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Objective The most commonly used staging system for renal cell carcinoma (RCC) is the tumor-node-metastasis (TNM) system. In the most recent TNM edition, lymph node (LN) involvement is defined as pN0, pN1, or pN2, depending on the number of metastatic LNs (none, 1, or >1). This study evaluated the prognostic value of this classification and tried to improve its clinical impact by considering an additional parameter, that is, LN density (ratio between number of positive LNs and total number of LNs retrieved). Methods All pathologic reports of radical nephrectomies performed for RCC in two urologic centers between November 1983 and December 1999 were reviewed. For each patient, complete clinical and pathologic data, number of LNs removed, location and number of positive LNs, and LN density were recorded. The Kaplan-Meyer method and the log-rank test were used to calculate cause-specific survival rates and to compare survival curves, respectively. Results A total of 735 patients underwent radical nephrectomy. Lymphadenectomy was performed in 618 cases, and the rate of positive LNs was 14.2%. The 5-yr cause-specific survival rate of pN+ patients was 18%, with no statistically significant difference between pN1 and pN2. The average number of LNs removed was 13 (range, 1–35). The median number of LNs involved was 3 (range, 1–18). LN density ranged between 3.7% and 100% (median, 22.9%). The number of LNs removed had no impact on survival in pN+ patients. The only significant unfavorable prognostic factors were >4 LNs involved ( p =0.02) and LN density >60% ( p =0.01). Conclusion The results show that in RCC the current TNM stratification of positive LNs is not significantly correlated with prognosis. From our data it appears that classification as ≤4 or >4 LNs involved, supported by LN density, better reflects the impact of the disease on survival.

Ehlers-Danlos syndrome type IV (vascular EDS), is a life-threatening inherited connective tissue disorder resulting from mutations in the COL3A1 gene coding for type III procollagen. Vascular EDS causes severe fragility of connective tissues. We report a case of a 26-year-old male with bilateral staghorn renal calculi, the patient underwent a left nephrolithotomy, during the suspension of the renal artery incredibly, it was lacerated by the vessel loop, without any actraction. Subsequently, all hemostatic attempts, although gentle, resulted in important and catastrophic aortic and caval injures; the patient died due to an uncontrollable abdominal and thoracic hemorrhage. The early diagnosis of the vascular EDS is difficult if there are no known cases. Every surgical procedure in patients with Enlers-Danlos syndrome has a high risk of fatal vascular injuries.

OBJECTIVE To determine the number of lymph nodes that need to be examined to accurately stage the pN variable in patients undergoing radical nephrectomy (RN) for renal cell carcinoma (RCC). PATIENTS AND METHODS We reviewed the operative and pathology reports of 725 patients with RCC submitted for RN. All tumours were classified using the fifth edition of the Tumour-Nodes-Metastasis classification. For each patient the number of lymph nodes removed was recorded. The patients were divided into five different groups according to the number of nodes removed, i.e. group 1, 1–4; group 2, 5–8; group 3, 9–12; group 4, 13–16; and group 5, ≥ 17. We evaluated the factors that affected the number of lymph nodes removed with nodal dissection and the variables that influenced the incidence of nodal involvement. RESULTS Lymphadenectomy was performed in 608 patients (83.8%); in these patients the rate of lymph node metastases was 13.6%. The median (range) number of nodes removed was 9 (1–43); there was a statistically significant correlation between the number of nodes removed and the percentage of nodal involvement (r = 0.6; P 12 lymph nodes need to be assessed for optimal staging.

Objective : Female urinary incontinence and bladder prolapse are very common conditions whose treatment is not standardized. The aim of this study was to evaluate retrospectively the long-term results of Burch colposuspension and anterior colpoperineorrhaphy in the treatment of stress urinary incontinence (SUI) and cystocele, respectively. Materials and methods : We rewieved 36 female patients with a mean follow-up of 53 months. Mean patient age at time of surgery was 57.3±9.6 years (range 37–76). All patients were submitted to urodynamic investigation. Anterior colpoperineorrhaphy was performed in 18 cases (13 with cystocele, one with SUI and four with both). Burch colposuspension was performed in 14 cases (six with SUI and eight with both cystocele and SUI). The association of the two surgical procedures was used in four cases with both cystocele and SUI. Results : Satisfactory results, such as disappearance of SUI with Burch colposuspension and cystocele with colpoperineorrhaphy, were obtained in the 88.8% and 85.8% of the cases, respectively. These results are even more excellent considering that 22.5% of the patients failed previous surgery. We observed no significant complications. Conclusions : The high percentage of long-term success confirms that anterior colpoperineorrhaphy and Burch colposuspension are two effective therapeutic choices for cystocele and SUI, respectively. The new mini-invasive techniques have to be compare with these traditional surgical treatments which efficacy is consolidated.

Despite the efficacy of new chemotherapy regimens, the medical treatment of genitourinary tubercolosis leads to recovery without sequelae in only 17–47% of cases. Open or endoscopic surgery therefore maintains an important role in treatment of the disease. Eighty years ago nephrectomy was the treatment of choice of renal tubercolosis. Nowadays some authors limit nephrectomy to patients with intractable pain, uncontrollable secondary infections, life-threatening hematuria, uncontrollable hypertension or resistance of the mycobacterium to medical therapy. We believe nephrectomy should be performed in cases of extensive renal damage, with or without complete functional loss, and in any case should be associated with exeresis of the whole ureter. In the presence of localised lesions, such as infundibular scarring with closed-off calyx, we generally perform a calycectomy in order to avoid a relapse of the disease and other possible complications. Also in these cases, however, surgery is controversial. Another aspect under debate concerns the association between chemotherapy and steroids. These stenoses, often involving the ureter, can be treated endoscopically (placement of ureteral stent, balloon dilatation, ureterotomy) or surgically (pyeloplasty, ureteral reimplantation, ileal ureter replacement, renal auto-transplantation). A serious consequence of urogenital tuberculosis is the loss of bladder capacity. This condition may be effectively treated with cytoplasty using an intestinal segment. In conclusion, conservative or radical surgery is still necessary to treat many cases of urogenital tubercolosis.

Objectives : Prostatic carcinoma is a common disease of aging male subjects. Owing to structural population changes, its incidence is increasing, making it a major social problem. Epidemiological studies are useful but often do not fully rely on clinical data. The purpose of the present study was to investigate characteristics of prostatic carcinoma from both a clinical and epidemiological point of view. Methods : A multiphased clinicoepidemiological study was initiated in Italy, involving 26 urological centers operating in districts where national tumor registries are active. Demographic and clinical data on stage, pathology, prostate-specific antigen (PSA), and first-line treatment of 819 patients recruited during the prospective 1-year clinical phase of the study were examined. Results : The study showed that most patients with prostate carcinoma were symptomatic, that incidental cases were 10% and distant metastases were present at first observation in 15.3% of patients. PSA within the normal range was found in about 60% of incidental cases and in about a third of stage B cases. Most patients were treated with hormonal therapy. Radical surgery showed a limited incidence of capsular involvement and lymph node metastases. Conclusions : These preliminary data show that in Italy, prostate carcinoma is diagnosed mainly when symptoms are present and that in 53% of cases the disease is locally advanced or disseminated. Treatment appears quite homogeneous for advanced cases but controversies exist for stage A1 (19% treated with hormones, 23% with radical surgery and 52% with watchful waiting), for stage A2 (52% treated with hormones, 23% with watchful waiting), and for stage B (58% of B2 treated with hormones against 27% only treated with radical prostatectomy). A special analysis is planned to investigate the cause of the low incidence of capsular invasions and D1 in operated cases.

Fournier's gangrene is an uncommon disease. It is characterised by superficial cellulitis involving the external genitalia, with a quick necrotic evolution. The origin of infection is often unclear. Generally the disease has a good prognosis, without systemic toxicity or compromising the patient's life. Many cases of Fournier's gangrene with bad prognosis, sepsis, have been described, however, in literature. In these cases the infection propagates from the colorectum, the periurethral glands or the urethra. We believe that these cases must be described as urinous phlegmon which unlike Fournier's gangrene, is a deep cellulitis. The 5 cases that we report, confirm our opinion.

Osteosarcoma is one of the most frequent bone tumours in paediatric age. It has a strong tendency to metastatic spread. Secondary involvement of the kidney with clinical evidence is a rare event (6 cases have been reported in literature). Primary osteogenic sarcoma of the urinary tract is also very unusual (20 cases of primary renal osteosarcoma have been reported until now). To our knowledge primary ureteral osteosarcoma has never been described. We present here one case of symptomatic kidney metastasis of osteosarcoma in a 20-year-old female patient and the first case of primary osteosarcoma of the ureter in an 81-year-old male patient.

— Within the superficial layers of healthy skin and of some mucosae there is a Population of accessory cells of the immune system, able to interact with T helper lymphocytes. Such cells, called tissular dendritic cells (DCs), increase their density and display different morphological features in a variety of immunologically-mediated dermatological disorders. In the present work we investigated DCs within the various urethral segments, both in normal conditions and in urethral stenosis. The specimens, obtained from urethrectomies and urethroplasties with end-to-end anastomosis, were stained with anti-S100 protein antibody and immunofluorescence techniques. We demonstrated an increasing density of S100 protein-positive epithelial DCs from the Prostatic urethra to the glandular one, where DCs were also larger and richer in dendritic Processes. In urethral stenosis the intraepithelial infiltrate of ramified DCs was much denser than any other control. We therefore hypothesize a role for the immune system in the development and maintenance of urethral stenoses, where, as already demonstrated for other types of pathological scarring, morphological changes of DCs serve as clues to their functional activation.

Among tumour markers in clinical practice, interest has been aroused by the products of the cellular membrane, such as LASA (Lipid Associated Sialic Acid). The aim of our work was to assess the clinical value of LASA in patients affected by prostatic cancer at different stages and grades, and to compare the usefulness of LASA as a tumour marker over Prostate Acid Phosphatase (PAP) and Prostate Specific Antigen (PSA), which are well known markers of tumour extension in prostatic cancer. In this study we perfomed serum dosage of LASA, PAP and PSA in fifty-five patients with prostatic adenocarcinoma, 10 cases of stage A1/A2, 13 B1/B2, 6 C1/C2 and 26 D1/D2. This study shows that LASA may complement diagnostic and prognostic values of other existing tumour markers for prostate cancer.

The possibility of distinguishing prostate cancer from BPH with the prostate specific antigen (PSA) determination is particularly poor when PSA levels are between 4.1 and 10 ng/ml. In these cases the quotient of serum PSA and prostate volume, defined as prostate specific antigen density (PSAD), seems to enhance the accuracy of PSA alone. In this study we evaluated retrospectively the preoperative PSA levels in 139 patients with BPH and in 26 patients with prostate cancer who underwent surgical treatment at our Department. We calculated the prostate volume with the following formula: length x width x depth x 0.52. The three dimensions were obtained from the surgical specimen in the patients with prostate cancer and using transrectal ultrasound in the cases of BPH. In patients with a serum PSA level of 4.1 to 10 ng/ml, PSA alone was not able to distinguish benign from malignant prostate disease; the PSAD values, on the contrary, provided a statistically significant (p < 0.003) stratification between BPH and prostate cancer (mean PSAD of 0.0088 and 0.191 respectively). Only 6% of patients with BPH had a PSAD greater than 0.15 compared to 76% of patients with prostate cancer. These results suggest the usefulness of PSAD in predicting the presence of prostate cancer in patients with intermediate levels of serum PSA.

The prognostic accuracy of the current TNM 2002 staging system for locally advanced renal cell carcinoma has been questioned. To contribute to the development of a more accurate classification for this stage of disease we assessed the correlation between patterns of invasion in the pT3 category and outcomes in a large multi-institutional series.Pathological data and clinical followup on 513 pT3 renal cell carcinoma cases treated with radical nephrectomy between 1983 and 2005 at 3 Italian academic centers were retrospectively reviewed. Cause specific survival rates were calculated with the Kaplan-Meier method and multivariate analysis was performed using the Cox proportional hazards regression model.Estimated overall 5-year cause specific survival was 50.1% at a median followup of 61.5 months in survivors. The current TNM classification was not a significant outcome prognosticator. Patients with a tumor invading only the perirenal or sinus fat were at lowest risk for death from the disease. Patients at intermediate risk had tumors with invasion of the venous system alone. Simultaneous perirenal fat and sinus fat invasion or perirenal fat and vascular invasion as well as adrenal gland involvement characterized high risk tumors. Low risk tumors could be further divided into 2 groups with different outcomes based on a size cutoff of 7 cm. Our classification was a significant predictor of survival on multivariate analysis as well as M stage, N stage, Fuhrman grade and tumor size.We confirm that the prognostic usefulness of the current 2002 TNM system for pT3 renal cell carcinoma is limited. We have identified 4 groups of tumors with distinct patterns of invasion and significantly different survival probabilities in this category. Large prospective series are needed to validate these findings.

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

— Intravesical immunotherapy with BCG has become a standard treatment of superficial recurrent transitional cell carcinoma and in-situ bladder carcinoma. Studies on the mechanism of action have demonstrated the role of T lymphocytes. Moreover clinical and experimental results suggest a role by cytochines and delayed type hypersensitivity. BCG, while effective in the treatment of bladder cancer, has a defined morbidity that can be ascribed to the fact that it consists of viable bacterial cells. We evaluated the complications and side effects of this therapy in 71 patients who had received intravesical BCG (Pasteur strain BCG was instilled weekly for 6 weeks, fortnightly for three months and monthly for 12 months at a dose of 75 mg). Our findings showed the following complications: cystitis (63.3%), hematuria (28.1%), fever (7%), two cases of pruritus (2.8%), one case of hepatitis with persistent fever. Granulomatous prostatitis was noted in four cases (5.6%), a higher incidence than reported in literature, but it is a localized and self-limiting process that does not require specific therapy. In conclusion, the treatment with intravesical BCG has a significant morbidity, but the rate of complications is low and most need no treatment.

The real significance of pelvic lymphadenectomy, cure or staging, is still unknown. The morbility of this procedure is surely proportional to the extension of lymph node ablation. Bleeding, intraoperative lesions of nervous structure (lumbo-sacral trunk) post-operative lymphocele, but also lesion of the inferior hypogastric plexus and pelvic branches are more frequent in the case of extended (all the hypogastric and pre-sacral lymph nodes) than limited procedures. Therefore pelvic lymphadenectomy in the case of urologic malignancy is obviously incomplete. Nevertheless the incidence of recurrences in the remaining lymphatic structure is neither high nor clinically significant an therefore the indication for limited procedures is reinforced.

We investigated the clinical value of serum prostate specific antigen in 35 patients with apparently localized prostate cancer who underwent retropubic radical prostatectomy at our Department. In this series preoperative prostate specific antigen levels tended to increase with the increasing severity of pathological stage. The positive and negative predictive values were 68.1% and 63.6% respectively, accuracy was 66.6%. In the case of lymph node involvment, PSA values were lower than 10 nanog./ml in 20% of cases. Prostate specific antigen values not useful to predict preoperatively the final pathological stage of the prostate cancer because of the wide range of values among patients within each stage.

Between May 1984 and November 1998 a total of 27 consecutive patients with bladder tumor (26 transitional cell carcinomas and 1 leiomyosarcoma) underwent supra-ampullar cystectomy and ileal orthotopic neobladder (2 Camey I and 25 Camey II). Mean patients age was 51.1 years (range 23-65). Pre-operatively 22 patients had superficial bladder carcinoma. An involvement of prostatic urethra was excluded by biopsy. The bladder, part of the prostate with prostatic urethra and regional lymph nodes were removed while was deferens, deferential ampullae, seminal vesicles, ejaculatory ducts and peripheral portion of the prostate were saved. Mean follow-up was 56.5 months (range 4-178). One patient was lost to follow-up at 60 months. Of the 27 patients 6 died of bladder cancer (1 with local relapse, 1 with local and distant recurrence and 5 with metastases) and the remaining 21 had neither local nor distant relapse. Four patients died of other causes. Potency was preserved in 25 patients (92.5%) who reported satisfactory sexual intercourse. Sixteen patients (59.2%) also maintained ejaculation allowing procreation in two of them. Supra-ampullar cystectomy provides good results in term of quality of life allowing to preserve sexual function in nearly all the cases without compromise the control of the neoplastic disease. The indication must be restricted to bladder cancer without risk of local recurrence and concomitant prostatic carcinoma.

Nowadays, renal cell carcinomas (RCC) are mostly detected incidentally, following abdominal ultrasound performed for non-urological complaints. These asymptomatic tumors are often small and with low stage. However, about 25% of the RCC are still detected in advanced stage, with synchronous metastasis. Since few years ago, there was no effective treatment for the advanced RCC that shows resistance to the traditional systemic chemotherapy and radiotherapy. Today, two different treatments, either alone or in association, have provided interesting results in these setting, mostly in term of stabilization of the disease. Continuous systemic chronobiological chemotherapy with Floxuridine and immunotherapy with recombinant Interleukin-2 administered intravenously or subcutaneously, represent the treatment of choice of advanced RCC. Both treatment are well tolerated by the patients (except the intravenous Interleukin-2) and do not preclude radical nephrectomy. This paper reports a review of recent literature and the results of the authors' experience.

Idiopathic retroperitoneal fibrosis (IRF) is a rare urological disease, for which many pathogenic theories have been proposed. The authors report a series of 13 cases of IRF in order to evaluate the clinical, diagnostic, laboratory, therapeutic and prognostic aspects. They also report a rare case (the ninth case reported in the literature) of multifocal fibrosclerosis. A possible genetic predisposition was studied by testing for the presence of immunophenotype HLA-B27; this test was positive in 44% of cases. A study of the immunological profile and lymphocyte populations revealed the typical features of chronic immune disease. Experience with medical and surgical treatment is reported, comparing various procedures: ureterolysis followed by application of a vascularized omental flap over the ureter (without subsequent corticosteroid therapy) gave the best results, with complete resolution of the symptoms and long-term successful alleviation of ureteric obstruction in 100% of patients, with a mean follow-up of 58 months.

Metastatic renal cell carcinoma has a poor prognosis, requiring systemic therapy, in addition to radical nephrectomy. Since August 1989, 50 patients were treated with continuous, systemic, chronobiological infusion of FUDR (floxuridine) at our Institution. We reported 11.7% of objective responses, a long period of stable disease and low toxicity. We also compared our actuarial survival with the results obtained with recombinant IL-2 treatment.

The rat adrenal gland contains nitric oxide-producing ganglion cells, contributing to its innervation. In a previous study postnatal number and morphology of these adrenal neurons were analyzed by NADPH-diaphorase histochemistry in the two sexes. A transient sex-related difference in the number of NADPH-diaphorase positive neurons per adrenal gland was found at postnatal day 10, when the number of stained neurons in males was nearly twice that found in females. In the present work we studied the effects of perinatal hormonal manipulation on the number of adrenal NADPH-diaphorase-positive neurons during the second postnatal week. The number of labeled adrenal neurons at postnatal day 10 was higher in females receiving perinatal androgen treatment than in control untreated females, and was similar to that of control untreated males. In contrast, in males that underwent perinatal deprivation of testosterone the number of labeled adrenal neurons was lower than in control males, and similar to that of control females. These differences were found in both the adrenal cortex and medulla. In males and in testosterone-treated females there was a higher proportion of stained multipolar neurons than in females and in androgen-deprived males. No intergroup differences were found in the size of stained neurons. Thus, we demonstrated that the postnatal difference in the number of NADPH-diaphorase-positive adrenal neurons in the two sexes is related to the epigenetic action of gonadal hormones during perinatal maturation.

Conservative surgery was initially limited to patients with localized RCC present bilaterally or in a solitary kidney, in whom radical nephrectomy would necessitate immediate renal replacement therapy. Today, the widespread use of abdominal ultrasound as screening modality in patients with nonspecific or unrelated symptoms allows the detection of renal parenchymal tumors rarely seen before: asymptomatic, small and unilateral neoplasms, often surrounded by a thick and complete pseudocapsule. Global renal function and contralateral kidney are usually normal and the patients show good performance status. For these reasons and because of the generally good results of the first experiences, several authors advocate conservative surgery as an elective indication. Recently, some studies have reported promising results with this approach. On the other hand, some controversial issues persist (multifocality of RCC, low risk of local relapse and renal failure after radical surgery, low incidence of tumor in the contralateral kidney) reducing the opportunity to perform nephron-sparing surgery when the contralateral kidney is normal. In the present study, we report our experience of nephron-sparing surgery for RCC and we review the current and international opinion concerning this treatment.

Prostatic carcinoma is a common disease of aging male subjects. Owing to structural population changes, its incidence is increasing, making it a major social problem. Epidemiological studies are useful but often do not fully rely on clinical data. The purpose of the present study was to investigate characteristics of prostatic carcinoma from both a clinical and epidemiological point of view.A multiphased clinicoepidemiological study was initiated in Italy, involving 26 urological centers operating in districts where national tumor registries are active. Demographic and clinical data on stage, pathology, prostate-specific antigen (PSA), and first-line treatment of 819 patients recruited during the prospective 1-year clinical phase of the study were examined.The study showed that most patients with prostate carcinoma were symptomatic, that incidental cases were 10% and distant metastases were present at first observation in 15.3% of patients. PSA within the normal range was found in about 60% of incidental cases and in about a third of stage B cases. Most patients were treated with hormonal therapy. Radical surgery showed a limited incidence of capsular involvement and lymph node metastases.These preliminary data show that in Italy, prostate carcinoma is diagnosed mainly when symptoms are present and that in 53% of cases the disease is locally advanced or disseminated. Treatment appears quite homogeneous for advanced cases but controversies exist for stage A1 (19% treated with hormones, 23% with radical surgery and 52% with watchful waiting), for stage A2 (52% treated with hormones, 23% with watchful waiting), and for stage B (58% of B2 treated with hormones against 27% only treated with radical prostatectomy). A special analysis is planned to investigate the cause of the low incidence of capsular invasions and D1 in operated cases.

Pelvic lymphadenectomy is a staging procedure for most urologists. It is therefore limited to the lymph nodes that can be approached in the easiest and least dangerous way. The dissection generally removes the lymph nodes situated below the bifurcation of the common iliac arteries; lymphatic drainage from bladder and prostate is also directed to pre-sacral nodes. As the main aim of lymphadenectomy is staging with minimal discomfort for the patient, the laparoscopic technique is clearly the most well-suited for this purpose. In the round table we will discuss the main features of “open” and laparoscopic lymph node dissection.

We report the findings on computed tomography (CT) in idiopathic and secondary retroperitoneal fibrosis in 7 patients. In all cases CT showed the fibrotic mass, accurately defining its extent and the involvement of adjacent anatomic structures. The densitometric and anatomopathologic aspects were correlated; contrast uptake was less in areas thought to be dense in collagen than it was in areas with more vascular regions of inflammatory change. CT assessed the extent and nature of the fibrotic plaque.