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There is still controversy among urologists on the best treatment for ureteric pelvic stones. Recent advances in ureteroscopy with new methods of stone fragmentation (laser, electrohydraulic and ballistic lithotripsy) and current availability of small semirigid and flexible ureteroscopes have made this procedure rapid, easy and safe. Similarly, improvement in ESWL technology has also facilitated identification and treatment of stones above the iliac bone ring. In just over eight years (3/'88 - 6/'96)we treated 355 ureteral pelvic stones. The first approach was ESWL in 252 cases (by Dornier HM3 in 176, Dornier MPL 9000 in 42, Piezolith Wolf 2300 in 39 and EM plus Dormia basket in 15), ureteroscopy in 38 (by electrohydraulic) lithotripsy in 31, ultrasound lithotripsy in 5 and Lithoclast in 2) and litholapaxy by Dormia basket in 58. The overall stone-free rate was 75.5%, 95.3% and 84.5% respectively. The second line of treatment in unsuccessful cases was ULL or Dormia basket extraction and ESWL in 7 cases only. The overall success rate was 100%. Only 3 patients underwent open surgery (0.7%). There were 5 cases of ureteral perforation during ULL, which did not require surgical repair. No major complications occurred with either ESWL or Dormia basket procedures. We consider in-situ ultrasound-guided ESWL as first choice in managing ureteral pelvic stones, as the procedure is rapid, safe and technically simple. Ureteroscopy is a salvage procedure after ESWL failure. Endoscopic removal by Dormia basket is still a safe, effective procedure for small stones.

Between May 1991 and October 1993, 16 male patients with bladder neoplasms underwent surgical hemiKock's technique of continent urinary reservoir: 7 patients were staged T1, 4 patients were T2, 3 patients were T3 and 2 patients were T4. 5 patients underwent neo-adjuvant M-VAC chemotherapy before surgery, 2 patients underwent radiotherapy and 2 patients underwent adjuvant chemotherapy after surgery. Demolition of the bladder, prostate and seminal vesicles was made by both an ascending and descending manoeuvre, and was sectioned just below the veru montanum to spare the external urinary sphincter. In 7 patients we followed Walsh's technique to spare neurovascular bundles. 60 to 62 cm of small intestine was selected for reservoir construction, stopping 20-30 cm before the ileo-cecal valve. Particular care was adopted for construction of the antireflux nipple valve; uretero-ileal anastomosis was made following Wallace's technique. Mean term of surgery was 6 hours. Sovrapubic cystostomy was removed after 8 days, and urethral catheter after 21 days. After a mean follow up of 3-30 months our results are the following: 2 patients deceased for a pelvic relapse and general metastasis. In one patient we had a neoplastic relapse just on the ileo-urethral anastomosis, so permanent catheterism was necessary.

Between August 1992 and June 1993, 6 high surgical risk patients affected by prostatic cancer with serious irritative symptoms underwent prostatic transrectal hyperthermia (one application of 60 minutes twice a week for 5 times). Transrectal hyperthermic treatment showed good results in subjective symptomatology with rated changes in urinary flow, but without any change in the progression of the disease. Best results may be obtained in association with radiotherapy or chemotherapy.

Intraoperative autotransfusion is the ideal method for restoring blood loss during surgical procedures. In the last few years the confirmation of damage due to transfusion of stored blood, plus risingcosts, led to a revaluation of this procedure. From March 1990 to December 1991, 18 patients underwent intraoperative autotransfusion during radical prostatectomy for carcinoma stage B, utilizing a Dideco Autotrans BT 795 processor. Recovered blood was washed by physiological solution, centrifuged and filtered for air bubble and aggregate elimination, then reinfused. Average recovered blood rate was 853 ml (640-1087), the retransfused rate was 557 ml (410-727). Preoperative Ht rate was between 38.6% and 42.7% (average 40.8%); in the immediate post operative period (4–6 hours after procedure) Ht rate was between 34.3% and 38.6% (average 36.8%). No stored blood was required. We propose a wider utilization of this procedure for safety and lower cost.

Percutaneous debulking and subsequent ESWL treatment has proved a successful approach to complex stones. Out of 232 patients treated with PCNL from March 1984 to March 1992, 102 (45%) were managed by PCNL debulking and ESWL or EPL (Extracorporeal piezoelectric lithotripsy). Recently (Zingonia period 1988–1992) only 21 patients with bulky or staghorn stones were treated by combination therapy. In our series, there were 1.3 sessions of PCNL and 1.8 sessions of ESWL for each patient. We report a high frequency of retained stone fragments (45% at 3 months follow-up). Out of 21, 3 patients underwent further ESWL procedures because the fragments were conglobed. No complications occurred in present series. In the one case we observed a rise in serum creatinine. In our opinion debulking PCNL and ESWL is the treatment of choice in the following cases: burden pyelitic stones, staghorn stones larger than 3 cm. and smaller than 5 cm., partial staghorn filling renal pelvis and 1 calyx; short length of calyces; pyelitic portion exceeding caliceal mass; infected stones in working kidney, stone in solitary kidney larger than 2 cm and hard; previous surgery.

During the last year we have observed 57 patients aged over 70 years, affected by infiltrating bladder carcinoma. Cystectomy prevents haemorrhagic, septic and obstructive complications of the neoplastic bladder, with a better quality of life, but, except in the initial stages, is probably not able to heal the patient. Cystectomy is however the most effective therapeutic option and with an adequate preparation it is possible to operate elderly patients without serious complications.

In this study we present our experience in extracorporeal lithotripsy using a third generation lithotripter with ultrasound localization system and tubeless shock wave coupling as in the Dornier MPL 9000. The aim was to evaluate the efficacy, range of indications and tolerance in 110 patients treated in 1990–1991. No side effects were observed. Success rate was 76% for renal stones, 70% for ureteral stones. Pain free ESWL was possibile on generator voltage (14–17) which is used in the majority of our cases.