Fitoterapia para los síntomas del tracto urinario inferior en el varón: ¿qué ocurre después? Diez años de investigación / Phytotherapy for male luts: What happens then? 10-year research

Introducción y objetivos Nuestro objetivo es evaluar los resultados de la fitoterapia a largo plazo, centrándonos en el intervalo entre la fitoterapia y los tratamientos farmacológicos y los factores de riesgo que predisponen a dicho cambio en un seguimiento de 10 años. Material y métodos Se revisaron retrospectivamente los datos de los pacientes varones que tomaban fitoterapia para los síntomas del tracto urinario inferior (STUI) de leves a moderados entre enero y diciembre de 2010, a partir de una base de datos mantenida prospectivamente. Se realizó un seguimiento de los pacientes durante 10 años mediante consultas médicas presenciales y telefónicas. Resultados Ciento dos pacientes se sometieron al menos a un ciclo de fitoterapia para los STUI. Veinte (19,6%) pacientes resolvieron sus síntomas tras un ciclo fitoterápico y abandonaron el tratamiento, 27 (26,4%) continuaron con la fitoterapia y 52 (51%) cambiaron a bloqueadores alfa y/o inhibidores de la 5a-reductasa tras un intervalo medio de 24 meses. El motivo del cambio de tratamiento fue la sintomatología (n=45) o la progresión clínica (aumento del volumen residual n=15; retención urinaria, n=5). Los pacientes que cambiaron a fármacos sintéticos tenían una mediana de edad más alta (60 frente a 49), mayor volumen prostático (40 frente a 26cc) y antígeno prostático específico (1,9 frente a 0,9ng/ml), volumen residual más elevado (40 frente a 0cc) y una tasa de flujo máximo (Qmáx) más baja (12 frente a 15ml/s) en el momento de la presentación. Conclusiones El 46% de los pacientes con STUI leves o moderados sometidos a fitoterapia estarán libres de tratamiento o seguirán con la fitoterapia a los 10 años de la presentación de la enfermedad. Los pacientes de mayor edad, con próstatas más grandes, con volumen residual y antígeno protático específico más alto, deben ser informados sobre un mayor riesgo de progresión sintomática o clínica (AU)

Introduction and objectives Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up. Material and methods The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations. Results 102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n=45) or clinical progression (increased residual volume n=15; urinary retention, n=5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26cc), prostate specific antigen (PSA) (1.9 vs 0.9ng/ml), residual volume (40 vs 0cc), and a lower maximum flow rate (Qmax) (12 vs 15ml/sec) at presentation. Conclusions 46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years (AU)

Phytotherapy for male luts: What happens then? 10-year research.

INTRODUCTION AND OBJECTIVES: Our objective is to assess the long-term results of phytotherapy, focusing on the interval between phytotherapy and pharmacological treatment and the predisposing risk factors to such switch on a 10-year follow-up. MATERIAL AND METHODS: The data of patients taking phytotherapy for mild to moderate male lower urinary tract symptoms (LUTS) from January to December 2010 were retrospectively reviewed from a prospectively maintained database. Patients were followed for 10 years through medical visits and telephone consultations. RESULTS: 102 patients underwent at least one cycle of phytotherapy for LUTS. Twenty (19.6%) patients resolved their symptoms after one phytotherapy cycle and stopped any treatment, 27 (26.4%) continued phytotherapy, and 52 (51%) switched to alpha-blockers and/or 5a-reductase inhibitors after a median interval of 24 months. The reasons for treatment switch were symptoms (n = 45) or clinical progression (increased residual volume n = 15; urinary retention, n = 5). Patients switching to synthetic drugs had median higher age (60 vs 49), prostate volume (40 vs 26 cc), prostate specific antigen (PSA) (1.9 vs 0.9 ng/ml), residual volume (40 vs 0 cc), and a lower maximum flow rate (Qmax) (12 vs 15 ml/s) at presentation. CONCLUSIONS: 46% patients with mild to moderate LUTS undergoing phytotherapy will be either free of treatment or still on phytotherapy at 10 years from disease presentation. Older patients with larger prostates, increased residual volume and PSA, should be informed regarding their higher risk of symptomatic or clinical progression: the risk of a treatment switch to alpha-blockers or 5a-reductase inhibitors becomes an actual fact after an average span of 2 years.

Fluorescence-guided selective arterial clamping during RAPN provides better early functional outcomes based on renal scan compared to standard clamping.

To compare the functional and operative outcomes of robot-assisted partial nephrectomy with selective arterial clamping guided by near infrared fluorescence imaging (NIRF-RAPN) versus a cohort of patients who underwent standard RAPN without selective arterial clamping (S-RAPN). 62 consecutive patients underwent RAPN from January 2016 to May 2017: the last 20 patients underwent NIRF-RAPN. Preoperative and postoperative renal scan at 1 month were performed to evaluate the glomerular filtration rate (GFR) of the operated renal unit and total function. Functional and operative outcomes of cases were compared with a cohort of 42 patients undergoing S-RAPN. Selective clamping was performed in 15 patients (75%), whereas five (25%) cases were converted to S-RAPN, due to incomplete ischemic appearance of the tumor after selective clamping. Median tumor diameter was 40 mm in both groups. Median selective clamping was 24 min in both groups. Operative time (206' vs 190') and blood loss (200 vs 170 cc) were comparable. No major complications have been reported in the NIRF-RAPN group, whereas three acute hemorrhages with embolization were found in the S-RAPN group. The analysis of renal scan data revealed that a greater loss of GFR in the operated renal unit was observed after S-RAPN compared to NIRF-RAPN [21.5% vs. 5.5%; p = 0.046], as well as total GFR loss [8% vs 0%; p = 0.007]. The use of NIRF imaging was associated with improved short-term renal functional outcomes compared to RAPN without selective arterial clamping. To our knowledge, this is the first comparative study analyzing the GFR obtained from renal scan.

First case of robotic laparoendoscopic single-site radical prostatectomy with single-site VesPa platform.

This study aimed at reporting our first experience with robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with single-site VesPa platform (Intuitive Surgical Inc.). A 68-year-old-man presenting with a cT1c adenocarcinoma Gleason Score 3 + 4 = 7 in 4/12 bilateral cores underwent a transperitoneal robotic LESS-RP with a single-site Vespa platform. Initial PSA, prostate weight, and body mass index (BMI) were 4.4 ng/ml, 45 g, and 25, respectively. Instruments and camera cross within the Single-Site port; the da Vinci System software detects and reassigns the user's hands with the instruments position. The single-site port is inserted through a 2-cm intraumbilical incision. The robotic 8.5 mm scope and two surgical curved instruments (fenestrated bipolar forceps and cautery hook) are introduced through the ports and used for most of the procedure, whereas a wristed needle driver on the right hand is used for the reconstructive steps. An additional 12 mm port (Air Seal, SurgiQuest) is placed in a midline between the umbilicus and the right iliac spine in order to facilitate table assistance during surgery and to place a drain at the end of the procedure.Operative time and blood loss were 300 min and 400 mL, respectively. The postoperative course was uneventful. The drain and the catheter were removed on days 1 and 6, respectively. The patient experienced a temporary mild stress incontinence (one pad at sixth month) and erectile dysfunction.Our first robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with the single-site VesPa platform was associated with acceptable operative times and perioperative outcome. This procedure is feasible without complications, provided that a proper patient selection has occurred. Limited movements together with the lack of the fourth robotic arm require a considerable expertise in robotic surgery. Some tricks can help overcome technical limitations. The Robotic LESS-RP reduces in some measure the limitations of conventional LESS RP, although further refinement of the robotic instruments is necessary.

Free DNA in urine: a new marker for bladder cancer? Preliminary data.

The aim of the present preliminary study was to investigate the presence of free DNA (FDNA) in urine as a possible marker for the diagnosis of bladder cancer. Naturally voided morning urine specimens were collected from 57 patients with suspected bladder cancer before cystoscopy. A standard urine test was performed; the specimens were then processed in order to obtain a quantitative evaluation of the presence of free DNA in the urine. Twenty-two patients were excluded from the study because they had leukocyturia and/or bacteriuria. Free DNA concentrations higher than 250 ng/mL were found in all 16 patients showing bladder cancer at cystoscopy and in seven (36.8%) of the 19 patients with negative cystoscopy. Urinary FDNA seems to have an excellent sensitivity: we observed no false negative cases and 36.8% false positive cases. By contrast, only 6.25% of the bladder cancer patients had positive urine cytology. Our results seem promising, although further studies and larger numbers are needed to define urinary free DNA as a reliable marker of bladder cancer.

Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study.

OBJECTIVE: To assess the results of our experience in correcting primary varicocele using a modified technique of antegrade scrotal sclerotherapy. PATIENTS AND METHODS: From December 1997 to February 2000, 201 patients with primary varicocele underwent antegrade scrotal sclerotherapy. Before treatment all patients were evaluated by a physical examination, colour Doppler ultrasonography of the spermatic cord, and abdominal and scrotal ultrasonography. Sperm samples were analysed only in patients aged > 18 years. The treatment was administered using a special venous catheter system with a Y-adapter. Complications after treatment and the rate of persistence of reflux were assessed 3 and 6 months after the antegrade scrotal treatment, by clinical examination and colour-Doppler ultrasonography of the spermatic cord. RESULTS: The mean operative duration was 15 min; there were no significant complications during treatment and all patients were discharged within 4 h. Complications after treatment occurred in 10 of the 201 patients (5%); four patients had epididymo-orchitis, three a scrotal haematoma, one a surgical wound infection, one persistent scrotal pain and one persistent flank pain on the same side as the surgery. Reflux was persistent in 12 patients (6%). CONCLUSIONS: Antegrade scrotal sclerotherapy is a simple, minimally invasive and highly effective technique for blocking spermatic vein reflux, with a low rate of complications. The technical changes simplified the cannulation of the spermatic vein and facilitated antegrade phlebography and sclerotherapy using the air-block technique.

Adrenal incidentalomas: surgical treatment in 28 patients and update of the literature.

INTRODUCTION: Adrenal masses discovered by imaging techniques for reasons unrelated to adrenal diseases are called adrenal incidentalomas (Al). The aim of this study was to find out the clinical outcome of 28 patients operated for incidentally discovered adrenal mass and to update the literature concerning this topic. PATIENTS AND METHODS: From September 1976 to December 1999 we operated on 28 patients for adrenal incidentaloma. Adrenal masses were unilateral in 25 cases and bilateral in 5. Average age was 57 years (range 10-73). Hormonal study was performed in all patients. All patients underwent adrenalectomy by the transabdominal subcostal approach. RESULTS: Histopathology assessed the adrenal masses as primary in 19 patients and secondary in 9. 24-hour urinary vanillylmandelic acid (VMA) excretion was elevated in 2 patients. Adrenal insufficiency was detected in 1 case. Average tumor diameter resulted 5.8 cm (range 2-17). Histopathologic features of primary adrenal masses included pheochromocytoma in 5 cases, cysts in 4, myelolipomas in 3. nodular hyperplasia in 2, tuberculous mass in 1, cortical adenoma in 1, extra-bone marrow hemopoiesis in 1, cortical carcinoma in 1 and neuroendocrine tumor of the adrenal medulla in 1. The 9 adrenal metastasis resulted by renal cell carcinoma in 7 patients, urothelial carcinoma of the upper urinary tract in I and primary renal lymphoma in 1. Average follow-up was 68 months (range 6-246). Patients alive were 18 (64%), deal 10 (36%). Of the 19 patients with primary adrenal tumors 16 (84%) were alive and disease free and 3 (16%) died (I for disease and 2 for reasons unrelated to the primary tumor). Of the 9 patients with adrenal metastasis 2 (22%) were alive (I disease free and I with progression of the disease) and 7 (78%) died for disease. Replacement therapy for adrenocortical hormones was given 5 patients. CONCLUSIONS: Management of Al need CT or MRI and hormonal investigation in order to detect malignancy and subclinical hypersecretory syndromes. Subclinical functional adrenal masses, single adrenal metastasis and primary nonhypersecretory adrenal tumors sized 4 cm are treated by surgery. A close morpho-functional follow-up is indicated for primary adrenal incidentalomas when nonhypersecretory and smaller than 4 cm.

Prognostic value of renal cell carcinoma nuclear grading: multivariate analysis of 333 cases.

OBJECTIVE: To evaluate the independent predictive value of the nuclear grading system according to Fuhrman in relation to the disease-specific survival of patients with renal clear cell carcinoma. MATERIAL AND METHODS: 333 patients who underwent radical nephrectomy for renal clear cell carcinoma between 1983 and 1999 were evaluated. In all patients we retrospectively studied nuclear grading, average tumor size, multifocality, pathologic stage of primary tumor, vein invasion, lymph node involvement and distant metastases. The Kaplan-Meier method was applied to evaluate disease-specific survival rates. The log rank test was used to compare survival curves and for univariate analysis. The Cox proportional hazards model was used for the multivariate analysis. RESULTS: Histologic grade was G1 in 83 cases (25%), G2 in 117 cases (35%), G3 in 110 cases (33%) and G4 in 23 cases (7%). Our data showed that nuclear grading according to Fuhrman is related to medium tumor size (p < 0.0001), pathologic stage of cancer (p < 0.001), venous system invasion (p < 0.001), lymph node involvement (p < 0.001) and distant metastases (p < 0.001). The disease-specific survival after 5 and 10 years was 94 and 88%, respectively, in patients with G1, 86 and 75% in patients with G2, 59 and 40% in patients with G3 and 31% in patients with G4 (log rank p value < 0.0001). Multivariate analysis showed that nuclear grading by Fuhrman has a prognostic independent predictive value (hazard ratio = 1.8461, p = 0.002). CONCLUSIONS: Nuclear grading is an important independent predictive factor of disease-specific survival in patients with renal cell carcinoma.

The TURP syndrome: importance of expiratory ethanol measurement and high serum levels of glycine.

OBJECTIVE: In a prospective study it was our intention to evaluate the reliability and the predictive value of expiratory ethanol for the early detection of the occurrence of TURP syndrome and emphasize the role of the serum levels of glycine in clinical manifestation. METHODS: We studied 30 patients scheduled for elective traditional transuretral resection of the prostate performed with subarachnoid anesthesia. Serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were monitored at scheduled intervals. Continuous heart rate and blood pressure monitoring was performed during the perioperative period in the operativing room and, later, in the recovery room. Occurrence of cardiocirculatory, respiratory and neurologic symptoms were recorded. Statistics included Bonferroni's t-test and Fisher's exact test. A decision level plot for end-expiratory ethanol level was performed for the choice of predictivity criterion. RESULTS: In our population we identified three groups of patients: Group I (15 patients) in which no symptom was recorded; Group II (6 patients) in which non-specific anesthesia-related symptoms occurred; Group III (9 patients) in which TURP syndrome of various degree of severity was observed. In this group of patients changes in serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were significantly different compared with the other two groups. In regard to end-expiratory ethanol levels, we identified a cut-off point at 0.05 mg/ml. In Group III two patients developed transient blindness. These patients had the highest serum glycine concentrations (> 4000 mumol/ml). Mortality was nil. CONCLUSIONS: Our data show the reliability and accuracy of end-expiratory ethanol levels as a predictive test of the occurrence of TURP syndrome. Further, we emphasize the role of serum glycine concentration in the occurrence of neurologic symptoms related to the transurethral resection of the prostate.

Primary lymphoma of the epididymis: case report and review of the literature.

OBJECTIVE: To report an extremely rare clinical pathological observation of a case of primary lymphoma of the epididymis, without testicular or systemic involvement, and to update the relevant literature. MATERIALS AND METHODS: A 25-year-old white male patient complaining of right scrotal pain was referred to our department. Clinical examination detected a hard painful mass at the right epididymal head. Epididymitis was diagnosed and conservative therapy with antibiotics and anti-inflammatory drugs was given. After 2 months of therapy the patient was admitted to our department because a tumor was suspected. Tumor markers were normal. Right scrotal exploration was performed through a standard inguinal incision. The epididymal head was completely replaced by a hard white mass. Fresh frozen sections indicated a malignant tumor. Right radical orchiectomy was performed. RESULTS: High-grade primary epididymal non-Hodgkin's lymphoma with diffuse large cells (group G according to the Working Formulation) was diagnosed. Clinical pathological staging detected stage IE (extranodal) primary epididymal lymphoma. The patient was referred to the Hematologic Unit for combined chemotherapy, according to the VACOP-B protocol. After an 18-month follow-up the patient is well and disease free. CONCLUSIONS: When an epididymal mass does not benefit from medical treatment, scrotal exploration and fresh frozen sections of the lesion should be done. The possible bilateral involvement by primary epididymal lymphoma has to be kept in mind. Radical orchiectomy is the treatment of choice for primary lymphoma of the epididymis. Adjuvant chemotherapy is indicated in high-grade malignant lymphoma. Prognostic parameters of the disease may be the grade of malignancy and the size of the tumor.

Renal vein and vena cava involvement does not affect prognosis in patients with renal cell carcinoma.

OBJECTIVES: The prognostic value of tumor extension into the renal vein or vena cava is still a controversial issue. The aim of this study is to report our experience with radical surgery in patients with renal cell carcinoma (RCC) extending into the renal vein or subdiaphragmatic vena cava. METHODS: We evaluated 142 patients with RCC involving the renal vein or inferior subdiaphragmatic vena cava. RCC had extended into the renal vein in 118 patients and into the inferior vena cava in the remaining 24. Radical nephrectomy was performed in all cases with renal vein invasion. Radical nephrectomy with cavotomy and tumor thrombus removal was carried out in all cases with inferior subdiaphragmatic vena caval invasion. Cause-specific survival was calculated by means of the Kaplan-Meier method. The log rank test was used for survival comparisons and univariate analysis. RESULTS: The 5- and 10-year cause-specific survival rates were 51.5 and 39%, respectively, in the group of patients with tumor extension into the renal vein and 33.4% in those with inferior vena caval involvement. In 52 patients (44%), RCC extended only into the renal vein. In the remaining 66 patients, renal vein invasion was associated with other adverse prognostic factors. Life expectancy was lower for patients with other concurrent adverse prognostic factors than for those affected by renal vein involvement alone (p < 0.0001). In the latter group, survival expectancy was similar to those with stage T2N0M0 tumor. In 7 cases (29%), inferior vena caval invasion was not associated with other adverse prognostic factors. In the remaining 15 patients (71%), vena caval involvement was associated with other adverse prognostic factors. Concurrence of other adverse prognostic factors with vena caval invasion significantly decreased the disease-specific survival expectancy in comparison with the patients in whom vena caval involvement was the main prognostic factor (p = 0.008). In these patients, disease-specific survival was similar to those with stage T2N0M0 tumor. CONCLUSION: Renal vein or inferior subdiaphragmatic vena caval involvement does not significantly affect prognosis in patients with RCC.

The pathophysiology, diagnosis and therapy of the transurethral resection of the prostate syndrome.

In this article, the authors analyze a syndrome first described by Creevy in the 1940s, which may occur during a transurethral resection of the prostate (TURP). The syndrome is characterized by cardiocirculatory and neurological problems due to rapid changes in intravascular volume and plasma solute concentrations caused by excess irrigating fluid absorption. This article reviews the available literature and reports on the experience of our clinic, a specialist department in the physiopathology, diagnosis, therapy and prevention of TURP syndrome.

Nephrogenic adenoma of the urinary bladder: our experience and review of the literature.

OBJECTIVE: To assess our experience in the treatment and clinical outcome of bladder nephrogenic adenoma (NA) updating and reviewing the literature concerning this issue. PATIENTS AND METHODS: From September 1976 to June 1999, bladder NA was diagnosed in 8 patients: 6 men and 2 women with a 3:1 male ratio, aged 26-80 (mean 58.3) years. Follow-up ranged from 4 to 194 (mean 93.5) months. RESULTS: NA was associated with transitional cell carcinoma in 3 cases. Predisposing factors were assessed in all patients. Previous surgery of the lower urinary tract was detected in 5 cases: ureterocystoneostomy in 2, partial cystectomy in 1, repair of vesicouterine fistula in 1, and multiple urethroplasties in 1. Previous endoscopic treatments were carried out in 2 patients, transurethral resection of the prostate in 1 and repeated transurethral resection of the vesicle in the other. A history of intravesical instillation of bacillus Calmette-Guérin was assessed in 1 case. Patients complained of irritative voiding symptoms in 6 cases and hematuria in 2. Endoscopically, the lesions appeared polypoid and multifocal in 5 patients, and flat and single in 3. The lesions were removed endoscopically, providing relief of symptoms in all cases. Histopathology assessed the diagnosis of nephrogenic adenoma, detecting focal atypic cells in 1 case only. Five patients (63%) relapsed 2-24 months after management. Recurrences were also treated endoscopically. CONCLUSIONS: Clinical and endoscopic features of bladder NA are not specific, simulating urothelial carcinoma or chronic cystitis. Endoscopic management allows accurate histological diagnosis and provides long-lasting relief of symptoms. NA needs careful and long-term follow-up, because of the high risk of recurrences and the potential neoplastic degeneration of the metaplastic urothelium.

High flow priapism due to a bilateral arteriosinusoidal fistula--an unusual conservative treatment.

The authors report a rare case of high flow priapism due to a bilateral arteriosinusoidal fistula conservatively treated. Twenty months after the treatment the patient claimed to have a normal sexual activity.

General state of health and psychological well-being in patients after surgery for urological malignant neoplasms.

OBJECTIVE: To evaluate the general state of health and the psychological well-being in a group of 155 patients after surgery for urological malignant neoplasms. MATERIALS AND METHODS: Surgery was performed in 55 patients for renal cell carcinoma, in 54 for invasive bladder carcinoma, in 30 for adenocarcinoma of the prostate, and in 16 for squamous penile carcinoma. All patients were invited to self-compile the General Health Questionnaire (GHQ) - 12 items according to Goldberg and the Hospital Anxiety and Depression Scale. Results were compared with those in a group of patients who underwent retropubic prostatectomy for benign prostatic hyperplasia. RESULTS AND CONCLUSION: The general state of health was significantly more impaired in neoplastic patients than in the control group. Levels of anxiety were significantly higher but depression levels were similar in both groups. As far as the type of tumor is concerned, patients who underwent radical cystectomy for bladder carcinoma and those treated with partial penectomy for squamous penile carcinoma showed a significant impairment of the general state of health compared with controls. Higher levels of anxiety were observed in patients who underwent ileal conduit after radical cystectomy, in those treated with radical prostatectomy for prostate cancer and in those who underwent partial penectomy. Significantly higher levels of depression than in the control group were observed only in patients with ileal conduit.

Experience in the surgical treatment of Fraley's syndrome.

OBJECTIVE: To report our 20-year experience with nephron-sparing surgery in the treatment of Fraley's syndrome. MATERIALS AND METHODS: From September 1976 to July 1996, 6 women, 18-43 years old, underwent surgical treatment. All patients had been suffering debilitating right flank pain for at least 6 months before the operation. Diagnosis was in call cases made with the use of intravenous pyelography and renal arteriography, which showed a vascular impression on the superior infundibulum with secondary dilatation of the upper pole calyx. This was localized only on the right side in 5 cases, while in 1 it was bilateral though more severe on the right. Ipsilateral nephroptosis was observed in 2 of the patients. In 2 cases in whom the superior infundibulum was sufficiently long, an infundibulo-infundibulostomy with everted flaps was performed. In a case in whom a short infundibulum was compressed between a venous and an arterial branch, Fraley's infundibulopyelostomy was carried out. In 1 patient in whom the infundibulum was compressed by the anterior-superior segmental artery, a Heineke-Mikulicz-type infundibulorrhaphy was combined to vasopexy. In the remaining 2 cases, the infundibulum was not cut: in one case, a simple vasopexy of two vascular branches was carried out, while in the other, a minor arterial branch was ligated and divided. In 4 patients, nephropexy was also performed. RESULTS: No significant intra- or postoperative complications were observed. Follow-up averaged 102.5 months. Pain relief was complete in 5 cases, in whom disappearance of the vascular impression was also radiologically demonstrated. Only 1 patient, who underwent infundibulorrhaphy and vasopexy, experienced occasional flank pain and urinary infection after the operation, with just a slight improvement in the excretory urogram. CONCLUSIONS: Surgical treatment of Fraley's syndrome is indicated only in symptomatic and/or complicated cases; in relation to the type of obstruction and the anatomy of the intrarenal structures, whether excretory or vascular, several effective nephron-sparing techniques can be selected.

[Our experience in the treatment of retroperitoneal fibrosis]. / Nostra esperienza nel trattamento della fibrosi retroperitoneale.

To discuss retroperitoneal fibrosis (RPF) etiopathogenesis and to report on our experience in the treatment of the disease. From 1977 to 1998 26 RPF patients, 15 idiopathic (I group) and 11 secondary (II group), entered our clinic. Vascular risk factors of the I group were cigarette smoking (73.3%) and arterial hypertension (46.6%). Etiologic factors of the II group were aorta abdominal aneurysm (four cases), radiation therapy for female genital tract cancer (four case), aorto-bifemoral bypass for aorta aneurysm (two cases), retroperitoneal non-Hodgkin lymphoma (one case). Treatment performed for idiopathic disease was medical in eight cases (alone in two, with endourologic measures in six) using corticosteroids in five and tamoxifen in three; only endourological in three and surgical in four (nephrectomy in two patients, ureterolysis and ureteroneocystostomy in one, pyeloureterolysis in one) with perioperative corticosteroid treatment in three cases. Treatments performed in patients with secondary disease were endourologic in five surgical in three (ureteroureterostomy, ureteroneocystostomy, pyeloureterolysis and pyeloreduction), medical with corticosteroids in two; one patient affected by perianeurysmatic fibrosis did not require any treatment because of disease's spontaneous recovery. Medical treatment induced symptom remission and plaque reduction in all patients. Surgery determined complete recovery in all patients except for one in whom the disease relapsed with controlateral urinary tract involvement. Medical RPF treatment for idiopathic or secondary disease is effective in the first stage. Disease management with tamoxifen is easy to perform, safe and effective. In the steady state of RPF the best results are obtained by surgery and perioperative glucocorticoid therapy reduced significantly fibrosis' relapse.

Treatment of retroperitoneal fibrosis with tamoxifen: case report and review of literature.

OBJECTIVE: To evaluate the efficacy of tamoxifen in the treatment of idiopathic retroperitoneal fibrosis in one patient and to review the results reported in the literature. METHODS: A 68-year-old man with idiopathic retroperitoneal fibrosis and obstructive acute renal failure was admitted to our department. Bilateral ureteral stents were placed and tamoxifen 20 mg daily p.o. was started. RESULTS: The ureteral stents were removed five months after tamoxifen therapy. IVP demonstrated normal appearance of the ureters nine months after medical treatment. An MRI scan showed an important decrease of the fibrotic periaortic mass at 12 months and then we stopped tamoxifen. CONCLUSIONS: Actually tamoxifen represents an attractive and safe choice of medical treatment for retroperitonea fibrosis, particularly in the acute stages. Nevertheless, the duration of treatment, the effectiveness and the persistence of the results are still uncertain because few cases have been reported in the literature.