Fournier's gangrene secondary to locally advanced prostate cancer: case report and review of the Literature.

Fournier's gangrene is a rare and potentially lethal condition. Previously described as an idiopathic process, this necrotising fasciitis is secondary to infection and in 95% of cases the cause arises from ano-rectum (30-50%), uro-genitalia (20-40%) or genital skin (20%). Cancer could lead to a Fournier's gangrene thanks a Romacompromised host immunity condition. In the past the rate of death was high ranging from 20% to 80%, while currently mortality is decreasing to 10%. We report a case of a 76-years-old man with Fournier's Gangrene due to locally advanced prostate cancer. The multimodal therapeutic management included broad-spectrum antibiotic therapy, intravenous fluid resuscitation and surgical debridement that was delayed by the will of the patient. To our knowledge, this is the first case of Fournier's gangrene caused by prostate cancer without common predisposing factors. In order to improve the knowledge about this rare disease, we performed a narrative review of the literature.

Colovesical fistula: review on conservative management, surgical techniques and minimally invasive approaches.

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Main causes are represented by complicated diverticular disease, colonic and bladder cancer and iatrogenic complications. Diagnosis is often based on patognomonic signs: faecaluria, pneumaturia and recurrent urinary tract infections. Treatment of CVF includes non-surgical and surgical strategy. The non-surgical treatment is reserved to selected patients who are unfit for surgery. Surgery of CVFs is determined by the site of the colonic lesion and patient's comorbidity. However the surgical one-stage approach should be preferred, reserving the multi-stage procedure in patients with a pelvic abscess, or with advanced malignancy, or previous radiation therapy. The sole defunctioning stoma may be an option to improve the quality of life in patients unfit for bowel resection. In open surgery the standard operative management consists in resection and anastomosis of the involved bowel segment and closure of the bladder. Laparoscopic treatment of CVFs is feasible and safe if performed by skilled surgeons. Robotic surgery for CVF treatment is safe and feasible similarly to laparoscopic one and it seems to reduce the conversion rate with respect to laparoscopy. However, further studies are needed to evaluate the advantages of robotic surgery over laparoscopy in the management of CVF. Currently, in Literature it is still debated which is the best surgical approach for CFV treatment due to the lack of RCTs and CCTs, the small sample size and the short follow-up. Further studies with higher quality and larger sample size are necessary to state the gold standard surgical treatment of CVFs.

Morphological changes of bladder mucosa in patients who underwent instillation with combined sodium hyaluronic acid-chondroitin sulphate (Ialuril®).

OBJECTIVE: To investigate what changes are endoscopically evident after glycosaminoglycans (GAGs) therapy by hyaluronic acid (HA) and chondroitin sulphate (CS) (Ialuril®) in female patients affected by bladder pain syndrome(BPS)/ interstitial cystitis (IC) or recurrent urinary tract infections (rUTIs). PATIENTS AND METHODS: 21 female patients over 18 years affected by rUTIs or BPS/IC received intravesical instillation of HA and CS (4 weekly instillations followed by 2 instillations every 2 weeks and 2 instillation monthly). Post-treatment evaluation included cystoscopy and patient assessment of improvement in symptoms and satisfaction on a visual analogue scale (VAS) from 0 to 10. RESULTS: The post-treatment endoscopy showed a positive effect on bladder mucosa morphology. In 2 cases, treatment did not change endoscopic findings and clinical symptoms. In the other patients, when macroscopic features of the bladder mucosa normalized, the clinical picture improved. CONCLUSIONS: GAGs therapy by HA and CS (Ialuril) improves the morphology of bladder mucosa in patients with rUTI or BPS/IC.

The management of pelvic organ prolapse: a review.

The increase of the prevalence of pelvic organ prolapse (POP) and urinary incontinence (UI), associated to changes in longevity, population demographics, and lifestyle expectation, is leading to a different set of urogynecological surgical challenges for 21st century women The objective of this review is to determine the characteristics and the effects of the different surgical technique in the management of POP. Here, we reviewed traditional techniques as well as we are going to take in consideration the introduction of several new procedures involving the use of different meshes or grafts, with or without introducer kits. Finally the laparoscopic approaches and the rapidly evolving robotic surgery will be discussed. Waiting for studies with high level of evidence, due to the plethora of techniques, mesh or graft material, absorbable (synthetic and biological) and non-absorbable, at present, there seems to be no final evidences about the best management.

Mini-invasive techniques for the treatment of female stress urinary incontinence.

AIM: The aim of this study was to review recent literature on mini-invasive surgical technique for the treatment of female stress urinary incontinence (SUI). Surgical aspects, intraoperative and perioperative complications and objective and subjective outcomes were analyzed and compared. METHODS: The PubMed databank from 2000 to February 2007 was searched for original prospective and randomized studies in English, on surgical treatment of female SUI, which avoided a laparotomic access to the female pelvis. Studies had to investigate at least 40 women with a minimum follow-up of 12 months. RESULTS: A total of 38 prospective studies were found: 27 of them were on mid-urethral slings; 8 assessed urethral injections; and 3 radiofrequency treatment. Fifteen studies were randomized. Follow-ups ranged from 12 to 60 months, except for sexual function which had a 6-month follow-up. Ten out of 38 studies assessed patients who did not refer pelvic organ prolapse or detrusor overactivity and had not undergone any previous anti-incontinence procedure. CONCLUSION: Mid-urethral slings showed good outcomes and are safe and brief to perform and have a relatively short learning curve. Urethral injections showed discouraging results, as they have poor outcomes and repetitive treatments are frequently necessary. Injections can be used in women with contraindications to major surgical procedures, with intrinsic sphincter deficiency as the main cause of incontinence. Radiofrequency showed worse results than mid-urethral slings and is a valuable choice in women who refuse more invasive procedures. The development of studies with longer follow-ups on mini-invasive surgical techniques are encouraged.

New therapeutic options for refractory neurogenic detrusor overactivity.

AIM: Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment. METHODS: Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment. RESULTS: With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points. CONCLUSION: In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

[Ultrasonography and Doppler color ultrasonography in kidney neoplasms: the demands of the clinician]. / Ecografia ed eco-color Doppler nella patologia neoplastica del rene: le esigenze del clinico.

The high number of diagnostic methods for images (ultrasound, computer tomography--CT, magnetic nuclear resonance--MNR) has allowed the urologist diagnosis more precocious of renal masses contributing to increase the survival rate and quality of life of patients affected by renal carcinoma. Although many are the advantages that the ultrasound scan gives to the urologist, still today in presence of ultrasound scan results showing expansive renal masses, probably malignant, many perform a CT or MNR for diagnostic confirmation and tumor extension.

[Role of Doppler color ultrasonography in the diagnosis of renovascular abnormalities associated with stenosis of the pyeloureteral junction]. / Ruolo dell'eco-color Doppler nella diagnosi di anomalie vascolari renali associate a stenosi della giunzione pieloureterale.

The obstruction of the pielo-ureteral junction, in most of the cases, recognizes an intrinsic etiopathogenesis, the presence of a segment ureteral aperistaltic and alteration of the ureteral musculature. The association of GPU stenosis and the presence of vascular anomalous shanks are frequent. The knowledge of this anatomical situation is important for choosing the therapeutic strategy and the surgical technique. The pre-operative diagnosis of the anomalous vase could condition the choice of the technique (endoscopic technique, laparoscopic), opting for open surgery to have a better control of the vascular shank. We have examined the use of the echo-color Doppler to diagnose the presence of anomalous vase. We have studied 13 patients (6 men and 7 women) between 18 and 62 years of age (average 35 years); the side interested by the obstruction was in 8 cases the right and in 5 cases the left. During surgery in 4 cases out of 13 examined anomalous vases were present. The pre-operative color Doppler found 3 anomalous shanks with a negative false, a positive false and 8 negative trues, showing a sensibility of 75%, a specificity of 88% with a global diagnostic ability of the 84%. We therefore believe that the echo-color Doppler is reliable enough in the pre-operative diagnosis of vascular anomalies associated to stenosis of the GPU and that could be used for pre-operative diagnosis of this urological affection.

[Ultrasonographic study of urethral sphincter in vesico-sphincter dyssynergia]. / Lo studio ecografico dello sfintere uretrale nella dissinergia vescico-sfinterica.

The ultrasound study of bladder neck and urethral sphincter in men could be performed by means of transrectal ultrasound scan in longitudinal scanning or by probing the surface in transperineal scanning. The endocavitary ultrasound scan study gives the best indications in the evaluation of the bladder neck in men. The neuromuscular bladder dysfunctions' (neurologic bladder), which can be studied by ultrasound scan are dyssinergia, striped detrusor, detrusor-bladder-neck dyssinergia, detrusorial iper-reflexy bladder instability. In paraplegic subjects the exam should be performed in gynecological position or in side decubitus, and micturition is obtained by means of sovrapubic percussion and compression or with prevailing action of the abdominal press. The detrusor-striped dyssinergia is the dysfunction of the bladder where the ultrasound scan results are more meaningful and give the best elements. In these cases, already in basal conditions, could be present a bladder neck half-opened. During micturition there is an ample opening of the bladder neck and of the prostatic urethra, but scarce relaxation of the membranous urethra; sometimes a protrusion of the back lip of the bladder neck could be present too. In iper-reflexy (unstable bladders) and in detrusorial ipo-reflexy, ultrasound scans could result poorly specific and non-significative.

[Diagnostic and therapeutic problems of "second look" in acute intestinal ischemia]. / Problematiche diagnostiche e terapeutiche nel "second look" delle ischemie intestinali acute.

The authors present their diagnostic approach to acute intestinal ischemia. They underline the need for early specific diagnosis because the therapeutic options vary widely in relation to different types of acute intestinal ischemia. Selective arteriography preceded by an aortogram is considered the diagnostic "gold standard". Although at present mesenteric ischemia is a serious, and often lethal, disease, an aggressive therapeutic approach can improve the outcome of this group of patients.