Androgen receptor expression in clinically localized prostate cancer: immunohistochemistry study and literature review.

AIM: To evaluate androgen receptor (AR) expression in clinically localized prostate cancer (PCa). METHODS: Specimens were studied from 232 patients who underwent radical prostatectomy for clinically localized prostatic adenocarcinoma without neoadjuvant hormonal therapy or chemotherapy at our institution between November 2001 and June 2005. Immunohistochemical study was performed using an anti-human AR monoclonal antibody AR441. The mean AR density in the hot spots of different histological areas within the same sections were compared and the correlation of malignant epithelial AR density with clinicopathological parameters such as Gleason score, tumor, nodes and metastases (TNM) stage and pre-treatment prostate-specific antigen (PSA) value was assessed. RESULTS: AR immunoreactivity was almost exclusively nuclear and was observed in tumor cells, non-neoplastic glandular epithelial cells and a proportion of peritumoral and interglandular stromal cells. Mean percentage of AR-positive epithelial cells was significantly higher in cancer tissues than that in normal prostate tissues (mean +/- SD, 90.0% +/- 9.3% vs. 85.3 +/- ?9.7%, P < 0.001). The histological score yielded similar results. The percentage of AR immunoreactive prostatic cancer nuclei and histological score were not correlated with existing parameters such as Gleason score, tumor, nodes and metastases stage and pre-treatment PSA value in this surgically treated cohort. CONCLUSION: The results of the present study suggest that there may be limited clinical use for determining AR expression (if evaluated in hot spots) in men with localized PCa.

Urodynamic changes and response rates in patients treated with permanent electrodes compared to conventional wire electrodes in the peripheral nerve evaluation test.

OBJECTIVES: Sacral neuromodulation having become established as an essentially effective new therapeutic modality, both in patients with anticholinergic-therapy refractory overactive bladder (OAB) and with chronic urinary retention. It is important to establish which patients might profit from this kind of therapy in order to ensure, by means of a peripheral nerve evaluation (PNE) test, that the implantation of a permanent stimulating device is effective. In a retrospective study we compared the urodynamic outcome of two different techniques (implantation of the permanent neurostimulation electrodes so-called "two-stage-implantation" vs. conventional PNE). METHODS: We performed a sacral nerve stimulation in 53 patients (30 urinary retention, 23 OAB syndrome). In 42 patients, we performed a conventional PNE, 11 patients received "two-stage-implantation" with implantation of the permanent electrodes. RESULTS: In 20 cases the conventional PNE-test (cPNE) was successful (47.6% of all cPNE). The response rate of "two-stage-implantation" (permanent electrodes) was 81.8%. In patients with overactive bladder the bladder capacity was increased by 30% with cPNE (P = 0.068) versus 52% when permanent electrodes were used (P = 0.017). Bladder instabilities were reduced by ca. 75%. In urinary retention, the cPNE versus permanent electrodes led to an increase of the maximum detrusor pressure by 68 versus 94% with reduction of residual urine by 71% (P = 0.068) versus 66% (P = 0.042). CONCLUSIONS: The results of this study show that application of permanent quadripolar electrodes during PNE prior to chronic neuromodulator implantation leads to significantly higher responder rates and enables more efficient patient selection.

Nocturnal tumescence: a parameter for postoperative erectile integrity after nerve sparing radical prostatectomy.

PURPOSE: The exact process and time required for rehabilitation of erectile function after nerve sparing prostatectomy remain unclear to date. Different theories of the pathophysiology of postoperative erectile dysfunction are currently being discussed. In a prospective study we performed recordings of nocturnal penile tumescence and rigidity during the acute phase after nerve sparing radical prostatectomy, ie in the first night after removal of the catheter, to assess the organic penile integrity. MATERIALS AND METHODS: In 27 patients with local prostate carcinoma who had been sexually active before the intervention, we performed unilateral or bilateral nerve sparing radical prostatectomy. Preoperative sexual function of all patients was evaluated by the International Index of Erectile Function-5 questionnaire. On the day of catheter removal (postoperative day 7 to 14) an NPTR recording was performed on the following night with an erectometer (RigiScan). RESULTS: All patients had a preoperative IIEF score greater than 18. After removal of the catheter 25 of 27 patients (93%) showed 1 to 5 nocturnal rigidity increases by greater than 70% for at least 10 minutes. In a control group of 4 patients who underwent radical prostatectomy without nerve sparing, no nocturnal erections were recorded. CONCLUSIONS: NPTR recording during the acute phase after nerve sparing radical prostatectomy showed residual erectile function as early as the first night after catheter removal. These results are significant for selecting adequate pharmacological treatment for optimal therapy and rehabilitation of satisfactory erections and sexual function. In cases of early nocturnal tumescence, application of a PDE5 inhibitor can support successive organ rehabilitation. However, if tumescence does not occur, penile injection therapy is recommended.

Penile carcinoma (pT1 G2): surveillance or inguinal lymph node dissection?

BACKGROUND: Due to the low incidence of squamous cell penile cancer and lack of well-designed studies, controversies persist over the therapeutic approach in patients with pT1 G2 carcinoma. PATIENTS AND METHODS: Between 1992 and 2003, 16 patients with T1 squamous penile cancer were treated in our institution either by surveillance or by inguinal lymph node dissection (ILND). RESULTS: A total of 8 primary lesions were classified as pT1 G2 carcinoma with 4 tumors developing early or delayed inguinal metastatic disease. CONCLUSIONS: The natural behavior of pT1 G2 squamous penile carcinoma and its metastatic potential has been underestimated in recent literature. Since morbidity after early ILND has markedly decreased and its superiority over delayed ILND has been shown, we advocate the early modified inguinal lymph node dissection until strong prognostic factors for positive inguinal lymph nodes have been validated.

Extracorporeal shockwave lithotripsy compared with ureteroscopy for the removal of small distal ureteral stones.

INTRODUCTION: The treatment of small distal ureteral stones smaller or equal to 5 mm in size is still highly controversial. In distal ureteral stones larger than 5 mm in size, ureteroscopy (URS) has been shown in many studies to be superior to shockwave lithotripsy (SWL). The objective was to analyze the stone-free rate after treatment of distal ureteral stones with in situ SWL or URS. MATERIALS AND METHODS: A total of 3,857 SWL treatments were performed at our institution between 1996 and 2001. During this period 45 in situ SWL procedures were performed with the Dornier MFL 5000 lithotripter on distal ureteral stones regardless of the stone size. A total of 262 URS treatments were performed on distal ureteral stones. URS for small (5 mm or less) distal ureteral stones was performed in 110 cases. RESULTS: Distal ureteral stones smaller or equal to 5 mm in size were treated successfully stone free in 78% in one SWL session. Patients required a second SWL in 14% of the cases and 8% of the patients required a third SWL session. URS patients were successfully stone free after the procedure in 97% of the cases. Failed URS that needed an additional URS were performed in 2 and 1% of the patients had one SWL in situ treatment. CONCLUSIONS: URS treatment has shown to be the therapy of choice for distal ureteral stones. It is more effective than SWL treatment in this stone location. In experienced hands URS is a safe though even more invasive procedure than SWL. This can be expected as urologists perform more than 40 URS procedures per year.

Findings with Bilateral Sacral Neurostimulation: Sixty-two PNE-Tests in Patients with Neurogenic and Idiopathic Bladder Dysfunctions.

We performed bilateral PNE (peripheral nerve evaluation) tests to identify which diagnostic groups are the most likely to profit from bilateral sacral neuromodulation since the results published so far have been obtained exclusively on the basis of unilateral sacral root stimulation. In contrast to the original unilateral technique, we performed bilateral PNE test stimulation in 62 patients (36 with urinary retention symptoms and 26 with overactive detrusor; 21 with idiopathic and 41 with neurogenic bladder dysfunction) over 3-4 days. We used an advanced electrode, model #3057 (Medtronic, Inc. Minneapolis, MN). The stimulation amplitudes were adjusted individually for each side. Retrospectively, we analyzed our data according to diagnostic characteristics (retention vs. overactive bladder and neurogenic vs. idiopathic) of those patients who had positive PNE test results. The PNE test was successful in 32 patients (51.6%). Of these, 27 suffered from neurogenic bladder dysfunction; in five cases the cause was idiopathic. We conclude that bilateral PNE test stimulation with side-specific amplitude adjustment and the use of advanced PNE electrodes led to a positive PNE result in 51.6% of the patients, which is a substantially increased response rate compared to previous studies. Of the diagnostics groups, the group with neurogenic bladder dysfunctions showed the highest response rate.

Neuromodulación crónica sacra bilateral con una técnica de implantaciónmínimamente invasiva en pacientes con alteraciones funcionales de la vejiga / Bilateral chronic sacral neuromodulation with a minimally invasive implantation technique in patients with bladder dysfunction

OBJETIVO: El porcentaje de fracasos con la técnica descrita por Tanagho y Schmidt para la neuromodulación sacra crónica con estimulación unilateral alcanza hasta el 50 por ciento. Con el objetivo de mejorar la efectividad de la modulación, así como el posicionamiento y fijación de los electrodos, hemos optado por la laminectomía sacra mínima con instalación bilateral de electrodos. MÉTODOS: En un total de 30 pacientes (16 con diagnóstico de inestabilidad del detrusor refractaria a terapia y 14 con hipoactividad del detrusor) se implantó un modulador neurológico con instalación de electrodos sacros bilaterales, previa certificación de la indemnidad de los nervios periféricos con el test de evaluación correspondiente. Con el propósito de asegurar una adecuada instalación y fijación de los electrodos se llevó acabo una laminectomía sacra mínima. RESULTADOS: En los pacientes con inestabilidad del detrusor se observó una reducción del promedio de episodios de incontinencia de 7,2 a 1 por día y la capacidad vesical aumentó de 198 a 348 ml. En los pacientes con hipoactividad del detrusor se constató una disminución en los residuos postmiccionales de 350 a 58 ml. La contracción máxima del detrusor durante la micción aumentó de 12 cm H2O a 34cm H2O. El seguimiento promedio fue de 28 meses. No hubo signos de deterioro en el efecto modulador en ninguno de los pacientes. CONCLUSIÓN: La modulación neurológica sacra bilateral, en conjunto con la técnica de implantación mínimamente invasiva desarrollada por nosotros, permite alcanzar resultados óptimos en pacientes con inestabilidad del detrusor refractaria a terapia así como también en pacientes con detrusor hipoactivo (AU)

Urolithiasis in children.

In general, the criteria for the treatment of urolithiasis in children are the same as those for adults. Today, extracorporeal shock wave lithotripsy (ESWL) is the method of choice in the treatment of most pediatric urinary stones. Stone-free rates between 67% and 93% at short-term follow-up, and 57% to 92% at long-term follow-up, have proven the efficacy of ESWL treatment in children. Nevertheless, the demand for auxiliary measures still remains. In order to achieve the most beneficial success rates under low complications, it is advisable to perform this type of ESWL in centers that claim the experience necessary for ESWL and endourological measures in children.

Tratamiento de la urolitiasis en niños y adolescentes mediante litotricia extracorpórea y procedimientos urológicos auxiliares / Treatment of urolithiasis in children and adolescent with extracorporeal shock wave lithotripsy and auxiliary urological procedures

OBJETIVO: El objetivo de este trabajo fue plantear la eficiencia de litotricia extracorpórea por ondas de choque ( LEOC ) en niños y la frecuencia de la utilización de otros procedimientos urológicos auxiliares para el manejo de la urolitiasis. Para ello se llevo a cabo un análisis retrospectivo de la evolución de los niños posterior a LEOC mediante el conteo del número de complicaciones y medidas auxiliares adicionales utilizadas, así como los casos libres de cálculos. MÉTODOS: De enero del 90 a enero del 99 se trataron 56 cálculos en totalidad (28 niñas y 21 niños). Las litotricias se realizaron con una máquina Lithostar Plus y una Modulith SL20/SLX. Las medidas auxiliares adicionales utilizadas, se clasificaron como curativas (ureterorrenoscopias y nefrolitolapaxias percutáneas) y adyuvantes (colocación de catéteres ureterales y nefrostomías). RESULTADOS: Posterior a la primer LEOC el 34,7 por ciento de los niños resultaron libres de cálculos residuales, en el 40,8 por ciento de los niños los fragmentos posteriores a LEOC tuvieron las dimensiones adecuadas para expulsarse espontáneamente, el 24,5 por ciento de los pacientes se sometieron nuevamente a una LEOC. Otras medidas urológicas auxiliares adicionales, fueron necesarias en el 28,6 por ciento de los casos (18,3 por ciento adyuvantes y 10,3 por ciento curativas). CONCLUSIÓN: La litotricia por ondas de choque extracorpóreas, es también en los niños una terapia para la litiasis, altamente efectiva. No obstante son necesarias medidas de auxilio adicionales tanto curativas como adyuvantes.Para obtener un alto promedio de éxito y bajo porcentaje de complicaciones es necesario que la LEOC, se lleve a cabo en un centro en el cual exista bastante experiencia, tanto en LEOC como en procedimientos endourológicos en niños (AU)