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In this paper, we have explored the possibility of assigning the humanthemed engravings from La Marche to their authors, according to the method outlined by J.M. Apellaniz in the 1980s. The method employed here follows the first of the three stages postulated by Apellaniz: macroscopic observation, microscopic analysis and experimental protocol. From our study emerged a pattern of five groups and sixteen hands at work in this site. We believe, therefore, that it is possible to speak of La Marche as an “art workshop”, where portable art was produced and taught.

The diluition of urine decreases the risk of stone formation by lowering the concentration of calcium, oxalate and uric acid, but involves a simultaneous decrease of the concentration of the inhibitors of crystallization. On the other hand the ion content of the drinking water used for stone prevention could by itself modify urine composition. We tested the effect of the administration of a mild-calcium high-bicarbonate content water on urine composition of a group of calcium renal stone formers. A group of 40 calcium renal stone formers was instructed to drink 3 l/day of a mild-calcium (57 mg/l) and high-bicarbonate (180 mg/l) content water (Rocchetta) for a 7 day period. A 24-h collection was obtained before and after water administration for analyses of calcium, magnesium, oxalate and citrate. Urine volume was significantly increased after water administration (1601 +/- 357 vs 1878 +/- 339). Daily urinary calcium, magnesium and citrate were significantly increased, whereas daily urinary oxalate was unchanged after water administration. In conclusion the mild-calcium high-bicarbonate content water administration seems suitable for stone prevention because of the increased excretion of urinary inhibitors counterbalancing increased urinary calcium excretion.

Percutaneous US guided nephrostomy is the simplest and most direct technique to drain an obstructed kidney. The indications are included in two groups: temporary drainage and permanent drainage; the former is indicated in the non endoscopically superable ureteral obstruction, in pyonephrosis, in pregnant women and in transplanted kidneys (due to the easier access), the latter is exclusively reserved to neoplastic obstructions. The only real contraindication to the method, besides a documented allergy to local anaesthetics, is represented by a severe coagulopathy. Positioning techniques are the "one shot" technique, in which dilation and positioning are synchronous (it can avoid fluoroscopy but it is more traumatic) and angiographic derived Seldinger's technique, that utilizes fluoroscopy and an instrumentation including a guidewire and a set of Amplatz dilators. Complications are due to the access route; the choice of an intercostal access is always inadvisable, due to the risk of pneumothorax or pulmonary injury; the most frequent complications are vascular (hemorrhage, retroperitoneal hematoma) and usually well controlled; more severe lesions (renal artery laceration and arteriovenous fistula) may require intervention or embolization, but the incidence of nephrectomies due to vascular injury accounts for one per thousand.

Melatonin (MLT) is directly or indirectly related to cell growth (both of normal and neoplastic cells), to the immune system stimulation and to the endocrine system modulation. This controlled study was carried out to evaluate urinary excretion of MLT in patients suffering from urogenital tract disorders. Eighty-one patients affected by urogenital disorders were divided in two groups (neoplastic and non-neoplastic) and urinary excretion of MLT was evaluated. Mean diurnal (from 8 a.m. to p.m.) urinary excretion of MLT was 4.97 + 6.08 pg/12 h in non-oncologic patients and 4.82 + 6.21 pg/12 h in oncologic patients (p = 0.50). Mean nocturnal (from 8 p.m. at 8 a.m.) urinary excretion of MLT was 11.97 + 9.34 pg/12 h in non-oncologic patients while in oncologic patients it was 7.86 + 8.95 pg/12 h. Statistically significant variation in nocturnal urinary excretion of melatonin was observed in oncologic patients (p = 0.022) versus non oncologic patients.

Due to the increasing use of sophisticated imaging techniques, up to 30% of diagnosed renal cell carcinoma (RCC) are asymptomatic and diagnosed incidentally. Getting the cue from our personal survey of conservative renal surgery for renal cell carcinoma with a cancer specific survival of 95.5% after a mean follow up of 32.7 months, a review of the literature is illustrated: numerous studies have documented the technical success rate with this approach as well as long term disease free survival, comparable to that obtained by radical nephrectomy, in patients with unilateral, small, low stage tumors and normal opposite kidney. Patient selection is of extreme importance in case of partial resection in the presence of a normal contralateral kidney. The tumor must be < 3-4 cm, solitary, well delineated on CT, without invasion of the perinephric far or pyelocaliceal system (T1 and T2), easily resectable with at least 1 cm of healthy parenchyma. Only well informed patients who agree on a careful follow up after surgery can be candidates for kidney sparing surgery. In case of imperative surgery the follow up must be strict and personified for every single patient. Those patients who underwent a partial nephrectomy in presence of a normal contralateral kidney should be monitored with a conventional follow up monitored in order to detect an eventual local recurrence: 12 monthly ultrasonography and contrast enhanced CT scan alternately every 6 months for the first five years after surgery and then lifelong once a year by echography and/or CT scan.

Urethral bladder substitution is traditionally suggested to good prognosis cystectomized patients. In our series this diversion was chosen for all but the salvage cystectomized men. Between the 1st of February 1991 and the 30th of April 1996, one hundred consecutive men underwent lower urinary tract reconstruction after radical cystoprostatectomy for bladder cancer. An orthotopic ileal neobladder was constructed (in 84 cases according to Kock's technique and in 16 to Studer's technique). Total early complication rate was 29% (29/100), including one perioperative death due to sepsis (mortality rate 1%). 13 patients required surgery (6 retroperitoneal hematomas, 2 wound dehiscences, 1 urinary fistula, 1 lymphocele, 1 rectal-neobladder fistula, 1 rectal-cutaneous fistula, 1 necrosis of the terminal ureter). The late complication rate was 19% (19/100); in 8 cases reparative surgery was required (1 mechanical ileus, 2 bladder neck stenoses, 3 stenoses of the ureteral anastomosis, 2 laparoceles). Four patients were lost at the follow-up; out of the 96 remaining patients only 85 were evaluable for continence: continence during the day was achieved in a period between there to six months in 78 patients (91.7%); night continence was achieved with planned awakenings in 60 patients (70.5%). Eight patients recovered potency, another 7 had successful intercourses after PGE1 intracavernous injection. Renal function based on creatinine value was mildly impaired in 5/78 evaluable patients (6.4%) (peak creatinine 2.8 mg%). In 29 patients tumour progression was observed (29%): 9 pelvic and 20 metastatic. Among the latter 2 urethral recurrences were observed (2%). Twenty-four patients died for metastatic cancer, one for primitive lung cancer, one patient for postoperative septic shock. Adjuvant chemotherapy was administered in 11 patients without complication with an indwelling catheter in the neobladder to avoid drug reabsorption. Four patients showed complete response (2 are alive after a mean of 12 months), 6 were non responders and 1 had a partial response. In our series the ileal neobladder is a feasible method of urinary diversion when urethral cancer involvement is ruled out. Early and late complications are proportionally decreasing with experience and overall continence is satisfactory. The fate of the neobladder depends on both the technique and patient's compliance. Only educated patients can cope successfully with neobladder diversion without major complications. All the patients operated for non salvage cystectomy deserve to be diverted with a continent urethral bladder substitution.

From June 1991 to June 1995 we treated 20 patients affected by T1 G3 TCC of the bladder, 18 men and 2 women, with a mean age of 65.1 years (46-71). In 11 patients the disease was monofocal, with diameter of the tumor under 3.5 cms; in 5 patients monofocal with diameter of the tumor over 3.5 cms; in 1 patient multifocal and in 3 patients complex (mono or multifocal associated with CIS). The 11 patients with monofocal disease under 3.5 cms were treated with TUR-B, the other 9 (all males) were submitted to radical cystectomy with OINB diversion as first choice treatment. The mean follow up (all patients) was 3.2 years (6 months-14 years). Out of the patients of the former group only 3 did not show any relapse, the other 8 showed multiple relapses or metachronous tumors: 5 were treated with TUR-B+BCG, 3 were cystectomized. The patients submitted to cystectomy as first choice treatment did not show any progression of the disease after a mean follow-up of 19.8 months.

To evaluate the effectiveness of Alpha-blockers, TUI-P and TUR-P in the treatment of obstruction due to BPH, 50 patients, never before treated, were considered. Fifteen were treated with alfuzosin chlorhydrate 7.5 mg/day for four months, 15 were submitted to TUI-P and 20 to TUR-P. In all patients linear purr was carried out before treatment and was repeated from 60 to 90 days after intervention in surgical patients and during the fourth month of treatment in patients treated with alfuzosin. The data obtained were analyzed with the T-test both for dependent and independent samples. The results show that Alpha-blocker contain an increase in maximal flow, without decreasing bladder voiding pressures. On the contrary TUI-P and TUR-P, besides the increase in maximal flow obtain a significant reduction of bladder pressures. The conclusions are the following: maximal flow alone is not a sufficient parameter to evaluate the work of the bladder, the entity of the obstruction and the effectiveness of the therapy. The treatment with Alpha-blockers is unable to reduce the obstruction due to BPH. TUI-P and TUR-P realize an effective deobstruction. Under the same deobstructing effect TUR-P assures a better voiding performance by obtaining higher flow values.

The underlying BPH related mechanisms of outlet obstruction are outlined (modification of the shape of the bladder neck, failure of funnel formation, geometric variations of the urethra, alpha 1 adrenoceptors mediated sympathetic hyperactivity at the level of the lower genito-urinary tract). Bladder voiding dysfunction in response to prostate obstruction is also discussed and correlated to ultrastructural patterns and clinical symptoms. Finally, a pathogenetic mechanism for detrusor overactivity in obstructed bladder is suggested.

From October 1992 to June 1994, 12 nephrectomies (all for benign diseases), one nephropexy and 7 adrenalectomies (one pheochromocitoma, three adenomas, one cyst) were performed. In all the cases the retroperitoneal working space was created with direct CO2 insufflation (without balloon) with the patient in prone position. Four 10-12 mm ports were always inserted in the lumbar area. Eighteen procedures were successful (90%), 2 failed (one nephrectomy and one adrenalectomy) and underwent open surgery. Twelve procedures were carried out with the patients in prone position, six (one nephropexy and 5 nephrectomies) were performed with the patients in lateral de cubitus. The removal of organs was managed either through an enlarged port (phi 2 cm.) or by joining vertically the stabs of the two ports lateral to the sarcospinalis muscle. The average operative time was 4.10 hours) range 2.30-5.20). Both CO2 absorption and blood loss were negligible. No major complications were observed. Postoperative pain never required medications. All patients were able to stand on the 1st postoperative day. Mean postoperative hospitalisation was 4 days. Direct retroperitoneal approach provides optimal access for laparoscopic renal, proximal ureteral and adrenal surgery, avoiding extensive dissection and handling of intraperitoneal structures.

Thirty-three two port laparoscopic internal spermatic vein ligations have been performed in 31 patients in our Department. The procedure carried out through two 10 mm ports in a mean time of 25 minutes decreases both the invasivity of intervention and the costs when reusable instruments are used. The technique is feasible with an operative laparoscope (working channel diameter 4 mm) through which a grasp can be maneuvered. The two port procedure is as safe as the three port procedures. Preliminary follow up indicated only one recurrence of varicocele (4%). Out of the 19 patients treated for male subfertility who have at least a 6 month follow up, eleven reported an improvement in seminal quality. All the patients but one were discharged on the first postoperative day. Laparoscopic internal spermatic vein ligation provides a real alternative to different surgical techniques decreasing postoperative pain and shortening period of convalescence with immediate return to full activity. The advantages of laparoscopic internal spermatic vein ligation are increased with the two port procedure.

The authors describe a new technique of laparoscopic nephrectomy; the retroextraperitoneal approach has been successfully performed in 4 patients with the following indications: 2 non functioning hydronephrotic kidneys, 2 atrophic chronic pyelonephritic kidneys. The patient was put in a proneoblique position after the retrograde placement of a ureteral catheter up to the renal pelvis, through which the contrast medium was injected. The Veress needle is inserted under fluoroscopic guidance into the perirenal fatty space which was insufflated with CO2. One 12 mm and three 10 mm Trocars were inserted into the cavity created by gas in the trapezoid area whose boundaries are: the 12th rib, the iliac crest, the posterior axillary line and the sacrospinalis muscle. The kidney was progressively dissected free with the traditional laparoscopic instruments (forceps and scissors). The artery has always been closed with clips. In two patients the vein has been stapled and cut with EndoGIA. After the section of the clipped ureter the kidney was removed en block by pulling it out through the 20 mm Kleiber Trocar in two cases and in the other two cases by extending to a length of 4 cm the port of one Trocar. The average total operating time was 4.35 hours and blood loss < 200 cc. The patients were all discharged on the fourth postoperative day. The advantages of the retroextraperitoneal approach with respect to open surgery are synthetically the following: a less traumatic and a more accurate dissection almost always bloodless; a shorter hospitalization period; an almost painless postoperative course.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacterial adherence to biomaterials as an element of clinical relevance is a well-known factor in the pathogenesis of sepsis. Drainages, intravascular catheters, surgical prostheses and other devices are susceptible to bacterial colonization with clinical consequences. In the last few years attention has been paid to coagulase-negative Staphylococcus (S. epidermidis), mainly to some strains able to produce a highly adhesive polysaccharide substance, called glycocalix or slime. This promotes adherence either interbacterial either between bacteria and biologic tissues or synthetic materials acting as a pathogenetic factor in sepsis being able to increase bacterial resistance to phagocytes and antibiotics. Bacterial contamination of 40 abdominal drainage tubes in patients operated in elective and in emergency surgery for various pathology has been evaluated. Sonication of the tip of the drainage was utilized in order to promote the detachment of adherent colonies and its effectiveness was compared to that of microcentrifugation. Culture of 25 drainages (62.5%) showed no bacterial contamination; 7 drainages (17.5%) have proved to be colonized by S. epidermidis, in 4 cases the isolated strains were also methicillin-resistant, 2 of which slime-producing. Out of the 7 drainages colonized by S. epidermidis, 4 were removed from patients operated in emergency: none of the isolated strains was slime-producing. Six drainages (15%) were colonized by Gram+ bacteria (S. fecalis, P-sensible cocci, rods), 1 (2.5%) by E. coli and 1 (2.5%) by P. aeruginosa, S. epidermidis appears to be the chief contaminant of abdominal drainages, especially in emergency surgery; slime production has always been observed in methicillin-resistant strains: this confirms the hypothesis that slime production is typical of specialized, virulent strains.(ABSTRACT TRUNCATED AT 250 WORDS)