Rare perinephric myxoid pseudotumor of fat causing ureteropelvic junction obstruction: a case report.

Ureteropelvic junction obstruction (UPJO) is a congenital or acquired functionally significant impairment of urinary transport from the renal pelvis to the ureter. Congenital UPJO typically results from intrinsic disease such as the presence of an aperistaltic segment of the ureter, aberrant vessels or kidney abnormalities. Rare conditions can sometimes mimic an UPJO. We present a case of an 86-year-old woman with a UPJO diagnosed on CT. The patient was counseled on treatment options and elected to undergo a left uretherorenoscopy (URS) plus left laparoscopic pyeloplasty. The definitive histopathologic diagnosis was perinephric myxoid pseudotumor of fat, an extremely rare neoplasm, mass-forming. To the best of our knowledge, this is the first known case of a pseudotumor of fat causing UPJO. 6-month follow-up showed neither recurrence nor residual UPJO. We describe a rare presentation of extrinsic perinephric myxoid pseudotumor of fat causing UPJ obstruction. In elderly patients with no history of malignancy, UPJ obstruction can occur because of atypical masses.

Revisión del acceso laparoscópico: ¿hay un método de entrada más seguro? / Laparoscopic access overview: Is there a safest entry method?

Antecedentes: La laparoscopia es una técnica mínimamente invasiva para acceder a la cavidad abdominal, para aplicaciones diagnósticas o terapéuticas. La optimización de la técnica de acceso es un paso importante para los procedimientos laparoscópicos. El objetivo de este estudio es evaluar los resultados de las diferentes técnicas de acceso laparoscópico e identificar el más seguro. Métodos: El cuestionario de acceso laparoscópico fue remitido por correo electrónico a los 60 centros que son socios en el grupo de trabajo para la cirugía laparoscópica y robótica de la Sociedad Italiana de Urología (SIU), y sus centros de referencia de América y Europa. Resultados: a tasa de respuesta fue del 68,33%. El número total de procedimientos considerados fue de 65.636. El 61,5% de los cirujanos utiliza aguja de Veress para crear el neumoperitoneo. La técnica de trocar ciego es la más comúnmente utilizada, pero tiene el mayor número de complicaciones. La técnica de trocar óptico parece ser la más segura, pero es la menos utilizada comúnmente. El 28,2% de los cirujanos adoptan técnica abierta de Hasson. La tasa total de complicaciones intraoperatorias fue del 3,3%. La tasa de conversión abierta fue del 0,33%, la tasa de transfusión fue del 1,13% y la tasa de complicaciones postoperatorias totales fue del 2,53%. Conclusión: El acceso laparoscópico es una técnica segura, con una baja tasa de complicaciones. La mayoría de las complicaciones se pueden gestionar de forma conservadora o por vía laparoscópica. La elección de la técnica de acceso puede afectar la tasa y el tipo de complicaciones, y debe ser planeada de acuerdo a la experiencia del cirujano, la seguridad de cada técnica y las características de los pacientes. Todos los tipos de acceso tienen complicaciones perioperatorias. De acuerdo con nuestro estudio la técnica de trocar óptico parece ser la más segura

Background: Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one. Methods: Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers. Results: The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%. Conclusion: Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest

Laparoscopic access overview: Is there a safest entry method? / Revisión del acceso laparoscópico: ¿hay un método de entrada más seguro?

BACKGROUND: Laparoscopy is a minimally invasive technique to access the abdominal cavity, for diagnostic or therapeutic applications. Optimizing the access technique is an important step for laparoscopic procedures. The aim of this study is to assess the outcomes of different laparoscopic access techniques and to identify the safest one. METHODS: Laparoscopic access questionnaire was forwarded via e-mail to the 60 centers who are partners in working group for laparoscopic and robotic surgery of the Italian Urological Society (SIU) and their American and European reference centers. RESULTS: The response rate was 68.33%. The total number of procedures considered was 65.636. 61.5% of surgeons use Veress needle to create pneumoperitoneum. Blind trocar technique is the most commonly used, but has the greatest number of complications. Optical trocar technique seems to be the safest, but it's the less commonly used. The 28,2% of surgeons adopt open Hasson's technique. Total intra-operative complications rate was 3.3%. Open conversion rate was 0.33%, transfusion rate was 1.13%, and total post-operative complication rate was 2.53%. CONCLUSION: Laparoscopic access is a safe technique with low complication rate. Most of complications can be managed conservatively or laparoscopically. The choice of access technique can affect the rate and type of complications and should be planned according to surgeon experience, safety of each technique and patient characteristics. All access types have perioperative complications. According with our study, optical trocar technique seems to be the safest.

Positron-emission tomography in imaging and staging prostate cancer.

With increasing application of positron-emission tomography (PET) imaging, familiarity with the applications of PET in genitourinary oncology, especially prostate-cancer (PCa) imaging, becomes important. PET studies provide functional information using radiolabeled tracers, with fluoro-dexoxy-glucose (FDG) being the most commonly used. Nevertheless FDG has limitations for evaluation of PCa patients and therefore alternative tracers are being investigated. To date, the best results have been obtained with 11C-choline and 11C-acetate PET, which seem to demonstrate similar values in this field. We review the current role of PET in PCa patients based on data published in the literature as well as our own experience. Most studies of PET imaging of PCa address three goals: a) detecting primary PCa; b) staging PCa; and c) assessing PCa recurrence. From available results, routine clinical use of 11C-choline PET cannot be recommended for detecting and staging primary PCa. At present, the only clinical indication for imaging PCa with 11C-choline-PET is evaluation of suspected recurrence after treatment.

11C-choline positron emission tomography/computerized tomography for tumor localization of primary prostate cancer in comparison with 12-core biopsy.

PURPOSE: (11)C-choline positron emission tomography is an innovative imaging technique for prostate cancer. We assessed the sensitivity of positron emission tomography used together with computerized tomography for intraprostatic localization of primary prostate cancer on a nodule-by-nodule basis, and compared its performance with 12-core transrectal biopsy. MATERIALS AND METHODS: In 43 patients with known prostate cancer who had received positron emission tomography/computerized tomography before initial biopsy, we assessed sensitivity of positron emission tomography/computerized tomography for localization of nodules 5 mm or greater (those theoretically large enough for visualization) using radical prostatectomy histopathology as the reference standard. Comparison with transrectal ultrasound guided biopsy was based on sextant assessment of all cancer foci following sextant-by-sextant matching and reconstruction. Sensitivity/specificity of positron emission tomography/computerized tomography and magnetic resonance imaging for prediction of extraprostatic extension was also assessed. RESULTS: Positron emission tomography/computerized tomography showed 83% sensitivity for localization of nodules 5 mm or greater. At logistic regression analysis only nodule size appeared to influence sensitivity. At sextant assessment positron emission tomography/computerized tomography had slightly better sensitivity than transrectal ultrasound guided biopsy (66% vs 61%, p = 0.434) but was less specific (84% vs 97%, p = 0.008). For assessment of extraprostatic extension, sensitivity of PET/CT was low in comparison with magnetic resonance imaging (22% vs 63%, p <0.001). CONCLUSIONS: Positron emission tomography/computerized tomography has good sensitivity for intraprostatic localization of primary prostate cancer nodules 5 mm or greater. Positron emission tomography/computerized tomography and transrectal ultrasound guided biopsy show similar sensitivity for localization of any cancer focus. Positron emission tomography/computerized tomography does not seem to have any role in extraprostatic extension detection. Studies of diagnostic accuracy (as opposed to tumor localization) are needed in patients with suspected prostate cancer to see whether positron emission tomography/computerized tomography could have a role in not selected patients.

Clinical evaluation of percent free prostate-specific antigen using the AxSYM system in the best analytical scenario.

OBJECTIVE: Percent free prostate-specific antigen (PSA) is a promising tool for prostate cancer (CaP) diagnosis. However, its diagnostic performances have not yet been established. The present study was carried out with the aim of evaluating percent free PSA in the most favourable analytical conditions. MATERIALS AND METHODS: Eighty-eight patients affected by newly diagnosed, untreated, primary CaP, and 169 cases with biopsy-confirmed, untreated, benign prostatic hypertrophy (BPH) were prospectively enrolled. Abbott AxSYM total and free PSA were measured by the same technician using the same instrument and the same reagent batch. RESULTS: Percent free PSA was more effective than total PSA in differential diagnosis between CaP and BPH in every evaluated dose range of total PSA. In cases with total PSA >4 microg/l, percent free PSA could have reduced by about 50% the rate of unnecessary biopsies with a probably still acceptable 93% cancer detection rate. The likelihood of CaP after the determination of percent free PSA was in fact higher than 50% using cut-off points which provide low sensitivity values (i.e. 58% in men aged 50-59 years). CONCLUSIONS: Percent free PSA is superior to total PSA in distinguishing primary CaP from BPH in patients with total PSA between 2 and 30 microg/l and in reducing the rate of unnecessary biopsies in men with total PSA higher than 4 microg/l. However, percent free PSA should be cautiously interpreted in decision making in individual patients since post-test probability is relatively low in men aged 50-70 years.

Percent free prostate-specific antigen in assessing the probability of prostate cancer under optimal analytical conditions.

Although general consensus exists that percent free prostate-specific antigen (PSA) is superior to total immunoreactive PSA for prostate cancer (CaP) detection, its diagnostic performance is not yet well established. Analytical problems may account for difficulties in evaluating percent free PSA because the free PSA concentration is substantially lower than that of total PSA. The aim of the present study was to establish the diagnostic performances of the IMMULITE percent free PSA assay from Diagnostics Products Corp. under experimental conditions optimized to minimize analytical variability. Eighty-five patients with untreated primary CaP and 261 with untreated benign prostate hypertrophy (BPH) were prospectively enrolled. The Diagnostics Products IMMULITE total (Third Generation) and free PSA were measured by the same technician, using the same instrument and the same reagent batch. We calculated the post-test probability to express how the likelihood of the diagnosis of CaP changed after the percent free PSA was determined. Areas under the ROC curves of percent free PSA were better than those of total PSA in every evaluated range of total PSA. The percent free PSA could have reduced the rate of unnecessary biopsies by 47% in patients with total PSA >/=4 microg/L with only 3.8% false-negative results. The post-test probability of percent free PSA was, however, <50% in men 50-70 years of age, using cutoff points providing sensitivity from 99% to 80%. Percent free PSA is superior to total PSA in distinguishing primary CaP from BPH in patients with total PSA between 2 and 30 microg/L. In men with low total PSA, the diagnostic performance of the percent free PSA assay may be optimized by controlling methodological variability. The percent free PSA assay is effective in reducing the rate of unnecessary biopsies in men with total PSA >4 microg/L. However, the post-test probability provided by percent free PSA is relatively low in asymptomatic patients 50-70 years of age.

Prostate cancer probability after total PSA and percent free PSA determination.

UNLABELLED: The percent free PSA value is a promising diagnostic tool for prostate cancer. However, its actual role has not yet been established because of the widely diverging sensitivity and specificity values. This could depend at least in part on analytical difficulties, since the free PSA concentration is much lower than that of total PSA. The present investigation was designed to evaluate the diagnostic performance of the percent free PSA in the most favorable analytical conditions. MATERIALS AND METHODS: 81 patients affected by newly diagnosed, untreated primary prostate cancer (CaP) and 239 patients with untreated benign prostatic hyperplasia (BPH) were prospectively enrolled. Hybritech total and free PSA were measured by the same technician using the same reagent batch. RESULTS: The percent free PSA was not significantly associated with age, tumor stage, gland volume, Gleason score, and total PSA, nor was it significantly affected by concomitant prostatic complications either in CaP or BPH. Percent free PSA was more effective than total PSA in the differential diagnosis between CaP and BPH in every evaluated dose range of total PSA. Percent free PSA determination could have reduced the rate of unnecessary biopsies in cases with total PSA > or = 4 ng/mL and > or = 10 ng/mL (avoided biopsies 61% and 63%, respectively). The post-test probability of the disease, which represents the proportion of patients with a positive percent free PSA value who have the disease, was, however, relatively low in younger patients with total PSA within the normal range. CONCLUSIONS: The diagnostic performance of the percent free PSA value is enhanced when the methodological variability is reduced, particularly in men with low total PSA. Percent free PSA is superior to total PSA in distinguishing primary CaP from BPH in patients with total PSA between 2 and 30 ng/mL. The percent free PSA value is effective in reducing the rate of unnecessary biopsies in men with total PSA higher than 4 or 10 ng/mL. However, due to its relatively low post-test probability, the percent free PSA value should be interpreted with caution in the decision-making related to individual patients and should be used in association with clinical and instrumental evaluation of the patient.

[BCG vs. BCG plus recombinant alpha-interferon 2b in superficial tumors of the bladder]. / BCG vs. BCG plus alpha-interferon 2b ricombinante nei tumori superficiali della vescica.

BCG intravesical instillation is a well established therapy for superficial bladder carcinoma as adjuvant and/or prophylactic treatment. However side-effects are frequent when full doses are employed and therefore low dose alternative schedules were proposed. Interferon intraluminal therapy for bladder TCC has been used with similar indication but the results did not encourage further single drug trials. A double arm random study, BCG full dose vs. BCG low dose, is presented. The results point out that the combination treatment is superior to BCG full dose therapy in terms of side effects and similar to BCG full dose as regards efficiency (5/18 vs 4/18 recurrences) after a follow-up of 24.11 +/- 8.15 for BCG and 16.72 +/- 8.7 for BCG + IFN.

A new device for self-adjustment of colposuspension.

One of the major problems with the colposuspension technique is the tension applied to the stitches which is usually adjusted on the basis of experience or by means of endoscopic observation of the bladder neck with the patients immobile and under anesthesia. The outcome of the procedures may be different during active life and in an upright position resulting in under- or overcorrection. Therefore, the authors developed a device to be applied on the 4th to 5th postoperative day after standard Gittes or Raz-Pereyra procedures and checked continence during walking and voiding. Up to November 1993, 13 females with recurrent incontinence had been treated with this method; good results were obtained in 12 cases. The authors advocate the use of this device as a solution in cases with imperfect outcome due to assessment of colposuspension during surgery.

Actinomycosis of bladder and intrauterine devices.

PIP: Vesical actinomycosis, though rare, is being discovered more among women who use IUDs. The case study is presented of a 32 year old woman with actinomycosis of the bladder. An analysis of the disease reveals that human actinomycosis is caused primarily by actinomyces israeli. It grows anaerobically and a number of strains are micro-aerophilic. Infection can begin principally in 3 ways: 1) when endogenous actinomyces penetrate damaged tissues following trauma, 2) other infections of foreign bodies, or 3) surgical manipulation. Pelvic actinomycosis is now being seen in women with IUDs. Urinary tract infection seldom occurs, and kidneys are affected more than ureters or the bladder. In appearance, vesical actinomycosis resembles a retropubic mass. It is possible that female organs, when confronted by a foreign body, may make it possible for the development of a undetectable actinomycotic pelvic infection. Treatment for actinomycosis is extensive antibiotic therapy with penicillin, tetracycline, clindamycin, or erythromycin. Surgery may be necessary when the disease produces a large mass and there's a need to drain abscesses, or to extirpate sinus tracts.^ieng