Subarachnoid anaesthesia has been demonstrated to be safe and effective in elderly patients. Isobaric Ropivacaine 0.5% has been recently introduced for subarachnoid anaesthesia: aim of our trial is to compare this drug with 0.5 Levobupivacaine in elderly patients scheduled for endoscopic urological surgery.
Premedication: Atropine 0.5 mg + Fenotiazine 50 mg im. Lumbar intrathecal anaesthesia, Group L (n=25) receiving Levobupivacaine 15 mg, Group R (n=25) receiving Ropivacaine 18.05 mg (relative motor blocking potency ratio Ropivacaine / Levobupivacaine = 0.83). Statistical analisys: Bonferroni test and variance analisys.
No statistically relevant differences between the 2 groups in terms of antropometric characteristics, onset time and duration of sensitive and motor block, perioperative complications, postoperative analgesic consumption and customer satisfaction. Large presence of comorbidities in the studied population.
The presence of cases of subtotal anaesthetic coverage (with necessity to recur to general anaesthesia), and others with good anaesthetic coverage, but difficultly treatable hypotensions show that the best dosage of these local anaesthetics is to be found yet. The indications to use a standard dosage for every patient have to be re-evalutated. As positive point, very important the postoperative fast recovery from under limb motor block. A longer recovery time (typical with hyperbaric local anaesthetics) was frequently cause of cognitive alterations in a population of elderly patients.
INTRODUCTION. It is not well known how many Small Volume Prostate Cancers (SVPC) may host high grade (Gleason pattern 4/5) or have extraprostatic extension in particular in the national setting. Features of SVPC are very interesting since they raise controversies in diagnosis and have important clinical implications in treatment strategies. The diagnosis may be difficult and the treatment ranges from active surveillance to radical surgery. AIM. We evaluate clinical and pathological features of SVPC in surgical specimens of patients who underwent biopsy and radical prostatectomy. METHODS. We analysed a consecutive series of 849 radical prostatectomies performed between 2005 and 2008. Inclusion criteria were: biopsy specimen available, pathological tumor volume analysis according to standard criteria, whole-mount section 3 mm step analysis according to Stanford protocol, clinical parameters (PSA, DRE, number of core biopsy taken).
any hormonal manipulation before surgery and cT1A/B stage. Data were analysed using SPSS for statistical comparison. RESULTS. 238 patients were evaluated. SVPC<0.5 cc was observed in 58 (24.3%). Overall in 17/58 (29.3%) a clinical/pathological relevant disease was observed. In 16/58 (27.5%) pathological Gleason Score (GS) was 7-8, in 5/58 (9%) pathological stage was T3. The number of tumor foci was >1 in 78.3%, tumor-involving in both lobes in 55%. Unifocal disease was observed in 22%. Clinically relevant disease is significantly associated with total cancer volume (0.20 versus 0.31, p 0.007), but not to tumor foci (2.5 versus 2.0). PSA, age, no. of positive cores, DRE were not predictive of clinical relevant disease. Six of 17 (35%) cases with SVPC - who were in the low risk category (PSA <10, biopsy Gleason score <7 and negative DRE), had clinical relevant disease. CONCLUSION. SVPC are clinically relevant in 29.3% since they have a Gleason pattern 4 (27.5%) or have only pathological T3 (9%). Early diagnosis techniques and treatments have to consider that SVPC prostate cancer may contain high risk disease in 1/4 of cases. Clinical parameters are not useful to accurately detect high risk SVPC.
Modern flexible ureterorenoscopy allows a retrograde approach to urothelial tumors in the upper urinary tract (UUTT) of small dimensions (<1.5 cm), of low grade and non-invasive. The percutaneous renal approach, although more invasive, provides an alternative treatment in case of larger dimension neoplasia or difficult retrograde access. The key to the success of endoscopic treatment of UUTT is an accurate patient selection. We will bring our experience in the treatment of UUTT by conservative endoscopic retrograde treatment.
Treatment through endoscopic retrograde approach with rigid or flexible ureterorenoscopy has been applied to 105 patients; lesions were treated with electrocution or lasers using thin laser fibers type Ho:YAG. We evaluated the recurrence rate and the intra- and perioperative complications.
The recurrence rate was equal to 30.4%. In no case was it necessary to recur to blood transfusion; 15% of wall perforations treated in a conservative manner occurred without following complications.
Technological innovations, miniaturization and the increase of energy sources, such as fiber laser Holmium, have improved the management of endoscopic instruments for upper urinary tract tumors. The endoscopic retrograde conservative treatment is considered a valid alternative approach in the case of low-stage tumors, low-grading and small in dimensions.
Dilation of the renal pelvis is a problem Urologists have often to deal with. One of the key aspects is to clear if the dilation is the consequence of an obstruction to the outflow or a simple anatomic variant. Aim of this study was to compare two diuretic renographic procedures, F-15 vs the new procedure F+10SP (Seated Position) in a group of hydronephrotic patients, in order to increase the accuracy in the differential diagnosis between non-obstructive and obstructive dilation.
34 Patients (14 male, 20 female, 18-71 yrs range), 27 pts having an unilateral hydronephrosis and 7 pts a bilateral hydronephrosis diagnosed by ultrasound, were enclosed in the study. They were subjected to two 99mTc-MAG3 diuretic renography with furosemide consecutively, with different modalities: 1) 40 mg of furosemide were administered IV to patient in supine position 15 minutes before tracer injection (Test F-15, by English); 2) the new procedure: 20 mg of furosemide were administered IV to patient in Seated Position (SP), 10 minutes after tracer injection during dynamic acquisition (Test F+10 SP). The average interval between the two tests was 7 days. Two different physicians analyzed all the tests. The results were classified as: non-obstruction (only F+10SP can distinguish between normal and dilated without obstruction), obstruction, equivocal and not applicable.
Among the 68 renal units (RU) included in the analysis, the F+10SP test showed normal findings in 21 RU (30,8%), dilation without obstruction in 21 RU (30,8%), obstruction in 25 RU (36.8%) and equivocal result in 1 RU. The F-15 renography showed non-obstructive results in 35 RU (51.5%), obstruction in 20 RU (29.4%) and equivocal findings in 11 RU (16.1%); the test was not applicable in 2 RU (2.9%) due to insufficient renal function. Side effects reported for the F-15 renogram were hypotension in 1 patient, renal colic in 3 patients, bladder filling in 13 patients, disruption because of voiding in 4 patients. No complications were observed during or after the F+10SP renography. The 20 RU diagnosed with obstruction at the F-15 test were considered obstructed also at the F+10SP test.
The "equivocal" test rate lowered from 16% for the F-15 test to less than 1.5% for the new F+10 SP test. The F+10SP procedure is easy, well tolerated, time saving and seems to be a more reliable tool in assessment of obstructive uropathy in adults.
Even if brachytherapy (BT) in low-risk prostate cancer (CaP) is a common practice since more than 20 and 10 years in U.S.A. and Italy, respectively, it is still an uncommon procedure because of the problems related to the organization and collaboration among urologists, radiotherapists and physics, to the competition of alternative therapies, to dogmatic and educational beliefs, and to the poor knowledge of this technique.
Between May 1999 and September 2010, 250 patients with low risk CaP underwent I125BT using a "real time" approach; the seeds implantation was performed using Mick applicator, in the first 190 patients, and the "Quick-Link" technique in the last 60 cases. Oncologic results were reported in the first 150 cases with a mean follow-up of 95 months, while functional outcomes and complications were assessed in all the patients at different time points with a mean follow-up of 65 months.
A good quality implantation was assessed in 88% of patients (D90 >140 Gy). Overall, a biochemical failure was assessed, in accordance with Phoenix criteria, in 10 patients (6.6%). Among these patients, the prostatic biopsy showed a CaP in 6/10 patients, who underwent retropubic radical prostatectomy (4 pts) and external RT (2 pts); only one patient developed a systemic progression with secondary bone lesions and died after 122 months and 36 months from BT and RRP, respectively. The 4/10 patients with negative biopsy were treated with total androgen blockade (2 pts) and with watchful waiting (2 pts). Regarding functional results, we assessed a moderate incidence of irritative disorders (70%) during the first six months and a good recovery of erectile function after one year from surgery (78.8%).
Brachytherapy in the low-grade risk prostatic cancer represents a good alternative to RRP with excellent functional and oncologic results
Following the latest guidelines, management of LUTS/BPH includes not only conventional prostatic surgery, but also the minimally invasive treatment (MIT) of symptoms, with great attention given to improvement in the quality of life. One such MIT for BPH is the Prostiva RF Therapy (Transurethral Needle Ablation). The aim of the study was to evaluate the results obtained from 127 patients (pts) treated with Prostiva.
The Prostiva RF Therapy is a MIT indicated in the treatment of BPH<50 gr with no median lobe and with PSA inside normal limits. This procedure employs low-level radio frequency energy delivered from a generator. From October 2004 to January 2009 120 pts (mean age: 64 years) were treated with Prostiva RF Therapy at two Italian centers. International Prostate Symptom Score (I-PSS), Quality of life (QoL) and Index of Erectile Dysfunction (IIEF5) were compared between baseline and last follow-up.
Mean FU was 27 months ± 24. At baseline, the mean prostate size was 36.62±16 gr. At enrollment, 70 of 120 pts (58%) were under pharmacological treatment for BPH. 102 pts were treated under spinal anesthesia and 18 under local anesthesia. The total average time of the procedure was 28'. The average number of ablations was 5. Uroflowmetry showed a significant improvement in 67% of pts. 63% reported overall satisfaction with I-PSS and QoL improvement. 25% pts needed further therapies (15% pharmacological, 10% TURP). There were no serious complications, 12% needed prolonged catheterization (max 7 days), 6% experienced transient irritation (max 2 weeks), 5 pts experienced transitory ejaculation disorders, and 1 pt anejaculation. There were no significant differences in IIEF -5 either before or after the procedure. CONCLUTIONS: In our experience the PT was effective in 66% of treated patients. The procedure was easy, safe and feasible to be carried out under local anesthesia.
We report the case of a patient arrived because of urological symptoms characterized by terminal hematuria, strangury and dysuria due to migration into the bladder of an intrauterine contraceptive device (IUD) placed 14 years before and penetrated into the bladder with formation of lithiasis. These cases have already been described in literature, but the particular feature of this case is that the patient had been pregnant and had a eutocic delivery, she never voluntarily removed the IUD and nor was it found during a gynecologic laparoscopy. The patient underwent the surgical removal of the IUD and of the bladder stone, without detecting adjacent connective routes between uterus and bladder.
Starting from the UK experience, we decided to test both the feasibility and the advantages of this diagnostic pathway now established in an Italian hospital. We analyzed the outcomes in detecting transitional cell carcinoma (TCC) of the bladder, other malignant and non-malignant conditions.
Between April and December 2010, one hundred and fifty patients presenting with hematuria were referred to the Hematuria One Stop Clinic (HOSC) at our Institution. Each patient underwent a visit, a Urinary Tract Ultrasound, a Cystoscopy and CT IVP in selected cases (evidence of alterations or lesions of the renal parenchyma, presence of stones of the urinary tract, evidence of doubtful or positive urinary cytology). Where a TCC of the bladder was diagnosed, the patient underwent TUR-BT. In other cases (stones, BPH etc.) the appropriate therapeutic pathway was followed.
25.3% of patients with hematuria were found to have a bladder cancer; 21.3% had a urinary stone (2% in the bladder); 1.3% had prostate cancer; 1.3% had a renal cell carcinoma. The mean age was 69.8 yrs. 6% of the patients (23.6% on patients with TCC of the bladder) had a G3 disease. The mean time from admission to the HOSC until the operation day, in case of TCC of the bladder, was 10.61 days.
The Italian experience of the One Stop Clinic confirms a high rate of bladder cancer detection. Furthermore, a high rate of non-malignant conditions was detected, stressing the importance of the HOSC not only as a cancer clinic but as a complete general urological clinic. We report a shorter waiting time to operation, especially for bladder TCC G3 patients.
The Nesbit procedure is the most common surgical technique to correct congenital or acquired penile curvature. It is a common opinion that this surgical procedure has to be completed with a circumcision to prevent foreskin necrosis or phimosis. According to our experience we believe that some procedural "tricks" could strongly reduce that mechanical and ischemic trauma on the foreskin responsible for these complications.
From 1988 to 2010 we selected 158 patients treated with Nesbit's corporoplasty. The procedure was recommended to patients who presented a penile curvature wider than 30° and reporting however some difficulty or pain at coitus, or to patients who complained about aesthetical problems (123 patients presented a La Peyronie disease and 35 presented a congenital curvature).
Eleven patients underwent circumcision during surgery because of a pre-operative phimosis, or according to their own desire. Among the patients who did not undergo circumcision (147), paraphimosis was present in 3 patients. We reported only one case of curvature recurrence in a patient who had a sexual intercourse the day after surgery. We also had one case of hourglass effect in a congenital curvature.
We believe that some tricks during Nesbit surgical procedure could prevent tissue and vascular trauma that give rise to tissue retraction, and consequently to phimosis and foreskin necrosis: a coronal incision to 0.5-1cm from the gland line would allow to let intact an adequate amount of reflection of skin (prepuce) bound of preputial skin reflection , maintaining good vascularity. The careful degloving with preparatory isolation of the dissection plan between dartos and Buck's fascia, can reduce vascular trauma of the fascia, minimizing bleeding and ensuring tissue vitality. Moreover, execution of only two hydraulics erections, after degloving and after correction, causes a minimal tissue stress.
Circumcision must not be considered a mandatory time in Nesbit procedure: on the contrary, mandatory is the respect of the anatomical structures surgically attacked to avoid preputial resection.
Fluorescence cystoscopy (FC) with hexaminolevulinate (HAL) is a recently introduced technique of photodynamic diagnosis (PDD), which aims to improve the accuracy of white light cystoscopy (WLC) in the diagnosis of superficial bladder tumors (NMIBC), and especially of flat urothelial lesions (dysplasia and Ca in situ). We report our experience of a number of cases of WLC and FC in a single moment with HAL in the diagnosis and follow-up of NMIBC.
The method was applied to 184 selected patients with a diagnosis or clinical suspicion - instrumental or early recurrence of bladder neoplasia. The lesions found in white light (WL) and/or blue light (FC) were sampled separately for histological examination. We evaluated the results in terms of diagnostic gain compared to treatment with one WL, false positivity and recurrence-free survival compared to historical reference group treated with WL only.
26.1% of the lesions were found only by the PDD method. The false positivity due to the method adopted was 21.2%. The gain in terms of recurrence-free survival (compared with historical reference group treated only with WL) was 22.3% at 12 months and 24.4% at 20 months. It did not show any systemic side effects.
The PDD is a technique that can significantly increase the diagnostic accuracy of NMIBC.
The introduction of PSA in clinical practice has resulted in decreasing the death rate form prostate cancer and in a downward shift of the pathological stage in radical prostatectomy specimens. This seems not to be the case for bladder cancer. In order to verify this assumption, we have reviewed the charts of the patients operated on of radical prostatectomy and radical cystectomy between 1994 and 2006.
456 and 491 consecutive patients, respectively, underwent radical cystectomy and radical prostatectomy with bilateral lymph nodes dissection. We excluded all the patients who had received neoadjuvant treatment or did not undergo node dissection. The patients were divided into two consecutive groups according to the year of treatment: group 1 included pts treated from 1994 to 2000, and group 2 pts from 2001 to 2006. The histopathological findings of the two groups of pts were compared. The difference among TNM systems has been balanced evaluating histopathological reports critically and converting them to the 2002 edition.
For patients with prostate cancer, those in group 2 had a decrease in the incidence of extracapsular extension and lymph nodes invasion. The bladder cancer patients belonging to group 2 had a greater number of T2, but there was an increased number of pN+ in this group.
Even if there is a decline in locally advanced disease in patients with bladder cancer, our retrospective analysis did not show a comparable success in early diagnosis as it did for prostate cancer. There is undoubtedly an increase in the lymph node dissemination, whether this is due to a more extended lymph node dissection or to a premature dissemination remains questionable. Public awareness regarding bladder cancer and its risk factors is limited, but several studies have reported that a delay in diagnosis of invasive bladder cancer is an adverse prognostic factor. A higher care in the development of new diagnostic markers for bladder tumors and especially in the screening protocols together with an earlier radical therapy could hopefully improve the management of such a pathology, as it happened for prostate cancer.
Laparoscopic RPLND for low-stages NSGCTT is controversial: it is performed and recommended by excellent laparoscopic surgeons, but it is not widely used. The aim of this paper is to evaluate the results achieved by a senior surgeon, expert in open RPLND, who was introduced to laparoscopic surgery by excellent laparoscopists (LN, CU, GJ).
of the 48 operated patients, 36 had primary RPLND for clinical stage I disease (22 TIN0, 7 TxN0, 5 T2-3 N0 and 2 TIS1 N0) and 12 had post-chemotherapy surgery for IIA and IIB retroperitoneal nodes with normalized AFP and HCG. L-RPLND was performed with 4 ports and the en bloc removal of unilateral retroperitoneal nodes with the spermatic vessels. No post-operative adjuvant chemotherapy was planned for patients with documented nodal metastases as for open RPLND since 1985.
Average operative time was 3.30' for the 36 clinical stage I patients and 4 hours for post-chemotherapy surgery. Blood loss was minimal in all cases, because of early conversion to open surgery in all patients with no immediate hemostasis at L-RPLND. Metastases were found in 6 (17%) out of the 36 clinical stage I patients: none in the 22 pTI, 1 in the 7 Tx, 3 in the 5 pT2-3 and in 2 of the 2 pT1S1 patients. Residual teratoma was found in 6 of the 12 patients who received neo-adjuvant chemotherapy for clinical stage IIA or IIB disease. The other 6 had fibrosis-necrosis. Further metastases developed in 2 of the 30 patients with negative nodes: 1 in the lung in a pT1, and 1 in a pT2 patient with increasing markers. Surprisingly, the first two pT2-3 patients with positive nodes developed liver metastases in a few months after L-RPLND. Consequently, all following patients with active metastases at L-RPLND received 2 courses of adjuvant PEB. All 4 patients who relapsed were cured, are alive and disease-free.
L-RPLND is a very demanding operation, which appears to be more a staging procedure than a curative operation. It is ideal for pT1 clinical stage I and for post-chemotherapy stages IIA& B with residual teratoma and normalized markers, but wait & see in good risk and open RPLND in high risk patients are very competing. Only few reports compared laparoscopic versus open RPLND, but not in a randomized study.
2,8-Dihydroxyadenine (DHA) urolithiasis is a rare type of urinary stone disease secondary to deficiency of adenine phosphoribosyltransferase (APRT) activity, a rare, inherited autosomal recessive disease with an incidental rate from 0.4 to 1.2%. The prevalence is higher among Japanese than other ethnic groups. APRT normally catalyzes the conversion of adenine to adenosine monophosphate and its deficiency results in 2,8-dihydroxyadenine (2,8-DHA) accumulation. This compound is extremely insoluble and its crystallization can lead to stone formation and renal failure. We report the case of 2,8-dihydroxyadenine (DHA) urolithiasis in a 52-year-old male patient.
In December 2008 a 52-year-old Caucasian man was admitted to our hospital with sudden pain in the left lumbar region. Abdominal X-ray did not show any radiopaque urinary stone. I.V. pielography showed a radiolucent left lumbar ureteral (0.6 mm) and renal (1.5 cm) stone. After therapy with tamsulosin, the ureteral stone was excreted. Successful ESWL treatment was performed for renal stone. He presented a clinical history of several episodes of bilateral renal colic and two prior ESWL treatment for radiolucent stones. Chemolitholysis was never successful. RESULTS. Stone analysis by infrared spectroscopy and microscopic examination of urine reveal typical 2,8-DHA crystals. APRT deficiency was detected in the hemolysate of erythrocyte. Partial deficiency of APRT in the patient's relatives showed heterozygosity of the enzyme defect. Allopurinol therapy successfully prevented further stone formation. 20 months later the patient remains stone free.
Two types of deficit are commonly distinguished, depending on the level of residual APRT activity. Type I is complete enzyme deficiency. Type II shows residual activity in cell lysates, but enzyme activity is not demonstrable in intact cells. About 78% of the Japanese patients belong to type II. The diagnosis of the disease is based on stone analysis by infrared spectroscopy or microscopic examination of urine, which may reveal typical 2,8-DHA crystals. Molecular approach can identify mutations, which are responsible of this inherited disease. Excessive water intake, restriction of foods with high adenine contents and administration of allopurinol are useful treatments. APRT deficiency is a rare disease but we can consider this pathology in case of recurrent radiolucent stones after chemolitolysis.
Urologist 2.0: how to lead the changeModern urology started about 150 years ago in France, with a strong contribution made by other European countries including Italy. The figure of the modern urologist is linked to a technological evolution but also to the contribution made by great men who have played a crucial role in the evolution of the surgical technique and in the clinical approach to the discipline. An analysis of the evolution of the surgical technique of radical prostatectomy can be paradigmatic in describing the development and, above all, the direction of the hyper-specialization concerning the urologic discipline. To this kind of centrifugal fragmentation is associated a fragmentation at the scientific level which can be defined as centripetal, with a multiplicity of national societies that ultimately complicate the management of the urology discipline. This pathway, made up of divisions and hyper-specializations, contrasts with another less travelled one, which foresees a drastic revision of the figure of the urologist and of the urological discipline in its totality. One which places the patient at the center of the scene, and not only his pathology. Urology cannot become the mere execution of surgical acts, and the objective of our National Residency Programmes should not be solely to form the "perfect surgeon", but to produce a complete specialist able to manage prevention and a correct diagnosis and to guarantee a therapeutic approach including the uro-andrological follow-up of the patient. It is necessary that both basic research and translational research become an integral part of the formative baggage of the young urologist.
During the last 3 decades ultrasonographic and cross-sectional imaging techniques have been widely adopted in the pre-operative staging of renal masses with a progressive technological refinement. The aim of this study is to evaluate if, according to such a change, the accuracy of pre-operative staging is getting better.
A retrospective analysis of 1935 patients, surgically treated at our Institute since 1983 for a renal neoplasm, has been carried out. Dividing the experience in 2 periods, before and after the year 2000, the diagnostic tools adopted during pre-operative staging and their accuracy have been evaluated by a comparison with the post-operative data (accuracy=true positive+true negative/total number of cases), also taking into account each single aspect of staging (dimension of tumor, local extension, venous invasion, lymphnodal and distant metastasis).
994 patients have been treated before 2000, and 941 afterwards. During time, a progressive reduction in the use of urography and, on the other hand, a diffusion of chest CT have been observed, whereas NMR maintained a similar and limited field of application in both periods. During time, the overall accuracy of staging has not significantly improved (69.5% vs 72.3%, p=0.18), but a slightly better staging of distant (93.9% vs 96.7%, p=0.01) and lymphnodal metastasis (90.9% vs 94.8%, p=0.01) can be found.
The pre-operative staging of renal cancer has not really improved during the last 3 decades, in spite of the availability of more precise radiological tools. Anyway, due to the diffusion of CT scan, a slightly better definition of lymphnodal and distant metastasis can be observed. This fact could play a role in indicating a targeted therapy for advanced disease, especially in the light of a neo-adjuvant setting.
Biomarkers (BTA, NMP22, FDP etc.) have been and continue to be evaluated as adjuncts or substitutes for cystoscopy, which is invasive and uncomfortable for some patients. Nuclear matrix protein-22 (NMP22) is involved in the regulation of nuclear processes. The main objective of the present study is to evaluate the clinical utility of urinary NMP22 as a tumor marker in the follow-up of transitional cell carcinoma (TCC) of the bladder.
Materials and Methods
The study included 62 patients undergoing follow-up, who had had TCC of bladder but who were disease-free at the beginning of the study, as confirmed by cystoscopy. Urine samples were collected for urinary cytology and NMP22 test before the cystoscopy. All samples were processed according to the instructions provided with the manufacturer's kit instructions.
12 cases of TCC recurrences were detected with biopsy. Cystoscopy was positive in 8 cases, NMP22 test was positive in 11 cases, and in only one case the cytopathology yielded positive results. In 14 cases NMP22 resulted as false positive.
Urinary NMP22 appeared to be a potential tumor marker for detecting TCC of the bladder, which might rise the sensitivity of cystoscopy especially in high-grade cancer surveillance more than cytology might do.
Predictors of positive surgical margins after nephron-sparing surgery for renal cell carcinoma: retrospective analysis on 298 consecutive patientsObjectives
Aim of our study was to evaluate the predictive factors of positive surgical margins (PSM) in a cohort of patients who underwent partial nephrectomy (PN) for renal cell carcinoma.Material and Methods
We retrospectively evaluated our Institutional database of patients treated with open or laparoscopic PN between 200 and 2013. Categorical variables were compared using Pearson's chi-square test and linear-by-linear association. Multivariable Cox analysis was used in order to evaluate independent predictors of PSM.ResultsSurgical margins were found to be negative in 274 out of 298 patients (91.9%), and the remaining 24 (8.1%) patients had PSM at the final pathological exam. The median clinical size was significantly lower in patients with PSM than those with negative margins (2.6 vs. 3 cm, p=0.03). At univariable analysis, a shorter operative time (p=0.04), a malignant histotype (p=0.04) and higher Fuhrman grade (p=0.02) were observed in patients with positive surgical margins compared to those without PSM. At multivariable analysis, median tumor dimension (p=0.02), the malignant histotype (p=0.01) and the high Fuhrman grade (3-4) (p=0.01) were found to be independent predictive factors of PSM.Conclusions
The most important goal of any PN is to reach negative surgical margins. In our study, clinical tumor dimensions, malignant tumor histotype and the high Fuhrman grade demonstrated to be independent predictive factors of PSM after nephron sparing surgery for renal cell carcinoma. Other prospective, multi-institutional studies are needed in order to confirm these results.
Serenoa repens (saw palmetto) has been employed for the treatment of lower urinary tract symptoms (LUTS) for several years. Its mechanism of action is believed to be due to antiandrogenic, antiproliferative and antinflammatory properties. An association of Serenoa with the nettle "Urtica dioica" showing antiproliferative activity and the pine "Pinus pinaster" derivative, showing antinflammatory action, has been proposed in recent years. Such an action is hoped to act not only by reducing LUTS but also by preventing the development of prostate cancer.
Material and methods:
During the years 2007 and 2008, 320 patients suffering from LUTS were treated with an association of Serenoa repens 320 mg, Urtica dioica 120 mg and Pinus pinaster 5 mg, named IPBTRE. This treatment was administered to all patients for a minimal duration of 30 days to a maximum of a year, either alone or in association with antibiotics or alpha-blockers, if needed. Outcome analysis was based on evaluation of symptoms, prostate volume and maximum flow rate (Qmax).
From a careful analysis of the data collected in our database, the following observations can be made: ages varied between 19 and 78 years. The patients were affected by BPH in 46% of cases, chronic prostatitis syndrome in 43%, chronic genital-pelvic pain in 7% and other conditions in 4%, the absolute numbers being 147, 138, 22 and 7 patients, respectively. No untoward side effect was reported in any case. Variations in symptom score could be fully evaluated only in 80 of 320 patients (25%), of whom 68 (85%) reported a significant benefit, with special reference to an improvement of pain, urgency, strangury and nocturia. Data on variations in prostate volume, as measured by digital rectal examination, were available in 84 (26.5%) patients. No significant change was observed. Qmax after treatment was measured in 83 (26%) patients. It did not show significant changes from the initial values.
The association tested in our study appeared to be safe and well tolerated. No changes in flow rate and prostate volume were observed, but a marked reduction of LUTS was observed in 85% of evaluable cases, especially with regard to pain and irritative symptoms. Whether or not such an association may display a prevention of prostate cancer, may be investigated in additional studies.
Introduction: Brachytherapy (BT) with real-time technique for the treatment of low and medium risk prostate cancer (CaP) has been a well known practice for over 25 years in the USA and for over
15 years in Italy. However, it is an uncommon procedure, because of problems related to the organization and cooperation among urologists, radiotherapists and physics, to the competition of alternative therapies, to dogmatic and educational beliefs, and to the poor knowledge of this technique.
Methods: Between May1999 and July 2013, 400 patients with low and medium risk CaP underwent I 125 BT using a "real-time" approach. The seeds implantation was performed using a Mick applicator in the first 190 patients and the "QuickLink" technique in the last 210 cases. Oncologic results were reported for the first 250 cases with a mean follow-up of 10 years, while functional outcomes and complications were assessed in 350 patients with a minimum follow-up of 1 year.
Results: A good quality implantation was assessed in 90% of the patients (D90>145 Gy). A biochemical failure was assessed, based on Phoenix criteria, in 12 patients (4.8%). Out of these patients,
10 underwent prostate biopsy (the other 2 patients showed a systemic disease). The biopsy showed a CaP in 6/10 patients who underwent retropubic radical prostatectomy (4 patients) and external radiotherapy (2 patients) respectively. The remaining 4/10 patients with negative biopsy were treated with total androgen blockade (3 patients) and watchful waiting (1 patient) respectively. Functional results showed an incidence of postoperative irritative disorders in 70% of the patients during the first six months and a good recovery of erectile function in 78.8% and 68.2% of the patients after one and five years from BT respectively.
Conclusion: Brachytherapy is a good alternative to radical prostatectomy in the low and medium risk prostatic cancers with excellent oncologic and functional results.