The histologic finding of teratoma occures in aproximately 40% of all postchemotherapy retroperitoneal lymphadenectomy (PC-RPLA) for disseminated nonseminomatous testicular tumors (NSTT). We evaluated patients undergoing PCRPLA for teratoma to determine risk factors for recurrence and clinical outcome. Among a survey of 193 patients submitted to PC-RPLA due to metastatic NSTT from 1980-2005, we identified 82 patients (42%) who were found to have only teratoma in the retroperitoneum. Sixty-seven patients (82%) received only induction cisplatin-based chemotherapy, and 15 (18%) required 2nd line chemotherapy. PC-RPLA histology revealed mature teratoma (MT) in 86%, immature teratoma (IMT) in 12% and teratoma with malignant transformation (TMT) in 2%. Sixteen patients (19%) relapsed within median free interval of 22 months. Among 13 patients submitted to redoRPLA, discordant histology occurred in 6 patients (46%) (2 TMT, 4 viable germ cell tumors [GCT]), all with worst histology in comparison to primary RPLA. One relapsing patient with only elevated serum tumor markers (STMs) achieved complete response with chemotherapy alone. Two patients relapsed at 21 and 74 months with widespread metastasis and died despite salvage chemotherapy. Seven of 13 patients (54%) who were rendered free of disease (FOD) with redo-RPLA, relapsed again. All but one died despite salvage treatment (2 of chemotherapy related toxicity) within mean survival time (MST) of 86.7+/-26.1 (95% confidence interval [CI], 98.79- 149.21). At mean follow-up (MFU) of 135+/-62.6 months (95% CI, 98.79-149.21), alive and free of disease (AFD) are 90% patients. The probability of being reccurence-free at 5- and 10- year was 87% and 81%, respectively. The 5- and 10- year probability of disease speciphic survival (DSS) were 98% and 89%, respectively. On multivariate analysis residual mass size (p<0.005) and worse IGCCCG risk group (p=0.01) predicted disease recurrence. Patients with residual teratoma after PC-RPLA continue to exibit a 19% risk of recurrence even 10 years after RPLA, with 46% recurrence being with worse histology. These data support that these patients should undergo long-term surveillance of their retroperitoneum in the setting of a large residual mass or elevated IGCCCG classification risk.

The aim of this study is to examine how the introduction of medical therapy for symptomatic benign prostatic hyperplasia (BPH) might have changed the indications, patient characteristics and outcome in men undergoing transurethral resection of the prostate (TURP) over two decades (1991.- 2011.). All patients who underwent TURP for symptomatic BPH at our institutions in 1991. (before the introduction of medical therapy for BPH), 2001. (when medical therapy was becoming an important therapy for BPH) and 2011. (when medical therapy was the first line therapy for BPH), were reviewed. We assessed the total number of TURPs, indications for surgery, patient age, health status, weight of resected tissue, and pre and post-operative events/ complications. Our institutions provided primary urological care for 989, 1815 and 2162 men > 50 years of age in 1991., 2001. and 2011., respectively. There was a 60% decrease of TURPs from 1991. to 2011. with a slight increase in number in 2001. Failure of medical therapy was not an indication in 37% and 88% of patients in 2001. and 2011., respectively. There was a substantial rise in the percentage of men at risk presenting with acute or chronic retention (AUR and CUR) at the time of their TURPs ( from 23% in 1991. to 55% in 2001. and from 14% in 1991. to 38% in 2011. for AUR and CUR, respectively) (P<0.05). There was also rise in the percentage of patients presenting with preoperative hydronephrosis (2% in 1991., 13% in 2001. and 6% in 2011.) (P<0.05) and gradual decrease of UTI before TURP overtime (14%, 10% and 12%, respectively).The mean operative time was lower in 2011., compared with either of the two previous cohorts (P<0.05), postoperative stays decreased (from 4.1 days in 1991. to 2.7 days in 2001. and 2.1 days in 2011.)(P<0.05), but the number of patients discharged with catheter increase over two decades (from 3.5% in 1991 to 4.8% in 2001., and to 8.8% in 2011.)(P<0.05). The postoperative complications of our three cohorts differed significantly (14% in 1991., 6.4% in 2001. and 20.6% in 2011.)(P<0.05). The increasing use of medical therapy as a first line treatment for BPH has resulted in a dramatic decrease in TURPs which, in turn, has been associated with an apparent increase in risk of poor pre- and postoperative outcomes seems to be related to earlier catheter removal and hospital discharge, although a causal relationship cannot be established. The present study covering the last two decades would suggest that we are not delaying surgery for patients who will eventually require it. We are now selecting the appropriate patients for TURP, rather than using TURP as our only means of BPH therapy as we did two decades ago.

The aim of the present study is to prospectively investigate the presentation of germ cell testicular tumors (GCCTs) in terms of clinical stage (CS) or histology, as the incidence of this malignancy in increasing. Patients diagnosed with GCTTS between 1976 and 2005 were categorized into 3 period depending on date of diagnosis of GCTTs and presentation characteristics assessed. For purpose of analysis patients were assigned into 1 of 3 similar groups in term of duration (10 years) (1976-1985, 1986-1995, 1996-2005). These 3 periods were compared statistically to identify the possible changes in the presentation of GCTTs. Among 1935 patients, the number diagnosed in each period was 111 (6%), 695 (36%) and 1129 (58%), respectively. There was substantial rise in the percentage of patients with GCTTs during the period of 30 years, particularly in 3rd vs. 2nd and 1st decade (P<0.0001). Overall, 46% of patients were diagnosed with seminoma and 54% with nonseminoma. The greater proportion of the entire cohort of patients presented in CS I (65%). Also, seminoma and nonseminoma occurred more frequently in CS I (78% and 51%, respectively). The median (range) age of the whole cohort of patients was 34 (14-80) years. The median age for developing metastatic seminoma was 4 years more than in CS I disease (38 vs. 42 years, respectively), while the median age for the presentation of CS I and metastatic nonseminoma was identical (31 years). The proportion of seminoma increased significantly in time (40% vs 55%) and this was accompanied by a significant decrease of nonseminoma (60% vs. 45%)(P<0.001). The proportion of patients in CS I disease also increased significantly with time (45% vs. 77%), while the proportion of patients with metastatic disease decreased (55% vs. 23%)(P<0.001). There was a significant rise in proportion of patients with CS I seminoma (27% vs. 47%) (P<0.001) and nonseminoma (18% vs. 30%) (P<0.001), accompanied by a significant decrease in the proportion of patients presenting with metastatic nonseminoma (46% vs. 15%)(P<0.0001). However, the proportion of patients with metastatic seminoma remained largery unchanged (13% vs. 9%). The present study shows a progressive increase of GCTTs during the observation period of 30 years, with increase in the proportion of patients with GCTTs confined to the testis, as opposed to metastatic disease. The other finding is that there has been an increase in the proportion of patients presenting with seminoma rather than nonseminoma. The reason for this remain unclear and require further investigation.

We compared the safety and efficacy of transurethral vapor resection (TUVRP) and transvesical prostatectomy (TVP) for prostate > 50 ml in retrospective study. Ninety patients with urodynamic obstruction and prostate volume (PV) in range between 50 and 100 ml were analyzed according to the mode of operative treatment (TUVRP vs. TVP). Patients were assessed preoperatively and followed-up at 3 and 12 months postoperatively. All patients underwent general and urological standard evaluation before surgery, including urine analysis, urine culture, blood samples tests, with determination of PSA, DRE, abdominal and minor pelvis ultrasound (US), transrectal ultrasound (TRUS), maximal flow rate (Qmax), postvoid residual urine(PVR), and self assessment by International Prostate Symptom Score (IPSS) and Quality of Life Score (QoLS). Urethrocystoscopy was obligatory done before TUVRP. TRUS-guided biopsies of the prostate were performed in patients with PSA > 4 ng/ml, abnormal DRE, and/or suspicious echogenicity on TRUS. IPSS, QoLS, Qmax and PVR were obtained at each follow-up. Of 90 patients eligible to participate, 69 patients completed 12 months of follow-up (TUVRP, n=35; TVP, n=36). TUVRP procedure was not faster than TVP procedure (P=0.41); 43.6% and 84.8% of prostatic tissues were resected after TUVRP and TVP, respectively (P<0.001). In TVP group, IPSS, QoLS, Qmax and PVR volume were significantly better than those in TUVRP group at 3 and 12 months of followup. At 12 months postoperatively, IPSS improved 62.7% and 87.9% (P<0.001), QolS decrease by 41.9% and 71.9% (P<0.001), mean Qmax increased by 6.3 ml/s (102.0%) and 11.4 ml/s (230.2%) (P=0.001) and mean PVR volume decreased by 65.4 ml (70.5%) and 71.2 ml (88.6%) (P=0.001) in TUVRP and TVP group, respectively. Two TUVRP patients developed urethral stricture and 1 bladder neck sclerosis postoperatively, requiring internal urethrotomy and TUIP, respectively. TVP may be more effective and safer than TUVRP for benign prostatic hyperplasia (BPH) patients whose PV is > 50 ml.

We investigated whether finasteride given before transurethral vapor resection (TUVRP) treatment has an impact on intra- and postoperative bleeding. Forty-two patients with diagnosis of benign prostatic hyperplasia (BPH) who had prostate volume (PV) > 30 mL underwent TUVRP: group A (n=21) received preoperatively finasteride 5 mg per day for median time of 7 months and group B (n=21) no finasteride. Preoperative evaluation include assessment of International Prostatic Symptom score (IPSS), Quality of Life (QoL), PV, maximum flow rate (Qmax) and postvoid residual (PVR). Patients mean age was 71.4± 2.1 vs 69.8 vs ± 3.4 years, respectively. Median PV was 55.5 ±21.2 vs 57.1 ±28.8 mL, respectively. Twenty-two (52%) patients had complete retention (29% vs 76%) (p<0.001). At baseline mean IPSS, QoL, Qmax and PVR were 18.1±5.9 vs 19.8±5.04, 3.3±1.7 vs 3.3±1.7, 8.1±4.4 vs 6.9±1.6 mL/s, and 146±106.9 vs 151.6±112.1 mL, respectively. The mean operation time was 59±16.8 vs 64±19.2 min, mean volume of irrigation fluid intraoperatively was 14.1±7.01 vs 15.2±8.1 L and postoperatively 7.0±2.1 vs 8.1 ±1.3 L, respectively. Mean blood loss was 312±85.9 vs 425±68.5 mL, respectively. The mean weight of resected tissue was 31.3±5.8 vs 30.75±8.4 gr, respectively. Mean duration of postoperative irrigation was 6.1 ± 4.7 vs 6.2 ±5.1 h, respectively. Thirty-six (85.7%) patients were discharged within 12 h postoperatively and the catheter is removed on 2.0±0.5 vs 2.5 ± 0.6 days, respectively. No patients received blood transfusion postoperatively. At 3 months postoperatively IPSS was 6.7±4.2 vs 5.2 ±2.01 (p<0.001), QoL 1.1±0.9 vs 1.1±0.7, Qmax 18.1±10.3 vs 17.5±8.1 mL/s (p<0.01) and PVR 41±46.1 vs 45±51.3 mL (p<0.05). The present study failed to demonstrate that preoperative treatment of BPH with finasteride did not have significant impact of perioperative bleeding at TUVRP.

Cilj ove studije je procena rezultata lečenja pacijenata sa intermedijarnim i lošim rizikom po kriterijumima “International Germ Cell Cancer Collaborative Group” (IGCCCG) metastatskih neseminomskih tumora testisa (NSTT) pomoću hemioterapije i retroperitonealne limfadenektomije (RPLA). U periodu od 1982do 2005, 82 pacijenta sa metastatskim NSTT, klasificiranih kao intermedijarna (65) i loša (17) rizična grupa po IGCCCG kriterijumima, su imali posthemioterapijsku (PH)-RPLA za srednje praćenje od 95meseci. Srednji dijametar RP rezidualne mase (RM) je iznosio 3.0 cm, 15 (18.3%) pacijenata je imalo povišene vrednosti tumorskih markera u serumu (TMS) pre PH-RPLA. Dvadeset i sedam (32.9%) pacijenata je iziskivalo administraciju hemioterapije druge linije, a kod 75 (91.5%) RP RM je kompletno resecirana. Retroperitonealna histološka analiza je pokazala prisustvo fibroze kod 20 (26%), teratoma kod 36 (42%) i vitalnog karcinoma kod 26 (32%), sa preživljavanjem u 76%, 80% i 38%, respektivno. Pacijenti podvrgnuti drugoj hemioterapijskoj liniji su imali signifikantno veću učestalost vitalnog karcinoma na PHRPLA (49% prema 24%)(P<0.001). Pacijenti sa lošim rizikom NSTT nisu imali signifikantno veću verovatnoću progresije (47% prema 55%)(P=0.5) i gori ishod (53% prema 69%)(P=0.2) nego sa intermedijarnim rizikom. Analiza pacijenata koji su primali hemioterapiju prve linije pokazuje signifikantno veću verovatnoću slobode progresije (VSP) (66% prema 41%) i bolje preživljavanje (74% prema 48%)(P<0.01) posle PH-RPLA nego oni koji su primili hemioterapiju druge linije. Konstatovano je bolje preživljavanje kod pacijenata sa prvom prema drugoj liniji hemioterapije pre PH-RPLA u pogledu nalaza na RP histologiji kod fibroze (94% prema 20%), teratoma (88% prema55%) i vitalnog karcinoma (54% prema 23%)(P<0.001). Ukupno, 5-godišnja VSP i preživljavanja su iznosili 57%(95% IP, 50%-62%) i 69%(95% IP, 61%-77%). Multivarijantna analiza je pokazala da nepotpuna resekcija (P<0.001), veličina PH RM (P=0.01) i nalaz teratoma i vitalnog karcinoma (p<0.01) na PH-RPLA predstavljaju nezavisne prediktivne faktore za recidiv bolesti. Pacijenti sa uznapredovalim NSTT imaju dug vremenski interval do progresije kada se hemioterapija kombinuje sa resekcijom RM. Naši nalazi ukazuju da odgovor tumora na hemioterapiju u kombinaciji sa kompletnom resekcijom svih RM, predstavlja garanci

The aim of the present study is to analyse fate and survival in patients with pure testicular teratoma (PTT) according to clinical stage (CS) and applied therapy. Among a survey of 1275 patients with nonseminomatous germ cell testicular tumors (NSGCT) observed from January 1982 and June 2005, we indentified 49 (4%) patients with PTT. In CS I, 3 (15%) of 20 patients on surveillance relapsed. Complete response (CR) is achieved with chemotherapy in 1 patient and combined with postchemotherapy retroperitoneal lymphadenectomy (PC RPLA) in 2 patients (fibrosis 1, teratoma 1). Four patients managed with primary RPLA had universal survival. Among 4 patients treated initially with primary chemotherapy due to persistently elevated serum tumor markers (STMs) postorchiectomy, 1 patient died at 18 months. In CS I, 27 (96%) of 28 patients are alive and free of disease (AFD) at median follow-up (MFU) of 161.6 months. In the PC group, 1 patient with partial response (PR) is lost to follow-up at 6 months, 1 patient died of disease at 27 months. Eight patients achieved CR with induction chemotherapy, whereas only 1 patient relapsed at 24 months and is rendered free of disease with RPLA (teratoma). Twelve patients underwent PC RPLA due to PR following induction chemotherapy, combined with thoracic cytoreductive surgery in 2 patients. RP histology demonstrated the finding of fibrosis in 2, teratoma in 8, teratoma with malignant transformation in 1, and vital carcinoma in 1. The patients with fibrosis, teratoma and teratoma with malignant transformation are AFD, whereas the patient with vital carcinoma on desperation RPLA died. According to initial CS IIB, IIC and III PC surgery was indicated in 20%, 91% and 50%, relapse rate was 0%, 18% and 20%, with disease specific survival (DSS) in 100%, 90% and 100%, respectively. At MFU of 189.7 months, 19 (95%) of 20 fully available patients are AFD. Overall, 46 (94%) patients had no evidence of disease (NED) at last follow-up. These data underscore the metastatic potential of PTT. A significant proportion (32%) of patients with low-stage PTT had RP disease. Furthermore, a high proportion (36%) presented initially with advanced disease and demonstrated a considerable risk of relapse despite complete resection or favorable histologic features in the resected surgical specimen.

We reviewed our experience with retroperitoneal lymphadenectomy (RPLA) after multiple cisplatin-based chemotherapy regimens in nonseminomatous testicular tumors (NSTT) patients and specifically evaluated clinicopathologic and treatment trend in addition to potential predictors of survival. Fort-one patients with NSTT underwent their RPLA between 1982 and 2005 after ≥ 2 regimens of chemotherapy. Thirteen patients (32%) necessitate redo-RPLA, combined with nephrectomy in 6 patients. 13 extra-RP (ERP) resections were performed in 11 patients (27%), including pulmonary (7), neck (4) and liver (2) sites. Thirty patients (73%) are rendered free of disease and 26 (63%) obtained serologic remission. Nine patients who relapse, necessitated new salvage chemotherapy+surgery (3 teratoma, 6 vital carcinoma [VC]). Four of 9 relapsing patients (44%) are currently free of disease with redoRPLA. Alive, free of disease are 19 pts (46%) at median follow-up of 131 months. Study of RP pathology demonstrated the presence of fibrosis in 15%, teratoma in 39% and VC in 46%, with survival in 67%, 56% and 32%, respectively. Different histology occurred in 38% at redo-RPLA and in 64% at ERP resection in comparison to previous RP pathology. Univariate analysis of clinicopathologic parameters associated with VC at RPLA included RP masses ≥ 5 cm (p<0.05), elevated AFP (p<0.001) or HCG (p<0.05) and ERP resection (p<0.04). On univariate analysis survival was worse in patients with RP masses ≥ 5 cm (p<0.04), elevated AFP (p<0.05) or HCG (p<0.007), ERP resection (p<0.01) and VC (p<0.004). On multivariable analysis, a RP masses ≥ 5 cm (p<0.03) and VC (p<0.005) predicted a worse prognosis. Our data support the continued use of salvage RPLA in three separated groups of patients: 1. Patients who achieved a complete response (CR) to 2nd -line chemotherapy and have no radiologic evidence of disease should undergo RPLA; 2. Patients who achieved a partial response (PR) to chemotherapy should undergo RPLA with ERP surgery, as indicated; 3. Highly selected group of patients with residual masses and elevated serum tumor markers (STM), particularly AFP, after chemotherapy may be candidate for surgery.

The present study is performed to determine whether retroperitoneal lymphadenectomy (RPLA) perioperative mortality (PM) rates reported from center of excellence [Indiana University: 0% for primary and 0.8% for postchemotherapy (PC) RPLA] are applicable to institution at large. Between 1975 and 2005, 327 assessable patients with nonseminomatous testicular tumors (NSTT) were treated with RPLA: primary in 134 (41%) and PC-RPLA in 193 (59%) patients. The observed PM rates were stratified according to age, clinical stage (CS) and type of RPLA. The median age at RPLA was 28 years (range 16-54) : < 29 years in 194 (56.3%), 30-39 years in 90 (30.3%) and > 40 years in 44 (13.4%) patients. Of 327 RPLA patients, 81 (27.8%) were performed for localized (CS-I), 179 (54.7%) for regional (CS-II) and 57 (17.5%) for metastatic (CS-III) disease. Ten (3.1%) patients died during initial 90 days after RPLA: 1 patient from pulmonary embolism, 2 of chemotherapyrelated toxicity and 7 of progressive disease due to preoperative worse prognostic factors. Of the entire cohort 30, 60 and 90-day PM rate was 0.3%, 1.0% and 1.3%, respectively. PM rate increase with increasing age: < 39 years 0%, 30-39 years 5.0% and > 40 years 9.3% (x2 trend test, P=0.002). PM rate also increased with CS: 0% localized, 2.8% for regional and 8.8% for metastatic disease (x2 trend test, p<0.001). PM rate at primary and PC-RPLA was increased with CS: 0% localized, 2.8% for regional and 8.8% for metastatic disease (x2 trend test, p<0.001). PM rate at primary and PC-RPLA was 0.7% and 3.1% 9P<0.001). RPLA was associated with virtually no or low (2.8%) PM rate in patients with localized and regional disease, respectively. In contrast, the PM rate of 8.8% for patients with distant metastases and group > 40 years of age (9.3%) implies that RPLA for these patients should be performed at centers of excellence, with intent of reducing PM rate.