Recovery of sexual function after nerve-sparing radical retropubic prostatectomy: is cavernous nitric oxide level a prognostic index?

The preservation of NANC nerve fibers (producing nitric oxide, NO) is necessary for erection recovery after retropubic radical prostatectomy (RRP). Yet, it is impossible to establish when and if a patient will recover erections; therefore, we investigate the prognostic value of cavernous blood NO levels on this parameter. Nerve-sparing RRP was performed on 14 patients for localized prostate cancer. We evaluated all patients 3 months after surgery by IIEF score: no patients had erections. A cavernous blood sample was also taken to determine NO levels (as nitrite). Patients were evaluated again 18 months after surgery. In six cases, erectile function was compromised, whereas in seven cases, potency was restored. Statistical analysis showed a relationship between nitrite levels in cavernous blood 3 months after surgery and the recovery or erectile function at 18 months. We propose that cavernous NO blood levels are a prognostic index of erection recovery.

New therapeutic options for refractory neurogenic detrusor overactivity.

AIM: Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment. METHODS: Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment. RESULTS: With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points. CONCLUSION: In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

Stage pT1 renal cell carcinoma: review of the prognostic significance of size.

INTRODUCTION: The last TNM classification (before 1997) defined T1 kidney tumour as a tumour <2.5 cm, limited to the kidney: this cut-off point was changed in 1997 and T1 neoplasm was defined as <7 cm. This new cut-off now includes past T1 and T2 diseases, without any differences in terms of prognoses. We performed a retrospective analysis of our cases and specifically investigated if there were any differences in terms of prognosis in a group of patients, currently identifiable as pT1, if they were divided into two subgroups based on tumour pathological sizes. MATERIALS AND METHODS: Our analysis involved 128 patients (mean age 57.6 years) who underwent radical nephrectomy or nephron-sparing surgery in the period between 1990 and 2000. All these patients were pT1 according to the new TNM classification and were divided into two groups according to different cut-off point sizes (from 2.5 to 5 cm). We analysed the surgical approach, overall survival and cancer-specific mortality in the two subgroups, renamed as pT1a and pT1b, and performed a statistical analysis of the results using the Kaplan-Meier method to prove if this substaging identified changes in survival outcome. RESULTS: We obtained more interesting results for a 5-cm cut-off: the two groups showed a similar follow-up and overall survival rate but different cancer-specific mortality rate (6 vs. 12.1%). The statistical analysis showed that the two survival curves (pT1a vs. pT1b disease) had a similar trend up to about 60 months; after this period the two curves diversify with a drop in survival rate among patients with larger tumours (pT1b patients). CONCLUSIONS: It would seem reasonable to reassess the TNM classification of stage pT1 in order to better define prognosis in this group of patients.

Renal cell carcinoma: histological findings on surgical margins after nephron sparing surgery.

PURPOSE: We evaluated the incidence of peritumoral satellite lesions in nephron sparing surgery and examined whether these findings have a negative effect on cancer specific survival and on the percent of local recurrence. MATERIALS AND METHODS: We performed nephron sparing surgery in 63 patients with kidney cancer, including 53 elective (group 1) and 10 imperative (group 2) operations. In all cases we removed 10 mm. of apparently healthy peritumoral parenchyma with the tumor. This tissue was subsequently examined by an anatomical pathologist to identify any satellite lesions. RESULTS: Four satellite lesions were identified, including 3 in group 1 and 1 in group 2, at a mean of 5.3 mm. from the primary lesion. None of the patients in either group had local recurrence at followup. Cancer specific survival was 96.3% in group 1 (mean followup 61 months) and 58% in group 2 (mean followup 39 months). It was not influenced by the presence of satellite micro-lesions. CONCLUSIONS: Despite common perplexities concerning the risk of multifocality in renal cell carcinoma we believe that the nephron sparing procedure in select patients is as effective as radical surgery. Based on our experience the surgical safety margin must be at least 10 mm. of macroscopically healthy, peritumoral tissue.

Differing expression of enzymes of the glyoxalase system in superficial and invasive bladder carcinomas.

This work aimed to study the activities of the glyoxalase system enzymes (glyoxalase I (GI) and glyoxalase II (GII) and their gene expression in human bladder carcinomas compared with the corresponding normal mucosa. Samples of these tissues were collected from 26 patients with superficial (SBC) or invasive bladder cancer (IBC) and used to evaluate enzyme activity and gene expression by northern blot analysis. In keeping with the electrophoretic pattern and the expression level of the respective genes, GI activity significantly increased in SBC samples, while it remained unchanged in IBC samples compared with the normal mucosa. In contrast, GII showed a higher activity in the tumour (either SBC or IBC samples) versus normal tissues. These results confirm the role of the glyoxalases in detoxifying cytotoxic methylglyoxal (MG) in bladder cancer. The differing levels of GI activity level and gene expression of GI between the SBC and IBC samples could help in their differential diagnosis.

Peyronie's disease: corporoplasty using saphenous vein patch graft.

OBJECTIVE: To establish who the best candidates for corporoplasty are. The standard guidelines include patients with partial erections, and/or recurvature preventing normal and satisfying intercourse. In our unit we prefer to implant prostheses even in patients with slight erectile dysfunction, therefore patients with full erections routinely undergo corporoplasty. MATERIALS AND METHODS: We report our experience with corporoplasty using a vein patch graft after plaque incision or excision in 12 patients affected by Peyronie's disease. RESULTS: The operation is easy to perform. Recovery of normal spontaneous erectile activity was observed in 10/12 (83%) patients at a mean of 1 month postoperatively. The results of checkups with Rigiscan and EchocolorDoppler have confirmed the stability of the graft and recovery of potency. DISCUSSION: Autologous material is easy to harvest and it is elastic enough to support traction during erection. The patch can be modelled to fashion patches in any shape required. The risk of scar shrinkage, with the consequent onset of recurvature, is lower than with other materials such as Gore-tex or Derma. Corporoplasty ensured rapid rehabilitation of sexual functions in all patients. We do not usually perform the Nesbit procedure as shortening of the penis (which is characteristic of Peyronie's disease) would, in most patients, be accentuated by albuginea plication.

Ureterointestinal anastomosis in orthotopic neobladders.

OBJECTIVE: This study reports our experience with a ureteroileal reimplantation technique based on the Leadbetter-Clarke method, which is used for orthotopic neo-bladders, constructed preferably with the Camey II technique. METHODS: We carried out 114 ureteroileal reimplantations using this technique in 58 patients undergoing radical cystectomy and orthotopic neobladder reconstruction. The incidence of neobladder-ureteral stenosis and reflux were analyzed during the follow-up. RESULTS: During the mean follow-up of 31 months, the incidence of stenosis was 2.6% (3 ureteroileal implants, including 1 case of neoplastic stenosis). The incidence of slight-to-moderate reflux was 9.6% but did not cause any deterioration in renal function or an increased incidence of reflux-related pyelonephritis. CONCLUSION: This technique provided good functional results and a low incidence of complications, and may be recommended as a valid alternative to standard methods of creating ureterovesical anastomosis.

Detubularized rectosigmoid neobladder in women after cystectomy for bladder cancer.

BACKGROUND AND OBJECTIVES: We present the long-term functional results of a new technique for bladder substitution after cystectomy for bladder cancer in women. METHODS: Between 1991 and 1995, 10 women underwent radical cystectomy for bladder cancer with a new technique. We created a detubularized rectosigmoid neobladder associated with either a terminal colostomy or intrasphincteric perineal colostomy section (Heitz-Boyer-Hovelacque). We evaluated neobladder functioning over almost 5 years by means of urodynamic studies, ultrasound scans, urograms and pouchgrams, and renal function tests. RESULTS: Neobladder function was excellent in all patients, with good diurnal and nocturnal urinary continence, voiding patterns, and preservation of the upper urinary tract. CONCLUSIONS: This new technique, which is a modification of the standard rectal or rectosigmoid neobladder technique, is a valid alternative to the ortothopic neobladder in women, with good functional results.

[Hyperhydration with low mineral Rocchetta water after extracorporeal lithotripsy]. / Iperidratazione con acqua oligominerale Rocchetta dopo litotrissia extracorporea.

Both prophylaxis and stone-free status after ESWL are most important goals in treating urinary stone disease, because his high social cost. In order to this situation, we matched two homogeneous groups of patients that underwent ESWL because renal stones: during a one year follow-up with several US controls, daily 1.5 litres of low mineral content water was drank by I group patients; vice versa, daily 3 litres (1st ten days) and afterwards 2 litres of Rocchetta low mineral content water was drank by II group patients. This last kind of approach led to a significant improvement in stone fragments elimination time, in inferior calix stone cure and in stone recurrences rate. So we conclude that hyperhydration using right low mineral content water, is a simple and cheap way to improve both treatment and prophylaxis of urinary stones.

Penile prosthesis implantation and couple's satisfaction.

OBJECTIVE: Implant surgery is the most acceptable curative choice for patients with erectile dysfunction and their partners, since the results are excellent with regard to the couple's pleasure and the materials used are extremely manageable. MATERIALS AND METHODS: We performed 46 prosthesis implantations in patients with erectile dysfunction: in 22 patients we implanted soft prostheses; in 20 malleable prostheses; in 1 a mono-component prosthesis, and in 3 patients a tri-component model. All patients and partners were evaluated using a questionnaire. RESULTS: We obtained a degree of satisfaction equal to 82% against 18% dissatisfaction due to a sensation of 'unnaturalness' report by the partner, with low perioperative and postoperative complications. CONCLUSION: In our opinion the degree of satisfaction of the patient is currently the only legitimate indicator to establish the effectiveness of therapy.

Open prostatectomy in benign prostatic hyperplasia: 10-year experience in Italy.

This study reports the experience of 47 Italian urology units together with the urology unit at the University of Perugia concerning open surgery in the management of benign prostatic hyperplasia (BPH). Until 20-25 years ago, open surgery was the most common approach. In the late 1970s the development of endoscopes and their methodology has led to a gradual reduction in open surgery operations, which decreased rapidly with the introduction of mini-invasive endoscopic techniques. Therefore, open surgery for BPH is declining, though still performed. Skill in traditional surgery is mandatory because, until an alternative is devised, indications for open surgery still exist and cannot be ignored. The survey shows the indications and contraindications, complications and results of a 10-year nationwide experience. Guidelines for open surgery in patients with BPH have been drawn up.

Efficacy and tolerability of brodimoprim at two different dosage schedules in the treatment of acute uncomplicated bacterial cystitis: comparative study vs. pefloxacin.

In an open study, 172 male and female adult patients with acute uncomplicated bacterial cystitis were randomly allocated to three treatment groups. Two groups received brodimoprim 200 mg tablets as follows: a single dose of two 200 mg tablets on day 1, followed by one tablet per day on days 2 and 3 (58 patients); or a single daily dose of two tablets, for 2 days (63 patients). The third group received a single dose of pefloxacin, as two 400 mg tablets, for 1 day (51 patients). Complete urinalysis, sediment and urine culture examinations were carried out before treatment and 10 days after the last dose. Evaluation also comprised, at the time of enrolment and 48 h after the last dose, measurement of corporal temperature and assessment of symptoms (dysuria, pollakiuria, strangury, suprapubic pain, burning sensation during urination and urgency) on a 4-point scale. The eradication rate for the pathogen concerned was 98.3% and 96.7% in the groups receiving brodimoprim for 3 and 2 days, respectively, and 92.8% in the pefloxacin group (between-group comparison n.s.). There was significant regression of symptoms (P < 0.001) in the three groups (between-groups comparison n.s.). Mainly gastrointestinal adverse events occurred in 3 patients receiving brodimoprim for 2 days and in 4 patients from each of the other two groups.

Vagal control of lymphocyte release from rat thymus.

The effects of the efferent vagal innervation on the thymus gland of the rat were investigated in vivo by means of section and stimulation experiments. It has been shown that section of the right vagus produces a decrease in the number of lymphocytes released from the thymus into the venous circulation, an effect that disappears after section of the recurrent laryngeal nerve. Vagal stimulation produces a transient increase in the number of lymphocytes released from the thymus, an effect that also disappears after section of the recurrent nerve. The effects of vagotomy are mimicked by nicotinic blocking agents, which also suppress the effects of vagal stimulation, whereas muscarinic blocking agents were ineffective. It is concluded that the vagal fibres running in the recurrent laryngeal nerve exert a tonic and phasic facilitatory influence on the mechanisms responsible for lymphocyte release from the thymus, and that this action is mediated through nicotinic receptors.

[Vesico-cutaneous fistula of the thigh as a late manifestation]. / Fistola vescico-cutanea della coscia a manifestazione tardiva.

Vesico-cutaneous fistulas rarely occur in the urinary tract (1.7% of all urinary fistulas). Trauma, neoplasias, inflammation and iatrogenic pathologies are among the principal causes. The external mouth of the fistula is usually found in the hypogastric area, scrotum, perineum and rarely elsewhere. This report describes the case of a 48 year old woman who, after severe trauma suffered bladder laceration, treated only with cystorraphy. Sepsis and gangrene followed involving the pubic area and the right thigh, associated with acute renal and adrenal gland cortex failure. After emergency treatment, the patient was discharged with an indwelling catheter. Ten months later she was referred to our urology clinic because of a suspected bladder-vaginal fistula. The indwelling catheter was removed and the bladder resumed functioning well. Six months later the external mouth of the fistula appeared on the right inner thigh. NMR confirmed the diagnosis of a vesico-cutaneous fistula. Surgery resolved the abnormality.