D. Melloni

Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions.

OBJECTIVES Contemporary series of open prostatectomies from Western countries are rare. Frequently, the analysis of the outcome of open prostatectomy refers to old experiences or to series from developing countries. Any comparison with transurethral resection of the prostate can be invalidated by complications of open surgery because of the lack of an adequate healthcare system and technology. METHODS The Sicilian-Calabrian Society of Urology performed a retrospective study to assess the surgical management of benign prostatic hyperplasia in Sicily and Calabria in 1997 and 1998. A three-page questionnaire was sent to the 36 urologic units of these two Italian regions with more than 7.5 million inhabitants. RESULTS Twenty-six units (72.3%) replied. Of 31,558 patients treated for symptomatic benign prostatic hyperplasia, 5636 underwent surgery. Open prostatectomy (n = 1804) accounted for 32% of all surgical treatment. The median prostate volume was 75 cm(3) and the median serum prostate-specific antigen level was 3.7 ng/mL. The postoperative median hospitalization time was 7 days. Concomitant low urinary tract disease was present in 25% of the patients. Severe bleeding occurred in 11.6% of open prostatectomies. Blood transfusions were given in 8.2% of cases. Sepsis was reported in 8.6% of the patients. Reinterventions, within 2 years, mainly due to bladder neck stenosis, were reported in 3.6% of cases. CONCLUSIONS The results of the present survey provide a current picture of open prostatectomy. This procedure, even if performed nowadays and in Western countries, shows the same significant rate of early and late complications reported in the past or in less-developed countries.

PSA reduction (after antibiotics) permits to avoid or postpone prostate biopsy in selected patients.

Microscopic foci of prostatitis may induce prostate-specific antigen (PSA) increase. PSA reduction after antibiotics might identify those patients in whom biopsy can be avoided. Ninety-nine patients received ciprofloxacin for 3 weeks, of whom 59 showed PSA reduction. Histology detected small foci of prostatitis in 65% of cases. Carcinoma was found in 40 and 20.3% of patients with unchanged or decreased PSA, respectively (P=0.03). No cancer was detected if PSA decreased below 4 ng/ml or more than 70%. Biopsy can be postponed, with a low risk of missing a cancer, if PSA decreases more than 70% or below 4 ng/ml.

ESWL Prediction of Outcome and Failure Prevention

Based on our own experiences and a review of the recent literature, this article evaluates recent developments in predicting outcomes and failures of shockwave lithotripsy when treating patients with urinary tract stones. After a detailed MEDLINE research, the authors identified several variables that influence and predict extracorporeal shockwave lithotripsy (ESWL) success. These variables may be categorized as stone variables, patient variables and operator variables. Only multivariate analysis on a large number of homogenous patients may offer an objective evaluation of the factors conditioning ESWL outcome.

Biological aggressiveness evaluation in prostate carcinomas: immunohistochemical analysis of PCNA and p53 in a series of Gleason 6 (3+3) adenocarcinomas

We selected 63 prostate tumors with Gleasons grade 6 (3+3), commonly showing both tubular and cribrous patterns. We compared in both patterns the expression of two of the most used biologic markers: PCNA and p53, with the aim to verify the validity of the Gleasons grading system to compare the morphologic grade with biologic aggressiveness and prognostic value. We did not find any statistical difference in the protein immunopositivity, indicating that both patterns could have identical biologic behaviour; then we confirmed the validity of Gleasons system for considering both tubular and cribrous patterns as an intermediate grade of tumoral differentiation. Moreover, we found a linear relationship between the increase of PCNA and the accumulation of mutated p53; this datum could confirm the hypothesis that p53 mutation is a late event in prostate carcinogenesis.

A Randomized Trial Comparing Tamoxifen Therapy vs. Tamoxifen Prophylaxis in Bicalutamide-Induced Gynecomastia

BACKGROUND Tamoxifen (TAM) has been shown to be active against the bicalutamide-induced breast events (BEs) gynecomastia, and breast pain in patients with prostate cancer (PC). Optimal doses and schedules are not yet established. Debate still exists about whether prophylaxis with TAM is more effective than treatment of BEs when diagnosed. The results of a randomized study comparing TAM prophylaxis vs. TAM therapy are presented. METHODS One hundred seventy-six patients with prostate cancer (PC) who were candidates for bicalutamide monotherapy were randomized to receive TAM 20 mg daily orally within 1 month from the onset of BEs (arm A) vs. TAM 10 mg daily starting simultaneously with bicalutamide (arm B). TAM was administered for up to 1 year. BEs were evaluated by a self-administered visual analogue scale. Neither ultrasonography nor calipers were used to measure the degree of gynecomastia. RESULTS In arm A, BEs showed a prevalence, increasing with time up to 78.3%. After therapy with TAM they persisted in 27.7% of cases. Two patients (3%) interrupted TAM therapy because of dizziness, and 3 patients (4%) interrupted bicalutamide therapy because of painful gynecomastia. In arm B, the prevalence of BEs was 35% after 12 months of therapy. The difference in BEs between the 2 arms was statistically significant (P < .0001). The differences in prevalence of gynecomastia and breast pain between the 2 arms both favored TAM prophylaxis (P < .0001 and P < .001, respectively). Up to 35% of patients had BEs of low intensity, never requiring bicalutamide withdrawal. Two patients (3%) interrupted the treatment because of gastrointestinal intolerance. No difference emerged between the 2 arms in terms of prostate-specific antigen (PSA) response, plasma testosterone levels, and tumor progression. CONCLUSION Bicalutamide-induced BEs can be prevented to a significant degree by prophylaxis with TAM 10 mg/day or effectively treated with TAM therapy 20 mg/day. Persisting BEs are of higher intensity after therapy than after prophylaxis.

Pathophysiology and Clinical Aspects of Urinary Lithiasis

Urine is a complex balanced solution containing dissociated and non-dissociated solutes. Any variation in urine saturation grade (number of crystals dissolved in a volume of urine), urinary pH and the concentration of crystallization inhibitors can break the normal existing balance and lead to urolithiasis. In the present article we analyze the principal mechanisms (absorptive, renal, resorptive) of hypercalciuria. It will be also shown how heredity directly influences the clinical aspects of cystine, xanthine and oxalate lithiasis and how diet, in association with metabolic disorders, interferes in uric acid and oxalate stone formation. Finally, we report on the roles of urinary tract malformations, urinary tract infections and drugs in the clinical characterization of urolithiasis.

Relationship of flow rate with symptoms, quality of life and other clinical parameters in patients with LUTS suggestive of BPH.

Aim: The uroflowmetry data of a selected number of patients who took part to the QUIBUS study (366 traces selected after quality control by a central panel of reviewer) were evaluated for their relationships with age, prostate volume, and IPSS and ICS-BPH scores. Waiting time, flow time, voided volume, maximum flow rate (Qmax) and average flow rate (Qave) were the flow variables considered for analysis. Only measurements with total voided volume exceeding 100 ml were included. Results: An increasing percentage of subjects with voided volume <200 ml was observed over 65 years of age. Age did not affect neither Qave nor Qmax (p = n.s. at correlation analysis). In particular, Qmax was <15 ml/s in about 70% of patients independently of age. Prostate enlargement was inversely associated with voided volume, Qmax and Qave, showing a worsening of urinary function for increasing values of prostate volume Qmax was negatively correlated with IPSS total score and with most single items with the exception of two storage symptoms such as repeated urination and nocturia). Accordingly, Qmax was inversely associated with the total score ICS-BPH for voiding symptoms to a higher extent (r = –0.31, p < 0.01) than with the one for storage symptoms (r = –0.22, p < 0.01). Flow variables were inversely correlated with IPSS-QoL. Conclusion: Uroflowmetry and IPSS, although not allowing a definitive diagnosis of obstruction, may nonetheless satisfy the clinical need of a rapid, easy and accurate tool for the noninvasive screening of LUTS patients.

Management of Symptomatic Benign Prostatic Hyperplasia in Southern Italy: A Retrospective Analysis of the Sicilian-Calabrian Society of Urology (SSCU) of 32,000 Patients

Introduction: The availability of new pharmacological and surgical options is responsible for important changes in the management of symptomatic benign prostate hyperplasia (BPH). The Sicilian-Calabrian Society of Urology performed a retrospective survey to assess the management of BPH in southern Italy in 1997 and 1998. Patients and Methods: A 3-page questionnaire was sent to the 36 urological units of these two regions. The real number of patients treated was required. The numbers were checked with data obtained from the Health Regional Offices. Results: Twenty-six urological units (72.3%) replied. Almost all patients underwent urinalysis, determination of serum prostate-specific antigen and creatinine levels, and renal and postvoid vesical echography. Uroflowmetry was performed in 69% and transrectal ultrasound in 56% of the patients. International Prostate Symptom Score or other symptom scores were used in 36% of the cases. Out of 31,558 patients with symptomatic BPH, 5,636 were surgically treated. Admission was due to acute urinary retention in 1,324 cases (23.5%). Transurethral resection of the prostate was the commonest procedure, accounting for 59.5% of the interventions. Open prostatectomy was performed in 1,804 patients (32%). Minimally invasive therapies accounted for less than 9% of the treatments. Conclusions: The present survey provides a picture of the current surgical practice in BPH in southern Italy in the late 1990s. Symptom scores are not routinely adopted. The low rate of transurethral prostate resections is in keeping with the worldwide decline. On the contrary, a high rate of open prostatectomies has been detected.

[S1 Herpes zoster localization: acute urinary retention in woman].

Acute urinary retention in women is rare. The varicella-zoster virus causes inflammatory lesions of the sensory-root ganglions, meninges and, less frequently, spinal cord. Herpes zoster has been reported to affect, although rarely, lower urinary tract innervations, and acute urinary retention can be thought to occur in the presence of sacral dermatome involvement. Usually it is located in S2–4 dermatome and the prognosis for acute urinary retention is benign resolving in about 20 days. We present a case in which the S1 dermatome was interested and acute urinary retention developed. After 10 days of specific therapy and self catheterism the problem resolved.

Sarcomatoid Carcinoma of Urinary Bladder: Immunohistochemical Study of an Uncommon Case

A case of sarcomatoid carcinoma of the bladder is reported herein. Immunohistochemical staining with human pancytokeratin antibody was negative, while vimentin staining was strongly positive, suggesting a diagnosis of sarcoma of the bladder. Further immunohistochemical analysis revealed positivity for AE1/AE3 cytokeratins, permitting a correct diagnosis of sarcomatoid carcinoma of the bladder. It can be difficult to distinguish between sarcomatoid carcinoma, undifferentiated carcinoma and sarcoma, particularly if the biopsy specimens are of small size. In rare cases, sarcomatoid tumors may express epithelial markers different from those revealed by human pancytokeratin staining.