[An exceptional case of renal angiomyolipoma extended to the inferior vena cava. Successfull surgical management]. / Um caso excepcional de angiomiolipoma renal com extensão à veia cava inferior. Tratamento cirúrgico com êxito.

The clinical case of a 39 years old female is reported, with the diagnosis of tumor of the right kidney extending into the infra-hepatic vena cava, assuming the shape of a floating thrombus. The patient underwent right radical nephrectomy, followed by resection of the intra caval tumor. Both the procedure and post operative course were uneventfull. Histopathological evaluation of the specimens, associated to specific imunohistochemistry studies, confirmed the diagnosis of angiomyolipoma of the kidney. A review of the literature concluded that this is the 27th case published of a kidney angiomyolipoma extending into the inferior vena cava, thus justifying its presentation and divulgation.

[Grawitz tumor with invasion of the inferior vena cava and right atrium: surgical management with a multidisciplinary team]. / Tumor de grawitz com invasão da veia cava inferioraté à auricula direita: tratamento cirúrgico com equipa multidisciplinar.

In this paper, the clinical condition of a 56 year old male patient is reported, with the diagnosis of renal cell carcinoma, complicated by a tumoral thrombus, extended from the renal vein into the vena cava and right atrium, who underwent surgical treatment. The operation consisted in the radical nephrectomy associated to the vena caval thrombectomy, under extracorporeal circulation, utilizing a multidisciplinary team composed by urologists, vascular and cardio-thoracic surgeons. The main features related to the diagnosis and surgical management of this case are described and discussed, according to data taken from the most recent publications of the literature on the subject.

[Urinary infection in the adult]. / Infecção urinária do adulto.

Infections of the urinary tract are common--only respiratory infections occur more often. Urinary tract infections (UTI) are a serious health problem producing significant morbidity in a vast number of people each year and mostly affecting the quality of life of young women. Accurate diagnosis and treatment results in successful resolution of most urinary tract infections. To achieve that objective, we present clinical guidelines focussing on specific categories of adult urinary tract infection based on host factors and clinical findings. Categorization of urinary tract infections allows more efficient use of laboratory testing in the workup of UTI and the most appropriate selection of treatment for UTI. Shorter course therapy and prophylactic antimicrobials have reduced the morbidity and cost associated to recurrent cystitis in women. New antimicrobial agents that achieve high urinary levels, administered orally and that are not nephrotoxic, have improved the ability to treat severe infections, reducing the need for hospitalization. Early identification of patients with complicated infections for urological referral remains compulsory.

Maximal androgen blockade: final analysis of EORTC phase III trial 30853. EORTC Genito-Urinary Tract Cancer Cooperative Group and the EORTC Data Center.

OBJECTIVES: This prospective, randomized phase III study was initiated to compare the efficacy and side effects of bilateral orchiectomy versus a combination of a luteinizing hormone-releasing hormone agonist depot formulation, goserelin acetate (3.6 mg s.c. once every 4 weeks) and flutamide (250 mg 3 x daily) in patients with metastatic prostate cancer. METHODS: Relative treatment efficacy was assessed by comparing the two treatment groups with respect to response, time to first progression, progression-free survival, duration of survival and time to death due to malignant disease. RESULTS: There was a difference in response only with respect to a more frequent decrease to normal of the serum prostate acid phosphatase in patients assigned to maximal androgen blockade treatment. Additionally, maximal androgen blockade treatment showed significantly better results for duration of survival (p = 0.04), time to death due to malignant disease (p = 0.008), time to first progression (p = 0.009) and progression-free survival (p = 0.02). The most frequent side effects for both treatments included hot flushes and gynaecomastia. CONCLUSIONS: Increased time to progression and duration of survival is achieved by the combination of flutamide and goserelin when compared to bilateral orchiectomy.

[Curriculum planning. The direct way]. / Planeamento curricular. A via directa.

An attempt is being made in several Portuguese Medical Schools to reduce the Medical Course to five academic years. It will be easier and much more rigorous to base these changes on a detailed list of Educational Objectives. The choice of Educational Objectives must take into account the professional and social context surrounding the non-specialist physician (family doctor, general practitioner, etc), the background and maturity of the students, the manpower and resources of the Medical School and the results of the evaluation of the medical graduates as they finish their undergraduate training. This paper is an attempt to produce a list of Educational Objectives for undergraduate training in urology. Since we lack adequate information in relation to Portugal, we relied on epidemiological data from other countries as well as the experience obtained in similar attempts carried out in the USA.

Metabolic adaptations induced by long-term fasting in quails.

After up to 21 days without food, adult male quails (Coturnix coturnix japonica) lost about 45% of the initial body weight (100-150 g). As in naturally fast-adapted and larger birds, three phases were identified during prolonged fasting in quails. Phase I lasted 2-3 days and was characterized by a rapid decrease in the rate of body weight loss and high fat mobilization. Phase II was longer and characterized by a slow and steady decline in the rates of body weight loss and of nitrogen excretion. The third (critical) period was marked by an abrupt increase in the rates of body weight loss and of nitrogen excretion. Despite their small size, the duration of phase II in quails was relatively long, a clear advantage for the study of the relationships between the several metabolic events that occur during this crucial adaptative period. Also, the beginning of phase III could be precisely determined. Changes in blood glucose, plasma FFA and triacylglycerols levels, as well as in liver and carcass lipid content were similar to those found in other species of birds. Therefore, quails seem to be a suitable model to investigate the biochemical mechanisms involved in the metabolic adjustments to prolonged food deprivation in non fasting-adapted birds.

Orchidectomy versus goserelin plus flutamide in patients with metastatic prostate cancer (EORTC 30853). European Organization for Research and Treatment of Cancer--Genitourinary Group.

A total of 327 patients with metastatic prostate cancer were randomized to receive bilateral orchiectomy or treatment with Zoladex and flutamide. The trial aimed to evaluate subjective and objective time to progression, survival, and incidence and duration of response. Strict quality control and evaluation by independent ad hoc committees were organized. Progression was assessed for each of 13 parameters. The time to subjective and objective progression was in favor of the combination treatment, with statistical significances of P = 0.009 and P = 0.008, respectively. This delay in objective progression resulted in increased survival in favor of the combination treatment for death by cancer (P = 0.02) or overall survival (P = 0.05). Survival differences were more marked in the patients with better prognostic factors. The clinical significance of these differences for the individual patient requires detailed assessment.

Goserelin acetate and flutamide versus bilateral orchiectomy: a phase III EORTC trial (30853). EORTC GU Group and EORTC Data Center.

Maximal androgen blockade (MAB), the eradication of the effects of adrenal androgens on prostate cancer cells after castration, has been used with differing success in the treatment of prostatic carcinoma. The aim of this randomized phase III study was to compare the efficacy and side effects of bilateral orchiectomy versus a combination of a luteinizing hormone-releasing hormone agonist (LHRH-A) depot formulation, goserelin acetate (3.6 mg s.c. once every four weeks), and flutamide (250 mg three times daily), in patients with metastatic cancer. Treatment usually continued until disease progression (or for a minimum of three months). Efficacy was assessed by response, time to disease progression, and duration of survival. Clinical evaluations, standard laboratory tests, and imaging examinations were carried out regularly. A total of 327 patients were entered in this study. There was a difference in response only for prostatic acid phosphatase (PAP) with a more frequent decrease of the serum values to normal in the serum in patients assigned to MAB treatment. The MAB treatment, however, proved significantly better for time to subjective progression, time to objective progression, time to first (subjective and objective) progression, and duration of survival. The most frequent side effects for both treatments included hot flushes and gynecomastia. In conclusion, significant time to progression and survival benefits are achieved by adding flutamide to an LHRH-A regimen, probably improving the quality of life of patients with metastatic cancer.

Total androgen ablation: European experience. The EORTC GU Group.

Zoladex plus flutamide significantly delays the time to progression (subjective, objective, first progression) compared with orchiectomy, but no difference in survival (death from all causes or from malignant disease) could be detected. Thus, a delay in the appearance of progression has not improved survival. In fact, the duration of survival after progression tends to be shorter on Zoladex plus flutamide. There is thus no evidence to suggest any survival benefit with Zoladex plus flutamide. The quality control of our data revealed acknowledged problems in defining responses in patients with advanced prostate cancer. The review of the Bone Scan Committee provided the data for Tables 5 to 7. These data must provoke some reflections and emphasize once again the heterogeneity of the studied patient population. Table 4 on pain response after 4 weeks is just one of the many items to be analyzed by the committees for response criteria and quality of life. We expect that the other trials face similar problems. More work and patience are needed to obtain a firm answer to this clinical problem. These efforts will never be wasted, however, because the combined results of these trials will increase our knowledge of the treated history of prostate cancer and will, we hope, indicate a net treatment benefit in some subsets of patients. An individually tailored treatment for each patient selected from the anonymous mass of cases of advanced prostate cancer would be the highest reward of our continued collaboration with all the study groups.

Orchidectomy versus Zoladex plus Eulexin in patients with metastatic prostate cancer (EORTC 30853).

A total of 327 patients with metastatic prostate cancer have been randomized to either orchidectomy or treatment with goserelin (Zoladez) 3.6 mg depot preparation combined with flutamide (Eulexin) 250 mg t.i.d. in a phase III study (EORTC 30853). A small but statistically significant difference in time to subjective and objective progression of disease was found in favour of the combination treatment. However, time from objective progression to death was longer in the group initially allocated to orchidectomy. Thus no difference was found in overall survival between the two treatment groups. The clinical significance of these differences requires further follow up and analysis.

Orchidectomy vs. Zoladex plus flutamide in patients with metastatic prostate cancer. The EORTC GU Group.

Treatment with bilateral orchidectomy was compared with Zoladex, 3.6 mg depot, plus flutamide, 250 mg t.i.d., in a randomized prospective study by the European Organization for Research and Treatment of Cancer (EORTC). Small but statistically significant differences in time to subjective and objective progression of disease were found in favor of Zoladex plus flutamide. However, time from objective progression to death was longer in the orchidectomy group. The clinical significance of these differences requires further follow-up and analysis. No difference was found in overall survival between the 2 treatment groups.

Apical membrane area of rabbit urinary bladder increases by fusion of intracellular vesicles: an electrophysiological study.

Mammalian urinary bladder undergoes, in a 24-hour period, a series of slow fillings and rapid emptying. In part the bladder epithelium accommodates volume increase by stretching the cells so as to eliminate microscopic folds. In this paper we present evidence that once the cells have achieved a smooth apical surface, further cell stretching causes an insertion of cytoplasmic vesicles resulting in an even greater apical surface area per cell and an enhanced storage capacity for the bladder. Vesicle insertion was stimulated by application of a hydrostatic pressure gradient which caused the epithelium to bow into the serosal solution. Using capacitance as a direct and nondestructive measure of area we found that stretching caused a 22% increase in area. Removal of the stretch caused area to return to within 8% of control. An alternate method for vesicle insertion was swelling the cells by reducing mucosal and serosal osmolarity. This perturbation resulted in a 74% increase in area over a 70-min period. Returning to control solutions caused area to decrease as a single exponential with an 11-min time constant. A microtubule blocking agent (colchicine) did not inhibit the capacitance increase induced by hypoosmotic solutions, but did cause an increase in capacitance in the absence of a decreased osmolarity. Microfilament disrupting agent (cytochalasin B, C.B.) inhibited any significant change in capacitance after osmotic challenge. Treatment of bladders during swelling with C.B. and subsequent return to control solutions increased the time constant of the recovery to control values (22 min). The Na+-transporting ability of the vesicles was determined and found to be greater than that of the apical membrane. Aldosterone increased the transport ability of the vesicles. We conclude that some constituent of urine causes a loss of apical membrane permeability. Using electrophysiological methods we estimated that the area of cytoplasmic vesicles is some 3.3 times that of the apical membrane area. We discuss these results in a general model for vesicle translocation in mammalian urinary bladder.

Role of the adrenal glands in insulin-induced free fatty acid mobilization in the chicken.

The effects of the administration of insulin on plasma free fatty acid (FFA) levels of adrenalectomized and sham-operated (SO) chickens were compared in order to determine if the lipid-mobilizing action of the hormone is mediated by the adrenal glands. Plasma FFA levels of adrenalectomized and SO chickens were the same before hormone administration (0.69 +/- 0.03 vs 0.72 +/- 0.03 mu Eq/ml, N = 15 for each group). Injection of insulin (1 U/kg, iv) caused a significant increase of plasma FFA of SO chickens (103%) but did not modify FFA levels of adrenalectomized chickens. Blood sugar levels were higher in SO than adrenalectomized birds (163 +/- 4 vs 126 +/- 3 mg/100 ml, N = 9 for each group) before insulin administration but the magnitude of the reduction of blood sugar induced by insulin was similar for both groups. The marked lipolytic effect of glucagon (0.2 mg/kg, iv) on intact chickens was affected only to a small extent by adrenalectomy but, in contrast, the blood sugar response to glucagon was greatly reduced (27%) in adrenalectomized chickens. Significant increases (38%) in plasma FFA levels of intact chickens were obtained during the first few hours after a single intravenous injection of hydrocortisone (10 mg/kg, iv). The data show that the presence of the adrenal glands is essential for the increase in plasma FFA induced by insulin in chickens, and suggest that the lipid-mobilizing effect of the hormone in this species is due to an increased secretion of endogenous glucocorticoids following insulin-induced hypoglycemia.