Use of pedicle flap from the labia minora for the repair of female urethral strictures.

INTRODUCTION: We present the method of pedicle labial urethroplasty for urethral reconstruction in female patients treated for urethral strictures. PATIENTS AND METHODS: We performed urethral reconstruction using a pedicle labial flap in 2 female patients (23 and 70 years old) for urethral stricture (posttraumatic and postinflammatory origin). We used as a patch a pedicle skin flap obtained from the labia minora. The pedicle flap is slid beneath the vulvovaginal wall, until the urethra is reached. RESULTS: In both cases a normal micturition was obtained, and cystourethrography after 24 months showed a good urethral silhouette, without residual urine. CONCLUSION: The pedicle labial urethroplasty seems to be a reliable technique for the repair of urethral strictures.

Damage to the erectile function following radical pelvic surgery: prevalence of veno-occlusive dysfunction.

A retrospective study was carried out to investigate the prevalence of venoocclusive dysfunction (VOD) in 44 patients who developed impotence following radical cystectomy (24 patients, 55%) and radical prostatectomy (20 patients, 45%) for invasive cancer, performed using a non nerve-sparing technique. Patient evaluation included sexual history, hormone profile, intracavernosal injection test and, in the nonresponders to the test, dynamic infusion cavernosometry and cavernosography (DICC). The follow-up period investigated ranged from 6 months to 9 years and 5 months (average 2.5 years). Our data indicate a 11% prevalence (5 patients) of postsurgical VOD with impotence following radical cystectomy and a 5% prevalence (2 patients) of impotence following radical prostatectomy. In the 7 patients (5 after cystectomy and 2 after prostatectomy) who underwent DICC, cavernosal artery insufficiency was detected. No correlation was found between VOD and the time from surgery (from 6 months to 9 years, average 4.4 years), in both the post-cystectomy and post-prostatectomy groups. Our data indicate that there are not only neurogenic causes of impotence following radical pelvic surgery, VOD and cavernosal artery insufficiency can also be partly responsible. Furthermore, it was shown that erectile inactivity, even in the long-term, does not affect the possible return of drug-induced sexual potency.

[Sex-dynamic characterization of patients subjected to radical pelvic cavity surgery]. / La caratterizzazione sessodinamica nei pazienti sottoposti a chirurgia radicale dello scavo pelvico.

A retrospective study was carried out using sexual case histories, hormonal profiles, vasoactive drugs test, dynamic cavernosometry and cavernosography on 46 patients who underwent radical cystectomy (26 patients: 57%) and radical prostatectomy (20 patients: 43%) for neoplasia, conducted by means of traditional surgical non-nerve sparing methods, in order to characterize the type of damage affecting the erectile function as a result of surgery. The study was carried out at a minimum of 2 months, a maximum of 9 years and 5 months, an average of 2 years and 6 months, after surgery. One patient (2%) reported intact erectile function and withdrew from the study. 37 patients (80%) showed neurological damage, while the remaining 8 (18%) had prevalently vascular damage.

[Ureteritis]. / Le ureteriti.

We relate our experience about ureteritis, especially non specific ureteritis. The traumatic, radiation ureteritis will be discussed in others chapters. Most cases of ureteritis are infective, and may be due to any of the organism normally found in urinary tract infections, particularly Escherichia Coli, staphylococci, streptococci, enterococci, proteus and pyocyaneus. It is really primary, but it usually ascending from an associated cystitis, descending from pyelonephritis, or due to direct spread from and adjacent inflammatory lesion such as appendicitis or salpingitis. The infection may also reach the ureter by lymphatic spread, particularly from the prostate and seminal vesicles. Any associated abnormalities of the ureter, such as stricture, megaloureter, ureterocele, and so on, will naturally predispose to infective ureteritis. As ureteritis is rarely primary, the first step in treatment must be toward the elucidation and cure of any underlying lesion. Thus calculi, cystitis, pyelitis, and so on, will need appropriate therapy, and this in itself will considerably improve or cure the ureteritis, and specially in the more acute cases. In the chronic cases with stricture formation, dilation or even excision of the stenosed portion may be required. For the treatment of the strictures we want emphasize the role of the ureteral stenting thinking its use is necessary to preserve the renal function.

[Primary ureteral neoplasia]. / Neoplasie ureterali primitive.

From 1983 to 1992, 29 patients with primitive ureteral tumors have been recovered in our department. All the tumors were urothelial. Urography, spontaneous and selective urinary cytology, retrograde ureteropyelography permitted a correct diagnosis in 86% of them. Ureteroscopy is not performed routinely but only when conventional radiology is doubtful or a conservative treatment can be proposed. Controlled trials on endoscopic therapy of ureteral tumours are very few and even if our results are encouraging we believe that this therapeutic option is effective and safe only in selected case and nephroureterectomy is the treatment of choice.

[Controversies on the subject of traumatic lesions of the ureter]. / Controversie in tema di lesioni traumatiche dell'uretere.

The injuries to the ureter, whether from external trauma or iatrogenic, are rare. Some problems are common to this type of pathology, independently from the causes of injuries. It is necessary a prompt diagnosis of the lesion to avoid the urinar leakage, the infection and the fibrosis of the ureteral's stumps. If the diagnosis is not prompt, the clinical pattern may be silent for some days; after, many complications will arise up: sepsis, urinomas and fistulas. When the lesion is incomplete, and there is no devascularization, the urine drainage alone, positioned above the level of the lesion, is indicated for spontaneous repairing. When the ureteral tissue loss is extensive, it is not enough a simple anastomosis between the ureteral's stumps; in these cases is necessary a more complex repair surgery or ureteral substitution.

[Idiopathic retroperitoneal fibrosis]. / Fibrosi retroperitoneale primitiva.

Idiopathic retroperitoneal fibrosis is generally held to be uncommon. Its etiology is unknown. The disease continues to present with early bilateral ureteric involvement. Nowadays imaging techniques permit so a timely diagnosis to preserve and reduce renal damage. The optimum method of management is still controversial. Controversies on pharmacological, endourological and surgical treatment are debated. The advantages of various types of surgery are reviewed. In the urological department of the Civic Hospital in Brescia from February 1984 to June 1992, 87 patients (6 females and 2 males) with IRP were observed. Surgical treatment was combined with corticosteroids in 6 patients. Ureterolysis was performed with omental wrapping in 5 patients, with ureteric intraperitonealisation in 2 other ones. In the last case an ileal loop replacement was performed. In 5 out of 8 patients the ureteral stricture was resected and a termino-terminal anastomosis was necessary. Long-term follow-up is satisfactory. The authors conclude that omental wrapping is the safest method of choice.

[Controversies concerning the treatment of ureteral complications following kidney transplantation]. / Controversie nel trattamento della patologia dell'uretere trapiantato.

The ureteral complications after renal transplantation are urine leakage, stenosis and vesicoureteral reflux. The treatment is influenced by immunosuppression and difficult surgery (for bleeding and fibrosis). We report 8 cases with ureteral complication after renal transplantation. Stenosis were present in 5 cases: we performed ureterocystoneostomy by Politano-Leadbetter technique in 4 and pyelocystoanastomosis in 1. Vesicoureteral reflux were present in 3 cases: we preformed ureterocystoneostomy by Politano-Leadbetter technique in 2 and endoscopic infiltration with teflon of ureterovesical junction in 1. At present all patients have a normal renal function and absence of urinary tract infection.

[Our experience in surgery of metastases of parenchymal renal neoplasms: mean follow-up time results]. / Nostra esperienza nella chirurgia delle metastasi da neoplasia renale parenchimale: risultati a medio termine.

The Authors report their experience about surgical treatment of metastases from renal cell carcinoma. From January 1983 to December 1989, twenty eight patients, 19 males and 9 females, with a median age of 58 years (range 42-79), have been submitted to contemporary or subsequent metastasectomy. Metastases were synchronous in 10 cases, while they appeared after a free disease mean-time of 28 months after nephrectomy in 18 patients. Recovery period has always been normal and all the patients were controlled, every six months, with routine blood and urine examinations, Chest X-ray, abdominal CAT and bone scan. Among the 10 patients with synchronous metastases 5 died, 3 are in progression and 2 are NED after a mean-time follow up of 36 months. Among 18 patients who underwent surgery for metachronous metastases, 2 died, 4 are in progression and 12 NED (mean follow up of 36 months). In conclusion, while the presence of synchronous metastases is an unfavourable prognostic factor even after their surgical removal (8 out of 10 patients died or are in progression shortly after metastasectomy), results after metachronous metastases surgery are encouraging, but the real efficiency of this treatment is still to be confirmed.

[Bladder neck cysts: role of transrectal echography]. / Cisti del collo vescicale: ruolo dell'ecografia transrettale.

High frequency probes for transrectal sonography are well tolerated and permit us to study the cervico-urethral unit carefully. We are allowed to single out some rare causes of obstruction, otherwise difficult to diagnose. Bladder neck obstruction secondary to a cyst is one of these. Our case report is about a young patient with complete retention secondary to bladder cyst discovered by transrectal sonography.

[Echography versus nuclear magnetic resonance in the preoperative dynamic evaluation of plastic penile induration]. / Ecografia versus risonanza magnetica nucleare nella valutazione dinamica preoperatoria dell'induratio penis plastica.

Recently Ultrasonography (US) and Magnetic Resonance Imaging (MRI) has been successfully used as painless and non invasive techniques for depicting dense fibrous connective tissue of Peyronie's Disease (PD). The purpose of this study is to demonstrate the extent of disease and to prove the accuracy of US versus MRI. Twenty patients (aged 20-70; mean 43) with clinical diagnosis of PD were studied. All patients were studied with flaccid and erected penis after an intracavernous injection of Papaverine (variable dose). US and MRI examinations were performed independently by 2 groups of observers who knew clinical findings but not the results of the other technique. Both methods gave satisfactory images: they show the capacity to depict and to measure Peyronie's plaques clinically appreciated. US in 4 patients and MRI in 3 patients identified not palpable lesion which infiltrate the septum. Although the most common area of PD involvement is the dorsal surface of tunica albuginea, sometimes fibrous plaques are along the septum between the corpora cavernosa and the corpus spongiosum. In the present study, US and MRI are too able to identify not palpable lesion in the septum. In our opinion US has to be used for its high accuracy and low cost.

[Surgical treatment of caval thrombosis caused by parenchymal renal neoplasms]. / Trattamento chirurgico della trombosi cavale da neoplasia renale parenchimale (N.R.P.).

The incidence of renal cell carcinoma with a vena caval tumour thrombus has been reported in the literature, form 4% to 19%. Vena caval involvement causes serious diagnostic and therapeutic problems. Surgical treatment is usually conditioned by the tumor thrombus cranial extension and the possible invasion of the vena caval wall. Using Diagnostic Imaging (ECHO, CAT, MRI) we are able to establish the real presence, dimension and extension of the tumor thrombus, but we can not evaluate precisely its nature or the infiltration of the vena caval wall. We report our own experience in 27 patients with renal cell carcinoma extending into the vena cava (22 cases with tumor thrombus extending under the diaphragm and 5 cases over the diaphragm) and describe our favourite approach for thrombus extending into the right atrium using extracorporeal circulation, profound hypothermia and cardiac arrest (3 cases). From our data, we believe that the vena cava involvement doesn't make the prognosis any worse, if it isn't associated with the infiltration of the vena caval wall and nodal disease.

[Comparison of prostatic biopsy guided or not guided by echography]. / Comparaison entre biopsie prostatique aveugle et sous échographie.

We studied 151 patients aged from 49 to 85 years (mean 71) with a clinical suspect of prostatic cancer. 104 underwent a transrectal digitally directed prostatic biopsy, while 47 an ultrasonically perineal guided prostatic biopsy. Transrectal fine needle aspiration was performed in the whole group. Both techniques showed a high cyto-histologic concordance: 83.6% with transrectal digitally directed biopsy, 78.7% with perineal ultrasonically guided biopsy. The ultrasound guided biopsy has been able to downset the rate of cytologic false negatives in comparison to the digitally guided biopsy. In case of pathological rectal examination, digitally directed prostatic biopsy is still available and those who haven't an ultrasound apparatus, can equally perform a traditional biopsy with a limited possibility of mistake.

[Carcinoma of the penis: our current therapeutic attitude]. / Carcinoma del pene: nostro attuale orientamento terapeutico.

24 cases of penile carcinoma, occurred from 1970 to 1979, have been examinated. The role of limphoadenectomy, the treatment of the primitive lesions and their consequences are discussed. It is opinion of the authors that the risks and the benefits of the treatment must be carefully evalued.