Intramedullary epidermoid cyst presenting with abnormal urological manifestations

STUDY DESIGN

Report of an epidermoid cyst with intramedullary localization.

OBJECTIVE

To describe an atypical presentation of intramedullary epidermoid cyst.

SUMMARY OF BACKGROUND DATA

Intramedullary epidermoid cysts are rare entities with a marked variability in the clinical presentation, essentially of neurological pertinence.

METHODS

Case report of a spinal epidermoid cyst in a 13-year-old girl presenting with urological symptoms: she had a 12-month history of recurrent low urinary tract infections, urinary frequency and nocturnal enuresis. A urodynamic evaluation was performed and showed the presence of involuntary bladder contractions with detrusor instability and low bladder compliance. Magnetic resonance imaging of the spine demonstrated an intramedullary lesion of the dorsal spinal cord.

RESULTS

The mass was excised and 6 months after surgical excision, urological manifestations improved with decreased detrusor hyper-reflexia, increased bladder capacity and compliance and no later report of urinary tract infections.

CONCLUSIONS

In our patient, unusual clinical manifestations of the tumor have delayed the diagnosis, but its complete removal has led to remission of symptoms. Detailed neurological examination and investigations are indicated in patients with clinical and urodynamic features, suggestive of neuropathic bladder.

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.

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.

Valsalva leak point pressure: how to chose the best method

Urinary continence is ensured as long as the urethral closure pressure remains greater than the intravesical pressure, in the presence of adequate support to the bladder and the proximal urethra. In order to select the appropriate surgical treatment, a correct diagnosis must be made; recently urodynamic evaluation has assumed a central role. In particular, the introduction of a new urodynamic parameter, the Valsalva Leak Point Pressure (VLPP), has provided new impetus to research in this area, even if different technical approaches have limited universal acceptance. The aim of the work is to describe the reasons why the authors have been led to prefer double measurement, both at partial filling and at maximum cystometric capacity, considering that this does not involve any additional economic burden. The authors underline the promising potential of the method, once standardized, in the urodynamic evaluation of urinary incontinence.

Unilateral testicular microlithiasis

Testicular microlithiasis is a rare pathology which usually affects both testicles (less than 100 cases have been described in the literature), histologically characterized by numerous calcified deposits situated inside the seminiferous tubules, the diameter of which does not usually exceed 2 mm. The pathogenesis of the phenomenon is not completely clear; it has however been noted that there is a higher incidence in patients affected by cryptorchidism, subfertility, Klinefelter's syndrome and in particular those with testicular neoplasms, although the reason for this remains obscure. The case reported seems atypical in that there is no association with the conditions mentioned above and the finding is monolateral, something which is unusual in the literature reviewed.

Urethral Diverticulum in Women with Neurologic Bladder

Female urethral diverticulum is a rather rare pathology, often ignored, which affects from 1 to 4% of the white population. In this study we report our series, limited to a selected population of women affected by neurologic bladder (6 paraplegic patients; 2 patients with multiple sclerosis) who were referred to our Urosurgical Unit within the space of four years. The diagnostic work-up relevant to these patients is discussed, together with the therapeutic strategies carried out and the long-term results obtained.

[Therapy of vasomotor syndrome in the treatment of advanced prostatic cancer: apropos of 37 cases]

Castration, whether surgical (orchiectomy) or pharmacological (androgen blockade), used in the management of advanced prostatic carcinoma, induces as a secondary effect, immediately following impotence, the onset of a vasomotor syndrome characterized by hot flushes and sweating. This syndrome which may present with such intensity and frequency as to severely affect the quality of life and even the psychological equilibrium of the patient. Treatment with progestinic agents leads to the release of opioid peptides at hypothalamic level, thus decreasing the level of catecholamines responsible for the vasomotor syndrome. In the 37 cases treated with progestogens, a therapeutic efficacy of 80% was observed following cyproterone acetate and of 70% following medroxyprogesterone acetate.

Therapy Suggested in the Treatment of 94 Cases of Vesico-Ureteral Reflux in Neurologic Bladder after a Traumatic Spinal Cord Lesion

The Authors present their experience in the treatment of vesico-ureteral reflux in 623 patients, admitted to the “A. Gemelli” Hospital from 1976 to 1995, with neurologic bladder due to traumatic spinal cord lesion. Ninety-four patients with medium-high level reflux were treated; in 71 cases, the reflux was bilateral. The various therapies practised and the medium-long term results achieved are given.

The ice-water test in the diagnosis and treatment of the neurogenic bladder

OBJECTIVE

To determine the usefulness of the ice-water test (IWT) in the diagnosis and treatment of neurological bladder disease.

PATIENTS AND METHODS

The IWT was carried out in 148 patients with neuropathic bladder dysfunction resulting from a traumatic lesion, to assist in their diagnosis and treatment, and in 130 patients with neuropathic bladder dysfunction and multiple pathogenic disorders; the results of the IWT were used to classify those patients with hyperactive bladders.

RESULTS

The IWT was positive in 95% of patients affected by complete and in 86% of patients with incomplete medullary lesions. The IWT in patients with lower motor neuron medullary lesions was always negative. The test was used diagnostically in all patients with lower and in 43% of those with upper motor neuron lesions. In the latter, it was used in 48% of patients as a rehabilitation method during the medullary-shock phase to accelerate the appearance of the micturition reflex. In 9% of patients it was used to induce micturition during cystography.

CONCLUSION

Because it is simple to perform, the IWT is a useful complement to urodynamic examinations in patients with neurological bladder disease and in patients with micturitional disorders that are otherwise difficult to interpret.

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 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.

Validity of Ice Water Test in Diagnosis and Treatment of Neurogenic Bladders

After having illustrated the physiopathological basis of the micturition reflex to cold water (a reflex tied to specific receptors and carried by type C unmyelinated fibres) the Authors report the results in the diagnosis and treatment of neurological bladder. The Ice Water Test (IWT) was carried out on 148 patients with neurological bladder resulting from traumatic lesion for diagnostic and treatment purposes and in 130 patients with neurological bladder and multiple pathogenic disorders for diagnosis and treatment and to classify hyperactive bladders. The IWT served as an aid in performing cystographic exams in 24 patients with neurological bladder. In normal control subjects the test results are always negative. Because it is simple to perform, it is considered to be a useful complement to every urodynamic examination in patients with neurological bladder or when there is difficulty in interpreting micturitional disorders.

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.