Aims and methods. LUTS suggestive of BPH

OBJECTIVE

Few epidemiological studies are available on Italian patients with lower urinary tract symptoms and their QoL. QUIBUS (QUality of life Investigated in BPH patients with Urinary Symptoms) is an observational longitudinal study aimed at evaluating symptoms and QoL in a large sample of Italian patients and investigating their correlation with demographic, social and clinical characteristics of BPH.

PATIENTS AND METHODS

Patients with lower urinary tract symptoms and prostate enlargement suggestive of BPH (both old and new diagnosis) were enrolled between November 1998 and May 1999 in 31 Italian centers of urology. This longitudinal investigation consists of an enrollment visit, in which demographic, social and clinical aspects are recorded as baseline data, and a follow-up visit after 1 year of treatment freely assigned by the investigators. Symptoms and QoL are assessed by means of IPSS, ICS-BPH (at both visits) and SF-36 (only at the follow-up visit) questionnaires.

RESULTS

1,033 patients were enrolled. The follow-up visit is still under evaluation. In this series of papers the baseline results are presented and discussed in terms of (i) medical management, (ii) life-style, (iii) symptoms, bothersomeness and QoL, (iv) sexual function of a large and representative sample of Italian patients and (v) uroflowmetry.

Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones

OBJECTIVES

To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones.

METHODS

This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an "adjunctive" treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group.

RESULTS

Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate (P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 (P = 0.02).

CONCLUSIONS

The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.

Lower urinary tract symptoms: what are the implications for the patients?

Patients with lower urinary tract symptoms (LUTS) suggestive of benign prostatic hyperplasia (BPH) complain about symptoms such as weak stream, dribbling, intermittency, frequency, nocturia and urgency. To effectively manage these symptoms, it is important to better understand the epidemiology and/or the bothersomeness of these symptoms, the impact of the symptoms on the patient's quality of life and life style, when and why patients seek medical advice and the subsequent management of LUTS/BPH in clinical practice. This paper gives an overview of these issues considering 3 recently conducted European surveys. Although voiding symptoms are more frequent in patients with LUTS/BPH, storage symptoms, such as frequency, urgency, nocturia and urge incontinence, seem to be more bothersome to the patients. LUTS seem to have a negative impact on the patient's quality of life and sexuality and to interfere strongly with daily life activities. With regard to sexuality, interference with the patient's overall sex life and erection problems is experienced as much more bothersome than ejaculation problems. After the initial symptoms, most patients postpone a visit to the physician and try to adjust their life style to self manage their symptoms. Eventually they seek medical advice because they are too much bothered by their LUTS. In Italy, medical therapy is the most frequently administered treatment option by urologists (57% of patients) followed by surgery (37% of patients). alpha(1)-Adrenoceptor antagonists are the predominant medical therapy prescribed (70% of all medically treated patients), particularly tamsulosin (35% of all medically treated patients). An interview with European urologists confirms that alpha(1)-adrenoceptor antagonists, especially newer uro-selective ones like tamsulosin, are a very appropriate initial treatment choice in the management of both voiding and storage LUTS.

Impact of early pelvic floor rehabilitation after transurethral resection of the prostate

We examined the results of teaching pelvic floor muscle exercises (PME) on micturition parameters, urinary incontinence, post-micturition dribbling, and quality of life in patients after transurethral prostatectomy (TURP). Fifty-eight consecutive patients who were selected to undergo TURP for benign prostatic hyperplasia (BPH) were admitted into the study: 28 were randomly assigned to a control group (A), 30 formed the investigational group (B) during an initial visit conducted before surgery. In group B patients, perineal exercises were demonstrated in detail, and tested for their correct use via simultaneous rectal and abdominal examination. After the removal of the urethral catheter, these patients were instructed to perform pelvic floor muscle exercises at home and were evaluated before the exercises and at weekly intervals postoperatively. The American Urological Association Symptom Score improved significantly after TURP in both groups. The average quality of life score improved more significantly in group B after TURP, from 5.5 to 1.5 (P < 0.001). The grade of muscle contraction strength after 4 weeks of PME increased from 2.8 to 3.8 in group B (P < 0.01); it was unchanged in the group A. The number of patients with incontinence episodes and post-micturition dribbling was significantly lower in the group B at weeks 1, 2, and 3 (P < 0.01). Our results show that pelvic floor muscle re-education produces a quicker improvement of urinary symptoms and of quality of life in patients after TURP. Its early practice reduces urinary incontinence and post-micturition dribbling in the first postoperative weeks. The exercises are simple and easy to perform in the clinical setting and at home, and therefore should be recommended to all cooperative patients after TURP.

Holmium:YAG laser ureterolithotripsy

OBJECTIVE

To report on the experience obtained in the treatment of a series of 150 cases of ureteral stone disease by means of the holmium:yttrium-aluminum-garnet (Ho:YAG) laser.

METHODS

One hundred and fifty consecutive cases treated by means of Ho:YAG laser ureterolithotripsy have been reviewed in order to assess the results. In 81 cases the stones were located in the lower third, in 47 in the medium third, and in 22 cases in the upper third of the ureter. The laser was set at a power of 8-10 W and at a frequency of between 6 and 10 Hz. Thin ureteroscopes were selected, such as the 7-Fr Gautier or the new ultrathin 4.8-Fr Wolf instrument. In some cases other ureteroscopes were chosen.

RESULTS

Lasertripsy was effective in every kind of stone, allowing fragmentation into portions measuring at most 4 mm (largest diameter) or disintegration. The clearance rate of the stones was 92.6% during the 30-day follow-up period. Calcium dihydrate stones were of course more easily broken than monohydrate ones. No damage to the ureter was observed following the vaporization which is produced by this kind of laser, since particular attention was paid to avoid any contact between the laser beam and the ureteral mucosa. In some instances ureteroscopic maneuvering provoked some slight lacerations. In a few cases accidental contact of the laser beam with the ureteral mucosa produced extremely small coagulations of no immediate or postoperative relevance.

CONCLUSIONS

The Ho:YAG laser constitutes an effective instrument for the fragmentation of any kind of ureteral stone; it allows the use of thin or ultrathin instruments and, if manipulated with care, does not damage the ureteral mucosa or the ureteral wall.

Ureteroscopic approach to early postoperative ureteral obstruction in the renal transplant patient

The ureteroscopic treatment of acute postoperative ureteral obstruction in a kidney transplant patient is presented. This approach was made possible by the use of thin instruments, which do not require predilation, and was chosen in place of antegrade nephrostomy or open surgical access. The concept that the ureteroscope must be adapted to the ureter and its characteristics and not vice versa is stressed. The increasingly widespread availability and use of thin and ultrathin ureteroscopes will ensure that this approach is likely to become the rule rather than the exception in the future.

Human ejaculatory duct: parameters of smooth muscle motor activity and modulatory role of autonomic drugs

The contractile behaviour and effects of several autonomic drugs on the motor activity of human isolated ejaculatory ducts were investigated. Ejaculatory ducts exhibited spontaneous contractions characterised by an amplitude of 2.35 +/- 0.28 mN, a duration of 62. 9 +/- 3.72 s and a frequency of 0.64 +/- 0.014 waves min-1. Acetylcholine (10-5-10-4 m) induced a slight increase in basal tone and in the frequency of the contraction waves. These effects were suppressed by atropine (10-4 m). Noradrenaline (norepinephrine) increased the basal tone and frequency of spontaneous contractions in a dose-dependent manner. These responses were competitively inhibited by HEAT, a selective a1-adrenoceptor antagonist. These preliminary functional findings, indicating the presence of spontaneous motor activity of human ejaculatory ducts and its possible control by adrenergic agonists, suggests a physiological role for human ejaculatory duct in the propulsion of semen from the seminal vesicle towards the urethra.

Large benign prostatic hyperplasia means impossible ureteroscopy: myth or reality?

OBJECTIVE

We intended to ascertain the true role played by large-size prostatic glands with BPH in impeding ureteroscopy; since no such impediment was experienced by the authors, we then listed the most frequent obstacles to ureteroscopy, contrary to what is commonly reported in literature.

MATERIALS AND METHODS

Endourological reports on a series of 2,147 diagnostic or therapeutic ureteroscopies were examined, together with the patients' clinical records. Male patients accounted for 1,288 cases. In 45 cases, the operators found the prostate so enlarged as to be worthy of note. In 9 of these cases, the procedure was performed bilaterally; thus, a total of 54 ureteroscopies was undertaken in patients with enlarged prostates or large median lobes.

RESULTS

None of the surgical reports indicated that the ureteroscopic procedure was hindered by an enlarged prostate. On the other hand, the most frequent causes preventing ureteroscopy are, for both male and female patients, some types of tumor: uterine, ovarian, ureteral, bowel, bladder and prostate cancer, and inflammation.

CONCLUSIONS

Benign prostatic hypertrophy (BPH) is not of itself an impediment to ureteroscopy when it is performed by an expert operator equipped with suitable instruments. On the other hand, tumours of the female reproductive system, as well as bladder and prostate tumours and serious inflammations and infections may make the procedure impossible or cause serious problems during its performance, at times requiring combined antegrade and retrograde maneuverings. At the root of this obstacle lies neoplastic or inflammatory infiltration and stiffening which attaches itself to the organs and hardens their connections. In the case of BPH, we do not find infiltration, but only a dislocation, which can be compensated by means of a few technical stratagems. Some interesting expedients in the incannulation of difficult meatuses were already suggested in 1914 by Heitz-Boyer and Marion.

Evaluation of morbidity of multi-channel pressure-flow studies

This prospective study was carried out to evaluate the morbidity and complication rate of invasive urodynamics of the lower urinary tract after receiving oral antibiotic prophylactic treatment. A total of 105 patients, 55 men and 50 women, were included in the study and underwent pressure flow study (PFS) as part of the diagnostic assessment. Clinical diagnosis was prostatic obstruction from benign prostatic hyperplasia (BPH) in men and stress urinary incontinence or voiding dysfunction in women. Urine was screened for infection both before and after testing, and the incidence of urinary tract infections (UTI), dysuria, and other complications were assessed at 1-week follow-up to evaluate post-investigation morbidity. Dysuria of mild degree was experienced by 33% of patients, with no significant difference between male and female patients. Post-investigational UTI and fever were reported in 3.6% of men and 4% of women. Six patients had macroscopic hematuria of mild degree. No patient had urinary retention or severe complaints after the investigation and no patient required hospitalization. Post-void residual volume was higher in men with BPH obstruction compared to women; a significant difference between post-investigational UTI and residual volume could not be demonstrated (P = 0.8). We conclude that the objective morbidity rate of invasive urodynamic investigation is low. Mild dysuria is common, while severe complications, fever, and hematuria are seldom reported, and the risk of developing UTIs is low with antibiotic prophylaxis, with no significant difference between men and women. Neurourol. Urodynam. 18:647-652, 1999.

Urodynamic analysis of voiding dysfunction in orthotopic ileal neobladder

We examined the urodynamics, particularly voiding dysfunction, in patients with a neobladder. Free uroflowmetry, pressure-flow study, and voiding cystourethrography were performed in 22 patients (mean age 65 years) at a mean of 21 months after ileal neobladder substitution. The results of free uroflowmetry were used to divide patients into two groups: the good voiders and the poor. Daytime continence was achieved in all patients, while 10 (45%) had nighttime continence. To void 250 ml urine the good voiders strained 2 +/- 1.5 times, and the poor voiders 6 +/- 5 times. The neobladder neck was at the most caudal portion of the reservoir in good voiders, and there was wide funneling. In the group with poor emptying ability, the outlet was not located at the most dependent position. The principal factors for ensuring good voiding function in neobladder patients are the ability to perform effective straining and the location of the neobladder neck.

[Temporary retrograde and anterograde ureteral catheterization]

This article examines the technical modalities or ureteral catheterization. The authors also discuss unconventional modalities which, if used without prejudice, can sometimes constitute brilliant and economic solutions to complex problems which are often impossible to resolve otherwise. After a summary of the history of ureteral catheterization, the authors present the main indications for temporary ureteral catheterization: radiographic and fluoroscopic examination of the ureter; separate cytological harvesting; separate bacteriological harvesting; confirmation of the side of unilateral haematuria; preliminary temporary dilatation of the ureter to prepare it for ureteroscopy; temporary drainage of the excretory tract after endourological investigation. The authors also present particular situations may be observed temporary catheterization, or even permanent stenting, for example in the case of procedures in children, pregnant women and renal transplant recipients.

Urinary symptoms in women with gynecological disorders: the role of symptom evaluation and home uroflowmetry

OBJECTIVE

The aim of our study was to analyze the effect of gynecological dysfunction on voiding symptoms in women.

METHODS

A modified AUA symptom index questionnaire was self-administered and an ambulatory home uroflowmetry was performed, using a specially designed home uroflowmetry apparatus for multiple flow measurements. Urinary symptoms and home uroflowmetry (Home Urodata TM System) were evaluated in 68 women: 34 patients with gynecological dysfunction, and 34 normal controls. A total of 156 urination episodes was recorded, with a mean of 5.4 measurements per patient.

RESULTS

Symptom index showed lower values in the group of normal controls than in the group with gynecological dysfunction. Voided volume, peak flow rate and average flow rate were all significantly better in the group of normal controls than in the group with gynecological disorders; the most remarkable changes were observed in patients with genital prolapse and with large uterine fibroma. In both groups the total urine volume was lower between midnight and 8 a.m. (2460 ml), if compared with the total urine volume between 8 a.m. and 4 p.m. (3360 ml) and the total urine volume between 4 p.m. and midnight (3072 ml) (p < 0.05).

CONCLUSIONS

Noninvasive home uroflowmetry combines the information of a typical flowchart with uroflow parameters and supplies the physician with multiple consecutive voiding episodes, minimizing the environmental artifacts of the study. In our experience it was found to be useful to evaluate urinary symptoms reported by 18/34 patients (52.9%) with gynecological dysfunction. It can help to select which patients require further urodynamic investigation to improve the diagnostic accuracy and choose the correct treatment.

Transurethral electrovaporization of the prostate in benign prostatic hyperplasia. Evaluation of results using different urodynamic parameters

We studied the obstruction-relieving capabilities of transurethral electrovaporization of the prostate (TVP) in 32 symptomatic patients with benign prostatic hyperplasia (BPH). Urodynamic studies with pressure-flow analysis were performed before and 6 months after treatment. All 32 patients showed significant improvement of both subjective and objective obstruction parameters. There were few postoperative irritative symptoms and one patient required recatheterization. In conclusion, TVP is a promising modification of performing transurethral resection of the prostate, and it is indeed capable of relieving bladder outflow obstruction.

Results of treatment of refractory interstitial cystitis with intravesical hyaluronic acid

Interstitial cystitis is a chronic benign disease of the bladder that causes bothersome and debilitating symptoms and mainly affects women. Since interstitial cystitis (IC) might result from a defective glycosaminoglycan layer of the bladder epithelium, we conducted a trial of hyaluronic acid (HA), used intravesically, to test its activity in the treatment of this disease. A total of 10 patients with typical findings of IC were included. Following bladder catheterisation, the patients received a dose of 40 mg, weekly for 6 weeks, and then monthly. Response to therapy was evaluated by comparing the pre-treatment and post-treatment symptom scores and voiding diaries. There was a 30% positive response rate at week 6, which was maintained until week 24. No significant local or general side-effects were noted during the course of treatment. Although we recorded a low incidence of success in our group of patients, the results of our limited study were satisfactory in the group of responsive patients (30%), who had no relapses during the observation period of 6 months. The intravesical administration of HA was well tolerated in all cases.

Urolume double prosthesis in the treatment of complex urethral strictures: a 5-year follow-up case report

The 5-year follow-up of the implantation of a UroLume double urethral stent in 2 patients with recurrent, post-traumatic urethral strictures is presented. The double implantation for each patient was done by the long extension of the urethral lesion. Only 1 patient presented a single phosphatic concretion in the implantation area during the extended follow-up. Urinary flow rates remained absolutely normal. Sexual life was unaffected. This simple modification of the UroLume implantation may offer effective treatment for extended and recurrent posterior urethral strictures in young sexually active men, for almost 5 years without early or delayed complications of clinical relevance.

Urinary tract dysfunction in multiple sclerosis: is there a relation with disease-related parameters?

The lower urinary tract is affected by multiple sclerosis in many patients. We screened urologically and neurologically 120 patients with a confirmed diagnosis of multiple sclerosis. The mean age was 42 years (range 22 to 69 years). Urodynamic investigation as well as neuro-urophysiological investigations were performed in all patients. Renal ultrasound was used to study morphology, and excretory urogram (IVU) was used to assess renal function and the upper urinary tracts in 105 patients. Obstructive symptoms were found more commonly than irritative symptoms. The urinary symptoms were found to be related to disease duration and not to disability status. Urodynamic abnormalities were statistically significantly related to disease duration (X2 = 38.51; P = 0.0001), and to the disability status (X2 = 76.70; P = 0.0001). Few patients, only 3.3%, had upper urinary tract dilatation. With medical management, hydronephrosis disappeared in all of the patients and did not recur. A combination of oral pharmacological agents and clean intermittent catheterization was used in the majority of the patients. We conclude that lower urodynamic abnormalities can be present in every patient with multiple sclerosis, and appear to be related to disease duration and disability status, thus early treatment based upon urodynamic evaluation and close follow-up can reduce morbidity and improve the quality of life.

Severe recurrent ureteral stricture: the combined use of an anterograde and retrograde approach in the prone split-leg position without X-rays

We report on a 50-year-old woman first treated by us in 1990 for uroseptic fever. Urography showed occlusion of the terminal tract of the lower third of the left ureter. The patient was submitted to successful left ureteroneocystostomy (UNCS). Three months later, she had a relapse of uroseptic fever, and urography showed right ingravescent dilation and excellent functional activity of the left urinary tract. Right UNCS was performed. A further relapse on the right side was again treated with UNCS and psoas-hitch bladder, but both the dilation and the occlusion persisted. Considering the state of the patient, and in order to remove the right nephrostomy that had been applied in the meantime, and to reduce the state of inflammation in view of further surgery, it was decided to treat the right ureteral total stenosis with ureteroscopic resection through the ureter facilitated by an other luminous flexible ureteroscope inserted upstream via nephrostomy. This technique is based on concepts searching for stenotic ureteral zones in transplanted kidneys, with the help of an adequate luminous catheter. An X-ray follow-up 9 months later evidenced that the maneuver was totally successful.

Behçet's disease and the neuropathic bladder: urodynamic features: case report and a literature review

We report on a 16-year old patient with a neuropathic bladder secondary to Behçet's disease, which is an uncommon vasculitis usually involving venules. The genitourinary manifestations of this disease are discussed, a neuropathic bladder being a rare complication of the involvement of the nervous system. Urodynamic assessment is important when voiding dysfunction is present; three patients previously reported revealed a bladder function changing from normal detrusor to overactivity. Our patient showed early and severe involvement of the nervous system, and detrusor areflexia two years after the onset of the disease. Spontaneous voiding was restored two months after urological management (intermittent catheterization) was started.

Diagnosis and treatment of ureteral calculi during pregnancy with rigid ureteroscopes

PURPOSE

There is still excessive debate as to the preferred diagnostic and therapeutic approach to urolithiasis in pregnancy. We report our experience with 15 pregnant patients with renoureteral colic marked by pain not responsive to analgesia, dilatation and fever. We focused on the usefulness of ureteroscopy with thin instruments and ultrasound in the diagnosis and treatment of ureteral stone and ureteral colic during pregnancy.

MATERIALS AND METHODS

Between 1990 and 1993 we performed ureteroscopy and ureterolithotripsy on 15 pregnant patients 16 to 30 years old. Gestation time ranged from 20 to 34 weeks. All patients underwent ureteroscopy with thin rigid 7.0F or 9.5F ureteroscopes without dilation of the ureteral meatus. The use of ionizing radiation was avoided before, during and after the procedures. A stone was extracted from the lower third of the ureter in 2 cases, displaced into the kidney from the middle third of the ureter in 3, and fragmented with the pulsed dye laser in 3, the holmium:YAG laser in 3 and the ballistic lithotriptor in 2. Finally absence of ureteral calculi was confirmed in 2 cases. A double pigtail ureteral catheter was placed via echographic guidance in 14 cases to monitor curling of the pigtail in the renal pelvis, while in 1 a cylindrical ureteral catheter was used. In 5 cases no anesthesia was necessary, while 10 required neuroleptic analgesia.

RESULTS

There were no complications after the procedure. All pregnancies were full term.

CONCLUSIONS

Rigid ureteroscopy may be performed on the entire urinary tract even during advanced pregnancy. Stones may be fragmented, extracted or displaced and double pigtail ureteral catheters may be applied with only sonographic guidance, at times without use of anesthesia. The use of small instruments, such as the Gautier ureteroscope, that do not require dilation or any particular manipulation of the ureteral meatus seems to be essential together with an accurate ureteroscopic technique. In this manner it is possible to diagnose and treat ureteral calculi during pregnancy without resorting to ionizing radiation but using only ultrasound monitoring and ureteroscopy.

Evaluation of bladder contractility in men undergoing transurethral resection of the prostate

OBJECTIVE AND METHODS

We analyzed preoperative and postoperative urodynamic parameters in 26 patients who underwent transurethral prostatic resection with the aid of a computer program. The parameters URA, W and Wmax were evaluated: URA affords a monitoring of the removal of obstruction, while Wmax and W function monitor changes in detrusor contractility, which appear significant after prostatic resection in obstructed patients.

RESULTS

Many patients had a fading contraction, that is detrusor contractility decreased during micturition: in most of them the removal of obstruction restored this pattern to normal.

CONCLUSION

Evaluation of these parameters is recommended for preoperative assessment and postoperative follow-up.

Ureterolithotripsy in children

OBJECTIVES

The pediatric application of ureteroscopy was initially hindered by the size of the instruments and the fear of damaging the urethra and ureterovesical junction during endoscopic maneuvers. This review of our experience is focused on the usefulness of thin and ultrathin ureteroscopes such as the 7 F Gautier rigid ureteroscope with rod lens optics (Wolf) or the new, ultrathin 4.8 F Wolf ureteroscope, semirigid, fiberoptic, in conjunction with atraumatic sources of energy such as pulsed dye laser or ballistic lithotripter, for the treatment of ureteral stones in children.

METHODS

Between 1989 and 1994, we performed ureteroscopy and ureterolithotripsy on 7 children less than 10 years old. There were 6 male patients and 1 female patient, with a mean age of 6 years (range, 3.5 to 10). We used the pulsed dye laser Pulsolith and the ballistic lithotripter Lithoclast, the Gautier (Wolf) rigid, rod lens ureteroscope (7 F), without the sheath or the blunt needle 4.8 F semirigid (Wolf), fiberoptic ureteroscope. In all cases a double pigtail ureteral catheter was left in situ.

RESULTS

In all 7 cases, the treatment was successful without early or delayed complications. In particular, no case of vesicoureteral reflux was observed in any of the children during subsequent follow-ups.

CONCLUSIONS

This article demonstrates the feasibility of ureteroscopy and ureterolithotripsy in children less than 10 years old with ureteral stones. We believe that because of the fragility of the ureter in the pediatric age group, ureteroscopic maneuvers should be performed and handled by experienced endourologists in well-equipped centers.

Urodynamic changes in benign prostatic hyperplasia patients treated by transurethral microwave thermotherapy

Our study describes the results obtained in 44 patients with benign prostatic hyperplasia (BPH) who underwent transurethral microwave thermotherapy (TUMT) and their follow-up at 12 months. Prostatron, a prostatic TUMT device which comprised a microwave heat generator and a cooling system, was used at our centre. Forty-four out of the 60 patients given the treatment had a 12-month follow-up to be evaluated. The evaluation of subjective symptoms, according to the Boyarsky symptom score, demonstrated a significant rate of response (p < 0.0005). The analysis of pressure-flow recordings demonstrated a reduction of mean detrusor opening pressure (p < 0.0005), a reduction of detrusor pressure at maximum flow 12 months after treatment (p < 0.0005) and an improvement of mean values of maximum flow after treatment (p < 0.0005). This study shows that TUMT, though it cannot be considered an alternative to surgical or endoscopic therapy of BPH for severely obstructed patients, can produce improvement of both subjective and objective parameters of mild prostatic bladder outflow obstruction.

Behaviour and urodynamic properties of orthotopic ileal bladder substitute after radical cystectomy

The study included 18 men, submitted to urodynamic investigation 9-18 months after cystoprostatectomy for bladder cancer and bladder substitution with a detubularized ileal segment as described by Studer-Zingg. Sixteen patients were continent by day and 3 were incontinent during the night so as to require the use of a condom catheter. The residual urine was over 100 ml in 3 patients, while it was low or absent in the remainder. Micturition was performed by straining, and maximal flow rates were normal, although the pattern was intermittent. The incidence of nocturnal incontinence was 55.5%. Measurement of the urethral pressure profile revealed a shortened functional length, and low pressure was found in 3 patients, with a maximum urethral closure pressure < 45 cm H2O. During extramural ambulatory urodynamic monitoring, pressure values in the neobladder usually ranged below 20 cm H2O and exceeded 34 cm H2O in only 2 patients who complained of daytime and nocturnal incontinence. The urodynamic features of the neobladder in patients who underwent radical cystoprostatectomy and bladder replacement with a detubularized ileal segment indicate low pressure at high-level filling.

Metastatic renal cell cancer treated with recombinant alpha 2a interferon and vinblastine

42 patients with advanced renal cell carcinoma were treated with a combination therapy with interferon alpha 2a (mean dosage 16 x 10(6) U i.m. 3 times/week) and vinblastine (0.1 mg/Kg every 21 days). 12 patients (28.5%) had a positive response. Of them 1 presented a complete response (2.38%), 5 a partial response (11.9%) and 6 a stable disease (14.2%). No significant side effects were observed apart from the flu-like syndrome (all patients) and a moderate leukopenia (45.2%). The median duration of responses was 10+ months (range 3-37 months). At 4-year follow-up the median survival time was 16.0 months (range 4-37 months).

[Simple renal cysts, biochemical analysis of the cystic fluid, and comparison with blood parameters]

62 specimens of cystic fluid drawn back by ultrasound guided needle-aspiration in 37 males and 25 females were evaluated biochemical analysis including magnesium, calcium, phosphorus, chloride, uric acid, total protein, sugar, urea, creatinine, sodium, potassium, total cholesterol, AST, ALT, ALP, ACP, PAP, alpha-amilasys. In our study Cl, Na and sugar showed similar concentrations in the two fluids. Uric acid, and urea were more concentrated in the cystic fluid while Mg, Ca and total protein were more pronounced in the blood. The results obtained seem to indicate that simple renal cyst could originate from glomerular proximal tubulus part of the nephron as consequence of an obstructive cause.

Evaluation of efficacy and tolerability of Nilutamide and Buserelin in the treatment of advanced prostate cancer

Several different medical strategies have been proposed for the treatment of advanced prostatic cancer: androgen withdrawal by surgical castration on indirect suppression of androgen production by estrogen or estrogen-like substances, antiandrogen compounds or LH-RH analogues. The Authors evaluated in detail tolerability and efficacy of a combination therapy of a LHRH analogue (Buserelin) and a pure antiandrogen (Nilutamide) in a group of 15 patients with advanced prostate cancer (stage D) followed over a period of six months.

Serum and urine ferritin in patients with transitional cell carcinoma of the bladder

Erythrocyte, serum and urine ferritin concentrations were evaluated in 20 patients suffering from transitional cell carcinoma of the urinary bladder and in 20 healthy men. No clinical or biochemical signs of liver disorders, chronic inflammatory states or infections were present in both the patients and the controls. Our results showed no significant difference in the erythrocyte ferritin concentration in both groups. On the contrary there was a statistically significant difference in mean serum (p less than 0.05) and urine (p less than 0.01) ferritin concentration between the two groups. The mean serum ferritin concentration in the patients was 102.23 +/- 63.38 ng/ml while it was 258.41 + 250.68 ng/ml in normal subjects. The mean urine ferritin concentration was 6.30 +/- 5.35 ng/ml in normal subjects and 22.66 +/- 25.59 ng/ml in patients with bladder cancer. Our data seem to demonstrate that the assessment of the ferritin either in the serum or preferably, in the urine, could become an interesting tumoral marker for bladder cancer.

[Ureteral lithotripsy with rigid ureteroscopy and pulsed dye laser]

Pulsed dye laser lithotripsy represents nowadays a new approach to ureteral stones. 27 patients were treated with a pulsed dye laser unit (Pulsolith TM) at our department from november 1989 to january 1990. 21 had a single stone and the remaining a multiple ureteral lithiasis. The pulsed dye laser operated at a wave length of 504 nm, energy ranged between 90 and 160 mj with pulse of 1,5 ms. A 320 theta diameter quartz fiber with Helium Neon red laser (to visualize the top of the fiber) introduced in a rigid 9.5 ureteroscope (Wolf) was used during the procedure. Spinal, peridural or general anesthesia was done in all patients and the time of the procedure ranged between 8-150 minutes. Fiber was inserted in a 4 Ch ureteral catheter which provided easier manipulation of the fiber. Complete fragmentation was achieved in 88.9% of the patients, and combined manoeuvres were requested in another 3.7%. Failures were 7.4%. Minimal lesions of the ureter, due to ureteroscope advancement subsided spontaneously after placement of double F catheter. Pulsed dye laser lithotripsy seems to be a safe and useful procedure for treatment of impacted ureteral calculi and seems to offer low morbidity in respect of ultrasonic or electrohydraulic procedures especially when the stone location does not permit an ESWL approach.

[Clinical observations about an oligomineral water from the "Funtana Piscamu" of San Leonardo di Siete Fuentes]

In this study we evaluated the effects induced by the administration of a natural oligomineral water "Funtana Piscamo" di San Leonardo di Siete Fuentes on patient with urinary stone disease. Urine from 30 stone formers attending our metabolic stone clinic were compared with freshly voided urine of 20 normal volunteers. A marked increase in urinary magnesium (p less than 0.001) and a change in the urinary Ca/Mg ratio (p less than 0.005) were the most striking features disclosed in patients with stone disease. This natural oligomineral water drawn from "Funtana Piscamu di San Leonardo di Siete Fuentes" seems to have a long-term efficacy in urinary stone prevention.

[Monitoring of erection function in patients with prostatic carcinoma treated with Casodex]

This study evaluates the sleep-related erections in 5 patients with locally advanced prostate cancer (T3NOMO) during 6 months treatment with Casodex by multinight continuous monitoring of penile tumescence and rigidity. Mean serum LH, Testosterone and Estradiol levels shown a no statistically significant increase at the six months control. We found no significant modifications in the number of NPT episodes, maximum penile circumference and rigidity time before and after therapy. Penile arterial flow and neurologic examination were also unmodified. All patients had a stable disease and unchanged performance status after 6 months. This pure antiandrogen in a men with prostate cancer does not seem to interfere with self reported libido and erectile capability.

[Qualitative analysis of 1447 patients with urinary calculi in the period 1979-1989 in Sardinia]

In this work we have examined the results obtained from the chemical analysis of 1447 urinary stones. The data concerning the frequency are distinguished according to the sex. Then we examined the difference between frequency of pure and mixed calculi in a sample, analyzing the results obtained by a subdivision in two periods of five years each. Our data are compared with those obtained in other regions of our country.

[Antibiotic prophylaxis with netilmicin in patients undergoing cystoscopic study]

Thirty adults of either sex, in several cases affected by severe urinary pathology, underwent check cystoscopy. An intramuscular injection of netilmicin 200 mg was administered one hour before the diagnostic procedure as antibiotic prophylaxis. Treated patients were controlled up to three months after cystoscopy, in order to verify the presence of urinary infections. Data obtained proved the efficacy of netilmicin in preventing postcystoscopy urinary infections in 87% of the cases. Safety was very good in all patients.

The effect of flutamide on basal and ACTH-stimulated plasma levels of adrenal androgens in patients with advanced prostate cancer

The effect of flutamide on basal and ACTH-stimulated plasma levels of adrenal androgens was investigated in 6 patients with untreated advanced prostate cancer, aged 52-75 yr. Flutamide was administered (250 mg three times daily) for 10 days; before and after treatment, a synthetic ACTH1-24 stimulation test (250 micrograms im, with blood sampling immediately before and 60 min after the stimulus) was performed. Basal plasma 17OH-pregnenolone (delta 5-17OHP), 170H-progesterone (delta 4-17OHP), androstenedione (A), dehydroepiandrosterone (DHEA) and its sulphate (DHEAS) were unchanged by flutamide treatment. In contrast, basal plasma testosterone (T) concentrations significantly increased (p less than 0.05). The response of cortisol delta 4-17OHP, delta 5-17OHP, A and DHEA to ACTH, as well as the ACTH-stimulated delta 5-17OHP/delta 4-17OHP, delta 5-17OHP/DHEA, delta 4-17OHP/A and DHEA/A ratios, were unchanged by flutamide treatment. These findings indicate that: a) Short-term flutamide administration enhances testicular steroidogenesis, via augmented LH pulse frequency; b) Adrenal steroidogenesis seems to be not affected by the drug, since ACTH-stimulated plasma levels of adrenal androgens and precursors/products ratios were unchanged.

Transitional cell carcinoma of the bladder in a young man. A multidisciplinary approach

A multidisciplinary diagnostic approach to a case of bladder carcinoma in a 19-year-old male smoker is presented. The transitional cell carcinoma was submitted to conventional histological examination, flow cytometry and cytogenetic analysis. Serum and urine tumour markers were also investigated. The tumour was diploid, with an increased proliferative phase, and a chromosome marker was found. A net decrease in serum and urine ferritin concentrations was noted after transurethral resection of the neoplasm and its low malignancy was confirmed at follow-up.

Short term effects of flutamide administration on hypothalamic-pituitary-testicular axis in man

The effect of short term administration of flutamide on the hypothalamic-pituitary-gonadal axis was studied in six patients with advanced prostate cancer (C2 stage). Flutamide significantly increased LH pulse frequency in all patients (p less than 0.05 by Wilcoxon's test). The FSH pulse analysis disclosed a similar pattern of LH. Plasma IC-T clearly increased following flutamide therapy; mean IC-T values were 2.67 +/- 0.47 ng./ml. and 4.67 +/- 0.62 ng./ml. before and after flutamide administration, respectively (p less than 0.05 by paired Student's t test). Our study demonstrates that flutamide acts in humans as a selective and specific antiandrogen compound.

Cytogenetic investigation on 30 bladder carcinomas

Cytogenetic study of 30 bladder carcinomas confirmed the heterogeneity and the complexity of the karyotypic picture in this type of tumor. Presence of numerical and/or structural chromosome aberrations was observed in all tumors. Clonal abnormalities were found in 19 cases. Chromosomes most frequently involved in changes were chromosome #1, #3 and #11(36.6%, 26.6%, and 20% of the cases respectively). Trisomy 7 and monosomy 9 were the sole abnormalities in one case each.

The effect of androgen blockade on pulsatile gonadotrophin release and LH response to naloxone

In order to clarify the effects of androgen blockade on the hypothalamic-pituitary-testicular axis in man, four patients with advanced prostate cancer, not previously treated, were given oral flutamide, 250 mg three times daily for 9 days. Before, and 7, 8 and 9 days after starting flutamide treatment, on separate days, the following tests were performed: a gonadotrophin pulsatility study, with 20 min interval blood sampling for 12 h, a naloxone test and a GnRH test. Flutamide induced a significant increase in both LH and FSH pulse frequency, while pulse amplitudes and plasma integrated concentrations (IC) of LH and FSH were unaffected. Plasma integrated concentrations of testosterone and oestradiol rose significantly, while that of prolactin was unaffected. The increase in plasma LH concentration induced by naloxone injection was abolished by flutamide treatment. On the other hand, the small FSH response to naloxone was unaffected by flutamide treatment. Response to GnRH was unaffected by flutamide. These results suggest that flutamide exerts effective androgen blockade at the hypothalamic level, since, despite increased plasma testosterone concentrations, gonadotrophin pulse frequency increased and the LH response to naloxone was abolished.

Identification of marker chromosomes in bladder tumor

Sequential staining with Giemsa and quinacrine mustard on direct cytogenetic preparations was employed to characterize the karyotype of five bladder tumors of different stage and grade (TNM classification). The use of QFQ-banding allowed: the characterization of 2 euploid and 1 pseudodiploid cases, and the identification, in the two hyperdiploid cases, of a number of rearranged chromosomes otherwise morphologically indistinguishable from the normal ones. The importance of banding technique on direct cytogenetic preparations is stressed.

Derivative 11 marker chromosome in bladder carcinoma

Cytogenetic studies on bladder carcinomas from two patients were carried out on preparations obtained by a direct method. The chromosome mode was 49 and 55, respectively. Several karyotypic changes were found in the tumors. Moreover, the analysis of Q-banded chromosomes revealed the presence in both cases of a chromosome 11p+. These rearranged chromosomes showed a very similar banding pattern. The finding of a der(11) chromosome marker in two patients is intriguing, and suggests the possibility of nonrandom chromosome changes in bladder carcinoma, as already found in other kinds of tumors. The occurrence of chromosome #11 aberrations in tumors of the urinary tract is discussed in connection with the current theories on oncogenesis.