Gianni Malossini

The Role of Asymptomatic Bacteriuria in Young Women With Recurrent Urinary Tract Infections: To Treat or Not to Treat?

BACKGROUND Little is known about the role of asymptomatic bacteriuria (AB) treatment in young women affected by recurrent urinary tract infection (UTI). We aimed to evaluate the impact of AB treatment on the recurrence rate among young women affected by recurrent UTI. METHODS A total of 673 consecutive asymptomatic young women with demonstrated bacteriuria from January 2005 to December 2009 were prospectively enrolled. Patients were split into 2 groups: not treated (group A, n = 312) and treated (group B, n = 361). Microbiological and clinical evaluations were performed at 3, 6, and 12 months. Quality of life was also measured. Recurrence-free rate at the end of the entire study period was the main outcome measure. RESULTS At baseline, the 2 most commonly isolated pathogens were Escherichia coli (group A, 38.4%; group B, 39.3%) and Enterococcus faecalis (group A, 32.7%; group B, 33.2%). At the first follow-up visit, there was no difference between the 2 groups (relative risk [RR], 1.05; 95% confidence interval [CI], 1.01-1.10), whereas after 6 months, 23 (7.6%) in group A and 98 (29.7%) in group B showed recurrence with a statistically significant difference (RR, 1.31; 95% CI, 1.21-1.42; P < .0001). At the last follow-up, 41 (13.1%) in group A and 169 (46.8%) in group B showed recurrence (RR, 3.17; 95% CI, 2.55-3.90; P < .0001). One patient in group A and 2 patients in group B were found to have pyelonephritis. CONCLUSIONS This study shows that AB should not be treated in young women affected by UTI, suggesting it may play a protective role in preventing symptomatic recurrence.

Prognostic Factors in Patients with Renal Cell Carcinoma: Retrospective Analysis of 675 Cases

OBJECTIVES To identify independent predictors of cause-specific survival in patients affected by renal cell carcinoma (RCC). MATERIAL AND METHODS We evaluated retrospectively 675 patients who underwent in our department from 1976 to 1999 radical nephrectomy for RCC. Pathological stage of the primary tumor (TNM, 1997) was pT1 in 326 cases (48%), pT2 in 133 (20%), pT3a in 66 (10%), pT3b in 138 (20%) and pT4 in 12 (2%). According to TNM classification (Union International Contre le Cancer (UICC), 1997) the pathological stage was I in 303 cases (45%), II in 119 (18%), III in 150 (22%) and IV in 103 (15%). Histological grading was assigned according to Fuhrmans classification in only 333 cases: G1 in 25%, G2 in 35%, G3 in 33% and G4 in 7%. RESULTS Cause-specific survival was 77% at 5 years, 69% at 10 years, 64% at 15 years and 57% at 20 years. Five and 10 year cause-specific survival was, respectively 91.4 and 88.5% in pT1 tumors, 84.8 and 72.7% in pT2, 57.4 and 35.6% in pT3a, 47.2 and 33.6% in pT3b-c, and 29.6% in pT4 (P < 0.0001). In relation to the pathological stage according to TNM classification, 5 and 10 year cause-specific survival was, respectively 94 and 91.6% in stage I tumors, 89.7 and 78% in stage II, 63.4 and 46.4% in stage III and 28 and 16.3% in stage IV (P < 0.0001). In relation to the nuclear grade of the primary tumor 5 and 10 year cause-specific survival was, respectively 94 and 88% in G1 tumors, 86 and 75% in G2, 59 and 40% in G3 and 31% in G4 (P < 0.0001). At multivariate analysis pathological stage of the primary tumor, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading resulted all independent predictors of cause-specific survival in patients with RCC. CONCLUSION Pathological stage of primary tumors, lymph nodes involvement, presence of distant metastases at diagnosis and nuclear grading according to Fuhrman resulted all independent predictors of cause-specific mortality in patients with RCC.

Prognostic Value of Renal Cell Carcinoma Nuclear Grading: Multivariate Analysis of 333 Cases

Objective: To evaluate the independent predictive value of the nuclear grading system according to Fuhrman in relation to the disease-specific survival of patients with renal clear cell carcinoma. Material and Methods: 333 patients who underwent radical nephrectomy for renal clear cell carcinoma between 1983 and 1999 were evaluated. In all patients we retrospectively studied nuclear grading, average tumor size, multifocality, pathologic stage of primary tumor, vein invasion, lymph node involvement and distant metastases. The Kaplan-Meier method was applied to evaluate disease-specific survival rates. The log rank test was used to compare survival curves and for univariate analysis. The Cox proportional hazards model was used for the multivariate analysis. Results: Histologic grade was G1 in 83 cases (25%), G2 in 117 cases (35%), G3 in 110 cases (33%) and G4 in 23 cases (7%). Our data showed that nuclear grading according to Fuhrman is related to medium tumor size (p < 0.0001), pathologic stage of cancer (p < 0.001), venous system invasion (p < 0.001), lymph node involvement (p < 0.001) and distant metastases (p < 0.001). The disease-specific survival after 5 and 10 years was 94 and 88%, respectively, in patients with G1, 86 and 75% in patients with G2, 59 and 40% in patients with G3 and 31% in patients with G4 (log rank p value < 0.0001). Multivariate analysis showed that nuclear grading by Fuhrman has a prognostic independent predictive value (hazard ratio = 1.8461, p = 0.002). Conclusions: Nuclear grading is an important independent predictive factor of disease-specific survival in patients with renal cell carcinoma.

Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections.

BACKGROUND Women suffering from recurrent urinary tract infections (rUTIs) are routinely treated for asymptomatic bacteriuria (AB), but the consequences of this procedure on antibiotic resistance are not fully known. The aim of this study was to evaluate the impact of AB treatment on antibiotic resistance among women with rUTIs. METHODS The study population consisted of 2 groups of women who had previously been enrolled in a randomized clinical trial: group A was not treated, and group B was treated. All women were scheduled for follow-up visits every 6 months, or more frequently if symptoms arose. Microbiological evaluation was performed only in symptomatic women. All women were followed up for a mean of 38.8 months to analyze data from urine cultures and antibiograms. RESULTS The previous study population consisted of 673 women, but 123 did not attend the entire follow-up period. For the final analysis, 257 of the remaining 550 patients were assigned to group A, and 293 to group B. At the end of follow-up, the difference in recurrence rates was statistically significant (P < .001): 97 (37.7%) in group A versus 204 (69.6%) in group B. Isolated Escherichia coli from group B showed higher resistance to amoxicillin-clavulanic acid (P = .03), trimethoprim-sulfamethoxazole (P = .01), and ciprofloxacin (P = .03) than that from group A. CONCLUSIONS This study shows that AB treatment is associated with a higher occurrence of antibiotic-resistant bacteria, indicating that AB treatment in women with rUTIs is potentially dangerous.

Adherence to European Association of Urology Guidelines on Prophylactic Antibiotics: An Important Step in Antimicrobial Stewardship

BACKGROUND The evolution of resistant pathogens is a worldwide health crisis and adherence to European Association of Urology (EAU) guidelines on antibiotic prophylaxis may be an important way to improve antibiotic stewardship and reduce patient harm and costs. OBJECTIVE To evaluate the prevalence of antibiotic-resistant bacterial strains and health care costs during a period of adherence to EAU guidelines in a tertiary referral urologic institution. DESIGN, SETTING, AND PARTICIPANTS A protocol for adherence to EAU guidelines for antibiotic prophylaxis for all urologic procedures was introduced in January 2011. Data for 3529 urologic procedures performed between January 2011 and December 2013 after protocol introduction were compared with data for 2619 procedures performed between January 2008 and December 2010 before protocol implementation. The prevalence of bacterial resistance and health care costs were compared between the two periods. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The outcome measures were the proportion of resistant uropathogens and costs related to antibiotic consumption and symptomatic postoperative infection. We used χ2 and Fishers exact tests to test the significance of differences. RESULTS AND LIMITATIONS The proportion of patients with symptomatic postoperative infection did not differ (180/3529 [5.1%] vs. 117/2619 [4.5%]; p=0.27). A total of 342 isolates from all patients with symptomatic postoperative infections were analysed. The rate of resistance of Escherichia coli to piperacillin/tazobactam (9.1% vs. 5.4%; p=0.03), gentamicin (18.3% vs. 11.2%; p=0.02), and ciprofloxacin (32.3% vs. 19.1%; p=0.03) decreased significantly after protocol introduction. The defined daily dose (DDD) use of ciprofloxacin fell from 4.2 to 0.2 DDD per 100 patient-days after implementation (p<0.001). Antibiotic drug costs (€76,980 vs. €36,700) and costs related to postoperative infections (€45,870 vs. €29,560) decreased following introduction of the protocol (p<0.001). CONCLUSIONS Adherence to EAU guidelines on antibiotic prophylaxis reduced antibiotic usage without increasing post-operative infection rate and lowered the prevalence of resistant uropathogens. PATIENT SUMMARY We analysed the impact of adherence to European Association of Urology guidelines on antibiotic prophylaxis for all surgical urologic procedures on the prevalence of infections and resistant bacterial strains and on costs. We found that adherence to the guidelines reduced the rate of bacterial resistance, in particular against piperacillin/tazobactam, gentamicin, and ciprofloxacin, and reduced costs without increasing the risk of postoperative infection after urologic procedures. We recommend adherence to the guidelines as an important part of antibiotic stewardship programmes.

Nephrogenic adenoma of the urinary bladder: our experience and review of the literature.

Objective: To assess our experience in the treatment and clinical outcome of bladder nephrogenic adenoma (NA) updating and reviewing the literature concerning this issue. Patients and Methods: From September 1976 to June 1999, bladder NA was diagnosed in 8 patients: 6 men and 2 women with a 3:1 male ratio, aged 26–80 (mean 58.3) years. Follow-up ranged from 4 to 194 (mean 93.5) months. Results: NA was associated with transitional cell carcinoma in 3 cases. Predisposing factors were assessed in all patients. Previous surgery of the lower urinary tract was detected in 5 cases: ureterocystoneostomy in 2, partial cystectomy in 1, repair of vesicouterine fistula in 1, and multiple urethroplasties in 1. Previous endoscopic treatments were carried out in 2 patients, transurethral resection of the prostate in 1 and repeated transurethral resection of the vesicle in the other. A history of intravesical instillation of bacillus Calmette-Guérin was assessed in 1 case. Patients complained of irritative voiding symptoms in 6 cases and hematuria in 2. Endoscopically, the lesions appeared polypoid and multifocal in 5 patients, and flat and single in 3. The lesions were removed endoscopically, providing relief of symptoms in all cases. Histopathology assessed the diagnosis of nephrogenic adenoma, detecting focal atypic cells in 1 case only. Five patients (63%) relapsed 2–24 months after management. Recurrences were also treated endoscopically. Conclusions: Clinical and endoscopic features of bladder NA are not specific, simulating urothelial carcinoma or chronic cystitis. Endoscopic management allows accurate histological diagnosis and provides long-lasting relief of symptoms. NA needs careful and long-term follow-up, because of the high risk of recurrences and the potential neoplastic degeneration of the metaplastic urothelium.

Epidemiological features and resistance pattern in uropathogens isolated from chronic bacterial prostatitis

Chronic bacterial prostatitis (CBP) is, usually, caused by uropathogens, especially gram-negative bacilli, although infection is sometimes due to Gram-positive and atypical microorganisms. A recent increasing in prevalence of Gram-positive strains has been reported. The aim of this study was to explore the epidemiological features and resistance rates in uropathogens isolated from CBP outpatients in last 10 years. All consecutive outpatients with demonstrated CBP attending a single Sexually Transmitted Disease centre from January 1997 and December 2008, were enrolled and underwent microbiological cultures in first void early morning urine, midstream urine, expressed prostatic secretion, and post prostate massage urine. Prevalence of different bacterial strains was stratified in four different periods: 1997–1999, 2000–2002, 2003–2005, 2006–2008. Any changes observed in epidemiological features and resistance rates in uropathogens over the whole study period have been analyzed. The present study has been planned, thus, as in vitro study. From 6,221 patients, 4,601 Gram-positive and 1,620 Gram-negative bacterial strains have been isolated. Enterococcus faecalis and Escherichia coli strains are the first and second frequent pathogens found, respectively. Significant differences between E. faecalis prevalence in the 1997–1999 and 2006–2008 periods were found. E. coli showed a significant difference between prevalence in 1997–1999 and 2006–2008 periods. Gram-positive organisms showed a decreasing of susceptibility to ciprofloxacin as well as Gram-negative strains, while a good susceptibility to the levofloxacin was evidenced. E. faecalis prevalence seemed to be raised in 2006–2008 periods. Moreover, a decreasing of activity of ciprofloxacin and a good activity profile of levofloxacin have been reported.

Effect of human papillomavirus and Chlamydia trachomatis co-infection on sperm quality in young heterosexual men with chronic prostatitis-related symptoms

To investigate the effect of human papillomavirus (HPV) and Chlamydia trachomatis (Ct) co‐infection on sperm concentration, motility and morphology, in a large cohort of young heterosexual male patients with chronic prostatitis‐related symptoms.

Human papillomavirus and non-muscle invasive urothelial bladder cancer: Potential relationship from a pilot study

The relationship between urothelial bladder cancer and high-risk human papillomaviruses (HR-HPV) is still a poorly understood entity, even if some studies have supposed a probably correlation. The aim of the present study was to assess the potential relationship between the presence of HR-HPV and non-muscle invasive urothelial bladder cancers (NMIBC). One hundred and thirty-seven subjects (78 patients affected by NMIBC and 59 controls) were recruited in this prospective study. HR-HPV DNA was evaluated both in urine and tumour tissues. Data from patients were compared with data from controls. The relationship between patients and controls, in terms of HR-HPV presence was performed. The relationship between all pathological data and HR-HPV presence in patient group was carried out. HR-HPV DNA in tissue was found in 27 of 78 (34.6%) tumour samples and in 6 of 59 (10.1%) specimens from TUR-P, with a statistically significant difference (p=0.0009; dF=1; χ2=10.98). HR-HPV DNA in urine was found in 36 of 78 (46.1%) samples obtained from patients, whereas in only 8 of 59 (13.5%) samples from controls (p<0.0001: dF=1; χ2=16.37). A statistical significant difference in terms of HR-HPV frequency between high-grade and low-grade urothelial bladder cancer, was found (p=0.032; RR=0.52-95% CI 0.27-0.93; OR=0.34-95% CI 0.13-0.90). In conclusion, this study highlights the correlation between urothelial bladder cancer and high-risk type HPV infection, suggesting the potential etiopathogenetic role of HR-HPV in urothelial bladder cancer development.

Semen Quality in Patients With Chlamydia trachomatis Genital Infection Treated Concurrently With Prulifloxacin and a Phytotherapeutic Agent

Chronic prostatitis (CP) due to Chlamydia trachomatis (Ct) infection has a significant impact on young male fertility, and eradication of Ct infection after antibiotic therapy does not always result in recovery of semen quality. The study aim was to evaluate the effects on fertility parameters of L-arginine, L-carnitine, acetyl-L-carnitine, and ginseng extracts (FERTIMEV) associated with prulifloxacin in patients affected by CP and oligoasthenoteratozoospermia due to Ct infection. Two hundred and six patients with proven Ct genital infection and oligoasthenoteratozoospermia were enrolled in a prospective, randomized, and controlled study. Prulifloxacin (600 mg) was administered daily for 14 days, and patients were divided into 2 groups: group A: antibiotic therapy alone; and group B: antibiotic therapy and additional therapy with FERTIMEV (1 vial daily for 6 months). Microbiological and semen parameter analyses were performed both at enrollment and after 6 months. National Institutes of Health Chronic Prostatitis Symptom Index and International Prostatic Symptom Score questionnaires were applied. Of the 206 patients, 109 were assigned to group A and 97 to group B. At the enrollment time, no differences were reported with regard to clinical, instrumental, and laboratory data. Six months after treatment, statistically significant differences were demonstrated between both groups in terms of sperm concentration (21.3 ± 13.2 millions/mL vs 11.5 ± 13.2 millions/mL) (Cohens d = 0.61) (P < .001, df = 2, F = 62.10) and percentage of motile sperm (42.4% ± 5.2% vs 29.3% ± 11.0%) (Cohens d = 1.52) (P < .001, df = 2, F = 91.48). In this study treatment with FERTIMEV together with prulifloxacin improved semen parameters in patients with Ct genital infection and oligoasthenoteratozoospermia compared to treatment with prulifloxacin therapy alone.