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Female urethral diverticulum is a rather rare pathology, often ignored, which affects from 1 to 4% of the white population. In this study we report our series, limited to a selected population of women affected by neurologic bladder (6 paraplegic patients; 2 patients with multiple sclerosis) who were referred to our Urosurgical Unit within the space of four years. The diagnostic work-up relevant to these patients is discussed, together with the therapeutic strategies carried out and the long-term results obtained.

The Authors present their experience in the treatment of vesico-ureteral reflux in 623 patients, admitted to the “A. Gemelli” Hospital from 1976 to 1995, with neurologic bladder due to traumatic spinal cord lesion. Ninety-four patients with medium-high level reflux were treated; in 71 cases, the reflux was bilateral. The various therapies practised and the medium-long term results achieved are given.

The authors present the results of TURP performed on patients with small obstructive adenomas, which allowed anterograde ejaculation to be preserved in over 80% of the cases. The technique, involving supramontanal prostate tissue sparing, was developed following new findings using endorectal ultrasonography during ejaculation, which revealed the absence of the accumulation stage. Contraction during ejaculation of the preserved portion of the prostate enables anterograde ejaculation to be preserved without causing a significant obstacle to micturition.

After having illustrated the physiopathological basis of the micturition reflex to cold water (a reflex tied to specific receptors and carried by type C unmyelinated fibres) the Authors report the results in the diagnosis and treatment of neurological bladder. The Ice Water Test (IWT) was carried out on 148 patients with neurological bladder resulting from traumatic lesion for diagnostic and treatment purposes and in 130 patients with neurological bladder and multiple pathogenic disorders for diagnosis and treatment and to classify hyperactive bladders. The IWT served as an aid in performing cystographic exams in 24 patients with neurological bladder. In normal control subjects the test results are always negative. Because it is simple to perform, it is considered to be a useful complement to every urodynamic examination in patients with neurological bladder or when there is difficulty in interpreting micturitional disorders.

— The authors report their results on 154 patients with neuropathic bladder due to a previous spinal cord injury, who underwent sphincterotomy. The Authors dwell on indications, surgical endoscopic techniques, complications, short- (2 years) and long- (5 years) term sphincterotomy-related results: reduction of symptomatology of about 70% after 2 years and about 25% after 5 years. The Leak Point Pressure proves to have a predictive valve for long-term results. The authors conclude that sphincterotomy is effective in reducing detrusorial hyperreflessia and dissynergia short-term and, above all, it blocks the mechanisms that lead to upper urinary tract failure. Moreover, the sphincterotomy may be repeated.

Definizione di uno strumento di diagnosi delle prestazioni energetiche degli edifici in base ai consumi energetici rilevati.

Twelve healthy, unpremedicated women scheduled for total abdominal hysterectomy were given either isoflurane (n = 6) or halothane (n = 6) anaesthesia. They all received general anaesthesia for a period of 3 h, with surgery being carried out only in the last hour. The anaesthesia consisted of thiopentone, pancuronium and a mixture of oxygen-enriched air (FiO2 = 34%) supplemented with 1 MAC of either isoflurane or halothane. The patients were maintained normothermic, and with an arterial SaO2 above 95% throughout the period of the study. The following measurements were made before, during and after anaesthesia (with and without surgery): oxygen consumption (VO2), carbon dioxide production (VCO2); circulating concentrations of various hormones (insulin, growth hormone and cortisol); various metabolites; selected amino acids and albumin; forearm arterio-venous concentration difference of glucose, lactate, free fatty-acids and selected amino acids (four patients in each group). Whole body VO2 decreased significantly by over 20% during anaesthesia (with or without surgery), P < 0.05). Although the circulating concentration of most amino acids showed little or no change during anaesthesia alone, there was a tendency for the flux of most metabolites to decrease, and this persisted during surgery (P < 0.05). During anaesthesia alone there was a twofold reduction in the plasma cortisol concentration (P < 0.05), and a decrease in albumin concentration (P < 0.01). With the onset of surgery, plasma cortisol concentration increased rapidly (in association with several other hormones and metabolites) but hypoalbuminemia persisted.

We organized a training program for oral fiber optic intubation (FOI) under conscious sedation. The efficacy of the program was evaluated by comparing the performances of experts and novices.The training procedure was divided into two sessions: a theoretical session on difficult airways, the fiber optic bronchoscope (FOB), remifentanil, topical anesthesia and patient interactions; and a session involving simulations of the FOI technique on dummies. For in vivo FOI, we enrolled patients requiring orotracheal intubation for elective surgery. Electrocardiograms, mean arterial pressure (MAP) values, peripheral O(2) saturation (SpO(2)) values, respiratory rates (RR) and sedation scores (OAA/S) were acquired. Remifentanil infusion was started at 0.05-0.1 microg*kg(-1)*min(-1), and patients' upper airways were anesthetized with lidocaine. Remifentanil was titrated to achieve an OAA/S of 9-12. FOBs were inserted, and topical laryngeal anesthesia was achieved ("spray as you go" technique). The instrument was passed into the trachea, the OT tube was railroaded over the fiberscope, and tracheal intubation was completed. The procedure duration and patients' vital parameters and satisfaction were recorded.Three experts and four less-experienced anesthesiologists who performed 29 (10, 10 and 9) and 25 (6, 6, 6 and 7) FOIs, respectively, joined the study. To reach the target OAA/S, the remifentanil dosage was progressively increased to an average dose of 0.15+/-0.05 microg*Kg(-1)*min(-1). MAP and SpO(2) values were stable throughout the procedures, HR was slightly increased (from 77+/-16 to 90+/-23 bpm, P=0.02), and RR was decreased (from 16+/-3 to 12+/-4 bpm, P0.05). No differences were recorded between the experts and less-experienced anesthesiologists. The average duration of FOI was 3.3+/-2.0 min for experts and 4.2+/-2.4 min for novices (P=0.03). Procedures were successful in both groups, with patients in each group being equally satisfied with the procedures.This study highlights the importance of a structured FOI training program, demonstrating that it is possible to learn to perform FOI proficiently by practicing on dummies.

We present our experience with a modified technique for constructing a continent ileal reservoir, using the terminal ileum in a pre-peritoneal position. The ureters were implanted using the Le Duc-Camey technique; the Benchekroun valve was used as a continence mechanism. This technique was used in 18 patients and its advantages and complications are discussed.

The Authors refer to current opinions regarding the neuro-pharmacologic control of bladder voiding. They report their experience concerning 162 patients with detrusor-sphincter dyssynergia: 86 pts were affected by multiple sclerosis and 76 by neurobladder after spinal cord injury.

Background The authors studied the effects of the beach chair (BC) position, 10 cm H2O positive end-expiratory pressure (PEEP), and pneumoperitoneum on respiratory function in morbidly obese patients undergoing laparoscopic gastric banding. Methods The authors studied 20 patients (body mass index 42 +/- 5 kg/m2) during the supine and BC positions, before and after pneumoperitoneum was instituted (13.6 +/- 1.2 mmHg). PEEP was applied during each combination of position and pneumoperitoneum. The authors measured elastance (E,rs) of the respiratory system, end-expiratory lung volume (helium technique), and arterial oxygen tension. Pressure-volume curves were also taken (occlusion technique). Patients were paralyzed during total intravenous anesthesia. Tidal volume (10.5 +/- 1 ml/kg ideal body weight) and respiratory rate (11 +/- 1 breaths/min) were kept constant throughout. Results In the supine position, respiratory function was abnormal: E,rs was 21.71 +/- 5.26 cm H2O/l, and end-expiratory lung volume was 0.46 +/- 0.1 l. Both the BC position and PEEP improved E,rs (P < 0.01). End-expiratory lung volume almost doubled (0.83 +/- 0.3 and 0.85 +/- 0.3 l, BC and PEEP, respectively; P < 0.01 vs. supine zero end-expiratory pressure), with no evidence of lung recruitment (0.04 +/- 0.1 l in the supine and 0.07 +/- 0.2 in the BC position). PEEP was associated with higher airway pressures than the BC position (22.1 +/- 2.01 vs. 13.8 +/- 1.8 cm H2O; P < 0.01). Pneumoperitoneum further worsened E,rs (31.59 +/- 6.73; P < 0.01) and end-expiratory lung volume (0.35 +/- 0.1 l; P < 0.01). Changes of lung volume correlated with changes of oxygenation (linear regression, R2 = 0.524, P < 0.001) so that during pneumoperitoneum, only the combination of the BC position and PEEP improved oxygenation. Conclusions The BC position and PEEP counteracted the major derangements of respiratory function produced by anesthesia and paralysis. During pneumoperitoneum, only the combination of the two maneuvers improved oxygenation.

– The authors describe the function of Benchekroun's hydraulic valve. They propose a modification of the valve to reduce the percentage of disinvaginations, which are the main cause of loss of the continence mechanism. Results are described.

In a model of acute lung injury, we showed that positive end-expiratory pressure (PEEP) and tidal volume (VT) are interactive variables that determine the extent of lung recruitment, that recruitment occurs across the entire range of total lung capacity, and that superimposed pressure is a key determinant of lung collapse. Aiming to verify if the same rules apply in a clinical setting, we randomly ventilated five ALI/ARDS patients with 10, 15, 20, 30, 35, and 45 cm H2O plateau pressure and 5, 10, 15, and 20 cm H2O of PEEP. For each PEEP-VT condition, we obtained computed tomography at end inspiration and end expiration. We found that recruitment occurred along the entire volume-pressure curve, independent of lower and upper inflection points, and that estimated threshold opening pressures were normally distributed (mode = 20 cm H2O). Recruitment occurred progressively from nondependent to dependent lung regions. Overstretching was not associated with hyperinflation. Derecruitment did not parallel deflation, and estimated threshold closing pressures were normally distributed (mode = 5 cm H2O). End-inspiratory and end-expiratory collapse were correlated, suggesting a plateau-PEEP interaction. When superimposed gravitational pressure exceeded PEEP, end-expiratory collapse increased. We concluded that the rules governing recruitment and derecruitment equally apply in an oleic acid model and in human ALI/ARDS.

Urinary continence is ensured as long as the urethral closure pressure remains greater than the intravesical pressure, in the presence of adequate support to the bladder and the proximal urethra. In order to select the appropriate surgical treatment, a correct diagnosis must be made; recently urodynamic evaluation has assumed a central role. In particular, the introduction of a new urodynamic parameter, the Valsalva Leak Point Pressure (VLPP), has provided new impetus to research in this area, even if different technical approaches have limited universal acceptance. The aim of the work is to describe the reasons why the authors have been led to prefer double measurement, both at partial filling and at maximum cystometric capacity, considering that this does not involve any additional economic burden. The authors underline the promising potential of the method, once standardized, in the urodynamic evaluation of urinary incontinence.

Castration, whether surgical (orchiectomy) or pharmacological (androgen blockade), used in the management of advanced prostatic carcinoma, induces as a secondary effect, immediately following impotence, the onset of a vasomotor syndrome characterized by hot flushes and sweating. This syndrome which may present with such intensity and frequency as to severely affect the quality of life and even the psychological equilibrium of the patient. Treatment with progestinic agents leads to the release of opioid peptides at hypothalamic level, thus decreasing the level of catecholamines responsible for the vasomotor syndrome. In the 37 cases treated with progestogens, a therapeutic efficacy of 80% was observed following cyproterone acetate and of 70% following medroxyprogesterone acetate.

Objective To determine the usefulness of the ice-water test (IWT) in the diagnosis and treatment of neurological bladder disease. Patients and methods The IWT was carried out in 148 patients with neuropathic bladder dysfunction resulting from a traumatic lesion, to assist in their diagnosis and treatment, and in 130 patients with neuropathic bladder dysfunction and multiple pathogenic disorders; the results of the IWT were used to classify those patients with hyperactive bladders. Results The IWT was positive in 95% of patients affected by complete and in 86% of patients with incomplete medullary lesions. The IWT in patients with lower motor neuron medullary lesions was always negative. The test was used diagnostically in all patients with lower and in 43% of those with upper motor neuron lesions. In the latter, it was used in 48% of patients as a rehabilitation method during the medullary-shock phase to accelerate the appearance of the micturition reflex. In 9% of patients it was used to induce micturition during cystography. Conclusion Because it is simple to perform, the IWT is a useful complement to urodynamic examinations in patients with neurological bladder disease and in patients with micturitional disorders that are otherwise difficult to interpret.

We investigated the amino acid (AA) tolerance during Total Parenteral Nutrition (TPN) in adult patients undergone liver transplant (LTX). The treatment (Glucose and AA), induced on the 2nd postoperative day, was later maintained with 27 kcal/kg Ideal Body Weight (IBW) as glucose and 0.12 (12 patients: protocol #1), 0.18 (10 patients: protocol #2) and 0.25 g nitrogen (N)/kg IBW (13 patients: protocol #3) till end of the 6th postoperative day. The N intake was sequentially modified in protocol #2 and #3 to increase the supply of the amino acid (AA) that resulted in an infusion plasma level below the expected “normal” range (between 1 and 1.6 times the overnight fasting plasma level of volunteer). 35 consecutive adult patients without diabetes and organ failures for the entire study period.Measurements: Plasma AA profile was measured before LTX and at the last TPN day under continuous infusion. During #1 and #2 protocol, many AA resulted below or at the lower range of the norm while, during 0.25 gN/kg IBW infusion, the majority of the administered AA significantly increased with respect to reference values. Nevertheless, they remained in the “normal” plasma range indicating that they were supplied in an optimal amount (particularly the aromatic and sulphurated ones, potentially toxic if liver function is impaired, and the branched chain AA (BCAA) given at consistent dosage: 0.5 g/kg). Arginine resulted significantly increased (Arg: 1.9 times the reference) and cystine (Cys: 0.45), serine (Ser: 0.8) and taurine (Tau: 0.85) remained significantly lower than “normal” as well as the not administered citrulline (Cit: 0.58) and alfa amino butyric acid (Aba: 0.41). The AA (and calorie) load almost balanced the N losses during the 5th (0.411±0.038) and 6th study day (0.305±0.019 gN/kg). 0.25 gN/kg could be considered the minimum N load in the uncomplicated adult LTX recipients, for reassuring a balanced plasma AA pattern and body N turnover in the early postoperative phase.

Bladder diverticula may be involved in inguinal hernias usually in the form of a sliding hernia. We studied three patients with scrotal herniation of bladder diverticulum, one of them having a neurogenic bladder. All our patients have had the diagnosis before undergoing hernia repair--so iatrogenic lesions of the bladder during surgical manipulations could be avoided. Methods for an early diagnosis of this rare occurrence are discussed along with aspects of surgical approach.

A fine-bore 28G CoSpan spinal catheter was used to provide continuous spinal anesthesia for major upper and lower abdominal, peripheral vascular, and orthopedic surgery in 90 patients, aged 31-91 years.Initial doses (0.5-2.0 mL) of hyperbaric bupivacaine 0.5% were given and followed, if needed, by additional doses of 0.5-1.0 mL to achieve a satisfactory blockade for the proposed type of surgery. The incidence of hypotension, ambulatory postdural puncture headache, and technical problems encountered with insertion of the spinal catheters were recorded.The technique of continuous spinal anesthesia was successful and easy to learn. Satisfactory sensory and motor blockade was achieved within 12-18 minutes, and surprisingly small amounts were needed in those patients undergoing limb surgery.Mild postdural puncture headache occurred in four patients, but none of the patients required blood patch. One catheter broke during removal; since then, it has been our policy to remove a catheter with the patient in a flexed position.

We present our experience with a modified technique for constructing a continent ileal reservoir, using the terminal ileum in a pre-peritoneal position. The ureters were implanted using the Le Duc-Camey technique; the Benchekroun valve was used as a continence mechanism. This technique was used in 18 patients and its advantages and complications are discussed.

A plasmatic concentration for each aminoacid, between 1 and 1.5 times the normal value in fasting healthy subjects, is considered as an optimal target during total parenteral nutrition (TPN) in malnourished patients. We have analyzed the correlation between the aminoacid input and the aminoacid plasmatic concentration during TPN at different aminoacid composition. By exponential regression curves we then calculated the input required to keep each aminoacid plasma concentration in the optimal range.

Ten-three patients were investigated during the early postoperative phase after orthotopic liver transplantation to assess the adequacy of the amino acid (AA) supply during both parenteral (days 1-5) and enteral (days 6-9) nutrition. Plasma AA profile was determined preoperatively, on day 4 and 5 during TPN and on day 8 and 9 during EN, urea production rate was measured every day. Calories input was 28 kcal.kg-.day as glucose, nitrogen intake was 0.25 g.kg- day, supplying individual AA on the basis of previous studies. Urea nitrogen production during TPN (9-11 gN/m2.day) outlines the ability of the transplanted liver to manage the overall nitrogen load. Individual AA plasma profile was considered the expression of an adequate input when comprised between 1 and 1.5 times the normal value, in this respect we obtained adequate levels of all essential AAs. Particularly phenylalanine, methionine and branched chain AA, critical during liver failure, were kept in this range by supplying 68, 48 and 500 mg.kg-1.day. According to AA profile the supply of cystine and tyrosine (conditionally essential AAs), and of histidine, taurine, proline and serine could be safely increased. Not given dispensable AAs (glutamine, asparagine, citrulline and alfa amino butyric) showed a plasma level below the norm and should be added to the diet.