Male infertility and urological tumors: Pathogenesis and therapeutical implications

Most genitourinary tract cancers have a negative impact on male fertility. Although testicular cancers have the worst impact, other tumors such as prostate, bladder, and penis are diagnosed early and treated in relatively younger patients in which couple fertility can be an important concern. The purpose of this review is to highlight both the pathogenetic mechanisms of damage to male fertility in the context of the main urological cancers and the methods of preserving male fertility in an oncological setting, in light of the most recent scientific evidence. A systematic review of available literature was carried out on the main scientific search engines, such as PubMed, Clinicaltrials.Gov, and Google scholar. Three hundred twenty-five relevant articles on this subject were identified, 98 of which were selected being the most relevant to the purpose of this review. There is a strong evidence in literature that all of the genitourinary oncological therapies have a deep negative impact on male fertility: orchiectomy, partial orchiectomy, retroperitoneal lymphadenectomy (RPLND), radical cystectomy, prostatectomy, penectomy, as well as radiotherapy, chemotherapy, and hormonal androgen suppression. Preservation of fertility is possible and includes cryopreservation, hormonal manipulation with GnRH analogs before chemotherapy, androgen replacement. Germ cell auto transplantation is an intriguing strategy with future perspectives. Careful evaluation of male fertility must be a key point before treating genitourinary tumors, taking into account patients' age and couples' perspectives. Informed consent should provide adequate information to the patient about the current state of his fertility and about the balance between risks and benefits in oncological terms. Standard approaches to genitourinary tumors should include a multidisciplinary team with urologists, oncologists, radiotherapists, psycho-sexologists, andrologists, gynecologists, and reproductive endocrinologists.

Sport, Infertility and Erectile Dysfunction

In the last decades a growing interest has been dedicated to prevention, diagnosis and therapy of male genital pathologies, such as varicocele, infertility and erectile dysfunction in the population involved in sport activities. High incidence (up to 30%) of varicocele has been reported in a population of athletes and up to 60–80% in the subgroup of body-builders. The incidence of varicocele specifically increases with hours of training, in a linear model. Controversial data come from literature about the effects of physical activity on fertility, with prevalence of trials demonstrating worsening of seminal parameters. Furthermore, it has been demonstrated that physical stress in healthy male athletes can interfere with LH levels. Bicycling is one of the major risk factors for erectile dysfunction, with incidence of 13–24%. This is due to the prolonged compression of perineal arteries leading to reduced chronic penile perfusion. Bioengineering studies have been the basis for industry to produce specifically shaped saddles that significantly reduce and minimize compressive effects. Finally, high frequency of lower urinary tract symptoms (LUTS) in cyclists has been related to increased incidence of erectile dysfunction in comparison with normal population.

Sports and Genitourinary Traumas

Introduction

Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas.

Methods

Literature review of peer-reviewed articles published by May 2009.

Results

Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade 1–11 lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma.

Conclusions

Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

Prostatitis Syndromes and Sporting Activities

Introduction

Prostatitis-like syndromes are high prevalent health problems and frequently considered by patients and physicians as strictly correlated to sports causing perineal compression. These syndromes and their relationships with sporting activities have been discussed in this report.

Methods

We reviewed peer-reviewed scientific articles published by May 2009 and searched according to the following term selection: prostatitis, pudendal nerve, sport, cycling.

Results

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a major healthcare burden heavily affecting patients’ Quality of Life. No clear evidence of any direct etiologic relationship has been found in literature between prostatitis, either bacterial or non-bacterial, and sports activities. On the other hand, some types of sport causing perineal compression, such as cycling, can exacerbate symptoms of acute and chronic prostatitis; a temporary sport discontinuation is justified in these patients. CP/CPPS may be often caused by pudendal nerve entrapment (PNE). Prostatitis-like urogenital neuropathic pain together with voiding and sexual dysfunctions are the hallmark of PNE. A common feature is that flexion activities of the hip, such as climbing, squatting, cycling provoke or worsen urogenital pain or pelvic pain. Many of the patients with PNE are cyclists, played American football, lifted weights, or wrestled as teenagers and young adults. PNE represents the most common bicycling associated urogenital problems.

Conclusions

Overall, studies show that no causal relationship has been demonstrated between prostatitis and sporting activities. Conversely, urologists should be aware that sports involving vigorous hip flexion activities or prolonged perineal compression are a potential and not an infrequent cause of uroand rological symptoms caused by pudendal nerve entrapment.

Pituitary-tumour-transforming-gene 1 expression in testicular cancer

Genomic instability is a feature of germ cell tumours. The pituitary-tumour-transforming-gene 1 (PTTG1) is the major effector of chromosome segregation during mitosis, protecting the cell from aneuploidy. The protein expression of this gene has been evaluated in testicular tumours by immunohistochemistry. Formalin-fixed and paraffin-embedded specimens of testicular tissues from 83 patients undergoing therapeutic orchidectomy for seminomas (n = 53), embryonal carcinoma (n = 10), yolk sac tumour (n = 10) and teratoma (n = 10) were examined. Seminoma was associated with in situ carcinoma (CIS) in 23 samples. PTTG1 immunostaining was performed using rabbit anti-PTTG1 as a primary antibody. In CIS, only isolated cells showed nuclear staining for PTTG1. In the peripheral area of seminoma, PTTG1 was mostly detected as localised in the nucleus; in the central area of seminoma, PTTG1 staining was more intense in cytoplasm. PTTG1-positive cells were also present in the areas of seminoma infiltration. On the other hand, in embryonal carcinoma, cells had a diffuse positive immunostaining, mainly cytoplasmatic, while we did not observe an expression of PTTG1 in yolk sac tumour and mature teratoma. We firstly identified the PTTG1 expression pattern in normal testis, CIS and testicular cancer. Further investigation is needed to clarify the functional activity of PTTG1 in testicular oncogenesis.

The role of iron impurities in the toxic effects exerted by short multiwalled carbon nanotubes (MWCNT) in murine alveolar macrophages

Lung toxicity mediated by multiwalled carbon nanotubes (MWCNT) has been widely demonstrated and recently associated with induction of carcinogenic asbestos-like effects, but the chemical features that drive this toxic effect have still not been well elucidated. The presence of metals as trace contaminants during MWCNT preparation, in particular iron (Fe) impurities, plays an important role in determining a different cellular response to MWCNT. Our goal was to clarify the mechanisms underlying MWCNT-induced toxicity with correlation to the presence of Fe impurities by exposing murine alveolar macrophages to two different MWCNT samples, which differed only in the presence or absence of Fe. Data showed that only Fe-rich MWCNT were significantly cytotoxic and genotoxic and induced a potent cellular oxidative stress, while Fe-free MWCNT did not exert any of these adverse effects. These results confirm that Fe content represents an important key constituent in promoting MWCNT-induced toxicity, and this needs to be taken into consideration when planning new, safer preparation routes.

[Prostatitis syndromes and sporting activities]

INTRODUCTION

Prostatitis-like syndromes are high prevalent health problems and frequently considered by patients and physicians as strictly correlated to sports causing perineal compression. These syndromes and their relationships with sporting activities have been discussed in this report.

METHODS

We reviewed peer-reviewed scientific articles published by May 2009 and searched according to the following term selection: prostatitis, pudendal nerve, sport, cycling.

RESULTS

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is a major healthcare burden heavily affecting patients' Quality of Life. No clear evidence of any direct etiologic relationship has been found in literature between prostatitis, either bacterial or non-bacterial, and sports activities. On the other hand, some types of sport causing perineal compression, such as cycling, can exacerbate symptoms of acute and chronic prostatitis; a temporary sport discontinuation is justified in these patients. CP/CPPS may be often caused by pudendal nerve entrapment (PNE). Prostatitis-like urogenital neuropathic pain together with voiding and sexual dysfunctions are the hallmark of PNE. A common feature is that flexion activities of the hip, such as climbing, squatting, cycling provoke or worsen urogenital pain or pelvic pain. Many of the patients with PNE are cyclists, played American football, lifted weights, or wrestled as teenagers and young adults. PNE represents the most common bicycling associated urogenital problems.

CONCLUSIONS

Overall, studies show that no causal relationship has been demonstrated between prostatitis and sporting activities. Conversely, urologists should be aware that sports involving vigorous hip flexion activities or prolonged perineal compression are a potential and not an infrequent cause of uroandrological symptoms caused by pudendal nerve entrapment.

[Sport, infertility and erectile dysfunction]

In the last decades a growing interest has been dedicated to prevention, diagnosis and therapy of male genital pathologies, such as varicocele, infertility and erectile dysfunction in the population involved in sport activities. High incidence (up to 30%) of varicocele has been reported in a population of athletes and up to 60-80% in the subgroup of body-builders. The incidence of varicocele specifically increases with hours of training, in a linear model. Controversial data come from literature about the effects of physical activity on fertility, with prevalence of trials demonstrating worsening of seminal parameters. Furthermore, it has been demonstrated that physical stress in healthy male athletes can interfere with LH levels. Bicycling is one of the major risk factors for erectile dysfunction, with incidence of 13-24%. This is due to the prolonged compression of perineal arteries leading to reduced chronic penile perfusion. Bioengineering studies have been the basis for industry to produce specifically shaped saddles that significantly reduce and minimize compressive effects. Finally, high frequency of lower urinary tract symptoms (LUTS) in cyclists has been related to increased incidence of erectile dysfunction in comparison with normal population.

[Doping and urologic tumors]

Several substances such as growth hormone (GH), erythropoietin (Epo), and anabolic steroids (AS) are improperly utilized to increase the performance of athletes. Evaluating the potential cancer risk associated with doping agents is difficult since these drugs are often used at very high doses and in combination with other licit or illicit drugs. The GH, via its mediator, the insulin-like growth factor 1 (IGF-1), is involved in the development and progression of cancer. Animal studies suggested that high levels of GH/IGF-1 increase progression of androgen-independent prostate cancer. Clinical data regarding prostate cancer are mostly based on epidemiological studies or indirect data such as IGF-1 high levels in patients with prostate cancer. Even if experimental studies showed a correlation between Epo and cancer, no clinical data are currently available on cancer development related to Epo as a doping agent. Androgens are involved in prostate carcinogenesis modulating genes that regulate cell proliferation, apoptosis and angiogenesis. Most information on AS is anecdotal (case reports on prostate, kidney and testicular cancers). Prospective epidemiologic studies failed to support the hypothesis that circulating androgens are positively associated with prostate cancer risk. Currently, clinical and epidemiological studies supporting association between doping and urological neoplasias are not available. Nowadays, exposure to doping agents starts more prematurely with a consequent longer exposition period; drugs are often used at very high doses and in combination with other licit or illicit drugs. Due to all these elements it is impossible to predict all the side effects, including cancer; more detailed studies are therefore necessary.

[Sports and genitourinary traumas]

INTRODUCTION

Statistical data referring to sports-related traumas of the urinary tract are quite scarce; nevertheless, it is possible to draw general data on the relationship between sports and urological traumas.

METHODS

Literature review of peer-reviewed articles published by May 2009.

RESULTS

Urological traumas account for about 10% of all traumas, and about 13% of them is sports-related. Genitourinary traumas are among the most common cause of abdominal injuries in sports. Blunt injuries are more common than penetrating ones and renal injuries are by far the most common, followed by testicular injuries; ureters, bladder and penis injuries are much more infrequent. Considering chronic microtraumas, injuries of bulbar urethra are also common in sports that involve riding. Overall, the incidence of genitourinary trauma due to sports is low. Renal traumas in sports injuries usually consist of grade I-II lesions and usually do not require surgical treatment. Cycling is the sporting activity most commonly associated with genitourinary injuries, followed by winter sports, horse riding and contact/collision sports. Literature data suggest that significant injuries are rare also in athletes with only one testicle or kidney. General preventive measures against sport-related injuries, along with the use of protective cups for male external genitalia, are generally sufficient to reduce the incidence of urogenital trauma.

CONCLUSIONS

Overall, studies show that urogenital injuries are uncommon in team and individual sports, and that most of them are low-grade injuries. Participation in sports that involve the potential for contact or collision needs to be carefully assessed in the athletes with only one testicle or kidney, even though urogenital injuries should not preclude sports participation to an appropriately informed and counseled patient. Further research is needed to acquire more knowledge on genitourinary injuries according to age, sports type and technical skill.

Contrast Media in Urogenital Radiology

Background

Contrast media are widely used in urogenital radiology. The ideal contrast agent should be totally inert, causing no interactions with organism, and with a rapid and complete excretion. Adverse reactions could occur after using any type of contrast media. Contrast enhanced procedures are performed with increasing frequency and the patients population is progressively older and with multiple co-morbid conditions, thus contrast media toxicity is becoming a serious problem. Contrast media-induced nephropathy (CIN) is considered an important cause of hospital-acquired renal failure. The administration of gadolinium-based contrast agents has been recently associated with the development of a serious adverse reaction, potentially lethal in patients with renal insufficiency, named nephrogenic systemic fibrosis (NSF).

Methods

Literature review on contrast media in urogenital radiology, CIN, NSF.

Conclusions

Since 1996, the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has released its guidelines regarding safety about the use of contrast media. CIN, and the emerging NSF, are topics of increasing interest for urologists, radiologists, nephrologists, dermatologists and all the clinicians. Contrast media have progressively become safer in the last years. Even if rare, some adverse reactions still occurr up to now. CIN and its prevention remain an issue under debate. In the past, whenever a patient required a contrast-enhanced imaging study, the trend was to select magnetic resonance imaging with gadolinium-based contrast agents in order to avoid the well-known CIN of iodinated-based contrast agents. The awareness of NFS is changing the contrast–enhanced imaging in patients with renal failure. At present we have to investigate NSF etiopathogenesis, in order to prevent and eventually to cure it. The understanding of the risk factors for both CIN and NSF is an emerging need, the adoption of all preventive measures to reduce the risks remain a mandatory issue.

[Contrast media in urogenital radiology]

BACKGROUND. Contrast media are widely used in urogenital radiology. The ideal contrast agent should be totally inert, causing no interactions with organism, and with a rapid and complete excretion. Adverse reactions could occur after using any type of contrast media. Contrast enhanced procedures are performed with increasing frequency and the patients population is progressively older and with multiple co-morbid conditions, thus contrast media toxicity is becoming a serious problem. Contrast media-induced nephropathy (CIN) is considered an important cause of hospital-acquired renal failure. The administration of gadolinium-based contrast agents has been recently associated with the development of a serious adverse reaction, potentially lethal in patients with renal insufficiency, named nephrogenic systemic fibrosis (NSF). METHODS. Literature review on contrast media in urogenital radiology, CIN, NSF. CONCLUSIONS. Since 1996, the Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR) has released its guidelines regarding safety about the use of contrast media. CIN, and the emerging NSF, are topics of increasing interest for urologists, radiologists, nephrologists, dermatologists and all the clinicians. Contrast media have progressively become safer in the last years. Even if rare, some adverse reactions still occurr up to now. CIN and its prevention remain an issue under debate. In the past, whenever a patient required a contrast-enhanced imaging study, the trend was to select magnetic resonance imaging with gadolinium-based contrast agents in order to avoid the well-known CIN of iodinated-based contrast agents. The awareness of NFS is changing the contrast-enhanced imaging in patients with renal failure. At present we have to investigate NSF etiopathogenesis, in order to prevent and eventually to cure it. The understanding of the risk factors for both CIN and NSF is an emerging need, the adoption of all preventive measures to reduce the risks remain a mandatory issue.

Distal urethral reconstruction of the glans for penile carcinoma: results of a novel technique at 1-year of followup

PURPOSE

No satisfactory techniques are available to replace the anatomy and function of the penile glans after radical surgery for penile carcinoma. We report a new technique of glans reconstruction using distal urethra. We evaluated anatomical, physiological and esthetic features as well as short-term and long-term clinical outcomes.

MATERIALS AND METHODS

A total of 14 patients with a mean age of 54 who had squamous penile carcinoma underwent glans reconstruction after simple glansectomy in 8 and after amputation of the distal third of the shaft in 6. Glans sensibility, erectile function, ejaculation, orgasm, penile length, local recurrence, patient and partner satisfaction, and quality of life were evaluated before and after the operation. Mean followup was 13 months.

RESULTS

All patients noticed subjective and objective thermal and tactile epicritic sensibility in the area of the neoglans. Ten of 14 patients (71%) noticed spontaneous and/or induced rigid erections. Interestingly International Index of Erectile Function scores in the ejaculation and orgasm domains did not significantly change in the period before and after surgery. No local disease recurrence or penile retraction were reported at long-term followup.

CONCLUSIONS

Reconstructive glanuloplasty with distal urethra in penile tumor surgery is an innovative, easy and rapid surgical technique with appreciable functional and esthetic results.

Peyronie’s Disease: Lights and Shadows

Peyronie's disease (PD) is characterized by the onset of fibrous plaque inside the tunica albuginea of the penile corpora cavernosa that can cause pain and bending during the erection, making intercourse difficult or impossible. Evidence of the literature supports the autoimmune etiology of PD and suggests genetic and familiar conditions, penile traumatisms, and a history of genital tract diseases as risk factors, but no definitive conclusions arise about the pathogenesis of the disease. Few randomized trials demonstrated that medical therapies, such as vitamin E, colchicine, potassium aminobenzoate, tamoxifen, and injection therapy with verapamil, can stabilize the acute phase of the disease. Extracorporeal shock wave therapy and iontophoresis cannot be considered first-line or gold standard therapies. Satisfactory results have been published with the Nesbit operation in large series with low-stage disease, whereas plication procedures have shown significant relapse rates. A high incidence of long-term penile retractions has been reported in high-stage disease treated with plaque incision and simple graft insertion. Malleable, soft, or inflatable prostheses combined with graft implantation have given the best results in terms of penile straightening and lengthening and patient satisfaction. In conclusion, the etiopathogenesis of PD is not yet clearly understood, no medical therapy is fully effective, and surgery remains the gold standard in patients with severe deformity and/or erectile dysfunction.

[Stapled versus hand sewn anastomosis in elective and emergency colorectal surgery]

We studied the incidence of anastomotic leakage in colorectal surgery with the alternative use of stapled anastomosis, hand sewn anastomosis and stapled/hand sewn anastomosis. 477 consecutive patients admitted for elective or emergency colon surgery were divided in: Group I? 337 elective patients submitted to mechanical bowel preparation; Group II - 140 emergency patients operated without mechanical bowel preparation. We analyzed surgical complications in the two group considering the different anastomosis made (stapled, hand sewn and stapled/hand sewn). Anastomotic leakages were 11 (3.3%) in Group I: 7 in stapled (3,4%), 2 in hand sewn (2,1%) and 2 in stapled/hand sewn anastomosis (5,3%); 10 patients (91%) with peritonitis or intra-abdominal abscess required re-intervention and there was a correlated death. In Group II there were 6 anastomotic leakages (4,2%): 1 in stapled (1,4%), 3 in hand sewn (8,3%) and 2 in stapled/hand sewn anastomosis (5,7%); four patients required re-intervention and there were no correlated deaths. Mean postoperative stays were similar among the different techniques of suture in the two groups. No statistically significant differences in surgical complications were noted among stapled, hand sewn and stapled/hand sewn anastomosis. The choice should be based on personal preference and surgeon experience, considering costs, using hand sewn suture whenever is possible.

Blood gas changes in the corpora cavernosa: metabolic and histomorphometric implications in the patient with erectile dysfunction

PURPOSE

We evaluated corpora cavernosa metabolism in flaccidity and in erection, analyzing some blood gas analytical parameters and comparing them by histomorphometric examination to find a direct relation between biochemical-metabolic parameters and histological data.

MATERIALS AND METHODS

We selected 33 patients with erectile dysfunction and divided them into 2 groups, including 1-those with congenital penile deviation who were responders to prostaglandin E1, and 2-those with severe organic erectile dysfunction who were not responders to prostaglandin E1. We evaluated O(2) and CO(2) pressure, pH and O(2) saturation in blood samples. We then made a histomorphometric study of cavernous tissue. We obtained specimens by cavernous biopsies and calculated O(2) and CO(2) exchange, the Haldane effect and the respiratory quotient into the corpora cavernosa. All data were evaluated by statistical analysis.

RESULTS

Mean O(2) arterial pressure and saturation +/- SD were lower in group 2 than in group 1 (74.85 +/- 8.78 versus 96.43 +/- 14.87 and 94.98 +/- 1.4 versus 97.35 +/- 0.83, respectively). Mean CO(2) arterial pressure was 35.59 +/- 4.78 group 1 versus 38.8 +/- 2.71 in group 2 with borderline statistical significance. The Haldane effect was superior in flaccidity than in erection because of the influence of arterial-venous O(2) difference and the respiratory quotient, which was also an inverse ratio. Cavernous histomorphometry showed that in group 1 smooth muscle was a mean of 38.8 +/- 8.94% of cavernous tissue versus 24.9% in group 2.

CONCLUSIONS

Our study shows that starting with blood gas analytical data we can completely study the metabolism of the corpora cavernosa and its relationships to erectile dysfunction. Cavernous histomorphometry can suggest the presence of smooth muscle into cavernous tissue, whereas our mathematical elaboration allowed us to evaluate all data in a more complete manner.

Cyclic sciatica related to an extrapelvic endometriosis of the sciatic nerve: new concepts in surgical therapy

Sciatic pain caused by endometriosis of the sciatic nerve is an uncommon clinical finding and seems to have been verified histologically in only a few cases. Patients complain of typical signs and symptoms of common sciatica that are cyclic in nature. Suggested compression of lumbar root or sciatic nerve or its plexus could be confirmed by electromyography, computed tomography, or magnetic resonance imaging, and by prompt response to hormonal suppression of ovarian function with regression of the radiologic findings. Patients often have required radical surgery with total hysterectomy and bilateral salpingo-oophorectomy. However, conservative surgery with excision of the endometriosis from the nerve can be successful in selected patients who wish to preserve reproductive function. We report a case of sciatic nerve involvement explored by magnetic resonance imaging, with endometriosis in contact with the nerve in the right sciatic trunk.

Radical surgery in Peyronie's disease. Graft comparison

The paper concerns the experience of our Institute in the field of radical plaque removal in Peyronie's disease with special focus to the new biomaterials used as a graft on replace the fibrotic tunica albuginea. This is a retrospective study that evaluated clinical outcomes with a follow-up ranging from the early post-operative period to six years later. Ninety-eight patients aged from 32 to 64 with compliant of high stage Peyronie's disease have been treated. Which surgery meanly occurred 12 months after the first diagnosis. The different biomaterials implanted have been studied in terms of biophysical properties and clinical features at short and long term follow-up. These results suggest that surgical therapy appears as the main option in the treatment of Peyronie' disease, specially in the advanced state, plaque surgery being the most radical one; today we have a lot of different materials for substitution of albuginea but maybe noone represents the real gold standard. As concerns elasticity and biocompatibility, vein gave the best results, even if the operating time is longer. A new enthusiasm comes from SIS (porcine intestinal sub-mucose), whose early clinical and biological results are satisfactory in terms of elasticity and reduced operating time.

Selective liquid phase hydrogenation of citral on Au/Fe2O3 catalysts

Gold supported on iron oxide hydrogenates citral (an alpha,beta-unsaturated aldehyde) to the corresponding alpha,beta-unsaturated alcohols (geraniol and nerol) with a selectivity higher than 95%.

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.

Treatment of metastases of the cervical spine

On the experience of 73 patients, the authors state their guidelines on the treatment of bone metastases on the cervical spine. Most of the cases on which no vertebral collapse occur neither neurological deficit, radiation therapy and external support are suggested. Surgery is necessary on case of severe bone destruction, collapse with or without subsequent neurological impairment. Anterior excision is considered the best approach, sometimes complemented by posterior stabilisation.

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.

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.

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.

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.

Osteoid osteoma of the upper limb: case report

The authors present the features and discuss the characteristics and the distribution of osteoid osteoma (O.O.) of the upper limb. The importance of this study pertains to the rare incidence at this site, and the variability of the symptomatology. The surgical management is described with particular reference to the choice and the indications for treatment. The rare incidence of osteoid osteoma at this site brings aut the need not only for very accurate diagnostic investigation requiring routine radiology and scintigraphy, but most paticularly computed tomography. The latter is required not only to identify and define the lesion, but also to plan the surgical approach. The authors report six cases in which as a result of early diagnosis they were successful in total eredication of the lesion resulting in definitive cure in each case.

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.

[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.

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.

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.

Clinical and radiographic long term results of acetabular fractures associated with dislocations of the hip

The authors carried out a long term review of 246 cases of fracture dislocation of the hip, based on a new classification of these injuries into six types. The average follow-up was 10 years (minimum 4 years). The review was aimed at ascertaining and comparing the clinical and radiographic results in each group in relation to type of treatment, age, sex, quality of reduction and time to weight-bearing. The survey revealed discrepancies between the clinical and radiographic results that underlined the essential difference between idiopathic osteoarthritis and post-traumatic arthritis. The most important factor in reducing the incidence of ischaemic necrosis was reduction of the dislocation within 24 hours. Arthritis was more dependent on the quality of reduction than on the method of treatment used to achieve it, and was also less frequent when weight-bearing had been delayed for 60 days. The overall results were better in younger subjects.

Fat embolism as a cause of idiopathic necrosis of the head of the femur. Review of forty five cases of post traumatic fat embolism

It has been postulated in recent years that idiopathic necrosis of the head of the femur may possibly be caused by arteriolar obstruction by fat emboli emanating from a fatty liver, which would act as a reservoir, due to various causes such as alcoholism and prolonged steroid therapy. A similar situation has been found in human pathology in post traumatic fat embolism. The writers have reviewed forty five cases of post traumatic fat embolism which had passed the pulmonary filter. All the cases were reviewed after a minimum of two years, since this is considered the minimum time within which necrosis can manifest itself radiologically. In none of these cases was there any evidence of necrosis of the head of the femur. These findings, supported by other critical considerations. do not lend support to the theory of fat embolism as a case of idiopathic bone necrosis.