Nerve ablation after bronchial thermoplasty and sustained improvement in severe asthma.

BACKGROUND: Bronchial thermoplasty (BT) is a non-pharmacological intervention for severe asthma whose mechanism of action is not completely explained by a reduction of airway smooth muscle (ASM). In this study we analyzed the effect of BT on nerve fibers and inflammatory components in the bronchial mucosa at 1 year. METHODS: Endobronchial biopsies were obtained from 12 subjects (mean age 47 ± 11.3 years, 50% male) with severe asthma. Biopsies were performed at baseline (T0) and after 1 (T1), 2 (T2) and 12 (T12) months post-BT, and studied with immunocytochemistry and microscopy methods. Clinical data including Asthma Quality of Life Questionnaire (AQLQ) and Asthma Control Questionnaire (ACQ) scores, exacerbations, hospitalizations, oral corticosteroids use were also collected at the same time points. RESULTS: A statistically significant reduction at T1, T2 and T12 of nerve fibers was observed in the submucosa and in ASM compared to T0. Among inflammatory cells, only CD68 showed significant changes at all time points. Improvement of all clinical outcomes was documented and persisted at the end of follow up. CONCLUSIONS: A reduction of nerve fibers in epithelium and in ASM occurs earlier and persists at one year after BT. We propose that nerve ablation may contribute to mediate the beneficial effects of BT in severe asthma. TRIAL REGISTRATION: Registered on April 2, 2013 at ClinicalTrials.gov Identifier: NCT01839591 .

[Percutaneous nephrolithotomy (PCNL) in a 9-year-old patient with horseshoe kidney]. / Paziente di nove anni con rene a ferro di cavallo.

INTRODUCTION: The horseshoe kidney is the most frequent renal anomaly, with a prevalence of 0.25% and a male to female ratio of 3:1. Although the pathogenesis remains controversial, the consequences of the impaired urinary drainage are well known: up to two third of patients present with urinary stasis, infection and urolithiasis. Percutaneous nephrolithotomy (PCNL) is a successful procedure for urolithiasis in horseshoe kidneys. MATERIALS AND METHODS: A 9-year-old patient with a 4-cm stone associated with horseshoe kidney underwent Percutaneous nephrolithotomy (PCNL). During the procedure, a flexible uretheroscopy was performed in order to obtain a complete vision and an optimal management of the procedure. RESULTS: At the end of the procedure, the patient was stone-free. We reported no hemorrhagic complications, no pain and no infection. The patient was discharged after 48 hours. CONCLUSIONS: The procedure is safe and effective, as long as the surgeon pays attention to the recommendations below.

[Endourological management of ureteral stenosis and vesicoureteral reflux after renal transplantation].

INTRODUCTION AND OBJECTIVES. Ureteral stenosis and vesicocoureteral reflux after renal transplantation represent a key concern because of their incidence and the associated morbidity. Prompt diagnosis and minimally invasive treatment are mandatory in immunosuppressed patients with single kidney. The aim of this study is to evaluate the success rate of the endourological techniques in the management of such complications. MATERIALS AND METHODS. Between January 1996 and December 2006, 647 kidney transplants were performed. Urinary tract continuity was re-established by ureteroneocystostomy according to Gregoir-Lich technique. We observed 13 cases of ureteral stenosis (2%) and 11 cases of symptomatic vesicoureteric reflux (1.7%). The endourogical procedure was performed in 13 patients: 5 cases of II-III grade vesicoureteric reflux, 4 early ureteral stenosis and 4 late ureteral stenosis. Patients with vesicoureteric reflux underwent endoscopic injection of macroplastique in 4 cases and Durasphere in 1. Early ureteral stenoses were treated using balloon dilation in 2 cases, balloon dilation and laser endoureterotomy in 3, ureteral stent placement in the other. Recipients with late stenosis underwent laser incision and balloon dilation in 2 cases, balloon dilation in 1 and a laser incision only in the last case. Combined antegrade and retrograde endoscopic approach was performed in 7 patients, whereas retrograde access in 1. RESULTS. Endourologic treatment was successful in 9 cases (69.2%); 2 patients required open reconstructive surgery due to endourological technique failure (early ureteropelvic junction stricture, late ureterovesical anastomotic stricture). Vesicoureteric reflux was corrected in 3 patients (60%), 2 patients underwent uretero-ureterostomy for recurrent reflux. No technique-related morbidity was observed. With a mean follow- up of 81.6 months, 8 patients show normal renal function, 5 patients have returned to haemodialysis (4 for chronic rejection, 1 for carcinoma in the graft). CONCLUSIONS. Considering their low morbidity and the satisfactory success rate, we claim that endourological procedures should be considered the preferred treatment for ureteral stenosis and vesicoureteric reflux in selected patients.

[Early enteral nutrition in patients treated with major surgery of the abdomen and the pelvis]. / Nutrizione enterale precoce nei pazienti sottoposti a chirurgia maggiore del distretto addomino-pelvico.

Hypercatabolism after operations has a negative influence on nutritional status, the healing process, infective complications and hospital stay. Moreover, the immune status of the patient has been shown to be equally important for septic morbidity and mortality. It is extensively accepted that in critical situations, an adequate nutritional support (enteral or parenteral) is absolutely necessary, but subjects such as the best way of feeding, the kind of nutrients to be used and the administration time are still debatable issues. Our aim was to evaluate the effectiveness (nutritional and immunological features) and clinical outcomes (septic morbidity and mortality) of total parenteral nutrition (TPN), early enteral nutrition and early enteral immunonutrition (EEN, EEIN) in 171 patients undergoing major abdominal and urological surgery for neoplastic pathology. Our prospective, randomised study showed no significant differences among the 3 nutritional supports (TPN, EEN, EEIN) with regard to restoration of normal nitrogen balance during the acute phase of surgical stress. No correlations were found in the 3 groups with immunoglobulin percentage, lymphocyte subpopulations and their functional patterns as studied by specific immunological tests. The skin test, on the other hand, seems to be more representative of the immune condition of the patients, demonstrating a faster improvement in immunological status in the EEIN group as compared to the control group. A smaller percentage of septic morbidity and mortality was found in both enteral nutritional groups (EEN and EEIN), although there was a statistically significant difference only between the TPN and EEIN groups. The hospital stay was 3.5 days shorter in enteral feeding patients (EEN, EEIN). Finally, EEN was less expensive than the other nutritional conditions, this result depending on the cost of the different materials used (infusion sets, linear filters, prepacked diets, etc.).

One shot: a novel method to dilate the nephrostomy access for percutaneous lithotripsy.

BACKGROUND AND PURPOSE: The creation of the nephrostomy access is a fundamental step of percutaneous nephrolithotripsy (PCNL). Dilation of the track is usually achieved with multiple incremental flexible exchange dilators of the Amplatz type, metal telescoping dilators of the Alken type, or a balloon. Currently, balloon dilation is regarded as the most modern and safest system, though it has the disadvantage of relatively high cost. The aim of this study was to demonstrate that a procedure that we named "one shot," which consists of a single dilation of the track with a 25F or 30F Amplatz dilator, compares favorably in terms of efficacy, costs, and length with the other techniques of track dilation, without a significant increase in morbidity. PATIENTS AND METHODS: Seventy-eight consecutive patients who underwent PCNL for stone disease from June 1998 to July 1999 were considered and divided into three groups according to the type of tract dilation used: A (Alken telescoping dilators), B (balloon), or C (one shot). Radiologic exposure, blood loss, and costs were evaluated. RESULTS: The one-shot procedure compared favorably with both of the other dilation techniques without an increase in morbidity and with significant reductions in X-ray exposure and costs. Indeed, significant differences in estimated blood loss were observed between groups B and C and the minor bleeding for group C. CONCLUSION: Our experience indicates that one-shot dilation is feasible in the majority of patients. It is as safe and effective as the technique regarded today as the gold standard but less time consuming and less expensive. These encouraging results should be confirmed by further studies.

[Unusual case of mesothelioma of the tunica vaginalis associated with prostatic adenocarcinoma]. / Raro caso di mesotelioma della vaginale del testicolo associato ad adenocarcinoma della prostata.

Malignant mesothelioma of the tunica vaginalis testis, is a very rare neoplasm with highly aggressive biological behaviour. It usually occurs in patients aged between 55 and 75 years. A testicular mass is always observed, often accompanied with hydrocele. The response to chemotherapy and radiotherapy is poor. Initial aggressive surgery is necessary. The median survival, without surgical treatment is 23 months. A rare case of malignant mesothelioma of the tunica vaginalis testis, observed in a patient affected by prostate neoplasm is reported. A radical retropubic prostatectomy was performed. The patient was suffering from dysuria and there was a suspect area at the digital examination. Rectal ultrasonography and biopsy showed an adenocarcinoma at T1c clinical stage. A radical prostatectomy was carried out and histology showed an adenocarcinoma, Gleason score 7 pT3bN0M0. Surgery was followed by radiation therapy. After three years, a pleural seroma, a cutaneous mass and testicular nodule were observed and cytological examination showed endothelial cells. Scrotal orchiectomy was performed, because he was suffering from emphysema. Cytological examination confirmed malignant mesothelioma of the tunica vaginalis testis. Only 73 cases of this tumour have been reported in the last 30 years. The therapeutic options for this aggressive neoplasm are discussed. Since chemotherapy and radiation therapy had poor results, a rapid surgical treatment, by radical orchiectomy, is important.

[Surgical treatment of urologic complications of idiopathic retroperitoneal fibrosis. Our experience]. / Trattamento chirurgico delle complicanze urologiche della fibrosi retroperitoneale idiopatica. Nostra esperienza.

The chief complications of retroperitoneal fibrosis RPF in the ureteric compression ab extrinseco by fibrotic tissue. In the period 1994 to 1999, we treated two cases of idiopathic RPF: the first case a 49 years aged man, presented a left hydronefrosis and bilateral ureteral displacement to the midline. RMN showed widespreads fibrotic tissue in the retroperitoneal space. At operation, the histological findings was that of aspecific fibrositis. The surgical procedure was ureterolysis and lateralization of both ureters with the aid of a wrapping with a pedicled omental graft. The patient was also treated with metilprednisolon, 8 mg-die, for altogether twelve months, Now he is asymptomatic. The second case, a man aged 60, had a compression of both ureter by fibrotic tissue down to the pelvic tract; the histologic picture was the same of that of the first case. A difficult ureterolysis was carried on, plus an omentoplasty and a left ureteral reimplantation to the bladder. Medical treatment followed, following the above scheme. Seven months after surgery the patient is well. This experience of ours urological complications of RPF is confirmatory of the importance of a sound surgical approach and of a tight follow up as well as a sustained corticosteroid therapy in order to prevent relapse.

[Report of 2 cases extragonadal germ cell neoplasia with primary burnt out tumor of the testis]. / Descrizione di due casi di neoplasia extragonadica a cellule germinali in tumore primitivo burnt out del testicolo.

If the histogenesis of the extragonadal germ cell tumor is a still debatable subject, its clinical diagnosis remains a question of no immediate solution. In fact, only the keen histologic evaluation of microfocuses and/or scar tissue in the testis, possibly on the guide of US finding, could give the answer about the primitiveness or not of the extragonadal neoplasia. Which implies, of course, some problems of compliance on the part of young locally symptomless men, especially on the ground of possibly bilateral involvement.

[The use of early enteral nutrition (EEN) after major urologic surgery]. / Impiego della nutrizione enterale precoce (NEP) dopo chirurgia urologica maggiore.

PURPOSE: To evaluate the efficacy of early enteral nutrition in management of patients operated by major urologic surgery and to demonstrate her advantages versus total parenteral nutrition. MATERIALS AND METHODS: 20 patients, operated by radical cystectomy and urinary diversion by ureteroileocutaneostomy, Padua ileal bladder or ureterosigmoidostomy are inserted in our study: 12 were treated by early enteral nutrition for 8 days and eight by total parenteral nutrition for the same period: in each group nutritional and immunological parameters at day -1, +3 and +7, the length of postoperatory stay, the incidence of complications, with particular respect for infections have been evaluated and correlated one to each other. RESULTS: We have no death in each group; in the first group no gastroenteric allergy to the nutrient, less incidence of venous catheter and surgical wound infections (respectively p < 0.01 and p < 0.005); we have no significant decrease of postoperatory stay length; the effective problem in this group was the incidence of diarrhea, that in one case have made necessary the suspension of enteral nutrition. Enteral nutrition costs were about half of those of total parenteral nutrition. CONCLUSIONS: We believe that early enteral nutrition is an effective and safe nutrition method in patients operated by major urologic surgery: with this is possible a better nutrition, that reduce the incidence of postoperative complications, mainly infections, and maybe the length of postoperatory stay (our champion is too small for statistical evaluation), that may lead to a decrease in management costs of these patients.

[Renal lymphoma: an atypical mass in search of characterization]. / Linfoma renale: una massa atipica in cerca di caratterizzazione.

We report the case of a B cell, renal non-Hodgkin lymphoma come to our attention due to urologic symptoms. A review of the literature is provided and it is discussed the differential diagnosis with renal cell carcinoma.

[The mini-invasive surgery of stress urinary incontinence (SUI): the use of the Vesica kit]. / Chirurgia mini-invasiva dell'incontinenza urinaria da sforzo (I.U.S).: impiego del kit Vesica.

From February 1996 to March 1997, we have performed with the Vesica system the percutaneous bladder neck suspension in 13 pts (group 1) and the vaginal wall sling in 7 pts (group 2). After a mean follow-up of 12 months for group 1, 10 patients (76.9%) were "dry", 1 pt "improved" and 2 "failed"; in the group 2 (mean follow-up of 5 months) 6 pts/7 were "dry". Overall morbidity has been minimal. The percutaneous bladder neck suspension and the vaginal wall sling with Vesica system are minimally invasive surgical procedures for the urinary stress incontinence (hypermobility of bladder outlet and intrinsic sphincter deficiency).

[The conservative surgery of renal carcinoma]. / Chirurgia conservativa del carcinoma renale.

In the period 1986-1997, 387 cases of renal carcinoma were operated upon, at the Department of Urology, Parma General Hospital (Italy). Among these, thirty patients (all together 31 operations, 26 men and 5 women, mean age 58 +/- 11.3 years) have had conservative, nephron-sparing surgery; in 8 patients, conservative procedure was mandatory, due to previous contralateral nephrectomy or renal unreliability (4 RCC, 1 TCC, 1 severe injury, 1 pyonephrosis, 1 end stage insufficiency); in 23 patients, with normal contralateral kidney, the tumor was less than 4 cm in diameter and unique. Preoperatively, all cases had been staged by abdominal TC, chest X-ray, bone scan, renal angiography. 23 of 30 cases showed pathological stages I-II (pT1-T2), while 8 patients had stage III (pT3) tumors. After dismissal we recommended: abdominal echography after three months; again US and TC, chest X-ray after further three months. Then US and/or TC every six months, should the former results suggest a relapse, either locally and/or at a distance. Mean follow-up was 40 months. 6/30 patients (19.3%) died of metastatic disease (mean survival time: 27 months). 25 patients are alive and tumor free after a mean follow-up of 43.1 months. Immediate postoperative complications were 2 cases of urinary fistula treated by ureteral stenting.

[Percutaneous treatment of postoperative stenosis of ureteropelvic junction. Use of the Korth stent]. / Trattamento percutaneo delle stenosi post-chirurgiche del GPU. Utilizzo dello stent di Korth.

Endopyelotomy is, in our opinion, the most proper therapeutic strategy for the treatment of UPF post-surgery stenosis, as a traditional re-operation is often difficult to be carried out and not exempt from possible stenotic relapse. We report 2 cases of secondary stenosis and inferior caliceal stones associated. As a first step we subjected the patients to a percutaneous lithotomy of the calculi and we kept a trans-calyceal nephrostomy in situ for about 5 days. Among the different EPT techniques, we chose the "transurethral traction" Rippa-Franch set, as the dynamic combined transurethral traction of the cold-knife allows a smooth dissection of the strongest cicatrix pad, too. The stenting of the dissected UPF has been carried out for few days by means of a Korth's temporaneous nephrostomy and subsequently, at light-coloured urine, by using the definitive Korth endostent by subcutaneous anchorage. This internal stenting system seems to be the most suitable one, as the patient can stand it quite well for long periods of time (3-6 months) too and it is not burden with V-U refluxes that could jeopardize the good result of the operation. The easy performance and good results achieved by this way, persuade us to suggest this two combined techniques as an effective endourological solution for UPF post-surgery stenosis.

[Calyceal diverticula: notes on endourological technique]. / Diverticoli caliciali: note di tecnica endourologica.

Percutaneous approach to complicated small caliceal diverticula is the first choice therapy. Generally, the open surgery is used large diverticula with renal parenchymal damage but, in selected cases, a percutaneous (PCN) treatment may be an effective alternative. The Authors report a case of inferior caliceal diverticulum associated to a parenchymal damage successfully treated using directed PCN management (electrical fulguration) and consequent injection of human fibrin glue.

[Use of terazosin and alfuzosin in the treatment of benign prostatic hypertrophy (BPH): our experience]. / Uso della terazosina ed alfuzosina nella terapia dell'ipertrofia prostatica benigna (IPB): nostra esperienza.

Dynamic and static factors cause infravesical obstruction in men with BPH. The dynamic component is determined by alpha 1-adrenoceptor-mediated contractions of the prostate smooth muscle and bladder neck. Using alpha-receptor-blockers will relieve bladder outlet obstruction, improving urinary flow rates and obstructive and irritative symptoms as well as the physician's global assessment. This study was performed to evaluate the efficacy and safety of alpha 1 blockers (terazosin and alfuzosin) in ambulatory patients (n = 20) with BPH. After 24 weeks of therapy, the peak flow rate increased 54% from a baseline average of 8.5 ml/s to 13.1 ml/s (p < 0.01). The mean flow rate increased 49%, from a baseline of 4.61 ml/s to 6.9 ml/s (p < 0.01); residual volume decreased 74% from 48.3 ml to 12.5 ml (p < 0.001). Mean systolic blood pressure decreased significantly (p < 0.05) from baseline, but this change wasn't clinically important. The clinical experience with alpha-blockers in BPH indicates that these drugs increase urinary flow rates, decrease obstructive and irritative symptoms, without serious side effects.

[Uroflowmetry in the assessment of patients with benign prostatic hyperplasia]. / Ruolo dell'uroflussometria nella valutazione del paziente con ipertrofia prostatica benigna (IPB).

Uroflowmetry is the most physiologic and non invasive assessing method of lower urinary tract obstruction: it proves to bring objective evidence of the prostatic blockage degree. We performed 1094 urinary flow tests in 264 patients with BPH, suffering from voiding problems; 188 males had undergone surgical treatment and 86 medical therapy. These patients were examined again about 3 months after prostatectomy and about 3, 6, 9 months during pharmacologic treatment. Symptoms were valued according to international prostatic symptomatologic score (I-PSS). The assessment of residual urine was performed by bladder ultrasound. Among the 264 patients, nocturia was present in 81.8%, weakness of stream in 75% and urgency in 47.7%. The average I-PSS for obstructed patients and postoperative were respectively 26 (21-32) and 5 (0-7). Frequency and weakness of stream were commonly (80% of cases) associated with a reduction in the maximum flow rate (Qmax). Qmax and average flow (Qave) improved after prostatectomy respectively from 7.1 ml/s to 18.9 ml/s and 4.1 ml/s to 8.3 ml/s. 6/264 males with normal Qmax and 132/264 with Qmax < 10 ml/s were shown to have residual urine > 80 ml. Among the uroflowmetry parameters analysed, the best correlation with the degree of prostatic obstruction degree is Qmax. Residual urine is a sign of an abnormality of bladder function rather than the direct result of urethral blockage. Uroflowmetry is a useful clinical tool in the diagnosis and follow-up of males with BPH.

[The role of LH-RH analogue in benign prostatic hyperplasia]. / Uso degli analoghi LH-RH nell'ipertrofia prostatica benigna.

In our study 7 patients considered high risk for any surgical and anesthetic intervention, with benign prostatic hyperplasia, whose 2 with permanent catheter, were treated for 6 months with luteinizing hormone-releasing hormone analogue. The treatment resulted in an average decrease in prostatic volume of 21.7%; reduced the serum PSA/PAP values of 52% and 43%, respectively; 4 pz improved their symptom score (1 pz removed the permanent catheter), 2pz kept stationary and 1 pz made worse. No particular side effects were presented and all patients finished the therapy. We conclude that LH-RH analogue therapy should be restricted to selected patients and then it will have to be continued for a long period of time.