Anti-Müllerian hormone: a novel biomarker for aggressive prostate cancer? Emerging evidence from a prospective study of radical prostatectomies.

PURPOSE: Prostate cancer patients are a heterogeneous group as regards the aggressiveness of the disease. The relationship of steroid hormones with the aggressiveness of prostate cancer is unclear. It is known that the anti-Müllerian hormone (AMH) inhibits prostate cancer cell lines in vitro. The aim of this study is to investigate the relationship of AMH and steroid hormones with the aggressiveness of prostate cancer. METHODS: This was a prospective study of consecutive radical prostatectomy patients. We measured the following hormones: total testosterone, sex hormone-binding globulin, albumin, luteinizing hormone, follicle-stimulating hormone, estradiol, dehydroepiandrosterone sulfate, androstenedione, and AMH. The minimum follow-up after radical prostatectomy was 5 years. For the aggressiveness of prostate cancer, we considered the following three variables: post-operative Gleason score (GS) ≥ 8, TNM pΤ3 disease, and prostate-specific antigen (PSA) biochemical recurrence (BCR). RESULTS: In total, 91 patients were enrolled. The mean age and PSA were 64.8 years and 9.3 ng/dl, respectively. The median post-operative GS was 7. Low AMH blood levels were correlated with higher post-operative GS (p = 0.001), as well as with PSA BCR (p = 0.043). With pT3 disease, only albumin was (negatively) correlated (p = 0.008). ROC analysis showed that AMH is a good predictor of BCR (AUC 0.646, 95% CI 0.510-0.782, p = 0.043); a cutoff value of 3.06 ng/dl had a positive prognostic value of 71.4% and a negative prognostic value of 63.3% for BCR. Cox regression analysis showed that AMH is a statistically significant and independent prognostic marker for BCR (p = 0.013). More precisely, for every 1 ng/ml of AMH rise, the probability for PSA BCR decreases by 20.8% (HR = 0.792). Moreover, in Kaplan-Meier analysis, disease-free survival is more probable in patients with AMΗ ≥ 3.06 ng/ml (p = 0.004). CONCLUSIONS: Low AMH blood levels were correlated with aggressive prostate cancer in this radical prostatectomy cohort of patients. Therefore, AMH could be a prognostic biomarker for the aggressiveness of the disease.

Epigenetics and prostate cancer: defining the timing of DNA methyltransferase deregulation during prostate cancer progression.

DNA methyltransferases (DNMTs) regulate gene expression by methylating cytosine residues within CpG dinucleotides. Aberrant methylation patterns have been shown in a variety of human tumours including prostate cancer. However, the expression of DNMTs in clinical samples across the spectrum of prostate cancer progression has not been studied before. Tissue microarrays were constructed from the prostatectomy specimens of 309 patients across the spectrum of prostate cancer progression: hormone-naïve low-grade prostate cancer (n=49), hormone-naïve high-grade prostate cancer (n=151), hormonally treated high-grade prostate cancer (n=65), and castrate-resistant prostate cancer (CRPC) including neuroendocrine carcinoma (n=44). Adjacent non-neoplastic parenchyma was also available in 100 patients. In 71 patients with high-grade carcinoma and lymph node metastasis, tissue from the metastasis was also available for analysis. Immunohistochemical staining was performed with antibodies against DNMT1, DNMT2, DNMT3A, DNMT3B, and DNMT3L. Our results showed that DNMT1 and DNMT3L were upregulated early in prostate cancer progression, whereas DNMT2 was upregulated as a response to androgen ablation. DNMT1, DNMT3A, and DNMT3B were higher in the late stages of prostate cancer progression, i.e., the emergence of castrate resistance and androgen-independent growth. Lastly, DNMT1, DNMT2, and DNMT3L were upregulated in lymph node metastases compared to primary carcinomas. Our results highlight a cascade of epigenetic events in prostate cancer progression.

Deep sedation in GreenLight laser prostatectomy.

INTRODUCTION: Evaluation of ketamine and propofol combination for the performance of photoselective vaporization of prostate (PVP). PATIENTS AND METHODS: Twenty-six patients undergoing PVP for benign prostatic hyperplasia were included in the study. Co-morbidities were present in 24 patients. Midazolam 2 mg intravenous was administered for the induction to anesthesia. Propofol (10 mg/ml) and ketamine (1 mg/ml) were administered with the use of two pumps. An initial bolus dose of 0.03 ml/kg of propofol and 5 mg of ketamine was administered intravenously. The anesthesia was maintained by continuous infusion of 0.01 ml/kg/min of propofol and 2 ml/min of ketamine. Fentanyl was administered when deemed necessary. The level of sedation, peri-operative parameters and side-effects were recorded. RESULTS: The average periods from the induction of anesthesia and intraoperative infusion were 12.38 ± 5.84 min and 59.5 ± 22.15 min, respectively. Average propofol and total ketamine dose were 85.5 ± 10.62 µg/kg/min and 144.9 ± 45.62 mg, respectively. The average dose of fentanyl administered was 29.81 ± 27.40 µcg. An average period between the end of the infusion and the discharge to the urology clinic was 34.62 ± 22.89 min. Ten patients experienced nausea and five eventually vomited. Hallucinations were observed in five cases while visual disturbances in two patients. CONCLUSION: The combined use of ketamine and propofol for the performance of PVP proved to be an efficient method for anesthesia. The "deep sedation" provided by these drugs was not associated with significant side-effects. Moreover, the use of the above method is indicated in patients with significant co-morbidities that should undergo PVP.

Computed tomography cephalometric and upper airway measurements in patients with OSA and erectile dysfunction.

PURPOSE: Erectile dysfunction (ED) has been linked to obstructive sleep apnea (OSA). This study used computed tomography (CT) to identify cephalometric and upper airway anatomic features in patients with OSA that correlate with the presence of ED. METHODS: In this prospective study, 20 CT cephalometric and upper airway measurements, most commonly associated with OSA, were analyzed in 53 age- and BMI-matched consecutive eligible subjects. Twenty-two were diagnosed with OSA and ED (OSA+/ED+), 17 with OSA without ED (OSA+/ED-), and 14 without OSA and ED (OSA-/ED-) serving as a control group. RESULTS: Although OSA+/ED+ did not differentiate significantly in CT measurements from OSA+/ED-, they showed more alterations when compared to OSA-/ED-, which included narrower bony oropharynx, longer soft palate and uvula (PNS-P), and narrower retropalatal and retrolingual airway diameter (p < 0.05). Binary forward stepwise model analysis showed that PNS-P was the only significant variable in the predictive model for ED in patients with OSA (OR = 1.129, 95 % CI = 1.0005-1.268, p = 0.041). In the OSA+/ED+ group, PNS-P correlated with the percentage of total sleep time with oxygen saturation <90 % (r = 0.61, p < 0.01) and was the only determinant in the relevant predictive model (n = 22, model R = 0.612, adjusted R (2) = 0.337, F = 10.167, p < 0.005). CONCLUSIONS: Characteristics of the craniofacial and upper airway structures suggest that a longer soft palate and uvula may be important risk factors for the concurrence of ED in patients with OSA. Only OSA+/ED+ showed significant narrowing in the retropalatal, retrolingual, and bony oropharynx level when compared with BMI-matched OSA-/ED-.

Contemporary pharmacotherapy for the prevention of skeletal complications in patients with prostate cancer.

INTRODUCTION: Bones represent the most common metastatic sites in prostate cancer (PCa) patients, and in addition with androgen deprivation therapy, they represent the causative reasons of bone mineral density loss and the onset of skeletal-related events. AREAS COVERED: An extensive search of PubMed/Medline was performed to identify randomized, Phase II/III controlled trials reporting results regarding the prevention of skeletal morbidity in patients with PCa. EXPERT OPINION: Preventing bone health is an imperative issue for preserving quality of life and elongate survival and, thus, a concerted effort should be made to monitor skeletal changes and to apply treatment for preventing bone loss. Although several agents have received approval for routine use, it is of paramount importance to identify the appropriate patients who would mostly be benefited by the use of these agents with attention to documenting the toxicity and economic implications. Additionally, it remains to be justified the frequency of administration in order to balance the efficacy and the potential complications.

Early hospital admission and treatment onset may positively affect spontaneous passage of ureteral stones in patients with renal colic.

OBJECTIVE: To evaluate the impact of early hospital admission and onset of medical expulsive therapy (MET) in spontaneous passage of ureteral stones causing renal colic. METHODS: We recruited 392 patients referred to the emergency room with symptoms of renal colic. All patients received standard MET of oral tamsulosin 0.4 mg at the time of diagnosis. In group A, patients who received MET in <2 hours from the symptom onset were included, whereas group B consisted of patients treated in >2 hours. The association of MET onset and stone-free rates after 6 weeks of follow-up was evaluated. Early MET onset predictive impact on spontaneous stone passage was evaluated as well. RESULTS: The stone-free rate in group A and B patients was 71.2% and 59.7% (P=.018), respectively. A significant association was observed between spontaneous calculus elimination and stone size (P≤.001), location within the ureter (P=.007), and the interval between pain onset and pharmaceutical management (P=.018). Patients who received a late-onset MET had an increased risk to develop febrile upper urinary tract infection during the follow-up period (P=.040). In the multivariate analysis, size (P≤.001) and early therapy onset (P=.019) were statistically important predictors for stone-free status after the surveillance period. CONCLUSION: Patients with renal colic who admitted to the emergency department earlier since symptom onset may have increased potential to be stone free during the surveillance period.

The role of PSA density to predict a pathological tumour upgrade between needle biopsy and radical prostatectomy for low risk clinical prostate cancer in the modified Gleason system era.

OBJECTIVES: We evaluate the role of prostate-specific antigen (PSA) density to predict Gleason score upgrade between prostate biopsy material and radical prostatectomy specimen examination in patients with low-risk prostate cancer. METHODS: Between January 2007 and November 2011, 133 low-risk patients underwent a radical prostatectomy. Using the modified Gleason criteria, tumour grade of the surgical specimens was examined and compared to the biopsy results. RESULTS: A tumour upgrade was noticed in 57 (42.9%) patients. Organ-confined disease was found in 110 (82.7%) patients, while extracapsular disease and seminal vesicles invasion was found in 19 (14.3%) and 4 (3.0%) patients, respectively. Positive surgical margins were reported in 23 (17.3%) patients. A statistical significant correlation between the preoperative PSA density value and postoperative upgrade was found (p = 0.001) and this observation had a predictive value (p = 0.002); this is in contrast to the other studied parameters which failed to reach significance, including PSA, percentage of cancer in biopsy and number of biopsy cores. Tumour upgrade was also highly associated with extracapsular cancer extension (p = 0.017) and the presence of positive surgical margins (p = 0.017). CONCLUSIONS: PSA density represents a strong predictor for Gleason score upgrade after radical prostatectomy in patients with clinical low-risk disease. Since tumour upgrade increases the potential for postoperative pathological adverse findings and prognosis, PSA density should be considered when treating and consulting patients with low-risk prostate cancer.

Bilateral cancer in prostate biopsy associates with the presence of extracapsular disease and positive surgical margins in low risk patients: a consideration for bilateral nerve sparing radical prostatectomy decision.

PURPOSE: To evaluate the epidemiological, clinical and pathological parameters that may predict the presence of positive surgical margins and extraprostatic disease in patients with low risk [prostate specific antigen (PSA) < 10, and Gleason score ≤ 6, stage T1c)] prostate cancer. MATERIALS AND METHODS: We retrospectively analyzed the medical records of patients who had undergone radical prostatectomy from January 2005 until January 2011. The analysis comprised patients age, preoperative serum prostate specific antigen (PSA) level, prostate volume, PSA density, biopsy Gleason score, the presence of bilateral disease according to the results of biopsy cores analysis, the percentage of cancer in biopsy material and the presence of high grade prostatic intraepithelial neoplasia. RESULTS: A total of 117 patients were included in the study. Positive surgical margins were found in 37 (31.6%) patients and 23 (19.7%) had advanced disease. The results of the multivariate analysis showed that bilateral disease was the single significant predictor for advanced disease prediction (P = .04). Same results was obtained by the univariate analysis of the variables for prediction of positive surgical margins, where bilateral disease after biopsy cores analysis was the only factor to be statistical significant (P = .018). CONCLUSION: Bilateral prostate cancer in prostate biopsy is significantly associated with positive surgical margins and advanced disease in patients that are operated for prostate cancer of low risk.This observation may assist the selection of patients in whom a bilateral nerve sparing radical prostatectomy is planned to be performed.

Early continence recovery after preservation of maximal urethral length until the level of verumontanum during radical prostatectomy: primary oncological and functional outcomes after 1 year of follow-up.

PURPOSE: To investigate the effect of preventing maximal urethral length until the level of verumontanum during radical prostatectomy on both oncologic and functional outcomes. PATIENTS AND METHODS: We recruited 329 patients, and they underwent an open radical prostatectomy by a single surgeon. The study cohort was randomized in 2 groups. A standard radical prostatectomy was performed in group A patients, while in group B the urethra was preserved until the level of verumontanum. RESULTS: There was no statistically significant difference between the study groups in terms of positive surgical margins or biochemical relapse. Regarding the functional results, the incidence of incontinence, urgency, and nocturia at 1st month, statistically significant higher rates were seen in group A. In addition, there was a statistically significant difference in the number of pads/day in favor of group B at the 1st, 3rd, and 6th months after surgery. However, this difference was eliminated at 12 months postoperatively. Similar results were seen with the scores of the ICIQ-SF and IIQ-SF questionnaires. CONCLUSIONS: Without compromising the oncological outcome, our surgical modificated technique showed earlier recovery of continence in the first 6 months, having though the same rates of continence at 12 months.

Expression of syndecan-4 and correlation with metastatic potential in testicular germ cell tumours.

Although syndecan-4 is implicated in cancer progression, there is no information for its role in testicular germ cell tumours (TGCTs). Thus, we examined the expression of syndecan-4 in patients with TGCTs and its correlation with the clinicopathological findings. Immunohistochemical staining in 71 tissue specimens and mRNA analysis revealed significant overexpression of syndecan-4 in TGCTs. In seminomas, high percentage of tumour cells exhibited membranous and/or cytoplasmic staining for syndecan-4 in all cases. Stromal staining for syndecan-4 was found in seminomas and it was associated with nodal metastasis (P = 0.04), vascular/lymphatic invasion (P = 0.01), and disease stage (P = 0.04). Reduced tumour cell associated staining for syndecan-4 was observed in nonseminomatous germ cell tumours (NSGCTs) compared to seminomas. This loss of syndecan-4 was associated with nodal metastasis (P = 0.01), vascular/lymphatic invasion (P = 0.01), and disease stage (P = 0.01). Stromal staining for syndecan-4 in NSGCTs did not correlate with any of the clinicopathological variables. The stromal expression of syndecan-4 in TGCTs was correlated with microvessel density (P = 0.03). Our results indicate that syndecan-4 is differentially expressed in seminomas and NSGCTs and might be a useful marker. Stromal staining in seminomas and reduced levels of syndecan-4 in tumour cells in NSGCTs are related to metastatic potential, whereas stromal staining in TGCTs is associated with neovascularization.

Evaluating PSA Density as a Predictor of Biochemical Failure after Radical Prostatectomy: Results of a Prospective Study after a Median Follow-Up of 36 Months.

Purpose. To evaluate the predictive ability of PSA density for biochemical relapse after radical prostatectomy in patients operated for clinically localized disease and to compare its predictive strength with preoperative PSA and Gleason score. Patients and Methods. The study evaluated 244 patients with localized disease who underwent an open retropubic radical prostatectomy between February 2007 and April 2011. PSA was measured every 3 months after surgery with a mean follow-up period of 36 months. Two consecutive rises >0.2 ng/mL were considered as biochemical relapse. Results. Biochemical recurrence was observed in 71 (29.1%). A great correlation was found between relapse and PSA (P = 0.005), PSA density (P = 0.002), Gleason score (P = 0.015), pathological stage (P = 0.001), positive surgical margins (P = 0.021), and invasion of seminal vesicles (P < 0.001) and lymph nodes (P < 0.001). We also found that PSA density was associated with adverse pathological findings. In univariate and multivariate analysis both PSA (P = 0.006) and PSA density (P = 0.009) were found to be significant predictors for relapse in contrast to tumor grade. Conclusion. PSA density is a valuable parameter in estimating the danger of biochemical failure and it may increase predictive potential through the incorporation in preoperative nomograms.

Clinical and pathological variables that predict changes in tumour grade after radical prostatectomy in patients with prostate cancer.

INTRODUCTION: Preoperative Gleason score is crucial, in combination with other preoperative parameters, in selecting the appropriate treatment for patients with clinically localized prostate cancer. The aim of the present study is to determine the clinical and pathological variables that can predict differences in Gleason score between biopsy and radical prostatectomy. METHODS: We retrospectively analyzed the medical records of 302 patients who had a radical prostatectomy between January 2005 and September 2010. The association between grade changes and preoperative Gleason score, age, prostate volume, prostate-specific antigen (PSA), PSA density, number of biopsy cores, presence of prostatitis and high-grade prostatic intraepithelial neoplasia was analyzed. We also conducted a secondary analysis of the factors that influence upgrading in patients with preoperative Gleason score ≤6 (group 1) and downgrading in patients with Gleason score ≤7 (group 2). RESULTS: No difference in Gleason score was noted in 44.3% of patients, while a downgrade was noted in 13.7% and upgrade in 42.1%. About 2/3 of patients with a Gleason score of ≤6 upgraded after radical prostatectomy. PSA density (p = 0.008) and prostate volume (p = 0.032) were significantly correlated with upgrade. No significant predictors were found for patients with Gleason score ≤7 who downgraded postoperatively. CONCLUSION: Smaller prostate volume and higher values of PSA density are predictors for upgrade in patients with biopsy Gleason score ≤6 and this should be considered when deferred treatment modalities are planned.

Parameters predicting postoperative unilateral disease in patients with unilateral prostate cancer in diagnostic biopsy: a rationale for selecting hemiablative focal therapy candidates.

BACKGROUND: Focal hemiablative therapy for prostate cancer is a new treatment alternative. Unilateral and unifocal disease are its main limitations. The aim of this study was to identify the epidemiological, clinical and pathological parameters that may predict unilateral disease in patients diagnosed with prostate cancer. METHODS: We performed a retrospective analysis of patients at our institution between January 2005 and January 2011. Only patients with unilateral disease in prostate biopsy were part of the study. The analysis included age, preoperative prostate-specific antigen (PSA) and its density, prostate volume, biopsy first and second Gleason pattern and Gleason summary, number of biopsy cores, percentage of cancer in biopsy material and the presence of high-grade prostatic intraepithelial neoplasia. Their role as potential predictors was evaluated by univariate and multivariate analysis. RESULTS: A total of 161 patients had unilateral disease after prostate biopsy. A significant correlation was found between prostate volume, PSA density and percentage of cancer in biopsy material and the presence of unilateral disease in the surgical specimen. These are the same factors significant in the univariate analysis. The results of the multivariate analysis demonstrated that PSA density (p = 0.015) and percentage of cancer in biopsy material (p = 0.028) are the most significant predictors. INTERPRETATION: Our results demonstrate that PSA density and the percentage of cancer in biopsy cores are significant predictors for prostate cancer unilaterality and should be considered for the selection of hemiablative focal therapy candidates.

Neoadjuvant Chemotherapy prior to Radical Prostatectomy for Patients with High-Risk Prostate Cancer: A Systematic Review.

High-risk prostate cancer represents a pretentious clinical problem since a significant number of its patients will relapse and progress after radical prostatectomy. Neoadjuvant chemotherapy may be valuable since its efficacy in hormone-resistant prostate cancer has been established. In this paper, we report studies of neoadjuvant chemotherapies that have been used in high-risk patients prior to radical prostatectomy. Even though the results regarding the prognostic surrogates are not significant, the effects on clinical and pathological outcomes are promising, while toxicity in most of the studies is in the expected field.

Correlation of ultrasound-estimated bladder weight to urodynamic diagnoses in women with lower urinary tract symptoms.

OBJECTIVE: To test the hypothesis that the ultrasound-estimated bladder weight (UEBW) will correlate with the urodynamic diagnoses in women with lower urinary tract symptoms, in particular, detrusor underactivity and bladder outflow obstruction. Ultrasonography has been increasingly used in the assessment of lower urinary tract conditions. METHODS: Adult women referred to the urodynamics suite for investigation of lower urinary tract symptoms were enrolled. After urodynamic evaluation, the portable BladderScan BVM 6500 device was used to calculate the bladder wall thickness and UEBW according to a standardized protocol. The patients were categorized according to the urodynamic findings. Women with normal findings, despite the symptoms for which they were referred, were used as the control group. The UEBW and bladder wall thickness measurements were compared between the groups and controls, using the Mann-Whitney and Kolmogorov-Smirnov tests. P <.05 was considered statistically significant. RESULTS: A total of 187 women were enrolled. The UEBW was significantly lower in the patients with detrusor underactivity than in the controls (39.3 ± 3.0 g vs 45.7 ± 3.1 g, P <.001). Significant differences were also noted between the controls and patients with bladder outflow obstruction, with or without detrusor overactivity (45.7 ± 3.1 g vs 52.1 ± 3.9 g and 52.3 ± 6.2 g, respectively; P <.001 for both). The difference, in terms of the UEBW, between controls and patients with detrusor overactivity was not statistically significant (45.7 ± 3.1 g vs 45.3 ± 3.0, P > .05). CONCLUSION: A significantly reduced UEBW in female patients with detrusor underactivity and a significantly increased UEBW in patients with bladder outflow obstruction were found. However, the finding of a significantly increased bladder weight in patients with detrusor overactivity was not confirmed in the present study.

A systematic review of the role of adjuvant and neoadjuvant pharmacotherapy in patients undergoing radical prostatectomy.

INTRODUCTION: Between 25 and 30% of patients with newly diagnosed prostate cancer are classified as high risk for an adverse prognosis. A significant number of these will progress to biochemical or clinical relapse. As there is no consensus regarding the optimal treatment of these cases, a multimodal therapeutic approach, including radical prostatectomy, remains an option. AREAS COVERED: The Pubmed/Medline database was searched to identify trials that have evaluated adjuvant and neoadjuvant pharmaceutical protocols combined with radical prostatectomy and provided information regarding efficacy and safety. EXPERT OPINION: Improvements in adverse pathological findings, following operations in patients who received neoadjuvant treatment, have been reported in the majority of the reviewed studies. Furthermore, the addition of pharmacotherapy to radical prostatectomy has produced beneficial results in survival surrogates. However, no benefits in overall survival were observed with adjuvant or neoadjuvant protocols and toxicity was a concern, especially in combination regimens. New studies on the effects of current pharmacotherapy and of new agents on overall survival and quality of life, after defining well-established criteria for patient stratification and inclusion, are required urgently.

PSA density is superior than PSA and Gleason score for adverse pathologic features prediction in patients with clinically localized prostate cancer.

INTRODUCTION: Prostate-specific antigen (PSA) and its kinetics have changed prostate cancer screening and diagnosis. The aim of the present study was to evaluate their value in prostate cancer prognosis by determining the predictive potential of PSA density for adverse pathologic features after radical prostatectomy, in terms of positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and/or lymph node invasion (LNI), and to compare their predictive ability with preoperative PSA and biopsy Gleason score. METHODS: We retrospectively analysed 285 patients diagnosed with prostate cancer and underwent a retropubic radical prostatectomy for clinically localized disease. Data concerning preoperative PSA, biopsy Gleason score and PSA density were collected and analyzed. PSA density was calculated by dividing preoperative PSA and the pathological volume of the prostate. RESULTS: There was a significant difference in PSA density values between patients with PSM, ECD, SVI and LNI. Areas under the curve for PSA density were higher than those of PSA and Gleason score for all parameters of adverse pathology. In multivariate analyses, it was shown that PSA density and Gleason score were the only statistically significant predictors for PSM and ECD, PSA density and PSA for SVI and only PSA density for LNI. CONCLUSION: PSA density is an accurate predictor for adverse pathology prediction in patients undergoing radical prostatectomy. These results demonstrate that this parameter is useful to determine the aggressiveness of prostate cancer and can be used as an adjunct in predicting outcomes after surgery.

Role of white blood cell and neutrophil counts in predicting spontaneous stone passage in patients with renal colic.

OBJECTIVE: To determine the clinical, imaging and laboratory variables that can predict spontaneous passage of ureteral stones causing renal colic and the role of white blood cell (WBC) and neutrophil counts for the prediction of spontaneous calculi passage. PATIENTS AND METHODS: A total of 156 patients who were referred to the emergency department complaining of renal colic due to a ureteral stone entered the analysis. Several clinical, laboratory and imaging parameters were evaluated for their potential ability to predict stone passage in a time interval of 1 month. The study design had two objectives. Primarily we analyzed all patients irrespective of stone size and secondly we analyzed patients with calculi of 10 mm maximum length. RESULTS: Spontaneous stone passage was observed in 96 (61.5%) patients in the overall population and in 84 (65.1%) of 129 patients with calculi <10 mm. Increased concentrations of serum WBCs and neutrophils at the time of the acute phase of a renal colic were associated with increased likelihood of spontaneous passage. In the multivariate analyses we found that WBC and neutrophil counts were the most important predictors of stone elimination. CONCLUSIONS: Active surveillance of patients suffering from ureteral lithiasis is an acceptable option. Identifying the parameters which can predict those patients who will mostly benefit from this is of great importance. Based on our results, WBC and neutrophil counts should be considered when patients with renal colic secondary to ureteral calculi are evaluated since they can significantly add to spontaneous elimination prediction. Their consideration in addition to other important factors, like stone size and location, would maximize their predictive ability.

Predictors for spontaneous stone passage in patients with renal colic secondary to ureteral calculi.

OBJECTIVES: To determine the clinical, laboratory, and imaging variables that can predict spontaneous stone passage in patients with renal colic secondary to ureteral calculi. METHODS: We prospectively analyzed the medical records of 114 patients who admitted to the emergency department for renal colic from June until November of 2010. Forty-six of them were excluded. The presence of ureteral calculi was confirmed by either a kidney-ureter-bladder plain film or an ultrasound or a computer tomography. In all patients, a second visit after 1 month was planned and the stone status was checked by the same imaging techniques. RESULTS: From the 68 patients, 16 had a calculus in the upper ureter, 10 in the mid ureter, and 42 in lower part. Stone size was ranged from 2.3 to 15 mm, 52.9% of them were located in the left ureter and 51.5% were radiopaque. Stones passed spontaneously in 36 patients. In multivariate analysis, serum white blood cell count found to be the most significant predictor (P = 0.028) for spontaneous passage followed by stone size (P = 0.037). In analysis of patients with stone size <10 mm, left side (P = 0.017) and serum white blood cell count (P= 0.032) found to be significant predictors. CONCLUSIONS: Serum white blood cell count is an easy to assay variable in everyday practice. This study showed that its value, at the acute phase of a renal colic, is a significant predictor for stone spontaneous passage and should be considered. Stone size remains a valuable predictor. Stones <10 mm on the left ureter have a higher likelihood to pass spontaneously.

Stenting or not prior to extracorporeal shockwave lithotripsy for ureteral stones? Results of a prospective randomized study.

PURPOSE: To determine the need for pre-treatment stenting in patients undergoing extracorporeal shockwave lithotripsy (ESWL) for ureteral stones sized 4-10 mm. METHODS: A prospective randomized study was conducted between September 2009 and March 2011. Included 156 patients randomized in stented and non-stented groups and underwent a maximum of 3 ESWL sessions. Radiographic follow-up was used to assess the stone fragmentation and clearance. Results were compared in terms of stone-free rates, post-treatment morbidity and complications. RESULTS: Overall efficacy was 76.9%. Stone-free rates were statistically significantly lower (P = 0.026) in the stented group (68.6%) compared to the non-stented ones (83.7%). Furthermore, stenting was significantly correlated with post-treatment lower urinary tract symptoms (P ≤ 0.001), need for more ESWL sessions (P = 0.019) and possibility for operation due to ESWL failure (P = 0.026). A multivariate analysis was conducted to identify the parameters which may predict complete stone removal after ESWL. Stone size (P = 0.026), stone location (P = 0.011) and stenting (P = 0.007) were the most significant factors. CONCLUSIONS: ESWL is an efficient and safe treatment for 4- to 10-mm ureteral stones. Pre-treatment stenting is limiting stone-free rates and is significantly influencing post-ESWL morbidity and quality of life in a negative manner, while it contributes minimally to the prophylaxis of complications.