Issues n.1 - 2012


n.1 - 2012

The role of bladder neck preservation during radical prostatectomy: Clinical and urodynamic study

Marco Grasso, Fabrizio Torelli, Caterina Lania, Salvatore Blanco


Aims: Bladder neck preservation has caused an increase in urinary continence following radical prostatectomy, and has given rise to much controversy. We have reviewed our clinical and urodynamic experience collected since 1995 in patients subjected to radical prostatectomy with bladder neck preservation.

Materials and Methods: 180 patients were followed postoperatively using a pad test, an incontinence questionnaire and PSA dosage. In 66 early continent patients, test of maximum urethral closing pressure, functional length and active urethral continence were carried out, together with Valsalva leak point pressure tests and a pressure/flow study. The obtained data were then analysed.

Results: Urinary continence was achieved in 132/180 men (73%) already to weeks after operation. Three months, six months and one year later the continence rate was 89%, 95.5% and 97.7% (176/180) respectively. As far as the urodynamic parameters of the 66 patients fully tested are concerned, all showed high results. The active urethral continence capacity exceeded 200 cm/water, and the Valsalva leak point pressure equalled or exceeded 150cm/water.

Conclusions: Following an accurate dissection of the distal urethra, bladder neck preservation guarantees early recovery of continence, as confirmed by local urodynamic figures, and restores functional integration of both the urethral sphincteric-smooth proximal and distal striated units. 

Stem cell markers aldehyde dehydrogenase type 1 and nestin expressions in renal cell cancer

Emin Ozbek, Gokhan Calik, Alper Otunctemur, Tamer Aliskan, Suleyman Cakir, Murat Dursun, Adnan Somay


Objectives: To identify stem cell markers aldehyde dehydrogenase type 1 (ALDH-1) and nestin expression in renal cell carcinoma (RCC).

Materials and methods: 95 RCC patients who had radical or partial nephrectomy were included in this study. Normal renal tissue samples of the same patients were designated as the control group. Paraffin blocks of RCC patients were studied immunohistochemically. Expressions were analyzed semiquantitively. Relation of tumor grade and stage with these expressions was determined. Results were calculated with Mann Whitney U and Kruskal Wallis tests.

Results: There were 55 male (57.8%) and 40 (42.2%) female patients in the study. Age and sex of the patients were not correlated with their antibody expressions (p > 0.05). ALDH-1 and nestin expression was higher in cancer tissues than normal tissues (p < 0.05). Nestin expression in renal cencer tissue was inversely related with tumor stage (p < 0.05) but there was no relation with Fuhrman grade. ALDH-1expression was correlated with tumor grade (p < 0.05) but not with tumor stage (p > 0.05).

Conclusions: ALDH-1and nestin expression have a role in RCC pathophysiology. There is a need to perform more studies about stem cell markers in RCC with more patients and in these future studies lymph node metastasis, distant organ metastasis and survival rates should be included.

Paediatric balanitis xerotica obliterans: An 8-year experience

Aza Mohammed, Igbal S. Shegil, Demetris Christou, Azhar Khan, Jayanta M. Barua


Objective: Balanitis Xerotica Obliterans (BXO) is rarely described in the paediatric population. We report our 8-year experience, at Harold Wood Hospital, with BXO in circumcised boys.

Materials and methods: Pathological tissue diagnoses of BXO from 1997 to 2005 were extracted from our histopathology database. Patient records were reviewed and demographic features, clinical presentation, referral history, operative procedure(s) and postoperative course were recorded.

Results: A total of 40 patients had a confirmed tissue diagnosis of BXO. Mean patient age was 9.6 years. The most common referral diagnoses were phimosis (70%), balanitis (25%) and only 2 patients (5%) had a referral diagnosis of BXO. 35 (87%) underwent curative circumcision and had no recurrence at a median follow-up of 13.5 months. A total of 5 patients (15%) had BXO involvement of the meatus and underwent circumcision combined with meatotomy or meatoplasty. No patients required extensive plastic operations of the penis.

Conclusions: The incidence of BXO in paediatric age group may be higher than previously reported. Early recognition of this condition is important because of the associated urethral stricture formation. Hence, we recommend that all circumcision specimens are sent for histopathological analysis (especially in areas where circumcision in widely practiced for ritual and religious reason) and patients should be followed up appropriately.

The prognostic role of preoperative Chromogranin A expression in prostate cancer after radical prostatectomy

Lorenzo Masieri, Michele Lanciotti, Paolo Gontero, Giansilvio Marchioro, Annalisa Mantella, Stefano Zaramella, Andrea Minervini, Alberto Lapini, Marco Carini, Sergio Serni


Purposes: The aim was to analyze the prognostic role of preoperative Chromogranin A (CgA) as a marker of poor prognosis and recurrence after radical prostatectomy (RP) and to find a correlation with the other well known prognostic variables.

Materials and Methods: This study comprises 306 patients with prostate cancer prospectively recruited who underwent RP from between 2000 and 2005. A blood sample for the determination of serum preoperative CgA value was obtained in all cases. Spearman correlation test was used to compare CgA to other variables, Kruskal-Wallis test to analyze CgA differences among ≥ 3 groups (PSA, GS, Stage), Mann-Whitney test for 2 grouping variables. Survival analysis was estimated by Kaplan-Meier method, log-rank test to estimate differences among the analyzed variables.

Results: Median CgA level was 68 ng/ml.Correlation between age and CgA levels was positive and statistically significant (p < 0.001). Patient were divided in 2 groups based on median age.The difference was statistically significant (p = 0.002). Comparison of CgA among patients grouped according to other variables and patient stratified on normal (123 ng/ml) and cut-off value (68 ng/ml) of CgA did not achieve significant risk stratification.

Conclusion: Studies on a possible prognostic role of CgA have provided conflicting results. In our series we found a significant positive correlation between CgA and age, but no significant statistical correlation with other available variables analyzed.

Does transrectal color Doppler ultrasound improve the diagnosis of prostate cancer?

Alessandro Del Rosso, Ezio Domenico Di Pierro, Stefano Masciovecchio, Giuseppe Paradiso Galatioto, Carlo Vicentini


Objective: To prospectively evaluate whether TRUS guided biopsy associated with Color Doppler (CD) imaging improves the detection of PCa.

Material and Methods: From January 2008 to December 2010, 144 subjects, with an increased PSA value or with a suspect digital rectal examination, were enrolled. Transrectal grey-scale Ultrasound (US) and CD examination were performed in all patients. CD US was considered positive or negative on the basis of the presence or absence of vascular abnormality. Prostate biopsy was performed immediately after grey-scale and Doppler evaluation, with a mean of 10 core-biopsy for each patient as well as a selective biopsy of all US abnormal areas (hypoechoic lesion or CD abnormality areas).

Results: PCa has been detected in 71 (49.3%) patients. 58 of the 71 patients had a hypoechoic area at US scan and 27 had a CD abnormality. The PSA value was < 4 ng/ml in 11 patients (Group 1), in 63 patients PSA ranged between 4 and 10 ng/ml (Group 2) and in 70 patients PSA was greater than 10 ng/ml (Group 3). The detection rate was 36.7, 36.5 and 62.8% respectively. In Group 1 we detected 5 hypoechoic areas and 4 CD abnormal areas. Moreover 6 of 11 patients had a positive DRE. In the Group 2, 20 patients were positive to DRE; we visualized 21 hypoechoic areas and 7 CD abnormality. In the Group 3, 38 patients had a positive DRE, with 32 hypoechoic areas and 16 CD abnormalities found. We obtained 1537 total bioptic cores, 1440 randomly from peripheral gland, 70 from hypoechoic areas and 27 from abnormal CD flow areas. The detection rate was 17.1, 65.7 and 22.2% respectively.

Conclusion: CD US showed to be a complement to grey-scale imaging of prostate unless insufficiently sensitive to replace the standard systematic 8-12 core random peripherally biopsy. Furthermore it should be associated routinely to TRUS to easily focus suspect areas.

Comparative study of seminal parameters between samples collected in 1992 and samples collected in 2010

Jlenia Elia, Norina Imbrogno, Michele Delfino, Tiziana Rossi, Rossella Mazzilli, Italo Nofroni, Vincenzo Toscano, Fernando Mazzilli


Objective: The aim of this study was to conduct a comparative study of semen quality in two large populations; one evaluated in 1992 and another in 2010, in order to evaluate any possible decline in male fertility due, at least in part, to environmental factors.

Material and Methods: A total of 701 subjects in 1992 (TOTAL group 1992) and a total of 626 subjects in 2010 (TOTAL group 2010) were enrolled in our Andrology Unit. Each group was subdivided into 3 subgroups: Subfertile, Pathology and Control.

Standard semen analysis was performed using the Superimposed Image Analysis System, according to WHO guidelines 1987 (for TOTAL group 1992) and WHO guidelines 1999 (for TOTAL group 2010).

Results: The mean values of sperm number (concentration/ml as well as the total ejaculate) and progressive motility were significantly higher in TOTAL group 2010 than TOTAL group 1992. Atypical forms in TOTAL group 1992 semen samples were significantly lower than TOTAL group 2010. The mean age of TOTAL Group 2010 was significantly higher compared with TOTAL Group 1992. In particular, the mean age gap was more evident in Subfertile subjects.

Conclusions: In conclusion, environmental factors have not determined a significant decline in seminal parameters in the past 18 years.

Does Ki-67 staining improve quantitative histology in preoperative prostate cancer staging?

Pietro Pepe, Filippo Fraggetta, Giuseppe Candiano, Francesco Aragona


To evaluate accuracy of Ki-67 expression on biopsy specimens in comparison with quantitative histology findings for preoperative prostate cancer (PCa) staging. From January 2008 to January 2010, 126 patients (median age 63 years) underwent radical retropubic prostatectomy; median PSA was 9.1 ng/mL; 98 and 28 patients had a clinical stage T1c and T2, respectively. The following variables of quantitative histology were evaluated as predictive of non organ-confined (OC) PCa: Gleason score > 6, TPC > 20%, GPC > 50%, cancer-positive cores > 2, presence of cancer-positive cores in both lateral margins and bilateral PCa. Value of Ki-67 % staining in all cancerous cores was calculated. Sixty (47.7%) patients had a non OC-PCa with positive nodes in 12 (20%) cases. The mean Ki-67 score was 4.4%: 3.7% in OC-PCa and 5.6% in non-OC-PCa, respectively. Predictive positive value (PPV) of quantitative histology, Ki-67 (cut-off > 5%) and both parameters to predict a non-OC-PCa vs an OC-PCa was equal to 90%, 40% and 93.4%, vs 36.6%, 78.8% and 78.8%, respectively.

Ki-67 staining on biopsy specimens does not improve quantitative histology in predicting non-OC-PCa; moreover, the low expression of Ki-67, even in presence of advanced disease, decreases its prognostic value in predicting an OC-PCa.

Development of a rapid food screener to assess the potential renal acid load of diet in renal stone formers (LAKE score)

Alberto Trinchieri

Aim of the study: The potential renal acid load of foods (PRAL) has been proposed as a causative factor of renal stone formation in patients with calcium stones. Evaluation of the dietary PRAL seems to be advisable to evaluate the lithogenic potential of the diet of the individual patient.

Materials and Methods: On the basis of a dietary questionnaire administered to a sample of 75 renal stone formers living in the urban area of Milan (Northern Italy), we selected the most frequently reported foods for each of 11 categories: grains, meats, cured meats, eggs, cheeses, legumes, potatoes, vegetables, fruit and juices, milk and dairies and bread. The PRAL per 100 g of each food was calculated considering its mineral and protein composition, the mean intestinal absorption rate for each nutrient and the metabolism of sulfur-containing amino acids.The PRAL/100 g of each main food category was then calculated considering the frequency of the most represented (up to six) foods in the respective food group and the PRAL/100 g of each food. Subsequently the PRAL/100 g value for each main food category was adjusted for the standard serving size. Finally, according to the value of the adjusted PRAL value a score was assigned to each group of foods and named as LAKE (Load of Acid to Kidney Evaluation) score.

Results: The scores computed for grains, meats, cured meats, eggs, cheeses, legumes,potatoes, vegetables, fruit & juices, milk & dairies and bread were +2, +10, +6, +4, +10, -2, -10, -10, -10, +1 and +1, respectively. Two report forms were designed to allow a rapid collection of data about the intake of each food group.Time requested for filling the forms and to compute scores ranges from 2 to 4 minutes (report forms can be requested to Questo indirizzo e-mail è protetto dallo spam bot. Abilita Javascript per vederlo. ).

Conclusion: LAKE score can be an useful and simple tool in order to evaluate the dietary PRAL and to suggest modifications to achieve its reduction for the prevention of calcium nephrolithiasis and other diseases.

An innovative combined antero-retrograde approach for the resolution of the complete iatrogenic obliteration of ureteral ostium: A case report

Stefano Masciovecchio, Giuseppe Paradiso Galatioto, Pietro Saldutto, Alessandro Del Rosso, Ezio Domenico Di Pierro, Elona Toska, Vikiela Galica, Carlo Vicentini


In selected cases of endoscopic surgery of bladder cancer, in order to reach an oncologic radicality, the resection of the ureteral ostium affected by the disease is requested. Although infrequent, a possible complication of this manoeuvre is represented by the complete obliteration of theresected ostium. Literature suggests that the traditional “open” surgery and the latest “laparoscopic” surgery are effective in the resolution of this complication, in contrast with the techniques of endourological and uro-interventional radiology which, although minimally invasive, do not appear to be completely appropriate in the treatment of this condition. We believe that an innovative, minimally invasive anterograde trans-nephrostomic and retrograde endoscopic combined approach can be decisive in restoring complete patency of the neo-ostium.

Amelanotic malignant melanoma of the penis. A case report and literature review

Eran Rosenberg, Amir Horev, Endre Z. Neulander


Malignant melanoma (MM) of the penis represents an uncommon form of genitourinary malignancies, which account for about 1% of all cases of melanoma. Amelanotic malignant melanoma (AMM) lacks the pigmented elements, which is the hallmark of melanoma. This is a challenging diagnosis since confusion might be made with a variety of benign lesions, causing a delay in appropriate medical treatment. Taking into consideration that prognosis is the same for melanotic and amelanotic melanoma, early diagnosis is crucial. We describe a patient with amelanotic melanoma of the penis, treated with partial penectomy.

Disorders of bladder depletion in a young man because of a prostatic cyst: Case report

Lucio Dell’Atti

Symptomatic prostatic cysts presenting with recurrent urinary tract infections and urinary obstructive disorders in young men may be misdiagnosed as benign prostatic hyperplasia, urethral stenosis or neuropathic bladder.

We report a case of a 28 year old young man with obstructive and irritative voiding disorders caused by a prostatic cyst, located in the anterior and left lateral lobe of the prostate gland. The cyst appeared to obstruct the bladder outlet by a “ball-valve” mechanism. The prostatic cyst was incised and marsupialized by transurethral resection. At post-operative follow up we observed an increase in Qmax with no residual urine and negative urine culture. The patient showed no retrograde ejaculation nor erectile dysfunction.