Francesco Iori

The evolution of detrusor overactivity after watchful waiting, medical therapy and surgery in patients with bladder outlet obstruction.

PURPOSE We analyzed the evolution of detrusor overactivity in patients with bladder outlet obstruction treated with either medical or surgical therapy or watchful waiting. MATERIALS AND METHODS Of 255 patients with symptomatic benign prostatic enlargement who completed the International Prostate Symptom Score and underwent full urodynamic investigation 161 presented with bladder outlet obstruction. Of the 161 men 101 were reevaluated with a second clinical evaluation and urodynamics 1 to 5 years (mean 2) after watchful waiting in 20, medical treatment (alfuzosin 20 and finasteride 16) in 36 and surgery (transurethral incision of the prostate 13 and prostatectomy 32) in 45. For statistical analysis Wilcoxon matched paired data and Kruskal Wallis tests were used as appropriate. RESULTS Overall detrusor overactivity was present in 53 patients (52%) at baseline and 41 (40%) at followup. Detrusor overactivity was present in 9 patients (45%) at baseline and 11 (55%) at followup in the watchful waiting group (p = 0.17); 7 (35%) at baseline and 6 (30%) at followup in the alfuzosin group (p = 0.37); 10 (62.5%) at baseline and 10 at followup in the finasteride group (p = 1); 6 (46%) at baseline and 4 (30%) at followup in the transurethral prostate incision group (p = 0.48); and 21 (68%) at baseline and 10 (31%) at followup in the prostatectomy group (p = 0.02). CONCLUSIONS Detrusor overactivity is highly prevalent (52%) in patients with bladder outlet obstruction, and appears to persist for long periods when obstruction is left untreated or treated only with medical therapy. However, surgical treatment of bladder outlet obstruction, prostatectomy in particular, significantly reduces the incidence of detrusor overactivity and lessens the chance of its de novo appearance for up to 5 years.

Bipolar Transurethral Resection of Prostate: Clinical and Urodynamic Evaluation

OBJECTIVES To report our experience with the clinical effectiveness of endoscopic resection of the prostate using the bipolar Gyrus PlasmaKinetic System. METHODS A total of 120 patients with lower urinary tract symptoms were observed from 2002 to 2005. Of these 120 patients, 90 developed benign prostatic hyperplasia and were considered to have obstruction, and 51 of these 90 were scheduled for prostate surgery. The patients were randomized 1:1, using envelopes, into two groups: bipolar transurethral resection of the prostate (TURP) using the Gyrus PlasmaKinetic System (PK group) and monopolar TURP (standard TURP group). All patients were evaluated at baseline and follow-up (12 months after treatment) by medical history, International Prostate Symptom Score, inclusive of the question on quality of life, and physical examination, including digital rectal examination, transrectal ultrasonography, and pressure flow study. Statistical analysis was applied on the change in International Prostate Symptom Score and urodynamic parameters comparing the endpoints with baseline and comparing the baseline and follow-up characteristics between the two groups. RESULTS The mean resection time was 39.1 minutes and 31.7 minutes for the PK and standard TURP groups, respectively (P = 0.437). The mean postoperative hemoglobin reduction at 24 hours of follow-up was 1.25 g/dL, with a 2.1% hematocrit reduction, in the PK group and 1.81 g/dL, with a 3.2% hematocrit reduction, in the standard TURP group (P = 0.716). Improvements in flow rate, International Prostate Symptom Score, quality-of-life score, and bladder outlet obstruction grade were comparable between the two groups. CONCLUSIONS Bipolar TURP using the bipolar Gyrus PlasmaKinetic System seems to be a safe and effective procedure that is potentially associated with fewer side effects and could result in this procedure being more attractive for high-risk patients or, as recently proposed, for training purposes.

Role of 99mTc-bombesin scan in diagnosis and staging of prostate cancer.

Aim of this work was to asses whether a novel 99mTc labeled Bombesin (BN) can play a clinical role in diagnosis and staging of prostate cancer. 14 patients were studied with trans-rectal ultrasonography-guided biopsy, CT and MRI and with 99mTc BN Scintigraphy. Five patients were also imaged by 111In Octreotide (O) scan. All the patients but one were submitted to surgery and final diagnosis was reached by pathology, taken as the gold standard method. Two patients showed benign adenoma and 12 patients showed cancer at biopsy. 99mTc BN SPECT was positive in all 12 patients with cancer. Four of these patients also showed pelvic focal uptake, referred to inguinal lymph-nodal involvement. MRI and CT provided similar findings in only three cases. Pathologic evaluation after operation confirmed the invasion of nodes in all four subjects. Both 99mTc BN and 111In O scans provided normal findings in the two subjects affected by benign adenoma, while 111In O was positive in only two of three patients with cancer and was always unable to detect nodal invasion. These preliminary data suggest that 99mTc BN SPECT scan could be useful to detect primary prostate cancer and to reveal loco-regional node involvement.

Role of 5-aminolevulinic acid in the diagnosis and treatment of superficial bladder cancer: improvement in diagnostic sensitivity

OBJECTIVES To use 5-aminolevulinic acid (5-ALA) in diagnostic cystoscopy and during transurethral resection of the bladder (TURB) to treat transitional cell carcinoma. The efficacy of this new technique was compared with standard cystoscopy. METHODS The 5-ALA, instilled in the bladder 2 hours before cystoscopy, makes the pathologic tissue fluorescent when illuminated with blue light (375 to 400 nm). This allows a better recognition of the neoplastic forms for both diagnostic and therapeutic purposes during TURB. This method has been used since May 1997 on 49 patients in whom bladder tumor was diagnosed either immediately or during postchemotherapy follow-up. RESULTS One hundred seventy-nine biopsies were taken of fluorescent and nonfluorescent areas (3.5 per patient) to check the effectiveness of the new method compared with standard cystoscopy. A good correlation was found between 5-ALA cystoscopy and the histopathologic diagnosis, with a good sensitivity (87%). The 5-ALA cystoscopy allowed the diagnosis of a tumor in 24 patients with negative standard cystoscopic findings. Furthermore, 5-ALA cystoscopy detected 7 cases of carcinoma in situ. Neither local nor systemic (because of endovesical instillation) side effects were noted. CONCLUSIONS We believe that 5-ALA could be routinely used in the diagnosis of superficial bladder tumors, as it was shown to improve the diagnostic sensitivity for carcinoma in situ and to reduce the risk of recurrence related to missed cancerous lesions or incomplete TURB.

Long-term maintenance bacille Calmette-Guérin therapy in high-grade superficial bladder cancer.

OBJECTIVES To assess the long-term results of intravesical bacille Calmette-Guérin (BCG) induction plus long-term maintenance treatment for high-grade superficial bladder cancer. METHODS Between 1994 and 2000, 41 patients who presented to our clinic with superficial urothelial carcinoma of the bladder (T1G3, T1G3 plus carcinoma in situ, or recurrent TaG2-3) were treated by transurethral resection of all visible tumor and an induction cycle of BCG plus a long-term maintenance BCG course consisting of 11 monthly instillations followed by 4 quarterly instillations and then by 6 six-monthly instillations. The median follow-up was 40 months. RESULTS Thirty patients remained tumor free throughout the follow-up period. Ten patients had a recurrence of superficial tumor, 9 patients during the monthly instillation course and 1 patient during the quarterly instillation course. One patient presented with progression. CONCLUSIONS Adjuvant immunotherapy with BCG after complete transurethral resection of bladder tumor represents a highly effective primary treatment for high-grade superficial bladder cancer. Our maintenance course of BCG seemed to improve the worldwide accepted effectiveness of the BCG induction course without any important side effects.

Percutaneous Sclerotization of Simple Renal Cysts with 95% Ethanol Followed by 24–48 h Drainage with Nephrostomy Tube

Aim of the Study: We propose some technique devices for treating simple renal cysts with percutaneous puncture (PCN) to reduce recurrences. Materials and Methods: Between January 1995 and December 1998, a series of 42 patients, 13 females and 29 males, ranging in age between 49 and 73 were treated for symptomatic kidney cystic disease. The cysts varied between 7.4 and 13.6 cm in diameter and from 100 to 570 cm3 in volume. This technique consists of echo-guided emptying of the cyst, and slowly inserting a quantity of pure 95% ethanol, equivalent to about 1/3 of the cyst volume, into the cavity. This acts as a sclerosant agent on the cyst walls. The protocol of this technique also includes positioning a curled drainage catheter, for 24–48 h, in suction, to ensure a correct collapse of the cyst walls and to avoid cyst recurrence. Results: Of the 42 patients treated, only 4 did not complete the protocol. In 3 cases, the patients were not able to stand the procedure because of intense pain during cyst filling with alcohol. The other patient had intracystic hemorrhage. The results were evaluated by ultrasonography at 7 days post-operatively and then at 1, 3, 6, 9 and 12 months later. There was a further follow-up lasting from 12 to 36 months. Of 38 patients treated, 29 (76%) did not have any recurrence. 8 patients (21%) developed a small liquid layer of 3–4 cm, which did not enlarge in subsequent check-ups. We observed a recurrence, which spontaneously reduced in volume, only in 1 patient. Conclusions: This procedure was simple to apply in an out-patient setting and used low-cost materials which are easily obtained. Moreover, the results appear to confirm the validity of this technique.

Challenging the role of cremasteric reflux in the pathogenesis of varicocele using a new venographic approach.

PURPOSE Cremasteric or extrafunicular reflux is considered by many a major cause of primary and recurrent varicocele. Therefore, surgical techniques that allow ligation of the intrafunicular and extrafunicular veins are often performed. We evaluated the incidence of cremasteric reflux in patients with primary or recurrent varicocele with a new and simple venographic technique. MATERIALS AND METHODS A series of 73 patients with primary (54) or recurrent (19) varicocele underwent venography of the left iliac vein while standing and performing Valsalvas maneuver to reveal the possible presence of reflux in cremasteric or other extrafunicular veins. In patients with recurrent varicocele antegrade transcrotal spermatic venography was also performed immediately before surgery. RESULTS None of the patients presented with reflux of contrast material from the left iliac vein to the left pampiniform plexus via the extrafunicular veins. Cremasteric veins, in particular, were always continent at the confluence with the epigastric vein even when grossly dilated at spermatic antegrade venography in recurrent cases. CONCLUSIONS Cremasteric reflux seems to have a limited role if any in the pathogenesis of primary and even recurrent varicocele. Dilatation of the extrafunicular veins is not necessarily a sign of reflux but may represent only a consequence of venous overflow due to insufficiency of the internal spermatic vein and possibly partial obstruction of the left iliac vein. The rationale of surgical treatments aimed at ligation of the extrafunicular veins should be questioned.

Superficial Bladder Tumors in Patients under 40 Years of Age: Clinical, Prognostic and Cytogenetic Aspects

Bladder carcinoma with transitional cells is the most frequent neoplasia in the urinary system, but it is quite rare in patients under 40 years of age (0.4–2%). An analysis of 21 patients under 40 and a review of other reports show that tumors in patients under 20 years old have little tendency to recur and to progress, while tumors in patients aged between 21 and 40 have a behavior pattern similar to older age groups regarding recurrence and disease progression. Preliminary results of a study using fluorescent in situ hybridization with probes for the centromere of chromosomes 7 and 17 showed a high incidence of aneusomy with regard to these chromosomes and a genetic difference between superficial tumors in the young and in adults. Using probes from chromosomes already described in bladder carcinogenesis, we obtained higher sensitivity and specificity in detecting aneuploid events.

Clinical and Pressure-Flow Changes after Long-Term Treatment with Alfuzosin SR

Objectives: The aim of our study was to evaluate the symptomatic and urodynamic changes after 1–5 years of treatment with alfuzosin in patients with benign prostatic hyperplasia. Methods: Out of 255 patients with lower urinary tract symptoms observed from 1992 to 1997, who completed the International Prostatic Symptom Score (I-PSS) and underwent full urodynamic investigation, 161 were found to be obstructed (Schäfer classes 2–6). One hundred and two subsequently consented to a second clinical and urodynamic evaluation. Out of these, 46 underwent surgical treatment, 20 were elected for watchful waiting (WW) and 36 received a medical treatment. Twenty out of these, with a mean age of 65 years, a mean prostatic volume of 44 ml (20–70) a median Schäfer’s obstruction class of 3 (range 2–5) were treated with slow release alfuzosin 5 mg twice a day. We re-evaluated these 20 patients with a second I-PSS and pressure-flow study after 1–5 years (mean: 2 years) of treatment. The patients in the WW group with comparable baseline characteristics were considered as controls. The Wilcoxon matched-pairs signed rank test and the Kruskal-Wallis test were used for statistical analysis. Results: In the group treated with alfuzosin, no differences were noted for I-PSS (14.9 ± 6,8; 13.3 ± 5); maximum flow (124 ± 6; 14 ± 6) and projected isometric pressure (105 ± 36; 105 ± 26). Statistically significant differences were noted for residual urine (103 ± 100; 33 ± 38, p = 0.02); detrusor pressure at maximum flow (64.4 ± 23; 53 ± 12, p = 0.04), minimum urethral opening pressure (36.5 ± 9; 31 ± 9, p = 0.02), Schäfer class (2.7 ± 0.7; 2 ± 0.8, p = 0.04); urethral resistance algorithm (34.7 ± 11; 27 ± 7, p = 0.02). Statistically significant differences between baseline and follow-up were noted for none of the clinical and urodynamic parameters in the WW group. Conclusions: Patients with bladder outlet obstruction seem to remain clinically stable and to improve urodynamically when treated with alfuzosin for a long period of time.

DNA aberrations in urinary bladder cancer detected by flow cytometry and FISH: Prognostic implications

We evaluated the genetic changes in bladder cancer biopsy by fluorescence in situ hybridization (FISH) and related them to stage and grade of the tumor, ploidy (FCM) and clinical outcome, to determine a simple method to identify tumors with a poorer prognosis. Using FISH the numerical aberrations of chromosomes 1, 7, 9, 17 in tumors imprints of 70 patients with transitional cell cancer (TCC) were determined. First of all, the data demonstrated that the sensitivity of FISH in detecting quantitative DNA aberrations exceeds FCMs sensitivity. The frequency of chromosome 1 and 9 aberrations did not show significant differences in diploid and aneuploid tumors in different stage and grade. On the contrary, the chromosome 7 and 17 aneusomy showed greater differences between pT1 and pT2-3 tumors (p<0.032 and p<0.0006, respectively) than between stage pTa and pT1. In our investigation, an increasing number of aberrations was observed in all chromosomes examined in tumors of patients who afterwards underwent cystectomy and/or had recurrent tumors. These results suggest that chromosome 7 and 17 aneusomy could be predictive of adverse outcome in a subgroup of patients with superficial tumors at presentation.