Is Health-Related Quality of Life after Radical Cystectomy Using Validated Questionnaires Really Better in Patients with Ileal Orthotopic Neobladder Compared to Ileal Conduit: A Meta-Analysis of Retrospective Comparative Studies.

INTRODUCTION: From the most recent systematic revision of the literature, an orthotopic neobladder would seem to show marginally better health related quality of life (HR-QoL) scores compared with an ileal conduit. The aim of this study was to review all relevant published studies about the comparison between ileal orthotopic neobladder (IONB) and ileal conduit using validated HR-QoL questionnaires. MATERIALS AND METHODS: Studies were identified by searching multiple literature databases. Data were synthesized using meta-analytic methods conformed to the PRISMA statement. RESULTS: The literature search identified 10 papers; pooled effect sizes of combined quality of life outcomes for ileal conduit versus IONB showed a significantly better HR-QoL in patients with IONB (Hedges' g = 0.278; p = 0.000);. The present study has an important limitation due to the type of the analyzed comparative studies, all retrospective and not randomized. CONCLUSION: This meta-analysis of not-randomized, retrospective comparative studies on the impact of ileal conduit versus IONB on HR-QoL showed a significant advantage of IONB subgroups.

Postoperative Quality of Life in Patients with Ileal Neobladder at Short-, Intermediate- and Long-Term Follow-Up.

BACKGROUND: To evaluate the difference at different steps of follow-up of the postoperative quality of life (QoL) in patients who had undergone radical cystectomy and ileal orthotopic neobladder derivation. PATIENTS AND METHODS: A multicentric, cross-qualitative study was performed in 5 Italian centers of reference for the treatment of bladder cancer. One hundred seventy one patients who underwent radical cystectomy and creation of ileal orthotopic neobladder according to 'Vescica Ileale Padovana' between 2006 and 2011 have been analyzed. The validated and dedicated questionnaires EORTC QLQ-C30, IOB-PRO and EORTC QLQ-BLM30 were used. RESULTS: All data gathered were then processed, specifically means ± SD were included for comparison during 4 periods of follow-up (quartile): the first ranging from 1 to 18 months; the second ranging from 19 to 36 months; the third from 37 to 72 months and the fourth >72 months. Cancer-specific and health-related factors were analyzed separately, and the change was determined during follow-up. CONCLUSIONS: The global QoL, highlighted by validated cancer-specific and health-related questionnaires, is certainly on a satisfactory level. Thus, the education of the patient, the exploration of the pros and cons of an orthotopic neobladder and the active participation in treatment decision seem to be the keys to better improve the post-operative QoL during the follow-up period.

Quality of Life Assessment With Orthotopic Ileal Neobladder Reconstruction After Radical Cystectomy: Results From a Prospective Italian Multicenter Observational Study.

OBJECTIVE: To assess health-related quality of life (HRQoL) parameters in patients who received radical cystectomy (RC) with ileal orthotopic neobladder (IONB) reconstruction and to identify clinic-pathologic predictors of HRQoL. PATIENTS AND METHODS: From January 2010 to December 2013, a multicenter, retrospective on 174 RC-IONB patients was carried out. All patients completed the following questionnaires: the European Organization for Research and Treatment of Cancer (EORTC) generic (QLQ-C30) and bladder cancer-specific instruments (QLQ-BLM30) and the IONB-Patient Reported Outcome (IONB-PRO). Univariate and multivariate analyses were computed to identify clinic-pathologic predictors of HRQoL. RESULTS: Median age was 66 years (range, 31-83), and 91.4% of patients were men. Median follow-up period was 37 months (range, 3-247). The EORTC QLQ-C30 revealed that age >65 years, absence of urinary incontinence, and absence of peripheral vascular disease were independent predictors of deteriorated body image. A follow-up > 36 months and the presence of urinary incontinence were independent predictors of worsened urinary symptoms, whereas the absence of urinary incontinence was an independent predictor of a worsened body image according to EORTC QLQ-BLM30 results. A follow-up >36 months and the absence of urinary incontinence were independent predictors of better functioning in terms of relational life, emotional life, and fatigue as revealed by the IONB-PRO. CONCLUSION: Age, presence of urinary incontinence, length of follow-up, and comorbidity status may influence postoperative HRQoL and should all be taken into account when counseling RC-IONB patients.

Development of a questionnaire specifically for patients with Ileal Orthotopic Neobladder (IONB).

BACKGROUND: The ileal orthotopic neobladder (IONB) is often used in patients undergoing radical cystectomy. The IONB allows to void avoiding the disadvantages of the external urinary diversion.In IONB patients the quality of life (QoL) appears compromised by the need to urinate voluntarily. The patients need to wake up at night interrupting the sleep-wake rhythm with consequences on social and emotional life.At present the QoL in IONB patients is evaluated by generic questionnaires. These are useful when IONB patients are compared with patients with different urinary diversions but they are less effective when only IONB patients are evaluated. To address this problem a specific questionnaire-the IONB-PRO-was developed. METHODS: A) Based on a conceptual framework, narrative-based interviews were conducted on 35 IONB patients. A basic pool of 43 items was produced and organized throughout two clinical and four QoL dimensions. An additional 15 IONB patients were interviewed for face validity testing.B) Psychometric testing was conducted on 145 IONB patients. Both classic test strategy and Rasch analysis were applied. Psychometric properties of the resulting scales were comparatively tested against other QoL-validated scales. RESULTS: The IONB-PRO questionnaire includes two sections: one on the QoL and a second section on the capability of the patient to manage the IONB. For evaluation of the QoL, three versions were delivered: 1) a basic 23-item QoL version (3 domains 23-items; alpha 0.86÷ 9.69), 2) a short-form 12-item QoL scale (alpha = 0.947), and 3) a short-form 15-item Rasch QoL scale (alpha = 0.967). Correlations of the long version scales with the corresponding dimensions of the EORTC-QLQ C30 and the EORTC-BLM30 were significant. The short forms exhibited significant correlations with the global health dimension of the EORTC-QLQ and with the urinary subscales of the EORTC-BLM30. The effect size was approximately 1.00 between patients at the 1-year follow-up period and those with 3, 5, and > 5-year follow-up periods for all scales. No relevant differences were observed between the 12-item short-form and the Rasch scale. CONCLUSIONS: The IONB-PRO long and short-forms demonstrated a high level of internal consistency and reliability with an excellent discriminanting validity.

Immunohistochemical evaluation of androgen receptor and nerve structure density in human prepuce from patients with persistent sexual side effects after finasteride use for androgenetic alopecia.

Finasteride is an inhibitor of 5-α-reductase used against male androgenetic alopecia (AGA). Reported side effects of finasteride comprise sexual dysfunction including erectile dysfunction, male infertility, and loss of libido. Recently these effects were described as persistent in some subjects. Molecular events inducing persistent adverse sexual symptoms are unexplored. This study was designed as a retrospective case-control study to assess if androgen receptor (AR) and nerve density in foreskin prepuce specimens were associated with persistent sexual side effects including loss of sensitivity in the genital area due to former finasteride use against AGA. Cases were 8 males (aged 29-43 years) reporting sexual side effects including loss of penis sensitivity over 6 months after discontinuation of finasteride who were interviewed and clinically visited. After informed consent they were invited to undergo a small excision of skin from prepuce. Controls were 11 otherwise healthy matched men (aged 23-49 years) who undergone circumcision for phimosis, and who never took finasteride or analogues. Differences in AR expression and nerve density in different portions of dermal prepuce were evaluated in the 2 groups. Density of nuclear AR in stromal and epithelial cells was higher in cases (mean 40.0%, and 80.6% of positive cells, respectively) than controls (mean 23.4%, and 65.0% of positive cells, respectively), P = 0.023 and P = 0.043, respectively. Conversely, percentage of vessel smooth muscle cells positive for AR and density of nerves were similar in the 2 groups. The ratio of AR positive stromal cells % to serum testosterone concentrations was 2-fold higher in cases than in controls (P = 0.001). Our findings revealed that modulation of local AR levels might be implicated in long-term side effects of finasteride use. This provides the first evidence of a molecular objective difference between patients with long-term adverse sexual effects after finasteride use versus drug untreated healthy controls in certain tissues.

Behavioural profile and human adaptation of survivors after radical cystectomy and ileal conduit.

BACKGROUND: There is a lack of good data in the literature evaluating the Health-Related Quality of Life (HR- QoL) in patients with urinary diversions. The aim of this study was to examine the changes in expectation and needs in terms of human adaptation and behavioural profiles in patients with ileal conduit (IC) after radical cystectomy (RC) for bladder cancer (BC). MATERIALS AND METHODS: A qualitative, multicenter cross-sectional study using a "narrative based" approach was planned. We proceed with a sampling reasoned choice (purposive), selecting groups of patients with follow-up from one up to more than 7 years after surgery. Data were collected through individual interviews. RESULTS: Thirty patients participated in the study. The processing of the interviews allowed us to identify 2 major profiles: positive and negative. Patients with a positive profile resumed normal daily activities with no or limited restrictions both on the personal and the social level. This profile reflects a good HR-QoL. The negative profile reflects the patients for whom the ostomy has meant a worsening of HR-QoL. A positive profile was statistically more frequent in older patients (p = 0.023), with a longer follow-up (p = 0.042) and less complications rates (p = 0.0002). According to the length of follow-up and the occurrence of complitations, we identified further 5 intermediate profiles. CONCLUSIONS: Patients' satisfaction is related to the degree of adaptation to their new life with an urinary stoma and its correct management. Live "with urinary diversion" represents a new phase of life and not a deterioration.

Varicocele treatment: a 2-centers comparison between non microsurgical open correction, laparoscopic approach and retrograde percutaneous sclerotization on 463 cases.

OBJECTIVES: To determine whether there are differences in sperm parameters improvement after different varicocele correction techniques. To determine the role of age in sperm parameters improvement. METHODS: 2 different European centers collected pre- and postoperative sperm parameters of patients undergoing varicocele correction. Among 463 evaluated patients, 367 were included. Patients were divided in procedure-related and age-related groups. Ivanissevich inguinal open surgical procedure (OS), lymphatic-sparing laparoscopic approach (LSL) and retrograde percutaneous transfemoral sclerotization (RPS) were performed. As outcome measurements sperm count (millions/mL, SC) and percentage of mobile sperms were analyzed. Univariate and multivariate regression between the defined groups; bivariate regression analysis between age and sperm count and motility. RESULTS: Number of patients: OS 78; LSL 85; RPS 204. Mean age 30.2 (SD 6.83); postoperative SC increased from 18.2 to 30.1 (CI 95% 27.3-32.9; p < 0,001); motility from 25.6 to 32.56% (30.9-34.2; p < 0.001). OS: SC varied from 16.9 to 18.2 (p < 0.001); sperm motility from 29% to 33% (p < 0.001). LSL: SC from 15.5 to 17.2 (p < 0.001); motility from 27 to 31% (p < 0.001). RPS: SC from 18.9 to 36.2 (p < 0.001); motility from 24% to 32% (p < 0.001). Univariate and multivariate analysis confirmed the significant difference of SC variation in RPS, compared to the other groups (p < 0.001). No significance between LSL and OS (p = 0.826). No significant differences regarding motility (p = 0.8). CONCLUSIONS: Varicocele correction is confirmed useful in improving sperm parameters; sclerotization technique leads to a better sperm improvement compared to other studied procedures; improvement in seminal parameters is not affected by age of the patients treated.

Comparison of open and laparoscopic pyeloplasty in ureteropelvic junction obstruction surgery: report of 49 cases.

OBJECTIVE: This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution. METHODS: From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively. RESULTS: Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5% (9/24) with laparoscopy vs. 32% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7% for laparoscopic pyeloplasties and 20% for open pyeloplasties. The success rates were 90.5% for laparoscopy and 90.9% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction. CONCLUSIONS: The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results. These findings may suggest, that the laparoscopic dismembered pyeloplasty has the potential to replace open surgery and may be considered the first option for the treatment of ureteropelvic junction obstruction in expert hands.

Intractable haematuria: long-term results after selective embolization of the internal iliac arteries.

OBJECTIVE: To determine the feasibility and efficacy of transarterial embolization (TAE) in haemorrhagic urological emergencies, and to assess the perioperative morbidity, effect of timing of intervention on the requirement for blood transfusion, and the long-term follow-up. PATIENTS AND METHODS: Between October 1997 and March 2009, 44 patients (30 men and 14 women; mean age 79 years, range 51-95) with intractable haematuria secondary to advanced pelvic tumour arising from or invading the bladder, underwent internal iliac TAE. Twenty-four patients had transitional carcinoma of the urinary bladder, 12 adenocarcinoma of the prostate, five carcinoma of the uterus, one cancer of the vagina, two carcinoma of the rectum, three carcinoma of the kidney, two simultaneous carcinoma of prostate and bladder, one simultaneous carcinoma of prostate and kidney and one had haemorrhagic cystitis after radiotherapy. RESULTS: TAE of the internal iliac arteries produced initial complete control of bleeding in 36 of the 44 patients (82%). At a mean (range) follow-up of 10.5 (1-97) months TAE there was permanent control of bleeding in 19 (43%) patients. A second TAE session was use in five (11%) patients and it was successful in two of them. There were 24 patients (55%) who required a mean of 4 (1-17) transfusion units before embolization; only 13 (30%) required more blood products after TAE. The mean haematocrit level before and after TAE was 27% and 31% (P < 0001), and the respective haemoglobin level were 8.7 and 10.3 g/dL (P < 0001). During the follow-up there were no major complications related to TAE; minor complications were post-TAE syndrome in 12 (27%) patients, fever (11%), gluteus pain (14%), nausea (2%), and exterior genital oedema (5%). The 6- and 12-month mortality rates were 66% (29 patients) and 18% (eight), respectively. CONCLUSIONS: TAE should be considered as an alternative less-invasive palliative measure and the treatment of choice in these situations. TAE should always be bilateral, the catheter should advance distally to the origin of the superior gluteal artery and the artery embolized with unresorbable particles. Our study confirms the efficacy and safety of TAE in patients with pelvic malignancy, and indicates that this technique should be considered before surgery. The procedure combines the benefits of a minimally invasive approach in decreasing the cost of surgery and operating time, while maintaining low blood loss and analgesia requirement.

Role of renospermatic basal reflow and age on semen quality improvement after sclerotization of varicocele.

OBJECTIVES: To determine the relationship between renospermatic basal reflow at color Doppler ultrasound (CDU) evaluation and the improvement in seminal quality after sclerotization of varicocele, and the role of patients' age. No clear predictive factors are available for selecting patients who will show a better seminal improvement after varicocele correction. METHODS: Between 2002 and 2008 we selected 113 patients with left unilateral varicocele, meeting the criteria of low sperm density, no endocrinological failures and no varicocele recidivating. Varicocele correction was performed using the retrograde sclerotization technique or, if not possible, the anterograde one. Patients underwent a physical examination, follicle-stimulating hormone assessment, sperm analysis (density, motility, and morphologic analysis), scrotal ultrasound, and CDU evaluation. Patients were divided into 5 groups using the CDU classification (Sarteschi). Three months postoperatively, they were assessed with the same protocol. Mean age was 32.2 years. RESULTS: We found improvement in seminal quality among the entire population. We found no significance in differences among semen quality improvement in patients of different ages. Patients with basal renospermatic reflow at preoperative CDU evaluation (groups 3, 4, and 5) showed a better improvement in sperm density (+139%) than patients with no basal reflow (groups 1 and 2; +61%). CONCLUSIONS: The presence of a basal reflow at preoperative CDU is a strong predictive factor of a better seminal quality improvement after varicocele correction. On the contrary, patient's age showed no significant relationship.

Efficacy and safety of combined oral therapy with tadalafil and alfuzosin: an integrated approach to the management of patients with lower urinary tract symptoms and erectile dysfunction. Preliminary report.

INTRODUCTION: Alpha1-blockers (AB) are the first-line monotherapy for lower urinary tract symptoms (LUTS). Phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for erectile dysfunction (ED). Numerous studies have supposed a significant association between ED and LUTS, but a causal relationship cannot be established. AIM: The aim was to evaluate the efficacy of a combined therapy with an AB (alfuzosin) and PDE5 inhibitors (tadalafil) in patients with LUTS and ED. METHODS: This was a randomized, open-label, three-arm study. A total of 66 men complaining of ED and LUTS were included in the study. Patients were assessed at baseline and after 12 weeks of study treatment, and then underwent randomized allocation to either alfuzosin 10 mg once a day (22 patients) or tadalafil 20 mg on alternative days (21 patients), or a combination of both (23 patients). MAIN OUTCOME MEASURES: All participants completed the erectile function domain of the International Index of Erectile Function (IIEF-EF) and the International Prostatic Symptom Score (IPSS). Other efficacy variables included maximum urinary flow rate (Qmax) and medium urinary flow rate (Qave). RESULTS: IIEF-EF tended to improve with alfuzosin alone (+15%), while it was clearly improved with tadalafil alone (+36.3%). The greatest improvement was experienced with the combination therapy (+37.6%). Improvement in Qmax was observed in all groups, but patients receiving combination therapy had greater improvement (29.6%) than patients receiving either only alfuzosin (21.7%) or only tadalafil (9.5%). IPSS was significantly improved in alfuzosin group (27.2%), was more marked with the combination therapy (41.6%), and a small increase, although not significant, was also observed with tadalafil (8.4%). CONCLUSIONS: Combined therapy improved ED and LUTS as demonstrated by the significant improvement in uroflowmetry measures and in IPSS and IIEF-EF scores. A significant improvement was also observed in quality of life assessments. The beneficial effects of tadalafil on LUTS similar to the benefits of alfuzosin on ED, although present, were smaller.

Semen quality before and after orchiectomy in men with testicular cancer.

OBJECTIVE: We evaluated the impact of removal of the tumour bearing testis on semen quality in men with testicular cancer and the effect of tumour histologic feature on semen quality. MATERIAL AND METHODS: We took into account the semen analysis before and after orchiectomy in 30 patients. RESULTS: The median sperm concentration before and after orchiectomy was respectively of 26.7 x 10(6)/ml (range: 0-120 x 10(6)/ml) and 16.6 x 10(6)/ml (range: 0-75 x 10(6)/ml) (p = 0.001). Median sperm concentration before and after surgery in patients affected by seminomatous cancer were respectively of 35.47 x 10(6)/ml and 23.99 x 10(6)/ml, while cases of non-seminomatous cancer were respectively of 17.9 x 10(6)/ml and 8.16 x 10(6)/ml. CONCLUSIONS: Semen quality at the diagnosis was poorer in patients affected by non-seminomatous testicular cancer. Sperm concentration deteriorated after orchiectomy. Our findings suggest that the most appropriate time for cryopreservation of semen is before orchiectomy.

Comparative experimental evaluation of guidewire use in urology.

OBJECTIVES: To evaluate the characteristics and mechanical properties of five different guidewires principally used in urology to provide a guide to the best choice in every situation. This objective was achieved by performing mechanical tests on each guidewire and on the same guidewire in relationship to a real human ureter. Finally, the mechanical properties of a real human ureter were evaluated experimentally. METHODS: Five different guidewires with a 0.035-in. external diameter were studied to determine their mechanical properties of interest: tip buckling, shaft permanent deformation, guide friction on the human ureter, and the force at which the tip perforated a real human ureter. RESULTS: Nitinol guidewires with hydrophilic coating had the least dangerous tip in the tip buckling and tip piercing force tests and the lowest friction values on the friction guide test. The shaft of the polytetrafluoroethylene-coated guidewires was stiffer on the bending resistance and plastic deformation tests. CONCLUSIONS: The ideal endourologic guidewire should be sufficiently flexible and lubricated to negotiate a tortuous ureter and pass possible obstructions. However, high strength against bending is also required when we need to pass a stent or catheter over a guidewire.

Intratesticular varicocele: evaluation using grey scale and color Doppler ultrasound.

Intratesticular varicocele is a rare condition with a variable clinical and ultrasound presentation. The purpose of this study was to evaluate the grey scale and color Doppler appearances of intratesticular varicocele (ITV). Herein we present seven new cases of intratesticular varicocele. From 2003 to 2005 we evaluated 342 patients referred to our department for routine andrological evaluation by scrotal color Doppler ultrasound. We detected seven entirely asymptomatic cases of ITV by use of grey scale ultrasound. In color Doppler sonography the patients showed retrograde blood flow, either spontaneously or during Valsalva manoeuvre. In all seven cases left side ITV with testicular volume disproportion between the right and left testis (2 ml) was found. Five patients had an extratesticular varicocele. In all patients the diameters of intratesticular vein were less than 2 mm. Intratesticular varicocele is a clinically occult lesion that may occur in association with extratesticular varicocele. Further investigations are needed to clarify its clinical significance, however, considering the temperature mediated damage on the affected testis, it is our opinion that all ITV must be considered for treatment even if an extratesticular varicocele is not present.

Tissue-resonance interaction method for the noninvasive diagnosis of prostate cancer: analysis of a multicentre clinical evaluation.

OBJECTIVE: To determine, in a multicentre prospective study, the accuracy of the tissue-resonance interaction method (TRIMprob, new technology developed for the noninvasive analysis of electromagnetic anisotropy in biological tissues) in the diagnosis of prostate cancer. PATIENTS AND METHODS: Two hundred patients (mean age 67.4 years) scheduled to have prostatic biopsies (because of a prostate-specific, PSA, antigen level of >/=4 ng/mL or a suspicious digital rectal examination, DRE) were preliminarily examined while unaware of their clinical details using TRIMprob in five different centres. The final diagnosis obtained with TRIMprob was compared with the final histological diagnosis after extended biopsies. RESULTS: Of the 188 evaluable patients (mean PSA level 9.3 ng/mL, sd 8.8; mean prostate volume 62.0 mL, sd 32.4), 61 (32.4%) had a positive biopsy for adenocarcinoma of the prostate. The overall sensitivity, specificity, positive predictive value, negative predictive value (NPV) and accuracy of TRIMprob were 80%, 51%, 44%, 84% and 60%, respectively. The prostate cancer detection rate after biopsy was significantly higher in patients with a positive examination (49/111, 44%) than in patients with a negative TRIMprob (12/77, 15%; P < 0.001). When TRIMprob results were combined with DRE findings the sensitivity and NPV both increased to 92%. CONCLUSION: TRIMprob seems to be a useful tool in the diagnosis of prostate cancer and can increase the accuracy of PSA or DRE results. The high NPV suggests that this new technology might be useful to reduce the indications for prostatic biopsy or repeated series of biopsies in patients suspected of having prostate cancer.

Evaluation of tumor thrombi in the inferior vena cava with intraoperative ultrasound.

To report and discuss four cases of renal cell carcinoma (RCC) in which preoperative investigations yielded contradictory results regarding the cranial extension of propagation of the tumor thrombus into the vena cava. An intraoperative ultrasound scan (IOU) was performed in all cases to identify the exact level of the tumor thrombus. We have performed an IOU of the vena cava in four patients with RCC propagation into the inferior vena cava. Preoperative investigations were performed in all patients and consisted of abdominal Ultrasound scan (USS), contrast enhanced CT scan and gadolinium enhanced MRI scan. Intraoperative ultrasound has identified correctly the cranial extension and the absence of tumor thrombus infiltration in all patients. The thrombus reached the suprahepatic vena cava in two cases and was confined to the infrahepatic vena cava in the remainder. Preoperative imaging investigation had failed to determine the correct cranial extension of the tumor thrombus in two patients.IOU is a very useful tool to accurately assess the precise extent of tumor thrombus and eventually the presence of vein wall infiltration. These data are of paramount importance to plan the optimal surgical approach. According to our experience this type of investigation identifies the cranial extent of a tumor thrombus inside the vena cava better than standard imaging techniques.

Major invasive surgery for urologic cancer in octogenarians with comorbid medical conditions.

OBJECTIVES: We retrospectively reviewed the records of the octogenarian patients who underwent major surgery for urologic cancer at two institutions. The aims of our study were to assess intra- and postoperative morbidity and mortality rates, and to identify potential risk factors that can predict postoperative complications and, as a consequence, surgical outcome. METHODS: Fifty-five patients (median age: 83 yr) underwent major surgery for urologic cancer. Radical nephrectomy was performed in 27 patients, radical cystectomy with urinary diversion was done in 20 patients, and nephroureterectomy was performed in the remainder. Significant comorbidity was present in 51 patients. RESULTS: The perioperative mortality rate was 9%. The overall mortality rate was 69%; cancer-specific mortality was 28%. Intraoperative complications occurred in 11% of patients. Postoperative intensive care monitoring was required in 29% of patients. The early postoperative complication rate was 33%. Only the presence of more than two comorbidities (p<0.05) and chronic obstructive lung disease (COLD) (p=0.017) resulted in independent prognostic factors for morbidity. Sixteen percent of patients developed a late postoperative complication within the first 6 mo. Median hospital stay was 14 d (range: 6-55), and hospital stays were significantly longer among patients with complications (p<0.05). The 3-yr and 5-yr overall survival rates were 36% and 26%, respectively; these rates were significantly lower in patients with COLD (p<0.01). There was no significant difference between cancer-specific and non-cancer-specific survival rates. CONCLUSIONS: Major surgery for urologic malignancies can be safely performed in selected octogenarian patients.

Application of ultrasound contrast agents for the characterization of female urethral vascularization in healthy pre- and postmenopausal volunteers: preliminary report.

OBJECTIVES: Vascularization of the female urethra is an important factor contributing to the sealing effect responsible for the normal urethral closing system. The aim of this study was to assess whether contrast enhanced ultrasonography can be used to evaluate changes in urethral vascularization between pre- and postmenopausal women. METHODS: We studied the vascularization of female urethra in 11 healthy premenopausal females during the midfollicular phase of the menstrual cycle and 10 healthy postmenopausal volunteers using ultrasound contrast agents with a 2-5 MHz curved-array transducer by a translabial approach. Reperfusion curves were analyzed by a blinded investigator. Ultrasound contrast agents were measured with specifically designed software, and results were evaluated using the Mann-Whitney U-test. RESULTS: The data suggest that the enhancement characteristics of the urethra were different in pre- and postmenopausal women and that the percent of blood volume and blood flow decreased with age. No changes were observed between pre- and postmenopausal women regarding the velocity of blood flow. CONCLUSIONS: The study of female urethra vascularization by ultrasound contrast agents is safe, feasible, and noninvasive.

The simultaneous use of telomerase, cytokeratin 20 and CD4 for bladder cancer detection in urine.

OBJECTIVE: Because of the low sensitivity of urinary cytological diagnosis of urinary bladder carcinoma, new molecular diagnostic methods have been proposed. We decided to verify the expression of telomerase mRNA coding for the catalytic component (hTRT), cytokeratin 20 (CK20) and CD4 antigen mRNAs in urine as possible diagnostic tool. METHODS: Evaluation of hTRT, CK20, CD4 mRNAs was performed in 50 ml of naturally voided urine of 205 patients of which 153 with bladder cancer (Tis, n = 11; TaGx, n = 4; TaG1, n = 25; TaG2, n = 26; TaG3, n = 8; T1G1, n = 16; T1G2, n = 17; T1G3, n = 20; T2G2, n = 6; T2G3, n = 13; T3G3, n = 7) and 52 controls. A quantitative expression of hTRT at mRNA level versus TRAP (telomeric repeat amplification protocol) assay was performed in 20 patients and 14 controls. The expression of RT-PCR for hTRT, CK20, CD4 versus urinary cytology was analysed in 44 patients with bladder cancer. Evaluating the three molecular markers together, the result was considered correct when at least two of the markers were positive, suspected when only one marker was positive and negative for diagnosis of tumour when all markers were negative. The performance of the diagnostic model resulted from the logistic analysis evaluated with receiver operating characteristics (ROC) curve analysis. RESULTS: The sensitivity detected for each tumour marker was as follows: for hTRT 90.8%, for CK20 84.3% and for CD4 was 64.7%, while the specificity was 94.2% for CD4 and 78.8% for both hTRT and CK20. When a simultaneous evaluation of the three tumour markers was considered, 88.2% of the diagnoses were correct, 11.8% were suspected for tumour and none were mistaken. When compared with cytology, the simultaneous use of the three markers allowed reaching a correct diagnosis in 88% of the cases in comparison to 25% by urinary cytology. The sensitivity in the detection of bladder cancer was higher for hTRT at mRNA level in comparison with the enzymatic activity detection with TRAP (90% vs. 35%) while the specificity for both markers resulted very high (100%). CONCLUSIONS: These data show that in the future the diagnostic improvement of urine based molecular markers for the detection of bladder cancer in the urine could improve the sensitivity of urinary cytology reducing the need of a cystoscopy.