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The Authors analyze the more frequent uro-andrological pathologies correlated with male infertility and consider the causes of impoverishment in semen in industrialized countries. They analyze preventing possibilities to maintain the normal physiological level of fertility in young male in various uro-andrological pathologies.

In our clinical practice we encountered urgency-frequency syndrome in female patients. Only in the 3.6% is possible to diagnose a typical interstitial cystitis (IC). In the 63.6% we observed only local trigonal squamous metaplasia (leucoplasia), it could be considered a paraphysiological condition present in 50-70% of fertile women, its rigid, not impermeable epithelium may offer an aethiological hypotesis for the dysuric syndrome. In the treatment of this lesion by endoscopic infiltration we had syntomatological results with 47.8% of patients even if only for a short period (one-two years). This treatment is simple and can be repeated, if the patient is responsive. We noticed that the results did not change even if we used different drugs probably due to the role of a physical detachment of leucoplasia from bladder trigon.

Penile acquired curvatures are related to the effects of the evolution of Peyronie's disease or to the results of conservative treatments. All the others (post-traumatic, post surgical) are quite rare and often therapeutically similar. More than 50% of penile acquired curvatures can today take advantage from pharmacophysical managements thanks to the technological progresses of industry and of the personal experience (cavernopharmacoperfusion) both being clinically suitable application for the effective results: more than 60% of stop in progression with decrease of the recurvatum enough to resume comfortable sexual intercourse. Last, when erectile failure is present, we suggest prosthesis implant preferring flexible-malleable device such as AMS 600. More recently we started an effective experience with the new silicone elastomers of Subrini (Virilis II). Both implants never required complementary surgery of the plaque to achieve straightening and sexual activity of satisfactory level.

Incontinence isn't itself a disease but the feature of possible urinary tract alterations or outside of it. Incontinence is frequent above all in the elderly but it can be on charge of both sexes at every age. In Italy, according to recent evaluations, people affected with this disease would be more than 4 millions. Incontinence is therefore an important failure for its health aspects but also for economic and social ones. The problem is to evaluate if incontinence can't be prevented and as consequence needs only an assistance management, or it can be considered a preventable disease able to be cured, as we deeply believe, suggested also by the positive results of new therapeutical procedures, in association with traditional surgery and rehabilitation such as injectables or mini-invasive quick operations such as colpocleisis or percutaneous vaginal colposuspension (PVC), matters of this presentation and always performed according to correct diagnosis and indication. Bovine dermal collagen highly purified, poorly viscous and easily injectable, despite traditional rehabilitation and surgery, is a further procedure, endoscopic and minimally invasive to treat stress incontinence. Collagen is employed to perform a bladder neck plasty, increasing urethrosphincterial competence, to obtain continence without the creation of an obstruction. Genital prolapse, that is hysterocolpocele or simple vaginal vault prolapse, has course in high proportion (37%) in elderly (after 80 years). Surgical management of severe failures of continence and often also of the voiding function, such as: hyscuria with vesicoureteral reflux, obstinate constipation related to severe genital prolapse with allied rectocele is often hardly performed in elderly owing to the age and general health conditions: colpoclesis is a vaginal surgical approach that can be easily performed by the urologist too, it is an effective alternative to permanent catheterization or maxipad to be offered to the patient to improve her quality of life. In between the above maintained procedures takes place the percutaneous vaginal colposuspension (PVC). It is an original technique made up in our Institute to treat incontinence by the bladder neck resuspension to Cooper ligament according to a complete miniinvasive retropubic tension free transvaginal colposuspension, in local anaesthesia and complementary light narcosis in Day Surgery. Urinary incontinence is today a disturbance easy to be cured thanks to injectables and to miniinvasive surgical procedures as reported in this presentation concerning the most advanced approaches to its management.

Actually scrotal ambulatory surgery represents a necessity for the surgeon because of the more and more greatest request to admittance and because of the impossibility to admit patients with less severe diseases. Ambulatory treatments allows psychological advantage, less discomfort, less hospital complications for the patients and a reduction of sanitary expense. Light general anaesthesia with concomitant administration of local anaesthesia is performed in our Institute. Surgical treatment must be short, with low haemorragic risk, scarcely algogenic and aseptic. Since January 1994 till December 1997, 484 patients underwent scrotal ambulatory surgery in our Institute. We reported one cardiac black and two lypothymia attacks associated with anaesthesia. Therefore combined general anaesthesia results a valid technique but unvoid of complications. Ambulatory surgery for scrotal surgery represents a sure advantage for patients and for the sanitary expense.

Semen analysis is still today a fundamental stage in male fertility diagnosis. In fact it's essential to evaluate didimal functional state and particularly the sperm genesis. But a semen analysis with normal parameters does not assure male fertility. Except the cases of azoospermia it does not distinguishes fertile from infertile patients, but when the sperm quality decrease, the pregnancy rate also decrease but rarely touch zero. Reliability of the analysis depends on the experience and on the analyst's ability who has to give an opinion about fundamental parameters like motility and sperm morphology. It is most correct to talk about semen analysis instead of semen examination because is possible to obtain not only number and quality of spermatozoa but also hormonal, immunological, bacteriological, cytogenetic, biomolecular data. Furthermore in the last ten years a lot of functional tests have been perfected, able to value accurately the integrity of some spermatozoa's "functional compartments" like membrane, acrosoma, DNA, nuclear proteins but these examinations have been considered at level assessment only for select cases. Semen analysis remains therefore a fundamental examinations in the study of male infertility even if rarely it is able to express definitive trials about infertility. In fact this always represents a couple problem, particularly of the couple in study.

Presence of bacteria in the sperm is often associated to a reduction of fertility in relationship with a decrease in number and motility of spermatozoa and with an augmentation of the abnormal spermatic cells. In the most severe cases, chronic and complicated phlogosis may lead to obstruction of seminal pathways with consequent azoospermia. Clinical features of seminal phlogosis are extremely variable both in acute and chronic evolutions. In every case the first diagnostical step is sperm count and seminal complete analysis which can give evidence of phlogistic alteration in quantity and quality of spermatic cells with a typical presence of an excess in white blood cells (leukospermia) as consequence of infection. The great variety in clinical and bacteriological aspects and the particular biological features of the organs involved, as the prostate, makes treatment a difficult problem to solve with particular regard to the choice of an effective antibiotic which pharmacokinetic has to result suitable for the microorganism as well as for the tissue of the infection site. All those efforts are indispensable to reduce the too frequent therapeutical failures in the management of seminal phlogistic pathology with complications of organic but also physiological relevancy for the patient and the partner too, such as azoospermia.

The endoscopic therapy has an elective role in the distal obstructive azoospermia for urogenital carrefour pathologies both organics and functional and differently in the resection and/or aspiration with sperm recovery forms. Resolutely attends to the symptomatology and positively to the fertility re-establishment, in front of a short sickness-rate. The Authors describe the different techniques with relative indications, results and complications. Instead medical therapy has a role in the obstructive above all post infection and post inflammatory lesions prevention. Furthermore propose to oneself the goal to improve the seminal quality by the improvement of the semen fertilization capacity and to reduce the affections symptomatology. Finally concurs with the sperm selection techniques to fertility potential wealth.

Advances in the knowledge of penile haemodynamics make evidence of two fundamental mechanisms in the physiology of erection: 1) arterial vasodilatation; 2) blockage of venous outflow. Therefore peripheric vasculogenic erectile impotence presents two pathogenetic possibilities: 1) from insufficient arterial flow; 2) from increased venous outflow. It is therefore very important to make the correct diagnosis of the patient with erectile disturbances in order to determine an appropriate therapy. The following examinations are routine tests carried out at our Institution: NPT test, basal and dynamic Doppler-sonography, OOE-OME (evaluation of output obtaining and maintenance erection), basic and dynamic cavernosography, digital angiography, dynamic NMR. After an accurate diagnostic assessment medical treatment can begin, based essentially on the cavernous infusion of vasoactive drugs, in light forms; surgery is resorted to severe cases, or in cases of failure of medical therapy. Proposed operations may be divided into 3 groups: 1) arterio-cavernous by-pass; 2) arterio-arterial by-pass; 3) venous surgery. Since 1978 the successive experiences of the Authors in this field and the better knowledge of penile vascular structures have led to a standardization of the methods used, with partly original techniques (epigastro-dorsal antiflow and orthoflow double by-pass), which, with selective application, have raised the percentage of pulsing anastomoses at 18 months of 82%.

The radical surgical option we propose for Peyronie's disease consists in removing the sclero-hyanolitic focus (plaque) and replacing it by an autologous dermal graft taken from the upper outer thigh area. Between 1981 and 1994, we operated 564 patients with Induration penis plastica (IPP), 418 of whom underwent plaque excision and dermal grafting. All could be assessed at two-year follow-up. Two main complications were observed: penile flexure relapse (71 Pts, 17% of cases), and erectile dysfunction with decreased corporal rigidity (84 Pts, 20% of cases). A mild deviation of the penis can occur some months after surgery and it is not due to disease progression (as it should have evolutive characteristics) but is mere scar retraction (44 Pts, 76% of examined relapsed flexures). The degree of this graft retraction is linked to the individual's histologic response and can be due to an idioptic tissular response or to an insufficient size of the patch. In some cases, the post-op penile flexure can result from a progression of disease (14 Pts, 24% of examined relapses flexures) and can be due either to a new "focus" or to an incomplete removal of the previous plaque. As the patient will date the onset of a possible postoperative erectile deficit from the time of the operation, it is advisable to assess preoperatively the real erectile ability of all patients. Furthermore, a post-op impaired erectile response (84 Pts, 20%) could result from a subalbuginear fibrosis of the erectile tissue that leads to a caverno-occlusive dysfunction (60%). In more than 35% of patients we found a psychogenic component, due to post-surgical stress, that involves an adrenergic hypertone with peripherical vasoconstriction. In few cases (4%) the post-op erectile dysfunction is the consequence of peroperative arterial damages that results in hypoaesthesia of the glans (injury of dorsal arteries) or in failure to obtaining corporal rigidity (damage of cavernosal arteries). A review of our experience involving plaque excision and dermal grafting led us to propose this option in case of mechanical disturbance during coitus and when the association of erectile dysfunction can be excluded.

The recent clinical and experimental research innovations in Andrology make possible the following classification of impotence: "Failure to initiate" "Failure to store" "Failure to fill" The last aspect, including veno-occlusive dysfunction, is continuously reevaluated by andrologic studies. The main diagnostic procedure of this complex problem, in constant evolution, is represented by cavernometry. Recently, but with full success, we are utilizing direct radioisotopic penogram in video sexy stimulation: in preselection function but probably in future with substitutive function of the more invasive and traditional cavernometry. In spite of this methodologic progress the findings of cavernometry are in continuous discussion as in tumultuous evolution, in anatomo-physiological environment, is the intracavernous district that, for many aspects, necessity of ulterior histochemical, pharmacodynamic and neurophysiological acknowledgements.

Dynamic cavernosography remains today an important step in diagnosis of veno-occlusive impotence, as support to cavernosometry: cavernosometry facilitate the diagnosis and the evaluation of venous-defect, but a contemporary show-timed cavernosography takes many informations about the site of venous-escape; these date allow to perform a correct selective vein ligation or percutaneous procedures, recently introduced in the clinical practice as an alternative or in association with vein ligation. Static cavernous-spongiosography, instead, has many indications in neoplasms and severe malformations.

After the remark of the own results on an epidemiological research about andropausal sexual problems, the Authors analyze the alterations of ejaculatory mechanism with elderly, focusing frequency and etiopathogenesis. They underline the need of prevention of ejaculatory disturbances deriving from chronic disease or of iatrogenic origin.