Search

Context: Pharmacological thromboprophylaxis involves a trade-off between a reduction in venous thromboembolism (VTE) and increased bleeding. No guidance specific for procedure and patient factors exists in urology., Objective: To inform estimates of absolute risk of symptomatic VTE and bleeding requiring reoperation in urological non-cancer surgery., Evidence Acquisition: We searched for contemporary observational studies and estimated the risk of symptomatic VTE or bleeding requiring reoperation in the 4 wk after urological surgery. We used the GRADE approach to assess the quality of the evidence., Evidence Synthesis: The 37 eligible studies reported on 11 urological non-cancer procedures. The duration of prophylaxis varied widely both within and between procedures; for example, the median was 12.3 d (interquartile range [IQR] 3.1-55) for open recipient nephrectomy (kidney transplantation) studies and 1 d (IQR 0-1.3) for percutaneous nephrolithotomy, open prolapse surgery, and reconstructive pelvic surgery studies. Studies of open recipient nephrectomy reported the highest risks of VTE and bleeding (1.8-7.4% depending on patient characteristics and 2.4% for bleeding). The risk of VTE was low for 8/11 procedures (0.2-0.7% for patients with low/medium risk; 0.8-1.4% for high risk) and the risk of bleeding was low for 6/7 procedures (≤0.5%; no bleeding estimates for 4 procedures). The quality of the evidence supporting these estimates was low or very low., Conclusions: Although inferences are limited owing to low-quality evidence, our results suggest that extended prophylaxis is warranted for some procedures (eg, kidney transplantation procedures in high-risk patients) but not others (transurethral resection of the prostate and reconstructive female pelvic surgery in low-risk patients)., Patient Summary: The best evidence suggests that the benefits of blood-thinning drugs to prevent clots after surgery outweigh the risks of bleeding in some procedures (such as kidney transplantation procedures in patients at high risk of clots) but not others (such as prostate surgery in patients at low risk of clots)., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Context: Pharmacological thromboprophylaxis involves balancing a lower risk of venous thromboembolism (VTE) against a higher risk of bleeding, a trade-off that critically depends on the risks of VTE and bleeding in the absence of prophylaxis (baseline risk)., Objective: To provide estimates of the baseline risk of symptomatic VTE and bleeding requiring reoperation in urological cancer surgery., Evidence Acquisition: We identified contemporary observational studies reporting symptomatic VTE or bleeding after urological procedures. We used studies with the lowest risk of bias and accounted for use of thromboprophylaxis and length of follow-up to derive best estimates of the baseline risks within 4 wk of surgery. We used the GRADE approach to assess the quality of the evidence., Evidence Synthesis: We included 71 studies reporting on 14 urological cancer procedures. The quality of the evidence was generally moderate for prostatectomy and cystectomy, and low or very low for other procedures. The duration of thromboprophylaxis was highly variable. The risk of VTE in cystectomies was high (2.6-11.6% across risk groups) whereas the risk of bleeding was low (0.3%). The risk of VTE in prostatectomies varied by procedure, from 0.2-0.9% in robotic prostatectomy without pelvic lymph node dissection (PLND) to 3.9-15.7% in open prostatectomy with extended PLND. The risk of bleeding was 0.1-1.0%. The risk of VTE following renal procedures was 0.7-2.9% for low-risk patients and 2.6-11.6% for high-risk patients; the risk of bleeding was 0.1-2.0%., Conclusions: Extended thromboprophylaxis is warranted in some procedures (eg, open and robotic cystectomy) but not others (eg, robotic prostatectomy without PLND in low-risk patients). For "close call" procedures, decisions will depend on values and preferences with regard to VTE and bleeding., Patient Summary: Clinicians often give blood thinners to patients to prevent blood clots after surgery for urological cancer. Unfortunately, blood thinners also increase bleeding. This study provides information on the risk of clots and bleeding that is crucial in deciding for or against giving blood thinners., (Copyright © 2017 European Association of Urology. Published by Elsevier B.V. All rights reserved.)

Currently, radical cystectomy associated with pelvic lymph node dissection is the gold standard surgical treatment for muscle invasive bladder cancer. However, although there is consensus on the need for pelvic lymph node dissection, controversies still exist regarding its extent and exact role. Evidence from the literature is based on retrospective data from high volume, often multicentre studies. Different series report very different templates of lymphadenectomy, thereby complicating data analysis. Furthermore, morbidity related to lymphadenectomy does not seem to be influenced by the extent of the procedure. The role of the pathologist and the modality of node retrieval have a pivotal role in the quality of node assessment. Different prognostic factors regarding node status (number of nodes retrieved, lymphovascular invasion, lymph node density, extracapsular extension, gross node involvement, and extent of primary bladder tumour related to positive nodes) have been introduced and analysed, although the impact on staging and survival are still under investigation. The correct use and assessment of these prognostic factors should help to provide an accurate staging in order to identify those patients who need adjuvant therapy. Future studies should, therefore, be prospective and include all information achievable from a lymphadenectomy., (Copyright © 2009 Elsevier Ltd. All rights reserved.)

Context: Holmium laser enucleation of the prostate (HoLEP) and 532-nm laser vaporisation of the prostate (with potassium titanyl phosphate [KTP] or lithium borate [LBO]) are promising alternatives to transurethral resection of the prostate (TURP) and open prostatectomy (OP)., Objective: To assess safety, efficacy, and durability by analysing the most recent evidence of both techniques, aiming to identify advantages, pitfalls, and unresolved issues., Evidence Acquisition: A Medline search of recently published data (2006-2008) regarding both techniques over the last 2 yr (January 2006 to September 2008) was performed using evidence obtained from randomised trials (level of evidence: 1b), well-designed controlled studies without randomisation (level of evidence: 2a), individual cohort studies (level of evidence: 2b), individual case control studies (level of evidence: 3), and case series (level of evidence: 4)., Evidence Synthesis: In the last 2 yr, several case-control and cohort studies have demonstrated reproducibility, safety, and efficacy of HoLEP and 80-W KTP laser vaporisation. Four randomised controlled trials (RCTs) were available for HoLEP, two compared with TURP and two compared with OP, with follow-up >24 mo. Results confirmed general efficacy and durability of HoLEP, as compared with both standard techniques. Only two RCTs were available comparing KTP laser vaporisation with TURP with short-term follow-up, and only one RCT was available comparing KTP laser vaporisation with OP. The results confirmed the overall low perioperative morbidity of KTP laser vaporisation, although efficacy was comparable to TURP in the short term, despite a higher reoperation rate., Conclusions: Although they are at different points of maturation, KTP or LBO laser vaporisation and HoLEP are promising alternatives to both TURP and OP. Sufficient data proves HoLEP's durability for most prostate sizes at long-term follow-up; KTP laser vaporisation needs further evaluation to define the reoperation rate. Increasing the number of quality prospective RCTs with adequate follow-up is mandatory to tailor each technique to the right patient.

Objectives: To evaluate the feasibility and safety of nerve-sparing radical retropubic prostatectomy (NSRRP) for localised prostate cancer after holmium laser enucleation of the prostate (HoLEP) for bladder outlet obstruction due to benign prostatic enlargement (BPE)., Methods: Fifteen consecutive patients with prostate cancer following HoLEP underwent NSRRP. They were matched with an equal number of patients who also underwent NSRRP following transurethral resection of the prostate (TURP group) or open prostatectomy (OP group). Patients were preoperatively assessed with validated questionnaires (International Prostate Symptom Score [IPSS] and International Index of Erectile Function-Erectile Function [IIEF-EF]). Intraoperative, perioperative, and follow-up functional data according to validated questionnaires (IPSS, IIEF-EF, International Consultation on Incontinence Questionnaire-Short Form [ICIQ-SF]) were evaluated with analysis of variance and chi2 tests., Results: At diagnosis, the prostate-specific antigen (PSA) level, clinical stage, Gleason sum distributions, body mass index, ICIQ-SF, and IPSS were not significantly different among the groups. IIEF-EF scores was higher in the HoLEP group (p=0.02). Mean operative time was longer in the OP group (p=0.02), but no difference was found in mean blood loss (p=0.5). Final pathology showed no substantial differences among the groups, although a lower positive surgical margin rate was found in the HoLEP group (p=0.04). Mean follow-up was 23.8+/-10.5 mo. The groups showed no statistical differences in urinary continence rate (p=0.6), IPSS (p=0.3), or IIEF-EF (p=0.4)., Conclusions: NSRRP is feasible in prostate cancer patients who previously underwent HoLEP for BPE and provides satisfactory functional outcomes.

Objectives: Radical nephrocapsulectomy and cavoatrial thrombectomy with median sternotomy and abdominal access, using extracorporeal circulation (ECC) and deep hypothermic circulatory arrest (DHCA), has become the gold standard treatment for renal cell carcinoma (RCC) with neoplastic thrombosis of the suprahepatic and intrapericardial inferior vena cava (IVC) and right atrium (RA). Any modification of surgical techniques should be compared with this therapeutic strategy., Methods: In our quest to identify a minimally invasive approach and to apply available technology to ensure patient safety, even in cases of RCC with suprahepatic IVC and RA thrombosis, we identified a therapeutic approach that foresees en bloc radical nephrocapsulectomy, with ECC and DHCA in right anterior minithoracotomy. Furthermore, to make surgery even safer, we made some modifications and used auxiliary maneuvers. We present the case of a 39-year-old man with a neoplasm that involved the right kidney and suprahepatic IVC thrombosis, undergoing radical nephrocapsulectomy and thrombectomy with ECC and DHCA in right anterior minithoracotomy., Conclusions: Radical nephrocapsulectomy and thrombectomy of the suprahepatic and intrapericardial IVC and/or of the RA with ECC and DHCA in right anterior minithoracotomy for RCC is a valid minimally invasive alternative to standard surgical techniques. Compared with standard median sternotomy access, right anterior minithoracotomy allows a more rapid functional recovery, a reduction in risk of infection of the wound, and a reduction in pain during postoperative convalescence, and has considerable esthetic advantages, without limiting surgical therapeutic chances, regardless of the cranial extension of the thrombus.

Objectives: A prospective study to assess safety, efficacy, and medium-term durability of holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of bladder outlet obstruction (BOO) due to benign prostate enlargement (BPE)., Methods: Between January 2000 and July 2003, 330 consecutive patients underwent HoLEP at our institution. All patients were pre-operatively assessed with transrectal ultrasound gland volume evaluation, maximum urinary flow rate (Q(max)), international prostate symptoms score (IPSS), and the single-question quality of life (QoL). Intra-, peri-, and postoperative parameters were evaluated and the patients were reassessed at 1-, 3-, 6-, 12-, 18-, 24-, and 36-mo follow-up with the same examinations., Results: Patients' mean age was 66+/-8.1 yr; prostate volume was 62+/-34 cc. Enucleation time was 45.4+/-22.9 min and morcellation time 17.3+/-14 min, whilst resected weight was 40+/-27.5 g. Catheter time was 23+/-14.7h and hospital stay was 48+/-26 h. Mean serum hemoglobin and sodium did not drop significantly from baseline after the procedure (p=013). A significant improvement occurred in Q(max) (25.1+/-10.7 ml/s), IPSS (0.7+/-1.3), and QoL (0.2+/-0.5) at the 3-yr follow-up compared with baseline (p<0.05). Twenty-eight percent of patients complained of irritative urinary symptoms, typically self-limiting after 3 mo; transient stress incontinence was reported in 7.3% of patients. Nine patients (2.7%) had persistent BOO, requiring reoperation., Conclusions: HoLEP represents an effective and safe surgical intervention. The relief from BOO also proved to be durable after 3-yr follow-up. The present report adds to the evidence that HoLEP could be the standard "size-independent" surgical treatment for symptomatic BPE-related BOO.

Mixed epithelial and stromal tumor of the kidney is a recently recognized category of lesions occurring mostly in adult, middle-age women with a history of hormonal treatment. We present a rare case of a 58-year-old asymptomatic man without a history of hormonal treatment with a tumor characterized by proliferation of multiple cysts lined by single layers of epithelial cells and hypercellular stroma of spindle "ovarian-like" cells. Immunohistochemically, the stromal cells reacted against estrogen and progesterone receptors, vimentin, desmin, and CD34. A follow-up computed tomography scan performed 8 months after surgical enucleation of the lesion showed no signs of recurrence.

Objectives: To assess overall safety, histopathological outcomes, and early functional results after robotic-assisted laparoscopic radical prostatectomy (RALP) with a new lateral approach for the interfascial dissection of the neurovascular bundles without tension and any use of electrocautery., Methods: Between April and September 2006, 100 consecutive patients with organ-confined prostate cancer (age < 70 yr, PSA < or = 10 microg/dl, Gleason score < or = 7, and IIEF > or = 17) underwent RALP by the same senior surgeon. Pre-, intra-, and perioperative data were recorded. The operative technique is described step by step. Patients were assessed at the 4-mo follow-up., Results: RALP was successfully completed in all patients. Neither blood transfusions nor reintervention were necessary. One week following catheter removal, complete early urinary continence was achieved in 80% of patients, and spontaneous erections or penile tumescence was reported by 46 patients. Positive surgical margins were 12.1% in the pT2 group and 29% in the pT3 group. Ninety-three patients were available for analysis at the 4-mo follow-up. Of them, 92.4% were completely continent, 5.4% used 1 pad a day, and 2.2% used 2 or more pads a day. Concerning the IIEF-EF domain score, 64.5% of the patients reported a total score > or = 17, and 17.2% of them scored > or = 26., Conclusions: The novel approach described for RALP is safe and allows excellent dissection. It maintains good margin status and provides encouraging early continence and erectile functional results in selected patients. Long-term follow-up is necessary to assess the impact of this approach on oncological outcome., (European Association of Urology)

Objective: Prospectively evaluate perioperative outcomes and 2-yr follow-up after holmium laser enucleation (HoLEP) and standard open prostatectomy (OP) for treating benign prostatic hyperplasia-related obstructed voiding symptoms, with prostates >70 g., Methods: From March 2003 to December 2004, 80 consecutive patients were randomised for surgical treatment with HoLEP (n=41) or standard OP (n=39). All patients were preoperatively assessed with International Prostate Symptom Score and International Index of Erectile Function questionnaires and complete urodynamic evaluation. Intraoperative and perioperative parameters such as blood loss, catheter removal, and hospital stays were assessed. Early and late complications were recorded. Patients were evaluated at 1-, 3-, 12-, and 24-mo follow-ups with the same tests., Results: Operating room time was significantly shorter for the OP group (72.09+/-21.22 min vs. 58.31+/-11.95 min, p<0.0001); catheter removal (1.5+/-1.07 d and 4.1+/-0.5 d, p<0.001) and hospital stay (2.7+/-1.1 d vs. 5.4+/-1.05 d, p<0.001) were shorter in the HoLEP group. Blood loss was less and blood transfusions fewer in the HoLEP group (p<0.001). In both groups urodynamic and uroflowmetry findings improved from baseline, were still evident at the 24-mo follow-up, and were comparable between the two groups. Late complications were also comparable., Conclusions: HoLEP is a feasible technique for treating large prostates. Functional results are similar to OP at the 2-yr follow-up. Reduced catheterisation, hospital stay, and blood loss make HoLEP an attractive option for the treatment of large prostates.

Objectives: To assess the baseline erectile function (EF) of patients with clinically localized prostate cancer (pCa), who are candidates for a bilateral nerve-sparing radical retropubic prostatectomy (BNSRRP) to (a) objectively rate the preoperative self-reported subjective patient's EF and (b) investigate possible correlations between preoperative EF and demographic data and comorbidities., Materials and Methods: Two-hundred-thirty-four patients, who verbally self-reported they were preoperatively fully potent and strongly motivated to maintain postoperative EF, underwent a BNSRRP. A comprehensive medical and sexual history was obtained on hospital admission the day prior to surgery. Subjectively reported potency rate was compared with the scores of the International Index of Erectile Function (IIEF)., Results: The EF domain of the IIEF showed a baseline normal EF in only 43% of the subjects. In contrast, 13% had a mild erectile dysfunction (ED), 8% had a mild to moderate ED, 8% complained of a moderate ED, and as many as 28% reported severe EF impairment. Interestingly, 38% of the patients with severe ED did not attempt any intercourse during the last 4 weeks prior to surgery., Conclusions: A significant proportion of patients with clinically localized pCa and self-reported total potency already had suffered from ED preoperatively. Incorrect timing of questionnaires administration, the potential influence of preoperative patient's psychological distress, and the implication of the patient's partner's psychological and sexual health may be contributing factors to the contradictory finding. The preoperative use of validated questionnaire may help to identify patients who can actually expect to regain potency following a BNSRRP.

Objectives: To compare the cost of open transvesical prostatectomy (OP) with that of holmium laser enucleation (HoLEP) in the treatment of bladder outlet obstruction (BOO) attributed to benign prostatic hyperplasia., Methods: From February to May 2004, 63 consecutive patients with symptomatic benign prostatic hyperplasia in a large prostate (70 to 220 g) and documented BOO were randomized to surgical treatment with OP (29 in group 1) or HoLEP (34 in group 2). All costs associated with the procedures during the hospital stay were recorded prospectively, and a cost-effectiveness analysis of the critical perioperative (ie, intraoperative and postoperative to hospital discharge) data was performed., Results: The cost analysis showed a mean perioperative cost of 2868.9 euros (3556.3 dollars) for group 1 and 2356.5 euros (2919.4 dollars) for group 2. A direct comparison analysis showed that the most significant cost factors were the operative time (average 16.1% and 25.1% to the cost of OP and HoLEP, respectively), operating room surgical setup/disposables, including laser fiber and resectoscope loop in group 2 (average 13.3% and 29.3% to the cost of OP and HoLEP, respectively), and length of postoperative hospital stay (average 53.3% and 32.0% to the cost of OP and HoLEP, respectively). Overall, the hospitalization cost of HoLEP was 9.6% less than that for OP., Conclusions: Our data have demonstrated that HoLEP is associated with a significant hospital net cost savings compared with OP in patients undergoing surgery for symptomatic benign prostatic hyperplasia in large glands.

Objectives: To prospectively compare intra- and peri-operative outcomes of open radical retropubic prostatectomy (RRP) and laparoscopic prostatectomy (LRP) by a single surgeon., Patients and Methods: One-hundred-twenty, consecutive, age-matched patients diagnosed with clinically localized prostate cancer were eligible for surgery. Sixty patients underwent RRP and 60, LRP. Intra- and peri-operative parameters, pathologic findings and early complications were recorded. A validated visual analogue scale was used to assess pain in the recovery room, 3 h after the operation and on post-operative days 1, 2 and 3. A cystogram was performed on post-operative day 5., Results: Operating time was significantly shorter in the RRP group versus the LRP group (mean+/-SD, 170+/-34. 2 vs 235+/-49.9 min, p<0.001). Blood loss was significantly less in the LRP group versus the RRP group (mean+/-SD, 853.3+/-485 vs 257.3+/-177 ml, p<0.001), but no patient in either group underwent early re-intervention for bleeding. The RRP group showed a trend for higher use of analgesia. A watertight anastomosis was shown at cystourethrography and the catheter removed in 86% and 66% of LRP and RRP patients, respectively. The overall percentage of post-operative complications and positive margins were comparable., Conclusion: Laparoscopic prostatectomy is an attractive alternative to open prostatectomy, offering the advantages of reduced blood loss and safe early catheter removal. Furthermore, the laparoscopic procedure proved to be safe oncologically. Long-term follow-up is required to compare functional results in terms of continence and potency.

Objectives: To compare urodynamic findings after holmium laser enucleation of the prostate (HoLEP) and transurethral resection of the prostate (TURP) for the treatment of benign prostatic hyperplasia-related bladder outlet obstruction., Methods: From January to October 2002, 100 consecutive patients with benign prostatic hyperplasia with obstructive lower urinary tract symptoms were randomized to surgical treatment with either HoLEP (group 1, n = 52) or TURP (group 2, n = 48). All patients were preoperatively assessed using the International Prostate Symptom Score and quality-of-life question, total serum prostate-specific antigen measurement, transrectal ultrasonography, and complete urodynamic study. The operative time, catheterization time, and overall hospital stay were also recorded for both groups. All patients were assessed at 1, 6, and 12 months postoperatively using a complete urodynamic evaluation., Results: All patients were obstructed preoperatively (Schäfer grade greater than 2). Both groups were comparable in terms of age, total serum prostate-specific antigen level, International Prostate Symptom Score, and urodynamic results. At 1, 6, and 12 months of follow-up, no statistically significant differences were recorded in terms of detrussor pressure at maximal urinary flow rate, Schäfer grade (linear passive urethral resistance relation), maximal urinary flow rate, International Prostate Symptom Score, and quality-of-life score. In the HoLEP group, the catheterization time and hospital stay were significantly shorter. Transitory lower urinary tract symptoms after 3 months of follow-up and dysuria were more frequent in the HoLEP group than in the TURP group, although at 12 months of follow-up, the results were comparable., Conclusions: Both HoLEP and TURP were equally effective in relieving bladder outlet obstruction. Although associated with greater early self-resolving irritative symptoms, HoLEP can guarantee a shorter catheterization time and hospital stay with longer operative times, proposing itself as an attractive alternative to standard TURP.

We present the case of a 44-year old man, presenting with acute left flank pain and gross haematuria, affected by bilateral renal mass and massive para-aortic and mediastinic lymphadenopathy, highly suspicious for metastatic renal cancer.

Objective: To compare the outcomes of dorsal onlay graft urethroplasty using penile skin (PS) or buccal mucosa (BM) free grafts in the repair of adult bulbourethral strictures., Methods: From January 1998 to March 2003, 30 patients with bulbar urethral strictures underwent urethral reconstruction with PS (17) or with BM free graft (13). Follow-up was done at 6, 12 and 18 months postoperatively, and every year subsequently. Success was defined as normalization of IPSS and a stable Q(max) value >20 ml/s. Any further instrumentation for stricture recurrence was considered a failure., Results: Mean follow-up was 51 months (20-74). The overall success rate was 80% (85% in the BM and 76% in the PS group). Improvement of uroflowmetry, IPSS and QoL did not show a significant difference between the two groups. A significant improvement of the orgasmic function domain of the IIEF was found in patients treated with a PS graft. Post-operative complications were lip hypoesthesia (30%), retraction of the ventral skin of the penis (7%), post-voiding dribbling (8% with BM graft, and 7%, with PS graft). Six patients, 2 with BM (15%) and 4 with PS graft patch (24%) required further treatment due to stricture recurrence., Conclusion: Results of PS or BM graft are comparable at 18 month follow-up, although orgasmic function is significantly improved in patients receiving a PS graft. Nevertheless, with extended follow-up, the use of PS seems to be associated with a higher failure rate.

Objectives: To describe a technique for open nerve-sparing radical retropubic prostatectomy., Methods: The technique basically implies incising the levator and prostatic fasciae high anteriorly (1 and 11 o'clock positions) over the prostate, developing the plane between the prostatic capsule and prostatic fascia, and displacing the neurovascular network localized between the two fasciae laterally. This allows for a minimal-touch dissection of the external urethral sphincter and a very efficient dissection of the neurovascular bundles at the level of membranous urethra and prostatic apex., Results: Forty-two patients underwent a bilateral nerve-sparing operation and were followed- up for 6 months. Six patients (14.3%) had positive margins: 4 patients had pT2 disease (in all, the positive margin was monofocal) and 2 patients had pT3 disease (both had multifocal positive margins). Continence (defined as being dry or having one pad remain dry for 24 hours) was achieved in 44% of patients at catheter removal, and in 60%, 72%, and 90% of patients at the 1-, 3-, and 6-month follow-up visits. Potency (defined as an erectile function domain score > or =26) was obtained in 15%, 40%, and 52% of patients at the 1-, 3-, and 6-month follow-up visits. All patients used a PDE5-inhibitor during the investigation period., Conclusions: These preliminary results suggest that the high incision of the levator and prostatic fasciae may facilitate efficient preservation of the external urethral sphincter and the neurovascular bundles innervating the corpora cavernosa and the sphincter.

Objective: To compare the effects of sildenafil and sublingual (sl) apomorphine on nocturnal erections., Methods: In a prospective, single-blinded, placebo-controlled at-home study we compared the effect of apomorphine sl and sildenafil on sleep-related erectile activity in 30 healthy potent volunteers (mean age, 26.4 years; range, 23-35 years; Erectile Function domain of the International Index of Erectile Function > or =26), not reporting any subjective sleep abnormality during 4 consecutive nights with rigidity monitoring (NPTR) with the RigiScantrade mark device. After the first night of adaptation, they were randomized to receive placebo or apomorphine sl 2mg or sildenafil 50mg taken at bedtime during the following 3 consecutive nights., Results: Sildenafil increased the mean+/-SE number of erections, overall length of erectile events, and the time of erections with rigidity >60% at both tip and base, as compared to placebo. The same parameters were reduced after administration of apomorphine sl. Similar findings were observed with regards to Rigidity Activity Units and Tumescence Activity Units., Conclusions: Our results confirm that sildenafil taken at bedtime might increase nocturnal erectile activity also in young potent men as compared to placebo. Apomorphine sl taken at bedtime seems to have the opposite effect.

Introduction: Superficial bladder cancer can be treated by transurethral resection (TUR) and adjuvant intravesical therapy. Intravesical bacillus Calmette-Guérin (BCG) has been proven to be more efficacious with respect to recurrence prevention than intravesical chemotherapy, although at the cost of more severe side effects. There is a need for a new treatment modality with higher efficacy and less toxicity. The subject of this study is the efficacy of local microwave hyperthermia and chemotherapy treatment in intermediate or high risk superficial transitional cell carcinoma (TCC) of the bladder., Patients and Methods: Ninety eligible patients received adjuvant treatment with a combination of mitomycin-C (MMC) and local microwave hyperthermia. All patients had multiple or recurrent Ta or T1 TCC of the bladder and were classified as intermediate or high risk according to EAU criteria. In total, 41 patients were BCG failures. The treatment regimen included 6 to 8 weekly sessions followed by 4 to 6 monthly sessions. Follow-up consisted of video-cystoscopy and urine cytology every 3 months. All patients were observed for 2 years., Results: Kaplan-Meier analyses of the total group (N = 90) indicated that 1 year after treatment only 14.3% (SE 4.5%) of all patients experienced a recurrence. After 2 years of follow-up the risk of recurrence was 24.6% (SE 5.9%). No progression in stage and grade was observed., Conclusion: Microwave induced hyperthermia combined with MMC has promising value in intermediate or high risk superficial bladder cancer patients compared to literature data of BCG and/or intravesical chemotherapy, particularly where other treatments, i.e. BCG, have failed., (Copyright 2004 Elsevier B.V.)

Objectives: To evaluate the impact of general anesthesia (GA) versus spinal anesthesia (SpA) on intraoperative and postoperative outcome in patients undergoing radical retropubic prostatectomy., Methods: Seventy-two consecutive patients with clinically localized prostate cancer were randomized into group 1 (GA: 34 patients) or group 2 (L2-L3 or L3-L4 SpA: 38 patients) and underwent radical retropubic prostatectomy. The intraoperative and postoperative anesthetic and surgical variables were evaluated., Results: The mean +/- SEM operative time was not significantly different between the two groups (P = 0.43). The overall blood loss was less in group 2 (P = 0.04). The mean +/- SEM postoperative time in the postoperative holding area was significantly shorter after SpA than after GA (P <0.0001). The perioperative pain outcome in the postoperative holding area was significantly better for group 2 than for group 1 (P = 0.0017), but postoperative pain on day 1 was not significantly different between the two groups. The postoperative sedation score was significantly less in group 2 than in group 1 (P <0.0001). On day 1, first flatus passed in a significantly larger number of patients in group 2 (P <0.0001), and the overall gait was greater for group 2 patients (P = 0.02)., Conclusions: These results suggest that SpA allows good muscle relaxation and a successful surgical outcome in patients undergoing radical retropubic prostatectomy with pelvic lymphadenectomy for clinically localized prostate cancer. Moreover, SpA results in less intraoperative blood loss, less postoperative pain, and a faster postoperative recovery than GA.

Objectives: To evaluate the effectiveness of combined local bladder hyperthermia and intravesical chemotherapy for the treatment of patients with high-grade (G3) superficial bladder cancer., Methods: Patients with G3 bladder tumors (Stage Ta or T1) were treated with combined intravesical chemotherapy with mitomycin-C and local radiofrequency hyperthermia of the bladder wall. The patients were treated with either a prophylactic protocol (40 mg mitomycin-C) after complete transurethral resection of all tumors or with an ablative protocol (80 mg mitomycin-C) when visible tumor was seen on video-cystoscopy or bladder biopsies were positive for carcinoma in situ., Results: Combined chemo-thermotherapy was administered to 52 patients with high-grade superficial bladder cancer (40 patients with Stage T1 tumor, 11 with Ta, and 3 with concomitant or isolated carcinoma in situ). At a median follow-up of 15.2 months (mean 23, range 6 to 90), no stage progression to T2 or disease-related mortality had occurred. The bladder preservation rate was 86.5%. The prophylactic protocol was administered to 24 patients. After a mean follow-up of 35.3 months, 15 patients (62.5%) were recurrence free. The bladder preservation rate was 95.8%. The ablative protocol was administered to 28 patients. Complete ablation of the tumor was accomplished in 21 patients (75%). After a mean follow-up of 20 months, 80.9% of these patients were recurrence free. The bladder preservation rate for the ablative group was 78.6%., Conclusions: Combined local bladder hyperthermia and intravesical chemotherapy has a beneficial prophylactic effect in patients with G3 superficial bladder cancer. Ablation of high-grade bladder tumors is feasible, achieving a complete response in about three quarters of the patients.

Primary neuroendocrine tumors of the prostate are very rare and their biologic behaviour is not yet well known. Clinical and histopathologic features of two cases, one with lymph-node involvement and one organ-confined are described. Young age, clinical presentation and good outcome after radical retropubic prostatectomy were comparable in both patients.