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Although viruses are common in the urinary tract in healthy people, viral infections can become a major concern in immunocompromised individuals. Patients undergoing hematopoietic stem cell or solid organ transplantation may be particularly susceptible to BK and other viruses, and experience a high risk of mortality. The most common presentation in this setting is hemorrhagic cystitis. The treatment is mostly supportive, including the reduction of immunosuppression; a variety of experimental agents has also been proposed. A different context is offered by chronic (HBV, HCV, HIV) or acute/subacute (Dengue, Hantavirus, etc.) infections, where the kidneys can be secondarily involved and suffer from several glomerular syndromes. Many protocols based on different oral direct-acting antivirals and combined antiretrovirals are available, according to the systemic infection. Viral infections can be classified according to the organ involved, i.e. lower (bladder) or upper urinary tract (kidneys, ureters), and to the mechanism of injury. A section is dedicated to the current breakout of SARS-CoV-2, which does not spare the urinary tract, sometimes with serious implications. Even if this topic is mostly the discipline of ultra-dedicated physicians, this overview has a practical approach and could be useful to a wider medical audience, especially in times of viral pandemics.

PURPOSE OF REVIEW: To describe and critically discuss the most recent evidence regarding stone management during the coronavirus disease 2019 (COVID-19) and post-COVID-19 era. RECENT FINDINGS: There is a need to plan for resuming the normal elective stone surgery in the post-COVID era, keeping a clear record of all surgeries that are being deferred and identifying subgroups of surgical priorities, for the de-escalation phase. Telehealth is very useful because it contributes to reduce virus dissemination guaranteeing at the same time an adequate response to patients' care needs. Once the pandemic is over, teleurology will continue to be utilized to offer cost-effective care to urological patients and it will be totally integrated in our clinical practice. SUMMARY: This COVID-19 pandemic represents a real challenge for all national health providers: on the one hand, every effort should be made to assist COVID patients, while on the other hand we must remember that all other diseases have not disappeared in the meanwhile and they will urgently need to be treated as soon as the pandemic is more under control. A correct prioritization of cases when surgical activity will progressively return back to normality is of paramount importance.

A posterior reconstruction (PR) might improve the fluidity and delicacy of the maneuvers related to the neovesico-urethral anastomosis during robotic-assisted radical cystectomy (RARC). Our objective is to describe in detail the surgical steps of PR and to assess its feasibility and functional outcomes. The data regarding patients undergoing a totally intracorporeal RARC with neobladder and PR for high-grade and/or muscle-invasive urothelial cancer of the bladder at Karolinska University Hospital between October 2015 and November 2016 by a single surgeon (PW) were reviewed. Prior to the anastomosis, a modified posterior Rocco’s repair involving the Denonvillier’s fascia, the rhabdosphincter, and the posterior side of the ileal neobladder neck was performed. The steps are shown in a video at https://doi.org/10.1089/vid.2019.0029 . The primary outcome was urinary continence; the secondary outcomes were urinary leakage, intermittent catheterization, and complications related to the reconstructive steps. Eleven male patients with a median age and BMI of 67 years and 24, respectively, underwent RARC with PR associated to the neovesico-urethral anastomosis. Overall and posterior reconstruction time were 300′ (195–320) and 6′ (4–7), respectively. The daytime and nighttime continence rates were 100% and 44% at 12 months, respectively; the median pad weight was 3.5 g and 108 g at daytime and nighttime, respectively. One urinary leakage from the urethrovesical anastomosis was treated conservatively. Two patients perform intermittent catheterization. The posterior reconstruction during RARC is safe and feasible, providing good continence rates. It supported a careful suturing of the anastomosis as well as an uncomplicated catheter placement.

Objective: A prospective longitudinal cohort study on the impact of anthropometric measures on the sexual function and continence recovery in patients treated with laparoscopic radical prostatectomy (LRP) is presented.Material and methods: Anthropometric measures, International Index of Erectile Function (IIEF-5) and International Prostatic Symptoms Score questionnaires, were collected before surgery and at the end of follow-up period. All patients were assigned into the following groups: A) non-obese; B) non-obese with central adiposity; C) obese without central adiposity; D) obese with central adiposity. Urinary and sexual functions were the outcome measures. Results: At the end of follow-up, in 29 patients with visceral adiposity (VA) the median IIEF-5 was 14 (IQR 7-18) while in 49 non-VA patients (62.8%) was 22 (IQR 17-24) (p < 0.001). Twenty-three patients (79.3%) with VA reported complete continence, while 6 (20.7%) used ≥ 2 pads per day. Forty-eight patients (97.9%) without VA reported complete continence. VA was confirmed as a strong independent predictor for worse continence (HR 3.67; 2.75-4.51 CI95% p = 0.003) and sexual function recovery (HR: 4.51; 3.09-5.63 CI95% p < 0.001). Conclusion: We truly believe obese with visceral adiposity patients with prostate cancer should receive detailed preoperative counseling before surgery, including higher risk of suboptimal functional outcomes.

To measure the early impact of robot-assisted partial nephrectomy (RAPN) on renal function as assessed by renal scan (Tc 99m-DTPA), addressing the issue of risk factors for ischemic damage to the kidney. All patients undergoing RAPN for cT1 renal masses between June 2013 and May 2014 were included in this prospective study. Renal function as expressed by glomerular filtration rate (GFR) was assessed by Technetium 99m-diethylenetriaminepentaacetic acid (Tc 99m-DTPA) renal scan preoperatively and postoperatively at 1 month in every patient. A multivariable analysis was used for the determination of independent factors predictive of GFR decrease of the operated kidney. Overall, 32 patients underwent RAPN in the time interval. Median tumor size, blood loss, and ischemia time were 4 cm, 200 mL, and 24 min, respectively. Two grade III complications occurred (postoperative bleeding in the renal fossa, urinoma). The GFR of the operated kidney decreased significantly from 51.7 ± 15.1 mL/min per 1.73 m(2) preoperatively to 40, 12 ± 12.4 mL/min per 1.73 m(2) 1 month postoperatively (p = 0.001) with a decrease of 22.4 %. On multivariable analysis, only tumor size (p = 0.05) was a predictor of GFR decrease of the operated kidney. Robotic-assisted partial nephrectomy had a detectable impact on early renal function in a series of relatively large tumors and prevailing intermediate nephrometric risk. A mean decrease of 22 % of GFR as assessed by renal scan in the operated kidney was found at 1 month postoperatively. In multivariable analysis, tumor size only was a significant predictor of renal function loss.

Percutaneous nephrolithotomy is the gold standard for large kidney stones. Supine approach has proved to be safe and effective. Herein we present an educational video about our stepwise technique of supine PCNL in a safe way.

Objective:In recent years, several biomarkers alternative to standard prostate specific antigen (PSA) for prostate cancer (PCa) diagnosis have become available. The aim of this systematic review is to assess the current knowledge about alternative serum and urinary biomarkers for the diagnosis of PCa.Material and Methods:A research was conducted in Medline, restricted to English language articles published between December 2014 and June 2018 with the aim to update previously published series on PCa biomarkers. The preferred reporting items for systematic reviews and meta-analyses (PRISMA) criteria were used for selecting studies with the lowest risk of bias.Results:Emerging role and actual controversies on serum and urine alternative biomarkers to standard PSA for PCa diagnosis, staging and prognosis assessment, such as prostate health index (PHI), PCA3, ConfirmMDx, Aberrant PSA glycosylation, MiPS, miRNAs are critically presented in the current review.Conclusion:Although the use of several biomarkers has been recommended or questioned by different international guidelines, larger prospective randomized studies are still necessary to validate their efficacy in PCa detection, discrimination, prognosis and treatment effectiveness. To date, only PHI and 4Kscore have shown clinical relevance for discriminating more aggressive PCa. Furthermore, a new grading classification based on molecular features relevant for PCa risk-stratification and tailoring treatment is still needed.

Purpose: We aim to evaluate the efficacy of pollen extract in association with vitamins in patients affected by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) and to evaluate the level of the pro-inflammatory mediators interleukin (IL)-6, IL-8, and IL-10. Materials and Methods: Patients diagnosed with CP/CPPS between January and December 2015 were enrolled in this study. Participants were randomly assigned to receive oral capsules of pollen extract and vitamins (group A) or bromelain (group B) for 3 months. At the enrolment time and 3 months after enrolment, all patients completed questionnaires (the National Institutes of Health Chronic Prostatitis Symptom Index [NIH-CPSI] and the Short Form-36 and underwent urological examinations and microbiological evaluation. Levels of IL-6, IL-8, and IL-10 were evaluated in seminal plasma. Results: Sixty-five male patients (mean age of 32.7±4.7 years) were analysed (group A, n=32; group B, n=33). At the follow-up examination, 24 of the 32 patients in group A showed a significant reduction in the NIH-CPSI total score compared with 8 of the 33 patients in the bromelain group (p＜0.001). Moreover, the mean level of IL-8 was significantly lower in the pollen extract and vitamins group when compared with the bromelain group (298 pg/mL vs. 736 pg/mL, respectively; p＜ 0.001). In group A we found a statistically significant reduction in the levels of IL-8 between enrolment and the follow-up visit (878 pg/mL vs. 298 pg/mL, respectively; p＜0.001). Conclusions: Treatment with pollen extract and vitamins improved the quality of life in CP/CPPS patients by reducing the levels of pro-inflammatory IL-8.

Objective: In the last years there is a growing interest in nutraceutical substances that seems able to improve clinical symptoms in patients with lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). In this paper, we evaluated both efficacy and safety of a combination of daidzein with isolase and zinc in patients with LUTS due to BPH. Materials and methods: In a phase I-II study clinical trial we enrolled patients with clinical and instrumental diagnosis of LUTS associated to BPH that received a six-month treatment with a combination of daidzein with isolase and zinc (1 tablet/day). Clinical, laboratory and instrumental analyses were carried out at the time of admission (T0) and 6 months after the ending of the treatment (T1). The Italian version of International Prostatic Symptom Score (IPSS), International Index of Erectile Function (IIEF-5) and Quality of Well-Being (QoL) questionnaires were used. The development of adverse drug reactions (ADRs) and drug interactions (DDIs) were recorded using the Naranjo scale and drug interaction probability scale. Student’s t test and Anova test were used for statistical analysis, and the threshold of statistical significance was set at P < 0.05. Results: We enrolled 71 patients, 62 (87.3%) completed the follow-up and we documented a significant differences between T0 and T1 in terms of IPSS [21.5 ± 1.2 vs 16.2 ± 1.5; (-4.8); p < 0.001], Cmax [9.7 ± 3.7 vs 15.3 ± 2.5; (+5.6); p < 0.001] and QoL [0.56 ± 0.15 vs 0.84 ± 0.19; (+0.28); p < 0.001]. In contrast, no significant difference were recorded in terms of IIEF-5 [p = 0.50] and PSA [p = 0.67]. Finally, we did not record any significant ADRs or DDIs during the study. Conclusions: In this study, we documented that a combination of daidzein with isolase and zinc, reduces the clinical symptoms of LUTS and improves the quality of life in patients with BPH, without the development of ADRs or DDIs.

Liposarcoma accounts for 20% of all sarcomas and is a rare occurrence in the paratesticular region. We present the case of a 66-year-old man with a massive liposarcoma of the right scrotum invading the lower limb and the abdominal wall skin. The case concerns an unusually large and aggressive liposarcoma (25 cm), presenting with multiple lung and nodal metastases. The patient had an unfavourable evolution with rapid progression of metastases, although there were no signs of local disease. In this case, a wide local excision was performed in order to obtain local control of the disease. Even though paratesticular sarcomas might have a more favourable evolution, the association with lung involvement carries an ominous prognosis. Diagnosis of paratesticular sarcoma should be kept in mind in case of irregular necrotic masses in the inguinal and scrotal region.

Quantitative analysis of biopsy specimens of the testis represents the most direct indicator of spermatogenic function, whereas conventional microscopical procedures are open to subjective interpretation. In this study, the quantification of germ cell lines by means of flow cytometry was investigated and the results compared to histological findings. We studied 23 infertile men with azoospermia or oligospermia. The percentage of haploid-A, diploid –-D, tetraploid-T compartments was determined for each patient. Spermatogenesis was considered normal, decreased or in complete maturation arrest when histograms showed A>D>T, D>A>T or D>T>A patterns respectively. Comparing histograms and histological findings, excellent correlation was found in cases displaying absence of aploid cells, while 3 out 7 histograms showing hypospermatogenesis corresponded to normal spermatogenesis on biopsy specimens. Additionally, one case with complete maturation arrest histogram showed hypospermatogenesis on histologic sample. DNA flow cytometry provides a rapid and objective assessment of spermatogenesis in the investigation of male infertility. Importantly, this procedure might also be performed on aspiration biopsy, avoiding the costs and complications of surgery.

The therapeutic efficacy for chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is currently unsatisfactory. The aim of the present study was to assess the safety and efficacy of pollen extract in association with vitamins (DEPROX 500®) in males with CP/CPPS. All patients with a diagnosis of CP/CPPS attending the same urologic centre between March and October 2012 were enrolled in this randomised controlled phase III study. Participants were randomised to receive oral capsules of DEPROX 500® (two capsules every 24 h) or ibuprofen (600 mg, one tablet three times a day) for four weeks. The National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI), International Prostate Symptom Score and Quality of Well-Being (QoL) questionnaires were used. In the intention-to-treat analysis, 87 males (25 class IIIa and 62 class IIIb) with a mean age of 33.6±5.9 years were randomly allocated to the DEPROX 500® (n=41) or ibuprofen (n=46) treatment groups. At the follow-up examination (following one month of treatment), in the DEPROX 500® group, 31/41 patients (75.6%) reported an improvement in quality of life, defined as a reduction of the NIH-CPSI total score by ≥25%, compared with 19/46 (41.3%) in the control group (P=0.002). The greater improvement in the DEPROX 500® group compared with the ibuprofen group was statistically significant (treatment difference in the NIH-CPSI pain domain, −2.14±0.51, P

Objectives. To assess the risk of continued intravesical therapy and delayed cystectomy in the management of superficial bladder cancer refractory to bacillus Calmette-Guerin (BCG) therapy. Methods. We retrospectively reviewed the medical records of 24 patients who underwent an experimental intravesical treatment with BCG plus interferon alpha-2b or valrubicin for transitional cell carcinoma of the bladder. All patients had Stage Tis and/or T1 transitional cell carcinoma and had failed multiple prior courses of intravesical therapy, including at least one course of BCG. Results. Patients were followed up for a median of 28.5 months (range 6 to 48). One patient died of unrelated disease. All other patients were alive at last follow-up. Fourteen patients with preserved bladder were continuing cystoscopic surveillance: four had no recurrence, five had recurrence limited to the mucosa (Ta or Tis) and became free of disease after an additional course of intravesical therapy, and five had recurrent Ta or Tis or positive cytologic findings. The remaining 9 patients underwent radical cystectomy. All pathologic specimens showed no evidence of progression to muscle-invasive disease. Tis of the resected ureters in 6 and involvement of the prostate in 4 of the 9 patients (three in the urethral ducts and glands and one in the prostatic stroma) were noted. Conclusions. A select group of patients with BCG-refractory transitional cell carcinoma and a poor surgical risk for cystectomy may benefit from continued intravesical therapy without a significant risk of progression. However, a cautious approach to this treatment modality is recommended, and very close follow-up is necessary to detect bladder recurrences and involvement of the upper tract and prostatic urethra.

Objectives. To compare the epidemiologic, clinical, and pathologic characteristics of incidental and symptomatic renal cell carcinoma in a large series of patients, with emphasis on age distribution and its potential impact in defining groups of patients that may benefit from early detection programs. Methods. Records of 1092 patients with renal tumors from 1982 to 1997 were reviewed. Age, clinical presentation, and pathologic stage and grade were analyzed. Special attention was given to the age distribution and its relationship to the incidental or symptomatic diagnosis. Results. The overall mean age and proportion of patients older than 65 gradually increased (from 57 to 62.6 years and from 24.7% to 48.7%, respectively) from 1982 to 1997. The mean age in the incidental group rose steadily higher than in the symptomatic group. A progressive increase of incidental tumors from 13.0% in 1982 to 1983 to 59.2% in 1996 to 1997 was observed. A lower stage (74.3% versus 49.1%), grade (75.5% versus 56.9%), and percentage of metastases at presentation (10.4% versus 19.6%) were registered in the incidentally found neoplasms than in the symptomatic neoplasms. Eighty-two (80.4%) of 102 patients who underwent conservative surgery had incidental renal cell carcinoma. Conclusions. Our data confirm a rapid and dramatic change in the epidemiologic and clinical characteristics of renal cancer, with an increasing number of incidentally found tumors presenting with lower stage, grade, and percentage of metastases. An unexpected but significantly higher rate of renal neoplasms was observed in older patients. The stage, grade, and patient age observed in our series of incidentally found tumors raises the question of whether to leave the current diagnostic approach unaltered, thus benefiting a subgroup of patients with clinically unrecognized and possibly indolent renal cell carcinoma, or to extend early detection programs to younger patients with potentially more aggressive tumors.

Background The therapeutic efficacy of CP/CPPS is not very satisfactory and the impact on young male's quality of life is considerable. The aim of the present study is to evaluate the efficacy of pollen extract associated with vitamins (DEPROX 500®) in order to improve the quality of life of young patients affected by chronic prostatitis type Illb (CP/CPPS) by pain relieving. Methods All patients with clinical and instrumental diagnosis of CP/CPPS (class b) underwent DEPROX 500® 2 tablets in a single dose daily for 30 days. Clinical and microbiological analyses were carried out at the enrolment and after 1 month. NIH-CPSI and IPSS questionnaires have been used. The main outcome measure was the improvement of quality of life at the end of the whole study period, evaluated by questionnaires results. Results 20 men (mean age 32.8 ∓ 6.78) were enrolled in this pilot study. The baseline questionnaire mean scores were 25.90 ∓ 2.1 and 8.01 ∓ 3.64 for NIH-CPSI and IPSS, respectively. At the follow-up examination (1 month after treatment), 18 out of 20 patients (90.0%) reported an improvement of quality of life, in terms of pain reduction. The questionnaire results after 1 month from treatment were as follows: NIH-CPSI 12.8 ∓ 2.20, IPSS 7.6 ∓ 1.58. Statistically significant differences were then reported between the two visits, in terms of NIH-CPSI scores (pConclusions The pollen extract associated with vitamins (DEPROX 500®) significantly improved total symptoms, pain, and QoL in patients with non-inflammatory CP/CPPS without severe side effects.

We report a case of an uncommon site of metastasis of a renal cell carcinoma. The most common sites of renal cell carcinoma metastasis are the lung, lymph nodes, liver, bone and adrenal glands; skeletal muscle metastasis is a rare occurrence. We report the case of a 75-year-old female who underwent a laparoscopic left radical nephrectomy for a renal neoplasm in 2011. The histological examination revealed the presence of a renal cell carcinoma, Fuhrman grade 2, with extensive necrosis and phlogosis areas (TNM 2009 RCC pT2a). Ten months later, the patient noted an indolent swelling on the proximal third of the right thigh and underwent a ultrasonographic and CT evaluation, documenting the presence of a pathological, solid bulk in the front of the right iliac vessels and in the rectus femoris muscle. The fine needle biopsy revealed a metastasis of renal cell carcinoma. The patient underwent 4 cycles of sunitinib therapy, followed by 3 cycles of salvage therapy with sorafenib, which were well tolerated. This unpredictable behaviour of RCC suggests the need to perform a thorough follow-up of patients.

To evaluate the safety of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC)7 cm, addressing the issue of modality and risk factors for complications and open conversion, and to assess the oncologic outcome.The data of 222 patients undergoing LRN for RCC7 cm prospectively enrolled from 2002 to 2010 at 5 urologic centers were reviewed. Transperitoneal LRN was performed by 5 experienced laparoscopic surgeons. The Clavien-Dindo classification was used to assess complications. Multivariable analysis of factors predictive of conversions was performed. Oncologic outcomes for survival were estimated using the Kaplan-Meier method.Median tumor size was 8.5 cm, operative time was 180 minutes, and blood loss was 280 mL. Forty-two patients (19%) received a blood transfusion. Six (2.7%) patients had grade III-IV complications: 2 with postoperative bleeding requiring abdominal re-exploration and 1 each with adrenal injury, splenic injury, wound diastasis, and respiratory insufficiency. Twelve patients (5.4%) were converted to open surgery. The diameter was 11.9 in converted groups and 8.5 cm in nonconverted groups (P = .001). Multivariable analysis revealed that pathologic stage was the only independent predictor of conversion (P = .002). The 5-year overall (OS), cancer-specific (CSS), and progression-free (PFS) survival was 74%, 78%, and 66%, respectively. The 5-year stage-adjusted CSS was 89% in pT2 and 40% in pT3 patients (P .0001). Limitations of this study were its retrospective nature and the relatively short follow-up period for oncologic outcome.LRN for large RCC is a safe operation. Stage pT3 is a risk factor for open conversion and is associated to significantly lower cancer-specific survival compared with pT2 stage.

This study aimed to evaluate whether the interleukin-6 (IL-6) and interleukin-10 (IL-10) ratio (IL-6/IL-10) can be used as a prognostic marker of recurrence following bacillus Calmette-Guerin (BCG) therapy in patients with high-risk non-muscle invasive bladder cancer (NMIBC). One hundred and twenty-one consecutive urological patients (72 affected by high-risk NMIBC and 49 controls) were selected for this prospective study. Urine samples for dipstick and interleukin analyses were collected from each subject before surgery. All patients underwent transurethral resection of bladder tumours (TUR-BT), followed by six weekly BCG instillations. IL-6 and IL-10 concentrations in urine were determined by solid phase ELISA Quantikine IL-6 and IL-10 Immunoassay. Patients with NMIBC were stratified in accordance with IL-6/IL-10: group A ≤0.09 and group B >0.10. The main outcome measures were time to first recurrence and recurrence rate following BCG therapy. At enrolment, IL-6/IL-10 was not statistically different between patients and controls (p=0.763, degrees of freedom (df)=1, F-test result (F)=0.092). Of the 72 patients with NMIBC, 38 (52.7%) had an IL-6/IL-10 of ≤0.09 (group A), while 34 (47.3%) had an IL-6/IL-10 of >0.10 (group B). A significant difference between IL-6/IL-10 and status at follow-up was found (p=0.016, df=1, χ2=5.800). The Kaplan-Meier curves demonstrated that group B patients had a significantly higher probability of being recurrence-free than group A patients [p=0.003; recurrence rate (RR)=3.1]. At multivariate analysis, IL-6/IL-10 (p

Objectives To define whether six-core biopsies still have a role in patients presenting with prostate-specific antigen (PSA) levels greater than 10 ng/mL and abnormal digital rectal examination (DRE) findings. Recent studies have suggested that the six-core biopsy is inadequate for the diagnosis of prostate cancer; however, it remains controversial whether an increased number of cores is justified in all patients. Methods From June 2002 to February 2005, 122 (18.8%) of 650 patients underwent prostate biopsy because of a PSA level greater than 10 ng/mL and abnormal DRE findings. All patients underwent transperineal ultrasound-guided prostate biopsy in a standardized fashion: a six-core biopsy was performed first, followed by six additional cores during the same session, four in the peripheral and two in the transition zone. Results The detection rate in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings was 72.1% (88 of 122) and 75.4% (92 of 122) using the 6-core and 12-core biopsy, respectively. One case of tumor was missed by the six-core biopsy among patients with a PSA level greater than 15 ng/mL and abnormal DRE findings. No cases of tumor were missed by six-core biopsy in the group with a PSA level greater than 20 ng/mL and abnormal DRE findings. Conclusions Six-core biopsy provided a similar cancer detection rate compared with 12-core biopsy in patients with PSA levels greater than 10 ng/mL and abnormal DRE findings. An initial approach with 6-core biopsy is reasonable in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings and is advocated in those with PSA greater than 20 ng/mL and abnormal DRE findings.

Aim: To evaluate the efficacy of a new sclerotization technique with pure ethanol in the treatment of symptomatic renal cysts. Patients and Methods: Fourteen patients having renal cysts with a meant diameter of 10 (range 5–15) cm were treated. Our technique includes: ultrasound-guided percutaneous puncture with an 18-gauge needle, positioning of a 5-Fr catheter, complete cyst fluid aspiration, injection of pure alcohol equal to 15% of the initial cyst volume, and alcohol aspiration after 90 min. The procedure was repeated eight times within 5 days. The patients were followed up by ultrasound and/or CT scan for 1 year. Results: All patients became symptom free. Follow-up showed a progressive reduction of the cyst diameter in all cases. Three cysts only (in 2 patients; cyst diameter Conclusions: In our experience, injections of pure ethanol in renal cysts, repeated after some days, were effective in eliminating recurrences and related symptoms. The procedure was not associated with significant complications. Our findings suggest that it be considered the first-choice procedure in the treatment of renal cysts, due to the good results and the low cost of ethanol.

INTRODUCTION AND OBJECTIVES: Laparoscopy is replacing open surgery in the management of renal masses, but its role for large primary tumors is not clearly established. Our objective is to evaluate the feasibility and outcome of laparoscopic radical nephrectomy (LRN) for renal cell carcinoma (RCC) greater than 7cm. METHODS: The records of patients who underwent laparoscopic (transperitoneal) radical nephrectomy for 7cm or larger RCC from January 2001 to September 2008 at four urologic centers in Northern Italy were reviewed. Demographics, operative, pathologic and follow-up data were evaluated. RESULTS: Overall, 134 patients underwent LRN in the study period. The median tumor size was 8.2cm (range 7-14), operative time 192 minutes (100-310), and blood loss 300ml (range 0-1500). 29 (21%) patients received blood transfusion. 16 (12%) cases in 2 centers were converted to open surgery, due to vascular/hemorrhagic complications (n=6), failure to progress (n=5), oncological concerns regarding the ability to completely resect extensive disease (n=4). Complications included: postoperative renal insufficiency (n=6) or hypertension (n=3), anemization (n=4), abdominal hematoma (n=2), wound diastasis/incisional hernia (n=2), splenectomy (n=1, occurring after open conversion). Pathologic stage was: pT2 in 92, pT3a in 22, pT3b in 18, pT4 in 2; 7 cases were pN+. 113 conventional, 5 chromophobe, 4 papillary, and 12 mixed or sarcomatoid RCC were resected. After a median follow-up time of 27 months (range 3-81), 93 (69%) patients were alive with no evidence of disease, 13 (10%) died of recurrent disease or progression, 22 (16%) are alive with disease. CONCLUSIONS: LRN for large renal tumors is feasible and efficacious without substantial complications and morbidity. However, the conversion rate was significant in our experience. Parasitic vessels and displacement of the surrounding organs by large renal masses can increase the risk of vascular/hemorrhagic complications or inability to completely resect the lesion. LRN for large masses confirms the advantages of laparoscopic surgery, but it remains a technically challenging operation, requiring advanced laparoscopic skills.

A 72-year-old woman with a history of hematuria presented with a three-month history of weight loss and anorexia. Computed tomography (Panel A) and ultrasonography showed a solid mass infiltrating the renal pelvis of the nonfunctioning right kidney. The serum creatinine concentration was 1.1 mg per deciliter (97.2 μmol per liter), and cytologic examination of the urine revealed no abnormalities. Subsequent radical nephrectomy confirmed the presence of the mass at the upper pole and also revealed a complete staghorn pyelocaliceal and ureteral mass (Panel B). Histologic analysis showed that the lesion was a poorly differentiated renal-cell carcinoma (stage pT3aN0M0 according to . . .

A double-blind study was carried out in a group of 9 patients with partially reversible airway obstruction, to evaluate the bronchodilator effect of gradually increased doses of fenoterol (cumulative doses: 100, 200, 400, 800 and 1,600 micrograms), ipratropium bromide (40, 80, 160, 320 and 640 micrograms) and a combination of these (100 + 40, 200 + 80 micrograms, etc.), denominated Duovent. The three treatments were carried out at random at the same time on 3 days, usually not consecutive days, whereby 1, 1, 2, 4 and 8 puffs (altogether 1, 2, 4, 8 and 16 doses) of each product were given in identical pressurized aerosols at intervals of 60 min. Respiratory (spirometry and flow-volume curve) and cardiovascular (blood pressure, heart rate) parameters were measured under basal conditions and 60 min after each administration. On average, with all three products, the bronchodilatory effect showed a linear correlation with the logarithm of the dose given. With the same number of puffs the side-effects (tremor in particular) of the combination fenoterol and ipratropium bromide or Duovent (FIB) were markedly fewer than those of fenoterol, while ipratropium bromide was very well tolerated. The three dose-response curves (parallel) show that, in respect of an increase in FEV1, 1 puff of Duovent (100 micrograms fenoterol + 40 micrograms ipratropium bromide) is approximately equal to 2 puffs of fenoterol (200 micrograms) and 4 puffs of ipratropium bromide (160 micrograms). FIB, therefore, makes it possible to maintain the same bronchodilatory effect as the full dose (400 micrograms) of fenoterol while improving the therapeutic value.

The effect of the combination fenoterol-ipratropium bromide (Duovent) as a bronchodilator drug versus salbutamol and placebo was investigated in 20 patients with chronic obstructive lung disease in a random cross-over trial. Our study was performed not only to evaluate the bronchodilator response, but especially to quantify the possibly more prolonged action of Duovent versus salbutamol, based on registration of prevention of asthma attacks, time effects and protective activity, management and tolerance. Each patient received therapy for 3 weeks; in each week only one of the preparations: salbutamol, Duovent or placebo was used. Respiratory function tests were determined every week on the 3rd, 5th and 7th days at the same time exactly at 30 and 60 min after drug inhalation. Additionally we registered, for each patient, daily symptomatology (e.g., asthma attacks, cough, additional daily puff use, adverse reactions) by using a personal clinical diary. The results and analysis of the pulmonary tests (especially FEV1 and peak expiratory flow) confirmed the bronchodilator effect of both drugs, higher for Duovent but not sufficient to reach statistical significance. Clinical condition, regarding number, severity of asthma crises and additional puff use, showed a significant statistical variation for each symptom either as regards advantage of Duovent and salbutamol versus placebo, or advantage of Duovent versus salbutamol. Therefore, the results of this trial reveal an excellent bronchodilator effect of both drugs and confirm a higher clinical efficacy of Duovent if used in long-term treatment, with good tolerability.

Restricted ocular myasthenia gravis (OMG) and generalised myasthenia gravis (GMG) have been shown to differ in a number of respects. In OMG, antiacetylcholine receptor, antistriational and antinuclear antibodies were rare relative to their frequency in GMG. In contrast, antithyroid antibodies and a history of thyroid disease were much more prevalent in OMG than in GMG, OMG was not associated with the female predominance seen in GMG and appeared to be relatively common in some races rather than others. It is suggested that different pathogenetic mechanisms are responsible for these two forms of MG.

It is generally thought that hospital discharges are underutilized, both for planning and for epidemiological research purpose (1,2).