S. Guercio

The number of lymph nodes examined and staging accuracy in renal cell carcinoma.

To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC).

Metabolic effects of single-dose pamidronate administration in prostate cancer patients with bone metastases

BACKGROUND Increased osteolysis usually accompanies sclerotic bone metastases from prostate cancer. This provides a rationale for the use of bisphosphonates to treat bone pain and prevent skeletal complications. METHODS The fasting urinary levels of calcium, hydroxyproline (OHPRO), pyridinolines (PYD), deoxypyridinolines (DPYD), collagen cross-linked N-telopeptide (NTX) and the serum values of calcium, total alkaline phosphatase and relevant bone isoenzyme, bone gla protein (BGP), carboxy-telopeptide of type I collagen (ICTP) and parathyroid hormone (PTH) were determined at baseline and on the 15th, 30th, 60th and 90th days after single-dose (90 mg) pamidronate administration in 35 consecutive prostate cancer patients with bone metastases. These biochemical indices and serum interleukin 6 (IL-6) were also measured after four days in the last consecutive 17 cases. RESULTS PYD, DPYD and NTX showed a significant decrease lasting four weeks (p<0.01, <0.01 and <0.001, respectively). OHPRO and ICTP did not change significantly. The NTX decline was greater than that of PYD and DPYD (maximum percent decrease: -71.3, -23.1 and -28.2, respectively). Bone formation markers and serum calcium did not change significantly. Serum PTH showed a rapid initial increase followed by a slow decrease (p<0.001). DPYD and NTX patterns did not correlate with changes in bone pain. As observed in the last 17 cases, the maximum osteolysis inhibition after pamidronate occurred on the fourth day after drug infusion. Serum IL-6 levels showed a short-lived decrease preceded by a transient rise on the fourth day. CONCLUSIONS Pamidronate is able to induce a decrease in bone resorption without significantly influencing bone formation. The maximum decrease in bone resorption occurs very early. NTX is the most sensitive bone resorption marker in bisphosphonate therapy monitoring. Changes in IL-6 but not bone resorption markers may be useful in the prediction of symptomatic response.

INTRAVESICAL BACILLUS CALMETTE-GUERIN (BCG) AS INDUCER OF TUMOR-SUPPRESSING PROTEINS P53 AND P21Waf1-Cip1 DURING TREATMENT OF SUPERFICIAL BLADDER CANCER

PURPOSE Previous in vitro investigations recorded an inhibition of cell proliferation by BCG when added to different cell cultures. The induction of apoptosis by BCG is controversial. Our study aimed to evaluate the influence of BCG on the expression of tumor suppressing proteins p53 and p21Waf1-Cip1 and apoptosis of the urothelial cells in vivo. MATERIALS AND METHODS Twenty-one cases of superficial bladder cancer, treated with TUR and subsequent intravesical BCG, were studied retrospectively. The assays evaluated the expression of p53 and p21Waf1-Cip1 by immunochemistry (IHC), and the presence of apoptosis by TUNEL assay. The estimates were performed, in each case, on the following specimens: one tumor sample and one non-neoplastic sample collected during the TUR which preceded the administration of BCG; one non-neoplastic sample collected 3 months after the diagnosis; and one non-neoplastic sample collected in the first 2 weeks after the completion of the treatment. Samples of 6 cancer recurrences detected during BCG were examined too. RESULTS As usual for non-neoplastic urothelium, the pre-BCG samples displayed poor p53 and p21Waf1-Cip1 immunoreactivity. By contrast, the samples collected during and in the aftermath of BCG showed an overall increase of the expression of both proteins. The rare occurrence of apoptosis proved to be chronologically unrelated to the BCG treatment. DISCUSSION The relationship between changes of the IHC features and BCG suggests that BCG, at least under some circumstances, can induce the activation of wild type p53 and p21Waf1-Cip1 in the urothelium. The mechanism of the BCG-p53 status interaction and its role in the antitumor activity of BCG remain to be clarified.

Seminal Monolateral Nerve-Sparing Radical Prostatectomy in Selected Patients

Introduction: In recent years there has been a shift in prostate cancer stage with the majority of patients nowadays being operated with cT1c disease, prostate-specific antigen levels of <10 ng/ml, and a decreased rate of seminal vesicle invasion. Recent data suggest the role of preservation of the seminal vesicle in improving continence and/or potency. We describe our preliminary experience with seminal-sparing, unilateral nerve-sparing retropubic radical prostatectomy. Patients and Methods: 21 selected patients with clinically localized prostate cancer underwent seminal unilateral nerve-sparing retropubic radical prostatectomy (seminal-sparing group, SSG). We compared the postoperative continence, erectile function and quality of orgasm results to those obtained in a control group (CG) of 21 patients who underwent unilateral nerve-sparing radical prostatectomy. Sexual function was evaluated preoperatively and 9 months postoperatively with the 5-item International Index of Erectile Function (IIEF-5) questionnaire and with oth er self-administered questionnaires. The quality of orgasm was evaluated 9 months postoperatively. Results: 1 month postoperatively, 95 and 28% of the patients in the SSG and CG were continent (p < 0.001). The median postoperative drop in IIEF-5 score was 5 points in SSG and 14.5 points in CG (p < 0.0001). Nine months postoperatively, 90 and 62% of the patients in SSG and CG, respectively (p = 0.05), maintained the ability to achieve orgasm. Conclusions: In our experience seminal-sparing radical prostatectomy showed good feasibility and improved early postoperative urinary continence, erectile function and quality of orgasm, without compromised cancer control.

Randomized Prospective Trial Comparing Immediate Versus Delayed Ureteroscopy for Patients with Ureteral Calculi and Normal Renal Function Who Present to the Emergency Department

PURPOSE To compare the safety and efficacy of emergency vs scheduled ureteroscopy with a prospective study that included patients who presented to the emergency department (ED) with renal colic from ureteral stones. PATIENTS AND METHODS There were 271 consecutive patients who were enrolled in this prospective study. Patients were randomized to emergency ureteroscopy (group A) or delayed ureteroscopy (group B). All patients underwent helical unenhanced CT (HUCT). Stone-free status was defined as the complete absence of residual fragments at 1 week postoperatively, assessed with HUCT, with no need for ancillary interventions after ureteroscopy. RESULTS Group A included 139 assessable patients. The overall stone-free rate was 93%. Neither location nor size was a significant prognostic factor (P>0.05). Single-session ureteroscopy failed to clear nine ureteral stones. A Double-J stent was placed in 27/139 patients. Group B included 100 assessable patients. Patients in the control group were scheduled for ureteroscopy after their departure from the ED. The overall stone-free rate was 90%. Single-session ureteroscopy failed to clear 10 ureteral stones. A Double-J stent was placed in 80/100 patients. There were no statistical differences with regard to stone diameter and location, complications, and stone-free rate between group A and group B patients. The rate of Double-J stent positioning was significantly higher (P<0.05) in group B patients. CONCLUSIONS In our experience, emergency ureteroscopy showed equal efficacy and safety compared with the elective procedure. It has the main advantage of providing both immediate relief from pain and stone fragmentation.

MP24-12 A MODIFIED ILEO CONDUIT TECNIQUE TO AVOID URETEROENTERIC STRICTURE.

METHODS: Between January 1992 and April 2016, 51 children (27 boys and 24 girls) underwent a Mitrofanoff appendico-vesicostomy as external continent urinary diversion. we exclude at once those presented at end stage renal failure and required renal transplantation. The remaining (45) were aged between 5 and 15 years (mean 10.27); all of them underwent MAV in their right iliac fossa. Etiologies were dominated by neuropathic bladder (41 cases) ,mainly due to spina bifida defect with myelo-meningocele ; a posterior urethral valves causing altered bladder (2 cases) and complicated bladder exstrophy (2 cases). Diagnosis was established at advanced stage in all patients with mild renal failure (11) or moderate renal insufficiency in (34) with mean creatinine clearance of( 41 ml/min/1.73m2). RESULTS: The average follow-up was approximately 135 months (ranging from 12 to 256 months). All children became continent, 43 (95% ) after a single intervention. Minor complications consisted mainly on difficulties in intermittent catheterization (11.2%), they were treated merely by external stoma refection. The renal function deteriorated to severe renal failure (1 case), 6 years after surgery, then the patient underwent renal transplantation in his left iliac fossa; it remained stable at better levels with no need to dialysis, in 33 cases (average creatinine clearance of 58 ml/min/ 1.73m2), with mean follow up of 9 years; it returned to normal (11 cases). In addition, intermittent self-catheterization was well accepted by all children and their families, with complete readaptation to daily activities with good quality of life . CONCLUSIONS: The Mitrofanoff appendico-vesicostomy operation is usually associated to good results in children who suffer of some form of renal insufficiency. It ensures better continence status and a satisfactory educational rehabilitation. Our results demonstrate that it could also stabilize damaged renal function for quite a long time before renal replacement programmes if it was associated to mild or moderate renal failure.

LB22 Prognostic role of plasma chromogranin a levels in prostate cancer patients with hormone refractory disease

9563 Background: neuroendocrine (NE) differentiation in prostate cancer (PC) is more frequently expressed in hormone refractory patients than in those with hormone naive disease. Chromogranin A (CgA) is the most employed marker to detect NE features. METHODS plasma CgA (ELISA kit, DAKO, Glostrup-Denmark, reference range in PC patients 2-20 U/L) was evaluated at baseline conditions in 108 consecutive patients with hormone refractory PC. RESULTS patients characteristics were as follows: median age 74 yrs (range 58-86), median ECOG performance status 1 (range 0-3). 105 patients (97.2%) had metastatic bone disease, 91 patients (84,2%) had elevated PSA values (median 97.0 ng/ml, range 0.1-3393.0). Median CgA values was 17.3 U/L (range 3.0-394.0), supranormal CgA values were recorded in 45 patients (43.3%). Baseline elevated plasma CgA correlated with a shorter survival perspect: 11.13 months (range: 3.5-18.7) vs 22.37 months (range: 13.7-31.0) (p=0.02). In a multivariate analysis, plasma CgA provided independent prognostic information [Hazard Risk 1.28 (95% Confidence interval 1.08-1.53), p<0.005] with respect to serum PSA [Hazard Risk 1.10 (95% Confidence Interval 1.02-1.19), p=0.01]. Plasma CgA was prospectively evaluated after 3, 6, and 9 months in 50 patients submitted to chemotherapy. Median CgA plasma levels (range) were: 13.3 U/l (3.0-141.0) at baseline and 19.1 (3.0-486.0), 20.8 (3.0-702.0) and 39.4 (3.0-414.0) after 3, 6 and 9 months, respectively (p<0.01); the corresponding supranormal rates were 17/50 (34%), 23/50 (46%), 26/50 (52%) and 34/50 (68%) (p<0.005). CONCLUSIONS elevated plasma CgA is frequently observed in PC patients with hormone refractory disease and correlates with poor prognosis. The prognostic role of plasma CgA is independent to that of serum PSA. Plasma CgA values show a progressive increase during chemotherapy, suggesting that NE phenotype expression in hormone refractory PC patients is a time-dependent phenomenon and is not influenced by the cytotoxic treatment. [Table: see text].

Prognostic value of the involvement of the urinary collecting system in renal cell carcinoma (RCC)

OBJECTIVES The prognostic role of the invasion of the urinary collecting system (UCS) by renal cell carcinoma (RCC) has not attracted a notable amount of attention. The aim of this study was to investigate incidence and prognostic value of UCS involvement in RCC. MATERIAL AND METHODS All pathological reports of radical nephrectomies performed in two centres of urology from November 1983 to December 1999 were reviewed in order to evaluate the invasion of the UCS (calices, renal pelvis, ureter). Patients were divided into two groups according to presence (Group 1) or absence (Group 2) of UCS invasion. The stage was determined according to the TNM 6th edition. Overall and cause-specific survival rates were evaluated. Univariate and multivariate analyses were performed. RESULTS The evaluable specimens were 671 from the 735 examined; in 64 cases it was not possible to ascertain or to exclude UCS involvement. Invasion of the UCS was found in 59 cases (8.8%). Median follow-up was 59.0 months (range 0-216). Tumours invading the UCS were usually symptomatic, with high nuclear grade and predominantly high stage. At univariate analysis the 5 year overall and cause-specific survival rates of tumours invading the UCS were significantly lower when compared to those without UCS invasion (42.8% versus 60.8% and 45.5% versus 64.7%, respectively). When groups were stratified, according to the pT category, the 5-year cause-specific survival rate was only significantly different for the pT2 category (33.3% versus 76.9%). At the multivariate analysis TNM staging, symptoms at diagnosis and tumour grade were the only independent prognostic factors. CONCLUSION The invasion of the UCS by RCC is unusual, particularly in small tumours. UCS involvement does not represent an independent prognostic factor. However, in organ-confined tumours (i.e. pT2) UCS involvement has an influence on the prognosis and should be taken into account when planning adjuvant treatments and follow-up.