Morphometric analysis of the fibroadipose tissue of the female pelvis

PURPOSE

The structure of the retroperitoneal connective tissue of the female pelvis was evaluated to determine whether its spatial arrangement may have a role in supporting the pelvic viscera.

MATERIALS AND METHODS

After in situ formalin fixation the pelvic viscera with the surrounding connective tissue were removed together with the pelvic floor from 18 female cadavers 48 to 68 years old. Serial macrosections of the bladder base, cervix, lower rectum and pelvic floor complex, cut in coronal (4 cases) and horizontal (10 cases) planes, were stained with azan-Mallory, and the remaining 4 were cut in the horizontal plane and plastinated using von Hagens E12 technique. Morphometry of the retroperitoneal connective tissue was performed using a computerized system for image analysis connected through a black and white television camera to an optic microscope. The diameters of the adipose lobules and density of the connective tissue were evaluated in the proximity of the visceral adventitia and the parietal pelvic fascia, respectively.

RESULTS

The retroperitoneal connective tissue of the female pelvis consists of varying amounts of adipose tissue divided into small lobules by thin connective laminae. These laminae are connected to the visceral and parietal layers of the pelvic fascia, and are closely connected to the vascular and nervous bundle sheaths crossing the pelvis. At the level of the sacrouterine and cardinal ligaments we were unable to find any connective ligamentous structure. Only an areolar tissue was seen, which after removal of the lipids demonstrated a fibrillar structure. The mean area of the adipose lobules was smaller (average of 1.41 mm.2) near the viscera with respect to the lateral retroperitoneal connective tissue (average of 1.73 mm.2) due to greater ramification of the connective laminae.

CONCLUSIONS

In the absence of real connective ligaments the retroperitoneal connective tissue forms a 3-dimensional network of thin connective laminae that are connected to the visceral adventitia, parietal layer of the pelvic fascia and neurovascular bundles crossing the pelvis. These connective laminae are bounding adipose lobules of different size (smaller near the viscera, larger at the periphery). Overall, the retroperitoneal connective tissue constitutes an anatomical structure that, beyond the functional limits of any individual ligament, may have supporting properties.

Duplication and overexpression of the mutant allele of the MET proto-oncogene in multiple hereditary papillary renal cell tumours

Previous karyotyping showed a combined trisomy of chromosome 7 and 17 in sporadic and hereditary papillary renal cell tumours (RCT). A recent molecular analysis revealed a mutation in the MET tyrosine kinase (chromosome 7q31) in the germline of four out of seven families with hereditary papillary RCT (HPRCT). We have analysed germline cells as well as multiple tumours obtained from HPRCT families and sporadic cases for alteration of the MET tyrosine kinase and for allelic duplication at chromosome 7 and 17. We have detected a germ line mutation in the MET tyrosine kinase in one of the two families with HPRCTs and also found the same mutation in the germ line of one patient with clinically recognized multiple, bilateral papillary RCTs but without family history. The mutant MET allele is consequently duplicated and overexpressed in tumour cells indicating that duplication of the mutant MET allele is necessary before cells enter the tumorigenic pathway. The lack of germline mutation in two members of another HPRT family and duplication of the same parental allele of chromosome 7 in multiple tumours suggests that a germ line event other than mutation of MET tyrosine kinase is involved in the development of these tumours. Duplication of different alleles of chromosome 7 in sporadic and of chromosome 17 in both types of tumours excludes a germline mutation at these chromosomal sites.

Bone density and skeletal metabolism are altered in idiopathic hypercalciuria

OBJECTIVE

To study bone density in hypercalciuric patients, when classified according to the main metabolic defect.

METHODS

We studied 49 patients, aged 19-60 years with calcium stones and idiopathic hypercalcuria. All subjects underwent an evaluation of mineral metabolism and a spinal and femoral DEXA measurement. Then, patients were classified as having Fasting (FH, 31 subjects) or Absorptive (AH, 18 patients) Hypercalciuria according to a standard oral calcium load.

RESULTS

Spinal bone density was lower only in FH patients as compared to controls (p <0.001). Bone alkaline phosphatase and urine hydroxyproline were higher with respect to controls only in patients with FH (p <0.005 and p <0.015, respectively). After low calcium diet, hydroxyproline excretion continued to be higher in FH patients (p <0.05). Although in the normal range, serum and urine uric acid were higher in hypercalciuric subjects (p <0.03 and p <0.005, respectively); blood pH was lower in hypercalciuric patients than in controls (p <0.01). In FH patients urine hydroxyproline negatively correlated with spinal and femoral density (p <0.001 and p <0.005, respectively), and blood pH positively correlated with spinal density.

CONCLUSIONS

a disordered bone metabolism and bone loss are present only in patients with fasting hypercalciuria. An excessive acid load, possibly of dietary origin, might be involved as a pathogenetic factor.

Functional response of cavernosal tissue to distension

We studied rabbit isolated erectile tissue responses to changes in preload and to active tension development with norepinephrine. The effects of antagonists of endothelin-1, prostaglandins E2 and F2alpha and of nitric oxide were also tested on normal and de-endothelialized preparations. Tissue distension was found to elicit spontaneous rhythmic contractions. Increase in preload diminished the latency of the spontaneous activity and augmented the developed force. Active tension development and the inhibitor of the Na+,K+ pump, ouabain, opposed the spontaneous activity. A marked reduction in the resting tension with abolition of the spontaneous activity was observed on normal, but not on de-endothelialized tissues, following the addition of the specific prostaglandin E2 and F2alpha receptor antagonist, SC-19220. At 3 x 10(-4) M, the highest concentration used, the endothelin-A receptor antagonist BQ-123 failed to change the pattern of the spontaneous activity and the resting tension of normal tissues. The nitric oxide synthesis inhibitor, L-NAME, did not produce reliable effects. These findings point to a causal relation between cavernosal tissue distension and phasic and tonic contractions. Phasic contractions appear to be elicited by smooth muscle cells through the enzyme Na+,K+-ATPase. Increase in the resting tone could be mediated, at least in part, by the endothelium, through the release of prostaglandins E2 and/or F2alpha but not of endothelins. We discuss the hypothesis that, in cavernosal tissue, mechanotransduction of distension to contractile responses is an important determinant of detumescence.

Structural and ultrastructural changes in ileal neobladder mucosa: a 7-year follow-up

OBJECTIVE

To investigate the long-term morphological changes in the intestinal segment used to create an orthotopic ileal neobladder.

MATERIALS AND METHODS

Periodic endoscopy with biopsy of the ileal mucosa was performed in 90 patients 3-84 months after radical cystectomy and urinary diversion via an orthotopic neobladder. Three cold-cup biopsies were taken from each patient and mucosal specimens processed for light and electronic microscopy.

RESULTS

Early changes (up to 1 year after surgery) comprised a marked shortening of the villi with loss of microvilli. After 4 years, the prevalent finding was of flat, avillous epithelium that tended to stratify in some areas. The avillous areas were mixed with islets of villous mucosa. There was no dysplasia or malignancy in any of the 90 patients.

CONCLUSIONS

Prolonged contact with urine elicited a biphasic response in the ileal mucosa, i.e. an early inflammatory phase, ascribed to the noxious action of urine, followed by a regressive phase in which the epithelium tended to assume a morphology similar to the urothelium. The atrophic changes were almost totally completed after 4 years, although areas with marked modifications alternated with others where the morphology was normal, even many years after surgery. Late changes in the ileal neobladder mucosa appear to be an expression of a functional adaptation of the mucosa to the new environment.

Neuropsychologic effects of carotid endarterectomy

This study assessed neuropsychologic changes after internal carotid endarterectomy using a design that limited the confounding effects of surgical and anesthesiological stress. Twenty-eight patients (mean age = 65.9 years, SD = 8.4, range 45-79), underwent extensive neuropsychological assessment before and on the seventh day after carotid endarterectomy for symptomatic carotid stenosis greater than 75%. A similarly assessed control group of 30 patients underwent elective orthopaedic surgery. A third cognitive assessment was performed 4 months postoperatively on a subgroup of the study patients. No significant cognitive change occurred in the control group. The study patients showed significant improvement in verbal memory, constructive abilities, verbal attainment, and visual attention; a trend towards further improvement of verbal functions was evident at the late postoperative assessment. No side-specific cognitive change was observed. In conclusion, carotid endarterectomy performed for currently accepted indications significantly improves several cognitive functions.

Bone density and skeletal metabolism in patients with orthotopic ileal neobladder

The interposition of a bowel segment as a bladder substitute into the urinary tract may result in impaired calcium metabolism. We studied 25 male patients (aged 45 to 77 yr) who had undergone a Vescica Ileale Padovana (VIP) reconstruction following cystectomy 29 to 75 mo before. Bone mineral density of the spine and femur was measured by dual x-ray absorptiometry. Blood and 24-h urine samples were analyzed for the main parameters of bone metabolism. Sixteen healthy men were enrolled as a control group. Although blood pH did not differ between patients and control subjects, VIP subjects showed lower levels of plasma HCO3- (P < 0.005) and higher serum chloride (P < 0.001). Bone alkaline phosphatase was higher (P < 0.001), and urine calcium, phosphate, and creatinine levels were lower in VIP patients (P < 0.01, P < 0.01, and P < 0.05, respectively). Bone mineral density at the femoral neck (P < 0.03) and Ward's triangle (P < 0.05) was decreased in VIP patients. When subdivided according to time since operation, patients who had the ileal neobladder implanted for a shorter period of time showed lower blood pH (P < 0.03) and urine calcium (P < 0.05) levels and higher urinary hydroxyproline (P < 0.02). Duration of the ileal neobladder was positively correlated with PTH (r = 0.46, P < 0.03) and blood pH (r = 0.47, P < 0.02). Furthermore, pH values were positively correlated with urine calcium (r = 0.48, P < 0.02). In conclusion, in patients with ileal neobladder, a mild metabolic acidosis is responsible for an increased bone turnover and lower bone mass. Moreover, a decrease over time in the absorption capacity of the ileal pouch might result in calcium malabsorption, which represents an additional risk factor for reduced bone mass in these patients.

[Vesica ileale Padovana (VIP): surgical technique, long-term functional evaluation, complications and management]

OBJECTIVE

An original technique for complete bladder replacement using an ileal segment--the VIP pouch--is described. The long-term functional results and early and late complications are presented.

METHODS

The records of 209 VIPs performed following radical cystectomy for invasive bladder cancer from 1987 through 1995 were reviewed. Follow-up ranged from 6 to 87 months (mean: 24 mo.); the age of the patients ranged from 35 to 76 years (mean: 59.6 yrs.).

RESULTS

188 patients with a follow-up of at least 6 months have been evaluated. There was 1 postoperative death from massive pulmonary embolism, 23 pts. died from tumor progression and 4 are still alive with metastases. Early complications were observed in 10.5% of the pts., comprising 9 cases of prolonged ileus (5 functional and 4 obstructive), 3 pelvic hematomas, 2 deep venous thrombosis and 2 fistulas between the enteric anastomosis and the VIP pouch. Late complications were observed in 39.5%, in particular, 28 uretero-ileal stenosis (15%), 21 urethro-ileal stenosis (11%) and 15 laparoceles (8%). Clinically relevant metabolic disturbance has not been observed. Complete daytime continence was achieved in more than 90% of the cases and night-time continence was observed in 75% of the patients. The mean VIP manometric capacity was around 400 ml with low pressure during reservoir emptying; 39 patients (20%), showed voiding problems with a mean postmicturition residual of 150 ml (3 pts. require clean intermittent self-catheterization).

CONCLUSIONS

VIP offers a simple and easy-to-perform surgical technique to provide a good capacity, low pressure, non refluxing reservoir employing only a 40 cm. ileal segment. The clinical and urodynamic results are good and offer high quality of life to patients undergoing cystectomy. The overall rate of late complications is fairly high, although conservative management is effective in most cases.

Gene expression and autoradiographic localization of endothelin-1 and its receptors A and B in the different zones of the normal human prostate

PURPOSE

To investigate the gene expression and tissue distribution of prepro Endothelin-1 (ET-1), Endothelin Converting Enzyme (hECE-1), and ETA and ETB receptors in the central (CZ), transition (TZ) and peripheral (PZ) zones of normal human prostates.

MATERIALS AND METHODS

Sections of the different zones of histologically normal prostates from 35 year-old men were obtained and autoradiographically studied with 125I ET-1 with and without the ETA antagonist BQ-123, the ETB agonists sarafotoxin 6C, and excess cold ET-1. Specimens from PZ and CZ and DU145 and PC3 human prostate cancer cell lines were also investigated by reverse transcription (RT)-PCR.

RESULTS

The mRNAs of all genes were detected in all specimens examined. No ETB expression was found in either cell lines. Specific intense 125I ET-1 binding with clear-cut differences among zones was found. In the CZ the main subtype in the glandular stroma and epithelium was the ETA and ETB, respectively, in the PZ the opposite was true. In PZ, the ETA receptors were detected on the glandular epithelium; in the TZ both receptor subtypes were only in the stroma.

CONCLUSIONS

These receptors' zonal distribution differences may be relevant for the pathogenesis of BPH and prostatic cancer.

Time-dependent remodeling of the bladder wall in growing rabbits after partial outlet obstruction

PURPOSE

We asked whether a urethral constriction gradually developed during growth would give rise to a structural remodeling of the bladder wall distinct from that of the mature rabbits in terms of cellular response.

MATERIALS AND METHODS

We examined the serosa and detrusor muscle in immature rabbits whose urethra was obstructed at 30 days postnatal and studied 7 to 30 days after partial outlet obstruction. Morphometry, bromo-deoxyuridine (BrdU) incorporation, Western blotting and immunocytochemical staining with a panel of monoclonal antibodies specific to selected cytoskeletal, cytocontractile and membrane-related proteins unique to non-muscle and smooth muscle cells (SMC) were used to analyze the effects of obstruction on the differentiation pattern.

RESULTS

In comparison with results in adult obstructed bladders, we have found that in growing rabbits: (1) the cell conversion from fibroblasts to SMC, occurring within the 'extrinsic' region of serosal thickening, takes place earlier; (2) newly formed SMC are localized exclusively to the thickened serosa, and can group in bundles depending on the density of the regional innervation; (3) the peak level of BrdU incorporation is more elevated than in the adult bladder wall; and (4) change in the phenotypic profile of SMC of detrusor muscle is delayed.

CONCLUSION

These data indicate that the basic features of structural remodeling in the two models are similar, though partial outlet obstruction produced in growing animals accelerates the fibroblast conversion to SMC and their spatial, differentiation-specific arrangement in the serosa. The late phenotypic changes in obstructed detrusor muscle correlate with the decline of the DNA synthesis level after an initial burst and strongly suggest that newly formed SMC in the serosa do not derive from pre-existing SMC.

Chronic treatment with cyclosporine A in New Zealand rabbit: aortic and erectile tissue alterations

Transplanted patients frequently present erectile impotence. In order to test any interference by cyclosporine A (CsA), which is commonly used in the post-transplantation management, we investigated the in vitro contractile and relaxant responses of corpus cavernosum and aorta from rabbits chronically treated with CsA. Male New Zealand White rabbits 6 months of age were treated with CsA (25 mg/kg per day s.c.) or solvent (corn oil) for 3 weeks. Descending thoracic aorta and erectile tissue were studied in vitro at the end of treatment. Isometric tension was recorded. In thoracic aorta, noradrenaline (0.1-30 mM) induced a concentration-dependent contraction with no difference between the two groups. Acetylcholine (30 nM-3 mM) produced relaxation (52 +/- 4% at 1 mM) that was significantly reduced in comparison to controls (67 +/- 4%, P < 0.05). ATP (3-10 mM) relaxation was not significantly different (maximal 78 +/- 10% and 62 +/- 12% in CsA-treated and controls). The relaxation produced by sodium nitrite was reduced in CsA-treated rabbits (at 10 mM and 0.1 mM concentrations). In erectile tissue, no significant variation in the response of isolated erectile tissue to the above drugs was observed between CsA-treated and control animals. These data indicate that chronic treatment with CsA in rabbits, despite alteration of the in vitro response of thoracic aorta, does not directly influence the function of penile tissue with relaxants.

Characterization of in vitro relaxant mechanisms in erectile tissue from rabbits of different ages

In the present study we investigated the in vitro relaxant response of erectile tissue obtained from rabbits of different ages (3, 7 and 24 months) in order to detect the progression with age of cavernosal activity in response to substances acting via endothelium-dependent or -independent mechanisms. Noradrenaline induced a concentration-dependent contraction (0.1 microM-3 mM), with an increase in the contractility in the 24-month-old group. Acetylcholine produced a concentration-dependent relaxant effect in the three age groups, with a reduction of the maximal relaxant effect in older animals. ATP (10 microM-1 mM) and adenosine (10 microM-1 mM) induced a concentration-dependent relaxant effect that was higher in the older group. The presence of the NO2-synthase inhibitor N omega-nitro-L-arginine methyl ester (L-NAME) (0.1 mM) or of the P2-purinoceptor antagonist suramin did not affect ATP relaxation. Relaxation induced by sodium nitrite and nifedipine was reduced in older animals. In conclusion, aging selectively alters the in vitro responsiveness of rabbit erectile tissue. Purinergic system remains more active despite a decrease in the maximal endothelial cholinergic activity and the direct smooth muscle relaxant component.

Gonadal atrophy as a cause of thymic hyperplasia after chemotherapy

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Self-injection devices for intracavernosal pharmacotherapy: operational classification and safety considerations

Several self-injection devices have been recently proposed as an aid to home intracavernosal self-injection treatment for erectile dysfunction, with the purpose of allowing an easier drug administration, decreasing the artificiality of intracavernosal pharmacotheraphy, with the overall goal of increasing the acceptability of this treatment. We propose a classification of these devices according to the type of mechanical impact on the cavernosal tissue: self-injection pens, allowing for manual needle insertion and manual drug delivery; autoinsertors, with automatic needle insertion and manual drug delivery, and autoinjectors, that provide both automatic needle insertion and automatic drug delivery. The use of autoinjectors bears two theoretical risks: extra-corporal drug delivery in cases of wrong injection site, and trabecular damage due to high delivery pressure. In one device pressures 15 times higher the values reached by manual injection, and statistically higher than pressures obtained by maximal strength manual injection, were observed in an in-vitro investigation. Specific studies are needed to define a threshold pressure value for trabecular damage in the flaccid state; accordingly, information on autoinjector developed pressures should be provided by manufacturers. Clinical studies with adequate follow-up are needed as well, to verify the risk of autoinjector-induced extracorporal drug delivery, and the occurrence of intracavernosal nodules or penile curvature, compared to manual self-injection.

Cytoskeletal and cytocontractile protein composition of stromal tissue in normal, hyperplastic, and neoplastic human prostate. An immunocytochemical study with monoclonal antibodies

Monoclonal antibodies specific for protein markers of smooth muscle and nonmuscle cell differentiation were applied to cryosections of normal, hyperplastic, and neoplastic human prostate specimens in order to determine whether differences in the distribution of target antigens could be detected among the various tissues. Immunofluorescence assays showed that vimentin, desmin, smooth-muscle-type alpha-actin, and both smooth muscle and nonmuscle myosin heavy chains do not change their patterns of labeling in the stromas of normal, BPH, and carcinomatous prostates. By contrast, cytokeratin 18, a differentiation marker of simple epithelia, and to a lesser extent cytokeratin 8, was consistently found in stromal tissue of the "transition zone", but only scarcely in the stroma of the "peripheral zone" from normal prostate, and was completely unexpressed in benign hyperplasia. Prostatic carcinoma from the "peripheral zone" expressed this cytoskeletal component only in trace amounts. Moreover, in prostate showing coexistence of hyperplasia and neoplasia (in the "peripheral zone"), the stroma of BPH closely resembled the stroma surrounding the carcinoma; that is, it was completely unreactive with the anti-cytokeratin 18 antibody. Expression of cytokeratins in extraepithelial tissues has been previously correlated with the achievement of a proliferative state, notably in embryogenesis, in tissue regeneration, and in various pathological forms of proliferation and growth, including some tumors of mesenchymal origin. Our results indicate the following: (1) cells in the stromal tissue of normal prostate are of smooth muscle type and are heterogeneous as concerns cytokeratin distribution; (2) we show, for the first time, the existence of a marker that is differentially distributed in the "transition" versus "peripheral" zone; (3) the expression of cytokeratins in the stroma is lost with the development of hyperplasia and only partially recovers with neoplasia; (4) the pattern of stromal tissue, concerning cytokeratin 18 expression, does not change with different BPH locations ("transition" versus "peripheral" zone); and (5) contrary to expectations, cytokeratin 18 expression disappears in conditions presumably involving stromal cell proliferation.

Proliferation of submesothelial mesenchymal cells during early phase of serosal thickening in the rabbit bladder is accompanied by transient keratin 18 expression

Partial outlet obstruction of the rabbit bladder induces serosal thickening and smooth muscle (SM) hypertrophy. Within thickened serosa, submesothelial (mesenchymal) cells differentiate into SM cells after 30 days of obstruction[S. Buoro et al. Lab. Invest. 69, 589-602, 1993]. Here, we show that submesothelial cells transiently express keratin (K) 18 but not K8 soon after obstruction. We investigated a possible relationship between keratin expression and cell proliferation/differentiation in vivo and in vitro. The results of this study indicate that expression of K18 is spatiotemporally related to the pattern of cell proliferation with respect to the localization of an elastic membrane which divides the thickened serosa into an "extrinsic" and an "intrinsic" region. Moreover, K18 is not present in bladder mesenchyma during early development, indicating that its expression in the adult is not attributable to a dedifferentiation process. However, simultaneous K18, K8, and desmoplakin (DP) expression can be induced in normal and thickened serosa upon treatment with bromo-deoxyuridine. Our results indicate that K18 is a marker of proliferating mesenchymal cells in rabbit serosa, whereas the combined expression of K18, K8, and DP might be related to the hypothesized alterations in the stability of gene expression. A model is proposed in which keratin-containing submesothelial cells can act as a "transit" cell phenotype involved in both regenerating mesothelial cells and formation of SM cells.

Conclusions

— The progress made in the diagnosis and therapeutic possibilities of this type of tumour is underlined. Thanks to more precise pre-operative knowledge and staging of the neoplasm, nowadays a more selective as well as less invasive therapy can be applied (traditional, endoscopic and percutaneous surgery). In many cases topical pharmacological therapy can overcome recurrences of the disease while in particularly serious, extensive cases, extreme conservative surgery allows easy endoscopic access for endocavitary treatment during follow-up in order to avoid dialysis. There are many therapeutic solutions and methods for this type of tumour, but they must be studied in depth to be able to alternate them wisely, regulating the therapy according to the course of the disease.

Nutritional assessment: a primary component of multidimensional geriatric assessment in the acute care setting

OBJECTIVE

To test the prognostic role of nutritional variables as a component of geriatric multidimensional assessment and to study the effect of hospitalization on nutritional status.

DESIGN

Validation cohort study: multidimensional assessment on admission and at discharge and a weekly nutritional assessment.

SETTING

General Medicine and Geriatrics wards in an acute-care university hospital.

PATIENTS

A consecutive sample of 302 patients aged 79 +/- 6 years, range 70-96 years.

MAIN OUTCOME MEASURES

Mortality, longstay (> 29 days), loss of lean body mass as expressed by a negative change in mid-arm muscle circumference (MAMC).

RESULTS

Incidence of mortality, longstay, and decreased MAMC was 6.9%, 24.8%, and 64.2%, respectively. According to logistic regression analysis, mortality was independently predicted by preadmission dependency in at least one Activity of Daily Living (odds ratio = 2.08, confidence limits = 1.19-3.65), clinical diagnosis of malnutrition (OR = 1.89, CL = 1.11-3.21), serum albumin < 3.5 g/dL (OR = 1.82, CL = 1.06-3.14). This predictive model allowed us to recognize 75% of the patients at risk of death by targeting 23% of the population. Longstay was independently predicted by stroke (OR = 1.54, CL = 1.01-2.35), clinical diagnosis of malnutrition (OR = 1.41, CL = 1.04-1.93), and more than five comorbid diseases (OR = 1.39, CL = 1.01-1.94). Dependency in at least one ADL was the only independent predictor of decreased MAMC (OR = 1.71, CL = 1.27-2.30).

CONCLUSIONS

Nutrition variables are a cardinal component of multidimensional assessment in the acute-care setting. Nutritional status deteriorates during the hospital stay, mostly in physically dependent patients.

Transitional cell carcinoma of the upper urinary tract: Follow-up and prognostic factors

— Of the 176 patients treated in our Institute over the last 16 years for upper tract transitional cell carcinoma (UTTCC), 155 were included in this study, 97 of whom had undergone nephroureterectomy, 28 conservative surgery and 30 endourologic treatment. The overall survival rate at 5 and 10 years was 73% and 58%, respectively. Univariate analysis of overall survival rate (O.S.) and disease-free survival rate (D.F.S.) showed no difference between patients with superficial and with invasive tumours, while multivariate analysis highlighted a difference. No difference was evident upon univariate and multivariate analysis of the patients with superficial tumours who underwent conservative (19) vs. radical (45) surgery. The same can be said for the so-called good prognosis tumours (pTa-T1-G2) and poor prognosis tumours (pT1-G3, pT2-4, G2-3) submitted to radical surgery. Overall survival was better in patients with no recurrent tumours compared to those with recurrences; furthermore prognosis was worse for patients with more than 2 recurrences. Tumour site, mono or multifocality and associated bladder tumour did not influence prognosis. Our experience confirms the basic importance of grade as a prognostic factor for UTTCC and the favourable prognosis for patients with superficial tumours, regardless of surgical technique. A rigid follow-up is mandatory for patients with more than 2 recurrences.

Randomized open labelled comparative study of the efficacy, safety and tolerability of leuprorelin acetate 1M and 3M depot in patients with advanced prostatic cancer

OBJECTIVES

In a European, prospective, 1:2 randomized phase II multicentre study, 237 patients with advanced or metastatic prostate cancer were treated with either the 1M- (80 patients) or 3M-depot formulation (157 patients) of leuprorelin acetate for 9 months to compare efficacy and safety.

METHODS

Standard clinical investigations and methods were employed in the study. Leuprorelin levels were determined using a specially modified RIA.

RESULTS

The two formulations produced virtually identical effects with a pronounced fall in testosterone and gonadotropin serum levels and a marked reduction in PSA levels. After 9 months' treatment, PSA was normalized (< or = 4 ng/ml) in 65.2 and 66.1% of the 1M and 3M depot patients, respectively. The best response to 1M vs. 3M depot during the study was as follows: complete remission in 5 vs. 5.7%, partial remission in 36.3 vs. 33.8% and stabilization in 40.0 vs. 40.8%. The main side effects of both formulations were related to androgen deprivation.

CONCLUSIONS

Comparable results were recorded for the two formulations of leuprorelin acetate in terms of clinical response, endocrine effects and tolerability. The newly developed leuprorelin acetate 3M depot, as a refinement of the established 1M depot, offers an opportunity to improve patient compliance and provides individualized and optimized, patient-orientated treatment by reducing the number of injections to four per year.

Is stage pT4a (D1) reliable in assessing transitional cell carcinoma involvement of the prostate in patients with a concurrent bladder cancer? A necessary distinction for contiguous or noncontiguous involvement

PURPOSE

A series of patients with concurrent transitional cell carcinoma involvement of the prostate and bladder is reviewed to define the impact of prostate involvement pathways and the degree of prostate invasion on survival rate.

MATERIALS AND METHODS

A total of 72 patients who underwent radical cystectomy for pathological stage pT4a (D1) cancer was divided into contiguous--stage pT4a, transitional cell carcinoma of the bladder extended into the prostate through the bladder wall and noncontiguous--stage pT4a simultaneous transitional cell carcinoma of the prostate and bladder carcinoma that did not directly infiltrate into the prostate through the bladder wall. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement, stromal invasion and extracapsular extension. The survival rate was estimated by the Kaplan-Meier and Cox proportional hazards methods. Comparisons between curves were performed by univariate log rank and multivariate L-ratio tests.

RESULTS

The overall 5-year survival rate for stage pT4a was 21.5% (median followup 64 months). Furthermore, 46% and 7% of patients in noncontiguous and contiguous pT4a groups, respectively, were estimated to be alive (p < 0.000). Those with positive nodes experienced a poor outcome in both groups. Of patients with noncontiguous pT4a stage 100% with urethral mucosal involvement, 50% with ductal/acinar involvement and 40% with stromal invasion were estimated to be alive. The major prognostic factors were bladder tumor stage, nodal involvement and degree of prostate invasion.

CONCLUSIONS

The invasion pathways of the prostate in patients with transitional cell bladder carcinoma have a statistically significant prognostic role. Contiguous and noncontiguous involvements are 2 distinct clinicopathological features and they should not be included in the same stage. In the noncontiguous stage pT4a group bladder and prostate transitional cell carcinoma should be separately staged, and prostate involvement also should be staged according to invasion degree.

[Malnutrition in the acute care hospital: a very common problem]

The adequacy of caloric intake of geriatric patients in medical and surgical wards in the acute care hospital was assessed in a prospective, observational study. Fifty-one surgical and 80 medical nonterminal patients aged over 70 years underwent a multidimensional assessment on admission and a nutritional reassessment on discharge. The average daily caloric intake was also measured. Patients were divided into two groups according to whether the ratio of the actual to the needed caloric intake was inferior to 40% or not, and their differences, with regard to baseline values, were assessed. Patients whose caloric intake was inferior to 40% of the needed were older than the remaining ones (79.4 +/- 6.6 vs 76.6 +/- 4.9 years, p < 0.05), had higher prevalence of preadmission functional dependency (21.6% vs 15%, p < 0.001), lower body mass index (22.9 +/- 5.4 vs 24.8 +/- 3.9, p < 0.004) and higher comorbidity (coexisting diseases: 3.6 +/- 1.9 vs 2.8 +/- 1.6, p < 0.02) on admission. In conclusion, a simple assessment on admission allows targeting geriatric patients at risk for in-hospital starvation. No difference exists between surgical and medical wards in the quality of nutritional support.