Digital fluorographic video-urodynamics in the long-term morphofunctional evaluation of Alcini's Ileocecourethrostomy and ileal reservoir.

INTRODUCTION: The authors present the functional long-term follow-up by means of digital fluorographic video-urodynamics (DFVUDM) of two different surgical urinary diversions. MATERIALS AND METHODS: 64 of 101 patients submitted to radical cystectomy from 1983 to 1999 for infiltrating bladder cancer, were diverted by means of an Alcini's ileocecourethrostomy (ICUS+T), and the remaining 37 patients by means of an ileal reservoir (IR). All of those orthotopically diverted patients were submitted to an accurate follow-up which included DFVUDM 1, 3, 6, and 9 years after the surgical procedure (mean follow-up 51 +/- 42 months). RESULTS: All the evaluated patients showed a neobladder with good function during both the filling and the voiding phases. In 88.8% of the DFVUDM examinations, it was possible to find a residual peristaltic activity of the neobladder walls. Such a residual peristaltic activity caused urinary leakage during the examination in 11.1% of cases, while vesico-ureteral reflux was detected in 12.5%. The patients voided by relaxing the perineal floor and/or by contracting the abdominal muscles: the emptying of the reservoir was often excellent with average residual urine of 28.5 ml. None of the patients needed clean intermittent catheterization. EMG evaluation of the pelvic floor in some of patients showed a peculiar EMG pattern characterized by an insufficient voluntary control of the perineal musculature with a slight increase of EMG activity during bladder filling. Moreover, an insufficient relaxation of the pelvic floor muscles in the beginning of and during the micturition has been seen. This particular EMG pattern was present in 22.22% of all patients included in this study while it was particularly high (81.81%) in patients with leakage. CONCLUSION: DFVUDM evaluation represents a highly sophisticated tool which allows an accurate long-term morphofunctional evaluation of the urinary diverted patients. In this study, it is shown that the functional results of the two studied surgical procedures, namely Alcini's ICUS+T and IR, are quite similar, demonstrating that the taeniotomies on the cecal tract may have almost the same functional effects of detubularization. Although DFVUDM revealed imperfect functional performances in some patients, the quality of life of diverted patients in our series seems to be satisfactory.

Benign prostatic hyperplasia: correlations between receptor density and binding affinity of alpha(1)-adrenoceptors and several clinical parameters.

The aim of the study was to determine whether relations do exist between the concentration and activity of alpha(1)-adrenoceptors, both inside the prostatic adenoma and the periurethral zone corresponding to the bladder neck, and clinical and biological parameters such as symptoms, evaluated by the American Urological Association (AUA) score, age, weight of the prostate, PSA, and the flow rate. Twenty patients with symptomatic benign prostatic hyperplasia were selected for an open prostatectomy. One gram of tissue was dissected from inside the adenoma and 1 g from the periurethral zone corresponding to the bladder neck. The alpha(1)-adrenoceptors were evaluated for the apparent dissociation constant (K(d)) and the maximal number of binding sites (B(max)). A correlation seems to exist between receptor density inside the adenoma and the bladder neck and an inverse correlation between receptor density and the AUA total symptoms score. Finally, a highly significant difference was found in patients with an AUA score of <15 or >15. No relationship was found between receptor binding affinity and the considered clinical parameters.

Long-term behavior of secretory immunity in ileocecal and ileal orthotopic neobladders.

OBJECTIVE: To compare secretory immunity in cecal and ileal orthotopic neobladders, and to detect its permanence over time. PATIENTS AND METHODS: IgA was studied in the urine of 33 patients with ileocecourethrostomy (ICUS) and 13 patients with ileal reservoir (IR). The mean follow-up was 55 months. Results were compared in terms of the type of operation, a healthy control group, and the time since surgery. RESULTS: Urinary IgA levels were significantly higher in ICUS and IR patients than in normal controls. No significant differences in IgA concentrations were detected in patients with different reservoirs and with regard to time. CONCLUSION: Both the reservoirs maintain the function of producing IgA. In particular no differences were detected over time and urine could be a permanent antigenic stimulus. IgA could be considered an adjunctive factor for upper urinary tract protection. For this reason we prefer to use a simple, indirect antireflux mechanism, thus avoiding direct manipulation of the uretero-intestinal anastomosis.

Acid-base and electrolyte balance in urinary intestinal orthotopic reservoir: ileocecal neobladder compared with ileal neobladder.

OBJECTIVES: To compare acid-base and electrolyte balance in ileocecal and ileal neobladders. METHODS: Acid-base and electrolyte balance were studied in 45 patients with an ileocecourethrostomy and 18 patients with an ileal reservoir. The mean follow-up was 51 months. Results were compared with regard to both the type of operation and the time since surgery. RESULTS: No significant differences were found with regard to either the type of operation or the length of follow-up. A preserved renal function is important in maintaining a healthy status. CONCLUSIONS: The use of 35 to 40 cm of ileum or 10 cm of cecum with the ileocecal junction seems to be safe even after a long follow-up. The length rather than the kind of bowel used for bladder replacement appears to be important in safeguarding hydroelectrolyte and acid-base homeostasis. This is particularly true in the presence of preserved renal function.

Haemodynamic changes detected during open prostatectomy and transurethral resection for benign prostatic hyperplasia.

To detect possible intraoperative haemodynamic differences, 60 patients undergoing transurethral (n = 18) or open prostatectomy (n = 42) for benign prostatic hyperplasia were evaluated. The same type of general anaesthesia was used in the two groups. Data, including temperature and cardiac output, were collected at five standard times during the procedures. No significant differences were found between the two groups. However, in all patients, irrespective of the operation, significant decreases in cardiac output and increases in systemic resistance occurred during surgery. Body temperature showed a mild, insignificant decrease, which may play a role in determining the mild haemodynamic derangement observed in all patients. Our patients subjected to open prostatectomy and transurethral resection presented the same kind of haemodynamic derangement, with no significant differences. Therefore it seems unlikely that the kind of surgery could play a relevant role in the late mortality rate of these patients.

[DRG charge and real cost of a radical prostatectomy: preliminary considerations before a study of cost reduction]. / Tariffa DRG e costo reale di una prostatectomia radicale: considerazioni preliminari a uno studio per il contenimento della spesa.

Aim of the work was to evaluate the real cost of a radical prostactemy in comparison with the DRG's tariff rates. This work has been conduct before a next study whose objective is the reduction of the costs. The unitary estimated cost of the radical prostatectomies performed from 1997 to April 1998 in the Urological Division of the Università Cattolica S. Cuore has been extrapolated from the entire clinical activity of the same period. The real cost of an uncomplicated radical prostatectomy was also detected. The estimated cost was Lit. 8,225,872 in comparison to the DRG's tariff rate of Lit. 8,842,000; instead the real cost was Lit. 9,085,407. Forty-seven percent of this sum was for routine care in the Division, while 30% for operating room, 5% for pharmacy, 4% for laboratory and 14% for other items. In our institution an operation of high specialization like radical prostatectomy already performed without any complication is little remunerative. Routine care was the major cost: we think its improvement is the first step in order to contain the expense. In this way we can expect secondarily also a reduction in the days of stay.

[Staghorn kidney calculi. A very unusual case of bilateral fistulization and abscess]. / Calcolosi renale a stampo. Un rarissimo caso di fistolizzazione ed ascessualizzazione bilaterale.

A rare case of bilateral pararenal abscess secondary to staghorn calculi is reported. It is characterized by a singular evolution in both side, with fistulization along iliopsoas muscle until the Scarpa triangle. Considering the seriousness of this illness, the importance of an early surgical therapy of complicated staghorn lithiasis is underlined.

Patient selection criteria in the surgical treatment of veno-occlusive dysfunction.

PURPOSE: We evaluated short and long-term results of simple and complex venous surgery in patients with veno-occlusive dysfunction unresponsive to maximum recommended doses of intracavernous alprostadil, who were selected with newly developed diagnostic indicators. MATERIALS AND METHODS: A total of 23 impotent men with a mean age of 41 years (range 20 to 50) underwent complex penile venous surgery. Only patients fulfilling at least 3 criteria were included in study. The criteria were mild cavernous leak assessed by cavernosometry (grades 1 and 2), more than 30% cavernous smooth muscle tissue (histomorphometric analysis), normal analogical corpus cavernosum electromyography recordings according to international standards, cavernosal oxygen tension greater than 65 mm. Hg at erection and age younger than 50 years. RESULTS: Of 23 patients 17 (74%) had normal erections within a year after surgery, and 5 of them (29%) complained of recurrent erectile dysfunction. At long-term followup 6 of 12 patients had spontaneous erections. CONCLUSIONS: Careful selection with advanced diagnostic techniques should be mandatory before performing venous surgery in patients with high degree veno-occlusive dysfunction as the only alternatives are major therapeutical solutions.

Terazosine and tamsulosin in non bacterial prostatitis: a randomized placebo-controlled study.

Eighteen patients with inflammatory process of the prostate met criteria for the inclusion in the study: 1) non bacterial prostatitis; 2) no previous treatment. Then they were randomized into three groups as it follows: terazosine, tamsulosin and placebo. Alpha-blockers and placebo were given for two months, after which further uroflowmetry was performed. Symptom score was evaluated before and after treatment. Terazosine was effective in reducing TO (p = 0.01) as tamsulosin and placebo did not. Both terazosine (p = 0.034) and tamsulosin (p = 0.006) reduced max TQ as placebo did not. Symptom score significantly improved in patients receiving terazosine (p = 0.0002) and tamsulosin (p = 0.001) while insignificantly in whose receiving placebo.

Two atypical cases of renal leiomyosarcoma: clinical picture, diagnosis and therapy.

The Authors report two cases of renal leiomyosarcomas with atypical clinical features. Despite a malignant histological picture, nephron-sparing surgery was performed. The two patients are alive and disease-free at six years and fifteen months respectively. Specific radiologic findings, indications and rationale for conservative treatment are discussed.

Xylose absorption and metabolic status in urinary intestinal orthotopic reservoir: ileocecal compared with ileal neobladder.

PURPOSE: We compare the absorption of D-xylose and vitamin B12, and the metabolic status in ileocecal and ileal orthotopic neobladders. MATERIALS AND METHODS: D-xylose plasma levels after an oral load, body composition, plasma vitamin B12, acid base and electrolyte balance were studied in 33 patients with an ileocecal reservoir and 13 patients with an ileal reservoir. Mean followup was 55 months. Results of both types of operation and a healthy control group were compared. RESULTS: Plasmic levels of D-xylose and vitamin B12 were significantly lower in the ileal reservoir than in ileocecal reservoir group and normal controls. CONCLUSIONS: Despite an acceptable body composition, intestinal malabsorption could be present in patients with an ileal reservoir but the ileocecal tract appears to be safe.

Adenocarcinoma of the urachus: radical or conservative surgery? A report of a case and a review of the literature.

AIMS: To identify the most appropriate surgical strategy for carcinoma of the urachus. METHODS: Analysis of a case of adenocarcinoma of the urachus and an examination of the current literature were carried out. CONCLUSIONS: Partial cystectomy is considered the most appropriate surgical strategy but the need for close follow-up is underlined.

The natural history of metachronous renal cell carcinoma.

A case of metachronous renal cell carcinoma is reported in a 52-year-old male patient who had previously undergone radical nephrectomy for cancer in 1989. He was thereafter monitored with annual CT-scans. In January 1994, a small, solid, renal parenchymal mass was detected in the opposite kidney. Following that, three consecutive abdominal CT-scans were carried out over the year in order to evaluate any changes. Subsequently, elective right nephron-sparing resection was performed. This report discusses neoplasm detection, evolution and clinical approach in a patient with previous nephrectomy for cancer.

Clinical review of 100 consecutive surgically treated patients with upper urinary tract transitional tumours.

OBJECTIVE: To determine the outcome of conservative or radical treatment in a retrospective study of 100 consecutive patients with upper urinary tract tumours. PATIENTS AND METHODS: From 1965 to 1995, 100 patients (78 men and 22 women, mean age 65 years, range 27-82) with upper urinary tract tumours were treated surgically, using nephroureterectomy with excision of a cuff of bladder in 53 and organ-sparing treatment in 47. The outcome was assessed as survival and recurrence during a follow-up of up to 15 years. RESULTS: After radical and organ-sparing treatment, the 15-year cancer-specific survival was 69% and 25%, respectively; metastases developed in 17% and 19% and global recurrence in 40% and 70%, respectively. While locoregional and bladder recurrences were similar in the two groups (9% vs 8% and 30% vs 38%, respectively), ureteric-stump recurrence in the conservative group was 23%. There were no significant differences in survival rates between patients with single or multiple presentation, or for localization, while the grading of the lesions proved to be an accurate prognostic indicator. CONCLUSION: This experience of urothelial neoplasia of the upper tract highlights the difficulty in diagnosing this pathology and in entrusting screening to a non-invasive technique such as urinary cytology. The percentage recurrence observed after organ-sparing therapy indicates that this treatment should be used cautiously.

Immunologic findings in Peyronie's disease: a controlled study.

OBJECTIVES: Recent literature suggests the hypothesis of an immune etiology of Peyronie's disease. In this controlled study, the immune response pattern of the disease is investigated. METHODS: Sixty-six patients with Peyronie's disease and 20 age-matched controls were studied. In all patients, skin test (multitest), in vitro lymphocyte transformation test (LTT), serum immunoglobulin (Ig) A, G, and M, anti-DNA, antinuclear and anti-smooth muscle cell antibodies, C3 and C4 complement fractions, antistreptolysin, and C-reactive protein titers were evaluated. RESULTS: A fair percentage (75.8%) of the patients with Peyronie's disease exhibited at least one abnormal immunologic test, in comparison to only 10% among controls (chi-square = 27.8, df = 1; P < 0.0001). Alterations of cell-mediated immunity (multitest, LTT) were observed in 48.5% of patients, alterations of humoral immunity (Ig) in 31.8%, and alterations of markers of autoimmune disorders (autoantibodies, complement activation) in 37.9% of the cases. CONCLUSIONS: Our results support the hypothesis that there is some involvement of the immune system in the pathogenesis of Peyronie's disease, although the available data still appear to be insufficient to formulate a definite pathogenetic hypothesis.

[Diagnostic difficulties in renal leiomyosarcoma. Case report and review of the literature]. / Difficoltà diagnostiche nel leiomiosarcoma renale. Case report e review della letteratura.

The authors report a case of renal leiomyosarcoma and a review of the literature, underlining the difficulties of making a correct differential diagnosis with the benign neoplasms of the kidney and in performing correct surgical therapy.

The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years' experience.

OBJECTIVE: To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement. PATIENTS AND METHODS: Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation. RESULTS: All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred. CONCLUSIONS: The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

Bladder replacement in women: a new experience.

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

A rare case of perirenal myelolipoma. Diagnostic approach and therapeutic strategy.

A very rare case of perirenal myelolipoma and the problems of differential diagnosis are reported. The non-specificity of, and sometimes even the lack of, radiological and haematological data prevents physicians from preoperatively excluding a malignant neoplasm with a certain degree of confidence. Surgical exploration remains a compulsory step in myelolipoma management and its simple removal seems to be the therapy of choice.