Claudio Milani

Results of Contemporary Radical Cystectomy for Invasive Bladder Cancer: A Clinicopathological Study With an Emphasis on the Inadequacy of the Tumor, Nodes and Metastases Classification

We reviewed 261 patients who underwent a radical operation at a single institution as definitive treatment of invasive bladder cancer to evaluate the survival and accuracy of the tumor, nodes and metastasis system in characterizing the prognosis. Between January 1979 and June 1987 the 261 evaluable patients underwent 1-stage radical cystectomy with pelvic node dissection and urinary diversion. No chemotherapy and/or radiation therapy was given before or after the operation. The postoperative mortality rate was 1.8%. The over-all staging error between clinical and pathological stages was as high as 44%. The over-all actuarial 5-year survival rate was 54.5%. The 5-year survival rates were 75% for stage pT1, 63% for stage pT2, 31% for stage pT3 and 21% for stage pT4 disease. A significant difference in the survival (p less than 0.002) was observed in stage pT3 by dividing tumors confined within the bladder wall (pT3a, 50%) from those extending throughout the bladder wall (pT3b, 15%). A careful evaluation of transitional cell involvement of the prostate in stage pT4a cancer led to the identification of 2 different patterns: 1) contiguous when a bladder tumor extended directly into the prostate through the bladder wall and 2) noncontiguous when a bladder tumor and a transitional cell carcinoma of the prostate were found simultaneously. These patterns had completely different (p less than 0.05) survival rates (6 versus 37%). The patients with high grade tumors had a worse prognosis in comparison with those with grades 1 and 2 tumors (41 versus 56%, p less than 0.005). The over-all 5-year survival of patients with positive nodes was 4% in comparison with 60% of those without nodal involvement (p less than 0.001). Despite current optimal surgical treatment, nearly 50% of all patients with invasive bladder cancer continue to die. The need for a modification of the current tumor, nodes and metastasis tumor classification to provide the clinician a more reliable staging system for planning treatment modalities is indeed mandatory.

A Low Dose Bacillus Calmette-Guerin Regimen in Superficial Bladder Cancer Therapy: Is it Effective?

Bacillus Calmette-Guerin (BCG) intravesical therapy represents a major advance in the treatment of superficial transitional cell carcinoma of the bladder. To date, however, the optimal treatment schedule must be defined and the toxicity related to the treatment is significant. The preliminary results of a randomized ongoing study performed to evaluate the effectiveness and relative toxicity of a low dose (75 mg.) BCG regimen in the treatment of superficial bladder cancer therapy are reported. A total of 126 patients (70 for prophylaxis of recurrent stages Ta and T1 papillary tumors and 56 for treatment of carcinoma in situ or with microinfiltration of the subepithelial connective tissue) underwent a 6-week course of 75 mg. BCG (Pasteur vaccine). An additional course was given in patients who failed to respond to the induction course. Maintenance therapy was administered in complete responders monthly for 1 year and then quarterly for 1 year. The prophylaxis group (transurethral resection plus BCG) was randomized versus transurethral resection alone (63 patients, control group). A complete response in the prophylaxis, control and therapy groups was observed in 74, 17 and 57% of the patients, respectively, while 4, 17 and 12.5%, respectively, experienced tumor progression. The additional course of therapy increased the response rate. On the contrary, previous unsuccessful intravesical chemotherapy did not affect the response rate. In regard to toxicity, irritative disturbances (27%) and fever (17%) appeared to be significantly decreased compared with the rates reported in the literature. No major complications were experienced. In conclusion, a low dose (75 mg.) Pasteur strain BCG regimen was effective as prophylaxis against recurrent superficial papillary tumors and as treatment of carcinoma in situ or with microinfiltration of the subepithelial connective tissue. Toxicity related to the treatment appeared to be low.

Functional and cytologic features of the contralateral testis in cryptorchidism

OBJECTIVE To characterize the testicular cytologic pictures in cryptorchild and contralateral testis related to seminal pattern. DESIGN Controlled clinical study. SETTING Andrological and urologic academic setting. PATIENTS One hundred nine patients orchidopexied because of unilateral cryptorchidism compared with 35 normospermic subjects. INTERVENTIONS Bilateral testicular fine-needle aspiration cytology. MAIN OUTCOME MEASURES Seminal parameters; testicular cytologic features; plasma levels of FSH, LH, and T; and ultrasound testicular examination. RESULTS The cytologic analysis revealed an important quantitative and qualitative impairment of spermatogenic line in all the excryptorchid testes. These alterations are present in the contralateral testes only when azoospermia or severe oligozoospermia were observed, whereas in moderate oligozoospermic subjects a normal tubular status was evident. A compensatory activity in normally descended testis of normozoospermic patients was present. CONCLUSIONS In unilateral cryptorchidism, a frequent testicular damage in the orchidopexied and in the contralateral descended testis suggests that this condition is the end point of different pathological conditions, including testicular intrinsic (congenital) and extrinsic (anatomical) causes. Fine-needle aspiration cytology of both testes represents a tool in the assessment of the tubular status in excryptorchid subjects.

Clinical value of pathologic changes after intravesical BCG therapy of superficial bladder cancer

Bladder pathologic features related to intravesical bacillus Calmette-Guerin (BCG) therapy in superficial bladder cancer (Ta, T1, Tis) were evaluated and related to clinical outcome. A total of 105 patients were treated with 75 mg Pasteur BCG weekly for six consecutive weeks. When tumor was not demonstrated a maintenance course was given. An additional six-week course was given when tumor recurrence or persistence, without progression, was observed after the induction course. An inflammatory change in the bladder was the most common pathologic finding. Granuloma was the only specific BCG-related feature and did not appear to be a prognostic factor because of low incidence (24%) and lack of correlation with clinical course. Dysplasia occurred more frequently (57%) in nonresponder patients and (26%) in responder patients, often heralding recurrence of tumor. All patients showing concurrent squamous and/or glandular metaplasia were unresponsive to BCG therapy. Histology and cytology did not correlate perfectly: cytology was ineffective in low-grade tumors and improved diagnostic accuracy, particularly when dysplasia was histologically evident.

Obstruction or no obstruction

The authors review critically such parameters as symptomatology, post-micturition residual urine, bladder trabeculation and uroflowmetry that in the actual state of the art appear more accredited in the evaluation of lower urinary tract obstruction. All have some interpretative limits. However, uroflowmetry appears to be the most reliable and for this reason it is the first step in the study of suspected infravesical obstruction. It can discover equivocal situations in which pressure-flow studies only supply diagnostic help in order to avoid false diagnosis of infravesical obstruction and useless therapeutic approaches.

Renal agenesis, ureteral ectopia into seminal vesicle, vas deferens agenesis and hemivertebra: An incomplete form of caudal regression syndrome?

The association of seminal vesicle cyst and upper urinary tract malformation is well known in the literature [1]. More rarely, urogenital malformations are associated with vertebral [2] or anorectal anomalies [3].A 35-year-old infertile man with unilateral renal and deferential agenesis, seminal vesicle cyst and hemivertebra is reported.This complex malformative syndrome has been reported previously by Sheih et al. [4] and, to our knowledge, this is the third case described in the literature.

A four-year experience with Holmium-YAG laser:parameters of use

In the last years, laser has gained increasingly high popularity in Endourology. The newer generation Ho-YAG lasers represent the most updated laser used in Urology, being able to successfully treat both urinary stones and soft tissue lesions. The aim of this work was to report a multicentre 4-year experience using the Ho-YAG laser in the treatment of stones and soft tissue lesions, in order to offer parameters and modalities of use in several different situations. MATERIALS AND METHODS. Two urological Centers were asked between 2002 and 2005 to use Coherent Versa Pulse 20 Ho-YAG laser source in the treatment of urinary stones in 212 patients, and urinary soft tissue lesions (urethra, ureter or bladder neck strictures or urinary tract tumors) in 56 patients. According to the various situations (either stone fragmentation or treatment of soft tissue lesions), pulse frequency and energy per impulse were differently dosed and set. RESULTS. The following parameters were identified as the starting points for the correct use of the Ho-YAG laser: a) lithotripsy with rigid endoscope: 365 μm fiber, 0.8 - 1.2 Joule (J) energy and 6-8 Hz frequency; 365 μm fiber, 0.8-1.2 J energy and 10-12 Hz frequency; 550 μm fiber, 1.0-1.5 J energy and 10-12 Hz frequency. b) lithotripsy with flexible endoscope: 270 μm fiber, 0.6-1.0 J energy and 6-10 Hz frequency. c) soft tissue resection in case of: c1) ureteral stricture, 365 μm fiber, 0.6 J energy and 14-16 Hz frequency; c2) urethral stricture, 365 μm fiber, 0.7 J energy and 16-18 Hz frequency; c3) upper urinary tract tumors, 365 μm fiber, 0.7 J energy and 16 Hz frequency; c4) bladder tumors 365 μm fiber, 0.8 J energy and 16-20 Hz frequency; c5) bladder neck strictures, 365 μm fiber, 1.0 J energy and 16-18 Hz frequency. CONCLUSIONS. In the light of these parameters, Ho-YAG laser is a very handy instrument for the treatment of both urinary stones and soft tissue lesions, which allows to put aside the current tools used for the same purposes.