C. Scoffone

The number of lymph nodes examined and staging accuracy in renal cell carcinoma.

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

Monoclonal Antibody Ki-67 in the Study of the Proliferative Activity of Bladder Carcinoma

We studied the proliferative activity of bladder carcinoma using monoclonal antibody Ki-67, which is able to stain a nuclear antigen exclusively present in cells in the cell cycle, that is with activated deoxyribonucleic acid (DNA). We used this immunohistochemical technique on neoplastic tissue removed by transurethral resection from 101 patients. A significant correlation was observed (p less than 0.003) between cells with activated DNA and histological grading, even though within the context of each grade we observed tumors with a different proliferation index. Furthermore, we studied the location of the activated cells in the context of the tumor. In invasive tumors (stages T1 to T4) cells with activated DNA were always present at the base of implant of the tumor and in the neoplastic tissue that infiltrates the bladder wall. In regard to noninvasive tumors (stage Ta), in 57% of the cases most cells with activated DNA were present in the vegetative portion of the tumor and there were no recurrences at followup, while in 43% of the cases such cells were present also or especially at the base of implant of the tumor, near the lamina propria. In the latter patients we observed a 94% recurrence rate. These results suggest that the immunohistochemical assessment of the proliferative activity of transitional tumors of the bladder, using monoclonal antibody Ki-67, and the evaluation of the location of stained neoplastic cells provide a more reliable estimate of biological aggressiveness than that obtained with histopathological patterns alone.

Results from an international multicentre double-blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate: COMPARISON OF B-TURP VS M-TURP IN A MULTICENTRE RCT SETTING

Study Type – Therapy (RCT)

Results from an international multicentre double‐blind randomized controlled trial on the perioperative efficacy and safety of bipolar vs monopolar transurethral resection of the prostate

Sir, Voiding symptoms due to BPH are common, with endoscopic transurethral resection (TUR) of the obstructing tissue still considered the ‘ gold standard ’ with 20 000 procedures undertaken in the UK in 2007, at an average annual cost of ≈ £ 70 million [ 1 ] . The authors are correct that traditional monopolar TUR of the prostate (mTURP) does have historical disadvantages for blood loss and risk of electrolyte disturbance, and as such, alternative technologies have been developed to match the symptom improvement, whilst reducing morbidity and hospital stay. This well designed randomised controlled trial highlights data in accordance with the contemporary clinical impression that the rates of TUR syndrome (0.7%) and blood loss requiring transfusion (2.9%) for mTURP are low; and that the total complication rate is comparable with the newer bipolar TURP (bTURP) technology (31 vs 27%) [ 2 ] . Although the authors have compared catheterisation times between mTURP and bTURP (3.0 vs 3.1 days), the data is conspicuously lacking in not addressing the important question of hospital stay between the groups. This parameter is widely used as the economic driver for the introduction of laser or bipolar technology as a day case procedure. Health services across the globe are facing unprecedented reforms. With budget static in real terms, the UK ’ s NHS needs to fi nd effi ciencies worth £ 15 – 20 billon over the next 4 years to keep pace with rising demand. Increasing the relative amount of day-case and short-stay elective surgery is an obvious source of savings. However, the evidence for an economic benefi t with bTURP is limited, and often dependent on comparative mTURP hospital stays of > 2 days [ 1,3 – 5 ] . We would argue that a 23-h stay should be the preoperative intention in all patients undergoing mTURP, and routine in-patient stays in excess of this should be consigned to history. We audited 125 mTURP cases at our institution over 12 months, with the intention preoperatively of undertaking them as a short-stay procedure. The median hospital stay was < 23 h in all-comers. The mean weight of tissue resected was 23.4 g. The median time to trial without catheter (TWOC) was 4 days; with a successful TWOC rate of 94%. We have achieved this through a combination of improved patient and staff education and hence expectation; meticulous haemostasis; and the addition of postoperative diuresis with one dose of i.v. furosemide or mannitol. The patient is managed in a streamlined 23-h short-stay unit with bladder irrigation discontinued in recovery, and early mobilisation encouraged. This has maximised throughput of patients without compromising outcomes.

Midterm Results from an International Multicentre Randomised Controlled Trial Comparing Bipolar with Monopolar Transurethral Resection of the Prostate

BACKGROUND Pooled data from randomised controlled trials (RCTs) with short-term follow-up have shown a safety advantage for bipolar transurethral resection of the prostate (B-TURP) compared with monopolar TURP (M-TURP). However, RCTs with follow-up >12 mo are scarce. OBJECTIVE To compare the midterm safety/efficacy of B-TURP versus M-TURP. DESIGN, SETTING, AND PARTICIPANTS From July 2006 to June 2009, TURP candidates with benign prostatic obstruction were consecutively recruited in four centres, randomised 1:1 into the M-TURP or the B-TURP arm and regularly followed up to 36 mo postoperatively. A total of 295 patients were enrolled. INTERVENTION M-TURP or B-TURP using the AUTOCON II 400 electrosurgical unit. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Safety was estimated by complication rates with a special emphasis on urethral strictures (US) and bladder neck contractures (BNCs) recorded during the short-term (up to 12 mo) and midterm (up to 36 mo) follow-up. Efficacy quantified by changes in maximum urine flow rate, postvoid residual urine volume, and International Prostate Symptom Score was compared with baseline, and reintervention rates in each arm were also evaluated. RESULTS AND LIMITATIONS A total of 279 patients received treatment after allocation. Mean follow-up was 28.8 mo. A total of 186 of 279 patients (66.7%) completed the 36-mo follow-up. Posttreatment withdrawal rates did not differ significantly between arms. Safety was assessed in 230 patients (82.4%) at a mean follow-up of 33.4 mo. Ten US cases were seen in each arm (M-TURP vs B-TURP: 9.3% vs 8.2%; p=0.959); two versus eight BNC cases (M-TURP vs B-TURP: 1.9% vs 6.6%; p=0.108) were collectively detected at the midterm follow-up. Resection type was not a significant predictor of the risk of US/BNC formation. Efficacy was similar between arms and durable. A total of 10 of 230 patients (4.3%) experienced failure to cure and needed reintervention without significant differences between arms. High overall reintervention rates, withdrawal rates, and sample size determination not based on US/BNC rates represent potential limitations. CONCLUSIONS The midterm safety and efficacy of B-TURP and M-TURP are comparable. TRIAL REGISTRATION Netherlands Trial Register, NTR703 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=703).

Position: prone or supine is the issue of percutaneous nephrolithotomy.

INTRODUCTION The prone position has been considered the only position for percutaneous access to the kidney for the past 25 years, whereas the supine Valdivia position has recently started to gain acceptance, although it was originally described in the late 1980s. Even more recently, the Galdakao-modified supine Valdivia position was described. However, there is no consensus on which is the best position for percutaneous nephrolithotomy, and the choice is currently based on the surgeons preference. MATERIALS AND METHODS The prone, supine, and modified supine positions are described, pointing out the advantages, disadvantages, and results of each technique. RESULTS A number of potential advantages have been described for the supine over the prone position: less cardiovascular change; no need for patient repositioning (with less associated risk of central and peripheral nervous system injury); less X-ray exposure to the surgeon; and less risk of colonic injury. The recently described Galdakao-modified supine Valdivia position allows for a simultaneous anterograde and retrograde approach to the renal cavities for the one-stage treatment of complex renal stones or concurrent renal and ureteral calculi. Moreover, the use of a flexible ureteroscope allows for Endovision puncture to achieve perfect access to the kidney. CONCLUSIONS The prone position still represents the standard for percutaneous access to the kidney, and other positions should be compared with this position. However, the supine and the modified supine positions have potentially important advantages for both patients and surgeons that need to be investigated in a large randomised trial to define their superiority over the traditional prone position.

Does imaging modality used for percutaneous renal access make a difference? A matched case analysis.

OBJECTIVE To assess perioperative outcomes of percutaneous nephrolithotomy (PCNL) using ultrasound or fluoroscopic guidance for percutaneous access. METHODS A prospectively collected international Clinical Research Office of the Endourological Society (CROES) database containing 5806 patients treated with PCNL was used for the study. Patients were divided into two groups based on the methods of percutaneous access: ultrasound versus fluoroscopy. Patient characteristics, operative data, and postoperative outcomes were compared. RESULTS Percutaneous access was obtained using ultrasound guidance only in 453 patients (13.7%) and fluoroscopic guidance only in 2853 patients (86.3%). Comparisons were performed on a matched sample with 453 patients in each group. Frequency and pattern of Clavien complications did not differ between groups (p=0.333). However, postoperative hemorrhage and transfusions were significantly higher in the fluoroscopy group: 6.0 v 13.1% (p=0.001) and 3.8 v 11.1% (p=0.001), respectively. The mean access sheath size was significantly greater in the fluoroscopy group (22.6 v 29.5F; p<0.001). Multivariate analysis showed that when compared with an access sheath ≤ 18F, larger access sheaths of 24-26F were associated with 3.04 times increased odds of bleeding and access sheaths of 27-30F were associated with 4.91 times increased odds of bleeding (p<0.05). Multiple renal punctures were associated with a 2.6 odds of bleeding. There were no significant differences in stone-free rates classified by the imaging method used to check treatment success. However, mean hospitalization was significantly longer in the ultrasound group (5.3 v 3.5 days; p<0.001). CONCLUSIONS On univariate analysis, fluoroscopic-guided percutaneous access was found to be associated with a higher incidence of hemorrhage. However, on multivariate analysis, this was found to be related to a greater access sheath size (≥ 27F) and multiple punctures. Prospective randomized trials are needed to clarify this issue.

Evaluation of c-RAS oncogene product (p21) in superficial bladder cancer

OBJECTIVES The aim of our study is the evaluation of the prognostic importance of p21 protein in superficial bladder cancer. METHODS One hundred and fourteen patients with an initial diagnosis of monofocal bladder cancer (stage Ta-T1) following TUR were investigated. On the tissue removed by TUR, besides the usual pathological evaluation, an immuno-histochemical investigation was carried out in order to ascertain the presence of c-ras oncogene product (protein p21). The actuarial curves concerning the time free from the first recurrence were computed, comparing different subgroups in regard to protein p21 presence, grade and stage of the tumour. RESULTS The analysis of the results shows the importance of tumour stage as a predictor of recurrence, as well as that of the presence of c-ras products. This last factor increases the risk of recurrence almost 2-fold, in the same time lag, for c-ras-positive patients (p < 0.001). The prognostic significance of c-ras is independent of stage. CONCLUSION Our data underline the possibility of acquiring important information on the prognosis of superficial bladder cancer patients, pointing out the significance of c-ras oncogene product.

Bipolar vs monopolar transurethral resection of the prostate: evaluation of the impact on overall sexual function in an international randomized controlled trial setting

The effect of TURP on overall sexual function and particularly erectile function (EF) is controversial with conflicting results based on a low level of evidence. The effects of monopolar and bipolar TURP (M‐TURP and B‐TURP, respectively) on EF are similar, as has been shown in a few non‐focused randomized control trials (RCTs). For the first time, the present study offers focused results of a comparative evaluation of the effects of B‐TURP and M‐TURP on overall sexual function, as quantified with the International Index of Erectile Function Questionnaire (IIEF‐15) in an international, multicentre, double‐blind RCT setting.

ECIRS (Endoscopic Combined IntraRenal Surgery) in the Galdakao-modified supine Valdivia position: a new life for percutaneous surgery?

BackgroundPercutaneous nephrolithotomy (PNL) is still the gold-standard treatment for large and/or complex renal stones. Evolution in the endoscopic instrumentation and innovation in the surgical skills improved its success rate and reduced perioperative morbidity. ECIRS (Endoscopic Combined IntraRenal Surgery) is a new way of affording PNL in a modified supine position, approaching antero-retrogradely to the renal cavities, and exploiting the full array of endourologic equipment. ECIRS summarizes the main issues recently debated about PNL.MethodsThe recent literature regarding supine PNL and ECIRS has been reviewed, namely about patient positioning, synergy between operators, procedures, instrumentation, accessories and diagnostic tools, step-by-step standardization along with versatility of the surgical sequence, minimization of radiation exposure, broadening to particular and/or complex patients, limitation of post-operative renal damage.ResultsSupine PNL and ECIRS are not superior to prone PNL in terms of urological results, but guarantee undeniable anesthesiological and management advantages for both patient and operators. In particular, ECIRS requires from the surgeon a permanent mental attitude to synergy, standardized surgical steps, versatility and adherence to the ongoing clinical requirements. ECIRS can be performed also in particular cases, irrespective to age or body habitus. The use of flexible endoscopes during ECIRS contributes to minimizing radiation exposure, hemorrhagic risk and post-PNL renal damage.ConclusionsECIRS may be considered an evolution of the PNL procedure. Its proposal has the merit of having triggered the critical analysis of the various PNL steps and of patient positioning, and of having transformed the old static PNL into an updated approach.