[PHYTOTHERAPY AND NATURAL AGENTS IN SYMPTOMATIC BENIGN PROSTATIC HYPERPLASIA (BPH)].

INTRODUCTION: Benign prostatic hyperplasia (BPH) is a very common condition among men over 50 years of age. Some patients require immediate surgical intervention for urinary retention. However, most men have a variety of symptoms that may require treatment. Medical therapy for BPH has been well known for many years including alpha-adrenergic receptor blockers and 5-alpha reductase inhibitors. In recent years, men also receive anti-cholinergic agents, PDE5 inhibitors and other medical interventions. However, many men pursue alternative treatments and herbal medicines for BPH. We review herbs and herbal medicines that are used worldwide for symptomatic BPH. Many of them are supported by laboratory and clinical data. Mostly, mechanism of action are not fully understood but clinical benefit does support their use. Serenoa repens in hexanic extract (Permixon) is the only medicine that is backed with clinical data in high-quality clinical trials.

Low Alanine Aminotransferase, as a Marker of Sarcopenia and Frailty, Is Associated with Shorter Survival Among Prostate Cancer Patients and Survivors. A Retrospective Cohort Analysis of 4064 Patients.

Background: Sarcopenia is characterized by loss of muscle mass and function and is associated with frailty, a syndrome with higher likelihood of falls, fractures, physical disability, and mortality. Both frailty and sarcopenia are known markers of shorter survival in various cancer patient populations. Low alanine aminotransferase (ALT), reflecting loss of muscle mass (sarcopenia), may be associated with greater frailty and shorter survival in multiple cancers. Objective: To assess the potential association between low ALT and shorter survival among prostate cancer (PCa) patients and survivors. Design setting and participants: This was a retrospective analysis of a historical cohort of PCa patients and survivors. Patients were defined as those still actively receiving PCa treatment, while those no longer receiving such treatment were classified as PCa survivors. Outcome measurements and statistical analysis: ALT data were obtained from results for basic biochemical blood testing carried out for patients on their first hospital admission. Patients were divided into two groups: those with ALT ≥17 IU/l and those with ALT <17 IU/l. Univariate and multivariable analyses were conducted for between-group survival comparisons. Results and limitations: We identified 9489 PCa records. The final study cohort with ALT data available included 4064 patients with ALT <40 IU/l. Of this cohort, 536 patients were actively receiving medical anticancer therapy for PCa. The mean age for the entire cohort was 74.6 yr (standard deviation 9.6) and the median ALT level was 19.28 IU/l; 1676 patients (41%) had low ALT (<17 IU/l). On univariate analysis, low ALT was associated with a 78% increase in mortality risk (95% confidence interval [CI] 1.62-1.97; p < 0.001). A sensitivity analysis of the 536 patients actively receiving medical anticancer treatment revealed that low ALT was associated with a 48% increase in mortality risk (95% CI 1.19-1.85; p = 0.001). In a multivariable model controlled for age, kidney disease, history of cerebrovascular event/transient ischemic attack, and baseline prostate-specific antigen, low ALT was still associated with a 35% increase in mortality risk (95% CI 1.12-1.63; p = 0.001). Limitations include the single-center, retrospective design. Conclusions: Low ALT, which is indicative of sarcopenia and frailty, is associated with shorter survival among PCa patients and survivors and could potentially be used for treatment personalization. Patient summary: We compared survival for prostate cancer patients and survivors according to their blood level of the protein alanine aminotransferase (ALT). Low ALT levels in the general population are associated with loss of muscle mass. We found that in our group of prostate cancer patients and survivors, the risk of death from any cause was higher for those with low ALT levels.

Autoimmune disorders caused by intravesical bacillus Calmette-Guerine treatment: A systematic review.

Intravesical bacillus Calmette-Guérin (BCG) is a common and highly effective treatment for non-muscle invasive urothelial carcinoma of the urinary bladder. BCG may cause an autoimmune reaction in some patients. One hundred and fifty-eight papers were analyzed, for a total of hundred and thirty patients with reactive arthritis, sixty patients with ocular manifestations and eighteen patients with other rheumatologic diseases. Among 130 subjects with reactive arthritis, an autoimmune symptom occurred after 5 instillations of intravesical BCG (IQR 4-6), which represents 5 weeks in most cases. Fifty-one patients had concurrent ocular involvement. The resolution of symptoms was achieved in a median of 32.5 days (IQR 14-90). Forty-two men and twenty women had ocular manifestations, most commonly conjunctivitis. Patients with HLA-B27 typing had earlier presentation of ocular symptoms related to the number of instillations (4.5 vs 6 [p < 0.05]. Resolution of symptoms was achieved at a median of 128 days (IQR 21-150). Among patients treated with NSAIDs (either with or without steroids), the duration of the disease was significantly shorter in both the articular and the ocular groups (28 vs. 120 [p < 0.05] and 30 vs.105 [p < 0.05], respectively). Other autoimmune manifestations included general autoimmune diseases, such as vasculitis, psoriasis and myasthenia gravis.

[PARADIGM SHIFTS IN DIAGNOSIS AND MANAGEMENT OF LOCALIZED PROSTATE CANCER IN 2022].

INTRODUCTION: In recent years, we witnessed significant changes in the way we diagnose prostate cancer and the options for management of low risk localized prostate cancer. This review discusses today's approach to men with elevated PSA. The use of biomarkers and or prostate MRI is strongly recommended prior to the decision on a biopsy. Following a suspicious finding in MRI the best approach is MRI-guided biopsy. Traditionally, biopsies are performed transrectally but the emerging transperineal biopsy has considerable advantage. With a new diagnosis of low risk prostate cancer, each man should have a lengthy discussion with his urologist and in many cases the preferred way is to proceed with active surveillance and avoid radical treatment.

Low Alanine Aminotransferase as a Marker for Sarcopenia and Frailty, Is Associated with Decreased Survival of Bladder Cancer Patients and Survivors-A Retrospective Data Analysis of 3075 Patients.

BACKGROUND: Sarcopenia is characterized by the loss of muscle mass and function and is associated with frailty, a syndrome linked to an increased likelihood of falls, fractures, and physical disability. Both frailty and sarcopenia are recognized as markers for shortened survival in a number of medical conditions and in cancer patient populations. Low alanine aminotransferase (ALT) values, representing low muscle mass (sarcopenia), may be associated with increased frailty and subsequently shortened survival in cancer patients. In the current study, we aimed to assess the potential relationship between low ALT and shorter survival in bladder cancer patients and survivors. PATIENTS AND METHODS: This was a retrospective analysis of bladder cancer patients and survivors, both in and outpatients. We defined patients with sarcopenia as those presenting with ALT < 17 IU/L. RESULTS: A total of 5769 bladder cancer patients' records were identified. After the exclusion of patients with no available ALT values or ALT levels above the upper normal limit, the final study cohort included 3075 patients (mean age 73.2 ± 12 years), of whom 80% were men and 1362 (53% had ALT ≤ 17 IU/L. The mean ALT value of patients within the low ALT group was 11.44 IU/L, while the mean value in the higher ALT level group was 24.32 IU/L (p < 0.001). Patients in the lower ALT group were older (74.7 vs. 71.4 years; p < 0.001), had lower BMI (25.8 vs. 27; p < 0.001), and their hemoglobin values were lower (11.7 vs. 12.6 g/dL; p < 0.001). In a univariate analysis, low ALT levels were associated with a 45% increase in mortality (95% CI 1.31-1.60, p < 0.001). In a multivariate model controlling for age, kidney function, and hemoglobin, low ALT levels were still associated with 22% increased mortality. CONCLUSIONS: Low ALT values, indicative of sarcopenia and frailty, are associated with decreased survival of bladder cancer patients and survivors and could potentially be applied for optimizing individual treatment decisions.

[UPPER TRACT UROTHELIAL CARCINOMA].

INTRODUCTION: Upper tract urothelial carcinoma is a relatively rare malignancy, but with an increasing prevalence. The main risk factor for the disease is smoking. The most common presentation is hematuria or flank pain. Workup is made by imaging of the upper tract - CTU/MRU (Computed Tomography-Urography/Magnetic resonance (MR) urography) and diagnostic uretero-nephroscopy with biopsy. In the past several years there is major advancement in our understanding of the disease and how to treat it, mainly in nephron-sparing treatments. A risk-stratification is usually conducted according to parameters such as tumor size, distribution, and pathologic diagnosis. The low-risk group is usually offered nephron-sparing treatments such as segmental ureterectomy, endoscopic treatments, and lately - local chemotherapy. The high-risk group is usually offered radical resection of the kidney and ureter, with the possible addition of new-adjuvant and adjuvant treatments. In this article we will review the epidemiology, risk factors, diagnosis, and treatment of this malignancy, with a distinction between the risk groups.

Salvage re-irradiation using stereotactic body radiation therapy for locally recurrent prostate cancer: the impact of castration sensitivity on treatment outcomes.

BACKGROUND: Advances in imaging, biomaterials and precision radiotherapy provide new opportunities to salvage locally recurrent prostate cancer (PC). This study evaluates the efficacy and safety of re-irradiation using stereotactic body radiation therapy (SBRT). We hypothesized that patients with castrate-resistant PC (CRPC) would benefit less from local salvage. METHODS: A prospective clinical database was reviewed to extract 30 consecutive patients treated with prostate re-irradiation. Gallium prostate specific membrane antigen (PSMA) ligand positron emission tomography was performed following prostate-specific antigen failure in all patients and biopsy was obtained in 18 patients (60%). Re-irradiation was either focal (n = 13) or whole-gland (n = 17). Endo-rectal balloons were used in twenty-two patients and hydrogel spacers in eight patients. The median prescription dose was 5 fractions of 6.5 (range: 6-8) Gray (Gy). RESULTS: Median follow-up was 28 months. Failure occurred in 10 (out of 11) CRPC patients versus 6 (out of 19) castrate-sensitive patients (91% vs. 32%, p = 0.008) after a median of 13 and 23 months, respectively. Metastases occurred in 64% (n = 7) of CRPC patients versus 16% (n = 3) of castrate-sensitive patients (p = 0.007). Two patients experienced local in-field recurrence, thus local control was 93%. The 2 and 3-year recurrence-free survival were 84% and 79% for castrate-sensitive patients versus 18% and 9% for CRPC patients (p < 0.001), and 3-year metastasis-free survival was 90% versus 27% (p < 0.01) for castrate-sensitive and CRPC patients, respectively. Acute grade II and III genitourinary (GU) toxicity occurred in 27% and 3%, and late GU toxicity in 30% and 3%, respectively. No ≥ grade II acute gastrointestinal (GI) toxicity occurred, and only one patient (3%) developed late grade II toxicity. CONCLUSIONS: Early delivery of salvage SBRT for local recurrence is associated with excellent 3-year disease control and acceptable toxicity in the castrate-sensitive phenotype. PSMA imaging for detection of local recurrence and the use of precision radiotherapy with rectal protective devices should be further investigated as a novel salvage strategy for radio-recurrent PC.

Is Ultra Hypofractionated Radiation Therapy a Safe and Effective Treatment for Invasive Bladder Cancer in the Elderly?: A Retrospective Single Institution Review.

PURPOSE: The aim was to determine the efficacy, safety, and tolerability of weekly ultra hypofractionated radiation therapy for older unfit patients with invasive bladder cancer. METHODS: We retrospectively analyzed a cohort of patients with muscle invasive bladder cancer deemed unfit for chemoradiation therapy and thus treated with 6 weekly doses of 6 Gy using intensity modulated radiotherapy. Charlson comorbidity was calculated retrospectively. Cystoscopy and computed tomography were used to evaluate local control and toxicity using the common terminology criteria. Survival outcomes were estimated using the Kaplan-Meier method. RESULTS: Twenty-two patients with a median age of 84 (range: 70 to 96) years were included. The median comorbidity index was 6±1.5 SD. Nineteen (90%) patients received the full 36 Gy dose. Median follow-up was 10±7 months (range: 6 to 27 mo). Local control in the bladder was achieved in 16 of 19 evaluable patients (84%). One-year overall survival was 62.5%, 1 patient had a retroperitoneal nodal recurrence and 3 patients developed distant metastasis. Grade 3 genitourinary and gastrointestinal toxicity was observed in 4 (18%) and 1 (4.5%) patients, respectively. CONCLUSION: Weekly ultra hypofractionated intensity modulated radiotherapy with image guidance and bladder training is an effective, safe, and well-tolerated regimen for older patients with invasive bladder cancer unfit for radical treatment.

Tumor-infiltrating lymphocytes from human prostate tumors reveal anti-tumor reactivity and potential for adoptive cell therapy.

Advanced prostate cancer remains incurable and is the second leading cause of mortality in men. Immunotherapy based on the adoptive transfer of tumor-infiltrating lymphocytes (TIL) has demonstrated promising clinical results in patients with metastatic melanoma and lately also in other solid tumors. However, the ability to obtain TIL from patients with prostate cancer, considered poorly immunogenic, remains unknown. In this study, we investigate the feasibility of isolating and expanding TIL from primary prostate tumors. We collected tumor specimens from eight patients with diagnosed prostate adenocarcinoma undergoing radical prostatectomy and were able to successfully expand multiple autologous TIL cultures from all patients. Twenty-eight prostate-TIL cultures were further expanded using a standard rapid expansion procedure under Good Manufacturing Practice conditions. TIL cultures were phenotypically characterized for T cell subset composition, differentiation status and co-inhibitory/stimulatory markers such as PD-1, TIM-3, LAG-3, and CD28 and were found to have in general similarity to TIL obtained from patients with melanoma and lung carcinoma previously treated at our center. All analyzed TIL cultures were functional as determined by the capability to produce high level of IFNγ upon stimuli. Most importantly, co-culture assays of prostate-TIL with autologous tumors demonstrated anti-tumor reactivity. In conclusion, these findings demonstrate that functional and anti-tumor reactive TIL can be obtained, despite the immunosuppressive microenvironment of the cancer, thus this study supports the development of TIL therapy for prostate cancer patients.

Salvage Radiation Therapy for Biochemical Failure Following Radical Prostatectomy.

BACKGROUND: Radiotherapy to the prostate bed is used to eradicate residual microscopic disease following radical prostatectomy for prostate cancer. Recommendations are based on historical series. OBJECTIVES: To determine outcomes and toxicity of contemporary salvage radiation therapy (SRT) to the prostate bed. METHODS: We reviewed a prospective ethics committee-approved database of 229 patients referred for SRT. Median pre-radiation prostate-specific antigen (PSA) was 0.5 ng/ml and median follow-up was 50.4 months (range 13.7-128). Treatment was planned and delivered using modern three-dimensional radiation techniques. Mean bioequivalent dose was 71 Gy (range 64-83 Gy). Progression was defined as two consecutive increases in PSA level > 0.2 ng/ml, metastases on follow-up imaging, commencement of anti-androgen treatment for any reason, or death from prostate cancer. Kaplan-Meier survival estimates and multivariate analysis was performed using STATA. RESULTS: Five year progression-free survival was 68% (95%CI 59.8-74.8%), and stratified by PSA was 87%, 70% and 47% for PSA < 0.3, 0.3-0.7, and > 0.7 ng/ml (P < 0.001). Metastasis-free survival was 92.5%, prostate cancer-specific survival 96.4%, and overall survival 94.9%. Low pre-radiation PSA value was the most important predictor of progression-free survival (HR 2.76, P < 0.001). Daily image guidance was associated with reduced risk of gastrointestinal and genitourinary toxicity (P < 0.005). CONCLUSIONS: Contemporary SRT is associated with favorable outcomes. Early initiation of SRT at PSA < 0.3 ng/ml improves progression-free survival. Daily image guidance with online correction is associated with a decreased incidence of late toxicity.

Urothelial-based reconstructive surgery for upper- and mid-ureteral defects: Long-term results.

INTRODUCTION: Ureteral strictures can result in obstructive nephropathy and renal function deterioration. Surgical management of ureteral defects, especially in the proximal- and mid-ureter, is particularly challenging. Our purpose was to analyze the long-term outcomes of urothelial-based reconstructive surgery for upper- and mid-ureteral defects. METHODS: We conducted a retrospective analysis of a single tertiary centre's database, including 149 patients treated for ureteral defects between 2001 and 2011. Thirty-one patients (21%) underwent complex urothelial-based surgical repairs for upper- and mid-ureter defects. Patients' median age was 61 years. The mean length of the ureteral strictures was 2.5 cm, located in upper-, mid-ureter, or in between in 19 (61%), 10 (32%), and two (6%) patients, respectively. All patients were treated with a primary urothelial-based repair. Median followup time was 26 months. The primary outcome of the study was the long-term preservation of renal function and lack of clinical obstruction. The secondary endpoint of the study was the assessment of the intra- and postoperative complication rates. RESULTS: Most of the lesions were benign (22, 71%), while nine strictures (29%) were malignant. Seven patients (23%) suffered from postoperative complications, five of which were infectious. The median pre- and postoperative calculated glomerular filtration rates were 66 ml/min/1.72m2 and 64ml/min/1.72m2, respectively. Success rate was 84%, defined as lack of need for re-operation or kidney drainage at the last followup. CONCLUSIONS: Upper- and mid-ureteral defects present a complex pathology necessitating experienced reconstructive surgical skills. Our data suggest good long-term results for primary urothelial-based reconstructions for these pathologies.

A novel urine cytology stain for the detection and monitoring of bladder cancer.

PURPOSE: CellDetect® is a unique platform technology comprising a proprietary plant extract and 3 dyes that enables color discrimination between malignant (red) and benign (green) cells based on specific metabolic alterations exclusive to the former. Preclinical studies and clinical trials demonstrated the applicability of the new technology in many cell culture lines and various cancers. We explored its performance characteristics in bladder cancer. MATERIALS AND METHODS: We performed an open label, 2-step study at tertiary medical centers. The study enrolled patients with newly diagnosed or a history of urothelial carcinoma. Step 1 involved staining archived biopsies. Slides were evaluated by 2 independent pathologists, who determined the concordance of the new staining technology with the hematoxylin and eosin based diagnosis. Step 2 included staining urine specimens with the new method and comparing findings to the patient final diagnosis and the results of standard urine cytology. RESULTS: A total of 58 archived biopsies were collected. The concordance of staining using the new platform technology with the hematoxylin and eosin based diagnosis was 100%. The new method applied to 44 urine smears showed 94% sensitivity and 89% specificity to detect urothelial carcinoma. Compared to standard urine cytology the new technology had overall superior sensitivity (94% vs 46%), particularly for low grade tumors (88% vs 17%, each p <0.005). There was no significant difference in specificity between the 2 staining techniques. CONCLUSIONS: Findings show the capability of CellDetect to accurately identify urothelial carcinoma. This indicates that the technology can be further developed to provide an alternative urine cytology test with diagnostic value that may have significant clinical benefits.

Risk of prostate cancer in patients with schizophrenia.

OBJECTIVES: To examine the rate of prostate cancer in a cohort of schizophrenia in-patients in the PSA-era as compared to expected rates. There is conflicting evidence on the relative risk of prostate cancer in men with schizophrenia. METHODS: the study sample was comprised of schizophrenia patients who had been admitted to a tertiary care mental health center between 1990 and 2011. The data for the sample was cross-referenced with the National Cancer Registry. Analyses of Standardized Incidence Rates (SIR) for prostate cancer and for lung cancer (representing an organ system not sensitive to sex hormones) were performed. RESULTS: Of 4,326 schizophrenia patients included in the present study, 181 (4.2%) were diagnosed with cancer at any site. Only 10 of these patients were diagnosed with prostate cancer. This reflects a reduced risk; SIR of 0.56 (95% CI 0.27-1.03). In the same cohort, 33 schizophrenia patients were diagnosed with lung cancer presenting a SIR of 1.43 (95% CI 0.98-2.01) in this sample. CONCLUSIONS: The present study suggests a reduced rate of prostate cancer in patients admitted for schizophrenia. There are several possible explanations for this finding including chronic state of hyperprolactinemia induced by antipsychotic drugs.

[InoPro trial: collaboration between urologists and primary care physicians in the treatment of osteoporosis in prostate cancer patients].

INTRODUCTION: Osteoporosis is more common in elderly men than previously suspected. Prostate cancer patients may have an increased rate of osteopenia and osteoporosis independent of therapy. Osteopenia and fracture risk are accelerated in men receiving androgen deprivation therapy. Nevertheless, little is done by primary care physicians and urologists to diagnose and treat osteoporosis in men. AIMS: (1) Assess prostate cancer patients' compliance and adherence to bisphosphonate therapy; (2) Increase awareness for osteoporosis in men diagnosed with prostate cancer among urologists and primary care physicians and to evaluate collaboration between the two disciplines. METHODS: We included patients with confirmed diagnosis of prostate cancer who fulfilled one or more of the following criteria: (1) age 70 and above; (2) age 60 and above with androgen deprivation therapy or (3) prior diagnosis of osteopenia and osteoporosis. Qualified patients were referred to DXA bone density test. Patients with osteopenia or osteoporosis, who were naïve to bisphosphonates, received recommendations for oral bisphosphonates. Follow-up lasted 6 months and included 2 office visits to ensure patients' compliance and adherence to recommended therapy. RESULTS: A total of 28 community-based urologists recruited 180 patients. Of the 180 prostate cancer patients, 87 (48%) had osteoporosis and 93 (52%) osteopenia, all were naïve to bisphosphonates. Of the 180 patients, 153 (85%) patients started treatment with bisphosphonates after inclusion; 147/180 (82%) and 136/180 (76%) patients stayed on bisphosphonates for 3 and 6 months respectively. Primary care physicians adopted recommendations for bisphosphonate in 123/180 (68%). CONCLUSIONS: This study showed high compliance and adherence of prostate cancer patients for bisphosphonate recommendation.

Hematospermia--the added value of transrectal ultrasound to clinical evaluation: is transrectal ultrasound necessary for evaluation of hematospermia?

Hematospermia is usually caused by nonspecific inflammation of the prostate and seminal vesicles. Transrectal ultrasound (TRUS) is a safe and inexpensive modality for evaluating patients with hematospermia. The aim of this study is to describe the findings of TRUS and its contribution to patients' management. A total of 115 consecutive patients presented with hematospermia and evaluated with TRUS between 2006 and 2012. All patients exhibited an abnormality in the TRUS examination. A 12-core TRUS-guided biopsy of the prostate was taken from 10 patients, but none of these samples were positive for tumor. In the vast majority of cases, a benign cause can be identified using TRUS. These causes usually do not require treatment.

The role of a combined regimen with intravesical chemotherapy and hyperthermia in the management of non-muscle-invasive bladder cancer: a systematic review.

CONTEXT: Due to the suboptimal clinical outcomes of current therapies for non-muscle-invasive bladder cancer (NMIBC), the search for better therapeutic options continues. One option is chemohyperthermia (C-HT): microwave-induced hyperthermia (HT) with intravesical chemotherapy, typically mitomycin C (MMC). During the last 15 yr, the combined regimen has been tested in different clinical settings. OBJECTIVE: To perform a systematic review to evaluate the efficacy of C-HT as a treatment for NMIBC. EVIDENCE ACQUISITION: The review process followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. An electronic search of the Medline, Embase, Cochrane Library, CancerLit, and ClinicalTrials.gov databases was undertaken. Relevant conference abstracts and urology journals were also searched manually. Two reviewers independently reviewed candidate studies for eligibility and abstracted data from studies that met inclusion criteria. The primary end point was time to recurrence. Secondary end points included time to progression, bladder preservation rate, and adverse event (AE) rate. EVIDENCE SYNTHESIS: A total of 22 studies met inclusion criteria and underwent data extraction. When possible, data were combined using random effects meta-analytic techniques. Recurrence was seen 59% less after C-HT than after MMC alone. Due to short follow-up, no conclusions can be drawn about time to recurrence and progression. The overall bladder preservation rate after C-HT was 87.6%. This rate appeared higher than after MMC alone, but valid comparison studies were lacking. AEs were higher with C-HT than with MMC alone, but this difference was not statistically significant. CONCLUSIONS: Published data suggest a 59% relative reduction in NMIBC recurrence when C-HT is compared with MMC alone. C-HT also appears to improve bladder preservation rate. However, due to a limited number of randomized trials and to heterogeneity in study design, definitive conclusions cannot be drawn. In the future, C-HT may become standard therapy for high-risk patients with recurrent tumors, for patients who are unsuitable for radical cystectomy, and in cases for which bacillus Calmette-Guérin treatment is contraindicated.

Laparoscopic partial nephrectomy for central tumors: analysis of perioperative outcomes and complications.

PURPOSE: We report our experience with laparoscopic partial nephrectomy for central tumors compared to peripheral tumors to analyze the feasibility and safety of the laparoscopic approach to these complex cases. MATERIALS AND METHODS: Between October 2002 and July 2007, 212 patients underwent laparoscopic partial nephrectomy. In 53 patients the tumor was central and in 159 it was peripheral. The preoperative, intraoperative and postoperative data, the type and incidence of complications, and the quality of excision in terms of surgical margin status were compared between the 2 groups. RESULTS: Mean estimated blood loss (320 and 360 ml, respectively, p >0.05) and mean operative time (126 and 118 minutes, respectively, p >0.05) were similar in the central and peripheral tumor groups. Mean warm ischemia time in the central tumor group was longer (37 and 28 minutes, respectively, p <0.05) but median time was similar (30 and 29 minutes, respectively, p >0.05). The open conversion rate was significantly lower in the study group (1% vs 5.6%, p <0.05). The urological complication rate was similar in the 2 groups (9.4% vs 8.4%, p >0.05). However, different types of complications developed in each group. Four patients (7.5%) with central tumors had late hematuria (arterial pseudoaneurysm) and only 1 (1.9%) had a urine leak. Central tumors were larger (3.2 vs 2.5 cm) and more frequently malignant (94% vs 82%, p >0.05). Positive surgical margins were diagnosed in 0% vs 5% of cases (p <0.05). CONCLUSIONS: Provided that there is adequate laparoscopic expertise the outcome of laparoscopic partial nephrectomy for central tumors is comparable to that of peripheral tumors. The main major complication in this group was late onset hematuria, which necessitated angiographic embolization. This facility should be available at centers where these advanced procedures are performed.

[Alpha blockers in use for symptomatic benign prostatic hyperplasia--are all drugs born equal?].

Alpha-adrenergic blockers are an established form of medical treatment for symptomatic benign prostatic hyperplasia (BPH). Several medications of the class are available, each with its own characteristics. The authors attempted to define the differences between the currently available medications (Terazosin, Doxazosin, Alfuzosin, and Tamsulosin), and to present an evidence-based recommendation for choosing the best treatment option. A literature search was conducted, using Medline queries and the references of review papers, in search of pertinent studies. These included controlled studies comparing the results of treatment with alpha blockers to placebo, or direct comparative studies of alpha blockers, and real life practice, community studies of each of the medications. A similar efficacy emerged from the reviewed articles, but with a different adverse events profile. A higher rate of vasodilatatory, cardiovascular side effects (dizziness, fatigue, and hypotension) was observed with terazosin and doxazosin, when compared with the uroselective alfuzosin and tamsulosin. Of the latter two, hypotension was more frequent with alfuzosin, while ejaculatory dysfunction was more frequent with tamsulosin. In conclusion, each of the four medications is a possible treatment option for BPH, but we believe alfuzosin and tamsulosin are the better choice. In light of an identical efficacy, these medications offer better tolerability, and ease of use of a once daily treatment without dose titration. The choice between the two should be tailored to the individual patient, with alfuzosin associated with hypotensive side effects, and tamsulosin causing ejaculatory dysfunction.

Laparoscopic partial nephrectomy: single center experience with 140 patients--evolution of the surgical technique and its impact on patient outcomes.

PURPOSE: We analyzed the outcome of laparoscopic partial nephrectomy in 140 patients and defined the evolution of the operative technique and its impact on patient outcomes. MATERIALS AND METHODS: Preoperative tumor characteristics, intraoperative parameters (blood loss, ischemia time, complication and conversion rates) and postoperative parameters (complications, surgical margins status and followup) were compared between the initial 30 patients (group 1) and the last 110 (group 2). Statistical analysis was done using the Student t test with p <0.05 considered significant. The impact of modifications in the surgical technique on the outcome of surgery is discussed. RESULTS: Group 1 consisted of exophytic, peripherally located tumors, whereas in group 2 central and hilar tumors were also included. The 2 groups were also different regarding mean tumor size (2.6 vs 3.9 cm p <0.05), conversion rates (10% vs 2.7%, p <0.05), postoperative complication rates (urine leakage 10% vs 1.4% and reoperation 6% vs 1.8%, p <0.05) and positive margins (10% vs 3.6%, p <0.05). Mean warm ischemia time (32 vs 29 minutes) and blood loss (460 vs 510 ml) were similar (each p >0.05). Renal cell carcinoma was found in 78% and 86% of cases, respectively. Overall 7 cases (5%) had focally positive surgical margins, including 3 in group 1 and 4 in group 2. At followup no tumor recurrences were observed. CONCLUSIONS: Laparoscopic partial nephrectomy is a challenging procedure with potentially major complications. However, accumulated experience and adherence to a standardized surgical technique translate into improved outcomes.

Renal artery occlusion during nephron-sparing surgery: retrospective review of 301 cases.

OBJECTIVES: Temporary occlusion of the renal artery during nephron-sparing surgery may facilitate complete tumor resection and reduce operative bleeding. However, it may also entail a greater risk of ischemic kidney damage. In contrast, when vascular occlusion is not applied, the risk of bleeding, as well as the risk of positive margins, may be increased. To study these issues, we retrospectively evaluated our results with nephron-sparing surgery for kidney masses using renal artery occlusion compared with patients in whom vascular occlusion was not applied. METHODS: From 1988 to 2003, 301 consecutive patients underwent nephron-sparing surgery for a kidney mass at our institutions. At the surgeons' discretion, the renal artery was temporarily occluded in 181 patients (60%) and was not in 120 (40%). RESULTS: No statistically significant differences were found between the two groups regarding blood loss, transfusion rates, and overall complication rates. The loss of the renal unit because of ischemia was noted in 2 patients (1.2%) after renal artery occlusion and in none of the nonoccluded group. Positive tumor margins were found in 5 patients (4.2%) in the nonoccluded group and in 1 patient (0.6%) in the vascular occlusion group. CONCLUSIONS: Our results suggest that although vascular occlusion during nephron-sparing surgery may increase the risk of permanent kidney damage, patients with no vascular occlusion may have a greater risk of positive tumor margins after surgery. These two factors should be taken into consideration and could be discussed with the patient when attaining informed consent.