Evaluating urinary continence and preoperative predictors of urinary continence after robot assisted laparoscopic radical prostatectomy.

PURPOSE: We evaluated urinary continence using a validated questionnaire in a series of consecutive patients who underwent robot assisted laparoscopic radical prostatectomy, and identified the preoperative predictors of the return to urinary continence. MATERIALS AND METHODS: The clinical records of 308 consecutive patients who underwent robot assisted laparoscopic radical prostatectomy for clinically localized prostate cancer at a tertiary academic center were prospectively collected. All patients were continent before surgery. Urinary continence was evaluated using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form instrument. All of the patients reporting no leak in response to the question, "How often do you leak urine?" were defined as continent. RESULTS: A total of 273 patients (90%) were continent 12 months after robot assisted laparoscopic radical prostatectomy. Continent patients were significantly younger (61.4 +/- 6.4 vs 64.1 +/- 6.1 years, p = 0.02) than those who were incontinent. On univariable regression analysis patient age at surgery (OR 1.075, p = 0.024) and Charlson comorbidity index (OR 1.671, p = 0.007) were significantly associated with 12-month continence status. On multivariable analysis age (OR 1.076, p = 0.027) and Charlson comorbidity index (OR 1.635, p = 0.009) were independent predictors of continence rates. CONCLUSIONS: Using the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form 90% of patients undergoing robot assisted laparoscopic radical prostatectomy reported no urine leak 12 months after surgery. Patient age at surgery and Charlson comorbidity index were independent predictors of the return to urinary continence, whereas notably no variable related to prostate cancer was significantly correlated with urinary continence.

Antegrade scrotal sclerotherapy in the treatment of varicocele: a prospective study.

OBJECTIVE: To assess the results of our experience in correcting primary varicocele using a modified technique of antegrade scrotal sclerotherapy. PATIENTS AND METHODS: From December 1997 to February 2000, 201 patients with primary varicocele underwent antegrade scrotal sclerotherapy. Before treatment all patients were evaluated by a physical examination, colour Doppler ultrasonography of the spermatic cord, and abdominal and scrotal ultrasonography. Sperm samples were analysed only in patients aged > 18 years. The treatment was administered using a special venous catheter system with a Y-adapter. Complications after treatment and the rate of persistence of reflux were assessed 3 and 6 months after the antegrade scrotal treatment, by clinical examination and colour-Doppler ultrasonography of the spermatic cord. RESULTS: The mean operative duration was 15 min; there were no significant complications during treatment and all patients were discharged within 4 h. Complications after treatment occurred in 10 of the 201 patients (5%); four patients had epididymo-orchitis, three a scrotal haematoma, one a surgical wound infection, one persistent scrotal pain and one persistent flank pain on the same side as the surgery. Reflux was persistent in 12 patients (6%). CONCLUSIONS: Antegrade scrotal sclerotherapy is a simple, minimally invasive and highly effective technique for blocking spermatic vein reflux, with a low rate of complications. The technical changes simplified the cannulation of the spermatic vein and facilitated antegrade phlebography and sclerotherapy using the air-block technique.

Primary lymphoma of the epididymis: case report and review of the literature.

OBJECTIVE: To report an extremely rare clinical pathological observation of a case of primary lymphoma of the epididymis, without testicular or systemic involvement, and to update the relevant literature. MATERIALS AND METHODS: A 25-year-old white male patient complaining of right scrotal pain was referred to our department. Clinical examination detected a hard painful mass at the right epididymal head. Epididymitis was diagnosed and conservative therapy with antibiotics and anti-inflammatory drugs was given. After 2 months of therapy the patient was admitted to our department because a tumor was suspected. Tumor markers were normal. Right scrotal exploration was performed through a standard inguinal incision. The epididymal head was completely replaced by a hard white mass. Fresh frozen sections indicated a malignant tumor. Right radical orchiectomy was performed. RESULTS: High-grade primary epididymal non-Hodgkin's lymphoma with diffuse large cells (group G according to the Working Formulation) was diagnosed. Clinical pathological staging detected stage IE (extranodal) primary epididymal lymphoma. The patient was referred to the Hematologic Unit for combined chemotherapy, according to the VACOP-B protocol. After an 18-month follow-up the patient is well and disease free. CONCLUSIONS: When an epididymal mass does not benefit from medical treatment, scrotal exploration and fresh frozen sections of the lesion should be done. The possible bilateral involvement by primary epididymal lymphoma has to be kept in mind. Radical orchiectomy is the treatment of choice for primary lymphoma of the epididymis. Adjuvant chemotherapy is indicated in high-grade malignant lymphoma. Prognostic parameters of the disease may be the grade of malignancy and the size of the tumor.

Nephrogenic adenoma of the urinary bladder: our experience and review of the literature.

OBJECTIVE: To assess our experience in the treatment and clinical outcome of bladder nephrogenic adenoma (NA) updating and reviewing the literature concerning this issue. PATIENTS AND METHODS: From September 1976 to June 1999, bladder NA was diagnosed in 8 patients: 6 men and 2 women with a 3:1 male ratio, aged 26-80 (mean 58.3) years. Follow-up ranged from 4 to 194 (mean 93.5) months. RESULTS: NA was associated with transitional cell carcinoma in 3 cases. Predisposing factors were assessed in all patients. Previous surgery of the lower urinary tract was detected in 5 cases: ureterocystoneostomy in 2, partial cystectomy in 1, repair of vesicouterine fistula in 1, and multiple urethroplasties in 1. Previous endoscopic treatments were carried out in 2 patients, transurethral resection of the prostate in 1 and repeated transurethral resection of the vesicle in the other. A history of intravesical instillation of bacillus Calmette-Guérin was assessed in 1 case. Patients complained of irritative voiding symptoms in 6 cases and hematuria in 2. Endoscopically, the lesions appeared polypoid and multifocal in 5 patients, and flat and single in 3. The lesions were removed endoscopically, providing relief of symptoms in all cases. Histopathology assessed the diagnosis of nephrogenic adenoma, detecting focal atypic cells in 1 case only. Five patients (63%) relapsed 2-24 months after management. Recurrences were also treated endoscopically. CONCLUSIONS: Clinical and endoscopic features of bladder NA are not specific, simulating urothelial carcinoma or chronic cystitis. Endoscopic management allows accurate histological diagnosis and provides long-lasting relief of symptoms. NA needs careful and long-term follow-up, because of the high risk of recurrences and the potential neoplastic degeneration of the metaplastic urothelium.

[BICAP tumor probe in the palliative treatment of malignant esophageal stenosis]. / BICAP tumor probe en el tratamiento paliativo de la estenosis esofágicas malignas.

BACKGROUND: BICAP tumor probe is a device that consists in an energy source and olives that deliver bipolar electricity. It can be used for the fulguration of esophageal tumors after endoscopic dilatation. AIM: To report the experience in the treatment of malignant esophageal stenoses using the BICAP tumor probe. PATIENTS AND METHODS: Patients with advanced esophageal tumors in aphagia, that were not candidates for palliative surgery were included in this study. After endoscopic dilatation, the tumor was fulgurated with the BICAP tumor probe. RESULTS: Twenty one patients (nine male, aged 43 to 91 years old) were treated with the device. A mean of 1.3 sessions with BICAP were necessary to obtain tumor permeabilization, which was obtained in all patients. One patient died of pneumonia 15 days after the procedure. All other patients were ingesting liquid or semisolid diets after two months of follow up. Mean survival after the procedure was 3.8 months. CONCLUSIONS: Electrical fulguration of esophageal tumors is a valid therapeutic alternative in aphagic patients.

Modern imaging methods and preoperative management of pheochromocytoma: review of the literature and case report.

OBJECTIVES: To discuss the modern imaging techniques and preoperative management of pheochromocytoma and to report on one additional case. METHODS: A 66-year-old male with an incidentally discovered left adrenal mass is described. The adrenal medulla strongly accumulate 131 I-metaiodobenzylguanidine (MIBG). The patient underwent left adrenalectomy after preoperative therapy with alpha and beta-blockers. The recent literature on pheochromocytoma modern imaging techniques and preoperative management is reviewed. RESULTS: MIBG scintigraphy diagnosed a benign functioning adrenal pheochromocytoma, allowing preoperative medical management. Postoperative workup was unremarkable. Diagnosis of pheochromocytoma was confirmed by immunohistopathology. At 18 months follow-up, the patient is alive and disease-free. CONCLUSIONS: Incidentally discovered adrenal masses have to be investigated to detect malignancy and subtle hormonal overproduction. MIBG scintigraphy has a high specificity (100%) in detecting pheochromocytoma, metastasis, surgical residual tumor, local relapse and other adrenal crest tumors. Positive results of octreotide scintigraphy in detecting malignant pheochromocytoma have been reported. Currently, pheochromocytoma removal is a safe operation with mortality rates ranging from 0 to less than 3%. Preoperative alpha adrenergic blockage with phenoxybenzamine or prazosin is important in decreasing the operative risk. Beta-blockers may be necessary for cardiac arrhythmia. Intraoperative invasive monitoring of hemodynamic variables may be both diagnostic and therapeutic of inadequate preoperative management. Lifelong follow-up for patients with pheochromocytoma is important.

Surgical treatment of penile carcinoma: our experience from 1976 to 1997.

OBJECTIVE: The purpose of this work is to evaluate our experience with the surgical treatment of penile squamous carcinoma, analyzing the therapeutic results in terms of local recurrence rates, survival and mortality rates. MATERIAL AND METHODS: From 1976 to 1997, 47 patients were treated at our institution for carcinoma of penis. Treatment of primary tumor was conservative in 8 patients (17%). Partial penectomy was performed in 30 patients (63.8%); total penectomy in 5 (10.7%) and emasculation in 4 (8.5%). Pathological stage was pTis in 2 cases (4.2%), pT1 in 20 (42.6%), pT2 in 21 (44. 7%) and pT3 in 4 (8.5%). The tumor was clinically overstaged in 13 patients (27.7%) and understaged in 4 (8.5%). Bilateral inguinal lymphadenectomy was performed only in 4 patients clinically N+ (pN2) and in 3 clinically N0 (pN0). RESULTS: Local recurrence rate was 43% in the patients with pT1 stage tumor treated conservatively. No local recurrence was observed after penectomy. 19 patients (40.4%) are alive and disease-free; 17 patients (36.2%) died of the tumor and 11 patients (23.4%) died of other causes but disease-free. Mean follow-up is 69.43 months. The overall 5-year survival rate was 34%. CONCLUSION: Partial penectomy gives better results than conservative treatment in the local management of the T1 stage tumor. Survival and mortality rates are related to both pathological and histological stages. The high mortality rate observed in the pT2 stage tumors in our experience might be related to the fact that in this stage an inguinal lymphadenectomy was not performed as a rule.

[Our experience in the conservative surgical treatment of megaureter in the adult]. / Nostra esperienza nel trattamento chirurgico conservativo del megauretere nell'adulto.

Surgical treatment of the megaureter in adults is only indicated when important symptoms and/or complications occur. The Authors report their experience with eight adult patients affected by megaureter, undergone to conservative surgery. The average age of the patients was 36 years (range 21-52). The disease was unilateral in five cases (four on the right side and one on the left), bilateral in three. In five patients megaureter was primary (obstructed in four, refluxing in one). A case of megaureter with ectopic orifice in the prostatic urethra was observed. The remaining two cases, already operated in other hospitals, were a segmentary megaureter associated with vesico-ureteral reflux secondary to endoscopic incision of an ureterocele and a bilateral refluxing megaureter in a patient undergone to bilateral ureterocystoneostomy because of primary megaureter in his childhood. All patients underwent ureterocystoneostomy, performed with Politano-Leadbetter antireflux technique in six cases and with direct non-antireflux technique in two. A reductive Hendren ureteroplasty was also performed in 7 cases. The average length of follow-up is actually of 82 months (range 5-231). Satisfactory results were obtained in three primary obstructed megaureters, in the megaureter with ectopic orifice and in the segmentary megaureter associated with reflux. In two patients with refluxing megaureter surgery was unsuccessful and a new operation was necessary. Finally, one patient with primary obstructed megaureter underwent endoscopic dilatation of the strictured vesico-ureteral anastomosis two months after the ureterocystoneostomy.

[Long-term results of the veno-occlusive percutaneous treatment of erectile disorders of venous origin]. / Risultati a lungo termine del trattamento percutaneo veno-occlusivo della disfunzione erettile di origine venosa.

The treatment of impotence due to venous leakage is remedied by creating an increase in the resistance of the venous outflow in order to trap arterial blood within the corpora cavernosa of the penis during erection. The percentage of success reported in Literature after resection of the deep dorsal vein and ligature of the cavernous veins varies from a minimum of 12.5% to a maximum of 75%. Interventional radiology represents a valid alternative to traditional surgery in the non-prosthesis treatment of erectile dysfunction of venous origin due to the absence of complications and lack of intrusiveness and for the encouraging short and mid term results obtained. From May 1991 to February 1997, seventeen patients (aged between 24-54, average age 36 years) affected by venous leakage underwent embolisation of the principal veins of drainage of the corpora cavernosa. All patients were previously strictly selected in order to exclude those affected by arterial, neurological, endocrine or ++psychological disease. Pathologic venous drainage was shown by pharmacocavernosometry and pharmacocavernosography. The technique employed consisted in isolation and catheterization of the deep dorsal vein of the penis with a cannula needle of 14 G and subsequent ligature and simple section of the vein; venous leakage fluoroscopic evaluation; coils placement under radiological control, in the distal tract of each vein chosen to be occluded; and then at last, embolization of the deep dorsal vein. A fluoroscopic control performed after these procedures showed the correct vascular occlusion. The operation has an average duration of 120 minutes and requires two-day hospitalisation. In 12% (2/17) of the selected cases a technical failure was recorded due to difficult catheterization of the periprostatic plexus, therefore only surgical ligature and section was carried out in the penile deep dorsal vein. Only in one case (6%) there was a slight and transitory oedema of the penis observed. The average follow-up is 34 months (range 3-72 months). Up to now, 11 patients over 15 (73.4%) refer a good improvement of erectile dysfunction together with a satisfactory sexual activity. In two cases (13.3%) only partial improvement have been referred. Only 2 cases (13.3%) did not obtain any benefit from treatment.

A case of testicular metastasis from carcinoma of the prostate.

Authors report a rare case of testicular metastasis from carcinoma of the prostate in a patient treated with anti-androgen therapy. The report of this kind of testicular metastasis was more frequent in the past years, when the neoplasm was often treated with bilateral orchiectomy. Metastatic carcinoma of the prostate to the testis is commonly accepted as a sign of advanced disease and it is usually accompanied by multiple metastases to other organs. The prognostic significance of testicular localization is still unknown.

[Treatment of renal cysts by percutaneous drainage and alcoholization. Our experience]. / Le traitement des kystes rénaux par drainage et alcoolisation percutanés. Notre expérience.

Since many years renal cysts have been treated by percutaneous puncture and successive aspiration. The introduction of various sclerosing substances has been associated with this manoeuvre. In our study we examined 44 patients with renal cysts submitted to percutaneous puncture, aspiration and injection with 95% ethanol. We thought right to leave a small pig tail catheter so that the sclerosing substance could be easily and completely eliminated allowing the adhesion of the cystic walls in the following days, without any accumulation of cystic and/or exudative liquid. The follow up (12-24 months) has shown no relapsing in 40/44 cases. Only in 4 patients a cyst was present, but with dimensions lower than 30% of the original volume.

[Parapyelic cysts]. / Le cisti parapieliche.

The Authors present four cases of major pyelocaliceal obstruction secondary to parapelvic cyst. The treatment was surgical in all four cases and consisted in the cruentation of the wall of the cyst.

[Protein-sparing peripheral parenteral nutrition in urologic surgery]. / Nutrizione parenterale periferica "protein sparing" nella chirurgia urologica.

The use of parenteral nutrition in patients operated on for cystectomy is a basic post-operative therapeutic aid used for maintaining an adequate state of nutrition. In the present paper, the authors report the results of a study conducted for the purposes of comparing the efficacy of protein-sparing parenteral nutrition versus TPN.

The vesicosigmoidal fistula: diagnosis and surgical treatment.

The authors report their experience in the diagnosis and treatment of 10 cases of vesicosigmoidal fistula. In accordance with the literature the most frequent presenting symptoms were of urinary origin. For the diagnosis urography was helpful, cystography and cystoscopy allowed the observation of a fistulous orifice, while barium enema confirmed, or removed probable doubts about the nature of the intestinal pathology. Surgical treatment varied from one-stage to multi-stage procedures.

A case of anomalous adrenal position: the adrenal-renal heterotopia.

The authors describe a case of adrenal-renal heterotopia. The embryological basis for this anomaly and its clinical significance are reviewed.

[Inverted papilloma of the bladder (considerations on a clinical case )]. / Il papilloma invertito della vescica (considerazioni su un caso clinico).

The Authors present one case of inverted papilloma of the bladder. Morphology, clinical features and prognosis of this lesion are discussed.