Intravesical therapy of superficial bladder cancer.

Transurethral resection (TUR) of the superficial transitional cell carcinoma (TCC) of the bladder is known to be insufficient in controlling the disease because of the unacceptable rates of recurrence, progression and ultimate cystectomy. Adjuvant intravesical chemo-and/or immunotherapy is administered in an effort to enhance the efficacy of surgery alone. The initial tumor stage and grade, the multifocality of this cancer and the history of previous recurrences remain the determinant factors in survival. It is important to decide exactly which patients are at risk, and, therefore, do need treatment. Knowledge of the natural history of the disease will facilitate this decision making, although the natural history of TCC is largely unpredictable owing to tumor heterogeneity. Several cytotoxic and immune modifying agents have been used intravesically in different treatment schedules. However, despite their effectiveness, no consensus exists about the optimal antineoplastic regimen. The selection of the latter is a subject of continuous investigation. Intravesical treatment with cytotoxic drugs has been demonstrated to achieve an acceptable reduction in short- and intermediate-term recurrence rates, but has no proven ability in preventing disease progression to muscle-invasive cancer or prolonging survival. On the other hand, bacillus Calmette-Guerin (BCG) currently appears to be the most effective agent for intravesical use, especially in patients with high grade and stage neoplasms but the optimum strain, dosage and duration schedule have not been determined. Clinical trials have shown that BCG provides long-term protection from tumor recurrence, while there is evidence that it may favorably alter the progression rate of the disease with prolongation of survival. Toxicity of intravesical chemo- and immunotherapy still remains a major problem and attempts at reducing the dosage, and, thus, toxicity without affecting efficacy are underway. This review endeavors to present updated information on intravesical chemotherapy in treating superficial bladder cancer, the expanding role of intravesical immunotherapy, the recent work comparing various immunotherapeutic regimens with chemotherapeutic intravesical therapies, and the progress made towards achieving optimal treatment regimens.

Clinical evaluation of temocillin in urinary tract infections.

A group of 27 female and 2 male urological patients, aged 19 to 80 years (mean 44 years), were treated with intravenous temocillin 500 mg twice daily for 5 to 7 days. The diagnoses were acute pyelonephritis (n = 20), acute cystitis (n = 6), and acute cystitis and pyelonephritis combined (3). The causative organisms were Escherichia coli (n = 20). Proteus species (n = 9). Klebsiella species (n = 4). Streptococcus faecalis (n = 2). Staphylococcus epidermidis (n = 1), and Providencia stuartii (n = 1). 27 of the 29 patients (93%) were clinically and bacteriologically cured; bacteriuria persisted in 2 patients with prolonged obstructive uropathy. In acute non-obstructive pyelonephritis, the urinary excretion of beta-2-microglobulin rapidly decreased, documenting a prompt renal tubular restitution during therapy. The drug was well tolerated and proved very safe with regard to haematological, hepatic and renal parameters. Also, Candida haemagglutination titres did not increase significantly during therapy. Temocillin therapy should preferably be commenced after the results of the urine culture are available.

Primary endourologic re-establishment of urethral continuity after disruption of prostatomembranous urethra.

A new technique for the early management of traumatic disruption of the prostatomembranous urethra has been used in 4 consecutive young patients. Urethral realignment by stenting the injured urethra with a catheter was achieved by combined urethroscopy and suprapubic instrumentation one to three days after the injury. We describe herein our experience with this technique and we suggest that it could be a valuable alternative in posterior urethral repair.

Penile duplication.

We report on a case of penile duplication in an eight-year-old boy. While diphallia was incomplete, there was a common root of the penis which divided into two shafts of different size, doubling in frontal plane. Only one urethra left the bladder along the lower and smaller penile shaft and ended with a hypospadiac meatus. After surgical plastic repair, the patient had a good functional and cosmetic result. In addition, this patient had a horseshoe kidney.

Vesical diverticula: etiology, diagnosis, tumorigenesis, and treatment. Analysis of 74 cases.

A thirteen-year review of bladder diverticula was undertaken and 74 cases were identified. In 8 patients primary neoplasms arose in the diverticula, and their treatment included diverticulectomy or partial cystectomy with or without postoperative irradiation, irradiation only, and transurethral resection of the tumor combined with fulguration of the diverticular wall and postoperative bladder instillations with doxorubicin or thiotepa solutions. Early diagnosis with additional visualization of the interior of vesical diverticulum is mandatory, since carcinoma arising in it has a poor prognosis.

Complicated urinary tract infections.

The term complicated urinary tract infection is usually used to convey an infection that occurs in a patient with a structural or functional abnormality impeding urine flow, or in a host with altered defences. The distinction between complicated and uncomplicated infections is important because, when complicating factors are present, antimicrobial resistance is more common and the response to therapy is often disappointing, even with agents active against the causative microbial pathogen. In addition, severe complications frequently occur which may lead to urosepsis, renal scarring or even end-stage disease. Drug treatment of complicated urinary tract infections often must be complemented with endoscopic and/or surgical intervention. Only a few well designed treatment studies have been published and therefore sources for definitive therapeutic guidelines remain inadequate.

Milk of calcium cysts masquerading as renal calculi.

Milk of calcium renal cysts contain a colloidal suspension of calcium crystals. By routine radiography and sonography in supine position this rare condition may be misinterpreted as renal lithiasis for which an unnecessary surgical intervention may be performed as it happened in our two cases that are presented here. Postoperatively, the characteristic finding of half-moon contour on upright abdominal plain views was lacking in one case, but in both cases computed tomography revealed the typical calcific suspension layering. However, upright plain views and computed tomography are not routinely performed in patients in whom a renal stone has initially been considered. This entity should be considered in the differential diagnosis of renal paracalyceal calcifications of obscured origin.

A comparative study on aztreonam, ceftazidime and amikacin in the treatment of complicated urinary tract infections.

In a prospective, randomized trial, aztreonam (1 g intravenously or intramuscularly, twice daily) was compared with ceftazidime (1 g intravenously or intramuscularly, twice daily) and amikacin (500 mg intravenously or intramuscularly, twice daily) in 76 patients aged 24 to 84 years (mean, 59.7 years) with complicated urinary tract infections. Initial pathogens included Escherichia coli (47.5%), Pseudomonas aeruginosa (22.5%), Klebsiella spp. (9%), Proteus spp. (7.5%) and Enterobacter spp (6%). In four patients initial urine cultures yielded more than one organism. All pathogens were sensitive to the three study drugs. Including performance of 4- to 6-week follow-up cultures, eradication of the pathogens occurred in 72% of patients treated with aztreonam, in 74% of those treated with ceftazidime and in 71% treated with amikacin (p greater than 0.05). Clinical success was observed in 84% of patients treated with aztreonam, in 82% of those treated with ceftazidime and in 85% treated with amikacin (p greater than 0.05). All drugs were well tolerated. It is concluded that aztreonam, ceftazidime and amikacin are equally effective and safe for the treatment of complicated urinary tract infections due to susceptible organisms.

Efficacy of prophylactic antimicrobial regimens in preventing infectious complications after transrectal biopsy of the prostate.

In a prospective study on 81 patients undergoing transrectal needle biopsy of the prostate, the efficacy of prophylaxis in preventing postbiopsy infectious complications was determined. The patients were divided randomly into four groups, and a comparison of the rate of postbiopsy complications in each group was made. In 11 and 17% of the patients in Group A (n = 18) who received povidone-iodine enema alone, bacteriuria and bacteraemia, respectively, occurred. When parenteral piperacillin alone in Group B (n = 22) was administered, the rates of the same complications were 9 and 14%, respectively, while both rates were as low as 4% in Group C (n = 25) when piperacillin in combination with povidone-iodine enema was given. On the other hand, in 31 and 37.5% of the patients in Group D (n = 16), who served as controls, bacteriuria and bacteraemia developed. The study has thus shown that parenteral piperacillin in combination with povidone-iodine enema significantly reduces the incidence of infectious complications associated with transrectal prostatic biopsy.

The role of chlamydiae in epididymitis.

In 21 men suffering from acute or chronic epididymitis who underwent scrotal surgical exploration, diagnostic microbiological studies consisting in cultures of the epididymal tissues and mid-stream urine specimens, as well as examination of the urethral swabs--before and after prostatic massage--were performed. Laboratory tests revealed that 55 per cent of the patients younger than 40 years were infected by Chlamydia trachomatis, and 36 per cent by urinary tract bacteria. On the other hand, in only 10 per cent of the patients older than 40 years the causative organisms were Chlamydiae, whereas in 70 per cent the common urinary tract bacteriae were the agents of epididymal infection. The aforementioned microbiological examinations were proved to be reliable in demonstrating the causative bacteria for epididymitis.

BCG versus epirubicin in the prophylaxis of multiple superficial bladder tumours: results of a prospective randomized study using modified treatment schemes.

A prospective randomized trial on 94 eligible patients evaluated and compared the efficacy of adjuvant intravesical epirubicin and bacillus Calmette-Guérin (BCG) after complete resection of multifocal superficial bladder cancer. BCG treatment schedule consisted of an induction 6-week course of instillations (150 mg Pasteur BCG per instillation) and single maintenance doses to patients who remained free of recurrences at follow-up examinations for a total treatment period of 2 years. These initial responders received additionally a separate 4-week course of therapy 6 months after the start of treatment. Chemoprophylaxis included an early (on the second postoperative day) instillation followed by 4 weekly treatments with epirubicin (50 mg per instillation) and then by 10 monthly treatments for the initial responders during the first year of follow-up and at every follow-up examination for a total treatment period of 2 years. The overall treatment results did not differ significantly between the 2 arms (54% of patients of the epirubicin group remained free of recurrences compared to 65% of those treated with BCG) for an identical mean follow-up of 35.1 months. However, a significant benefit in favour of BCG when compared with epirubicin was shown in patients who had stage T1 and grade 3 tumours and in terms of relative risk of recurrences, disease-free interval and recurrence rate per 100 patient-months. Both drugs were proved to be safe with manageable toxicity.

Aspects concerning posterior urethral valves.

Twenty-six boys were evaluated and treated for posterior urethral valves. At the time the valves were diagnosed unilateral or bilateral vesicoureteral reflux was present in 58% of the ureters and 69% of the children, while dilatation of the upper urinary tract was present in 88% and 92%, respectively. There was a variety of symptoms and signs, but the most prominent in neonates and infants were vesical urine retention, palpable kidneys and failure to thrive, whereas in the older children voiding dysfunction, incontinence and urinary infection were the most common. Twenty-four out of 26 boys were managed by primary valve ablation and in 62.5% of them this type of treatment was adequate in resolving or sufficiently improving clinical manifestations and roentgenologic findings, requiring no further management. Urinary diversion in the form of vesicostomy and cutaneous ureterostomy was preserved for those patients who did not improve with valve ablation alone. The current aspects concerning posterior urethral valves are also discussed.

Stamey endoscopic vesical neck suspension in female urinary stress incontinence: results and changes in various urodynamic parameters.

A total of 32 female patients with urinary stress incontinence who underwent a Stamey endoscopic bladder neck suspension were clinically and urodynamically studied pre- and postoperatively. Complete cure was obtained in 78% of the patients and improvement in 6%, the overall success rate being 84% for a mean follow-up of 11.1 months (range 6-19). Complications occurred in 22% of the patients. Comparison of the pre- and postoperative urodynamic data revealed that the maximum urine flow rate, functional urethral length and maximum urethral closure pressure were changed significantly after operation. In addition, when studying the abdominal pressure transmission to the entire urethra during stress, there was a significant conversion of negative to positive pressure transmission after surgical repositioning of the urethra.

Multiple (five) synchronous primary malignant neoplasms of dissimilar histogenesis including a malignant fibrous histiocytoma of the bladder.

A unique case was recently encountered involving the synchronous presentation of five primary malignancies of different histology. Malignant neoplasms of the colon, kidney, prostate and bladder were treated surgically. Bladder was affected by two separate tumours: a transitional cell carcinoma and a malignant fibrous histiocytoma. The latter constitutes an extremely rare malignant lesion of the organ. The pathologic characteristics, histogenesis, differential diagnosis and treatment considerations of this soft tissue sarcoma, and the incidence, terminology and incriminating factors of multiple primary malignant neoplasms, as well as their association with the genitourinary system are reviewed.

Nonfunctional adrenal cortical carcinoma. Report of a case and review of the literature.

Nonfunctional carcinomas of the adrenal gland are quite rare. By presenting a 47-year-old woman with such a tumour, a review of the literature is made, with special emphasis on the epidemiology and histologic criteria in predicting malignant behaviour. In addition, the clinical, pathological and radiographic findings, as well as the treatment modalities of this neoplasm are discussed.

Intravesical bacillus Calmette-Guérin administration in the prophylaxis of superficial bladder cancer.

A total of 68 patients received prophylactic/adjuvant intravesical Pasteur strain bacillus Calmette-Guérin (BCG) instillations following transurethral resection for superficial bladder carcinoma. An induction phase consisting of 6 weekly instillations was followed by a maintenance phase consisting of 1 instillation given every 3 months. A second 6-week course of BCG was administered to initial failure followed again by a quarterly maintenance therapy. The response rate for patients treated with one 6-week course was 56%, while complete response was achieved in 72% when both treatment courses were considered. Follow-up period lasted at least 2 years after each course of BCG. These results suggest that additional courses of BCG increase the prophylactic efficacy of intracavitary BCG. Regarding the purified protein derivative (PPD) skin test and granulomatous response in the bladder, it has been shown in the present study that, although favourable results occurred more frequently among patients with either PPD conversion from negative to positive or vesical granuloma formation, neither of these indices should be considered reliable prognostic indicators.