Simultaneous laparoscopic management of ureteropelvic junction obstruction and renal lithiasis: the combined experience of two academic centers and review of the literature.

INTRODUCTION: Approximately one out of five patients with ureteropelvic junction obstruction (UPJO) present lithiasis in the same setting. We present our outcomes of simultaneous laparoscopic management of UPJO and pelvic or calyceal lithiasis and review the current literature. METHODS: Thirteen patients, with a mean age of 42.8±13.3 years were diagnosed with UPJO and pelvic or calyceal lithiasis. All patients were subjected to laparoscopic dismembered Hynes-Anderson pyeloplasty along with removal of single or multiple stones, using a combination of laparoscopic graspers, irrigation, and flexible nephroscopy with nitinol baskets. RESULTS: The mean operative time was 218.8±66 minutes. In two cases, transposition of the ureter due to crossing vessels was performed. The mean diameter of the largest stone was 0.87±0.25 cm and the mean number of stones retrieved was 8.2 (1-32). Eleven out of 13 patients (84.6%) were rendered stone-free. Complications included prolonged urine output from the drain in one case (Clavien grade I) and urinoma formation requiring drainage in another case (Clavien grade IIIa). The mean postoperative follow-up was 30.2 (7-51) months. No patient has experienced stone or UPJO recurrence. CONCLUSION: Laparoscopy for the management of UPJO along with renal stone removal seems a very appealing treatment, with all the advantages of minimally invasive surgery. Concomitant renal stones do not affect the outcome of laparoscopic pyeloplasty, at least in the midterm. According to our results and the latest literature data, we advocate laparoscopic management as the treatment of choice for these cases.

The role of CXC-chemokine receptor CXCR2 and suppressor of cytokine signaling-3 (SOCS-3) in renal cell carcinoma.

BACKGROUND: Chemokine receptor signaling pathways are implicated in the pathobiology of renal cell carcinoma (RCC). However, the clinical relevance of CXCR2 receptor, mediating the effects of all angiogenic chemokines, remains unclear. SOCS (suppressor of cytokine signaling)-3 is a negative regulator of cytokine-driven responses, contributing to interferon-α resistance commonly used to treat advanced RCC with limited information regarding its expression in RCC. METHODS: In this study, CXCR2 and SOCS-3 were immunohistochemically investigated in 118 RCC cases in relation to interleukin (IL)-6 and (IL)-8, their downstream transducer phosphorylated (p-)STAT-3, and VEGF expression, being further correlated with microvascular characteristics, clinicopathological features and survival. In 30 cases relationships with hypoxia-inducible factors, i.e. HIF-1a, p53 and NF-κΒ (p65/RelA) were also examined. Validation of immunohistochemistry and further investigation of downstream transducers, p-JAK2 and p-c-Jun were evaluated by Western immunoblotting in 5 cases. RESULTS: Both CXCR2 and IL-8 were expressed by the neoplastic cells their levels being interrelated. CXCR2 strongly correlated with the levels of HIF-1a, p53 and p65/RelA in the neoplastic cells. Although SOCS-3 was simultaneously expressed with p-STAT-3, its levels tended to show an inverse relationship with p-JAK-2 and p-c-Jun in Western blots and were positively correlated with HIF-1a, p53 and p65/p65/RelA expression. Neither CXCR2 nor SOCS-3 correlated with the extent of microvascular network. IL-8 and CXCR2 expression was associated with high grade, advanced stage and the presence/number of metastases but only CXCR2 adversely affected survival in univariate analysis. Elevated SOCS-3 expression was associated with progression, the presence/number of metastasis and shortened survival in both univariate and multivariate analysis. CONCLUSIONS: Our findings implicate SOCS-3 overexpression in RCC metastasis and biologic aggressiveness advocating its therapeutic targeting. IL-8/CXCR2 signaling also contributes to the metastatic phenotype of RCC cells but appears of lesser prognostic utility. Both CXCR2 and SOCS-3 appear to be related to transcription factors induced under hypoxia.

Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies.

UNLABELLED: Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C-index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial. OBJECTIVE: • To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN). PATIENTS AND METHODS: • Seventy-four consecutive patients in a single academic tertiary institution underwent open PN. • Incidence of 90-day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case. • The severity of complications was also categorized with the Clavien system. RESULTS: • The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73-1.00). • Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications. • Also, PADUA score ≥ 8 identified a group of patients with almost 20-fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79-28.35; P= 0.015). • Patients with papillary histology had greater risk for complications than those with clear-cell tumours (HR = 4.88; 95% CI, 1.34-17.76; P= 0.016). CONCLUSIONS: • The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre. • The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery. • However, it should be applied to laparoscopic and robot-assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

Quantitative study of mast cells in experimentally induced benign prostatic hyperplasia.

INTRODUCTION: Mast cells are involved in a number of biological responses to exocrine and endocrine stimuli, by releasing growth factors and certain cytokines. The aim of this study was to evaluate their number and distribution in experimentally induced benign prostatic hyperplasia in rats. MATERIALS AND METHODS: Adult Wistar rats (100 days old) were given citral transdermally for 1 month. Morphological characteristics and mast cell concentration were studied in proximal and distal zones after staining with hematoxylin-eosin and Giemsa, respectively. RESULTS: Citral induced mild benign prostatic hyperplasia. Mast cell numbers were increased significantly in both the proximal (2.97 +/- 0.52 vs. 1.4 +/- 0.17, p = 0.004) and distal zone (2.8 +/- 0.68 vs. 1.16 +/- 0.11, p = 0.011). CONCLUSION: Transdermal citral application resulted in a significant increase of mast cell numbers in the stroma of the rat ventral prostate. Furthermore, these mast cells were larger, contained a significant number of intracytoplasmic granules and degranulated. This finding suggests a role for mast cells in the pathogenesis of benign prostatic hyperplasia.

Evaluation of complications in endoscopic extraperitoneal radical prostatectomy in a modular training programme: a multicentre experience.

OBJECTIVES: Structured mentor-based "modular surgical training (MST)" has proved to be an effective way to teach endoscopic extraperitoneal radical prostatectomy (EERPE) safely to residents, even those without previous experience in laparoscopic surgery. We report on complications in early patient series from two centres where EERPE was established by MST held at the same teaching centre. METHODS: Three trainees from two departments underwent MST at the same teaching centre. Thereafter, they were supervised by their mentor at their hospital. Peri-operative and post-operative complications of the first 245 (centre 1) and 288 (centre 2) cases were analysed retrospectively by the revised Clavien classification and compared to a large series (n = 1300) from the teaching centre. P < 0.05 were considered significant. RESULTS: In total, 427 (80.1%) patients were without complications at the training centres. Intra-operative complications occurred in 8 (1.6%) patients. Among 98 (18.3%) patients with post-operative complications, 41 (7.7%) and 7 (1.3%) patients with Clavien grade I and II complications required no or pharmacological treatment, respectively. Totally, 40 (7.5%) patients required surgical intervention (Clavien grade III). Grade IV and V complications were observed in 9 (1.7%) and 1 (0.2%) cases, respectively. A comparison of complications from the training centres and the teaching centre revealed no statistically significant difference. CONCLUSIONS: Novice laparoscopic surgeons can safely learn EERPE by a structured, mentor based, modular surgical training programme without putting patients at risk. The complication rates in early patient series are low and comparable to those of the teaching centre.

Reconsidering the use of the International Index of Erectile Function questionnaire in evaluating the preoperative erectile function status of patients undergoing radical prostatectomy.

OBJECTIVE: To assess the use of the International Index of Erectile Function (IIEF), routinely used in patients being treated for localized prostate cancer, including potency-preserving, nerve-sparing radical prostatectomy (RP), as many patients complain that the results of the IIEF over 4 weeks before RP are not representative. PATIENTS AND METHODS: The study included 123 consecutive patients (mean age 64.6 years, range 52-78) who had endoscopic-extraperitoneal RP and who completed the IIEF. The interval between the diagnosis of the disease and surgery was >4 weeks in all. The patients completed the same questionnaire referring to the last 4 weeks before their prostate biopsy, as a modified index of their sexual status (IIEFm and EFm). RESULTS: The clinical stage of disease was cT1c (34.9%), cT2a (49.5%), cT2b (5.7%) and cT2c (9.9%) before RP. The mean IIEF score was 42.8 and the mean EF domain score was 16.9; the mean IIEFm was 54.9 and the EFm domain score was 23.7. All the differences were statistically significant (P < 0.001). CONCLUSION: The IIEF questionnaire scores are influenced by many factors. Depression after a diagnosis of cancer, and the prostate biopsy-related symptoms, e.g. prostatitis, perineal pain and haemospermia, might compromise the patients' well-being and libido, and thus affect the IIEF scores before RP. We therefore suggest using the IIEFm and EFm scores before prostate biopsy to assess the patients' sexual status before any treatment for localized prostate cancer.

Efficacy of tolterodine in preventing urge incontinence immediately after prostatectomy.

PURPOSE: Urgency and urge incontinence are frequently observed after prostatectomy. Although symptoms ameliorate within a relatively short time, they usually cause significant stress and anxiety to the patient as far as their duration is concerned. Aim of our study was to determine the efficacy of tolterodine in preventing urgency and urge incontinence after catheter removal in patients that underwent prostatectomy for benign prostate hyperplasia. PATIENTS AND METHODS: Twenty-seven patients with moderate/severe lower urinary tract symptoms due to benign prostatic enlargement, scheduled for prostatectomy, were randomised into two groups, Group A (14 pts) received tolterodine 2 mg b.i.d starting the day of surgery, while group B patients received no such treatment. Tolterodine treatment was discontinued 15 days after catheter removal. All patients completed the International Prostatic Symptom Score (IPSS) and the International Continence Society (ICS-BPH) forms the day before surgery, and three times more, one, fifteen and thirty days after catheter removal. RESULTS: Pre-operative total 1PSS and frequency of urgency/urge incontinence as determined by questions 3 and 4 of the ICS-BPH questionnaire were equally distributed between groups. Tolterodine was well tolerated and no adverse effects were reported. Post-operative IPSS and QoL scores did not differ between groups. However, the frequency of urge incontinence both the first day and fifteen days after catheter removal was significantly lower in the tolterodine group (16.6% vs. 69.2%, p=0.004 and 8.3% vs. 38.4%, p=0.039, respectively). CONCLUSION: Tolterodine was well tolerated in all patients and had a beneficial effect regarding the postoperative urge incontinence. Trials of a larger scale could determine which patients would benefit more, especially according to the presence of storage lower urinary tract symptoms prior to surgery.

Urgent superselective segmental renal artery embolization in the treatment of life-threatening renal hemorrhage.

INTRODUCTION: Renal hemorrhage is a major life-threatening condition that can be caused by trauma, operation, biopsy, as well as sudden spontaneous rupture of renal tumors or aneurysms. We report our experience with superselective segmental renal artery catheterization and embolization as therapeutic options for such cases. PATIENTS AND METHODS: Over the last 8 years, 28 patients with severe renal hemorrhage were admitted for evaluation and possible further treatment. Twenty of them had a history of previous biopsy (6 of them one of a transplanted kidney), 1 patient had a recent percutaneous nephrostomy, 4 patients presented with renal mass ruptures (2 patients renal cell carcinoma, 1 patient angiomyolipoma, 1 patient hemorrhagic cysts), 1 patient had rupture of a renal aneurysm during delivery, 1 patient suffered bleeding after partial nephrectomy, and 1 patient was hospitalized after a car accident. They all presented with clinical signs of hemodynamic instability. Angiographic investigation of the kidneys preceded further intervention in all cases. 26 out of the 28 patients underwent superselective embolization of the specific bleeding vessel with the use of microcoils and/or Gelfoam particles. RESULTS: All patients treated by superselective segmental renal artery embolization had a successful outcome, including a steady renal function and a stable clinical course. No complications occurred. CONCLUSION: Superselective segmental renal artery catheterization and embolization is a safe and efficient method for the treatment of patients with severe renal hemorrhage, preserving healthy renal parenchyma and renal function.

Delayed life-threatening haematuria from a renal pseudoaneurysm caused by blunt renal trauma treated with selective embolization.

Pseudo-aneurysms complicating blunt renal traumas, although very rare, represent significant causes of secondary haematuria, potentially life-threatening. Initial surgical repair of the injured kidney does not preclude the presence of an obscure pseudo-aneurysm that could become evident later on. We herein present a patient with a grade III blunt renal trauma initially treated surgically. Thirty days after the trauma, he developed secondary haematuria caused by a renal pseudo-aneurysm located far from the oversewed area. This vascular lesion was successfully treated using selective arterial embolization.

In vivo effect of the lipido-sterolic extract of Serenoa repens (Permixon) on mast cell accumulation and glandular epithelium trophism in the rat prostate.

The Serenoa repens lipido-sterolic extract (SRLSE, Permixon, Pierre Fabre Medicament, Castres, France) is used to treat benign prostate hyperplasia. We studied the in vivo effect of SRLSE on mast cell accumulation and the histological characteristics of the rat ventral prostate. Adult Wistar rats received either tocopherol or SRLSE (50 and 100 mg/kg body weight, respectively) every second day for 90 days. Histological features were studied in hematoxylin-eosin stained tissue sections while mean mast cell numbers were determined in Giemsa-stained sections. The central region of the ventral prostate in treated animals showed significant changes with acinar epithelium becoming flat or low cuboidal. In the same region, mean mast cell number per optical field in the control, low-dose and high-dose groups were, respectively, 4.7+/-0.7, 3.4+/-1.0 and 2.4+/-0.6, showing a dose-dependent, statistically significant decrease. Administering SRLSE significantly reduces mast cell accumulation and provokes epithelium atrophy within the central area of the rat ventral prostate. These phenomena may participate in the clinical activity of the drug.