Surgical treatment of atypical metastasis from renal cell carcinoma (RCC).

UNLABELLED: What's known on the subject? and What does the study add? The interest in metastatic renal cell carcinoma has increased in the last few years, mainly due to the advent of targeted therapies, but metastasectomy remains the sole therapy that can lead to a complete and durable regression, even if only in a minority of patients. The literature reports quite large series of metastasectomies for the most common sites of metastasis, e.g. lung, liver, bone, adrenal and brain, whereas little is known about the management of metastasis in 'atypical' sites. The prognosis of patients submitted to metastasectomy for a metastasis in an atypical site is equivalent to patients with lung metastasis. The characteristics of the primary tumour in these patients are not indicative, but atypical metastasis (AM) are often located in superficial sites and frequently associated with other metastases. So, physical examination should be included in all follow-up regimens and a complete re-staging should be performed after the diagnosis of an AM. OBJECTIVE: • To review the clinical characteristics and oncological results in patients submitted to surgical removal of metastasis from renal cell carcinoma (RCC) in atypical sites (atypical metastasis [AM], i.e. metastasis in sites other than the chest, liver, bone, adrenal, brain, kidney, and lymph nodes), compared with patients submitted to metastasectomy due to a lung metastasis (LM). PATIENTS AND METHODS: • From an institutional database of ≈1800 patients surgically treated for a RCC, we retrospectively identified 37 cases that had undergone metastasectomy for AM and 57 operated for LM. • Clinicopathological features of the primary RCC and metastasis, and cancer-specific survival (CSS) computed from the time of metastasectomy of patients with AM and LM, were compared. • A univariate and multivariable analysis applying a Cox regression model was used to evaluate CSS. RESULTS: • The patients with AM and LM were followed for an average of 40.8 and 50.7 months from metastasectomy, respectively (P= 0.372). • There were no significant differences in the characteristics of the primary tumour between patients with AM and LM. • In the cases with AM and LM the diagnosis was simultaneous with that of the primary tumour in 32.4% and 24.6%, (P= 0.40) respectively, and, when metachronous, occurred at an average delay of 53.4 and 44.3 months (P= 0.370). • More frequently in the cases with AM other metastases had been diagnosed in the previous medical history (35.2 vs 8.8%, P= 0.001) or simultaneously (48.6 vs 8.8%, P= 0.001). • CSS from metastasectomy was affected by the synchronicity in diagnosis between metastasis and primary tumour, and by the simultaneous presence of other metastases, while the type of metastasis (AM vs LM) did not affect CSS. In fact, metastasectomy in AM was as effective as in LM. CONCLUSION: • AM are an exceptional presentation of metastatic RCC, but the role of surgery is similar to that of pulmonary metastasis. In these cases, metastasectomy is accepted as possible care, and in AM the CSS after metastasectomy is similar.

Chromophobe renal cell carcinoma (RCC): oncological outcomes and prognostic factors in a large multicentre series.

UNLABELLED: Study Type - Outcomes (cohort) Level of Evidence 2b What's known on the subject? and What does the study add? About 80% of RCCs have clear cell histology, and consistent data are available about the clinical and histological characteristics of this histological subtype. Conversely, less attention has been dedicated to the study of non-clear cell renal tumours Specifically, published data show that chromophobe RCC (ChRCC) have often favourable pathological stages and better nuclear grades as well as a lower risk of metastasizing compared with clear cell RCC (ccRCC). Patients with ChRCC were shown to have significantly higher cancer-specific survival (CSS) probabilities compared with ccRCC. However, an independent prognostic role of RCC histotype was not confirmed in some large multicenter series and only a few studies have focused on the oncological outcomes of ChRCC. The present study is one of the few to evaluate cancer-related outcomes of ChRCC and represents to our knowledge the largest series of ChRCCs. Consequently, the present findings may assist in elucidating the natural history of surgically treated ChRCC. The present study confirms that ChRCCs have good prognosis and a low tendency to progress and metastasize. Only 1.3% of patients presented with distant metastases at diagnosis, and the 5- and 10-year CSS were 93% and 88.9%, respectively. However, although ChRCCs are generally characterised by an excellent prognosis, we observed that patients with locally advanced or metastatic cancers as well as those with sarcomatoid differentiation have a poor outcome. The study also investigated prognostic factors for recurrence-free survival (RFS) and CSS for this RCC histotype. The definition of outcome predictors can be useful for patient counselling, planning of follow-up strategies, and patient selection for clinical trials. In the present study, gender, clinical T stage, pathological T stage, and presence of sarcomatoid differentiation were significantly associated with RFS and CSS at multivariable analysis. We also identified N/M stage as an independent predictor of CSS. Notably, as Fuhrman grade was not an independent predictor of cancer-related outcomes, the present study confirms that this histological variable is not a reliable prognostic factor for ChRCC. OBJECTIVES: To investigate cancer-related outcomes of chromophobe renal cell carcinoma (ChRCC) in a large multicentre dataset. To determine prognostic factors for recurrence-free survival (RFS) and cancer-specific survival (CSS) for this RCC histological type. PATIENTS AND METHODS: In all, 291 patients with ChRCC were identified from a multi-institutional retrospective database including 5463 patients who were surgically treated for RCC at 16 Italian academic centres between 1995 and 2007. Univariable and multivariable Cox regression models were used to identify prognostic factors predictive of RFS and CSS after surgery for ChRCC. RESULTS: At a median follow-up of 44 months, 25 patients (8.6%) had disease recurrence and 18 patients (6.2%) died from disease. The 5-year RFS and CSS rates were 89.3% and 93%, respectively. Gender (P= 0.014), clinical T stage (P= 0.017), pathological T stage (P= 0.003), and sarcomatoid differentiation (P= 0.032) were independent predictors of RFS at multivariable analysis. For CSS, there was an independent prognostic role for gender (P= 0.032) and T stage (P= 0.019) among the clinical variables and for T stage (P= 0.016), N/M stage (P= 0.023), and sarcomatoid differentiation (P= 0.015) among the pathological variables. CONCLUSIONS: Patients with ChRCC have a low risk of tumour progression, metastasis, and cancer-specific death. Patient gender, clinical and pathological tumour stage, and sarcomatoid differentiation are significant predictors of RFS and CSS for ChRCC.

Prognostic role of tumour multifocality in renal cell carcinoma.

UNLABELLED: What's known on the subject? and What does the study add? In RCC about 5% of the patients presented multifocal disease. Prevalence of tumour multifocality was associated with a higher percentage of symptomatic RCC, higher pathological TNM stages, higher tumour grade and higher prevalence of tumour necrosis. Although in univariable analysis multifocal tumours had lower probability of CSS, tumour multifocality did not retain an independent predictive role in multivariable analysis. Patient age at surgery, gender, mode of presentation, pathological N stage and presence of metastases were independent predictors of CSS in multivariable analyses. OBJECTIVE: • To evaluate the prevalence and the prognostic role of multifocality in a large multi-institutional series of patients who underwent radical or partial nephrectomy for renal cell carcinoma (RCC). METHODS: • We retrospectively collected the data of 5378 patients who were surgically treated for RCC in 16 academic centres involved in the Surveillance and Treatment Update Renal Neoplasms (SATURN) project. • Univariable and multivariable Cox regression models addressed time to cancer-specific survival (CSS) after surgery. RESULTS: • Tumour multifocality was identified in 249 patients (5%). The median follow-up of the whole cohort was 42 months. At last follow-up, 786 (14.6%) were dead of cancer and 336 (6.2%) had experienced non-cancer-related death. • The 5- and 10-year CSS estimates were 84.1% and 77.3%, respectively, in patients with monofocal RCC, compared with 71.1% and 63.6%, respectively, in patients with multifocal disease (P < 0.001). • In univariable Cox regression analysis, tumour multifocality was significantly associated with CSS (hazard ratio [HR]= 1.83; P < 0.001). • On multivariate Cox regression analysis adjusted for the effects of other covariates, tumour multifocality did not retain an independent predictive value (HR = 1.24; P= 0.291). CONCLUSIONS: • In the present multi-institutional collaboration, about 5% of the patients presented multifocal RCC. • The presence of multifocal cancer was associated with some unfavourable clinical and pathological features. • Although in univariable analysis multifocal tumours had lower CSS probabilities, tumour multifocality did not retain an independent predictive role in multivariable analysis, once adjusted for the effect of the other clinical and pathological covariates.

Elective partial nephrectomy is equivalent to radical nephrectomy in patients with clinical T1 renal cell carcinoma: results of a retrospective, comparative, multi-institutional study.

OBJECTIVE: To compare the oncological outcomes of patients who underwent elective partial nephrectomy (PN) or radical nephrectomy (RN) for clinically organ-confined renal masses ≤7 cm in size (cT1). PATIENTS AND METHODS: The records of 3480 patients with cT1N0M0 disease were extracted from a multi-institutional database and analyzed retrospectively. RESULTS: In patients who underwent PN, the risk of clinical understaging was 3.2% in cT1a cases and 10.6% in cT1b cases. With regard to the cT1a patients, the 5- and 10-year cancer-specific survival (CSS) estimates were 94.7% and 90.4%, respectively, after RN and 96.1% and 94.9%, respectively, after PN (log-rank test: P = 0.01). With regard to cT1b patients, the 5-year CSS probabilities were 92.6% after RN and 90% after PN, respectively (log-rank test: P = 0.89). Surgical treatment failed to be an independent predictor of CSS on multivariable analysis, both for cT1a and cT1b patients. Interestingly, PN was oncologically equivalent to RN also in patients with pT3a tumours (log-rank test: P = 0.91). CONCLUSIONS: Elective PN is not associated with an increased risk of recurrence and cancer-specific mortality in both cT1a and cT1b tumours. Data from the present study strongly support the use of partial nephrectomy in patients with clinically T1 tumours, according to the current recommendations of the international guidelines.

Muscarinic receptors stimulate cell proliferation in the human urothelium-derived cell line UROtsa.

The widespread non-neuronal synthesis of acetylcholine (ACh) has changed the paradigm of ACh acting solely as a neurotransmitter. Indeed, the presence of ACh in many types of proliferating cells suggests a role for this neurotransmitter in the control of cell division. The parasympathetic system is a major pathway regulating micturition, but ACh-mediated control plays a more complex role than previously described, acting not only in the detrusor muscle, but also influencing detrusor function through the activity of urothelial muscarinic receptors. Here we investigated the role of muscarinic receptors in mediating cell proliferation in the human UROtsa cell line, which is a widely used experimental model to study urothelium physiology and pathophysiology. Our results demonstrate that UROtsa cells express the machinery for ACh synthesis and that muscarinic receptors, with the rank order of M3>M2>M5>M1=M4, are present and functionally linked to their known second messengers. Indeed, the cholinergic receptor agonist carbachol (CCh) (1-100 µM) concentration-dependently raised IP(3) levels, reaching 66±5% over basal. The forskolin-mediated adenylyl cyclase activation was reduced by CCh exposure (forskolin: 1.4±0.14 pmol/ml; forskolin+100 µM CCh: 0.84±0.12 pmol/ml). CCh (1-100 µM) concentration-dependently increased UROtsa cell proliferation and this effect was inhibited by the non-selective antagonist atropine and the M(3)-selective antagonists darifenacin and J104129. Finally, CCh-induced cell proliferation was blocked by selective PI-3 kinase and ERK activation inhibitors, strongly suggesting that these intracellular pathways mediate, at least in part, the muscarinic receptor-mediated cell proliferation.

Nerve growth factor signaling in prostate health and disease.

The prostate is one of the most abundant sources of nerve growth factor (NGF) in different species, including humans. NGF and its receptors are implicated in the control of prostate cell proliferation and apoptosis and it can either support or suppress cell growth. The co-expression of both NGF receptors, p75(NGFR) and tropomyosin-related kinase A (trkA), represents a crucial condition for the antiproliferative effect of NGF; indeed, p75(NGFR) is progressively lost during prostate tumorigenesis and its disappearance represents a malignancy marker of prostate adenocarcinoma (PCa). Interestingly, a dysregulation of NGF signal transduction was found in a number of human tumors. This review summarizes the current knowledge on the role of NGF and its receptors in prostate and in PCa. Conclusions bring to the hypothesis that the NGF network could be a candidate for future pharmacological manipulation in the PCa therapy: in particular the re-expression of p75(NTR) and/or the negative modulation of trkA could represent a target to induce apoptosis and to reduce proliferation and invasiveness of PCa.

Molecular and pharmacological detection of dopaminergic receptors in the human male urinary tract.

AIMS: Evidence indicates that dopamine (DA) and DA receptors play a role in the central nervous system (CNS) control of micturition; however, while the central DAergic role in the micturition physiology has been extensively investigated, the expression and the function of DA receptors in the urinary tract are still under investigation. Here, we studied the distribution of DA receptor subtypes in different parts of the human male urinary tract. METHODS: Fragments were collected from 34 men. The mRNAs encoding DA receptors were assessed by RT-PCR, followed by densitometric analysis. Adenylyl cyclase (AC) activity was evaluated using a commercially available RIA kit. Statistical analysis was carried out using one-way ANOVA, with the Bonferroni's post hoc test. RESULTS: Results obtained indicated that RT-PCR products of D(1), D(4), and D(5) subtypes were obtained in each part studied, while no signal was observed for the D(2) and D(3) receptor subtypes. The pharmacological characterization demonstrated that the expressed DA receptors were linked to AC. CONCLUSIONS: DA receptors were expressed throughout the human male urinary tract, from the ureter to the prostatic urethra. In particular, we observed a distinctive DA receptor subtype distribution, with evidence of the presence of mRNA encoding both subtypes of the D(1)-like DA receptor family (D(1) and D(5)), while the D(4) receptors were the only expressed subtype of the D(2)-like family. These results suggested that DAergic drugs used for the treatment of a number of diseases may influence the micturition physiology not only in the CNS, but at the peripheral level as well.

Tissue engineering in urinary bladder: morphological and functional characterization.

INTRODUCTION: In the last years, tissue engineering has attracted lots of researchers, in urology too. This is due to the possibility to use this technique in several pathologies' therapies, which generally require reconstructive surgical solutions. Our work's aim is to evaluate morphological and functional aspects of cultivated urothelial and detrusorial tissues, both in "monolayer growth" and on scaffolds, in order to understand the chance of using them in reconstructive surgery. MATERIALS AND METHODS: Tissue cultures of detrusorial and urothelial cells have been obtained from animals (pigs, rabbits) and men. The urothelial nature of obtained cells has been demonstrated by traditional histological observation (Hematoxylin - Eosin), by immuno-fluorescence assay (specific for cyto-keratins antibodies), by immuno-histo-chemistry techniques (using specific cyto-keratins 7, 17, and 20 antibodies). Detrusorial tissue has been studied by using antibodies specific for alpha-actin. RESULTS: Urothelial and smooth muscle cells, when isolated and expanded in vitro, keep the typical characteristics of original tissue, as showed by classical histological observation (H-E), immuno-histo-chemistry and immuno-fluorescence assays. These results were positive both in monolayer colonies and on scaffolds. In vitro results are encouraging and they demonstrate that it is possible to obtain in vitro vesical tissue that could have analogous characteristics to the original organ; even though clinical utilisation of this technique must be more investigated, both in vitro and in vivo.

Second surgery for renal relapse after nephron sparing surgery: review of seven cases.

OBJECTIVE: Anatomo-pathologic review of the cases which underwent a second surgery operation for a renal neoplasm relapsed after conservative surgery, in order to find possible relations with the surgical technique. PATIENTS AND METHODS: At our institution nephron sparing surgery (NSS) is currently indicated for neoplasms smaller than 4 centimetres in diameter. The technique involves the removal of the neoplasm with a margin of healthy parenchyma and with the perilesional fat. Patients are firstly monitored by a CT check after 4 months and then with ultrasound/CT checks every 6 months in the first 2 years and then once a year In this study we analyze in the 1994-2005 period the records of cases undergoing a second operation for a renal tumour relapsed in the operated kidney after NSS. All specimens were reviewed by an individual experienced uro-pathologist who determined the size of surgical margins and relations between the site of the recidivism and the site of the preceding NSS procedure. RESULTS: Seven cases with renal relapse have been found out of 267 undergoing conservative surgery in the same period (incidence 2.6%). The diagnosis has always been made in the lack of other localizations of disease at a complete re-staging and the average latency of the relapse was 19.4 months (8-46 months). In 5 cases the second tumour has been found in the site of the previous NSS: for these cases the minimum margin of the enucleo-resection was lower then 3 millimetres (median minimum margin 1.6 mm). Differently, in the remaining 2 cases, both with a wider surgical margin (median minimum margin 12.0 mm), the site of thefirst and that of the second neoplasm were distant. In particular, in one case a multifocal recidivism with a spread microvascular embolisation has been found, while in the other the primary neoplasms and the relapse presented a different histotype. CONCLUSIONS: In the 5 cases with a narrow resection margin and relapsing tumour in the site of the enucleo-resection one can hypothise the persistence of a peritumoral microscopic neoplastic disease. In the other 2 cases with a wider surgical margin the relapse can be attributed to the widespread microscopic multifocality in one case and to the development of a second de novo neoplasm in the other one. The extension of the surgical margin seems then to have played a role in determining a relapse in the site of enucleo-resection.

Quality of life evaluation by the EORTC QLQ-C30 questionnaire in patients treated with hormonal treatment in Italy. A QuABIOS group study.

OBJECTIVES: An observational study was planned by the QuABIOS group, to survey the hormonal treatment administered to prostate cancer patients in Italy within a time window of 12 months. We report here a prospective quality of life (QOL) evaluation over time and by hormonal treatment modalities. METHODS: Patients with diagnosis of prostate cancer and treated with hormonal therapy were eligible for this study. The EORTC QLQ-C30 v.3 questionnaire was administered at enrolment, after 6 months and after 12 months from enrolment. RESULTS: 587 patients were enrolled by 33 urological centers. When 1518 visits were considered together independently of time, antiandrogen monotherapy was associated with a significantly better QOL than LHRH-analogue containing treatment modalities in almost all functional scales; cyproterone acetate demonstrated a better physical function and general health status than bicalutamide. When QOL was analyzed in a prospective 12-month window, a worsening of physical function and general health status was observed, notwithstanding, antiandrogens remained significantly associated to a better QOL than LHRH-analogue therapies also over time: a favourable physical function and general health status appeared again to be related to cyproterone acetate than bicalutamide. CONCLUSIONS: Androgen deprivation therapy is associated with decline in QOL, particularly in the domains of physical function, energy, and general health status. This survey demonstrated that antiandrogens had a better QOL profile than LHRH-analogue containing therapies;furthermore, a more favourable tolerability for cyproterone acetate as compared to bicalutamide is suggested.

Durable and complete remission of a metastatic bladder sarcomatoid carcinoma with chemotherapic and surgical treatments.

The sarcomatoid carcinoma of the urinary bladder is a rare variant of transitional carcinomas with an extremely aggressive clinical course and dismal prognosis regardless therapies. The diagnosis of a bladder sarcomatoid carcinoma involving perivesical tissues with limphnodal, hepatic and lung metastasis was done in a 34-years old male. The disease underwent complete remission after neoadjuvant chemotherapy with adriblastine and ifosfamide, radical surgery and adjuvant chemotherapy with the same drugs, as confirmed by CT, vesical biopsies during chemotherapy and by the findings detected on the surgical specimen. Follow-up is negative for relapses at 72 months. The sarcomatoid bladder carcinoma is a rare variant of transitional carcinoma (0.31%), usually diagnosed in the late decades of life, with a survival time of a few months for metastatic patients regardless of any adopted therapies. The case presented is remarkable due to the young age of the patient but, overall, for the complete and durable regression of the disease achieved applying a chemotherapic scheme commonly adopted to treat pure sarcomatous mesenchimal neoplasms. Due to the rarity of the disease and the consequent unfeasibility of randomized studies, in our opinion these results, even if obtained in a single case, suggest a viable therapeutic option.

Use of the appendix as ureteral substitute in a patient with a single kidney affected by relapsing upper urinary tract carcinoma.

The treatment of upper urinary tract transitional cell carcinoma (UT-TCC) in single-kidney patients requires the radical removal of cancer, but also, when feasible, the preservation of the continuity of the urinary tract by various surgical techniques. In case of wide resections during ureteral surgery, a ureteral replacement could be advocated. In the literature, the cecal appendix has rarely been used as a ureteral substitute, moreover in benign pathological conditions, showing encouraging early results. The positive functional and oncological outcomes obtained after a lengthy follow-up in a single-kidney patient with UT-TCC treated by ureteral resection and appendix interposition confirm the viability of this surgical option.

Surgical treatment of metastases from renal cell carcinoma.

INTRODUCTION: Even if the number of curable renal cancers increased during the last decades, there is still a considerable amount of patients with distant metastases, evidenced at diagnosis or during the follow-up, without real curative therapeutic options. MATERIALS AND METHODS: In the period between January 1983 and December 2003 we observed 252 metastatic patients among the 1187 surgically treated for renal cancer (21.2%). The metastatic disease was evidenced at the diagnosis of renal tumour in 118 patients (9.9%), during the follow up at a mean distance of 18.6 months in 134 (11.3%) and was in a single organ in 200 patients, in multiple sites in 52. A surgical treatment of metastases was performed in 113 cases, associated with chemo-immunotherapy in 16. Conversely, 44 patients received chemo-immunotherapy alone, 18 radiotherapy, and in the remaining 77 cases no curative therapies were applied. RESULTS: The patients with a single-site metastasis who underwent of metastases removal, especially when pulmonary or adrenal, showed a better prognosis than the ones otherwise treated, while in the patients with bony metastases, multiple-site metastases and the ones who did not receive any curative therapies an extremely dismal prognosis was evidenced. However, a large amount of the patients with a single-site metastasis (79% on 159 treated patients) had a relapse of the disease, even when surgically treated (69%). CONCLUSIONS: At present, in the lack of any effective systemic therapies for metastatic renal cancer, surgery offers better survival rates than other choices (chemo-immunotherapy or radiotherapy). Thus, even if the initial bias in the selection of patients is surely significant, in our opinion, each patient with good performance status and a resectable metastatic lesion, better if pulmonary or adrenal, should undergo surgical treatment of metastases, that could provide long-term survival in a small part of the patients. The high rate of relapses remarks the actual need of an effective systemic therapy both for the patients who can and cannot undergo surgery for their metastatic disease.

Alpha1 adrenoceptor subtypes in human urinary bladder: sex and regional comparison.

A detailed study of the presence of alpha1 AR binding sites and alpha1 AR subtype mRNA expression in human urinary bladder areas involved in the micturition (i.e. detrusor, trigone and neck) is reported here, investigating whether or not there are differences between sexes. Results obtained indicated that alpha1 AR proteins were detectable in each bladder area. In both sexes, the detrusor and the neck expressed similar levels of alpha1 ARs: respectively, detrusor: 14.6 +/- 1.2 in men and 13.1 +/- 1.1 fmol/mg prot in women; neck: 16.9 +/- 3.2 in men and 17.5 +/- 4.1 fmol/mg prot in women. In the trigone, significantly higher alpha1ARs were found in women compared to men (20.6 +/- 1.1 vs 11.7 +/- 0.7 fmol/mg prot). Subtype analysis indicated that in women, each area was endowed with mRNA encoding for each alpha1 AR subtype. The men detrusor expressed alpha1a and alpha1d ARs, while in the trigone and the neck, each subtype was present. Since the detrusor muscle hypertrophy is a marker of bladder obstructive outlet, the selective alpha1 AR subtype targeting arouses much interest, as evidence indicates that there are differences in signalling pathways among the subtypes. Furthermore, the significance of the alpha1 ARs coexpression is still unknown; interestingly, recent papers demonstrate that alpha1 AR subtypes could dimerize. Thus, in the human urinary bladder it may be suggested a potential level of alpha1 AR complexity that could have an impact on drug development.

Recovery of renal function after right nephrectomy, cavectomy and left renal vein ligation.

Right nephrectomy and ligation of the left renal vein often lead to acute renal failure, but not obligatorily to renal infarction and chronic uremia, thanks to the peculiar venous supply of the left kidney. A man underwent right nephrectomy, inferior cavectomy and ligation of the left renal vein and became anuric. Hemodialysis was necessary for some days, but he partially recovered his renal function. Proteinuria occurred a few days after the operation and decreased but had not disappeared after ten months. Eventually the patient died of brain metastases. There are a few reports of similar operations, some successful, others not, but very few papers report an adequate follow-up of subsequent changes in renal function. Nephrologists could be involved in the postoperative care of these cases. They should be aware of the possible recovery of renal function and should try all possible strategies to help the left kidney recover its function.

[Ureteral endometriosis: urological features]. / Endometriosi ureterale: aspetti urologici.

Endometriosis affects about 10-20% of premenopausal women but ureteral involvement is an infrequent event occurring only in 0.1-0.4% of cases. Clinical presentation and radiological aspects are non-specific so that preoperative diagnosis is difficult, requiring a high index of suspicion. Intravenous urography is mandatory in all patients with pelvic endometriosis. Between 1995 and 2001, 10 patients with severe endometriosis of the ureter were referred to our center. Bilateral involvement was present in 3 cases. 6 patients showed a significant involvement of other pelvic organs, with subsequent surgical treatment. 1 patient with bilateral ureteral endometriosis was treated by bilateral stenting and medical hormonal therapy, with good results. 2 patients underwent ureteral resection with primary reanastomosis; one of them showed an ureteral relapse 22 months after surgery, with the necessity of a second resection and ureteroneocystostomy. Ureteric resection and ureteroneocystostomy were initially performed in the other 7 patients, without evidence of recurrences in all cases (median follow-up 31 months). Hormonal therapy or hysteroadnexiectomy, when feasible, are necessary to reduce the risks of relapses. In our opinion, ureteral resection associated with ureteroneocystostomy gives the best chances to cure severe ureteral endometriosis.

Epidemiology, clinical features and treatment of idiopathic retroperitoneal fibrosis: our experience.

Retroperitoneal fibrosis (RF) is an uncommon disease with an estimated incidence of 1 case on 200.000 inhabitants. Idiopathic RF (2/3 of cases) must be distinguished from secondary RF, caused by hexogen substances assumptions, radiotherapy and various diseases. The treatment of RF is not yet univocally defined. From 1984 to 2002 we observed 15 patients (1 case with idiopathic retroperitoneal fibrosis) i.e. 27 ureteral units (1 patient was previously nephrectomized and 2 showed a monolateral ureteral involvement). The mean age was 55 and the male:female ratio was 0.66:1. The commonest presenting symptoms were acute renal failure or renal colic. 14 patients needed preoperatory urinary drainage by nephrostomy or ureteral stenting. 6 patients were treated with steroids or tamoxifen without response so that all the 15 patients underwent surgery. 6 patients were lost to follow-up after 8 months while the other 9 underwent clinical and radiological controls for a mean time of 84 months (range 12-168) with evidence of normal canalization or steady dilatation of the excretory system for 8 of them. 1 patient developed a relapsing ureteral stenosis after ureterolysis and intraperitonealisation and needed ureterectomy with ileal interposition. In a case with monolateral presentation a controlateral stenosis was evidenced 5 years later. According to literature data, the surgical technique that ensured us the best results was ureterolysis with omental wrapping of the ureter. In our experience, medical treatments gave poor outcomes. However, in consideration of the low incidence of RF, perspective and multicentric studies are necessary to establish which is the most suitable treatment for each patient. Follow-up must be extended in patients with monolateral presentation to precociously reveal a possible contralateral involvement.

[Ileal conduit and urinary stoma complications]. / Ileal conduit and urinary stoma complications.

The ileal conduit has been widely used for urinary diversion. It is a safe procedure with acceptable results, but it has become clear that the conduit can give rise to serious complications, notably renal deterioration in the long run. Stenosis of the ileal conduit, usually developing insidiously many years after the diversion, may be the cause of upper urinary tract damage. In most cases, a variety of possible factors is considered, including microvascular ischemia, urine-borne toxic material, infectious and allergic stimuli and an immunologic defect. Crohn's disease may affect an ileal loop urinary conduit. It presents as a diffuse loop stenosis. Recurrent transitional carcinoma arising within an ileal conduit following cystectomy for malignant disease is rare, but late malignancy in bowel segments exposed to urine without fecal stream is well known. In literature, distinction between conduit complications of patients with underlying benign disease and those with malignancy has not always been clear. Stoma and skin complications are frequently observed and the patients who practiced inadequate stoma care routines are more likely to show peristomal skin complications. Patients bearing an abdominal urostomy should be followed up stringently in stoma centers.

["Post-actinic pelvic disease" and the ureter: the post-actinic ureter]. / La "malattia pelvica post-attinica" e l'uretere: l'uretere post-attinico.

PURPOSE: A retrospective study was done to analyze late urological complications following curative radiotherapy of primary gynecological carcinomas. METHODS: From 1990 to 2000, 167 patients with primary gynecological cancer treated with external radiotherapy or intracavitary applications were observed. During the follow-up, all signs, symptoms and therapy of late treatment complications were recorded. RESULTS: Most patients with ureteral stenosis or obstruction required surgical correction. Most patients with bladder fistulas were best served by creation of a cutaneous urinary diversion. CONCLUSION: Ureteral complications after radiotherapy of the pelvis are rare but severe. Surgical therapy of irradiated tissues has a higher complication rate compared to surgery on non irradiated tissue. A cutaneous urinary diversion may be an acceptable and safe procedure when the bladder is definitely compromised.

[Treatment of ureteral lesions during gynecologic surgery]. / Il trattamento delle lesioni ureterali in corso di chirurgia ginecologica.

Surgery of gynecologic area and of pelvic cavity in general is a risk situation for ureteral injury. The incidence of these injuries is about 1% and may be considered as "unavoidable", irrespective of the surgical approach which could be either abdominal, vaginal or laparoscopic. In this study, 37 patients who had undergone a previous gynecological surgery were assessed for 38 ureteral units. Ureteral injury was identified at the surgical table in 2 patients who were treated successfully during the same surgical session with an end-to-end anastomosis. In 8 patients, a double-J ureteral stent was placed and the cure was obtained in 7 patients. The single case of failure was converted to surgery. 22 female patients for 23 ureteral units were subjected to open surgery performing 16 ureterocystoneostomies, 6 of them with a combined psoas-bladder hitching. In 1 patient a termino-terminal anastomosis was performed due to an injury in an upper site. Finally, in 3 patients nephrectomy was carried out due to a nonfunctional kidney; 1 patient refused surgery, whereas in another patient a spontaneous canalization of the excretory tract was obtained after reposition of a percutaneous nephrostomy. The minimum follow-up is of at least 1 year. The diagnostic aspects and therapeutic indications are then described with a special emphasis on the so-called prognostic factors which could influence the outcome of the treatment. Finally, the main surgical correction techniques employed in case of leakage of ureteral substance, are reviewed.