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BACKGROUND. Serum prostate-specific antigen (PSA) exists in different molecular forms, and their respective concentration has been proposed as a useful tool to improve discrimination between benign prostatic hypertrophy (BPH) and prostate cancer (PC). METHODS. The relevance of the free to total PSA ratio was prospectively studied in a selected urology clinic population of 420 patients. Total serum PSA ranged from 2.1 to 30 ng/ml; 154 had PC and 266 had BPH. RESULTS. Receiver operating characteristic (ROC) curves were constructed for the total population (total-PSA range from 2.1 to 30 ng/ml) and for the diagnostic gray zone of 2.1-10 ng/ml. For the two groups, the free to total PSA ratio had a higher specificity than total-PSA for all sensitivity levels. Cut-off values were found to vary with prostate weight. CONCLUSIONS. Although free to total PSA ratio demonstrated better performances than total-PSA, its use in screening appears problematic, due to the low prevalence of prostate cancer. (C) 1996 Wiley-Liss, Inc.

Laparoscopic nephrolithotomy was used as an alternative to open surgery in a patient who had failed extracorporeal shock-wave lithotripsy and whose anteriorly located stone-bearing calix precluded percutaneous extraction. Endocavitary ultrasonography and color Doppler render the procedure safe and effective; localization of the stone, selection of an optimal nephrotomy site away from large vessels and where cortical thickness is minimal, and control of fragment clearance are greatly facilitated.

So far, laparoscopic approaches to kidney and adrenal have been limited because of their retroperitoneal location. We here report eight renal and adrenal endoscopic procedures performed in seven patients: two adrenalectomies for hyperaldosteronism, one adrenalectomy for isolated metastasis from an adenocarcinoma of the lung; two nephrectomies for end-stage infected hydronephrosis, two partial nephrectomies for small circumscribed lesions of the kidney, and one endoscopic resection for pain relief of a voluminous cyst at the kidney. The approach was transperitoneal in two cases and retroperitoneal in five cases using the retropneumoperitoneum insufflation technique. One patient was operated by a combined approach using the retro- and transperitoneal routes. All procedures were successfully completed endoscopically. The retroperitoneoscopic approach of the kidney is safe and does not interfere with the peritoneal organs. Its working space is tenuous, but allows a direct access on the kidney with good exposure of its pedicle. For adrenal surgery, the retroperitoneoscopic dissection is more difficult, because movements of instruments are often impaired by the closeness of the costal margin and the iliac crest. However, in case of difficulties we found it very convenient to switch from a retroperitoneal endoscopic approach to a combined coelioscopic and retroperitoneoscopic operation. Far from excluding each other, both approaches are complementary, particularly for difficult situations (i.e., previous peritoneal or retroperitoneal surgery).

Female stress urinary incontinence may need to be treated surgically following failure of non-surgical treatments. Many techniques are now available and are selected according to the pathophysiology of incontinence. Vesical colposuspension is considered to be the reference operation for the surgical treatment of female stress urinary incontinence (SUI). New suburethral sling techniques have been available for several years, such as TVT, SPARC, IVS or, even more recently, URATAPE. These new techniques not only allow restoration of continence, but are also minimally invasive and easily reproducible. They also facilitate re-operation in the case of failure or recurrence of incontinence. Currently, although the follow-up of these techniques is only 5 years, they ensure better management of the various types of urinary incontinence (stress, mixed and sphincter incompetence) than vesical colposuspension.

Undetectable prostate-specific antigen was found in three aging men despite the absence of any prostatic surgery or exogenous hormonal deprivation. Clinical and elementary hormonal workup revealed the presence of secondary hypogonadism. This finding confirms the hormonal dependency of this prostatic marker and may, in some cases, explain the discrepancy between prostatic volume and the value of serum prostate-specific antigen.

We reviewed the degree to which extension from transitional cell carcinoma into the prostate affects survival. We also compared whether prostatic stromal invasion occurring via direct extension through the bladder wall differs from stromal invasion arising intraurethrally.A total of 76 men who underwent radical cystectomy for transitional cell carcinoma also had prostate involvement. Patients were separated into group 1-18 with primary bladder tumor extending transmurally through the bladder wall to invade the prostate and group 2-58 with prostate involvement arising from within the prostatic urethra. In the latter group the degree of prostate invasion was classified as urethral mucosal involvement, ductal/acinar involvement and stromal invasion.The 5-year overall survival and recurrence-free rate were 22% and 28% in group 1 versus 43% and 45% in group 2, respectively. In group 2 survival rates were similar in those with prostatic urethral and ductal tumors (without stromal invasion). Five-year overall survival rates without and with stromal invasion were 49% and 25%, respectively (p = 0.024). Prostate involvement decreased survival, which varied according to primary bladder stages (Pis, P1, P2a/b and P3a/b, p = 0.004) or superficial (Pis, Pa and P1) and muscle invasive (P2a/b and P3/b, p = 0.045), disease in 2 groups. Those with positive lymph nodes experienced poorer outcomes in each group. The 5-year overall survival rate in the 19 men with positive lymph nodes was 13% and it was 44% with negative lymph nodes (p = 0.034). The major prognostic factors were age, degree of prostate invasion and lymph node involvement.The invasion pathways of prostate invasion in patients with transitional cell bladder carcinoma have a statistically significant prognostic role in survival. Transitional cell carcinoma of the bladder extending into the prostate through the bladder wall and bladder carcinoma that did not directly infiltrate the prostate through the bladder wall are 2 distinct clinicopathological entities that should not be included in the same staging grade.

The authors report a case of ruptured aneurysm of the renal artery in a 70-year-old man urgently admitted for massive haematuria and shock. As a result of a rapid diagnosis, ex situ resection of the aneurysm was performed with reconstruction of the renal artery pedicle using a vein graft and autologous renal transplantation in the iliac fossa. The patient had a favourable course at one year with normal renal function on laboratory tests and isotope scan. The authors review the literature concerning the epidemiology, classification, clinical features and management of aneurysms of the renal artery.

Neoplastic cellular contamination of the surgical bed may be responsible for late local failure after radical prostatectomy. Cytology analysis of the seminal and prostatic fluid collected intraoperatively was undertaken in 30 patients. Neoplastic cells were found in 2 patients both with seminal vesicle involvement. Although it is difficult to admit that tumor spillage during surgery would be a major cause of local recurrence, the presence of tumor cells in the ejaculate may be diagnostic of seminal vesicle invasion. All patients with pathologic stage T2 had a negative cytologic finding.

By stimulating blood lymphocytes from a renal cell carcinoma patient in vitro with the autologous tumor cells, we obtained cytolytic T lymphocyte (CTL) clones that killed several autologous and allogeneic histocompatibility leukocyte antigen (HLA)-B7 renal carcinoma cell lines. We identified the target antigen of these CTLs by screening COS cells transfected with the HLA-B7 cDNA and with a cDNA library prepared with RNA from the tumor cells. The antigenic peptide recognized by the CTLs has the sequence LPRWPPPQL and is encoded by a new gene, which we named RU2. This gene is transcribed in both directions. The antigenic peptide is not encoded by the sense transcript, RU2S, which is expressed ubiquitously. It is encoded by an antisense transcript, RU2AS, which starts from a cryptic promoter located on the reverse strand of the first intron and ends up on the reverse strand of the RU2S promoter, which contains a polyadenylation signal. This mechanism of antigen expression is unprecedented and further illustrates the notion that many peptides recognized by T cells cannot be predicted from the primary structure of the major product of the encoding gene. Antisense transcript RU2AS is expressed in a high proportion of tumors of various histological types. It is absent in most normal tissues, but is expressed in testis and kidney, and, at lower levels, in urinary bladder and liver. Short-term cultures of normal epithelial cells from the renal proximal tubule expressed significant levels of RU2AS message and were recognized by the CTLs. Therefore, this antigen is not tumor specific, but corresponds to a self-antigen with restricted tissue distribution.

Summary Retroperitoneal fibrosis, either idiopathic or associated with aortic inflammatory aneurysm, is a chronic fibrotic disease that causes progressive obstruction of ureters and vessels around the lower abdominal aorta. Treatment is often difficult (surgery) or hazardous (steroids). We report a case of a woman with retroperitoneal fibrosis associated with aortic inflammatory aneurysm, who was successfully treated with oral tamoxifen.

Objectives. Improved discrimination between prostate cancer (PC) and benign prostatic hyperplasia (BPH) is clearly needed. Our aim in this study was to evaluate whether the free to total prostate-specific antigen (PSA) ratio would be useful in the gray zone of 1.8-10 ng/mL total PSA range. Methods. In a consecutive series of 435 clinic patients referred for prostate evaluation, 308 had a total PSA

A total of 32 patients with symptomatic benign prostatic hyperplasia were treated with the right-angle firing neodymium:YAG laser fiber at a 60 W power setting. All these patients represented a high operative risk (ASA score > or = 3) and were excluded by the anesthesiologist for classic surgical treatment. Twenty-six patients were followed at least 24 months; the six remaining patients died of intercurrent disease. Efficacy of treatment was assessed at 3, 6, 12, 18, and 24 months postoperatively by International Prostatic Symptom Scores, peak urinary flow rates, prostatic volume, and radiographic or endoscopic imaging of the prostatic urethra. The mean preoperative symptom score was 25, the mean peak urinary flow rate 7.6 mL/sec, and mean prostatic volume 31 cc. At 2 years postoperatively, the mean symptom score was 5, the mean peak urinary flow rate was 19.3 mL/sec, and the mean prostatic volume was 18 cc. In two elderly patients, in spite of a significant improvement of symptomatology and peak flow rate, a surprisingly obstructed prostatic urethra was found endoscopically.

We evaluated 38 patients with a follow-up of 30 months after transurethral ultrasound-guided laser-induced prostatectomy (TULIP) for benign prostatic hyperplasia. The mean symptom score decreased by 54%, and peak urinary flow increased by 112%. For the entire series, 43.6% of the patients had an improved symptom score and 41% better urinary flow, but only 28.2% had improvement in both. Six patients (16%) required reoperation, two underwent a radical prostatectomy, and one patient presented total urinary incontinence. Also, 19% presented postoperative impotence, and 47% presented retrograde ejaculation. Although one third of the patients are improved with the TULIP procedure, the rate of complications is significantly higher than for TURP, which remains the most effective treatment of obstructive BPH.

We studied the influence of vessels crossing the ureteropelvic junction and of the grade of hydronephrosis in 86 patients who underwent endoureteropyelotomy. With a follow-up ranging from 1 to 12 years, the presence of crossing vessels had a significant negative influence on the outcome and recurrence rate of the procedure. The success rate was 82% when no vessels were present but only 33% when crossing vessels were documented. In 13 of 15 failures (87%), a crossing vessel was found at open pyeloplasty. The degree of hydronephrosis was a less potent detrimental factor, with an 81% success rate in low-grade and 54% in high-grade hydronephrosis. The best results (90% success) were obtained in patients with no crossing vessels and low-grade hydronephrosis and the worst (30% success) in those with high-grade hydronephrosis in the presence of crossing vessels. Selection of patients according to those prognostic factors is recommended. Conventional intravenous urographic imaging techniques proved insufficient, and only angiography provided diagnostic accuracy; less-invasive methods are desirable.

Of 102 consecutive endoureteropyelotomy cases followed for 1 to 10 years (mean 5) late recurrence was observed in 13% and long-term success was achieved in 73%. Of 67 cases with an available preoperative angiogram a strong association was noted between the existence of a vessel crossing the ureteropelvic junction and high grade hydronephrosis, and final failure and/or recurrence: long-term success rate was 39% when both factors were present and it was 95% when neither factor was present. Therefore, we recommend that the presence of a vessel should be determined preoperatively since it significantly influences the outcome.

Three specimens of ureteropelvic junction, obtained at dismembered pyeloplasty after successful endoureteropyelotomy, were studied. In the regenerative tissue, numerous cells were found with morphological, immunohistochemical and ultrastructural characteristics of mature smooth muscle cells; no regeneration of bundle arrangement was observed.

BACKGROUND: Bilateral testicular neoplasia is rare, with an incidence ranging from 1 to 5%. Long-term survival has improved in recent years due to advanced diagnostic approaches and new therapeutic methods that are highly effective against germ cell tumors. CASE PRESENTATION: We present the case of a patient with a primary seminomatous testicular tumor, who developed a contralateral metastasis and a subsequent metachronous tumor following chemotherapy and consolidation radiotherapy treatment. CONCLUSIONS: Strict follow-up, including physical examination and ultrasound examination of the contralateral testis, enabled early diagnosis of the second tumor, giving the patient a high likelihood of a definitive cure.