Semen quality and metabolic profile in people with type 1 diabetes with and without erectile dysfunction: a cross-sectional study.

PURPOSE: The aim of the present study is to evaluate the association of metabolic and glycemic variables with semen parameters in patients with type 1 diabetes (T1D) with and without erectile dysfunction (ED). METHODS: The study population included 88 adults with T1D using a continuous glucose monitoring, of whom 28 with ED (ED group) and 60 without it (NO ED group). All men completed the International Index of Erectile Function (IIEF-5) and underwent body composition analysis (BIA) and semen analysis. RESULTS: ED group showed worse HbA1c levels [median (IQR), 8.4 (7.7, 9.9) vs 7.4 (7, 8.2) %, P < 0.001)], higher insulin dose [60 (51, 65) vs 45 (38, 56) UI/die, P = 0.004)] and a higher total body water and intracellular water as compared with ED group. Men in the ED group presented higher semen volume [2.8 (2.6, 4.2) vs 2.5 (2.2, 2.7) mL, P < 0.001] and sperm concentration [24 (19, 29) vs 20 (12, 23) mil/mL, P = 0.010], but reduced sperm progressive motility [28 (25, 35) vs 35 (25, 36) %, P = 0.011], higher rate of non-progressive motility [15 (10, 15) vs 10 (5, 10) %, P < 0.001] and higher rate of typical morphology [7(5, 8) vs 5 (4, 5) %, P = 0.001]. Based on multivariate logistic regression analysis performed to assess the association between clinical variables and ED, intracellular water (OR 3.829, 95% CI 1.205, 12.163, P = 0.023) resulted as the only independent predictor of ED. CONCLUSION: Men with T1D and ED showed worse metabolic profile which is associated with poor semen quality, as compared with those without ED.

A prospective randomized comparison among SWL, PCNL and RIRS for lower calyceal stones less than 2 cm: a multicenter experience : A better understanding on the treatment options for lower pole stones.

PURPOSE: To prospectively evaluate the efficacy and safety of RIRS, SWL and PCNL for lower calyceal stones sized 1-2 cm. MATERIALS AND METHODS: Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicenter, randomized, unblinded, clinical trial study. Patients were randomized into three groups: group A: SWL (194 pts); group B: RIRS (207 pts); group C: PCNL (181 pts). Patients were evaluated with KUB radiography (US for uric acid stones) at day 10 and a CT scan after 3 months. The CONSORT 2010 statement was adhered to where possible. The collected data were analyzed. RESULTS: The mean stone size was 13.78 mm in group A, 14.82 mm in group B and 15.23 mm in group C (p = 0.34). Group C compared to group B showed longer operative time [72.3 vs. 55.8 min (p = 0.082)], fluoroscopic time [175.6 vs. 31.8 min (p = 0.004)] and hospital stay [3.7 vs. 1.3 days (p = 0.039)]. The overall stone-free rate (SFR) was 61.8% for group A, 82.1% for group B and 87.3% for group C. The re-treatment rate was significantly higher in group A compared to the other two groups, 61.3% (p < 0.05). The auxiliary procedure rate was comparable for groups A and B and lower for group C (p < 0.05). The complication rate was 6.7, 14.5 and 19.3% for groups A, B and C, respectively. CONCLUSIONS: RIRS and PCNL were more effective than SWL to obtain a better SFR and less auxiliary and re-treatment rate in single lower calyceal stone with a CT diameter between 1 and 2 cm. RIRS compared to PCNL offers the best outcome in terms of procedure length, radiation exposure and hospital stay. ISRCTN 55546280.

Complications associated with ureterorenoscopy (URS) related to treatment of urolithiasis: the Clinical Research Office of Endourological Society URS Global study.

INTRODUCTION: Ureterorenoscopy (URS) is a popular and growing option for management of ureteric and renal stones. The CROES URS Global Study was set up to assess the outcomes of URS in a large worldwide cohort of patients involving multiple centres. In this paper, we analysed the database for intra-operative and post-operative complications associated with ureterorenoscopy. METHODS: The CROES database was established via collaboration between 114 centres in 32 countries worldwide, and information on both intra-operative and post-operative complications was collected electronically between January 2010 and October 2012. RESULT: On analysis of a total of 11,885 patients, the overall complication and stone-free rates were found to be 7.4 and 85.6 %, respectively. The intra-operative and post-operative complication rates were 4.2 and 2.6 %, respectively, and in total 5 deaths were reported in the study period. Taking into account different world economies, there were no differences in the complication rates between the developing and developed nations or between different centres from different continents. CONCLUSION: Ureterorenoscopy is a safe and effective procedure for treatment of stones, the outcomes of which are broadly comparable in different parts of the world for similar patient and stone demographics.

Transuretral resection of the bladder (TURB): analysis of complications using a modified Clavien system in an Italian real life cohort.

INTRODUCTION: To evaluate the applicability of a modified Clavien classification system (CCS) in grading postoperative complications of transurethral resection of bladder tumours (TURB). MATERIALS AND METHODS: A series of patients undergoing monopolar TURB from April 2011 to March 2012 at five Italian centers were enrolled. All complications occurring within the first 30-day postoperative period were prospectively recorded and graded according to the CCS. RESULTS: Overall, 275 patients were included. Median age was 71 (63/78) years; median BMI was 28 (25.4/30.8) Kg/m(2), median tumour size was 2 (1-3) cm; median number of tumour lesions was 1 (1-3). Median operative time was 30 (20/45) min. Fifty-seven complications were recorded in 43 patients. Overall postoperative morbidity rate was 16%. Most of the complications were not serious and classified as Clavien type I (42 cases; 74%) or II (8 cases, 14%). Higher grade complications were scarce: CCS IIIa in 1 case (2%) and CCS IIIb in six cases (10%). No TURB related death was reported. Six patients were re-operated due to significant bleeding or clot retention on postoperative days 2-7. On univariate (73.5 ± 38 versus 36.7 ± 21.6 min) and multivariate analysis longer operative time was an independent predictor of complications (OR: 1.06 per min, 95%CI 1.04-1.08, p = 0.001). CONCLUSIONS: A modified CCS can be used as a standardized tool to objectively define the complications of TURB which confirms to be a safe procedure with a low surgical morbidity. This tool can be used to aid in patient counselling and to facilitate scientific assessment.

Health related quality of life after radical cystectomy: comparison of ileal conduit to continent orthotopic neobladder.

AIMS: To compare health related quality of life (HRQOL) between patients with two different types of urinary diversion, ileal conduit and orthotopic neobladder, and between them and an age-matched population of healthy subjects. MATERIALS AND METHODS: Eighty eight patients treated with radical cystectomy for bladder cancer at our institutions between 2002 and 2007 were contacted for this survey. All of them had a follow-up of more than 12 months after surgery and were recurrence free. The SF-36 questionnaire was provided to each patient during a follow-up visit at outpatient clinics. Overall, 79 patients (90%) returned the questionnaire and were included in this analysis. They were divided into two groups: group 1 comprised 44 patients with an ileal conduit diversion, and group 2 included 35 patients with a neobladder. As a control, normative values of an age-matched healthy Italian population were considered. RESULTS: No significant difference was found in scale scores between the neobladder and ileal conduit groups. Scale scores for role-physical functioning, social functioning and role-emotional functioning in both the neobladder and ileal conduit groups were significantly below the Italian population norm. Patients with a neobladder 65 years old or older (n=18) had significantly lower scores for role-physical functioning and role-emotional functioning than those younger than 65 years (n=17; p<0.05). CONCLUSION: Few differences between ileal conduit and orthotopic bladder substitution have been detected. Thus, the assumption that continent reconstruction provides better HRQOL than ileal conduit diversion cannot be supported. Patient education and active participation in treatment decisions seem to be the key to postoperative satisfaction.

Obesity and sexual dysfunction, male and female.

Obesity has become a worldwide public health problem of epidemic proportions, as it may decrease life expectancy by 7 years at the age of 40 years: excess bodyweight is now the sixth most important risk factor contributing to the overall burden of disease worldwide. Overweight and obesity may increase the risk of erectile dysfunction (ED) by 30-90% as compared with normal weight subjects. On the other hand, subjects with ED tend to be heavier and with a greater waist than subjects without ED, and also are more likely to be hypertensive and hypercholesterolemic. The metabolic syndrome, characterized by a clustering of risk factors associated with insulin resistance and abdominal obesity, associates with ED. Moreover, women with the metabolic syndrome have an increased prevalence of sexual dysfunctions as compared with matched control women. Lifestyle changes aimed at reducing body weight and increasing physical activity induce amelioration of both erectile and endothelial functions in obese men. Moreover, preliminary evidence suggests that a Mediterranean-style diet might be effective in ameliorating sexual function in women with the metabolic syndrome. Lifestyle changes, mainly focussing on regular physical activity and a healthy diet, are effective and safe ways to reduce cardiovascular diseases and premature mortality in all population groups; they may also prevent and treat sexual dysfunctions in both sexes.

Mediterranean diet improves sexual function in women with the metabolic syndrome.

In the present study, we tested the effect of a Mediterranean-style diet on sexual function in women with the metabolic syndrome. Women were identified in our database of subjects participating in controlled trials evaluating the effect of lifestyle changes and were included if they had a diagnosis of female sexual dysfunction (FSD) associated with a diagnosis of metabolic syndrome, a complete follow-up in the study trial and an intervention focused mainly on dietary changes. Fifty-nine women met the inclusion/exclusion criteria; 31 out of them were assigned to the Mediterranean-style diet and 28 to the control diet. After 2 years, women on the Mediterranean diet consumed more fruits, vegetables, nuts, whole grain and olive oil as compared with the women on the control diet. Female sexual function index (FSFI) improved in the intervention group, from a mean basal value of 19.7+/-3.1 to a mean post-treatment value of 26.1+/-4.1 (P=0.01), and remained stable in the control group. C-reactive protein (CRP) levels were significantly reduced in the intervention group (P<0.02). No single sexual domain (desire, arousal, lubrication, orgasm, satisfaction, pain) was significantly ameliorated by the dietary treatment, suggesting that the whole female sexuality may find benefit from lifestyle changes. A Mediterranean-style diet might be effective in ameliorating sexual function in women with metabolic syndrome.

A complete response with rituximab in metastatic diffuse large B-cell lymphoma of the testis: case report.

Primary testicular lymphoma is an uncommon testicular tumour. We present a case of a primary non-Hodgkin lymphoma of the testis, describing its clinical and pathological features and discussing our treatment strategy. A 68-year-old man showed a firm erythematous testicular mass within the right emiscrotum. Subsequent ultrasonography demonstrated a right inferior pole testicular mass with disomogenously hypoecogenic. The patient was submitted to inguinal orchidectomy. Light microscopy demonstrated the classic appearance of a diffuse large B-cell lymphoma. The immunohistochemical study showed tumour cells intensively positive for CD45, Ki67 and CD20. No evidence of extra-testicular involvement by lymphoma was found. At 6 months, a TC-PET showed a clinical relapse in lung and abdominal lymphonodes, while clinical examination demonstrated a single, indolent and erythematous nodule in the left foot. The histologic analysis confirmed diagnosis of CD-20 positive B-cell lymphoma. The patient was treated with an anti-CD 20 monoclonal antibody (rituximab) alone every 3 weeks. After 3 months a complete response was observed in all sites of disease. The patient was free from disease at 12 months follow-up.

Association of body weight with sexual function in women.

Sexual difficulties in women appear to be widespread in society; the relationship between female sexual function and obesity is unclear. This study aimed to investigate the relationship between body weight, the distribution of body fat and sexual function in women. Fifty-two, otherwise healthy women with abnormal values of female sexual function index (FSFI) score (< or =23) were compared with 66 control women (FSFI >23), matched for age and menopausal status. All women were free from diseases known to affect sexual function. FSFI strongly correlated with body mass index (BMI) (r=-0.72, P=0.0001), but not with waist-to-hip ratio (r=-0.09, P=0.48), in women with sexual dysfunction. Of the six sexual function parameters, desire and pain did not correlate with BMI, while arousal (r=-0.75), lubrication (r=-0.66), orgasm (r=-0.56) and satisfaction (r=-0.56, all P<0.001) did. FSFI score was significantly lower in overweight women as compared with normal weight women, while cholesterol and triglyceride levels were higher. On multivariate analysis, both age and BMI explained about 68% of FSFI variance, with a primacy of BMI over age (ratio 4:1). In conclusion, obesity affects several aspects of sexuality in otherwise healthy women with sexual dysfunction.

Endothelial microparticles correlate with erectile dysfunction in diabetic men.

Cell-derived microparticles are supposed to be involved in endothelial dysfunction and atherogenesis. This study aimed to evaluate circulating microparticles in diabetic subjects with erectile dysfunction (ED) and their relation with endothelial dysfunction. Thirty diabetic men with ED and 20 age-matched control subjects without ED were assessed for circulating microparticles and endothelial dysfunction. Flow cytometry was used to assess microparticles by quantification of circulating endothelial (EMP, CD31(+)/CD42b(-)) and platelet (PMP, CD31(+)/CD42b(+)) microparticles in peripheral blood. Endothelium-dependent flow-mediated dilation (FMD) was evaluated in the right brachial artery after reactive hyperemia. Compared with non-diabetic subjects, diabetic men presented significantly higher numbers of EMP (P=0.001), and reduced FMD (P=0.01), with a significant inverse correlation between the number of circulating EMP and the International Index of Erectile Function (IIEF) score (r=-0.457, P=0.01). Multivariate analysis correcting for age, anthropometric indices, glucose and lipid parameters, FMD and PMP identified EMP as the only independent predictor for IIEF score (P=0.03). EMP are elevated in impotent diabetic subjects and independently involved in the pathogenesis of ED.

Neuroendocrine immunophenotype as predictor of clinical recurrence in 110 patients with prostate cancer.

We evaluated the relationship between NE expression and well-known prognostic factors and assessed whether tumor relapse after radical surgery correlates with the extent of NE differentiation. Radical prostatectomy specimens from 110 patients with clinically localized prostate cancer were assessed. Patients were followed up every three months for the first two years after surgery and six monthly for 5 additional years until failure, or for a mean of 48 months from the time of surgery for those who did not experience failure. The percentage of cells showing CgA immunoreactivity was evaluated using a visual quantitative method. Tumor staining was categorized as positive if greater than 10 percent and negative if less than 10 percent of tumor cells were stained, to ensure that only cases with significant positivity were included in the positive group. The median follow-up was 5.4 years (range 1.8 to 7.2). The median time to clinical recurrence was 7.5 years and the median time to biochemical recurrence was 2.8 years. Of 31 patients (28 percent) who experienced a PSA recurrence, 15 developed a clinical recurrence. The mean preoperative PSA level was 9 ng/ml (range 2.7 to 25). Most cases were well differentiated (Gleason score less than 7), intraprostatic (less than pT2) tumors. Immunoreactivity in >or= 10 percent of the cells was seen in 17.2 percent (n=19) of the tumor specimens. The preoperative PSA level, Gleason score, use of neoadjuvant or adjuvant therapy, lymphnode positivity were not statistically associated with NE expression. Only the primary pathologic stage appeared to be associated with CgA staining in the primary tumor (p=0.001). On the univariate analysis NE expression did not predict biochemical recurrence free survival, whereas it was associated with clinical recurrence. NE differentiation in clinically localized prostate cancer can be associated with failure after definitive surgical treatment, even if no conclusions can be drawn regarding its value as an independent prognostic factor.

Role of dynamic sentinel node biopsy in penile cancer: our experience.

BACKGROUND AND OBJECTIVES: We report our initial experience with a relatively new technique, the so-called "dynamic sentinel node biopsy", in patients with penile cancer. METHODS: From January 2001 to February 2003, 17 consecutive patients with bilateral, clinically node negative penile cancer were enrolled. Dynamic sentinel node biopsy was followed by local excision of the primary lesion or penile amputation during the same session. Standard inguinal node dissection was performed 4 weeks after the first operation in all the patients. RESULTS: Pre-operative lymphoscintigraphy revealed no sentinel nodes in 1, unilateral sentinel nodes in 5, and bilateral in 11 patients. Metastases were noted in 5 out of 16 patients (31.25%), bilaterally in 3 of them. Among the five patients with sentinel node metastasis, this was the only tumor positive lymph node in one patient. In all cases with negative dynamic sentinel node biopsy, no metastatic nodes were found at the following inguinal node dissection. Therefore, the technique showed a 100% negative predictive value and an 88% sensitivity. CONCLUSIONS: We believe that dynamic sentinel node biopsy is a minimally invasive procedure that can be easily performed. The goal is to offer the possibility of less extensive surgery for selected low risk patients.

Dietary factors in erectile dysfunction.

The role of dietary factors in erectile dysfunction (ED) has never been addressed. In the present case-control study, we investigated the relation of the Mediterranean diet with ED. A total of 100 men with ED were compared with 100 age-matched men without ED. A scale indicating the degree of adherence to the Mediterranean diet was constructed: the total Mediterranean diet score ranged from 0 (minimal adherence to the Mediterranean diet) to 9 (maximal adherence). The percentage of physical inactivity was greater in the ED group (35 vs 19%, P=0.04), whereas the diet score was lower (4.7+/-0.5 vs 5.4+/-0.5, P<0.01), indicating a reduced adherence to the Mediterranean diet. In analyses adjusted for the prevalence of associated risk factors (hypertension, hypercholesterolemia), body mass index, waist, physical inactivity and total energy intake, the intake of fruits and nuts, and the ratio of monounsaturated lipids to saturated lipids remained the only individual measures associated with ED. In conclusion, the results of the present study show that dietary factors may be important in the development of ED: adoption of healthy diets would hopefully help preventing ED.

Mediterranean diet improves erectile function in subjects with the metabolic syndrome.

Men with the metabolic syndrome demonstrate an increased prevalence of erectile dysfunction (ED). In the present study, we tested the effect of a Mediterranean-style diet on ED in men with the metabolic syndrome. Men were identified in our database of subjects participating in controlled trials evaluating the effect of lifestyle changes and were included if they had a diagnosis of ED associated with a diagnosis of metabolic syndrome, complete follow-up in the study trial, and intervention focused mainly on dietary changes. Sixty-five men with the metabolic syndrome met the inclusion/exclusion criteria; 35 out of them were assigned to the Mediterranean-style diet and 30 to the control diet. After 2 years, men on the Mediterranean diet consumed more fruits, vegetables, nuts, whole grain, and olive oil as compared with men on the control diet. Endothelial function score and inflammatory markers (C-reactive protein) improved in the intervention group, but remained stable in the control group. There were 13 men in the intervention group and two in the control group (P=0.015) that reported an IIEF score of 22 or higher. Mediterranean-style diet rich in whole grain, fruits, vegetables, legumes, walnut, and olive oil might be effective per se in reducing the prevalence of ED in men with the metabolic syndrome.

Gynecomastia in patients with prostate cancer: update on treatment options.

Non-steroidal antiandrogen monotherapy offers potential quality of life benefits over other treatment modalities in patients with prostate cancer. Nevertheless, gynecomastia and breast pain still represent the most bothersome side effects during this treatment. In this update article, recent advances in the management options for gynecomastia/breast pain caused by hormonal manipulation are reviewed and critically analyzed.

Neuroendocrine differentiation after neoadjuvant hormonal treatment in prostate cancer.

AIM: Neuroendocrine (NE) differentiation occurs in various degree in the majority of prostatic adenocarcinomas and it has been correlated with tumor progression and poor prognosis. There is little knowledge about the impact of NE differentiation on tumor response to neoadjuvant hormonal treatment (NHT). The role of NE differentiation as a marker of recurrence after radical prostatectomy (RP) is also unclear. We evaluated whether there is an increase in NE differentiation during the course of NHT and whether the tumor relapse after radical surgery correlates with the extent of NE differentiation. METHODS: RP specimens from 44 patients submitted to 3 months of NHT and RP specimens from 40 nonpretreated patients were histologically assessed. Staining for NE differentiated prostate tumor cells was carried out using a specific monoclonal antibody against chromogranin A (CgA). RESULTS: CgA positive cells were found in 4 of 40 patients (10%) in the RP group and in 4 of 44 patients (9%) of the NHT+RP group. At follow-up, we had 21 biochemically relapsed patients. Among them, 6 were CgA positive (75% of 8 patients), whereas is were CgA negative (20% of 76 patients). CONCLUSIONS: The NE differentiation doesn't increase after NHT. Although not statistically significant a trend to higher risk of relapse among the chromogranin positive samples was observed. The significance of NE differentiation in the progression of the disease and its relation to other known prognostic factors remains unclear.

Expression of biomarkers modulating prostate cancer progression: implications in the treatment of the disease.

OBJECTIVES: To determine whether COX-2, bcl-2 and neoangiogenesis are related to human prostate cancer relapse after definitive surgical treatment and progression toward androgen independence and to evaluate the association between the patterns of these tumoral biomarkers and other standard clinico-pathological parameters (such as Gleason score, PSA, TNM stage). MATERIALS AND METHODS: We retrospectively analyzed the records on 126 prostate cancer samples from patients treated at our University Hospital from 1995 to 2002. The 72 patients with clinically localized disease (group 1) had undergone radical prostatectomy. Another 54 patients (group 2) had metastatic androgen-independent disease. Archived material relating to the subjects was then immunostained for bcl-2, COX-2 and CD-31, using an anti-bcl-2 monoclonal primary antibody, an anti-COX-2 polyclonal rabbit antibody and an anti-CD-31 monoclonal mouse antibody to evaluate neoangiogenesis (MVD, microvessel density). RESULTS: We found that bcl-2, COX-2 and MVD expression increased from group 1 to group 2. The intergroup difference was significant only for high MVD (P < 0.05). On the other hand, high MVD, high bcl-2 and high COX-2 expression was correlated with a higher PSA level (P < 0.01), whereas only a high MVD was also related with Gleason score (P < 0.05). We used univariate analysis to evaluate the prognostic impact of biologic and clinico-pathologic parameters on the disease-free-survival of 72 patients treated by radical prostatectomy. A total of 30 patients (41.6%) experienced biochemical relapse; bcl-2, COX-2 and MVD significantly correlated with disease relapse in these patients. In fact, we observed disease relapse in 24/45 (53%) with high bcl-2 expression, in 15/21 (71%) with a high MVD count and finally, in 30/58 (52%) with high COX-2 expression. Finally, PSA value and Gleason score were the only two biologic markers significantly associated to disease relapse in a multivariate analysis. CONCLUSIONS: Our results strongly support a role for bcl-2, COX-2 and angiogenesis in the development and progression of prostate cancer. Of course, we are aware of the small sample size considered in our study. Further investigations would better clarify the prognostic and therapeutic implications of these findings.

Expression of proto-oncogene c-kit in high risk prostate cancer.

AIMS: We determined whether c-kit proto-oncogene is expressed in prostate cancer and whether its expression is related with biochemical relapse in high risk localized prostate cancer patients. METHODS: c-Kit expression was evaluated by immuno-histochemistry in 94 prostate cancer samples from patients treated by radical prostatectomy followed by adjuvant hormonal therapy because all patients had a pT3a stage (initially cT2 stage). All patients presented a >7 Gleason score and a >10 pre-operative PSA value. We evaluated association between c-kit positive staining and disease free survival. RESULTS: In 26 of 94 prostate cancer, we found an epithelial positive c-kit expression. The epithelial expression was found in the peripheral zone of prostate tissue. 13/94 relapsed and, although not statistically significant (p 0.055), a trend to a higher risk of relapse among the c-kit positive samples was observed in our series of prostate cancer patients. CONCLUSIONS: Our study is only an initial experience and it is necessary to consider a higher number of patients to clarify whether c-kit is really an independent predictor for disease recurrence. Further study in this area will help to understand whether anti c-kit drugs could become an effective complement to the armamentarium of prostate cancer therapies.

Are extended biopsies really necessary to improve prostate cancer detection?

The aim of this study is to understand the value of specific sites in extended peripheral and transition zone biopsy schemes in order to define the optimal systematic biopsy regimen correlated with the percentage of positivity of each single bioptic site. A total of 165 consecutive patients underwent transrectal ultrasonography examination to detect prostate cancer followed by a lesion-directed and systematic 14-step biopsy scheme. The detection rate was examined for the lesion-directed and for each zone region biopsy. The frequency of positive biopsies in the various prostate regions was determined to evaluate the diagnostic yield of each biopsy site. Analysis was stratified for prostate-specific antigen (PSA), free-to-total PSA ratio, age, prostate size and digital rectal examination. The biopsy protocol detected 40% of patients (66/165) as positive and 55.1% (91/165) as negative for cancer. Standard sextant biopsy was expected to detect only 51 cancer on 66, lateral peripheral (PZ), transition (TZ) and central zone (CZ) biopsies only 56 cancer on 66, while the combination of sextant, PZ, TZ and CZ biopsies, for a total of 14 zone biopsies, detected 64 on 66 patients with cancer (97%) at recruitment. Sampling only the eight prostate regions with higher frequency of positive cancer biopsy was expected to detect 61 cancer patients against the 64 found with the 14-step scheme. This eight-biopsy regimen outperforms the conventional sextant regimen in cancer detection rate (93 vs 77%) and has an overall detection rate lower by only 3.1% (36.9 vs 40%) compared to the 14-biopsy regimen. This difference in detection rate is even smaller in patients with PSA values <10 ng/ml, age <70 y and prostate size <50 ml. This eight-biopsy scheme, including sampling in PZ and TZ toward the base, should be considered in an initial biopsy scheme to maintain a similar detection rate of an extensive biopsy scheme reducing the number of biopsies.

Adrenal sparing surgery in the treatment of renal cell carcinoma: when is it possible?

Despite the fairly low incidence of adrenal involvement, adrenalectomy continues to be performed routinely as part of radical nephrectomy. With the recent development of modern imaging techniques and their widespread use, the frequency of small, low stage renal cell carcinomas (RCC) has grown considerably, giving rise to more conservative surgical approaches. We conducted a retrospective study in order to evaluate the incidence and characteristics of adrenal metastasis in RCC, trying to clarify the accuracy of computerized tomography (CT) in the diagnosis and the real need for adrenalectomy during surgery for RCC. The medical records of 192 patients undergoing radical nephrectomy and ipsilateral adrenalectomy for localized or advanced RCC, from 1996 to 2001, were analyzed retrospectively. We considered two subgroups of patients, 73 with stage T1-2 disease (group 1) and 119 with T3-4N0-1M0-1 disease (group 2) according to the 1997 TNM classification. In all cases, a blinded review of the preoperative abdominal CT was performed and an adrenal gland was considered to be abnormal if there was any aberration. Histopathology records of the surgical specimens were examined to determine the accuracy of the CT in identifying adrenal involvement by RCC. Descriptive statistics were used to evaluate the collected data. The overall incidence of adrenal metastasis was 4.1%. Mean renal tumor size in patients with adrenal involvement was 7.8 cm. The tumor stage correlated with the probability of adrenal spread ( P<0.05), with T1-2 tumors accounting for 1.3% of cases only. An adrenal gland was diagnosed as abnormal on preoperative CT in 20 patients (10.4%). CT scans had 87.5% sensitivity, 92.9% specificity, 99.4% negative predictive value and 35% positive predictive value for adrenal involvement by RCC. Adrenal involvement is not likely in patients with localized early stage RCC, and adrenalectomy is unnecessary in such cases, particularly when the CT is negative. However, radical nephrectomy, including removal of the ipsilateral adrenal gland, should be performed in patients with large, high risk tumors.