C. Deliveliotis

Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing—effects on continence and positive margins

OBJECTIVES To determine the effect of puboprostatic ligament sparing and bladder neck preservation on postoperative continence and positive margins after radical retropubic prostatectomy. METHODS A total of 149 men with clinically localized prostate cancer underwent radical retropubic prostatectomy. A bladder neck preservation technique was used in 48 patients (group 1), puboprostatic ligament sparing in 51 patients (group 2), and both techniques in 50 men (group 3). Urinary continence and margin status were assessed. RESULTS A statistically significant difference in the early return of continence was found 3 and 6 months postoperatively between groups 1 and 2 (P < 0.05), as well as between groups 2 and 3 (P < 0.05), in favor of groups 1 and 3. However, the long-term continence rates recorded 1 year postoperatively did not differ, at 92%, 92%, and 94% for groups 1, 2, and 3, respectively. Positive margins were found in 10 patients (21%) from group 1, in 9 (18%) from group 2, and in 11 (22%) from group 3. Positive margins at the bladder neck were found in 3 (6%), 1 (2%), and 2 (4%) patients, respectively, in groups 1, 2, and 3. These were the sole sites found in 1 patient (2%) in each of groups 1 and 3 and in none of group 2 (0%). Positive margins on the prostatic apex were found in 3 patients (6%) in group 1, 2 patients (4%) in group 2, and 4 patients (8%) in group 3. The apex was the only site found in 0 (0%), 1 (2%), and 2 (4%) patients for groups 1, 2, and 3, respectively. No statistically significant difference was found in the margin status among the groups studied. CONCLUSIONS The final continence rates did not differ among the three groups. However, bladder neck preservation offered an earlier return of continence compared with the puboprostatic ligament-sparing technique. The positive margin status was similar for all three groups.

Management and Follow-Up of Impacted Ureteral Stones

Introduction: Impacted stones are those that remain unchanged in the same location for at least 2 months. Materials and Methods: We evaluated 42 patients with impacted ureteral stones, and followed them for two and a half years to check for long-term results. The calculi location included all three segments of the ureter (proximal, mid and distal). Patients’ age ranged from 22 to 83 years (mean 52.5 years). Primarily, patients were manipulated with extracorporeal shock wave lithotripsy (ESWL) in situ, or following stenting. If the result was not satisfactory, then we proceeded to retrograde ureteroscopy and ureterolithotripsy. Open ureterolithotomy was our final choice. Results: Thirty-six of the 42 patients (85.7%) were stone-free without the need of an open procedure. Follow-up period ranged from 10 up to 40 months, with a median period of 30 months and was achieved in 30 patients (71.4%). Stone recurrence was noted in 4 cases, while hydronephrosis without evidence of stone presence in 2. Conclusions: The initial approach for the treatment of impacted lithiasis should be attempted by ESWL. If this fails, alternative therapeutic solutions such as endoscopy can result in removal of the stone.

Prognostic significance of CA 125, CD44, and epithelial membrane antigen in renal cell carcinoma

OBJECTIVES To study retrospectively CA 125, CD44, and epithelial membrane antigen (EMA) expression in renal cell carcinoma and their role as prognostic factors. CD44 is a cell adhesion molecule, and CA 125 and EMA are tumor-associated antigens used in the diagnosis and monitoring of the outcome and response to treatment of various human malignancies. Their expression and prognostic significance after resection of renal cell carcinoma have not been adequately studied. METHODS The expression of CA 125, CD44, and EMA were studied immunohistochemically and correlated with the outcome of 92 patients who underwent nephrectomy for renal cell carcinoma. RESULTS Positive staining was found for CA 125 in 28 patients (30.43%), CD44 in 48 patients (52.17%), and EMA in 74 patients (80.43%). CA 125 expression was increased in those with higher T stage (P <0.001) and histologic grade (P = 0.007). An inverse relationship was found between EMA expression and grade (P <0.001). The median follow-up was 41.5 months (range 30 to 65). The median survival for positive and negative patients was 34.6 versus 54.3 months for CA 125 (P = 0.0044), 48.3 versus 51.5 months for CD44 (P = 0.4677), and 53.2 versus 34 months for EMA (P = 0.0046). Multivariate analysis showed that CA 125 and EMA expression were independent prognostic factors (P = 0.021 and P = 0.018, respectively). Subgroup analysis showed that CA 125 expression predicted a significantly higher probability of death (28.6% versus 8%, P =0.0413) in patients with T1 or T2 tumors. CONCLUSIONS CA 125 and EMA appear to be useful prognostic markers in renal cell carcinoma. Additional studies are needed to determine the value of these markers as a means of selection for postoperative management.

Adjuvant Intravesical Mitoxantrone versus Recombinant Interferon-α after Transurethral Resection of Superficial Bladder Cancer: A Randomized Prospective Study

Objective: To determine the efficacy and safety of two different doses of intravesical mitoxantrone and of recombinant interferon-α (IFNα-2b), instilled after transurethral resection (TUR) of superficial transitional cell carcinoma (TCC) of the bladder. Material and Methods: 208 patients (mean age 62.05 years) with primary or recurrent superficial (TaG1, T1G1, T1G2) bladder cancer were randomly allocated into four groups, after TUR of all visible tumors. Group A (45 patients) received no further therapy; group B (56 patients) received 10 mg of mitoxantrone (6 weekly and 20 fortnightly instillations), group C (54 patients) 20 mg of mitoxantrone (3 fortnightly and 10 monthly instillations) and group D (53 patients) received 100 MU of IFNα-2b (8 weekly, 8 fortnightly and 6 monthly instillations). Results: During the follow-up (mean 21.09 months), 29 (64.44%) patients in group A had recurrence, compared with 19 (33.92%) in group B, 17 (31.48%) in group C and 15 (28.3%) patients in group D (p < 0.005). Furthermore, the differences in simple recurrence rates were statistically more significant (p < 0.05), when group A was compared with the three other groups in the terms of T1G2, recurrent and multiple neoplasms. Twenty-nine patients (10, 7, 8, and 4 in groups A–D) experienced tumor progression, and the differences between the four groups were not statistically significant (p > 0.05). The mean recurrence time was 9.03 months in group A, 13.74 in group B, 14.24 in group C and 17.4 months in group D (p < 0.001), and the recurrence rate per 100 patient-months was 4.39, 1.57, 1.48 and 1.06, respectively (p < 0.05). Toxicity (grade 1–3) was recorded in 23.21% in group B, in 31.48% in group C and in 9.43% in group D (p < 0.01). Conclusion: The two doses of mitoxantrone resulted in similar efficacy for the prevention of superficial bladder cancer recurrences, with the dose of 10 mg of mitoxantrone being related to fewer side effects. In comparison with mitoxantrone, the adjuvant intravesical immunotherapy with 100 MU of IFNα-2b showed a better combination of efficacy and safety.

Solitary neurofibroma of the spermatic cord

We report a case of solitary neurofibroma of the spermatic cord. Such benign tumors arise from perineural and Schwann cells and may be located in various parts of the body, but are rarely observed in the spermatic cord. No clinical or laboratorial manifestations of von Recklinghausen disease (Neurofibromatosis) were identified. Distinct criteria have been established for a diagnosis of von Recklinghausen disease, so that a solitary neurofibroma may not represent this complex. Only a little number of solitary neurofibromas of the spermatic cord are reported in the literature.

Biopsies of the transitional zone of the prostate. Should it be done on a routine basis, when and why?

Purpose: In this prospective study we try to evaluate the necessity of performing additional transitional zone biopsies as part of the standard sextant biopsies procedure in order to detect prostate cancer. Materials and Methods: During a 12-month period we performed biopsies in 420 patients. All patients had two additional biopsies of the transitional zone biopsies. 289 of them were biopsies for the first time because they had an elevated PSA and/or a suspicious DRE. One hundred and thirty-one had a repeat biopsy because of the remaining elevated PSA after the previous negative one. Results: Of the 420 patients 143 (34%) had cancer, with 11 (7%) having cancer in the transitional zone only. Patients initially evaluated because of high PSA and or a positive DRE had only 2 (2.1%) cancers exclusively in the transitional zone. We found that this percentage rises (18.7%) when the patients had already at least one previous negative biopsy of the peripheral zone, and during the repeat biopsy the transitional zone is samples. Conclusions: The low yield of transitional zone biopsies (2.1%) during first time sampling of the prostate does not warrant their systematic use for the early detection of prostate cancer. Instead the effectiveness of biopsies in that area is higher when the biopsy is repeated after an initial previous negative biopsy of the peripheral zone.

Bcl-2 protein and DNA ploidy in renal cell carcinoma: Do they affect patient prognosis?

Abstract  Aim:  The aim of the present study was to correlate bcl‐2 protein expression and DNA‐ploidy status with established prognostic parameters in renal cell carcinoma (RCC) and to examine their impact on disease progression and patient survival.

Pathological Characteristics, Biochemical Recurrence and Functional Outcome in Radical Prostatectomy Patients on Statin Therapy

Introduction: We assessed the pathological characteristics of the radical prostatectomy specimen, the rate of biochemical failure and the functional outcome after surgery, in terms of incontinence and erectile dysfunction rate, in patients on statin medication. Materials and Methods: A total of 588 patients with a mean age 65.2 years (SD = 5.7 years) participated in the study. All patients were contacted and interviewed. Results: Users who had been on statin medication for more than 2 years had lower levels of preoperative serum PSA (p = 0.034), a 2.76 times greater likelihood of being staged as pT3a to pT3b rather than pT2a to pT2c, and a 5.39 times greater likelihood of having a postoperative Gleason score equal to seven or more. Positive surgical margins and urinary incontinence were not significantly associated with statin use. The probability of erectile dysfunction was significantly greater for statin users. Conclusion: Statin medication was associated with a statistically significantly lower PSA value and an increased rate of high Gleason score and pathologic stage in patients receiving medication for more than 2 years. Statins were found to be an independent predictor of recurrence. Lastly, statin users were more likely to present with preoperative and postoperative erectile dysfunction.

Estrogen receptor (α and β) but not androgen receptor expression is correlated with recurrence, progression and survival in post prostatectomy T3N0M0 locally advanced prostate cancer in an urban Greek population

The objective of this study was to evaluate the expression of estrogen receptors (ER(α) and ER(β)) and androgen receptors (ARs) as prognostic factors for biochemical recurrence, disease progression and survival in patients with pT3N0M0 prostate cancer (PCa) in an urban Greek population. A total of 100 consecutive patients with pT3N0M0 PCa treated with radical prostatectomy participated in the study. The mean age and follow-up were 64.2 and 6 years, respectively. The HSCORE was used for semi-quantitative analysis of the immunoreactivity of the receptors. The prognostic value of the ER(α) and ER(β) and AR was assessed in terms of recurrence, progression, and survival. AR expression was not associated with any of the above parameters; however, both ERs correlated with the prognosis. A univariate Cox regression analysis showed that ER(α) positive staining was significantly associated with a greater hazard for all outcomes. Increased ER(β) staining was significantly associated with a lower hazard for all outcomes in the univariate analysis. When both ER HSCORES were used for the analysis, it was found that patients with high ER(α) or low ER(β) HSCORES compared with patients with negatively stained ER(α) and >1.7 hSCORE ER(β) had 6.03, 10.93, and 10.53 times greater hazard for biochemical disease recurrence, progression of disease and death, respectively. Multiple Cox proportional hazard analyses showed that the age, preoperative prostate specific antigen, Gleason score and ERs were independent predictors of all outcomes. ER expression is an important prognosticator after radical prostatectomy in patients with pT3N0M0 PCa. By contrast, AR expression has limited prognostic value.

Influence of Preoperative Vesicle Biopsy on the Decision for Radical Prostatectomy

AbstractPurpose: The presence of seminal vesicle invasion (SVI) by prostate cancer is difficult to detect clinically and is associated with poor prognosis. The aim of our study was to identify the efficacy of transrectal ultrasound-guided seminal vesicle biopsies in the detection of seminal vesicle invasion (SVI) in patients with prostate cancer. Materials and methods: One hundred transrectal ultrasound-guided seminal vesicle biopsies were performed in 50 patients with clinically localized prostate cancer. Every patient underwent two biopsies, one for a each seminal vesicle. Radical retropubic prostatectomy was performed in all cases and the specimens with the attached seminal vesicles were examined for the presence of prostate cancer invasion. Results: Of a total of 100 seminal vesical biopsies 87 were identified as seminal vesicle by characteristic epithelium. Cancer was found in 7 (8%) biopsies, confirmed in all cases by pathology in the surgical specimen. Eighty biopsies (40 patients) were normal. Pathological analysis of these 40 radical prostatectomy specimens revealed that 6 seminal vesicles (5 patients) were invaded by prostate cancer (6 false negative biopsies, 7.5%). Transrectal ultrasound images of 15 seminal vesicles were suspicious for invasion while 85 were normal. Of the 15 suspicious cases 11 were invaded by cancer (73.3%). Of the sonographically benign seminal vesicles 5 (5.88%) were invaded by cancer. Our data were analyzed by the ARCUS PRO-STAT statistical package. Conclusions: We suggest that transrectal ultrasound-guided seminal vesicle biopsy is useful and reliable for a more exact preoperative staging of prostate cancer, therefore helpful in correct decision making for radical prostatectomy.