Evaluation of double immunocytochemical staining for CK20 and P53 as a potential adjunct to cytology for urothelial cancer diagnosis.

OBJECTIVE: To evaluate double immunocytochemical staining with p53 and CK20, as a tool for improving the accuracy of urinary cytology. The aim of the present study was to clarify the diagnostic significance of the expression of these markers and to investigate the possibility of using this information for better monitoring of bladder cancer patients during follow-up. MATERIAL AND METHODS: One hundred and twenty-five urine cytology cases were retrieved with corresponding histology from our files. One ThinPrep® smear was available for each of them and dual immunocytological staining for p53 and CK20 was performed. Eleven cases were excluded from the study because of hypocellularity. The material comprised 58 malignant, 36 atypical and 20 negative for malignancy cases. Immunocytochemistry was evaluated by two cytopathologists, blinded to the histological diagnosis or follow-up data. A cut-off threshold of five stained atypical cells, according to the literature, was used for evaluation. RESULTS: Fifty-two out of 58 malignant cases were positive for at least one of the markers (89.6%). In the atypical and negative groups, 18 (50%) and 5 (25%) cases were positive, respectively. Accuracy parameters evaluation for cytology versus the combination of cytology with immunocytological staining were: sensitivity 73.4% versus 91.1%, specificity 100% versus 74.3%, positive predictive value (PPV) 100% versus 88.9% and negative predictive value (NPV) 62.5% versus 78.8%. CONCLUSIONS: Double immunocytochemical staining for p53 and CK20 is easy to perform and evaluate and can improve cytology sensitivity. It is helpful in establishing a diagnosis of malignancy and may be used as a triage tool to select patients that require cystoscopy during clinical follow-up.

Audit of cytology of upper urinary tract.

OBJECTIVE: Cytology is an essential tool for the investigation of urinary tract malignancy. In this audit, we aimed to assess our laboratory performance in the diagnosis of upper urinary tract malignancy and to use the information provided to improve our service. METHODS: We retrieved cytology reports of upper urinary tract specimens from two periods, re-evaluated the cases, compared the reports with histology data and estimated the sensitivity, specificity and positive predictive value (PPV). In the time interval between the two periods, we adopted new terminology, established better communication with clinicians and gained experience in the field. Finally, the data from the two periods were compared. RESULTS: In phase A, we estimated a sensitivity of 73%, specificity of 86% and PPV of 84.6%. As a result of the cytological re-evaluation, correlation with histology and clinical follow-up, plus communication with the clinicians during the audit, we established new terminology and a new request form. A three tiered grading system of atypia (mild, moderate and severe) was replaced by a two tiered grading system. The first category "atypia probably benign" corresponded to "mild atypia" while the second category "atypia, not otherwise specified" corresponded to "moderate atypia". The cases diagnosed as "severe atypia" were reclassified as "suspicious for malignancy". In phase B, the sensitivity, specificity and PPV were 75%, 89% and 90%, respectively. CONCLUSIONS: Our laboratory performance is in concordance with reported data and has been improved through this study. The audit process is extremely valuable for the identification of problems, for taking action and, finally, for the improvement of the clinical cytology service in the field of upper urinary tract malignancy.

Treating anterior vaginal wall prolapse with polypropylene mesh via the transoburator route minimizing the complications with the use of preventing measures. A prospective study with 2-year follow-up.

AIM: Our objectives were to evaluate the efficacy of the Perigee™ transoburator (TOT) mesh kit (American Medical Systems [AMS]-Minnetonka, MN, USA) in the treatment of ≥ stage 2 symptomatic AVP following a 2-year follow-up and to discuss the role of the pre-, peri- and postoperative measures taken to prevent complications METHODS: A total of 50 patients were eligible and were subjected to AVP surgical treatment with the use of the Perigee™ system. All patients were followed-up at 4 weeks, 2, 6, 12 and 24 months. Our primary objective was treatment success and efficacy after anatomical examination of the patient at the 24-month follow-up. Efficacy was defined as ≤ stage I AVP. All patients completed the 24-month follow-up. Our secondary objective was to examine the complication rates in relation to the use of preventative measures. RESULTS: The proportion of patients with II to III stage significantly decreased postoperatively (P<0.001). A significantly improvement was found in all POP-Q measures (P<0.05) while mean vaginal length was similar to the preoperative values. At 24-month follow-up, 45 women were defined as ≤ stage I, indicating a 90% objective success rate (95% CI: 81.4-98.6%). Two patients had vaginal mesh extrusion (4.0%) both treated with conservative measures. No erosions occurred at any point postoperatively. De novo dyspareunia was reported in two of the 17 cases (11.8%) who reported being sexually active at follow-up. One of the two had also mesh extrusion and with appliance of the vaginal estrogen and the office excision of the exposed mesh the symptoms were resolved, while the other was treated with vaginal estrogen. Two cases (4.0%) reported de novo incontinence and both were treated with a TOT sling (monarc AMS) procedure three months after the cystocele repair. Three cases (6.0%) reported pain vaginal pain postoperatively and again our treatment of choice was vaginal estrogen cream for 4 weeks with the addition of antinflammatories for 10 days and their symptoms resolved. CONCLUSIONS: The treatment of AVP with the use of Perigee™ TOT system can be both effective and safe. The goal is the improvement of the quality of life of the patients and is important to avoid or to keep as minimum as possible the complications. Main complications that the surgeon should bear in mind are the vaginal erosion, vaginal mesh extrusion, de novo dyspareunia, de novo incontinence and vaginal pain. Proper patient selection, the appliance vaginal estrogen cream pre- and postoperatively and following strict surgical principles are the mainstay of the success of the TOT operation. It is crucial for POP procedures to be performed by high-volume surgeons in this field, with extensive knowledge of the pelvic floor anatomy and the mesh's characteristics. Of course this is a small study and further clinical studies with larger number of patients are needed in order to further scientific evaluate the TOT operation.

Radical cystectomy and lymphadenectomy to two patients with pelvic kidney: surgical pitfalls and considerations.

Our goal is to describe our experience in the difficulties encountered during radical cystectomy for muscle invasive bladder cancer in patients with contemporary pelvic kidney. Two patients with muscle invasive bladder cancer and contemporary pelvic kidney were subjected to radical cystectomy and extended lymphadenectomy with conversion to an ileal pouch. In both cases, lymphadenectomy was the first step after entering the true pelvis. In order to proceed to the cystoprostatectomy, careful dissection of the ectopic renal vessels and proper mobilization of the kidney were performed. In both cases, an ileal pouch was our choice. The pelvic kidney is the most common sight of renal ectopia. The etiology is the aborted ascent of the fetal kidney from its initial position in the pelvis. This is the first case series describing radical cystectomy for muscle invasive urothelial carcinoma of the bladder in patients with a pelvic kidney.