Clinical understaging in patients with prostate adenocarcinoma submitted to radical prostatectomy: predictive value of serum chromogranin A

PURPOSE: To evaluate whether the pretreatment determination of serum chromogranin A (CgA) can provide information beyond that obtained with serum prostate specific antigen (PSA) and Gleason score at biopsy as a predictive factor of clinical understaging (T2-pT3) of prostate adenocarcinoma. MATERIALS: In this prospective study, we analyzed 83 consecutive patients with clinical T2N0M0 prostate adenocarcinoma submitted to radical prostatectomy (RRP). On the same day of RRP, before surgery, a blood sample for the determination of serum total PSA and CgA levels (RIA) was obtained. RESULTS: After RRP, 27 of the 83 cases (32.5%) showed extracapsular disease extension (pT3) at the final pathological examination and were considered clinically understaged. A significant association between serum CgA and pathological stage (r = 0.3830; P = 0.0004) was found. At the multivariate analysis, serum CgA and PSA, but not biopsy Gleason score, were found to be significant pretreatment independent predictors of pT3 at RRP (P = 0.00004 and P = 0.0018, respectively). The relative risk of clinical understaging significantly varied according to serum CgA levels. Using a CgA cut-off value of 60 ng/ml, PPV and NPV for clinical understaging were 0.5161 and 0.7885, respectively (P = 0.0072). CONCLUSIONS: Serum CgA could be incorporated into risk assessment models of newly diagnosed prostate cancer.     

Liver harvesting surgical technique for the treatment of retro-hepatic caval thrombosis concomitant to renal cell carcinoma: perioperative and long-term results in 15 patients without mortality

OBJECTIVE: Radical surgical treatment improves the prognosis of patients affected by Inferior Vena Cava (IVC) thrombosis concomitant to renal carcinoma. However, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable haemorrhages and tumor fragmentation. We report the results of an innovative surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. In the presence of retro-hepatic IVC thrombosis, this technique improves vascular control and allows to perform a large cavotomy with an en-bloc removal of the thrombus and the tumor. METHODS: From January 1995 through June 2003, 15 patients with renal cancer and caval thrombosis were treated at our Institution. Four, ten and one patients were respectively affected by an infrahepatic (Level I), retro-hepatic (Level II) and atrial (Level III) IVC thrombosis. RESULTS: All patients underwent radical surgical treatment. In presence of Level II caval thrombosis, the patients underwent the above reported surgical technique. Perioperative mortality was absent; major morbidity occurred in one patient (6.7%). The thrombus was radically removed in all cases. After a mean follow-up of 53.9 months (5-100 months) all patients but one are still alive. One patient died 9 months after surgery with multiple bilateral pulmonary metastases. CONCLUSIONS: Isolation of the retro-hepatic IVC is a safe and effective manoeuvre to significantly reduce perioperative mortality and morbidity in patients affected by Level II caval thrombosis concomitant to renal carcinoma.     

Critical Review of Additive Mastoplastic with Arion Hydrogel Prosthesis

The author reviews his personal experience using additive mastoplastics with the hydrogel prosthesis produced in France by Arion. The enumeration of cases covers 143 patients (285 prothesis) with 36 months of follow-up evaluation. The positive aspects of this filling (especially the radiotransparency) and its complications are considered, with special attention paid to the wrinkling effect that may be caused by some physical instability of the hydrogel. The well-known controversy of 1992 concerning silicon mammary prostheses encouraged scientists to seek alternative solutions in the field of prosthetic extenders. This effort sometimes produced negative solutions such as the soya oil prosthesis, but at the same time provided materials with excellent physical–chemical qualities, with subsequent positive effects from a clinical point of view. This work is dedicated to one of these products, the Arion hydrogel. After 6-years of utilization with a 36-month follow-up period, 285 prosthesis have been fitted for 143 patients.     

Antenatal diagnosis of diaphragmatic hernia: parents' emotional and cognitive reactions

Purpose

The aim of this study was to assess parent’s emotional and cognitive reactions to the prenatal diagnosis of diaphragmatic hernia in their prospective children.

Methods

A survey was conducted by means of a questionnaire. In the period ranging from 1997 to 2002, 40 couples in whom an established diagnosis of diaphragmatic hernia was made in their fetus were seen for prenatal consultation at a tertiary referral center.

Results

Overall response rate was 93% (37 couples). Mean period since diagnosis for compilation of the questionnaire was 2 weeks. Mean gestational age at diagnosis was 25 weeks (range, 16 to 35 weeks). All parents lacked prediagnostic knowledge of diaphragmatic hernia and consider a single consultation with the paediatric surgeon inadequate to have a clear understanding of the anomaly. Only 1 mother and 1 father reported they understood all the information given by the surgeon. The most frequent (75%) feeling during and after the consultation was fear. Most parents (70%) referred to the intense emotions as the factor that made it difficult to follow the surgeon’s explanations as well as to ask questions.

Conclusions

Because of the incompatibility of emotional distress and optimum learning, impairment of early comprehension of information about diaphragmatic hernia is unavoidable. Therefore, we believe that follow-up antenatal consultations and provision of written and visual illustration are extremely important to facilitate informed choices.     

Lichen sclerosus of the male genitalia and urethral stricture diseases

INTRODUCTION: The true incidence of urethral involvement in patients with genital lichen sclerosus (LS) is unknown. We review the epidemiology and discuss the pathogenesis of LS and urethral stricture diseases. MATERIALS AND METHODS: During the period 1991-2002, of 925 patients who underwent urethroplasty for anterior urethral stricture, 130 patients (14%) received the diagnosis of LS. In all patients with LS the histology was re-examined to confirm the clinical diagnosis. Retrograde and voiding urethrography was used to establish urethral involvement in the disease. RESULTS: In 106 patients (82%) the histology provided the classical features of LS, and 24 patients (18%) showed some histological variations. In 49 patients (37%) the LS involved the pendolous urethra (meatus-navicularis-penile), and in 53 cases (41%) a panurethral stricture was evident. CONCLUSIONS: LS urethral involvement appears to be a much more common and extensive disease than previously reported, and requires particular care in its early diagnosis.     

Use of a branch patch with the cystic artery in living-related liver transplantation

Technical aspects in living-related liver transplantation are still under debate: the main pitfall is the arterial reconstruction due to the small diameter and the discrepancy between stumps, with a subsequent increased risk of arterial thrombosis. The gold standard is the microsurgical technique, that reports the lowest risk of thrombosis, but it is a time consuming procedure requiring a long training. Our method of choice reconstructing hepatic artery in right lobe is the use of the cystic artery as a branch patch with the recipient hepatic artery by loop magnification, saving time and with a low incidence of hepatic artery thrombosis.     

Surgical treatment of ureteral obstruction from endometriosis: our experience with thirteen cases

Endometriosis is a biologically benign albeit aggressive pathology marked by high local recurrences. Ureteral involvement accounts for only a minority of cases (0.1–0.4%) with often non-specific symptoms at clinical presentation and difficult preoperative diagnosis. Thirteen cases of severe ureteral endometriosis (i.e. causing significant obstruction to the urinary flow) were observed and surgically treated, out of 17 ureteral units affected (three cases of bilateral involvement, one case of complete pyeloureteral duplicity). The initial symptomatology was acute and related to ureteral obstruction in eight cases, silent and non-specific in the other five; a presumptive diagnosis was made only for the seven patients (53.9%) with a positive medical history for pelvic (and in two cases also ureteral) endometriosis. Preoperative drainage of urine proved necessary for eight patients due to the complete functional exclusion of the excretory axis. One patient (7.7%) underwent nephrectomy due to renal atrophy. Segmental ureteral resection and termino-terminal anastomosis were performed in two patients, while seven patients underwent segmental ureterectomy and ureterocystoneostomy, with bladder psoas hitching in four cases and vesical flap according to Casati-Boari in one case. All three cases of bilateral involvement were treated by bilateral segmental ureterectomy and trans-uretero-uretero-cystoneostomy with bladder psoas hitching. Following histological examination, all patients were diagnosed with active ureteral endometriosis, which was found to be intrinsic in five cases (38.5%) and extrinsic in the other eight. One of the two patients that had undergone ureterectomy and termino-terminal anastomosis had to undergo ureteral resection and ureterocystoneostomy 22 months later due to relapsing endometriosis-induced stenosis. Conversely, no ureteral endometriosis relapses occurred in the remaining 12 patients within the mean follow-up time of 41.1 months (range 6–91). Ureteral endometriosis is marked by non-specific symptoms, making preoperative diagnosis often difficult. Therefore, an ultrasound or urographic examination of the urinary tract in case of pelvic endometriosis is absolutely essential. In our experience, terminal ureterectomy with ureterocystoneostomy has provided long-term favourable results as extended ureteral resection can be performed and continuity of the urinary tract can be restored without resorting to the distal pelvic ureter, which is often affected by the disease besides being more subject to relapses. Editorial Comment: The authors present an appropriate treatment option for a difficult problem. Frequently, endometriosis involving the urothelium, bladder or ureter is not responsive to medical management. This article further emphasizes the need to screen all patients who present with severe endometriosis for ureteral obstruction. A recent article (Yohannes P (2003) J Urol 170:20) discusses attempts at conservative therapy. However, close follow-up is required during attempts at conservative management. Those patients who have failed medical management and/or have extensive scarring with reduction in renal function will require surgery.     

Usefulness of both operative cholangiography and conversion to decrease major bile duct injuries during laparoscopic cholecystectomy

Background/Purpose We evaluated the role of operative cholangiography and of conversion to decrease major bile duct injuries.Methods We report 1074 patients who underwent laparoscopic cholecystectomy, out of a total of 1195 patients who underwent laparoscopy, over an 8-year period. The planned laparoscopic operative procedure in all the patients was the standard four-port technique with the operator on the left side of the patient. Operative cholangiography was performed with Olsens pliers.Results We performed 993 (83%) operative cholangiographies; 121 (10.1%) patients were converted from laparoscopic to open cholecystectomy. Despite a prolonged time of dissection, 54 (4.5%) patients were converted because of unclear anatomy of Calots triangle. One hundred and ninety patients suffered acute cholecystitis and, of those, 52 (27.3% of 190 patients) were converted. Fifteen patients showed intraoperative biliary duct stones and they were converted. Seven (0.58%) bile duct injuries (one stricture and six fistulas) are reported.Conclusions The low number of major bile duct injuries reported in our study showed the value of operative cholangiography during laparoscopic cholecystectomy. Moreover, another important factor found to reduce major bile duct injuries was conversion when, despite accurate dissection, the anatomy of Calots triangle remained unclear.Presented at the poster session of the 103rd Congress of The Japan Surgical Society, Sapporo, Hokkaido, Japan, June 2003, and published in abstract form in the Journal of the Japan Surgical Society (2003) 104: 1072–1073 (data-related years 1993–2000).     

Smoking habit and labial microcirculation

Smoking habit is an important risk factor in oral diseases. In the last years, many studies tried to evaluate smoking effects on the microcirculation. It had never been used such a simple not invasive technique, like the video-capillaroscopic one. The aim of the research is to analyse "in vivo", the microcirculation labial characteristics, and to evaluate the smoking effects by means of computerised videocapillaroscopy techniques. 35 healthy no-smoker patients and 35 healthy smoker patients were examined. The characteristics of the microcirculation in the areas of labial mucous were examined using computerised videomicroscopic techniques. For each patient we evaluated the visibility, the course, the tortuosity and any images characteristic of capillary loops, besides the possible presence of microhaemorrhages, the average calibre of capillary loops and the number of capillary loops visible per square millimetre. The investigation was non invasive and repeatable for each patient. In both groups the investigation of labial mucous revealed a course of capillary loops parallel to the surface. In smoker patients, it was possible to underline capillaries of a smaller calibre (P<.001), and a higher number of detectable capillaries compared with no-smoker patients (P<.001). We observed an important correlation between the capillary tortuosity and the smoking habit (P<.001). Our research highlighted, that today it is possible to carry out a capillaroscopic investigation of labial mucous in a simple and reliable way. Furthermore, smoking habit represents a real risk factor of oral disease, greatly affecting the microcirculation.