Issues n.3 - 2011


n.3 - 2011

The European Union Interreg Program: Italian-Albanian experience with kidney transplants

Mustafa Xhani, Francesco Paolo Selvaggi, Michele Battaglia, Aurel Janko, Giuseppe Grandaliano, Antonio Schena, Giuseppe Lucarelli, Stefano Vittorio Impedovo, Pasquale Martino, Pasquale Ditonno


Introduction: A collaboration between the Regional Health Agency of Puglia (ARES), the Italian Ministry of Health and the Albanian Ministry of Health, was realized in 2008. One of the areas of interest was to promote the performance of kidney transplants in Albania by Albanian medical staff, funded with nearly 2 million euros. The program included two major goals: to transmit the required know-how to health care staff and to upgrade the Albanian facilities and equipment to the standards necessary for successful transplantation.

Materials and Methods: During the year 2008, two couples of Albanian patients were transplanted at the Department of Emergency and Organ Transplantation-Urology Unit in Bari, Italy. The surgical procedures were performed by mixed surgical teams, with the active participation of Albanian medical staff under the guidance of the Italian colleagues. The first kidney transplant was performed at the end of January 2008 and the second in June 2008. Both surgical procedures and post-transplant periods were clinically uneventful.

Results: After returning to Albania the trained team started to carry out team-work, preparing the patients for the first kidney transplantation. The first donor-patient couple was prepared for kidney transplantation at the end of 2008. On the 26th March 2009 the first kidney transplant was performed by the Albanian medical team, with the active participation of 2 Italian urologists from the University of Bari.

Conclusions: Appropriate training, equipment, and infrastructure are necessary to build a rational, functional national system for organ transplantation. Continuous exchange of ideas and data on kidney transplantation between Albania and Italy will probably contribute to extend such forms of cooperation to the western Balkans in the near future.

Distribution of Cajal like cells and innervation in intrinsic ureteropelvic junction obstruction

Muhammed Kuvel, Onder Canguven, Medine Murtazaoglu, Selami Albayrak


Objectives: C-kit positive interstitial cells of Cajal (ICC)-like cells are defined as pacemaker cells in the ureter, which produce and coordinate peristaltic motility. To investigate the changes in ICC-like cells and innervation in segments of intrinsic ureteropelvic junction (UPJ) obstruction.

Material and Methods: Full thickness specimens obtained from UPJ segments (n = 77) were divided into 3 groups. Group I included 32 intrinsic UPJ obstruction segments, separated into 3 subgroups: Group Ia (proximal), Group Ib (obstruction, intermediate) and Group Ic (distal segments). Group II included 30 normal UPJ segments derived from the nephrectomy specimens. In Group III, 15 UPJ segments of chronic obstruction were analyzed. Formalin fixed, paraffin embedded specimens from UPJs were analyzed immunohistochemically for CD117, S100 and synaptophysin protein expression in nerve plexus and ganglionic cells in the neuromuscular junction.

Results: Group Ib showed significantly decreased (p < 0.05) positive staning with c-kit protooncogene protein (CD117), S100 and synaptophysin proteins compared with Group Ia and Group Ic. ICC-like cells were observed in increased number (p < 0.05) in Group Ia compared to Groups II and III. Group Ib had lower synaptophysin positivity compared to Group II.

Conclusions: The findings support the hypothesis of decreased innervation in the etiopathogenesis of intrinsic UPJ obstruction. Increased number of ICC-like cells in Group Ia suggests that peristaltic activity is higher in pelvicalyceal region.

Integrated staging systems for conventional renal cell carcinoma: A comparison of two prognostic models

Oreste Martella, Giuseppe Paradiso Galatioto, Stefano Necozione, Roberto Pomante, Carlo Vicentini


Objective: The objective of the current study was to compare, in a single center experience, the discriminating accuracy of two prognostic models to predict the outcome of patients surgically treated for conventional renal cell carcinoma (RCC).

Patients and Methods: We retrospectively evaluated the clinical and pathological data of 100 patients surgically treated for RCC between 1998-2008 at our institution. For each patient, prognostic scores were calculated according to two models: the University of California Los Angeles integrated staging system (UISS) and the Stage, Size, Grade, and Necrosis (SSIGN) developed at the Mayo Clinic. The prognostic predictive ability of models was evaluated using receiver operating characteristic (ROC) curves.

Results: The median follow-up was 62 months (range 12-120). All clinical and pathological features that compound the algorithms were significantly associated with death from RCC in univariate and multivariate setting. The 5-year cancer-specific survival (CSS) according to the SSIGN score were 95% in the '0-2'category, 88% in '3-4', 60% in '5-6', 37% in '7-9' and 0% in the '! 10' group (long-rank p value < 0.001); according to the UISS the 5yr CSS probabilities in non-metastatic patients were 100% in low, 80% in intermediate and 54% in high-risk groups; in metastatic patients, the respectively CSS were 40% in low and 25% in high-risk groups (longrank p value < 0.001). The area under the ROC curve was 0.815 for the SSIGN score and 0.843 for the UISS (p = 0.632).

Conclusion: In our series the SSIGN and UISS discriminated well, without relevant differences. Currently both algorithms represent usefuls clinical tools that allow risk assessment after surgical treatment of RCC. We encourage the uro-oncologist to begin to routinely rely on them in real-life practice.

Need for emergent studies on dietary factors among infancy nephrolithiasis

Seyed Mohamad Hosein Mousavi Jazayeri, Mehrangiz Ebrahimi Mamaghani, Ali Pourmoghaddam, Anoosh Azarfar, Motahar Heidari Beni, Seyed Jalal Emam


The prevalence of pediatric nephrolithiasis has increased in recent years in some countries located in the Afro-Asian stone-forming belt. The increase may be a result of rapid variations in eating habits and changes in socio-economic conditions. Geographic variation such as climate was reported to contribute to the incidence of urolithiasis in children. It seems necessary to do population based studies to find out the real prevalence of nephrolithiasis among infants and it should be quite important to investigate the association between dietary intake and nephrolithiasis.

Nutritional aspects of idiopathic nephrolithiasis in Tunisian children

Akram Alaya, Rachid Sakly, Abdellatif Nouri, Mohamed Fadhel Najjar


Objective: We evaluated the metabolic and the nutritional aspects of 134 urolithiasic children, in order to outline the risk factors that contribute to idiopathic stone formation in children.

Material and Methods: In this prospective study 134 children (56 females, 78 males) with renal calculi were evaluated. The age of the patients ranged 6 months to 16 years. A dietary survey was performed on every child. All patients were investigated with respect to stone localization, serum and urine risk factors. Statistical analysis of data was carried out using software SPSS 11.0 for Windows. Statistical significance was determined using chi-square test.

Results: Hypercalciuria was the commonest risk factor detected in this group (28.3%). A decrease of water intake was noted in all age group specially in the rural area (549.6 vs 1150.6 ml /day), and an increase in animal protein intake in 17 cases (mean 1.9 g/kg). In addition, increased intake of starchy foods and food with high oxalate content (sorgum) was observed in our 10-16 years group (51%). Calcium oxalate monohydrate represents the principal component of idiopathic stone (58.2%), which is more frequent in children (68%) than infants (51.7%) (P < 0.02).

Conclusions: The high frequency of idiopathic urolithiasis highlights the influence of dietary habit in stone formers in our country. The increase in calcium oxalate stones in school-age children confirms the change in the etiology of urolithiasis according to age.

Incidence of ureteral stricture after ureterorenoscopic pneumatic lithotripsy for distal ureteral calculi

Selim Tas, Volkan Tugcu, Bircan Mutlu, Serdar Karadag, Alper Bitkin, Mehmet Yücel, Ali ihsan Tasçı


Backgroud and purpose: We investigated the incidence of ureteral stricture in patients treated with ureterorenoscopic pneumatic lithotripsy for distal ureteral calculi.

Patient and methods: Between April 2006 and January 2009, 154 patients requiring ureterorenoscopic pneumatic lithotripsy for distal ureteral calculi were enrolled into the study. We evaluated the stone size, impaction of a stone, the need for ureteral orifice dilatation and the need for application of double-J stent.

Results: A total of 154 patients underwent URS-PL for ureteral calculi. Mean calculi diameter was 12.17 ± 2.54 (range: 5-20 mm). Stone free rates after the first URS-PL operation were 97.4% of patients. In 2 patients (1.29%), ureteral perforation occurred as an early complication. We observed deep mucosal injury in 9 patients (5.84%). Partial stricture (partial obstruction) was observed in 9 patients (5.84%). Of 9 patients who had an ureteral stricture postoperatively, 7 patients had ureteral calculi ! 10 mm, 2 patients had calculi < 10 mm. We observed ureteral stricture in 2 (8.69%) out of 23 patients who had calculi < 10 mm, and in 7 (5.34%) out of 131 patients who had calculi ! 10 mm (p > 0.05). Ureteral stricture was observed in 2 (13.33%) out of 15 patients who had impacted calculi, and in 7 (5.03%) out of 139 patients who did not have impacted calculi (p < 0.05). We observed ureteral stricture in 3 (6.25%) out of 48 patients who required ureteral dilatation, and in 6 (5.66%) out of 106 patients who did not require ureteral dilatation (p > 0.05). Ureteral stricture was observed in 6 (15%) out of 40 patients who required ureteral double-J catheter placement, and in 3 (2.63%) out of 114 patients who did not require ureteral double-J catheter placement (p < 0.05).

Conclusion: The results of our study have demonstrated that the success rate was not related to the stone dimension, but the time of operation was found to be increased with larger stones. Main risk factors for formation of ureteral stricture were impacted ureteral calculi and reasons which merits double-J catheter placement like mucosal damage, perforation, impacted calculi and high stone burden.

First collaborative experience with thulium laser ablation of localized upper urinary tract urothelial tumors using retrograde intra-renal surgery

Lorenzo Defidio, Mauro De Dominicis, Luca Di Gianfrancesco, Gerhard Fuchs, Anup Patel


Purpose: Thulium laser ablation (TLA) outcomes with blinded performance evaluation after retrograde intra-renal surgical (RIRS) treatment of upper urinary tract transitional cell carcinomas (UUT-TCC).

Materials and Methods: A UUT-TCC patient cohort undergoing RIRS-TLA by an international endoscopic surgical collaboration in a European center (April 2005- July 2009), underwent outcomes evaluation. All 4 surgeons were blinded and independently scored both TLA and Holmium:YAG laser ablation performance aspects annually using a Likert scoring system (0-10).

Results: All patients (n = 59, median age 66 years, 9 with solitary kidney) had complete UUT inspection. Presenting lesion(s) were intra-renal (n = 30, 51%), ureteral (n = 13, 22%), and combined (n = 16, 27%). Single-stage TLA sufficed in 81.4% (tumors < 1.5 cm). Significant recurrence free survival differences occurred according to primary tumor size >/< 1.5 cm and multi-focality, but location made no difference. Median Likert scores were i) fiber-tip stability - 5.5/8.75, p = 0.016*; ii) reduced bleeding - 5/8.5, p = 0.004*; iii) fiber-tip precision - 5.5/8.5, p = 0.003*; iv) mucosal perforation reduction - 3.5/7.5, p = 0.001*; v) ablation efficiency tumors < 1.5 cm - 6/9, p = 0.017*; tumors > 1.5 cm - 6.75/6.75, p = 1, and vi) overall efficiency - 6/7.5, p = 0.09, for Holmium:YAG and TLA, respectively.

Conclusions: The Thulium laser delivered non-inferior recurrence free survival to RIRS-UUT-TCC Holmium:YAG laser ablation, but better median parameter performance scores in fiber-tip stability, precision, reduced bleeding and mucosal perforation reduction in expert ratings. Despite improved photothermal coagulation, and endo-visualization for tumors < 1.5 cm, both ablation and overall efficiency remained challenging for larger tumors with both existing laser technologies.

Saturation biopsy technique increase the capacity to diagnose adenocarcinoma of prostate in patients with PSA < 10 ng/ml, after a first negative biopsy

Roberto Giulianelli, Stefano Brunori, Barbara Cristina Gentile, Giorgio Vincenti, Stefano Nardoni, Francesco Pisanti, Teuta Shestani, Luca Mavilla, Luca Albanesi, Francesco Attisani, Gabriella Mirabile, Manlio Schettini


Objective: Aim of this study was to evaluate if saturation biopsy (SB) technique increases the cancer detection rate in patients with PSA < 10 ng/ml, after a first negative biopsy.

Material and Methods: From January 2004 to January 2006, 780 patients underwent prostate ultrasound guided transrectal (UGT) core biopsy: 186 (23.8%) presented prostate cancer (PCa) while 594 pts (76.2%), were disease free. For 1 year all the patients with no evidence of cancer were observed according to a follow-up schedule including PSA every 3 months and DRE every 6 months. During this period 140 patients showed an increase of PSA (< 10 ng/ml) or a low PSA free/total. This group underwent a second prostate UGT core biopsy with SB technique. In all the patients we evaluated PCa detection rates (DR) according to the PSA range. We also checked peri/post-operative complication rate (total post-operative hospitalization time, haemoglobin loss, catheterisation rate, pain rate, QOL).

Results: Of the 140 patients 50 (35.7%) had PCa showing a Gleason score (GS) of 4 or 5 in 26%, 6 or 7 in 75% and 8 to 10 in 9 % respectively. Sectors apical biopsies carried out in the anterior horn of peripheral zone tissue presented over 70% (35 patients) of cancer detection rate. Rectal bleeding was the major common complication. Cancer was clinically significant in 47 patients (94%) but 34 (68%) presented an organ confined disease after radical surgery.

Conclusions: SB technique increases of 35.7% the cancer detection rate (DR) in patients with PSA < 10 ng/ml, after a first negative biopsy, showing a higher positivity (70% PCaDR) if the SB included the anterior horn of peripheral zone tissue. No significantly pain and side effects were observed.

Robotic nephropexy in case of symptomatic nephroptosis

Emanuele Baldassarre, Paolo Marcangeli, Massimo Viganò, Ivano Vittoria, Domenico Pone, Arianna Gillo, Paolo Pierini


We found only a recent report of robotic-assisted nephropexy, in a young female with associated dismembered pyeloplasty. Herein we present the first case of isolated robotic nephropexy. A 34-year old female was referred to our Urological Division history of right flank pain and evidence at intravenous urography of a 5-6 cm descent of right kidney moving from supine to erect position. The robotic nephropexy was performed with a transperitoneal approach and 4 trocars. The kidney was wrapped up with a Parietex™ Composite (PCO) mesh (Tyco Healthcare), previously precut in an hockey stick shape to obtain a “spoon effect” to push up the lower pole of kidney. Despite the laparoscopic or retroperitoneoscopic procedures, the robotic-assisted nephropexy appears easier, with the particular advantages of the intracorporeal suturing and a better intraoperative view. The use of mesh, in our opinion, is preferable respect the decapsulation of the kidney, to avoid unnecessary blood loss and possible scarring.

Aggressive non-Hodgkin’s lymphoma mimicking unilateral transitional cell carcinoma of renal pelvis. The risk of making a diagnostic mistake

Rafael Boscolo-Berto, Daniela I. Raduazzo, Roberto Vezzaro, Dario Marino, Savina Maria Aversa, Marina Gardiman


A 78-year-old Caucasian man was referred to our department because of an incidental unilateral mass involving the right renal sinus. As the patient showed no urological disease at flexible ureterorenoscopy, a subsequent percutaneous CT-targeted biopsy was mandatory, confirming an aggressive non- Hodgkin disease involving the renal pelvis that is, to the best of our knowledge, the second reported case in literature. A whole body FDG-PET excluded multiple expression of this disease, and the patient underwent a chemotherapeutic scheme resulting in a stable marked reduction in tumor volume. To the date, the available experience on the management and outcome of such cases is extremely lean. In this scenario, our case can contribute to shorten the time-to-diagnosis by reporting a complete images overview comprising abdominal CT scan, MRI and FDG-PET-CT, hence making this clinical entity easier presumable in clinical daily practice and offering a possible suggestion for an effective treatment.

Unusual indications for transrectal pelvic ultrasound

Pietro Pepe, Giuseppe Candiano, Michele Pennisi, Francesco Aragona


Transrectal ultrasound (TRUS), routinely performed by urologists to guide prostate biopsy, could be usefully employed in atypical cases. We report our experience in some patients in whom TRUS allowed to obtain a diagnosis in a faster and easier way in comparison to other instrumental procedures usually recommended.