Lithotripsy in the treatment of urinary lithiasis.

Based on an extensive review of the literature and on our own clinical experience, this article attempts to present clear guidelines for the management of various kidney stones, particularly regarding the extracorporeal shock waves lithotripsy (ESWL) treatment nowadays. Few technical developments have changed medicine more within a short period of time than ESWL. Fifteen years after the first clinical application, ESWL has gained world-wide acceptance as first choice therapy for most forms of urolithiasis. Ninety-eight per cent of stones can be successfully fragmented by the application of shock-waves, but the ability of the kidney and ureter to clear the resulting fragments is far more important in terms of successful treatment outcome. Increasing experience with new ultrasound-guided lithotriptors has shown that there are some advantages: cost reduction, permanent monitoring and lack of exposure to ionising radiations. ESWL is a safe procedure for the treatment of urolithiasis; nevertheless some problems remain. In ureteric stones, ureteroscopy (rigid or flexible device) allows a rate of stone-free patients better than ESWL. For treatment of large staghorn calculi combined approach of PCNL and ESWL is preferred. For stones located at lower calyx, the stone-free rate in patients treated by ESWL fell to 50%, when unfavourable anatomy is present. The potential long-term renal damage, associated with ESWL in children, have delayed the acceptance of shock-waves into paediatric practice. Recent reports suggest that the renal damage, including the potential risk of hypertension induced by ESWL, is mild and transient. A subgroup of patients (e.g. solitary kidney, impaired renal function, children) required further attention. The fate of residual fragments is unclear. In some cases residual lithiasis tend to result in regrowth and further progression, although ESWL itself does not increase the recurrence rate of urolithiasis. Nevertheless follow-up of stone patients after ESWL is mandatory and the ultimate goal of treating stones by whatever means is to get the patient stone-free and prevent recurrence.

[Orthotopic ileal neobladder of the Emikock type: technical points and functional results]. / La neovescica ileale ortotopica tipo Emikock: attualità tecniche e risultati funzionali.

Ileal orthotopic neobladder represents, nowadays, the best urinary diversion after cystectomy. Emikock procedure was performed, in our institution, in 26 patients with bladder cancer T2-T4. At 6-60 months of follow-up 3 pts were died with local or at distance neoplastic recurrence, 2 were alive with neoplasms and 21 were NED. Nocturnal continence was good in 22 cases (88%) and only 3 patients were obstructed because of pseudodyssynergia in 2 and stricture in 1. Emikock neobladder even if needs a longer surgical time than other procedure and a long ileal tract is almost free from severe metabolic disorders. This technique offers a good protection of high urinary tract because of antireflux nipple and avoid the uretero-intestinal stricture. It not feasible, now, to know the functional trend of this reservoir on the long term. Adequate postoperative training is recommended to avoid the pseudodyssynergia and functional obstruction of reservoir.

[Iatrogenic obstructive azoospermia]. / Azoospermie ostruttive iatrogene.

Obstructive azoospermia is a common cause of sterility in men. In the past infection played an important role in the aetiology of obstructive azoospermia. Recently, however, the aetiology of obstructive azoospermia appears to be changing. So iatrogenic obstructive azoospermia has reached an important role in the field of obstructive azoospermia. In this work we show international literature about iatrogenic obstructive azoospermia. Unfortunately it is poor, in spite of an interesting item. We divided iatrogenic obstructive azoospermia into six groups, considering the possible anatomical site of obstruction. So we show the possible damages at the different levels: testis, epididymis, vas deferens, seminal vesicles, prostate and ejaculatory ducts.

[pT1G3 bladder carcinoma: parameters of a correct therapy]. / Carcinoma vescicale pT1G3: parametri per una corretta terapia.

Between 13.8% and 27% of all superficial bladder cancers are represented by pT1G3 neoplasm. In the Department of Urology of Policlinico S. Marco-Zingonia, between February 1988 and June 1994, we treated 22 patients suffering for pT1G3 bladder tumor. TUR-B has demonstrated to be a good approach for treatment of superficial bladder cancer, with low morbility; on the opposite side, we have to underline the high rate of recurrence and of progression of the urothelium disease. Now a day our best approach for the treatment of pT1G3 bladder tumor is represented by radical cystectomy supplied by chemotherapy.

[External devices: for which patients?]. / Dispositivi esterni: a quali pazienti proporli?

Vacuum therapy is a reversible, non-invasive form of treatment for partial impotence, with great success in USA. The story of vacuum therapy begins about 1960, when Osbon developed a vacuum tumescence device which he personally used for more than 20 years. The device was made commercially available many years ago and has been marketed under several names. The newer systems have incorporated a negative pressure pump to achieve vacuum. Osbon's system was patented in 1983, sale is permitted by the U.S. Food and Drug Administration, and it is available by prescription only. More than 10,000 units have been sold. There are four different types of vacuum therapy: 1) loading cone + constriction band; 2) external splint + negative pressure; 3) Negative pressure + constriction band; 4) Negative pressure + intracavernous injections, without the use of constriction band. Each basic system will be described. The authors make a comparison between the use of negative pressure devices plus tension band and the use of negative pression devices without tension band (plus C.I.D. with vaso-active agents). In the second case there's a sort of synergistic action between vaso-active agents and vacuum therapy, representing a sort of "vaso-active exercise" of the erectile tissue. There are no absolute contraindications to use of external penile devices and potential contraindications are few. The external penile devices described represent a reversible therapeutic modality that can augment an inadequate erection and they should prove useful in any man who needs erectile enhancement. These devices appear to be particularly effective in men with partial impotence in whom only erectile enhancement is needed.

[Radical prostatectomy: our experience]. / Prostatectomia radicale: la nostra esperienza.

Between July 1989 and June 1994 32 men (48-73 years old) underwent radical retropubic prostatectomy for prostate cancer. 26 patients (70%) presented with symptoms of bladder outflow obstruction. The primary tumour was understaged preoperatively in 5 patients (15.5%). At follow-up (6-66 months, average 24) significant urinary incontinence not occurred in our patients; sixty-two per cent reported a substantial problem with reduced or absent erection. A total of 23 patients was free of clinical or biochemical progression, observed in 28% of cases as distant or local progression. Radical prostatectomy is being performed with increasing frequency: trends in morbidity have been identified.

[TURP: what and when. Indications, results, complications: our experience]. / TURP: quale e quando. Indicazioni--risultati--complicanze: nostra esperienza.

Transurethral resection of the prostate (T.U.R.P.) has indeed replaced open surgery in the great majority of cases, particularly when the gland is estimated to weight 50-60 g or less. After prostatectomy the patient resumes a normal voiding pattern and obstructive symptoms quickly disappear, although irritative symptoms tend to persist for some time.

[Penile nuclear magnetic resonance (NMR)]. / La risonanza magnetica nucleare (RMN) peniena.

Nuclear Magnetic Resonance (NMR) is a new diagnostic technique with great opportunities of application in the field of the penile pathologies. A new interest for this diagnostic technique was born when the use of vasoactive agents, like papaverine or PGE1, and the use of para-magnetic contrast agents, like gadolinium, were introduced. The introduction of dynamic NMR in andrology allowed a better definition of anatomical details and a better knowledge of penile micro-circulation. N.M.R. is showing a great diffusion, because of a little invasiveness (X-rays are not used in this technique). The Authors show a wide spread of possible applications of NMR in penile pathologies, helping in the interpretation of the images. In conclusion the authors describe NMR as a diagnostic technique with great possibilities of improvement, even if the high costs don't allow a better diffusion until now.

[Urologic laparoscopy: preliminary experience]. / Laparoscopia urologica: esperienza preliminare.

Laparoscopy is a safe and reliable procedure for treatment of cryptorchid testicle, varix ligation, staging of lymph nodes in prostatic and in bladder cancer. Recently this procedure is adopted in management of renal cysts. From 2/92 to 7/92, we performed laparoscopic assessment in 31 patients: in 15 cases for varicocelectomy, in 9 for renal cysts, in 2 for lymph nodes dissection, in 3 for preoperatory evaluation, in 1 for unpalpable testicle and in 1 case for ileal perforation in orthotopic neobladder. In 1 case the procedure was unsuccessful because of damage of the spleen. All the patients were mobilized within 1 day postoperative treatment and discharged within 3 days. There are many present and potential application of laparoscopic surgery in urologic pathology, but we think that this technique must be carefully applied in order to avoid complications.

[Intracavernous infusion of drugs]. / La farmacoinfusione intracavernosa.

In 1982 Virag presented the initial experience of use in diagnosis and treatment of impotence. PGE1 has been showed a safe and effectiveness drug. From september 1989 to october 1991 210 patients with erectile disorders were managed by I.C.I. with PGE1 with minimal side effects.

[Endocavernous drug infusions revisited]. / La farmacoinfusione endocavernosa rivisitata.

From the beginning of the eighties papaverine was well established as the drug of choice for diagnosis and management of vasculogenic impotence. In the second half of the eighties decade many authors referred on experimental use of PGE1 in erection disease. PGE1 has been showed a safe and effectiveness drug. During the period September 1989-October 1990 at our Institution 98 pts. with erectile disorders were managed by I.C.I. with PGE1. Out of 98 cases 88 had success. Prolonged erection occurred in 4 pts. (4.2%). 10 pts. showed only tumescence. So there are been treated by I.C.I. with combined papaverine and PGE1 with better results. No side effects were formed in 10 pts. managed by self-injection of PGE1.

[Complications of percutaneous litholapaxy]. / Complicanze della litolapassi percutanea.

Percutaneous nephrolithotomy has been proved an efficient management of renal calculi. We report, in present review, the complications of PCNL procedure referred by several authors and our casistic since 1985. Major complications occurred in 3-6% of treated patients: severe bleeding, arteriovenosal fistulas, haematoma perirenal, water syndrome, sepsis, DIC, etc.). Nephrectomy was necessary in less than 1% of reported cases. 5 patients died for complications related to PCNL. Early complications occurred during the percutaneous puncture, tract dilation and lithotripsy. Postoperatively bleeding at the time of nephrostomic tube removal was reported in 0.5-1% of cases. Late sequelae of PCNL: stricture, fistulas, renal damage, renal function loss, high lithiasis recurrence rate were reported rarely. We, herein, believe PCNL is a safe and effective procedure with minimal rate of complications and late effects, according to other important authors.

[Complications and limitations of transurethral prostatic resection: retrospective study of 366 patients]. / Complicanze e limiti della resezione prostatica transuretrale: studio retrospettivo su 366 pazienti.

In present paper we report our experience on 366 patients underwent to transurethral resection of prostate from January 1988 to January 1990. All patients were controlled by uroflowmetry and retrograde plus minctional urethrography, with evaluation of the possible immediate and latest complications. Among the latest complications, the most representative had been urethral stricture, occurred in 24 patients (6.5%) according with international literature. We considered also various iatrogenics factors (operator experience, endoscopic time, catheter section, catheter permanence time, use of lubricator, presence of catheter before TURp, preventive Otis urethrotomy). From our study rises out that the most important risk factors are: a) catheter permanence time; b) TURp without preventive Otis urethrotomy.

[Neoadjuvant chemotherapy of locally advanced tumors of the bladder: preliminary experience]. / Chemioterapia neoadiuvante nei tumori vescicali localmente avanzati: esperienza iniziale.

From february 1988 to march 1989, 6 patients with locally advanced bladder cancer (T3b-T4, N0-N1, M0) were treated with 4 courses of neoadjuvant MP chemotherapy (methotrexate 300 mg/mq. + cisplatinum 100 mg/mq). In two patients chemotherapy was stopped because minimal or no response after two courses. Partial response (RP) was achieved in three patients (50%). Two patients died 2 and 5 month later. One patients developed metastases at 11 month. The remaining three cases showed NED at 3, 4 and 15 months of follow-up. In the same period 4 patients with metastatic bladder tumor were treated with M-VAC chemotherapy according to Yagoda before the cystectomy. M-VAC obtained a complete response in one case, and PR in 3 cases. All the metastases showed evidence of objective tumor regression. Reduction of bone pain was observed in one case. One patient died 15 months later with bone massive involvement. Another patient developed invasive tumor at 13 months. Two patients were disease-free at 3 and 5 months, respectively. Toxicity was more frequent in patient treated with M-VAC than with MP chemotherapy. M-VAC, we believe, represents a reliable neoadjuvant treatment of advanced metastatic bladder cancer.

[The Wolf piezolith 2300: lights and shadows]. / Piezolith 2300 Wolf: luci ed ombre.

Extracorporeal piezoceramic Wolf lithotripter was developed in West Germany by Ziegler and Associates in collaboration with Wolf GmbH. Piezolith 2300 has no cumbersome water tube and it was constructed as a mobile unit. It requires no patient irradiation, a special room adaptation, a electrodes replacement or any auxiliary staff. From February 1988 up to May 1989 a total of 230 stones in 218 patients, 18 to 79 years old, was treated with Piezolith 2300, in our Center. Ultrasound localization failed in 7 more cases of ureteral stones. Treatment resulted quite painless. Auxiliary measures before EPL, were performed in 12 cases, only (5%). 15 pts were managed with combined procedures: ESWL + EPL, PCNL + EPL, surgery + EPL. The mean of SW was 3000 (800-6500) for each piezoelectric session. In 27 pts (12%), 4 or more EPL sessions were performed. A successful disintegration was achieved in 210 cases (90.2%). Out of 20 unsuccessful cases, 15 were managed by Dornier HM3 mod lithotripter and 4 by ULL. Post EPL ancillary procedures were required in 4 pts (1.8%). No major complications were observed in our series. At the 30-days follow-up, 57.3% of the patients were stone free. At preliminary 3-month follow-up in 120 pts the rate of the entire success raised to 75%. We think, according to others authors, that EPL is the treatment of first choice in 70% of reno-ureteral stones.

[Possibility of using the piezoelectric lithotriptor in the treatment of severe cavernous fibrosis]. / Possibilità di impiego del litotritore piezoelettrico nel trattamento delle fibrosi cavernose gravi.

The treatment of serious cavernous corpora fibrosis due to priapism, a prosthesis explantation, iatrogenic causes, or Peyronie's disease, is by now still uncertain. Therefore we tried, when medical and physical therapy failed, to find out the possibility of extracorporeal lithotripter to treat such a complicated cases. From February 88 until now 16 patients underwent extracorporal shock waves treatment, out of 16, 9 had a serious Peronie's disease (a), in 3 fibrosis was a consequence of priapism (b), in 3 of prosthesis explantation (c), 1 patient of cavernosography (d). The treatment was performed by Wolf piezoelectric lithotripter (Piezolith 2300), the patients were treated once a week for 6 weeks. (800 SW; power ranged between 40 and 100 Mpa, frequency between 1 and 2.5 Hertz). In all the patients an orally steroid drugs was administered and a ionophoresis therapy associated. After one year of follow up a penile ultrasound scan, artificial erection tests, rigidometry. None side effects was noted but local ecchimosis. The were done results obtained might support our effort and suggest further studies.