Prognostic value of renal cell carcinoma nuclear grading: multivariate analysis of 333 cases.

OBJECTIVE: To evaluate the independent predictive value of the nuclear grading system according to Fuhrman in relation to the disease-specific survival of patients with renal clear cell carcinoma. MATERIAL AND METHODS: 333 patients who underwent radical nephrectomy for renal clear cell carcinoma between 1983 and 1999 were evaluated. In all patients we retrospectively studied nuclear grading, average tumor size, multifocality, pathologic stage of primary tumor, vein invasion, lymph node involvement and distant metastases. The Kaplan-Meier method was applied to evaluate disease-specific survival rates. The log rank test was used to compare survival curves and for univariate analysis. The Cox proportional hazards model was used for the multivariate analysis. RESULTS: Histologic grade was G1 in 83 cases (25%), G2 in 117 cases (35%), G3 in 110 cases (33%) and G4 in 23 cases (7%). Our data showed that nuclear grading according to Fuhrman is related to medium tumor size (p < 0.0001), pathologic stage of cancer (p < 0.001), venous system invasion (p < 0.001), lymph node involvement (p < 0.001) and distant metastases (p < 0.001). The disease-specific survival after 5 and 10 years was 94 and 88%, respectively, in patients with G1, 86 and 75% in patients with G2, 59 and 40% in patients with G3 and 31% in patients with G4 (log rank p value < 0.0001). Multivariate analysis showed that nuclear grading by Fuhrman has a prognostic independent predictive value (hazard ratio = 1.8461, p = 0.002). CONCLUSIONS: Nuclear grading is an important independent predictive factor of disease-specific survival in patients with renal cell carcinoma.

Renal vein and vena cava involvement does not affect prognosis in patients with renal cell carcinoma.

OBJECTIVES: The prognostic value of tumor extension into the renal vein or vena cava is still a controversial issue. The aim of this study is to report our experience with radical surgery in patients with renal cell carcinoma (RCC) extending into the renal vein or subdiaphragmatic vena cava. METHODS: We evaluated 142 patients with RCC involving the renal vein or inferior subdiaphragmatic vena cava. RCC had extended into the renal vein in 118 patients and into the inferior vena cava in the remaining 24. Radical nephrectomy was performed in all cases with renal vein invasion. Radical nephrectomy with cavotomy and tumor thrombus removal was carried out in all cases with inferior subdiaphragmatic vena caval invasion. Cause-specific survival was calculated by means of the Kaplan-Meier method. The log rank test was used for survival comparisons and univariate analysis. RESULTS: The 5- and 10-year cause-specific survival rates were 51.5 and 39%, respectively, in the group of patients with tumor extension into the renal vein and 33.4% in those with inferior vena caval involvement. In 52 patients (44%), RCC extended only into the renal vein. In the remaining 66 patients, renal vein invasion was associated with other adverse prognostic factors. Life expectancy was lower for patients with other concurrent adverse prognostic factors than for those affected by renal vein involvement alone (p < 0.0001). In the latter group, survival expectancy was similar to those with stage T2N0M0 tumor. In 7 cases (29%), inferior vena caval invasion was not associated with other adverse prognostic factors. In the remaining 15 patients (71%), vena caval involvement was associated with other adverse prognostic factors. Concurrence of other adverse prognostic factors with vena caval invasion significantly decreased the disease-specific survival expectancy in comparison with the patients in whom vena caval involvement was the main prognostic factor (p = 0.008). In these patients, disease-specific survival was similar to those with stage T2N0M0 tumor. CONCLUSION: Renal vein or inferior subdiaphragmatic vena caval involvement does not significantly affect prognosis in patients with RCC.

Genital treatment of penile carcinoma.

Squamous penile carcinoma is an uncommon neoplastic disease with an incidence of one in 100 000 men per year in Western countries. The role of penile-sparing treatment represents one of the three main issues in management of squamous carcinoma of the penis. Most authors consider conservative therapy as an indicated alternative treatment to partial or total penectomy in small size, low stage and grade tumours. At present, external or interstitial beam radiotherapy and lasertherapy represent the best available conservative therapeutic approaches. Another issue is the role of prophylactic inguinal lymphadenectomy in patients with negative palpable nodes. An early inguinal lymphadenectomy is indicated especially in patients with a high occult nodal micrometastases risk (G3 and pT2-4). The third point of discussion is represented by the use of chemotherapy in patients with metastatic disease. In this stage of disease, polychemotherapy with cisplatin, methotrexate and bleomycin seems to be more effective. The small number of patients investigated and the rapid evolution of the disease make it extremely difficult to carry out suitable perspective studies.

Prostate cancer and coexisting incidental Paget's disease--report on a case.

Prostate cancer coexisting with asymptomatic Paget's disease (osteitis deformans) may be difficult to stage. The skeletal lesions of both prostate cancer and Paget's disease may closely resemble each other, as appearing on imaging. A case of clinically localized prostate cancer coexisting with incidental Paget's disease is herein reported. Prostate cancer and coexisting incidental Paget's disease both need careful evaluation and close follow-up of the skeleton by imaging, because there is a risk of the former involving the skeleton at low clinical stages and low PSA serum levels, as well as the latter developing osteosarcoma.

Experience in the surgical treatment of Fraley's syndrome.

OBJECTIVE: To report our 20-year experience with nephron-sparing surgery in the treatment of Fraley's syndrome. MATERIALS AND METHODS: From September 1976 to July 1996, 6 women, 18-43 years old, underwent surgical treatment. All patients had been suffering debilitating right flank pain for at least 6 months before the operation. Diagnosis was in call cases made with the use of intravenous pyelography and renal arteriography, which showed a vascular impression on the superior infundibulum with secondary dilatation of the upper pole calyx. This was localized only on the right side in 5 cases, while in 1 it was bilateral though more severe on the right. Ipsilateral nephroptosis was observed in 2 of the patients. In 2 cases in whom the superior infundibulum was sufficiently long, an infundibulo-infundibulostomy with everted flaps was performed. In a case in whom a short infundibulum was compressed between a venous and an arterial branch, Fraley's infundibulopyelostomy was carried out. In 1 patient in whom the infundibulum was compressed by the anterior-superior segmental artery, a Heineke-Mikulicz-type infundibulorrhaphy was combined to vasopexy. In the remaining 2 cases, the infundibulum was not cut: in one case, a simple vasopexy of two vascular branches was carried out, while in the other, a minor arterial branch was ligated and divided. In 4 patients, nephropexy was also performed. RESULTS: No significant intra- or postoperative complications were observed. Follow-up averaged 102.5 months. Pain relief was complete in 5 cases, in whom disappearance of the vascular impression was also radiologically demonstrated. Only 1 patient, who underwent infundibulorrhaphy and vasopexy, experienced occasional flank pain and urinary infection after the operation, with just a slight improvement in the excretory urogram. CONCLUSIONS: Surgical treatment of Fraley's syndrome is indicated only in symptomatic and/or complicated cases; in relation to the type of obstruction and the anatomy of the intrarenal structures, whether excretory or vascular, several effective nephron-sparing techniques can be selected.

General state of health and psychological well-being in patients after surgery for urological malignant neoplasms.

OBJECTIVE: To evaluate the general state of health and the psychological well-being in a group of 155 patients after surgery for urological malignant neoplasms. MATERIALS AND METHODS: Surgery was performed in 55 patients for renal cell carcinoma, in 54 for invasive bladder carcinoma, in 30 for adenocarcinoma of the prostate, and in 16 for squamous penile carcinoma. All patients were invited to self-compile the General Health Questionnaire (GHQ) - 12 items according to Goldberg and the Hospital Anxiety and Depression Scale. Results were compared with those in a group of patients who underwent retropubic prostatectomy for benign prostatic hyperplasia. RESULTS AND CONCLUSION: The general state of health was significantly more impaired in neoplastic patients than in the control group. Levels of anxiety were significantly higher but depression levels were similar in both groups. As far as the type of tumor is concerned, patients who underwent radical cystectomy for bladder carcinoma and those treated with partial penectomy for squamous penile carcinoma showed a significant impairment of the general state of health compared with controls. Higher levels of anxiety were observed in patients who underwent ileal conduit after radical cystectomy, in those treated with radical prostatectomy for prostate cancer and in those who underwent partial penectomy. Significantly higher levels of depression than in the control group were observed only in patients with ileal conduit.

[Our experience in the treatment of retroperitoneal fibrosis]. / Nostra esperienza nel trattamento della fibrosi retroperitoneale.

To discuss retroperitoneal fibrosis (RPF) etiopathogenesis and to report on our experience in the treatment of the disease. From 1977 to 1998 26 RPF patients, 15 idiopathic (I group) and 11 secondary (II group), entered our clinic. Vascular risk factors of the I group were cigarette smoking (73.3%) and arterial hypertension (46.6%). Etiologic factors of the II group were aorta abdominal aneurysm (four cases), radiation therapy for female genital tract cancer (four case), aorto-bifemoral bypass for aorta aneurysm (two cases), retroperitoneal non-Hodgkin lymphoma (one case). Treatment performed for idiopathic disease was medical in eight cases (alone in two, with endourologic measures in six) using corticosteroids in five and tamoxifen in three; only endourological in three and surgical in four (nephrectomy in two patients, ureterolysis and ureteroneocystostomy in one, pyeloureterolysis in one) with perioperative corticosteroid treatment in three cases. Treatments performed in patients with secondary disease were endourologic in five surgical in three (ureteroureterostomy, ureteroneocystostomy, pyeloureterolysis and pyeloreduction), medical with corticosteroids in two; one patient affected by perianeurysmatic fibrosis did not require any treatment because of disease's spontaneous recovery. Medical treatment induced symptom remission and plaque reduction in all patients. Surgery determined complete recovery in all patients except for one in whom the disease relapsed with controlateral urinary tract involvement. Medical RPF treatment for idiopathic or secondary disease is effective in the first stage. Disease management with tamoxifen is easy to perform, safe and effective. In the steady state of RPF the best results are obtained by surgery and perioperative glucocorticoid therapy reduced significantly fibrosis' relapse.

Detection of bladder cancer by semi-automated microsatellite analysis of urine sediment.

Patients with transitional-cell carcinoma (TCC) require careful follow-up due to the high risk of recurrence. Cystoscopy and biopsy are reliable but invasive, while urine cytology is plagued by low sensitivity. It has recently been shown that allelic abnormalities detected by microsatellite analysis of DNA extracted from urine can be used to diagnose TCC with high reliability. As this analysis by classic techniques is unfeasible in a clinical setting, we performed a pilot study to determine the possibility of applying quick DNA extraction methods with laser detection and computer-based analysis of 15 fluorescently labeled PCR amplified microsatellites to detect molecular anomalies in urine sediment in 25 TCC follow-up patients. Of the eighteen cases with recurrent TCC, 14 (78%) were positive by the molecular test whereas only eight (44%) were detected by cytology. Of the seven patients with negative cystoscopy, one resulted positive by the molecular test and had recurrent TCC six-months later. Thus, this microsatellite analysis correctly predicted the clinical diagnosis in 84% (21/25) of cases, compared to 60% by cytology. The application of these semi-automated procedures allows the analysis of 18 samples with 15 markers in one day, encouraging a more expedient introduction into routine clinical use.

[Comparison of the quality of life of patients treated by surgery or radiotherapy in epidermoid cancer of the penis]. / Comparaison de la qualité de vie des patients traités pour cancer épidermoïde de la verge par chirurgie ou radiothérapie.

OBJECTIVE: The purpose of our work is to examine how partially or totally radical surgery and radiotherapy can weigh on quality of life in patients with squamous carcinoma of the penis, considering whether quality of life can be a good criterion in treatment options. MATERIAL AND METHODS: We have interviewed 17 patients alive and disease-free (average follow-up 69.43 months) after surgical treatment or radiotherapy for cancer of the penis (emasculation, 2; total amputation of the penis, 2; partial penectomy, 11; radiotherapy, 2). Tests used: General Health Questionnaire (G.H.Q.-12 by D. Goldberg); Hospital Anxiety and Depression Scale (H.A.D.S.); Social Problem Questionnaire (S.P.Q.); Overall Sexual Functioning Questionnaire (O.S.F.Q); Family APGAR Questionnaire (F.A.Q.); Performance Status ECOG. RESULTS: Thirty-five per cent of the patients presented limitations in their state of health and social problems. Anxiety was evident in 29.5% of the patients and depression in 6%. The global sexual function was compromised in 76.5%. CONCLUSION: The profile of quality of life resulted compromised in the patients who had undergone radical surgical treatment. The sexual function was the most altered component. The impact of the pathology and its treatment on the other domains of quality of life proved less significant.

Surgical treatment of penile carcinoma: our experience from 1976 to 1997.

OBJECTIVE: The purpose of this work is to evaluate our experience with the surgical treatment of penile squamous carcinoma, analyzing the therapeutic results in terms of local recurrence rates, survival and mortality rates. MATERIAL AND METHODS: From 1976 to 1997, 47 patients were treated at our institution for carcinoma of penis. Treatment of primary tumor was conservative in 8 patients (17%). Partial penectomy was performed in 30 patients (63.8%); total penectomy in 5 (10.7%) and emasculation in 4 (8.5%). Pathological stage was pTis in 2 cases (4.2%), pT1 in 20 (42.6%), pT2 in 21 (44. 7%) and pT3 in 4 (8.5%). The tumor was clinically overstaged in 13 patients (27.7%) and understaged in 4 (8.5%). Bilateral inguinal lymphadenectomy was performed only in 4 patients clinically N+ (pN2) and in 3 clinically N0 (pN0). RESULTS: Local recurrence rate was 43% in the patients with pT1 stage tumor treated conservatively. No local recurrence was observed after penectomy. 19 patients (40.4%) are alive and disease-free; 17 patients (36.2%) died of the tumor and 11 patients (23.4%) died of other causes but disease-free. Mean follow-up is 69.43 months. The overall 5-year survival rate was 34%. CONCLUSION: Partial penectomy gives better results than conservative treatment in the local management of the T1 stage tumor. Survival and mortality rates are related to both pathological and histological stages. The high mortality rate observed in the pT2 stage tumors in our experience might be related to the fact that in this stage an inguinal lymphadenectomy was not performed as a rule.

[Our experience in the conservative surgical treatment of megaureter in the adult]. / Nostra esperienza nel trattamento chirurgico conservativo del megauretere nell'adulto.

Surgical treatment of the megaureter in adults is only indicated when important symptoms and/or complications occur. The Authors report their experience with eight adult patients affected by megaureter, undergone to conservative surgery. The average age of the patients was 36 years (range 21-52). The disease was unilateral in five cases (four on the right side and one on the left), bilateral in three. In five patients megaureter was primary (obstructed in four, refluxing in one). A case of megaureter with ectopic orifice in the prostatic urethra was observed. The remaining two cases, already operated in other hospitals, were a segmentary megaureter associated with vesico-ureteral reflux secondary to endoscopic incision of an ureterocele and a bilateral refluxing megaureter in a patient undergone to bilateral ureterocystoneostomy because of primary megaureter in his childhood. All patients underwent ureterocystoneostomy, performed with Politano-Leadbetter antireflux technique in six cases and with direct non-antireflux technique in two. A reductive Hendren ureteroplasty was also performed in 7 cases. The average length of follow-up is actually of 82 months (range 5-231). Satisfactory results were obtained in three primary obstructed megaureters, in the megaureter with ectopic orifice and in the segmentary megaureter associated with reflux. In two patients with refluxing megaureter surgery was unsuccessful and a new operation was necessary. Finally, one patient with primary obstructed megaureter underwent endoscopic dilatation of the strictured vesico-ureteral anastomosis two months after the ureterocystoneostomy.

Renal staghorn calculosis: our experience with the percutaneous treatment with or without extracorporeal shock wave lithotripsy.

OBJECTIVES: In this paper we report our results in the treatment of renal staghorn stones by percutaneous lithotripsy (PCNL) with or without extracorporeal shock wave lithotripsy (ESWL). METHODS/RESULTS: Over a period of 5 years, 244 patients with renal calculosis were treated by PCNL in our Department. Seventy-four of these were cases of renal staghorn calculosis: 44 presented a partial staghorn stone and in 30 cases the stone formation completely occupied the pyelocalieal cavity. We performed first a PCNL via a rigid nephroscope. Stones were crushed using an ultrasonic lithotrite; an electrohydraulic probe was used when the calculus was resistant to ultrasound. The patients were submitted to one or more percutaneous treatments followed by extracorporeal lithotripsy to complete the operation, when required. The patients were divided into two groups according to the type of stone: the first group comprised 59 patients with a partial or complete simple staghorn stone and the second comprised 15 patients with a complete complex staghorn stone. Complete resolution was achieved in 55 of the 59 cases (93.2%) in the first group and in 9 of the 15 cases (60%) in the second. We had no complications. CONCLUSIONS: Our experience confirms that PCNL is the elective treatment for partial and complete staghorn stones and ESWL in these types of stones must be utilized only as ancillary treatment for residual fragments.

[Laparoscopic unilateral retroperitoneal lymphadenectomy in non-seminomatous neoplasms of the testis in clinical stage I]. / La linfadenectomia retroperitoneale monolaterale laparoscopica nelle neoplasie non seminomatose del testicolo in stadio clinic I.

Since June 1993, unilateral laparoscopic retroperitoneal lymph node dissection (LRPLND) was performed in 6 patients diagnosed with clinical stage I nonseminomatous germ cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor markers assessment, computerized tomography scan (CT) of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 min (275 to 420 min). The estimated peri- and postoperative blood loss was minimal. Of note, the comparison between the hematocrit and hemoglobin decrease of LRPLND and RPLND showed a statistically significant reduction (3.1 vs 11.1% P < 0.01 and 1.1 vs 3.2 g/dl P < 0.01). None of the patients required blood transfusion. In the case of the first patient the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining five cases the average hospitalization was 4.8 days ranging between 4 and 6 days. The patients resumed normal activities within 12 to 27 days (mean 16.2 days) postoperatively. Mean number of lymph nodes removed was 6.8, ranging between 5 and 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in two patients. Both of these patients were subject to adjuvant chemotherapy. The mean follow-up period is 33.3 months, ranging between 18 and 48 months. To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical stage I NSGCT.

Unilateral laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular neoplasm.

OBJECTIVE: The aim of this study is to evaluate the reliability of laparoscopic retroperitoneal lymph node dissection (LRPLND) in the management of clinical stage I nonseminomatous germ cell tumors (NSGCT). METHODS: Since June 1993, unilateral LRPLND was performed in 6 patients diagnosed with clinical stage I NSGCT. All patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in 3 cases and right-sided in the other 3 cases. Preoperative staging by means of tumor marker assessment, computerized tomography scan of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. RESULTS: All procedures were accomplished without any complications in a mean time of 325 min (275-420 min). The estimated perioperative blood loss was minimal (< 50 ml), and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining 5 cases, the average hospitalization was 4.8 days, ranging from 4 to 6 days. The patients resumed normal activities within 12-27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8, ranging from 5 to 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in 2 patients. Both of these patients received adjuvant chemotherapy. The mean follow-up period is 21.3 months, ranging from 6 to 36 months. To date, no relapses have been observed. CONCLUSION: In accordance with other reports, we believe that LRPLND is both feasible and effective. However, the definitive assessment of the efficacy and morbidity of this diagnostic procedure requires a larger and more comprehensive series as well as longer follow-up.

Unilateral laparoscopic retroperitoneal lymphadenectomy for clinical stage I nonseminomatous testicular cancer.

Since June 1993, unilateral laparoscopic retroperitoneal lymph-node dissection (LRPLND) has been performed in six patients with clinical Stage I nonseminomatous germ-cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor marker assessment, CT scan of the chest and abdomen, and chest radiography was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 minutes (275-420 minutes). The estimated perioperative and postoperative blood loss was minimal, and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days because of a widespread subcutaneous emphysema. In the remaining five cases, the average hospitalization was 4.8 days (range 4-6 days). The patients resumed normal activities within 12 to 27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8 (range 5-9). Histologic examination of these nodes revealed microscopic metastases from embryonal carcinoma in two patients, both of whom were subjected to adjuvant chemotherapy. The mean follow-up period is 27.1 months (range 12-42 months). To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical Stage I NSGCT.

Vesicovaginal fistulas: our experience and review of literature.

Vesicovaginal fistulas (VVF) still represent a sad complication of surgery of the female genital system. In this article an extensive review of the literature was conducted, analyzing the etiological, pathological and clinical aspects, as well as the therapeutical problems. For this purpose, we have compared the many surgical techniques proposed for treatment of VVF and have also evaluated their results. Furthermore, we report on our series of 35 patients who had undergone treatment for VVF.

Diagnostic and therapeutic problems in multicentric renal angiomyolipoma.

Multicentric renal angiomyolipoma is a rare form of benign tumor. However, its effective incidence as evaluated in autopsy studies may be as high as 8%. There are 2 main types of renal angiomyolipoma, that is isolated forms and those associated with other diseases, such as phakomatosis, polycystic kidneys and fibromuscular dysplasia. The tumor may also display malignant behavior with local invasiveness and regional lymph node involvement. However, the clinical course is benign and multicentricity is important for prognosis. Histopathological diagnosis often is difficult. Immunohistochemical analysis of surgical specimens using a panel of monoclonal antibodies, including HMB-45 and actin, enabled us to make a definitive diagnosis in 3 cases of multicentric renal angiomyolipoma.

[Continuous monitoring of nocturnal penile tumescence and rigidity in the evaluation of erection disorders. Preliminary data]. / Monitorización continua de la tumescencia y de la rigidez peneana nocturna en la valoración de los trastornos de la erección. Datos preliminares.

Nocturnal penile tumescence measurements continues to be an important step in the diagnosis of impaired erectile function. We present our experience with this technique employed on 65 patients who consulted at our andrologic center. Our results corroborate the importance of the NPR-R test with the Rigi-Scan in the evaluation of this pathology to ensure these patients receive the most appropriate treatment.

Small urothelial carcinoma: diagnosis and treatment by cold forceps biopsy.

From 1987 to 1988 we used cold biopsy forceps to remove completely 92 urothelial neoplasms ranging from 0.3 to 3 mm. Rigid biopsy forceps were used. The urologist usually treats these bladder neoplasms by diathermy coagulation, which obviously makes histological study impossible. On the other hand, due to the small size of these lesions even removal with the cutting loop inevitably causes deep regressive modifications that prevent accurate morphological evaluation. Histological examination of the neoplasms removed revealed the presence of low to medium grade (stage Ta, grades 1 to 2) noninfiltrating papillary carcinoma in 75 cases, high grade (stage Ta, grade 3) noninfiltrating papillary carcinoma in 9 and medium to high grade (stage T1, grades 2 to 3) infiltrating papillary carcinoma in 8, 1 of which had areas of squamous cell carcinoma. This method enabled us to study the morphology of the urothelial lesions in the initial phase. In our study population the number of high grade lesions and/or lesions with early signs of infiltration (17 of 92) appears to be noteworthy despite the small size of the tumors.