Elective segmental ureterectomy for transitional cell carcinoma of the ureter: long-term follow-up in a series of 73 patients.

UNLABELLED: What's known on the subject? and What does the study add? Upper Urinary Tract (UUT) Transitional Cell Carcinoma (TCC) is an uncommon disease and represents approximately 5% of all urothelial carcinomas. We report our series on 73 patients treated with Kidney Sparing Surgery for UUT TCC. Good results have been achieved in terms of oncological outcome comparing this conservative approach to the radical nephrourectomy. OBJECTIVES: • To report the long-term oncological outcome in patients with transitional cell carcinoma of the ureter electively treated with kidney-sparing surgery. • To compare our data with the few series reported in the literature. PATIENTS AND METHODS: • We considered 73 patients with transitional cell carcinoma of the distal ureter treated in five Italian Departments of Urology. • The following surgeries were carried out: 38 reimplantations on psoas hitch bladder (52%), 21 end-to-end anastomoses (28.8%), 11 direct ureterocystoneostomies (15.1%) and three reimplantations on Boari flap bladder (4.1%). • The median follow-up was 87 months. RESULTS: • Tumours were pTa in 42.5% of patients, pT1 in 31.5%, pT2 in 17.8% and pT3 in 8.2%. • Recurrence of bladder urothelial carcinoma was found in 10 patients (13.7%) after a median time of 28 months. • The bladder recurrence-free survival at 5 years was 82.2%. • The overall survival at 5 years was 85.3% and the cancer-specific survival rate at 5 years was 94.1%. CONCLUSION: • Our data show that segmental ureterectomy procedures do not result in worse cancer control compared with data in the literature regarding nephroureterectomy.

Heterogeneous nuclear ribonucleoprotein K: altered pattern of expression associated with diagnosis and prognosis of prostate cancer.

Using proteomic analysis of the nuclear matrix (NM), we found that heterogeneous nuclear ribonucleoprotein K (hnRNP K), a member of the hnRNP family with pleiotropic functions, was differentially expressed in prostate cancer (PCa) tissues. This study aimed to characterise the expression of hnRNP K and its subcellular localisation in PCa, utilising immunohistochemical and quantitative western blot techniques. Furthermore, the hnRNP K expression was studied in human PCa cell lines in order to determine its modulation by bicalutamide, the anti-androgen widely used in PCa therapy. Immunohistochemical staining of paraffin-embedded tissues showed that hnRNP K was overexpressed in PCa, where it was localised both in the cytoplasm and in the nucleus. Staining of non-tumour tissues showed exclusively nuclear localisation and a less intense or absent signal. Immunoblot analysis demonstrated that the hnRNP K level within the NM was higher in PCa compared with non-tumour tissues and closely correlated with Gleason score (P=0.008). Higher expression within the NM was significantly (P=0.032) associated with poor prognosis. In two-dimensional western blot analysis hnRNP K presented several isoforms; the one with pI 5.1 was the most differently expressed between non-tumour and PCa tissues. Preliminary results indicate that hnRNP K can be modulated in vitro by a non-steroidal anti-androgen. Taken together, our findings suggest that hnRNP K has potential implications at the diagnostic, prognostic and therapeutic levels in PCa.

Bicalutamide monotherapy versus flutamide plus goserelin in prostate cancer patients: results of an Italian Prostate Cancer Project study.

PURPOSE: To compare the efficacy of bicalutamide monotherapy to maximal androgen blockade (MAB) in the treatment of advanced prostatic cancer. PATIENTS AND METHODS: Previously untreated patients with histologically proven stage C or D disease (American Urological Association Staging System) were randomly allocated to receive either bicalutamide or MAB. After disease progression, patients treated with bicalutamide were assigned to castration. The primary end point for this trial was overall survival. Secondary end points included response to treatment, disease progression, treatment safety, quality-of-life (QOL), and sexual function. RESULTS: A total of 108 patients received bicalutamide and 112 received MAB. There was no difference in the percentage of patients whose prostate-specific antigen returned to normal levels. At the time of the present analysis (median follow-up time, 38 months; range, 1 to 60 months), 129 patients progressed and 89 died. There was no difference in the duration of either progression-free survival or overall survival. However, a survival trend favored bicalutamide in stage C disease but MAB in stage D disease. Overall and subgroup trends were confirmed by multivariate analysis. Serious adverse events and treatment discontinuations were more common in patients receiving MAB (P =.08 and P =.04, respectively). Fewer patients in the bicalutamide group complained of loss of libido (P =. 01) and of erectile dysfunction (P =.002). Significant trends favored bicalutamide-treated patients also with respect to their QOL, namely relative to social functioning, vitality, emotional well-being, and physical capacity. CONCLUSION: Bicalutamide monotherapy yielded comparable results relative to standard treatment with MAB, induced fewer side effects, and produced a better QOL.

Evaluation of sexual activity in patients treated with tadalafil: a randomized prospective placebo-controlled trial.

The chronological distribution of sexual intercourses in a group of patients treated with tadalafil versus placebo for 3 months was evaluated. In total, 120 patients with ED were randomized in two groups and treated, respectively, with one pill of tadalafil 20 mg or placebo on Tuesday and on Friday. After 3 months, we collected data using IIEF and SEP diaries. After 3 months, IIEF score and percentages of success SEP diaries increased in the tadalafil group (<0.01) versus placebo group. Considering all the successful intercourses of the 3 months of tadalafil assumption, the highest percentages were reported within 6-12 h range (35%) and 12-24 h range (28%). In tadalafil group, 41% of patients reported their first successful intercourse between 1 and 6 h and 78% of patients reported the recovery of spontaneous erections. In conclusion, after carrying out the first sexual attempt between 1 and 6 h, patients engaged in sexual activity between 6 and 24 h.

Comparison of algorithms for determining the end-point of the forced vital capacity maneuver.

The criteria of the American Thoracic Society (ATS) for determining the end-point of the forced vital capacity (FVC) maneuver were compared with an algorithm employed by a computer system (Hewlett-Packard), which yields a later end-point. The 150 subjects tested were divided into five groups of 30 on the basis of the following spirometric diagnoses: normal; small airways' obstruction (SAO); mild airways' obstruction (MAO); severe chronic obstructive pulmonary disease (COPD); or restrictive disease. The subjects performed a minimum of three maneuvers according to ATS standards, and the flow-volume curves with the greatest sum of FVC and forced expiratory volume in one second (FEV) were chosen for analysis by the two algorithms. Hewlett-Packard (HP) values for FVC and FVC time were always higher than the corresponding ATS values, and the HP values for flows were always lower than the corresponding ATS values. The higher differences were observed in the SAO group. In the group with severe COPD, high FVC differences and low flow differences were observed; on the contrary, in the restrictive group, low FVC differences and high flow differences were present. These results, in addition to the different location of the FVC end point, may be explained by the different morphology of the flow-volume curves. In conclusion, the ATS algorithm caused a systematic underevaluation of FVC and a systematic overevaluation of flows, which cause practical consequences only in the SAO group. In fact, 28 percent (17/60) of the subjects with SAO characteristics were considered "normal" using ATS criteria for the end-point.

The Giuliani muscle splitting and nerve-sparing anterolateral transabdominal approach to the kidney.

We report on an anterolateral transabdominal approach to the kidney, which is appropriate when vascular control is important (such as, radical nephrectomy, traumatic renal injury, and difficult nephrectomy). The technique splits muscles and spares nerves and that allows good exposure both downward as far as the aortic bifurcation and upward as far as the diaphragm. This approach has been used in 42 patients during the last 20 months (mean follow-up, 6.5). In all these patients the active control of the abdominal wall muscles has been completely preserved, while, during the period from 1974 to 1994, about half of 434 patients who underwent the same approach, but with muscle and nerve transection, showed abdominal wall relaxation.

Value of selective parathormone radioimmunoassay in primary hyperparathyroidism.

Nine cases of primary hyperparathyroidism (PHP) in patients with urinary calculi are reported and discussed. Selective venous catheterization and parathormone (PTH) radioimmunoassay confirmed the diagnosis in all cases, preoperatively discriminated between adenoma and diffuse parathyroid hyperplasia, and permitted exact preoperative localization of 5 of 7 adenomas. The interest of the urologist in PHP and the usefulness of selective PTH radioimmunoassay are discussed and emphasized.

Cavernous artery revascularization in vasculogenic impotence: new simplified technique.

A new simplified technique of cavernous artery revascularization is presented. The arterial inflow to the corpora is obtained through a counterflow end-to-end anastomosis of the inferior epigastric artery to the proximal stump of the transected dorsal penile artery. The revascularization of the cavernous artery occurs through the common penile artery. This operation is particularly suitable for patients showing pudendal or common penile artery obstruction at arteriography. Optimal distal perfusion is obtained by a cross end-to-side anastomosis of the distal stump of the dorsal artery to the contralateral dorsal penile artery. To date 5 patients have been operated on using this method with good functional results in 80 per cent.

Usefulness of preoperative transcatheter embolization in kidney tumors.

In recent years preoperative transcatheter embolization has been used widely in the management of kidney tumors. However, the effective clinical usefulness of this method has not yet been proved. Forty cases of kidney tumors treated by preoperative embolization and radical nephrectomy are reviewed and compared with a homogeneous group of patients who did not undergo preoperative embolization. Intraoperative blood loss, postoperative complication, and survival rate were statistically evaluated according to tumor stage. Advantages and disadvantages of preoperative transcatheter embolization of kidney tumors are reviewed.

Combined oral therapy with sildenafil and doxazosin for the treatment of non-organic erectile dysfunction refractory to sildenafil monotherapy.

The purpose of this work was to investigate the efficacy and safety of sildenafil in combination with doxazosin for the treatment of non-organic erectile dysfunction in patients who did not respond to sildenafil. We enrolled 28 patients with non-organic erectile dysfunction, for whom 3 months of sildenafil monotherapy had failed. They were divided in two random and homogeneous groups: 14 were treated with doxazosin (4 mg daily) and sildenafil (100 mg 1 h before sexual intercourse); the other 14 patients received sildenafil and placebo. The results were assessed by means of the IIEF questionnaire before the beginning of the study, after 30 days of therapy and after 60 days. Of the 14 patients treated with doxazosin and sildenafil, 11 (78.6%) showed a statistically significant increase of IIEF; in the placebo group, only one patient (7.1%) recorded a significant IIEF increase. The differences observed in the two groups were statistically very significant (P=0.0016). Blood pressure did not show significant alterations. Side effects were minimal and even present during sildenafil monotherapy. The combination therapy with sildenafil and doxazosin resulted in the safe and effective treatment of men with non-organic erectile dysfunction for whom sildenafil alone had failed.

Antibiotic prophylaxis in prosthetic penile surgery: critical assessment of results in 75 consecutive patients.

OBJECTIVE: Antibiotic prophylaxis in prosthetic surgery was administered prospectively according an original protocol. Routine pre-operative preparation included also scrupulous, repeated disinfection of the skin of the genital and perineal region. METHODS: Vancomycin 500 mg i.v. every 6 h on the day of surgery and gentamicin 1 mg/kg i.v. every 8 h on the day of surgery and for the following 48 h were administered to 75 consecutive patients. Overall 87 prosthetic devices were implanted. The patients were evaluated at 6 weeks and at 6 months after surgery. RESULTS: No infection was observed. CONCLUSION: Support from this study to antibiotic prophylaxis in penile prosthetic surgery is uncertain. The importance of scrupulous routine pre-operative preparation is probably underestimated.

Tubulovasostomy in the rat. A new experimental model.

Tubular patency is the primary concern in the evaluation of procedures for epididymovasostomy. The epididymal lumen easily becomes occluded or obstructed, with the resulting recurrence of azoospermia. Recently, two-layer direct anastomosis has been advocated. The aim of the present study was to present an experimental model of tubulovasostomy in the rat. Microsurgery was performed in 18 rats (16-40 X magnification). Suture material used was 11/0 Vycryl or nylon for the internal layer of the anastomosis and 10/0 Ethilon for the external layer. After 6 and 12 weeks, semen samples were obtained by electroejaculation and evaluated for sperm count and motility.

An experimental study of the effect of ischemia on testicular structure in the rat. Efficacy of intravenous inosine.

The damages caused by experimental testicular ischemia lasting 60 minutes have been examined in the rat. The histologic alterations of the germinal epithelium and of the tunica propria are studied, using semi-thin sections stained with 1% toluidine blue. The results show that a testicular ischemia of 60 minutes causes damages to the testicular structures. These damages cannot be prevented or avoided by either surface cooling or cold perfusion; however, intravenous inosine prior to ischemia has a protective effect.

[Transcatheter hypogastric embolization in life-threatening bladder hemorrages: immediate and long-term results (author's transl)]. / Die Embolisation der Arteria iliaca interna bei Karzinomen mit lebensbedrohlichen Blasenblutungen: Sofort- und Langzeitergebnisse.

Transcatheter embolization of the hypogastric arteries has become a more and more largely used therapeutic approach in mastering unrestrainable hemorrages in bladder cancer patients. In this paper the Authors report their experience with this method based on 9 cases, which could be followed for 1 year or until patient's death. The immediate and long-term results are presented and discussed. The Authors conclude that transcatheter hypogastric embolization is the best non-invasive method to handle neoplastic pelvic hemorrages.

Short schedule intravesical mitomycin preceding transurethral resection for recurrent Ta-T1, G1-G2 bladder cancer.

AIMS AND BACKGROUND: Intravesical instillations commonly follow resection, when all visible lesions have been removed, making impossible any direct assessment of efficacy. The study was conceived to evaluate the ablative effect on the tumor and the efficacy in reducing the risk of recurrence of short schedule intravesical chemotherapy administered before endoscopic resection. STUDY DESIGN: Four weekly intravesical instillations of mitomycin C followed by transurethral resection (TUR) were administered to 31 patients with recurrent small volume superficial bladder cancer. RESULTS: At TUR no evidence of disease was found in 22 patients (70.9%) and residual disease in the remaining 9 (29.1%). At a median follow-up of 15 months (range, 3-33) 16 of 31 patients (51.6%) had recurrence of disease. The treatment was well tolerated. CONCLUSIONS: Short-schedule intravesical chemotherapy can completely ablate small volume recurrent superficial bladder cancer in a relevant number of patients but is probably not sufficient to obtain long-term prophylaxis.

Roach's mathematical equations in predicting pathological stage in men with clinically localized prostate cancer.

AIMS AND BACKGROUND: The therapeutic choice in patients with clinically localized prostate cancer depends on preoperative clinical stage. Diagnostic instruments currently available for such an evaluation--considered separately--have not shown enough efficacy. Roach has recently introduced three simple mathematical equations that--on the basis of prostate-specific antigen and the biopsy Gleason score--are aimed at calculating the definitive pathological stage. We retrospectively analyzed our radical prostatectomy data base to assess the accuracy of the equations in predicting the final stage in patients with clinically localized prostate cancer. METHODS STUDY DESIGN: The study included 173 patients who had undergone radical retropubic prostatectomy at our Institution. Patients were divided into 25 groups, depending on preoperative PSA and the biopsy Gleason score. The risk of extracapsular neoplastic growth, seminal vesicle involvement and lymph node involvement was calculated for each group by means of Roach's equations. On the basis of definitive histological examinations, we compared the expected risk to the observed risk. RESULTS: The observed risk fell within the interval of expected risk in 16 of 17 groups (94%) regarding the evaluation of extracapsular growth, in 15 of 17 (88%) regarding the analysis of seminal vesicle involvement, and in 14 of 17 (82%) regarding the evaluation of lymph node involvement. Therefore, the observed event was in agreement with the expected event in 45 of 51 groups (88%). CONCLUSIONS: The equations represent a practical and effective instrument for preoperative clinical staging in patients with localized prostate cancer. By means of these mathematical formulas, one can assess the correct prognosis and--above all--plan the best therapeutic approach.

Medical therapy of prostate carcinoma.

Medical treatment of prostatic cancer is one of the most complex and challenging issues in oncologic urology, and probably of oncology itself. In fact, in spite of the well known sensitivity of the disease to hormonal manipulations, it is still substantially unclear whether hormonal therapy achieves survival improvement. Furthermore, many prostate cancers become hormone refractory within 18 to 36 months from the onset of therapy, and until now, no further treatment has been able to improve their prognosis, in spite of the often promising early results. Medical treatment is now being used as an adjunct to radical surgery and to radiotherapy, in both the adjuvant and the neoadjuvant setting, and this raises further controversies. This paper is an attempt to give to the readers the state of art of medical therapy, even within the limits of a concise review. The authors are aware of these limits but hope that this paper can be useful to the reader.

[Experimental microsurgical gastrocystoplasty] . / La gastrocistoplastica sperimentale microchirurgica.

BACKGROUND: Stomach tract used for bladder augmentation decreases urinary pH and produces the syndrome of dysuria and hematuria; gastric mucosa in contact with urine may develop prominent histopathological changes including proliferative lesions. The aim of this study was to investigate in an experimental model the possibility of detecting the factors involved in the mucosal damage. METHODS: Thirty-five Sprague Dawley rats randomly underwent microsurgical gastrocystoplasty or sham operation (5 controls). During operation elliptical gastric patch was isolated with its gastroepiploic vascular pedicle, bladder was opened with midline incision and anastomosis performed. Urine was aspirated from the bladder for culture, pH and electrolytes evaluation; venous blood was samples for electrolytes, BUN and creatinine. Mean follow-up time was 6 months. RESULTS: Of the 30 rats subjected to gastrocystoplasty 23 survived (77%). All of cultures were negative, the urinary pH decreased after operation and increased gradually two months later. Urinary sodium and potassium ions concentrations increased significantly in gastrocystoplasty (p < 0.05). There were no significant changes in serum electrolytes or renal function. CONCLUSIONS: This experimental model was useful to investigate the effects related to the presence of gastric mucosa in the urinary tract.

Microsurgery in urology.

Microsurgery is becoming increasingly widely accepted in the field of urology, and microsurgical training well become an integral part of the programs for Residents in University Schools of Urology. In this paper we outline the present clinical application of microsurgery in urology and perspectives, for example: workbench surgery, testis transplantation, vasovasostomy, revascularization for impotence, penis replantation, microsurgery of the urinary tract.