Asymptomatic bacteriuria in candidates for active treatment of renal stones: results from an international multicentric study on more than 2600 patients

The occurrence of asymptomatic bacteriuria concomitant to urolithiasis is an issue for patients undergoing renal stone treatment. Disposing of a preoperative urine culture is essential to reduce the risk of septic events. The endpoint of the study is to report which characteristics of candidates for renal stone treatment are frequently associated with positive urine culture. 2605 patients were retrospectively enrolled from 14 centers; inclusion criteria were age > 18 and presence of a single renal stone 1-2 cm in size. The variables collected included age, gender, previous renal surgery, comorbidities, skin-to-stone distance, stone size, location, density, presence of hydronephrosis. After a descriptive analysis, the association between continuous and categorical variables and the presence of positive urine culture was assessed using a logistic regression model. Overall, 240/2605 patients (9%) had preoperative bacteriuria. Positive urine culture was more frequent in females, patients with previous renal interventions, chronic kidney disease, congenital anomalies, larger stones, increased density. Multivariate analysis demonstrated that previous renal interventions (OR 2.6; 95% CI 1.9-3.4; p < 0.001), renal-related comorbidities (OR 1.31; 95% CI 1.19-1.4; p < 0.001), higher stone size (OR 1.06; 95% CI 1.02-1.1; p = 0.01) and density (OR 1.00; 95% CI 1.0-1.00; p = 0.02) were associated with bacteriuria; male gender and lower caliceal location were inversely related to it. Beyond expected risk factors, such as female gender, other parameters are seemingly favoring the presence of positive urine culture. The awareness of variables associated with bacteriuria allows to assess which individuals are at increased risk of presenting bacteriuria and reduce the rate of septic complications.

Medical treatment of weight loss in children and adolescents with obesity

Obesity remains one of the biggest health problems both in adults and children. Lifestyle modification, including diet and exercise, continues to be the mainstay of obesity prevention and treatment. Unfortunately, lifestyle modifications are often unsuccessful. Pharmacological treatment of obesity in pediatric patients can be applied in selected cases, and not before evidence of failure of the multidisciplinary lifestyle intervention. In this narrative review, we revised the most up-to-date evidence on medical treatment of weight loss in children and adolescents with obesity, including FDA- or EMA-approved and -experimented, not approved, drugs for pediatric population. Multidisciplinary treatment of childhood obesity, regulation of appetite control, energy balance and body weight were also discussed, in order to clarify the indications and mechanism action of drugs. Despite a substantial number of medications used for the treatment of obesity in adults, a limited number of drugs are approved by the drug regulatory agencies for pediatric population. Further research is needed to evaluate the efficacy and safety of novel pharmacological approaches for treatment of pediatric obesity in order to optimize weight management for children and adolescents and limit the development obesity-related comorbidities.

HPV Vaccination in Young Males: A Glimpse of Coverage, Parental Attitude and Need of Additional Information from Lombardy Region, Italy

Background: In the Lombardy Region, Italy, HPV vaccination is recommended and offered free of charge to 12-years-old males since 2017. The expected vaccination thresholds are still far to be reached. Methods: A cross-sectional survey to investigate parents’ attitudes towards the HPV vaccine and knowledge about HPV was administered to parents of boys aged 6 to 18 years attending a large pediatric hospital for outpatient specialistic evaluations. Two parallel multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for attitude towards HPV vaccination and perceived need for more information about HPV vaccination. Results: A positive attitude towards HPV vaccination was found in 74% of interviewed parents. Knowledge of HPV, having a generally positive attitude toward vaccination, and mothers filling in the survey were positively associated with a positive attitude to the HPV vaccine. Parents’ perceived need for more information about HPV vaccination was positively associated with the child’s age, general positive attitude toward vaccination, Christian religion, and positive attitude toward HPV vaccination; knowing that HPV vaccination is free of charge significantly reduced the risk of asking for more information on HPV vaccination. Conclusions: The majority of parents of male children and adolescents in our study have a positive attitude toward HPV vaccination. Attitude toward HPV vaccination and perceived need for more information on HPV vaccination were directly related to a positive attitude toward vaccines in general. In addition, knowledge of HPV and related pathologies favors a positive attitude toward HPV vaccination. Future health programs should target an even wider diffusion of evidence-based information on vaccines in general and on the HPV vaccine in young males, to support a positive attitude toward vaccines in the general population.

Antibiotic-Induced Neutropenia in Pediatric Patients: New Insights From Pharmacoepidemiological Analyses and a Systematic Review

Aim: to characterize pediatric cases of antibiotic-associated neutropenia through a multidisciplinary approach, focusing on the temporal association between the wide spectrum of treatment options and the occurrence of this relatively uncommon but potentially clinically relevant adverse event.

Methods: we carried out a pharmacoepidemiological analysis based on the FDA Adverse Event Reporting System (FAERS) database, a retrospective chart review and a systematic review of the literature, focusing on the time to onset (TTO) of this side effect, in the pediatric clinical setting.

Results: A total of 281 antibiotic-related neutropenia events, involving 11 categories of antibiotics, were included in the time to onset analysis. The median TTO ranged from 4 to 60 days after the start of the therapy. A shorter median TTO was found from the retrospective chart review [16 patients: median days (25th-75th percentiles) = 4 (3–5)], compared to 15 (9–18) vs. 10 (6–18) for literature (224 patients) and FAERS (41 cases), respectively. The Anatomical Therapeutic Chemical classes, J01X, J01F, J01E and J04A, and the median TTOs retrieved from more than one source revealed high accordance (p > 0.05), with J01X causing neutropenia in less than a week and J01F/J01E/J04A in more than 10 days. Antibiotics were discontinued in nearly 34% of cases. In FDA Adverse Event Reporting System reports, half of the patients experiencing neutropenia were hospitalized.

Conclusion: Whereas antibiotic associated neutropenia is benign in the majority of cases, yet it should not be neglected as, even if rarely, it may put children at higher risk of clinical consequences. Clinicians’ awareness of antibiotic-associated neutropenia and its mode of presentation contributes to the continuous process of monitoring safety of antibiotics.

Acanthosis Nigricans in Children and Adolescents with Type 1 Diabetes or Obesity: The Potential Interplay Role between Insulin Resistance and Excess Weight

Acanthosis nigricans (AN) is associated with obesity and type 2 diabetes, where insulin resistance (IR) is considered a predisposing factor. IR can also affect patients with type 1 diabetes (T1D). We evaluated the prevalence of AN in patients with T1D compared to subjects with obesity in order to define the interplay between IR and excess weight. We considered 138 pediatric patients who presented with T1D and 162 with obesity. As controls, 100 healthy normal-weight subjects were included. A physical examination with the detection of AN and biochemical assessments was performed. IR was calculated by using the homeostasis model assessment for IR in patients with obesity and the estimated glucose disposal rate in T1D. The AN prevalence was higher in T1D and obese subjects compared with controls in whom AN was not detected (p = 0.02 and p < 0.001, respectively). A greater number of AN cases were observed in subjects with obesity compared with T1D (p < 0.001). Patients with AN were older than subjects without AN (p = 0.005), and they had higher body mass index (BMI) values, waist circumference (WC), fasting triglycerides and blood pressure (all p < 0.001). Thirty-five patients with AN exhibited IR with an association between AN presence and IR in patients with obesity (p < 0.001). In T1D, there was an association between AN and being overweight/obese (p = 0.02), independently of IR. AN is a dermatological condition associated with obesity. In T1D, the presence of AN was significantly associated with overweight status or obesity but not IR. The presence of AN in the absence of IR supports the interplay role between impaired insulin signaling, IR and excess weight in the pathogenic mechanism.

Beta-blocker-associated hypoglycaemia: New insights from a real-world pharmacovigilance study

AIMS

To investigate the statistical association between hypoglycaemia and β-blocker use and to define what patient and drug characteristics could potentially increase the risk for its occurrence.

METHODS

We investigated the relationship between pharmacological parameters of β-blockers and the occurrence of hypoglycaemia by conducting a case/non case analysis using the Food and Drug Administration Adverse Event Reporting System database. Pharmacological properties that could represent a predictive factor for hypoglycaemia were analysed through a multilinear binary logistic regression (null hypothesis rejected for values of P < .05). We also performed a systematic review of clinical studies on this association.

RESULTS

Of 83 954 selected reports, 1465 cases (1.75%) of hypoglycaemia were identified. The association was found statistically significant for nadolol (reporting odds ratio [95% confidence interval]: 6.98 [5.40-9.03]), celiprolol (2.35 [1.35-4.10]), propranolol (2.14 [1.87-2.46]) and bisoprolol (1.42 [1.25-1.61]). Paediatric cases (n = 310) showed a positive association with hypoglycaemia for long half-life drugs (odds ratio [95% confidence interval]: 2.232 [1.398-3.563]) and a negative association for β1-selectivity (0.644 [0.414-0.999]). Seven papers were included in the systematic review. Because of great heterogeneity in study design and demographics, hypoglycaemia incidence rates varied greatly among studies, occurring in 1.73% of the cases for propranolol treatment (n total participants = 575), 6.6% for atenolol (n = 30) and 10% for carvedilol (n = 20).

CONCLUSION

Nadolol appears to be the β-blocker significantly most associated with hypoglycaemia and children represent the most susceptible sample. Furthermore, long half-life and nonselective β-blockers seem to increase the risk for its occurrence.

Histopathological findings after radiofrequency (RITA) treatment for prostate cancer

Radiofrequency interstitial tumor ablation (RITA) is a thermal ablation method that uses needles and low radiofrequency (RF) energy. The aim of our study was to evaluate the histopathology of thermal lesions induced by RF energy delivered interstitially in prostate cancer patients who subsequently underwent prostatectomy, and to determine the feasibility, effectiveness and safety of this new method in a pilot study.

Correlation of preoperative plasma IGF-I levels with pathologic parameters and progression in patients undergoing radical prostatectomy

OBJECTIVES

To test whether preoperative insulin-like growth factor (IGF)-I levels could predict pathologic stage and prognosis of prostate cancer in patients undergoing radical prostatectomy.

METHODS

The study group consisted of 120 consecutive patients who underwent radical prostatectomy for clinically localized prostate cancer. Preoperative plasma IGF-I levels were measured using the DSL-IGF-I Elisa assay. Surgically removed prostate specimens were analyzed pathologically, using a whole-mount step-section technique. Preoperative plasma IGF-I levels were compared with final pathologic parameters and with prostate-specific antigen (PSA) progression-free survival. Preoperative IGF-I levels in this cohort were also compared with IGF-I levels measured in 20 healthy men without any cancer and in 10 men with untreated, metastatic prostate cancer.

RESULTS

Plasma IGF-I levels predicted neither organ-confined disease (P = 0.5611) nor the risk of PSA progression (P = 0.8125) at a median follow-up of 48.6 months after prostatectomy. Furthermore, IGF-I levels did not correlate with preoperative PSA level (P = 0. 2811) or final Gleason score (P = 0.4906). IGF-I levels in radical prostatectomy patients were not significantly higher than those in healthy subjects or in patients with metastatic disease (mean 156.7 +/- 66 ng/mL, 148.6 +/- 49 ng/mL, and 148.6 +/- 93 ng/mL, respectively; P = 0.8442).

CONCLUSIONS

Circulating IGF-I levels may predict the future risk of developing prostate cancer, but our study found no association with other established markers of biologically aggressive disease or with disease progression in patients with clinically localized prostate cancer.

Transurethral needle ablation (TUNA) of the prostate: a clinical and urodynamic evaluation

OBJECTIVES

This prospective study evaluated the clinical and urodynamic changes in patients with obstruction due to benign prostatic hyperplasia (BPH) treated with transurethral needle ablation (TUNA).

METHODS

One hundred twenty patients with obstructive uropathy due to BPH were treated with the TUNA procedure between January 1994 and December 1995. All patients were selected according to the criteria established by the guidelines proposed by the International Consensus Committee (World Health Organization, Paris, 1993). The TUNA procedure was performed in an outpatient setting using topical intraurethral anesthesia (2% lidocaine gel).

RESULTS

Patients showed a decrease in irritative symptoms as measured by the international Prostate Symptom Score (IPSS) and postprocedure urodynamic parameters. The mean (+/- SD) pretreatment IPSS was 20.8 +/- 4.5. At 3 months, the IPSS decreased to 9.7 +/- 3.0 (108 patients) (P < 0.001). At 6 months it decreased to 6.8 +/- 3.1 (86 patients) and remained at 6.2 +/- 2.9 (72 patients) and 6.7 +/- 3.8 (42 patients) at 12 and 18 months, respectively (P < 0.001). At 1 year after treatment, the peak flow rate (Qmax) increased from 8.2 +/- 3.4 mL/s to 15.9 +/- 2.1 mL/s and was 14.1 +/- 2.5 mL/s at 18 months of follow-up (P < 0.01). Urodynamic re-evaluation performed in 72 patients 12 months after TUNA demonstrated the absence of obstruction in 30 (41.7%). An additional 30 patients (41.7%) had equivocal results, whereas the remaining 12 (16.6%) still had obstruction, according to the Abrams-Griffith nomogram. Mean detrusor pressure at Qmax decreased from 85.3 +/- 18.5 cm H2O to 63.7 +/- 24.9 cm H2O at 12 months of follow-up.

CONCLUSIONS

Our results confirm that the TUNA procedure is safe and effective when performed as an outpatient procedure. In addition, TUNA produced better results in patients presenting with moderate to severe irritative symptoms and minimal obstruction as determined by pressure/flow studies.

[Comparison of orthotopic neobladders: Studer vs modified Camey II]

A comparative study between modified Camey II and Studer ileal orthotopic neobladder was performed. The Camey II was modified as follows: 1) The ureters were implanted, using wallace technique, in an undetubularized ileal loop, 15-18 cm. long, to prevent vesico-ureteral reflux; 2) The neobladder was made using staplers. In such a way, time is saved (about one hour) and results are quite similar, with a low rate of ureteral stenosis in both groups.

[Transurethral needle ablation (TUNA) of the prostate: preliminary results]

A multicentric prospective study was designed in Italy to verify the efficacy and the safety of TUNA-BPH patients treatment. The study is co-ordinate by Progress in Urology Association was started in January 1994. Thirty five patients were treated (Mean age 68.4 +/- 4.1 aa). All patients were selected and evaluated to respect the recommendations of the International Consensus Committee (Paris 1993). The procedure was performed with lidocaine 2.5% urethral gel, oral intake of 10 mg of diazepam and steroidal antiphlogistic drugs 1 hour before treatment. Maximal number of prostatic lesions were 6; in 2 BPH initial cases were done 2 lesions alone. The treatment was interrupted at the third lesion in 2 patients because uncomfortable. Hematuria was observed in all patients, but it was resolved within 12 hours. Irritative symptoms were referred by 10 patients (28.6%) and they spontaneously were insignificant within 24 hours. One patient had an acute prostatitis. In 15 patients (42.6%) was necessary to put a suprapubic cystostomy, but all except one voided within 36 hours. We noted narrow connection between prostatic lesions number and urinary acute retention after TUNA. The average follow-up is 3.2 months (range 0.5-6). At the follow-up urine culture was always negative and PSA values increased in the first month. The value of PSA was always higher than pre-treatment, but from 1 month to 3 months progressively reduced.(ABSTRACT TRUNCATED AT 250 WORDS)

Effectiveness and safety of laparoscopic adrenalectomy

A laparoscopic approach was used to remove the adrenal gland in 7 patients with aldosterone-producing adenoma (Conn's disease), 2 with corticosteroid-producing adenoma (pituitary-independent Cushing's syndrome) and 2 with pheochromocytoma. The affected gland was on the right side in 3 patients and on the left side in 8. Mean operative time was 3 hours 10 minutes (range 140 to 370 minutes). The operation was uneventful in all patients and blood transfusions were never required. Mean postoperative hospitalization was 2.9 +/- 0.8 days (standard error). Only minimal doses of analgesics were used postoperatively. All patients returned to work within 10 days postoperatively (mean 8.4 +/- 1.2 days). Two months postoperatively no patient had clinical, biochemical or hormonal evidence of recurrent or persistent disease. We conclude that laparoscopic adrenalectomy is a safe and effective, minimally invasive approach for patients with benign adrenal neoplasms.

Prostatic UroLume Wallstent for urinary retention due to advanced prostate cancer: a 1-year followup study

We attempt to clarify the long-term clinical reliability of the prostatic UroLume Wallstent in the treatment of urinary retention due to advanced prostate cancer. The stent was placed in 11 stage D prostate cancer patients at high surgical risk and with urinary retention unrelieved by total androgen blockade. At preoperative urethroscopy, the bladder neck and verumontanum were clearly visible and not massively infiltrated by tumor. All patients voided spontaneously at the end of the procedure. At 1 year maximum flow nomograms demonstrated the definite relief of bladder outlet obstruction and of related symptoms in the 10 cases evaluated. As expected, the stent had no evident effect on the natural history of prostate cancer. There were no major complications. Bladder outlet obstruction due to advanced prostate cancer and unrelieved by conventional medical therapy can be treated safely and effectively by the prostatic UroLume Wallstent.

Open surgical revision of laparoscopic pelvic lymphadenectomy for staging of prostate cancer: the impact of laparoscopic learning curve

We attempt to clarify the impact of the learning curve on the first 30 laparoscopic pelvic lymphadenectomies performed at our institute. Open surgical revision of the area of laparoscopic dissection was performed at radical retropubic prostatectomy. The mean number of obturator and iliac lymph nodes removed laparoscopically was 8.7 and 8.8 from the right and left sides, respectively. The mean number of residual obturator and iliac lymph nodes removed at open operation was 3.2 and 3 from the right and left sides, respectively. The amount of residual lymph node tissue after laparoscopic lymphadenectomy progressively decreased with time, especially after the first 20 cases. A microscopic pelvic lymph node metastasis was found at open operation in patients 6, 14 and 15, who had false-negative results at laparoscopy. Due to the learning curve effect, the first 30 patients who undergo laparoscopic pelvic lymphadenectomy should be assessed again by an open operation at radical retropubic prostatectomy.

Clinical reliability of multi-drug intracavernous vasoactive pharmacotherapy for diabetic impotence

The aim of this study was to assess the effectiveness and safety of intracavernous injections of a four-drug vasoactive mixture in diabetic patients with organic impotence. A group of 60 diabetic patients with either pure neurogenic, pure vasculogenic or mixed neurovasculogenic impotence were treated with intracavernous injections of a combination of 12.1 mg/ml papaverine hydrochloride, 1.01 mg/ml phentolamine mesylate, 10.1 micrograms/ml prostaglandin E1 and 0.15 mg/ml atropine sulphate ('full-dose' mixture). A mixture of the same drugs but at one-third concentrations ('reduced-dose' mixture) was also used. The mean (+/- SEM) volumes of the full-dose and reduced-dose mixtures used were 0.21 +/- 0.03 ml and 0.31 +/- 0.02 ml, respectively. All the patients were able to sustain a rigid erection at the end of the titration phase of the study. At a mean follow-up of 18 months, 48 patients (80%) were successfully using the mixture, 6 patients (10%) were using the mixture at a dose lower than the initial dose and 6 patients (10%) had dropped out from the injection therapy. No major complications were seen. The association of multiple vasoactive drugs which use different mechanisms of action, thus exerting a pharmacological synergism, is an effective and safe procedure in intracavernous pharmacotherapy for diabetic patients with organic impotence.

Laparoscopic unroofing of simple renal cysts

OBJECTIVE

The aim of this study was to assess the clinical reliability of laparoscopic treatment for simple renal cysts.

METHODS

Twenty patients with symptomatic simple renal cysts underwent laparoscopic unroofing of the cysts. Four of these patients also underwent concomitant laparoscopic cholecystectomy because of symptomatic gallbladder stones.

RESULTS

In all cases the cyst wall was widely resected with no significant surgical complication. Cholecystectomy was easily performed without additional morbidity. Postoperative renal ultrasonography and intravenous urography demonstrated the absence of cyst recurrences and the integrity of the excretory tract. Symptoms were resolved by the operation in all cases.

CONCLUSIONS

Laparoscopic unroofing is a safe, effective, and minimally invasive treatment for selected symptomatic simple renal cysts.

Vascular abnormalities in Peyronie's disease: the role of color Doppler sonography

We attempted to clarify the role of color Doppler sonography in assessing the vascular function of untreated Peyronie's disease. A total of 50 patients with a mean 20-month history of penile curvature underwent color Doppler sonography with the penis in the flaccid state and after intracavernous injection of 20 micrograms. prostaglandin E1. Of the patients 41 (82%) complained of various degrees of erectile dysfunction, while 9 (18%) reported sustained rigid erections. Pathological peak systolic flow velocities (less than 30 cm. per second) of the cavernous arteries were found bilaterally in 10 patients (20%) and unilaterally in 10 (20%). Peak systolic flow velocity correlated positively with cavernous artery flow volume and with acceleration. Cavernous artery end diastolic velocity and resistance index, measured 15 and 30 minutes after vasoactive injection and genital manipulation, were indicative of corporeal veno-occlusive dysfunction (greater than 10 and less than 0.75 cm. per second, respectively) in 32 patients (65%). Of these patients, 11 (22%) had mixed arteriovenous dysfunction and 9 (18%) had normal cavernous artery flow velocities. Flow along the cavernous arteries is sometimes altered in cases of Peyronie's disease while corporeal veno-occlusive dysfunction seems to be the main hemodynamic abnormality. Color Doppler sonography should be considered as the initial step in the diagnostic evaluation of patients with Peyronie's disease who may be eligible for surgical treatment.

A comparison of transrectal hyperthermia, transurethral thermotherapy, urolume wallstent, and prostatic spiral for benign prostatic hyperplasia patients at poor operative risk

Transrectal hyperthermia, transurethral thermotherapy, prostatic stent, and prostatic spiral were used to treat 120 poor operative risk patients with symptomatic benign prostatic hyperplasia. The preoperative subjective and objective conditions of the four groups (each of 30 patients) were comparable. None of the patients had an indwelling catheter, but according to flow nomograms, all were obstructed. The greatest increase in peak flow rate was observed after stent placement, while the greatest decrease of residual urine volume was seen after the insertion of the stent and transrectal hyperthermia. According to maximum flow nomograms, only the placement of the stent resolved bladder outlet obstruction. The greatest improvement in subjective symptoms was the result of stent insertion, but the heating procedures also caused a significant reduction of symptom scores. The spiral produced satisfactory results only in the short term.

Patient-partner satisfaction with semirigid penile prostheses for Peyronie's disease: a 5-year followup study

The long-term acceptance of and satisfaction with penile prostheses were assessed in patients with Peyronie's disease and their partners. From 1985 to 1987, 50 men with advanced Peyronie's disease and associated erectile dysfunction were treated with a semirigid penile implant without additional plaque surgery. A total of 48 patients and 29 partners was reassessed at a followup of at least 60 months. Only 23 patients (48%) and 12 partners (40%) were totally satisfied with the long-term functional result and would repeat the same operation. Among the 25 dissatisfied patients (52%) loss of complementary erection resulting in a pencil-like penis, decrease in penile sensitivity, poor concealment and persistence of penile deviation were the major complaints. Of the partners 17 (60%) were dissatisfied due to poor penile girth, sensation of a cold glans penis, sensation of unnatural intercourse and dyspareunia. Eight patients (16%) chose to substitute the semirigid implant with a 3-component inflatable prosthesis. On a long-term basis, placement of a semirigid penile prosthesis for Peyronie's disease is associated with a significant patient-partner dissatisfaction rate.

Intracavernous vasoactive pharmacotherapy: the impact of a new self-injection device

The clinical effects of a new self-injection pen were investigated in 160 impotent patients undergoing intracavernous vasoactive pharmacotherapy. Of the patients previously using insulin syringes for self-injection 90% switched to the pen, since it was considered easier to use and several injections could be performed with the same drug cartridge, thus avoiding the preparation necessary before every single injection with the syringe. Dropout rates were 36% and 12% for patients using the syringe and the pen, respectively (p < 0.05). This self-injection pen can be used for any drug, either singly or in combination with others. It is well accepted by patients, and greatly increases acceptance of and satisfaction with intracavernous pharmacotherapy.

Prostatic UroLume Wallstent for benign prostatic hyperplasia patients at poor operative risk: clinical, uroflowmetric and ultrasonographic patterns

The prostatic UroLume Wallstent was positioned in 30 poor operative risk patients with bladder outlet obstruction due to benign prostatic hyperplasia. Preoperatively, 12 patients (40%) could still void spontaneously (group 1), while 18 (60%) had an indwelling catheter (group 2). Preoperative and postoperative assessment included scoring of subjective symptoms, physical examination, uroflowmetry with maximum flow nomogram, transrectal ultrasonography of the prostate, determination of residual urine volume and cystourethroscopy. All but 1 patient could void spontaneously after insertion of the stent. In group 1 preoperative and 1-year followup mean (plus or minus standard error) peak flow rates were 8.0 +/- 0.7 ml. per second and 15.8 +/- 1.8 ml. per second, respectively (p < 0.01), the mean residual urine volumes were 127 +/- 27 ml. and 38 +/- 11 ml. (p < 0.05), respectively, and the mean maximum flow nomograms (plus or minus standard deviation) were -2.6 +/- 0.1 and -1.4 +/- 0.4, respectively. In group 2 the 1-year followup mean peak flow rate, residual urine volume and maximum flow nomogram were 13.2 +/- 0.8 ml. per second (standard error), 32 +/- 14 ml. (standard error) and -1.5 +/- 0.1 (standard deviation), respectively. According to the maximum flow nomogram values all patients were nonobstructed postoperatively. At 1 year the stent was completely covered by prostatic epithelium in 90% of the patients, while in the remainder it was still partially visible at urethroscopy. Transrectal ultrasonography had an essential role in patient followup by accurately assessing the position of the stent. Placement of this prostatic stent is safe and effective for selected benign prostatic hyperplasia patients who cannot undergo surgical treatment due to poor operative risk.

Effectiveness and safety of multidrug intracavernous therapy for vasculogenic impotence

A four-drug vasoactive mixture (papaverine hydrochloride, prostaglandin E1, phentolamine mesylate, atropine sulfate) was used for intracavernous injection therapy in 94 patients with vasculogenic impotence as diagnosed by color Doppler sonography and dynamic infusion cavernosometry-cavernosography. At a mean follow-up of twenty months, 66 patients (70%) are using the injections with the initial dose and are satisfied; 14 patients (15%) are using the injections with a smaller dose than initially given; and 14 patients (15%) dropped intracavernous treatment. Only 4 patients (4%) were unable to achieve a sustained rigid erection during the mixture titration phase. Selected cases of vasculogenic impotence can be safely and effectively treated by the association of drugs which rely on different mechanisms of action, producing a pharmacologic synergism which enhances the overall therapeutic effect.

Morphodynamic assessment of penile circulation in impotent patients: the role of duplex and color Doppler sonography

Duplex and color Doppler sonography were used to assess the vascular status of 240 impotent patients. The tests were performed before and after intracorporal injection of a standard dose of a vasoactive mixture and measurements were done both at the crura and at the midshaft of the penis. Particular care was taken in the evaluation of cavernosal arteries diameter, wall pulsatility, morphology of spectral waveform, blood flow acceleration, systolic and diastolic flow velocity and flow volume. Resistance and pulsatility indexes of the cavernosal arteries were also measured. Flow along the deep dorsal vein was quantified when possible. Cavernosal artery peak systolic flow velocity, flow volume and acceleration were the best indicators of arterial penile circulation. Persistently elevated (> 10 cm/s) diastolic flow in the cavernosal arteries positively correlated with a diagnosis of venogenic impotence obtained by dynamic infusion cavernosometry--cavernosography in almost 80% of cases. Duplex and color Doppler sonography permit to thoroughly evaluate cavernosal arteries function and seem to have a promising role in the study of the veno-occlusive mechanism of the corpora cavernosa.

[Laparoscopic adrenalectomy: a case report]

The authors report the first case of laparoscopic adrenalectomy for Conn's disease. The operative technique and clinical results are thoroughly discussed.

Four-drug intracavernous therapy for impotence due to corporeal veno-occlusive dysfunction

Although veno-occlusive dysfunction is a frequent cause of impotence, a definitive therapeutic strategy has not yet been clearly defined. A total of 56 patients with corporeal veno-occlusive dysfunction diagnosed by dynamic infusion cavernosometry-cavernosography (flow to maintain erection greater than 10 ml. per minute and rate of corporeal pressure decrease after interruption of intracavernous infusion greater than 50 mm. Hg for 30 seconds) not considered suitable candidates for surgery underwent self-injection therapy. A vasoactive mixture composed of 12.1 mg./ml. papaverine hydrochloride, 10.1 micrograms./ml. prostaglandin E1, 1.01 mg./ml. phentolamine mesylate and 0.15 mg./ml. atropine sulfate was used. After dose titration of the drug mixture 54 patients (95%) were able to obtain sustained rigid erections that guaranteed satisfactory sexual activity. Mean (plus or minus standard error of mean) volume of injected mixture was 0.42 +/- 0.09 ml. (range 0.25 to 0.90 ml.). Four patients (7%) reported transient hypotension that did not recur after the application of a penile rubber band before injection. At a mean followup of 16 months 6 patients (11%) discontinued use of injections, 37 (69%) were satisfied and using the mixture, and 11 (20%) maintained rigid erections using a lower than initial dose. No major complications were encountered. The association of drugs with different mechanisms of action caused a synergism that potentiated the therapeutic activity and reduced side effects by decreasing the total drug dose.

[Doppler color echography in the diagnosis of impotence]

This study reports the experience achieved with duplex and color Doppler ultrasonography in 120 impotent patients. The following morphodynamic parameters of the cavernosal arteries were studies before and after intracorporal injection of a mixture of vasoactive drugs: arterial diameter, wall pulsatility, morphology of the spectral waveform, peak systolic velocity, end diastolic velocity and flow volume. The veno-occlusive mechanism of the corpora cavernosa was studied directly by determination of flow along the deep dorsal vein of the penis and indirectly by serial evaluation of the diastolic flow of the cavernous arteries.

Prostatic spiral versus prostatic urolume wallstent for urinary retention due to benign prostatic hyperplasia. A long-term comparative study

Thirty-eight high-risk surgical patients with urinary retention due to benign prostatic hyperplasia (BPH) were treated by placement of a prostatic spiral under local anesthesia (group 1: 20 patients) or a prostatic stent under intravenous sedation (group 2: 18 patients). At the 1-year follow-up, mean peak flow rate, residual urine volume and subjective symptoms scale were significantly better in the stent group (p < 0.01). The rate of postoperative urinary incontinence and dislocation of the device was greater in the spiral group. Cystoscopic manipulation and removal of the device were definitely easier with the spiral. Both the prostatic spiral and stent have specific roles in the treatment of urinary retention in the unfit BPH patient. The selection of the most suitable device depends on accurate patient assessment.

Long-term clinical reliability of transurethral and open prostatectomy for benign prostatic obstruction: a term of comparison for nonsurgical procedures

To elucidate the long-term reliability of prostatectomy, we evaluated 92 benign prostatic hyperplasia patients who had been submitted to either transurethral or open surgery at the 5-year follow-up. Ninety-five percent of the patients were still nonobstructed and subjectively satisfied of their urinary status. Postoperative mortality was presumably not related to the previous operation. Until now, nonsurgical procedures did not guarantee the results achieved by surgical treatment and should thus be reserved for patients at high operative risk or refusing surgery.

Velocity and flow volume gradients along the cavernosal artery: a duplex and color Doppler sonography study

Duplex and color Doppler sonography were used to assess 130 impotent patients and 8 potent controls. Cavernosal artery diameter, peak flow velocity and volume flow rate were evaluated at the level of the crura of the corpora cavernosa and 1 cm proximal to the corona penis. Potent controls and nonarteriogenic impotent patients showed a 20% reduction in hemodynamic parameters at the periphery of the cavernosal arterial tree. In patients with occlusive disease, involving either the upper arterial tree or the entire course of the cavernosal artery, the gradient was maintained. In patients with selective occlusive disease of the distal segment of the cavernosal artery the hemodynamic gradient almost doubled. Hemodynamic gradients can be identified along the cavernosal artery and provide additional information to arteriographic data for the selection of candidates for penile vascular reconstructive surgery.

Is there a role for transrectal microwave hyperthermia of the prostate in the treatment of abacterial prostatitis and prostatodynia?

Transrectal microwave hyperthermia of the prostate was administered to 54 patients with chronic abacterial prostatitis or prostatodynia, who failed to respond to several courses of conventional therapies. Hyperthermia was delivered in 60-min long sessions with three randomly chosen regimens (1 session/week for 4 weeks; 1 session/week for 6 weeks; 2 sessions/week for 3 weeks). A prostatic temperature of 42.5 +/- 0.5 degrees C was maintained throughout the entire duration of each session. Patients were assessed pre- and postoperatively by scoring of subjective symptoms, uroflowmetry with flow nomograms, determination of residual urine volume, and transrectal ultrasonography of the prostate. At the long-term follow-up, the subjective symptom score was significantly improved in all patients. Fifty percent of the patients also reported an improvement of life quality, 47% reported their condition unchanged, and 3% reported deterioration, despite therapy. Urodynamic parameters improved but did not reach statistical significance. No major complications were encountered. Our preliminary data indicate that transrectal microwave hyperthermia of the prostate is a safe therapy that can be beneficial as a second line treatment in selected patients with recurring symptoms of abacterial prostatitis or prostatodynia, which do not respond to medical therapy.

Transrectal microwave hyperthermia for advanced prostate cancer: long-term clinical results

Transrectal microwave hyperthermia was applied to 46 stages D1 and D2 prostate cancer patients to treat urinary symptoms and local pain unrelieved by total androgen ablation therapy. Hyperthermia was administered in 10, 60-minute sessions twice a week for 5 weeks. A calculated intraprostatic temperature of 43.5 +/- 0.5C was maintained throughout the treatment. At 2 years the mean residual urine volume was significantly decreased (p less than 0.05), while the mean peak flow rate and maximum flow nomogram were improved but not significantly. The majority of patients reported a notable amelioration of subjective symptoms and quality of life. The only complication was a prostatorectal fistula that was cured by leaving a urethral catheter in place for 4 weeks. Prostatic hyperthermia is a safe and effective palliative procedure for bladder outlet obstruction due to advanced prostate cancer.

[Use of ultrasonography in morphofunctional evaluation of orthotopic neo-bladder]

Seventeen patients submitted to radical cystectomy and orthotopic bladder replacement according to Reddy's technique were studied at the 1, 3, 6 and 12-month, then annually follow-up by physical examination, intravenous pyelogram, cystourethrography, suprapubic and transrectal ultrasonography and complete urodynamics. Sixteen patients (94%) reported day-time urinary continence and twelve patients (70%) day-time and nocturnal continence. Cysto-manometry showed a mean bladder capacity of 450 cc with a maximal endocavitary pressure of 40 cm. H2O and satisfactory peak flow rate. Vesico-ureteral reflux was never detected at roentgenography. Ultrasonography may be useful in the study of a possible reflux or stenosis of the neovesico-ureteral junction by detecting renal scars or dilatation of the renal cavities. Sovrapubic ultrasonography can quantify the capacity of the neo-bladder (300-600 cc), study its shape, walls and contractions that do not cause the involuntary opening of the neo-bladder neck. Transrectal ultrasonography studies the bladder neck shape and its dynamic function. Residual urine volume never exceeded 50 cc. Ultrasonography demonstrated its effectiveness and reliability and limited the application of more invasive roentgenographic procedures.

Prostatic urolume in high-operative-risk patients: Personal experience

The increase in high-operative-risk patients with obstructive prostatic hypertrophy has prompted research over the last ten years into alternative therapeutic methods, one of which is the prostatic Urolume. This study reports the positioning of the prostatic Urolume in 37 such patients who were divided into two groups: 18 without catheters (group 1) and 19 with indwelling catheters (group 2). At follow up, both groups were found to have no obstruction according to flow nomograph values. At follow up after six months the average maximum flow value in the first group was 16.7 ml/s while in the second group it was 12.8 ml/s. In this study the prostatic Urolume proved to be a safe and effective system for high-operative-risk patients with prostatic hypertrophy.

Intracavernous four-drug injection therapy for veno-occlusive dysfunction

Forty patients with erectile impotence due to veno-occlusive dysfunction were treated with intracavernous injection of a four-drug mixture composed of: papaverine 12 mg/ml, prostaglandin E1 10 microg/ml, phentolamine 1 mg/ml and atropine 0.15 mg/ml. This vasoactive mixture guaranteed a rigid erection lasting at least 30 minutes in all cases. At the six-month follow-up, three patients discontinued the treatment due to personal reasons while the others are still on treatment and completely satisfied. Multi-drug intracavernous vasoactive injection is an effective therapy for veno-occlusive dysfunction of the cavernous bodies.

[Comparison of rectal examination, transrectal echography, CAT and MRI in the local staging of prostatic carcinoma]

From January 1978 to June 1990, 120 prostate cancer patients were submitted to radical retropubic prostatectomy. Local pathological staging evidenced 70 patients (58%) in stage B of disease (intraprostatic disease) and 50 patients (42%) in stage C of disease (extraprostatic disease). Sensitivity of rectal examination, transrectal ultrasonography, CT or NMR for stage B was 61%, 75%, 54% respectively and for stage C 61%, 70%, 50%. This study underscores the effectiveness of transrectal ultrasonography in the diagnosis of prostate cancer non evidenced at rectal examination. CT and NMR are not valuable for local staging and are now used only in patients at risk for extraprostatic or systemic disease.

Postpubertal cryptorchidism: review and evaluation of the fertility

We assessed the fertility of 91 patients affected by unilateral cryptorchidism who were subjected to postpubertal orchidopexy in the last 15 years. All cases were clinically examined, evaluated by semen analysis and Doppler ultrasound of the spermatic artery. Twenty-two patients underwent testicular biopsy. The results indicate that orchidopexy is not the best treatment for postpubertal cryptorchid patients. After orchidopexy, 83.5% of patients were azoospermic or oligospermic, with or without asthenospermia.