Issues n.4 - 2010


n.4 - 2010

Effect of finasteride on the sensitivity of PSA to detect prostate cancer in rebiopsy series

Marco Oderda, Andrea Zitella, Lorenzo Richiardi, Alessandro Tizzani, Paolo Gontero


Objectives: To evaluate, in a prospective study, the diagnostic accuracy of PSA in patients with a prior negative prostate biopsy who were given finasteride for 6 months.

Materials and methods: 91 men with prior negative biopsy findings, including HGPIN and excluding ASAP, were instructed to take finasteride for 6 months. All patients were evaluated at study onset and after 6 months by clinical examination, digital rectal examination (DRE), International Prostate Symptom Score (IPSS) and National Institutes of Health Chronic Prostatitis Symptom Index (NHI-CPSI). Prostate biopsy was repeated at 6 months. PSA levels were measured at baseline and after 1, 3 and 6 months. We calculated the receiver operating characteristics (ROC) curve of PSA under the effect of finasteride for detecting prostate cancer.

Results: The median PSA level decreased similarly both in those with prostate cancer and in those without findings of cancer. There was no statistically significant difference between the two groups. The areas under the ROC curve (AUC) of PSA at study onset and after 6 months of therapy with finasteride were, respectively, 0.48 (95% CI 0.36-0.61) and 0.54 (95% CI 0.42-0.66). There was no statistically significant difference between the two areas.

Conclusions: The results of our study show that PSA itself has a low diagnostic accuracy for detecting prostate cancer in men with prior negative prostate biopsy findings. Finasteride does not seem to improve the accuracy of PSA in this particular population of patients.  

PSA supernormalisation: A surrogate of complete adenoma removal in men with benign prostatic hyperplasia

Oreste Martella, Giuseppe Paradiso Galatioto, Gianna Pace, Carlo Vicentini


It is known that serum prostate-specific antigen levels (PSA) decrease gradually following surgery for benign prostatic hyperplasia (BPH), but there is not an established cut-off value for normal PSA after relief of obstruction. We evaluated the impact of prostatic adenoma enucleation on PSA levels in 110 patients who underwent transvesical suprapubic adenomectomy for symptomatic BPH. We examined PSA levels before and after open surgery and weight of the prostatic adenoma as measured by the pathologist. Forty-eight percent of the patients had a preoperative PSA level between 0 and 4, 29% between 4 and 7, and 23% between 7 and 10 ng/ml. In patients with suspected abnormality on digital rectal examination or PSA > 4.0 ng/mL systematic multisite biopsies were performed preoperatively to rule out prostate cancer. The mean weight of enucleated adenoma was 87 gr (range 50201). The mean serum PSA decreased from 4.8 ng/ml preoperatively to 0.5 ng/ml postoperatively. The mean decrease in PSA was 90% (range 70-99%). PSA was resetted at lower level in all patients irrespectively of baseline PSA levels or BPH weight. The transvesical suprapubic adenomectomy supernormalises serum PSA lower than 1 ng/ml in 96% of patients. 100% of patients have a postoperative PSA value < 1.5 ng/ml. PSA supernormalisation represents an objective measure of complete adenoma removal. The urologists should be aware of this resetted level and they should take account of it when different ablative therapies for BPH are confronted.  

Is there a correlation between testosterone levels and the severity of the disease in male patients with obstructive sleep apnea?

Onder Canguven, Banu Salepci, Selami Albayrak, Ahmet Selimoglu, Muhsin Balaban, Mustafa Bulbul


Objectives: Obstructive sleep apnea (OSA) is a prevalent disease that can decrease quality of life. The aim of this study was to investigate the relationship between serum testosterone levels and the severity of the disease in patients with OSA.

Material and Methods: Severity of OSA was quantified with apnea-hypopnea index (AHI) which was defined as the total number of apneas and hypopneas per hour of sleep. Thirty-six male patients with mild-to-severe stable OSA and thirty age-matched subjects without OSA were included in this study. Erectile function was assessed by the International Index of Erectile Function (IIEF)-5. The association between severity of OSA and selected comorbidities was evaluated and compared with findings reported in the literature.

Results: Mean serum testosterone levels of OSA and control patients were 462.8 ± 160.3 ng/dL and 486.9 ± 163.2 ng/dL, respectively (p > 0.05). There was a significant negative correlation between serum testosterone levels and AHI in patients with OSA (r = - 0,502, p < 0.01). Mean IIEF scores of OSA and control patients were 17.5 ± 5.9 and 17.4 ± 4.7, respectively (p > 0.05). Body mass index (BMI) of the OSA patients and control group were as 30.1 ± 0.8 and 26.9 ± 0.4, respectively (p < 0.01).

Conclusions: Serum testosterone levels were negatively correlated with BMI and the severity of OSA. Measuring testosterone level may be an additional helpful indicator in diagnosis of severity and in follow-up of OSA.  

Increased testicular 8-hydroxy-2'-deoxyguanosine (8-OHdG) and inducible nitric oxide synthetase (iNOS) and nuclear factor kappa B (NF-KB) expressions in experimental rat varicocele

Volkan Tugcu, Asuman Gedikbas, Bircan Mutlu, Ekrem Güner, Mehmet Uhri, Gülnur Andican, Emin Özbek, Ali. Tascı


Objectives: To asses nuclear factor-KB (NF-KB), inducible NO synthase (iNOS) immunohistochemically, and 8-hydroxy-2'-deoxyguanosine (8-OHdG) biochemically, which are sensitive biological markers of oxidative damage and stress, in testes with experimental varicocele.

Materials and Methods: Adult rats were randomly divided into three groups. Control group (n: 10), sham group (n: 10), varicocele group (n: 10). Of 14 rats undergoing partial ligation of the left renal vein, 10 rats had developed dilation of the left spermatic vein when evaluated 3 months after varicocele-inducing surgery. The rats were sacrificed after 3 months of the varicocele-inducing surgery. Ipsilateral and contralateral testes were examined for 8-hydroxy-2'-deoxyguanosine (8-OHdG) biochemically, inducible NO synthase (iNOS) and nuclear factor-KB (NF-KB) expression immunohistochemically.

Results: Inducible NO synthase (iNOS), nuclear factor-KB (NF-KB) expressions and 8-hydroxy- 2'-deoxyguanosine (8-OHdG) levels in both testes of varicocele group were markedly higher compared with control and sham groups (p < 0.01). There was no difference between control and sham groups (p > 0.05).

Conclusions: Regarding to our results, we suggest that varicocele may produce oxidative stress in both of testes, and we believe that this stress may play a role in male fertility.  

New perineal tensive transobturator tape (T-TOT) for postprostatectomy urinary incontinence

Andrea Ceresoli, Andrea Guarneri, Davide Abed El Rahman, Alberto Cazzaniga, Gaetano Grasso Macola


Abstract: Bulbourethral transobturator sling data from other investigators report a success rate from 53% to 85%. Since the degree of sling tension and its adjustment seems to be important for achieving complete urinary continence we present results on the first consecutive 12 patients, with mild post prostatectomy stress urinary incontinence – defined as – less than 500 ml, who underwent a new perineal tensive transobturator polypropylene tape (T-TOT) procedure at our institution.

Results: Pre-operative mean abdominal leak point pressure (ALPP) was 23 cm H2O (sd +/- 10), retrograde leak point pressure (RLPP) was 24 cm H2O (sd +/- 6) and the mean pad test was 324 g (sd +/- 176). The overall success rate has been of 58.3% (7 patients) complete responders (CR), 33.3% (4 pts) partial responders (PR) and 8.33% (1 patient) failure. No significant urodynamic outlet obstruction nor urethral erosion occurred at 9-month follow up occurred. Post operative ICIQ-SF questionnaire score dropped from 11 to 3 with significant statistical evidence (p < 0.01).

Conclusion: perineal T-TOT showed safe and effective results similar to conventional bulbourethral transobturator male slings without obstructive symptoms despite maximal tension was used. Anyway longer prospective follow up is needed to determine the long-term efficacy of this procedure and the effective preservation from urethral erosion.

The role of Doppler ultrasound in the diagnosis of vasculogenic impotence

Debora Marchiori, Daniele Aloisi, Alessandro Bertaccini, Claudio Ferri, Giuseppe Martorana


Objective: Many authors have demonstrated that cardiovascular diseases (CVD) and their related risk factors can predict erectile dysfunction (ED). The penile Doppler ultrasonography is a method to evaluate the cavernous blood flow in people with suspected vasculogenic impotence. The goal of our study was to evaluate if erectile dysfunction is associated to a vascular disease and which is the role of penile Doppler investigation.

Material and Methods: 90 patients (group 1) complaining ED, but no symptoms of CVD were prospectively evaluated with penile Doppler ultrasound. The controls (group 2) were 45 apparently healthy subjects. Both groups were submitted to carotid and aortal-iliac Doppler ultrasonography. Results: 50 patients (mean age 60.5 ± 4.6 years ) in group 1 (IIEF < 15) and 45 subjects (mean age 59.5 ± 4.6 years) in group 2 (IIEF > 15) were recruited. Mean age, height, LDL-cholesterol and blood pressure value were not statistically different (p = 0.417) between the two groups. Statistically significant differences were found in weight values (p = 0.016). Only 8 patients (4%) were affected by arterial insufficiency and 42.1% by veno-occlusive mechanism insufficiency (p > 0.05). The cavernosal artery diameters were within 0.7 ± 0.2 and 1.2 ± 0.1 mm. All patients with a diagnosis of vasculogenic impotence of either arterial or venous origin were found asymptomatically affected by both a diffuse thickenings > 1 mm or a non hemodynamic plaque in the other vessels examined (carotid arteries or aorta or iliac arteries ).

Discussion: Looking at our results, erectile dysfunction is associated to diffuse thickness > 1 mm or with a non hemodynamic plaque of atherosclerotic origin in other vessels. These data confirm the theory that impotence has to be considered as a risk marker for cardiovascular disease (CVD) in men with no cardiovascular symptoms. In our opinion, the penile echo Doppler is not able to show any endothelial dysfunction in terms of loss of mediator releasing.

Conclusion: in case of suspect vasculogenic impotence, even if penile Doppler is not pathological, it would be worth performing a systemic Doppler evaluation of main arteries in order to investigate the presence of atherosclerotic finding and institute a preventive therapy for CVD.

Intraoperative frozen section in laparoscopic radical prostatectomy: Impact on cancer control

Paolo Emiliozzi, Mostafà Amini, Alberto Pansadoro, Marco Martini, Vito Pansadoro


Background: Intraoperative Frozen Section (IFS) with further tissue resection in case of positive margins has been proposed to decrease positive surgical margins rate during radical prostatectomy. There are a few reports on the benefits of this potential reduction of positive margins (PSM).

Objective: The aim of this study is to assess the oncological advantages of PSM rate reduction with the use of IFS and additional tissue excision in case of PSM. Design, setting and partecipants: 270 patients undergoing laparoscopic radical prostatectomy were included in a prospective study, to evaluate the results of further tissue excision in case of PSM at IFS. Median age was 65 yrs. Median PSA was 7.0 ng/ml.

Intervention: The prostate was extracted during the operation. IFS was performed in all patients on the prostate surface, at the base, the apex and along the postero-lateral aspect of the gland. In case of PSM additional tissue was excised from the site of the prostatic bed corresponding to the surgical margin.

Measurements: Endpoint was biochemical recurrence-free survival.

Results and limitations: PSM were found in 67 patients (24.8%). With additional tissue resection, PSM rate dropped from 24.8% to 12.6%. Decreased PSM after further resection didn’t improve biochemical-free survival. Patients with initial PSM at IFS rendered negative with further resection, had similar results if compared to patients with margins still positive, and worse results if compared to patients with negative margins (NSM). Biochemical recurrence rate was 2.95% at 58 months in 203 patients with NSM, 15.1% at 54 months in 33 patients with PSM at IFS that were rendered negative after further resection, and 11.7% at 67 months in 34 patients with still PSM after additional resection. These results were confirmed also according to: stage, nerve-sparing procedure, Gleason score.

Conclusions: Our data don’t support IFS during radical prostatectomy to improve biochemicalfree survival.

Orthotopic neo- bladder in women

Manlio Schettini


Introduction: Radical cystectomy is the most effective treatment madality for high grade urinary bladder carcinoma and orthotopic reconstruction is the better urinary diversion modality also in women.

Material and methods: From 2002 to 2007 we performed 14 radical cystectomies followed by orthotopic reconstruction in women aged between 47 and 68 years (mean age 56) affected by urinary bladder carcinoma. Our reconstructive technique requires the preparation of two strips of the recti muscles fascia, the sectioning of the bladder neck and, when the uterus is present, hysteroannessiectomy and cystectomy en block leaving intact the lateral and inferior vaginal walls. The pelvic floor is stabilized by a colposacropexis with a prosthesis and placing an omental flap over the prosthesis The orthotopic reconstruction is achieved via a neobladder according to the Padovana technique. The ureters are anastomized to the neobladder and splinted with single J stents.

Results: The pathological examination demonstrated in all patients the presence of a high grade carcinoma (G3): more specifically 4 patients had a full thickness intramural infiltration (T2), 2 patients had involvment of the perivescical fat (T3) ad 8 patients were in T1 stage. Lymphnodes were negative for tumour (N0). In 8 patients blood trasfusions were necessary to treat post surgical anemia. No significant intra-, peri- or post operative complications were noted. The mean follow-up was 45 months: a patient died for diffuse metastatic disease after 11 months. The remaining patients are still alive and report normal lifestyle: 10 with normal micturition and 4 with urinary retention treated with intermittent self-catetherization. Two patients report nocturnal incontinence treated with hourly micturition and one pad. The five patients who had normal preoperative sexual intercourse resumed a normal sexual activity.

Discussion: The possibility to orthotopically recontruct the female urinary bladder has been established long time after the introduction of orthotopic neobladder in males, when became obvious that bladder reconstruction had to be done in conjunction with the recostruction of the pelvic floor, in order to assure a satisfactory function af the new bladder. To avoid a posterior slippage of the vaginal stump we inserted the vaginal stump into a prolene tube which was then anchored posteriorly to the sacral periostium. We covered the prolene net with a flap of omentum pedicled down from the transverse colon and brought into the pelvis through the right colic space. This solid, stable and well protected support was able to accept the new bladder. We use the Padovana technique to facilitate the anastomosis of the bladder neck to the urethra. In the patients affected by uretrhal ipermotility we shaped a sub urethral sling using the recti muscles fascia pedicled by the pyramidal muscles. With this modality of reconstruction female pelvic anatomy is preserved as demonstrated by recovery of sexual activity.

The use of the hyperbaric oxygenation therapy in urology

Giandomenico Passavanti


The basic principle of the hyperbaric oxygenation therapy (HOT) is to increase the dissolved oxygen in the blood when it is administered at high pressure. Then O2 will be distributed to the tissues through the pressure gradient, in this way obtaining an hyper-oxygenation of the tissue that has anti-inflammatory and pain-killing effects and induces augmentation of bacterial permeability to the antibiotics, neo-angiogenesis, enhancement of lymphocytes and macrophages function, augmentation of the testosterone secretion (in male), and healing of wound. These positive effects can be used in urology in several conditions: Scroto-perineal fascitis; Radiation-induced cystitis (and proctitis); Interstitial cystitis (urgency-frequency syndrome); Chronic pelvic pain. Our experience and the specific literature on this subject, suggest that HOT, sometimes associated with other medical and surgical therapies, can be a useful tool for treating such urologic diseases; in some cases this use is codified (Fournier’s gangrene and Radiation-induced cystitis) in others (urgency-frequency syndrome and chronic pelvic pain) it represents a promising technique and needs further research.

Cerebellar pathology and micturitional disorders: Anatomotopographic and functional correlations

Tiziano Zago, Umberto Pea, Gian Luca Fumagalli, Leonardo Areta, Giuliano Marzorati, Filippo Bianchi

Cerebellar diseases represent about 2-3% of neurologic pathologies; they usually are classified as heredodegeneratives, pure cerebellar syndromes. Such diseases – aside from their aetiology – lead, through several evolutive stages, to different micturitional disorders, in most cases represented by hyperreflexic non dyssynergic bladder and urinary incontinence. On the basis of anatomopathological studies, also considering our 16 years long personal series (1992-2008), we were able to establish a relationship between such disorders and specific cerebellum anomalies, mostly of Purkinje network.

Fibromuscular dysplasia causing renal artery aneurysm and renovascular hypertension: A case report

Andrea Solinas, Rossano Cadoni, Massimo Usai, Mauro Frongia


Objective: Renal artery aneurysm is a rare disease and usually is due to fibromuscular dysplasia. We describe a case in a woman who had renovascular hypertension due to aneurysm of fibromuscular dysplasia-associated renal artery.

Material and methods: The clinical presentation, renal function, radiologic data, complications and treatment were studied.

Results: To report a case of 37-year-old female with a history of hypertension in the last year in pharmacological therapy and in absence of other clinical symptoms. A Doppler ultrasound and a spiral tomography revealed the presence of a right renal artery aneurysm with a hypoplastic kidney. Controlateral kidney was normal. We carried out total nephrectomy to resolve high blood pression and the risk of rupture. The patient was discharged home in 5th post operative day. Serum creatinine level remained normal as it was before. Her blood pressure normalized over a period of several months using a single antihypertensive medication.

Conclusion: We suggested that in presence of renovascular hypertension in young adult fibromuscular dysplasia-related renal artery aneurysm will be suspected. When possible aneurysmectomy and angioplastic renal artery closure or segmental renal artery reimplantation and renal artery bypass are the gold standard while nephrectomy will be reserved for unreconstructable renal arteries or advanced parenchymal disease.

Headache: A unique clinical presentation for renal cell carcinoma (RCC)

Giuseppe Candiano, Pietro Pepe, Giuseppe Grasso, Francesco Aragona


Brain metastases of renal cell carcinoma (RCC) are generally seen in advanced stages of disease with a short life-expectancy. A solitary, synchronous brain metastasis of RCC is rare and neurological symptoms may be the presenting sign of cancer. An aggressive surgical approach is justified in patients with favorable prognostic factors (good performance status, age under 65 years, absence of extracraneal lesions) for palliation of symptoms and improvement of cancer-related survival.

First Italian experience in single incision laparoscopic nephrectomy. Assessing and overcoming new challenges

Stefano Gidaro, Luca Cindolo, Fabiola Raffaella Tamburro, Luigi Schips


Background: The need to enlarge one of laparoscopic holes for specimen retrieval at the end of a laparoscopic nephrectomy, suggested us to use this final access for the entire procedure. We describe our technique placing trocars directly on the fascia once the skin and the subcutaneous layers were prepared.

Material and methods: A 10 consecutive patients series operated by Single Incision Laparoscopic Nephrectomy (SILN) is presented. With a 5 cm mean skin incision, the fascia was prepared and 3/4 trocars inserted separately directly on the fascia. Surgical strategy followed the standard technique, except for the use of articulating instruments and 5 mm optic. Demographics, Body Mass Index (BMI), operative time, blood loss, perioperative complications, transfusions, hemoglobin decrease, analgesic requirement, length of stay, final pathology were recorded. Postoperative and prior-to-discharge Video Analogue Scale Pain (VAS) evaluation were also collected, together with the limitations inherent to the instruments placing and parallel driving during the procedure.

Results: SILN was successfully completed in all but one cases. The mean operative time was 169 min (mean blood loss 113 ml). Without major perioperative complications, the patients were discharged early (mean 5.3 days). Four patients had a BMI > 30. For specimen retrieval (neoplasms) two trocars holes were joined. One patient required analgesics; the mean post-operative and prior-to-discharge VAS scores were 5.7 and 1.4, respectively. Pathology examination confirmed 4 pyelonephritic kidneys, 4 renal carcinoma and 2 upper-urinary tract carcinoma.

Conclusion: SILN is feasible, safe, with favourable perioperative and short-term outcomes. It’s technically more challenging than standard laparoscopy requiring advanced surgical skills.  

Retrograde ejaculation and abnormal hormonal profile in a subject under treatment with valproate and phenytoin

Jlenia Elia, Norina Imbrogno, Michele Delfino, Fernando Mazzilli


Anti-epileptic drugs may have negative effects on sexual function and hormonal profile. The exact mechanisms involved, however, have yet to be completely understood. We report a case of ejaculation failure and abnormal hormonal profile in a patient affected by epilepsy. A 59-year-old man, under treatment with valproate and phenytoin for 15 years, complained of orgasmic anejaculation over the previous 6 months. He was not affected by other relevant pathologies and he had not undergone pelvic surgery. We found spermatozoa in post-orgasmic urine, which confirmed our suspicion of retrograde ejaculation. The hormonal profile showed high levels of FSH, LH and, surprisingly, increased levels of total testosterone and SHBG. We hypothesized bladder sphincter inhibition and receptor alterations due to the anti-epileptic drugs.

Alfuzosin induced thrombocytopenia after treatment for benign prostatic hyperplasia

Sebnem Güner, Bircan Mutlu, Ekrem Güner, Ali Ihsan Tasçı  


We report on 1 case of alfuzosin induced thrombocytopenia after treatment for benign prostatic hyperplasia. This side effect has been recognized 3 months after the alfuzosin treatment. The diagnosis was made by complete blood count (CBC). Peripheral blood smear of the patient was referred to an hematologist to exclude pseudothrombocytopenia and review of the peripheral smear confirmed the decreased platelets with no clumping. Manual count of platelets was similar to the result of complete blood count. After cessation of alfuzosin treatment thrombocytopenia improved and thrombocyte count reached to normal on week 2 following the discontinuation of treatment. Recovery of thrombocytopenia after discontinuation of alfuzosin treatment and recurrent depletion of platelet count after initiation of alfuzosin, supports our thoughts about drug-induced thrombocytopenia (DITP) caused by alfuzosin. The patient was prescribed different alfa blocker and he faced no problem.

Open intervascular nephron-sparing surgery for pyelocaliceal transitional cell carcinoma in solitary kidney planned with contrast-enhanced multidetector CT

Francesco Rocco, Luigi Alberto Cozzi, Franco Gadda, Gabriele Cozzi, Serena Maruccia, Isabella Oliva, Elisabetta Finkelberg


A 69-year-old man presented with a tumor involving the right renal pelvis and the middle and lower calyces in a solitary kidney. The patient was determined to preserve left renal function. Intervascular nephron-sparing surgery (NSS) was planned. A contrast-enhanced multidetector computed tomography (MDCT) was performed, providing 3-D reconstructions of the renal artery and collecting system in regard to the tumor. Two trunks of the anterior branch of the renal artery directed to the lower and middle parenchymal segments were identified. After dissection of the renal vessels, the anterior branch of the renal artery was identified. The trunks directed to the middle and lower segments were ligated and sected, producing an ischemic area. In cold ischemia, the renal pelvis and the middle and lower segments and calyces were ablated. An anastomosis between the ureter and the upper calyx was performed. Thirty days after surgery, serum creatinine was 3 mg/dl.