The impact of age on intravesical instillation of Bacille Calmette-Guerin treatment in patients with high-grade T1 bladder cancer.

Intravesical instillation of Bacille Calmette-Guèrin (BCG) is the standard adjuvant treatment for high-risk non muscle invasive bladder cancer (NMIBC). Since its mechanism of action is supposed to be linked to the immune system efficiency and senescence could negatively affect this efficiency, BCG efficacy in the elderly has been questioned. This study aimed to assess the impact of age on BCG efficacy and safety in patients with high-grade T1 bladder cancer (BC).Among 123 patients with high-grade T1 BCG scheduled for BCG treatment, 82 were <75 year-old (group A) and 41 were ≥75 year-old (group B). Follow-up: urine cytology and cystoscopy every 3 months for the first 2 years, every 6 months for the third year, and then yearly. Tumor recurrence was defined as pathological evidence of disease at the bladder biopsy; tumor progression was defined as pathological shift to muscle invasive disease at the bladder biopsy or the imaging techniques showing recurrent BC and distant metastasis likely related to it.The median follow-up was 65 months (range 11-152). Recurrence occurred in 35 patients, 19 (23.2%) in the group A and 16 (39%) in the group B. Progression occurred in 18 patients, 12 (14.6%) in the group A and 6 (14.6%) in the group B. Recurrence free rate was similar in both groups up to 2 years. The 5 years progression rate was almost the same in both groups A and B (85.9% vs 84.7%), whereas the 5 years cancer-specific survival (CSS) was 92.6% in the group A and 85.4% in the group B. Of the 18 patients with progression, 11 underwent cystectomy; 12 patients died because of their BC. Kaplan-Meier plots pointed out no difference in recurrence-free, progression-free, and CSS between the 2 groups. Adverse events were similar in the 2 groups. Only 4 (3.3%) patients, 2 (2.4%) in the group A and 2 (4.8%) in the group B, experienced mild adverse reactions compatible with treatment.Elderly patients with high-grade T1 BC are not poorer candidates to BCG treatment, as they had similar benefit and adverse reactions than those aging ≥75 years.

Suprapubic-assisted Transurethral Excision of a Vaginal Mesh Eroded Into the Bladder.

A 56-year-old woman with irritative voiding symptoms and recurrent urinary infections was found to have erosion into the bladder of a tension-free vaginal tape placed 61 months before. To achieve radical excision, a 26Fr Amplatz sheath was placed suprapubically under endoscopic vision. A rigid nephroscope with grasping forceps was used to pull the eroded mesh out of the bladder wall while excising it transurethrally with a resectoscope. Postoperative course was uneventful; 12 months after surgery the patient remains asymptomatic. This novel technique provides an effective means of radically removing a mesh eroded into the bladder either transurethrally or suprapubically.

ID2-VEGF-related pathways in the pathogenesis of Kaposi's sarcoma: a link disrupted by rapamycin.

The Id-proteins are a family of four related proteins implicated in the control of differentiation and cell-cycle progression. Down-regulation of Id-gene expression is essential for the differentiation of several cell types. In addition, deregulated Id2 activity inhibits the Rb tumor suppressor pathway and promotes the expression of vascular endothelial growth factor (VEGF). Several members of VEGF family could be involved in Kaposi's sarcoma (KS) development and progression. Lymphatic vascular endothelial hyaluronan receptor-1 (LYVE-1) is the first marker of lymphatic endothelial competence during development in the mature vasculature, and is also expressed on KS spindle cells. Rapamycin (RAPA), an immunosuppressive drug, has been shown to reverse KS growth and to reduce tumor angiogenesis. We evaluate, in transplantation-associated KS and in cultured KS-cells the RAPA effect on Id2 and on de novo lymphangiogenesis. Markers of lymphatic-endothelial-cells (VEGFR-3, LYVE-1) and Id2, expressed at low levels within the normal skin, were up-regulated in KS and returned to normal levels after RAPA introduction. The association between Id2 and lymphangiogenesis is suggested by co-localization of Id2, VEGFR-3 and LYVE-1. RAPA inhibition on Id2 expression was confirmed in vitro in KS-cells, both in basal conditions and upon stimulation with VEGF. In conclusion, our data would suggest a novel molecular mechanism for the antineoplastic effects of RAPA in posttransplant KS.

Asymptomatic spontaneous migration of double pigtail ureteral stent outside the ureter.

We report a case of asymptomatic spontaneous migration outside the ureter of a double pigtail ureteral stent. This previously undescribed complication confirms the need for regular follow-up of patients with indwelling stents.

Vasoactive intestinal polypeptide (VIP) is not an androgen-dependent neuromediator of penile erection.

The effects of castration on vasoactive intestinal polypeptide (VIP) immunostaining in human corpus cavernosum (CC) and the relationship between VIP immunostaining and erectile function were studied in patients with localised prostate cancer who had (Group 1 = castrated) or had not (Group 2 = control) undergone 3-month neoadjuvant chemical castration before radical prostatectomy. Evaluation of erectile function included medical and sexual history, physical examination, and measurement of total serum testosterone. CC biopsies were taken at the end of radical prostatectomy and samples immunostained with anti-human VIP antibody. Specific staining was quantified by image analysis and expressed in arbitrary units (AU). Chemical castration induced erectile function deterioration in 70% of patients due to loss of sexual interest and confidence in the ability of having an erection rather than reduced ability of obtaining sexually induced erections. Average VIP content was 34.5 AU in Group 1 and 39 AU in Group 2 and this difference was not statistically significant. Chemical castration does not influence VIP immunostaining of human CC, suggesting that VIP is not an androgen-dependent neuromediator of penile erection and that it can be responsible for sexually induced erections in castrated patients.

The effects of androgen depletion on human erectile function: a prospective study in male-to-female transsexuals.

The objective of the study was to determine the effects of androgen depletion on erectile function in a population of male-to-female transsexuals. The erectile function of 25 consecutive male-to-female transsexuals on androgen depletion treatment and scheduled for surgical gender reassignment was prospectively evaluated using medical and sexual history, physical examination, total serum testosterone, International Index of Erectile Function (IIEF-15) questionnaire, penile colour-coded Doppler ultrasonography (CDU) after pharmacological stimulation and nocturnal penile tumescence (NPT) test. All but one had undetectable or low testosterone. Subjective erectile function, according to IIEF-15 scores, and penile CDU findings did not correlate with testosterone levels, whereas NPT test findings correlated well with testosterone levels. These findings would suggest that nocturnal erections are androgen-dependent whereas sexually induced erections are androgen-independent. It can also be assumed that testosterone is important but not essential for male erectile function and that other androgen-independent pathways can be responsible for sexually induced erections.

Antimicrobial prophylaxis for transrectal prostatic biopsy: a prospective study of ciprofloxacin vs piperacillin/tazobactam.

OBJECTIVE: To compare the efficacy of short-term parenteral prophylaxis with piperacillin/tazobactam (P/T) with long-term oral prophylaxis with ciprofloxacin in preventing infective complications after transrectal prostatic biopsy (TPB). PATIENTS AND METHODS: Patients scheduled for TPB were randomized to receive P/T (2250 mg intramuscular) twice daily for 2 days (Group 1), or ciprofloxacin (500 mg orally) twice daily for 7 days (Group 2), beginning on the evening before the procedure in both groups. All patients received a 100-mL phosphate enema 3 h before TPB. Evaluation included self-recording of body temperature in the 3 days after TPB, and culture of mid-stream urine (MSU) samples taken before and 3 and 15 days after TPB. Patients with indwelling urethral catheters or taking antibiotics or immunosuppressive drugs were excluded, as were patients with positive MSU cultures before TPB. RESULTS: Of the 138 evaluable patients, 72 received parenteral P/T and 66 oral ciprofloxacin. Bacteriuria (> 105 c.f.u./mL) after TPB occurred in two of 72 (2.8%) patients in Group 1 and in three of 66 (4.5%) patients in Group 2; this difference was not statistically significant (P > 0.1). However, of the five patients with bacteriuria, two were symptomatic and both were in Group 2. Pyrexia occurred in only one patient in Group 2 with symptomatic urinary tract infection, and required hospitalization. No other patient reported a body temperature openface> 37.5 degrees C or drug-related side-effects. CONCLUSIONS: This prospective study showed that short-term prophylaxis with P/T was associated with a low rate of asymptomatic bacteriuria, requiring no further treatment, whereas although the rate was similar on long-term prophylaxis with ciprofloxacin patients required further treatment, with one needing hospitalization. We recommend short-term prophylaxis with P/T despite its disadvantages of cost and parenteral administration.

Tunica albuginea plication for the correction of penile curvature.

OBJECTIVE: To evaluate the efficacy of tunica albuginea plication (TAP) in the correction of congenital and acquired penile curvatures and determine key points for a successful outcome of this procedure. MATERIALS AND METHODS: From December 1995 to January 2001, 40 patients with penile curvature (10 congenital and 30 secondary to Peyronie's disease) underwent surgical correction by TAP. Indications were difficult or impossible penetration, normal erectile function, stable disease. For TAP we used non-absorbable inverted stitches tied with the assistant pushing down the tunica albuginea with a mosquito clamp to create an adequate groove for the knot. The results were evaluated subjectively and objectively. RESULTS: At mean follow-up of 30 months, full subjective and objective success (straight penis, mild shortening, normal erection, penetration and sensation) was achieved in 37 (92.5%) patients. Objective but not subjective success was achieved in 2 patients (5%), 1 complaining of psychogenic erectile dysfunction and the other of excessive penile shortening. There was only one failure, namely persistent glans numbness due to damage of the non-mobilized neurovascular bundle. CONCLUSIONS: TAP is a simple and effective method for the correction of congenital and acquired penile curvatures. Key points for successful outcome are adequate preoperative evaluation and counselling, careful preparation of tunica albuginea, mobilization of urethra or neurovascular bundle when needed, use of inverted stitches carefully buried, objective postoperative evaluation with a pharmacological erection test.

Calyceal rupture and perirenal urinoma as a presenting sign of recurrent ovarian cancer.

BACKGROUND: Rupture of the urinary collecting system with peripelvic extravasation of urine is an uncommon pathologic condition usually associated with ureteral obstruction from calculi. CASE: We report a patient with calyceal rupture and peripelvic extravasation of urine secondary to distal ureteral obstruction by recurrent ovarian carcinoma. Diagnosis was established with computed tomography and renal scans. Placement of an indwelling ureteral stent via a nephrostomy resolved the urinoma. CONCLUSION: Gynecologic oncologists should be aware that calyceal rupture is a potential complication of gynecologic malignancy. Causes of perirenal urinary extravasation and approaches to diagnosis and management are reviewed.

Bacterial adhesion to urethral catheters: role of coating materials and immersion in antibiotic solution.

OBJECTIVE: To determine whether new coating materials (silver and hydrogel) or immersion in antibiotic solution may reduce or prevent bacterial adhesion to urethral catheters. METHODS: Precut segment of Teflon-, silver- and hydrogel-coated urethral catheters were incubated with two uropathogenic bacterial strains with and without previous immersion in antibiotic solution. Tobramycin, ceftriaxone and ciprofloxacin solutions were used as these antibiotics are commonly administered for the prophylaxis and treatment of urinary tract infection (UTI), especially in hospitals. RESULTS: Microbiological analysis showed that the new coating materials (silver and hydrogel) did not reduce bacterial adhesion to urethral catheters, whereas immersion in antibiotic solution yielded a statistically significant (p<0.05) reduction in bacterial adhesion to the test items. Among the antibiotic solutions tested, ciprofloxacin performed significantly better (p<0.005) than ceftriaxone and tobramycin. CONCLUSIONS: Immersion in a suitable antibiotic solution may significantly reduce bacterial adhesion to urethral catheters and consequently reduce the risk of UTI in connection with these devices. Although experimental, these findings may be of clinical relevance and provide grounds for further studies in vivo.

Nocturnal enuresis can be caused by absorptive hypercalciuria.

OBJECTIVE: The aim of this study was to determine whether nocturnal enuresis (NE) can be caused by absorptive hypercalciuria. MATERIALS AND METHODS: From 1981 to 1995, 406 patients with primary monosymptomatic nocturnal enuresis were studied. Up to 1989 (Group 1), urinary electrolytes and urinary creatinine were not evaluated, but since 1990 (Group 2) these tests have been performed routinely. In doing so, we noticed that in 8 patients in Group 2 and in 13 patients in Group 1 with persistent NE the urinary calcium and the urinary calcium/creatinine ratios were significantly high (p < 0.001). These patients were submitted to Pak's test and parathyroid hormone (PTH) and antidiuretic hormone (ADH) measurements. RESULTS: In all 21 patients, PTH and ADH levels were normal, while the Pak's test showed absorptive hypercalciuria. They were given an appropriate diet. After 3 months, NE had ceased completely in 4 patients (19%); bedwetting episodes diminished and calciuria levels were found to be borderline in the remaining 17. A new urodynamic evaluation showed normal patterns in 12 and detrusor instability (DI) in 5. Patients with DI received oxybutinine: enuresis disappeared in all. The remaining 12 children with persistent NE and normal urodynamic findings and the child with DI and persistent NE empirically received DDAVP; enuresis ceased in all of them within 1 month and calciuria stabilized at normal levels. CONCLUSIONS: This study revealed that absorptive hypercalciuria can be responsible for NE and can be treated with the combination of diet and DDAVP.

Resistance index as a prognostic factor for prolonged erection after penile dynamic colour Doppler ultrasonography.

OBJECTIVE: To identify an objective and reliable prognostic factor for prolonged erection after penile dynamic colour Doppler ultrasonography (CDU). METHODS: From June 1995 to July 1996, 156 patients suffering from erectile dysfunction were submitted to penile dynamic CDU at our institution. From June to December 1995 (Group 1), patients with rigid erection at the end of the test were invited to wait 90 min for a review. If detumescence had not occurred at the first review, they were invited to wait another 60 min for a second review. If detumescence had not occurred at this stage, they were given an intracavernous injection (ICI) of etilefrin to induce detumescence. To test the validity of the findings obtained in Group 1, from January to July 1996 (Group 2) patients with rigid erection and resistance index (RI) < or = 1.00 at the end of penile dynamic CDU were sent home and invited to return to the hospital if erection lasted more than 2 h, while those with rigid erection and RI > 1.00 were immediately given an ICI of etilefrin to induce detumescence. RESULTS: Of the 62 patients in Group 1, 31 yielded a rigid erection. Seven refused to wait for a review. They were given an ICI of etilefrin and excluded from the study. Of the 24 evaluable patients, 10 presented spontaneous detumescence at the first review. RI was < or = 1.00 in 7, and > 1.00 in the other 3. None of the remaining 14 patients presented spontaneous detumescence at the second review. RI was > 1.00 in all of them. They were successfully managed with an ICI of etilefrin. Of the 94 patients in Group 2, 43 yielded a rigid erection. Twenty had a RI < or = 1.00 and therefore were sent home. None of them returned to the hospital. Contacted by phone, they all said that spontaneous detumescence had occurred within a couple of hours. Of the 23 patients with RI > 1.00, 22 were immediately given an ICI of etilefrin. One who refused returned to the hospital 4 h later with a prolonged erection which was successfully managed with an ICI of etilefrin. CONCLUSIONS: This study showed that RI is a reliable prognostic factor for prolonged erection. In patients with RI > 1.00 at the end of penile dynamic CDU, immediate prevention of prolonged erection is recommendable to avoid unpleasant sequelae.

Immersion in antibiotic solution prevents bacterial adhesion onto biodegradable prostatic stents.

OBJECTIVE: To determine whether immersion in antibiotic solution reduces or prevents bacterial adhesion onto biodegradable prostatic stents. MATERIALS AND METHODS: Pre-cut segments of polyglycolic acid (PGA) and polylactic acid (PLA) prostatic stents were incubated with two common uropathogenic bacterial strains (Enterococcus faecalis and Escherichia coli) with and without previous immersion in antibiotic solution. Tobramycin, ceftriaxone and ciprofloxacin solutions were used, as these antibiotics are commonly administered for the prophylaxis and treatment of urinary tract infection (UTI). RESULTS: Immersion in ciprofloxacin solution prevented the adherence of both bacterial strains. Immersion in ceftriaxone solution prevented only the adherence of the E. coli strain. Immersion in tobramycin solution had no effect on either of the strains. The stent materials per se did not influence bacterial adhesion. After immersion in ciprofloxacin, the stent segments retained significant antibacterial activity even after one day's incubation in saline. CONCLUSION: Immersion in a suitable antibiotic solution may significantly reduce and even prevent bacterial adhesion onto biodegradable prostatic stents. Preventing bacterial adhesion may reduce the risk of UTI during the use of these devices.

Is it possible to prevent bacterial adhesion onto ureteric stents?

The aim of this study was to determine whether the use of bactericidal coatings or immersion in antibiotic solution reduces or prevents bacterial adhesion onto ureteric stents. Precut segments of full silicone, silver-coated and hydrogel-coated ureteric stents were incubated with two uropathogenic bacterial strains with and without previous immersion in antibiotic solution. Tobramycin, ceftriaxone and ciprofloxacin solutions were used, as these antibiotics are commonly administered for the prophylaxis and treatment of urinary tract infection (UTI). Microbiological analysis showed that immersion of ureteric stents in ceftriaxone and ciprofloxacin yielded a significant reduction of bacterial adhesion, whereas immersion in tobramycin did not. The surface material of the stents had no direct influence on bacterial adhesion. In this experimental study, neither the silver nor the hydrogel coat reduced bacterial adhesion onto ureteric stents whereas immersion in a suitable antibiotic solution significantly reduced and even prevented this phenomenon, probably due to the adhesion of the antibiotic onto the stent surface. Prevention of bacterial adhesion onto ureteric stents is essential to reduce the risk of UTI in connection with these devices.

Fibromatosis of the female pelvis.

BACKGROUND AND AIMS: Desmoid tumour is a rare entity characterized by benign proliferation of fibroblasts. Although non malignant, this tumour can be life-threatening due to its invasive property and high recurrence rate. MATERIAL AND METHODS: We report a case of pelvic fibromatosis whereby the tumour was completely resected without sacrificing organs or major vessels. RESULTS: Thirty months after surgery the patient is asymptomatic, without any sign of recurrent disease. CONCLUSIONS: Radical surgery represents the main primary treatment for pelvic fibromatosis. The other available therapeutic options are discussed.

[Utility of ultrasonography in patients with ambiguous external genitalia: a clinical case]. / Utilità dell'ultrasonografia in pazienti con ambiguità dei genitali esterni: caso clinico.

We report a case in which the use of ultrasonography in the perinatal evaluation of ambiguous genitalia could have avoided psychological, physiological and also medico-legal problems for the patient.

[Role of dynamic penile color Doppler echography in the evaluation of the patient with La Peyronie's disease]. / Ruolo dell'ecocolor Doppler penieno dinamico nella valutazione del paziente con malattia di La Peyronie.

From March 1995 to February 1996, sixteen consecutive patients with Peyronie's Disease (PD) were routinely submitted to penile dynamic colour-coded doppler ultrasonography (CCDU). The test yielded normal results in 6 patients who had no erectile problems and in other 4 patients who conversely complained of reduced erectile function. In the other 6 patients who complained of reduced erectile function, the test pointed out pure arteriogenic failure in 1 case, pure venogenic failure in 4, and mixed arteriogenic and venogenic failure in 1. CCDU enables a precise assessment of erectile function as well of the site, kind and entity of the penile curvature to be corrected. These data are very useful when planning the surgical approach for each patient.

[Penile dynamic color Doppler echography in the diagnosis of erection disorders]. / Ecocolor Doppler penieno dinamico nella diagnostica dei disturbi dell'erezione.

Penile dynamic colour-coded doppler ultrasonography (CCDU) provides reliable information on both hemodynamic factors, arterial inflow and veno-occlusive mechanism, involved in erectile function. However false negative results may occur due to sympathetic discharge and consequent incomplete smooth muscle relaxation. From March 1994 to February 1996, 150 patients suffering from ED were submitted to penile dynamic CCDU after high-dose (40 micrograms) pharmacostimulation and manual genital stimulation. False negative results occurred only in 3 (2%) patients. This experience suggests that high-dose pharmacostimulation and manual genital stimulation may reduce the occurrence of false negative results, further increasing the diagnostic value of CCDU.

A positive pharmacological erection test does not rule out arteriogenic erectile dysfunction.

PURPOSE: We tested the assumption that a positive pharmacological erection test implies normal penile vascular status. MATERIALS AND METHODS: From March 1991 to February 1995, 372 patients with erectile dysfunction were referred to our institutions. Penile hemodynamics were studied in 205 patients with color coded Doppler ultrasonography after intracavernous injection of 40 micrograms. prostaglandin E1. RESULTS: Of the 205 patients undergoing color coded Doppler utrasonography 92 had a rigid erection, that is a positive pharmacological erection test. Doppler wave analysis showed that 76 of the 92 patients (82%) had normal and 7 (8%) had borderline arterial function (peak systolic velocity greater than 35 and 25 to 35 cm. per second, respectively), while 9 (10%) had arterial insufficiency (peak systolic velocity less than 25 cm. per second). All 92 patients had a normal veno-occlusive mechanism (resistance index greater than 0.90). Of the 9 patients with pure arteriogenic erectile dysfunction 8 had risk factors for arterial insufficiency, such as aortoiliac occlusive disease (5), diabetes mellitus (3), longer than 20-year smoking history (8) and hypertension (7). CONCLUSIONS: Our study shows hemodynamically that a positive pharmacological erection test does not rule out arteriogenic erectile dysfunction.

Aortofemoral surgery and sexual function.

OBJECTIVES: To determine the incidence and pathophysiology of erectile dysfunction (ED) in patients with aortoiliac occlusive disease (AIOD) and the effects of aortofemoral surgery, including endarterectomy (E) and reconstruction (R), on erectile function (EF). DESIGN: Evaluation of EF before and 3 months after surgery. METHODS: 31 out of 40 male patients scheduled for aortofemoral surgery were given multiple choice questionnaires and penile dynamic Colour Doppler Ultrasonography. RESULTS: Of the 31 who agreed to enter the study five (16%) were found to be potent and 26 (84%) to suffer from ED. This was purely arteriogenic in 8% of the cases, purely venogenic in 23%, combined arteriogenic and venogenic in 53%, and neurogenic in 16%. Twenty patients returned for postoperative evaluation of EF, nine who had undergone E and 11 who had undergone R. Improvement of EF, in terms of increased penile arterial inflow, occurred in seven patients, six who had undergone E and one who had undergone R. EF remained unchanged in nine patients, three who had undergone E and six who had undergone R. Deterioration of EF occurred in four patients, all who had undergone R, and was attributable to decreased arterial inflow in two cases and to neurogenic surgical injury in the other two. CONCLUSIONS: The majority of patients with AIOD suffers from ED. Reduced penile arterial inflow and cavernovenous leakage are equally important in the pathophysiology of ED in patients with AIOD, suggesting that atherosclerosis may also compromise the penile veno-occlusive mechanism. Endarterectomy seems more likely than reconstruction to improve or maintain EF.