C. Fiori

Effectiveness of nifedipine and deflazacort in the management of distal ureter stones

OBJECTIVES To evaluate the effectiveness of medical therapy during watchful waiting in patients with distal ureter stones. METHODS Ninety-six patients with radiopaque stones located in the distal tract of the ureter and with stone sizes of 1 cm or smaller were involved in the study. The patients were randomly divided into two groups. Group A (n = 48) received oral treatment with 30 mg of deflazacort daily (maximum 10 days) plus 30 mg of slow-release nifedipine daily (maximum 4 weeks). Group B (n = 48) underwent a wait-and-watch approach. Both groups of patients were allowed to use diclofenac on demand. Statistical analyses were carried out using Students t test, the chi-square test, and Fishers exact test. RESULTS The average stone size was 5.8 +/- 1.8 mm for group A and 5. 5 +/- 1.4 mm for group B. No statistically significant difference was found in stone size. Stone expulsion was observed in 38 (79%) of 48 patients in group A and in 17 (35%) of 48 patients in group B. The average expulsion time was 7 days (range 2 to 10) for group A and 20 days (range 10 to 28) for group B. A statistically significant difference was observed in both the expulsion rate and the expulsion time (P <0.05). The mean amount of sodium diclofenac used was 15 mg per patient for group A and 105 mg per patient for group B (P <0.05). CONCLUSIONS The medical treatment proved to be effective and safe, as demonstrated by the increased stone expulsion rate, decreased expulsion time, and reduced need for analgesic therapy.

Randomised Controlled Trial Comparing Laparoscopic and Robot-assisted Radical Prostatectomy

BACKGROUND The advantages of robot-assisted radical prostatectomy (RARP) over laparoscopic radical prostatectomy (LRP) have rarely been investigated in randomised controlled trials. OBJECTIVE To compare RARP and LRP in terms of the functional, perioperative, and oncologic outcomes. The main end point of the study was changes in continence 3 mo after surgery. DESIGN, SETTING, AND PARTICIPANTS From January 2010 to January 2011, 120 patients with organ-confined prostate cancer were enrolled and randomly assigned (using a randomisation plan) to one of two groups based on surgical approach: the RARP group and the LRP group. INTERVENTION All RARP and LRP interventions were performed with the same technique by the same single surgeon. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The demographic, perioperative, and pathologic results, such as the complications and prostate-specific antigen (PSA) measurements, were recorded and compared. Continence was evaluated at the time of catheter removal and 48 h later, and continence and potency were evaluated after 1, 3, 6, and 12 mo. The student t test, Mann-Whitney test, χ(2) test, Pearson χ(2) test, and multiple regression analysis were used for statistics. RESULTS AND LIMITATIONS The two groups (RARP: n=60; LRP: n=60) were comparable in terms of demographic data. No differences were recorded in terms of perioperative and pathologic results, complication rate, or PSA measurements. The continence rate was higher in the RARP group at every time point: Continence after 3 mo was 80% in the RARP group and 61.6% in the LRP group (p=0.044), and after 1 yr, the continence rate was 95.0% and 83.3%, respectively (p=0.042). Among preoperative potent patients treated with nerve-sparing techniques, the rate of erection recovery was 80.0% and 54.2%, respectively (p=0.020). The limitations included the small number of patients. CONCLUSIONS RARP provided better functional results in terms of the recovery of continence and potency. Further studies are needed to confirm our results.

Assessment of surgical margins in renal cell carcinoma after nephron sparing: a comparative study: laparoscopy vs open surgery.

PURPOSE We compared the status of the peritumoral parenchyma after open and laparoscopic nephron sparing surgery for renal cell carcinoma. MATERIALS AND METHODS The records of 64 consecutive patients who underwent nephron sparing surgery for renal cell carcinoma of 4 cm or less were reviewed retrospectively. Patients in group 1 underwent open retroperitoneal surgery (1998 to 2000) and patients in group 2 underwent laparoscopic (transperitoneal or retro peritoneal) surgery (2001 to March 2004). A single pathologist was employed to analyze the specimens, and comparative analysis included examination of tumor size, weight, histological cell type, intraoperative histological biopsies and margin status. RESULTS The 2 groups were comparable in terms of clinical data, and mean lesion size was 31.4 mm in group 1 and 32 mm in group 2. Positive margins were found in 1 of 30 patients in group 1 and in 1 of 34 in group 2 (p = 0.9). An analysis of margins was performed by taking measurements at the minimum and maximum points of the section. The minimum mean measurement was 2 mm in group 1 and 2.08 mm in group 2 (p = 0.75). The maximum mean measurement was 4.56 mm in group 1 and 5.2 mm in group 2 (p = 0.09). The difference between minimum and maximum margin thickness was 2.56 mm in group 1 and 3.16 mm in group 2 (p = 0.04). Mean followup for group 1 was 50 months (range 30 to 72) and 16 months (range 2 to 35) for group 2. One local recurrence was recorded in group 1 and treated with radical nephrectomy, while no recurrence was recorded in group 2. CONCLUSIONS In this study we further confirmed the efficiency of resectioning lesions using laparoscopy. In our experience there is no difference between the 2 procedures in terms of efficient surgical margins. However, despite these encouraging results it is necessary to obtain more extensive followup data, which will allow us to be more specific in reporting on laparoscopic margin quality.

Long-Term Functional Evaluation of the Treated Kidney in a Prospective Series of Patients Who Underwent Laparoscopic Partial Nephrectomy for Small Renal Tumors

BACKGROUND Renal scintigraphy may allow long-term monitoring of ischemic damage after partial nephrectomy (PN). OBJECTIVE Evaluate use of renal scintigraphy for evaluating long-term effects of warm ischemia on renal function in patients with a normal contralateral kidney. DESIGN, SETTING, AND PARTICIPANTS We prospectively examined kidney function of 54 patients who underwent laparoscopic PN (LPN). Minimum follow-up time was 4 yr. INTERVENTION LPN was performed with warm ischemia by transperitoneal or retroperitoneal approach. MEASUREMENTS Demographic, perioperative, and pathologic data and postoperative complications were registered. Split renal function (SRF) and effective renal plasma flow (ERPF) were evaluated by renal scintigraphy preoperatively, at 3 and 12 mo postoperatively, then yearly. Baseline weighted differentials (b-WDs) of both SRF and ERPF in the affected kidney were calculated between baseline condition and every time point. Multivariate linear regression was used to find independent variables for increased b-WDs at 3 and 48 mo. P values<0.05 were considered significant. RESULTS AND LIMITATIONS The SRF and ERPF of kidneys treated by LPN decreased significantly at month 3 and subsequently remained stable through the duration of follow-up. Conversely, neither serum creatinine nor estimated glomerular filtration rate changed significantly during follow-up. The regression model showed statistical significance at month 3 for warm ischemia time (WIT) and age, whereas at 48 mo, statistical significance was reached by WIT alone. No new onset of cardiovascular disease was registered. No evidence of local recurrence was recorded with computed tomography scan. Our study may be underpowered due to small sample size; however, this is one of the largest long-term prospective series using renal scintigraphy to evaluate the renal function after LPN. CONCLUSIONS WIT contributes to irreversible kidney damage observed at month 3 that does not appear to worsen.

Heparin Coating on Ureteral Double J Stents Prevents Encrustations: An in Vivo Case Study

PURPOSE To evaluate the ability of heparin coating to inhibit Double J stent encrustation and compare it with the classic polyurethane Double J stent. PATIENTS AND METHODS The study involved five patients with bilateral obstructions, who required bilateral ureteral Double J stent placement. Every patient received a heparin-coated Double J stent and a traditional polyurethane Double J stent for 1 month. After removal, the stents were analyzed using field emission scanning electron microscopy (FESEM), energy dispersive spectroscopy (EDS), and micro-infrared spectrophotometry (Micro-IR). These same techniques were used to analyze the heparin-coated and uncoated stents before insertion. The thickness, extension, and composition of encrustation of the coated and uncoated stents were compared. Moreover, two heparin-coated stents were analyzed with the same techniques after they had been in place for 10 and 12 months. RESULTS FESEM analysis showed that the difference in encrustation thickness and extension between the two groups was significant. EDS and Micro-IR confirmed that in the heparinized stents the encrustations were not as uniform and compact as those in the uncoated stents. The stents that were left in place long-term were free of encrustations and had no changes in the heparin layer. CONCLUSIONS Heparin coating reduces stent encrustation. Moreover, as no changes were seen in the heparin layer, we concluded that covalent heparin bonding enhances its adhesion to the polyurethane surface and ensures its stability for long periods. The heparin-coated stent appears to be a useful tool for long-term urinary drainage.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy

OBJECTIVES To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma. METHODS A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearsons correlation coefficient, Fishers exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results. RESULTS A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conns adenoma, Cushings adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters. CONCLUSIONS Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Addition of Docetaxel to Androgen Deprivation Therapy for Patients with Hormone-sensitive Metastatic Prostate Cancer: A Systematic Review and Meta-analysis

CONTEXT Several randomized clinical trials (RCTs) have recently tested the early addition of docetaxel to androgen deprivation therapy (ADT) in hormone-sensitive metastatic prostate cancer (PCa). OBJECTIVE To perform a systematic review and meta-analysis of RCTs evaluating the combination of docetaxel and ADT in hormone-sensitive metastatic PCa. The primary end point was overall survival (OS). Secondary end point was progression-free survival. Exploratory subgroup analysis according to high-volume versus low-volume disease was performed. EVIDENCE ACQUISITION A systematic review of PubMed/Medline, Embase, and the proceedings of major international meetings was performed in June 2015 and updated in August 2015. Three trials were selected for inclusion. EVIDENCE SYNTHESIS Overall, 2951 patients were included in the three trials. Two trials enrolled only metastatic patients; in the third trial, 61% were metastatic. A total of 2262 patients (951 docetaxel and ADT; 1311 ADT alone) were metastatic. Most patients had a good performance status. In metastatic patients, the addition of docetaxel was associated with improved OS (hazard ratio [HR]: 0.73; 95% confidence interval [CI], 0.60-0.90; p=0.002), with nonsignificant heterogeneity among the three trials. Considering the whole study population (2951 patients), the addition of docetaxel was associated with a similar OS improvement (HR: 0.74; 95% CI, 0.61-0.91; p=0.003). Although with limited statistical power, no significant interaction was demonstrated between the addition of docetaxel and the high or low volume of disease (p=0.5). The addition of docetaxel was associated with improvement in progression-free survival (metastatic patients: HR: 0.63; 95% CI, 0.57-0.70; p<0.001). CONCLUSIONS This meta-analysis shows a significant OS benefit from concomitant administration of docetaxel and ADT in patients with metastatic hormone-sensitive PCa. PATIENT SUMMARY We synthesized the evidence available about the early administration of docetaxel in patients starting hormonal treatment for metastatic prostate cancer. Based on the results of this meta-analysis, we believe the combination of chemotherapy and hormonal treatment should be considered in fit patients.

A debate on laparoscopic versus open adrenalectomy for adrenocortical carcinoma

Adrenocortical cancer (ACC) is a rare disease that is difficult to treat. Surgery remains the primary treatment modality and the only chance for cure in these patients. Since the early 1990s, laparoscopic adrenalectomy (LA) has replaced open adrenalectomy (OA) as the gold standard for addressing adrenal disorders of benign origin; however, the oncologic effectiveness of laparoscopic adrenalectomy for resection of primary adrenocortical malignancies remains unclear. Since the initial consensus statement from the International Adrenal Cancer Symposium held in Ann Arbor, MI in 2003, a number of studies have investigated the question of equivalence of LA compared to OA for ACC. Several controversial topics were debated during the 3rd International Adrenal Cancer Symposium held in Wurzburg, Germany in 2011. This debate sought to review the advantages and disadvantages of OA versus LA and review findings of recent studies related to the topic. As all studies involving this topic have methodological flaws, some more than others, the results of each study must be interpreted with caution. In conclusion, this debate will undoubtedly continue well into the future; however, it is clear that an oncologically appropriate surgical resection is of the utmost importance for the treatment of ACC and there is only one chance to achieve this. Poor outcomes will result from inadequate surgery, whether performed by an open or laparoscopic approach. Therefore, there is no doubt that surgery for suspected ACC should only be performed in specialized centers.

Is laparoscopic adrenalectomy feasible for adrenocortical carcinoma or metastasis

To review our experience with laparoscopic adrenalectomy (LA), to evaluate the effectiveness and safety of this procedure in patients with adrenal malignancy.

Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: impact of learning curve and tumour anatomical characteristics.

To present our laparoscopic partial nephrectomy (LPN) results according to the margin, ischaemia and complications (MIC) system recently proposed for the standardized reporting of partial nephrectomy (PN) outcomes. To assess the role of learning curve and tumour anatomical characteristics on the outcomes by using MIC system.