R. Minervini

Regional lymph node dissection in the treatment of renal cell carcinoma : is it useful in patients with no suspected adenopathy before or during surgery?

Objectives To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery.

Glansectomy with split-thickness skin graft for the treatment of penile carcinoma

Using our prospectively derived database, we identified 17 patients with squamous-cell carcinoma involving the glans penis, who were treated using organ-sparing surgery between March 2003 and January 2008. Of them, two were treated with partial glansectomy with primary glans closure, and 15 underwent total glans amputation and reconstruction of a new glans using a split-thickness skin graft (STSG). These 15 patients represent the subject of our study (mean age 51 years, range 42 to 59 years). Overall, two patients had early partial loss of the graft and of them, one required surgical regrafting. Two late complications occurred, consisting of one meatal stenosis and one postoperative phimosis. At a mean follow-up of 36 months, functional results were extremely satisfactory. All patients maintained their erectile function with good vaginal penetration starting from 3 months after surgery, with a range between 2 and 6 months. Orgasm and ejaculation were preserved in all patients, although reduced glans sensitivity was reported by all patients. No local recurrences were reported.

Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies

Objective  To evaluate the feasibility and results of prosthetic venous replacement, as inferior vena cava (IVC) and iliofemoral vein resection and replacement are sometimes necessary when they are extensively involved by a large and fixed tumour thrombus from renal cell carcinoma (RCC) or other urological malignancies.

Prognostic Role of Histological Necrosis for Nonmetastatic Clear Cell Renal Cell Carcinoma: Correlation With Pathological Features and Molecular Markers

PURPOSE We defined the prognostic role of tumor necrosis and its extent in nonmetastatic clear cell renal cell carcinoma. Also, we further investigated its pathogenesis by correlating this tumor feature with other pathological characteristics and molecular markers related to the von Hippel Lindau-hypoxia inducible factor pathway and to tumor proliferation. MATERIALS AND METHODS A total of 213 patients with nonmetastatic clear cell renal cell carcinoma were evaluated. Mean followup was 66 months. The presence and extent of histological necrosis were correlated with clinicopathological factors, Ki-67 antigen expression calculated by the MIB-1 (Ki-67 antibody) index, pVHL, HIF-1alpha, the tumor infiltrating lymphocyte subset and cancer specific survival. RESULTS Histological necrosis was present in 63.8% of clear cell renal cell carcinoma cases. Necrosis was significantly associated with grade and the degree of tumor infiltrating lymphocytes, while its extent correlated significantly with grade, the degree of tumor infiltrating lymphocytes and stage. Tumor necrosis was a significant prognostic factor, which was confirmed even when limiting analysis to patients with intracapsular renal cell carcinoma. On multivariate analysis histological necrosis was not an independent predictor of cancer specific survival. The extent of tumor necrosis was not a significant prognostic factor. The presence and extent of histological necrosis was not associated with high Ki-67 expression and it did not correlate with pVHL expression or with nuclear and cytoplasmic HIF-1alpha expression. CONCLUSIONS Based on our results we cannot support histological necrosis and its extent as prognostic factors for clear cell renal cell carcinoma. Efforts should be made to develop nomograms that use routinely available and objective predictor variables. The precise mechanism that causes tumor necrosis remains unknown but the host immune response might significantly contribute to its development.

Nuclear Expression of Hypoxia-inducible Factor-1?? in Clear Cell Renal Cell Carcinoma is Involved in Tumor Progression

ObjectivesThe most frequent genomic abnormality in clear cell renal cell carcinoma (cc-RCC) is inactivation of Von Hippel-Lindau gene (VHL). pVHL19 is a ligase promoting proteosomal degradation of hypoxia-inducible factor-1alfa (HIF-1α); pVHL30 is associated with microtubules. VHL exert its oncogenetic action both directly and through HIF-1α activation. TNM classification is unable to define a correct prognostic evaluation of intracapsular cc-RCC. The nucleo-cytoplasmic trafficking in VHL/HIF-1α pathway could be relevant in understanding the molecular pathogenesis of renal carcinogenesis. This study analyzes VHL/HIF-1α proteins in a large series of intracapsular cc-RCCs, correlating their expression and cellular localization with prognosis. Materials and MethodsTwo anti-pVHL (clones Ig32 and Ig33) and 1 anti-HIF-1α were used on tissue microarrays from 136 intracapsular cc-RCCs (mean follow-up: 74 mo). Clone 32 recognizes both pVHLs, whereas clone 33 only pVHL30. Results were matched with clinicopathologic variables and tumor-specific survival (TSS). ResultsA strong cytoplasmic positivity was found for all antibodies in the largest part of cases, associated to a strong nuclear localization in the case of HIF-1α. All pVHL-negative cases were associated with high HIF-1α expression. pVHL negativity and HIF-1α nuclear positivity significantly correlated with shorter TSS. In multivariate analysis both pVHL negativity and HIF-1α nuclear expression were independent predictors of TSS. ConclusionsThe localization of the proteins well matches with their role and with the supposed tumor molecular pathways. The correlation with prognosis of VHL/HIF-1α alterations confirms the relevance of their molecular pathway and of the cellular trafficking of their products in the pathogenesis of renal cancer.

Evaluation of the 1997 tumour, nodes and metastases classification of renal cell carcinoma: experience in 172 patients

Objective To compare the prognostic relevance of the 1987 and 1997 tumour, nodes and metastases (TNM) systems for staging renal cell carcinoma (RCC) in predicting patient outcome.

Results of Vardenafil Mediated Power Doppler Ultrasound, Contrast Enhanced Ultrasound and Systematic Random Biopsies to Detect Prostate Cancer

PURPOSE We evaluated the ability of the phosphodiesterase-5 inhibitor vardenafil to increase prostate microcirculation during power Doppler ultrasound. We also evaluated the results of contrast and vardenafil enhanced targeted biopsies compared to those of standard 12-core random biopsies to detect cancer. MATERIALS AND METHODS Between May 2008 and January 2010, 150 consecutive patients with prostate specific antigen more than 4 ng/ml at first diagnosis with negative digital rectal examination and transrectal ultrasound, and no clinical history of prostatitis underwent contrast enhanced power Doppler ultrasound (bolus injection of 2.4 ml SonoVue® contrast agent), followed by vardenafil enhanced power Doppler ultrasound (1 hour after oral administration of vardenafil 20 mg). All patients underwent standard 12-core transrectal ultrasound guided random prostate biopsy plus 1 further sampling from each suspected hypervascular lesion detected by contrast and vardenafil enhanced power Doppler ultrasound. RESULTS Prostate cancer was detected in 44 patients (29.3%). Contrast and vardenafil enhanced power Doppler ultrasound detected suspicious, contrast enhanced and vardenafil enhanced areas in 112 (74.6%) and 110 patients (73.3%), and was diagnostic for cancer in 32 (28.5%) and 42 (38%), respectively. Analysis of standard technique, and contrast and vardenafil enhanced power Doppler ultrasound findings by biopsy core showed significantly higher detection using vardenafil vs contrast enhanced power Doppler ultrasound and standard technique (41.2% vs 22.7% and 8.1%, p <0.005 and <0.001, respectively). The detection rate of standard plus contrast or vardenafil enhanced power Doppler ultrasound was 10% and 11.7% (p not significant). CONCLUSIONS Vardenafil enhanced power Doppler ultrasound enables excellent visualization of the microvasculature associated with cancer and can improve the detection rate compared to contrast enhanced power Doppler ultrasound and the random technique.

Correlation between Gleason score of needle biopsy and radical prostatectomy tissue

Gleason score has been identified as an important variable to predict disease extent and biologic behaviour of prostate cancer. However, the correlation between Gleason score of needle biopsy and surgical specimen is often poor.We studied 72 patients who underwent needle biopsy and radical prostatectomy to correlate Gleason score with PSA, clinical and pathological tumour stage.Only 47.2% of Gleason scores were identical in the biopsy and specimens, 37.5% were undergraded and 15.2% were overgraded. Correlations between clinical and pathological stage were identical in 30.5% of patients, 61.1% of patients were understaged and 8.3% overstaged.In conclusion, accuracy of clinical staging and grading of prostate cancer is low. Although the Gleason score on needle biopsy might be useful to predict the final stage and grade, correlation with surgical specimen is poor.

Functional Evaluation of Different Ileal Neobladders and Ureteral Reimplantation Techniques

Objectives: To compare and assess the function of ileal neobladders with different reconfiguration and with several types of ureteral reimplantation. Methods: Forty-five male patients underwent radical cystectomy and detubularized ileal neobladder. In 20 patients an ileal neobladder was carried out according to Studer’s technique, in 12 a ‘W’- and in 13 a ‘U’-shaped neobladder. In the Studer’s patients 60 cm of ileum was used, in the ‘W’ 40 and in the ‘U’ 30 cm. For the uretero-ileal anastomosis Nesbit’s technique was utilized in the Studer’s, in the ‘W’ and ‘U’ neobladders Camey Le Duc’s technique was performed instead. Four patients underwent a serous-lined extramural tunnel reimplantation. Follow-up included a functional and morphological study of the urinary system and a urodynamic study. Results: All Nesbit’s uretero-ileum anastomoses resulted refluent when the reservoir was filled up, 15 of 50 ureteral reimplantations according to the Camey Le Duc technique showed reflux at full filling. At 3, 6 and 12 months follow-up, the double reconfiguration reservoirs (Studer’s and ‘W’) showed a larger capacity and a lower maximum pressure than neobladders with a single bending. At 12 months, continence and the voiding interval time was significantly higher in the double reconfiguration than in the ‘U’ neobladders. Conclusion: The double reconfiguration of the reservoir (‘W’) might be preferable to that with a single one. As for the type of ureteral anastomosis to select, the problem is still debatable even if in our case-control study we have had better results in terms of reflux and stenosis with the uretero-enteric anastomosis with Nesbit’s and associated afferent long tubular ileal limb than with Studer’s technique.

Bladder Involvement in Systemic Sclerosis: Urodynamic and Histological Evaluation in 23 Patients

Lower tract involvement of systemic sclerosis is an uncommon manifestation. In this study we have evaluated the functional and morphologic vesical changes in 23 female patients with systemic sclerosis to investigate if bladder dysfunction was correlated with an extended skin slerosis and/or a more serious organ involvement. Urodynamic alterations were observed in only 3 cases. Urinary symptoms and urodynamic features were correlated neither with severity of vesical fibrosis nor with visceral involvement. Autonomic dysfunction was detected in 13 patients.