Ablative Treatments for Small Renal Masses and Management of Recurrences: A Comprehensive Review.

This review focuses on ablative techniques for small renal masses (SRMs), including radiofrequency ablation (RFA), cryoablation (CA), microwave ablation (MWA), and irreversible electroporation (IRE), and discusses recurrence management. Through an extensive literature review, we outline the procedures, outcomes, and follow-up strategies associated with each ablative method. The review provides a detailed examination of these techniques-RFA, CA, MWA, and IRE-elucidating their respective outcomes. Recurrence rates vary among them, with RFA and CA showing comparable rates, MWA demonstrating favorable short-term results, and IRE exhibiting promise in experimental stages. For managing recurrences, various strategies are considered, including active surveillance, re-ablation, or salvage surgery. Surveillance is preferred post-RFA and post-CA, due to slow SRM growth, while re-ablation, particularly with RFA and CA, is deemed feasible without additional complications. Salvage surgery emerges as a viable option for larger or resistant tumors. While ablative techniques offer short-term results comparable to surgery, further research is essential to understand their long-term effects fully. Decisions concerning recurrence management should consider individual and tumor-specific factors. Imaging, notably contrast-enhanced ultrasounds, plays a pivotal role in assessing treatment success, emphasizing the necessity of a multidisciplinary approach for optimal outcomes. The lack of randomized trials highlights the need for further research.

Unraveling the Dietary Puzzle: Exploring the Influence of Diet, Nutraceuticals, and Supplements on Bladder Cancer Risk, Outcomes, and Immunotherapy Efficacy: Insights from the BLOSSOM Study and Beyond.

Bladder cancer is considered a global health concern characterized by significant morbidity and mortality rates. The complex relationship between diet and bladder cancer is examined, with a specific focus on the role of diet in risk, outcomes, and treatment efficacy. Attention is drawn to the burgeoning field of immunotherapy in bladder cancer treatment, and the possible influence of diet on its outcomes is explored. While evidence remains limited, prior studies in other cancer types have suggested a potential connection between diet and immunotherapy response. To address this knowledge gap, the ongoing BLOSSOM study is presented, which aims to investigate the link between dietary factors, lifestyle, and the effectiveness of immunotherapy in patients with non-muscle-invasive bladder cancer. Ongoing efforts to decipher the intricate relationship between diet and bladder cancer care are highlighted, emphasizing the quest to unravel the dietary puzzle for the improvement of bladder cancer management.

"Could Patient Age and Gender, along with Mass Size, Be Predictive Factors for Benign Kidney Tumors?": A Retrospective Analysis of 307 Consecutive Single Renal Masses Treated with Partial or Radical Nephrectomy.

Due to the increased use of common and non-invasive abdominal imaging techniques over the last few decades, the diagnosis of about 60% of renal tumors is incidental. Contrast-enhancing renal nodules on computed tomography are diagnosed as malignant tumors, which are often removed surgically without first performing a biopsy. Most kidney nodules are renal cell carcinoma (RCC) after surgical treatment, but a non-negligible rate of these nodules may be benign on final pathology; as a result, patients undergo unnecessary surgery with an associated significant morbidity. Our study aimed to identify a subgroup of patients with higher odds of harboring benign tumors, who would hence benefit from further diagnostic examinations (such as renal biopsy) or active surveillance. We performed a retrospective review of the medical data, including pathology results, of patients undergoing surgery for solid renal masses that were suspected to be RCCs (for a total sample of 307 patients). Owing to the widespread use of common and non-invasive imaging techniques, the incidental diagnosis of kidney tumors has become increasingly common. Considering that a non-negligible rate of these tumors is found to be benign after surgery at pathological examination, it is crucial to identify features that can correctly diagnose a mass as benign or not. According to our study results, female sex and tumor size ≤ 3 cm were independent predictors of benign disease. Contrary to that demonstrated by other authors, increasing patient age was also positively linked to a greater risk of malign pathology.

Synchronous bladder and prostate cancer specimens obtained from radical cystoprostatectomy: A single­center retrospective analysis.

The aim of the present study was to analyze incidence, histopathological features and clinical outcomes of patients undergoing radical cystoprostatectomy (RCP) for bladder cancer, in which incidental prostate cancer (PCa) was found. How these types of cancer impacted the patients' management and whether prostate-sparing cystectomy could be an option for these patients was determined. The current study retrospectively analyzed the data of a cohort of patients from 'Umberto I' Hospital of Nocera Inferiore who underwent RCP for bladder transitional cell carcinoma. Patients with a preoperative diagnosis or clinical suspicion of PCa were excluded. Patients affected by incidental PCa in the RCP specimens were identified, and then their demographic, histopathological and clinical outcome data were collected. Overall, it was revealed that of the 303 patients undergoing RCP for bladder cancer, 69 (22.7%) had incidental PCa, with a median age of 71.6 (age range, 54-89 years). In total, 23 (33.33%) of the 69 patients with incidental PCa were considered to have clinically significant prostate disease. In conclusion, it was relatively common to identify incidental PCa in RCP specimens but no preoperative predictive factors were identified that were able to determine 'non-aggressive' PCa status. Therefore, the present results demonstrate the need for a careful and complete prostate removal during RCP. Nevertheless, since organ-sparing surgeries are widely performed in young population, due to the impossibility of predicting aggressive prostate cancer, these patients require close monitoring through lifelong PSA surveillance, particularly focusing on the possible relapse of PCa after RCP.

"To Be or Not to Be Benign" at Partial Nephrectomy for Presumed RCC Renal Masses: Single-Center Experience with 195 Consecutive Patients.

In daily medical practice, an increasing number of kidney masses are being incidentally detected using common imaging techniques, owing to the improved diagnostic accuracy and increasingly frequent use of these techniques. As a consequence, the rate of detection of smaller lesions is increasing considerably. According to certain studies, following surgical treatment, up to 27% of small enhancing renal masses are identified as benign tumors at the final pathological examination. This high rate of benign tumors challenges the appropriateness of surgery for all suspicious lesions, given the morbidity associated with such an intervention. The objective of the present study was, therefore, to determine the incidence of benign tumors at partial nephrectomy (PN) for a solitary renal mass. To meet this end, a total of 195 patients who each underwent one PN for a solitary renal lesion with the intent to cure RCC were included in the final retrospective analysis. A benign neoplasm was identified in 30 of these patients. The age of the patients ranged from 29.9-79 years (average: 60.9 years). The tumor size range was 1.5-7 cm (average: 3 cm). All the operations were successful using the laparoscopic approach. The pathological results were renal oncocytoma in 26 cases, angiomyolipomas in two cases, and cysts in the remaining two cases. In conclusion, we have shown in our present series the incidence rate of benign tumors in patients who have been subjected to laparoscopic PN due to a suspected solitary renal mass. Based on these results, we advise that the patient should be counseled not only about the intra- and post-operative risks of nephron-sparing surgery but also about its dual therapeutic and diagnostic role. Therefore, the patients should be informed of the considerably high probability of a benign histological result.

Association between obesity and frequency of high-grade prostate cancer on biopsy in men: A single-center retrospective study.

The present study aimed to investigate the relationship between BMI and the prostate cancer (PCa) risk at biopsy in Italian men. Retrospective analyses of the clinical data of 2,372 consecutive men undergoing ultrasound-guided multicore (≥10) prostate biopsy transrectally between May 2010 and December 2018 were performed. BMIs were categorized, according to Western countries' classification of obesity, as follows: <18.5 kg/m2 (underweight), 18.5-24.99 kg/m2 (normal weight), 25-30 kg/m2 (overweight) and >30 kg/m2 (obese). The distribution of patients undergoing biopsy was compared with a model population from the official survey data. Patient characteristics and the relationships between characteristics were investigated using correlation analysis, ANOVA, Kruskal-Wallis and Dunn's tests. The present study estimated the influence on cancer incidence not only of BMI but also of other patient characteristics using multi-variable logistic modelling and compared, using the models, the expected outcomes for patients who differed only in BMI. From a sample of 2,372 men, the present study enrolled 1,079 men due to a lack of clinical data [such as prostate specific antigen (PSA) and BMI data] in the other patients undergoing prostate biopsy. Their distribution was significantly different from the model distribution with the probability of undergoing biopsy increasing with increasing BMI. The median age was 69.4 years. The median BMI was 26.4 kg/m2, while the median PSA level was 7.60 ng/ml. In total, the biopsies detected PCa in 320 men (29.7%) and high-grade PCa (HGPCa) in 218 men (20.2%). Upon applying the aforementioned Western countries' criteria for BMI categories, there were 4 (0.4%) underweight, 318 (29.5%) of normal weight, 546 (50.6%) overweight, and 211 (19.6%) obese patients. ANOVA/Kruskal-Wallis tests revealed that overweight and obese men were younger than the normal-weight men, while there was no statistical difference in their PSA values. Furthermore, 29.3% of normal-weight men, 29.5% of overweight men and 29.9% of obese men were diagnosed with PCa, while 19.5% of normal-weight men, 20.1% of overweight men and 21.8% of obese men were affected by severe cancer. BMI was found to be positively correlated with PCa risk and negatively correlated with both age and PSA level. Age and PSA level were both positively correlated with PCa risk, while digital rectal examination (DRE) outcome was strongly indicative of PCa discovery if the test outcome was positive. Logistics models attributed a positive coefficient to BMI when evaluated against both PCa risk and HGPCa risk. In patients having a negative DRE outcome who differed only in BMI, logistic regression showed a 60% increased risk of PCa diagnosis in obese patients compared with in normal-weight patients. This risk difference increased when other characteristics were less indicative of PCa (younger age/lower PSA), while it decreased when patient characteristics were more indicative (older age/higher PSA, positive DRE). In conclusion, the present study demonstrated that, in men with higher BMIs, the risk of PCa is higher. The relative difference in risk between low and high BMI is most pronounced in younger patients having a lower PSA level and a negative DRE outcome.

When a Multidisciplinary Approach Is Life-Saving: A Case Report of Cardiogenic Shock Induced by a Large Pheochromocytoma.

BACKGROUND: Pheochromocytoma is known for its instantaneous presentation, especially in the younger population. Hemodynamic instability may be the cause of severe complications and impede patients' ability to undergo surgical treatment. These tumours are surgically difficult to treat due to the risk of catecholamine release during their manipulations, and when they are large, the tumour size represents an additional challenge. In our report, cardiogenic shock developed due to increases in systemic vascular resistance, and the lesion's size induced surgeons to perform open surgery. CASE PRESENTATION: A 46-year-old female patient was admitted to our intensive care unit with hypertension and later cardiogenic shock. Systolic dysfunction was noted, along with severely increased systemic vascular resistance. A CT scan showed a left-sided 8.5 cm adrenal mass, which was confirmed as pheochromocytoma using meta-iodobenzylguanidine scintigraphy. Anaesthesiologists and the surgical team planned an effective strategy of treatment. Given the lesion's size and its apparent invasion of the neighbouring organs, open adrenalectomy (after prolonged hemodynamic stabilisation) was considered safer. The surgery was successful, and the patient remains free from disease two years after the initial event. CONCLUSIONS: Large pheochromocytoma can be safely and effectively treated with open surgery by experienced hands but only by seeking to reach hemodynamic stabilisation and minimising the release of catecholamine before and during surgery.

Incidence rate and management of diaphragmatic injury during laparoscopic nephrectomies: single-center experience.

Pneumothorax is a rare complication in laparoscopic renal surgery. However, due to the increasing renal pathologies managed by laparoscopic technique, this infrequent complication is a potential risk. We investigated the incidence rate of this complication in our experience of laparoscopic renal surgery, taking into account the laparoscopic approach, the type of intervention, the character of the pathology (neoplastic or other), the site of the intervention, as well as the localization of the lesion (in case of malignant pathology). About 384 laparoscopic nephrectomies were reviewed at our institution, with a total of four cases (1.04%) of diaphragmatic injury. Diaphragmatic repair was always carried out by intracorporeal suturing, with no complications. Repair of diaphragmatic injuries should always be attempted with intracorporeal suture since this is a safe and effective technique. Then, although in the retroperitoneal approach pneumothorax is more likely, our experience has shown that transperitoneal access is not free from this complication.

Near-infrared fluorescence imaging with intraoperative administration of indocyanine green for laparoscopic radical prostatectomy: Is it a useful weapon for pelvic lymph node dissection?

Near-infrared fluorescence imaging with indocyanine green has emerging applications in urologic surgery. This technology is strongly used in robotic surgery for several ablative and reconstructive procedures. On the contrary, it is not used at all in the urological laparoscopic surgery. To date, bilateral pelvic lymph node dissection represents the most accurate and reliable staging procedure for the detection of lymph node invasion in prostate cancer and bladder cancer. However, it is not devoid of complications. In this field, indocyanine green fluorescence-guided sentinel lymph node identification is an emerging technique, as accurate staging of urologic cancer could be enhanced by an intraoperative lymphatic mapping. Our goal was to show a high spatial resolution, real-time intraoperative imaging technique to recognize the main lymphatic drainage networks, avoiding at same time lymphatic vessel damage. Furthermore, the use of such an imaging system represents an absolute novelty in the field of urological laparoscopy.

'Burned-out' syndrome of testicular teratoma: A case report.

The majority of testicular tumors are germ cell tumors (GCTs) which, although rare, frequently present in young adults. In exceptional circumstances, spontaneous regression of the primary tumor occurs. The appellation 'burned-out' is applied to situations in which a metastatic GCT is found to be present, accompanied by histological regression of the primary testicular lesion. It is of crucial importance that a clinical examination of the testis is performed, and scrotal sonography is essential in the preliminary diagnosis of such neoplasms. In the present case report, a burned-out, non-seminomatous testicular GCT case is described. A CT scan revealed that a 29-year-old male patient who was experiencing loss of weight and appetite had retroperitoneal and mediastinal masses. A testicular examination did not reveal the presence of any palpable lesion, and an ultrasound examination of the scrotum disclosed a normal left testis and an atrophic right testicle with heterogeneous architecture, but with no evidence of a tumor. Chemotherapy was administered to the patient following surgical intervention into the retroperitoneal and mediastinal mass. It is evident that it remains problematic to accurately differentiate between a primary retroperitoneal tumor and a metastatic testicular tumor with an occult testicular primary or a 'burned-out' testicular cancer. The burned-out phenomenon is a rare occurrence, and further research into its pathogenesis is required. Both the rarity of this phenomenon and the difficulties encountered in diagnosis prompted the writing of the present case report, especially considering that teratomas are categorized as belonging to the histology group that shows the least likelihood of regressing.

Single-session laparoscopic cystectomy and nephroureterectomy: is it real and useful choice of treatment or fiction?

Patients with recurrent high grade and/or muscle-invasive bladder cancer and concomitant upper urinary tract disease, e.g. urothelial tumors or afunctional hydronephrotic kidneys, may be candidates for simultaneous laparoscopic cystectomy and nephroureterectomy. So, such patients, especially when affected by multiple comorbidities, can benefit from the avoidance of extended laparotomy. We report our experience with simultaneous laparoscopic radical cystectomy and right nephroureterectomy in a 67-year-old-male patient affected by recurrent polyfocal high grade bladder cancer and an associated right upper tract carcinoma. This laparoscopic approach was technically successful without the need for conversion to open surgery. More than a year after the surgery, the patient is still alive, showing no tumor relapse of at the established instrumental controls. This laparoscopic approach, performed in a single session, can be safe and feasible in selected cases as an alternative approach to the open surgery, offering good oncological and functional results.

Physical activity decreases the risk of cancer reclassification in patients on active surveillance: a multicenter retrospective study.

BACKGROUND: Physical activity (PA) is associated with favorable outcomes in prostate cancer (PCa) patients. We assessed its effect on the risk of PCa reclassification (PCaR) during active surveillance. METHODS: Anthropometric, demographic, and clinical data concerning men diagnosed with a low-risk PCa and initially managed with active surveillance at the two participating institutions were retrospectively collected. The Physical Activity Scale for the Elderly (PASE) was used for patients' self-assessment of their daily exercise and their consequent stratification into three groups: sedentary (PASE ≤ 65), moderately active (65 < PASE < 125), active (PASE ≥ 125). Kaplan-Meier model was used to evaluate the predictive role of PA on PCaR, computed at 2, 5, 10 years after diagnosis; differences between lifestyle groups were assessed using the log-rank and uni-/multivariable Cox analyses applied to identify predictors of reclassification. RESULTS: Eighty-five patients were included in the analysis, with a median age of 66 years (IQR: 59-70); 16% were active, 45% were former smokers, and 3 presented with metabolic syndrome (MetS). Prostate-specific antigen (PSA) density was 0.12 (IQR: 0.07-0.15); 34 men showed a PSA doubling time <10 years. The Median PASE score was 86 (IQR: 61.5-115.8): 24 patients were sedentary, 46 moderately active, and 15 active. At a median follow-up of 37 months (IQR: 14-53), 25% of patients experienced PCaR. These were less physically active (PASE score 69.3 vs 87.8; p = 0.056) and presented with significantly smaller prostates (46 ml vs 50.7 ml; p = 0.001) and a higher PSAD (0.14 vs 0.10; p = 0.019). At 2 years, the risk of reclassification was 25 ± 5%, while it was 38 ± 7% at both 5 and 10 years. The risk was significantly different in the three PA groups (Log Rank p = 0.033). PASE score was the only independent predictor of PCaR (HR: 0.987; 95%CI: 0.977-0.998; p = 0.016). CONCLUSIONS: PA influences PCa evolution, as increasing levels are associated with a significantly reduced risk of tumor reclassification among patients undergoing active surveillance.

High-Risk Prostate Cancer: A Very Challenging Disease in the Field of Uro-Oncology.

Prostate cancer (PCa) is the most common cancer in males and affects 16% of men during their lifetime [...].

Clinical Characteristics of Metastatic Prostate Cancer Patients Infected with COVID-19 in South Italy.

BACKGROUND: To date, the clinical characteristics of coronavirus disease 19 (COVID-19)-infected urologic cancer patients are unknown. METHODS: We have analyzed all patients with prostate cancer undergoing hormonal or chemotherapy treatment and receiving telephone and in person pre-triage between March 1 and 27, 2020, at the Tortora Hospital, Pagani, Italy. RESULTS: Among 72 patients, 48 and 24 were hormone-sensitive (HS) and castration-resistant prostate cancer (CRPC), respectively; 0 HS and 2 (8.3%) CRPC (p < 0.05) were positive for COVID-19. Both patients were receiving LHRH agonist therapy, and 1 patient was receiving enzalutamide. Urgent intensive care unit admission was required due to clinical worsening. Blood tests showed severe lymphopenia, anemia, and an increase in platelets. Retroviral therapy, antibiotics, heparin, and chloroquine were prescribed at the beginning. One patient also received tocilizumab as a salvage treatment. After 3 weeks of hospitalization, the patients were discharged from the hospital. Both patients suffered from an aggressive COVID-19 course due to concomitant comorbidities. CONCLUSIONS: Investigating whether hormonal therapy, especially in advanced disease, acts as a protective factor or a risk factor during COVID-19 could be useful.

A Large Paraprostatic Mass in A Man: Rare Presentation of Aggressive Angiomyxoma.

Aggressive angiomyxoma is a rare lesion with infiltrative growth and a tendency to recur locally. We present the images of a rare case of aggressive angiomyxoma in the pelvic region of a male patient presenting as a retrovesical, paraprostatic mass causing urinary symptoms.

Prognostic impact of ReTURB in high grade T1 primary bladder cancer.

PURPOSE: To evaluate whether pathological outcomes of ReTURB have a prognostic impact on recurrence and progression of primitive T1HG bladder cancer. MATERIAL AND METHODS: Patients affected by primitive T1HG TCC of bladder underwent restaging TURB (ReTURB). Patients with muscle invasive disease at ReTURB underwent radical cystectomy; those with non-muscle invasive residual (NMI-RT) and those with no residual tumour (NRT) received an intravesical BCG therapy. We compared recurrence and progression in NMIRT patients and NRT patients at restaging TURB. Patients were followed every 3-6 months with cystoscopy and urine cytology. RESULTS: 212 patients were enrolled in the study. At ReTURB, residual cancer was detected in 92 of 196 (46.9%) valuable patients: 14.3% of these were upstaged to T2. At follow up of 26.3 ± 22.8 months, there were differences in recurrence and progression rates between NRT and NMIRT patients: 26.9% and 45.3% (p < 0.001), 10.6% and 23.4% (p 0.03), respectively. Recurrence-free and progression-free survivals were significantly higher in NRT compared to NMIRT patients: 73.1% and 54.7% (p < 0.001), 89.4% and 76.6 (p 0.03), respectively. CONCLUSIONS: ReTURB allows to identify a considerable number of residual and understaged cancer. Patients with NMIRT on ReTURB have worse prognosis than those with NRT in terms of recurrence and progression free survival. These outcomes seem to suggest a prognostic impact of findings on ReTURB that could be a valid tool in management of high grade T1 TCC.

Dietary treatment of urinary risk factors for renal stone formation. A review of CLU Working Group.

OBJECTIVE: Diet interventions may reduce the risk of urinary stone formation and its recurrence, but there is no conclusive consensus in the literature regarding the effectiveness of dietary interventions and recommendations about specific diets for patients with urinary calculi. The aim of this study was to review the studies reporting the effects of different dietary interventions for the modification of urinary risk factors in patients with urinary stone disease. MATERIALS AND METHODS: A systematic search of the Pubmed database literature up to July 1, 2014 for studies on dietary treatment of urinary risk factors for urinary stone formation was conducted according to a methodology developed a priori. Studies were screened by titles and abstracts for eligibility. Data were extracted using a standardized form and the quality of evidence was assessed. RESULTS: Evidence from the selected studies were used to form evidence-based guideline statements. In the absence of sufficient evidence, additional statements were developed as expert opinions. CONCLUSIONS: General measures: Each patient with nephrolithiasis should undertake appropriate evaluation according to the knowledge of the calculus composition. Regardless of the underlying cause of the stone disease, a mainstay of conservative management is the forced increase in fluid intake to achieve a daily urine output of 2 liters. HYPERCALCIURIA: Dietary calcium restriction is not recommended for stone formers with nephrolithiasis. Diets with a calcium content ≥ 1 g/day (and low protein-low sodium) could be protective against the risk of stone formation in hypercalciuric stone forming adults. Moderate dietary salt restriction is useful in limiting urinary calcium excretion and thus may be helpful for primary and secondary prevention of nephrolithiasis. A low-normal protein intake decrease calciuria and could be useful in stone prevention and preservation of bone mass. Omega-3 fatty acids and bran of different origin decreases calciuria, but their impact on the urinary stone risk profile is uncertain. Sports beverage do not affect the urinary stone risk profile. HYPEROXALURIA: A diet low in oxalate and/or a calcium intake normal to high (800-1200 mg/day for adults) reduce the urinary excretion of oxalate, conversely a diet rich in oxalates and/or a diet low in calcium increase urinary oxalate. A restriction in protein intake may reduce the urinary excretion of oxalate although a vegetarian diet may lead to an increase in urinary oxalate. Adding bran to a diet low in oxalate cancels its effect of reducing urinary oxalate. Conversely, the addition of supplements of fruit and vegetables to a mixed diet does not involve an increased excretion of oxalate in the urine. The intake of pyridoxine reduces the excretion of oxalate. HYPERURICOSURIA: In patients with renal calcium stones the decrease of the urinary excretion of uric acid after restriction of dietary protein and purine is suggested although not clearly demonstrated. HYPOCITRATURIA: The administration of alkaline-citrates salts is recommended for the medical treatment of renal stone-formers with hypocitraturia, although compliance to this treatment is limited by gastrointestinal side effects and costs. Increased intake of fruit and vegetables (excluding those with high oxalate content) increases citrate excretion and involves a significant protection against the risk of stone formation. Citrus (lemons, oranges, grapefruit, and lime) and non citrus fruits (melon) are natural sources of dietary citrate, and several studies have shown the potential of these fruits and/or their juices in raising urine citrate levels. CHILDREN: There are enought basis to advice an adequate fluid intake also in children. Moderate dietary salt restriction and implementation of potassium intake are useful in limiting urinary calcium excretion whereas dietary calcium restriction is not recommended for children with nephrolithiasis. It seems reasonable to advice a balanced consumption of fruit and vegetables and a low consumption of chocolate and cola according to general nutritional guidelines, although no studies have assessed in pediatric stone formers the effect of fruit and vegetables supplementation on urinary citrate and the effects of chocolate and cola restriction on urinary oxalate in pediatric stone formers. Despite the low level of scientific evidence, a low-protein (< 20 g/day) low-salt (< 2 g/day) diet with high hydration (> 3 liters/day) is strongly advised in children with cystinuria. ELDERLY: In older patients dietary counseling for renal stone prevention has to consider some particular aspects of aging. A restriction of sodium intake in association with a higher intake of potassium, magnesium and citrate is advisable in order to reduce urinary risk factors for stone formation but also to prevent the loss of bone mass and the incidence of hypertension, although more hemodynamic sensitivity to sodium intake and decreased renal function of the elderly have to be considered. A diet rich in calcium (1200 mg/day) is useful to maintain skeletal wellness and to prevent kidney stones although an higher supplementation could involve an increase of risk for both the formation of kidney stones and cardiovascular diseases. A lower content of animal protein in association to an higher intake of plant products decrease the acid load and the excretion of uric acid has no particular contraindications in the elderly patients, although overall nutritional status has to be preserved.

[Clinical practice and adherence to the diagnosis and treatment of NMIBC guidelines: a report of a recognition based clinical cases study]. / Pratica clinica e aderenza a Linee Guida nella diagnosi e terapia delle neoplasie vescicali non muscolo-invasive: report di uno studio ricognitivo basato su casi clinici.

For non-muscle invasive bladder cancer, a disease with a considerable epidemiological and socio-economic impact, the introduction of the Guidelines has always evoked as a tool for the resolution of long-standing disputes in terms of diagnosis and therapy. Check the degree of routine clinical practice adherence to the Recommendations is for this disease, more than for other uro-oncology pathology, an urgent need felt by the urological community. To assess the level of Guidelines adherence's, and study issues related to the paths of diagnosis and treatment of non-muscle invasive bladder cancer, and identifying the processes actually implemented in daily clinical practice, a series of case studies has submitted to a group of experts. The acknowledgement study allowed testing the impact of the current Evidence Based Medicine Recommendations in the everyday clinical practice identifying strengths and weaknesses. Questions Responses Analysis' of 5 clinical cases (Ta low grade, T1 low grade, T1 high grade, T1 high grade + CIS, Ta low-grade multiple recurrence) showed a moderate amendment to the European Association of Urology (EAU)-Guidelines. On the other hand, it was emphasized that there are clear discrepancies between what should be done, in accordance with the Evidence Based Medicine Recommendations, and what is actually do in everyday clinical practice. The most common reason for the low Recommendations adherences are structural and organizational practical limitations.