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Background: Benign prostatic hyperplasia and prostate cancer (PCA) alter the normal growth patterns of zonal anatomy with changes of prostate volume (PV). Chronic inflammatory infiltrates (CII) type IV are the most common non-cancer diagnosis of the prostate after biopsy., Objective: To evaluate associations of both PV index (PVI), i.e. the ratio of transitional zone volume (TZV) to peripheral zone volume (PZV), and CII with PCA in patients undergoing biopsy., Subjects and Methods: Between January 2007 and December 2008, 268 consecutive patients who underwent prostate biopsy were retrospectively evaluated. PV and TZV were measured by transrectal ultrasound. PZV was computed by subtracting the PV from the TZV. CII were evaluated according to standard criteria. Significant associations of PVI and the presence of CII (CII+) with PCA risk were assessed by statistical methods., Results and Limitations: We evaluated 251 patients after excluding cases with painful rectal examinations, prostate-specific antigen (PSA) >20 μg/ml and metastases. The PCA detection rate was 41.1%. PVI was a negative independent predictor of PCA. A PVI ≤1.0 was directly [odds ratio (OR) = 2.36] associated with PCA, which was detected more frequently in patients with a PVI ≤1.0 (29.1%) than in those with a PVI >1.0 (11.9%). CII+ was inversely (OR = 0.57) and independently associated with PCA, which was detected less frequently in cases with CII (9.9%) than in those without CII (21.1%). Potential study limitations might relate to the fact that PV was not measured by prostatectomy specimens and there was PSA confounding for CII and PCA., Conclusions: Low values of PVI are directly associated with risk of PCA, which was almost 2.5 times higher in patients with a PVI ≤1.0. The PVI might be an effective parameter for clustering patients at risk of PCA. CII+ was inversely associated with risk of PCA and decreased the probability of detecting PCA by 43%. The role of the PVI and CII in PCA carcinogenesis needs further research., (2014 S. Karger AG, Basel)

Background: The ideal bioptic strategy for CaP detection is still to be completely defined. The aim of our study is to compare transperineal (TP) and transrectal (TR) approaches, in a 14-core initial prostate biopsy for CaP detection., Material and Methods: A prospective controlled study was conducted enrolling 108 consecutive patients with a PSA level greater than 4 ng/mL and/or an abnormal DRE. TR versus TP 14-core initial prostatic biopsies were performed on 54 and 54 patients, respectively, with a randomisation ratio of 1:1., Results: The cancer detection rates were 46.29 (25 out of 54 patients), and 44.44% (24 out of 54 patients), respectively, using the TR or the TP approach (p = 0.846). The overall cancer core rate was significantly higher when the TP approach was used: 21.43% (162 out of 756 cores) and 16.79% (127 out of 756 cores), with the TP and the TR approach, respectively (p = 0.022). The cores were significantly longer performing TP approach: at the site "1" (14.92 versus 12.97 mm, p = 0.02); at "5" (15.53 versus 13.69 mm, p = 0.037); at "7" (15.06 versus 12.86 mm, p = 0.001); at "9" (14.92 versus 13.38 mm, p = 0.038); at "11" (16.32 versus 12.31 mm, p = 0.0001); at "12" (15.14 versus 12.19 mm, p = 0.0001); at "13" (17.49 versus 13.98 mm, p = 0.0001); at "14" (16.77 versus 13.36 mm, p = 0.0001). As to the biopsy related pain, the mean pain level perceived by patients during the TR approach was 1.56 ± 1.73 versus 1.42 ± 1.37 registered during TP approach (p = 0.591)., Conclusions: No significant differences were found in cancer detection rate, cancer core rate between TP and TR approaches for prostatic biopsy. Even in terms of complication rate or pain level, it cannot be concluded that one procedure is superior to the other one. Apparently, strictly following our protocol, TP approach seems to offer a better sampling at the level of the apex and the TZ, however without adding any significant advantage in terms of overall cancer detection rate.

Prostate cancer (CaP) is the most common malignancy in men and the second cause of cancer-related mortality after lung cancer. Several studies have evaluated the correlation between bioptic and pathological Gleason score (GS), documenting a correlation ranging between 30 and 60%. The aim of this study was the evaluation of the association between bioptic and pathological GS in a series of patients undergoing prostate needle biopsy and subsequent radical prostatectomy. We also aimed to evaluate the possible prognostic factors of upgrading and upstaging. We prospectively collected and retrospectively reviewed data from 300 consecutive patients who underwent radical retropubic or robot-assisted prostatectomy at our Institution. Patients who underwent prostate needle biopsy, transrectal or transperineal, with a minimum of 5 samples, were included in this study. Upgrading and downgrading were defined as increase or decrease, respectively, from one prognostic grade group to another, similar to up- or downstaging. The mean age of the patients was 62.97 years and the mean prostate-spesific antigen (PSA) level was 7.83 ng/ml. A total of 51.3% of the population underwent a transperineal prostate biopsy. The most frequently represented bioptic GS was 3+3 (64.0%) followed by 3+4=7 (15.6%); the most frequent pathological Gleason score was 3+4 (44.3%), followed by 3+3 (31.0%). With reagard to the bioptic GS 4-5-6 group, approximately half of the specimens (46.7%) were subsequently upgraded to GS 3+4, and 5.3% to 4+3. With regards to the bioptic GS 3+4 group, 57.4% was confirmed in the surgical specimen. In the 4+3 group, 23.5% of the cases was downgraded to 3+4 and 35.3% was confirmed. With regards to stage, ~39.7% of the patients received an upstaging on the pathological specimen. We evaluated the correlations between preoperative serum PSA level, prostate volume, digital rectal examination and biopsy type and none of the variables considered exhibited a correlation with any upgrading (P>0.05). Moreover, we evaluated the correlations between the aforementioned variables and upstaging and, at the multivariate analysis, only a serum PSA <4 ng/ml was found to be an independent variable predictive of upstaging (P=0.017). Therefore, new tools are required to predict upgrading and upstaging of our patients, in order to ensure better counseling for optimal treatment planning.

This study was conducted to test a new substaging system in a population of patients with stage T1 bladder cancer (BC) at diagnosis and assess its prognostic role in terms of disease progression and disease-specific survival (DSS). Patients with primary stage T1G3 urothelial carcinoma of the bladder were stratified according to the following models: i) T1a [the tumour does not infiltrate the muscularis mucosae-vascular plexus, (MM-VP)]; T1b (the tumour partially infiltrates the MM-VP); and T1c (the tumour infiltrates and invades the MM-VP). ii) T1m (diameter of tumour infiltrating the lamina propria ≤0.5 mm under a high-resolution microscope; and T1e (diameter of tumour infiltrating the lamina propria >0.5 mm). Age, gender, tumour size and multifocality were not found to be of statistical significance. Using the T1a/T1b/T1c system, patients with stage T1a disease exhibited a 5- and 10-year progression rate of 13.3 and 20%, respectively, without reaching statistical significance. Moreover, patients with stage T1a disease exhibited a 5- and 10-year DSS of 93.3 and 73.3%, respectively, which was higher compared to T1b and T1c but not statistically significant. Using the T1m/T1e system, patients with stage T1m disease exhibited a disease progression rate of 8.3 and 16.7% at 5 and 10 years, respectively, which was not statistically significant. Moreover, patients in group T1m presented with DSS rates of 91.7 and 83.3% at 5 and 10 years, respectively, which were higher compared to those in the T1e group (71.4 and 60.7%), although not reaching statistical significance. In conclusion, in our study, neither of the two substaging systems of stage T1 BC reached the prognostic conventional significance level for tumour progression or DSS.

Portal vein thrombosis refers to an obstruction of blood flow in the portal vein; this rare disease can be both local and systemic. Local risk factors, accounting for about 70% of cases, can be abdominal cancers, inflammatory of infective diseases, surgical procedures or cirrhosis. A 62-year-old man, affected by hypertension and taking acetylsalicylic acid after a myocardial infarction in 1994, developed deep venous thrombosis on the right leg. Six months later the patient was admitted to the emergency unit due to abdominal pain. A CT scan revealed the presence of a complete splanchnic vein thrombosis and a primary tumor on the right kidney. The patient was treated with total parenteral nutrition and intravenous solution of heparin sodium first and then, because of occurrence of allergy, fondaparinux, with improvement of the abdominal pain. Subsequently he underwent right radical nephrectomy., (Copyright © 2013 S. Karger AG, Basel.)

Objective: Different fast track programs for patients undergoing radical cystectomy (RC) can be found in the current literature. The aim of this work was to develop a new enhanced recovery protocol (ERP)., Patients and Methods: The ERP was designed after a structured literature review focusing on reduced bowel preparation, standardized feeding, postoperative nausea, vomiting and pain control. In order to test the ERP, a pilot observational prospective cohort study was planned, enrolling all patients consecutively undergoing RC and Vescica Ileale Padovana (VIP) neobladder. These patients were compared with a matched group of subjects who had undergone RC and VIP neobladder before implementation of the ERP. To achieve good comparability, a propensity score-matching was performed. The primary aim was to assess the ERP's feasibility; the secondary outcome measures were early morbidity and mortality., Results and Limitations: After an exhaustive literature search and a multidisciplinary consultation, an ERP was designed. Nine consecutive patients participated in the pilot study and were compared to 13 patients treated before implementation of the ERP. We did not find any statistically significant difference in terms of mortality rate (none died peri- or postoperatively in both groups). The complication rate, according to the modified Clavien classification, was significantly lower in the ERP group (22.22 vs. 84.61%, p < 0.004). The major limitations are the low number of patients enrolled to test the protocol and the lack of randomization for the comparative evaluations., Conclusion: The introduction of our ERP was proven to be feasible in the management of patients undergoing RC and intestinal urinary diversion with VIP neobladder. The postoperative course was enhanced by a significant reduction in both nasogastric tube insertion and parenteral nutrition support, with early postoperative feeding. All these findings were associated with no deleterious effect on morbidity or mortality, indeed there was a reduced occurrence of postoperative complication rates., (2013 S. Karger AG, Basel)

Aims: High intensity focused ultrasound (HIFU) is an emerging alternative for the treatment of prostate adenocarcinoma. Alpha-methylacyl-CoA racemase (AMACR) has been shown to be a sensitive immunomarker for prostate cancer, however, there is no information available concerning its utility and that of other immunomarkers for the detection of malignancy after HIFU therapy., Methods: AMACR expression was examined in 11 cases of prostatic carcinoma treated by HIFU, with histological evidence of residual carcinoma. In seven cases tumour was examined from thin core biopsies and in four cases from tissue fragments obtained by transurethral resection of prostate (TURP). In addition to AMACR, immunostaining was also undertaken for p63, cytokeratin 34betaE12, cytokeratin 5, cytokeratin 8-18, prostate specific alkaline phosphatase (PSAP), prostate specific antigen (PSA), chromogranin and CD56., Results: In two of the cases foci of tumour were cut out in serial sections. AMACR was expressed in eight of nine evaluable cases (4/5 biopsies and 4/4 TURP specimens). Cytokeratin 8-18 and PSAP were positive in all cases, whereas PSA was positive in five of nine cases. Cytokeratin 34betaE12, cytokeratin 5, and p63 marked the basal layer in normal prostatic glands, but were negative in neoplastic glands. In four cases we found tumour cells with positive staining for CD56 and chromogranin., Conclusions: A panel with positive markers for AMACR, and negative markers for p63/cytokeratin 5/cytokeratin 34betaE12 confirms the neoplastic nature of the residual glands on biopsies or TURP fragments sampled after HIFU therapy.

Purpose: We analyzed the surgical outcomes of antegrade scrotal sclerotherapy in a large, prospective, multisurgeon, consecutive series of patients treated for idiopathic varicocele., Materials and Methods: We prospectively collected data on 697 consecutive patients undergoing antegrade scrotal sclerotherapy between 1997 and 2005. For every patient we evaluated age, side, clinical and Doppler ultrasound grade, and seminal impairment. Perioperative complications were evaluated 1 month after surgery. At 12 months after antegrade scrotal sclerotherapy all patients underwent Doppler ultrasound. In those with seminal impairment semen analysis was also performed. Failure was defined as at least Doppler grade 1 varicocele., Results: Median age of the 697 analyzed patients was 28 years. Mean surgical time was 15 minutes. All surgeries were performed using local anesthesia and no intraoperative complications were observed. All patients were discharged home within 4 hours. Postoperatively complications developed in 35 patients (5%) and failure occurred in 63 (9%). Persistent reflux was observed in 6.5% of adolescents, in 9.4% of adults and in 7.5% of patients with recurrent varicocele. Failure rates were similar for different grades and sides. The failure rate was significantly higher in patients treated by surgeons during the learning curve (p = 0.007). In the 414 patients with seminal impairment median sperm count and the median percent of progressive motility and normal forms significantly improved after surgery (p <0.001)., Conclusions: Considering the low persistence and complication rates in all patient categories (adolescents, adults, first diagnosis, and bilateral and recurrent disease) antegrade scrotal sclerotherapy can be proposed as a safe and efficacious first choice treatment for varicocele. A specific learning curve is required to achieve the best outcome.

Objective: To report the successful and feasible use of transperineal fine needle aspiration of seminal vesicles (FNASV) for sperm retrieval in obstructive azoospermia., Design: Case report., Setting: Outpatient care in institutional clinic., Patient(s): A 31-year-old man with obstructive azoospermia due to a middle prostatic müllerian cyst., Intervention(s): Transperineal FNASV using a coaxial 17-gauge TruGuide needle., Main Outcome Measure(s): Feasibility of sperm retrieval suitable for future in vitro fertilization., Result(s): Transperineal FNASV made it possible to aspirate 11 mL of fluid with a sperm count of 100 million/mL and 15% motility. This sample was cryopreserved for in vitro fertilization using intracytoplasmic sperm injection., Conclusion(s): Transperineal FNASV using a coaxial needle may be a further method for sperm retrieval to add to the repertoire of assisted reproduction technologies.

Objective: To analyse the length of needle cores sampled as a quality indicator in systematic transperineal prostate biopsy. We assessed the correlation of core length with the other clinical and topographic parameters., Material and Methods: We prospectively evaluated data from 509 consecutive patients who underwent a first set of transrectal ultrasound-guided transperineal prostate biopsy for suspected prostate cancer. Fourteen cores were sampled from each patient. Needle cores were stretched and placed in tissue cassettes between two nylon meshes according to the pre-embedding methods of prostate needle biopsy specimens. For single biopsy core, the measurement of length (in millimetres) and any percentage of cancer in the biopsy specimen were reported., Results: The mean length of 7,126 analysed cores was 14.14+/-4.35mm. All cores were longer than 10mm. The mean length of needle cores sampled did not correlate with patient age, total prostate-specific antigen value, digital rectal examination, and prostate volume. The whole mean length of the six samples from the peripheral zone of the right lobe was higher than the mean corresponding value of the six samples from the left lobe peripheral zone (p<0.001). The transperineal approach allows a greater sampling of the prostate apex than of the midgland and prostate base (p<0.001)., Conclusions: The length of the needle cores sampled during transperineal prostate biopsy fulfils the parameters of quality required by pathologists for an appropriate evaluation of the biopsy specimen.

Objectives: We compared the detection rates of different transperineal prostate biopsy protocols with the aim to optimize the number of cores to sample according to prostate volume., Material and Methods: From October 2002 to October 2004 we evaluated 480 consecutive patients with PSA between 2.5 and 20 ng/ml undergoing the first set of prostate biopsy. All patients underwent a 14-core TRUS-guided transperineal prostate biopsy, including 12 cores in the peripheral and two in the transitional zone. The detection rate of the 14-core scheme was compared to the one of the other biopsy schemes obtained through the exclusion of pairs of cores. Data were stratified according to the different TRUS estimated prostate volumes., Results: The detection rate of the standard sextant was 35.2%, while those of the 8-core schemes ranged from 37.1 to 38.8%. The 10-core schemes yielded detection rates of 39.6-40.8% and the protocol with 12 biopsies in the peripheral zone diagnosed prostate cancer in 42.1% of the patients. In patients with <30 cc prostate volume, the detection rate of the 14-core scheme was 43.8% and resulted statistically overlapping to the 8-peripheral cores protocol. In patients with 30.1-50 cc prostate volume a 12-peripheral core biopsy reproduced the results of the 14-core sampling. In prostates larger than 50 cc, an even more extensive procedure was mandatory, considering the low detection rate of the 14-core scheme (24.2%)., Conclusion: Transperineal prostate biopsy is a safe procedure with a very low complication rate and high cancer detection rate. Prostate volume is the most relevant variable in the planning of the optimal number of cores in the extensive first biopsy set. A protocol with more than 8 peripheral cores) is recommended only in patients with prostate volume larger than 30 cc.

CD10 has been considered a useful marker in the diagnosis of renal carcinomas, because of its expression in clear cell and papillary renal cell carcinomas and its absence in chromophobe renal cell carcinomas. On the other hand, chromophobe renal cell carcinoma expresses parvalbumin, which is absent in clear cell and papillary renal cell carcinomas. To further address the relevance of these markers, we studied the expression of CD10 and parvalbumin in 42 samples of chromophobe renal cell carcinoma (seven of which had aggressive features, including invasion beyond the renal capsule, renal vein invasion, metastases, or sarcomatoid transformation), 75 clear cell renal cell carcinomas (eight metastatic) and 51 papillary renal cell carcinomas (two metastatic). CD10 was found in 100% of clear cell renal cell carcinomas, 63% of papillary renal cell carcinomas and in all metastatic cases of both types. At variance with previous studies, we found CD10 expression in from 30 to 90% of the neoplastic cells, in 11 of 42 (26%) chromophobe renal cell carcinomas. The CD10-positive cases included five of the seven (71%) chromophobe renal cell carcinoma with aggressive features. Statistical analysis showed significant association of CD10-positive tumors with clinicopathologic aggressiveness (P=0.003) and mitotic figures (P=0.04). Parvalbumin was strongly expressed in all primary and metastatic chromophobe renal cell carcinomas. Western blot analysis was utilized to confirm the expression of both CD10 and parvalbumin in chromophobe renal cell carcinomas.

Objectives: To verify whether the latest version of the TNM staging system (2002) could predict different cancer-specific survival in patients with localized renal cell carcinoma (RCC; Stage T1-T2N0M0)., Methods: According to the 2002 TNM staging system, we reassigned the pathologic stage of 702 patients who had undergone surgical treatment for RCC from 1976 to 2000. We selected 491 patients with localized RCC (pT1-T2N0M0). In 334 patients (68.0%), we had performed radical nephrectomy; in 121 (24.6%), elective nephron-sparing surgery; and in 36 (7.3%), imperative nephron-sparing surgery. Cancer-specific survival was estimated according to the Kaplan-Meier method. The log-rank test and Cox's proportional hazard model was used for univariate and multivariate analysis, respectively., Results: Of the 491 tumors, 249 (50.7%) were classified as pT1a, 155 (31.6%) as pT1b, and 87 (17.7%) as pT2. The median follow-up was 75 months. The 5-year and 10-year cancer-specific survival probabilities were, respectively, 97.4% and 95.6% in the pT1a patients, 92.5% and 89.8% in the pT1b patients, and 89.3% and 78.5% in the pT2 patients. The survival curve comparison was statistically significant both between pT1a and pT1b (log-rank test, P = 0.01) and between pT1a and pT2 (log-rank test, P = 0.0007). No statistically significant difference was observed between the pT1b and pT2-specific survival probabilities (log-rank test, P = 0.42)., Conclusions: The 2002 TNM staging system does not seem able to predict different cancer-specific survival between pT1b and pT2 RCC. These data highlight the need to define an optimal breakpoint to stratify patients with localized RCC.

Introduction: Adrenal masses discovered by imaging techniques for reasons unrelated to adrenal diseases are called incidentalomas with pheochromocytomas accounting for about 20%. The aim of this study was to report on our experience of 5 patients operated for incidentally discovered adrenal pheochromocytoma and update the literature concerning this subject., Patients and Methods: From September 1976 to December 2000 we operated on 28 for adrenal incidentaloma, and pheochromocytoma was detected in 5 patients (19%). Average age was 61.4 years (range 54-65). All patients underwent adrenal hormonal as well as imaging investigation. Preoperative care for pheochromocytoma was performed in 3 patients. All patients were followed up., Results: Average tumor diameter, as detected by CT, was 5.5 cm (range 3-10). Urinary 24/h excretion of VMA resulted elevated in 2 cases (40%). Two patients during adrenalectomy developed paroxysmal hypertension which was readily controlled by intravenous administration of nitroprussiate and trandate. Postoperative outcome was uneventful. Average tumor size, as detected by pathology, resulted 8.9 cm (range 3-12). Mean follow-up was 60.4 months (range 32-122) and overall survival rate was 60%. Three patients are alive and disease-free and 2 died after a follow-up of 32 and 36 months for reasons unrelated to the primary disease., Conclusions: Every incidentally discovered adrenal mass should be investigated for pheochromocytoma since accounting for about 20%. Undetected pheochromocytomas undergoing surgery without preoperative care for avoiding cardiovascular disturbances confer a high risk for morbidity and mortality, especially in pregnancy and childhood. Nonfunctional and small tumors sized 3 cm or lesser may be closely followed up by imaging and hormonal investigation. Surgery is indicated when tumors are functional or larger than 3 cm. Actually, laparoscopy is the new gold-standard in treating adrenal pheochromocytomas. Adrenal sparing surgery as well as autotransplantation of adrenal tissue are both effective and safe in treating patients with bilateral pheochromocytomas, thus improving quality of life since avoiding lifelong steroid dependency. When managed appropriately, the outlook for pheochromocytoma is excellent with a free survival rate of 92% and 80% at 5 and 10 years respectively. Unfortunately, malignant pheochromocytomas are still difficult to treat.

Objectives: To assess whether the use of a coaxial needle reduces discomfort in patients undergoing multiple-core transperineal prostate biopsy to detect prostate cancer., Methods: From October 2002 to January 2003, we enrolled 102 consecutive patients with a suspicion of prostate cancer. In every case, we performed a 14-core transperineal prostate biopsy under transrectal ultrasound guidance. The patients were randomized into two groups: group 1 (n = 51) in which we used the 17-gauge coaxial TruGuide needle, and group 2 (n = 51) in which the conventional transperineal technique was used. At the end of the procedure, patients were asked to complete a questionnaire regarding the level of pain experienced., Results: The studied groups were comparable in age, total prostate-specific antigen value, and prostate volume. The whole procedure was significantly less painful in group 1 (2.20 +/- 1.20 versus 2.90 +/- 1.73, P = 0.01). We failed to show any significant pain score differences during rectal probe insertion (P = 0.10), transrectal ultrasonography (P = 0.16), and execution of local anesthesia (P = 0.11). The pain score recorded during the multiple-core prostate sampling was significantly lower in group 1 (1.53 +/- 1.5 versus 2.43 +/- 1.86, P = 0.009). No statistically significant differences were found in the complication rates between the two groups., Conclusions: The use of a coaxial needle reduces the procedure's invasiveness and patient's pain compared with the conventional transperineal prostate biopsy.

Purpose: To evaluate the prognostic significance of different detection modalities of renal cell carcinoma (RCC) in a large cohort of patients who had been previously submitted to surgery in two teaching hospitals in Italy., Materials and Methods: We reviewed the clinical records of 1446 patients who had been submitted to surgical treatment for RCC at the Departments of Urology of Padua (n=747) and Verona (n=699) from 1976 to 2000. Patients were classified into two groups according to the detection mode: symptomatic and incidental. The cancer-specific survival probability was estimated according to the Kaplan-Meier method. In order to compare the survival curves the log rank test was used. The predictive independent value of the variables was examined using the Cox proportional hazards model., Results: Six hundred and thirty patients (43.6%) were treated for incidental RCC and 816 (56.4%) for symptomatic RCC. In the incidental group, the size (p<0.001), the pathological stage (p<0.001) and the nuclear grading (p<0.001) of tumors were lower than those causing symptoms. The 5-year and 10-year cancer-specific survival probability were 84% and 75% in the incidental group, and 66% and 54.5% in the symptomatic group (p<0.0001), respectively. At a multivariate analysis, the mode of detection was an independent predictive variable (H.R. 1.559), as well as pathological stage (H.R. 1.809), nuclear grading (H.R. 1.411), size

Primary small cell carcinoma of the urinary bladder is a highly aggressive disease and accounts for less than 0.5% of all primary bladder tumors. Quite often, clinical presentation is related to local and/or systemic involvement of the disease. Histogenesis is still unknown, but investigators consider the tumor originating from a multipotent undifferentiated stem cell of the bladder urothelium. Hematuria is the first and most frequent symptom that patients complain at the clinical presentation of the disease. The primary local tumor is treated by radical surgery or radiation therapy, while systemic involvement requires polychemotherapy according to the M-VAC protocol. Prognosis is worse and related to the pathological stage of the disease and to chemotherapy reply. Herein we report on 3 cases of primary small cell carcinoma of the urinary biadder. We also review and update the literature concerning this topic.

Introduction and Objectives: Adrenal myelolipomas are rare benign non functioning tumors which are mostly detected incidentally by imaging (8-15%). The aim of this study was to find out the clinical outcome of 3 patients operated for incidentally discovered adrenal myelolipoma as well as to update the literature concerning this topic., Patients and Methods: During a 24 year period (1976-2000) we operated on 28 of 39 (72%) patients for incidentally discovered adrenal mass and pathology assessed 3 myelolipomas (11%). All patients were males and average age was 54.3 years (range 46-66). Myelolipoma was associated with arterial hypertension in 2 patients and BPH in 1. Patients underwent unilateral adrenalectomy. Results Myelolipomas, all unilateral, were right-sided in 2 cases (67%) and left sided in 1. Average tumor diameter, as detected by CT scan, resulted 10.3 cm range (3-17). Endocrine investigation was negative. Average tumor size, as detected by pathology, resulted 9.3 cm (range 3-14) and mean weight 653 gr (range 210-980). Histopathology assessed primary adrenal myelolipoma in all cases. Mean follow-up is 110.6 months (range 102-128) and all patients are alive and disease free., Conclusions: Ultrasound (US), computed tomography (CT) and magnetic resonance imaging (MRI) are effective in diagnosing adrenal myelolipomas in about 90% of cases. Fine needle aspiration (FNA) cytology under CT or US control has an important role in investigating as well as diagnosing undefined masses suspected of adrenal or extraadrenal myelolipoma thus avoiding unnecessary surgery. The increasing number of incidentally discovered adrenal myelolipomas arise the question of appropriate treatment modalities which range from watchful waiting to surgical removal. Small asymptomatic tumors sized less than 4 cm can be monitored expectantly. Tumors when symptomatic or larger than 4 cm should be removed since the risk of spontaneous rupture with retroperitoneal hemorrhage and life threatening shock. Bilateral adrenalectomy for large and symptomatic tumors implies lifelong substitution with hydrocortisone. Actually, laparoscopic adrenalectomy is the new gold standard in treating myelolipomas since both showing more effective postoperative recovery than open surgery as well as reducing the number of patients who undergo long and close follow up.

Objectives: To report on a case of primary renal lymphoma (PRL) and update the literature concerning this topic., Materials and Methods: A 48-year-old woman underwent surgery for the presumed diagnosis of renal cell carcinoma with bilateral adrenal metastases., Results: The neoplasm was assessed as primary renal non-Hodgkin high grade lymphoma, diffuse large B-cell type. Then the patient underwent polychemotherapy according to the VACOP-B protocol. Unfortunately, 5 weeks later the patient was lost since missing chemotherapy and follow-up., Conclusions: PRL is a distinct pathological and clinical entity which is extremely rare and highly aggressive since disseminating rapidly from its origin. The disease usually affects adults with an average age of 60 years and slight male preponderance; however it has also been reported in childhood. Etiology factors for PRL are unknown. Several histogenetic theories of the disease have been postulated since the kidney does not normally contain lymphoid tissue. Investigators reported many classes of non-Hodgkin lymphoma which include large, small, intermediate and mixed cell types with high, intermediate or low grade histologies. The neoplastic lymphoid cells may express both B and T immunoblastic phenotypes, primary renal Hodgkin lymphoma has also been reported. The disease may present with progressive renal failure of either oliguric or non oliguric type. Imaging studies in diagnosing and staging primary renal lymphomas include ultrasound examination (US) and computed tomography (CT); there are also some reports of magnetic resonance imaging (MRI). Total body bone scan and bone marrow biopsy will complete disease clinical staging. Renal biopsy is important in assessing the diagnosis of PRL as well as of acute renal failure for bilateral lymphomatous infiltration of the kidneys. Up to now, there are no standard treatment modalities for this entity since the small number of cases reported. Multidrug chemotherapy is mandatory for high grade lymphoma and when the disease is diagnosed preoperatively. High dose chemotherapy in the future may offer a curative approach in primary bilateral renal disease and without end-stage renal disease. Survival is extremely poor since 75% of patients die less than 1 year after operation. Prognosis may be improved by early detection of disease and by performing systemic chemotherapy.

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 Fuhrman's 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.

Objective: To comparatively assess the psychological, social well-being and general state of health in patients with stage 1 renal cell carcinoma (RCC) (according to 1997 TNM), who underwent either elective nephron sparing surgery (NSS) or radical nephrectomy., Patients and Methods: We evaluated the health-related quality of life (HR-QoL) in 88 patients who underwent radical nephrectomy and in 56 treated with elective NSS. The measurement of the main QoL components has been made using domain-specific questionnaires tested and validated in Italian language. Each questionnaire has been self-administrated during follow-up (cross-sectional study)., Results: The two analysed group resulted perfectly comparable regarding age, gender, civil status, educational level, profession and mean follow-up. A low level anxiety has been documented in 11.4% of patients after radical nephrectomy and in 1.8% of those treated with an elective conservative surgery. The mean score difference between the two groups resulted statistically significant (p = 0.003). A mild depression has been recorded in 7% of patients who underwent radical nephrectomy and in 2.3% of NSS group. The mean score difference between the two groups was statistically significant (p = 0.01). The general health status was impaired in 12.5% of cases after radical nephrectomy and in 7% after elective NSS. Social problems were present in 18% of patients who underwent radical nephrectomy and in 18% of NSS group. There was no significant difference between radical and conservative group in terms of both General health Questionnaire and Social Problem Questionnaire mean scores., Conclusion: HR-QoL in patients who underwent surgery for RCC is not particularly negatively affected. Nevertheless, the comparative analysis of the results showed that, at a long term follow-up, radical surgery seems to eventually cause a more relevant negative impact on the psychological well-being than conservative surgery.

Objectives: This retrospective study was performed to evaluate histopathologic prognostic risk factors in 75 patients on clinical stage 1 nonseminomatous germ cell cancer of the testis (NSGCTT)., Methods: From September 1976 to February 2000 we operated on 75 patients for NSGCTT on clinical stage 1 disease. Average age was 29.5 years (range 16-71). After orchiectomy, therapeutic options included retroperitoneal lymph node dissection (RLND) for 44 patients (58.6%), surveillance for 26 (34.6%) and neoadjuvant chemotherapy for 5 (6.6%). Testis primary tumor samples were assessed for studying prognostic risk factors that included vascular and/or lymphatic invasion (IV/IL+), percentage of embryonal carcinoma (%EC) and absence of yolk sac tumor (YS-)., Results: All patients were alive and disease-free. The average age follow-up was 84.5 months (range 1-254). Relapses occurred in 11 (14.6%) patients after an average follow-up of 9.09 months (range 3-24). Prognostic risk factors were detected as follows: IV/IL+ in 17 cases (22.7%), (50-80%) EC in 23 (30.6%), CE% > 80 in 23 (30.6%), YS- in 55 (72%). In 8 (10.6%) patients there was not any prognostic risk factor. Disease relapse related to prognostic risk factors was detected as follows: 18.1% for VI/LI, 90.9% for EC% > 50 (27.2% for 50-80% EC and 63.6% for CE% > 80) and 90.9% for YS-. Relapsing rates between patients with EC% > 80 and 50-80% EC resulted statistically significant (p = 0.02, odds ratio = 12.25). Relapsing rates between patients on surveillance and those who underwent RLND was next to be significant (p = 0.05, odds ratio 3.68)., Conclusions: EC% > 80 is a prognostic risk factor for disease relapse in patients with clinical stage 1 NSGCT who are selected in a high risk group requiring RPLND or neoadjuvant chemotherapy as therapeutical option.

The authors report on a rare pediatric case of adrenal extramedullary hematopoiesis in a patient with beta-thalassemia disease. The lesion was clinically discovered as incidentaloma of the right adrenal gland and treated by surgery. Adrenal extramedullary hematopoiesis may clinically be detected as incidentaloma. Adrenal incidentalomas presenting with hematologic disorders, such as agnogenic myeloid aplasia and beta-thalassemia, need careful imaging as well as adrenal hormonal investigation in order to exclude malignancy and subclinical hypersecretory syndromes. Ultrasound or CT-FNA of the lesion are effective in finding out the disease.

Objectives: The prognostic value of tumor extension into the renal vein or vena cava is still a controversial issue. The aim of this study is to report our experience with radical surgery in patients with renal cell carcinoma (RCC) extending into the renal vein or subdiaphragmatic vena cava., Methods: We evaluated 142 patients with RCC involving the renal vein or inferior subdiaphragmatic vena cava. RCC had extended into the renal vein in 118 patients and into the inferior vena cava in the remaining 24. Radical nephrectomy was performed in all cases with renal vein invasion. Radical nephrectomy with cavotomy and tumor thrombus removal was carried out in all cases with inferior subdiaphragmatic vena caval invasion. Cause-specific survival was calculated by means of the Kaplan-Meier method. The log rank test was used for survival comparisons and univariate analysis., Results: The 5- and 10-year cause-specific survival rates were 51.5 and 39%, respectively, in the group of patients with tumor extension into the renal vein and 33.4% in those with inferior vena caval involvement. In 52 patients (44%), RCC extended only into the renal vein. In the remaining 66 patients, renal vein invasion was associated with other adverse prognostic factors. Life expectancy was lower for patients with other concurrent adverse prognostic factors than for those affected by renal vein involvement alone (p < 0.0001). In the latter group, survival expectancy was similar to those with stage T2N0M0 tumor. In 7 cases (29%), inferior vena caval invasion was not associated with other adverse prognostic factors. In the remaining 15 patients (71%), vena caval involvement was associated with other adverse prognostic factors. Concurrence of other adverse prognostic factors with vena caval invasion significantly decreased the disease-specific survival expectancy in comparison with the patients in whom vena caval involvement was the main prognostic factor (p = 0.008). In these patients, disease-specific survival was similar to those with stage T2N0M0 tumor., Conclusion: Renal vein or inferior subdiaphragmatic vena caval involvement does not significantly affect prognosis in patients with RCC., (Copyright 2001 S. Karger AG, Basel)

Polyorchidism is a rare anomaly with approximately 70 cases reported in literature. The exact explanation for the production of polyorchidism is not known, although several theories have been proposed, including anomalous appropriation of cells, initial longitudinal duplication of the genital ridge and transverse division of the genital ridge, either through some local accident of development of peritoneal bands. A functional classification based upon the embryogenic development is provided. Type I: the supernumerary testis lacks an epididymis and vas. The split-off part of the primordial gonad does not communicate with the mesonephric tubules from which the epididymis develops. Type II: the supernumerary testis is linked to the regular testis by a common epididymis and shares a common vas with it. The division of the genital ridge occurs in the region where the primordial gonads are attached to the mesonephric ducts, although the latter are not divided (incomplete division). Type III: the supernumerary testis has its own epididymis but shares the vas with the regular testis. This variant results from a complete transverse division of the genital ridge. In the majority of the reported cases, the patients are asymptomatic and have painless groin or testicular masses. Approximately 50% occur as maldescent or cryptorchidism, and about 30% are associated with indirect hernia. The remaining 20% are discovered variously in relation to torsion, or are associated with hydrocele, epididymitis, varicocele or infertility. Moreover, since there is a 20 to 40 fold increase in testicular malignancy in patients with cryptorchidism compared with the normal testis, tumours of the supernumerary testicles are not unusual. We reported two cases of polyorchidism: the first patient is probably a longitudinal division of the genital ridge and the second is a completely duplication of the primordial gonads. The patients described vague, intermittent, testicular pain. Physical examination and the scrotal sonography and magnetic resonance revealed in the first patient a supernumerary testis in the right scrotal space and in the second a bilateral double testis. In conclusion we think that in the absence of any concomitant disorder and if testicular tumor can be ruled out by ultrasonography and magnetic resonance imaging, surgical exploration with biopsy is unnecessary.

After having described the surgical anatomy of the lumbar region, with particular regard to the relationships with pleura and peritoneum, as well as to the course of the nervous structures of the region (12th intercostal, ileohypogastric and ileoinguinal), the authors describe the possible complications related with the surgical approaches to the lumbar region. Pathogenesis of post-operatory pains and parietal hypotonies is especially evaluated; these complications may be caused by section, ligature or compression of one or more nervous trunks. The authors conclude that the respect of the anatomic structures located in the lumbar region represents the best way in order to prevent most complications related to lumbotomies.

Anuria is a rare complication after prostate adenomectomy. Three cases of complete bilateral anuria and one case of monolateral anuria are reported following transvesical prostate adenomectomy, characterized by immediate onset without any apparent cause and by spontaneous resolution within 48 hours. After a thorough review of the literature, the authors analyze the pathophysiological and clinical aspects of post-prostate-adenomectomy anuria and postulate an "obstructive" aetiology for the anuria cases observed in their series.

Surgery seems to be the only effective treatment for bilateral kidney neoplasms as shown by the better survival rate of operated patients compared with those otherwise treated or untreated at all. The best conservative treatments, regarding radicality and security required by these neoplasms, are the enucleation and the partial in situ nephrectomy. Our study is based on 11 patients affected by bilateral kidney neoplasms; 8 of them, in which there were no signs of metastatization, have undergone surgical treatment. In 2 patients (18%) a bilateral enucleation was performed and in 6 (55%) monolateral enucleation together with a controlateral radical nephrectomy. All tumors developed simultaneously have been operated in the same session. No postoperative complications were observed except in 2 patients which developed a transient renal insufficiency. The follow up was from 2 to 66 months. All patients were examined with echotomography or CT scan at least once a year and are, up today, in good health condition and tumor free.