Supine versus prone position during percutaneous nephrolithotomy: a report from the clinical research office of the endourological society percutaneous nephrolithotomy global study

PURPOSE

To determine differences in patients' characteristics, operative time and procedures, and perioperative outcomes between prone and supine positioning in percutaneous nephrolithotomy (PCNL) using the Clinical Research Office of the Endourological Society (CROES) PCNL Global Study database.

PATIENTS AND METHODS

Between November 2007 and December 2009, prospective data were collected on a total of 5803 consecutive patients who were treated over a 1-year period at each of 96 participating global centers. Patients with data on body position were dichotomized into prone or supine PCNL.

RESULTS

The majority of PCNL treatments were performed in the prone position (n=4637; 80.3% of sample). Differences in patient characteristics included in the prone group: A greater proportion of males (57.4% vs 52.2%); younger age (48.8 y vs 51.0 y); less frequent history of shockwave lithotripsy (19.5% vs 28.6%); greater frequency of American Society of Anesthesiologists score of 1 (54.7% vs 46.8%); and a Clavien grade of 2 or more (10.0% vs 7.2%). The mean operative time was significantly lower for prone vs supine PCNL (82.7 min vs 90.1 min) regardless of the method of tract dilation, while the stone-free rate was significantly higher (77.0% vs 70.2%). Compared with supine patients, prone patients exhibited higher rates of blood transfusions (6.1% vs 4.3%) and fever (11.1% vs 7.6%), but lower rates of failed procedures (1.5% vs 2.7%).

CONCLUSIONS

Since operative time and stone-free rates favor prone PCNL, but patient safety favors supine PCNL, the choice of patient position should be tailored to individual patient characteristics and the surgeon's preference.

The current role of percutaneous needle biopsies of renal tumours

The role of percutaneous biopsy of renal masses has been traditionally limited by concerns about its safety, accuracy and sampling errors. The increasing incidence in the diagnosis of incidental small renal masses (SRMs), the development of conservative and minimally invasive treatments for low risk renal cell carcinomas (RCCs) and the discovery of novel targeted treatments for metastatic disease are now leading to wider indications for renal tumor biopsy. Percutaneous biopsy of renal tumors can be performed in an outpatient setting under ultrasound and/or CT guidance. 18 gauge needles loaded in an automatic biopsy gun are used to retrieve cores and 21 gauge needles to obtain FNA specimens through a 17 gauge coaxial cannula placed close to the tumor. A careful check of the quality of biopsies and aspirates is paramount to maximize the diagnostic yield of the procedure. With the development of new biopsy techniques the risk of tumor seeding appears negligible and significant bleeding is unusual and very rarely clinically significant. In centres with expertise, needle core biopsy with or without FNA can provide adequate specimens for an accurate diagnosis in over 90% of cases. Incidental SRMs are frequently detected in elderly patients and have a very heterogeneous biological behaviour At surgery up to one third have benign histologies and most of those that are malignant are low grade RCCs. Pretreatment percutaneous biopsy can significantly decrease the number of unnecessary surgeries for benign disease and assist the urologist in clinical decision making, especially for elderly and unfit patients who are possible candidates for active surveillance and/or minimally invasive ablative therapies. Finally, there is potential for stratifying initial therapy of metastatic RCC by histological subtype on needle biopsies.

Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status

BACKGROUND

Continence after laparoscopic radical prostatectomy is critical to patients and to surgeons. In this setting, the management of deep venous complex (DVC) without involvement of the sphincter fibres could be an important step of the procedure.

OBJECTIVE

To evaluate the effects of a personal selective suture of the plexus (selective ligature of the deep venous complex [SLDVC]) on continence, blood loss, and surgical margin status during laparoscopic radical prostatectomy (LRP).

DESIGN, SETTING, AND PARTICIPANTS

We planned a prospective randomised study. Sixty consecutive patients with clinically localised prostate cancer were involved in the study and were divided into two groups: group A (30 patients) underwent LRP with extraperitoneoscopic approach with standard management of DVC; group B (30 patients) underwent LRP with SLDVC.

INTERVENTION

In group A, a standard ligature of DVC was performed (ligature and subsequent section); in group B, a selective ligature of DVC after its section was performed.

MEASUREMENTS

Continence was evaluated during follow-up visits at catheter removal, and after 1, 3, 6, and 12 mo, perioperative variables and pathologic features of specimens were recorded.

RESULTS AND LIMITATIONS

The two groups were comparable in terms of age, body mass index (BMI), prostate-specific antigen (PSA) values, and Gleason score at biopsy. No differences were found between the two groups in terms of operative times, blood loss, catheterisation time, and postoperative stay or histologic status. As far as continence rate is concerned, a significant difference was recorded between the groups (53% in group A vs 80% in group B) after 3 mo.

CONCLUSIONS

This selective ligature of the DVC after its section can contribute to early recovery of continence. Our data suggest that SLDVC compromises neither the safety of the procedure nor its oncologic effectiveness.

Proposal of an improved prognostic classification for pT3 renal cell carcinoma

PURPOSE

The prognostic accuracy of the current TNM 2002 staging system for locally advanced renal cell carcinoma has been questioned. To contribute to the development of a more accurate classification for this stage of disease we assessed the correlation between patterns of invasion in the pT3 category and outcomes in a large multi-institutional series.

MATERIALS AND METHODS

Pathological data and clinical followup on 513 pT3 renal cell carcinoma cases treated with radical nephrectomy between 1983 and 2005 at 3 Italian academic centers were retrospectively reviewed. Cause specific survival rates were calculated with the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model.

RESULTS

Estimated overall 5-year cause specific survival was 50.1% at a median followup of 61.5 months in survivors. The current TNM classification was not a significant outcome prognosticator. Patients with a tumor invading only the perirenal or sinus fat were at lowest risk for death from the disease. Patients at intermediate risk had tumors with invasion of the venous system alone. Simultaneous perirenal fat and sinus fat invasion or perirenal fat and vascular invasion as well as adrenal gland involvement characterized high risk tumors. Low risk tumors could be further divided into 2 groups with different outcomes based on a size cutoff of 7 cm. Our classification was a significant predictor of survival on multivariate analysis as well as M stage, N stage, Fuhrman grade and tumor size.

CONCLUSIONS

We confirm that the prognostic usefulness of the current 2002 TNM system for pT3 renal cell carcinoma is limited. We have identified 4 groups of tumors with distinct patterns of invasion and significantly different survival probabilities in this category. Large prospective series are needed to validate these findings.

[Tadalafil versus sildenafil citrate in the treatment of ED:Italian patients' preferences and explanatory notes]

This is an open, multicentre, randomized, crossover study having the aim to evaluate the preference for sildenafil citrate or tadalafil in a population of Italian patients affected by ED, and to compare the efficacy and safety of these two drugs. MATERIAL AND METHODS. From October 2003 to November 2004, thirteen Italian centers enrolled ED patients (age >18) being in steady and naïve relation to ED treatment, both through PDE5 inhibitors and any other treatment option. These patients were randomized to sildenafil or tadalafil for 12 weeks, after which they were switched to the alternative treatment for a further 12 weeks. The preference was evaluated through the Treatment Preference Question (TPQ): "During this clinical trial you have taken tadalafil and sildenafil for the treatment of erectile dysfunction. Which medication do you prefer to take for the next 8 weeks of treatment?". Moreover, patients were asked to express their preference as "strong" or "moderate" and to answer some questions to clarify the reasons behind their preference. SEP and IIEF-EF questionnaires were used for a comparison of efficacy. RESULTS. 167 patients were enrolled, 144 of whom completed both treatment periods. On being asked the TPQ, 75% of patients (n=108) decided to continue treatment with tadalafil, in particular because it made it possible to have an erection many hours after taking the medication (first or second preference reason for 64.8% of patients), while 25% (n=36) preferred sildenafil (p=0.001). Both drugs improved the IIEF-EF and SEP scores compared to baseline, with a slightly but significantly greater improvement with tadalafil for both parameters. CONCLUSIONS. Tadalafil and sildenafil are both effective and well tolerated. Most of the patients prefer tadalafil thanks to the possibility of having sexual intercourse many hours after taking the medication.

Treatment outcomes in the STAR study: a subanalysis of solifenacin 5 mg and tolterodine ER 4 mg

OBJECTIVE

To compare OAB symptom outcomes following initial randomised treatment with solifenacin 5 mg or tolterodine ER 4 mg at the 4-week clinic-visit and again at 12 weeks for patients choosing to remain on this treatment dose from 4 weeks.

METHODS

A prospective, double blind, double-dummy, two-arm, parallel-group, 12-week study (The STAR study) was conducted to compare the efficacy and safety of solifenacin 5/10 mg and tolterodine extended release (ER) 4 mg in OAB patients.

RESULTS

At 4 weeks mean improvements in OAB symptoms, including urgency, frequency (primary variable), incontinence and nocturia, were larger in patients randomised to solifenacin 5 mg; with the difference for incontinence being statistically significant (mean reduction in incontinence episodes/24 hrs in the solifenacin group of -1.30 vs. -0.90 (p=0.0181); the mean result for solifenacin 5 mg amounted to a 44% additional improvement.) There was an associated significant reduction in pad use (reduced by -1.21 vs. -0.80; p=0.0089); the mean result for solifenacin 5 mg amounted to a 51% additional improvement over that of tolterodine ER 4 mg. For patients choosing to remain on these treatments improvements in favour of solifenacin were maintained at study end (12-weeks). Treatments were well tolerated.

CONCLUSIONS

Within 4 weeks solifenacin 5mg was statistically significantly better than tolterodine ER 4 mg in improving incontinence and reducing incontinence pad use. Differences in efficacy in favour of solifenacin 5 mg were maintained from 4 weeks for the duration of the study for patients choosing to remain on their starting dose.

Combined endoscopic and laparoscopic en bloc resection of the urachus and the bladder dome in a rare case of urachal carcinoma

Urachal carcinoma is a rare neoplasm treated with surgical resection. We report a case of adenocarcinoma of the urachus treated with a new surgical technique. In a 44-year-old man affected by urachal carcinoma we performed a combined endoscopic-laparoscopic surgical en bloc resection of the urachus and bladder dome. The procedure lasted 240 min, and no postoperative complications were recorded. The patient was discharged on fourth day and the catheter was removed on eighth day. Bladder capability resulted normal with no evident physical change. Multiple bladder biopsy and computed tomography scans at 6, 12 and 18 months proved negative.

Clinically Overt Venous Thromboembolism after Urologic Cancer Surgery: Results from the @RISTOS Study

OBJECTIVE

Incidence of venous thromboembolism (VTE) and need for thromboprophylaxis in urologic surgery have received little attention since only one randomised study has addressed this issue in the last 20 yr. The present prospective observational study evaluated incidence and risk factors for clinically overt VTE in a wide spectrum of consecutive patients undergoing surgery for cancer and compared findings in urologic patients with those in patients undergoing general or gynaecologic surgery.

METHODS

Patients having cancer surgery (general surgery, gynaecology, urology) were assessed for clinically overt VTE occurring up to 30+/-5 d after intervention or more if the hospital stay was longer. All suspected VTE events were evaluated by an external independent Adjudication Committee.

RESULTS

A total of 2373 patients, 1238 (52%) undergoing general surgery, 685 (29%) urologic, and 450 (19%) gynaecologic surgery were evaluated. In urologic patients, most procedures (61%) were endoscopic, with bladder and prostate cancer being the most frequent tumours. In-hospital thromboprophylaxis was given to 71.7% of patients, whereas 32.5% received prophylaxis after discharge. The incidence of VTE in urologic patients was lower (0.87%) than that in general surgery and gynaecologic patients (2.8% and 2.0%, respectively). VTE consisted of three cases of nonfatal and three cases of fatal pulmonary embolism (PE). In four of the six cases, VTE occurred during prophylaxis.

CONCLUSIONS

VTE still represents a severe complication and remains the most common cause of death after urologic cancer surgery. Efforts should be made to optimise prophylactic measures to further reduce such risk.

Italian Validation of the Urogenital Distress Inventory and Its Application in LUTS Patients

OBJECTIVES

The objective of this study was to validate the Italian version of the Urogenital Distress Inventory (UDI) in a sample of women with lower urinary tract symptoms (LUTS).

METHODS

The linguistic validation of the questionnaire was performed through a multistep process: backward and forward translations coordinated by clinical investigators, followed by a pretest. The final version was administered to a larger sample of female patients, aged 18 years or older who had been having LUTS for at least 3 months, numbering 53 subjects. To evaluate test-retest reliability, patients were re-rated after 1 week. To test the questionnaire's capacity to discriminate women with or without LUTS (cases and controls, respectively), a sample of 53 healthy women was enrolled. A 72-h voiding diary was used as a gold standard and compared with the UDI.

RESULTS

The correlation coefficient between ratings was >or=0.80, and the discriminant power between cases and controls was confirmed. The UDI showed good internal consistency for all domains, except irritative symptoms (total score's Cronbach alpha=0.86). Factor analytic structure revealed urinary incontinence to be opposite to the other urologic symptoms, with bed wetting being loaded separately. The average daily number of urgent micturitions was higher in patients who reported they "experience a strong feeling of urgency to empty bladder" in the UDI than those ones who did not (p<0.01).

CONCLUSIONS

The Italian version of the UDI is a valid and robust instrument, which can now be used reliably in daily practice and clinical research.

Pathological changes of high-grade prostatic intraepithelial neoplasia and prostate cancer after monotherapy with bicalutamide 150 mg

OBJECTIVES

To evaluate the morphological changes induced by a 3-month course of neoadjuvant bicalutamide 150 mg/day before radical prostatectomy (RP) on prostatic adenocarcinoma and high-grade prostatic intraepithelial neoplasia (HGPIN).

PATIENTS AND METHODS

In all, 90 patients with cT1-T2 prostate cancer and HGPIN on prostatic biopsy were randomized to receive bicalutamide (150 mg/day for 3 months) before RP, or to have immediate surgery. Surgical specimens were assessed for the histopathological features of cancer, HGPIN and benign epithelium in a blinded manner. The volumes of prostate cancer and HGPIN were evaluated using a stereological (i.e. grid) method.

RESULTS

Compared with the bicalutamide-treated group, the ratio of stroma to epithelium, evaluated by visual microscopic assessment in the normal epithelium of the three prostate zones, was significantly lower in the control group, at 2.27 (sd 1.13), than in the treated group, at 1.87 (sd 0.72) (P = 0.048). The mean (sd) tumour volume was significantly lower in the bicalutamide-treated than in the control group, at 0.914 (0.13) vs 1.47 (0.24) mL (P = 0.044). Similarly, the mean (sd) volume of HGPIN was significantly lower in the bicalutamide-treated than in the control group, at 0.34 (0.06) vs 0.62 (0.07) mL (P = 0.003). At RP, specimen Gleason scores in the bicalutamide-treated group were similar to those in the control group, and were no different from the biopsy Gleason scores.

CONCLUSIONS

Involution and epithelial shrinkage of prostate cancer and HGPIN were evident after neoadjuvant treatment with bicalutamide 150 mg. There was no evidence of the emergence of higher-grade cancer after treatment.

Reassessing the Current TNM Lymph Node Staging for Renal Cell Carcinoma

OBJECTIVE

The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved).

METHODS

All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively.

RESULTS

A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1-35). The median number of LNs involved was 3 (range, 1-18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved (p = 0.02) and LN density >60% (p = 0.01).

CONCLUSION

The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as < or =4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.

Italian validation of the International Consultation on Incontinence Questionnaires

OBJECTIVE

To validate the Italian version of two questionnaires for lower urinary tract symptoms (LUTS), i.e. the long (LF) and the short form (SF) of the International Consultation on Incontinence Questionnaire (ICIQ).

METHODS

Two native Italian speakers and a native English speaker collaborated with clinical investigators through a multistep process to obtain a consensus version of the questionnaires. The resulting Italian versions were then pre-tested during a pilot study on 16 women for the LF and 10 for the SF. The final versions of the ICIQ-LF and ICIQ-SF were administered to two samples of consecutive female patients, aged > or = 18 years, who had been having LUTS for > or = 3 months, with respectively 82 and 50 women. Internal consistency and test-retest reliability were then assessed; to evaluate the latter, a subset of patients (25 for the ICIQ-LF and 42 for ICIQ-SF) was re-rated. To test the capacity of the questionnaires to discriminate women with or without LUTS (respectively cases and controls), a sample of healthy women was also enrolled and assessed.

RESULTS

Both scales showed good psychometric properties overall. The correlation coefficient between ratings was > 0.75 in both questionnaires, and the discriminant power between cases and controls was confirmed for both scales. The ICIQ-SF showed good internal consistency for the total score (Cronbach's alpha 0.90). The sections of the ICIQ-LF 'impact of incontinence on everyday life', 'emotional aspects', 'urinary symptoms' and the degree of bother seemed to be internally consistent (Cronbach's alpha > 0.70); there was a weak relationship for items related to 'sexual matters' (Cronbach's alpha 0.38).

CONCLUSION

The Italian version of both questionnaires is a valid and robust instrument which can now be used reliably both in daily practice and in clinical research.

Immune response in prostate cancer

Surprisingly perhaps for a tumor where there is such clear proof of a primary hormonal basis to its development, there is emerging evidence that all elements playing a key role in prostate cancer somehow affect the host immune system. This review turns the spotlight on some previously unsuspectable aspects, able to interact with the immune system in prostate cancer patients PSA, sex hormones, inflammatory infiltrates, cytokines, growth factors, neoformed blood vessels, neurotransmitters and neurotrophins, cigarette smoking, diet, therapeutic approaches. The concept of exploiting the immune system to combat cancer is not new, but only nowadays immunotherapy is a reality. Prostate cancer is an excellent target, involved in an increasing number of clinical immunotherapeutic trials. The main current purpose is to overcome the host immune tolerance of tumor cells. The most recent progresses in gene, monoclonal antibody and vaccine therapies are reported.

Predictive factors for skeletal complications in hormone-refractory prostate cancer patients with metastatic bone disease

Factors predictive of skeletal-related events (SREs) in bone metastatic prostate cancer patients with hormone-refractory disease were investigated. We evaluated the frequency of SREs in 200 hormone-refractory patients consecutively observed at our Institution and followed until death or the last follow-up. Baseline parameters were evaluated in univariate and multivariate analysis as potential predictive factors of SREs. Skeletal-related events were observed in 86 patients (43.0%), 10 of which (5.0%) occurred before the onset of hormone-refractory disease. In univariate analysis, patient performance status (P=0.002), disease extent (DE) in bone (P=0.0001), bone pain (P=0.0001), serum alkaline phosphatase (P=0.0001) and urinary N-telopeptide of type one collagen (P=0.0001) directly correlated with a greater risk to develop SREs, whereas Gleason score at diagnosis, serum PSA, Hb, serum albumin, serum calcium, types of bone lesions and duration of androgen deprivation therapy did not. Both DE in bone (hazard ratio (HR): 1.16, 95% confidence interval (CI): 1.07-1.25, P=0.000) and pain score (HR: 1.13, 95% CI: 1.06-1.20, P=0.000) were independent variables predicting for the onset of SREs in multivariate analysis. In patients with heavy tumour load in bone and great bone pain, the percentage of SREs was almost twice as high as (26 vs 52%, P<0.02) and occurred significantly earlier (P=0.000) than SREs in patients with limited DE in bone and low pain. Bone pain and DE in bone independently predict the occurrence of SREs in bone metastatic prostate cancer patients with hormone-refractory disease. These findings could help physicians in tailoring the skeletal follow-up most appropriate to individual patients and may prove useful for stratifying patients enrolled in bisphosphonate clinical trials.

Prognostic value of the involvement of the urinary collecting system in renal cell carcinoma

OBJECTIVES

The prognostic role of the invasion of the urinary collecting system (UCS) by renal cell carcinoma (RCC) has not attracted a notable amount of attention. The aim of this study was to investigate incidence and prognostic value of UCS involvement in RCC.

MATERIAL AND METHODS

All pathological reports of radical nephrectomies performed in two centres of urology from November 1983 to December 1999 were reviewed in order to evaluate the invasion of the UCS (calices, renal pelvis, ureter). Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of UCS invasion. The stage was determined according to the TNM 6th edition. Overall and cause-specific survival rates were evaluated. Univariate and multivariate analyses were performed.

RESULTS

The evaluable specimens were 671 from the 735 examined; in 64 cases it was not possible to ascertain or to exclude UCS involvement. Invasion of the UCS was found in 59 cases (8.8%). Median follow-up was 59.0 months (range 0-216). Tumours invading the UCS were usually symptomatic, with high nuclear grade and predominantly high stage. At univariate analysis the 5 year overall and cause-specific survival rates of tumours invading the UCS were significantly lower when compared to those without UCS invasion (42.8% versus 60.8% and 45.5% versus 64.7%, respectively). When groups were stratified, according to the pT category, the 5-year cause-specific survival rate was only significantly different for the pT2 category (33.3% versus 76.9%). At the multivariate analysis TNM staging, symptoms at diagnosis and tumour grade were the only independent prognostic factors.

CONCLUSION

The invasion of the UCS by RCC is unusual, particularly in small tumours. UCS involvement does not represent an independent prognostic factor. However, in organ-confined tumours (i.e. pT2) UCS involvement has an influence on the prognosis and should be taken into account when planning adjuvant treatments and follow-up.

Is laparoscopic unilateral sural nerve grafting during radical prostatectomy effective in retaining sexual potency?

OBJECTIVES

To present a pilot study of laparoscopic unilateral sural nerve grafting during radical prostatectomy, with the aim of preserving sexual potency.

PATIENTS AND METHODS

Because they had localized prostate cancer, 29 men had a laparoscopic radical prostatectomy with deliberate wide unilateral neurovascular bundle resection and preservation of the contralateral bundle. Fifteen men (group A) had an interposition sural nerve graft on the sectioned bundle, and 14 (group B) had laparoscopic radical prostatectomy with preservation of the unilateral bundle only. The men were also involved in a rehabilitation programme, and erectile function was evaluated after surgery, and at 3, 8, 12 and 18 months, using the five-item version of the International Index of Erectile Function (IIEF-5) questionnaire.

RESULTS

The two groups had similar clinical characteristics (age, prostate-specific antigen level, body mass index, prostate volume, clinical stage, Gleason score before and after surgery, postoperative stage). The follow-up was complete for 12 men in group A and 10 in group B. Group A had significantly higher erectile function scores on the IIEF-5 at 12 and 18 months than immediately after surgery (P < 0.01), whereas in group B the improvement was not statistically significant. Overall, by 18 months after surgery five of 12 men in group A had achieved spontaneous unassisted erection or erection assisted with sildenafil, while three of 10 in group B achieved an erection assisted with sildenafil (not significant).

CONCLUSIONS

These data suggests that laparoscopic sural nerve grafting during radical prostatectomy is feasible and safe; nevertheless we cannot conclude that sural nerve grafting is more effective than preserving the neurovascular bundle alone in retaining sexual potency. More research is required to validate the effectiveness of this technique.

Laparoscopic telementored adrenalectomy: The Italian experience

BACKGROUND

Laparoscopy is widely accepted as the gold standard for adrenalectomy. Telementoring has been developed to reduce the complications associated with surgeon inexperience. We report our preliminary experience with laparoscopic telementored adrenalectomy.

METHODS

From July 2002 to May 2003, eight laparoscopic telementored adrenalectomies were performed between two separate operating sites 430 km apart. Six of these procedures were monolateral laparoscopic adrenalectomies, and one was bilateral. All cases were performed by an expert open surgeon who was skilled in laparoscopic procedure but who had no experience in laparascopic adrenalectomy

RESULTS

All the procedures were successfully performed in a telementored fashion. The mean operative times, blood loss, and postoperative morbidity results were comparable to those for standard laparoscopic adrenalectomies reported in the literature.

CONCLUSIONS

This preliminary experience has demonstrated the feasibility of national telementoring. It is a viable method that can potentially add to surgical education and decrease the likelihood of complications due to inexperience with new techniques.

Independent prognostic role of circulating chromogranin A in prostate cancer patients with hormone-refractory disease

The presence of neuroendocrine (NE) differentiation in the context of predominantly exocrine prostate cancer may play a key role in androgen-independent tumor growth. The prognostic significance of plasma chromogranin A (CgA) was assessed in a series of consecutive prostate cancer patients with hormone-refractory disease. One hundred and eight patients with newly diagnosed hormone-refractory prostate cancer entered the study. Plasma CgA levels and other biochemical parameters, such as serum prostate specific antigen, serum alkaline phosphatase, serum lactate dehydrogenase, serum albumin and hemoglobin concentration, were measured at baseline (i.e. when hormone refractoriness occurred) and their prognostic role was evaluated together with patient performance status, Gleason score (at diagnosis of prostate cancer) and the presence of visceral metastases. Furthermore, plasma CgA was prospectively evaluated in 50 patients undergoing chemotherapy. At baseline, 45 patients (43.3%) showed elevated CgA values. Plasma CgA negatively correlated with survival, either in univariate analysis (P=0.008) or in multivariate analysis, after adjusting for previously mentioned prognostic parameters (P<0.05). In the patient subset undergoing chemotherapy, median CgA (range) values were 13.3 (3.0-141.0) U/l at baseline, 19.1 (3.0-486.0) U/l after 3 months, 20.8 (3.0-702.0) U/l after 6 months and 39.4 (3.0-414.0) U/l after 9 months (P<0.01). The corresponding supranormal rates were 17/50 (34%), 23/50 (46%), 26/50 (52%) and 34/50 (68%) respectively (P<0.005). Elevated plasma CgA levels are frequently observed in prostate cancer patients with hormone-refractory disease and correlate with poor prognosis. NE differentiation in hormone-refractory patients is a time-dependent phenomenon and is not influenced by conventional antineoplastic treatments.

Home and office uroflowmetry for evaluation of LUTS from benign prostatic enlargement

A group of 107 patients with lower urinary tract symptoms (LUTS) from benign prostatic enlargement (BPE) participated to the HOUSE Study (Home and Office Uroflowmetry Specific Evaluation). Patients received routine investigation, consisting of medical history taking, physical examination including digital rectal examination, prostate-specific antigen (PSA), assessment of symptoms listed both on the International Prostate Symptom Score and on ICS-male questionnaire. We examined the results of uroflowmetry evaluation in this population; data were analysed to observe if any circadian changes of parameters obtained with home uroflowmetry could be detected. We searched a correlation between Q(max), Q(ave) and ICS-benign prostatic hyperplasia symptom score: a significantly inverse correlation was found only for Q(max), confirming Q(max) as a reliable parameter to quantify subjective symptoms. When examining the multiple flow curves recorded in the same patient with home uroflowmetry, voided volume and flow time had usually higher values during night-time: the existence of circadian changes of uroflowmetry parameters in patients with LUTS from BPE was confirmed, and lower values of average and maximum flow rates during sleep hours were recorded in the same patient. In conclusion, when evaluating the natural history or treatment outcome of individual patients or group of patients in clinical trials for evaluation of BPE and LUTS, an assessment including multiple measurements may be useful and of value.

Is laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis?

OBJECTIVE

To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.

PATIENTS AND METHODS

The study included patients who underwent LA from 1995 to 2002, with histologically identified adrenocortical cancer (ACC) or metastasis. Indications for LA were adrenal masses with no radiological evidence of involvement of the surrounding structures, or solitary metastasis with well-controlled primary cancer. The variables evaluated were: size of the lesion, operative duration, estimated blood loss, intraoperative complications, local, port-site and intra-abdominal recurrence, distant metastasis, and survival time.

RESULTS

Fourteen malignant adrenal lesions in 205 LAs (7%) were confirmed with histological diagnoses that showed a primary ACC in six and metastasis in another seven (in one there was bilateral metastasis). The mean (sd) size of the malignant lesions was 5.9 (2.8) cm. The 12 unilateral procedures required a mean operative duration of 164 (47) min; the bilateral procedure lasted 215 min. There was one conversion to open surgery caused by local infiltration, whereas there were no intraoperative complications. The mean follow-up was 30 months, during which three patients died, one from endoperitoneal and trocar port-site seeding.

CONCLUSION

When the malignancy is confined to the adrenal gland, LA seems to be a feasible option if the principles of oncological surgery are respected. Nevertheless, further investigations are required to evaluate the appropriateness of this operation.

Vasopressin excitatory action on smooth muscle from human renal calyx and pelvis

The motor response to vasopressin, a neuropeptide promoting the reabsorption of water, was isometrically investigated in vitro in human renal calyces and pelvis in relation to possible modulation of urinary flow by these tubular structures. Kidneys were obtained from nine male patients who underwent nephrectomy for either renal or ureteral cancer. Minor calyces and pelvis were carefully removed. Strips (10 mm x 3 mm) were cut from infundibular region of minor calyces and from renal pelvis and placed in 10 ml organ bath for isometric tension recordings. Calyceal and pelvic smooth muscle strips exhibited spontaneous phasic contractions which occurred with regular frequency and amplitude. Vasopressin induced a dose-dependent [10(-10) to 10(-6) M] enhancement of basal tone (P <0.01) and a decrease of spontaneous contractions on isolated strips from minor calyces and pelvis. The effect of vasopressin was inhibited by prior administration of D(CH2)5Tyr(Me)2-Arg8-Vasopressin antagonist [10(-7) M]. The excitatory response to vasopressin was Tetrodotoxin [TTX]-resistant and was not affected by pre-treatment with phentolamine [10(-5) M], atropine [10(-5) M], and hexamethonium [10(-5) M]. After incubation of the specimens in Ca2+-free medium containing EGTA [0.5 mM] or after treatment with nifedipine [10(-5) M], both spontaneous and vasopressin-induced contractions [10(-10) to 10(-6) M] were completely inhibited in all specimens. Our results can be interpreted to imply that the tonic contractions induced by vasopressin facilitate the reabsorption of water by increasing the hydraulic resistance of the tubular structures below collecting ducts.

A comparison of the efficacy and tolerability of tamsulosin and finasteride in patients with lower urinary tract symptoms suggestive of benign prostatic hyperplasia

In this multicentre, double-blind study, patients with LUTS/BPH were randomised to 26 weeks with finasteride 5 mg once daily (n=204) or tamsulosin 0.4 mg once daily (n=199). Double-blind treatment was continued for another 26 weeks (total treatment duration: 1 y). The primary efficacy parameter was the difference in mean change in total Symptom Problem Index (SPI) from baseline to end point at week-26 in the intention-to-treat (ITT) and per protocol (PP) populations. Tamsulosin induced a greater improvement in total SPI (-5.2 points or -37%) compared to finasteride (-4.5 points or -31%) at week-26 (P=0.055 in ITT and P=0.032 in PP). Tamsulosin improved urinary symptoms (particularly the more bothersome storage symptoms) and flow more quickly than finasteride. The difference was statistically significant for the SPI from week-1 (reduction, respectively, -2.5 vs -1.8 points, P=0.043) to week-18 and for Qmax from week-1 (increase, respectively, 2.3 vs 0.7 ml/s, P=0.0007) to week-12. Both treatments were well tolerated with a comparable incidence of adverse events, including urinary retention.

Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery

We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.

Is laparoscopic bladder diverticulectomy after transurethral resection of the prostate safe and effective? Comparison with open surgery

PURPOSE

In a retrospective nonrandomized study, we compared our experience with transurethral resection of the prostate (TURP) plus sequential laparoscopic bladder diverticulectomy with a series of combined open bladder diverticulectomies with transvesical prostatectomy.

PATIENTS AND METHODS

We considered 12 consecutive patients (group A) having 16 diverticula who underwent sequential TURP and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group B) having 13 diverticula who underwent open bladder diverticulectomy and transvesical prostatectomy. We evaluated the size and position of the diverticulum, adenoma volume, operative time, postoperative hemoglobin variations, analgesia requirement, complications, postoperative hospital stay, and uroflowmetry results.

RESULTS

No statistically significant differences existed between the groups in adenoma volume or diverticulum size or position. However, a significantly longer operative time was recorded in group A. The endolaparoscopic approach proved to be statistically superior to open surgery regarding blood loss, postoperative analgesia requirement, and hospital stay. No intraoperative complications were recorded. In addition, no statistically significant difference was found in uroflowmetry results.

CONCLUSIONS

In our experience, the endolaparoscopic approach has proved to be safe, effective, and minimally invasive and therefore superior to transvesical prostatectomy and open bladder diverticulectomy. Its only disadvantage is the longer operative time.

Y-neobladder: an easy, fast, and reliable procedure

OBJECTIVES

To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses.

METHODS

Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients.

RESULTS

The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O.

CONCLUSIONS

The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.

Background to and management of treatment-related bone loss in prostate cancer

Prostate cancer is a common disease among older men. Androgen suppression by either orchiectomy or administration of luteinising hormone-releasing hormone (LHRH) analogues is the mainstay of treatment. Since the use of prostate-specific antigen (PSA) serum testing has become widespread, however, the timing of endocrine therapy has expanded considerably to include patients with limited involvement of extraprostatic sites and patients presenting an isolated elevation of PSA after radical treatments. These patients are expected to be treated for a long time, since they have a rather low risk of disease progression and there is no recommended time limit for LHRH analogue therapy. The long-term adverse effects of androgen deprivation therapy, therefore, deserve more attention than they have received in the past. Osteoporosis represents a special concern for men with prostate cancer receiving androgen deprivation therapy. The rate of bone loss in these men seems to markedly exceed that associated with menopause in women, and fractures occur more frequently than in the healthy elderly male population. Serial bone mineral density (BMD) evaluation could allow the detection of patients with prostate cancer who are at greater risk of osteoporosis and adverse skeletal events after androgen deprivation therapy, such as patients already osteopenic or osteoporotic at baseline and men with rapid bone loss during treatment. BMD evaluated during treatment could also be a potential surrogate parameter of antiosteoporotic therapeutic efficacy. Treatment of bone loss induced by androgen deprivation comprises general prevention measures, antiosteoporotic drugs and the use of alternative endocrine therapies. Optimising lifestyle and diet is important, although it cannot completely prevent bone loss. Patients with nonsevere bone disease may benefit from calcium and vitamin D supplements. Men who are osteoporotic before androgen deprivation or men becoming osteoporotic during treatment and/or experiencing adverse skeletal events may also require bisphosphonates. The effectiveness of these drugs in preventing fractures has been shown in a single randomised study involving patients with osteoporosis, but it has not yet been established in a prostatic cancer population without bone metastases given androgen deprivation therapy. Different forms of endocrine therapy such as low-dose estrogens, antiandrogens and intermittent androgen ablation are under investigation. They could offer the advantage of avoiding (or limiting) treatment-related bone loss. In our opinion, however, the data available so far are not robust enough to recommend these alternative endocrine therapies instead of standard androgen deprivation in routine clinical practice.

The number of lymph nodes examined and staging accuracy in renal cell carcinoma

OBJECTIVE

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

PATIENTS AND METHODS

We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1-4; group 2, 5-8; group 3, 9-12; group 4, 13-16; and group 5, >or= 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement.

RESULTS

Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1-43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P < 0.01). The rate of pN+ was significantly higher in the patients with >or= 13 than in those with < 13 nodes examined (20.8% vs 10.2%; P < 0.001). For organ-confined and locally advanced tumours there was a statistically significant difference in the pN+ rate between patients with < 13 or >or= 13 nodes examined (3.4% vs 10.5%, and 19.7% vs. 32.2%, respectively).

CONCLUSIONS

The proportion of tumours classified as pN+ increased with the number of lymph nodes examined. In RCC,> 12 lymph nodes need to be assessed for optimal staging.

Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery

OBJECTIVES

To compare our experience with transurethral resection of the prostate and sequential laparoscopic bladder diverticulectomy with a previous series of combined open bladder diverticulectomy and transvesical prostatectomy.

METHODS

We compared the data of 10 consecutive patients (group 1) who underwent sequential transurethral resection of the prostate and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group 2) who underwent traditional combined open bladder diverticulectomy and transvesical prostatectomy. The following parameters were considered: size and position of the diverticulum, transrectal ultrasound adenoma volume, operative time, postoperative hemoglobin variations, analgesic requirement, complications, postoperative hospital stay, and urinary flowmetry.

RESULTS

No statistically significant differences existed between the two groups either for diverticulum size (6.8 versus 7.2 cm) or diverticula position. A significant difference was observed in the operative time (247 minutes for group 1 versus 136 minutes for group 2, P <0.0001), mean postoperative hemoglobin decrease (2.6 g/dL for group 1 and 3.9 g/dL for group 2, P = 0.001), analgesic requirement (1.3 ampoules of buprenorphine cloritrate for group 1 versus 1.8 ampoules for group 2, P = 0.45), and postoperative hospital stay (3 days for group 1 versus 9.6 days for group 2, P <0.0001). No statistically significant difference was recorded for control flowmetry. No intraoperative complications were recorded for the two groups.

CONCLUSIONS

In our series, sequential transurethral resection of the prostate and transperitoneal laparoscopic diverticulectomy for large diverticula proved to be a safe, effective, and minimally invasive procedure, despite the longer operative times compared with transvesical prostatectomy and open bladder diverticulectomy.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

OBJECTIVES

To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma.

METHODS

A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results.

RESULTS

A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters.

CONCLUSIONS

Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Metabolic effects of single-dose pamidronate administration in prostate cancer patients with bone metastases

BACKGROUND

Increased osteolysis usually accompanies sclerotic bone metastases from prostate cancer. This provides a rationale for the use of bisphosphonates to treat bone pain and prevent skeletal complications.

METHODS

The fasting urinary levels of calcium, hydroxyproline (OHPRO), pyridinolines (PYD), deoxypyridinolines (DPYD), collagen cross-linked N-telopeptide (NTX) and the serum values of calcium, total alkaline phosphatase and relevant bone isoenzyme, bone gla protein (BGP), carboxy-telopeptide of type I collagen (ICTP) and parathyroid hormone (PTH) were determined at baseline and on the 15th, 30th, 60th and 90th days after single-dose (90 mg) pamidronate administration in 35 consecutive prostate cancer patients with bone metastases. These biochemical indices and serum interleukin 6 (IL-6) were also measured after four days in the last consecutive 17 cases.

RESULTS

PYD, DPYD and NTX showed a significant decrease lasting four weeks (p<0.01, <0.01 and <0.001, respectively). OHPRO and ICTP did not change significantly. The NTX decline was greater than that of PYD and DPYD (maximum percent decrease: -71.3, -23.1 and -28.2, respectively). Bone formation markers and serum calcium did not change significantly. Serum PTH showed a rapid initial increase followed by a slow decrease (p<0.001). DPYD and NTX patterns did not correlate with changes in bone pain. As observed in the last 17 cases, the maximum osteolysis inhibition after pamidronate occurred on the fourth day after drug infusion. Serum IL-6 levels showed a short-lived decrease preceded by a transient rise on the fourth day.

CONCLUSIONS

Pamidronate is able to induce a decrease in bone resorption without significantly influencing bone formation. The maximum decrease in bone resorption occurs very early. NTX is the most sensitive bone resorption marker in bisphosphonate therapy monitoring. Changes in IL-6 but not bone resorption markers may be useful in the prediction of symptomatic response.