Is antibiotic prophylaxis in invasive urodynamics a useful procedure in postmenopausal subjects?

OBJECTIVES. To define the incidence rate of urinary tract infections (UTI) and the usefulness of antibiotic prophylaxis in postmenopausal female undergoing invasive urodynamics (IU). METHODS. 262 postmenopausal females underwent IU, being previously double-blindly randomized in 2 homogenous age-matched groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400 mg dose of norfloxacin. Group 2 (132 patients) was given placebo. The statistical analysis was performed using a Chi-Square test, in order to evaluate any difference between groups for UTI incidence rate. RESULTS. 54 patients out of 262 (20.6%) developed a UTI [24 out of 130 subjects who received antibiotic prophylaxis (18.4%), and 30 out of 132 subjects who received placebo (22.7%)]. As per the UTI incidence rate, no statically significant difference (p>.05) was shown between patients receiving and those not receiving the antibiotic prophylaxis. CONCLUSIONS. The UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by the administration of antibiotic prophylax.

Ultrastructural basis for the efficiency of an ileal orthotopic neobladder 27 years after surgery.

The morphological and functional basis of the excellent clinical outcome of ileal orthotopic neobladders are largely unknown. Only long-term follow-up studies will provide an adequate answer to this unsettled question. We have studied a patient who underwent this type of surgery over 27 years ago. Besides an important secretive adaptation we have found, at the ultrastructural level, that the monolayered epithelium does not show signs of true metaplasia and that changes had occurred in the intercellular junctions, namely that desmosomes are significantly increased. Although limited to a single case, these features, if confirmed by further observations, suggest a working hypothesis for the understanding of the definitive phenotypic adaptation of the ileal epithelium to the new aggressive environment.

Successful management of para-aortic lymphocyst with laparoscopic fenestration.

Para-aortic lymphocyst occasionally follows retroperitoneal para-aortic node dissection for neoplastic diseases. We present a case in which the leakage of chylous fluid and then a para-aortic lymphocyst followed right nephrectomy and para-aortic node dissection for kidney cancer. Our method of treatment utilized conservative management of chylous ascites and laparoscopic internal drainage of the retroperitoneal lymphocyst.

[Pelvic floor rehabilitation as treatment of female urinary incontinence. Our experience]. / Riabilitazione del pavimento pelvico come trattamento dell'incontinenza urinaria femminile. Nostra esperienza.

We refer herein on a simple program of rehabilitation that may be a first approach the treatment of, U.S.I. In our urodynamic service, we treated 38 female patients, affected by this condition, aged between 37-73 years. The same procedure was applied to all the patients, consisting of 10 seances twice weekly, during which we subjected the patients to biofeedback and vaginal electrostimulation of 50 Hz frequency. The results after 3 months were: 38% restored to normal, 51% improved, 11% unchanged; after 1 year were: 27% restored to normal, 49% improved, the remaining unchanged. As a whole, perineal rehabilitation by this technique can be curative in selected cases and, should it be necessary, can be repeated; its advantages are simplicity, low cost and lack of collateral effects. Motivation and compliance on the part of the patients are, anyhow, the chief factor of success. Moreover, the procedure does not preclude alternative treatments. It is suitable to chose cases where surgery is not so, or else is ill-accepted or has failed.

Histological adaptation of orthotopic ileal neobladder mucosa: 4-year follow-up of 30 patients.

OBJECTIVE: For 4 years we have monitored the histological evolution of ileal neobladders in a single cohort of 30 patients in order to systematically describe the histological changes occurring after surgery. The aim of the study was to evaluate the long-term evolution of many histological parameters with functional relevance as to the metabolic outcome of the reservoirs. METHODS: Ileal samples were collected during surgery and by random biopsies during cystoscopy 6, 12, 18, 24, 36 and 48 months later. At each step qualitative and quantitative assessment of the histological and cytological conditions of the samples was carried out. RESULTS: Morphological changes develop relatively early but the situation tends to level out in about 1 year. The morphological changes are topographically uneven and, although mucosal flattening becomes progressively prevalent, areas with shortened villi persist indefinitely. Goblet cells prevail over enterocytes and the secretive pattern shifts towards sialomucins. The overall replication rate decreases initially but tends to restore in 1 year. Dysplasia or atrophy were never recorded. CONCLUSIONS: The 4-year systematic follow-up revealed a typical histological adaptation pattern in the ileal neobladder without signs of dysplasia. The changes seem to be induced by the aggressive environment and develop in the time lag required for functional adaptation of the epithelium.

[Correlation between the leak point pressure and the clinical grade of incontinence]. / Correlazione tra leak point pressure e grado clinico d'incontinenza.

We evaluated one-hundred and forty-six women with stress urinary incontinence (SUI), mean age 61.5 years, with clinical examination, urodynamics and patient history, grading the subjective degree of SUI according to SEAPI QMM classification. SUI was grade 1 in 73 pts (mean LPP 107, 7 cmH2O, mean maximal urethral closure pressure 59, 13 cmH2O), grade 2 in 36 (mLPP 55, 4 cmH2O, mMUCP 50, 3 cmH2O), grade 3 in 37 (mLPP 32, 29 cmH2O, mMUCP 33, 76 cmH2O). There is statistically significant difference in mLPP (p = 0.001) and mMUCP (p = 0.02) among three groups. The grade of SUI increases as the likelihood that LPP will be < or = 90 cmH2O or < or = 60 cmH2O (72.2% of pts with grade 2 has a LPP < or = 60 cmH2O, 100% of pts with grade 3 has a LPP < or = 60 cmH2O). Women with severe leakage and/or predisposing factor (PF) to intrinsic sphincter deficiency are likely to have a low LPP: all patients with SUI grade 3 and PF have a LPP < or = 60 cmH2O, 77% of pts with SUI grade 3 or PF has a LPP < or = 60 cmH2O. Women with higher grades of leakage and PF are significantly more likely to have a very low LPP and intrinsic sphincter deficiency.

[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.

[Repair of vesicovaginal fistula by the Martius technique]. / Riparazione di fistola vescico vaginale secondo la tecnica di Martius.

Vesico-vaginal fistula (VVF) is still an unpleasant complication of female genital system surgery. We report the case of a 57-years-old woman undergone to neoadjuvant radiotherapy and afterwards abdomino-perineal resection who developed after one months a VVF.

Histomorphology of an ileal orthotopic neobladder: 24 Year's follow-up.

No morphological data are so far available about long-term (over 15 years) adaptation and outcome of ileal neobladders. In this single case report we have studied a 72-year-old man who underwent reconstruction of an ileal neobladder 24 years ago. The ileal epithelium shows changes toward a colonic aspect with villous atrophy and increased goblet cell number although, as in normal ileum, sialomucins are the most abundant secretory products. Neuroendocrine cells are reduced to a few elements of a single morphological class. Even in the presence of a low apoptotic rate reduced cell proliferation causes mucosal thinning. These adaptive mechanisms grant an excellent clinical and functional result even beyond 20 years after surgery. It is suggested that ileal neobladder can constitute an important model for the study of epithelial differentiation control.

[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).

[Valsalva leak point-pressure (LPP) and maximal urethral closure pressure (MUCP) in women with stress urinary incontinence (SUI)]. / Valsalva leak point-pressure (LPP) e massima pressione di chiusura uretrale (MUCP) in donne con incontinenza urinaria da stress (IUS).

One-hundred and twenty-two women with USI have been evaluated with clinical examination and urodynamics and divided in two groups: only in 74 patients with urinary loss during the Valsalva manoeuvre, LPP was compared to MUCP by linear regression analysis and its ability (cut-off = 60 cmH2O) to predict a MUCP < or = 20 cmH2O was tested. Weak correlations were observed between MUCP and LPP (r = 0.56). Fifty-two patients presented a LPP < or = 60 cmH2O, in 6 of them MUCP was < or = 20 cmH2O; none with LPP > 60 cmH2O showed a MUCP < or = 20 cmH2O. Median MUCP and intravesical pressures at the instant of leakage of patients with LPP < or = 60 cmH2O were significantly different from those of patients with LPP > 60 cmH2O (p < 0.01). The specificity and positive predictive value of LPP < or = 60 cmH2O for the detection of a "low pressure urethra" were respectively 32% and 11.5%, while sensibility and negative predictive value were 100%. LPP can not be regarded as a specific test for urethral sphincteric deficits. For its sensibility, it can be an useful screening tool for patients at high risk of type III urinary incontinence.

[Gittes' pubovaginal suspension in the treatment of stress urinary incontinence (SUI)]. / Sospensione pubo-vaginale secondo Gittes nel trattamento dell'incontinenza urinaria da sforzo (I.U.S).

Since the 1993, a series of 22 women with stress urinary incontinence underwent bladder neck suspension, according to Gittes (pubovaginal suspension). No patients had preoperative detrusor instability or intrinsic sphincter dysfunction; 14 pts had a significant cystocele (II-III degree). We followed up 20 pts at 6 months: 9 pts (45%) were cured, 3 were significantly improved and 8 were not improved. Disappearance or marked improvement of moderate or severe cystocele wasn't confirmed in all pts. No serious complications were recognized. We believe that this procedure is quick and easy to perform with low morbidity and is useful where the indication is correct: patients with stress incontinence without significant anterior vaginal wall prolapse.

[Rouxel-Coadou method of ileal neobladder: clinico-functional considerations]. / A propos de la néovessie Iléale détubulée selon Rouxel-Coadou: considérations clinico-fonctionnelles.

Twelve patients are submitted to orthotopic ileal neobladder, performed using staplers. The simplicity and speed of automatic stapling devices in the Rouxel-Coadou's surgical technique are reported. All patients underwent clinical and urodynamic evaluation at 3, 6, 12 months, after surgery (mean follow-up 6 months). They preferred complete daytime continence and 2 pts/4 night-time continence too. At one year, postvoid residual volume was absent, mean neobladder capacity was 450 ml and mean pressure at maximum capacity was 30-40 cm H2O. These preliminary results indicate that this technique guarantees a low-pressure reservoir with good capacity and compliance.

[Polyp fibroangioma of the ureter. Endoscopic treatment]. / Fibroangioma peduncolato dell'uretere: trattamento endoscopico.

Fibroangiomatous polyps and its histological variants most often occur in the ureters of young adult. They may be multiple, and rarely occur in the renal pelvis. Microscopically, normal or hyperplastic urothelium cover loose, vascular, edematous, fibrous stroma that may be inflamed. Etiologic factors are unknown. Intermittent flank pain is the most common symptom; dysuria and hematuria occur less frequently. A case of fibroangiomatous polyps of the left ureter, in a 37-years old woman, is presented. We emphasize the endoscopic conservative treatment of this lesion as a valid alternative to the surgical approach; beside, it's important to obtain pre-operative histological finding, confirming the benign lesion.

[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.

[Use of glidewires in urology. Note on endourological technique]. / L'uso delle glidewires in urologia. Note di tecnica endourologica.

In urology, the use of angiographic wires (glidewires) allows the anterograde, retrograde and "mixed" approach in obstructive and not obstructive uropathies stenting. The Authors reported a case of oligoanuria in a patient with progressing prostatic cancer resolved with endoscopical recanalization and secondary indwelling double-J ureteral stenting.

[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.

[Transurethral bladder echography in staging neoplasms: histopathological correlation (T/pT). Methodological proposal and preliminary results]. / Ecografia vescicale transuretrale nella stradiazione delle neoplasie: correlazione istopatologica (T/pT). Proposta metodologica e risultati preliminari.

By real-time ultrasounds through an intra-vesical probe, bladder mucosal features, wall thickness and external profile, as well as their pathological changes, are beautifully imaged; therefore, the role of this echographic technique in the clinical pre-treatment assessment of tumor local staging is expected to be accurate and reliable, accordingly to the first results by Holms and co-w. We have intended to verify the value of the method, by comparing the pre-treatment staging by the more traditional non-invasive clinical procedures plus intra-vesical sonography to the pathological staging (pT) from the removed tumor samples. Our preliminary results are herein presented, from which the overall accuracy of this staging approach seems to be confirmed and a wider experimentation to be justified.

[Diagnostic problems in non-acute prostatitis: experience in 150 cases]. / Problemi diagnostici nelle prostatiti non acute--una esperienza di 150 casi.

The rules for a diagnostic approach to non-acute prostatitis, as applied during a one-year trial in this Division of Urology, are reviewed and their results on a clinical ground of 150 cases are discussed. In fact, this clinical conditions is apt to present often some problems, as far its cure is concerned, due to its variety of symptoms, and not seldom to un-correct previous therapeutic approach, for defect of a precise diagnostic appraisal.

[Omentoplasty and a temporary internal stent in the treatment of recurrent peri-pyelo-ureteritis. Surgical technic. Apropos of a case]. / Omentoplastica e tutore interno a dimora temporanea nel trattamento della peripieloureterite recidiva. Nota di tecnica chirurgica. A proposito di un caso.

Repetitive surgery on the upper urinary tract calls for extensive and sometimes difficult dissection, therapy exposes to the risk of vascular and nervous injury, as far as tissue trophism is concerned, moreover to secondary severe perivisceral fibrosis. The ureter is particularly liable to such early or late damages. The use of a self-retaining stent, even for a long period of time, and of a pedicle omental graft wrapping ensures a better recovery and the prevention of fistulae or strictures from secondary retroperitoneal fibrosis.