Benign prostatic hyperplasia: correlations between receptor density and binding affinity of alpha(1)-adrenoceptors and several clinical parameters

The aim of the study was to determine whether relations do exist between the concentration and activity of alpha(1)-adrenoceptors, both inside the prostatic adenoma and the periurethral zone corresponding to the bladder neck, and clinical and biological parameters such as symptoms, evaluated by the American Urological Association (AUA) score, age, weight of the prostate, PSA, and the flow rate. Twenty patients with symptomatic benign prostatic hyperplasia were selected for an open prostatectomy. One gram of tissue was dissected from inside the adenoma and 1 g from the periurethral zone corresponding to the bladder neck. The alpha(1)-adrenoceptors were evaluated for the apparent dissociation constant (K(d)) and the maximal number of binding sites (B(max)). A correlation seems to exist between receptor density inside the adenoma and the bladder neck and an inverse correlation between receptor density and the AUA total symptoms score. Finally, a highly significant difference was found in patients with an AUA score of <15 or >15. No relationship was found between receptor binding affinity and the considered clinical parameters.

Digital fluorographic video-urodynamics in the long-term morphofunctional evaluation of Alcini's Ileocecourethrostomy and ileal reservoir

INTRODUCTION

The authors present the functional long-term follow-up by means of digital fluorographic video-urodynamics (DFVUDM) of two different surgical urinary diversions.

MATERIALS AND METHODS

64 of 101 patients submitted to radical cystectomy from 1983 to 1999 for infiltrating bladder cancer, were diverted by means of an Alcini's ileocecourethrostomy (ICUS+T), and the remaining 37 patients by means of an ileal reservoir (IR). All of those orthotopically diverted patients were submitted to an accurate follow-up which included DFVUDM 1, 3, 6, and 9 years after the surgical procedure (mean follow-up 51 +/- 42 months).

RESULTS

All the evaluated patients showed a neobladder with good function during both the filling and the voiding phases. In 88.8% of the DFVUDM examinations, it was possible to find a residual peristaltic activity of the neobladder walls. Such a residual peristaltic activity caused urinary leakage during the examination in 11.1% of cases, while vesico-ureteral reflux was detected in 12.5%. The patients voided by relaxing the perineal floor and/or by contracting the abdominal muscles: the emptying of the reservoir was often excellent with average residual urine of 28.5 ml. None of the patients needed clean intermittent catheterization. EMG evaluation of the pelvic floor in some of patients showed a peculiar EMG pattern characterized by an insufficient voluntary control of the perineal musculature with a slight increase of EMG activity during bladder filling. Moreover, an insufficient relaxation of the pelvic floor muscles in the beginning of and during the micturition has been seen. This particular EMG pattern was present in 22.22% of all patients included in this study while it was particularly high (81.81%) in patients with leakage.

CONCLUSION

DFVUDM evaluation represents a highly sophisticated tool which allows an accurate long-term morphofunctional evaluation of the urinary diverted patients. In this study, it is shown that the functional results of the two studied surgical procedures, namely Alcini's ICUS+T and IR, are quite similar, demonstrating that the taeniotomies on the cecal tract may have almost the same functional effects of detubularization. Although DFVUDM revealed imperfect functional performances in some patients, the quality of life of diverted patients in our series seems to be satisfactory.

Long-term behavior of secretory immunity in ileocecal and ileal orthotopic neobladders

OBJECTIVE

To compare secretory immunity in cecal and ileal orthotopic neobladders, and to detect its permanence over time.

PATIENTS AND METHODS

IgA was studied in the urine of 33 patients with ileocecourethrostomy (ICUS) and 13 patients with ileal reservoir (IR). The mean follow-up was 55 months. Results were compared in terms of the type of operation, a healthy control group, and the time since surgery.

RESULTS

Urinary IgA levels were significantly higher in ICUS and IR patients than in normal controls. No significant differences in IgA concentrations were detected in patients with different reservoirs and with regard to time.

CONCLUSION

Both the reservoirs maintain the function of producing IgA. In particular no differences were detected over time and urine could be a permanent antigenic stimulus. IgA could be considered an adjunctive factor for upper urinary tract protection. For this reason we prefer to use a simple, indirect antireflux mechanism, thus avoiding direct manipulation of the uretero-intestinal anastomosis.

Terazosine and tamsulosin in non bacterial prostatitis: a randomized placebo-controlled study

Eighteen patients with inflammatory process of the prostate met criteria for the inclusion in the study: 1) non bacterial prostatitis; 2) no previous treatment. Then they were randomized into three groups as it follows: terazosine, tamsulosin and placebo. Alpha-blockers and placebo were given for two months, after which further uroflowmetry was performed. Symptom score was evaluated before and after treatment. Terazosine was effective in reducing TO (p = 0.01) as tamsulosin and placebo did not. Both terazosine (p = 0.034) and tamsulosin (p = 0.006) reduced max TQ as placebo did not. Symptom score significantly improved in patients receiving terazosine (p = 0.0002) and tamsulosin (p = 0.001) while insignificantly in whose receiving placebo.

Acid-base and electrolyte balance in urinary intestinal orthotopic reservoir: ileocecal neobladder compared with ileal neobladder

OBJECTIVES

To compare acid-base and electrolyte balance in ileocecal and ileal neobladders.

METHODS

Acid-base and electrolyte balance were studied in 45 patients with an ileocecourethrostomy and 18 patients with an ileal reservoir. The mean follow-up was 51 months. Results were compared with regard to both the type of operation and the time since surgery.

RESULTS

No significant differences were found with regard to either the type of operation or the length of follow-up. A preserved renal function is important in maintaining a healthy status.

CONCLUSIONS

The use of 35 to 40 cm of ileum or 10 cm of cecum with the ileocecal junction seems to be safe even after a long follow-up. The length rather than the kind of bowel used for bladder replacement appears to be important in safeguarding hydroelectrolyte and acid-base homeostasis. This is particularly true in the presence of preserved renal function.

[DRG charge and real cost of a radical prostatectomy: preliminary considerations before a study of cost reduction]

Aim of the work was to evaluate the real cost of a radical prostactemy in comparison with the DRG's tariff rates. This work has been conduct before a next study whose objective is the reduction of the costs. The unitary estimated cost of the radical prostatectomies performed from 1997 to April 1998 in the Urological Division of the Università Cattolica S. Cuore has been extrapolated from the entire clinical activity of the same period. The real cost of an uncomplicated radical prostatectomy was also detected. The estimated cost was Lit. 8,225,872 in comparison to the DRG's tariff rate of Lit. 8,842,000; instead the real cost was Lit. 9,085,407. Forty-seven percent of this sum was for routine care in the Division, while 30% for operating room, 5% for pharmacy, 4% for laboratory and 14% for other items. In our institution an operation of high specialization like radical prostatectomy already performed without any complication is little remunerative. Routine care was the major cost: we think its improvement is the first step in order to contain the expense. In this way we can expect secondarily also a reduction in the days of stay.

[Staghorn kidney calculi. A very unusual case of bilateral fistulization and abscess]

A rare case of bilateral pararenal abscess secondary to staghorn calculi is reported. It is characterized by a singular evolution in both side, with fistulization along iliopsoas muscle until the Scarpa triangle. Considering the seriousness of this illness, the importance of an early surgical therapy of complicated staghorn lithiasis is underlined.

Haemodynamic changes detected during open prostatectomy and transurethral resection for benign prostatic hyperplasia

To detect possible intraoperative haemodynamic differences, 60 patients undergoing transurethral (n = 18) or open prostatectomy (n = 42) for benign prostatic hyperplasia were evaluated. The same type of general anaesthesia was used in the two groups. Data, including temperature and cardiac output, were collected at five standard times during the procedures. No significant differences were found between the two groups. However, in all patients, irrespective of the operation, significant decreases in cardiac output and increases in systemic resistance occurred during surgery. Body temperature showed a mild, insignificant decrease, which may play a role in determining the mild haemodynamic derangement observed in all patients. Our patients subjected to open prostatectomy and transurethral resection presented the same kind of haemodynamic derangement, with no significant differences. Therefore it seems unlikely that the kind of surgery could play a relevant role in the late mortality rate of these patients.

Patient selection criteria in the surgical treatment of veno-occlusive dysfunction

PURPOSE

We evaluated short and long-term results of simple and complex venous surgery in patients with veno-occlusive dysfunction unresponsive to maximum recommended doses of intracavernous alprostadil, who were selected with newly developed diagnostic indicators.

MATERIALS AND METHODS

A total of 23 impotent men with a mean age of 41 years (range 20 to 50) underwent complex penile venous surgery. Only patients fulfilling at least 3 criteria were included in study. The criteria were mild cavernous leak assessed by cavernosometry (grades 1 and 2), more than 30% cavernous smooth muscle tissue (histomorphometric analysis), normal analogical corpus cavernosum electromyography recordings according to international standards, cavernosal oxygen tension greater than 65 mm. Hg at erection and age younger than 50 years.

RESULTS

Of 23 patients 17 (74%) had normal erections within a year after surgery, and 5 of them (29%) complained of recurrent erectile dysfunction. At long-term followup 6 of 12 patients had spontaneous erections.

CONCLUSIONS

Careful selection with advanced diagnostic techniques should be mandatory before performing venous surgery in patients with high degree veno-occlusive dysfunction as the only alternatives are major therapeutical solutions.

Xylose absorption and metabolic status in urinary intestinal orthotopic reservoir: ileocecal compared with ileal neobladder

PURPOSE

We compare the absorption of D-xylose and vitamin B12, and the metabolic status in ileocecal and ileal orthotopic neobladders.

MATERIALS AND METHODS

D-xylose plasma levels after an oral load, body composition, plasma vitamin B12, acid base and electrolyte balance were studied in 33 patients with an ileocecal reservoir and 13 patients with an ileal reservoir. Mean followup was 55 months. Results of both types of operation and a healthy control group were compared.

RESULTS

Plasmic levels of D-xylose and vitamin B12 were significantly lower in the ileal reservoir than in ileocecal reservoir group and normal controls.

CONCLUSIONS

Despite an acceptable body composition, intestinal malabsorption could be present in patients with an ileal reservoir but the ileocecal tract appears to be safe.

Two atypical cases of renal leiomyosarcoma: clinical picture, diagnosis and therapy

The Authors report two cases of renal leiomyosarcomas with atypical clinical features. Despite a malignant histological picture, nephron-sparing surgery was performed. The two patients are alive and disease-free at six years and fifteen months respectively. Specific radiologic findings, indications and rationale for conservative treatment are discussed.

Adenocarcinoma of the urachus: radical or conservative surgery? A report of a case and a review of the literature

AIMS

To identify the most appropriate surgical strategy for carcinoma of the urachus.

METHODS

Analysis of a case of adenocarcinoma of the urachus and an examination of the current literature were carried out.

CONCLUSIONS

Partial cystectomy is considered the most appropriate surgical strategy but the need for close follow-up is underlined.

The natural history of metachronous renal cell carcinoma

A case of metachronous renal cell carcinoma is reported in a 52-year-old male patient who had previously undergone radical nephrectomy for cancer in 1989. He was thereafter monitored with annual CT-scans. In January 1994, a small, solid, renal parenchymal mass was detected in the opposite kidney. Following that, three consecutive abdominal CT-scans were carried out over the year in order to evaluate any changes. Subsequently, elective right nephron-sparing resection was performed. This report discusses neoplasm detection, evolution and clinical approach in a patient with previous nephrectomy for cancer.

[Serum ferritin determination: is it useful in the early diagnosis of renal carcinoma?]

The aim of the study was to evaluate the usefulness of ferritin as an early marker in the diagnosis of renal cell carcinoma (RCC). The Authors dosed the pre-operative concentration of ferritin in the sera of 22 patients (16 males and 6 females) affected by stage I-II, according to Robson's classification, RCC. Plasma concentrations of ferritin were matched for the presence of tumor and for the tumor volume. The results did not evidence any relationship between plasma concentration of ferritin and the presence of renal cancer. In the same way a linear correlation did not show any significant relationship between serum concentration of ferritin and tumor diameter. Ferritin does not seem to be a usefull marker in the early diagnosis of renal cell carcinoma.

Vitamin B12 and folic acid plasma levels after ileocecal and ileal neobladder reconstruction

OBJECTIVES

To compare the plasma levels of vitamin B12 and folic acid following resection of ileocecal or ileal segments used for orthotopic bladder substitution.

METHODS

Hemoglobin, hematocrit, and plasma levels of vitamin B12 and folic acid were measured in 34 patients with ileocecourethrostomy (ICUS) and in 16 patients with ileal reservoir (IR), with a mean follow-up of 59.8 +/- 41.9 months. The results were compared with regard to both the type of operation and the length of time since surgery.

RESULTS

The level of folic acid was normal in all patients. The mean level of vitamin B12 in the ICUS group was 413.67 +/- 160.45 ng/mL compared to 257.63 +/- 121.36 for the IR group. This difference was statistically significant. In the IR group, 18.75% of the patients had a level of vitamin B12 below normal.

CONCLUSIONS

There is a tendency for vitamin B12 levels to fall in patients in whom the ileum is used. Resection of the ileocecal segment including the junction does not alter the level of vitamin B12.

A rare case of perirenal myelolipoma. Diagnostic approach and therapeutic strategy

A very rare case of perirenal myelolipoma and the problems of differential diagnosis are reported. The non-specificity of, and sometimes even the lack of, radiological and haematological data prevents physicians from preoperatively excluding a malignant neoplasm with a certain degree of confidence. Surgical exploration remains a compulsory step in myelolipoma management and its simple removal seems to be the therapy of choice.

Clinical review of 100 consecutive surgically treated patients with upper urinary tract transitional tumours

OBJECTIVE

To determine the outcome of conservative or radical treatment in a retrospective study of 100 consecutive patients with upper urinary tract tumours.

PATIENTS AND METHODS

From 1965 to 1995, 100 patients (78 men and 22 women, mean age 65 years, range 27-82) with upper urinary tract tumours were treated surgically, using nephroureterectomy with excision of a cuff of bladder in 53 and organ-sparing treatment in 47. The outcome was assessed as survival and recurrence during a follow-up of up to 15 years.

RESULTS

After radical and organ-sparing treatment, the 15-year cancer-specific survival was 69% and 25%, respectively; metastases developed in 17% and 19% and global recurrence in 40% and 70%, respectively. While locoregional and bladder recurrences were similar in the two groups (9% vs 8% and 30% vs 38%, respectively), ureteric-stump recurrence in the conservative group was 23%. There were no significant differences in survival rates between patients with single or multiple presentation, or for localization, while the grading of the lesions proved to be an accurate prognostic indicator.

CONCLUSION

This experience of urothelial neoplasia of the upper tract highlights the difficulty in diagnosing this pathology and in entrusting screening to a non-invasive technique such as urinary cytology. The percentage recurrence observed after organ-sparing therapy indicates that this treatment should be used cautiously.

Immunologic findings in Peyronie's disease: a controlled study

OBJECTIVES

Recent literature suggests the hypothesis of an immune etiology of Peyronie's disease. In this controlled study, the immune response pattern of the disease is investigated.

METHODS

Sixty-six patients with Peyronie's disease and 20 age-matched controls were studied. In all patients, skin test (multitest), in vitro lymphocyte transformation test (LTT), serum immunoglobulin (Ig) A, G, and M, anti-DNA, antinuclear and anti-smooth muscle cell antibodies, C3 and C4 complement fractions, antistreptolysin, and C-reactive protein titers were evaluated.

RESULTS

A fair percentage (75.8%) of the patients with Peyronie's disease exhibited at least one abnormal immunologic test, in comparison to only 10% among controls (chi-square = 27.8, df = 1; P < 0.0001). Alterations of cell-mediated immunity (multitest, LTT) were observed in 48.5% of patients, alterations of humoral immunity (Ig) in 31.8%, and alterations of markers of autoimmune disorders (autoantibodies, complement activation) in 37.9% of the cases.

CONCLUSIONS

Our results support the hypothesis that there is some involvement of the immune system in the pathogenesis of Peyronie's disease, although the available data still appear to be insufficient to formulate a definite pathogenetic hypothesis.

[Diagnostic difficulties in renal leiomyosarcoma. Case report and review of the literature]

The authors report a case of renal leiomyosarcoma and a review of the literature, underlining the difficulties of making a correct differential diagnosis with the benign neoplasms of the kidney and in performing correct surgical therapy.

The ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement: an alternative to detubularized neobladders. Morphological, functional and metabolic results after 9 years' experience

OBJECTIVE

To evaluate the results from the long-term follow-up of ileocaeco-urethrostomy with multiple transverse taeniamyotomies for bladder replacement.

PATIENTS AND METHODS

Since 1987, 60 male patients have undergone bladder replacement using a technique of ileocaeco-urethrostomy with multiple transverse taeniamyotomies. Avoiding detubularization, sectioning the caecal taeniae improved reservoir morphology and reduced internal pressures and wall tension, limiting the potential complications of the operation.

RESULTS

All patients achieved diurnal continence with socially acceptable intervals between micturitions. Immediately after the operation, the nocturnal continence rate was good (79% of patients with a follow up < 3 years), reaching 86% after > 3 years. After 5 years, the reservoir capacity remained within the physiological range (mean volume 469 mL) with a mean maximum internal pressure of 47.6 cmH2O, while the mean post-micturition residual volume was 28 mL; no patient needs to use self-catheterization. Given the short intestinal length used, no metabolic clinical problems have occurred.

CONCLUSIONS

The concept of using the caecum arose from physiological and anatomical assumptions, i.e. receptive relaxation, the presence of taeniae and ileocaecal sphincter. Taeniamyotomies can achieve the same goals as detubularization, i.e. a reduction of wall tension and internal pressure and a near-spherical shape, but, in contrast, by leaving the circular muscle intact, they allow a good basal tone to be maintained thus obtaining optimal emptying and avoiding deterioration of the reservoir.

Bladder replacement in women: a new experience

Bladder replacement in women in a new experience. In this article the authors reviewed in a critical way the patho-physiological principles involved in the previous male bladder replacement techniques and the results achieved both leading to the recent experience of bladder replacement in women. The authors present the recent acquirements about pelvic surgical anatomy and postcystectomy oncological radicality in female, and the more common surgical techniques for building a neobladder in women with the results achieved up to now. They also examined the problems arising from this exciting but precocious experience which will surely involve the urological community in the future.

Non-Hodgkin's lymphoma: a case report of a secondary bladder involvement

Bladder secondary involvement rate in non-Hodgkin's lymphoma (NHL) reaches 13%. Nevertheless, clinical evidence of such an involvement is very rare (less than 0.5%). We report a case of a NHL arising from the Peyer's plaques of the gut and involving secondly the bladder. The onset symptomatology was urologic. Pathophysiology and clinical features of secondary bladder lymphoma are discussed.

Immunohistochemical quantitation of 4-aminobiphenyl-DNA adducts and p53 nuclear overexpression in T1 bladder cancer of smokers and nonsmokers

An immunoperoxidase method, using a monoclonal antibody which recognizes 4-aminobiphenyl (4-ABP)-DNA adducts, was developed for the detection and quantitation of DNA damage in bladder tissue and applied to stored paraffin blocks of transurethral resection specimens of 46 patients with T1 bladder cancer. Mean relative staining intensity for 4-ABP-DNA adducts was significantly higher in current smokers (275 +/- 81, n = 24) compared to nonsmokers (113 +/- 71, n = 22) (P < 0.0001). There was a linear relationship between mean levels of relative staining and number of cigarettes smoked with lower levels in the 1-19 cig/day group (205 +/- 30, n = 5), compared to the 20-40 (289 +/- 40, n = 7) and the >40 cig/day group (351 +/- 57, n = 3)(P < 0.001). Nuclear overexpression of p53, analyzed by immunoperoxidase staining, was observed in 27 (59%) of the 45 stage T1 tumors analyzed. There was a significant correlation between p53 overexpression and recurrence of disease (odds ratio = 12.3, P < 0.01). Nuclear staining of p53 was also correlated with smoking status, cig/day and 4-ABP-DNA adducts. This work demonstrates that the immunohistochemical method has sufficient sensitivity for detection of 4-ABP-DNA adducts in human bladder samples. The method has several advantages including small sample size, the possibility of retrospective analysis of stored paraffin blocks, the ability to analyze binding in specific cell types, and a relatively low cost.

Penile Mondors' disease: an underestimated pathology

OBJECTIVE

To report the aetiological, diagnostic and therapeutic aspects of penile Mondor's disease treated with non-steroidal anti-inflammatory drugs (NSAIDs) or surgery.

PATIENTS AND METHODS

During the last 3 years, 10 patients (mean age 35 years, range 20-57) were treated for superficial penile vein thrombophlebitis. The main aetiological factors were prolonged and excessive sexual intercourse, operations for inguinal hernia and deep vein thrombosis. All patients had noticed sudden and almost painless cord-like induration on the penile dorsal surface. Doppler ultrasonography was useful in both diagnosis and follow-up. Eight patients were treated with NSAIDs and platelet drugs.

RESULTS

The mean interval to resolution of symptoms was 3 weeks. Two patients who did not respond to drug therapy underwent surgery (dorsal vein resection).

CONCLUSION

Medical therapy and, when indicated, vein resection are successful and effective in treating penile Mondor's disease.

Bladder replacement by detubularized ileal loop: 10 years of experience using a personal technique

OBJECTIVE

To evaluate the results obtained with a technique of bladder replacement using a detubularized ileal tract, developed by the authors.

PATIENTS AND METHODS

Since 1983, 34 patients have undergone an orthotopic bladder replacement using 35-40 cm of ileum, detubularized and shaped into an 'S' to create a neobladder with a capacity of 100-120 mL. The ureters were anastomosed directly to a 10 cm long intact afferent loop which serves as an anti-reflux mechanism, while a 2 cm long efferent, spatulated loop was used for urethral anastomosis. The mean (SD) follow-up was 32 (33) months.

RESULTS

All the patients were continent during the day, with socially convenient intervals between voids; 3 years after the operation, 10 of 12 patients were continent during the night, with intervals of 2-4 h between voids. The mean post-void residual urine volume was 41 mL and no patient required self-catheterization. There were no derangements of the metabolic status of patients.

CONCLUSION

This technique was applied knowing that a detubularized intestinal loop has the remarkable ability to increase in capacity over time. Therefore, to maintain the reservoir in good condition over a long period it is important to construct it with an intra-operative capacity of < 120 mL, thus reducing the length of intestine required. This may explain the satisfactory metabolic status of these patients. Moreover, the triplication of the mesentery helps to maintain the sphericity of the neobladder and provides support for the neobladder in the lower pelvis, where it retains the same position as a normal bladder.

Three consecutive cases of adenomatoid tumour of the epididymis: histological considerations and therapeutical implications. Review of the literature

Adenomatoid tumour is an uncommon neoplasm of the male genital tract. The Authors report their recent observation of three consecutive cases of adenomatoi tumour of the epididymis. In all cases the diagnosis was difficult and done only by an accurate histological examination. The treatment was conservative, consisting in the removal of the neoplasm. After a follow up of at least two years the patients do not show any sign of relapses confirming the validity of the surgical therapeutical approach performed. Because of the unfrequent observation of these forms and the difficulty in the diagnosis, the Authors stress the necessity of the surgical exploration with an accurate microscopic examination of the specimens. Moreover a review of the literature from a histological and therapeutical point of view was done and reported.

Should venous surgery be still proposed or neglected?

Forty-four men aged 20-56 years (mean 42) complaining a venous erectile dysfunction underwent penile venous surgery. Fifteen patients (34.1%) were treated by DDVL, 29 cases (65.9%) underwent DDVL + corporopexy. All patients were followed-up at short and long-term periods. In short-term follow-up, eight patients (57.2%) of 15 treated by DDVL showed spontaneous erection, six patients (42.8%) showed persistent erectile dysfunction. In long-term follow-up, four patients of this group (28.6%) showed spontaneous erection. The others, 10 patients (71.4%), were then treated by other therapeutical alternatives. Twenty-two patients (75.8%) of 29 operated with DDVL + corporopexy showed spontaneous erection in short-term follow-up. After one year, in long-term follow-up, whereas total 15 patients (51.7%) of them were obtaining full erection, the others required other forms of treatments. In both groups in a long-term follow-up, total 19 patients of 43 (44.2%) showed full spontaneous erection, four patients (9.3%) needed intracavernous injection and six patients (13.9%) were treated with penile prosthetic implants. A total of 29 patients (67.4%) were able to have acceptable sexual intercourse. We concluded that venous surgery is still useful in selected patients having no better therapeutical alternatives.

Signal-averaged electrocardiography and echocardiography in the evaluation of myocardial involvement in progressive systemic sclerosis

To assess the myocardial involvement in progressive systemic sclerosis we evaluated the presence of late potentials by signal-averaged electrocardiography (signal-averaged ECG) and the left ventricular function by M-mode, two dimensional and Doppler echocardiography. Fifteen outpatients, 7 with diffuse progressive systemic sclerosis and 8 with CREST syndrome variant, without clinical or electrocardiographic evidence of cardiac disease were studied and compared with 18 normal subjects. Late potentials occurred in 5 out of 15 progressive systemic sclerosis patients (33%) with a significant difference versus controls (P < 0.05) and were present only in the patients with diffuse progressive systemic sclerosis (P < or = 0.001 vs. controls). All progressive systemic sclerosis patients showed a normal left ventricular systolic function. Abnormal left ventricular filling was found in 9 progressive systemic sclerosis patients (5 with diffuse progressive systemic sclerosis and 4 with CREST). A more severe impairment of the mean values of diastolic function indexes was found in diffuse progressive systemic sclerosis than in CREST. In all diffuse progressive systemic sclerosis patients at least one method showed altered results, whereas half the CREST patients showed no pathological findings with both techniques. These results confirm a lower myocardial involvement in the CREST syndrome than in diffuse progressive systemic sclerosis and consequently this is probably related to a better prognosis.

Early experience of corpora cavernosa electromyography in impotent patients after radical cystoprostatectomy

OBJECTIVES

To assess the effects of autonomic nerve damage on the basis of cavernous electrical changes.

METHODS

A study was carried out on the cavernous electrical activity in healthy volunteers (controls) and impotent patients after radical cystoprostatectomy using a specific electromyographical device, the 'SPACE-recorder 7500'.

RESULTS

A significant reduction in the amplitude of potentials was recorded after pharmacological stimulation in both the controls and impotent patients. The healthy controls showed amplitude values which were significantly higher than the impotent patients after radical cystectomy (715 +/- 141 vs. 381 +/- 227 microV, p < 0.01). After 'nerve-sparing' radical cystectomy with a mean amplitude similar to controls (500-700 microV), the patients showed rigid erections after injection of intracavernous drugs in a high percentage of cases.

CONCLUSION

In our experience, corpora cavernosa electromyography seems a reliable method which can directly point out damage in the cavernous smooth muscle and the penile autonomic nerves.

Corpus cavernosum electromyography (CC-EMG): a new technique in the diagnostic work-up of impotence

We have studied cavernous electrical activity in 42 subjects, healthy volunteer controls and groups of impotent patients using a nonspecific electromyographic device (PICO-MENFIS) and a specific one, the SPACE-recorder 7500 designed to achieve electric recordings from the corpora cavernosa. In all of the patients, we detected under basal conditions a mean amplitude of 583 +/- 323 microV, a mean duration of 4.9 +/- 7 s, a mean polyphasicity of 3.5 +/- 1.4. It should be emphasized that a significant reduction of potential amplitudes was recorded after pharmacological stimulation in both the controls and the impotent patients. The healthy controls showed amplitudes significantly higher than the impotent patients after radical cystectomy (715 +/- 141 microV versus 381 +/- 227 microV, p < 0.01). The patients after a "nerve-sparing" radical cystectomy with a mean amplitude similar to the controls (500-700 microV) reacted well to the intracavernous drugs in a high percentage of cases. In our experience, CC-EMG seems to be a reliable method which can pinpoint directly lesions to the cavernous smooth muscle and penile autonomic nerves. It has also been able to assess the effects of stress, anxiety and pain on the erectile mechanisms.

Could standardized cavernosometry be helpful in therapeutic management of veno-occlusive dysfunction?

PURPOSE

Due to the lack of a gold standard for performing cavernosometry, we selected 30 patients with veno-occlusive dysfunction to evaluate the internal relationships of cavernosometric parameters and their reliability for therapeutic decisions.

MATERIALS AND METHODS

Cavernosometry was performed after injection of 20 to 40 micrograms of prostaglandin E1. Maintenance flow rates, intracavernous pressure decay following cessation of flow and intracavernous pressure changes after compression maneuvers were the main parameters considered.

RESULTS

Cavernosometric results were standardized as grade 1-7 patients with maintenance flow rate less than 20 ml. per minute (mean 18 +/- 2.5) and intracavernous pressure decay 27.5 +/- 15%, grade 2-11 with maintenance flow rates significantly lower (p < 0.001) than grade 1 (mean 37 +/- 11 ml. per minute) and intracavernous pressure decay 33 +/- 20%, and grade 3-12 with only recorded induction flows greater than 70 ml. per minute and intracavernous pressure less than 50 mm. Hg. A strong statistical correlation (p < 0.01) was noted between maintenance flow rate and percent of intracavernous pressure decays.

CONCLUSIONS

These parameters allowed us to choose different therapies, such as complex venous surgery, mixed pharmacotherapy or prosthetic implants. Good sexual function was restored in 85% of the cases. We can conclude that our model of standardized cavernosometry has made easier the therapeutic choices in patients who do not respond to intracavernous drugs.

Bilateral renal tumours: a hard surgical problem. Case report

Three cases of bilateral renal tumours are reported. A radical nephrectomy in the side with the larger tumour and a nephron-sparing surgery (partial nephrectomy or enucleo-resection) in kidney with smaller lesions was performed in two cases. A bilateral partial nephrectomy was performed in the last patient (tumours larger than 5 cm). Two of them performed a needle CT-guided biopsy before surgery, but full disagreement was found between pre and post-operative histological results. In addition, we outline that a second lesion was found intraoperatively in the case n. 3, without any radiological and sonographic finding. We stress the importance of a conservative surgery in case of bilateral neoplasms. Only surgery could assure a careful staging and histological diagnosis.

Cardiac valve involvement in systemic lupus erythematosus and primary antiphospholipid syndrome: lack of correlation with antiphospholipid antibodies

The aim of this study was to determine the prevalence of cardiac valve disease in systemic lupus erythematosus or in patients with primary antiphospholipid syndrome and to assess the role of the antiphospholipid antibodies as risk factor for endocardial lesions. We studied 39 consecutive patients with systemic lupus erythematosus (mean age 34 +/- 12 years, 38 female and one male), 20 women with primary antiphospholipid syndrome (mean age 32 +/- 4 years) and 20 normal subjects (mean age 35 +/- 8 years, 15 female and five male). All patients with primary antiphospholipid syndrome had increased levels of serum anticardiolipin antibodies and recurrent fetal abortions; some of them also had arterial and/or venous thrombosis and/or thrombocytopenia. M-mode, two-dimensional and Doppler echocardiography were performed in all patients. IgG anticardiolipin antibodies were measured by an enzyme-linked immunosorbent assay. Valvular lesions were observed in 15 patients (38%) with systemic lupus erythematosus. These abnormalities included: mitral valve thickening or vegetation, mitral valve prolapse and aortic valve vegetation; mitral, aortic and tricuspid regurgitation; mitral stenosis. None of the patients with primary antiphospholipid syndrome and of the normal subjects was found to have valvular abnormalities. In systemic lupus erythematosus, high levels of anticardiolipin antibodies were detected in 73% of the patients with valvular lesions and in 67% of the patients without valvular lesions (P > 0.05). We conclude that valvular involvement is frequent in patients with systemic lupus erythematosus but it is apparently unrelated to antiphospholipid autoimmunization.

125I seeds implantation plus pelvic lymphadenectomy in the management of localized prostate cancer

In this study the authors present their experience of treatment of intraglandular prostate cancer with 125I seed implantation. At ten years, the overall survival for T1 and T2 stages is 71% and 57% respectively; and for G1, G2 and G3 grades the survival rate is 84%, 54% and 44% respectively; NED ten-year survival is 53% and 52% for T1 and T2 stages, 84%, 40% and 33% for G1, G2, and G3 grades respectively. The statistical evaluation seems to confirm that iodine brachytherapy is suitable for well differentiated and small volume tumors. Local recurrences, complications and side effects are also reported and compared to corresponding data collected following external radiotherapy and radical prostatectomy; the survival results are similar, but the incidence of complications is lower following implantation and in particular regarding continence and potency. In conclusion, the authors believe that iodine seed implantation could offer patients, who are often young and asymptomatic, satisfactory chances of survival and a very high quality of life.

[Correlation between ultrasonography imaging and surgical findings in scrotal trauma]

The Authors report their experience of 20 cases of scrotal trauma. The etiopathogenesis of lesions are stressed as well as the importance of an early diagnosis, in order to plan a correct treatment avoiding immunological and atrophic outcomes. All of the patients underwent a diagnostic ultrasonographic examination. Eighteen of them were surgically treated, whereas last two recovered by means of a week antibiotic and anti-inflammatory medical therapy. The scrotal sonography showed a 100% sensibility for testis injuries and a 80% specificity for albuginea fractures. In fact a fracture of the tunica albuginea was found in two cases although they showed a normal scrotal sonogram. It is worth of mention that in the authors' experience the ultrasonography generally understages the testis damages. Only the surgical exploration is believed to be able to make a sure diagnosis of type and seriousness of the scrotal injury.

[Struma cordis: right intraventricular ectopic thyroid]

The authors report the case of a benign tumour composed of hyperplasic thyroid tissue in the right ventricle, diagnosed in a 43 year old woman by echocardiography after a syncopal episode. The outcome was favourable with a 13 year follow-up after surgery.

Growth-inhibitory effect of quercetin and presence of type II estrogen binding sites in primary human transitional cell carcinomas

Eight cases of transitional cell carcinoma (TCC) of the bladder were investigated for the presence of estrogen receptors (ER) and Type II estrogen binding sites (Type II EBS). All these tumors specifically expressed type II EBS, while only 3 of 8 cases contained low amounts of ER. All the cases assayed for the presence of both nuclear and cytoplasmic type II EBS revealed the presence of these binding sites in the two compartments. Both cytoplasmic and nuclear receptors were similar to type II EBS described in other tissues relative to their binding specificity for estrogens and quercetin and their sensitivity to reducing agents. Quercetin, 10 microM., was effective in inhibiting in vitro bromodeoxyuridine (BrdUdR) incorporation by TCC cells. Rutin, which bound little if any to type II EBS, did not show any inhibitory effect on in vitro BrdUdR incorporation by tumor cells, suggesting a type II EBS mediated effect of flavonoids. Although the mechanism of the antiproliferative activity of quercetin remains to be fully clarified, the possible therapeutic potential of quercetin and related flavonoids should be considered.

Refluxes in orthotopic neobladders: can the ileocecal sphincter be considered an adequate antireflux mechanism?

OBJECTIVES

To evaluate the usefulness of the ileocecal sphincter in preventing ureteral refluxes in ileocecal orthotopic neobladder, thus avoiding the use of antireflux technique for ureteroileal anastomosis.

METHODS

From 1980 to 1992, 95 patients underwent orthotopic bladder substitution. In 30 our detubularized ileal reservoir was used and in 65 first only an integral ileocecal segment was used and subsequently multiple transverse teniamyotomies on the cecal portion to increase the capacity and reduce the pressure. The upper urinary tract was indirectly protected in the ileal reservoir technique by leaving an integral 8 to 10 cm long afferent segment folded behind the reservoir and in the ileocecal technique by the ileocecal sphincter, thus keeping the anastomosis between ureters and ileum simple and direct.

RESULTS

The mean follow-up of the 65 patients with ileocecourethrostomy is 37 +/- 33 months (range, 2 to 141 months); in 13.8% of the patients (9/65) monolateral refluxes appeared, but without any evident clinical consequences. The appearance of monolateral stenosis on the ureterointestinal anastomosis requiring treatment occurred in 4 patients (6%): 3 underwent an endoscopic treatment and 1 a surgical one. Modifications of renal function with respect to the preoperative status were not verified in any of the patients.

CONCLUSIONS

The ileocecal sphincter is an effective antireflux mechanism for an orthotopic neobladder in which multiple transverse teniamyotomies (5 to 7) increase the capacity of the neobladder itself, reduce its internal pressure, and confer a nearly spherical configuration. Moreover, a correct anastomosis between the cecum and membranous urethra decisively reduces the resistance to emptying of the neobladder, thus avoiding too strong pressures against the ileocecal sphincter. The integrity of the circular muscular layer maintains a healthy tonic wall: this fact, combined with the low peripheral resistances, ensures good emptying and a stable capacity. The procedure is easy to perform and not time-consuming; these considerations lead us to consider the ileocecal unit an excellent structure for bladder substitution.

Randomised controlled study with cyproterone acetate (100 mg/die) versus Pygeum africanum (200 mg/die) in benign prostatic hypertrophy

A multi-centre comparative study was carried out on 143 patients with benign prostatic hypertrophy and reduced or no sexual activity. 74 patients were treated with a low dose of CPA (100 mg a day) and 69 with PYG (200 mg a day), administered orally and assigned randomly. The patients were evaluated at 4,12 and 24 weeks. Results showed a significant statistical difference in favour of the CPA treatment for almost all parameters (flow, post-micturitional residue, symptomatological score). There was a decrease in prostate volume, equal to 19.3% compared to the initial values, only in those patients treated with CPA who completed the treatment. Considerable improvement in nicturia and micturitional urgency was noted in about half the patients, without a significant difference between the two groups.

The role of ultrasonography in scrotal traumas

Fourteen patients with a variety of scrotal lesions have been investigated. In 12 cases surgical exploration was performed, and 2 patients with scrotal wall haematoma received drug treatment. In the early detection of scrotal traumas ultrasonography is of utmost importance for the definitive diagnosis to be set up.

Results of 4 years of experience with bladder replacement using an ileocecal segment with multiple transverse teniamyotomies

Since 1987, 30 patients with bladder cancer underwent cystoprostatectomy with bladder replacement via ileocecourethrostomy. Multiple transverse teniamyotomies were made in the cecum to assure a large capacity reservoir with low pressures. The particular anatomy and physiology of the cecum, short length of the intestinal segment needed and teniamyotomies are the 3 factors that have allowed for good functional and metabolic results. All patients achieved daytime continence. After 3 years of followup 67% of the patients were continent at night if they voided every 3 or 4 hours and 22% if they voided every 2 or 3 hours, while 11% experienced enuresis. Urodynamic data after 1 year showed a mean capacity of 396 ml. for the new bladder, a mean full filling pressure of 28 cm. water and a mean maximum pressure of 55 cm. water. Post-micturition residual urine volume was consistently less than 55 ml. These results indicate that the ileocecal segment can be enlarged with myotomies through the tenia to produce an adequate capacity and a low pressure bladder replacement without the need for formal detubularization.

Urethrospongiosal fistulas: clinical and therapeutic considerations

From 1986 to 1990, 8 cases of urethrospongiosal fistulas were observed. All the patients had a history of bleeding after a difficult catheterization. The symptoms were not pathognomonic but the fistulas were visible only by X-ray examination. The authors suggest that urethrospongiosal fistulas are more common than one expects, especially in cases of bleeding after complicated catheterization. This is more frequent when coexistent urethral strictures or prostatic hypertrophy make the maneuver difficult. The authors also suggest that the urinary extravasation in the corpus spongiosum could explain the pathophysiology of the urethral manipulation syndrome according to Kelamy.

[Oncocytic carcinoma in a horseshoe kidney]

The Authors report a rare case of oncocytoma in a horseshoe kidney. The diagnostic path needed to assess the precise anatomy of the malformation and tumoral staging is out lined. Oncological problems dealing with oncocytoma are further discussed, together with the technical and surgical issues pertinent to the clinical case.

A comparative enzyme histochemical study of glucose metabolism in the conduction system of mammalian hearts

A histochemical study of some enzymes of glucose metabolism was performed on the heart conduction system of rat, dog, rabbit, pig, calf and lamb. Histochemical activities revealed a higher rate of anaerobic metabolism and a lower rate of aerobic metabolism in the conducting cells in comparison with the working myocardial fibres. An increase of the histochemical activities from the atrioventricular node to the distal portions of bundle branches was noted. The importance of the high glycogen content and the high phosphorylase activity in the heart conduction system was discussed.

Anatomo-functional considerations on venogenic impotence

The authors report their clinical experience with cavernosography and cavernosometry on impotent patients. The indications of method and its correct place in the diagnostic workup are underscored. The methods of evaluation are described, highlighting the advantages of a diagnostic pharmacological approach in respect to a near as possible physiological haemodynamic evaluation. Finally they propose a future development for the method, such as the use of PGE1 instead of the commonly employed drugs, and a new classification for the veno-occlusive disease with stage and grade.

[Aneurysm of the left sinus of Valsalva with fistula in the right atrium. A case report]

A case of an aneurysm of the left sinus of Valsalva ruptured in the right atrium is reported. This anomaly was diagnosed in a 30 year old woman who had a continuous systo-diastolic murmur and no signs of cardiac failure. The diagnosis of aneurysm of the left sinus of Valsalva was been determined using 2-D echocardiography, Cardioangiography, in addition, enabled us to recognize the fistula which connected the left sinus of Valsalva with the right atrium. The rarity of this case is supported by two pieces of data: A) aneurysms of the left sinus of Valsalva are the rarest of the sinus of Valsalva aneurysms; B) generally the sinus of Valsalva aneurysms rupture into the adjacent cardiac cavities, while the anomalous fistolous conduits are quite uncommon. The case reported confirms that from an aneurysm of the sinus of Valsalva an atypical fistolous conduit may arise. This could be detected by cardioangiography. In addition echocardiography, is very important, at least as a preliminary examination, for the diagnosis of the sinus of Valsalva aneurysms.