Effects on renal function of obstructive and nonobstructive dilatation of the upper urinary tract in ileal neobladders with refluxing ureteroenteric anastomoses.

AIMS: To investigate the incidence and long-term effects on kidney function of obstructive and nonobstructive dilatation of the upper urinary tract in patients with ileal neobladder with refluxing ureterointestinal anastomoses. METHODS: We retrospectively analyzed a prospectively derived database of 110 patients with bladder cancer and who were treated with an ileal neobladder between 1996 and 2007 using refluxing end-to-side ureterointestinal anastomoses on a short afferent limb. The mean follow up was 65 months. At every follow up visit the patients had an analysis of serum creatinine, urine culture, abdominal CT or ultrasonography, and, if there was dilatation of the upper urinary tract, 99mTc-DTPA renal scintigraphy was requested. RESULTS: In all, 206 renoureteral units were included in the study. Overall, seven had anastomotic stricture and of those, three were symptomatic and were corrected; while four were asymptomatic and of those, only two, with preserved split GFR, were surgically treated, while the remaining two, with a poor split GFR, were followed up. The last 99mTc-DTPA showed a preserved split GFR in the reimplanted units and further split renal function decrease in untreated units. Nonobstructive dilatation of the upper urinary tract, caused by reflux, was diagnosed in 13 units. The dilatation was bilateral in three patients with recurrent UTIs and urosepsis, and the split GFR was bilaterally reduced at diagnosis with a further reduction at the last 99mTc-DTPA. The remaining seven units with sterile urine, showed a preserved split GFR during follow up. CONCLUSIONS: All strictures, regardless of their severity, should be immediately corrected. Reflux per se does not provoke renal impairment unless recurrent UTIs and urosepsis are present.

Glansectomy with split-thickness skin graft for the treatment of penile carcinoma.

Using our prospectively derived database, we identified 17 patients with squamous-cell carcinoma involving the glans penis, who were treated using organ-sparing surgery between March 2003 and January 2008. Of them, two were treated with partial glansectomy with primary glans closure, and 15 underwent total glans amputation and reconstruction of a new glans using a split-thickness skin graft (STSG). These 15 patients represent the subject of our study (mean age 51 years, range 42 to 59 years). Overall, two patients had early partial loss of the graft and of them, one required surgical regrafting. Two late complications occurred, consisting of one meatal stenosis and one postoperative phimosis. At a mean follow-up of 36 months, functional results were extremely satisfactory. All patients maintained their erectile function with good vaginal penetration starting from 3 months after surgery, with a range between 2 and 6 months. Orgasm and ejaculation were preserved in all patients, although reduced glans sensitivity was reported by all patients. No local recurrences were reported.

Corporeal herniation after Nesbit plication with partial thickness shaving for congenital penile curvature.

A 24-year-old man with penile congenital curvature who underwent partial thickness tunical shaving and plication with absorbable suture presented 1 month after surgery with a mass at the base of the right corpus cavernosum at the level of the original plication. We believe that corporeal herniation after tunical shaving and plication must be considered a complication of the technique independent from the type of suture used for the plicatures and probably related both to the opening of plications of the albuginea before permanent adhesion of the tunical layers, and to the decreased resistance of the albuginea, probably because of excessive shaving.

Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies.

OBJECTIVE: To evaluate the feasibility and results of prosthetic venous replacement, as inferior vena cava (IVC) and iliofemoral vein resection and replacement are sometimes necessary when they are extensively involved by a large and fixed tumour thrombus from renal cell carcinoma (RCC) or other urological malignancies. PATIENTS AND METHODS: Five men and two women (age range 41-75 years) were treated over a 10-year period (1991-2001) by aggressive venous surgery to achieve complete tumour resection, with prosthetic graft replacement to re-establish venous flow. The tumours included RCC of the right kidney (two), retroperitoneal liposarcoma (two), bladder cancer (one), retroperitoneal fibrosarcoma (one) and inguino-pelvic lymphoma (one). Two patients had a vena caval replacement, of whom one had a circular reinforced PTFE and one a Dacron silver graft; five patients had either an iliofemoral or an ilio-iliac circular reinforced PTFE graft. The prosthetic diameter was 18-20 mm for the IVC grafts and 8-10 mm for the iliac grafts. In all the patients, graft patency was evaluated during the follow-up by colour flow duplex imaging, and in one it was determined by angio-computed tomography scan and venography. RESULTS: One patient died 30 days after surgery; of the remaining six patients one had no evidence of regional recurrence or metastatic disease at 12 months, and five died from recurrent tumour 8-30 months after surgery. The mean time to death was 23 months. At 3 months all six prosthesis were patent; at 6 months four were patent and at 12 months three of five prostheses were patent. CONCLUSION: Resecting and replacing the IVC allows complete tumour resection and avoids renal failure, providing durable relief from the symptoms of venous obstruction. Iliofemoral prosthetic reconstruction for urological-related malignancies represents a viable option to avoid venous engorgement and lower extremity swelling, at least in the early postoperative period. The mean time to death for the present patients must be considered the limit for these aggressive operations.

Regional lymph node dissection in the treatment of renal cell carcinoma: is it useful in patients with no suspected adenopathy before or during surgery?

OBJECTIVES: To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery. PATIENTS AND METHODS: A series of 167 patients with RCC, free from distant metastases at diagnosis, and who underwent radical nephrectomy at our hospital between January 1990 and October 1997, was reviewed. The mean (median, range) follow-up was 51 (45, 19-112) months. Of the 167 patients, 108 underwent radical nephrectomy alone and 59 had radical nephrectomy with regional LND limited to the anterior, posterior and lateral sides of the ipsilateral great vessel, from the level of the renal pedicle to the inferior mesenteric artery. Of these 59 patients, 49 had no evidence of nodal metastases before or during surgery. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables. RESULTS: The overall 5-year survival was 79%; the 5-year survival rate for the 108 patients who underwent radical nephrectomy alone was 79% and for the 49 who underwent LND was 78%. Of the 49 patients with no suspicion of lymph node metastases, one (2%) was found to have histologically confirmed positive nodes. CONCLUSION: These results suggest that there is no clinical benefit in terms of overall outcome in undertaking regional LND in the absence of enlarged nodes detected before or during surgery.

Evaluation of the 1997 tumour, nodes and metastases classification of renal cell carcinoma: experience in 172 patients.

OBJECTIVE: To compare the prognostic relevance of the 1987 and 1997 tumour, nodes and metastases (TNM) systems for staging renal cell carcinoma (RCC) in predicting patient outcome. PATIENTS AND METHODS: A series of 172 consecutive patients with RCC who underwent radical nephrectomy from January 1990 to October 1997 was evaluated comparatively according to the 1987 and 1997 TNM classifications. The median (range) follow-up of the patients was 50 (19-112) months. The probability of survival was estimated by the Kaplan-Meier method, using the log-rank test to estimate differences among levels of the analysed variables. RESULTS: Using the 1997 TNM classification resulted in a redistribution of 99 patients from stage pT2 on the 1987 TNM classification to stage pT1. As the staging criteria for pT3 and pT4 did not change, there was no re-classification of these patients. Kaplan-Meier survival curves showed a similar separation in 5-year survival between stage pT1 and pT2 using both systems; 100% vs 80% for the 1987 TNM and 86% vs 69% for the 1997 TNM systems. This difference in survival rates between patients with pT1 and pT2 disease was statistically significant only for the 1997 TNM staging system. However, when the 1987 TNM staging classification was applied, the separation in 5-year survival rates between pT2 and pT3 disease was greater. CONCLUSION: This study confirms the prognostic relevance of the 1987 TNM system, as established in the present patients. The 1997 TNM classification resulted in a better stratification of patients with pT1-pT2 disease, but had similar prognostic value for pT2 and pT3 disease.

Functional evaluation of different ileal neobladders and ureteral reimplantation techniques.

OBJECTIVES: To compare and assess the function of ileal neobladders with different reconfiguration and with several types of ureteral reimplantation. METHODS: Forty-five male patients underwent radical cystectomy and detubularized ileal neobladder. In 20 patients an ileal neobladder was carried out according to Studer's technique, in 12 a 'W'- and in 13 a 'U'-shaped neobladder. In the Studer's patients 60 cm of ileum was used, in the 'W' 40 and in the 'U' 30 cm. For the uretero-ileal anastomosis Nesbit's technique was utilized in the Studer's, in the 'W' and 'U' neobladders Camey Le Duc's technique was performed instead. Four patients underwent a serous-lined extramural tunnel reimplantation. Follow-up included a functional and morphological study of the urinary system and a urodynamic study. RESULTS: All Nesbit's uretero-ileum anastomoses resulted refluent when the reservoir was filled up, 15 of 50 ureteral reimplantations according to the Camey Le Duc technique showed reflux at full filling. At 3, 6 and 12 months follow-up, the double reconfiguration reservoirs (Studer's and 'W') showed a larger capacity and a lower maximum pressure than neobladders with a single bending. At 12 months, continence and the voiding interval time was significantly higher in the double reconfiguration than in the 'U' neobladders. CONCLUSION: The double reconfiguration of the reservoir ('W') might be preferable to that with a single one. As for the type of ureteral anastomosis to select, the problem is still debatable even if in our case-control study we have had better results in terms of reflux and stenosis with the uretero-enteric anastomosis with Nesbit's and associated afferent long tubular ileal limb than with Studer's technique.

[Prostatic endoprosthesis in the treatment of prostatic obstruction: preliminary experience with the new Trestle model]. / Le protesi endoprostatiche nel trattamento dell'ostruzione prostatica: esperienza preliminare con il nuovo modello Trestle.

The urethral stent is a relatively new treatment modality for benign prostatic hypertrophy ostruction. Although the ultimate prostatic endoprosthesis has yet to be developed, various stents have been produced and investigated with good results. We review the several currently available stents and we report the preliminary clinical experience with a new device (Trestle).

Bladder involvement in systemic sclerosis: urodynamic and histological evaluation in 23 patients.

Lower tract involvement of systemic sclerosis is an uncommon manifestation. In this study we have evaluated the functional and morphologic vesical changes in 23 female patients with systemic sclerosis to investigate if bladder dysfunction was correlated with an extended skin sclerosis and/or a more serious organ involvement. Urodynamic alterations were observed in only 3 cases. Urinary symptoms and urodynamic features were correlated neither with severity of vesical fibrosis nor with visceral involvement. Autonomic dysfunction was detected in 13 patients.

Correlation between Gleason score of needle biopsy and radical prostatectomy tissue.

Gleason score has been identified as an important variable to predict disease extent and biologic behaviour of prostate cancer. However, the correlation between Gleason score of needle biopsy and surgical specimen is often poor. We studied 72 patients who underwent needle biopsy and radical prostatectomy to correlate Gleason score with PSA, clinical and pathological tumour stage. Only 47.2% of Gleason scores were identical in the biopsy and specimens, 37.5% were undergraded and 15.2% were overgraded. Correlations between clinical and pathological stage were identical in 30.5% of patients, 61.1% of patients were understaged and 8.3% overstaged. In conclusion, accuracy of clinical staging and grading of prostate cancer is low. Although the Gleason score on needle biopsy might be useful to predict the final stage and grade, correlation with surgical specimen is poor.

Painless treatment of hydrocele: EMLA cream anaesthesia and fibrin adhesive sclerotherapy.

Sclerotherapy for hydroceles was performed in 18 patients. Cutaneous anaesthesia was induced with an anaesthetic cream (lidocaine and prilocaine, EMLA cream) and a fibrin sealant (Tissucol) was injected into the sac after fluid aspiration. Patients experienced no pain during needle insertion and sclerosant procedure; 2 recurrences were observed during follow-up. EMLA cream anaesthesia and fibrin adhesive sclerotherapy represent a useful alternative to surgical treatment of hydroceles.

Use of new nephrostomy catheter for treatment of renal neonatal candidiasis.

Systemic candidiasis with renal involvement is a rare but well-recognized complication during neonatal intensive care treatment. In addition to intravenous administration of amphotericin B, decompression of the renal pelvis and irrigation of the involved kidney with the same drug through a nephrostomy tube will provide a high concentration of antifungal agent with a flushing effect. This procedure is not always possible due to the small size of the neonatal kidneys. We have conceived a new percutaneous trocar nephrostomy which allows its application directly in an incubator without using X-rays during a single procedure. In 3 cases a bilateral percutaneous nephrostomy was performed directly in the incubator using a one-step ultrasonically guided maneuver under local anesthesia. The funguria was successfully eradicated in all cases. The availability of a nephrostomy trocar of small dimensions leads us to an improved renal approach in newborns.

The use of a modified surgical instrument for the ligation of a Santorini's venous plexus.

The authors, after reviewing the literature concerning various instruments used for ligating the Santorini's plexus, have reported their experience to control the dorsal venous complex with a Deschamps' needle modified by themselves.

Urodynamic evaluation of urinary incontinence following radical prostatectomy: our experience.

Thirty-four patients after retropubic radical prostatectomy, were evaluated with urodynamic studies. Patients were divided in three groups depending on the degree of urinary continence. A statistically significant difference was found between different groups for the mean functional profile length and maximal urethral closure pressure. Detrusor instability was detected in 11 patients with moderate incontinence and in 1 patient with severe incontinence. Neither differences of age, previous prostatic surgery, tumour extension, nor preservation of the neurovascular bundles had any significant influence on recovery of continence.

Recurrences and progression of superficial bladder cancer following long-term intravesical prophylactic therapy with mitomycin C: 48-month follow-up.

A total of 208 patients with superficial transitional-cell carcinoma of the bladder (STCC) after transurethral resection were treated with 30 mg intravesical instillations of mitomycin C (MMC) weekly for 8 weeks, followed by monthly maintenance doses for 12 months. All patients were controlled with a urinary cytological examination every 2 months and with cystoscopy every 3 months. Mean follow-up was 47.8 and 49.3 months in the prophylaxis and control groups, respectively. The incidence of tumor recurrences at the 12th and 48th months was 29 and 44%, respectively, in the MMC group and 45 and 58%, respectively, in the control group. Progression evaluated by grade and stage was significantly higher in the control group. These data indicate that MMC appears to be effective in the prophylaxis of STCC, but the possibility of long-term relapse suggests maintenance of a longer therapy.

Bladder instability and incontinence after radical prostatectomy.

Thirty-nine patients were evaluated after retropubic prostatectomy, by urodynamic studies. They were divided into three groups depending upon the degree of urinary continence. A statistically significant difference was found between different groups in mean functional profile length and maximal urethral closure pressure. Differences in age, previous prostatic surgery, tumour extension, or preservation of the neurobundles did not have any significant influence on recovery of continence.

Vacuum constriction device and topical minoxidil for management of impotence.

OBJECTIVE: We report our preliminary experience with a vacuum constriction device and topical minoxidil for the management of impotence. METHODS: We evaluated 18 patients, 8 with neurogenic and 10 with psychogenic impotence with a vacuum constriction device and topical minoxidil (1 ml 2% solution). RESULTS AND CONCLUSIONS: All patients responded to treatment but 100 cases refused home use because of psychological impact. Twelve patients did not need the application of the constrictive ring because of the erection facilitation effect of minoxidil. No side effects were observed. In our opinion the association of the vacuum constriction device with topical minoxidil might be useful in the treatment of impotence; however, several factors must be evaluated in selecting patients. Application of minoxidil before vacuum constriction device might be useful to reduce the time of device application, to increase the efficacy of the device and in some cases to avoid the use of the constrictive ring.

[Laser and ultrasonic therapy in simultaneous emission for the treatment of plastic penile induration]. / Laser e ultrasuoni terapia in emissione simultanea nel trattamento dell'induratio penis plastica (IPP).

Induratio penis plastica (IPP) or Peyronie's Disease is characterized by the presence of one or more fibrous patches in the tunica albuginea or intercavernous septum. IPP is a slowly evolving disease which may cause a bending of the penis as well as pain during erection. As an alternative to the numerous pharmacological therapies already existing, or in association with them, some kinds of physical treatments, such as ionophoresis, ultrasound therapy and laser therapy, have recently been used. In this study we have evaluated the effectiveness of physical therapy combined with laser and Ultrasounds in the treatment of IPP. Sixty-eight patients were randomly divided into three groups: the first group was treated with orgotein infiltrations, the second with laser and Ultrasounds and the third with an association of both treatments. On the basis of this study, we can affirm that the effectiveness of laser therapy associated with ultrasounds in treating painful symptomatology of IPP at its initial phase overlaps that of orgotein infiltrations. No measurable modifications were documented neither in patch dimensions nor in their echostructures and in no case remarkable modifications of the penile bending were evidenced. Therefore laser therapy associated with ultrasounds represents at the moment an efficacious alternative to medical treatment of IPP at the initial phase, as it does not present any kind of contraindications and it is surely better tolerated than any treatment with penile infiltrations.

Densitometric and biochemical alterations in bony tissue induced by ureterosigmoidostomy.

The mineral content of bone was measured in 134 male patients who underwent ureterosigmoidostomy within the past 18 years. Moreover, the principal humoral indices of bone metabolism, together with hematic pH and alkaline reserve (BE) values were evaluated. This study showed that after approximately 6 years from a ureterosigmoidostomy there was significant bone demineralization. These data, supported by a parallel increase of serum osteocalcin, show that ureterosigmoidostomy represents a risk factor for osteoporosis especially in those patients who already have below normal values of bone mineral density prior to surgery.