Permanent stenting in the treatment of ureteral strictures.

Permanent metallic stents have found wide application for use in the vascular and biliary systems and currently devices are also available for use in the urinary tract. Permanent stenting of the ureter has proven to be an useful option in the management of obstruction caused by external compression due to malignancy whereas the efficacy of permanent stenting in the treatment of benign ureteral strictures is still controversial. We treated three patients with benign ureteral strictures by implantation of a self-expanding endoluminal stent that resulted in ureteral patency persisting up to 24 months.

[Urethral implantation of collagen in the treatment of urinary incontinence. Comparison of transurethral and periurethral approach]. / Impianto uretrale di collagene nel trattamento dell'incontinenza urinaria. Confronto tra accesso transuretrale e periuretrale.

BACKGROUND: In mini-invasive surgery for the treatment of urinary incontinence injectable substances such as politef, autologous fat or bovine collagen, which can increase urethral resistance or support the sphincteric one are particularly used. It's a simple procedure in which patients may undergo local anesthesia, in short time and in "day hospital" regimen. Collagen, used as an injectable bulking agent, is the gold standard for this surgical technique because of complete biocompatibility, no evidences of adverse immunogenic effects, foreign-body reaction, migration of injected material, and because of higher fluidity which allows the use of thin needles compared to Politef (polytetrafluoroethylene) where an injection device is requested. Bovine collagen is partially reabsorbed within 24-36 months and a reinjection is often necessary. Although autologous fat is cheaper than bovine collagen, its injection shows more difficulties due to the need of higher needle diameter and time to store and prepare the material to inject. METHODS: The results obtained by two different approaches: transurethral injection of collagen and periurethral injection of collagen have been studied. A total of 48 patients underwent collagen injection for treatment of urinary incontinence: 24 treated by transurethral approach and 24 by periurethral approach. Follow-up at 6, 12, 24 months after treatment includes: objective exam, PAD test, functional evaluation, complete urodynamic evaluation (uroflow, cystomanometry, LPP, pressure/flow study, UPP). RESULTS: No clinical differences between peri/trans-urethral approach were found although collagen injection via transurethral technique need fewer material, reducing cost of treatment: an efficacy of treatment in 80% of patients and restoration of a complete urinary continence in 50% of patients was obtained. Although no clinical differences were demonstrated between the two different sites of injection, transurethral approach can be used similarly in both sexes even if without a modified resector as "injection device" it's more difficult to inject collagen in the right position, at the level of bladder neck submucosa. Perineal approach, exclusive of female sex, realizes the procedure without bleeding of urethral mucosa and no waste of collagen, though a longer period of training by surgeon is requested. After four years of experience the authors agreed that with an adequate injection device (modified resector), transurethral approach should be preferred, thus depending on the possibility to inject collagen in a correct position, just under bladder neck mucosa, which is possible to manage with this technique, in order to reduce reabsorption process of collagen and to obtain a longer efficacy of treatment reducing the number of reinjection and of course the cost of treatment. Collagen injection should be considered within an integrated therapeutical picture together with topic and systemic pharmacotherapy, physiotherapy, not excluding surgery techniques such as implantation of an artificial sphincter device in man or a sling procedure in woman. CONCLUSIONS: The urethral collagen injection for the treatment of urinary incontinence is a safe, durable and valid technique to improve urinary continence through a non obstructive effect increasing urethral resistance. Performed under local anesthesia this procedure allows the treatment of patients who may not be candidates suitable for general anesthesia and conventional surgery.

[Male and female urinary incontinence: treatment in day surgery]. / Incontinenza urinaria maschile e femminile: trattamento in Day Surgery.

Incontinence isn't itself a disease but the feature of possible urinary tract alterations or outside of it. Incontinence is frequent above all in the elderly but it can be on charge of both sexes at every age. In Italy, according to recent evaluations, people affected with this disease would be more than 4 millions. Incontinence is therefore an important failure for its health aspects but also for economic and social ones. The problem is to evaluate if incontinence can't be prevented and as consequence needs only an assistance management, or it can be considered a preventable disease able to be cured, as we deeply believe, suggested also by the positive results of new therapeutical procedures, in association with traditional surgery and rehabilitation such as injectables or mini-invasive quick operations such as colpocleisis or percutaneous vaginal colposuspension (PVC), matters of this presentation and always performed according to correct diagnosis and indication. Bovine dermal collagen highly purified, poorly viscous and easily injectable, despite traditional rehabilitation and surgery, is a further procedure, endoscopic and minimally invasive to treat stress incontinence. Collagen is employed to perform a bladder neck plasty, increasing urethrosphincterial competence, to obtain continence without the creation of an obstruction. Genital prolapse, that is hysterocolpocele or simple vaginal vault prolapse, has course in high proportion (37%) in elderly (after 80 years). Surgical management of severe failures of continence and often also of the voiding function, such as: hyscuria with vesicoureteral reflux, obstinate constipation related to severe genital prolapse with allied rectocele is often hardly performed in elderly owing to the age and general health conditions: colpoclesis is a vaginal surgical approach that can be easily performed by the urologist too, it is an effective alternative to permanent catheterization or maxipad to be offered to the patient to improve her quality of life. In between the above maintained procedures takes place the percutaneous vaginal colposuspension (PVC). It is an original technique made up in our Institute to treat incontinence by the bladder neck resuspension to Cooper ligament according to a complete miniinvasive retropubic tension free transvaginal colposuspension, in local anaesthesia and complementary light narcosis in Day Surgery. Urinary incontinence is today a disturbance easy to be cured thanks to injectables and to miniinvasive surgical procedures as reported in this presentation concerning the most advanced approaches to its management.

[Orthotopic ileal neobladder: urodynamic and metabolic aspects. Our experience]. / Neovescica ileale ortotopica: aspetti urodinamici e metabolici. Nostra esperienza.

We subjected to a functional and metabolic evaluation (urodynamic examination + cystography) 10 patients underwent to radical cystectomy with a ileal orthotopic reservoir (VIP) for bladder cancer. At the moment patients have a minimum 3-years follow-up and they are out of disease. The medium capacity of the reservoir is about 447 ml, with a low pressure flow, a medium pressure of ureteral closing of 62.5 cm of H2O. At the cystography neither ureteral reflux nor post miction residuum have been proved. All the patients are continent, with the exception of one patient suffering from episodes of nocturnal enuresis. The metabolic evaluation hasn't proved substantial changes except the presence of hypocitraturia in the only patient in metabolic acidosis. In conclusion the ileal orthotopic reservoir showed a good long-term functionality without considerable complication of metabolism.

[Nonsurgical and endoscopic therapy in obstructive azoospermia]. / Terapia non chirurgica ed endoscopica nelle azoospermie ostruttive.

The endoscopic therapy has an elective role in the distal obstructive azoospermia for urogenital carrefour pathologies both organics and functional and differently in the resection and/or aspiration with sperm recovery forms. Resolutely attends to the symptomatology and positively to the fertility re-establishment, in front of a short sickness-rate. The Authors describe the different techniques with relative indications, results and complications. Instead medical therapy has a role in the obstructive above all post infection and post inflammatory lesions prevention. Furthermore propose to oneself the goal to improve the seminal quality by the improvement of the semen fertilization capacity and to reduce the affections symptomatology. Finally concurs with the sperm selection techniques to fertility potential wealth.

[Radical perineal and retropubic prostatectomy: comparison of technics]. / Prostatectomia radicale perineale e retropubica: tecniche a confronto.

Today we may consider radical perineal prostatectomy as an example of mild invasive surgery compared with the retropubic. Technique is found less traumatic account of the precision of the approach, the accuracy of hemostasis and urethral bladder suture and the speed of postoperative handling. The only disadvantage related with the impossibility of transperineal pathological lymph node staging can today be satisfactory overcome after the advent of laparoscopic lymph node methods which permits safe non invasive preoperative hystological examination. The authors show the technique of laparoscopic and surgical therapy, concluding that perineal prostatectomy is a better approach toward retropubic radical prostatectomy, if combined with preoperative laparoscopic pelvic lymphadenectomy.

[Stress urinary incontinence after perineal radical prostatectomy]. / Incontinenza urinaria da stress dopo prostatectomia radicale perineale.

22 pts treated by radical perineal prostatectomy have been submitted to pelvic floor training soon after catheter removal, in order to assess faster continence reappraisal than that normally described in literature. 18 pts resulted dry within 4 months from surgical care. 2 pts resulted with stabilized mild stress incontinence due to daytime activity within 6 months from prostatectomy. 2 pts complained strong stress urinary incontinence over a period of more 9 months from surgery, but none resulted affected from continuous leakage. In this pts we observed a maximum time of continence reappraisal of 6 months with a minimum of 1 and an average of 4. An high perineal test has been found statistically correlated in the first three months from surgery with nocturnal continence reappraisal and the begging of diurnal micturion events (p < 0.005). Pelvic floor exercises has been found useful in the treatment of post radical perineal prostatectomy stress urinary incontinence.

[Erectile function and ablative surgery of penile tumors]. / Funzione erettile e chirurgia demolitiva nei tumori del pene.

The Authors try to show the possibility to combine radical excision with minimal invasiveness in the surgery of penile cancer. The focal point of every therapeutic decision is correct clinical staging. Unfortunately there's some confusion in the two international staging systems (TNM and Jackson's classification). In fact it's not clear the anatomical difference between epithelioma of the glans infiltrating corpus spongiosum and subcoronary epithelioma of the shaft infiltrating the corpora cavernosa. It's obvious that the infiltration of the corpora cavernosa is a far more aggressive oncological manifestation than that of tumour infiltrating the corpus spongiosum. So we consider Jackson's classification more congenial. In terms of surgery this anatomical independence makes it easy to consider the corpora cavernosa as a distinct entity, so they remain perfectly functional when separated from the glandulo-spongio-urethral unit with its vasculo-nervous bundle. This makes conservation of the erectile function, when clinical staging show us that the tumour is not infiltrating the corpora cavernosa. The Authors show their results, which seem to be rather good.

Repair of a recurrent urethrovaginal fistula with an island bulbocavernous musculocutaneous flap.

This paper describes a case of recurrent postpartum urethrovaginal fistula. The extent of the vaginal tissue loss and the perilesional scarring made direct closure of the defect not practicable. After suturing of the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Seven months after surgery, the flap healed well, and cystography showed a regular voiding without periurethral suffusions. Healing of thedonor site also was aesthetically satisfactory.

Bulbocavernous myocutaneous flap: a new technique in repair of recurrent urethrovaginal fistula.

This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.

[Treatment of prostatitis with a new laser probe with optic fiber]. / Trattamento delle prostatiti con nuova sonda laser in fibra ottica.

The present treatment of the subacute abatteric prostatitis, prostatodinia, prostatosis (the most common prostatic flogistic diseases) is represented by the transrectal applications of infrared Laser. The concrete opportunity of applying such an energy directly to the prostate in cases of flogistic diseases--a very frequent pathology treated in many different and controversial ways--is a stimulating therapeutical method which we tested and that we presently use in our clinics. The thanks to the realization of an high technology equipment, easy to handle, cheap, safe, perfectly suitable, formed by a new infrared Laser probe, transrectal, atermical, made by a optical fibre, which we present. Micturition, ejaculation, fertility may draw a relevant improvement, provided that the same treatment is performed after a specific medical diagnosis and following a strict protocol.

Perineal biofeedback versus pelvic floor training in the treatment of urinary incontinence.

Perineal floor training and perineal biofeedback allow to reach a good improvement of clinical discomfort in the treatment of stress and urge urinary incontinence. The aim of this study is the real evaluation of the benefit due to a 6 week perineal biofeedback and pelvic floor training (PFT) versus PFT alone. 8 female patients have been treated with a 6 week trial with perineal biofeedback plus PFT trial and 22 with a 3 month PFT alone one. PFT alone, permits a good improvement but 10% less than if associated to perineal biofeedback.

Treatment of adult primary uncomplicated nocturnal enuresis by pelvic floor training and behaviour modification therapy.

A therapeutical trial based on pelvic floor training, reduced evening fluid intake and a 3 hour nocturnal awakening has been performed by 12 adult primary enuretics. The aim of this study is to verify if diurnal pelvic floor training is useful to gain a nocturnal micturition control.

[Treatment of urinary incontinence in the patient operated on for benign prostatic hyperplasia]. / Trattamento della incontinenza da urgenza nel paziente operato per IPB.

A potential complication of prostatic adenomectomy and TURP is urinary incontinence. The incidence of this problem ranges from 0.1 to 1%. we reviewed our experience with 15 patients who were incontinent between 10 to 24 months after prostatectomy. We treated these patients with bladder training. At first, patients were evaluated for the type and extent of incontinence. Perineal exercise were taught in detail, tested for their correct use via simultaneous and abdominal examination. Patients were evaluated weekly for compliance. No pharmaceutical agents were used. All the 15 patients improved in the number of incontinence episodes 5 patients achieved total continence, while only one showed a little change. We conclude that patients who are incontinent after prostatectomy can improve with a well-done behavioral training program.

Long-term followup after extracorporeal shock wave lithotripsy treatment of kidney stones in solitary kidneys.

A total of 64 treatments by the Dornier HM3 lithotriptor was performed on 52 solitary kidneys with stones. A slight increase but no significant variations in serum creatinine was noted in 15 patients without obstruction just after treatment (p greater than 0.05). No significant increases in serum creatinine were found even at the short-term, mid-term and long-term followup. After 12 to 56 months hypertension developed in only 1 previously normotensive patient. Of 37 patients at mid-term followup (12 to 24 months) 62% were stone-free, 24% had passable fragments, 8% had recurrent stones and 5% had regrowth of the residual fragments. At long-term followup (24 to 56 months) 50% of 26 patients were stone-free, 19% had dust or passable fragments, 19% had recurrences and 11% had regrowth of the residual fragments. The demonstrated effectiveness, small number of complications at the short-term followup, lack of sequelae at the long-term followup and relatively small number of recurrences confirm that extracorporeal lithotripsy is not only effective but also safe. It can be proposed as the treatment of first choice even when the stone is in a single remaining kidney.

[Treatment of ureteral calculi with extracorporeal lithotripsy. Comparison between the original Dornier HM3 and the modified lithotriptor]. / Trattamento della calcolosi ureterale con litotrissia extracorporea. Confronto tra il litotritore Dornier HM3 originale e modificato.

From January 1985 till June 1989, 222 patients with ureteral stones, underwent ESWL treatment. 109 patients were treated with the original Dornier HM3 under general or epidural anaesthesia and 113 patients were treated with the modified Dornier HM3 under anglosedation. 156 stones were in the upper ureter, 15 in the middle ureter, 51 in the lower ureter. We performed a total of 269 ESWL treatments. Out of 109 patients treated with the original HM3 and 113 patients treated by the modified HM3 12 (11%) and 28 (24.7%) needed, respectively, two or more ESWL sessions. In 89.9% and 88.5% of the patients, respectively, has been performed an ureteral manipulation before the treatment to push up or to localize the stone. The treatment was unsuccessful in 10 patients of whom 3 underwent anterograde lithotripsy by percutaneous access, 4 transureteral lithotripsy and 3 surgery. At three months the percentage of patients stone free was as follows: original HM3 patients 88% modified HM3 patients 92.9%. The extracorporeal lithotripsy is now-day the treatment of choice for the ureteral stone without any limitation, due to the stone localisation. The clinical use of modified HM3 on ureteral stones didn't low our success rate, but increased the shock wave out of session.

[Extracorporeal lithotripsy using the HM3 Dornier lithotriptor and the modified HM3 lithotriptor]. / Litotrissia extracorporea con litotritori dornier HM3 ed HM3 modificato.

Extracorporeal shock waves lithotripsy is a well established procedure for the treatment of renal and ureteral calculi. From January 1985 to December 1987, 1034 patients underwent 1152 treatments with the Dornier HM3 lithotripter; from January 1988 and December 1988, 466 patients underwent 566 treatments with the modified Dornier HM3. Treatments with the original HM3 were performed mainly under general anaesthesia (97%). Only 2.4% of modified Dornier HM3 treatments have been performed under general anaesthesia; the 97.6% were treated under a combination of anxiolytic and analgesic drugs. An average of 1900 and 2300 shock waves was applied with the original HM3 and the modified one, respectively. The rate of secondary treatment increased from 10.3% to 17.4% respectively. At three month follow-up the 85.6% of the patients treated with the original HM3 and the 76.7% of those treated with the modified Dornier were free from stones. Low energy lithotripsy with the modified semi ellipsoid has proved to be equally effective as the older generators working with high shock wave pressure.

[An overview of extracorporeal lithotriptors in current clinical use: technical notes]. / Panoramica sui litotritori extracorporei attualmente in uso clinico: note techniche.

ASWL ten years ago opened a new era for kidney stone treatment and recently it's showing a new therapeutical approach to biliary stones. Dornier HM3 is since 1983 the first lithotripter with a wide clinical employment. Actually we know about twenty extracorporeal lithotripter in clinical use. Our review try to classify old and new extracorporeal lithotripsy devices looking at technical aspects and lithotripsy center organization.

Neuroendocrine structures in normal and diseased human lung.

The increasing amount of histological, immunohistochemical and ultrastructural information on some endocrine secretions in human lung cancers suggest the need to revise the classification of neuroendocrine lesions on surgical material. The aim of the present investigation based on lung specimens removed surgically is to give further support to recent proposal for an updated classification of neuroendocrine lung carcinomas. Our study includes 58 squamous cell carcinomas, 58 adenocarcinomas, 6 large cell carcinomas, 27 neuroendocrine carcinomas, and 30 nontumourous cases. Using histological methods (HE, Alcian PAS, Grimelius silver impregnation), we illustrate the presence of neuroendocrine cells and neuroepithelial bodies with their pathological evolutions, ranging from hyperplasia, to dysplasia, and overt neoplasia. On the basis of our experience we propose the following classification of neuroendocrine carcinomas (NEC): typical carcinoids (NECNID), peripheral carcinoid or well-differentiated NEC (NECWED), NEC of intermediate or poorly differentiated type (NECINT) and NEC of small celled or microcytoma type (NECMIC).