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Changes in sulphur and nitrogen pollution in Swedish forests have been assessed in relation to European emission reductions, based on measurements in the Swedish Throughfall Monitoring Network. Measurements were analysed over 20 years with a focus on the 12-year period 1996 to 2008. Air concentrations of SO(2) and NO(2), have decreased. The SO(4)-deposition has decreased in parallel with the European emission reductions. Soil water SO(4)-concentrations have decreased at most sites but the pH, ANC and inorganic Al-concentrations indicated acidification recovery only at some of the sites. No changes in the bulk deposition of inorganic nitrogen could be demonstrated. Elevated NO(3)-concentrations in the soil water occurred at irregular occasions at some southern sites. Despite considerable air pollution emission reductions in Europe, acidification recovery in Swedish forests soils is slow. Nitrogen deposition to Swedish forests continues at elevated levels that may lead to leaching of nitrate to surface waters., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Nitrogen leaching from boreal and temporal forests, where normally most of the nitrogen is retained, has the potential to increase acidification of soil and water and eutrophication of the Baltic Sea. In parts of Sweden, where the nitrogen deposition has been intermediate to high during recent decades, there are indications that the soils are close to nitrogen saturation. In this study, four different approaches were used to assess the risk of nitrogen leaching from forest soils in different parts of Sweden. Nitrate concentrations in soil water and C:N ratios in the humus layer where interpreted, together with model results from mass balance calculations and detailed dynamic modelling. All four approaches pointed at a risk of nitrogen leaching from forest soils in southern Sweden. However, there was a substantial variation on a local scale. Basing the assessment on four different approaches makes the assessment robust., (Copyright © 2010 Elsevier Ltd. All rights reserved.)

Objective: To investigate the type of urinary diversion performed after cystectomy in patients with muscle-invasive bladder cancer in Sweden, using data from a population-based national register., Material and Methods: Since 1997, the Swedish Bladder Cancer Register has included more than 90% of all patients with newly diagnosed bladder cancer. The different types of urinary diversion performed in 1997-2003 were analysed, comparing non-continent diversion (ileal conduit) with continent reconstruction (bladder substitution or continent cutaneous diversion)., Results: During the study period, 3463 patients were registered with clinical T2-T4 non-metastatic bladder cancer. Cystectomy was performed in 1141 patients with ileal conduit in 732 (64%) and continent reconstruction in 409 (36%). Ileal conduit was used more frequently in females than males (p = 0.019), in patients older than 75 years (p < 0.00001), and in those with less favourable TNM classification. Continent reconstruction was done more often at university hospitals than at county hospitals (p < 0.00001), but rarely in the northern and western healthcare regions compared with other regions (p < 0.00001). Nationwide, the proportion of registered continent reconstructions decreased, although the absolute number was relatively stable (50-60 per year)., Conclusions: Continent reconstruction after cystectomy for muscle-invasive bladder cancer is performed more often in some healthcare regions and in patients at university hospitals than in county hospitals, indicating a substantial provider influence on the choice of urinary diversion. Over time, the proportion of these procedures has decreased, while the absolute number has remained low and stable; therefore, concentration in high-volume hospitals specialized in bladder cancer and continent reconstruction seems appropriate.

Background: Bacillus Calmette-Guérin (BCG) instillation is regarded as the most effective bladder-sparing treatment for patients with high-grade T1 tumours and carcinoma in situ (CIS). The major problem with this therapy is the side-effects, making maintenance therapy difficult, even impossible, in a proportion of patients. Thus, alternative schedules and drugs have been proposed., Objective: To compare BCG to the combination of epirubicin and interferon-alpha2b as adjuvant therapy of T1 tumours., Design, Setting, and Participants: This is a Nordic multicenter, prospective, randomised trial in patients with primary T1 G2-G3 bladder cancer. Initial transurethral resection (TUR) was followed by a second-look resection. Patients were randomised to receive either regimen, given as induction for 6 wk followed by maintenance therapy for 2 yr., Measurements: The drugs were compared with respect to time to recurrence and progression. Also, side-effects were documented., Results and Limitations: A total of 250 patients were randomised. At the primary end point, 62% were disease free in the combination arm as opposed to 73% in the BCG arm (p=0.065). At 24 mo, there was a significant difference in favour of the BCG-treated patients (p=0.012) regarding recurrence, although there was no difference regarding progression. The subgroup analysis showed that the superiority of BCG was mainly in those with concomitant CIS. In a multivariate analysis of association with recurrence/progression status, significant variables for outcome were type of drug, tumour size, multiplicity, status at second-look resection, and grade. A corresponding analysis was performed separately in the two treatment arms. Tumour size was the only significant variable for BCG-treated patients, while multiplicity, status at second-look resection, and grade were significant for patients treated with the combination., Conclusions: For prophylaxis of recurrence, BCG was more effective than the combination. There were no differences regarding progression and adverse events between the two treatments.

Mercury (Hg) levels are alarmingly high in fish from lakes across Fennoscandia and northern North America. The few published studies on the ways in which silviculture practices influence this problem indicate that forest operations increase Hg in downstream aquatic ecosystems. From these studies, we estimate that between one-tenth and one-quarter of the Hg in the fish of high-latitude, managed forest landscapes can be attributed to harvesting. Forestry, however, did not create the elevated Hg levels in the soils, and waterborne Hg/MeHg concentrations downstream from harvested areas are similar to those from wetlands. Given the current understanding of the way in which silviculture impacts Hg cycling, most of the recommendations for good forest practice in Sweden appear to be appropriate for high-latitude regions, e.g., leaving riparian buffer zones, as well as reducing disturbance at stream crossings and in moist areas. The recommendation to restore wetlands and reduce drainage, however, will likely increase Hg/MeHg loadings to aquatic ecosystems.

The European Union Water Framework Directive (WFD) requires a good chemical and ecological status of European surface waters by 2015. Integrated, risk-based management of river basins is presumed to be an appropriate approach to achieve that goal. The approach of focusing on distinct hazardous substances in surface waters together with investment in best available technology for treatment of industrial and domestic effluents was successful in significantly reducing excessive contamination of several European river basins. The use of the concept of chemical status in the WFD is based on this experience and focuses on chemicals for which there is a general agreement that they should be phased out. However, the chemical status, based primarily on a list of 33 priority substances and 8 priority hazardous substances, considers only a small portion of possible toxicants and does not address all causes of ecotoxicological stress in general. Recommendations for further development of this concept are 1) to focus on river basin-specific toxicants, 2) to regularly update priority lists with a focus on emerging toxicants, 3) to consider state-of-the-art mixture toxicity concepts and bioavailability to link chemical and ecological status, and 4) to add a short list of priority effects and to develop environmental quality standards for these effects. The ecological status reflected by ecological quality ratios is a leading principle of the WFD. While on the European scale the improvement of hydromorphological conditions and control of eutrophication are crucial to achieve a good ecological status, on a local and regional scale managers have to deal with multiple pressures. On this scale, toxic pollution may play an important role. Strategic research is necessary 1) to identify dominant pressures, 2) to predict multistressor effects, 3) to develop stressor- and type-specific metrics of pressures, and 4) to better understand the ecology of recovery. The concept of reference conditions to define the ecological status is hard to apply and tends to ignore the fact that ecosystems can be highly dynamic. A better understanding of ecosystem responses to changes as well as early warning systems and concepts sensitive to various stressors to discriminate disturbances from natural variation are required. Because ecosystems are closely interconnected, an integrated monitoring, diagnosis, and stressors-based management of the whole water, sediment, groundwater, soil, and air system is required considering land use and the interaction with a changing climate. Extending this holistic approach beyond a consideration of existing pressures by anticipating on future ones to use and protect the aquatic environment in a sustainable way is one of the big challenges.

Objective: To analyse the management of muscle-invasive bladder cancer in a population-based national register, and specifically to investigate the role of curative therapy (i.e. cystectomy or radiotherapy) in relation to patient, tumour and hospital characteristics., Material and Methods: The Swedish Bladder Cancer Register covers more than 90% of all patients in the country who have been diagnosed with such disease since 1997. Results from 1997-2003 were analysed regarding curative-intent treatment given within 3-6 months of diagnosis of muscle-invasive bladder cancer., Results: In total, 3463 patients with clinical T2-T4 bladder cancer were included in the analysis. Of those patients, 1426 (41%) received curative-intent treatment in the form of radiotherapy (285, 20%) or cystectomy (1141, 80%). Male gender, age < 76 years, favourable TNM category and registration at a high-volume hospital were associated with such treatment. Curative-intent treatment was given to significantly more patients registered at high-volume hospitals (1003/2227, 45%) than at low-volume hospitals (423/1235, 34%) (chi(2)=37.7, p<0.00001). Cystectomy was performed more often in those registered at high-volume than at low-volume hospitals (826/2227, 37%, and 316/1235, 26%, respectively, chi(2)=47.3, p<0.00001)., Conclusions: Lower rates of curative-intent treatment were found in patients registered at low-volume than at high-volume facilities, and the same was seen when comparing females with males, and patients aged 76-80 years with younger patients. Since many of these bladder cancer patients were registered at and eventually treated at hospitals handling fewer than 10 such cases annually, it seems desirable to concentrate treatment of this disease at more specialized centres.

Nitrogen (N) is often considered to be the major factor limiting tree growth in northern forest ecosystems. An increased N availability, however, increases the demand for other nutrients such as base cations and phosphorous (P) which in turn may change which nutrient is the limiting factor. If P or base cations become limiting, N will start to leach which means a risk of increased eutrophication of surface waters. As many studies focus on base cations, this study instead aims at estimating P budgets on a regional scale for different harvesting scenarios relevant for Swedish conditions. P budget calculations were carried out for 14,550 coniferous sites from the Swedish National Forest Inventory, as weathering+deposition-harvesting-leaching. Three scenarios with different harvest intensities were used: 1) no harvesting, 2) stem harvesting and 3) whole-tree harvesting. The input data were derived from measurements and model results. The P budget estimates indicate that harvesting, especially whole-tree harvesting, result in net losses of P in large parts of Sweden. The highest losses were found in southern Sweden due to high growth rate in this area. In the whole-tree harvesting scenario the losses exceeded 1 kg ha(-1) y(-1) on many sites. N budget calculations on the same sites indicate that N generally accumulates in the whole country and especially in the southern parts. Consequently, the N and P budget calculations indicate that the forests in southern Sweden are in a transition phase from N-to P-limitation to growth. This transition will proceed as long as the accumulation of N continues. These results are important in a sustainable forestry context, as a basis for assessing the risk of future N leaching, and in designing recommendations for abatement strategies of N deposition and for application of wood ash recycling and N fertilization.

Objective: To analyse the management and outcome of patients with Ta T1 urinary bladder cancer in a population-based national database., Material and Methods: Between 1997 and 2001, 94% of all newly diagnosed cases of urinary bladder cancer were registered in the Swedish National Bladder Cancer Register. Data were analysed regarding gender, healthcare region, stage and grade for patients with Ta T1 tumours. The choice of initial treatment in different regions was reviewed. Survival was analysed by calculating relative survival., Results: Out of 9859 registered patients, there were 4442 Ta tumours and 2139 T1 tumours. The median age at diagnosis was 72 and 73 years for patients with Ta and T1 tumours, respectively. Seventy-six percent of the patients were men. The choice of treatment varied between different healthcare regions. A significant trend towards an increased use of intravesical therapy was seen over time. Significantly fewer older than younger patients received such therapy. There was also a tendency towards more intensive therapy in men. The bladder cancer relative 5-year survival rate was 93% for Ta and 75% for T1 tumours. Survival was similar for men and women., Conclusions: Our analysis revealed a regional variation in the treatment of bladder cancer. A large group of patients, even those at high risk, were still undertreated. However, the recent publication of guidelines may have contributed to an increased use of intravesical treatment. Urologists tended to treat TaG3 and T1G3 tumours more aggressively than T1G2 tumours. Therapeutic aggressiveness decreased as the age of the patients increased. The survival rate of patients with bladder cancer in Sweden seems to remain at the levels previously reported for the 1980s.

Objective: To study residual tumours at second-look resection in patients resected 4-8 weeks earlier for T1 tumours of the urinary bladder., Material and Methods: All patients randomized in the ongoing Nordic T1G2-G3 Bladder Sparing Study with monitored data available were included in the study. Data on residual tumours at second-look resection were compared to basic patient and tumour characteristics., Results: There were 72 patients (56%) without and 57 with residual exophytic tumours. In the former group, 20 patients (28%) had carcinoma in situ, compared to 19 (33%) in the latter group. Potentially dangerous tumours (either carcinoma in situ, T1 or Ta grade 3) were observed in 55 patients (43%). Multiple tumours at primary resection were more prone to residual tumour at second-look resection than single tumours. No other tumour or patient characteristics could predict the occurrence of a residual tumour., Conclusions: Residual tumours are frequently observed at second-look resection 4-8 weeks after primary resection of T1 tumours. The majority of residual tumours detected at this stage are potentially dangerous; therefore, early second-look resection followed by intravesical instillation therapy is mandatory in patients with T1 tumours of the urinary bladder.

Objectives: To record the occurrence of well-differentiated bladder carcinoma reported as T1 G1 to the Swedish Urinary Bladder Cancer Registry, to review the staging and grading of the carcinomas and to scrutinize the validity of the data on T1 G1 tumours reported to the registry during the period 1997-2000., Material and Methods: The primary histopathological diagnoses of 98 cases of well-differentiated bladder carcinoma reported to the Registry were compared with the data delivered by the local urologists. Also, the histopathology slides were obtained from the local laboratories and re-examined., Results: Fifty-five cases had been erroneously reported to the Registry as T1 tumours by the urologists, even though they were clearly described as non-infiltrating G1 tumours by the pathologists. The results of the re-examination of the pathology slides were concordant with the judgements of the local pathologists in only 50% of cases (20 stage T and 29 grade G tumours). Most importantly, the re-evaluation did not reveal a single invasive G1 tumour. Simply by providing the urologists with information about this problem, it was possible to reduce the number of errors in the reports from 27 in 1997 to only five in 2000., Conclusions: Well-differentiated urothelial carcinoma (G1) has no propensity to infiltrate the bladder mucosa. For investigating specific problems the data collected in the Swedish Urinary Bladder Cancer Registry have to be validated.

The main source of atmospheric ammonia (NH3) in Scotland is livestock agriculture, which accounts for 85% of emissions. The local magnitude of emissions therefore depends on livestock density, type, and management, with major differences occurring in various parts of Scotland. Local differences in agricultural activities therefore result in a wide range of NH3 emissions, ranging from less than 0.2 kg N ha(-1) year(-1) in remote areas of the Scottish Highlands to over 100 kg N ha(-1) year-1 in areas with intensive poultry farming. Scotland can be divided loosely into upland and lowland areas, with NH3 emission being less than and more than 5 kg N ha(-1) year(-1), respectively. Many semi-natural ecosystems in Scotland are vulnerable to nitrogen deposition, including bogs, moorlands, and the woodland ground flora. Because NH3 emissions occur in the rural environment, the local deposition to sensitive ecosystems may be large, making it essential to assess the spatial distribution of NH3 emissions and deposition. A spatial model is applied here to map NH3 emissions and these estimates are applied in atmospheric dispersion and deposition models to estimate atmospheric concentrations of NH3 and NH4+, dry deposition of NH3, and wet deposition of NHx. Although there is a high level of local variability, modelled NH3 concentrations show good agreement with the National Ammonia Monitoring Network, while wet deposition is largest at high altitude sites in the south and west of Scotland. Comparison of the modelled NHx deposition fields with estimated thresholds for environmental effects ("critical loads") shows that thresholds are exceeded across most of lowland Scotland and the Southern Uplands. Only in the cleanest parts of the north and west is nitrogen deposition not a cause for concern. Given that the most intense effects occur within a few kilometres of sources, it is suggested that local spatial abatement policies would be a useful complement to traditional policies that mitigate environmental effects based on emission reduction technologies.

Despite global and local attempts to end genital mutilation, in their various forms, whether of males or females, the practice has persisted throughout human history in most parts of the world. Various medical, scientific, hygienic, aesthetic, religious, and cultural reasons have been used to justify it. In this symposium on circumcision, against the background of the other articles by Hutson, Short, and Viens, the practice is set by the author within a wider, global context by discussing a range of rationalisations used to support different types of genital mutilation throughout time and across the globe. It is argued that in most cases the rationalisations invented to provide support for continuing the practice of genital mutilation--whether male or female--within various cultural and religious settings have very little to do with finding a critical and reflective moral justification for these practices. In order to question the ethical acceptability of the practice in its non-therapeutic forms, we need to focus on child rights protection.

The invasion of Salvinia molesta in the Lower Senegal River Delta in Mauritania and Senegal in 1999 posed a serious threat to the socioeconomic conditions of the local people as well as to wetland biodiversity. Eventually, an effective biological control of S. molesta was obtained by means of the weevil Cyrtobagous salviniae, which was introduced in the river in Senegal and Mauritania in May 2000 and in Senegal in April 2001. In October 2001, it became apparent that the weevils were doing a magnificent job. The color of the plants was turning from green to dark-brown or black, and subsequently the plants started to sink to the bottom. Detailed monitoring of the dispersal of C. salviniae in November-December 2001 confirmed the visual observations of the outcome of biological control. In April 2002, it could be concluded that S. molesta was no longer a problem in the Senegal River.

Objectives: To evaluate whether, in patients with carcinoma in situ (CIS) of the urinary bladder, alternating instillation therapy with mitomycin C (MMC) and bacillus Calmette-Guerin (BCG) was more effective and less toxic than conventional BCG monotherapy., Methods: Patients were stratified prospectively for primary, secondary, and concomitant CIS and randomized to one of two regimens. Patients in the alternating group received six weekly intravesical instillations of MMC 40 mg, followed by alternating monthly instillations of BCG 120 mg and MMC for one year. In the monotherapy group, only BCG was instilled on the same schedule., Results: Of 323 enrolled patients, 304 were eligible for analysis. After an overall median follow-up of 56 months, the Kaplan-Meier disease-free estimate for BCG monotherapy was significantly better than that for alternating therapy (p=0.03; log rank test). Risk for progression appeared lower in the BCG monotherapy group (p=0.07), but no differences existed in survival. Besides the regimen, CIS category also predicted outcome to some extent. BCG monotherapy caused significantly more local side-effects and premature cessation of instillation treatment than did the alternating therapy. However, no differences were observed in the number of serious side-effects., Conclusion: One-year BCG monotherapy was more effective than the alternating therapy for reducing recurrence and compared well with the best regimens reported from substantially smaller series. The alternating therapy was better tolerated.

A systematic review of radiation therapy trials in several tumour types was performed by The Swedish Council of Technology Assessment in Health Care (SBU). The procedures for evaluation of the scientific literature are described separately (Acta Oncol 2003; 42: 357-365). This synthesis of the literature on radiation therapy for urinary bladder cancer is based on data from 3 meta-analyses and 33 randomized trials. The studies include 4333 patients. The results were compared with those of a similar overview from 1996 including 15,042 patients. The conclusions reached can be summarized as these points: There is moderate evidence for an overall survival benefit with preoperative radiotherapy followed by cystectomy compared to curative radiotherapy based on early studies (1964-1986). Since that time surgical as well as radiation techniques have developed considerably. Therefore, the conclusion may not be relevant to modern treatment of invasive urinary bladder carcinoma. There is only one small study reporting on curative radiotherapy where increased dose per fraction is compared with conventionally fractionated radiotherapy to the same total dose. Thus, no conclusions can be drawn concerning optimal fraction dose. A meta-analysis based on two studies on hyperfractionated radiotherapy gives moderate evidence of a survival benefit at 5 and 10 years and an increased local control rate compared with conventional fractionation. The documentation of local control and overall survival rate after split-course radiation treatment compared to continuous therapy is conflicting. No firm conclusions can be drawn. Four small and early studies have compared radiation treatment using neutrons with photon treatment. The reports favour therapy with photons with respect to overall treatment results. There is moderate evidence for this conclusion. There is fairly strong evidence in early studies that radiation treatment in combination with hyperbaric oxygen does not confer a treatment benefit compared to radiation in normal atmosphere. There is no indication of a treatment benefit with the addition of either hyperthermia or misonidazole. A large number of phase II studies, suggesting an increased possibility for bladder preservation with concomitant chemoradiotherapy compared to radiotherapy alone, have been reviewed in a previous SBU report on chemotherapy. Only one small randomized study has been reported where concomitant chemoradiotherapy with cisplatin is compared to radiation alone. No conclusion on the therapeutic benefit of combined treatment can be drawn. Large randomized studies are needed. There is some evidence that preoperative radiotherapy followed by cystectomy does not confer any significant survival benefit compared to cystectomy alone. There is moderate evidence that palliative radiotherapy of invasive bladder carcinoma can rapidly induce tumour-related symptom relief. There is moderate evidence that palliative hypofractionated radiotherapy, 3 fractions during one week, gives the same relief of symptoms as 10 fractions during 2 weeks.

Objectives: On behalf of the European Association of Urology (EAU), Guidelines for Diagnosis, Therapy and Follow-Up of Renal Cell Carcinoma Patients were established. Criteria for recommendations were evidence based and included aspects of cost-effectiveness and clinical feasibility., Method: A systematic literature research using Medline Services was conducted. References were weighted by a panel of experts on renal cell carcinoma (RCC)., Results: RCC is characterised by a constant rise in incidence over the last 50 years, with a predominance of men over women and an incidence peak in the 6th and 7th decade. There is no risk factor established and the current TNM system (UICC, 1997) is endorsed for staging purposes. Clinical signs and symptoms of RCC are becoming less frequent, incidental discovery constitutes already a majority of cases. Diagnosis is established by ultrasound and abdominal CT, extension assessment in routine cases is done by chest X-ray. Additional examinations may be required in select cases. The therapy of choice in organ-confined RCC is surgery. Radical tumour nephrectomy is considered as a standard. Efficacy and side-effects of organ-sparing surgery, lymphadenectomy and inclusion/omission of ipsilateral adrenalectomy in selected cases is a matter of ongoing clinical research. In metastatic cases, tumour nephrectomy should only be considered in the context of modern systemic immunotherapy. A follow-up at regular intervals is recommended because certain cases of recurrences may be candidates for surgery and/or immunomodulating therapy., Conclusion: A rise in incidence, improved diagnostic procedures, and evolving multimodality therapeutic concepts justify the need for rational guidelines on this most challenging urologic malignancy.

The Nordic Urological Association Urothelial Group has been organizing phase 3 trials in urinary bladder cancer therapy since 1986. In total, around 1,000 patients from three countries have entered these studies. The results of the different trials are reviewed, and the problems with cooperative trials are discussed. The importance of these kind of trials in setting up management guidelines is underscored.

Within the Western bioethical framework, we make a distinction between two dominant interpretations of the meaning of moral personhood: the naturalist and the humanist one. While both interpretations of moral personhood claim to promote individual autonomy and rights, they end up with very different normative views on the practical and legal measures needed to realize these values in every day life. Particularly when we talk about the end of life issues it appears that in general the arguments for euthanasia are drawn from the naturalist interpretation of moral personhood while the arguments against euthanasia, for their part, are derived from the idealist and/or humanist understanding of the same concept. This article focuses on examining the metaphysical assumptions and internal contradiction found behind the opposing arguments presented by two prominent philosophers of these two traditions: Peter Singer and Ludger Honnefelder. The author claims that neither side of the debate succeeds in defending its normative position without reconsidering how to take the social aspects of moral personhood into account. The author holds that, despite our need to set individual's decision making into social context, the current communitarian narrative concept of personhood fails to offer a convincing alternative. Instead of merely trying to replace psychological and atomistic view of personhood with a collective understanding of an individual's moral identity, we need to discuss the normative relation between the concept of 'moral personhood' and the demand for respect of individual autonomy in Western bioethics within a wider philosophical perspective.

Renal cell carcinoma (RCC), although occurring less frequently than prostate and bladder cancer, is actually the most malignant urologic disease, killing >35% of affected patients. Therefore, investigation of the nature of premalignant lesions of the kidney is a relevant issue. Following the most recent histological classification RCC can be subdivided into four categories: conventional RCC; papillary RCC; chromophobe RCC; and collecting duct carcinoma. In contrast to many genitourinary malignancies, premalignant alterations in the kidney are scarcely described. Intratubular epithelial dysplasia has been recognized as the most common precursor of RCC. In analogy to prostatic intraepithelial neoplasia (PIN), the premalignant lesions of the kidney are described as high or low-grade renal intratubular neoplasia. In contrast, precancerous lesions have been described as part of the von Hippel-Lindau syndrome (VHL) where the evolution from a simple cyst to an atypical cyst with epithelial hyperplasia to cystic or solid conventional-type RCC is well documented. Finally, in the genesis of papillary RCC an adenoma-carcinoma sequence has been recognized with specific genetic changes. There are no data on the epidemiology of premalignant lesions of the kidney, but research into the etiology of RCC has been extended substantially. Familial and genetic factors are well documented in VHL disease, in hereditary papillary RCC, in the tuberous sclerosis complex and in familial RCC. Cigarette smoking and obesity are established risk factors for RCC. Hypertension or its medication has also been associated with an increased risk. Among dietary factors an inverse relation between risk and consumption of vegetables and fruit has been found. Occupational exposure to substances such as asbestos and solvents has been linked to an increased risk of RCC. Specific RCC variants have distinctive chromosome alterations and several genes have been implicated in the development of RCC. Loss of material from the 3p chromosome characterizes conventional RCC and the deletion of the VHL suppressor gene plays an important role in the genesis of this RCC variant. In contrast, numerical changes with trisomy of chromosomes 7 and 17 and loss of the sex chromosome are typical changes in papillary tumors, whereas papillary RCC have additional trisomies. Chromophobe RCC is characterized by loss of chromosomes with a combination of monosomies. Less consistent genetic alterations are associated with collecting duct carcinoma. The traditional treatment of RCC is surgery by radical or partial nephrectomy. The latter approach carries a risk of tumor recurrence as a result of unrecognized satellite lesions or premalignant lesions that might have been present at the time of surgery. However, the reported recurrence rates after partial nephrectomy are <1% and therefore the possible presence of premalignant disease does not alter the actual treatment strategy advocated. Although multifocality and bilateral occurrence of RCC are much more likely in cases of papillary RCC, biopsy of the renal remnant or contralateral kidney is not justified even in patients with this tumor type. Conversely, patients with RIN in a partial or radical nephrectomy specimen or in a renal biopsy taken for whatever reason should be subjected to closer follow-up with regularly repeated ultrasound. When an effective chemopreventive regimen becomes available it might be useful for patients with an inherited risk of RCC as well as in those who are at risk of tumor recurrence after intervention. Mass screening with the purpose of detecting RCC at its earliest stage is not recommended at the present time, but screening focused on certain risk groups can be advocated. Further research is needed to identify avoidable risks, develop effective chemoprevention and recognize patients at risk.

The survival of patients with bladder cancer has not improved significantly during the past decades in spite of new diagnostic methods and treatment modalities. This observation underlines the need for improved routines to ensure earlier detection of the disease by patients and doctors and thereby start the treatment sooner. The common finding of treatment failures in patients who have shown no sign of local recurrence but have undergone radical cystectomy indicates that subclinical metastases are primarily responsible for the poor outcome in most cases. This indicates that, in addition to radical surgery, effective chemotherapy is needed to counteract the systemic spread of the disease.

Purpose: We investigated the occurrence and extent of metastatic spread, especially regarding lymph nodes, of renal cell carcinoma., Materials and Methods: From 1958 to 1982, 554 cases of renal cell carcinoma were diagnosed at autopsy. Clinical data and autopsy findings were reevaluated, and the occurrence of lymph node metastases was analyzed by histological examination of retroperitoneal, mediastinal, supraclavicular, axillary and inguinal lymph nodes., Results: Distant metastases were revealed in 119 cases (21.5%), including 31 (5.6%) with single metastases. In 88 cases (16%) renal cancer was the cause of death. Lymphatogenous dissemination was detected in 80 cases of which 75 had additional, mostly multifocal metastatic spread. Consequently lymph node metastases restricted to the paracaval and/or para-aortic lymph nodes were noted in only 5 cases (0.9%)., Conclusions: Of the 554 cases of clinically unrecognized renal cell carcinoma almost all with lymphatic spread had additional distant metastases. Therefore, the therapeutic effect of extensive retroperitoneal lymph node dissection in association with radical nephrectomy seems to be low. However, more limited lymph node dissection may be useful, mainly as a staging procedure.

Purpose: Chemotherapy is widely used in patients with locally advanced bladder cancer but until now there has been no conclusive evidence that this therapy improves survival. The Nordic Cooperative Bladder Cancer Study Group conducted a randomized phase III study to assess the possible benefit of neoadjuvant chemotherapy in patients with bladder cancer undergoing radical cystectomy after short-term radiotherapy., Materials and Methods: Our trial included 325 patients with locally advanced stage T1 grade 3 or stages T2 to T4aNXM0 bladder cancer allocated randomly into a chemotherapy or no chemotherapy group (control). The chemotherapy schedule consisted of 2 cycles of 70 mg./m.2 cisplatin and 30 mg./m.2 doxorubicin with a 3-week interval between the cycles., Results: After 5 years the overall survival rate was 59% in the chemotherapy group and 51% in the control group (p = 0.1). The corresponding cancer specific survival rate was 64 and 54%, respectively. In regard to treatment, no difference was observed for stages T1 and T2 disease, while there was a 15% difference in overall survival for patients with stages T3 to T4a disease (p = 0.03). In a multivariate analysis only chemotherapy and T category emerged as independent prognostic factors. The relative death risk for patients who received chemotherapy was 0.69 (95% confidence interval 0.49 to 0.98) compared to the control group after adjustment for the other tested factors., Conclusions: Neoadjuvant chemotherapy seems to improve long-term survival after cystectomy in patients with stages T3 to T4a bladder carcinoma, while no survival benefit was found for stages T1 to T2 disease.

Purpose: We evaluate the efficacy and morbidity of laser and conventional treatment in 32 men with penile cancer., Materials and Methods: Of 32 men treated for squamous cell carcinoma of the penis observed for an average of 44 months 19 were treated with the combined carbon dioxide and neodymium: YAG lasers. The 13 patients treated conventionally had more advanced disease and they were a mean 17 years older than those in the laser treated group., Results: All laser treated patients were disease-free after a mean of 31 months. Among the 13 conventionally treated patients there were only 5 long-term survivors., Conclusions: The cosmetic and functional outcome of laser treatment for stages Tis to T2N0M0, grades 1 and 2 squamous cell carcinoma of the penis is excellent, and the associated morbidity rate is low.

Iohexol and 99mTc-DTPA were used in 43 patients to determine the relative glomerular filtration rate (GFR), i.e., the GFR of each kidney in percent of total GFR. The amount of any GFR marker accumulating in Bowman's space, tubuli and renal pelvis within a few minutes after i.v. injection, before any marker had left the kidney via the ureter, was defined as proportional to the GFR of that kidney. The renal accumulation of iohexol was determined by CT using 10 slices of 8-mm thickness 1 to 4 minutes after injection. The renal accumulation of 99mTc-DTPA was determined with a gamma camera within 2 minutes after injection. The correlation coefficient between the two methods was 0.98. Due to the higher radiation dose from CT than from 99mTc-DTPA injection, relative GFR determination with CT should be performed when there is also a diagnostic need to reveal morphology.

We followed 62 men treated with the carbon dioxide laser for lichen sclerosus et atrophicus for an average of 30 months (3 months to 7 years). Of the patients 47 (76%) became asymptomatic and 10 (16%) had minor residual symptoms. In 26 patients (40%) concomitant superficial meatal stenosis was simultaneously treated with laser meatotomy. The cosmetic and functional results of treatment were highly encouraging. Provided that radicality is achieved at the primary application, the carbon dioxide laser is an excellent therapeutic modality for lichen sclerosus et atrophicus.

Compartment syndrome has been reported in a few cases after prolonged surgery with patients in leg supports. A recent case in our hospital (57-year-old man undergoing cystourethrectomy because of cancer) made us interested in the problem. This case together with six from the literature are analysed. Moreover, the first 11 cases operated on with a pelvic pouch and ileoanal anastomosis at our department were reviewed. They had been in the leg support position for a median duration of 6.4 (5.8-8) h. In four of them leg pain and swelling developed within 12 h. Three showed regression within a few days, one after a week. In one patient with swelling compartment pressure was measured with a transducer tipped catheter. Intermittently the pressure was up to 50 mm Hg. There was an obvious decrease in pressure on knee bending. Also, in a patient without swelling large pressure variations were seen but not to critical levels.

36 mongrels were subjected to splenic artery implantation into the left kidney. A stenosis of the left renal artery was created in 33 of the dogs. The revascularization process from the implanted artery was studied by angiography in vivo and ex vivo, by histological examination and by blood flow measurements. After creation of the stenosis and eventual occlusion of the left renal artery, newly formed intrarenal vessels could be demonstrated next to the implanted artery. These vessels formed communications between the splenic and intrarenal arteries. The experimental animals survived contralateral nephrectomy and ligature of the ipsilateral renal artery with a slight or moderate elevation of the serum creatinine level, provided that a slowly progressing stenosis of the renal artery was created.

Renal revascularization by splenic artery implantation was performed in 5 dogs using a temporary arteriovenous fistula in the distal end of the implanted artery for the purpose of increasing the blood flow and counteracting the thrombus formation in the artery. Following creation of renal artery stenosis, the revascularization process was evaluated by serial consecutive splenic arteriographies and by estimation of blood flow through the implanted arteries. The experimental animals survived occlusion of the ipsilateral renal artery and contralateral nephrectomy with maintenance of a reasonably good renal function. The present study also indicates a facilitation of a vascularization from the implanted artery when the initial thrombus formation within the artery was prevented by creation of such a fistula.

Percutaneous nephrostomy was performed in 32 patients: in 8 patients for permanent and in 24 for temporary drainage. The most common indication was obstruction of the distal ureter due to malignancy. Puncture of the renal pelvis was performed with the aid of fluoroscopy and/or ultrasound. Change to larger catheters was achieved using the Seldinger technique. Complications in the form of bleeding occurred in 5 patients and were in conjunction with repuncture after the initial catheter had slipped out, or occured in connection with change to larger catheters. With the routine use of ultrasound and specially designed catheters the method should be an effective alternative to operative nephrostomy also in the nonemergency patient.

Computed tomography is recognized as a valuable adjunct to clinical staging of bladder carcinomas, with a diagnostic accuracy of 70%-80%. Technique modifications in order to improve the diagnostic results include the use of various intravesical contrast agents. All hitherto described contrast agents suffer from drawbacks, either due to insufficient contrast resolution or to partial volume effect. Arachis (peanut) oil has been used in 69 patients and seems to meet many of the demands that can be made on a good intravesical contrast agent. Both bladder wall and tumor are well delineated, and diffuse and local thickening of the wall can be appreciated., The oil is nonhygroscopic and may therefore be used together with other contrast agents, if necessary.

Renal vascularization by splenic artery implantation into the kidney was studied in 11 dogs. Renal function and blood flow were evaluated after creation of stenosis of the ipsilateral renal artery. It was concluded that the method can be used to revascularize an ischemic kidney resulting in a sufficient renal blood flow with an adequate distribution of blood and maintenance of a reasonably good renal function after contralateral nephrectomy and division of the ipsilateral renal artery.

Carcinoma in situ of the renal pelvis in a patient with an ileal conduit is reported. By fiberendoscopy, using gastrointestinal instruments, both ureters were catheterized. Cytological investigation of urine from each kidney revealed that malignant cells were exfoliated from the left side exclusively. The correct diagnosis of a carcinoma in situ of the left renal pelvis was confirmed by a histological examination of the operative specimen.

The efficacy of a short (Group I) and a prolonged (Group II) course with ciprofloxacin was assessed in patients undergoing transurethral prostatic resection and compared with that of controls without antibiotic (Group III). Both regimens significantly reduced the frequency of post-operative bacteriuria (p less than 0.01) and of severe infectious complications (p = 0.004) compared to the controls. Both regimens were equally effective in preventing peri-operative and post-operative acquisition of bacteriuria in patients without bacteriuria at surgery. In patients with bacteriuria before surgery, bacteriuria was found post-operatively in 35% in Group I and in 9% in Group II (p = 0.012), but in 82% of the patients in Group III. Ciprofloxacin inhibited all but 7 of 176 bacterial strains at an MIC of less than or equal to 1 microgram/ml. Given orally, ciprofloxacin is a valuable alternative antimicrobial for use in conjunction with transurethral prostatic resection. A short course is sufficient for prophylaxis, and adequate therapy is achieved with a prolonged regimen.

In a prospective multicenter study, 244 men with highly or moderately differentiated prostatic cancer in stage I, II or III (VACURG) were consecutively randomized to three groups of treatment: Group A (77 patients) received polyestradiol phosphate (Estradurin, Leo) 80 mg i.m. every fourth week + ethinyl estradiol (Etivex, Leo) 150 micrograms daily, group B (72 patients) estramustine phosphate (Estracyt, Leo) 280 mg twice daily, and group C (76 patients) no therapy. Only men without current or previous other malignancy and without cardiovascular disease were admitted to the study. After 4 1/2 years 125 of the 244 patients had left the study, 9 because of cancer progression (stage IV, VACURG). The most serious complications were cardiovascular, including ischemic heart disease, cardiac decompensation, cerebral ischemia and venous thromboembolism, which occurred in 24 patients from group A and 9 from group B as compared to only one patient in group C. The subgroup superficial or deep venous thrombosis comprised 11 group A and 2 group B patients. Estrogens (E + e) offered as palliative treatment to patients with non-generalized prostatic carcinoma is burdened with a high incidence of serious cardiovascular complications.

Intravesical Adriamycin treatment was given to 22 patients with carcinoma in situ of the urinary bladder. The treatment schedule consisted of monthly Adriamycin instillations in a dose related to bladder capacity. Endoscopic inspection with multiple bladder biopsies and cytoanalysis of urine was performed after every third instillation. In two patients there was lasting disappearance of the carcinoma in situ. Another 10 patients possibly had a beneficial effect of the treatment. The remaining 10 patients showed persistent malignancy and in 6 of these, progression of carcinoma in situ during Adriamycin treatment necessitated cystectomy or radiotherapy. The histologic and cytologic findings showed distinct variability in most patients, with atypia or even absence of malignant cells often followed by recurrence. Adriamycin was discontinued in four cases because of severe cystitis, and in one case because of an anaphylactoid reaction following instillation of the drug.

2 cases of lesions of the dorsal renal artery in surgery for renal pelvic calculus are described. In 1 of the cases hypertension developed. Anatomic factors and previous operations predispose to this complication. An arterial complication should be suspected when hypertension develops postoperatively. The blood pressure of patients with known renal vascular complications should be checked repeatedly for several months postoperatively. The diagnosis is radiological, renal angiography being the definite procedure although a reduction of kidney size observed at urography may indicate the vascular lesion.

The records of 115 patients with bladder carcinoma and five years or longer post-diagnosis survival were surveyed after reclassification of the histologic specimens according to UICC. Late recurrence, 5-10 years after the initial diagnosis, was found in 39 patients (34%). Fourteen patients (12%) had died of bladder carcinoma during the observation period, generally as a consequence of transformation to higher tumour stage. Intercurrent disease, i.e. cardiovascular disorders or a second malignancy, led to 21 intercurrent deaths (18%). Large size and high grade of the primary tumour, but not multiplicity, were significantly associated with poorer long-term prognosis. The study underlines the importance of close long-term follow-up of patients with bladder carcinoma in order to permit early detection and treatment or recurrent tumours.