[Extensive stone formation in the prostatic bed following enucleation of an adenoma. Combined endourological treatment of an interesting case]. / Ausgedehnte Steinbildung in der Prostataloge nach Adenomenukleation. Endourologische Kombinationstherapie zur Behandlung dieses interessanten Falles.

We report on a patient with extensive stone formation in the prostatic bed 4 years after open suprapubic prostatectomy for benign prostatic hyperplasia. The patient was successfully treated with a combination of transurethral and percutaneous suprapubic lithotripsy in the same session.

Abdomino-perineal repair of recurrent and complex bladder neck-prostatic urethra contractures.

OBJECTIVE: To evaluate the effectiveness of abdomino-perineal repair in treating complex and recurrent bladder neck-prostatic urethra contractures. METHODS: The study included 6 patients retrospectively. Their ages ranged from 66 to 75 years (67.83+/-8.13, mean + SD). All presented with a long history of voiding difficulty and urinary incontinence. Prior to definitive treatment all the patients had been subjected to multiple unsuccessful transurethral resections of bladder neck-prostatic urethra contractures. They were all subjected to diagnostic work-up including retrograde and voiding urethrogram, urethroscopy and urodynamics. Finally all the patients underwent abdomino-perineal excision of the stenotic area and end to end anastomosis. All of them received simultaneously an artificial urinary sphincter insertion for concurrent sphincteric deficiency and three were subjected simultaneously to clam type ileocystoplasty for intractable detrusor instability. The follow-up ranged from 8 to 56 months (24.42+/-19.64, mean + SD). RESULTS: The actual surgical time ranged from 3.5 to 5.5 h (4.1+0.4, mean + SD). Five patients void satisfactorily remaining unobstructed through the entire follow-up period, while one has to empty his augmented bladder by means of clean intermittent self catheterization. Five patients are continent and one significantly improved. Major complications due to infection-erosion of the prosthetic material were encountered in one patient. CONCLUSIONS: Abdomino-perineal repair is an effective surgical procedure for the management of recurrent and complex bladder neck-prostatic urethra contractures, although it is time consuming and requires in the majority of cases combined techniques in order to achieve optimal results.

Intravesical therapy of superficial bladder cancer.

Transurethral resection (TUR) of the superficial transitional cell carcinoma (TCC) of the bladder is known to be insufficient in controlling the disease because of the unacceptable rates of recurrence, progression and ultimate cystectomy. Adjuvant intravesical chemo-and/or immunotherapy is administered in an effort to enhance the efficacy of surgery alone. The initial tumor stage and grade, the multifocality of this cancer and the history of previous recurrences remain the determinant factors in survival. It is important to decide exactly which patients are at risk, and, therefore, do need treatment. Knowledge of the natural history of the disease will facilitate this decision making, although the natural history of TCC is largely unpredictable owing to tumor heterogeneity. Several cytotoxic and immune modifying agents have been used intravesically in different treatment schedules. However, despite their effectiveness, no consensus exists about the optimal antineoplastic regimen. The selection of the latter is a subject of continuous investigation. Intravesical treatment with cytotoxic drugs has been demonstrated to achieve an acceptable reduction in short- and intermediate-term recurrence rates, but has no proven ability in preventing disease progression to muscle-invasive cancer or prolonging survival. On the other hand, bacillus Calmette-Guerin (BCG) currently appears to be the most effective agent for intravesical use, especially in patients with high grade and stage neoplasms but the optimum strain, dosage and duration schedule have not been determined. Clinical trials have shown that BCG provides long-term protection from tumor recurrence, while there is evidence that it may favorably alter the progression rate of the disease with prolongation of survival. Toxicity of intravesical chemo- and immunotherapy still remains a major problem and attempts at reducing the dosage, and, thus, toxicity without affecting efficacy are underway. This review endeavors to present updated information on intravesical chemotherapy in treating superficial bladder cancer, the expanding role of intravesical immunotherapy, the recent work comparing various immunotherapeutic regimens with chemotherapeutic intravesical therapies, and the progress made towards achieving optimal treatment regimens.

The urodynamic profile of prostatodynia.

OBJECTIVE: To evaluate urodynamically patients with prostatodynia, and thus define a specific urodynamic pattern that might add to the pathophysiology of the syndrome and possibly aid definitive treatment. PATIENTS AND METHODS: Forty-three patients (mean age 38.1 years, sd 9.25, range 24-59) with symptoms suggestive of chronic prostatitis, e.g. dysuria, frequency of micturition and a burning sensation in the perineum, were classified as having prostatodynia after excluding prostatic infection by standard bacteriological methods. Thereafter, the patients were evaluated urodynamically, including the measurement of free flow-rate, filling (water) cystometry, a pressure/flow study of micturition, with fluoroscopy and electromyography of the external urethral sphincter. RESULTS: Twenty-eight patients (65%) had a low maximum free flow rate (Qmax ), with a mean (sd) of 10.91 (1.26) mL/s. Of the 42 patients who underwent filling cystometry, 26 (62%) had a first sensation of filling, and 28 (67%) a first desire to void, at low volumes (<150 mL and <300 mL, respectively). Of the 25 patients who underwent a pressure/flow study, 16 (64%) had an obstructive pattern of micturition, as defined by a low Qmax of 10.04 (1.38) mL/s and a high intravesical pressure at Qmax of 83.3 (5.3) cmH2O. The site of obstruction was at the level of the bladder neck, as confirmed by fluoroscopy. CONCLUSION: A significant proportion of these patients had a particular urodynamic pattern of functional infravesical obstruction at the level of the bladder neck and sensory disturbances.

Incidence and histological findings of unsuspected prostatic adenocarcinoma in radical cystoprostatectomy for transitional cell carcinoma of the bladder.

OBJECTIVE: The present study is designed to evaluate the incidence, histological features and significance of prostatic adenocarcinoma in patients undergoing cystoprostatectomy for Transitional Cell Carcinoma (TCC) of the bladder. PATIENTS, MATERIAL AND METHODS: From January 1990 to December 1996, 59 male patients (mean age 66.5 years), with no evidence of prostatic malignancy on preoperative clinical and biochemical assessment, underwent cystoprostatectomy for TCC of the bladder. The bladder was adequately sampled and the entire prostate sectioned at 5-mm intervals and examined histologically, in order to identify unsuspected prostatic cancer (PCa). RESULTS: Sixteen out of 59 patients (27%) were found to have PCa, which was multifocal in 5 cases (31.25%). The mean tumor size was 0.24 cm. The tumors were equally distributed in the anterior and posterior parts of the prostate and in the peripheral and transition zones, with uniform distribution in both prostatic lobes. In 5 patients (31.25%), the single focus of the tumor was in the apex. All were grade I tumors except one, and all were organ-confined with no capsular penetration. The follow-up ranged from 12-74 months (mean 39 months). Within this period, 7 patients died from metastatic bladder cancer. One patient with PCa localized in the prostatic apex had recurrent prostatic disease in the urethro-ileal anastomosis of an orthotopic bladder substitute; he is alive and on androgen deprivation. The remaining patients are relapse-free. CONCLUSIONS: Incidental PCa is quite a common finding in cystoprostatectomy specimens of bladder cancer patients. Its tendency to appear in the apex of the prostate demands careful and complete excision of the organ.

Can p53 nuclear over-expression, Bcl-2 accumulation and PCNA status be of prognostic significance in high-risk superficial and invasive bladder tumours?

AIMS: To evaluate p53 and Bcl-2 expression and proliferating status (PCNA) in subgroups of patients with high-risk superficial and invasive bladder cancer, with relation to cancer progression and death, and to correlate the results with established clinical prognostic factors. METHODS: Paraffin-embedded sections from 42 high-risk superficial (T1G2,T1G3) and 33 invasive (T2-T4aG3 N0M0) tumours were investigated immunohistochemically for p53, Bcl-2 and PCNA. The median follow-up was 52 months. RESULTS: In the cohort of superficial tumours, statistical analysis showed that p53 and PCNA positivity were significant prognostic factors (P-values: 0.008 and 0.006, respectively) for disease-specific death (DSD). When life expectancy was evaluated (log-rank test), p53(+) (P = 0.015) and PCNA(+) (P = 0.017) offered the most accurate prognosis compared to grade, tumour size and multiplicity. Bcl-2 status had no significant effect on patient survival. In the subset of muscle-invasive tumours we failed to demonstrate any important role of p53, Bcl-2 or PCNA positivity. CONCLUSIONS: p53 and PCNA over-expression may offer valuable additional prognostic information in high-risk subgroups of superficial bladder tumours. From our results, Bcl-2 does not appear to contribute significantly to the prognosis of these patients. None of the studied markers offered prognostic information in muscle-invading disease.

Transvaginal incisionless bladder neck suspension. A simplified technique for female genuine stress incontinence.

OBJECTIVES: Purpose of the present study is to evaluate the efficacy of a modified Gittes procedure in the management of Type I and Type II stress urinary incontinence of the female. PATIENTS AND METHODS: Thirty-two female patients with urodynamically proven Type I and Type II stress urinary incontinence had been subjected to transvaginal incisionless bladder neck suspension (modified Gittes procedure) from September 1991 to June 1996. Their mean age was 55.2 (32-78) years. The preoperative evaluation included provocative video-urodynamics and occasional profilometry to exclude Type III stress incontinence in certain cases. The procedure described by Gittes was performed with the modification of approaching the rectus fascia through two small suprapubic incisions instead of the percutaneous original Gittes puncture. RESULTS: The mean follow-up was 41 (10-66) months. Two of our patients had been lost from follow-up and were excluded from analysis. Of the remaining 30 patients, 26 (86.7%) are clinically continent. Six of them (20%) developed de novo postoperative urgency and/or urge incontinence due to bladder instability not present preoperatively. All six of them successfully managed with oral oxybutynin chloride. One diabetic patient was unable to void spontaneously and had to use the technique of clean intermittent self-catheterization (CISC) to evacuate her bladder. Of the remaining 4 (13.3%) incontinent patients, one was subjected to insertion of an artificial urinary sphincter (AUS) and one to a Burch colposuspension, both successfully. There were no major peri- or postoperative complications, with the exception of one patient with recurrent cystitis, who was treated with long-term chemoprophylaxis. CONCLUSION: The modified Gittes bladder neck suspension is a simple and effective procedure, with no major complications and thus a good alternative to abdominal approaches.

Incontinence after surgery for benign prostatic hypertrophy: the case for complex approach and treatment.

OBJECTIVE: Whether incontinence after surgery for benign prostatic hypertrophy (BPH) requires simple workup and treatment or being a more complex condition and multifactorial in etiology requiring combined surgical techniques should be investigated in more detail. METHODS: We retrospectively reviewed the records of 56 patients referred to us for post-prostatectomy incontinence after surgery for BPH. All patients were subjected to urodynamics. Twenty-three (41.1%) patients required additional ascending urethrogram and/or cystourethroscopy, according to their associated symptomatology and the urodynamic findings, for a definitive diagnosis to be established. RESULTS: Twenty-four patients (42.8%) were found to have complex incontinence (either mixed or any type associated with bladder outlet stenosis), requiring combined treatment. Twenty-three (41.1%) had a simple type of incontinence, i.e., pure sphincter incompetence or unstable detrusor. Three patients had residual adenoma and 1 urethral stricture, while 5 patients (8.9%) remained unclassified. Thirty-seven patients were subjected to treatment, 27 (73%) of them to single-modality treatment (artificial urinary sphincter insertion, oxybutynin chloride, transurethral prostatectomy, optical urethrotomy) and the other 10 (27%) to combined treatment (artificial urinary sphincter insertion plus urethroplasty, ileocystoplasty, permanent urethral stent implantation etc.). The overall socially acceptable continence rate (cured plus significantly improved) of the patients subjected to artificial urinary sphincter insertion reached 85%, being better (90%) for the uncomplicated sphincter incompetence group. CONCLUSIONS: Incontinence after surgery for BPH represents a condition that requires careful evaluation. In a significant proportion of patients, a combination of prosthetic and reconstructive techniques is needed for an optimal result to be achieved.

Combined reconstructive and prosthetic surgery in complicated lower urinary tract dysfunction.

PURPOSE: The combined use of the appropriate reconstructive technique and available prosthetic material was evaluated to achieve an optimal functional result in complicated lower urinary tract dysfunction. MATERIALS AND METHODS: The study included 16 male and 8 female patients. Urinary dysfunction was classified into 2 main categories: 1) neuropathic and 2) nonneuropathic. Of the patients 22 underwent some form of augmentation (21) or substitution (1) cystoplasty, 24 received an artificial urinary sphincter, 2 underwent abdominoperineal urethroplasty and 2 received a permanent urethral stent. One patient underwent renal transplantation and 1 received a penile prosthesis for concurrent impotence. RESULTS: A total of 20 patients (83.3%) became continent, 10 void spontaneously, while 14 must empty the bladder or pouch by clean intermittent self-catheterization. All patients have stable or improved renal function. CONCLUSIONS: Combined reconstructive and prosthetic surgery has an important role in the treatment of lower urinary tract dysfunction, with a high success rate and good quality of life.

Is beta-human chorionic gonadotrophin production by transitional cell carcinoma of the bladder a marker of aggressive disease and resistance to radiotherapy?

The biopsies from 75 patients with transitional cell carcinoma of the bladder (25 Ta-T1; 45 T2-T4, 5M) were studied immunohistochemically for the expression of beta-human chorionic gonadotrophin (beta-HCG). Only 5 Ta-T1 tumours contained a small number of beta-HCG positive cells but 24 invasive tumours and all patients with metastases showed increased numbers of positive cells. A significant correlation was found between beta-HCG immunoreactivity and tumour category. In 30 patients with muscle-invasive disease (T2-T4,N0,M0) who were treated with radical radiotherapy a significant correlation was observed between response to treatment and beta-HCG expression; beta-HCG positive tumours did not respond to treatment. A difference in survival was found between patients with tumours negative for beta-HCG compared with patients with positive tumours, all treated with radical radiotherapy. The results indicate that beta-HCG expression increases with tumour invasiveness and the use of immunohistochemistry may prove a useful means of identifying radioresistant and aggressive forms of bladder cancer.