Extended Lymphadenectomy during Radical Nephrectomy for Renal Cell Carcinoma. A Prospective Study

The role and extension of lymphadenectomy during radical nephrectomy for renal cell cancer still remain a matter of debate. From June 1989 to March 1992, 137 consecutive extended lymphadenectomies were performed in patients undergoing radical nephrectomy for renal cell cancer at the Department of Urology of Padua. Ten patients (7.3%) had a pathologically proved nodal involvement. Only 2 patients had a distant nodal involvement in the absence of metastases to hilar nodes. Both patients with microscopic metastases had massive involvement of hilar nodes. Due to short median follow-up no clinical consideration on survival can be drawn.

[Benign prostatic hypertrophy: the therapeutic options]

BPH is a very diffuse condition among males increasing in incidence with the age. This explains the large interest in the evaluation of the different strategies concerning BPH treatment. The gold standard has still to be considered the transurethral resection of the prostate which all the other treatments must be compared to. More recently as alternatives to the invasive therapy, so called minimally invasive treatments have been proposed (thermotherapy, prostate dilatation, intraprostatic stents) whose real significance is not completely evaluable yet. As far as medical treatment is concerned, phyto-therapeutic agents have been partially replaced by different substances (alfa- blockers; 5-alfa reductase blockers) that are expected to have a promising future.

Vesico-vaginal fistulas

— Fifty-four patients were treated at the Department of Urology, University of Padova for vesico-vaginal fistulas from May 1978 to June 1992. Twenty-six were operated by suprapubic transvesical approach with no long-term relapse. Twenty-eight patients presented complex vesico-vaginal fistulas: 23 were treated by single-stage transvesical repair. In 5 cases a urinary diversion was performed, ileal in 2 cases, colonic in 3. Only 1 case of relapse was observed (3.5%) in this group, and the patient was successfully re-operated. Authors underline classificative and etiologic factors involved in vesico-vaginal fistulas. Diagnostic and technical details of suprapubic transvesical repair are discussed.

Female urethral diverticula

— Urethral diverticula are rarely found clinically, partly due to a lack of adequate examination by the urologist. The etiopathogenesis of this pathology is controversial, but the tendency at present is towards the hypothesis of infection. Over a period of 15 years (1976–1991) 97 cases of female urethral diverticula were treated in the Urological Clinics of the Universities of Padua and Brescia and the Urology Units of Treviso and Bergamo. 3 patients had forms of micro-diverticulosis, 89 had single diverticula and 5 multiple diverticulosis. Treatment for the 3 cases of micro-diverticulosis consisted of calibrating the urethra and a meatotomy, while 2 marsupializations and 92 diverticulectomies were performed on the remaining patients: there were no particular post-operatve complications. First-choice treatment by all units was the “typical excision”, which despite being laborious is “anatomic” and “economic” in the sense of sparing structures. The authors underline the fact that treatment must be based on a precise choice of indications and accurate surgery, aimed not only at obtaining immediate optimal results but also at preserving maximum urethral anatomo-functional integrity in case of future pathologies involving the distal area of the urinary tract.

Round Table: “Urological surgery by vaginal approach” Introduction

— Urologists should regard the female lower urinary tract not as a separate entity, but as an inseparable genito-urinary area both from the therapeutic and physiologic point of view. The necessity for gynaecologists and urologists to co-operate is also underlined.

Clinical value of pathologic changes after intravesical BCG therapy of superficial bladder cancer

Bladder pathologic features related to intravesical bacillus Calmette-Guerin (BCG) therapy in superficial bladder cancer (Ta, T1, Tis) were evaluated and related to clinical outcome. A total of 105 patients were treated with 75 mg Pasteur BCG weekly for six consecutive weeks. When tumor was not demonstrated a maintenance course was given. An additional six-week course was given when tumor recurrence or persistence, without progression, was observed after the induction course. An inflammatory change in the bladder was the most common pathologic finding. Granuloma was the only specific BCG-related feature and did not appear to be a prognostic factor because of low incidence (24%) and lack of correlation with clinical course. Dysplasia occurred more frequently (57%) in nonresponder patients and (26%) in responder patients, often heralding recurrence of tumor. All patients showing concurrent squamous and/or glandular metaplasia were unresponsive to BCG therapy. Histology and cytology did not correlate perfectly: cytology was ineffective in low-grade tumors and improved diagnostic accuracy, particularly when dysplasia was histologically evident.

Case Report: A Patient with Hodgkin's Disease after Treatment for Testicular Cancer

A young patient developed Hodgkin's disease 11 years after surgical, chemotherapeutic and radiation treatment for stage IIIA embryonal carcinoma of the testis. The importance is stressed of establishing a tissue diagnosis when there is an unexpected course of the disease.

Role of Open Surgery

According to anatomo-morphologic studies, the authors define the role of open surgery in enucleating an adenoma, which is only partially removed with endoscopy, especially if large. Retrospective studies also show a higher probability of a further operation after endoscopy rather than after surgery, with a greater mortality risk due to cardiovascular reasons. In the four-year period from 1987–90, the joint experience of the University Urological Clinics of Padua and Brescia and the Hospital Urological Departments of Bergamo and Treviso, shows that out of 3851 operations, endoscopic treatment was carried out in 84% and surgery in 16%, with a marked prevalence of retropubic adenomectomy (84% of cases). 1989 was taken as a sample year and surgery was performed in 160 out of 935 cases, with excellent results in 87% of the patients. The authors, on the basis of their personal experience, results and literature, confirm that surgical treatment of prostatic hypertrophy is still valid.

The Role of Transurethral Surgery

313 TURP were performed at the four institutions (University Departments of Padua and Brescia and Hospital Departments of Treviso and Bergamo) between 1987 and 1990. 85% of patients with obstructive prostatic hypertrophy underwent TURP. A metallic sheath (24–25ch.) was routinely used, while Iglesias or Reuter Trocar were chosen in a few selected cases. 200 patients (50 from each institution) operated in 1989 were evaluated: detrusor contractility, deficiency and irritative symptoms (urgency-frequency) were also Present in 22% of patients. Follow up shows that procedures to remove the obstruction do not always cure irritative symptoms. No major complications or deaths are reported. 55 Patients (80%) were treated endoscopically for bladder stones and 5 patients (28%) underwent TURP followed by surgical diverticulectomy. BPH and superficial bladder tumors, when present together, are preferably treated separately to avoid neoplastic contamination of the prostatic fossa.

Round Table: “Benign Prostatic Hypertrophy: Modern Aspects” Introduction

BPH represents a multiform disease in its different aspects: development, progression, clinical presentation and response to treatment. This partially derives from the complex structure of the prostatic gland where stromal and epithelial components influence each other even by means of other factors (like EGF). The same complexity can be found in the clinical evaluation of obstruction where different factors are involved (mechanical, dynamic and muscular). The aim of this Round Table is to clarify some of the above mentioned aspects

Renal cell carcinoma with extension into the inferior vena cava: problems in diagnosis, staging and treatment

Management of renal cell carcinoma with extension into the vena cava is one of the highest challenges in urology. The delineation of the upper level of the endocaval thrombus, its possible extension into the hepatic veins and possible involvement of the caval wall are crucial points and dictate the operative strategy. From 1978 to 1989, at the Department of Urology of the University of Padua, 29 patients with renal cell carcinoma and caval extension were submitted to surgery. Seventeen patients were staged V2 according to the UICC TNM Staging System 1983, 2 patients V3 and 10 V4. The median patient age was 57 years and the male:female ratio was 1.9:1. A complete thrombus removal was accomplished in all patients. In 2 patients, a caval resection was necessary. Five patients died during the perioperative period. The patient survival rate was comparable to that of T3N0M0-staged cases. Survival rates at 1 and 4 years were, respectively, 96.8 and 40% for V2 cases, 100 and 100% for V3, 85.7 and 40% for V4. It seems, therefore, that in patients with locoregional disease and satisfactory conditions, the presence of vascular invasion did not lead to a worst prognosis. By itself, the extent of the caval thrombus seems not to influence the prognosis.

BCG in superficial bladder cancer: a review of phase III European trials

Shortly after Morales' original report, several phase II trials confirmed the effectiveness of intravesical bacillus Calmette-Guérin (BCG) in superficial bladder cancer therapy. Concerns have been expressed about the toxicity related to this new therapeutic modality. These phase II trial data led European urologists to try to answer some questions related to BCG therapy, such as the optimal schedule and dose, the most effective BCG strain and the value of BCG compared with current chemotherapeutic drugs. To date, phase III trials have shown that BCG is more effective than thiotepa and doxorubicin in reducing tumour recurrences and progression and that BCG seems to be as effective as mitomycin C. Toxicity is significantly higher with BCG compared to chemotherapeutic drugs; no strain of BCG seems to be superior in this respect. Further studies are required to identify the optimal schedule and dose, as well as the best therapeutic efficacy/toxicity ratio.

Mitomycin C in multiple superficial bladder tumors: short-term therapy, long-term results

At the Institute of Urology, University of Padova, 125 patients with multifocal superficial bladder cancer underwent treatment with intravesical Mitomycin C (MMC; 1 weekly instillation of 40 mg for 8 consecutive weeks) between January 1982 and December 1988. Eighty-four patients had multifocal papillary tumors (stages Ta-T1) and 41 patients had carcinoma in situ of the bladder. At 6 and 36 months the tumor free percentage in the group with papillary tumors was 69 and 36%, respectively; for carcinoma in situ the complete response percentage at the same intervals was 80 and 36%. Thirty-one patients previously unsuccessfully treated with adriamycin did not show any difference compared to untreated ones. The authors emphasize the efficacy and low toxicity of intravesical MMC in multiple superficial bladder cancer. The possibility of long-term relapse suggests maintenance therapy.

Preoperative and postoperative evaluation of prostate-specific antigen in localized prostatic cancer treated by radical prostatectomy

Preoperative prostate-specific antigen (PSA) values were determined in 73 patients with clinically localized prostatic cancer and candidates for a radical procedure. Correlation of preoperative PSA with a final pathological stage was attempted. Only in 44.8% of our 22 patients with organ-confined disease was the PSA value within the normal range; in 17.3% of cases PSA values were higher than 20 ng/ml. 18.2% of the patients with locally advanced disease showed normal PSA values, while 45.5% had concentrations above 20 ng/ml. In the case of lymph node involvement, PSA values were normal in 22.7% of the cases. Our data indicate that no strict relationship can be suggested between PSA and the final pathological stage and grading of the tumor in patients who underwent radical prostatectomy.

DNA content, nuclear grading and early tumor progression in renal cell cancer: a prospective study on frozen specimens

Renal cell carcinoma is a neoplasia with an unpredictable behavior. Nuclear grade and pathologic stage are widely accepted as valuable prognostic factors. More recently DNA content has been proposed as an adjunctive parameter of the clinical course of the disease. In order to substantiate these findings we prospectively analyzed 36 frozen specimens from patients submitted to radical nephrectomy for renal cell carcinoma. The study population had a 2:1 male/female ratio with a median age of 57 years. Six of 33 patients died of tumor progression with a median survival time of 11 months. The tumor DNA index (DI) ranged from 0.86 to 2.06 with a mean coefficient of variation of 4.59. Ten cases (27.8%) had a diploid DNA content, whereas 26 (72.2%) showed a distinct aneuploid population. In 10 cases different DI values were observed in different samples from the same tumor. Aneuploidy was significantly associated with advanced pathologic stages, high nuclear grade, and tumor progression.

A low dose bacillus Calmette-Guerin regimen in superficial bladder cancer therapy: is it effective?

Bacillus Calmette-Guerin (BCG) intravesical therapy represents a major advance in the treatment of superficial transitional cell carcinoma of the bladder. To date, however, the optimal treatment schedule must be defined and the toxicity related to the treatment is significant. The preliminary results of a randomized ongoing study performed to evaluate the effectiveness and relative toxicity of a low dose (75 mg.) BCG regimen in the treatment of superficial bladder cancer therapy are reported. A total of 126 patients (70 for prophylaxis of recurrent stages Ta and T1 papillary tumors and 56 for treatment of carcinoma in situ or with microinfiltration of the subepithelial connective tissue) underwent a 6-week course of 75 mg. BCG (Pasteur vaccine). An additional course was given in patients who failed to respond to the induction course. Maintenance therapy was administered in complete responders monthly for 1 year and then quarterly for 1 year. The prophylaxis group (transurethral resection plus BCG) was randomized versus transurethral resection alone (63 patients, control group). A complete response in the prophylaxis, control and therapy groups was observed in 74, 17 and 57% of the patients, respectively, while 4, 17 and 12.5%, respectively, experienced tumor progression. The additional course of therapy increased the response rate. On the contrary, previous unsuccessful intravesical chemotherapy did not affect the response rate. In regard to toxicity, irritative disturbances (27%) and fever (17%) appeared to be significantly decreased compared with the rates reported in the literature. No major complications were experienced. In conclusion, a low dose (75 mg.) Pasteur strain BCG regimen was effective as prophylaxis against recurrent superficial papillary tumors and as treatment of carcinoma in situ or with microinfiltration of the subepithelial connective tissue. Toxicity related to the treatment appeared to be low.

Is there a relationship between benign prostatic hyperplasia and prostatic cancer?

No definite relationship can be demonstrated between benign prostatic hyperplasia (BPH) and prostatic cancer on the basis of various anatomic and morphologic features. However, interesting recent observations suggest a link between BPH and prostate cancer. Clinically, the simultaneous presence of benign and malignant disease is observed quite often, and this coexistence is bound to increase with the age of patients. Possible intermediate forms between BPH and early cancer have been investigated. Two premalignant lesions have been identified: atypical adenomatous hyperplasia and prostatic intraepithelial neoplasia.

Bilateral renal cell carcinoma with caval invasion in a woman with duplicated inferior vena cava

Workup of a woman presenting with a palpable right flank mass, detected bilateral renal solid lesions, later proved to be renal cell carcinomas, and caval invasion in the presence of duplicated inferior vena cava. This association does not appear to have been previously described. The patient underwent right radical nephrectomy, cavotomy and auriculotomy with caval thrombus removal and delayed enucleation of left renal masses and left adrenalectomy. Eighteen months after surgery the patient is alive and without local and distant recurrence.

Results of contemporary radical cystectomy for invasive bladder cancer: a clinicopathological study with an emphasis on the inadequacy of the tumor, nodes and metastases classification

We reviewed 261 patients who underwent a radical operation at a single institution as definitive treatment of invasive bladder cancer to evaluate the survival and accuracy of the tumor, nodes and metastasis system in characterizing the prognosis. Between January 1979 and June 1987 the 261 evaluable patients underwent 1-stage radical cystectomy with pelvic node dissection and urinary diversion. No chemotherapy and/or radiation therapy was given before or after the operation. The postoperative mortality rate was 1.8%. The over-all staging error between clinical and pathological stages was as high as 44%. The over-all actuarial 5-year survival rate was 54.5%. The 5-year survival rates were 75% for stage pT1, 63% for stage pT2, 31% for stage pT3 and 21% for stage pT4 disease. A significant difference in the survival (p less than 0.002) was observed in stage pT3 by dividing tumors confined within the bladder wall (pT3a, 50%) from those extending throughout the bladder wall (pT3b, 15%). A careful evaluation of transitional cell involvement of the prostate in stage pT4a cancer led to the identification of 2 different patterns: 1) contiguous when a bladder tumor extended directly into the prostate through the bladder wall and 2) noncontiguous when a bladder tumor and a transitional cell carcinoma of the prostate were found simultaneously. These patterns had completely different (p less than 0.05) survival rates (6 versus 37%). The patients with high grade tumors had a worse prognosis in comparison with those with grades 1 and 2 tumors (41 versus 56%, p less than 0.005). The over-all 5-year survival of patients with positive nodes was 4% in comparison with 60% of those without nodal involvement (p less than 0.001). Despite current optimal surgical treatment, nearly 50% of all patients with invasive bladder cancer continue to die. The need for a modification of the current tumor, nodes and metastasis tumor classification to provide the clinician a more reliable staging system for planning treatment modalities is indeed mandatory.

[Low-dose BCG in the therapy of superficial neoplasms of the bladder]

The preliminary results of a randomized ongoing study performed in order to evaluate the efficacy and the relative toxicity of a low dose (75 mg). BCG regimen in the treatment of superficial bladder cancer were considered. Ninety-eight patients (58 patients for prophylaxis of the recurrences of Ta-T1 papillary tumors; 40 patients for therapy of carcinoma in situ) received a 6-weeks course of 75 mg. BCG Pasteur vaccine. An additional course was given to non-responders. A maintenance therapy was administered in complete responders monthly for the first year and quarterly for the second. The prophylaxis group (TUR + BCG) was randomized vs TUR alone (40 patients = control group). Complete response in evaluated patients of the prophylaxis, control and therapy groups achieved 86%, 17% and 78%, respectively, after 18 months; 5%, 20% and 9% of patients, respectively, experienced tumor progression. As regards the toxicity, irritative disturbances (27%) and fever (16%) appeared significantly decreased in comparison with those reported in the literature. No major complications were experienced. In conclusion, the low dose (75 mg.) Pasteur BCG regimen used in our trial was effective as a prophylaxis against recurrent superficial papillary tumors and as a treatment of carcinoma in situ, with a significant decrease in toxicity.