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Objectives: To determine whether there are differences in sperm parameters improvement after different varicocele correction techniques. To determine the role of age in sperm parameters improvement., Methods: 2 different European centers collected pre- and postoperative sperm parameters of patients undergoing varicocele correction. Among 463 evaluated patients, 367 were included. Patients were divided in procedure-related and age-related groups. Ivanissevich inguinal open surgical procedure (OS), lymphatic-sparing laparoscopic approach (LSL) and retrograde percutaneous transfemoral sclerotization (RPS) were performed. As outcome measurements sperm count (millions/mL, SC) and percentage of mobile sperms were analyzed. Univariate and multivariate regression between the defined groups; bivariate regression analysis between age and sperm count and motility., Results: Number of patients: OS 78; LSL 85; RPS 204. Mean age 30.2 (SD 6.83); postoperative SC increased from 18.2 to 30.1 (CI 95% 27.3-32.9; p < 0,001); motility from 25.6 to 32.56% (30.9-34.2; p < 0.001). OS: SC varied from 16.9 to 18.2 (p < 0.001); sperm motility from 29% to 33% (p < 0.001). LSL: SC from 15.5 to 17.2 (p < 0.001); motility from 27 to 31% (p < 0.001). RPS: SC from 18.9 to 36.2 (p < 0.001); motility from 24% to 32% (p < 0.001). Univariate and multivariate analysis confirmed the significant difference of SC variation in RPS, compared to the other groups (p < 0.001). No significance between LSL and OS (p = 0.826). No significant differences regarding motility (p = 0.8)., Conclusions: Varicocele correction is confirmed useful in improving sperm parameters; sclerotization technique leads to a better sperm improvement compared to other studied procedures; improvement in seminal parameters is not affected by age of the patients treated.

Objective: This study aimed to evaluate laparoscopic dismembered pyeloplasty compared with open surgery and to determine whether the morbidity and outcome rates are different in each of these techniques. We report our 10-year experience with open and laparoscopic pyeloplasty at one istitution., Methods: From February 1999 to October 2010, 49 patients with ureteropelvic junction obstruction were assigned into two groups. 25 patients underwent open surgical pyeloplasty (period 1999-2010) and 24 underwent laparoscopic pyeloplasty (period 2004-2010). 25 patients undergoing open pyeloplasty had a retroperitoneal flank approach. Of the 24 laparoscopic cases 18 had a transperitoneal retrocolic access, 1 had a transperitoneal transmesocolic access and 5 had a retroperitoneal access. In all 49 cases an Anderson-Hynes dismembered pyeloplasty was used. We retrospectively compared the operative time, hospital stay, perioperative complications and follow-up of the two groups. Clinical symptoms were assessed before and after surgery, subjectively., Results: Patients dermographic data were similar between the two groups with mean age of 42 years (range 6-78) and with a male/female ratio of 1:1.45. A crossing vessel could be identified in 37.5% (9/24) with laparoscopy vs. 32% (8/25) in open surgery. Compared with open procedures, laparoscopic procedures were associated with a longer mean operating time (274 vs 143 min), a shorter mean hospital stay (9.9 vs 15.8 day) and the perioperative complication rates were 16.7% for laparoscopic pyeloplasties and 20% for open pyeloplasties. The success rates were 90.5% for laparoscopy and 90.9% for open surgery. Average follow-up was 40.9 month for the laparoscopic group and 72.3 month for the open group. Failed procedures showed no improvement in loin pain or obstruction., Conclusions: The efficacy (in term of success rate and perioperative complications) of laparoscopic pyeloplasty is comparable to that of open pyeloplasty, with shorter mean hospital stay and better cosmetic results. These findings may suggest, that the laparoscopic dismembered pyeloplasty has the potential to replace open surgery and may be considered the first option for the treatment of ureteropelvic junction obstruction in expert hands.

Objective: We evaluated the impact of removal of the tumour bearing testis on semen quality in men with testicular cancer and the effect of tumour histologic feature on semen quality., Material and Methods: We took into account the semen analysis before and after orchiectomy in 30 patients., Results: The median sperm concentration before and after orchiectomy was respectively of 26.7 x 10(6)/ml (range: 0-120 x 10(6)/ml) and 16.6 x 10(6)/ml (range: 0-75 x 10(6)/ml) (p = 0.001). Median sperm concentration before and after surgery in patients affected by seminomatous cancer were respectively of 35.47 x 10(6)/ml and 23.99 x 10(6)/ml, while cases of non-seminomatous cancer were respectively of 17.9 x 10(6)/ml and 8.16 x 10(6)/ml., Conclusions: Semen quality at the diagnosis was poorer in patients affected by non-seminomatous testicular cancer. Sperm concentration deteriorated after orchiectomy. Our findings suggest that the most appropriate time for cryopreservation of semen is before orchiectomy.

The early detection of prostatic neoplasm is nowadays a primary need in the urological field. The availability of transrectal ultrasound equipment alongside with bioptic tools made possible that transrectal ultrasound-guided biopsy of the prostate became the standard procedure to achieve this goal. With this work we would like to confirm the efficacy of this method which is also associated with a good tolerance and low complications rate. 82 patients that came to our Department between 1997 and 1999 were submitted to this procedure, 25 resulted positive for prostatic adenocarcinoma. Only 2 of them did not tolerate the procedure while all the others referred only mild discomfort at the moment of the puncture; 9 patients afterwards had to be admitted to the hospital due to fever (1 patient), acute retention of urine (3 patients) and persistent macroscopic hematuria (5 patients). Transrectal ultrasound-guided biopsy of the prostate reveals to be a safe and accurate method to obtain tissue samples of the prostate along with high tolerance and low incidence of serious complications.

The authors describe a case of renal metastasis from chondrosarcoma originating from the rib, with acute clinical onset characterised by serious anaemia secondary to retroperitoneal perineal haemorrhage. No similar cases have been reported in the literature. The interest of this case lies in both the symptoms of onset and in the metastatic site. From a diagnostic point of view an intraoperative ultrasound scan was useful, revealing the presence of a roundish neoformation, irregularly hypogenic, with a different appearance from anything observed by the authors in the other intraoperative ultrasound examinations of renal masses.

Prostatic cysts are rare; they are to be considered in the evaluation of obstructive azoospermia. A correct diagnosis is based on transrectal ultrasound of the prostate. Herein we describe our experience with perineal ultrasound cyst aspiration. During the last 10 years, 21 infertile patients underwent ultrasound puncture of an intraprostatic cyst. Patients were placed in the lithotomy position, a 16 G needle was adopted; by means of ultrasound was possible to follow the needle entering the cyst. The content was aspirated and, if no spermatozoa were detected in the cystic liquid, sclerosing agents were introduced. The technique was performed successfully in all patients with symptomatic cyst within the prostate. Follow-up prostatic ultrasound and semen analysis were performed in 17 patients. There was 1 recurrence that was aspirated again. In 12 cases an increase in sperms number and motility was obtained, in 3 cases oligoastenospermia remained unchanged and 2 patients are still azoospermic. In 3 cases the partners become pregnant.

All the concepts and principles commonly espoused in plastic surgery are very useful in urologic reconstructive operations too. Hypospadia's repair, neo-bladder reconstruction, microsurgery of the seminal way require as certain rules as an absolute respect for anatomy, sparing of the finest tissue vascularization and tension free sutures. Pedicled skin flaps harvesting and utilisation are techniques typical of plastic surgery but are also largely used in urologic adult and paediatric surgery. They are adopted for urethral, penile and corpora cavernosa reconstruction. Pedicled flaps are utilised for the closure of large skin defect in case of complicated wound or when an urinary fistula is present, especially after radiotherapy. A perfect knowledge of the flap nourishment and of the method of harvesting is crucial if the best results must be obtained. In our work we describe the surgical technique for the utilisation of gracilis muscle and forearm flap. Special care is taken to the anatomical description.

The aim of this prospective clinical trial was to compare the efficacy of rufloxacin, a once-daily fluoroquinolone administered as a single pre-operative dose versus the perioperative prophylaxis with ciprofloxacin in transurethral surgery. Two hundred and two patients undergoing transurethral resection of bladder tumors (132) or transurethral resection of the prostate (70) were selected for the study between January 1997 and June 1998. Patients were randomized to two treatment groups. Group A received a single oral 200 mg dose of rufloxacin three hours before surgery and group B was administered oral ciprofloxacin 250 mg bid until catheter removal. The two treatment groups were homogeneous with respect to patient characteristics. One hundred and seventy-three patients (89 rufloxacin and 84 ciprofloxacin) were assessed and 29 were excluded from the statistical analysis. The incidence of postoperative infection was similar in both treatment groups (5.7% rufloxacin, 4.7% ciprofloxacin). On the other hand, single-dose pre-operative prophylaxis with rufloxacin significantly reduced the cost of antibiotic prophylaxis. Results of the present study show that single dose oral rufloxacin may be used in routine clinical practice as a preoperative prophylactic antibiotic due to its low cost, its documented efficacy and its simple once daily dosage regimen.

Among the usual indications of intraoperative ultrasounds, we describe four infrequent applications that show how useful and powerful this technique could be for interventive urologists. The first case regards a 66 years old male who was affected by a renal metastasis from thoracic cage chondrosarcoma. The use of intraoperative ultrasounds permits to highlight atypical sonographic features of the secondary lesion that were not seen in preoperative radiologic exams and that are completely different from the usual renal lesions. The second case regards the treatment of prostatic abscess performed by echoguided transperineal puncture in which the use of transrectal ultrasound probe permits a precise and correct placement of the needle and the drainage in order to obtain a fast relief of the symptomatology. The third case shows the role of intraoperative ultrasounds in the localization of a parathyroid adenoma in a 52 years old male affected by primary hyperparathyroidism and with recurrent renal colics. In this case the blind surgical exploration of the parathyroid gland and so the possibility of iatrogenic lesions to the recurrent laryngeal nerve were avoided by the use of the intraoperative sonography for the identification of the adenoma. At the same time the operation times were reduced. The last case underlines the importance of using intraoperative ultrasounds in the real-time monitoring for the creation of the neovagina in sex reassignment surgery in male-to-female transexualism in order to avoid a dangerous postoperative complication represented by the iatrogenic lesion of the rectum during the dissection of the perineal region.

Endometriosis is relatively frequent in females of menstrual age and consists in the appearance of active endometrial tissue at site other than uterine cavity. Endometrial tissue has been described to colonise the urinary system, particularly the urinary bladder. The most common clinical features of vesical endometriosis are urgency and frequency, hypogastric pain and hematuria. We report on a case of vesical endometriosis whose presenting features were dysmenorrhea, stranguria and pelvic pain. MRI and CT did not provide different or more precise information than ultrasound scan: these findings were indistinguishable from an intrauterine lesion. On the contrary endovaginal sonography was more sensitivity than MRI and CT. Cystoscopy was negative. Nondiagnostic laparoscopy was performed. Patient underwent laparotomy and partial cystectomy. Histopatological findings demonstrated an endometriosis of the muscle layer of the bladder. The rarity of this condition prompted us to report on the problems encountered in making the differential diagnosis.

Large cell calcifying Sertoli cell tumor of the testis is an extremely rare type of sex cord tumor with low malignant potential that occurs in the first and second ecades of life. Twenty-eight cases have been reported in the literature and, to our knowledge, only 2 had an aggressive behaviour. Patient age, tumor size, histological malignant patterns such as pleomorphism and high mitotic rate seem to heavy influence the future neoplasm malignancy. Ultrasonography imaging of the large cell calcifying has described in only 6 cases. We report an experience with a large cell calcifying Seroli cell tumor of the testis and point out the unusual sonographic findings. Moreover, if histologic examination suggests no malignant features, we suggest local excision as ideal therapy for the preservation of testicular parenchyma.

Varicocele, which is the most common cause of infertility in man, is detected by means physical examination and color Doppler sonography. We analyzed the results of percutaneous sclerotherapy of the spermatic veins in 76 out of 103 patients with varicocele: antegrade sclerotherapy was performed in 11 patients while 92 men underwent retrograde scleroembolization. Color Doppler sonography was performed one month later and showed persistence of varicocele in 3 patients who underwent retrograde sclerotherapy. Retrograde percutaneous sclerotherapy of the spermatic vein represents, in our opinion, the gold standard in the treatment of primitive and recurrent left varicocele, because of its efficacy and minimal invasive nature. Antegrade sclerotherapy is an effective alternative treatment when retrograde access is not possible.

The Authors report on their specific experience on the funicular Doppler veocimetry, regarding the varicocele. In particular we enhance the semeiological spects of the C.W. Doppler velocimetry in the sub-clinical varicocele, in the bilateral one and in the characterization of the spermatic and cremasteric refluxes, and of the external pudenda vein. The Authors stress the utility of the definition of the amount of the reflux, so achieving an integration with the existing classification by degrees, that as it is now days expressed, it seems, to regard the elapsed time and the quantity of reflux caused by the Valsalva manoeuvre. In the practical velocimetry those elements have not been proved to have a parallel increment. Lastly, we report on some cases of veno-spermatic refluxes, uniquely observed in the clynostatism, along with a missing orthostatism. Moreover the Authors believe that some of these hemodynamical consideration could be revisited.

Bladder voiding implies activation of mictional reflex. The coordination of the latter is strictly dependent on center of miction situated in encephalo. The interruption of the nervous fibers linking pons with center of miction situated in sacral spinal cord causes the appearance of vesico-sphincter dyssynergia. On the contrary, the interruption of the fibers localized above the opns causes the loss of the voluntary control of miction. Finally the lesion of sacral spinal cord or of the nervous fibers connected with it is responsible for the appearance of detrusor areflexia with reduction of the smooth sphincter activity and paralysis of the striated one.

Diuretic ultrasound, described in Literature in the seventies from Rosenfield, is an effective technique if compared with the functional urodynamic study and the diuretic renography evaluation for the assessment of upper urinary tract obstruction. In our study we have compared the effectiveness of diuretic ultrasound with diuretic intravenous urography in the evaluation of obstructive pathology of ureteropelvic junction. The technique was performed on 47 patients 11 of whom were pediatrics making a total of 94 renoureteric units. Results show high sensibility of this technique either with severe obstructions (94%) or moderate obstructions (96%).

The employment of ultrasonography in urology is not well established yet. On this purpose a survey of present situation in different medical setting was conducted. 200 questionnaires were filled by about 1000 physicians operating in various medical centers. The most of answers was provided by assistant head physicians (41%) and head physicians (30%), with a clear prevalence of urologists (64%) and nephrologists (32%). The number of beds reported by each centers ranged from 0 to 90, while the average doctor-patient ratio was 3.6. 72% he centers could avail of B-mode echography (22% of them owned an echo-Doppler velocimeter). The data obtained reveal the great heterogenety of present medical system and the necessity of finding a correct equilibrium between specialistic and primary care settings. It can be concluded that the correct use of ultrasonography depends both on good knowledge of its real indications and on the proper professional training of the echografist.

Stress urinary incontinence (SUI) is called as the involuntary loss of urine without the presence of detrusor contraction with bladder pressure that is higher than maximum urethral pressure. The SUI may be caused either by hypermobility of urethra or by inefficacious intrinsic urethral sphincter activity. It is clear that female urinary continence is established by the balance of opposed forces in the pelvis. The elements that contribute to the maintenance of continence are: 1) maximum urethral closure pressure; 2) anatomical and functional length of urethra; 3) ability of perineum to increase the urethral pressure simultaneously with the Valsalva's manoeuvre; 4) appropriate localization of the sphincteric unit. The alteration of the above-mentioned elements may be caused from no functionally of pubo-urethral ligaments and the laxity of cardinal ligaments and of pubic-cervical fascia.

It's known that benign prostatic hypertrophy arise from the glands that surround the proximal prostatic urethra. In these cases voiding disorders may be due by detrusor instability alone or associated with cervical urethral obstruction. At first Griffiths and Schafer and subsequently Sarky have introduced some correlations that are able to differentiate the bladder outlet obstruction from the impaired detrusor contractility. On the contrary with regard to the behaviour of detrusor during obstruction, in connection with histological findings, several interpretations have been expressed. The theory more credited has been expressed by Gosling who has showed a reduction of the parasympathetic innervation of detrusor and consequent hypersensitivity due to denervation.

The impossibility to palpate organs and tissues is probably the most important drawback of the laparoscopic approach: laparoscopic sonography represent the only real alternative to manual palpation. The laparoscopic approach in the field of urology was initially limited to the identification of the undescended testes in paediatric urology and to the laparoscopic ligation of varicocele. More recently, it took into account the pelvic lymphadenectomy for staging prostatic and bladder cancer. The upper urinary tract and the retroperitoneum were approached more recently. In a preliminary phase the indications for laparoscopic nephrectomy were limited to benign diseases, such as atrophic kidney in patients with renal hypertension, and scarred pyelonephritic kidney. At present some preliminary experiences are reported about nephrectomy performed for carcinoma of the urether or of the upper collecting system and for renal masses of unknown origin. Another indication for a laparoscopic approach to the kidney is represented by symptomatic renal cysts. These cysts have been usually treated with percutaneous aspiration and/or sclerosis, but a high rate of recurrence is reported. Laparoscopy may be used to approach renal cysts with the advantage that most of the cystic wall could be excised, reducing the change of recurrence. Another possible indication for laparoscopy and laparoscopic sonography is the retroperitoneal lymphadenectomy in testes cancer with staging or therapeutic purposes. Nowadays preliminary experiences in laparoscopic adrenalectomy have been reported in a limited series of cases. In this report the Authors present their initial experience using a 7.5 MHz rigid probe having 400 crystal which can be inserted into a 10 mm trocar.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative ultrasound localization of the non palpable testicular lesions allows to detect small gonadal tumors or to well study benign testicular masses. Several methods have been proposed to study non palpable testicular masses including CT and NMR. Prospective studies of the efficacy of CT vs spermatic venography in localization of cryptorchid testes have also been reported: spermatic venography proved to be the most accurate of the two modalities even if possible neoplastic degeneration of testicular tissue is very difficult to investigate with this method. Herein we describe our clinical experience and particularly four cases in which we adopted intraoperative ultrasonography of testes with different results. M.S. a 28 year old infertile patient underwent testicular ultrasound during a check-up and a little image localized at the level of right testis was found. Even if no mass was palpable we decided to operate on the patient; an intraoperative testicular ultrasound revealed the precise localization so that the little mass was excised and examined at once. Histologic study confirmed the presence of tumoral tissue and orchiectomy was performed: deeper hystological studies confirmed it was a leydigioma. D.C. 27 year old bilaterally cryptorchid patient had been already operated on twice but no testicular structure was encountered at the level of inguinal channels. Neither preoperative abdominal ultrasound nor CT revealed the presence of the testes. At abdominal exploration both testes were localized in the iliac region. Intraoperative testicular ultrasound allowed us to localize a right testicular tumor: right orchiectomy and left autotransplantation were performed.(ABSTRACT TRUNCATED AT 250 WORDS)

Several Authors have discussed the long term efficacy of sclerotherapy; somebody supposes that percutaneous angiographic treatment of spermatic vein is not sure at all because the occlusion due to the sclerosing agents is not retained as long lasting. Studies have been done by other Authors about comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion: it is concluded that venous collaterals are identified easily by renal venography, and knowledge of these collaterals is helpful in planning further radiological treatment. Since 1980 we have always treated left varicocele by means of percutaneous sclerotherapy of the spermatic veins following renal phlebography: the treatment is done on an outpatient basis, in local anaesthesia. Sclerosing agents we usually adopt are: sodium-tetradecyl sulphate and alcohol. At our knowledge long-term results of this treatment have never been published; this is the reason for which long-term follow-up of 27 patients that 6 years ago underwent percutaneous sclerotherapy was done. Only 16 of them have accepted to repeat: a) physical examination; b) Doppler flowmetry; c) scrotal ultrasound. The presence of a varicocele was demonstrated in 2 out of 16 patients (12.5% of the case). These data confirms that percutaneous treatment performed following the procedures we adopted in 1986 has a long term efficacy in 87.5% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

The occurrence of an obstruction of the ejaculatory ducts, in spite of its rarity, must be considered by the Urologists in the screening of the etiologic causes of obstructive azoospermia. Nowadays, the diagnostic approach, which includes the biochemical study of seminal plasma and prostatic ultrasound, often leads to the preoperative recognition of the site of obstruction. Various surgical and endoscopic techniques have been adopted for the treatment of ejaculatory duct obstructions in different historical periods. Herein we describe our experience that starts from 1979. 17 infertile patients with intraprostatic cysts and 2 with a stenosis of the veru montanum were treated by us following these criteria: 9 azoospermic patients underwent scrototomy and endoscopy; 10 patients with a severe oligozoospermia underwent echo-guided puncture of an intraprostatic cyst. The patients were placed in the lithotomy position, a 16 G needle was adopted and by means ultrasound was possible to follow the needle entering the cyst. When no spermatozoa was detected in the cystic liquid, sclerosing agents (Sodium-tetradecyl-sulphate 30 mg in 1 l.) was introduced. This easy procedure was carried out on outpatients in local anaesthesia. One out of ten oligozoospermic patients had to repeat the echo-guided puncture of intraprostatic cyst as the first attempt had been followed by recurrence. Eight out of ten subfertile patients who had undergone percutaneous echo-guided treatment had longer than 1 year follow-up: in seven cases an increase in sperms number and motility was obtained; in one case sperm count remained unmodified. In three cases the partners became pregnant.