Urological and Andrological Sciences Founded in 1924 Official Journal

Transcription

Vol. 77; n. 2, June 2005
Founded
in 1924
by:
G. Nicolich
U. Gardini
G.B. Lasio
Indexed in
Medline/Index Medicus
EMBASE/Excerpta Medica
Medbase/Current Opinion
SIIC Data Base
Urological and Andrological Sciences
Echoguided drug infiltration in chronic prostatitis: results of a multi-centre study.
Federico Guercini, Cinzia Pajoncini, Robert Bard, Francesco Fiorentino, Vittorio Bini,
Elisabetta Costantini, Massimo Porena
Official Journal
of the SIEUN
Vladimir Startsev, Ivan Pouline
Ablation of non functioning renal allograft by embolization:
a valid alternative to graft nephrectomy?
Andrea Solinas, Franco De Giorgi, Mauro Frongia
Early surgical repair of penile fractures: our experience.
S.I.E.U.N.
Società
Italiana di
Ecografia
Urologica
Nefrologica e
andrologica
Gioacchino De Giorgi, Lorenzo G. Luciani, Claudio Valotto, Umberto Moro,
Silvio Praturlon, Filiberto Zattoni
Still a place for the classical systematic sextant technique?
Cancer detection rates and complications in 1025 consecutive prostatic biopsies.
Massimo Maffezzini, Lorenzo Gavazzi, Tiziana Calcagno, Giacomo Capponi, Roberto Bandelloni
Orbital metastasis as a first indication of prostate cancer: a case report.
Riccardo Autorino, Aniello Zito, Ferdinando Di Giacomo, Luca Cosentino, Giuseppe Quarto,
Giuseppe Di Lorenzo, Salvatore Mordente, Umberto Pane, Antonio Giordano, Massimo D’Armiento
Endoscopic treatment of a large leiomyoma of the bladder.
Giuseppe Carrieri, Tommaso Corvasce, Pasquale Annese, Isabella Tolve, Alessandro Caniglia,
Giuseppe Di Sabato
Bizarre leiomyoma of scrotum.
Antonio Celia, Morgan Bruschi, Stefano De Stefani, Beniamino Baisi, Anna Maria Cesinaro, Salvatore Micali,
Maria Chiara Sighinolfi, Giampaolo Bianchi
Liposarcoma of the spermatic-cord:
description of two clinical cases and review of the literature.
Michele Malizia, Eugenio Brunocilla, Alessandro Bertaccini, Fabiano Palmieri, Giovanni Vitullo,
Giuseppe Martorana
A rare case of bladder fibroepithelial polyp in childhood.
Athanasios George Zachariou, Ioannis Nikolaos Manoliadis, Paraskevi Antonios Kalogianni,
George Konstantinos Karagiannis, Dimitrios Jonh Georgantzis
Whither the andrologic pathology of Italian lads
with the end of medical check up to conscripts.
Nicola Mondaini, Gianluca Giubilei, Michelangelo Rizzo, Marco Carini
GOLDEN COMMUNICATIONS
64nd CONVEGNO ASSOCIAZIONE UROLOGI LOMBARDI - ERBUSCO (BS), 3 LUGLIO 2004
Official Journal
of the SIUrO
SIUrO
Poste Italiane S.p.A. - Spedizione in abbonamento postale - D.L. 353/2003 (conv. in L. 27/02/2004 n. 46) Art. 1, comma 1 DCB Milano
Adjuvant therapy in different risk-groups of patients with superficial bladder cancer.
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Urological and Andrological Sciences
Founded in 1924 by: G. Nicolich, U. Gardini, G.B. Lasio
Official Journal of theEditorial
SIEUN -board
Official Journal of the SIUrO
Editor in chief
Enrico Pisani
Associate editors
G. Martorana (SIUrO), F. Rocco (AUL), A. Trinchieri, G. Virgili (SIEUN)
Assistant editor
A. Bertaccini (SIUrO)
Editorial Board
G. Arcangeli (SIUrO), M. Battaglia (SIUrO), E. Belgrano (SIEUN), O. Bertetto (SIUrO), F. Boccardo (SIUrO),
E. Bollito (SIUrO), S. Bracarda (SIUrO), G. Conti (SIUrO), J.G. Delinassios (SIUrO), P. Martino (SIEUN), F. Micali (SIEUN),
E. Montanari, M. Porena (SIEUN), D. Prezioso (SIUrO), F.P. Selvaggi (SIEUN), G. Sica (SIUrO), C. Trombetta (SIEUN),
G. Vespasiani (SIEUN), G. Zanetti
Indexed in
Medline/Index Medicus - EMBASE/Excerpta Medica - Medbase/Current Opinion - SIIC Data Base
Contents
Original Paper
Echoguided drug infiltration in chronic prostatitis: results of a multi-centre study.
Federico Guercini, Cinzia Pajoncini, Robert Bard, Francesco Fiorentino, Vittorio Bini,
Elisabetta Costantini, Massimo Porena
Pag. 87
Pag. 93
Ablation of non functioning renal allograft by embolization: a valid alternative to graft nephrectomy?
Andrea Solinas, Franco De Giorgi, Mauro Frongia
Pag. 99
Early surgical repair of penile fractures: our experience.
Gioacchino De Giorgi, Lorenzo G. Luciani, Claudio Valotto, Umberto Moro, Silvio Praturlon,
Filiberto Zattoni
Still a place for the classical systematic sextant technique?
Cancer detection rates and complications in 1025 consecutive prostatic biopsies.
Massimo Maffezzini, Lorenzo Gavazzi, Tiziana Calcagno, Giacomo Capponi, Roberto Bandelloni
Pag. 103
Pag. 106
Case Report
Orbital metastasis as a first indication of prostate cancer: a case report.
Pag. 109
Riccardo Autorino, Aniello Zito, Ferdinando Di Giacomo, Luca Cosentino, Giuseppe Quarto,
Giuseppe Di Lorenzo, Salvatore Mordente, Umberto Pane, Antonio Giordano, Massimo D’Armiento
Endoscopic treatment of a large leiomyoma of the bladder.
Giuseppe Carrieri, Tommaso Corvasce, Pasquale Annese, Isabella Tolve, Alessandro Caniglia,
Giuseppe Di Sabato
Pag. 111
Antonio Celia, Morgan Bruschi, Stefano De Stefani, Beniamino Baisi, Anna Maria Cesinaro,
Salvatore Micali, Maria Chiara Sighinolfi, Giampaolo Bianchi
Pag. 113
Liposarcoma of the spermatic-cord: description of two clinical cases and review of the literature.
Michele Malizia, Eugenio Brunocilla, Alessandro Bertaccini, Fabiano Palmieri, Giovanni Vitullo,
Giuseppe Martorana
Pag. 115
A rare case of bladder fibroepithelial polyp in childhood.
Athanasios George Zachariou, Ioannis Nikolaos Manoliadis, Paraskevi Antonios Kalogianni,
George Konstantinos Karagiannis, Dimitrios Jonh Georgantzis
Pag. 118
To the Editor
Whither the andrologic pathology of Italian lads with the end of medical check up to conscripts.
Pag. 121
64nd CONVEGNO ASSOCIAZIONE UROLOGI LOMBARDI - ERBUSCO (BS), 3 LUGLIO 2004
The new transperineal-prerectal approach in posterior urethroplasty.
Edoardo Austoni, Andrea Guarneri, Fulvio Colombo, Enzo Palminteri
Pag. 122
Surgical treatment of metastases from renal cell carcinoma.
Alessandro Antonelli, Danilo Zani, Alberto Cozzoli, Sergio Cosciani Cunico
Pag. 125
Metastatic retroperitoneal renal cell carcinoma. A case for more aggressive approach. Risk and results.
Pietro Tombolini, Michele Ruoppolo, Giuseppe Malagola, Fabrizio Rovera
Pag. 129
Dorsal free graft urethroplasty according to Barbagli. Minimum follow-up of 2 years.
Paolo Parma, Bruno Dall’Oglio, Lino Schiavon, Marco Luciano, Stefano Guatelli
Vincenzo Galletta, Candido Bondavalli
Pag. 131
The reconstruction of “complex” ureteral lesions.
Pierpaolo Graziotti, Alessandro Piccinelli, Guido Giusti, Mauro Seveso Gianluigi Taverna,
Alessio Benetti, Luisa Pasini, Silvia Zandegiacomo
Pag. 133
Microscopic and microbiological findings for evaluation of chronic prostatitis.
Vittorio Magri, Lisa Cariani, Roberto Bonamore, Antonella Restelli, Maria Cristina Garlaschi,
Alberto Trinchieri
Pag. 135
The use of vesical irrigation system dual pump Endo FMS Urology in the endoscopic therapy
of benign prostatic hyperplasia.
Piero Larcher, Giorgio Borroni, Andrea Begani, Paola Franch, Massimo Grisotto
Pag. 139
The use of vesical irrigation system dual pump Endo FMS Urology in the endoscopic therapy
of the vesical neoplasms.
Piero Larcher, Giorgio Borroni, Andrea Begani, Paola Franch, Luca Carmignani
Pag. 141
Editorial
Dear Readers,
just one year ago, as president of SIUrO, I had announced with pleasure that
the “Italian Archives of Urology and Andrology” had become the official journal
of our Association.
This is a fact of great prestige for our members and for all experts on the subject interested
in scientific research. As you know, in fact, the “Italian Archives” is the only Italian urological
journal on Medline and quoted at the international level.
On the basis of an editorial cooperation, the SIUrO Board members have been selected for
reviewing all manuscripts focusing on uro-oncology, with respect to each scientific field.
We hope that the SIUrO members with theirs scientific contributions, will improve more and
more the quality of the journal.
For the first time this year, communications and posters that will be awarded in the course of
the next National SIUrO Congress (Giardini Naxos, 3-6 November 2005) will be published
“in extensor” in the first issue of 2006.
Another innovation of this year is that, in few months, it will be possible to download all the
issues, updated every three months, of the Italian Archives by the SIUrO web site.
This close collaboration with the editorial board will allow us to publish some supplementary
issues as it happened for the final program and abstracts related to free communications,
posters and videos of the last SIUrO National Congress all included in the supplement to
the September issue.
In the next months, we are planning to publish a supplement containing the data of the
important project carried out at the consensus conference on the guidelines for prostatic
biopsy which was held in Bologna last February.
I would like to thank our readers and authors of the articles which contribute to
the development and growth of this journal and to extend a special invitation to the SIUrO
members to carry on their scientific production and to send their contributions to
the official journal of our Association.
Giuseppe Martorana
Archivio Italiano di Urologia e Andrologia 2005, 77, 2
VII
ORIGINAL PAPER
Echoguided drug infiltration in chronic prostatitis:
results of a multi-centre study.
Federico Guercini1, Cinzia Pajoncini1, Robert Bard2, Francesco Fiorentino3,
Vittorio Bini4, Elisabetta Costantini1, Massimo Porena1
Urologic Department, Perugia University, Italy; 2Radiologic Department, New York University School;
Genoma Laboratory of Molecular Biology, Roma; 4Paediatrics and Gynaecologic Department, Perugia
University, Italy.
1
3
Summary
Objectives: In chronic prostatitis there are many causes that may provoke a therapeutical failure of a systemic antibiotic treatment. At the moment a consensus has not been
reached on the efficacy of the many therapeutical options that are available with not one
of these approaches being efficacious in all patients. In our view the main causes of treatment failure are the well-known hurdle to antibiotic diffusion inside the glandular
parenchyma associated with the so-called intraprostatic bacterial biofilms and the possible presence of local auto-immune reactions. Given this background, we tested ultrasound guided intraprostate infiltration of a cocktail of antibiotics and betamethasone, for a therapeutical options.
Material and Methods: 320 patients, referred to us because of symptoms indicative of chronic prostatitis, were enrolled in this study. The inclusion criteria were the severity of the symptoms and
the failure of repeated cycles of antibiotics in the previous 12 months. At the initial consultation
patients completed the NIH Prostatitis Symptoms Index (NIH-CPSI). All underwent: a) digital rectal examination (DRE), b) transrectal prostatic ultrasound scan (TRUS), c) uroflowmetry, d) cultures of first voiding and after prostatic massage urine and coltures of sperm for saprophytic and
pathogen germs, yeasts and protozoa, e) DNA amplification with polymerase chain reaction (PCR)
on urine and sperm, for Chlamydia trachomatis, Mycoplasmata (Ureaplasma urealyticum and
Mycoplasma hominis), Gonococcus, HPV and HCV. Patients on the basis of laboratory results
received a cocktail of antibiotics associated with betamethasone. The cocktail was administered as
prostate infiltration. Administration was repeated after 7 and 14 days. Final assessment of the efficacy of therapy included not only the NIH-CPSI scores but also the patient's subjective judgement
expressed as a "percentage overall improvement". The percentage judgements were arbitrarily
divided into 4 classes: 0-30% no improvement (Class I); 30-50% satisfactory improvement (Class
II); 50-80% good improvement (Class III; 80-100% cured (Class IV). Results: Statistical analysis
of the results showed 68% of patients were included in the Class IV and 13% were no responders
(Class I). Conclusions: In our opinion this is one of the more valid therapeutical approaches to
chronic bacterial or abacterial prostatitis also if it requires more studies.
KEY WORDS: Prostatitis; Drug prostatic infiltration; Chronic pelvic pain syndrome; Autoimmunity;
Cytokines.
INTRODUCTION
Many urologists loathe to deal with chronic prostatitis
even though it is one of the most common and invalidating pathologies of the male uro-genital system.
Although the incidence is not as high as the 30-50%
Drach and Barbalias originally estimated, prostatitis is
still very frequent. 5-10% of the male population is
affected, according to European estimates and about 89% according to the National Ambulatory Medical Care
Survey (1-3). Despite these figures, a consensus has not
been reached on the efficacy of the many therapeutical
options that are available (antibiotics, alpha blockers,
finasteride, Pentosan polysulphate, saw palmetto,
ProstaQ, surgery, etc.) with not one of these approaches
being efficacious in all patients (2, 4-6).
In our view the main causes of treatment failure are multiple. On the one hand the well-known hurdle to antibiArchivio Italiano di Urologia e Andrologia 2005; 77, 2
87
F. Guercini, C. Pajoncini, R. Bard, F. Fiorentino, V. Bini, E. Costantini, M. Porena
Table 1.
Perugia Urology Department Symptoms Index (PUD-PSI).
Voiding Symptoms
During the night I pass water
During the day I pass water
My urinary flow is
Flow properties
Dripping
0
never
>3 hours
strong
normal
absent
1
once
2 hours
impaired
abnormal
sometimes
2
twice
<2 hours
thread-like
***
always
3
more
more often
***
***
***
Pain Symptoms
Micturition burning
Perineal soreness
Inguinal soreness
Scrotal soreness
Coccygeal soreness
Suprapubic soreness
Ano-rectal soreness
absent
absent
absent
absent
absent
absent
absent
0
moderate
moderate
moderate
moderate
moderate
moderate
moderate
1
severe
severe
severe
severe
severe
severe
severe
2
***
***
***
***
***
***
***
Sexual Symptoms
Sexual desire
Erection
Ejaculation time
Ejaculation properties
Sperm aspect
Ejaculation jet energy
0
normal
normal
normal
normal
normal
normal
1
25% lost
25% lost
25% less
hampered
insufficient
decreased
2
50% lost
50% lost
50% less
painful
agglutinated
dripping
3
absent
absent
premature
absent
bloody
***
otic diffusion inside the glandular parenchyma associated with the so-called intraprostatic bacterial biofilms
and on the other the possible presence of local autoimmune reactions. The bacterial biofilms encapsulate
the infected areas and act as a barrier against antibiotics
and the immune defence system. The autoimmune reaction releases cytotoxic substances and pro-inflammatory
agents and create a vicious circle of infection and
inflammation (4, 7-10). The microfilm hypothesis was
developed by Nickel in 1994 (4) and later confirmed by
direct microscopy observations (7-8). Bacterial microfilms are caused by the adhesin-mediated sticking of
plancton microorganisms to a tubular surface such as
the walls of a prostatic duct. Microorganisms adhere in
groups of 10-12 cells to form adjacent encapsulated
micro-colonies which conglomerate and create the
mature biofilm. In vitro studies have shown that antibiotics’ concentration needs to be over 100 times the normal MIC in such conditions. Rupture of the biofilms
releases the germs and the required antibiotic dosage
drops to normal levels. Consequently biofilms formation creates a vicious circle of pathogen survival and
proliferation despite treatment with antibiotics; the bacterials’ agglomerates within the ducts obstruct the
lumen and facilitate accumulation of infected glandular
secretions. The micro-organisms produce a exopolysaccharide slime which, besides providing a habitat for
their hibernation, also strongly stimulates a damaging
immune response causing chronic inflammation of the
prostatic parenchyma.
88
Archivio Italiano di Urologia e Andrologia 2005; 77, 2
The possible cascade of events is as follows:
1) Acute bacterial or abacterial infection (Chlamydia,
Mycoplasmata, etc.) starts.
2) The prostate parenchyma is invaded and microbial
mucopolysaccharide biofilms form within the
prostate ducts and sequester the infectious agents.
3) Prostatitis becomes chronic.
4) Autoimmune process may start, maybe in the presence of a congenital genotype with low interleukine10 production (11) causing tissue auto-reactivity.
5) Chronic inflammation is by now independent of the
original infection and can no longer be treated with
standard therapy.
Hence the need for a different approach. In this study
we describe the effects of an innovative intraprostatic
infiltration of antibiotics and cortisone, that was
designed to overcome the encapsulating barrier and to
limit or inhibit local auto-immune reactions.
MATERIALS
AND
METHODS
320 patients with symptoms of chronic prostatitis were
enrolled in this study between 1999 and 2002. The
study is been submitted to the Ethical Committee of
each participant Centre. The inclusion criteria were
failure of repeated cycles of antibiotics in the previous
12 months and the severity of the symptoms with a
NIH-CPSI ≥ 21. Each patient signed an informed consent and provided a case history, the NIH Chronic
Prostatitis Symptoms Index Questionnaire (NIH-CPSI)
Is intraprostatic infiltration a new way to treat prostatitis?
Table 2.
Percentage of pathogens in urine before and after therapy (*as DNA and IGA) *Friedman test for related data
Baseline
3 Months
6 Months
12 Months
p*
Enterococcus sp
10%
0%
1.3%
4%
NS
Escherichia Coli
12%
1.8%
2%
2.8%
NS
Klebsiella
3.5%
0%
2.2%
1.5%
NS
Staphilococcus
9%
0%
2.1%
3.1%
NS
Streptococcus
1.2%
0%
1.1%
0%
0.000
Others
0%
1.0%
0%
0%
NS
Yeast
0%
0%
0%
0%
NS
Chlamydia*
4%
0%
1.3%
1.3%
NS
Gonococcus
1.7%
0.8%
0%
0%
0.000
HPV
8.8%
5.8%
7.0%
5.6%
NS
Micoplasmata
3.5%
0%
0%
0%
0.000
and the Perugia Urology Department Prostatitis
Symptoms Index (PUD-PSI) (Table 1) (12). All underwent: a) digital rectal examination (DRE), b) transrectal prostatic ultrasound scan (TRUS), c) uroflowmetry,
d) cultures of first voiding and after prostatic massage
urine and cultures of sperm for saprophytic and
pathogen germs, yeasts and protozoa, e) DNA amplification with polymerase chain reaction (PCR-DNA) on
urine and sperm, for Chlamydia trachomatis,
Mycoplasmata
(Ureaplasma
urealyticum
and
Mycoplasma hominis), Gonococcus, HPV and HCV.
DNA was extracted according to the phenol-chloroform
procedure (21). The PCR reaction was performed in a
total volume of 50 ml containing 5 ml of 10X PCR
Buffer II (500 mM KCl, 100 mM Tris HCl, pH 8.3 Applied Biosystems), 1.5 mM MgCl2, 200 mM of each
dNTP (Roche Diagnostic, Italy), 2.5 IU AmpliTaq Gold
Polymerase (Applied Biosystems), 10 pmol of each
primer (Table 5). The cycling condition used was 35
cycles of 30 sec at 94°C, 1 min at 55°C, 1 min at 72°C.
Each round of PCR was preceded by an initial 10 min
denaturation step at 95°C (to activate AmpliTaq Gold)
and followed by a final extension step of 10 min at 72°C.
A nested PCR approach was used to amplify Neisseria
gonorrhoeae. All the reactions were cycled on a
GeneAmp® PCR System 9700 (Applied Biosystems,
USA). For monitoring PCR amplification, 5 ml of each
PCR product was subjected to electrophoresis for 5 min
at 150V on 2% agarose gel in 1X Tris-Borate/EDTA
buffer stained with 0.5 mg/ml ethidium bromide.
Each patient received an intraprostatic infiltration of
dexamethasone 12 mg combined with rifampicyn 300
mg and levofloxacine 25 mg. In presence of Gonococcus
we replaced levofloxacin with ceftriaxone 1 g in presence of yeasts we add fluconazole 6 mg, and in presence
of protozoa we add methronidazole 15 mg.
Table 3.
Percentage of pathogens in sperm before and after therapy (*as DNA and IGA); *Friedman test for related data.
Baseline
3 Months
6 Months
12 Months
p*
Enterococcus sp
38.3%
2.5%
0%
3.7%
0.05
Escherichia Coli
14.2%
0.7%
0%
0%
0.001
Klebsiella
5.8%
0%
2.4%
5.2%
NS
Staphilococcus
12.9%
9.9%
5.5%
5.5%
NS
Streptococcus
3.9%
3.0%
1.1%
0%
0.000
Others
7.7%
1.0%
0%
0.5%
0.001
Yeast
0.2%
0%
0.4%
0.3%
NS
Chlamydia*
36.3%
12.7%
5.0%
3.3%
0.001
Gonococcus
17.5%
3.2%
0%
0%
0.000
HPV
14.9%
7.5%
8.2%
4.4%
0.05
4.5%
6.4%
4.0%
2.0%
0.05
Micoplasmata
89
Table 4.
Follow-up results; *Friedman test for related data.
Uroflowmetry (F.max)
NIH-PSS
PUD-PSI (voiding)
PUD-PSI (pain)
PUD-PSI (sexual)
Baseline
6 Months
12 Months
p*
19.6±3
21.7±3
21.5±2.7
NS
25±5
20±3
17±3
0.01
3±1
2.5±1
2.5±1.5
NS
4±0.5
3.2±1
3±0.5
0.01
4±1
3.1±0.5
3±0.5
NS
The antibiotic cocktail was administered by transperineal
echoguided intraprostatic infiltration either in a random
way or inside in any fibrous areas with the aim to sterilize them. We used Toshiba PowerVision 6000 ultrasound
scanner with transrectal biplanar multifrequency (6-10
MHz) probe equipped with angiodoppler. The injection
needle was Echojet® 23 gauge, 200 mm in length. The
needle was inserted 1 cm to the left or the right of the
median raphe, according to the site of inflammation, and
1 to 3 cm above the anal sphincter, this point corresponding to the projection of the prostate apex. After the needle had been inserted into the subcutaneous layer, 2 cc
local boluses of lidocaine were administered again and
again as the needle was pushed towards the apex of the
prostate. Attention was focused on anaesthetizing the
urogenital diaphragm and the prostatic capsule. A complete treatment included three infiltrations, performed
the 1st, the 10th and the 20th day.
Follow-up
Six and twelve months after the last infiltration, all
patients underwent uroflowmetry, all microbiological
testing, the NIH-CPSI and the PUD-PSI. For an overall
evaluation of therapy, each patient was asked to provide a
subjective assessment of treatment by quantifying the
improvement on a scale of 0-100. The results of this last
evaluation were divided into 4 classes: 0-30% “so called”
non-responders (Class I); 31-50% moderate improvement (Class II); 51-80% good improvement (Class III);
81-100% marked improvement/cured (Class IV).
Statistical Analysis
The Friedman test for related data was applied at the
basal time, 6 and 12 month check-ups to the
uroflowmetry results, the bacteriological examinations,
the NIH-CPSI and the PUD-PSI.
RESULTS
The mean age of patients was 38 years (range: 21-54
years) and the mean time since disease onset was 5.3
years (range: 6 months-22 years). The percentage of
pathogens detected in the sperm and urine by cultures
and PCR-DNA before and after therapy are reported in
Tables 2 and 3.
In the follow-up of overall patients, not statistical significant differences emerged in uroflowmetry results and in
90
the PUD-PSI regarding voiding and sexual symptoms.
Significant differences were observed in the NIH-CPSI
(p <0.01) and in the PUD-PSI regarding pain symptoms
(p <0.01) (Table 4).
The subjective improvement evaluated by each patient
demonstrated that 218 patients (68%) were marked
improved or cured (Class IV), 15 patients (5%) were
improved as good (Class III), 45 patients (14%) as moderate (Class II), while 42 patients (13%) fell into the
class of so-called non-responders (Class I). This last
class included a sub-group of 29 patients who did not
respond at all. The patients of Class IV showed a significant improvement at six and twelve months regarding
NIH-CPSI (p <0.001), PUD-PSI voiding (p <0.01), pain
(p <0.001) and sexual symptoms (p <0.01).
Side effects of treatment
a) Immediate: pain during infiltrations was very rare.
Somebody referred a mild burning sensation at the tip
of the penis. 11% of patients complained of a drop of
blood in the first 2 or 3 micturitions following an accidental perforation of the urethra (0.5% of cases). No
therapy was required.
b) Delayed: haemospermia in 81% of patients was
observed usually at the first post-infiltration ejaculation
and 2% required coagulant treatment (tranexamic acid
orally). Transient worsening of prostatitis symptoms
occurred in 13% of patients, usually on the 2nd day
after infiltration and disappeared within 24-36 hours.
Nimesulide, as pain-killing was prescribed in these cases
and symptoms were resolved quickly. Intra-prostatic
hematoma developed in 8 patients (3%) and was associated with perineal soreness for 48-72 hours and blood
in the ejaculate for up to 15 days. It resolved spontaneously in 7 cases while 8 required ultrasound guided
removal of the collection without any further complications.
c) Persistent: only one patient, two years after a single
infiltration, complains of abnormal penile sensitivity
and erectile disturbances even though NTP Rigiscan and
penile Echo-Doppler are normal.
DISCUSSION
The many theories on the pathogenesis of chronic prostatitis are not necessarily mutually exclusive. Acute urethral infection may rise to the prostate and become
Is intraprostatic infiltration a new way to treat prostatitis?
chronic because of insufficient therapy or an inadequate
immune defence system (13). A sterile uretro-prostatic
reflux with intra-parenchymal precipitation of urates
may trigger chronic inflammation as may local autoimmune reactions (9).
Repeated courses of antibiotics are undoubtedly helpful,
particularly in cases of bacterial prostatitis and most
urologists agree that even the so-called abacterial forms
of prostatitis benefit from prolonged antibiotic treatments (14). To reach a therapeutic concentration in prostatic tissue the ideal antibiotic needs to be liposoluble,
with a low grade of plasma ionization (pKa), an acid pH
and poor protein binding properties. However, treatment with even these agents often fails apparently
because of impenetrable bacterial biofilms within the
prostate and serious local auto-immune reactions (9-10).
For all these reasons we opted for a cocktail of antibiotics and cortisone. The etiology of prostatitis justifies
the use of antibiotics as the resistance of chronic prostatitis is due not only to the difficulty in diffusing the
drugs within the prostate but also to the presence of the
encapsulating bacterial biofilms. Besides in our previous
trial (15) we have doubted, the real existence of abacterial prostatitis. Dexamethasone was associated in an
attempt to break up the vicious circle of immune reactions and inflammation which is intrinsically linked to
the disease. Several other reasons underlie the decision
to infiltrate antibiotics with cortisone into the prostate.
When drugs are injected directly into the prostate they
reach local concentrations that are about 2,000-2,500
times higher than with systemic administration and they
can overcome, if present, the perimicrobial polysaccharide barrier of the biofilms. The quinolonics and the
macrolides inhibit cytokine release, particularly IL 2, IL
6 and TNF (16), which coincidentally are the same
cytokines that are found in high concentration in the
semen and EPS of men with prostatitis (11).
Furthermore, cortisone not only inhibits possible allergic reactions to antibiotics, which were not, by the way,
observed in any of our patients, but also inhibits
cytokine release. Conversely, high antibiotic concentrations counteract the hypothetical risk of steroid-induced
intra-prostate abscess or weakening of the host defence
system.
This study may be criticized on its lack of a control
group which, for obvious ethical reasons, could not be
recruited as the invasive nature of the infiltration precluded its use to administer placebo. Moreover, in studies without a placebo group it is important to establish
that the treatment given did actually cause improvement. This question can be answered by comparing for
each patient the incidence and the improving of symptoms before and after the treatment. Besides these
patients acted as a control group for themselves as they
had already undergone several unsuccessful cycles of
systemic antibiotic therapy before being recruited to this
study. Another limitation is our use of a subjective
assessment of efficacy as the overall percentage of
improvement. However, in our experience, the assessment of the overall efficacy of therapy could not be evaluated simply in terms of negative bacteriological results,
even though the difference between the pre and post
infiltrations tests was significant, or evaluated in a reduction in the symptom scores, because chronic prostatitis
has a marked psychological and behavioral impact. In
fact, the disappearance or the improvement of some
symptoms is not always associated with the patient's
awareness of recovery and vice versa.
CONCLUSIONS
Over the years the results of intra-prostate infiltration of
antibiotics have been, on the whole, disappointing. The reasons for the success of our approach appear to be in a depth
bacteriological analysis, aimed at detecting Chlamydia and
Gonococcus and in the use of a high definition ultrasound
probe (7-10 MHz) to visualize and infiltrate areas of inflammation and fibrosis.
The fibrotic areas definitively must be infiltrated in order to
make them "explode", which is the only way to ensure they
are sterilized.
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1. McNaughton M, Stafford RS, O’Leary M., Barry MJ. How common is prostatitis? A National Survey of phisicyan visits. J Urol
1998; 159:1224
2. Nickel JC, Nyberg LM, Hennenfent M. Reasearch guidelines for
chronic prostatitis: Consensus report from the first National
Institutes of Health International Prostatitis Collaborative Network.
Urology 1999; 54:229
3. Schaeffer AJ, Landis JR, Knauss JS, Propert KJ, Alexander RB,
Litwin MS, Nickel JC, O'Leary MP, Nadler RB, Pontari MA, Shoskes
DA, Zeitlin SI, Fowler JE Jr, Mazurick CA, Kishel L, Kusek JW,
Nyberg LM. The Chronic Prostatitis Collaborative Research
Network Group. Demographic and clinical characteristics of men
with chronic prostatitis: the National Institutes of Health chronic
prostatitis cohort study. J Urol 2002; 168: 593
4. Nickel JC, Costerton JW, McLean RJ, Olson M. Bacterial biofilms:
influence on the pathogenesis, diagnosis and treatment of urinary
tract infections. J Antimicrob Chemother 1994; 33 (Suppl A):31
5. Dimitrakov J, Diemer T, Ludwig M, Weidner W. Recent developments in diagnosis and therapy of the prostatitis syndromes. Curr
Opin Urol 2001; 11:87
6. Shoskes DA, Katske F, Kim S. Diagnosis and management of
acute and chronic prostatitis. Urol Nurs 2001; 21:255
7. Anderson GG, Palermo JJ, Joel D. Schilling JD, Roth R, Heuser J,
Scott J, Hultgren SJ. Intracellular Bacterial Biofilm-Like Pods in
Urinary Tract Infections Science 2003; 301:105
8. Parsek MR, Singh PK. Bacterial Biofilms: An Emerging Link to
Disease Pathogenesis. Annu Rev Microbiol 2003; 57:v677
9. Alexander RB, Brady F, Ponniah S. Autoimmune prostatitis:
Evidence of T cell reactivity with normal prostatic proteins. Urology
1997; 50:893
10. Alexander RB. Immunology and prostatitis. Third Annual
International Prostatitis Network Meeting 2000 Washington. Rev
Urol 2001; 3:94
11. Shoskes DA, Albakri Q, Thomas K, Cook D. Cytokine polymorphisms in men with chronic prostatitis/chronic pelvic pain synArchivio Italiano di Urologia e Andrologia 2005; 77, 2
91
drome: association with diagnosis and treatment response. J Urol
2001; 168:331
12. Guercini F, Pajoncini C, Bini V, Porena M. Symptoms correlated with prostatitis. Eur Urol (Suppl.) 2002; 1:175
17. Robert R, Prat-Pradal D, Labat JJ, Bensignor M. Anatomic
basis of chronic perineal pain: role of pudendal nerve. Sur Radiol
Anat 1998; 20:93
13. Lipsky BA. Prostatitis and urinary tract infection in men:
What’s new; What’s true. Am J Med 1999; 106:327
18. Nickel JC, Costerton JW. Bacterial localization in antibiotic-refractory chronic bacterial prostatitis. Prostate 1993;
23:107
14. McNaughton Collins M, Fowler FJ Jr., Elliott DB, Albertsen PC,
Barry MJ. Diagnosing and treating chronic prostatitis: do urologists
use the four-glass test? Urology 2000; 55:403
19. Luzzi GA. Chronic prostatitis and chronic pelvic pain in men:
aetiology, diagnosis and management. J Eur Acad Dermatol
Venereol 2001; 16:253
15. Guercini F, Mazzoli S, Pajoncini C, Porena M. Does Abacterial
Prostatitis really exist?. J Urol 2003; 169:29
20. Batstone GR, Doble A, Gaston JS. Autoimmune T cell responses to seminal plasma in chronic pelvic pain syndrome (CPPS). Clin
Exp Immunol 2002; 128:302
16. Galley HF, Nelson SJ, Dubbels AM, Webster NR. Effect of
ciprofloxacin on the accumulation of interleukin-6, interleukin-8,
and nitrite from a human endothelial cell model of sepsis. Crit Care
Med 1997; 25:1392
21. Sambrook J., Russell DW, Inwin N. Molecular Cloning: A laboratory manual. Spring Harbor Laboratory Press, Cold Spring
Harbor, New York, 3° ed, 2000
Correspondence: Federico Guercini, MD, Via Archimede 44 - 00197, Rome, Italy; E-mail: [email protected]
92
ORIGINAL PAPER
Adjuvant therapy in different risk-groups of patients
with superficial bladder cancer.
Urology Dept., Regional Oncological Hospital, St. Petersburg, Russia.
Summary
Objectives: We assessed and compared the outcomes of two different courses of adjuvant
therapy to patients with superficial bladder TCC. Methods: The study included 142
patients (28 women and 114 men with a median age of 58.5 years) with newly diagnosed
bladder transitional cell carcinoma (TCC), who underwent transurethral resection of
bladder tumor (TURBT) between October 2002 and October 2003. Before surgery
patients underwent routine examination, including measurement of tPSA level and transrectal
ultrasound sonography (TRUS). In 26 (18.3%) patients with considerably enlarged prostate and
LUTS we simultaneously performed TURBT and transurethral resection of the prostate (TURP).
Pathological findings showed pTa stage in 20 (14.1%), pT1G1-2 in 99 (69.7%), pT1G3 in 15
(10.6%) and pTis in 3 (2.1%) cases; we additionally examined prostate specimens after TURP. The
main criteria for adjuvant treatment were: grade, number and location of the tumor in the bladder. The group of patients (group A) with G3 and multicentric lesions, localized at the lower third
of the bladder, underwent BCG-therapy according the conventional schedule (60 patients, 42.3%).
In group B (82 patients, 57.7%) patients underwent local chemotherapy (Thiotepa 80 mg p/week
or Doxorubicin 50 mg p/week), started within 24 hours after operation. A second-look TURBT was
performed within 6 weeks of treatment course in both groups. The morphological records of surgery were reviewed, compared with the initial findings and analysed statistically. Results:
Recurrence rate in groups A and B was 18.3% (11 patients) and 25.6% (21 patients), respectively
(with common level 22.5%) (p=0.04). Three (5.0%) patients of group A and five (6.1%) of group B
withdrew consent. We observed recurrent low-grade pTa tumours in 4 patients (36.4%) and 8
patients (38.1%) respectively in group A and B (p<0.03) and pT1 G1-2 tumours in 5 patients
(45.5%) and 8 patients (38.1%) respectively in group A and B (p<0.005). We observed pT1G3 in
two (18.2%) cases of group A, and in two (9.5%) cases of group B. In addition, two (9.5%) patients
of B group had T2G2 lesions. Adiuvant therapy was continued in all patients, except four patients
with G3 and two patients with T2 stage who underwent more aggressive treatment (4 cystectomies
and 2 external beam radiotherapy). We switched 16 patients in group B with recurrent cancer to
BCG treatment. Nobody of TURP-operated patients had recurrence in the distal part of urethra,
and toxicity level of TURP-operated patients was not worse than in the whole patients cohort (not
more than grade II). Conclusion: BCG adjuvant therapy demonstrated good results in the treatment of the recurrence of superficial TCC. However, in patients with low recurrence risk we used
chemotherapy successfully. A second-look TURBT within 6 weeks after the initial surgery provided important prognostic information. Patients with T1G3 tumors, being at high risk of residual, or
even invasive, cancer, could be offered definitive therapy within a 1-year period. Patients who
underwent simultaneous TURP for relief of LUTS did not show cancer recurrences in the operated area or an higher toxicity of adiuvant treatment.
KEY WORDS: Bladder Cancer; Chemotherapy; Immunotherapy
INTRODUCTION
Lower urinary tract tumors account for about 10% of all
cancers and for 5% of all cancers in women all over the
world. In fact, the incidence and the morbidity of this
disease tend to increase. More than 90% of such cancers,
both in Europe and USA, are TCC (1).
The incidence of bladder cancer in Russia is also very
93
V. Startsev, I. Pouline
high: it was established that from 1990 to 1997 it
increased from 4.0% to 4.6% (2). The rate of initial
superficial TCC tends to increase from 39.4% in 1990 to
40.8% in 1999 (3).
It is well-known that in patients with superficial bladder
cancer (Ta, T1 or Tis) about 70% will recur within 5
years after a transurethral resection (TURBT) alone (4).
It is crucial to distinguish the small group of lesions that
are at serious risk of progression to life-threatening muscle invasion, the vast majority of superficial tumors
rarely progress (4, 5). It has been observed that between
5% and 50% of patients with superficial bladder cancer
during the observing period of adjuvant treatment have
progressed to stage T2 (i.e. muscle-invasive disease)
with worsening prognosis (6, 7).
The recurrence and progression rate depends on the
tumor grade, stage, presence or absence of CIS, and length
of follow-up of patients (4, 8). In the National Bladder
Cancer Group (NBCG) study (9) the recurrence rate
increased when there were associated mucosal abnormalities, positive cytology, four or more tumors, and tumors
larger than 5 cm in maximum diameter (1, 9, 10, 11).
The highest therapeutic ratio for adjuvant intravesical
therapy can be achieved in patients with high-risk
superficial TCC of the bladder who demonstrate multiple primary tumors, multiple recurrences, high-grade
tumor, T1 tumor, positive urinary cytology post resection, and diffuse CIS (12). The most important objective
in treating superficial bladder cancer is to prevent progression to muscle-invasive disease (13). Some authors
suggest aggressive treatment options in patients with
high-risk superficial T1-bladder cancer, including early
cystectomy or radiotherapy (7, 14, 15), others prefer the
goal of organ preservation by adjuvant intravesical therapy after transurethral resection (TURB) (16).
In the 1980s many investigators suggested adjuvant
chemotherapy, as method of choice (17-20). Controlled
studies demonstrated that Thiotepa (20, 21), doxorubicin (Adriamycin) (18), mitomycin C (Mutamycin) and
ethoglucid (Epodyl) (17, 22, 23) are active against TCC.
The reduction in size of residual TCC (after TURBT) was
seen in 29% of cases with thiotepa, 38% with doxorubicin and 47% with mitomycin (24). Chemotherapy is
an excellent measure, but it is not indicated in every
case.
Holmgren in Sweden was the first to report the use of
BCG to treat cancer in man in 1935 (25). After investigations on animals in 1950s, in 1976 Morales et al. (26)
reported their clinical trial of BCG in 9 patients with
recurrent tumors. Subsequents investigations showed
that the benefits of BCG immunotherapy appeared to be
durable (27-31). It was shown an average response rate
of 55% and 73% in treatment respectively of residual
TCC (32) and CIS (in 663 patients, 15 studies) (33, 34)
with BCG instillations.
Long-term studies of adjuvant BCG instillations in comparision with mitomycin C in cases with moderate or
high-risk cancer showed that the recurrence rate was
significantly lower with BCG than with only mitomycin
C in patients at high risk (11, 28, 35); there was no difference in disease progression, survival, adverse events
and cost (36, 37).
94
BCG is the standard intravesical therapy of choice for
T1G3 bladder tumors and CIS. In 2000 Brake et al. (38)
reported a 19% recurrence rate and a 13% muscle invasive progression in patients with T1G3 after 26-week
cycles of BCG. In cases intolerant of BCG, mitomycin C
may be a second choice of therapy (39).
Despite the risk of recurrence and progression of cancer,
several different treatment regimens, sometimes excluding BCG, have been proposed.
In Japan, epirubicin, at different doses, (6th Trial of the
JUCRG) showed good results, excluding T1G3 cases (40).
In China, BCG associated to chemotherapeutic agents (50
mg adriblastin or epirubicin) was administered in highrisk patients during a 15-year follow-up (41) with a recurrence rate of 44.4% at 10-year follow-up and a progression
rate of 24.0%, without statistically significant difference
between the two chemoterapeutic variants.
Interesting results were shown in 2004 by EORTC (42): it
has been observed a 30% decrease of recurrence rate with
a single immediate instillation of a chemotherapeutic
agent (epirubicin, mitomycin C, thiotepa or pirarubicin)
in patients with multiple Ta-1 tumors after TURBT in
comparision with TURBT alone. At present time many
clinicians suggest that chemotherapy instillations immediately after TURBT are “…the treatment of choice in
patients with a single, low risk papillary tumor” and may
be recommend as initial adjuvant treatment in patients
with higher risk tumors ( 16, 31, 37, 42.
Alternative treatments are intravesical administration of
recombinant human interferon-a2b (43, 44), photodynamic therapy (45, 46), and administration of other
immunologically active agents.
Additional intravesical immunotherapy can reduce the
risk of muscle-invasion as an alternative to cystectomy
as method of choice in the treatment of high-risk cancer
(47). The most important issue of conservative treatment is the quality of the initial TURBT. Recent papers
demonstrated that a routinely “second-look” or “repeat”
TUR, performed within 2-6 weeks, is advisable to control noninvasive tumors and to detect residual tumor in
a significant percentage of patients (48-51). In an evaluation of 96 patients, Herr (52) showed that only 24.0%
of patients were free of tumor at the second TUR, and
28.0% had previously undiagnosed muscle involvement
(52, 53). For this reason it is recommended to include
in the schedule of conservative treatment of T1 tumors
a second TURBT within 2 to 4 weeks after the first one
(47, 48, 50).
In our study we assessed and compared the outcomes of
two different regimens of adjuvant therapy (BCG and
chemotherapy) in patients with superficial bladder TCC.
MATERIALS
AND
METHODS
Patients. From September 2002 we selected, treated and
followed-up 142 consecutive patients with newly diagnosed bladder tumors. Out of them, 28 were women
and 114 men (1:4.1) with age ranging from 51 to 69
years (median 58.5 years). Between October 2002 and
October 2003 the information about the patients
observed in the outpatient clinic for routine surveillance
cystoscopy were entered into a database. The criteria of
Table 1.
Patient characteristics.
Group A
Group B
Males
66
76
Females
15
13
Sex:
0.462
Tumor size (cm):
0.024
Less than 2 cm
82
2-5 cm
36
Greater than 5
24
Tumor grade:
0.549
G1
9
31
G2
32
28
G3
15
–
3
–
Ta
–
20
T1
57
62
TURP-operated
patients
11
15
Stage:
Tis
p Value
(chi-square
test)
0.147
0.481
eligibility included untreated papillary and non-papillary transitional cell carcinomas (TCC) of the bladder in
absence of other active neoplasms or serious complications.
Methods. Before treatment physical examination, urinalysis, blood count, serum creatinine, liver function, chest
plain X-rays and intravenous pyelography (IVP) were
performed. In all the male subjects serum tPSA level,
transrectal ultrasound sonography (TRUS) and IPSStesting were obtained before surgery. The results of preoperative investigations are shown in Table 1. All
patients were fully informed about this trial and signed
the informed consent form. After routine preparation all
patients underwent complete transurethral resection of
the bladder tumors (TURBT) and were followed-up for
a minimum of 6 month. This period was to observe and
eliminate tumor recurrences. A 26 F cystoresectoscope
(AVVA-land, St.-Petersburg) was used for the surveillance cystoscopy and for bladder resection. In addition
to conventional TURBT we performed TUR-biopsies of
suspicious urothelial areas. In 26 (18.3%) patients with
considerably enlarged prostate and associated lower urinary tract symptoms (LUTS) with bladder neck obstruction (BNO) we simultaneously performed the
transurethral resection of the prostate (TURP). No surgical complication was observed. In case of TURP we
irrigated the bladder for a median duration of 2.1 days
(1.5-2.5 days). The median duration of irrigation in
patients after TURBT in 86 patients (60.6%) was 1.5
days (1-2.5 days).
Pathology specimens. All pathology specimens were
reviewed by one pathologist, tumor grade was assigned
as recommended by Koss. Resected tissue was immediately fixed in 10% buffered formalin and then embedded
in paraffin wax; each paraffin section was stained with
haematoxylin and eosin. All the patients included in the
study had superficial TCC of the bladder. According to
morphological investigations, primary cancer was stage
pTa in 20 (14.1%), pT1G1-2 in 104 (73.2%), pT1G3 in
15 (10.6%) and pTis in 3 (2.1%) cases. In addition, all
prostate specimens after TURP were diagnosed as benign
prostatic hyperplasia (BPH) with association of chronic
prostatitis. The median resected mass of the prostate was
18.7 g (range 16-24) (Table 1).
Classification. We used the grading system described by
Epstein et al. in the 1998 WHO International Society of
Urologic Pathology Classification (54, 55) in which
tumors are dichotomized as either low grade or high
grade. Patients considered at high risk for tumor recurrence were defined as those with a history of moderate
or high grade papillary tumors, any invasion or associated carcinoma in situ (CIS). Patients at low risk were
those with low grade papillary tumors or papilloma
with no invasion (stage Ta). Disease progression was
defined as any increase in clinical stage or development
of metastases.
Patients underwent different adjuvant treatment on the
basis of the recurrence risk.
BCG-treatment Schedule. Criteria for BCG immunotherapy (group A, n=60, 42.3%) were multicentric or highor moderate grade tumors or tumor with size more
than 2 cm, located mainly at the base of the bladder.
The adjuvant treatment was initiated within 2 weeks
after TURBT with the Pasteur strain BCG (80 mg suspended in 50 ml sterile saline held for 90 min in the
bladder). The treatment was continued as follows: once
per week till the second TURBT or the 6th week, after
monthly for 6 months, and finally quarterly for 1 year.
Blood count and serum creatinine were obtained every
7 days or more frequently if it was necessary. Patients
who underwent TURP were not excluded from the
immunotherapy group.
Chemotherapy-treatment Schedule. Adjuvant chemotherapy agents were administered in patients (group
B, n=82, 57.7%) with solitary, low grade papillary
tumors, with tumor size less than 2 cm, located in the
upper and middle third of bladder. The treatment
began within 24 hours after the operation, after receiving the pathological report of specimen analysis. We
used initially Thiotepa 40 mg (with subsequent dose of
80 mg weekly) or Doxorubicin 50 mg (with subsequent dose pf 50 mg weekly). Administration continued up to date of the second TURBT and then, on the
basis of pathological report, changed on more aggressive treatment or not. The total dose administered in
cases who completed the treatment were: Thiotepa 400
mg and Doxorubicin 300 mg.
Follow-up protocol. In both patient groups the secondary
TURBT was performed within 6 weeks from the first procedure. Pathology reports of the first and second TURBT
were reviewed, compared and analyzed statistically.
Patients with recurrences or progression of cancer underwent more aggressive treatment (change of the agent of
adjuvant treatment or cystectomy).
95
Table 2.
Pathological characteristics of recurrences
in both groups of patients.
Group A
Group B
Ta
4
8
<0.02
T1G1-2
5
8
<0.051
T1G3
2
2
T2G2
Total
p Value
(chi-square
test)
2
11
20
Patients were analyzed for disease-free and progressionfree survival. For statistical analysis we used SPSS 8.0
for Windows (SPSS Inc., Chicago, Illinois). Chi-square
test and Cox proportional hazards models with time
dependent covariates were used for evaluation. All p
values are 2-sided and considered significant if p<0.05.
RESULTS
Recurrence rate in groups A and B was 18.3% (11
patients) and 25.6% (21 patients), respectively (with
common level 22.5%) (p= 0.04). Fourteen patients with
progressive tumor died of the disease and 23 patients
died of other causes. Three (5.0%) patients of group A
and five (6.1%) of group B withdrew consent.
The pathological report results are in the Table 2.
As shown in Table 2, we observed recurrence stage pTa
in 4 (36.4%) and 8 (38.1%) patients (p<0.03), pT1G12 in 5 (45.5%) and 8 (38.1%) patients (p<0.05) in
group A and B, respectively. We observed a few recurrent pT1G3: 2 (18.2%) patients in group A and 2
(9.5%) in group B.
Table 3.
Local toxicity.
96
Group A
Group B
Gross haematuria
None
Mild
Moderate
Severe
50
7
2
1
78
3
1
–
Micturition pain
None
Mild
Moderate
Severe
53
5
1
1
60
7
3
2
Frequency
None
Mild
Moderate
Severe
51
6
2
1
Two (9.5%) patients of group B had T2G2 lesions. We
continued BCG-course in all the patients of group A,
except the two with T1G3. Since those patients had highgrade tumors also initially, they underwent radical surgery. We changed adjuvant treatment on more aggressive
therapy in the 2 patients of group B with T1G3 and in the
two with T2-stage (2 cystectomies and 2 organ-confined
treatment with external beam radiotherapy).
Treatment was selected on the basis of the co-morbidity
status of the patients.
Nobody of TURP-operated patients had recurrence in
the distal part of the urethra. We did not found statistically significant difference in recurrence rate among
patients treated or not with TURP.
Side effects. The most common were irritative bladder
symptoms (pain and frequency) and hematuria (Table
3). Instillations were never interrupted before the second TURBT. No significant difference in local toxicity
rate was observed between the 2 groups. Systemic toxicity was seen in group A consisting in general fatigue
and fever. Severe toxicity did not develop in any patients
of either group. The toxicity level in TURP-operated
patients was not worse than in the whole cohort of
patients (not more than grade II).
DISCUSSION
The effectiveness of BCG in preventing recurrences of
superficial bladder carcinoma is well recognized.
The question whether intravesical immunotherapy with
BCG is superior to intravesical chemotherapy remains
actual. There is no doubt about the efficacy of BCG in
eradicating CIS or preventing papillary tumors after
TURBT. Although series are not large and follow-up is
too short, several reports indicate that BCG is capable of
preventing muscle-invasive disease (30).
The administration of BCG in patients with low-grade or
intermediate stage and grade tumors is questionable
from the first clinical trials in BCG-therapy, whereas in
high-risk patients BCG remains the first choice.
BCG will never be the best treatment option for every
patient with superficial bladder cancer.
In conclusion, BCG-adjuvant therapy demonstrated
mainly good results in the treatment of the recurrences of high-risk superficial bladder cancer. On the
contrary, in patients with low recurrence risk,
chemotherapy is an alternative treatment. A “second
look” TURBT within 6 weeks after the initial procedure provided significant prognostic information.
Patients with T1G3 tumors, being at high risk of
residual, or even invasive, cancer, can be offered
definitive therapy with one year follow-up. Patients
who underwent simultaneous TURP for relief of LUTS
did not show cancer recurrences in the operated area
or higher toxicity.
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27. Pinsky CM, Camacho FJ, Kerr D, et al. Treatment of superficial
bladder cancer with intravesical BCG. In : Terry WD, Rosenberg SA
(Eds), Immunotherapy of Human Cancer. New York: Elsevier 1982,
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28. Rubben H, Krege S, Giani G, et al. Prospective randomized
study of adjuvant therapy after complete resection of superficial
bladder cancer: mitomycin C versus BCG connaught versus TUR
alone. In: de Kernion J. (Ed), International Society of Urology
reports. New York, NY: Churchill Livingstone; 1990 p 365
29. Herr H, Pinsky CM, Whitmore Jr WF, et al. Experience with
intravesical bacillus Calmette-Guérin therapy of superficial bladder
tumors. Urology 1985; 25:119
30. Herr HW. Bacillus Calmette-Guerin therapy alters the progression of superficial bladder cancer. J Clin Oncol 1988; 6: 1450
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31. Witjes JA. Bladder Carcinoma in Situ in 2003: State of the Art
Eur Urol 2004; 45:142
14. Rödel C, Dunst J, Grabenbauer GG, et al. Radiotherapy is an
effective treatment for high-risk T1-bladder cancer. Strahlenther
Onkol 2001; 177:89
32. Lamm D, et al. A randomized trial of intravesical doxorubicin
and immunotherapy with bacillus Calmette-Guérin for transitional
cell carcinoma of the bladder. N Engl J Med 1991; 325:1205
15. Malavaud B. T1G3 Bladder Tumours: The Case for Radical
Cystectomy. Eur Urol 2004; 45:406
33. Sosnowski J, Lamm D. Immunotherapy of bladder carcinoma.
In: Crawford E, Das S (Eds), Current genitourinary cancer surgery.
Philadelphia, PA: Lea & Febiger, 1990 p 480
16. Gohji K, Nomi M, Okamoto M, et al. Conservative therapy for
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17. Heney N. First-line chemotherapy of superficial bladder cancer: mitomycin C vs. thiotepa. Urology 1985; 26:27
18. Horn Y, Eidelman A, Walach N et al. Intravesical chemotherapy in a controlled trial with thiotepa versus doxorubicin. J Urol
1981; 125:652
19. Koontz W, Prout G, Smith W, et al. The use of intravesical
thiotepa in the management of noninvasive carcinoma of the bladder. Urology 1984; 131:43
35. Kaasinen E, Wijkström H, Malmström PU, et al. Alternating
Mitomycin C and BCG Instillations versus BCG Alone in Treatment
of Carcinoma in Situ of the Urinary Bladder: A Nordic Study. Eur
Urol 2003; 43:637
36. Bohle A, Bock PR. Intravesical bacille Calmette-Guerin versus
mitomycin C in superficial bladder cancer: formal meta-analysis of
comparative studies on tumor progression. Urology 2004; 63:682
20. Mori K, Lamm D, Crawford E. A trial of BCG versus
Adriamycin in superficial bladder cancer. Urol Int 1986; 41:254
37. Shelley MD, Wilt TJ, Court J, et al. Intravesical bacillus
Calmette-Guerin is superior to mitomycin C in reducing tumour
recurrence in high-risk superficial bladder cancer: a meta-analysis
of randomized trials. BJU Int 2004; 93:485
21. Flanagan R, Ellison M, Butler M. A trial of prophylactic
thiotepa or mityomycin C intravesical therapy in patients with
recurrent or multiple superficial bladder cancer. J Urol 1986;
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38. Brake M, Loertzer H, Horsch R, Keller H. Recurrence and progression of stage T1, grade 3 transitional cell carcinoma of the bladder following intravesical immunotherapy with bacillus CalmetteGuerin. J Urol 2000;163:1697
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39. Tolley DA, Parmar MK, Grigor KM, et al. The effect of intravesical mitomycin C on recurrence of newly diagnosed superficial
bladder cancer: a further report with 7 years of follow-up. J Urol
1996; 155:1233
40. Kuroda M, Niijima T, Kotake T, et al. Effect of prophylactic treatment with intravesical epirubicin on recurrence of superficial bladder
cancer--The 6th Trial of the Japanese Urological Cancer Research
Group (JUCRG): a randomized trial of intravesical epirubicin at dose
of 20mg/40ml, 30mg/40ml, 40mg/40ml. 6th Trial of the Japanese
Urological Cancer Research Group. Eur Urol 2004; 45:600
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Intravesical Therapy of T1G3 Urinary Bladder Cancer: a
Conservative Approach. Jpn J Clin Oncol 2004; 34:202
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immediate postoperative instillation of chemotherapy decreases the
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superficial bladder cancer: a Northern California Oncology Group
Study. J Clin Oncol 1988; 6:476
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alpha-2β interferon in carcinoma in situ of the bladder. J Urol
1990; 144:658
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prospects. Br J Cancer 1989; 60:151
46.Jr GP, Lin C, Benson R, et al. Photodynamic therapy with
hematoporphyrin derivative in the treatment of superficial transitional-cell carcinoma of the bladder. N Engl J Med 1987; 317:1251
47. Ozen H, Ekici S, Uygur MC, et al. Repeated transurethral
resection and intravesical BCG for extensive superficial bladder
tumors. J Endourol 2001; 15:863
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2004; 45:539
49. Langenstroer P, See W. The role of a second transurethral resection for high-grade bladder cancer. Curr Urol Rep 2000; 1:204
50. Zurkirchen MA, Sulser T, Gaspert A, et al. Second transurethral
resection of superficial transitional cell carcinoma of the bladder: a
must even for experienced urologists. Urol Int 2004; 72:99
51. Dalbagni G, Herr H., Reuter VE. Impact of a second transurethral
resection on the staging of T1 bladder cancer. Urology 2002; 60:822
52. Herr HW. The value of a second transurethral resection in evaluating patients with bladder tumors. J Urol 1999; 162:74
53.Brauer A, Buettner R, Jakse G. Second resection and prognosis
of primary high risk superficial bladder cancer: is cystectomy often
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2003; 43:1
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Correspondence: Vladimir Yu Starsev, M.D., Urologi Department, Leningrad Regional Oncological Hospital, St. Petersburg, 191104 Russia;
E-mail: [email protected]
98
ORIGINAL PAPER
Ablation of non functioning renal allograft
by embolization: a valid alternative to graft nephrectomy?
Andrea Solinas1, Franco De Giorgi2, Mauro Frongia1
Department of Renal Pathology, Unit of Urology; 2Service of Radiology, San Michele Hospital, Cagliari, Italy.
1
Summary
Objective: Transplantectomy for the treatment of graft intolerance syndrome (GIS) is
an invasive procedure with high risk, often performed in patients with poor general
conditions. Renal allograft embolization is a recent alternative treatment to surgical
nephrectomy. The aim of this study was to evaluate the efficacy and safety of allograft
embolization in a series of patients with GIS.
Patients and Methods: The study included 12 patients (9 males and 3 females) with irreversible
renal graft rejection and GIS. All patients were in hemodialysis and they have not responded
to medical treatment. Infection was ruled out by blood and urine cultures. The embolization
was performed using polyvinyl alcohol particles and steel coils. Vascular access was obtained
via femoral artery puncture in all the patients. Before starting embolization at the puncture
site local anaesthesia was performed. Results: Eleven of the twelve procedures were technically successful, but in one patient a second treatment was necessary, after a month, for the presence of collateral perirenal circulation caused hematuria. There were no major complications
and the mean hospital stay was 5 days. Conclusion: The graft embolization is a simple, safe
and effective technique that permits non-surgical ablation of a non-functioning renal allograft
in a significant number of patients.
KEY WORDS: Kidney transplantation; Renal embolization; Vascular graft occlusion.
INTRODUCTION
The gold standard for the treatment of non functioning
renal allograft with graft intolerance syndrome (GIS) has
been the graft nephrectomy. This procedure is associated with a high rate of morbidity and mortality (1, 2).
Hemorrhage, hematoma, abscess and vascular injury are
the most common complications of surgical transplantectomy (3, 4). Renal allograft embolization is a recent
alternative treatment to surgical nephrectomy (1).
However, the safety and long-term efficacy of this technique has not been established.
The graft can be left in situ when there are no additional complications. In some patients graft intolerance
occurs when the immunological treatment is completely withdrawn.
These patients may develop “flu like symptoms”, fever,
malaise, pain or tenderness in the graft zone (5). When
graft intolerance appears, the extended maintenance of
low-dose immunosuppressive drugs can be effective (6).
In the patients not responders to the medical treatment
the ablation of non functioning renal allograft is
inevitable. The aim of this study was to present the
results of our series of renal vascular embolization for
the treatment of graft intolerance syndrome in failed
allograft kidneys.
PATIENTS
AND METHODS
From January 1988 to December 2004, 504 transplanted kidneys was performed at our center. Until 2000 non
functioning renal allograft with GIS were treated with
the graft nephrectomy. With the advent and development of new angiography techniques, angio-embolization of these failed grafts is possible. From March 2001
to December 2004 renal graft embolization was performed in 12 patients with non-functioning renal allograft and GIS who have not responded to medical treatment and in the absence of simultaneous infectious disease. All patients were in hemodialysis.
Patients were 9 males and 3 female, the mean age was 44
(30-62) years and the mean graft survival 100 (13-174)
months. From the beginning of dialysis the graft was left
in situ for 5 (3-7) months. The causes of renal failure and
starting dialysis were chronic rejection in 11 (91.6%)
patients and de novo glomerulonephritis in one (8.3%).
99
A. Solinas, F. De Giorgi, M. Frongia
Figure 1.
Intra-arterial angiography of the right iliac region.
Renal artery patency with end-to-side anastomosis
with the iliac artery.
tion. Vascular access was obtained via femoral artery
puncture in all the patients. Before starting embolization, we assessed the renal allograft anatomy, renal
artery patency and the presence of perirenal collateral
supply (Figure 1). We performed selective retrograde
catheterisation of the allograft renal artery with a standard angiographic catheter.
Additionally, the renal artery branches were selectively
catheterised with a microcatheter to achieve occlusion at
the most distal point. The distal intrarenal vascular bed
was embolized using polyvinyl alcohol particles
between 150-350 micron in size and the renal artery
with steel coils deposited at the end of the procedure in
order to prevent recanalization (Figure 2). After completing renal embolization, intra-arterial angiography of
the aorto-iliac sector was performed to confirm occlusion of the renal artery and to check for collateral renal
supply. The day after embolization a Doppler sonography was taken to verify the disappearance of arterial
flow. Informed consent was obtained from each patient
prior to the examination.
RESULTS
Figure 2.
Post- embolization angiography. Total occlusion of the
allograft renal artery and the intrarenal branches.
Visualization of steel coils in main branch
of the renal artery.
All patients received cadaveric grafts. In ten patients it
was the first renal transplantation, the second in two.
Infection was ruled out by blood and urine cultures.
Symptoms included fever, graft pain, graft swelling,
malaise and anemia. Usually patients presented with
more than one symptom. In all cases, attempts to treat
the symptoms with steroids or non-steroidal antiinflammatory drugs failed. All the patients received
broad spectrum antibiotics intravenously before and
after the procedure. Renal embolization was performed
using local anaesthesia at the puncture site and no seda-
100
The embolization was a clinical success, defined as
alleviation of symptoms, in 11 patients. There were no
deaths and no major complications in any of the
patients. Only one patient, presented hematuria after a
month of the graft embolization. A new arteriography,
performed in this patient, demonstrated extensive collateral perirenal circulation originated in two circumflex iliac artery (Figure 3). In this patient, Doppler
study showed no flow either in the renal artery or the
intrarenal arteries, demonstrating that the vascular
embolization remained intact. In this case we were able
to embolize only one circumflex artery (Figure 4). This
partial embolization was sufficient to disappeared
hematuria. Post embolization syndrome, characterized
mainly by fever, occurred in all the patients and only
one patient experienced slight post-embolization pain
but there were no technical complications during
angiography.
The symptoms of GIS ceased within 1-7 days after
embolization, but in one patient though most of the
symptoms were relieved within 1 week, non-infectious
fever remained high for 20 days and the resolution was
successful with conservative management. The mean
hospital stay was 5 days, while 10 days were required
for 1 patient. The long-term results of allograft
embolization is good, with absence of clinical intolerance and complications in all the patients.
DISCUSSION
The kidney embolization, introduced in the 1973 for the
treatment of renal cell carcinoma (7) is today commonly accepted as palliative therapeutic option in non operable tumours with serious haemorrhage, pain or manifestations of the paraneoplastic syndrome. It is also used
in the treatment of the hemorragic complication of the
percutaneous nephrolithotomy (8) and in the iatrogenous kidney bleeding consequent to percutaneous
Embolization of non functioning renal allograft
Figure 3.
Angiography shows total occlusion of the main renal
artery, with cortical repatency originating in two circumflex iliac artery.
tions. Graft nephrectomy has been the treatment of
choice for non-functioning renal allograft with GIS,
often performed in patients with poor general conditions, and it is still practised in some hospital, though
studies report a morbidity of 6-25% and mortality of 07% (1, 2). The surgical procedure can be very difficult
because of the development of fibrosis around the kidney with severe potential complications such as haemorrhage, haematoma, abscess and vascular injury. Ablation
of non functioning renal allograft by embolization is a
less invasive method of treatment with a shorter hospital
stay and a lower complication rate (2, 4). In this study
the embolization was a clinical success in majority of the
patients with no major complications. The mean hospital stay was 5 days.
CONCLUSIONS
Figure 4.
The same case of Figure 3, angiography shows embolization of only one circumflex artery.
In summary our data confirmed, in accord with other
authors, that embolization of non functioning renal allograft can be used as treatment of choice for patients with
clinical signs of GIS (4, 14). Furthermore, it does not
preclude nephrectomy if symptoms of GIS persist, and
repeated transplantation is still possible.
The allograft nephrectomy is indicated in case of hyperacute rejection, kidney rupture, irreparable urological
complications, irreversible arterial or venous thrombosis, neoplasm and when embolization fails (4). In cases
of asymptomatic non-functioning grafts, nephrectomy
may not be necessary.
REFERENCES
1. Lorenzo V, Diaz F, Perez L et al. Ablation of irreversibly rejected
renal allograft by embolization with absolute ethanol: a new clinical
application. Am J Kidney Dis 1993; 22:592
2. Cofán F, Vilardell J, Gutierrez R et al. Efficacy of renal vascular embolization versus surgical nephrectomy in the treatment of nonfunctioning renal allografts. Transplant Proc 1999;
31: 2244
3. O’Sullivan DC, Murphy DM, Mc Lean P, Donovan MG.
Transplant nephrectomy over 20 years: factors involved in associated morbidity and mortality. J Urol 1994; 151:855
4 Cofán F, Real MI, Vilardell J et al. Percutaneous renal artery
embolisation of non-functioning renal-allografts with clinical intolerance. Transpl Int 2002; 15:149
5. Silberman H, Fitzgibbons T, Butler J, Berne T. Renal allograft
retained in situ after failure. Arch Surg 1980; 115:42
nephrostomy (9). This technique has shown to be a
valid alternative to the surgical nephrectomy also for not
neoplastic pathologies in patients who are at increased
risk for operative complications (10) or in the treatment
of non functioning hydronephrotic kidneys (11). In literature few cases are described in which it was used in
paediatric patients for the treatment of the pseudoincontinence (12, 13).
This approach was first reported by Lorenzo et al. (1) in
the treatment of non-functioning kidney graft; the
results were good and there were no severe complica-
6. González-Satué C, Riera L, Franco E, Escalante E, Dominguez J,
Serrallach N. Percutaneous embolization of the failed allograft in
patients with graft intolerance syndrome. BJU International 2000;
86:610
7. Almgard LE, Fernstrom I, Haverling M, Ljungqvist A. Treatment
of renal adenocarcinoma by embolic occlusion of the renal circulation. Br J Urol 1973; 45:474
8. Gremmo E, Ballanger P, Dore B, Aubert J. Hemorrhagic complications during percutaneous nephrolithotomy. Retrospective studies
of 772 cases. Prog Urol 1999; 9:460
9. Peene P, Wilms G, Baert AL. Embolization of iatrogenic renal
101
A. Solinas, F. De Giorgi, M. Frongia
hemorrhage following percutaneous nephrostomy. Urol Radiol
1990; 12:84
12. De Groote B, Van Laer P, Maurus K, Van Biervliet JP, Meeus L.
Embolization of ectopic kidney to control incontinence. Ped 1990; 85:217
10. Hom D, Eiley D, Lumerman JH, Siegel DN, Goldfischer ER,
Smith AD. Complete renal embolization as an alternative to
nephrectomy. J Urol 1999; 161:24
13. Solinas A, De Giorgi F, Frongia M. Embolization of a hypoplastic kidney with a vaginal ectopic ureter in a case of pseudo-incontinence. Arch Ital Urol Androl 2004; 76:117
11. Hirao Y, Okajima E, Yoshida K et al. Renal ablation with
absolute ethanol for non functioning hydronephrosis. Eur Urol
1993; 24:203
14. Delgado P, Diaz F, Gonzalez E et al. Transvascular ethanol
embolization: first option for the management of symptomatic nonfunctioning renal allografts left in situ. Transpl Proc 2003; 35:1684
Correspondence: Andrea Solinas, M.D., Azienda Ospedaliera “G. Brotzu, Ospedale San Michele, S.C. di Urologia, Via Peretti 3 - 09134 Cagliari,
Italy; E-mail: [email protected]
102
ORIGINAL PAPER
Early surgical repair of penile fractures:
our experience.
Gioacchino De Giorgi, Lorenzo G. Luciani, Claudio Valotto, Umberto Moro,
Silvio Praturlon, Filiberto Zattoni
Dipartimento Interaziendale di Urologia, Azienda Ospedaliera S.M. Misericordia, Università degli Studi, Udine.
Summary
Objective: Fracture of the penis is a relatively rare condition, defined as the rupture
of the tumescent corpora cavernosa. The fracture is quite easily recognized, whereas
its management remains controversial. Our experience regarding the early treatment
of penile fractures is herein reported. Materials and Methods: In a 7-year period
(1997-2004) 10 patients aged 23 to 42 years, presented with a penile fracture,
occurred during coitus. All patients were admitted to the hospital 1 to 10 hours after injury.
Diagnosis was made on clinical examination. Six patients referred a snapping sound at the
time of injury. Common clinical features included sudden penile pain, detumescence and penile
deviation. All patients showed penile haematoma; 3 had scrotal and perineal haematoma as
well. None of the patients had urethral bleeding. Results: all patients were surgically treated;
at the time of surgery unilateral albugineal rupture was found in all cases. With a mean follow-up of 37 months (range 1-78) all cases were able to achieve an adequate erection. No complications, such as deformations, penile plaque, urethral fistula or erectile dysfunction were
reported. Conclusion: Immediate surgical repair in case of penile fracture is recommended in
order to obtain better functional outcome and to avoid potential complications.
KEY WORDS: Penile fracture; Coital trauma; Penile degloving; Penile surgical repair.
INTRODUCTION
Penile fracture is a relatively rare urological emergency,
defined as a rupture of the tunica albuginea of the corpora cavernosa by blunt trauma. The fracture usually
occurs to the erect penis when one or both corpora cavernosa are ruptured. The rupture occurs during sexual
intercourse, rolling over in bed, or during sexual manip-
Table 1.
Patient’ characteristics.
Patients
S.D.
Z.G
C.M
S.L.
S.L.
L.A.
B.R.
N.L.
B.O.
O.M.
Age (yrs)
Site of haematoma
Time at observation
Site of tear of albuginea
of corpora
Follow-up
(months)
25
31
27
27
28
26
39
42
23
23
Penile
Scrotal/perineal
Scrotal/perineal
Scrotal/perineal
Penile
Penile
Penile
Penile
Penile
Penile
1h
10 h
6h
1h
1h
1h
1h
1h
1h
1h
right
left
right
left
right
right
right
left
right
left
78
66
60
45
42
41
21
14
2
1
103
G. De Giorgi, L.G. Luciani, C. Valotto, U. Moro, S. Praturlon, F. Zattoni
Figure 1.
Figure 4.
Peno-scrotal haematoma following penile fracture
occurred during coitus.
Outcome after early surgical repair
of penile fracture.
Figure 2.
ulation, because of a sudden increase in intracorporeal
pressure that overwhelms the tunica albuginea. The
simultaneous involvement of both corpora cavernosa
and/or corpus spongiosum and urethra was also reported (1). Penile fracture is easily recognizable, due to its
history and presentation. Clinical signs include
haematoma, swelling and skin discoloration; haematoma is confined to the penis, scrotum or perineum in
case of an undamaged Buck’s fascia. Many patients hear
a snapping sound and experience sharp penile pain followed by collapse of the erection.
The optimal treatment is still controversial (2), particularly in case of bilateral corporeal involvement or urethral damage. The long-term results of conservative
treatment indicated significant complications, such as
curved or painful erection, fibrotic plaque or erectile
dysfunction. Our experience with early surgical treatment of penile fractures is herein reported.
Intraoperative finding: left dorsolateral tear of the tunica
albuginea at the proximal third of the penis. Buck’s fascia
is open and cavernous tissue is evident. A haemostatic
lace is placed at the base of the penis.
Figure 3.
Intraoperative finding: Buck’s fascia is open, the edges
of the tunica albuginea are regularized and sutured
with PDS.
MATERIALS
AND METHODS
Between November 1997 and May 2004, ten patients
aged 23 to 42 years, were hospitalized with penile fracture at our Department. Patients’ characteristics are
reported in Table 1. All patients underwent immediate
surgery. Indications were based on clinical examination
in all cases (Figure 1). Penile degloving through a circumferential subcoronal approach, evacuation of the
haematoma, and primary repair of the tear in the tunica
albuginea with a PDS suture were performed in all
patients (Figure 2-4). No urethral injury was found. All
patients were discharged on postoperative day 2 and
checked again one week later.
RESULTS
The interval time from injury to observation ranged
from 1 to 10 hours. All patients reported penile trauma during coitus with sudden pain at the time of
104
Early surgical repair of penile fractures: our experience
rupture. Six patients heard a “snapping” sound,
sharp penile pain followed by collapse of the erection. In 7 cases a penile haematoma was present; in
3 cases the haematoma extended to scrotum and perineum. The penis was curved on the side of rupture
in all cases (Figure 1). Urethral discharge has never
been reported.
Mean follow-up after surgery was 37 months (range 178). All patients presented spontaneous erections early
postoperatively. In our experience no early or late complications have been reported at follow-up (infected
haematoma, fistulas, penile abscess, penile deformity or
induration, painful erection, erectile dysfunction).
Erection was adequate for sexual intercourse in all cases.
DISCUSSION
AND
CONCLUSIONS
Penile fracture, even if it is a relatively rare condition,
represents a true urological emergency. Ultrasonography
can be useful in showing the precise site of the tear of the
tunica albuginea and defining the extent of the injury. In
our experience, however, diagnosis and indication to
surgical treatment was based only on history and physical examination, making ultrasound unnecessary.
Previous studies advocated a conservative treatment
(splitting of the penis, pressure dressing over a Foley
catheter, ice packs) (3-5), although complication rates
were significantly high. Therefore, more recent studies
generally support the need for an early surgical
approach in case of penile fracture. This might preserve
the collagen function and avoid a fibrotic evolution of
the tunica albuginea with potential penile curvature,
painful erection or erectile dysfunction (6, 7).
With the strategy previously described, no short and
long-term complications were reported.
We can conclude that immediate surgical repair has to be
considered in all cases of penile fracture, as suggested by
other Authors (7, 8), in the light of the low invasiveness
of the procedure, short hospitalisation and low complication rate.
REFERENCES
1. Tsang T, Demby AM. Penile fracture with urethral injury. J Urol
1992; 147:466
2. Kalash SS, Young JD Jr. Fracture of the penis: controversy of surgical versus conservative treatment. Urology 1984; 24:21
3. Dincel C, Caskurlu T, Resim S, Bayraktar Z, Tasci AI, Sevin G.
Fracture of the penis. Int Urol Nephrol 1998; 30:761
4. Dever D, Saraf PG, et al. Penile fracture: operative management
and cavernosography. Urology 1983; 22:394
5. Farah R, Stiles R, et al. Surgical treatment of deformity and coital
difficulty in healed traumatic rupture of the corpora cavernosa. J
Urol 1978; 120:118
6. Ishikawa T, et al. Fracture of the penis: nine cases with evaluation of reported cases in Japan. Int J Urol 2003; 10:257
7. Anselmo G, Maccatrozzo L, Merlo F, Fandella A. Le lesioni traumatiche dei genitali esterni. In: Molinatti GM, Fontana D.
Andrologia-Fisiopatologia e Clinica. Roma: Verduci Editore,
1997:471
8. Gontero P, Muir GH, Frea B. Pathological findings of penile fractures and their surgical management. Urol Int 2003; 71:77
Correspondence: Dott. Gioacchino De Giorgi, Department of Urology, Azienda Ospedaliera S.M. Misericordia, P.le S.M.Misericordia, 15 33100 Udine; E-mail: [email protected]
105
ORIGINAL PAPER
Still a place for the classical systematic sextant
technique? Cancer detection rates and complications
in 1025 consecutive prostatic biopsies.
Massimo Maffezzini1, Lorenzo Gavazzi1, Tiziana Calcagno1, Giacomo Capponi1,
Roberto Bandelloni2
Struttura Complessa di Urologia e 2Servizio di Anatomia Patologica, Ospedali Galliera, Genova, Italy.
1
Summary
Objectives: To verify if there might still be an indication to the sextant biopsy technique we reviewed the cancer detection rate obtained and the complications encountered during a five years interval, at our hospital.
Methods: From January 1997 to December 2002 we have submitted to prostatic biopsy a total of 1025 consecutive patients with a clinical suspect of prostate cancer. A
total of six cores were obtained in all the patients with an additional core at suspect lesions.
Results: Overall, prostate cancer was present in the biopsies of 444 of 1025 patients giving a
detection rate of 43.3%. In patients with serum PSA levels between 4.1 and 10 ng/ml., 169 of
466 biopsies were positive, for a detection rate of 36.3%. An increase in percentage of positivity was observed with increasing decades of age. Overall complication rate was 1.4%.
Conclusions: In patients older than 70 years, and with PSA levels higher than 10 ng/ml, the
sextant technique may offer cancer detection rates comparable with techniques using an
increased number of cores, and with lower complication rates.
KEY WORDS: Prostate cancer diagnosis; Sextant biopsy; Cancer detection rates; Complications.
INTRODUCTION
The diagnosis of prostate cancer relies upon the results
obtained by sampling tissue from the gland. The sextant
biopsy technique popularized by Hodge et al. in 1989
(1) that has considered been so far as the gold standard,
has been recently recognized to carry a false negative
rate of 20 to 30% (2, 3). Therefore, based on the observation that the sextant technique may under estimate
cancer diagnosis, several studies have focused on
increasing the number of cores, above six, with the purpose to increase the cancer detection rate (3-10). We
review herein the cancer detection rate, and the complications encountered with the sextant technique at our
center, in order to verify if there might be still an indication for such biopsy strategy.
PATIENTS
AND
METHODS
We reviewed the clinical data, and the pathology reports
of all men referred to our Hospital, for a clinical suspect
of prostate cancer and submitted to prostatic biopsy,
from January 1997, to December 2002. The clinical suspect of cancer was based on one, or more, of the fol-
106
lowing findings: a positive digital rectal exam (DRE),
suspicious imaging at transrectal ultrasound (TRUS), or
an elevation on serum prostatic specific antigen (PSA).
Patient preparation consisted in a cleansing enema on
the night before, and oral administration of prophylactic
ciprofloxacin 500 mg on the morning of the biopsy. After
DRE, the prostate was imaged with the patient in the lateral knee chest position with a real time, bi-planar or
multi-planar multi-frequence, 7.5 MHz endorectal
probe, of a B and K ultrasound scanner. Biopsies were
taken with a 16 or 18 gauge tru-cut needle and a springloaded biopsy gun (Bard). A total of six cores were
obtained in all patients. An additional core was also
taken at suspicious ultrasound lesions, as described by
Hodges (1). The sampling of the peripheral zone was
performed directing the needle more laterally to the
midparasagittal line, as proposed by Stamey (11). The
specimens were placed in formalin solution, processed
with step sectioning and immunohistochemistry techniques, and reviewed by a single pathologist (RB). The
procedure was performed without anesthesia and the
patients were observed for two hours following the pro-
Still a place for the classical systematic sextant technique? Cancer detection rates and complications in 1025 consecutive prostatic biopsies.
Table 1.
(57.5%). The detection rates for the various serum PSA
levels, and age ranges are listed in Table 1.
Positivity rate according to serum PSA levels, and age
distribution.
PSA Range
0-4 ng/ml
4.1-10 ng/ml
10.1-20 ng/ml
>20.1 ng/ml
Positive/Totals
27/78
169/466
121/283
127/198
%
34.6
36.3
42.7
64.1
Age
< 50 y
50-59 y
60-69 y
70-79 y
> 80 y
Positive/Totals
10/17
25/106
126/358
228/442
65/113
%
58.8
23.5
35.2
51.6
57.5
COMPLICATIONS
The procedure was well tolerated. Although a variable of
degree of macroscopic hematuria was observed in the
majority of patients, complications that required hospital admission were observed in 15 patients (1.4%). The
complications are detailed as follows: gross hematuria in
10 patients, hematuria with clots retention in 2 patients,
fever and chills in 2, and rectal bleeding in one.
DISCUSSION
cedure to monitor side effects that were treated, and
recorded.
RESULTS
The population of the study is composed by 1025
patients who were evaluated primarily at our hospital,
or referred by other centers or by general practitioners,
and accepted to undergo prostatic biopsies. Median age
was 69.5 years, range 47 to 91. Overall, prostate cancer
was present in the biopsies of 444 of 1025 patients giving a detection rate of 43.3%. In patients with serum
PSA levels between 4.1 and 10 ng/ml, 169 of 466 biopsies were positive for carcinoma, for a detection rate of
36.3%. In patients with PSA levels between 10.1 and 20
ng/ml, 121 out of 283 biopsies were positive for cancer,
for a detection rate of 42.7%, whereas, for serum PSA
levels above 20.1 ng/ml, 127 of 198 patients had positive biopsies for cancer giving a detection rate of 64.1%.
An increase in the percentage of positive biopsies was
observed with increasing decades of age. Positive biopsies were found in 25 of 106 patients (23.5%) aged 50
to 59 years, in 126 of 358 patient aged 60 to 69 years
(35.2%), in 228 of 442 patients aged 70 to 79 years
(51.6%), and in 65 of 113 aged 80 years and beyond,
The systematic sextant technique has represented the standard for the diagnosis of prostate cancer since its introduction, in 1989 (1). Its validity has recently been challenged
by the objection that it under samples the far lateral regions
of the gland where a significant number of cancers may
reside. Therefore, different biopsy protocols including
additional number of cores have been investigated in which
the sextant method has been compared concurrently, in the
same session of biopsy, with methods including more than
6 cores (3-10) . An overall increase in the cancer detection
rate has been reported in the range of 8.1% to 14.8%. Such
gain is even higher among patients with PSA levels between
4 and 10 ng/ml, ranging from 20.8% to 53.6%. A summary of the results of such studies is given in Table 2. The only
negative trial was reported by Naughton et al (8). The study
failed to demonstrate any advantage for the 12 cores over
the 6 cores method. However, as the authors recognize, the
sub-optimal size of the study population may have influenced the interpretation of their results. Nevertheless, it is
of note that 7 out of 33 tumors, that is 21%, were diagnosed in the 12-core biopsy group.
In the present study the overall detection rate was 43.3%
and, in patients with PSA levels between 4 and 10 ng/ml,
the detection rate was 36.3%. Such figures are in the highest range of the literature, for the systematic sextant biopsies. An explanation for this finding may reside in the technique adopted since attention was paid at aiming the
gland by driving the needles more laterally respect to the
parasagittal plane, as suggested by Stamey (11). It is likely
that a higher amount of tissue sampled from the lateral
Table 2.
Detection rates with the 6 cores technique compared with > 6 cores biopsies.
Detection Rate ∆ Improvement ∆ Improvement
6xt
PSA 4-10 ng/ml
Author
Year
N° Pts
N°
Cores
Overall Detection
Rate
Norberg
1997
512
8-10
276/512= 52%
234/512= 37.2%
14.8%
n.s.
Eskew
1997
119
13-18
48/119= 40%
31/119= 26%
14%
15/28= 53.6%
Levine
1998
137
12
43/137= 31%
30/137=21.9%
8.1%
8/21= 38.1%
Presti
2000
483
10
202/483= 42%
161/483= 33.3%
9.7%
20.8%
Babaian
2000
362
11
110/362= 30%
74/362= 20%
10%
21/58= 36%
Naughton
2000
244
6-12
33/122= 27%
32/112= 26%
1%
n.d.
107
M. Maffezzini, L. Gavazzi, T. Calcagno, G. Capponi, R. Bandelloni
“horns” of the gland was present in our biopsies, thereby
increasing the detection rate. In addition, the sample
might reflect an involuntary selection of patients both for
age and PSA levels. The median age of the sample is 69.5
years, with almost one half of the patients aged 70 years,
or older. Elevated serum PSA, of 10.1 ng/ml and above,
was present in almost one half of the study population
(namely, 283 patients whose PSA was above 10 ng/ml, and
198 whose PSA was above 20 ng/ml).
An ideal biopsy should consist in a number of samples
adequate to give a realistic picture of the prostate, and
causing no discomfort. More importantly also, since the
majority of men will undergo the procedure for a nonmalignant condition, the procedure should cause no
complications. Today, the ideal number of cores is still
undetermined. Compared to the classical sextant an
increased number of cores can sample the gland more
adequately, as most of the recent studies point out (3,
10). Patients with large prostate glands, or with PSA levels in the “grey” area, and patients with persistent clinical suspect and negative histology are likely to benefit
the most from a more accurate sampling. It seems
almost inevitable that increasing the number of samples
beyond six will also increase the need of anesthesia as
well as the rate of complications. The incidence of complications, although not uniformly reported by all
authors, may vary between 3.5% as observed by
Norberg (4), to 12% as observed by Stewart (10) and by
Borboroglu (9), to 20% as reported by Eskew (5). Gross
hematuria and acute urinary retention are the two complications most frequently described. Generally, hematuria heals spontaneously and catheterization is
required only for persistent hematuria, or for retention.
The increase in complication rates, though, is likely to
be outscored by the gain on the information obtained.
In the present series of biopsies hematuria and acute
urinary retention requiring hospitalization have been
observed in 15 out of 1025 patients, that is 1,4%.
We conclude that there is a subset of patients, namely
those aged 70 years or older, and whose PSA level is
greater than 10 ng/ml, in whom the sextant technique
can offer detection rates comparable with techniques
using an increased number of cores with lower complication rates.
REFERENCES
1. Hodge KK, McNeal JE, Terris MK, Stamey TA. Random systematic versus directed ultrasound guided transrectal core biopsies of
the prostate. J Urol 1989; 142:71
2. Stroumbakis N, Cookson MS, Reuter VE, Fair WR. Clinical significance of repeat sextant biopsies in prostate cancer patients.
Urology 1997; 49:113
3. Levine MA, Ittman M, Melamed J, Lepor H. Two consecutive sets
of transrectal ultrasound guided sextant biopsies of the prostate for
the detection of prostate cancer. J Urol 1998; 159:471
4. Norberg M, Egevad L, Holmberg L, Sparen P, Norlen BJ, Busch
C. The sextant protocol for ultrasound-guided core biopsies of the
prostate underestimates the presence of cancer. Urology 1997;
50:562
5. Eskew LA, Bare LR, McCullogh DL. Systematic 5 region prostate
biopsy is superior to sextant method for diagnosing carcinoma of the
prostate. J Urol 1997; 157:199
6. Presti JC Jr, Chang JJ, Bhargava V, Shinohara K. The optimal systematic prostate biopsy scheme should include 8 rather than 6 biopsies: results of a prospective clinical trial. J Urol 2000; 163:163
7. Babaian RJ, Toi A, Kamoi K, et al. A comparative analysis of sextant and an extended 11-core multisite directed biopsy strategy. J
Urol 2000;163: 152
8. Naughton CK, Miller DC, Mager DE, Ornstein DK, Catalona
WJ. A prospective randomized trial comparing 6 versus 12 prostate
biopsy cores: impact on cancer detection. J Urol 2000; 164:388
9. Borboroglu PG, Comer SW, Riffenburgh RH, Amling CL.
Extensive repeat transrectal ultrasound guided prostate biopsy in
patients with previous benign sextant biopsies. J Urol 2000; 163:158
10. Stewart CS, Leibovich BC, Weaver AL Lieber MM. Prostate
cancer diagnosis using a saturation needle biopsy technique after
previous negative sextant biopsies. J Urol 2001; 166: 86.
11. Stamey TA. Making the most out of six systematic sextant biopsies. Urology 1995; 45:2
Correspondence: Massimo Maffezzini, M.D., Head of Urology, Ospedali Galliera, Mura delle Cappuccine, 14 - 16128 Genova,Italy;
108
CASE REPORT
Orbital metastasis as a first indication of prostate
cancer: a case report.
Riccardo Autorino1, Aniello Zito1, Ferdinando Di Giacomo1, Luca Cosentino1,
Giuseppe Quarto1, Giuseppe Di Lorenzo2, Salvatore Mordente2, Umberto Pane1,
Antonio Giordano2, Massimo D’Armiento1
Clinica Urologica, Seconda Università degli Studi di Napoli, Italy
Cattedra di Oncologia, Università Federico II, Napoli, Italy
1
2
Summary
Prostatic carcinoma accounts for only 3.6% of orbital metastases encountered in clinical
practice. We report the clinical presentation and response to treatment of a patient with
metastatic prostatic carcinoma to the sella turcica. A 73-year-old man presented with a
three-months history of progressive right proptosis associated with increasing diplopia in
downgaze and slightly decreased visual acuity. Gadiolinium-MRI scans of the head
revealed a left osteoblastic intrasellar mass, displacing the pituitary gland. Laboratory testing
revealed a serum PSA level of 22 ng/ml. Transrectal ultrasound-guided biopsy revealed prostatic
adenocarcinoma (Gleason score 4+3) in both lobes of the prostate. A bone scan was performed
showing that the patient had multiple secondary bony lesions. Total androgen blockade was initiated. Moreover, he was referred for radiotherapy of this metastatic lesion to the sella turcica. The
visual complaints regressed dramatically within the first month of the treatment. A follow-up MRI
scan at 6 months showed almost complete involution of the orbital metastatic process. However
the disease subsequently progressed and the patient died 22 months after diagnosis.
KEY WORDS: Metastatic prostate cancer; Orbital metastases, Sella turcica; Treatment.
INTRODUCTION
Orbital metastases are uncommon, representing only 2%
to 9% of all adult orbital neoplasms (1). The majority of
orbital metastases in adults are carcinomas, with lung carcinoma in men and breast carcinoma in women being the
most common primary lesion (2). Prostatic carcinoma has
a well recognized pattern of metastatic disease, most frequently involving the axial skeleton. It accounts for only
3.6% of orbital metastases encountered in clinical practice. Orbital metastases are more commonly osteoblastic
and frequently cause proptosis and diplopia, that can be
the presenting features of metastatic disease (3). We report
the clinical presentation and response to treatment of a
patient with metastatic prostatic carcinoma to the sella
turcica.
CASE REPORT
A 73-year-old man presented with a three-months history
of progressive right proptosis associated with increasing
diplopia in downgaze and slightly decreased visual acuity.
He denied any systemic symptoms and he had no history
of urological malignancies. On palpation, the left orbit was
tense, with increased resistance to retrodisplacement of
the globe. The left conjunctival vessels were hyperemic.
Immediately following complete clinical workup,
Gadiolinium-MRI scans of the head, encompassing the
orbit, middle cranial fossae and temporal fossae, were performed, revealing a left osteoblastic intrasellar mass, displacing the pituitary gland (Figure 1).
Laboratory testing revealed normal metabolic, hepatic
and throyd panels, an alkaline phosphatase level of
1230 U/l and serum PSA level of 22 ng/ml. He had normal digital rectal examination findings. Transrectal
ultrasound-guided biopsy revealed prostatic adenocarcinoma (Gleason score 4+3) in both lobes of the
prostate. A bone scan was performed showing that the
patient had multiple secondary bony lesions, including
the one to the orbit.
Therefore, total androgen blockade with gonadotropinreleasing hormone agonist in conjunction with an antiandrogen was initiated. Moreover, he was referred for
radiotherapy of this metastatic lesion to the sella turcica.
He was treated using Gamma-knife with a total dose of 36
Gy. The visual complaints regressed dramatically within
the first month of the treatment. He had no side effects
related to the radiotherapy. His PSA nadir was 0.4 ng/ml.
109
R. Autorino, A. Zito, F. Di Giacomo, L. Cosentino, G. Quarto, G. Di Lorenzo, S. Mordente, U. Pane, A. Giordan, M. D’Armiento
Figure 1.
MRI scan at presentation showing a left orbital mass.
Figure 2.
MRI scan at 6 months.
A follow-up MRI scan at 6 months showed almost complete involution of the orbital metastatic process (Figure
2). However the disease subsequently progressed and the
patient died 22 months after diagnosis.
carcinoma is important because certain metastases can
cause profound morbidity but may be treated effectively in
the palliation of advanced disease (3). This case was presented to remind both the urologists and ophtalmologists
of the diagnosis of metastatic prostate carcinoma to the
orbit and particularly to the sellar region.
DISCUSSION
The most comprehensive estimates of the prevalence of
orbital metastases are from large retrospective series of unilateral proptosis or orbital biopsy specimens in the ophthalmic literature (1, 2). The small number of published
cases may not reflect the true incidence of orbital occurrence. Case reports of widely disseminated tumors that
happen to include orbital metastases are unlikely to be
published. The tumor is likely to be reported only if it
appears to be an initial manifestation of previously undetected primary.
There are some unusual aspects of this case. Firstly, the
metastatic site. To our knowledge this is the sixth case of
prostate carcinoma metastatic to the sella turcica and two
of them were not localized to the bone (4-8). Secondly, in
our case, prior to the discovery of multiple bony lesions
after a bone scan was done, the patient denied any systemic manifestations other than those attributable to the
ophthalmic system. Thus, ocular complaints were the initial presenting symptoms that led to the diagnosis of
prostate cancer. We did not perform any biopsy to the
orbit for an histologic confirmation of our diagnosis.
Regarding the radiation therapy given to this patient, such
irradiation is generally effective in the treatment of distant
metastases from carcinoma of the prostate. Marked relief
of symptoms occurs in more than 80% of patients treated
with adequate doses (9). Nevertheless, the survival after
documentation of ocular metastasis is poor as confirmed
in the present case.
Recognition of unusual metastases from prostate adeno-
REFERENCES
1. Boldt HC, Naird JA. Orbital metastases from prostate carcinoma.
Arch Ophtalmol 1988; 106:1403
2. Bullock J, Yanes B. Metastatic tumors of the orbit. Ann Ophthalomol
1980; 12:1392
3. Long MA and Husband JES. Features of unusual metastases from
prostate cancer. Br J Radiol 1999; 72:933
4. Matsumoto I, Furusato M, Inomata I et al. Prostatic cancer presenting as metastatic adenocarcinoma of sphenoid sinus. Acta Pathol
Jpn 1986; 36:1753
5. Perloff JJ, Lemar HJ, Reddy BVV et al. Metastatic adenocarcinoma
of the prostate manifested as a sellar tumor. South Med J 1992;
85:1140
6. Losa M, Grasso M, Giugni E et al. Metastatic prostatic adenocarcinoma presenting as a pituitary mass: shrinkage of the lesion and clinical improvement with medical treatment. Prostate 1997; 32:241
7. Couldwell WT, Chandrasoma PT and Weiss MH. Pituitary gland
metastasis from adenocarcinoma of the prostate. J Neurosurg 1989;
71:138
8. Patel N, Teh BS, Powell S et al. Rare case of metastatic prostate adenocarcinoma to the pituitary. Urology 2003; 62:352
9. Di Lorenzo G, Autorino R, Ciardiello F et al. External beam radiotherapy in bone metastatic prostate cancer: impact on patients' pain
relief and quality of life. Oncol Rep 2003; 10:399
Correspondence: Riccardo Autorino, MD, Vico S. Spirito 54 – 80132 Napoli, Italy; E-mail: [email protected]
110
CASE REPORT
Endoscopic treatment of a large leiomyoma
of the bladder.
Giuseppe Carrieri1, Tommaso Corvasce2, Pasquale Annese2,
Isabella Tolve2, Alessandro Caniglia3, Giuseppe Di Sabato2
Division of Urology, University of Foggia, Italy
Departments of Urology and 3Pathology, Madonna delle Grazie Hospital, Matera, Italy
1
2
Summary
Leiomyoma is a benign neoplasm rarely found in the bladder. We present a case of a large
leiomyoma of the bladder treated successfully by endoscopic transurethral resection.
KEY WORDS: Leiomyoma; Bladder; Mesenchymal tumours.
CASE
DISCUSSION
A 47-year-old female patient was examined for irritative
symptoms. Bladder ultrasonography and CT showed a
voluminous mass, approximately 6 cm in diameter, in
the left hemitrigonum (Figure 1).
Endoscopically the lesion had a solid appearance and
was covered by an apparently normal mucosa. The
patient underwent transuretral resection of the mass,
weighing about 100 g, reaching the fat layer of the bladder (Figure 2).
The histological examination revealed a leiomyoma of
the bladder wall (Figure 3). In the following 3 years of
follow-up no relapse was found.
Benign mesenchymal tumours constitute 1% of all bladder
neoplasms; of these 35% are represented by leiomyomas
(1). These tumours have a higher incidence in females,
developing prevalently in the third - sixth decade of life.
Ovarian hormones seem to play an important role in their
pathogenesis as analogously occurs for uterine leiomyomas. Furuhashi (2) has recently demonstrated the presence of estradiol and progesterone receptors in bladder
leiomyomas. However, according to other authors, the
occurrence of this neoplasm in the post-menopausal period would discredit the role of the ovarian hormones in the
etiology and pathogenesis of bladder leiomyomas.
Figure 1.
CT: gross button-like formation, 6 cm in diameter, in the
left hemitrigonum.
Figure 2.
Complete resection of the lesion reaching the fatty tissue
layer surrounding the bladder.
111
G. Carrieri, T. Corvasce, P. Annese, I. Tolve, A. Caniglia, G. Di Sabato
Figure 3.
Histological characteristics of bladder leiomyoma: the classical disorderly band disposition of spindle-shaped cells
with vesicular nuclei. H & E Reduced from x 200.
toms caused by the growth of the neoplasm near the
bladder neck have been reported (3) as well as
hydronephrosis caused by ureteral obstruction (4).
Lesions which prevalently develop outside the bladder
may remain asymptomatic until they reach very large
dimensions.
For large neoplasms and/or in cases with a prevalent
extra-vesical development the treatment of choice still
today is partial cystectomy. Trans-urethral resection is
generally indicated for small tumours. In the case we
have reported we opted for an endoscopic procedure
even in the presence of a large lesion, resecting the
leiomyoma completely, reaching the extravesical fat; the
radical procedure represents the key to success in these
cases.
REFERENCES
1. Knoll LD, Segura J, Scheithauer BW. Leiomyoma of the Bladder.
J Urol 1986; 136:906
The leiomyoma presents singularly in 90% of cases and
65% develop endoluminally (3). The lesions, more often
peduncular than sessile, are highly vascularized, covered by epithelium with either a normal or necroticgranular appearance. The symptoms in cases that prevalently develop within the bladder are characterized by
urinary irritation and occasionally by episodes of
macroematuria; in some cases obstructive urinary symp-
2. Furuhaschi M, Suganuma N. Recurrent bladder leiomyoma with
ovarian steroid hormone receptors. J Urol 2002; 167:1399
3. Cortellini P. Manifestazioni Anatomo-Cliniche inconsuete di malattie urologiche. 1 ed. Mantova: Corraini Editore, 1996
4. Kirsh EJ, Sudakoff G, Steinberg GD, et al. Leiomyoma of the
bladder causing ureteral and bladder outlet obstruction. J Urol
1997; 157:1843
Correspondence: Giuseppe Carrieri, MD, Division of Urolgy and Renal Transplantation, Università degli Studi di Foggia, Viale Luigi Pinto,
71100 Foggia, Italy; E-mail: [email protected]
112
CASE REPORT
Antonio Celia, Morgan Bruschi, Stefano De Stefani, Beniamino Baisi,
Anna Maria Cesinaro, Salvatore Micali, Maria Chiara Sighinolfi, Giampaolo Bianchi
Chair of Urology, University of Modena and Reggio Emilia, Italy
Summary
Genital leiomyomas of the scrotal skin are extremely rare benign tumors, originating
from the tunica dartos of the scrotum. We report our experience with one patients with
schrotal bizarre leiomyoma.
KEY WORDS: Mesothelial tumors; Leiomyoma; Scrotum.
INTRODUCTION
DISCUSSION
Scrotal mesothelial tumors, and in particular the leiomyoma are very rare.
The leiomyoma is a benign tumor arising from smooth
muscle and in the scrotum it arises from vascular
smooth muscles, from pila erector muscles or from the
dartos.
In literature we found 54 cases described.
The leiomyoma arise at any age, they are often asymptomatic, but sometimes they seem like an aching bulk.
Generally, the mass is mobile, small, unilateral, and
sometimes it is pedicle, with smooth surface and with
slow growth.
The tumor diagnosis is histological and the surgery
ablation permits the recovery.
We report our experience with one patients with scrotal
bizarre leiomyoma.
The first case of scrotal leiomyoma was described by
Foster in 1858; since then 54 cases have been reported
in literature. The leiomyoma of the scrotum arises could
occur at any age (min. 1.5 years; max. 78 years), usually appear like a round mass, and they are rarely bilateral (1). They are occasionally pedunculated or ulcerated
and the size is variable (raging from 0.5 cm to 8 cm).
Six of 54 cases of scrotal leiomyoma reported in literature, at histological examination, show the presence of
bizarre nuclei, that is characterized by the presence of
nuclear pleomorphism, with big and vesicular nuclei,
intranuclear invagination of cytoplasmic globules that
produces pseudonuclei (2), like of our experience.
The presence of pleomorphic nuclei and internuclear
invagination of cytoplasmic glunules (pseudonuclei),
CASE REPORT
A 52 year-old man presented with acute pain at right
scrotal, and he complained 1-year history of right scrotal pain, where it was a small mass. Physical examination disclosed a superficial, regular mass with a smooth
surface in the right scrotal. The mass was excised
through a right scrotal approach. Macroscopically, the
tumor was like a nodular pedicle formation of 1.7 cm in
diameter, with smooth surface and yellowish. Histology
revealed that the tumor was composed from interlacing
fascicles of spindle-shaped cells, with abundant
eosinophilic cytoplasm. The cells showed nuclear pleomorphism, that it’s called “bizarre nuclei” with big and
vescicular nuclei, intranuclear invagination of cytoplasmic globules that produces pseudonuclei.
Without mitotic figures and areas of necrosis (Figure 1).
Immunohistochemically, the smooth muscle boundless
stained positively for actin and desmin (Figure 2).
Figure 1.
Spindle-shaped smooth-muscle cells with pseudonuclei
(H & E reduced from x200).
113
A. Celia, M. Bruschi, S. De Stefani, B. Baisi, A.M. Cesinaro, S. Micali, M.C. Sighinolfi, G. Bianchi
Figure 2.
Immunohistochemistry: the neoplastic cells are
positive for desmine antigens, showing muscular origin
of the lesion. Reduced from X100.
have relevant importance because this histological pattern is similar to malignancy (leiomyosarcoma). The
leiomyomas with bizarre nuclei are also called symplastic and they are similar to uterine symplastic
leiomyoma (3).
The absence of mitotic figures and necrosis leans
towards a benign lesion and the surgery ablation permits
the correct diagnosis and the recovery.
REFERENCES
1. Slone S, O'Connor D. Scrotal leiomyoma with bizaue nuclei: a
report of tree cases. Mod. Pathol. 1998; 11:282
2. Sanchez Merino JM, Gomez Cisneros SC, Fernandez-Flores A,
Parra Munter L, Lopez Pacius JC, Garcia Alonso J Scrotal
Leiomyoma. Actas Urol Esp 2001; 25:233
3. De Rosa G, Boscalino A, Giordano G, Donofrio V, Staibano S,
Maio C, et at. Symp1astic leiomyoma of the scrotum: a case report.
Pathologica 1996; 88:55
Correspondence: Antonio Celia, MD, Urologist, University of Modena and Reggio Emilia, Policlinico di Modena, via del Pozzo 72 - 41100
Modena, Italy; E-mail: [email protected]
114
CASE REPORT
Liposarcoma of the spermatic-cord: description of two
clinical cases and review of the literature.
Michele Malizia, Eugenio Brunocilla, Alessandro Bertaccini, Fabiano Palmieri,
Giovanni Vitullo, Giuseppe Martorana
Department of Urology, University of Bologna, Policlinico S. Orsola-Malpighi General Hospital, Bologna, Italy.
Summary
Spermatic cord liposarcoma is a rare tumor; currently only 161 cases are described in literature. Natural history of these tumors is marked by the high local recurrence rate.
Radical surgery represents the therapy of choice whilst uncertain is the role of regional
and retroperitoneal lymphadenectomy as well as the usefulness of adjuvant radiotherapy or chemotherapy. In this paper we describe our experience of two cases treated at our
Department between 1995 and 2002 and discuss about the clinical management of this misleading tumor in the light of the several experiences reported in literature.
KEY WORDS: Liposarcoma; Spermatic-cord; Orchiectomy; Lipoma-like; Lymphadenectomy.
FIRST CASE
A 73-year-old man underwent urological consultation
in January 1995 for a right scrotal mass lasting for several months and diagnosed by family doctor as inguinoscrotal hernia.
Physical examination confirmed the presence of a painless and irreducible soft scrotal mass.
The patient was admitted for a hernia repair.
Surgery resulted technically difficult because the spermatic cord was enveloped by a sort of capsulated adipose tissue, extending through the internal inguinal
ring, that prevented any attempt of dissection of the
funicle from peritoneal-bag.
Therefore a radical orchiectomy was performed.
Macroscopically, the lesion was a capsulated mass (15 x
10 x 4 cm) composed mostly of adipose tissue infiltranting the spermatic structures.
Histological examination revealed well differentiated
liposarcoma.
The patient was discharged on the 3rd post-operative
day. No adjuvant therapy was planned.
After 8 years he is well and free from local recurrence
and distant metastases.
increased epididymis volume and a painless mass
involving the spermatic cord.
Scrotal echography revealed a regular testis structure
while the distal portion of epididymis showed an irregular outline without anomalous echostructures.
Utrasounds of the lower abdomen as well as the testicular cancer markers turned out negative.
The patient underwent an explorative surgery which
revealed a mass of adipose tissue well capsulated, multiloculated, involving the epididymis and the vas deferens
(Figure 1), extending until 3 cm from the internal
inguinal ring.
Figure 1.
Surgical specimen: a mass of adipose tissue, well capsulated, that involves the epididymis and the vas deferens.
SECOND CASE
A 47-years old man came to our Department in February
2002 for a painless lump of the right emiscrotum. He
denied any injury or infection in the testis involved.
Physical examination revealed a normal testis, a slightly
115
M. Malizia, E. Brunocilla, A. Bertaccini, F. Palmieri, G. Vitullo, G. Martorana
The patient underwent right radical orchiectomy and
the histopathological diagnosis was a well differentiated
liposarcoma, lipoma-like, involving the structures of
spermatic cord.
The patient was discharged without any adjuvant therapy and at 20 months follow-up he is disease-free.
DISCUSSION
Paratesticular liposarcomas are rare tumors (1). They
may arise from the epididymis, the mesenchimal layers
surrounding the testis and the appendages or the spermatic cord (2).
In adults more than 75% of these lesions arise from SC
(3).
The wall of the spermatic funicle is composed by: 1) an
external fascia, wich is an extension of the external
oblique aponeurosis; 2) the cremasteric layer; 3) an
internal fascia, wich is an extension of the trasversalis
fascia. Often it is difficult to localize the precise origin of
the tumor.
Most of the spermatic cord tumours are benign (7080%) and include primarily lipomas (4, 6). Malignant
lesions of spermatic cord are usually sarcomas.
Rabdomyosarcomas are the most aggressive and predominate in young people. The other histological forms
of sarcomas (leiomyosarcomas, fibrosarcomas and
liposarcomas) are most frequently observed in the adult
population. Liposarcomas account approximately for 3
to 7% of all spermatic cord tumors (7). Liposarcoma of
the spermatic cord usually presents as a painless, irregular mass clearly distinct from the testis, usually negative on transillumination or lightly positive.
Liposarcomas of little dimension can be quite easy differentiated but the increased in size may be misleading
(3). The clinical diagnosis in these conditions may be
difficult, since the tumour can easily be mistaken for an
inguinal hernia, hydrocele, funiculocele, spermatocele,
hematocele as well as tumours of the testis and epididymis (7-9). Some authors reported that the incidence
of liposarcoma is approximately less than 0,1% of the
inguinal hernia (10).
The ultrasounds can evidentiate a mass with different
echo-densities but usually is not specific and decisive.
The computed tomographic scan (CT) may make the
diagnosis in the half of the cases and may have an
important role in defining the involvement of the anterior abdominal wall and/or retroperitoneum. Also magnetic resonance (MR) produces excellent images.
Conversely, lymphangiogram should be avoided
because it did not yield any positive findings.
Due to the high rate of local recurrence (55-70%) and
considering the advanced age of the patients involved,
a radical surgery with a wide local excision of the
tumor is appropriate. Occasionally, the inguinal tumor
may extend to lower abdomen and retroperitoneum.
Three cases have been reported in the literature. In
one, the mass originated from the spermatic cord and
extended through the internal inguinal ring to lower
abdominal region (11, 12). In another case, a large
retroperitoneal mass arising from spermatic left behind
was found on CT scan, one month post-operatively
116
(13). Liposarcomas tend to spread primarily by local
extension. No therapeutic advantage has been attributed to superficial inguinal or retroperitoneal lymphadenectomy because liposarcomas tend to metastasize hematogenously rather than lymphatics (10). In
only one case of paratesticular liposarcoma a retroperitoneal lymph node dissection was performed after
radiotherapy (14). Radiation therapy seems to have a
role in the control of some liposarcomas, especially
those at high risk for local failure (15, 16) but the
results are controversial. Likewise, a beneficial effect of
adjuvant chemotherapy has been reported in two
cases, but the follow-up has been too short (8).
Doxorubicin has been used occasionally (15).
Liposarcoma of the spermatic cord is a rare lesion that
should be considered in the differential diagnosis of
any non-cystic scrotal mass. Ultrasounds and, more
specifically, CT scan and MR may help in the diagnosis. Patients with tumors extending to the inguinal
ring should be assessed for intra-abdominal extension
of neoplastic lesion. The ideal treatment is radical
orchiectomy. Adjuvant radiotherapy should be considered in tumors of intermediate or high histological
grade and in recurrent liposarcoma. Retroperitoneal
lymphadenectomy does not seem to offer any additional therapeutic benefit. The role of chemotherapy is
not well defined.
REFERENCES
1. Soler JL, Zulavaga Gomez A, Hidalgo Dominguez MR.
Liposarcoma of the spermatic cord: a report of a new case and
review of the literature. Acta Urol Esp 1999; 23:447
2. Gowing NF. Paratesticular tumors of connective tissue and muscles. In: Pathology of the Testis. In: Pugh RC. Oxford: Blackwell
Scientific Publications (ed), 1976
3. Sogani PC, Grabstald H and Whitmore WF Jr. Spermatic cord
sarcoma in adults. J Urol 1978; 120:301
4. Banowsky LH and Schultz GN. Sarcoma of the spermatic cord
and tunics: review of the literature, case report and discussion of the
role of retroperitoneal lymphnode dissection. J Urol 1970; 103:628
5. El-Badawi AA and Al-Ghorab MM. Tumors of the spermatic
cord: review of the literature and report of a case of lymphangioma.
J Urol 1965; 94:445
6. Pack GT and Pierson JC. Liposarcoma: study of 105 cases.
Surgery 1954; 36:687
7. Certo LM, Avetta L, Hanlon JT, Jacobs D. Liposarcoma of spermatic cord. Urology 1988; 31:168
8. Johnson DE, Harris JD, Ayala AG. Liposarcoma of spermatic
cord. Urology 1978; 11:190
9. Vorstman B, Block NL, Politano VA. The management of spermatic cord liposarcomas. J Urol 1984; 131:66
10. Montgomery E, Buras R. Incidental liposarcomas identified
during hernia repair operations. J Surg Oncol 1999; 71:50
11. Treadwell T, Treadwell MA, Owen M, McConnel TH, Ashworth
CT. Giant liposarcoma of the spermatic cord. South Med J 1981;
74:753
Liposarcoma of the spermatic-cord: description of two clinical cases and review of the literature
12. Chan YF, Yuen MY, Ma LT and Li MK. Recurrent dedifferentiated liposarcoma of the spermatic cord simulating malignant
fibrous histiocytoma: an immunohistochemical and ultrasturctural
study. Phatology 1987; 19:99
13. Russo P, Brady MS, Conlon K, et al. Adult urological sarcoma.
J Urol 1992; 147:1034
14. Blitzer PH, Dosoretz E, Proppe KH and Shipley WU. Treatment
of malignant tumors of the spermatic cord: a study of 10 cases and
review of the literature. J Urol 1981; 126:611
15. Reitan JB and Kaalhus O. Radiotherapy of liposarcomas. Br J
Radiol 1980; 53:969
16. Ballo MT, Zagars GK, Pisters PW, et al. J Urol 2001; 166: 1306
Correspondence: Michele Malizia, MD, Department of Urology, University of Bologna, S. Orsola-Malpighi General Hospital, Via P. Palagi 9 40138 Bologna, Italy; E-mail: [email protected]
117
CASE REPORT
A rare case of bladder fibroepithelial polyp
in childhood.
Athanasios George Zachariou1, Ioannis Nikolaos Manoliadis2, Paraskevi Antonios
Kalogianni1, George Konstantinos Karagiannis1, Dimitrios Jonh Georgantzis1
Elpis Hospital, Volos, Greece; 2Interbalkan Medical Centre, Thessaloniki, Greece
1
Summary
Objective: To present a rare case of a benign polyp in a child. Very few cases of urinary tract fibroepithelial polyps in the bladder are reported in the international literarature and they are even less common in children. Material and Methods: A 14-yearold boy presented at the Urology Department of “Elpis” Hospital complaining of painless macroscopic hematuria during the last six months. The patient did not report previous urinary tract disorders. After a thorough laboratory investigation, which included urinalysis, urine culture, ultrasonography, intravenous pyelography and cystoscopy the presence
of an exophytic papillary tumor in the bladder was identified. The lesion was removed
transurethrally. Results: The biopsy set the diagnosis of fibroepithilial polyp, which is a rare
benign neoplasm and occurs in patients of nearly all ages. Polyps are located usually in the
ureteropelvic junction, the upper third of the ureter and the posterior urethra. They are rarely
found in the bladder, especially in the childhood.
KEY WORDS: Fibroepithelial polyp; Bladder; Childhood.
INTRODUCTION
Fibroepithelial polyps are rare benign neoplasms. They
have mesodermal origin like fibroma, leiomyoma, neurofibroma and hemangioma. They are usually located in
the upper part of the ureter, the ureteropelvic junction
in adults and in the posterior urethra in children (1). In
the international literature there are very few cases of
fibroepithelial polyps localised in the urinary bladder of
children (2).
MATERIAL
AND
METHODS
A 14-year-old male patient presented in the Urology
Department complaining of painless macroscopic
hematuria during the last six months. The patient did
not report urinary tract infections, injuries or other diseases (congenital or acquired) which could possibly
cause hematuria. A complete blood cell count, levels of
serum electrolytes and creatinine, and results of cytologic evaluation of voided urine were normal. Urine
examination showed 0 to 2 white blood cells and 18-20
red blood cells per optical field. Urine culture was sterile.
Ultrasonography of the kidneys gave no abnormal findings, ultrasonography of the bladder displayed a papillary
lesion in the posterior surface (Figure 1). The intravenous
118
pyelography that followed did not reveal anything pathological neither from the upper nor from the lower urinary
tract. In the bladder there were no filling defects.
Cystoscopy revealed a whitish exophytic papillary tumor
in the left posterior surface of the bladder, behind the
trigone, 1.5 in height and 1.5 cm in width (Figure 2).
There were no inflammatory lesions or other pathological structures somewhere else in the bladder.
Figure 1.
Ultrasonography of the bladder. A papillary lesion
is located in the posterior surface.
A rare case of bladder fibroepithelial polyp in childhood
Figure 2.
Cystoscopic view of the lesion.
Figure 3.
The fibroepithelial polyp is characterized by normal or
hyperplastic urothelium overlying an intact basement
membrane with extensive submucosal edema, dilated
blood vessels, chronic inflammatory cells, and fibrous
stroma (hematoxylin-eosin, x40).
RESULTS
The patient underwent transurethral resection without
postoperative complications. The histopathological
evaluation revealed a papillary lesion with fine fibrovascular stalk supporting epithelial layers of normal transitional cells. The epithelium in places was either absent
or formed intraepithelial nests. These findings suggested the diagnosis of fibroepithelial polyp of the bladder
(Figure 3). The patient did not have any more attacks of
hematuria and 4 months later had a cystoscopy which
revealed a normal bladder with no evidence of tumors.
Two years later the patient is free of any symptoms of the
urinary tract.
DISCUSSION
The fibroepithelial polyps of urinary tract are rare
benign neoplasms and occur in patients of nearly all
ages. They are located usually in the ureteropelvic junction, the upper third of the ureter and the posterior urethra (1, 3).
Bolton et al. reviewed the literature on fibroepithelial
polyps of the ureter (2). They estimated that approximately 140 cases had been reported in the English literature at the time of their review, but only 120 were
evaluable. Thirty of the patients were 0.1 to 15 years old
(mean age, 9 years; 80% males), and 90 patients were
17- to 76-years old (mean age, 37 years; 56% males).
For unexplained reasons, males were affected more
often in the younger age group, while there was a near
equal distribution of males to females in the older age
group.
In the international English literature there are very few
reports about bladder polyps. One was about a bladder
hamartoma in a 4-year-old girl with amartomatous
intestinal polyps contained mucinous glands, smooth
muscle and fibrous tissue (4). A bladder polyp was
reported in an 8-month-old boy with BeckwithWeidemann syndrome contained myxoid fibrous tissue
and smooth muscle bundles only (5). However, there
are many studies which concern polyps of the posterior
urethra (6, 7).
When the polyp is located in the upper urinary tract,
hematuria gross or microscopic, intermittent or constant, is the presenting symptom in 85% to 88% of
reported cases, regardless of age at presentation. Other
less frequent symptoms are pain, voiding problems,
infection and mass (8).
When the lesion is located in the lower urinary tract,
hematuria coexists with mild obstructive symptoms,
which in middle aged patients usually suggest benign
prostatic hyperplasia (1). Macroscopically, the polyps
were characteristically solid and firm with smooth
branching mucosal surfaces. Microscopically, normal or
hyperplastic urothelium enveloped an edematous loose
fibrovascular stroma (7).
The diagnosis in the majority of patients is based on
clinical and laboratory findings (urine examination, urinary cytology, intravenous urography, computed tomography and cystourethroscopy).
Cystourethroscopy is accepted as the most specific
examination for the diagnosis of polyps. However, it is
difficult for the doctor to collaborate with the child and
anaesthesia is a necessity. The most widely used examination for the diagnosis of polyps in childhood is ultrasonography of the bladder, where polyps appear as
echogenic foci projecting into the lumen.(9) Intravenous urography is rarely used because of radiation. In
that case, polyps appear as pedunculated, radiolucent
filling defects projecting into the lumen. The treatment
of these lesions is transurethral resection with very good
results.
Reports of fibroepithelial polyps with malignant transformation are found in the literature but are rare (10).
Rare instances of fibroepithelial polyps in association
with calculi (11), Peutz-Jeghers syndrome (12), ureteral
intussusception (13), and retrocaval ureter (14) have
also been reported.
REFERENCES
1. De Castro R, Campobasso B, Belloli G, Pavanello P. Solitary
polyp of posterior urethra in children: report on seventeen cases.
Eur J Pediatr Surg 1993; 3:2
2. Bolton D, Stoller ML, Irby P III. Fibroepithelial ureteral polyps
and urolithiasis. Urology 1994; 44:582
119
A. G. Zachariou, I. N. Manoliadis, P. A. Kalogianni, G. K. Karagiannis, D. J.Georgantzis
3. Fein AB, Mc Clennan BL. Solitary filling defect of the ureter.
Semin Roentgenol 1989; 24:201
4. Keating MA, Young RH, Lillihei CW, Retig AB. Hamartoma of
the bladder in a four year old girl with hamartomatous polyps of
the gastrointestinal tract. J Urol 1987; 138:366
5. Williams MP, Imprahim SK, Rickwood AM. Hamartoma of the
urinary bladder in an infant with Beckwith-Wiedemann syndrome
Br J Urol 1990; 65:106
6. Goldberg SD, Sugar L. Giant fibroepithelial polyps of the female
urethra: two case reports and review of the literature. Can J Surg
1989; 32:6
9. Hikmat, Gomez, Trane, Bove Giant Botryoid Fibroepithelial
Polyp of Bladder with Myofibroplastic Stroma and Cystitis Cystica
et Glandularis. Ped Devel Pathol 2003; 6:179
10. Zervas A, Rassidakis G, Nakopoulou L, et al. Transitional cell
carcinoma arising from a fibroepithelial polyp in a patient with
duplicated upper urinary tract. J Urol 1997; 157:2252
11. Oesterling JE, Lui HY, Fishman EK. Real-time multiplanar
computerized tomography: a new diagnostic modality used in the
detection and endoscopic removal of a distal ureteral fibroepithelial
polyp and adjacent calculus. J Urol 1989; 142:1563
12. Sommerhaug RG, Mason T. Peutz-Jeghers syndrome and
ureteral polyposis. JAMA 1970; 211:120
7. Blank C, Lissmer L, Kaneti J. Fibroepithelial polyp of the renal
pelvis. J Urol 1987; 137:962
13. Fukushi Y, Orikasa S, Takeuchi M. A case of ureteral intussusception associated with ureteral polyp. J Urol 1983; 129:1043
8. Young RH. Pseudoneoplastic lesions of the urinary bladder and
urethra: a selective review with emphasis on recent information.
Semin Diagn Pathol 1997; 14:1333
14. Clements JC, McLeod DG, Greene WR, Stutzman RE. A case
report: duplicated vena cava with right retrocaval ureter and ureteral tumor. J Urol 1978; 119:284
Correspondence: Athanasios G. Zachariou, MD, Spiridi 3, Volos - PC 38221 Greece; E mail: [email protected]
120
TO THE EDITOR
Whither the andrologic pathology of italian lads
with the end of medical check up to conscripts.
Department of Urology, University of Florence, Italy.
Whither the health of Italian lads with the end of conscription (1) as per January 1, 2005.
It’s hard to envisage the aftermath.
In Italy, medical check up at time of conscription was
a valid tool for epidemiological research, especially for
the study of incidence of andrological diseases among
males 18 years of age. For the record, conscription
begun in 1861, with the Unity of Italy (Unità d’Italia).
Since then, all males when they reached the age of 18
had to join the Arm Forces, if they were eligible, of
course. In the last 10 years, many studies (2) have
been made, involving 80,000 young males, such studies have proved that andrological disorder is present in
about 30-40% of youngsters who underwent examination performed by military medical doctors, and only
the 10-20% of them were aware of carrying the disease
(2-3). With such reports and figures in our hands, we
could not ignore the matter, but had to ponder over:
Whither the health of Italian lads, now that conscription has come to the end. Bearing in mind that for the
majority of these boys, check up of genitalia apparatus
was their first and most likely their last. In view of this
situation, we urge General Practitioners and Paediatricians alike to pay extra care when performing check
up. We strongly believe and must emphasize that if the
matter is not dealt with extreme care, the issue could
soon become serious, and the Public Health (in general) will have to face the appropiate consequences.
Resolute actions must be taken at once. Italian
Authorities, meanwhile, have promoted a congress in
December 2004 (4), for the occasion a committee has
been appointed in order to find a solution to solve the
problem. One solution that has been thought of is to
perform medical check up to all male students up to
Grammar School, viz. up to 14 years old. This solution
would help to prevent present and future sexual and
fertility failure, as reproductive pathologies are characterized at this point by a considerable valence for their
negative reflexes on birth rate as well.
REFERENCES
1. http://www.altalex.com/index.php?idstr=6&idnot=7675
2. Mondaini N, Bonafe’ M, Di Loro F, Biscioni S, Masieri L,
Ponchietti R. Andrologic disease in a population of 18 years old
young men during conscription screening: how many were a first
diagnosis? Minerva Urol Nefrol 2000; 52:63
3. Campodonico F, Michelazzi A, Capurro A, Carmignani G.
Andrologic disease detected during army medical visit. Arch Ital
Urol Androl 2003; 75:205
4. http://w3.uniroma1.it/MEDICFISIO/prev_andr_progr.ppt
Correspondence: Nicola Mondaini, MD, Via Colleramole, 8 - 50029 Impruneta (Firenze), Italy; E-mail: [email protected]
121
64° CONVEGNO ASSOCIAZIONE UROLOGI LOMBARDI - ERBUSCO (BS), 3 LUGLIO 2004
The new transperineal-prerectal approach
in posterior urethroplasty.
Edoardo Austoni1, Andrea Guarneri1, Fulvio Colombo1, Enzo Palminteri2
Department and Chair of Urology, University of Milan, San Giuseppe Hospital, Milan, Italy
Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy
1
2
Summary
Objective: A new posterior urethroplasty is suggested for patients with pelvic fracture urethral distraction defect (PFUDD). Methods: 12 men, with PFUDD were treated
with an anastomotic urethroplasty, using a transperineal-prerectal approach. All
patients had a suprapubic tube in place and were impotent after pelvic trauma. The
goal of this approach was to facilitate an extensive removal of the scar tissues around
the prostatic apex to promote successful bulbo-prostatic anastomosis. Results: No patients had
intraoperative, perioperative or postoperative complications. Urinary incontinence or rectourethral fistula was never observed. In 11 patients the postoperative mean peak flow was 20
ml/sec. The recurrence of the stricture occurred in 1 patient. Conclusions: The transperinealprerectal approach to the posterior urethra facilitated a free tension posterior end-to-end anastomosis, as an alternative to the transpubic anastomotic procedure.
KEY WORDS: Pelvic fracture urethral distraction defect (PFUDD); Perineal prostatectomy; Posterior urethroplasty; Prerectal approach; Transperineal approach.
INTRODUCTION
The pelvic fracture urethral distraction defects (PFUDD)
are currently managed by using a simple or elaborated
perineal approach (1). The elaborated approach is combined with inferior pubectomy, and rerouting the bulbar
urethra around the corporal bodies (1). The abdominal
transpubic approach could be suggested for complex
cases requiring a good exposure of the bladder neck (2).
We describe a surgical technique for posterior urethroplasty, that uses the anatomical knowledge’s and facilities
achieved for radical perineal prostatectomy. The perineum
and the prostate are approached by using a transperinealprerectal approach, the prostatic apex is freed from the
fibrous tissue due to the pelvic trauma, and pulled down
on the perineum. The bulbar urethra is mobilized, and a
free tension anastomotic repair is performed.
MATERIALS
AND METHODS
From 1996 to December 2002, 12 men 39-to 64-years old
(mean age 48), with PFUDD (Figure 1), underwent a
posterior urethroplasty using transperineal-prerectal
approach. All patients had a suprapubic cystostomy in
place. Seven patients underwent previous attempt to
repair by urethrotomy (4 cases) or urethroplasty (3 cases).
122
Figure 1.
Preoperative retrograde urethrography.
The new transperineal-prerectal approach in posterior urethroplasty
Figure 2.
A: the prostate is fully mobilized, by using a Foley catheter inside the bladder neck; B: the prostatic urethral mucosa is
opened and spatuled; C: the bulbar urethra is sutured to the prostate; D: the bulbo-prostatic anastomosis is completed.
A
B
C
D
All patients were impotent after the pelvic trauma. The
patient is placed in exaggerated lithotomy position, and a
perineal U-shaped inverted incision is made at 1 cm from
the anus towards to the ischial tuberositas. The superficial
perineal fascia is incised and the ischiorectal fossae are
exposed. The central tendon of perineum is identified and
divided. The intrasphineteric access is developed along the
rectal wall, and the recto-urethralis muscles are dissected.
The posterior layer of the Denonvillier’s fascia is opened
allowing the exposure of the membranous urethra and
prostatic apex. A perineal midline incision is made and the
bulbar urethra is freed, and transected at the bulbo-membranous junction. All the scar tissue is removed, and by
using a Foley catheter inserted into the bladder neck, the
prostate is fully mobilized, and pulled down (Figure 2 A).
The prostatic apex is spatuled for the anastomosis (Figure
2 B). The corpora cavernosa are divided on the midline,
and the bulbar urethra is sutured to the prostatic urethra
(Figure 2 C). The bulbo-prostatic anastomosis is made
without tension (Figure 2 D). A Foley silastic catheter 20
Ch. is left in place, and a suction drain is left in place for
2 days. Three weeks after surgery, a voiding cystourethrography is obtained, and the suprapubic tube is removed.
RESULTS
None of patients had intraoperative complications.
There were no associated perioperative morbidities of
bleeding or infection. No fistula or incontinence was
observed. Clinical outcome was considered a failure
anytime postoperative instrumentation was needed,
including dilation. Follow-up of the entire series ranged
between 12 to 60 months (mean 32). There were 11
successes (92%), and 1 failure (8%). In 11 patients the
urethrography after 1 month, 6 months, and 12 months
showed a wide lumen of the anastomosis without
obstruction (Figure 3), and the patients have continued
to void without difficulty or further instrumentation. In
all patients the urofloumetry was repeated any 6 months
and the peak flow ranged between 16 to 28 ml/sec
(mean 20). The recurrence of the stricture occurred, 6
months after repair, in 1 patient, and a successful management was accomplished by endoscopy. The intracavernous injection of prostaglandins was an efficacious
remedy to impotence in all patients.
DISCUSSION
One-stage perineal anastomotic repair can be accomplished in most instances using a stepwise approach of
urethral mobilization, corporal separation, inferior
pubectomy and supracrural urethral rerouting to
accomplish urethral reanastomosis (1). Some authors
sees no reason why urethral mobilization, crural separation, and urethral rerouting should be considered as risk
factors in experienced hands and under usual circumArchivio Italiano di Urologia e Andrologia 2005; 77, 2
123
E. Austoni, A. Guarneri, E. Colombo., E. Palminteri
Figure 3.
Voiding urethrography 1 year after surgery.
cumstances, a combined complex abdomino-perineal
transpubic anastomotic procedure is required (1, 2).
After a wedge pubectomy made during the transpubic
urethroplasty, there is a tendency for the penis to drop
back into the gap and cause erectile difficulties (2).
This problem is compounded by the fairly frequent
development of a hernia at this site, which can be difficult to repair (2, 5).
In our technique, the inferior pubectomy and supracrural urethral rerouting are unnecessary steps, and the bulbar urethra do not require an extensive mobilization,
thus reducing the risk of penile chordee, and ischemic
damage to the distal urethral. Moreover, by using a wide
dissection along the rectal wall, the scar tissues are more
extensively removed, and the prostatic apex is easier
mobilized, and pulled down on the perineum, thus
reducing the gap for a free tension anastomosis. The
vascular preservation of the distal bulbar urethra, the
extensive removal of scar tissues, and the free tension
anastomosis are all factors reducing the risk of failure
over time. The transperineal-prerectal approach to the
posterior urethra is not advisable when the patient is
potent after the trauma, because the erection’s neural
and vascular structures are fully compromised by the
surgical steps around the prostatic apex.
CONCLUSIONS
stances (2). The prostatic apex should be cleared of
fibrotic tissue, so that there is a clear channel through to
the apex of the prostate, a widely opened prostatic
urethra at the apex, and healthy prostatic urothelium
clearly exposed (2). Failure to remove enough of the
fibrotic tissue in the anastomotic area makes it difficult
to approximate the mobilized bulbar urethra to the prostatic apex, and it is a cause of anastomotic failure (3).
In the hands of inexperienced surgeon an inferior
pubectomy is the step that is most likely to cause vascular or neural damage, and it is difficult to manoeuvre
sutures within the depths of the perineum, particularly
if the prostate is higher than usual and the inferior pubic
arch is narrow (2).
However, elaborated perineal anastomotic repair provided a successful outcome in 92% of patients (4).
Most restrictures occur within 3 months after surgery
or immediately after catheter removal, in prepubescent
male and in redo cases (4), and are due to technical
failure or ischemia (2). About 5% of posterior urethral
distraction defects have complicating factors that preclude a perineal anastomotic repair (1). In these cir-
The wide use of the perineal radical prostatectomy allowed us to improve our anatomical knowledge of the
male perineum. In patients with complex PFUDD, in
which the perineal approach is not advisable, the urologist familiar with the radical perineal prostatectomy may
perform the bulbo-prostatic anastomosis by using a
transperineal-prerectal approach.
In experienced hands, the technique is safe and sure,
and may represent an alternative to the complex combined abdomino-perineal approach, including transpubic
urethroplasty.
REFERENCES
1.Carr LK, Webster GD. Posterior urethral reconstruction. Perineal
approach. Atlas Urol Clin North Am 1997; 5:125
2. Mundy AR. Reconstruction of posterior urethral distraction
defects. Atlas Urol Clin North Am 1997; 5:139
3. Dixon CM, Torre P. Complications of urethral reconstruction. In
Taneja SS, Smith RB, Ehrlich RM. (Eds), Complications of Urologic
Surgery, Ed 3. Philadelphia, WB Saunders Company, 2001, p 509
4. Flynn BJ, Delvecchio FC, Webster GD. Perineal repair of posterior urethral stricture and defect: experience in 79 cases in the last
5-years. J Urol 2002; 167:15
5.Lenzi R, Selli C, Stomaci N, Barbagli G. Bladder herniation after
transpubic urethroplasty. J Urol 1983; 130:778
Correspondence: Andrea Guarneri, M.D., Department and Chair of Urology, University of Milan, San Giuseppe Hospital,
via S. Vittore 12 - 20123 Milan, Italy; E-mail: [email protected]
124
Surgical treatment of metastases
from renal cell carcinoma.
Alessandro Antonelli, Danilo Zani, Alberto Cozzoli, Sergio Cosciani Cunico
Department of Urology, University of Brescia, Brescia, Italy.
Summary
Introduction: Even if the number of curable renal cancers increased during the last
decades, there is still a considerable amount of patients with distant metastases,
evidenced at diagnosis or during the follow-up, without real curative therapeutic
options.
Materials and Methods: In the period between January 1983 and December 2003 we
observed 252 metastatic patients among the 1187 surgically treated for renal cancer (21.2%).
The metastatic disease was evidenced at the diagnosis of renal tumour in 118 patients (9.9%),
during the follow up at a mean distance of 18.6 months in 134 (11.3%) and was in a single
organ in 200 patients, in multiple sites in 52. A metastasectomy was performed in 113 cases,
associated with chemo-immunotherapy in 16. Conversely, 44 patients received chemo-immunotherapy alone, 18 radiotherapy, and in the remaining 77 cases no curative therapies were
applied.
Results: The patients with a single-site metastasis who underwent metastasectomy, especially
when pulmonary or adrenal, showed a better prognosis than the ones otherwise treated, while
in the patients with bony metastases, multiple-site metastases and the ones who did not receive any curative therapies an extremely dismal prognosis was evidenced. However, a large
amount of the patients with a single-site metastasis (79% on 159 treated patients) had a relapse of the disease, even when surgically treated (69%).
Conclusions: At present, in the lack of any effective systemic therapies for metastatic renal cancer, surgery offers better survival rates than other choices (chemo-immunotherapy or radiotherapy). Thus, even if the initial bias in the selection of patients is surely significant, in our
opinion, each patient with good performance status and a resectable metastatic lesion, better
if pulmonary or adrenal, should undergo metastasectomy, that could provide long-term survival in a small part of the patients.The high rate of relapses remarks the actual need of an effective systemic therapy both for the patients who can and cannot undergo surgery for their metastatic disease.
KEY WORDS: Renal cancer; Metastasis; Surgical treatment; Metastasectomy.
INTRODUCTION
MATERIALS
The diagnosis of asymptomatic, small in diameter, lowstage and surgically curable renal neoplasms increased
during the last years due to the wide diffusion of imaging diagnostic tools. Nevertheless there is still a remarkable amount of patients with distant metastases evidenced at diagnosis or during the follow-up who cannot
benefit trom any curative therapies (1).
We present our experience on 252 patients with distant
metastases from renal cell carcinoma.
At our department, between January 1983 and
December 2003, among the 1187 patients that underwent surgery for renal cell carcinoma, distant metastases
were evidenced in 252 cases (21.2%), discovered at diagnosis in 118 (synchronous metastasis, incidence 9.9%)
and during follow-up in 134 (metachronous metastasis,
incidence 11.3%) at a mean distance of 18.6 months
(range 6-179 months) from the operation for renal
tumour.
AND
METHODS
125
A. Antonelli, D. Zani, A. Cozzoli, S. Cosciani Cunico
Table 1.
Involved organ and adopted therapy in the 200 patients with a single-site metastasis (*pleura, vagina, thyroid, breast,
pancreas, peritoneum, skin).
Surgery
Chemo-immunotherapy
Radiotherapy
No curative treatments
Total
Lung
35
33
1
24
94
Bone
16
2
14
8
40
Adrenal
28
-
-
-
28
Liver
3
3
-
6
12
Brain
3
1
-
1
5
Others*
11
5
3
3
21
Total
97
44
18
41
200
In 200 patients (79.3% of 252 metastatic patients) there
was a single-site metastasis, while in the remaining 52
cases two or more organs were involved.
In 97 patients with a single-site metastasis, a good performance status and a resectable mass, the metastatic
disease was approached by the sole surgical treatment,
while in 16 patients with a multiple-site metastatic disease, chemo-immunotherapy with interleukine-2 (IL-2)
and/or interferon-alfa (IFN-α) was applied to treat the
metastatic disease residuated after metastasectomy for a
resectable lesion.
No major surgical complications occurred following the
overall 113 metastasectomies.
A medical treatment with IL-2 and/or IFN-α was applied
to the 44 patients with a single-site metastasis, a good performance status but an unresectable metastatic mass.
A radiant therapy was adopted in 18 patients with single-site metastases, 14 of whom were affected by bone
metastasis.
The remaining 77 patients (30.5%, 41 with single-site
and 36 with multiple-site metastases) received only palliative therapies with no curative aims.
The Table 1 reports the involved organ and the adopted
therapy in the cases with a single-site metastasis.
Survival time was computed for all the patients starting
from the time of the diagnosis of metastasis, delayed
from the time of surgery for the renal tumour in the
cases with metachronous metastases. Survival curves
were estimated according to Kaplan-Meier method and
differences were evaluated using the log rank test.
stasectomy, 2 with chemo-immunotherapy and 2 by
radiotherapy. Nine patients (4.5%, 8 patients treated by
surgery, 1 with chemo-immunotherapy) are dead for
other causes without evidence of relapses at 76.3
months (range 3-163 months); 51 (24.5%) are alive
with a progression of the disease at 18.1 months (range
0-125 months); the remaining 106 cases (53%) died at
a mean distance of 21.5 months (range 0-98 months).
Altogether, at a mean distance of 21.2 months (range 3114 months) 126 on 159 (79%) patients affected by a
metastasis in a single organ and treated with a curative
aim, and, among them, 67 on the 97 surgically treated
(69%), showed a further relapse of the disease. The estimated 3 and 5-years overall survival rates in the cases
with a single-site metastasis were 55% and 45% respectively (Figure 1).
Computing survival times from the diagnosis of metastasis, no significant differences in survival were evidenced between the patients with synchronous or metachronous metastasis.
Concerning the cases with metastasis in a single site, the
patients treated by surgery showed cause-specific surviFigure 1.
Overall survival curves in patients with single-site or
multiple-site metastases.
10
Bg-rank test p<0.0001
8
Among the 52 patients with multiple-site metastatic disease, 39 (75%) died for the disease at a mean distance of
12.8 months from the diagnosis of the metastasis, while
the remaining 13 cases are alive with a progression of
the disease at a mean interval of 14.2 months. The 3 and
5-years overall survival rates were less than 20% and
10%, respectively (Figure 1), and no differences were
noted in dependence on the adopted therapies.
Indeed, among the 200 patients with a single-site metastasis, 34 (17%) are free of disease at mean interval time
of 56.6 months (range 6-184 months) from the diagnosis of the metastasis: 30 of them were treated by meta-
126
Cum. survival
RESULTS
6
4
Single-site
2
Multiple-site
0
0
25
50
75
100
Time
125
150
175
200
Surgical treatment of metastases from renal cell carcinoma
Figure 2.
Cause-specific survival curves depending on the adopted
treatment in patients with single-site metastasis.
10
Log-rank test p<0.0001
Cum. survival
8
6
4
Surgery
Radiotherapy
2
0
Chemo-immunotherapy
No therapies
0
25
50
75
100
125
150
175
200
Time
Figure 3.
Cause-specific survival curves depending on the site of
metastasis in patients with single-site metastasis treated
by metastasectomy.
10
Log-rank test p<0.0028
Cum. survival
8
6
4
Lung
2
Adrenal
Other sites
Bone
0
0
25
50
75
100
125
150
175
200
Time
val rates better than the ones of the patients treated by
other curative therapeutic choices (chemo-immunotherapy or radiotherapy), while the prognosis of the
patients who received only palliative therapies was markedly dismal (Figure 2).
In regard to the sole surgically-treated cases and comparing different metastatic sites, the adrenal (28
patients) and the lung (36 patients) sites yielded the
best survival rates, whereas the bone site (16 patients)
showed the worse results (Figure 3).
DISCUSSION
The clinical evidence of a distant metastasis represents
the visible presentation of an underlying undetectable
systemic metastatic disease that cannot be cured by the
sole surgical removal of the macroscopic lesions.
However, at the present time the surgical treatment of
metastasis from renal cell carcinoma finds its rationale in
the lack of any other effective alternative options, even if
achieving a complete cancer debulking could also
improve the autologus immune responses against renal
cancer. As a matter of fact some literature reports cautiously confirm that in a small and hardly selectable part
of the patients affected by a metastatic renal cancer, the
surgical treatment can offer curative results (2-6).
In our opinion metastasectomy for renal cancer is thereby advisable in all the patients with good performance
status and surgically resectable metastatic disease. In
these conditions the procedure is usually affected by a
minimum morbidity (“easy and safe”) and allows the
certainty of the diagnosis of metastasis, giving at the
same time a considerable psychological help to the
patient.
Even if it is quite obvious that the selection to indicate
or not a surgical treatment constitutes a bias which is a
matter of relevance and surely influences the better
results of metastasectomy evidenced in our and other’s
experiences (7), for these patients a correct prospectic
study to test different treatments is not feasible at present.
Confirming some literature data (8), also in our experience a multiple-site metastatic disease is burdened
with a dismal prognosis in spite of the adopted therapy,
while a single-site metastasis, especially if pulmonary
or adrenal, synchronous or even metachronous, in a
patient with good general conditions, constitutes the
best indication for metastasectomy which offers better
outcomes than other options. With these settings in a
smoll number of cases we obtained long survival times
without relapses of the disease after the metastasectomy, while with the other curative therapeutic options
(medical or radiant) the results have been less favourable. The evidence of a bony metastasis carries a bad
prognosis and any treatment should not be expected to
be curative.
Finally, we observed a high rate of relapses, even after
the radical surgical withdrawn of all the detectable metastatic tissue, and this fact remarks the pressing need of a
systemic therapy to treat patients with metastatic renal
cancer (9). An effective chemotherapy should be applied
when the metastasectomy is not feasible but should also
be required after surgery to treat the microscopic metastatic disease and to lower the rate of relapses.
CONCLUSIONS
In our experience, about 20% of patients with renal cancer shows distant metastases, detected at diagnosis or
during the follow-up. In the case of a single-site metastasis, moreover if pulmonary or adrenal, a resectable
mass and a good performance status the surgical therapy
shows better results than other choices and could give a
curative result for a small amount of patients.
Nevertheless an effective systemic way of treatment is
absolutely necessary to treat metastatic renal cell carcinoma.
127
A. Antonelli, D. Zani, A. Cozzoli, S. Cosciani Cunico
REFERENCES
1. Russo P. Seeking the solution to the problem of metastatic renal
carcinoma. Cancer 2003; 97:2941
renal cell carcinoma who responded to interleukin-2-based
immunotherapy. Cancer J Sci Am 1998; 4:86
2. Cozzoli A, Milano S, Cancarini G et al. Surgery of lung metastasis in renal cell carcinoma. Br J Urol 1995; 7:445
6. Janzen NK, Kim HL, Figlin RA, et al. Surveillance after radical
or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease. Urol Clin North Am 2003; 30:843
3. Kavolius JP, Mastorakos DP, Pavolvich C, et al. Resection of
metastatic renal cell carcinoma. J Clin Oncol 1998; 16:2261
7. Mickisch GH. Multimodality treatment of metastatic renal cell
carcinoma. Exp Rev Anticancer Ther 2002; 2:681
4. van der Poel HG, Roukema JA, Horenblas S et al.
Metastasectomy in renal cell carcinoma: a multicenter retrospective
analysis. Eur Urol 1999; 35:197
8. Han K-R, Pantuck AJ, Bui MHT et al. Number of metastatic sites
than location dictates overall survival of patients with node-negative renal cell carcinoma. Urology 2003; 61:314
5. Lee DS, White DE, Hurst R et al. Patterns of relapse and
response to retreatment in patients with metastatic melanoma or
9. Huland E, Heinzer H. Renal cell carcinoma: novel treatments for
advanced disease. Curr Opin Urol 2003;13:451
Correspondence: Alessandro Antonelli, M.D., Clinica Urologica, Piazzale Spedali Civili, 1 - 25123 Brescia; E-mail: [email protected]
128
Metastatic retroperitoneal renal cell carcinoma.
A case for more aggressive approach.
Risk and results.
Pietro Tombolini, Michele Ruoppolo, Giuseppe Malagola, Fabrizio Rovera
Department of Surgery, Operative Unit of Urology, S. Carlo Borromeo Hospital, Milan, Italy.
Summary
Our point of view in selected cases of bulky renal neoplastic disease was shown. A 43year-old white man was referred for large disseminated retroperitoneal mass after right
radical nephrectomy and hilar lymphoadenectomy for locally advanced PT3 N3 M0 G3
renal cell carcinoma followed by interleukin-2 based immunotherapy. We attemped
aggressive resection of visible disease with curative intent. Complete resection was
technically very difficult with intragorative bleeding representing the major risk. Accidental
injuries of aortic wall and vena cava were repaired. A partial incision of the right external iliac
vein was performed. Complete removal of the large adenopathic masses was obtained. At 9
month follow-up the patient was free of disease. In conclusion, aggressive surgical approach
with complete resection of disseminated retroperitoneal renal cell carcinoma may prolong disease-free survival.
KEY WORDS: Renal cell carcinoma; Retroperitoneal; Metastases.
INTRODUCTION
SURGICAL TREATMENT
Locally advanced renal cell carcinoma is a complex problem for both the physician and the patient. Although
there is no standard treatment for locally advanced renal
carcinoma, an aggressive surgical approach has been
recommended. In patients, with no evidence of distant
metastases and when the disease is confined in the
retroperitoneum, surgical resection in combination with
biological therapy should be considered. This paper
shows our point of view in selected cases of enlarged
neoplastic renal disease.
On day 10 of March 2004 the patient underwent an
aggressive attempt to resect visibile disease with curative intent, at our department. An abdominal midline
incision was performed and then we removed extensive adhesion between liver and gross bowel. After
mesenteric inferior arteria closure, retroperitoneum
was widely exposed. Adenopathic mass removal started from left renal vein and had proceeded towards
right edge. Complete surgical resection was technically
very difficult, as intraoperative bleeding represent the
major risk. In this patient a large accidental injury of
aortic wall occurred. The massive hemorrhage was
controlled with vascular clamps placed proximal and
distal to the injury on the iliac arteries, and the lesion
was repaired with a continuous 5-0 polypropylene
suture. During the retro-caval resection, a sudden tear
of the vena cava happened; because the impossibility
of positioning a Satinsky clamp, we performed the
suture after the application of two Allis clamps.
Profound hypotension, nevertheless, occurred. The
vena cava was reconstructed with the folding of its
wall. Another, deliberate, vascular lesion was caused
to completely remove a large mass involving the right
external iliac vein. In this case, we performed a partial
excision of the vein’s wall.
CASE REPORT
A 43-year-old white man was referred to us on February
2003, for large disseminated retroperitoneal mass. On
September 2003 the patient was managed, elsewhere, by
right radical nephrectomy and only hilar limphadenectomy for renal cell carcinoma locally advanced
pT3N3M0G3, and then treated by interleukin-2 based
immunotherapy according to Azpodien. CT scan shows
enlarged adenopathic running from renal vessels to iliac
bifurcation and moreover at iliac right vessel, both common and external. A bulky disease surrounded vena cava
and another mass involved contralateral renal pedicle.
The tumour had been estimated unresectable elsewhere.
129
P. Tombolini, M. Ruoppolo, G. Malagola, F. Rovera
RESULT
The patient was discharged by Hospital in 11th postoperative day. He only reported superficial disaesthesia in his
right leg, because of injury of femoral nerve. At 9-month
follow-up, the patient is free of disease. He is still receiving
adjuvant therapy with alpha-interferon and vinblastin.
DISCUSSION
Retroperitoneal disseminated renal cell carcinoma represent a complex problem for the physician and patient.
The 1-year survival rate ranging from 10 to 30%.
Although there is no standard treatment for advanced or
recurrent neoplastic disease, an aggressive surgical
approach has been recommended. A large review of
patients treated with an aggressive surgical approach as
a single modality for locally recurrent renal cell carcinoma shows that 30 to 40% of patients had no evidence of
disease at a median follow-up of 36-48 months. Many
previous reports have supported the importance of an
aggressive debulking surgical approach before starting
biological therapy. The combination of immunotherapy
and surgery was well tolerated and did not increase
morbidity above that of surgery alone.
Our experience demonstrates that some patients with disseminated retroperitoneal renal cell carcinoma treated with
an aggressive surgical approach may have prolonged disease-free survival. It is mandatory to obtain complete resection off all masses to achieve long-term control and decrease the risk of local or at-distant progression. However, this
approach is associated with potential risk of intraoperative
complications, particularly massive hemorrhage.
REFERENCES
1. Tanguay S, Pisters L, Lawrence D, Dinney C. Therapy of locally
recurrent renal cell carcinoma after nephrectomy. J Urol 1996;
155:26
2. Esrig D, Ahlering TE, Lieskovsky G, Skinner D. Experience with
fossa recurrence of renal cell carcinoma. J Urol 1992; 147:1491
Corrispondence: Pietro Tombolini, M.D., U.O. Urologia, Ospedale S. Carlo Borromeo, Via Pio XI, Milano. Italy
130
Dorsal free graft urethroplasty according to Barbagli.
Minimum follow-up of 2 years.
Paolo Parma, Bruno Dall’Oglio, Lino Schiavon, Marco Luciano, Stefano Guatelli
Vincenzo Galletta, Candido Bondavalli
Urologic Department C. Poma Hospital, Mantova, Italy.
Summary
Series of free graft methroplasties for structure of the urethra according to Barbagli.
Fifteen men underwent dorsal free graft methroplasty for structures situated in the
penile urethra in 6 cases, in the bulbous urethra in 7 and in the urethra geno bulbaris in 2. The length of the structures ranged from 1.5 to 13 cm. In all the patients but
one uroflow was satisfactory at a mean follow-up of 40 months. In one patient a reument structure occured 8 months after treatment and was successfully treated with cold urethrotomy. In conclusion, dorsal free graft urethroplasty is a safe and fairly simple procedure in
long bulbous stenosis and penile multi stenosis.
KEY WORDS: Urethra; Urethral stricture.
INTRODUCTION
the patch graft (1). Two weeks later a voiding urethroIn 1996, Barbagli developed a new technique of urethgraphy is done and if fistuals are not present the catheroplasty with the use of a free graft positioned on the
ter is removed.
dorsal part of the urethra (1). This procedure consists
of: isolating the urethra from the corpora cavernosa;
urethral rotation; longitudinal opening along its dorsal
MATERIALS AND METHODS
surface. A free skin graft or a buccal mucosa graft is
From Jannuary 1997 to April 1999, 15 men aged 26 to
sutured to the albuginea of the corpora cavernosa and
82 underwent dorsal free graft urethroplasty. The stricthen the margins of the open urethra are sutured to the
tures were situated in the penile urethra in 6 cases, in the
margins of the graft (1, 2).
bulbous urethra in 7 and in
In the close strictures of the
the urethra peno bulbaris in
proximal bulbar urethra
Figure 1.
2 cases. Stricture etiology
with spongiofibrosis assoPreoperative retrograde urethrography shows multiple
was iatrogenic in 8 patients,
ciated, it is easier to dissect
strictures of the anterior urethra for length of 13 cm.
traumatic in 4, inflammatory
completely the urethra at
in 1, unknown in 2. The
the level of the stricture, to
length of the strictures ransuture the free graft to the
ged from 1.5 to 13 cm
albuginea of the corpora
(Figure 1). 14 patients were
cavernosa and to the proxiuncircumcised and the foremal edge of the urethral
skin provided a graft of suffimucosa. The distal urethra
cient size and length. In the
is opened along its dorsal
case of the circumcised
surface and the left mucosal
patient a free graft buccal
margin of the opened distal
mucosa was used. All
urethra is sutured to the left
patients were evaluated
side of the patch graft. The
preoperatively with retrograurethra is rotated back to its
de and voiding urethrooriginal position and the
graphy to define stricture
right urethral margin is
location and length, and
sutured to the right side of
131
P. Parma, B. Dall’Oglio, L. Schiavon, M. Luciano, S. Guatelli, V. Galletta, C. Bondavalli
Figure 2.
Retrograde urethrography after dorsal preputial
free graft urethroplasty.
ultrasonography was performed to evaluate the extent of
spongiofibrosis. The follow-up of the patients consists
in performing a uroflowmetry every 4 months and a
cystourethrography yearly or when urine flow is less
than 13 ml per second.
RESULTS
In all patients but one, uroflow has mantained satisfactory at a mean follow-up of 40 months (range 27-52). In
1 patient a recurrent stricture occurred 8 months after
intervention and was succesfully treated with cold
urethrotomy. In 1 case of urethral stricture of 13 cm of
length a slight ventral recurvatum of the penis occurred.
The urethroplasty with dorsal graft of buccal mucosa
did not present recurrent stricture at a mean follow-up
of 32 months. Diverticulas, fistulas and graft necrosis
did not occur in any patients.
DISCUSSION
The primary indication for the use of dorsal free patch
urethroplasty is a lesion longer than 1 cm for strictures
of the penile urethra, and a lesion longer than 2 cm for
strictures of the bulbous urethra. Contraindications are
the presence of an extensive spongiofibrosis causing
almost complete obliteration of the urethral lumen and
the presence of chronic infection (associated urethral
stones, urethral pseudodiverticulus, fistulas or paraurethral abscesses) (1-3).
Dorsal free graft urethroplasty is easier to perform than
pedicle graft urethroplasty. The free patch dorsally placed receives a good mechanical support and an adequate vascular supply, so it has a low incidence of necrosis
and of urethrocele. With this approach, bleeding from
the corpus spongiosum is considerably reduced as the
urethral lumen is dorsally located (4).
Even if the graft should necrose, the urethral mucosa
regenerates according to the principles of Browne and
Monseur, provided that a catheter is left indwelling for
sufficient time.
CONCLUSIONS
In large bulbous stenosis and penile multi stenosis, dorsal free graft urethroplasty is a safe surgery (bleeding is
reduced and the degloving of the penis is not extensive),
fairly simple, with few complications and not influenced
by stenosis length.
We need a longer follow-up to test the efficacy of these
procedure as the strictures can also recurr 10 or 15 years
after surgery.
REFERENCES
1. Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty. J Urol 1996; 155:123
2. Barbagli G, Selli C, Tosto A. Reoperative surgery for recurrent
structures of the penile and bulbous urethra. J Urol 156:76
3. Barbagli G, Selli C, Di Cello V, Mottola A. A one stage dorsal
free-graft urethroplasty for bulbar urethral strictures. B J Urol
1996; 78:929
4. Andrich DE, Leach CJ, Mundy AR. The Barbagli procedure gives
the best results for patch urethroplasty of the bulbar urethra. BJU
International 2001; 88:385
Corrispondence: Paolo Parma, M.D., U.O. Urologia, Ospedale C. Parma, Mantova
132
The reconstruction of “complex” ureteral lesions.
Pierpaolo Graziotti, Alessandro Piccinelli, Guido Giusti, Mauro Seveso
Gianluigi Taverna, Alessio Benetti, Luisa Pasini, Silvia Zandegiacomo
Department of Urology, Istituto Clinico Humanitas, Rozzano, Italy.
Summary
A total of 13 patients with ureteral lesions wider than 12 cm in length and/or previous radiation treatment have been submitted to reconstructive treatment. Four
patients with lesions after radiation therapy were treated with ileal ureter and
contemporary bladder augmentation, one with ureteroneocistostomy combined
with psoas hitch procedure and one combining psoas hitch and Boori Plap technique. The association of psoas hitch with Boari Flap technique were also used to treat two
patients with the undesired outcome of vascular procedure.
A patient after complete ureteral stripping following ureteroscopy was submitted to ileal
bladder substitution. Two renal autotransplantations were performed in a patient with
extensive stricture of the ureter following multiple endourological procedure and in a
patient with negative outcome of previous attempt of open ureteral defect reconstrucion following abdominal trauma.
KEY WORDS: Ureter; Radiation treatment.
INTRODUCTION
With this arbitrary term we mean ureteral lesions,
ensuing from any etiological event, sharing at least
one of the following two conditions: extension wider
than 12 cm in length and/or previous radiation treatment.
As it is well known, these are the most difficult ureteral defects to repair either for the clinical strategy, or
surgical technique or the post-operative complications.
MATERIAL
AND METHODS
In our hospital from January 1998 to December 2002
a total of 13 patients have been submitted to a reconstruction of this kind of ureteral defects.
Seven were female and six male, with age ranging between 30 and 71 years (mean 47).
Six patients came to us for the complications following pelvic surgery combined with subsequent radiation treatment, two following a vascular surgery procedure, four after endourologic manoeuvre and one
after the failure of ureteral reconstructive operation
for major abdominal trauma.
In all cases the ureteral defect was unilateral and a
percutaneous nephrostomy drainage was always positioned before surgical repair attempt.
Four patients with lesions after radiation therapy were
treated with ileal ureter and contemporary bladder
augmentation, one with ureteroneocistostomy combined with psoas hitch procedure and one combining
psoas hitch and Boari flap technique.
The association of psoas hitch with Boari flap technique were also used to treat two patients with the undesired outcome of vascular procedure and for two
lesions following endourological procedure. The
extent of the defects allowed only a direct anastomosis
between upper ureter and the bladder flap, without
antireflux technique (Figures 1a and 1b).
A patient after a complete ureteral stripping following
ureteroscopy, were submitted to ileal ureter substitution.
Two renal autotranspantations were performed, one in
a patient with extensive stricture of the upper ureter
following multiple endourological procedures, and
one after the negative outcome of previous attempt of
open ureteral defect reconstruction following abdominal trauma.
RESULTS
Post-operative complications were limited.
Major bleeding requiring a second look and a subsequent laparocele was observed in a case of renal autotransplantation.
A patient, operated with the psoas bladder hitch +
Boari flap combined procedures, complained a pyeloArchivio Italiano di Urologia e Andrologia 2005; 77, 2
133
P. Graziotti, A. Piccinelli,G. Giusti, M. Seveso,G. Taverna, A.Benetti, L. Pasini, S. Zandegiacomo
nephritis after ureteral stent removal, promptly solved
with antibiotic therapy.
With a mean follow-up of 26 months (range 4-52) all
patients present a regular ureteral urine transit
without upper tract dilatation.
A temporary flank pain during micturition, spontaneously disappeared after few weeks, was reported by
all patients treated with psoas bladder hitch+Boari
flap procedure.
In a case of solitary kidney with preoperative impairment of renal function (serum creatinine 5.2 mg/dl),
despite the regular appearance of the reconstructed
urinary system, creatinine value did not return to normal (3.2 mg/dl), probably because of permanent
parenchymal renal damage.
Two patients treated with ileal ureter and bladder augmentation, complain episodes of nocturnal urine
incontinence and recurrent asymptomatic urinary
tract infection.
In one of these patients a significant silent dilatation
of controlateral ureter was also evident due to a progression of retroperitoneal fibrosis following radiation
therapy.
Figure 1.
A: Permanent lesion of lumbar ureter following vascular
surgery operation; B: IVP two years after surgery.
A
CONCLUSIONS
Long ureteral defects are lesions not commonly observed in daily practice and this is the main reason of our
limited experience in number of cases even if it is
quite wide for the type of lesions and the surgical
solutions adopted.
On the base of our data we can assert that with a very
precise therapeutic strategy and adequate experience
in reconstructive surgery, good results can be obtained
in the treatment of “complex” ureteral lesions.
B
REFERENCES
1. Pagano F, Graziotti P. Le grandi perdite di sostanza dell’uretere. Riv. Radiologia 1980; 20:9
2. Passerini Glazel G, Meneghini A, Aragona F, Oliva G, Milani
C, Pagano F. Technical options in complex ureteral lesions:
“ureter sparing” surgery. Eur Urol 1994; 25:273
3. Goodwin WE, Winter CC, Turner RD. Replacement of the
ureter by small intestine: clinical application of the ileal ureter..
J Urol 1959; 81:406
4. Novick AC, Jackson CL, Straffon RA. The role of renal autotransplantation in complex urological reconstruction. J Urol
1990; 143:406
Correspondence: Pierpaolo Graziotti, M.D., Istituto Clinico Humanitas, Rozzano, Milano, Italy
134
Microscopic and microbiological findings
for evaluation of chronic prostatitis.
Vittorio Magri1, Lisa Cariani2, Roberto Bonamore2, Antonella Restelli2,
Maria Cristina Garlaschi2, Alberto Trinchieri3
Urology and Sonography 1Outpatient Clinic; 2Microbiology Unit, ICP Milano;
3
Urology Unit, Ospedale di Lecco, Italy.
Summary
Objective: The aim of this study was to assess the significance of different diagnostic
methods for detecting prostatic inflammation/infection. Materials and Methods: :A group
of 233 with symptoms suggesting prostatitis without urethral discharge attending an outpatient Prostatitis Clinic was considered. All were evaluated by the same urologist
according to a protocol comprising medical history, physical and transrectal ultrasound
examination. Patients had a urethral swab for bacterial culture and additional swabs for identification of C. trachomatis, T. vaginalis, U. urealyticum, M. hominis and Candida spp. Patients also
underwent a four-specimen study according to Meares and Stamey (first voided urine VB1, midstream urine VB2, expressed prostatic secretion EPS and urine after prostatic massage VB3) and
culture of the seminal fluid. Results: Of 233 patients evaluated, 47% had a positive urethral culture, 35% a positive culture of the seminal fluid and only 13% a positive culture of one or more
samples of the four-specimen localization test. A positive culture of VB1 or VB2 was very rarely
associated with a negative swab culture respectively in 1% and 0.9%; on the contrary, a positive
swab culture was frequently associated with negative VB1 and VB2 culture respectively in 90%
and 91%. Of the patients with positive urethral culture only 8% and 2% had more than 10 leukocytes respectively in VB1 and VB2. A positive seminal culture was associated with negative EPS
and VB3 culture respectively in 89% and 83% cases; on the contrary, a positive culture of EPS or
VB3 was associated with a negative seminal fluid culture respectively in 67% and 27% cases. In
49% patients with positive culture of the seminal fluid, more than 10 leukocytes in VB3 were
observed. Only in 9 of the 47 patients with positive culture of the seminal fluid EPS can be obtained
and 3 of them (33%) had more than 10 leukocytes in EPS. Conclusions: Culture and determination of leukocytes in first voided and midstream urine showed a low sensitivity in detection of urethral infection/inflammation compared to urethral swab culture. On the contrary, microscopic
examination of urine after prostatic massage was confirmed as a useful indirect indicator in the
diagnosis of prostatic inflammation and showed to be more feasible compared with the analysis of
expressed prostatic secretion. In conclusion, urethral swab culture and post-massage urine culture
and microscopic examination could be proposed as an alternative standard protocol in order to
simplify the evaluation of prostatitis-like syndrome in the clinical practice.
KEY WORDS: Chronic prostatitis; Seminal fluid; Urethral swab.
INTRODUCTION
MATERIALS
Accurate diagnosis of urethral and prostatic inflammation
and/or infection represents a diagnostic challenge. The reference standard remains the “four-glasses” procedure for
the lower urinary tract localization, although additional
information could be obtained by urethral swabs and culture of the seminal fluid. The aim of this study was to
assess the significance of different diagnostic methods for
detecting inflammation/infection of the prostate.
A group of 233 with symptoms suggesting prostatitis
without urethral discharge attending an outpatient
Prostatitis Clinic was considered. All were evaluated by
the same urologist according to a protocol comprising a
thorough history, including standard symptom evaluation and sexual history and physical and transrectal
ultrasound examination.
Patients had a urethral swab for bacterial culture and addi-
AND
METHODS
135
V. Magri, L. Cariani, R. Bonamore, A. Restelli, M.C. Garlaschi, A.Trinchieri
Table 1.
Microbiological findings in VB1, VB2, EPS and VB3.
VB1
1
Chlamydia
VB2
1
Ureaplasma u
VB3
6
Chlamydia, Candida, E. coli, H. para, Streptococcus beta-hemolyticus (2)
EPS
10
Chlamydia (2), Streptococcus beta hemoliticus (3), E. coli (1), Proteus (1),
Morganella (1), Irl haem (1), E. coli+Streptococcus beta hemoliticus (1)
VB1+VB2+VB3
4
E. coli (3), Klebsiella (1)
VB2+VB3 (non eseguito VB1)
3
E. coli (2), Streptococcus beta hemoliticus (1)
VB1+VB3
2
E. coli (1), Enterobacter (1)
VB1+VB2
2
E. coli (2)
1
Streptococcus beta hemoliticus (1)
EPS+VB3
Total
30
tional swabs for identification of C. trachomatis, T. vaginalis, U. urealyticum, M. hominis and Candida spp. Patients
underwent a four-specimen study according to Meares
and Stamey (first voided urine VB1, midstream urine VB2,
expressed prostatic secretion EPS and urine after prostatic
massage VB3) and culture of the seminal fluid.
RESULTS
Of 233 patients evaluated, 101/214 (47%) had a positive urethral culture, 47/135 (35%) a positive culture of
the seminal fluid and 30/233 (13%) a positive culture of
the four-specimen localization test (VB1 alone 1 pt, VB2
alone 1 pt, VB1+2 two pts, VB1+3 two pts, VB2+3 three
pts, VB1+2+3 four pts, EPS alone 10 pts, VB3 alone 6
pts, EPS+VB3 one pt).
Positive cultures of VB1 and VB2 were associated to positive culture of VB3 in 9/13 cases (6/9 cases for VB1 and
7/10 for VB2). When VB1 and VB2 were positive in
absence of positive VB3, the isolated were Chlamydia t.
(VB1 positive alone), Ureaplasma u. (VB2 positive alone)
and E. coli (in 2 cases with VB1+VB2 positive).
Table 2.
Results of VB1 and VB2 cultures in relation to the result of urethral swab culture.
VB1 positive
VB1 negative
Total
1
95
96
Urethral swab negative
Urethral swab positive
8
77
85
Total
9
172
181
VB2 positive
VB2 negative
Total
1
113
114
Urethral swab negative
Urethral swab positive
Total
9
92
101
10
205
215
Table 3.
Results of VB3 and EPS cultures in relation to the result of seminal fluid culture.
VB3 positive
VB3 negative
Total
3
84
87
8
39
47
Seminal culture negative
Seminal culture
positive
Total
136
11
123
134
EPS positive
EPS negative
Total
Seminal culture negative
2
9
11
Seminal culture positive
1
8
9
Total
3
17
20
microscopic and microbiological findings for evaluation of chronic prostatitis
Table 4.
Presence of 10 or more leukocytes in VB1 and VB2 in relation to the result of culture of urethral swab.
Urethral Swab Negative
Urethral swab Positive
Total
VB1 < 10 WBC
VB1 > 10 WBC
Total
87
9
96
78
7
85
165
16
181
VB2 < 10 WBC
VB2 > 10 WBC
Total
Urethral Swab Negative
111
3
114
Urethral swab Positive
99
2
101
210
5
215
Total
Table 5.
Presence of 10 or more leukocytes in VB3 and EPS in relation to the result of culture of urethral swab.
Seminal culture Negative
VB3 < 10 WBC
VB3 > 10 WBC
Total
51
36
87
24
23
47
Seminal culture
Positive
Total
Seminal culture Negative
Seminal culture Positive
Total
75
59
134
EPS < 10 WBC
EPS > 10 WBC
Total
5
4
9
6
3
9
11
7
18
Culture of EPS was positive in 11 out of 20 cases in
which it was possible to obtain the sample: in 10 out of
these 11 cases the positive culture was not associated to
positive cultures of other samples (VB1, VB2 or VB3).
VB3 cultures were positive alone in 6/17 cases (Chlamidia
t. in 1, Candida sp. in 1, E.coli in 1, Haemophylus parainfluenzae in 1, Streptococcus beta haemoliticus in 2).
In 11 cases cultures were positive in more than one
sample (E. coli in 8, Klebsiella in 1, Enterobacter in 1,
Streptococcus beta-haemolyticus in 1).
In 181 cases in which we were able to obtain both urethral swab and VB1 culture, a positive VB1 culture was
associated to a negative urethral swab culture in only 1
out 96 cases.
Similarly in 215 cases in which we were able to obtain
both urethral swab and VB2 culture, a positive VB2 culture was associated to a negative urethral swab culture
in only 1 out 114 cases.
On the contrary, a positive swab culture was associated
with negative VB1 and VB2 culture respectively in
77/85 (90%) and 92/101 (91%) cases.
On the other hand in patients with positive urethral culture respectively only 7 out of 85 (8%) and 2 and 101
(2%) had more than 10 leukocytes in VB1 and VB2.
A positive seminal culture was associated with negative EPS and VB3 culture respectively in 8/9 (89%)
and 39/47 (83%) cases; on the contrary a positive culture of EPS or VB3 was associated with a negative
seminal fluid culture respectively in 2/3 (67%) and
3/11(27%) cases.
In 23 out 47 (49%) patients with positive culture of the
seminal fluid more than 10 leukocytes in VB3 were
observed.
Only in 9 of the 47 patients with positive culture of the
seminal fluid EPS can be obtained and 3 of them (33%)
had more than 10 leukocytes in EPS.
CONCLUSIONS
In the early 1960’s a diagnostic method was developed
in order to allow bacteriological assessment of the urethra and prostate by segmenting the voided urine into 3
sequential aliquots: VB1 (voided bladder one) collected
as the patient initiate the urinary stream, VB2 collected
when the patient has voided approximately 200 ml, and
VB3 obtained after EPS (expressed prostatic secretion)
collection by prostatic massage (1).
Associated to the performance of quantitative bacteriologic cultures, the microscopic appearance of the prostatic expressa together with the sediment of first voided
urine, the midstream urine and urine collected after prostatic massage was evaluated considering as pathologic
leukocytosis a white blood cells (WBC) count per high
power field (HPF) greater than 10 WBC.
This technique has been considered the most accurate
way to distinguish bacterial prostatitis from nonbacterial
types of prostatitis and to estabilish the diagnosis of
chronic bacterial prostatitis and has served as the basis of
considerable investigative work in prostatitis during the
past several years.
137
V. Magri, L. Cariani, R. Bonamore, A. Restelli, M.C. Garlaschi, A.Trinchieri
In more recent years the cost/efficacy of this diagnostic
method has been questioned (2-4).
In our experience culture and determination of leukocytes in first voided and midstream urine showed a low
sensitivity in detection of urethral infection/inflammation compared to urethral swab culture. On the contrary
microscopic examination of urine after prostatic massage was confirmed as a useful indirect indicator in the
diagnosis of prostatic inflammation and showed to be
more feasible compared with the analysis of expressed
prostatic secretion. In conclusion urethral swab colture
and post-massage urine culture and microscopic examination could be proposed as an alternative standard protocol in order to simplify the evaluation of prostatitislike syndrome in the clinical practice.
REFERENCES
1. Meares EM, Stamey TA. Bacteriologic localization patterns in
bacterial prostatitis and urethritis. Invest Urol 1968; 5:492
2. McNaughton M, Fowler FJ, Elliott DB, Albertsen PC, Barry MJ.
Diagnosing and treating chronic prostatitis: do urologists use the
four-glass test? Urology 2000; 55:403
3. Ludwig M, Schroeder-Printzen I, Ludecke G, Woeidner W.
Comparision of expressed prostatic secretions with urine after prostatic massage – a means to diagnose chronic prostatitis/inflammatory chronic pelvic pain syndrome. Urology 2000; 55:175
4. Krieger JN, Jacobs R, Ross SO. Detecting urethral and prostatic
inflammation in patients with chronic prostatitis. Urology 2000;
55:186
Correspondence: Dott.Vittorio Magri, Presidio dei Poliambulatori ICP, via Andrea Doria 52, Milano; E-mail: [email protected]
138
The use of vesical irrigation system dual pump
Endo FMS Urology in the endoscopic therapy
of benign prostatic hyperplasia.
Piero Larcher, Giorgio Borroni, Andrea Begani, Paola Franch, Massimo Grisotto
Urology Unit, Casa di Cura Igea, Milano, Italy.
Summary
Objective: Transurethral resection of the prostate (TURO) remains the reference standard treatment in the management of lower urinary tract symptoms (LUTS) secondary to benign prostatic hyperplasia (BPH). The objective of this study was to determine whether vesical irrigation during TURP with the dual pump system Endo FMS
Urology is more efficient than standard gravity irrigation. Methods: A group of 30
patients who underwent TURP using the Endo FMS Urology was compared to a group of 30
patients treated with standard vesical irrigation. Results: A 40% decrease of fluid irrigated, a
10% decrease of time for procedure and a 10% increase in the volume of the resected tissue was
observed in patients treated with the Endo FMS Urology compared to controls treated with
standard vesical irrigation.
KEY WORDS: Transurethral resection; Prostate; Vesical irrigation.
INTRODUCTION
From June 2003, in the Urology Unit of the Casa di
Cura Igea of Milan, the dual pump system for intracavitary irrigation ENDO FMS Urology was adopted.
The system is used for the endoscopic therapy of BPH,
for the endoscopic therapy of the vesical neoplasm,
for urethroscopy, and for diagnostic and therapeutic
ureteroscopy too.
MATERIALS
AND
METHODS
From June 2003 to March 2004 we submitted to
TURP 30 patients suffering from BPH using the Endo
FMS Urology. We compared these patients to the previous 30 patients treated endoscopically for BPH with
standard endovesical irrigation.
The volume of adenomas ranged 30-45 cc, total PSA
was <4 ng/ml, I.P.S.S. (International Prostate
Symptoms Score) 12-30 (medium and severe grade).
The two pumps of this system provide both constant
programmed irrigation at constant pressure and suction mataining an intracavitary low pressure (20 cm
H2O). The possibility of increasing the irrigation flow
by a microcomputer allows a faster and more careful
haemostasis. The endoscopic vision of prostatic cavity
is greatly improved. There is no risk of vesical overfilling. The time of resection has decreased because
there is no need to extract the rectoscope to evacuate
the bladder during resection.
RESULTS
No cases of T.U.R. Syndrome were observed. No
patient has been submitted to haemo-transfusion.
A 40% decrease of fluid irrigated, a 10% decrease of
time for procedure and a 10% increase in volume of
the resected tissue was observed.
No difference in terms of post-operative acute urine
retention epysodes was observed. Intra-operative
bleeding and post-operative consume of packed red
cell decreased in patients treated with the Endo FMS
Urology compared with patients treated with the
standard procedure.
CONCLUSIONS
The vesical irrigation dual pump system Endo FMS
Urology allows for a faster and safer resection of prostatic tissue because of the optimal view; it allows also
a reduction of the amount of irrigated fluid and the
maintenance of a low intracavitary pressure during
prostatic resection, thus preventing the T.U.R.
syndrome.
139
P. Larcher, G. Borroni, A. Begani, P. Franch, M. Grisotto
REFERENCES
1. Interventional therapy for benign prostatic hyperplasia. In
Chatelain C, Denis L, Foo KT, Khoury S, Mc Connell J (Eds).
Benign Prostatic Hyperplasia. 5th International Consultation on
Benign Prostatic Hyperplasia (BPH) June 25 – 28, 2000 Paris.
Plymouth (UK), Plymbridge Distributors Ltd, 2001
2. Madsen PO, Nielsen KT. Devices for monitoring intravesical
pressure during transurethral resection of the prostate. Med
Instrum 1988; 22:69
3. Schulman C. Benign hypertrophy of the prostate: which treatment, for whom? Rev Med Brux 1999; 20:A212
4. Hahn RG. Intravesical pressure during irrigating fluid absorption in transurethral resection of the prostate. Scand J Urol
Nephrol 2000; 34:102
Correspondence: : Piero Larcher, M.D, UO Urologia, Casa di Cura Igea, Milano, Italy
140
The use of vesical irrigation system dual pump
Endo FMS Urology in the endoscopic therapy
of the vesical neoplasms.
Piero Larcher1, Giorgio Borroni1, Andrea Begani1, Paola Franch1, Luca Carmignani2
Urology Unit, Casa di Cura Igea; 2Urology Unit, San Paolo Hospital, Milano, Italy
1
Summary
Objective: The objective of this study was to determine whether vesical irrigation
during transurethral resection of bladder tumours (TURBT) with the dual pump
system for the intracavitary irrigation Endo FMS Urology is more efficient than the
standard gravity technique. Methods: One hundred patients suffering from vesical
neoplasms underwent TURBT using the Endo FMS Urology (group A). They were
compared to 100 patients previously (2002-2003) treated endoscopically for vesical tumours
with the standard endovesical irrigation method (group B). Results: We demonstrad a reduction of the average time of resection of 10% in favour of patients of group A, a reduction of 39%
of the amount of fluid of vesical irrigated in favour of patients of group A. No differences were
observed in the recurrence rate of tumours at 3 months and in need of endoscopic revision in
the 48 hours following TURBT. Two patients required blood transfusion after TURBT in group
B, none in group A. The average time of hospitalisation in group A was less than one day.
Conclusions: On the basis of this experience the use of Endo FMS Urology Irrigation System
in TURBT is strongly recommended.
KEY WORDS: Vesical irrigation; Vesical neoplasms..
INTRODUCTION
The gold-standard in the treatment of superficial bladder tumours is transurethral resection (TURBT).
In the presence of a suspect vesical lesion TURBT is the
main diagnostic step and it is often the definitive treatment if the lesion is completely resecatable.
In consideration of the well known recurrence rate of
superficial bladder tumours, endoscopic treatment is
advisable because it is less invasive and can be easily
repeated.
The cleanness of the operating field and the possibility
of increasing/reducing the flow of the washing is essential for a correct procedure of resection.
Bulking tumours not infiltrating deeply the bladder wall
are susceptible of endoscopic conservative treatment if
the irrigation and washing system allows an optimal
view also in case of massive bleeding.
The accuracy of resection allows a radical removal of the
tumour reducing the risk of recurrence.
Resection with low pressure and constant washing flow
allows, after resection of the esophytic mass, to perform
deep biopsies and, if necessary, to perform planned perforations of the vesical wall to obtain a complete radical
resection or at least to exactly stadiate the tumour in
order to correctly plan a radical surgery.
In order to perform a planned perforation of the vesical
wall, it is necessary to obtain an optimal control of the
endovesical washing flow and of the endovesical gradient pressure.
The conventional endovesical irrigation system, that
works by the force of gravity, allows for a reduced modulation with limited possibility to increase pressure and/or
flow speed by means of artifices such as the squeezing or
the elevation of the fluid sack.
The dual pump system Endo FMS Urology, managed by
a computer, is equipped with a precise sensors that allow
to maintain the required filling of the bladder. Any difference of endovesical filling and pressure from the selected values causes the pump to stop or to start until the
correct value of pressure is achieved again. The constantly reduced endovesical pressure inhibits the overfilling of the bladder reducing to the minimum the risk of
re-absoption of the irrigation fluid.
The Endo FMS Urology is provided with two pedals that
allow an immediate increase in vesical pressure (red
141
P. Larcher, G. Borroni, A. Begani, P. Franch, L. Carmignani
pedal) and an increase in the filling (blue pedal). This
new system allows an optimal consume of the irrigation
fluid, not requiring to extract the resectoscope to evacuate the bladder and allows an optimal view of the operating field.
The increase in flow allows to easily identify the arterial
bleedings and a more careful and selective haemostasis.
MATERIALS
AND
METHODS
The Endo FMS Urology is a complete fluid management
system which provides a constant programmed irrigation pressure together with a suction flow. While a suction pump (master) removes fluid from the cavity
through the tubing connected to the resectoscope outer
sheat, an irrigation pump (slave), with pressure setting,
supplies fluid through the tubing connected to the
resectoscope inlet port and maintains the programmed
pressure. This provides two independent functions: irrigation pressure and suction flow. Pre-programmed
values of these parameters are linked by a microcomputer to maintain a low intravesical pressure of 10 to 20
cm H2O.
During TURBT the 2 stopcocks of the resectoscope must
be permanently opened. An audiovisual alarm warns if
programmed pressure is exceeded. Disposable tubing is
installed on the system to feed the continuous flow
resectoscope.
PATIENTS
From June 1st 2003 to March 31th 2004 100 unselected patients have been submitted to TURBT. These procedures were performed by using the endovesical washing system, operated by pumps and computers, called
Endo FMS Urology.
Characteristics of the patients who underwent TURBT
using Endo FMS were: male to female ratio 73/27, mean
age 64 years (range: 35-87). Tumour stage and grade
were T1 G1-G2 in 77; T2 G1 in 13; T2 G2 in 7; T3 G3
in 3 patients.
As control group we considered 100 consecutive
patients treated endoscopically from March 2002 to
June 2003 for vesical tumours with the standard endovesical irrigation method.
The mean time of resection was significantly reduced in
patients of group A compared to the patients of group B
(- 10%).
The recurrence rate was equal in the two groups.
The need of re-surgery for serious bleeding in the 48
hours following TURBT was 2% in both groups.Two
patients of group B requested haemo-transfusion, whereas no patients in group A was submitted to haemotransfusion. The post TURBT mean hospitalisation
period was one day less for patients of group A compared to group B.
CONCLUSIONS
Using the Endo FMS Urology instead of the standard
irrigation system we obtained a reduction of surgery
time; a reduction of the amount of fluid for irrigation;
a reduction of intra-operative bleeding owing to a
more selective haemostasia; the possibility to maintain
a low irrigation flow maintaining an optimal view
when bleeding is moderate; a reduction of the mean
period of hospitalisation. During the procedure, the
entrance and exit taps of the Iglesias resector were
always completely opened, so there is no need to
manually settle them and there is no risk of an accidental vesical over stretching.
With reference to the cost, in addition to the Endo
FMS Urology purchase cost or its mortgaging, you
have to consider the cost of the disposable sets of connection of the pump to the resector. These costs are
compensated by the reduced use of irrigation fluid,
from the reduced time of use of the endoscopic room
and from the shorter hospitalisation.
The resection of bulking tumours bodies is easier,
more safe and precise to the operator. The definitive
haemostasis is more precise and so more reliable.
Our study could be criticisable because of the lack of
randomisation between the two groups, but in our
opinion a randomised comparison between the dual
pump and the standard procedure was not ethic, due
to the obvious superiority of the dual pump system;
for that reason we preferred to refer to historical controls.
REFERENCES
RESULTS
The amount of fluids used for vesical irrigation during
the bladder resection was 39% less for the patients of
group A (treated with Endo FMS Urology) compared to
patients of group B (treated with standard irrigation).
1. Widman J. Controlled continuous flow method fro transurethral
resections. Urol 1983; 21:130
2. Briggs TP, Parker C, Connolly AA, Miller R. Fluid delivery system: high flow, low pressure, the key of safe resection. Eur Urol
1991; 19:277
Correspondence: Piero Larcher, M.D., UO Urologia, Casa di Cura Igea, Milano, Italy
142
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e le iniziative della Società e rinnovare il pagamento della quota associativa.
I prossimi appuntamenti SIEUN (da non mancare!)
Palermo, 18-22 giugno 2005 – Fiera del Mediterraneo
78° Congresso Nazionale della Società Italiana di Urologia – SIU, durante il
quale si terrà la lettura SIEUN dal titolo “Diagnostica ecografica in andrologia:
stato dell’arte” presentata dal dott. Lelio Mario Sarteschi (mercoledì 22 giugno)
Perugia, 2-3 luglio 2005
Riunione della Sezione Tosco-Umbro-Ligure della Società Italiana di Andrologia - SIA
durante la quale si terrà una Sessione SIEUN dedicata all’Ecografia Andrologica
(domenica 3 luglio)
Roma, 12-16 novembre 2005 – Cavalieri Hilton
XVII Congresso Nazionale SIUMB, durante il quale si terrà il Corso SIUMB-SIEUN di
“Ecografia Uro-Andrologica” (sabato 12 novembre)
La segreteria della Società
The Office
Via San Nicolò 14 - 34121 Trieste
Tel. 040.368343 int. 16 - Fax 040.368808
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Chi intende iscriversi alla Società o rinnovare la sua iscrizione sappia
che la quota associativa unica è di: EUR 50,00
È possibile pagarla:
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Urological and Andrological Sciences Founded in 1924 Official Journal

Transcription

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