A four-year experience with Holmium-YAG laser:parameters of use.

In the last years, laser has gained increasingly high popularity in Endourology. The newer generation Ho-YAG lasers represent the most updated laser used in Urology, being able to successfully treat both urinary stones and soft tissue lesions. The aim of this work was to report a multicentre 4-year experience using the Ho-YAG laser in the treatment of stones and soft tissue lesions, in order to offer parameters and modalities of use in several different situations. MATERIALS AND METHODS. Two urological Centers were asked between 2002 and 2005 to use Coherent Versa Pulse 20 Ho-YAG laser source in the treatment of urinary stones in 212 patients, and urinary soft tissue lesions (urethra, ureter or bladder neck strictures or urinary tract tumors) in 56 patients. According to the various situations (either stone fragmentation or treatment of soft tissue lesions), pulse frequency and energy per impulse were differently dosed and set. RESULTS. The following parameters were identified as the starting points for the correct use of the Ho-YAG laser: a) lithotripsy with rigid endoscope: 365 µm fiber, 0.8 - 1.2 Joule (J) energy and 6-8 Hz frequency; 365 µm fiber, 0.8-1.2 J energy and 10-12 Hz frequency; 550 µm fiber, 1.0-1.5 J energy and 10-12 Hz frequency. b) lithotripsy with flexible endoscope: 270 µm fiber, 0.6-1.0 J energy and 6-10 Hz frequency. c) soft tissue resection in case of: c1) ureteral stricture, 365 µm fiber, 0.6 J energy and 14-16 Hz frequency; c2) urethral stricture, 365 µm fiber, 0.7 J energy and 16-18 Hz frequency; c3) upper urinary tract tumors, 365 µm fiber, 0.7 J energy and 16 Hz frequency; c4) bladder tumors 365 µm fiber, 0.8 J energy and 16-20 Hz frequency; c5) bladder neck strictures, 365 µm fiber, 1.0 J energy and 16-18 Hz frequency. CONCLUSIONS. In the light of these parameters, Ho-YAG laser is a very handy instrument for the treatment of both urinary stones and soft tissue lesions, which allows to put aside the current tools used for the same purposes.

Renal cell carcinoma with extension into the inferior vena cava: problems in diagnosis, staging and treatment.

Management of renal cell carcinoma with extension into the vena cava is one of the highest challenges in urology. The delineation of the upper level of the endocaval thrombus, its possible extension into the hepatic veins and possible involvement of the caval wall are crucial points and dictate the operative strategy. From 1978 to 1989, at the Department of Urology of the University of Padua, 29 patients with renal cell carcinoma and caval extension were submitted to surgery. Seventeen patients were staged V2 according to the UICC TNM Staging System 1983, 2 patients V3 and 10 V4. The median patient age was 57 years and the male:female ratio was 1.9:1. A complete thrombus removal was accomplished in all patients. In 2 patients, a caval resection was necessary. Five patients died during the perioperative period. The patient survival rate was comparable to that of T3N0M0-staged cases. Survival rates at 1 and 4 years were, respectively, 96.8 and 40% for V2 cases, 100 and 100% for V3, 85.7 and 40% for V4. It seems, therefore, that in patients with locoregional disease and satisfactory conditions, the presence of vascular invasion did not lead to a worst prognosis. By itself, the extent of the caval thrombus seems not to influence the prognosis.

[Endourological treatment of ureteral stenoses]. / Le traitement endo-urologique des sténoses urétérales.

Conservative treatment of ureteral stenoses has been possible since the evolution in materials and methods available. We report our experience in 49 cases of ureteral stenoses (1 case with bilateral lesion). The etiology was as follows: 3 cases of tuberculous strictures, 10 late complications of endourological treatment of ureteral stones, 16 stenoses of ureteroenteric anastomoses or bladder reimplantation, 16 after radical pelvic surgery, 5 after external beam radiation therapy. Forty-two cases were treated with balloon dilation or by means of a coaxial dilator; in 7 cases a cold-knife treatment was performed. All patients had a ureteral stent for 40 days. The results were evaluated by IVP, sonography and DTPA renal scan, 6 to 20 months after stent removal. Overall success rate was 56%: it was lower than the 100% rate obtained in a 13 patients group surgically treated. In selected cases of ureteral stenoses, endourological approach should be the first choice treatment because of low morbidity and reduced hospitalization time.

Bilateral renal cell carcinoma with caval invasion in a woman with duplicated inferior vena cava.

Workup of a woman presenting with a palpable right flank mass, detected bilateral renal solid lesions, later proved to be renal cell carcinomas, and caval invasion in the presence of duplicated inferior vena cava. This association does not appear to have been previously described. The patient underwent right radical nephrectomy, cavotomy and auriculotomy with caval thrombus removal and delayed enucleation of left renal masses and left adrenalectomy. Eighteen months after surgery the patient is alive and without local and distant recurrence.

Quantitative analysis of trace elements in human clear cell carcinoma of the kidney by energy-dispersive X-ray fluorescence.

In a case-control study, 20 cases of renal cell carcinoma (RCC) were analyzed by energy-dispersive X-ray fluorescence in order to establish the concentration of Fe, Cu, Zn and Cd. Patients with RCC were examined and compared with 7 controls from selected autopsies. A significant decrease in Cd and Zn concentration was found in the neoplastic tissue in all cases. In contrast, no significant decrease in Cu concentration was detected in our cases.

[Mitomycin C in the topical treatment of superficial neoplasms of the bladder]. / La mitomicina C en el tratamiento tópico de las neoplasias vesicales superficiales.

From January 1982 to October 1987, 100 patients with multifocal superficial bladder cancer received intravesical MMC at the Institute of Urology, University of Padova. Seventy-three patients had papillary multifocal superficial bladder carcinoma (stages Ta-T1): treatment was divided into therapeutic (18 cases), and prophylactic (55 cases). 27 patients had carcinoma in situ. 39 patients affected by neoplasia relapsed to previous intravesical ADM treatment. All patients received 40 mg. intravesical MMC weekly for 8 consecutive weeks, repeating the cycle in cases of relapse. Complete response rates at 12 months was 53%, 50 to 67% for each group, respectively. Recurrence rate was lower compared to that before treatment; progression rate was also lower compared to a group who received only endoscopic treatment. In patients who relapsed with ADM treatment, the percentage of complete response was 69%. We underscore the efficacy of MMC in lowering relapse and progression in multifocal superficial bladder cancer, which represents the best indication for this kind of treatment.

[Renal parenchymal neoplasm as a chance finding during hepatobiliary echography]. / La neoplasia renale parenchimale come reperto occasionale durante ecografia epato-biliare.

Renal cell carcinomas are often diagnosed as incidental findings during abdominal US or CT carried out for extra-urological reasons. In order to ascertain the incidence of renal carcinoma two groups of patients were considered: a) 2400 outpatients who had undergone hepato-biliary US for routine screening; b) 1330 inpatients who had undergone US, for non-urological purposes, which had been systematically extended to the kidneys. Two cases of renal cell carcinoma (PT1) were found in group A. Four cases were found in group B--2 of them were stage PT1, and 2 were PT3. These results show how a certain number of unsuspected and early-stage renal cell carcinomas can be diagnosed by US, even when the examination is not intended as a renal study. On the basis of the above observations, we suggest that US be performed in all upper abdomen examinations. At any rate, right kidney US seems to us mandatory when hepatobiliary US is performed.

[Verrucous carcinoma of the penis. 2 cases and review of the literature]. / Carcinome verruqueux du pénis. Deux cas et revue de la littérature.

The Authors report general experience with two cases of penis verrucous carcinoma. Such a neoplasia, slowly evolving and not infiltrating the surrounding tissues, needs deep biopsies for a correct diagnosis. Surgical excision of the tumor is the choice treatment at an early stage: at an advanced stage demolitive therapy consisting in a partial or total penectomy is necessary. Recent findings of frank malignant squamous cell carcinoma arising in verrucous carcinoma raise serious concerns on the use of conservative therapies.

Prognostic factors in renal cell carcinoma.

In order to evaluate the prognostic factors of renal cell carcinoma (RCC), a retrospective study was carried out on 215 patients (150 men, 65 women) who had undergone surgical treatment from March 1979 to December 1986. The average age of the patients was 58 years (ranging from 15 to 85 years). The ratios of survival to tumor stage and grade, as well as to nodal and venous involvement, distant metastases at the time of diagnosis (as TNM classification) were evaluated by means of the actuarial method (life table). Corrected 5-year survival rates for stage T1-T4 were 100, 81, 68.9 and 0%, respectively. Grade 1 and grade 2 tumors had a 5-year survival rate of 66.5 and 52.8%, respectively; grade 3 had a 3-year survival rate of 46.5%. Nodal involvement at the time of diagnosis had a prediction value for the 3- and 5-year survival rate of 39.8 and 34.5%, respectively. Metastases at time of diagnosis had a 14.1% prediction value for a 3-year survival rate. Tumor extension to the vena cava (21 patients) affected survival in a significant way (55.8% at 3 years). A definite tendency towards lower stage and grade was observed in incidentally diagnosed RCC (11%). In conclusion, stage, grade, nodal and venous involvement as well as metastases at the time of diagnosis have a significant prognostic value in RCC. These data and the lack of early diagnostic methods for RCC suggest the routine use of renal ultrasonography in clinically asymptomatic patients during examination for suspected abdominal diseases and in high-risk patients (Von Hippel-Lindau disease smokers).

[Psychogenic retention of urine in women: diagnostic and therapeutic problems]. / La rétention psychogène d'urine chez la femme: aspects diagnostiques et thérapeutiques.

Psychogenic urinary retention is rare event. 6 cases are reported: diagnostic urologic and neurologic work-up is outlined. The final statement is the exclusion of rare or minimal neurogenic causes (silent disk prolapse, early multiple sclerosis and so on) and the evidence of cause-effect relationship between psychic trauma and starting of urinary symptoms are compulsory to join the diagnosis of psychogenic urinary retention.

Therapeutical aspects of intrarenal artery aneurysms.

The relative infrequency of aneurysms of the branches of the renal artery produces some indecision as to the surgeon's therapeutical choice. The purpose of this study is to carefully examine the indications for surgical treatment and to select precise therapeutical criteria on the basis of 8 patients in whom aneurysms of the main renal artery or of its branches were diagnosed from 1978 to 1986. In 1 patient, the disease was bilateral with a ruptured main artery aneurysm. 5 aneurysms were treated surgically (the ruptured one by nephrectomy, 2 by ex situ revascularization and 2 by in situ revascularization). In the remaining cases, only periodical controls were performed. In 4 surgically treated patients, angiographic follow-up demonstrated a regular renal revascularization and in 1 patient a thrombosis on the site of the anastomosis. On the basis of personal experience, surgical treatment is required for aneurysms larger than 1.5 cm in size without or with partial calcification, aneurysms occurring in pregnant women or in patients likely to conceive in the future, expanding aneurysms, and renin-mediated hypertension. The introduction of microsurgical techniques and renal preservation makes it possible for the urologist to chose between various therapeutical means for the treatment of intrarenal aneurysms. Reconstruction of anatomical continuity of the arterial supply avoiding unnecessary operative demolishment is feasible.

[Preventive bilateral pulmonary irradiation in renal neoplasms]. / Irradiation pulmonaire bilatérale "prophylactique" en cours de néoplasie rénale.

The aim of the study was to evaluate the role of bilateral lung radiotherapy in the prevention of lung metastases from renal cell carcinoma. The preliminary results are presented. Between 1981-1984, 38 patients with renal cell carcinoma with no evident lung metastases and with normal respiratory function (confirmed by gas analysis, spirometry, diffusion test) were submitted to radical nephrectomy with regional lymphadenectomy. The patients were randomly assigned to two groups. 19 patients were treated with lung radiotherapy (1,500 rad in 5 times with overlap on the mediastinum--3,000 rad) two weeks after surgery, 19 patients did not undergo further treatment after surgery. Chest X-rays and functional lung evaluation were performed at 3.6 and 12 months, and then every six months. Results in the first group (lung radiotherapy) showed no cases of lung fibrosis; 15 patients are disease-free (follow-up: 3-36 months); 4 patients died from cancer, only 1 of whom with lung metastases. In the second group (no lung Radiotherapy) 14 patients are disease-free whilst 5 patients died with lung metastases.

Echography in vena cava invasion from renal tumors.

The last 4 cases of our case series of renal cell carcinoma (RCC) with caval or cavo-atrial invasion were studied by ultrasonography (US), computerized tomography (CT scan), arteriography (AG) and venocavography (VC) (inferior and/or superior). A comparison is made with these different methods, with particular emphasis on (US). The authors' conclusions are that ultrasound may replace anterograde inferior cavography in the evaluation of thrombotic extension and, in addition, it seems to be capable of eliminating the false-positives or -negatives of this method. AG and VC are no longer necessary to determine the cavo-atrial extension of a tumor thrombus from RCC when US and CT scan are available and are correctly integrated.

[Treatment of bladder carcinoma in situ]. / La thérapie du carcinome in situ vésical.

The authors report their experience in the treatment of 21 patients with carcinoma situ of the bladder. Although the safest therapy is radical cystectomy this operation nevertheless is extremely mutilating. For these reason initially we prefer local chemotherapy with ADM continued with careful follow-up of the patient.

[Locoregional staging of prostatic neoplasms by extemporaneous histological examination of pelvic lymph nodes]. / Stadification loco-régionale des cancers prostatiques par l'examen histologique extemporané des ganglions pelviens.

Pelvic lymphadenectomy prior to radical prostatectomy is essential to detect lymph nodal extension of prostatic cancer. Accuracy obtained by means of frozen section examination of the nodes is particularly favourable. Frozen sections correspond to paraffin sections in 100% of the cases. Authors' experience in 42 consecutive patients candidates to radical prostatic procedure is herein presented.

[Occult urothelial neoplasia: diagnosis]. / La néoplasie urothéliale occulte: iter diagnostique.

The authors report their experience in the diagnosis of the hidden neoplasia based on the follow-up of 27 patients with carcinoma in situ of the bladder. Urine cytology and mapping histology are the most effective examinations for the detection and follow up of an occult urothelial neoplasm.

Nonrefluxing colon conduits with a modified ureterocolonic anastomosis.

Urinary diversion by means of a colon conduit is particularly advantageous. In comparison with the ileal conduit an antireflux ureterocolonic anastomosis can be created, thus preventing renal damage in patients with a long life expectancy. Herein the authors present the results of 5 years experience with colon conduits and Pagano's ureterocolonic anastomosis.

Five years of experience with a modified technique of ureterocolonic anastomosis.

The thick colonic wall permits the creation of an antirefluxing ureterocolonic anastomosis, which reduces the incidence of pyelonephritis and limits the deterioration of renal function. Since 1977 a simple procedure for ureterocolonic anastomosis performed entirely outside of the colon was used in 63 patients. Obstructive complications were encountered in 6.4 per cent, while ureterocolonic reflux occurred in 5.6 per cent of the renoureteral units. Acute pyelonephritis developed in 7 patients.