Renal cell carcinoma with caval involvement: contemporary strategies of surgical treatment

OBJECTIVES

We retrospectively evaluated the outcome of the surgical treatment of patients with renal cell carcinoma (RCC) and extensive inferior vena cava (IVC) involvement. Our aim was to investigate if a particular surgical technique could reduce morbidity and complications associated with this condition.

MATERIALS AND METHODS

From 1996 to 2007, 22 patients with RCC and extensive IVC involvement underwent radical surgical treatment with the intention to avoid, whenever possible, sternotomy and cardiopulmonary bypass. The level of the tumor thrombus was I (<2 cm above the renal vein) in 2 patients, II (below the intrahepatic vena cava) in 9 patients, III (intrahepatic vena cava below the diaphragm) in 7 patients, and IV (atrial) in 4 patients. Extracorporeal vascular bypass was used for 4 patients with level IV and for 2 patients with level III tumor thrombi, with hypothermic circulatory arrest in 2 patients. Extensive liver mobilization techniques were adopted in 16 patients. Overall and cancer-specific survival (CSS) were analyzed based on tumor extent (N0M0, N+M+), pathologic stage (pT3b, pT3c, pT4), thrombus level, and caval wall infiltration.

RESULTS

Two patients died within 1 month of surgery and the remaining 20 patients have a mean follow-up of 32.2 months (range 6-90): 8 are alive (overall survival 40%), but 2 with disease (CSS 30%). A total of 10 severe complications developed in 8 patients (36%). Both overall and CSS were significantly associated with tumor stage (Log-rank P = 0.0237 and 0.0465), presence of nodal or systemic metastases (Log-rank P = 0.0835 and 0.0669; Wilcoxon's test P = 0.0407 and 0.0411), and caval wall infiltration (Log-rank P = 0.0200 and 0.0418).

CONCLUSIONS

Despite the low overall survival, related to the high percentage of nodal and systemic metastases, aggressive surgical management with resection of synchronous metastatic disease for symptom palliation and cytoreduction, followed by immunotherapy is justified in this setting. A transabdominal approach to RCC and IVC involvement, even in patients with level III thrombus, can provide the surgeon with an exposure similar to thoracoabdominal incisions without the complications associated with thoracotomy.

The role and extension of lymphadenectomy in bladder cancer: a review of the current literature

Radical cystectomy (RC) with pelvic lymph node dissection (LND) is the gold standard for high grade and muscle invasive bladder cancer. Although consensus exists on the need for node dissection, its extent and role are still matter of debate. However, an ever-growing body of data supports an extended dissection since it may provide a survival advantage in both node positive and node negative patients without significantly increasing morbidity and mortality. Besides dissection extent, the modality of specimen submission and node retrieval have a key role in the quality of node assessment. Moreover the stage of primary bladder tumor, the total number of lymph nodes removed, the lymph node tumor burden, the extracapsular extension and the lymph node density have been demonstrated to be important prognostic variables in patients undergoing cystectomy with node metastases and could be useful to accurately stratify patient risk in order to identify those who may benefit from adjuvant therapies. Even if evidence from the literature is only based on retrospective studies, an extended dissection at the time of cystectomy appears to provide a more accurate staging and enhance survival; future prospective studies taking into account the new prognostic factors are needed.

Simultaneous penile and signet ring cell bladder carcinoma in renal transplant recipient: a first case

The incidence and prevalence of cancer increase with time after transplantation. Therefore, a risk-adapted screening process is very important in order to identify low-grade malignancies early in their development. This provides the opportunity to initiate appropriate immunosuppressive regimens depending on the tumor type and stage of development. The first case presented is one of a 65-year-old patient with a double genitourinary carcinoma (penis and bladder). The patient received kidney transplantation 7 years prior to this event. After adequate surgical treatment (partial amputation of the penis for squamous cell carcinoma and complete transurethral resection of bladder adenocarcinoma), the patient was noted to be free of tumor recurrence and had functioning renal graft with a 2-year follow-up.

Isolated polyarteritis nodosa of the genitourinary tract presenting with severe erectile dysfunction: a case report with long-term follow-up

INTRODUCTION

Polyarteritis nodosa (PAN) is a rare necrotizing vasculitis affecting small- and medium-sized arteries of multiple organs. Spreading to the genitourinary tract is very common, with invariable involvement of kidneys or testes, but its impact on erectile function remains undetermined.

AIM

We describe a case of isolated PAN of the genitourinary tract diagnosed in a young man presenting with severe erectile dysfunction (ED), debate the critical issues of the differential diagnosis, and provide the long-term follow-up outcome.

METHODS

The case report profiled a 36-year-old man who presented with progressively worsening erectile function and was incidentally found to suffer from genitourinary PAN. Extensive clinical, laboratory, and instrumental investigations, including brachial artery dilation test, suggested an arteriogenic etiology for ED and excluded a systemic involvement by PAN. Management featured use of a long-term, on-demand phosphodiesterase type 5 (PDE5) inhibitor regimen for ED, and close surveillance with no immunosuppressive therapy for PAN.

MAIN OUTCOME MEASURES

Clinical history data, brachial artery dilation test, response to PDE5 inhibitor therapy.

RESULTS

After 12 months of PDE5 inhibitor therapy, the patient recovered a normal erectile function, paralleled by restored endothelial function as assessed with brachial artery dilation test. At a 5-year clinical follow-up, he continued to have full erectile ability with only occasional use of PDE5 inhibitor, and no evidence of progressive PAN was documented.

CONCLUSIONS

We propose PAN as a novel cause of arteriogenic ED, report the effective therapy with PDE5 inhibitor, and confirm the good long-term prognosis of isolated genitourinary PAN without immunosuppressive treatment.

Pseudodiverticula of ureter: radiologic and histologic findings

A 70-year-old man with previous history of TUR-BT presented positive urinary cytology at one year follow-up. Cystoscopy with bladder mapping was negative, and IVP revealed multiple outpouchings of the right upper ureter without hydronephrosis. Ureteroscopy failed because of an underlying stricture. Surgical excision of the strictured segment and of 2.5 cm of cranial ureter was performed. Histopathology demonstrated focal hyperplasia of the urothelium with outpouchings involving only the mucosa, compatible with the diagnosis of pseudodiverticula.

The Italian linguistic validation of the ureteral stent symptoms questionnaire

PURPOSE

We validated the Italian version of the Ureteral Stent Symptoms Questionnaire in male and female patients with an indwelling ureteral stent.

MATERIALS AND METHODS

A double-back translation of the original Ureteral Stent Symptoms Questionnaire was performed by 3 urologists and 4 professional translators. A total of 78 patients (cases) with and 35 healthy subjects without (controls) an indwelling ureteral stent were asked to complete the Italian version of the Ureteral Stent Symptoms Questionnaire and a visual analog scale for pain as well as the International Prostate Symptom Score (men) and Urogenital Distress Inventory-6 plus Incontinence Impact Questionnaire-7 (women). Cases were evaluated at weeks 1 and 4 after stent placement, and at week 4 after removal, while controls were evaluated once. The psychometric properties of the questionnaire were analyzed.

RESULTS

A total of 66 cases and 30 controls were suitable for analysis. The questionnaire showed good internal consistency in all domains except global quality of life compared with that of the International Prostate Symptom Score (Cronbach's alpha >0.75). Test-retest reliability was good except for the sexual matters domain (Pearson's coefficient >0.7). Relatively high correlation coefficients (greater than 0.65) were found for the visual analog scale for pain, the International Prostate Symptom Score, the Urogenital Distress Inventory-6 and the Incontinence Impact Questionnaire-7 with the corresponding Ureteral Stent Symptoms Questionnaire domains, suggesting good convergent validity. Sensitivity to change and discriminant validity were also good (p <0.001).

CONCLUSIONS

The Italian version of the Ureteral Stent Symptoms Questionnaire is a reliable and robust instrument that can be self-administered to male and female Italian patients with an indwelling ureteral stent in the clinical and research settings.

Cold-knife incision of anastomotic strictures after radical retropubic prostatectomy with bladder neck preservation: efficacy and impact on urinary continence status

OBJECTIVES

To evaluate the incidence and characteristics of anastomotic strictures (AS) after radical retropubic prostatectomy (RRP) with bladder-neck preservation (BNP), the efficacy of management with cold-knife incision (CKI), and its impact on urinary continence.

METHODS

Seven hundred five consecutive patients who underwent RRP with BNP were prospectively followed with uroflowmetry at postoperative months 1, 3, 6, 9, 12, and investigated for urinary incontinence with the 1-h pad test at AS diagnosis obtained with urethroscopy. If the instrument could not dilate the stricture, CKI was subsequently performed. Follow-up after treatment was performed with uroflowmetry and 1-h pad test at months 1, 3, 6, 9, 12. Recurrent AS was always treated with repeated CKI.

RESULTS

Six hundred forty-eight patients were assessable. After a median time of 3.8 mo from RRP, 46 (7.1%) patients developed AS. Urinary incontinence was present in 21 (46%) men at AS diagnosis. Three (7%) patients were successfully managed by urethroscopic dilation only, whereas 43 (93%) required CKI. Eleven (26%) of the latter had recurrent AS. After a median follow-up of 48 mo from the last AS treatment, all patients are stricture-free, de novo urinary incontinence was never documented, and of the 21 originally incontinent men, 11 became continent, 8 improved and 2 remained unchanged.

CONCLUSIONS

In our experience, BNP does not decrease the incidence of AS after RRP; however, AS can be effectively managed with repeated CKI with a final 100% success rate. CKI has a possible positive impact on urinary continence in 90% of patients, without causing de novo incontinence.

Low velocity gunshot wound to the penis

A ricocheting 30-06 calibre bullet caused a low velocity penile injury in a 54-year-old man, shearing the right corpus cavernosum and crossing the ipsilateral thigh and gluteal muscles. Prompt surgical exploration with meticulous debridement and corporeal reconstruction through a degloving incision led to excellent cosmetic and functional results.

Multifocal and bilateral renal oncocytoma: a case report and review of the literature

A 78-year-old man presenting with synchronous, multifocal and bilateral renal oncocytomas underwent a staged nephron-sparing surgery with removal of six lesions. At 14-month follow-up the renal function was preserved and no recurrent disease was evident. A literature review demonstrated 17 similar cases, treated either with watchful waiting or with complete surgical removal. Reasons to prefer the surgical option are herein substantiated.

Continuing or Discontinuing Low-Dose Aspirin Before Transrectal Prostate Biopsy: Results of a Prospective Randomized Trial

OBJECTIVES

To determine whether the incidence and duration of bleeding complications after transrectal prostate biopsy (PB) in patients not discontinuing low-dose aspirin (LDA) are greater than in those discontinuing it.

METHODS

A total of 200 consecutive subjects taking chronic LDA were enrolled in a prospective trial and were randomly assigned to undergo transrectal PB while continuing LDA (group 1, n = 67), replacing LDA with low-molecular-weight heparin (group 2, n = 67), or discontinuing LDA (group 3, n = 66). The incidence and duration of hematuria, rectal bleeding, and hematospermia for each group were assessed with a self-administered questionnaire. On days 14 and 30 after PB, all men were evaluated with an outpatient visit and a telephone interview, respectively.

RESULTS

The cohort comprised 196 assessable subjects. The median number of biopsy cores taken was 10 (range 6 to 10). The overall bleeding rate was 78.5%, 69.7%, and 81.5% in groups 1, 2, and 3, respectively (P = 0.26). No significant difference was found for hematuria, rectal bleeding, or hematospermia among the groups. No severe bleeding complications occurred. The median duration of hematuria and rectal bleeding was significantly greater statistically in groups 1 and 2 compared with group 3 (6, 4, and 2 days versus 3, 2, and 1 days, respectively; P <0.0001). The proportion of men still reporting hematospermia at 30 days after PB was 21.4%, 18.5%, and 9.3% in groups 1, 2, and 3, respectively (P = 0.2).

CONCLUSIONS

The continued use of LDA in men undergoing transrectal PB did not increase the incidence of mild bleeding complications, although it prolonged the duration of self-limiting hematuria and rectal bleeding. Its effect, however, on severe bleeding remains to be determined.

Long-term followup after elective testis sparing surgery for Leydig cell tumors: a single center experience

PURPOSE

Although most Leydig cell tumors are benign, radical orchiectomy is currently considered the standard therapy. We retrospectively analyzed the long-term followup of a series of patients with Leydig cell tumors electively treated with testis sparing surgery.

MATERIALS AND METHODS

Between November 1990 and December 2005, 17 consecutive patients with Leydig cell tumors underwent testis sparing surgery on an elective basis. Preoperative evaluation included physical examination, serum markers for germ cell tumors, scrotal ultrasound, abdominal computerized tomography, chest x-ray and hormonal profile if clinically required. Testis sparing surgery was performed via an inguinal approach with spermatic cord clamping. Frozen section examination was performed in all cases, revealing Leydig cell tumors. Followup consisted of physical examination, scrotal ultrasound, abdominal computerized tomography and chest x-ray every 6 months for the first 2 years, then annually. Tumor recurrence and survival were evaluated.

RESULTS

Mean patient age was 41.6 years (range 28 to 55). Medical referral was prompted by symptoms/signs such as infertility, gynecomastia or self-palpation of scrotal mass in 11 patients (64.7%), while in the remaining 6 (35.3%) the lesions were incidentally diagnosed. Hormonal profile was performed in 9 patients, showing abnormalities in all. Mean tumor diameter was 13.4 mm (range 5 to 31). Definitive pathological examination confirmed benign Leydig cell tumor in all cases. After a mean followup of 91 months (range 12 to 192), neither local recurrence nor distant metastases have been detected and all patients are alive without evidence of disease.

CONCLUSIONS

In patients with Leydig cell tumors testis sparing surgery with frozen section examination provides an excellent long-term oncological outcome.

Granular cell tumour of the urinary bladder: a case report and review of the literature

Granular cell tumor of the urinary bladder is an exceedingly rare disease, with only 10 cases reported so far in literature. We report a case of granular cell neoplasm of the bladder incidentally found in a 44-year-old woman during an abdominal ultrasound examination for evaluation of stress urinary incontinence. The patient underwent a transurethral resection of the mass and histological examination revealed the presence of a granular cell tumor. Immunohistochemical staining for neuron-specific enolase and S100 protein was positive. At a 6-month follow-up the patient is free of bladder recurrence.

Value of image fusion in the staging of prostatic carcinoma

PURPOSE

We assessed the value of image fusion in the staging of prostatic cancer in a series of 32 patients who underwent preoperative evaluation with transrectal colour-Doppler ultrasonography (TRUS) and magnetic resonance imaging (MRI).

MATERIALS AND METHODS

Colour-Doppler TRUS exams were performed using a 7.5-MHz biplanar probe. MRI exams were done with a scanner operating at 1.5 Tesla (T) using an endorectal coil. All patients underwent radical prostatectomy within 2 weeks from the imaging assessment. Whole-mount sections were prepared from the surgical specimens and were subsequently digitised by using a high-resolution scanner. The Digital Imaging and Communications in Medicine (DICOM) TRUS and MR images as well as the digitised pathological images were transferred to a graphic workstation to perform image fusion.

RESULTS

Image fusion was technically possible in 25/32 cases in which axial TRUS images were available. The following fusion images were obtained: TRUS + pathological sections; MRI + pathological sections; TRUS + MRI + pathological sections. The final pathological staging concerning the T status was: four pT2b, fourteen pT2c, three pT3a and four pT3b. The three types of image fusion led to the following results: TRUS + pathological sections, correct staging in 20/25 cases (accuracy 80%); MRI + pathological sections, correct staging in 22/25 cases (accuracy 88%); TRUS + MRI + pathological sections, correct staging in 23/25 cases (accuracy 92%).

CONCLUSIONS

Our study suggests that by using image fusion between colour-Doppler TRUS and endorectal MRI, it is possible to improve the accuracy of pathological staging in patients who are candidates for radical prostatectomy.

Lidocaine–Prilocaine Administration during Transrectal Ultrasound-Guided Prostatic Biopsy: A Randomized, Single-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE

As many as 96% of patients report some kind of discomfort/pain during transrectal ultrasonography (TRUS)-guided prostate biopsy, and when pain is severe, it may be necessary to decrease the planned number of biopsies or interrupt the procedure. Various modalities have been recommended to alleviate the pain, but reports on efficacy are contradictory. We assessed the possible benefit of intrarectal and perianal lidocaine-prilocaine (EMLA) cream.

PATIENTS AND METHODS

A series of 98 patients without active anal and prostatic conditions underwent TRUS and, 10 to 31 days later, TRUS-guided biopsy. They were asked to grade their discomfort/pain using a 10- point linear visual analog pain scale (VAS). After TRUS, patients were divided into three groups on the basis of the VAS scores. Group 1 (N = 8) had pain scores <or=2 (mild pain/discomfort). Group 2 (N = 75) had pain scores between 2 and 5 (moderate pain/discomfort). Group 3 (N = 15) had pain scores >or=5 (severe pain/discomfort). Each group was then randomized to receive local anesthesia with intrarectal and anal EMLA cream (subgroup A) or intrarectal and anal ultrasound gel as placebo (subgroup B). Pain scoring was repeated after the biopsy.

RESULTS

In group 1, there were no significant differences in pain scores between subgroups A and B. In group 2, we could not complete the biopsy in one patient of subgroup B. A statistically significant difference was noticed between the VAS scores of subgroup A and subgroup B (P < 0.0001). In group 3, we were not able to complete biopsy in 5 patients of subgroup B. We noticed significantly higher VAS scores in subgroup B between TRUS and prostate biopsy (P < 0.0001), whereas similar scores were observed in subgroup A (P = NS). A statistically significant difference (P < 0.0001) was noticed between subgroup A and subgroup B scores during biopsy.

CONCLUSIONS

In patients with high tolerance for simple TRUS, needle trauma does not significantly alter tolerability, and anesthetic provides little benefit for prostatic biopsy. However, the opposite is true in patients presenting moderate to significant pain/discomfort at TRUS, who may benefit from intrarectal/anal administration of EMLA during prostate biopsy.