[Continence problems after radical prostatectomy: medical treatment]. / Problemi di continenza dopo prostatectomia radicale: la terapia medica.

OBJECTIVE: We hypothesized that a benefit can be obtained from both urine storage and urethral resistance after retropubic radical prostatectomy through the induction of artificial erections. MATERIAL AND METHODS: From January 1993 to December 2000 we have submitted 127 patients to radical retropubic prostatectomy. According to preoperative bladder behaviour, 59 patients (46.5%) presented voiding disorders, 10 (7.9%) filling disorders, 4 (3.1%) mixed disorders, whereas 54 (42.5%) were asymptomatic. The urethral catheter was removed between the 10th and the 12th postoperative day. Fourteen patients entered a programme of early sexual rehabilitation with intracavernous injection of prostaglandin E1 (ICI) within 7 days from catheter removal. RESULTS: After catheter removal the recovery of urinary continence occurred within 2.2 +/- 2.3 days. At dismissal from the hospital, 8 patients (6.2%) were almost totally incontinent; 2 (1.5%) were still incontinent after a 6-month period; 73 (57.4%) were dismissed with clinical signs of detrusor instability hence treated with anticholinergic drugs such oxybutynin or tolterodine; 3 (2.3%) resulted obstructed after surgery because of stenosis of the anastomosis. Almost all the patients submitted to early sexual rehabilitation referred an improvement of their incontinence after the first injection. The patients who did not begin an early sexual rehabilitation generally recovered from incontinence in a longer time. CONCLUSIONS: Our preliminary observations showed that artificial erection PGE1-induced is effective in improving or accelerating post radical prostatectomy incontinence recovery. The results apply also to patients with pre-operatory detrusor instability.

Cardiac dysrhythmias induced by extracorporeal shockwave lithotripsy.

PATIENTS AND METHODS: We evaluated in 269 consecutive patients the incidence and gravity of dysrhythmic complications during nonsynchronized extracorporeal shockwave lithotripsy (SWL) using an electromagnetic lithotripter. RESULTS: Dysrhythmia occurred during treatment in 22 patients (8.8%) with no previous cardiac dysrhythmia. Ventricular extrasystoles occurred in 14 patients, atrial extrasystoles in 7 patients, and sinus bradycardia in 1 patient. It was not necessary to terminate treatment because of the occurrence of dysrhythmia in any of the patients. For 13 of the 22 patients (59%), it was sufficient to interrupt the treatment momentarily to obtain resumption of the normal rhythm. For 8 patients (36%), treatment was continued after triggering the release of the shockwaves with the refractory phase of the heart cycle. For one case of bradycardia (42 beats/min), it was possible to continue with the treatment after intravenous administration of atropine 0.5 mg. Pretreatment dysrhythmias were revealed by the electrocardiographic examination in 16 of the patients studied (6.3%). CONCLUSIONS: Extracorporeal shockwave lithotripsy without ECG triggering has been found to be fast and efficient and not correlated with the occurrence of dysrhythmic episodes of any particular clinical significance. No significant correlation was found between the occurrence of dysrhythmia, the side treated, the number and strength of the shockwaves, or the administration of analgesics. It was found, however, that dysrhythmia occurred almost exclusively in treatments involving the kidneys. The ECG-triggering option was indispensable in some patients in order to complete the lithotripsy without complications.

A prospective study of recurrence rate and risk factors for recurrence after a first renal stone.

PURPOSE: We investigate further the recurrence rate and risk factors for recurrence in 300 consecutive patients who presented to our stone clinic after a first stone episode 7 to 17 years ago. MATERIALS AND METHODS: The medical records of the patients who presented consecutively with a first stone episode from 1980 to 1990 were studied and supplemented by a followup mail questionnaire and telephone interviews. At first visit serum samples were taken from all patients and 24-hour urine samples were collected for metabolic testing. RESULTS: A total of 195 patients were followed successfully, of whom 52 (27%) experienced symptomatic stone recurrence after a mean plus or minus standard deviation of 7.5+/-5.9 years. However, ultrasound examination of 36 symptom-free patients showed recurrent stones in 28%. Comparison of patients with or without recurrence confirmed that recurrence was not influenced by sex, family history of stones and urinary risk factors. However, age at onset of the disease was lower for patients who had 2 or more stones during followup than those who had only 1 stone or no recurrence. CONCLUSIONS: Stones can recur as long as 10 years after the first episode, although the rate is lower than previously reported. The metabolic evaluation after a first stone episode needs to be reappraised in terms of its cost-effectiveness, since recurrences do not seem to be predictable from standard laboratory tests.

[Extracorporeal SWL in the treatment of reno-ureteral calculosis in day hospital]. / Trattamento extracorporeo SWL della calcolosi reno-ureterale (SWL) in Day Hospital.

Eighteen years after the first clinical shock wave lithotripsy (SWL), no doubt remains as to its therapeutic efficacy in ureterorenal lithiasis. The advent of lithotriptors with a large shock wave energy range and integration of both ultrasound and radiologic imaging equipment at the shock wave source has meant that outpatients treatment of urolithiasis is now feasible in a good proportion of cases. In our lithotripsy center, from January 1995 to August 1996, 208 out of 310 patients who underwent SWL treatment for renal and ureteral stones, were outpatients. Pretreatment manoeuvres were performed in 10.6% of the patients. No major complications occurred during the treatment. Only three patients (1.4%) were admitted to hospital because of fever, colics or perirenal haematoma in the first two days after SWL therapy. The stone free rate was 67 and 84% respectively one and three months after treatment. In our experience, the possibility of performing SWL treatments without anesthesia and even analgosedation, the absence of complications and the high success rate, make outpatient treatment of urolithiasis safe and suitable in a large number of patients.

Hyperoxaluria in patients with idiopathic calcium nephrolithiasis.

We studied 476 patients with idiopathic renal calcium stone disease (286 M, 190 F) while they ate their customary diets. Each subject collected a 24-hour urine sample and completed a dietary diary for a 3-day period. Daily urinary oxalate excretion (M 0.24 +/- 0.15 mg/dl, F 0.23 +/- 0.15 mg/dl) and nutrient intake values were calculated and multiple regression analyses were performed. Daily urinary oxalate excretion was significantly (p < 0.001) related to urinary volume (R = 0.24), vitamin C intake (R = 0.33) and body mass index (R = 0.37) and inversely related to calcium intake (R = -0.35). We conclude that urinary oxalate reflects endogenous oxalate production, presumably related to body size, but also intestinal absorption of oxalate, related to dietary intake and to the effect of dietary calcium intake which reduces intestinal oxalate absorption.

A study of dietary calcium and other nutrients in idiopathic renal calcium stone formers with low bone mineral content.

PURPOSE: Patients with calcium renal stone are reported to have lower bone mineral density. The state of bone density in patients with renal stones have different explanations but the role of nutritional factors seems to be crucial. A group of 48 consecutive male calcium renal stone formers was studied to investigate the relationship between bone density and dietary intake. MATERIALS AND METHODS: Patients completed a dietary diary for a 3-day period during normal diet. Nutrients and calories were calculated by food composition tables using a computerized procedure. Bone densitometry was assessed at the lumbar spine and femoral neck, and expressed as Z score. A blood sample was collected and was analyzed for serum biochemistry including alkaline phosphatase, parathyroid hormone and 1,25 vitamin D. A 24-hour urine sample was analyzed for calcium, phosphate, oxalate, citrate and other electrolytes. RESULTS: Dietary calcium intake was significantly lower (p < 0.01) in patients with low than in those with normal bone mineral density. There was no difference in serum parathyroid hormone levels, phosphate and alkaline phosphatase between the 2 groups. The results suggest that some renal stone formers seem to be unable to decrease renal excretion of calcium on a low calcium diet leading to a negative calcium balance. CONCLUSIONS: A primary abnormality of bone metabolism could be a reasonable explanation of reduced bone density observed in renal stone formers on a low calcium diet since serum parathyroid hormone levels are in the normal range. From a therapeutic point of view these data confirm that restriction of dairy products in renal stone formers should be avoided.