a different risk of cancer detection; (c) flu-PSA and si-PSA patients develop PC in topographically different sites; (d) the behaviour of pre-operative PSA is an expression of a disease with defferent characteristics to the following radical prostatectomy. METHODS: The study involved 211 patients who underwent at least a second biopsy after a first negative prostate biopsy. PSA Slope, PSA velocity (PSAV) and PSA doubling time (PSADT) were estimated. Flu-PSA level was defined as a PSA series with at least one PSA value lower than the one immediately preceding it. RESULTS: 82 patients had flu-PSA levels and 129 si-PSA levels. There were no significant differences between the two groups in terms of cancer detection, clinical or pathological stage, but the si-PSA group with cancer had a higher Gleason score. No difference was found for PSA Slope between flu-PSA patients with cancer and those without. CONCLUSIONS: Our study demonstrates no difference in PC detection rate at repeat biopsy between patients with flu or si-PSA levels. PSA Slope, PSAV and PSADT were not found helpful tools in cancer detection.

Nephron sparing surgery of parenchymal kidney tumours in solitary kidney.

INTRODUCTION: The aim of this study is to assess the therapeutic efficacy of nephron sparing surgery (NSS) in our experience applied to patients with either bilateral renal cancer or patients with cancer in a solitary functioning kidney, from an oncological viewpoint as well as renal function. MATERIALS AND METHODS: From January 1997 to March 2006 we submitted 185 patients to NSS. Twenty-seven presented absolute indications with disease in functionally or anatomically solitary kidney. All but six patients presented with preoperative creatinine levels lower than 2 mg/dL. Access was always lombotomic. Nineteen patients underwent renal artery clamping and cold ischemia. Lesions were between 2 and 14 cm in size. In six cases the collecting system was formally opened. RESULTS: Follow-up was between 2 and 108 months. Final histology showed 17 patients with clear cell renal carcinoma, six papillary cell carcinomas, one chromophobe carcinoma, one oncocytoma and two angiomyolipomas. No major perioperative complications were recorded. Two patients died of lung metastases. Two patients present secondary tumours (lung and liver), whereas one patient is being treated with chemotherapy for colon cancer Twenty-two patients are disease-free. None of the 10 patients discharged with creatinine levels >2 mg/dL, were submitted to dialytic therapy during follow-up. None of the patients discharged with normal renal function developed kidney failure. CONCLUSIONS: Conservative surgery for patients with absolute indications, is a valid alternative to radical surgery that obviously commits patients to long-term dialysis or renal transplantation. Our cases showed minimal surgical complications, brief hospital stay and limited invasiveness for patients with small incidence of kidney failure associated to the all important cancer control.

Single small focus of prostate adenocarcinoma (< or = 1 mm and too small for grading) and clinical significant disease after radical prostatectomy.

OBJECTIVES: To determine whether a clinical significant adenocarcinoma of the cinoma (defined as a lesion < or =1 mm. and too small for grading) at needle biopsy, even repeated, and through prostate specific antigen (PSA), PSA density (PSAD) and free-to-total PSA ratio (f/t ratio). METHODS: Retrospectively 79/1610 consecutive patients undergoing prostatic needle biopsies presented one small focus of prostatic adenocarcinoma < or =1 mm and too small for grading. All patients underwent PSA, PSAD and f/t ratio to evaluate positive predictive value for clinically significant disease. All patients were submitted to radical retropubic prostatectomy (RRP) and were divided into three groups: group A (28/79 patients, 35.4%) submitted to RRP after diagnosis of just one small focus of adenocarcinoma at first biopsy; group B (26/79 patients, 32.9%) submitted to RRP after two successive diagnoses of small focus of adenocarcinoma; group C (25/79 patients, 31.6%) submitted to RRP after diagnosis of adenocarcinoma larger than 1 mm at successive biopsy in which Gleason score had been applied. RESULTS: The three groups resulted comparable for age, PSA, f/t ratio and PSAD. Clinically significant disease was found in 48 of 79 patients (60.7%); 16 patients of group A (33.3%), 15 patients of group B (31.2%) and 17 patients of group C (35.4%) respectively. Finally, PSA, f/t ratio, and PSAD showed no predictive value neither globally nor in the single groups. CONCLUSIONS: No selective criteria with consolidated predictive values emerge from our study and this is in agreement with data in the literature, where the risk to find no significant clinical disease is 9-48% approximately. The aim of this retrospective study is to analyze the correlation between a single small focus of adenocarcinoma by prostatic biopsy, even repeated, and the clinical significant disease on the following radical retropubic prostatectomy. Furthermore, we verified whether some preoperative parameters could be helpful to identify the subgroups of patients which could need a more or less aggressive and/or timely treatment. Our data show that 30-40% of patients did not harbor a clinically significant disease at the following RRP. Furthermore, the assumed predictive value of repeat biopsies has not been confirmed in these patients and no other preoperative predictive values can be helpful.

Incidence and treatment of complications in nephron sparing surgery.

UNLABELLED: Conservative renal surgery (enucleation or segmentary resection) has become the gold standard treatment for small and peripheral malignant kidney lesions or in cases of reduced renal function or bilateral lesions. The aim of this study is to evaluate the incidence and treatment of complications of this technique in our experience. MATERIALS AND METHODS: Between March 1997 and March 2005, 159 patients aged from 23 to 77 years (median 66 years) underwent conservative renal surgery. In 123 patients the indication was elective and in 36 imperative. In 92 patients lesions were located in the upper pole, 41 in the lower pole and 24 were meso-renal . Two patients suffered from von Hippel-Lindau (VHL) disease and therefore presented multicentric lesions. Mean lesion diameter was 3 cm ( range 1 to 9 cm). Retroperitoneal access with flank incision was the approach used in all patients. In 124 patients the technique consisted of enucleation with hypothermia from contact with sterile ice. Time to ischaemia was between 12 - 40 minutes. The collecting system was opened in 23 patients. RESULTS: Twelve cases of perioperative complications were encountered in this group of patients. Major complications were: two massive hemorrhage, two arteriovenous fistula, one lesion of the ureter, five cases of acute kidney failure. The two massive bleedings occurred within the first eight hours after surgery and necessitated surgical intervention to check a bleeding perinephric vessel. The arteriovenous fistulas, which occurred on the seventh and tenth postoperative day, were treated with selective percutaneous sclero-embolisation. The five acute kidney failures involved patients with functional or anatomical solitary kidney. No patient required dialysis in the post-operative period. Ureter lesion characterised the post-operative course of one solitary kidney patient affected by voluminous angiomyolipoma. Anuria and urine emission from drainage lead to exploratory lumbotomy which evidenced an iatrogenic lesion of the lumbar ureter that was treated with termino-terminal anastomosis. No other major complications were noted, with the exception of delay in intestinal canalization occurring in a 74 year old patient, and a wound infection in a patient with previous renal abscess associated to infundibular lithiasis and caliceal exclusion. There were no postoperative deaths. CONCLUSIONS: Conservative renal surgery is a valid alternative to radical surgery. In our study, as already reported in literature, surgical complications were slight in incidence and conservatively treatable. Therefore, nephron sparing surgery (NSS) can be performed with safety and maximum preservation of renal function.

The reconstruction of "complex" ureteral lesions.

A total of 13 patients with ureteral lesions wider than 12 cm in length and/or previous radiation treatment have been submitted to reconstructive treatment. Four patients with lesions after radiation therapy were treated with ileal ureter and contemporary bladder augmentation, one with ureteroneocystostomy combined with psoas hitch procedure and one combining psoas hitch and Boori Flap technique. The association of psoas hitch with Boari Flap technique were also used to treat two patients with the undesired outcome of vascular procedure. A patient after complete ureteral stripping following ureteroscopy was submitted to ileal bladder substitution. Two renal autotransplantations were performed in a patient with extensive stricture of the ureter following multiple endourological procedure and in a patient with negative outcome of previous attempt of open ureteral defect reconstruction following abdominal trauma.

Retropubic nerve and seminal sparing radical prostatectomy for recurrent bladder neck-prostatic urethra strictures.

OBJECTIVES: To verify if nerve and seminal sparing radical prostatectomy could represent surgical solution for iatrogenic bladder neck prostatic urethra contracture without external sphincter involvement. MATERIAL AND METHODS: At our institution 4 patients have been submitted to nerve and seminal sparing radical prostatectomy for recurrent bladder neck-prostatic urethra contracture following TURP for middle size adenoma. In all cases bladder neck was reconstructed and a 20F silicon catheter was left in place for two weeks to stint the vesico-urethral anastomosis. RESULTS: In all cases no significant perioperative complications were experienced. A normal voiding urethrogram preceded removal of the catheter 14 days postoperatively. Urinary continence was recovered by all of the patients. Uroflowmetry was persistently normal at periodic controls. With a mean follow-up of 36.3 months, no patient complained of symptomatic recurrence of urinary obstruction. In three previously potent patients, sexual activity with satisfactory intercourse was maintained. CONCLUSION: Even though our experience is very limited in terms of number of patients and length of follow-up, we think that nerve and seminal sparing radical prostatectomy, because of the limited risk of major complications and the good result in terms of preservation of both urinary continence and erectile function, can be a reasonable solution for iatrogenic bladder neck-prostatic contracture after prostatic surgery for BPH.

Retrograde endopyelotomy using the holmium laser: technical aspects and functional results.

INTRODUCTION: Endopyelotomy is considered standard treatment for primary and secondary ureteropelvic junction obstruction. The aim of this study is to report our initial experience with the retrograde endopyelotomy technique. MATERIALS AND METHODS: Between January 2000 and April 2003 we submitted to retrograde ureteroscopic holmium laser endopyelotomy 16 patients (9 males and 7 females) aged between 22 and 64 years. Obstruction was primary in 10 cases and secondary due to unsuccessful open pyeloplasty in the remaining six. No patient was affected by coexisting urinary lithiasis. Excretory urography and diuretic renal scintigraphy were performed preoperatively in all patients. Endopyelotomy was carried out using the holmium laser which delivered an energy level of 1.2 Joule at 10-15 Hertz. A double J ureteral stent remained indwelling postoperatively for 6 weeks and a vesical catheter for 24 hours. Average operative time was 75 minutes (range 50-90 minutes). Patients were assessed on follow-up by echotomography of the urinary tract and diuretic renal scintigraphy after 3 months and then at 6-month intervals. RESULTS: Patients were assessed on a mean follow-up of 18 months (range 6-41). Outcome was considered successful when symptoms were resolved and renal function improved. Success was obtained in 13 patients. Two patients were submitted to pyeloplasty with positive results and the procedure on one patient was converted to pyeloplasty due to intraoperative haemorrhage. Average postoperative stay was three days (range 1-4). No patient required blood transfusion with postoperative reduction in haematocrit of 0-9%, (mean 3%). Normal daily activity resumed after 3-4 days from discharge. CONCLUSIONS: Retrograde endopyelotomy in our initial experience is a safe and efficient technique that gives an excellent percentage of success with reduced complications and good patient compliance. The retrograde compared with the anterograde approach has the advantage of being less invasive, does not require nephrostomal derivation and further reduces hospital stay.

Can a Gleason 6 or Less Microfocus of Prostate Cancer in One Biopsy and Prostate-Specific Antigen Level <10 ng/mL Be Defined as the Archetype of Low-Risk Prostate Disease?

Prostate cancer (PC) remains a cause of death worldwide. Here we investigate whether a single microfocus of PC at the biopsy (graded as Gleason 6 or less, ≤5% occupancy) and the PSA <10 ng/mL can define the archetype of low-risk prostate disease. 4500 consecutive patients were enrolled. Among them, 134 patients with a single micro-focus of PC were followed up, and the parameters influencing the biochemical relapse (BR) were analysed. Out of 134 patients, 94 had clinically significant disease, specifically in 74.26% of the patients with PSA <10 ng/mL. Positive surgical margins and the extracapsular invasion were found in 29.1% and 51.4% patients, respectively. BR was observed in 29.6% of the patients. Cox regression evidenced a correlation between the BR and Gleason grade at the retropubic radical prostatectomy (RRP), capsular invasion, and the presence of positive surgical margins. Multivariate regression analysis showed a statistically significant correlation between the presence of surgical margins at the RRP and BR. Considering a single micro-focus of PC at the biopsy and PSA serum level <10 ng/mL, clinically significant disease was found in 74.26% patients and only positive surgical margins are useful for predicting the BR.

Fractal analysis of two-dimensional vascularity in primary prostate cancer and surrounding non-tumoral parenchyma.

Prostate cancer is the fifth most frequent cancer in the world. However, none of the actual prognostic factors provide a valid index for predicting patient outcome. Here, we evaluate the two-dimensional vascularity in primary prostate tumors and surrounding non-tumoral parenchyma by means of fractal geometry, and assess any correlations between the results and some clinical and pathological parameters of prostate carcinoma. Prostate sections from 27 carcinoma patients were treated with CD34 antibodies. Two >10mm(2) areas of tumoral and surrounding non-tumoral parenchyma were digitized using an image analysis system that automatically quantified the fractal dimension of the vascular surface. Data were correlated with patient's age, PSA level, clinical and pathological stage, Gleason score, tumor volume, vascular invasion, surgical margins, and biochemical relapse. Two groups of patients were distinguished on the basis of whether the fractal dimension of their tumoral vascular surface was higher (group 1) or lower (group 2) than that of the surrounding non-tumoral parenchyma. Statistically significant between-group differences were found in terms of serum PSA levels (p=0.0061), tumor volume (p=0.0017), and biochemical relapse (p=0.031). The patients in group 2 had a poorer outcome. Our findings suggest a group of prostate cancer patients with a poor outcome, and the vascular surface fractal dimension as a helpful geometrical index in clinical practice.

Miniperc? No, thank you!

OBJECTIVES: The aim of this retrospective study was to evaluate the results of our miniperc series through comparison with results from standard percutaneous nephrolithotomy (PNL) and tubeless PNL series in the treatment of stones <2 cm in diameter. PATIENTS AND METHODS: A total of 134 percutaneous treatments were performed for renal stones <2 cm in diameter. Among the treatments, 40 were minipercs, 67 were standard PNLs, and 27 were tubeless PNLs. RESULTS: Miniperc operative time was longer than that of standard PNL (155.5 vs 106.6 min, respectively) and tubeless PNL (95.9 min). Conversely, there was an advantage for miniperc over standard PNL in terms of a significantly reduced hematocrit drop (4.49% vs 6.31%). No miniperc patients required blood transfusions, whereas two did in the standard PNL group and one in the tubeless PNL group. There was no statistical difference in terms of the amount of analgesics between the standard PNL and miniperc groups, although this difference was statistically significant between the miniperc and tubeless PNL groups (73.8 vs 41.1mg, respectively). Hospitalization for the miniperc group was shorter than that required by the standard PNL group (3.05 vs 5.07 days), but tubeless PNL offered the best result (2.18 days). The stone-free rate was 100% in the tubeless PNL group, 94% in the standard PNL group, and 77.5% in the miniperc group. CONCLUSIONS: Our retrospective study failed to demonstrate significant advantages of the miniperc technique. As such, we no longer perform miniperc but instead use tubeless PNL when possible.

Holmium laser enucleation of the prostate combined with mechanical morcellation in 155 patients with benign prostatic hyperplasia.

OBJECTIVES: To report our experience with holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS: From January 2000 to May 2001, 155 consecutive patients with BPH underwent HoLEP combined with mechanical morcellation and were followed up for at least 6 months. A pulsed high-powered 80-W holmium-neodymium:yttrium-aluminum-garnet laser was used (power setting 2.0 J/pulse, 35 pulses/s, and 70 W). The enucleated tissue was removed by a transurethral mechanical morcellator. RESULTS: The preoperative mean prostate volume was 53 +/- 39 cm3; 38.7% of patients had an estimated gland volume greater than 50 cm3; 30.8% had BPH complicated by urinary retention, bladder calculi, bladder diverticula, or urethral stricture. The total mean operative time was 87 +/- 44 minutes, the resected weight was 37 +/- 26 g, and the morcellation efficiency was 1.9 +/- 1.6 g/min. The catheter time was 18 +/- 13.5 hours and the hospital stay 1.5 +/- 1.0 days. No patient needed a blood transfusion or experienced hyponatremia. The patients were followed up for a mean of 13 +/- 5 months (range 6 to 24). The International Prostate Symptom Score, quality-of-life score, and peak urinary flow rate had improved significantly 1 month after HoLEP and continued to improve in the next few months, regardless of whether the gland volume was more or less than 50 cm3. CONCLUSIONS: HoLEP combined with mechanical morcellation is an efficient surgical intervention for BPH, regardless of gland size.

A simple mathematical approach to calculate blood loss in radical prostatectomy.

INTRODUCTION: The aim of this study was to apply a simple mathematical approach to calculate blood loss in 126 patients undergoing radical retropubic prostatectomy (RRP). MATERIALS AND METHODS: Perioperative red blood cell loss (RBCL) was estimated by adding the difference in circulating red blood cells from before to after surgery to the allogeneic red blood cells transfused in the same period. RESULTS: Mean preoperative hematocrit was 45 +/- 4% and mean perioperative RBCL was 574 +/- 297 ml, corresponding to a mean equivalent whole blood loss (WBL) of 1,479 +/- 831 ml. Twenty of 126 patients (15.9%) received 42 units of allogeneic packed red blood cells (PRBC), for a mean of 2.1 +/- 1.2 U/patient. The transfusion rate was higher in patients with a preoperative hematocrit of 40% or less (45 vs. 13%, p = 0.014). CONCLUSIONS: Anatomical RRP is still associated with appreciable operative blood loss. Owing to the high preoperative hematocrit values, the allogeneic blood transfusion rate is low and the transfusion requirement of the majority of patients is limited to about 2 units of PRBC. Preoperative autologous blood augmentation strategies may not be routinely needed for patients with a basal hematocrit of >40%.