Roach's Mathematical Equations in Predicting Pathological Stage in Men with Clinically Localized Prostate Cancer

Aims and Background

The therapeutic choice in patients with clinically localized prostate cancer depends on preoperative clinical stage. Diagnostic instruments currently available for such an evaluation – considered separately – have not shown enough efficacy. Roach has recently introduced three simple mathematical equations that – on the basis of prostate-specific antigen and the biopsy Gleason score – are aimed at calculating the definitive pathological stage. We retrospectively analyzed our radical prostatectomy data base to assess the accuracy of the equations in predicting the final stage in patients with clinically localized prostate cancer.

Methods Study Design

The study included 173 patients who had undergone radical retropubic prostatectomy at our Institution. Patients were divided into 25 groups, depending on preoperative PSA and the biopsy Gleason score. The risk of extracapsular neoplastic growth, seminal vesicle involvement and lymph node involvement was calculated for each group by means of Roach's equations. On the basis of definitive histological examinations, we compared the expected risk to the observed risk.

Results

The observed risk fell within the interval of expected risk in I6 of 17 groups (94%) regarding the evaluation of extracapsular growth, in I5 of 17 (88%) regarding the analysis of seminal vesicle involvement, and in 14 of 17 (82%) regarding the evaluation of lymph node involvement. Therefore, the observed event was in agreement with the expected event in 45 of 51 groups (88%).

Conclusions

The equations represent a practical and effective instrument for preoperative clinical staging in patients with localized prostate cancer. By means of these mathematical formulas, one can assess the correct prognosis and – above all – plan the best therapeutic approach.

Can side-specific biopsy findings predict the side of nodal metastasis in clinically localized prostate cancer? Results from a multicenter prospective survey

BACKGROUND

To evaluate the correlation between the side of positive biopsy (Bx) and the risk of lymph-node metastases (LNMs) on each side and to quantify the risk of contralateral LNMs in patients with unilateral positive biopsy.

METHODS

We analyzed the outcomes of 1599 patients with complete data regarding the sides of positive Bx and LN (lymph-node). By dividing each prostate into two separate sides, we assessed the accuracy of the side-specific Bx details in determining the side of positive nodes; the area under the receiver-operating characteristic (ROC) (AUCs) was used. For patients with unilateral positive Bx, we assessed the risk of homolateral and contralateral LNMs according to the number of total Bx taken and the preoperative risk of LN invasion.

RESULTS

Considering the 3198 prostate sides, there was a strict correlation between the side of positive Bx and the side of LNMs. The ratio of positive/total Bx was more informative than the number of positive core. The AUC for ipsilateral LNMs was significantly higher than that for contralateral LNMs (P = 0.039). In the 805 patients with unilateral positive Bx, the percentage of contralateral LNMs was >30% even considering a more meticulous biopsy scheme and increased in the patients at a higher clinical risk for LN invasion.

CONCLUSION

PCa preferentially metastasizes to ipsilateral LNs but >30% of contralateral LNMs are present. A unilateral LN dissection that is limited to the tumor-bearing side of the gland should not be recommended because of the substantial risk of missing contralateral metastases.

[Transvestibular urethrolysis]

OBJECTIVE

Bladder outlet obstruction with obstructive and irritative urinary symptoms may be a complication of surgery for female urinary incontinence. In presence of persistent symptoms, the therapy is surgical and usually consists in an accurate urethrolysis. The way of approach is generally transvaginal. In this paper we propose and describe our experience with a transvestibular approach.

MATERIAL AND METHODS

18 women who had undergone anti-incontinence surgery (TVT 12 pts, TOT 3 pts, Burch retropubic colposuspension 3 pts) with obstruction and/or irritative symptoms underwent to a transvestibular urethrolysys. Five patients had urinary retention and the rest of patients had post voiding residual urine>100 ml. Using a scalpel blade a circum-meatal incision was performed and the urethra was progressively freed, dissecting just below the os pubis upwards and on the vaginal wall downwards, untethering it under direct vision in order to abtain a complete circular freeing of the urethra. In the end, the urethral meatus is repositioned with circular stiches.

RESULTS

The operation lasts between 20 and 40 minutes. An urethral catheter was left in place for 24-48 hours and no complications were observed. The post-voiding residual urine decreased in all of the cases and the irritative symptoms were reduced.

CONCLUSIONS

The transvestibular approach for urethrolysis is safe and effective regardless of the previous anti-incontinence surgery carried out. This procedure has the advantage of working in a relatively unscarred tissue, allows for a complete untethering of the urethra even in the retropubic space and leaves the vaginal wall intact.

Severe Case of Male External Genitalia Injury in a Poly-Traumatized Patient

We describe the case of a 34-year-old patient, polytraumatized during a motorcycle accident. The patient reported complete urethral rupture, bilateral avulsion of the testes by the scrotum, subtotal avulsion with complete amputation of the corpora cavernosa, and a deep open perineal wound. The reconstruction, performed by urologists, was postponed to the following day to ensure high standard of treatment with appropriate tools. This choice has yielded a good aesthetic and functional result.

Coexistence of Different Histotypes of Renal Carcinoma: Our Experience and Literature Review

The coexistence of multiple, synchronous primary tumors of different histology within the same kidney is a rare condition. We report herein a series of five patients with two tumors of different histology involving synchronously the same kidney.

Materials and Methods

We reviewed the pathology reports of a series of 381 patients who underwent surgery for primary renal tumors at our institution from 2000 to 2007. In the files of all patients with synchronous tumors of different histology, special attention was given to the results of imaging studies.

Results

Five out of 381 patients (1.37%) had coexistence of two primary tumors of different histology within the same kidney. Four patients had ultrasonography as the first imaging procedure, one patient had ultrasonography as the second imaging procedure; all had preoperative CT of the abdomen. Both lesions were detected by preoperative CT in 4/5 of the cases; in the remaining one, the smaller lesion was not visible, even in retrospect.

Conclusions

The coexistence of multiple and synchronous primary tumors of different histology within the same kidney has been only rarely described. To the best of our knowledge, in literature there are only case reports with the exception of a case of renal oncocytoma with evolving papillary RCC. We believe that this condition could be more frequent if the radiologist and the anatomopathologist try to find it.

[Is prophyilaxis necessary after urodynamic tests? Our experience]

Urodynamic studies should be performed only on patients with sterile urine. The use of prophylaxis after urodynamic investigation is debated (positive urinoculture in 9 to 15% of cases). The Units of Urodynamics at the Urological Clinic of the University of Genoa and of the Galliera Hospital of Genoa assessed the prevalence of bacteriuria on a sample of 336 patients (314 females and 22 males), average age 62.3, between January and December 2006. All patients with sterile urine before examination underwent a complete urodynamic test. Concomitant diseases were: diabetes (7.7%), multiple sclerosis (3.5%), Parkinson's disease (1.2%), urinary retention treated by autocatheterism (1.2 %). Urinoculture was performed seven days after the urodynamic study. All patients were asymptomatic; 40/336 urinocultures were positive (E. coli 80%, Proteus M. 10%, other 10%). The prophylaxis does not eliminate but only reduces post-urodynamic infections; we believe that the cost-benefit ratio is unfavorable.

Early vs Delayed Radical Cystectomy Compared in Highgrade Superficial Bladder Tumors

Objectives

The treatment of aggressive superficial TCC of the bladder remains controversial. In fact, although still classified as ‘superficial’, it has been shown that the biological characteristics of T1G3 bladder tumors are the same as those of the muscle-invasive group (T2 and above). Even with close monitoring and intensive intravesical therapy, the reported risk of muscle invasion in these patients is 53% and 1/3 die from this disease in the long-term. The aim of this study is to determine whether the timing of radical cystectomy affects the survival of patients with aggressive superficial bladder tumor.

Methods

We consider 74 patients who underwent radical cystectomy between November 1994 and October 2006 before a diagnosis of T1G3 bladder tumor. These patients were divided in 2 subgroups: group A (n=27, 25 M and 2 F) who underwent immediate radical cystectomy, and group B (n=47, 40 M and 7 F) who underwent other conservative treatments before radical cystectomy.

Results

The two subgroups were similar concerning age (66.29±8.37 yrs vs 66.87±8.6 yrs, respectively, p NS) and the timing of follow-up (respectively 77±45 vs 60±35 mths, p NS). Moreover, the progression-free survival was significantly higher in subgroup A (53.73±48.54 vs 31.94±35.19 mths, log-rank p<0.05) as well as the overall survival (59.73±45.37 vs 36.45±33.96 mths respectively, log-rank p<0.05). Comparing the histological examinations, the two subgroups were significantly different concerning the T stage (superficial tumors 14/27 vs 16/47, respectively, p<0.05; invasive tumors 13/27 vs 31/47, respectively, p<0.00005) and the lymphonodal dissemination (2N+/27 vs 11N+/47, respectively, p<<0.0005).

Conclusions

Delaying radical cystectomy for aggressive superficial bladder tumors leads to a worse progression-free survival; the overall survival is likely to be due also to an early lymphonodal dissemination, which occurs extending the timing between diagnosis and radical treatment.

Vesical Sequelae of Transverse Myelitis. Long-Term Urodynamics Observations in Adult Patients

Transverse myelitis is a rare autoimmune inflammatory disease often secondary to viral infection of the spinal cord; it frequently has vesico-sphynteric complications. Between January 2000 and December 2005 we performed urodynamic examination on 13 consecutive patients (7 females and 6 males) with previous diagnosis of transverse myelitis. Mean age was 54.5 years; transverse myelitis had been diagnosed a mean of 6.3 years earlier; etiology of myelitis was viral infection in 5 cases, autoimmune in 3 cases, insect bite in 1 case, unknown in 4 cases. The neurological sequelae included paraparesis in 3 cases and tetraparesis in 2 cases. Symptoms: dysuria 46%, slow stream 15%, pollakiuria 23%, urgency 30%; urge incontinence 38%, stress incontinence 15%. 3 patients performed 4 clean intermittent catheterisms (CIC), 2 patients 2 CICs. Eight patients had maximum cystometric capacity above 350 mL, the others had a mean capacity of 223 mL. Four patients showed no bladder sensitivity. Voluntary micturitional reflex was observed in 4 patients. Detrusor overactivity was diagnosed in 9 patients, 10 patients had mean residual post-micturition (RPM) of 218 mL, 2 patients showed detrusor-sphincter dyssynergia, 2 patients were found to be obstructed at pressure-flow study. Urodynamic follow-up is indicated in these patients with or without neurological complications (possibility of detrusor overactivity, urinary retention, detrusor-sphincter dyssynergia); the follow-up personalizes the diagnosis and therapy, and prevents complications.

Disease Progression in Bladder Cancer: Which Developments since 1994

Objectives

The introduction of PSA in clinical practice has resulted in decreasing the death rate form prostate cancer and in a downward shift of the pathological stage in radical prostatectomy specimens. This seems not to be the case for bladder cancer. In order to verify this assumption, we have reviewed the charts of the patients operated on of radical prostatectomy and radical cystectomy between 1994 and 2006.

Methods

456 and 491 consecutive patients, respectively, underwent radical cystectomy and radical prostatectomy with bilateral lymph nodes dissection. We excluded all the patients who had received neoadjuvant treatment or did not undergo node dissection. The patients were divided into two consecutive groups according to the year of treatment: group 1 included pts treated from 1994 to 2000, and group 2 pts from 2001 to 2006. The histopathological findings of the two groups of pts were compared. The difference among TNM systems has been balanced evaluating histopathological reports critically and converting them to the 2002 edition.

Results

For patients with prostate cancer, those in group 2 had a decrease in the incidence of extracapsular extension and lymph nodes invasion. The bladder cancer patients belonging to group 2 had a greater number of T2, but there was an increased number of pN+ in this group.

Conclusions

Even if there is a decline in locally advanced disease in patients with bladder cancer, our retrospective analysis did not show a comparable success in early diagnosis as it did for prostate cancer. There is undoubtedly an increase in the lymph node dissemination, whether this is due to a more extended lymph node dissection or to a premature dissemination remains questionable. Public awareness regarding bladder cancer and its risk factors is limited, but several studies have reported that a delay in diagnosis of invasive bladder cancer is an adverse prognostic factor. A higher care in the development of new diagnostic markers for bladder tumors and especially in the screening protocols together with an earlier radical therapy could hopefully improve the management of such a pathology, as it happened for prostate cancer.

Evolution of Our Experience in Diagnosis and Therapy for Urinary Infections

The therapy for urinary infections is advised according to the antibiogram; the symptoms request an empirical therapy based on urinary infections knowledge and drugs spectrum activity. We considered the urinoculture performed on 3834 patients, 3012 male and 822 female, hospitalized in our Institute in the period between 01/01/2005 and 31/10/2006; 444 of these were positive (12.7 % - 451 bacterial strains). Table 1: bacterial strains isolaed. We reported some evaluations obtained by antibiogram. E. coli strains Ciprofloxacin sensitive resulted in 60% of cases. Enterococcus species and Enterococcus faecalis strains Ampicillin sensitive resulted in 96.4% and 100% of cases, respectively.

In this study there is a Gram negative prevalence, whereas we had previously observed an equivalence between Gram negative and Gram positive (p 0.001). These data are useful for empirical therapy.

[Disease progression in bladder cancer: which developments since 1994]

Objectives The introduction of PSA in clinical practice has resulted in decreasing the death rate form prostate cancer and in a downward shift of the pathological stage in radical prostatectomy specimens. This seems not to be the case for bladder cancer. In order to verify this assumption, we have reviewed the charts of the patients operated on of radical prostatectomy and radical cystectomy between 1994 and 2006. METHODS 456 and 491 consecutive patients, respectively, underwent radical cystectomy and radical prostatectomy with bilateral lymph nodes dissection. We excluded all the patients who had received neoadjuvant treatment or did not undergo node dissection. The patients were divided into two consecutive groups according to the year of treatment: group 1 included pts treated from 1994 to 2000, and group 2 pts from 2001 to 2006. The histopathological findings of the two groups of pts were compared. The difference among TNM systems has been balanced evaluating histopathological reports critically and converting them to the 2002 edition. RESULTS. For patients with prostate cancer, those in group 2 had a decrease in the incidence of extracapsular extension and lymph nodes invasion. The bladder cancer patients belonging to group 2 had a greater number of T2, but there was an increased number of pN+ in this group. CONCLUSIONS Even if there is a decline in locally advanced disease in patients with bladder cancer, our retrospective analysis did not show a comparable success in early diagnosis as it did for prostate cancer. There is undoubtedly an increase in the lymph node dissemination, whether this is due to a more extended lymph node dissection or to a premature dissemination remains questionable. Public awareness regarding bladder cancer and its risk factors is limited, but several studies have reported that a delay in diagnosis of invasive bladder cancer is an adverse prognostic factor. A higher care in the development of new diagnostic markers for bladder tumors and especially in the screening protocols together with an earlier radical therapy could hopefully improve the management of such a pathology, as it happened for prostate cancer.

[Coexistence of different histotypes of renal carcinoma:our experience and literature review]

The coexistence of multiple, synchronous primary tumors of different histology within the same kidney is a rare condition. We report herein a series of five patients with two tumors of different histology involving synchronously the same kidney. MATERIALS AND METHODS. We reviewed the pathology reports of a series of 381 patients who underwent surgery for primary renal tumors at our institution from 2000 to 2007. In the files of all patients with synchronous tumors of different histology, special attention was given to the results of imaging studies. RESULTS. Five out of 381 patients (1.37%) had coexistence of two primary tumors of different histology within the same kidney. Four patients had ultrasonography as the first imaging procedure, one patient had ultrasonography as the second imaging procedure; all had preoperative CT of the abdomen. Both lesions were detected by preoperative CT in 4/5 of the cases; in the remaining one, the smaller lesion was not visible, even in retrospect. CONCLUSIONS. The coexistence of multiple and synchronous primary tumors of different histology within the same kidney has been only rarely described. To the best of our knowledge, in literature there are only case reports with the exception of a case of renal oncocytoma with evolving papillary RCC. We believe that this condition could be more frequent if the radiologist and the anatomopathologist try to find it.

Is Prophyilaxis Necessary after Urodynamic Tests? Our Experience

Urodynamic studies should be performed only on patients with sterile urine. The use of prophylaxis after urodynamic investigation is debated (positive urinoculture in 9 to 15% of cases). The Units of Urodynamics at the Urological Clinic of the University of Genoa and of the Galliera Hospital of Genoa assessed the prevalence of bacteriuria on a sample of 336 patients (314 females and 22 males), average age 62.3, between January and December 2006.

All patients with sterile urine before examination underwent a complete urodynamic test. Concomitant diseases were: diabetes (7.7%), multiple sclerosis (3.5%), Parkinson's disease (1.2%), urinary retention treated by autocatheterism (1.2 %). Urinoculture was performed seven days after the urodynamic study. All patients were asymptomatic; 40/336 urinocultures were positive (E. coli 80%, Proteus M. 10%, other 10%). The prophylaxis does not eliminate but only reduces post-urodynamic infections; we believe that the cost-benefit ratio is unfavorable.

[Vesical sequelae of transverse myelitis. Long-term urodynamics observations in adult patients]

Transverse myelitis is a rare autoimmune inflammatory disease often secondary to viral infection of the spinal cord; it frequently has vesico-sphynteric complications. Between January 2000 and December 2005 we performed urodynamic examination on 13 consecutive patients (7 females and 6 males) with previous diagnosis of transverse myelitis. Mean age was 54.5 years; transverse myelitis had been diagnosed a mean of 6.3 years earlier; etiology of myelitis was viral infection in 5 cases, autoimmune in 3 cases, insect bite in 1 case, unknown in 4 cases. The neurological sequelae included paraparesis in 3 cases and tetraparesis in 2 cases.

SYMPTOMS

dysuria 46%, slow stream 15%, pollakiuria 23%, urgency 30%; urge incontinence 38%, stress incontinence 15%. 3 patients performed 4 clean intermittent catheterisms (CIC), 2 patients 2 CICs. Eight patients had maximum cystometric capacity above 350 mL, the others had a mean capacity of 223 mL. Four patients showed no bladder sensitivity. Voluntary micturitional reflex was observed in 4 patients. Detrusor overactivity was diagnosed in 9 patients, 10 patients had mean residual post-micturition (RPM) of 218 mL, 2 patients showed detrusor-sphincter dyssynergia, 2 patients were found to be obstructed at pressure-flow study. Urodynamic follow-up is indicated in these patients with or without neurological complications (possibility of detrusor overactivity, urinary retention, detrusor-sphincter dyssynergia); the follow-up personalizes the diagnosis and therapy, and prevents complications.

Prulifloxacin versus ciprofloxacin in the treatment of adults with complicated urinary tract infections

INTRODUCTION

The present study was performed to evaluate the efficacy and safety of a 10-day regimen of prulifloxacin 600 mg once daily as compared to ciprofloxacin 500 mg twice daily in the treatment of patients with complicated urinary tract infections (UTIs).

MATERIALS AND METHODS

257 patients (mean age +/- SD 62.3 +/- 16.5) were enrolled and orally treated with prulifloxacin (127 patients) or ciprofloxacin (130 patients). The study was designed as a randomized, double-blind, double-dummy, controlled clinical trial. The primary efficacy parameter was the eradication of infecting strains (<10(3) cfu/ml). The clinical outcome and tolerability were also assessed.

RESULTS

At baseline, the most common infecting strains were Escherichia coli (62.8%), Proteus mirabilis (7.1%) and Klebsiella pneumoniae (4.1%). At the early follow-up, the rate of patients showing successful treatment was 90.8% in the prulifloxacin group, and 77.8% in the ciprofloxacin group (p = 0.008). A positive clinical outcome was observed in 94.8 and 93.3% of prulifloxacin- and ciprofloxacin-treated patients. Both drugs were well tolerated. Two patients dropped out for treatment-related adverse events.

CONCLUSIONS

The high urinary concentrations of prulifloxacin, combined with a broad-spectrum antimicrobial activity, allow its use in the empiric therapy of UTIs.

Evaluation of Sexual Activity in Patients Treated with Tadalafil: A Randomized Prospective Placebo-Controlled Trial

Evaluate the chronological distribution of sexual intercourses in a group of patients treated with Tadalafil versus placebo for three months.

Methods

120 patients with ED were randomized in two groups and treated respectively with one pill of Tadalafil 20mg or placebo on Tuesday and on Friday. After three months we collected data using IIEF and SEP diaries.

Results

After three months, IIEF score and percentages of success SEP diaries increased in Tadalafil group (< 0.01) versus Placebo group. Considering all the successful intercourses of the three months of Tadalafil assumption, the highest percentages were reported within 6–12 hours range (35%) and 12–24 hours range (28%). In Tadalafil group, 41% of patients reported their first successful intercourse between 1–6 hours and 78% of patients reported the recovery of spontaneous erections.

Conclusions

After doing the first sexual attempt between 1–6 hours, patients engaged in sexual activity between 6–24 hours.

Risk Factors for Female Urinary Incontinence and Pad-Test: Our Experience

If urinary incontinence in females is present upon effort or exertion, or on sneezing or coughing it is called stress urinary incontinence. If it is accompanied or immediately preceded by urgency it is called urge urinary incontinence. Many studies have shown that risk factors (age, parity, obstetric traumas, body mass index and others) are associated with the prevalence and severity of female urinary incontinence (any type), while other studies do not support this correlation. We reviewed the records at our institution to investigate the relationship between risk factors and severity of stress urinary incontinence.

Patients and methods

In the year 2002, we examined 118 consecutive patients - mean age 59 years SD ± 10.6 years (range 29 – 80 years) with urodynamic stress incontinence, at the Urodynamic Unit of our institution. The severity of stress incontinence was evaluated by Pad-test performed after cystometry (350 ml or maximum cystometric filling). Only results > 3 g were considered positive - mean 37.8 g SD ± 55.7 g (range 3 –281 g, Median ± MAD 17.0 g ± 10.0 g).

Results

We did not find any correlation between severity of incontinence and parity, obstetric traumas, or body mass index. However, we did find a statistically significant correlation between age and severity of urinary incontinence (Spearman Rank Correlation = 0.401, P=0.0014), whereas no association was found among women over 70 years of age.

Conclusions

Our study supports the association between age and severity of urodynamic stress incontinence, while we cannot confirm the correlation between severity of urinary incontinence and other risk factors.

Evaluation of sexual activity in patients treated with tadalafil: a randomized prospective placebo-controlled trial

The chronological distribution of sexual intercourses in a group of patients treated with tadalafil versus placebo for 3 months was evaluated. In total, 120 patients with ED were randomized in two groups and treated, respectively, with one pill of tadalafil 20 mg or placebo on Tuesday and on Friday. After 3 months, we collected data using IIEF and SEP diaries. After 3 months, IIEF score and percentages of success SEP diaries increased in the tadalafil group (<0.01) versus placebo group. Considering all the successful intercourses of the 3 months of tadalafil assumption, the highest percentages were reported within 6-12 h range (35%) and 12-24 h range (28%). In tadalafil group, 41% of patients reported their first successful intercourse between 1 and 6 h and 78% of patients reported the recovery of spontaneous erections. In conclusion, after carrying out the first sexual attempt between 1 and 6 h, patients engaged in sexual activity between 6 and 24 h.

Medical therapy of prostate carcinoma

Medical treatment of prostatic cancer is one of the most complex and challenging issues in oncologic urology, and probably of oncology itself. In fact, in spite of the well known sensitivity of the disease to hormonal manipulations, it is still substantially unclear whether hormonal therapy achieves survival improvement. Furthermore, many prostate cancers become hormone refractory within 18 to 36 months from the onset of therapy, and until now, no further treatment has been able to improve their prognosis, in spite of the often promising early results. Medical treatment is now being used as an adjunct to radical surgery and to radiotherapy, in both the adjuvant and the neoadjuvant setting, and this raises further controversies. This paper is an attempt to give to the readers the state of art of medical therapy, even within the limits of a concise review. The authors are aware of these limits but hope that this paper can be useful to the reader.

[Atypical presentation of angiomiolypoma in a patient with peritoneal metastases from ovarian cancer: a case report]

A renal mass with not typical instrumental characteristic in patient in follow-up for ovarian neoplasia sets to the surgeon serious doubts about proper surgical strategy. Achieve of the conservative renal surgery assisted by the intraoperative use of the radiofrequency energy has allowed to preserve the renal function and the diagnosis of unknown angiomyolipoma.

Patch Urethroplasty Using a Fascia lata Autograft in Male Rabbits

INTRODUCTION

Urethral reconstruction is difficult when the genital skin is not available for surgery. We evaluate the feasibility of using the autologous fascia lata as a graft for urethral repair.

MATERIALS AND METHODS

10 male rabbits underwent urethroplasty after creation of a ventral urethral defect. The defect was repaired using a graft harvested from the fascia lata. The animals were divided into three groups and sacrificed at 2, 4 and 12 weeks postoperatively. Radiologic control was performed after 10-12 days and before sacrifice.

RESULTS

In the 10 rabbits subjected to surgery, no case of death or wound infection was observed. During urethrography, a fistula was observed in 2 animals. In the remainder (n = 8), histological analysis showed the preservation of the original laminar structure without graft shrinkage or fibrosis. On the luminal side of the patch, a new line of urothelium appeared in the 2nd week after surgery. After 3 months, the new epithelium was multilayered and the graft edges were not detectable. No voiding dysfunction was detectable in 8 rabbits.

CONCLUSIONS

Our study suggests the feasibility of using the autologous fascia lata for urethral patch repair.

Incidental splenectomy during left radical nephrectomy: reasons and ways to avoid it

INTRODUCTION

Left radical nephrectomy is the second most common cause of incidental splenectomy during transabdominal oncological surgery in the upper left quadrant of the abdomen. The potential sequelae of splenic ablation are often underestimated and generally no systematic planned efforts have been undertaken to avoid a splenic injury.

MATERIAL AND METHODS

We evaluated the incidence of iatrogenic splenectomy in 333 cases of left radical nephrectomy for renal cancer performed at our institute between 1970 and 1999. Two slightly different surgical techniques were adopted and after 1995 particular attention was paid to the possible causes of intraoperative splenic injury and how to avoid it. In the first group of patients (1970-1994) an anterolateral xipho-umbilical-subcostal approach was used, and in the second group (1995-1999) a cruciate "Mercedes-like" incision was always adopted.

RESULTS

The incidence of iatrogenic splenectomy in the first group of patients was 13.2%, and only 2.6% in the second group. The mortality rate in the first group of patients was 6%; no mortality has been recorded in the second group. Postoperative infections averaged 12.1% in the first group and 11.6% in the second, without any difference between the two groups. However, if we consider the incidence of postoperative infections in splenectomy cases, the incidence reaches 24.2% in the first group versus no cases in the second.

CONCLUSIONS

Incidental splenectomy is a potentially severe complication of transabdominal left radical nephrectomy and is often considered a price that has to be paid, particularly in cases of large tumoral masses. A more detailed knowledge of splenic anatomy, a critical consideration of the intraoperative factors that may lead to splenectomy, and the adoption of a surgical tactic borrowed from the techniques of liver transplant significantly lower the incidence of iatrogenic splenectomy.

Retroperitoneal ancient schwannoma: case report and analysis of clinico-radiological findings

Ancient schwannoma is a rare subtype of typical schwannoma, with histological predominance of degenerative findings. We report the second case of retroperitoneal ancient schwannoma (occurred in a 45-year-old female referred to our institution for an unremitting right lumbar pain) and pinpoint clinical, radiological, prognosis and therapeutic aspects of this tumor.

Histological changes following two-step flap gastrocystoplasty in rats

INTRODUCTION

A gastric segment used to increase bladder capacity can undergo considerable changes over time, as can all intestinal segments implanted in the urinary tract and in contact with urine. This experimental study reports the differences between the histological alterations observed in the gastric patch transposed in the bladder both with its own pedicle and after deafferentation from the stomach.

MATERIALS AND METHODS

A group of 30 young male Sprague-Dawley rats underwent gastrocystoplasty. Survivors were divided into 3 groups: gastrocystoplasty alone (8 rats); gastrocystoplasty with vascular deafferentation at 15 days (7 rats), and at 2 months (8 rats). 5 rats were used as controls. Urinary pH was evaluated during a 6-month follow-up.

RESULTS

Histology showed that early devascularization hindered the fusion of the two mucosae in the junctional area but reduced papillary hyperplasia (p = 0.013) of the gastric mucosa. No changes were observed in urinary pH after patch devascularization.

CONCLUSIONS

Vascular deafferentation creates a gastric flap on the bladder which, even if it does not prevent urinary acidification, reduces the frequency of histologically detected changes susceptible for transformation into neoplasms.

Adult testicular pure yolk sac tumor

Here we describe the clinical, ultrasonographic and histological features of a rare pure adult yolk sac tumor detected in the right testis of a 44-year-old male. Due to the rarity of this neoplasm (less than 10 cases have been reported), there is no unanimous consensus for therapy following inguinal orchiectomy. We believe that nerve-sparing retroperitoneal lymph node dissection could be potentially curative and useful for future interpretations of this tumor's potential evolution.

Combined oral therapy with sildenafil and doxazosin for the treatment of non-organic erectile dysfunction refractory to sildenafil monotherapy

The purpose of this work was to investigate the efficacy and safety of sildenafil in combination with doxazosin for the treatment of non-organic erectile dysfunction in patients who did not respond to sildenafil. We enrolled 28 patients with non-organic erectile dysfunction, for whom 3 months of sildenafil monotherapy had failed. They were divided in two random and homogeneous groups: 14 were treated with doxazosin (4 mg daily) and sildenafil (100 mg 1 h before sexual intercourse); the other 14 patients received sildenafil and placebo. The results were assessed by means of the IIEF questionnaire before the beginning of the study, after 30 days of therapy and after 60 days. Of the 14 patients treated with doxazosin and sildenafil, 11 (78.6%) showed a statistically significant increase of IIEF; in the placebo group, only one patient (7.1%) recorded a significant IIEF increase. The differences observed in the two groups were statistically very significant (P=0.0016). Blood pressure did not show significant alterations. Side effects were minimal and even present during sildenafil monotherapy. The combination therapy with sildenafil and doxazosin resulted in the safe and effective treatment of men with non-organic erectile dysfunction for whom sildenafil alone had failed.

[Evaluation of the association between benign prostatic hyperplasia and sexual disorders]

OBJECTIVE

The aim of this study was to determine the incidence of sexual dysfunction in patients with benign prostatic hyperplasia (BPH).

METHODS

During the last 6 months 88 patients (mean age 65 years, range 55-78) suffering from BPH, without other chronic disease, were studied.

RESULTS

Andrological evaluation enabled us to find erectile dysfunction in 52% of patients, ejaculation problems in 41% and decrease of libido in 54%.

CONCLUSION

Due to the great impact of these disturbances in patients' quality of life, we believe that clinical and therapeutic approach in BPH patients should be global, with both urological and andrological assessment.

Scrotal extraperitoneal hernia of the ureter: case report and literature review

Ureteral herniation is a rare, often misdiagnosed event and serious surgical complications are possible. Until 1992, 128 cases of ureteral herniation were reported and in 54 (42%) the inguino-scrotal region was involved. From an anatomical and pathogenic standpoint, two types of uretero-inguinal hernias can be identified: paraperitoneal (more frequent, acquired, always presenting a peritoneal hernia sac, frequently associated with other herniated abdominal structures) and extraperitoneal (very uncommon, congenital, never associated with a true peritoneal sac, always composed only of the ureter). We describe a new case of scrotal extraperitoneal ureteral hernia and review the current urological, surgical and radiological literature to analyze the main clinical characteristics of this pathology and its ideal treatment.

Arterial priapism and cycling: a new worrisome reality?

Arterial priapism is a rare condition caused by the traumatic formation of an arteriolacunar fistula. We report 2 cases of arterial priapism after cycling injuries. Both patients sustained a violent perineal trauma against the top tube on the bicycle. In both cases, penile detumescence was obtained by superselective arteriographic embolization of the fistula with gelatin sponge or microcoil. The fistula was monolateral in the first case and bilateral in the second. Cycling should be considered a possible risk factor for arterial priapism as it is for urethritis, prostatitis, hematuria, testicular torsion, scrotal and penile numbness, and erectile dysfunction.

[Priapism: decisional algorithm, our experience, and role of sildenafil in sexual rehabilitation]

OBJECTIVE

We report our experience in the management of priapism.

MATERIALS AND METHODS

In a 2-year period we observed 7 patients of whom 4 presented with low flow and 3 with high flow priapism.

RESULTS

In 2 of the patients with ischemic priapism, simple blood aspiration from the corpora allowed for a quick detumescence, while in the other 2 cases a derivative intervention (1 spongio cavernous and 1 glans cavernous) had to be performed. In all the 3 patients with high flow priapism we performed a superselective arteriography that obtained the visualisation of the arteriovenous fistula. These patients restarted their sexual activity after about three months. At six months a patient with low flow priapism restored sexual activity due to sildenafil 50 mg.

CONCLUSION

The importance of distinguishing low and high flow priapism was confirmed.

Traumatic rupture of the corpora cavernosa: new physiopathologic acquisitions

OBJECTIVES

To investigate the physiopathologic mechanisms of the rupture of the corpora cavernosa by means of a histologic study of the tunica albuginea.

METHODS

In 6 patients (age range 28 to 49 years, mean 38) with traumatic penile rupture, samples of the tunica albuginea were taken during corrective surgery far from the site of the lesion. These specimens were analyzed with light microscopy by the same pathologist and compared with other samples of tunica albuginea taken from 7 patients who underwent penile surgery for other reasons.

RESULTS

Five of the 6 patients with traumatic penile rupture had histologic anomalies of the tunica albuginea (fibrosclerosis in all 5 patients [83%] and phlogistic cellular infiltrations composed of lymphocytes or histiocytes in 3 patients [50%]). Only 1 patient (17%) with traumatic rupture of the corpus cavernosum had a completely healthy tunica albuginea. None of the control specimens revealed any histologic alterations.

CONCLUSIONS

Structural anomalies could alter the mechanical properties of the tunica albuginea, representing a weakening factor of the corpora cavernosa and thus a predisposing factor for traumatic rupture of the penis. Therefore, patients with anomalous albuginea could undergo penile rupture even at intracavernous pressures inferior to pressures usually necessary to cause rupture in patients with healthy albuginea.