Experience with instrumental chemolysis for urolithiasis.

PURPOSE: We describe a more efficient solution for calcium magnesium stones, an irrigation technique devised by us, and the indications for and results of our 20-year experience with direct renal or ureteral chemolysis. MATERIALS AND METHODS: Renal and ureteral perfusion is performed with 2 coaxial catheters (where the interspace is 1-way circulation), a normal ureteral catheter to a nephrostomy tube or, if the ureter is impractical, a nephrostomy tube after inserting it in a thin catheter achieving coaxial circulation. The perfusion operates by gravity with continuous flow maintaining a negative pressure in the cavities and keeping the circuits sealed during treatment. All equipment is mounted on a mobile support which the patient can take anywhere in the hospital. RESULTS: During the last 20 years 8 cystine stones and 20 "difficult" stones have been completely dissolved and the volume of 39 staghorn struvite stones has been reduced an average of up to 80% before 1 or 2 final lithotripsy sessions without significant side effects. Small fragments remained in the inferior calices in only 2 cases. CONCLUSIONS: Chemolysis is useful for eliminating cystine stones as well as for cases in which lithotripsy or endourology is considered difficult or risky. Furthermore, chemolysis proved to be a useful method for reducing staghorn stones before performing lithotripsy.

[The basquet in day hospital]. / I1 basket in Day Hospital.

We use the basket as the first choice method to treat the pelvic ureteral stones, according to the standard technique. In the last two years ('96, '97) the basket has been used in 49 cases (27 and 22 respectively) with pelvic ureteral stone; 4 of them were treated also by ESWL. So, 45 Pz have been treated only by basket and the success was obtained in 43 cases (95.5%). The 74% (32/43) of the cases were completed in a single step procedure and the 72% (23/32) of them have been discharged on the subsequent morning. Considering these results it is possible to perform the technique during a day hospital on condition that some parameters are respected: little size of the stone, seat near the bladder, easy insertion of the basket and female patient preferably. In any case we have to inform the patient about the possibility to proceed with a delayed extraction.

[T1G3 bladder tumors]. / I tumori vescicali T1G3.

Bladder tumors T1G3 are aggressive and difficult for their staging. Out of 176 p. with tumor pT1, 16 (9%) presented pT1G3. Among the latter 4 were submitted to TUR and chemioimmunotherapy; 5 to surgical partial resection and radiotherapy; 7 to radical cystectomy. After a mean interval of 21.6 months free of relapse, 5 p. had recurrent T1 tumor below G3: 1 out of 4 after TUR; 1 out of 5 after surgical resection; 1 out of 7 after cystectomy. Clinical T1G3 8 revealed a greater pathological staging: 7 (50%) had a relapse in spite of an aggressive therapy (2 TUR; 4 surgical resection; 8 cystectomy); 5 out of the 7 relapsed revealed a greater pathological staging than T1; 2 died by metastasis. The therapeutical choice should be demolitive from the beginning. Should conservative therapy be decided, the convenience of surgical bladder resection has to be considered because, besides being effective, has some advantages over TUR: easier and unfailing staging possibility of contemporary lymphadenectomy healing of bladder by first intention.

[Radical versus conservative therapy in prostatic adenoma. Open adenomectomy]. / Terapia demolitiva versus terapia conservativa nell' adenoma prostatico. Adenomectomia a cielo aperto.

Our technical procedure for surgical adenomectomy of prostate is the Hey-Delinotte one. Indications for this type of procedure are large adenomas with a volume, estimated by ultrasonography, more than 50 cc. and with significant obstruction and urinary retention. In our experience during the past 3 years, in patients without severe operating risk, it was utilized a little more frequently than transurethral resection. We hope that in the future the new procedures will be as useful and resolutive as traditional ones.

[Instrumental chemolysis of cystine calculi]. / La chemiolisi strumentale dei calcoli di cistina.

ESWL and PCN have modified the urinary stones therapy. Nevertheless these therapeutic procedures are not much effective in cystine stone because of its protein structure and frequent recurrences; these procedures need to be combined to achieve the best results. In cystine stones the lithochemolysis, performed following recent technique has shown excellent results, without complications and easy to apply.

[Treatment of symptomatic bone metastases of prostatic carcinoma using strontium chloride (Sr-89)]. / Trattamento delle metastasi ossee sintomatiche da carcinoma prostatico con Cloruro di Stronzio (Sr-89).

Until now, patients with a progressive prostatic cancer, in whom all therapies failed and the disease spread locally and distally, was considered "a lost patient"; because it did not exist an effective therapy easily to be used. The skeletal pain control is a serious problem and it is a great responsibility also for the Urologists especially if the patient has not a short survival time and the quality of life is very poor. Physicians feel the need for a systemic, well tolerated and effective therapy also for a long time, uniform and repeatable, able to be efficient for these patients. Strontium 89 chloride seems to offer all these possibilities and to be the best procedure for Urologist, Radiotherapists and Nuclear Specialists in order to satisfy the patients requirements. International research has shown Sr-849 Chloride is a powerful new therapy. Sr-89 Chloride is a radiopharmaceutical product for the treatment of painful metastases from prostatic cancer. It is a new treatment but its effectiveness is well documented and results are reported in the most important international literature. In our Department a clinical research has started and our purpose is to produce more data for a clinical and biological evaluation of the results, hoping that a similar research will extend as a multicenter study.

[Recurrence of lithiasis after extracorporeal lithotripsy, percutaneous surgery, and open surgery for calculi of the upper urinary tract]. / Récidives lithiasiques après lithotritie extracorporelle, chirurgie percutanée et chirurgie ouverte pour calculs du haut appareil urinaire.

The safety and short-term effectiveness of percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL) have already been well established. However, long-term follow-up studies are essential to prove that the recurrence rate after PCNL and/or ESWL is equal or even better than that of surgery. We reviewed 57 patients treated with ESWL monotherapy, 45 patients treated by PCNL (or by PCNL combined with ESWL for complete staghorn stones) and 59 patients treated by open surgery who all had at least three years of follow-up. The overall recurrence rate for ESWL was 37% for PCNL and for open surgery 39%. ESWL, PCNL and open surgery all showed a higher rate of recurrence and persistent bacteriuria when associated with residual stones. Therefore every effort should be made to remove residual fragments following stone treatment. We conclude that because of its efficacy and low morbidity ESWL should be the treatment of choice for most of renal calculi. Complete staghorn calculi are best treated with open surgery because the complete elimination of all calculous material and the eradication of infection are achieved at a higher rate than by PCNL and ESWL.

[Treatment of symptomatic bone metastases of prostatic carcinoma with strontium (Sr-89) chloride: initial experience]. / Trattamento delle metastasi ossee sintomatiche da carcinoma prostatico con Cloruro di Stronzio (Sr-89), esperienza iniziale.

Until now, patients with a progressive prostatic cancer, in whom all therapies failed and the disease spread locally and distally, was considered "a lost patient"; because it did not exist an effective therapy easily to be used. The skeletal pain control is a serious problem and it is a great responsibility also for the Urologists especially if the patient has not a short survival time and the quality of life very poor. Physicians feel the need for a systemic, well tolerated and effective therapy also for a long time, uniform and repeatable, able to be efficient for these patients. Strontium 89 chloride seems to offer all those possibilities and to be the best procedure for Urologist, Radiotherapists and Nuclear Specialists in order to satisfy the patients requirements. International research has shown Sr-89 Chloride is a powerful new therapy. Sr-90 Chloride is a radiopharmaceutical product for the treatment of painful metastases from prostatic cancer. It is a new treatment but its effectiveness is well documented and results are reported in the most important international literature. In our Department a clinical research has started and our purpose is to produce more data for a clinical and biological evaluation of the results hoping that a similar research will extend as a multicenter study.

[Sedation with flunitrazepam and its antagonism with flumazenil in endoscopic urological procedures: our clinical experience]. / Sedazione con flunitrazepam e suo antagonismo con flumazenil nelle procedure urologiche endoscopiche: nostra esperienza clinica.

Patients, especially males, do not easily stand endoscopic urological diagnostic examinations. So flunitrazepam (0.01 mg/kg IV) has been used to insure a suitable sedation. At the end of such examination flumazenil, a selective benzodiazepine antagonist has been injected. The levels of sedation and orientation so obtained and the cardiorespiratory parameters have been collected during a one hour follow-up from the intravenous injection of the antagonist. This method presents minimal side effects (a marginal, but statistically significative, systolic arterial pressure reduction), a completely normal coordination of movements and awareness of space and time relationship at the end of the observation period. Therefore it is a very good solution for short time examinations giving the chance to safely and shortly dismiss the patient.

[Complications and limitations of pelvic ureter endoscopy]. / Complicanze e limiti dell'endoscopia dell'uretere pelvico.

We report complications and general limits of low ureteroscopy in relation to the use of ureteroscope in a normal or pathologic urinary tract and during rigid ureteroscopy for diagnostic purpose or instrumental procedures. It is plain that limits are represented by anatomic or pathologic urinary tract alterations whereas complications only depend on instrumental procedures. Complications are less frequent in the pelvic ureter and seem to give few negative results.

[Limitations and complications of the use of the basket]. / Limiti e complicanze nell'uso del basket.

During the last 15 years the Dormia stone dislodger has been used in 352 cases (80%) out of 435 of ureteral stones: 318 were at ileo pelvic, 34 at lumbar level. 303 ileo pelvic and 21 lumbar stones have been successfully removed (92%). Considering that the probability of stone removal is directly proportional to the ureteral expansibility and indirectly proportional to the volume of the stone, the Basket technique isn't indicated: When the stone is more than 1 cm.; When the ureter is widely stiff (as in Ormond d. or post-radiotherapy stiffness); When stenosis is present. The impossibility of bypassing the stone, the insufficient expansion of the Basket, the stone irremovability and the difficult extraction through the meatus, my limit the successes of this technique while iperating. The immediate complications have been: 4 sectoral rips of the mucosa surrounding the ureteral end, cured by catheterisation without aftereffects (1.2%); 1 sliding of the ureter through the trigone up to urethral meatus (in a woman), which has been repaired, without aftereffects, by direct catheterisation of the ureter, out of the urethra, after removal of the Basket and stone from the ureteral extremity. (0.3%) Strictures occurred in 5 cases (1.5%) and vescicoureteral reflux in 6 (1.8%). These results of the sole Basket technique (performed according to the well-known directions) seem to be much better than those (which have been illustrated) obtained with the endoscopic lithotripsy.