Chronic urine retention secondary to peripheral neuropathy with widespread vegetative involvement. Case description

In clinical practice it is common to find patients in whom urinary retention is not secondary to cervicourethral obstruction. Therapeutic measures, surgical or otherwise, do not live up to expectations in these patients. The Authors describe the case of a 54-year-old patient who presented with urinary retention. Neuro-urological exams excluded the presence of a cervicourethral obstruction and instead revealed probable parasympathetic denervation, subsequently confirmed by the Cutaneous Sympathetic Response recording and Cardiovascular Tests. In such cases correct diagnosis relies on close co-operation between the urodynamics and the neurophysiology doctors. These are undoubtedly particular cases, but an incorrect diagnostic framework could lead to inappropriate surgical treatment.

[Leydig cell tumor of the testis]

It represents a rare and mostly unilateral pathology with benign istological patterns. However, since the biological behaviour of the tumor is not foreseable from the istological characteristics, the follow-up must be prolonged. The treatment of this cancer is orchidofuniculectomy, sometimes associated, in selected cases, with retroperitoneal lymphadenectomy. In presence of tumor of small dimensions, above all if bilateral ones, it may be indicated a conservative treatment. Authors report six cases of Leydig cell tumors of the testis observed in sixteen years. All patients had orchidofuniculectomy by inguinal approach. In only one case has been associated retroperitoneal lymphadenectomy for the suspect of lymphatic metastasis. Follow-up of 3 months to 15 years is available for all patients: no one has died for the tumor and all are without signs of disease.

[Multicenter comparative study of meropenem vs. imipenem in the intramuscular treatment of hospital infections of the urinary tract]

A clinical, multicentre, randomised, comparative study in 283 adult hospitalized patients was carried out to assess efficacy of meropenem in the treatment of complicated and non-complicated urinary tract infections, in comparison to imipenem/cilastatin. Both antibiotics were administered intramuscularly, at a dose of 500 mg bid. The two groups were homogeneous, as regards the distribution between male and female, the mean age of the patients, the severity of infections and the mean duration of treatment. Clinical results were assessed at the end of therapy and follow-up (4-6 weeks). Bacteriological results were assessed at 5-9 days post-treatment and at follow-up. As regards clinical and bacteriological results patients showing a satisfactory response rate were compared, at the end of the treatments using a Chi square test. With both treatments high satisfactory clinical and bacteriological response rates were seen. As regards clinical satisfactory responses (97% of meropenem assessable patients versus 90% of imipenem/cilastatin assessable patients), there was a statistically significant difference in favor of meropenem. The bacteriological outcome was successful (eradication) for 75% of assessable patients in each group. Most failures were seen in the complicated infections, even when pathogens usually sensitives to carbapenemics were initially isolated. Safety was good with both drugs; no withdrawals in any group of treatment was seen because of side effects. The local tolerance of meropenem was globally rated as good.

Testicular neoplasms and tumoral markers

The use of tumoral markers and especially of BHCG and AFP in the diagnosis, staging and follow-up of patients affected by testicle germinai neoplasms is now widespread. Nevertheless, controversies stili exist in each one of these fields. Especially for clinical staging, high percentages of understaging of stage I tumours are reported in literature with considerable effects on therapeutical indications and prognosis. The Authors attempt a criticai review on the use of markers for diagnosis and staging of testicular neoplasms based upon their own experience of 79 cases over a 14-year period.

Flow cytometric DNA analysis in conservatively treated renal tumours

— The DNA histograms of 21 conservatively resected renal tumours were studied using DNA flow cytometry. Five patients had an imperative and sixteen an elective indication for conservative resection of the renal tumour. On the basis of DNA histograms twelve aneuploid tumours were pointed out. A mean follow-up of 34.2 months was considered to see whether the ploidy would provide criteria with a prognostic significance, to be useful as an additional parameter. None of the twenty-one patients had local recurrence or distant metastasis: in our series the DNA analysis had no influence on the prognosis of this group of patients. The tumour size seems to be the only selective parameter for choosing renal-conserving surgery.

Laparoscopic pelvic lymphadenectomy in the staging of prostatic cancer: Our experience in 37 cases

— This paper reports the result of our experience on 37 patients with prostatic carcinoma who underwent laparoscopic pelvic lymphadenectomy. The technique we practised is very similar to the one described by Schuessler in 1991. The average total number of lymph nodes removed and operative time were comparable to standard open techniques. Nine patients had distant metastasis (24.3%). We had no important complications in our series of patients. The minimally invasive approach and the rapid resumption of everyday activity widely balance the cost of this procedure if we consider its diagnostic use.

DNA analysis by using flow cytometry on vesical biopsy specimens: S-phase evaluation

— By using DNA flow cytometry (FCM) the Authors assessed the S-phase cell cycle values on 802 vesical biopsy samples removed from 293 patients who underwent urethrocystoscopy because of bladder tumours in progress or in the past. They found the following S-phase average percentage values: 12.70 ± 12.00 in transitional cell carcinomas; 10.54 ± 8.71 in urothelial dysplasias; 13.38 ± 12.05 in exfoliative cystitis; 10.27 ± 9.69 in aspecific inflammation; 7.35 ± 5.00 in normal urothelium. Such differences were statistically significant. Concerning urothelial carcinomas, the Authors noted different S-phase percentages according to stage, histological grade and ploidy. The analysis of average S-phase values demonstrated statistical significance. Instead the presence of wide standard deviations hampered the evaluation of well-determined thresholds which could identify cell populations with different clinical behaviour.

Laparoscopic treatment of varicocele

— This paper reports the result of our experience on laparoscopic varicocele treatment. Fifty-two patients underwent ligation of the spermatic vein. In 34 patients the procedure was monolateral and in 18 bilateral. Disposable trocars were used for umbilical access; non-disposable trocars were used for the others. Operative time was comparable to that of traditional surgery. Short hospitalization (24–48 hours) and the rapid resumption of everyday activity give the laparoscopic approach a favourable cost/benefit ratio in comparison with standard open techniques.

Vesicovaginal fistulas: our experience and review of literature

Vesicovaginal fistulas (VVF) still represent a sad complication of surgery of the female genital system. In this article an extensive review of the literature was conducted, analyzing the etiological, pathological and clinical aspects, as well as the therapeutical problems. For this purpose, we have compared the many surgical techniques proposed for treatment of VVF and have also evaluated their results. Furthermore, we report on our series of 35 patients who had undergone treatment for VVF.

Role of PSA on Diagnosis and Clinical Stadiation of Prostatic Cancer

The Authors review the literature and summarize the role of the PSA in early diagnosis, screening and clinical staging of prostatic carcinoma. Both advantages and limits of the test are emphasized. In spite of its limited sensitivity (57%) and low positive predictive value (49%) in early diagnosis of prostate cancer, the marker has an overall diagnostic efficiency of 64-70% and provides better detection rates of the tumor than digital rectal examination (DRE) and transrectal ultrasonography (TRUS). In screening studies, additional advantages of PSA in comparison with the other tests, are objectivity and better patient acceptance. Combination of PSA with DRE and TRUS provides the best results in early diagnosis of prostate cancer. The highest detection rates are observed with a positive DRE and high levels of PSA. The main controversies concern the group of patients with negative DRE and intermediate levels of PSA (4,1-10 ng/ml; Hybritech); in these cases other parameters, such as PSA density and/or PSA velocity, can be useful. The relationship between serie levels of the marker and age of the patients can also increase the diagnostic accuracy of the test. A screening programme in subjects at risk for prostate cancer (because of age, family history and race) may be founded on the association of PSA and DRE, using TRUS only when both PSA and DRE are positive or dubious. Lastly the Authors emphasize the importance of PSA in the clinical staging of the prostatic carcinoma, especially as predictor of bone metastases.

Flow Cytometry Role of DNA Analysis

We analyzed the results obtained by flow cytometry DNA analysis in prostatic cancer. We considered the diagnostic role of this investigation and the prognostic value observed from correlating the DNA analysis with usual diagnostic and prognostic factors such as staging, grading, PSA, size, etc. Results in literature suggest that further studies are necessary to explain both the biological and cytometrical heterogeneous aspects of this neoplasm.

Controversy regarding Diagnosis and Staging of Prostatic Carcinoma: The Role of Rectal Exploration and Imaging Methods

Although rectal examination (RE) represents the most utilized diagnostic tool, its reliability is limited by the large number of false positive results (low sensitivity) which” limit its use as a screening method. Transrectal ultrasound (TRUS) is very useful in the diagnosis of prostatic neoplasms, as the hypoechoic lesions are very likely to be cancerous and should be biopsied. Nevertheless tumoral hypoechogenicity is not specific and at most only 1 of 3 hypoechoic areas in the peripheral and central zones will prove to be cancer. Of palpable stage B cancers in the peripheral and central zones, 21% are reported to be isoechoic. Moreover cancers that arise in the transitional zone cannot ever be detected as hypoechoic tumors because of the heterogenic echo texture of this zone filled with diffuse hypoechoic nodules of BPH. The integration between RE, TRUS and PSA improves diagnostic accuracy. As far as neoplasm staging is concerned the proper evaluation of the Gleason score and spatial distribution of the tumor are referred by some authors to be assured only by means of “systematic” biopsies of the two prostatic lobes, independently of the echographic support. RNM and CT do not assure a better diagnostic or staging reliability, while endorectal RM is considered to afford, in comparison with TRUS, a better visualization of periprostatic structures and therefore a more reliable evaluation of neoplastic extracapsular extension.

Surgical Procedure for Treatment of Urinary Stress Incontinence

Genuine Stress Incontinence (GSI) is one of the most important chapters of female urology. Surgical treatment of GSI still remains an area of controversy in urology. The authors give an up-dated review of the subject; valuable support for people involved in this field.

Neurophysiology in Lower Urinary Tract Dysfunction

Although there is a great mass of data about specific aspects of normal vesico-urethral function, the physiology of the lower urinary tract remains poorly understood. Any attempt to write a coherent account of the subject will necessarily reflect the Author's bias. The reader should therefore remember that speculation will often creep in when substance is lacking.

Bladder Instability

Bladder instability is undoubtedly a major cause of incontinence. The condition is reasonably well-defined and advances in the last 20 years in the urodynamic diagnosis of the condition have stimulated a number of leading clinicians and research workers to focus their attention on this problem. The aim of this paper is to produce a better understanding of the unstable bladder.

Diagnostic and therapeutic problems in multicentric renal angiomyolipoma

Multicentric renal angiomyolipoma is a rare form of benign tumor. However, its effective incidence as evaluated in autopsy studies may be as high as 8%. There are 2 main types of renal angiomyolipoma, that is isolated forms and those associated with other diseases, such as phakomatosis, polycystic kidneys and fibromuscular dysplasia. The tumor may also display malignant behavior with local invasiveness and regional lymph node involvement. However, the clinical course is benign and multicentricity is important for prognosis. Histopathological diagnosis often is difficult. Immunohistochemical analysis of surgical specimens using a panel of monoclonal antibodies, including HMB-45 and actin, enabled us to make a definitive diagnosis in 3 cases of multicentric renal angiomyolipoma.

Laparoscopic pelvic lymphadenectomy

From March ‘92 we have introduced laparoscopic pelvic lymphadenectomy as an aid in staging prostatic cancer. In these patients precise lymph node dissection represents an important parameter for therapeutical decision. As regards this problem, up to now, the only efficacious technique was surgical lymphadenectomy. Pelvic lymph node dissection is usually considered to be part of a preliminary operation during radical prostatectomy, but it seems to be an extreme procedure regarding its pure staging finality. For these reasons we believe that laparoscopic lymphadenectomy represents a surgical technique destined to obtain much agreement between urologists. The technique we practise is very similar to the one described by Schuessler et al. Advantages of endosurgical lymph node dissection are mainly minor invasiveness that allows rapid recovery of the patient, together with a reduction of both postoperative morbility and hospitalization.

[Conservative surgical treatment of bilateral renal neoplasms]

Surgery seems to be the only effective treatment for bilateral kidney neoplasms as shown by the better survival rate of operated patients compared with those otherwise treated or untreated at all. The best conservative treatments, regarding radicality and security required by these neoplasms, are the enucleation and the partial in situ nephrectomy. Our study is based on 11 patients affected by bilateral kidney neoplasms; 8 of them, in which there were no signs of metastatization, have undergone surgical treatment. In 2 patients (18%) a bilateral enucleation was performed and in 6 (55%) monolateral enucleation together with a controlateral radical nephrectomy. All tumors developed simultaneously have been operated in the same session. No postoperative complications were observed except in 2 patients which developed a transient renal insufficiency. The follow up was from 2 to 66 months. All patients were examined with echotomography or CT scan at least once a year and are, up today, in good health condition and tumor free.

Considerations regarding a case of leiomyoma of the urinary bladder

In spite of its rarity, leiomyoma of the bladder deserves to be better known as its diagnosis is not always obvious, depending as it does mainly on urography confirmed by anatomo-pathological examination, and particularly because its treatment is simple and the prognosis always favourable, a fact worthy of note in dealing with a tumour of the bladder.