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PURPOSE: To assess the current treatment of metastatic renal cell carcinoma, focusing on medical treatment options. MATERIAL AND METHODS: The most important recent publications have been selected after a literature search employing PubMed using the search terms: advanced and metastatic renal cell carcinoma, anti-angiogenesis drugs and systemic therapy; also significant meeting abstracts were consulted. RESULTS: Progress in understanding the molecular basis of renal cell carcinoma, especially related to genetics and angiogenesis, has been achieved mainly through of the study of von Hippel-Lindau disease. A great variety of active agents have been developed and tested in metastatic renal cell carcinoma (mRCC) patients. New specific molecular therapies in metastatic disease are discussed. Sunitinib, Sorafenib and Bevacizumab increase the progression-free survival when compared to therapy with cytokines. Temsirolimus increases overall survival in high-risk patients. Growth factors and regulatory enzymes, such as carbonic anhydrase IX may be targets for future therapies. CONCLUSIONS: A broader knowledge of clear cell carcinoma molecular biology has permitted the beginning of a new era in mRCC therapy. Benefits of these novel agents in terms of progression-free and overall survival have been observed in patients with mRCC, and, in many cases, have become the standard of care. Sunitinib is now considered the new reference first-line treatment for mRCC. Despite all the progress in recent years, complete responses are still very rare. Currently, many important issues regarding the use of these agents in the management of metastatic renal cancer still need to be properly addressed.

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OBJECTIVE:The objective of our retrospective study was to provide evidence on the efficacy of the intercostal versus subcostal access route for percutaneous nephrolithotripsy. MATERIAL AND METHODS: 642 patients underwent nephrolithotomy or nephrolithotripsy from 1996 to 2005. A total of 127 had an intercostal access tract (11th or 12th); 515 had a subcostal access tract. RESULTS: Major complications included one pneumothorax (1.0%), one arterio-calyceal fistula (1.0%) and three arteriovenous fistulae (2.7%) for intercostal upper pole access; two pneumothoraces (1.7%), one arteriovenous fistula (1.0%), one pseudoaneurysm (1.0%), one ruptured uretero-pelvic junction (1.0%), 4 perforated ureters (3.4%) for subcostal upper pole access; one hemothorax (1.6%), one colo-calyceal fistula (1.6%), one AV fistula (1.6%), and two perforated ureters (3.2%) with subcostal interpolar access. Diffuse bleeding from the tract with a subcostal interpolar approach occurred 3.2% of the time compared with 2.4% with a lower pole approach. Staghorn calculi demonstrated similar rates of complications. CONCLUSION: Considering the advantages that the intercostal access route offers the surgeon, it is reasonable to recommend its use after proper pre-procedural assessment of the anatomy, and particularly the respiratory lung motion.

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OBJECTIVE: No consensus has yet been established regarding the best minimally invasive access for radical ablation of renal tumors. Our objective was to prospectively compare the surgical results and oncologic management of two currently used endoscopic techniques. MATERIAL AND METHODS: Over a four-year period, 50 patients with renal tumors and clinical stage T1b-T2, smaller than 12 cm, underwent a radical nephrectomy at two reference institutions, 25 underwent retroperitoneoscopic radical nephrectomy (RRN) and 25 a hand-assisted laparoscopic radical nephrectomy (HALRN). Mean follow-up of both cohorts was 50 months. Operative parameters and oncological management were compared. RESULTS: The mean operative time was 180 min in RRN and 108 min in HALRN (p < 0.001). The time required to access the renal pedicle in RRN was 30 min. and in HALRN 40 min., Learning curve was shorter in HALRN than RRN. Mean blood loss was 100 mL in RRN and 242 mL in HALRN. Mean incision size for specimen retrieval in RRN was 6.5 cm and in HALRN 7.5 cm. One patient with intra operative occurrence of ascites and subsequent pathological stage pT2N0M0 grade 3 operated via HALRN, had neoplasic implants in the Hand-port incision 3 months after surgery followed by death 4 months after recurrence. One patient, with pathological stage pT3N0M0 grade 3 in RRN had metastasis after 36 months. CONCLUSION: Both, RRN and HALRN techniques are accepted minimally invasive options for endoscopic radical nephrectomy with equivalent long term oncological outcome in the treatment of renal tumors.

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PURPOSE: Clinical studies produce conflicting results on pain relief for shock wave lithotripsy (SWL). We performed a systematic review and meta-analysis to compare non-steroidal anti-inflammatory drugs (NSAIDs) and opioids in pain relief for SWL powered by an electromagnetic generator. MATERIAL AND METHODS: A search of MEDLINE and EMBASE was performed and all randomized controlled trials comparing NSAIDs and opioids in pain relief for SWL using modern electromagnetic lithotripters were included in the analysis. Data from 3 trials (244 patients) were pooled. The primary outcome measure was adequate analgesia, defined as "if no additional pain relief was used". The difference in the proportion of patients with adequate anesthesia was compared between the NSAIDs and opioids groups as an odds ratio and odds ratio were pooled across the 3 trials with a fixed effects model. RESULTS: There was no statistically significant difference between using NSAIDs and opioids for pain relief during SWL using modern electromagnetic lithotripters (odds ratio 0.886, 95% CI 0.446-1,760, p = 0.730). CONCLUSIONS: Our analysis shows that in relieving pain during SWL using modern electromagnetic lithotripters NSAIDs are as effective as opioids.

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INTRODUCTION: Studies that compare the impact of different infectious entities of the male reproductive tract (MRT) on the male accessory gland function are controversial. MATERIAL AND METHODS: Semen analyses of 71 patients with proven infections of the MRT were compared with the results of 40 healthy non-infected volunteers. Patients were divided into 3 groups according to their diagnosis: chronic prostatitis NIH type II (n = 38), chronic epididymitis (n = 12), and chronic urethritis (n = 21). RESULTS: The bacteriological analysis revealed 9 different types of microorganisms, considered to be the etiological agents, isolated in different secretions, including: urine, expressed prostatic secretions, semen and urethral smears: E. Coli (n = 20), Klebsiella (n = 2), Proteus spp. (n = 1), Enterococcus (n = 20), Staphylococcus spp. (n = 1), M. tuberculosis (n = 2), N. gonorrhea (n = 8), Chlamydia tr. (n = 16) and, Ureaplasma urealyticum (n = 1). The infection group had significantly (p < 0.05) lower: semen volume, alpha-glucosidase, fructose, and zinc in seminal plasma and, higher pH than the control group. None of these parameters was sufficiently accurate in the ROC analysis to discriminate between infected and non-infected men. CONCLUSION: Proven bacterial infections of the MRT impact negatively on all the accessory gland function parameters evaluated in semen, suggesting impairment of the secretory capacity of the epididymis, seminal vesicles and prostate. These findings were associated with an infectious related significant increase of semen pH. None of the semen parameters evaluated can be suggested as a diagnostic tool for infection.

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Circumcisions are among the most frequently performed operations in children and numerous techniques are employed often with varying results. Use of the Plastibell™ (Hollister Incorporated, Illinois, USA), under local anesthetic, is popular for cultural and religious circumcisions but is not without its problems. Complications of Plastibell™ (slippage, migration, bleeding and serious infection) have been reported. Described is a prospective series of cases in which modifications to the standard Plastibell™ technique were utilized to improve outcomes, in particular, the risk of bleeding.

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OBJECTIVE: To assess the role of transforming growth factor-β1 (TGF-β1) in congenital ureteropelvic junction obstruction at diagnosis and during postoperative follow-up. MATERIAL AND METHODS: We conducted a case-control study including 19 patients with a mean age of 6.7 years and 19 matched controls. All patients presented negative voiding cystourethrography, obstructive diuretic renogram and underwent dismembered pyeloplasty. Urinary TGF-β1 and other markers were measured pre-, intra- and postoperatively. RESULTS: The mean bladder urine TGF-β1 concentration in obstructed patients prior to pyeloplasty was higher than in controls (92.5 pg/mL ± 16.8 vs. 35.8 pg/mL ± 16.2; p = 0.0001). The mean renal pelvic urine TGF-β1 concentration in the hydronephrotic kidney was higher than in the preoperative bladder urine sample (122.3 pg/mL ± 43.9 vs. 92.5 pg/mL ± 16.8; p = 0.036). Postoperative mean TGF-β1 concentration was significantly lower than preoperative TGF-β1 (48.7 pg/mL ± 13.1 vs. 92.5 pg/mL ± 16.8; p = 0.0001). CONCLUSION: TGF-β1 is a cytokine leading to renal fibrosis. The measurement of urinary TGF-β1 could become a useful tool for the diagnosis of obstructive hydronephrosis and the evaluation of the parenchyma function status, pre and postoperatively.

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PURPOSE: To assess the outcome of urologic evaluation in patients with voiding dysfunction due to multiple sclerosis (MS) and to determine the relationship between urological and neurological parameters of these patients. MATERIAL AND METHODS: We retrospectively reviewed the medical records of 249 consecutive patients (162 female and 87 male) with MS who were referred to our clinic between 1991 and 2006, with a median time of 4 years (range 3 months to 26 years) of MS onset. Data was analyzed with respect to patient demographics and findings of initial evaluation. Lower urinary tract symptoms were evaluated by Boyarsky symptom index. RESULTS: All patients except 13 had lower urinary tract symptoms and 70% manifested mixed symptoms. Total, storage and voiding symptom scores correlated with expanded disability status scale scores (p < 0.05). Twelve patients (5%) had abnormal upper urinary tract. Ultrasound findings of lower urinary tract were abnormal in 12 patients (5%). No demographic parameters were associated with abnormal findings of upper urinary tract on univariate analysis. Urodynamic evaluation of 75 patients (30.1%) revealed detrusor overactivity with or without detrusor-sphincter dyssynergia in 56 (75%). No correlation was found between urodynamic diagnosis and upper tract deterioration and urinary symptom scores (p > 0.05). CONCLUSIONS: The prevalence of mixed symptoms in patients with MS is higher than storage or voiding symptoms alone. Although detrusor overactivity and detrusor-sphincter dyssynergia were the most common urodynamic diagnoses, upper urinary tract deterioration was rare in our series.

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AIMS: To assess the technical feasibility of a new mini-invasive sling procedure (MiniArc®) and present short-term results in the treatment of female urinary incontinence. MATERIAL AND METHODS: A total of 97 women with mixed or stress urinary incontinence (SUI) were treated by placement of the new single-incision sling. Pelvic organ prolapse was graded using the POP-Q system (pelvic organ prolapse quantification system). Preoperative workup included urodynamic evaluation, cough stress test and introital ultrasound. Postoperatively, introital ultrasound was performed to determine residual urine and check tape position. Quality of life was measured using King's Health Questionnaire. A voiding diary and pad count served to verify the patients' subjective complaints. RESULTS: The MiniArc® single-incision sling procedure was the initial intervention in 37 (38.2%) patients and the second intervention in 60 (61.7%) patients with recurrent incontinence. The cough stress test was negative in 79 (83.1%) women 6 weeks after the sling procedure and in 74 (77.8%) at 12 months. De novo urge occurred in 32 (36.8%) women. Quality of life was significantly improved at 12-month follow-up in 65 (69.1%) patients (p < 0.001). The number of pads decreased significantly from 2.2 to 0.6 (p < 0.001) after the procedure. One patient developed an hematoma and bladder perforation occurred in another. CONCLUSIONS: Our short-term clinical results suggest that the MiniArc® is a safe and effective minimally invasive sling procedure for treating female SUI. Randomized comparative controlled trials and long-term results are still required to define the role of the new sling system in comparison to established mid-urethral tape techniques for treating incontinence.

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OBJECTIVE: Optical coherence tomography (OCT) is a unique technology, developed to provide high resolution, cross sectional images of human tissue. The objective of this study was to explore the feasibility of OCT for the evaluation of positive surgical margins and extra capsular extension in robotic prostatectomy specimens and compare it to histopathology. MATERIAL AND METHODS: Radical prostatectomy was performed in 100 patients. Twenty OCT images of each specimen were taken from the base of the seminal vesicles (SV), apical and vesicle margins, peripheral and posterolateral area and any palpable nodule. Predictions were made regarding positive surgical margin, SV involvement, capsular invasion and compared with the final histopathology. RESULTS: A total of 2000 OCT images were taken and analyzed. Out of 100 specimens, 85 had T2 disease, 15 had T3 disease with a median Gleason's score of 7 (range 6 to 9) and 10 had positive surgical margins. We predicted 21 specimens to have positive margins based on OCT images out of which 7 were truly positive and 14 were falsely positive. Based on OCT images, 79 specimens were predicted to have negative margins out of which 76 were truly negative and 3 were falsely negative. We found the sensitivity, specificity, positive predictive value and negative predictive value to be 70%, 84%, 33% and 96% respectively. CONCLUSION: Our initial feasibility study established the template for the visual OCT characteristics of the prostate, SV and cancerous tissue. The negative predictive value of evaluating surgical margins was high.

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OBJECTIVE: The aim of our study is to investigate the anti-neoplastic effect of curcumin in prostate cancer cell lines. Specifically, we are using the LNCaP cell line and another prostate cell line developed in our laboratory, PcBra1. The PcBra1 cells were derived from a localized, obstructive prostate cancer with a Gleason score of 9 (4+5). MATERIAL AND METHODS: A prostate cancer cell line was isolated from a localized, obstructive prostate cancer with a Gleason score of 9 (4+5), and it was characterized using immunohistochemistry. After six passages, the new cell line was treated with varying doses of curcumin: 10 µM, 25 µM or 50 µM. Apoptosis was detected by flow cytometry using Annexin V FITC. For comparison, the same experiment was performed using the well-established metastatic prostate cancer cell line, LNCaP. RESULTS: Increasing concentrations of curcumin promoted more apoptosis in the PcBra1 cells. Exposure to 10 and 25 µM curcumin induced apoptosis in 31.9% and 52.2% of cells, respectively. Late apoptosis was induced in 37% of cells after treatment with 10 µM curcumin and 35% of cells with a 25 µM treatment. Necrosis accounted for less than 10% of the death in these cells at those two concentrations. When curcumin was used at 50 µM, apoptosis was observed in 64.3% of the cells. Including late apoptosis and necrosis, 98.6% of the cells died in response to 50 µM curcumin. Results with the LNCaP cells were similar although late apoptosis was the main phenomenon at 25 µM. CONCLUSION: We have shown that curcumin acts on localized prostate cancer to induce apoptosis and may therefore be an option as a future therapeutic agent.