[Endometriosis: aetiopathogenetic basis]

Endometriosis, defined by the presence of endometrial tissue outside the uterine cavity, is a common condition affecting 10% of women in the reproductive age. Menstrual factors reported to increase risk include dysmenorrhea, early menarche, and shorter cycle lengths. The theory of retrograde menstruation with implantation of endometrial fragments, in conjunction with peritoneal factors to stimulate cell growth is the most widely accepted. There is a growing body of evidence that immunological factors and angiogenesis play a key role in the pathogenesis of endometriosis. In women with endometriosis, there appears to be an alteration in the function of peritoneal macrophages, natural killer cells and lymphocytes, with production of growth factors and inflammatory mediators in the peritoneal fluid. Survival, adhesion, proliferation, invasion and vascularization of endometrial tissue in abdominal cavity may be the consequence of retrograde menstruation and referred to as implantation theory.

[Calciphylaxis and penile necrosis: a case report and review of the literature ]

INTRODUCTION

Calciphylaxis is a rare clinic condition characterised by skin necrosis due to medial and intimal calcification of small and medium arteries. It's observed in patients affected by end stage renal disease associated to secondary hyperparathyroidism. Penile involvement has been documented in very few cases. We present both a case of penile calciphylaxis and a review of literature, in order to increase comprehension of pathophysiology, diagnosis and therapy of this rare disease.

MATERIALS AND METHODS

A retrospective review of literature was performed after treating a case of penile calciphylaxis. We describe patient characteristics, clinical presentation, laboratory and histo-pathologic findings, therapeutic strategy and outcomes of the case.

RESULTS

A 65 year-old man, affected by diabetes, chronic ischemic cardiopathy and chronic renal failure in hemodialytic treatment, was referred to our unit for the presence of increased consistency and significative pain of the distal portion of penis evolving in a complete glans necrosis. Blood levels of parathormone (PTH), calcium (Ca) and phosphorous (P) resulted pathologically elevated, promoting tissutal calcium deposition. The patient was treated with partial penectomy and the histologic findings confirm diagnosis of calciphylaxis, showing an ulcerative necrosis of glans with extensive calcium deposition and luminal narrowing of penile small arteries.

CONCLUSIONS

The increase of number of patients with chronic renal failure in hemodialytic treatment could make penile calciphylaxis more prevalent in the future. Early diagnosis, lowering of pathologic blood levels of Ca and P associated to surgical treatment of necrotic lesions of the patient could be fundamental for a better prognosis of this aggressive disease.

[Carcinoma of the collecting ducts of Bellini: a case report with cutaneous metastasis as the initial clinical manifestation]

INTRODUCTION

Bellini's collecting ducts carcinoma represents a rare tumor with an aggressive behaviour with a poor prognosis and often metastatic at diagnosis. We report the first case documented of Bellini tumor with an initial clinic presentation represented by a cutaneous metastasis of scalp.

MATERIALS AND METHODS

All pertinent clinical information were compiled, including patient age, sex, mode of presentation, preoperative laboratory data, radiologic findings, surgery type, macro and microscopic findings, survival data.

RESULTS

After reporting an histopathologic finding of cutaneous metastasis of unknown origin adenocarcinoma with poorly differentiation, a voluminous 6 cm left mesorenal mass is diagnosed through uro-CT. Consequently, it is performed a left radical transperitoneal nephrectomy with consensual exeresis of scalp cutaneous lozenge at the level of previous excision. The histopathologic diagnosis reported was Bellini tumor at stage pT3a-N2-M1. It has not reported significative responsiveness to adjuvant chemotherapy and the patient was died seven months after diagnosis of cutaneous metastasis.

CONCLUSIONS

Most of Bellini’s carcinoma are already metastatic at presentation. Analyzing literature, it is never documented a cutaneous metastasis as first sign at clinical presentation. In this context, radical nephrectomy, differently from others subtypes of advanced renal cell carcinoma, does not seem to improve survival of the patient but rather, it can keep a role in palliation or in the context of new chemotherapeutic protocols.

Calcifilassi e Necrosi Peniena: Case Report e Revisione Della Letteratura

Introduction

Calciphylaxis is a rare clinic condition characterised by skin necrosis due to medial and intimal calcification of small and medium arteries. It's observed in patients affected by end stage renal disease associated to secondary hyperparathiroidism. Penile involvement has been documented in very few cases. We present both a case of penile calciphylaxis and a review of literature, in order to increase comprehension of patophysiology diagnosis and therapy of this rare disease.

Materials and Methods

A retrospective review of literature was performed after treating a case of penile calciphylaxis. We describe patient characteristics, clinical presentation, laboratory and histopathologic findings, therapeutic strategy and outcomes of the case.

Results

A 65 year-old man, affected by diabetes, chronic ischemic cardiopathy and chronic renal failure in emodialithic treatment, was referred to our unit for the presence of increased consistency and significative pain of the distal portion of penis evolving in a complete glans necrosis. Blood levels of parathormone (PTH), calcium (Ca) and phosphorous (P) resulted pathologically elevated, promoting tissutal calcium deposition. The patient was treated with partial penectomy and the histologic findings confirm diagnosis of calciphylaxis, showing an ulcerative necrosis of glans with extensive calcium deposition and luminal narrowing of penile small arteries.

Conclusions

The increase of number of patients with chronic renal failure in emodialithic treatment could make penile calciphylaxis more p\revalent in the future. Early diagnosis, lowering of pathologic blood levels of Ca and P associated to surgical treatment of necrotic lesions of the patient could be fundamental for a better prognosis of this aggressive disease.

[Development of an acute stroke care pathway in a hospital with stroke unit]

INTRODUCTION

Care pathways (CP) are tools for standardizing the management of patient in certain diseases with a predictable course, and they have demonstrated usefulness in clinical practice. In-hospital stroke CP have been implemented in departments of Neurology, General Medicine or Rehabilitation, however there are few studies developing an integrated CP in hospitals with an acute Stroke Unit (SU). The aim is to develop a CP capable of organizing and homogenizing the stroke assistance, and integrating the quality standards, in a hospital with an Acute Stroke Unit (SU).

METHODS

Members of the Neurology, Rehabilitation, Emergency and Preventive Medicine departments established a schedule of nine fortnightly meetings. Several documents that compound the CP were elaborated following the FOCUS-PDCA model, according with the scientific evidence and the in force clinical guides.

RESULTS

The following documents were elaborated: scientific-technical framework which integrates all processes; information document for patient/relatives on-admission; nurses protocols (social risk, disphagya, falling down risk and pressure ulcers); stroke rehabilitation guidelines for staff; treatment, care and monitoring sheets; recommendations at discharge for patient/relatives; stroke rehabilitation guidelines for patient/relatives; specific didactic units for patient/relatives; patient/relatives satisfaction survey; and quality standard document.

CONCLUSIONS

A stroke CP in a hospital with SU potentially promotes a more organized and efficient stroke care, as well as improve the patient/relatives satisfaction.

Optical filter with very large stopband (approximately 300 nm) based on a photonic-crystal vertical-directional coupler

We have designed, fabricated, and demonstrated a vertical directional coupler based on the coupling between a polymer waveguide and a W1 photonic crystal waveguide. The filters have a bandwidth of approximately 2 nm within a stopband of Delta lambda approximately 300 nm and an on-chip insertion loss of 1 dB. This is the first (to our knowledge) demonstration of a filter with such a large stopband that overcomes the bandwidth limitation of existing filters.

A Rare Case of Female Bladder Spontaneous Rupture

Bladder spontaneous rupture in the woman represents an extremely rare urologic emergency; its cause can be iatrogenic, neoplastic or diabetic.

Materials and Methods

A 56-year-old woman was referred to our unit because of the presence of acute abdominal pain, oligoanuria and vomiting for two days. At physical examination, the patient presented with confusional state, acute urinary retention and gross hematuria after urethral catheterization. Laboratory data demonstrated important metabolic abnormalities: hyperglycemia (946 mg/dL), acute renal failure (serum creatinine: 3.25 mg/dL), hyponatremia (120 mEq/L) and metabolic acidosis. At the CT of her abdomen and pelvis, a suspected bladder rupture (right lateral wall) was revealed, and confirmed after performing a retrograde cystography. Personal history was negative for trauma; glycemia was never controlled despite an important familiarity for type I diabetes. An episode of painless gross hematuria had occurred one month before, treated by the physician with antibiotics. Firstly the metabolic and electrolyte imbalance was corrected and then an emergency explorative laparotomy was performed. An important urinary leakage in the pelvis and a mild peritoneal effusion were documented. Furthermore, an important leak of papillary-like neoplastic material from the vesical breach was detected. The neoplasm seemed to involve the whole bladder. The surgical treatment consisted in bladder raphia, accurate washing of perivesical space, difficult salvage cystectomy (tenacious adhesions due to the urinary leakage) and bilateral ureterocutaneostomy. During the postoperative stay, the patient showed a difficult glycemia control with insulin therapy and wound dehiscence healed by second intention. The hospital discharge was on day 30, with the patient in good health and acceptable glycemia control.

Results

The pathological diagnosis was a G2 non-invasive urothelial carcinoma, also involving a vesical diverticulum; the neoplasm was associated with an erosive chronic cystitis with aspects of transparietal micro-abscessual flogosis (pT1 G2 N0 Mx). The patient will perform a CT scan 3 months after surgery before possibly starting chemotherapy.

Conclusions

Bladder spontaneous rupture in the woman is an extremely rare pathology; in the reviews we analyzed, it is dealt with as a clinical condition that more often occurs in patients submitted to pelvic surgery followed by adjuvant radiotherapy. Invasive bladder neoplasms, predominantly the sarcomatoid ones, are the second more frequent cause mentioned in the literature. Diabetic uropathy of the bladder associated with purulent bacterial cystitis in the elderly is the third cause, which is mentioned in two articles only. At last, only one study indicates the superficial urothelial bladder cancer (pT1- G2) as the responsible for this dramatic event. In our case, the suspected bladder diabetic uropathy, characterized by reduced perception of micturition stimulus, the increase in vesical capacity and detrusorial hypocontractility, were probably an important concomitant cause of this dramatic clinic condition, in association with the large superficial urothelial neoplasm. Moreover, diabetic neuropathy could explain the delay of patient presentation to the physician. Urinary leak, probably occurred 2 days before diagnosis, created an important metabolic imbalance and remarkable surgical difficulties. The timely treatment allowed for the resolution of a clinical condition associated with an elevated mortality due to septic shock.

Urological concerns: Should trans-urethral catheter be located over or under the thigh?

INTRODUCTION

Bladder catheterization is a common practice after several surgical procedures; a wrong trans-urethral catheter position can affect the outcomes of some urological maneuvers. We assess with a physical model the variation of intra-vesical pressures due to different locations of the catheter.

MATERIALS AND METHODS

Using a plastic bag fulfilled with 5l of normal saline, we try to reproduce bladder condition assessing pressures in case of catheter located over or under the thigh.

RESULTS

In case of catheter over the thigh, the flow of liquid is not allowed, and only a pressure of 23 cm of water induces the passage of fluid.

CONCLUSION

A wrong catheter position may adversely affect intravesical pressures; this finding has to be taken into consideration, especially when dealing with post-urological surgery catheterization.

Design and modeling of tapered waveguide for photonic crystal slab coupling by using time-domain Hertzian potentials formulation

This work introduces a new simulation approach to the evaluation of the time-domain electromagnetic (EM) field useful in the modeling of tapered waveguide for the Photonic Crystal Slab (PCS) coupling. Only solutions of two scalar Helmholtz-equations are used in the evaluation of electric and magnetic Hertzian-potentials that yields the EM field and the frequency response of the tapered waveguide. By considering simultaneously an analytical and a numerical approximation it is possible to reduce the computational burden. In order to compare the computational time we analyze the 2D structure by also using the Finite Difference Time Domain (FDTD) method and by the 3D Finite Element Method (FEM). The method is applied by starting from design criteria of the tapered structures in order to set the correct geometrical and physical parameters, and considers the field-perturbation effect in proximity of the dielectric discontinuities by generators modeling.

Indwelling Ureteral Stents and Sexual Health: A Prospective, Multivariate Analysis

PURPOSE

Ureteral stents are common devices in urological practice. However, a stent may provoke lower urinary tract symptoms that severely affect quality of life. We evaluated the relationship between ureteral stents and male erection/female sexuality.

MATERIALS AND METHODS

A total of 30 men and 20 women undergoing ureteral stent positioning were considered. Patients affected by risk factors for erectile dysfunction or hormonal and metabolic alterations were excluded. Hystero-ovariectomy and menopause were considered exclusion criteria. Three questionnaires were administered before stenting and 45 to 60 days after stent positioning, including the International Prostate Symptom Score, the International Index of Erectile Function-5 for men and the Female Sexual Function Index for women.

RESULTS

Mean age was 45 years in men and 39 years in women. The mean+/-SD International Index of Erectile Function-5 score was 23.2+/-1.27 and the mean Female Sexual Function Index score was 32.15+/-2.71 before stent positioning. No lower urinary tract symptoms were reported before the procedure. After the ureteral stent was indwelling the mean International Index of Erectile Function-5 score was 13.5+/-4.01 and the mean Female Sexual Function Index score was 23.6+/-14.66 (p=0.000 and 0.007, respectively). Of 30 men 25 reported a pathological International Index of Erectile Function-5 score and 6 of 20 women denied any sexual activity due to stent related anxiety, resulting in the minimum Female Sexual Function Index score. In the remaining 14 women sexual life was not significantly impaired by the ureteral stent (p=0.08).

CONCLUSIONS

Ureteral stents impaired the quality of sexual life in male and female subjects. In men the most important distress was in regard to erectile function, probably related to lower urinary tract symptoms. Conversely female sexuality appeared to be severely impaired due to stent related psychological concerns.

[Development of a clinical pathway for the attention of patients with amyotrophic lateral sclerosis in a regional network. ALS Assistance Network-Comunidad de Madrid]

INTRODUCTION

Amyotrophic lateral sclerosis (ALS) requires complex multidisciplinary attention. Clinical pathways are assistance plans for certain diseases with a predictable course. These plans are established in isolated centers, not in multicenter regions. The aim is to develop a clinical pathway capable of organizing and homogenizing assistance given in ALS Assistance Network-Comunidad de Madrid which is made up of five hospitals, from the beginning until the end of the disease.

METHODS

In successive meetings, neurologists of these hospitals and members of the Madrid Health Service evaluated published therapeutic guidelines and other documents used in ALS assistance. A clinical pathway was developed adapting this information to social-health care conditions in the Comunidad de Madrid following the FOCUS-PDCA model.

RESULTS

A clinical pathway was created consisting of a scientist-technical framework which arranges the attention in relationship to the diagnosis and treatment, according to the degree of disease progression and a chronogram. This is accompanied by several patient information documents on the disease and the tests that are required, and a patient assistance evaluation form. The standards are established to reach and to promote 354 constant improvement in patient care.

CONCLUSIONS

Clinical pathway for the ALS assistance in a regional network organizes the attention and cares that the patients must receive from the beginning to the end of the disease. This arrangement and homogenization of the attention improves the quality of patient care, diminishes variability and rationalizes the use of the health care resources.

Efficacy of expulsive therapy using nifedipine or tamsulosin, both associated with ketoprofene, after shock wave lithotripsy of ureteral stones

Extracorporeal shock wave lithotripsy (ESWL) is currently considered one of the main treatments for ureteral stones. Some studies have reported the effectiveness of pharmacologic therapies (calcium antagonists or alpha-blockers) in facilitating ureteral stone expulsion after ESWL. We prospectively evaluated the efficacy, after ESWL, of nifedipine on upper-middle ureteral stones, and tamsulosin on lower ureteral stones, both associated to ketoprofene as anti-edema agent. From January 2003 to March 2005 we prospectively evaluated 113 patients affected by radiopaque or radiolucent ureteral stones. Average stone size was 10.16 +/- 2.00 mm (range 6-14 mm). Thirty-seven stones were located in the upper ureter, 27 in the middle ureter, and 49 in the lower ureter. All patients received a single session of ESWL (mean number of shock waves: 3,500) by means of a Dornier Lithotripter S (mean energy power for each treatment: 84%). Both ultrasound and X-ray were used for stone scanning. After treatment, 63 of 113 patients were submitted to medical therapy to aid stone expulsion: nifedipine 30 mg/day for 14 days administered to 35 patients with upper-middle ureteral stones (group A1) and tamsulosin 0.4 mg/day for 14 days administered to 28 patients with stones located in the distal ureter (group A2). The remaining 50 patients were used as a control group (29 upper-middle ureteral stones-B1-and 21 lower ureteral stones-B2-), receiving only pain-relieving therapy. No significant difference in stone size between the groups defined was observed. Stone clearance was assessed 1 and 2 months after ESWL by means of KUB, ultrasound scan and/or excretory urography. A stone-free condition was defined as complete stone clearance or the presence of residual fragments smaller than 3 mm in diameter. The stone-free rates in the expulsive medical therapy group were 85.7 and 82.1% for the nifedipine (A1) and tamsulosin (A2) groups respectively; stone-free rates in the control groups were 51.7 and 57.1% (B1 and B2, respectively). Five patients (14.3%) in group A1, 5 (17.8%) in group A2, 14 (48.3%) in group B1 and 9 (42.8%) in group B2 were not stone-free after a single ESWL session and required ESWL re-treatment or an endoscopic treatment. Medical therapy following ESWL to facilitate ureteral stone expulsion results in increased 1- and 2-month stone-free rates and in a lower percentage of those needing re-treatment. The efficacy of nifedipine for the upper-mid ureteral tract associated with ketoprofene makes expulsive medical therapy suitable for improving overall outcomes of ESWL treatment for ureteral stones.

Laparoscopic radical cystectomy: an Italian survey

BACKGROUND

Radical cystectomy with urinary diversion is the current gold standard procedure for muscle-invasive bladder cancer. However, laparoscopic radical cystectomy (LRC) has evolved rapidly worldwide during the past decade, despite its complexity due to both the demolitive step with management of a highly aggressive cancer and the reconstructive step. The authors performed a survey to assess the Italian experience with LRC and urinary diversion in an effort to point out the volume of the procedure in their country, providing some surgical details.

METHODS

A total of 10 Italian urologic departments with experts in laparoscopic urologic surgery were contacted and asked to participate in a two-page survey concerning indications for cystectomy, laparoscopic technique, intra- and postoperative complications, and follow-up evaluation of the procedure when available.

RESULTS

Five sites elected to participate, and a total of 83 LRCs were collected. All centers used five trocar ports. The mean operative time was 8 h and 40 min, and the estimated blood loss was 376 ml. In two cases, the procedure was converted to open surgery. Postoperative complications consisted of one urinary leakage, one fistula, and one atrium rupture. A retrieval sac was used in all cases. Urinary diversions consisted of 43 ileal conduits, 26 orthotopic diversions, and 14 other techniques. The mean follow-up period was 9 months (range, 1-36 months). No tumor seeding was recorded.

CONCLUSIONS

The LRC procedure is feasible although technically demanding. The morbidity of this procedure is evident, but may be reduced with further experience. Bowel management and reconstruction remain the most challenging part of the procedure.

Parapubic hernia and diabetes insipidus

According to the current literature parapubic hernia is regarded as a relatively rare pathology. The causative defect is usually related to pelvic surgery, traumatism, or bone malformation. Surgical treatment is difficult, because aponeurotic tissue on which to anchor a mesh on the caudal aspect of the defect is missing. This report describes a case of an incisional pubic hernia related to megabladder in a woman affected by diabetes insipidus and with a past clinical history of multiple pelvic interventions. As far as we are aware this report adds a new pathogenetic issue for parapubic hernias not previously described in the literature.

Medical Therapy of Urolithiasis

Nephrolithiasis treatment has become easier and less invasive with the development of extracorporeal shockwave lithotripsy (SWL) and endourologic techniques. However, medical therapy represents a well-established and complementary approach that can improve the efficacy of SWL and endourology. During recent decades, pharmacologic intervention has become more effective in stone disease: drugs can control the pain of renal colic, interfere at various levels in lithogenesis, and contribute to the expulsion of stones. It is well known that lithogenesis is a multifactorial process influenced by environmental-nutritional factors (low urinary volume, diet rich in animal protein, etc) and metabolic alterations; i.e., hypercalciuria, hyperuricosuria, and deficiency of stone-inhibiting factors (citrate, magnesium, glycosaminoglycans [GAGs]). Specific drugs such as citrate, allopurinol, and thiazide represent highly effective treatments for the promoting factors. Furthermore, recent findings suggest an interesting role for a phytotherapeutic agent, Phillantus niruri, and its inhibitory action on calcium oxalate crystallization related to the higher incorporation of GAGs into the calculi. Another step forward in medical management of stone disease is expulsive therapy. Many studies have proven the efficacy of medical expulsive therapy with nifedipine and alpha-blockers: their specific action on ureteral smooth muscle in association with anti-edema drugs accounts for their efficacy in expelling ureteral stones. In this paper, we provide an update on the medical treatment of stone disease, focusing our attention on what is known and what is new in renal colic and litholithic and expulsive medical therapy.

Can Phyllanthus niruri Affect the Efficacy of Extracorporeal Shock Wave Lithotripsy for Renal Stones? A Randomized, Prospective, Long-Term Study

PURPOSE

Phyllanthus niruri is a plant used in Brazilian folk medicine for the treatment of urolithiasis. We assessed the efficacy of P. niruri after extracorporeal shock wave lithotripsy for renal stones.

MATERIALS AND METHODS

We prospectively evaluated 150 patients with renal stones that were as large as 25 mm and composed of calcium oxalate. All patients received 1 to 3 extracorporeal shock wave lithotripsy sessions by Dornier Lithotriptor S. After treatment 78 of 150 patients (52%) underwent therapy with Uriston, a P. niruri extract (2 gm daily) for at least 3 months (group 1). Otherwise 72 of 150 patients (48%) were used as a control group (group 2). No significant difference in stone size between the 2 groups was found. Stone clearance was assessed after 30, 60, 90 and 180 days by abdominal x-ray and ultrasound scan.

RESULTS

Stone-free rate (stone-free defined as the absence of any stone or residual fragments less than 3 mm) was 93.5% in group 1 and 83.3% in group 2 (p = 0.48) at the end point of the followup (180 days). For lower caliceal stones (56 patients) the stone-free rate was 93.7% in the treatment group and 70.8% in the control group (p = 0.01). Re-treatment need for group 1 was 39.7% and for group 2 it was 43.3% (p = 0.2). No side effects were recorded with extracorporeal shock wave lithotripsy or P. niruri therapy.

CONCLUSIONS

Regular self-administration of P. niruri after extracorporeal shock wave lithotripsy for renal stones results in an increased stone-free rate that appears statistically significant for lower caliceal location. Its efficacy and the absolute lack of side effects make this therapy suitable to improve overall outcomes after extracorporeal shock wave lithotripsy for lower pole stones.