Search

Ileal orthotopic neobladder represents, nowadays, the best urinary diversion after cystectomy. Emikock procedure was performed, in our institution, in 26 patients with bladder cancer T2-T4. At 6-60 months of follow-up 3 pts were died with local or at distance neoplastic recurrence, 2 were alive with neoplasms and 21 were NED. Nocturnal continence was good in 22 cases (88%) and only 3 patients were obstructed because of pseudodyssynergia in 2 and stricture in 1. Emikock neobladder even if needs a longer surgical time than other procedure and a long ileal tract is almost free from severe metabolic disorders. This technique offers a good protection of high urinary tract because of antireflux nipple and avoid the uretero-intestinal stricture. It not feasible, now, to know the functional trend of this reservoir on the long term. Adequate postoperative training is recommended to avoid the pseudodyssynergia and functional obstruction of reservoir.

Between 13.8% and 27% of all superficial bladder cancers are represented by pT1G3 neoplasm. In the Department of Urology of Policlinico S. Marco-Zingonia, between February 1988 and June 1994, we treated 22 patients suffering for pT1G3 bladder tumor. TUR-B has demonstrated to be a good approach for treatment of superficial bladder cancer, with low morbility; on the opposite side, we have to underline the high rate of recurrence and of progression of the urothelium disease. Now a day our best approach for the treatment of pT1G3 bladder tumor is represented by radical cystectomy supplied by chemotherapy.

Vacuum therapy is a reversible, non-invasive form of treatment for partial impotence, with great success in USA. The story of vacuum therapy begins about 1960, when Osbon developed a vacuum tumescence device which he personally used for more than 20 years. The device was made commercially available many years ago and has been marketed under several names. The newer systems have incorporated a negative pressure pump to achieve vacuum. Osbon's system was patented in 1983, sale is permitted by the U.S. Food and Drug Administration, and it is available by prescription only. More than 10,000 units have been sold. There are four different types of vacuum therapy: 1) loading cone + constriction band; 2) external splint + negative pressure; 3) Negative pressure + constriction band; 4) Negative pressure + intracavernous injections, without the use of constriction band. Each basic system will be described. The authors make a comparison between the use of negative pressure devices plus tension band and the use of negative pression devices without tension band (plus C.I.D. with vaso-active agents). In the second case there's a sort of synergistic action between vaso-active agents and vacuum therapy, representing a sort of "vaso-active exercise" of the erectile tissue. There are no absolute contraindications to use of external penile devices and potential contraindications are few. The external penile devices described represent a reversible therapeutic modality that can augment an inadequate erection and they should prove useful in any man who needs erectile enhancement. These devices appear to be particularly effective in men with partial impotence in whom only erectile enhancement is needed.

Between July 1989 and June 1994 32 men (48-73 years old) underwent radical retropubic prostatectomy for prostate cancer. 26 patients (70%) presented with symptoms of bladder outflow obstruction. The primary tumour was understaged preoperatively in 5 patients (15.5%). At follow-up (6-66 months, average 24) significant urinary incontinence not occurred in our patients; sixty-two per cent reported a substantial problem with reduced or absent erection. A total of 23 patients was free of clinical or biochemical progression, observed in 28% of cases as distant or local progression. Radical prostatectomy is being performed with increasing frequency: trends in morbidity have been identified.

The optimal diagnostics of B.P.H. must be efficient, cheap and of spare invasiveness either physical than psychological. The optimization of diagnosis is the obtainment of high quality in the services provided, matched to a correct and shrewd utilisation of resources. To optimise a diagnosis efficiency is necessary, which means the largest degree of standardization of diagnostical procedures, with responsible management of economical factors. A course of standardization, cause his excessive simplification, cannot shared to a lot of Urologists, because in their opinion there is a risk to lose informations in every single patient, but is essential to use a universal language that make easy the comparison with patients and with results whether in order to clinics or trails. The standardisation of diagnostics consists to obtain the maximum of informations from present methodology and that is possible to realize in two way: improving the technique of execution and including the diagnostic test in the appropriate point of algorithm.

Transurethral resection of the prostate (T.U.R.P.) has indeed replaced open surgery in the great majority of cases, particularly when the gland is estimated to weight 50-60 g or less. After prostatectomy the patient resumes a normal voiding pattern and obstructive symptoms quickly disappear, although irritative symptoms tend to persist for some time.

Nuclear Magnetic Resonance (NMR) is a new diagnostic technique with great opportunities of application in the field of the penile pathologies. A new interest for this diagnostic technique was born when the use of vasoactive agents, like papaverine or PGE1, and the use of para-magnetic contrast agents, like gadolinium, were introduced. The introduction of dynamic NMR in andrology allowed a better definition of anatomical details and a better knowledge of penile micro-circulation. N.M.R. is showing a great diffusion, because of a little invasiveness (X-rays are not used in this technique). The Authors show a wide spread of possible applications of NMR in penile pathologies, helping in the interpretation of the images. In conclusion the authors describe NMR as a diagnostic technique with great possibilities of improvement, even if the high costs don't allow a better diffusion until now.

Laparoscopy is a safe and reliable procedure for treatment of cryptorchid testicle, varix ligation, staging of lymph nodes in prostatic and in bladder cancer. Recently this procedure is adopted in management of renal cysts. From 2/92 to 7/92, we performed laparoscopic assessment in 31 patients: in 15 cases for varicocelectomy, in 9 for renal cysts, in 2 for lymph nodes dissection, in 3 for preoperatory evaluation, in 1 for unpalpable testicle and in 1 case for ileal perforation in orthotopic neobladder. In 1 case the procedure was unsuccessful because of damage of the spleen. All the patients were mobilized within 1 day postoperative treatment and discharged within 3 days. There are many present and potential application of laparoscopic surgery in urologic pathology, but we think that this technique must be carefully applied in order to avoid complications.

A case of enterorrhagia sustained by arteriovenous malformation of the caecum in a young patient is reported. The importance of an early diagnosis to avert a serious anemia is underlined. Preminent role of colonscopy and selective visceral angiography in the diagnosis of such disease is discussed. At first a conservative urgently treatment of caecum bleeding is advised. Subsequently, when the patients is in more favourable conditions, an elective surgical operation is considered as essential.

In 1982 Virag presented the initial experience of use in diagnosis and treatment of impotence. PGE1 has been showed a safe and effectiveness drug. From september 1989 to october 1991 210 patients with erectile disorders were managed by I.C.I. with PGE1 with minimal side effects.

Authors emphasize the surgical risk in elderly. Mortality and morbidity are pointed out in male and female patients. They report on 30 aged patients operated for various pathologies also discussing the results.

About 1 to 5 percent of patients affected by chronic obstructive venous disease of the lower extremity, are eligible to surgical treatment, by veno-venous bypass, for the relief of unerely invalidating symptoms. Indications to operation include a class II to III chronic venous insufficiency of the deep venous system, failure of medical treatment continued for at least 12 months, good patency of outflow axis, a significant gradient of pressure between discared and outflow axis, a good quality saphenous vein to be utilized for bypass. The case of an aged patient, successfully treated with a femoro-femoral venous bypass, associating an artero venous fistula, is presented and indications to the operation in the older patients, together with indication to and technical details of performing the fistula are discussed.

The authors present different kinds of laser used in the treatment of several surgical affections in out patients. A review of the international literature and main uses of this technique are shown.

From the beginning of the eighties papaverine was well established as the drug of choice for diagnosis and management of vasculogenic impotence. In the second half of the eighties decade many authors referred on experimental use of PGE1 in erection disease. PGE1 has been showed a safe and effectiveness drug. During the period September 1989-October 1990 at our Institution 98 pts. with erectile disorders were managed by I.C.I. with PGE1. Out of 98 cases 88 had success. Prolonged erection occurred in 4 pts. (4.2%). 10 pts. showed only tumescence. So there are been treated by I.C.I. with combined papaverine and PGE1 with better results. No side effects were formed in 10 pts. managed by self-injection of PGE1.

The authors report two cases of hernia of Morgagni, respectively observed in a 42-year-old man and in a 16-year-old boy. In the first case the diagnosis was previous (20 yrs.) to surgical treatment. On the contrary, in the second case the diagnosis was not possible before surgery because of the patient's young age and mild symptoms. Surgical treatment, through thoracotomy in the first case and laparotomy in the second one, was able to repair the diaphragmatic gap.

A case of ganglioneurofibroma of the lung surgically managed is reported. Symptoms were those of an enlarging mass in the thorax. The essential clinical features of the condition are briefly discussed.

Currently, bronchopleural fistulas present a decreasing complication rate in thoracic surgery, especially since surgical management of tubercular infections is no longer needed. The introduction of non-reacting suture materials and the technological advances have also lowered the incidence of such complication. Although fistulas tend to be chronic, their treatment is possible. Today, in fact, the use of human fibrin glue gives positive results which depend on the extent of the fistula as well as the adherence of the glue to the bronchial wall. The authors report their experience in two cases treated with human fibrin glue.

In present paper we report our experience on 366 patients underwent to transurethral resection of prostate from January 1988 to January 1990. All patients were controlled by uroflowmetry and retrograde plus minctional urethrography, with evaluation of the possible immediate and latest complications. Among the latest complications, the most representative had been urethral stricture, occurred in 24 patients (6.5%) according with international literature. We considered also various iatrogenics factors (operator experience, endoscopic time, catheter section, catheter permanence time, use of lubricator, presence of catheter before TURp, preventive Otis urethrotomy). From our study rises out that the most important risk factors are: a) catheter permanence time; b) TURp without preventive Otis urethrotomy.

Percutaneous nephrolithotomy has been proved an efficient management of renal calculi. We report, in present review, the complications of PCNL procedure referred by several authors and our casistic since 1985. Major complications occurred in 3-6% of treated patients: severe bleeding, arteriovenosal fistulas, haematoma perirenal, water syndrome, sepsis, DIC, etc.). Nephrectomy was necessary in less than 1% of reported cases. 5 patients died for complications related to PCNL. Early complications occurred during the percutaneous puncture, tract dilation and lithotripsy. Postoperatively bleeding at the time of nephrostomic tube removal was reported in 0.5-1% of cases. Late sequelae of PCNL: stricture, fistulas, renal damage, renal function loss, high lithiasis recurrence rate were reported rarely. We, herein, believe PCNL is a safe and effective procedure with minimal rate of complications and late effects, according to other important authors.

Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biological side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lithotripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments.

The major complications of extracorporeal shock wave lithotripsy (ESWL) are perirenal hematomas for an incidence of less than 1 per cent. However in animal experiments histopathological effects of focused electrohydraulic shock waves on renal parenchyma have been reported, the most significant of which are hemorrhagic foci healing rapidly by cicatrization. Furthermore imaging studies have demonstrated morphological changes limited to the area of the kidney exposed to shock waves. Liver, skeletal muscle and pancreatic enzyme changes have been documented after ESWL. In our experience the urinary ratio of NAG (N-acetyl-glucosaminidase) to creatinine, a good marker of renal tubular damage, increased after treatment with both the original and the modified spark gap Dornier HM3 lithotripters and with the piezoelectric Wolf Piezolith 2200. Particularly the threshold of pathological urinary NAG excretion were 2,000 and 2,600 shocks respectively using the original and the modified Dornier HM3 and 7,000 shocks using the Wolf Piezolith 2200. The functional significance of the changes is not known, however in clinical practice it would seem prudent to avoid excessive exposure to shock waves.

50 patients were studied with respect to renal tubular damage related to open operative, percutaneous and extracorporeal shock wave treatment of renal stones. Preoperative and postoperative urinary N-acetyl-glucosaminidase (NAG) levels were measured as a marker of renal damage. There was no significant evidence of renal tubular damage in patients who underwent a conventional or percutaneous nephrolithotomy; urinary NAG excretion was significantly increased after ischaemic surgery. After extracorporeal shock wave lithotripsy (ESWL) serum NAG levels increased, probably because a damage of the white blood cells in cutaneous and renal circulation, but a slight increase of urinary NAG excretion could suggest a mild renal tubular damage especially in case of more than 2,000 shocks.

The treatment of serious cavernous corpora fibrosis due to priapism, a prosthesis explantation, iatrogenic causes, or Peyronie's disease, is by now still uncertain. Therefore we tried, when medical and physical therapy failed, to find out the possibility of extracorporeal lithotripter to treat such a complicated cases. From February 88 until now 16 patients underwent extracorporal shock waves treatment, out of 16, 9 had a serious Peronie's disease (a), in 3 fibrosis was a consequence of priapism (b), in 3 of prosthesis explantation (c), 1 patient of cavernosography (d). The treatment was performed by Wolf piezoelectric lithotripter (Piezolith 2300), the patients were treated once a week for 6 weeks. (800 SW; power ranged between 40 and 100 Mpa, frequency between 1 and 2.5 Hertz). In all the patients an orally steroid drugs was administered and a ionophoresis therapy associated. After one year of follow up a penile ultrasound scan, artificial erection tests, rigidometry. None side effects was noted but local ecchimosis. The were done results obtained might support our effort and suggest further studies.

In the Piezolith Wolf 2300 lithotripter, shock waves are generated by about 3000 piezoceramic elements aligned on a self-focusing spherical disk. No ECG-recording is required. Stone localization is obtained by two 4.5 MHz sector ultrasound scanners. Acoustic coupling is performed by a partial water bath. The focal region (pressure higher than P + 12) is only 11 X 3 mm. The positive peak pressure ranges by 300 two 1050 bar. The large exposure of the shock front causes low pressure at the skin level and gives quite painless treatment.

Extracorporeal piezoceramic Wolf lithotripter was developed in West Germany by Ziegler and Associates in collaboration with Wolf GmbH. Piezolith 2300 has no cumbersome water tube and it was constructed as a mobile unit. It requires no patient irradiation, a special room adaptation, a electrodes replacement or any auxiliary staff. From February 1988 up to May 1989 a total of 230 stones in 218 patients, 18 to 79 years old, was treated with Piezolith 2300, in our Center. Ultrasound localization failed in 7 more cases of ureteral stones. Treatment resulted quite painless. Auxiliary measures before EPL, were performed in 12 cases, only (5%). 15 pts were managed with combined procedures: ESWL + EPL, PCNL + EPL, surgery + EPL. The mean of SW was 3000 (800-6500) for each piezoelectric session. In 27 pts (12%), 4 or more EPL sessions were performed. A successful disintegration was achieved in 210 cases (90.2%). Out of 20 unsuccessful cases, 15 were managed by Dornier HM3 mod lithotripter and 4 by ULL. Post EPL ancillary procedures were required in 4 pts (1.8%). No major complications were observed in our series. At the 30-days follow-up, 57.3% of the patients were stone free. At preliminary 3-month follow-up in 120 pts the rate of the entire success raised to 75%. We think, according to others authors, that EPL is the treatment of first choice in 70% of reno-ureteral stones.

Percutaneous ultrasonic lithotripsy in association with endoscopic control and balloon catheter dilatation of stenosed cholangiojejunostomy was successfully used in the treatment of a 53-year-old man with intrahepatic gallstones and severe cholestasis. Previously, he had undergone several biliary surgery operations, but all interventions were complicated by stenosis. The good results obtained in this case lead us to consider percutaneous ultrasonic lithotripsy a possible alternative to surgical treatment of complicated gallstones.