PROGNOSTIC PARAMETERS IN ADULT IMPALPABLE ULTRASONOGRAPHIC LESIONS OF THE TESTICLE

PURPOSE

Through an analysis of individual published data we assessed whether prognostic criteria exist for adult impalpable testicular sonographic lesions.

MATERIALS AND METHODS

We performed a bibliographic search on PubMed, MEDLINE, EMBASE online databases from 1990 to May 2004 using search words such as sonographic lesions of the testicle, impalpable tumors of the testicle and impalpable testicular lesions. Six articles were found that presented a description of the histological characteristics, patient age, lesion dimensions, presence of cryptorchidism and association with tumors in other parts of the body. A multivariate analysis was performed comparing the characteristics that appeared more interesting from a univariate analysis.

RESULTS

The characteristics of the 48 impalpable sonographic lesions were examined. Histologically 15 of the lesions were Leydig cell tumors (31%), 12 (25%) seminomas, 7 (14.5%) nonseminomatous germ cell tumors, 2 (4.5%) Sertoli cell tumors, 12 (25%) benign forms (fibrosis, infarct, lipoma, mesothelial hyperplasia, adenomatoid tumor). The average age was 37.5, average dimension was 10.11 mm. The lesions were hypoechoic in 85% of the cases. Of the patients 31% were infertile. Multivariate analysis showed that histological data were correlated with lesion dimensions and presence of infertility. Dimension was particularly related to germ cell tumors (for dimensions between 16 and 32 mm relative risk ratio [RRR] = 13.97, p=0.0449). Infertility proved significant in defining stromal tumors (RRR = 9,681, p=0.022)

CONCLUSIONS

Although with the limits of a retrospective study consisting in an analysis of individual data, interesting correlations between malignant pathologies and the initial characteristics of impalpable sonographic lesions were revealed. In particular an interesting correlation was found between the dimensions of the lesion and the malignant pathology and between Leydig cell tumor and infertility.

Testicular-sparing microsurgery for suspected testicular masses

OBJECTIVE

To describe a microsurgical technique for removing suspected testicular masses with sparing of the testicular parenchyma, and to describe case studies.

PATIENTS AND METHODS

Six men were referred with testicular lesions (3-6 mm) detected on ultrasonography (US); in one, the lesion was palpable. US showed hypoechoic lesions and in two cases were mixed hypoechoic and anechoic. In these men, the testicular lesion was identified by US before surgery, giving three-dimensional coordinates to facilitate intraoperative recognition. A traditional inguinal incision was used and the funiculus clamped subinguinally without opening the canal. The testicle was isolated after sectioning the gubernaculum testis. In a separate operative field, an equatorial incision of the albuginea was made in a plane orthogonal to the major axis of the testicle, sparing the subtunical vasa. The parenchymal lobuli were dislodged and the seminiferous tubules dissociated, the nodule identified and completely removed, together with approximately 1 mm of surrounding healthy tissue. This technique can also be used for microsurgical testicular sperm extraction (MicroTESE), to retrieve sperm in infertile men.

RESULTS

In two infertile men MicroTESE was also performed. Histology revealed one case each of seminoma, Leydig-cell tumour, Leydig cell hyperplasia, atrophy, normality in the incidental forms, and complicated cysts of the albuginea. In the follow-up for infertility reasons, no scarring was observable on the tunica albuginea in the men who had conservative therapy. One year later the patient with seminoma was free of disease.

CONCLUSIONS

The increasingly frequent detection of benign testicular lesions, particularly in infertile men, calls for a surgical approach that must be as conservative as possible for the testicular parenchyma. We think that microsurgery should be the first-line technique in small suspected testicular lesions in infertile men.

Multidetector computed tomography of the head in acute stroke: predictive value of different patterns of the dense artery sign revealed by maximum intensity projection reformations for location and extent of the infarcted area

Maximum intensity projections reconstructions from 2.5 mm unenhanced multidetector computed tomography axial slices were obtained from 49 patients within the first 6 h of anterior-circulation cerebral strokes to identify different patterns of the dense artery sign and their prognostic implications for location and extent of the infarcted areas. The dense artery sign was found in 67.3% of cases. Increased density of the whole M1 segment with extension to M2 of the middle cerebral artery was associated with a wider extension of cerebral infarcts in comparison to M1 segment alone or distal M1 and M2. A dense sylvian branch of the middle cerebral artery pattern was associated with a more restricted extension of infarct territory. We found 62.5% of patients without a demonstrable dense artery to have a limited peripheral cortical or capsulonuclear lesion. In patients with a 7-10 points on the Alberta Stroke Early Programme Computed Tomography Score and a dense proximal MCA in the first hours of ictus the mean decrease in the score between baseline and follow-up was 5.09+/-1.92 points. In conclusion, maximum intensity projections from thin-slice images can be quickly obtained from standard computed tomography datasets using a multidetector scanner and are useful in identifying and correctly localizing the dense artery sign, with prognostic implications for the entity of cerebral damage.

The use of vesical irrigation system dual pump Endo FMS urology in the endoscopic therapy of the vesical neoplasms

OBJECTIVE

The objective of this study was to determine whether vesical irrigation during transurethral resection of bladder tumours (TURBT) with the dual pump system for the intracavitary irrigation Endo FMS Urology is more efficient than the standard gravity technique.

METHODS

One hundred patients suffering from vesical neoplasms underwent TURBT using the Endo FMS Urology (group A). They were compared to 100 patients previously (2002-2003) treated endoscopically for vesical tumours with the standard endovesical irrigation method (group B).

RESULTS

We demonstrated a reduction of the average time of resection of 10% in favour of patients of group A, a reduction of 39% of the amount of fluid of vesical irrigated in favour of patients of group A. No differences were observed in the recurrence rate of tumours at 3 months and in need of endoscopic revision in the 48 hours following TURBT. Two patients required blood transfusion after TURBT in group B, none in group A. The average time of hospitalisation in group A was less than one day.

CONCLUSIONS

On the basis of this experience the use of Endo FMS Urology Irrigation System in TURBT is strongly recommended.

Traumatic lesions of corpus callosum: early multidetector CT findings

Corpus callosum is one of the common sites of brain lesion, whose involvement is an indicator of a more severe prognosis, produced by traumatic shearing stresses resulting in diffuse axonal injury (DAI). Computed tomography (CT) in acute phase is considered to have a limited role for the detection of non-hemorrhagic or petechial hemorrhagic DAI lesions. New generation multidetector CT scanners allow faster acquisition of thinner-slice images and post-processing reformations. Three patients with severe closed head trauma underwent CT examinations using a multidetector scanner, a few hours and the day after injury. The review of original images with narrow window width and integration with reconstruction of thinner slices from raw-data and post-processing multiplanar reformations (MPR) helped to detect the onset of hypodense or predominantly hypodense areas of corpus callosum, not present at admission and afterwards confirmed by MRI.

Detection of testicular ultrasonographic lesions in severe male infertility

PURPOSE

We retrospectively assessed the number and histology of testicular lesions diagnosed clinically and by ultrasonography in a population of infertile men.

MATERIALS AND METHODS

From October 2000 to January 2003, 560 infertile men underwent physical examination, hormonal assessment (follicle-stimulating hormone, luteinizing hormone, testosterone) and scrotal ultrasonography. Eight men were diagnosed with focal testicular ultrasonographic lesions. In 4 cases there was a palpable lesion and in the other 4 cases the lesion was not palpable, diagnosed by ultrasonography (1 was cryptorchid). Only cases of lesions with clear-cut ultrasonographic edges and no history of recent genital infections were considered for explorative surgery through the groin. Microcalcifications were reported if present. The testicle was only preserved when frozen section examination revealed a benign lesion and the margins were negative.

RESULTS

Gynecomastia was not present in any patient. No microcalcifications were observed. Follicle-stimulating hormone was high in all patients (range 19.8 to 66.0 mUI/ml, mean 34.4). Luteinizing hormone levels were variable (range 1.32 to 28 mUI/ml, mean 12.3). Testosterone was normal in all cases (range 2.82 to 6.25 ng/ml, mean 4.2). Ultrasonographic features of the lesions were hypoechoic area (6 patients) and mixed hyper-hypoechoic area (2 patients). Histological outcomes of Leydig cell tumor (in 3 patients), focal Leydig cell hyperplasia (1 patient), fibrosis (1 patient), diffuse Leydig cell hyperplasia (1 patient), classic seminoma (1 patient) and embryonal carcinoma (in 1 patient) were observed.

CONCLUSIONS

Of 560 infertile patients 8 (1.4%) showed focal testicular lesions, 2 (0.4%) were diagnosed with germ cell tumors and 3 (0.5%) with interstitial cell neoplasms. The malignant tumors were both palpable and in 2 of 3 cases Leydig cell tumors were diagnosed only with ultrasonography.

High Incidence of Benign Testicular Neoplasms Diagnosed by Ultrasound

PURPOSE

We evaluated the clinical and histological significance of incidental ultrasonographic focal testicular lesions and assessed whether a conservative surgical approach may put the patient at higher oncological risk due to insufficient surgical eradication.

MATERIALS AND METHODS

From October 2000 to May 2002 all patients with infertility, scrotal swelling, scrotal pain, varicocele, scrotal trauma or erectile dysfunction underwent scrotal ultrasonography. A total of 1,320 patients were investigated. Focal testicular lesions were found in 27 patients (2%), palpable nodules were present in 17 (63%) and nonpalpable incidental lesions were diagnosed in 10. Nodule diameter was 3 to 24 mm. All patients underwent explorative surgery via inguinotomy and preventive clamping of the spermatic cord. The nodules were completely removed with biopsy of the resection margins. Nonpalpable lesions were removed under ultrasonographic guidance. The testicle was only preserved when frozen section revealed a benign lesion and margins were negative.

RESULTS

Of the 17 cases of palpable lesions (diameter 3 to 24 mm) conservative surgery was performed in 8 (47%). Definitive histological diagnosis showed Leydig cell tumor in 2 (25%), and large cell calcifying Sertoli's cell tumor, adenomatoid tumor, pseudofibrotic tumor of the tunica albuginea, epidermoid cyst, tubular fibrosis and non-Hodgkin's lymphoma in each 1 (12.5%). The remaining 9 patients (53%) underwent orchidectomy. Definitive histological examination revealed pure seminoma in 4 patients (44%), embryonal carcinoma in 4 (44%) and diffuse Leydig cell hyperplasia in 1 (12%). Seven of the 10 pts (70%) with nonpalpable nodules (diameter 4 to 16 mm) underwent conservative surgery. Histological study revealed focal Leydig cell hyperplasia in 1 case (10%), fibrosis in 3 (30%), infarction in 2 (20%) and mesothelial hyperplasia in 1 (10%). Orchiectomy was performed in the remaining 3 pts. Histology showed diffuse Leydig cell tumor in 2 pts (20%) and adenomatoid tumor with abscessed areas in 1 (10%). Neither atrophy nor local relapse was observed in pts who underwent conservative treatment during followup (mean: 1 month, range 19 to 9).

CONCLUSIONS

The incidental diagnosis of testicular ultrasound alterations is increasing and 80% show a benign histology. In these cases a conservative surgical approach is the best option and it does not expose the patient to the risk of relapse.

[Meaning and etiopathogenesis of sectorial transient hepatic attenuation differences (THAD)]

PURPOSE

To examine sectoral transient hepatic attenuation differences (THAD) in an attempt to correlate semeiotics with etiopathogenesis and to deduce a possible diagnostic value.

MATERIALS AND METHODS

Over a period of three years (January 1998-January 2001) we observed 130 THAD in 988 patients, and we selected 30 sectoral THAD in 18 patients (10 males and 8 females), ranging in age from 24 to 82 years (average = 63.3). The 18 patients comprised 6 cancer patients undergoing CT staging/restaging, 5 cirrhotic patients being studied for possible hepatocellular carcinoma, 7 patients undergoing helical CT to further investigate clinical and/or US findings. For each patient a biphasic helical CT liver examination was performed, during the arterial and portal dominant phase. After the first diagnosis, all patients were followed up for 12 months with at least one US and helical CT examination; 8/18 were also studied by MRI.

RESULTS

Thirty THAD were associated with 14 metastatic lesions, 4 hepatocellular carcinomas, 1 cholangiocarcinoma of the liver, 4 haemangiomas, 3 abscesses, 1 FNH, 2 cases of arterioportal shunting (APS) and 1 fine-needle percutaneous biopsy. Nine THAD turned out to be the sole sign of disease and occurred at least 3/6 months before the causal focal lesion had become detectable. At the first examination, all focal lesions had a maximum diameter of 2 cm; the size of THAD varied from 1 to 5 cm. All of the THAD were sectoral, with the base side represented by the glissonian capsule and the apex towards the parenchyma. 27/30 THAD were connected to focal lesions: 24/27 were fan-shaped and the lesion was situated at the apex of the triangle; 3/27 were roughly wedge-shaped and the lesion was entirely inscribed in the hyperattenuating area. 3/30 were not connected to focal lesions, being in 2 cases fan-shaped and in only one case irregularly shaped.

CONCLUSIONS

Sectoral THAD may or may not be connected to focal lesions. Whenever a sectoral THAD not connected to a focal lesion is detected, all of the possible causes should be considered: portal or superhepatic vein thrombosis, traumatic (biopsy) or cirrhotic intraparenchymal APS, or a benign occult nodule. If none of these explanations are confirmed, we should consider the possibility of an occult malignant lesion.

CT in acute stroke: improved detection of dense intracranial arteries by varying window parameters and performing a thin-slice helical scan

We evaluated the possibility of improving detection of a dense intracranial artery on CT in acute stroke by narrowing window width, varying window level and performing a thin-slice helical scan for the circle of Willis, in some cases followed by postprocessing maximum-intensity projections. We carried out 32 examinations of 31 patients with a documented cerebral ischaemic attack, performing cranial CT within 6 h of the onset of symptoms. Patients with intracranial haemorrhage were excluded, as were patients who went on to thrombolytic therapy. Varying window width and centre level on standard 5 mm thick contiguous axial slices, we detected a dense proximal middle cerebral artery (MCA) in a higher proportion of patients. A 1.1 mm thick helical scan through the circle of Willis improved recognition of a dense distal horizontal segment and the temporoinsular branches of the MCA and of a dense posterior cerebral artery.

Transient hepatic attenuation differences (THAD) not connected to focal lesions

PURPOSE

To report our experience with helical CT evaluation of transient hepatic attenuation differences (THAD), and in particular of those not associated with focal lesions, in an attempt to provide an aetiopathogenetic picture that accounts for the morphology, evolution and density of THAD.

MATERIALS AND METHODS

Between January 1998 and January 2001 we observed THAD in 130/988 biphasic helical CT liver examinations performed in the arterial and portal dominant phase. THAD were associated to focal hepatic lesions in 87 patients; in 43 patients there was no such association. This second group of patients, composed of 23 males and 20 females ranging in age from 17 to 80 years (average = 58.8), was enrolled in the study. THAD were associated to: Budd-Chiari syndrome (9), portal venous thrombosis (10), liver cirrhosis (7), acute inflammation of an adjacent organ (4), dilatation of the entire biliary tree (3), hepatic stasis caused by heart failure (2) and constrictive pericarditis (1), fine-needle percutaneous biopsy (2), arterioportal shunting (2), parenchymal compression by fractured ribs (2) and by a strengthened phrenic pillar (1). THAD were evaluated according to extension, morphology and density. For each case at least 10 density measurements were performed by sampling regions of interest on the parenchyma with THAD and on the contralateral parenchyma. The results (mean and standard deviation) were compared to those relative to 30 healthy patients. 22/43 patients were followed up for 6#150;24 months by at least one US and helical CT examination. During CT, the direct appreciation of vascular thrombus during the portal dominant phase was also considered.

RESULTS

We detected 18 localised and 25 diffuse THAD. The localised sectoral THAD (11), wedge-shaped with clear border sign, were associated to thrombosis of a portal branch (6), fine-needle percutaneous biopsy (2), arterioportal shunting (2) and partial Budd-Chiari syndrome (1). The localised non-sectoral THAD (7), with variable morphology and without the clear border sign, were associated to acute inflammation of an adjacent organ (4) and to parenchymal compression by the ribs or diaphragm (3). Diffuse THAD associated to Budd-Chiari syndrome (8) and to heart failure (3) showed mosaic enhancement of hepatic parenchyma (patchy pattern); those linked to portal trunk thrombosis (4) and cirrhosis (7) revealed predominant enhancement of external hepatic parenchyma (central-peripheral phenomenon); finally, those concurrent with dilatation of the entire biliary tree showed parenchymal enhancement close to the dilated bile ducts (peribiliary pattern). Follow-up (22/43) demonstrated complete THAD regression after removal (5/22) and less conspicuity of THAD after partial overcome of the stoppage (1/22). In 2/22 cases of arterioportal shunting no substantial changes were seen. The remaining 14/22 cases showed a gradual, slow tendency towards THAD regression with hypotrophy of the involved parenchyma and compensatory contralateral hypertrophy even in the case of endurance of the causative agents.

CONCLUSIONS

Based on our experience and the literature we suggest a classification for THAD unrelated to focal hepatic lesions. We recognise 4 causes: portal vein stoppage-obstruction, portal in-flow diversion, trauma and inflammation. When THAD is related to the first three causes pathogenesis is portal hypoperfusion. In the fourth group the mediators of the arterial phenomena are those of inflammation even though portal hypoperfusion might be involved as well. THAD identification makes the detection of vascular thrombi easier by comparison with their direct finding during the portal dominant phase. Finally, THAD are to be investigated for their potential utility in the detection and characterisation of several hepatic diseases. As a consequence, hepatic CT studies cannot ignore arterial dominant phase evaluation, even if no focal hepatic lesions are expected.

[Physiology of the urethral sphincteric vesico-prostatic complex]

We propose a review of the literature about innervation and physiology of the urethral sphincteric complex. Parasympathetic innervation of the pelvic viscera comes from ventral branches of the sacral nerves (S2-S4). The orthosympathetic component derives from superior hypogastric plexus and runs down the hypogastric nerves to form the right and left pelvic plexus together with the parasympathetic component. The pelvic plexus is situated inferolaterally with respect to the rectum and runs on the surface of the levator ani muscle down to the prostatic apex. The pelvic plexus gives innervation to the rectum, the bladder, the prostate and the urethral sphincteric complex. The pelvic muscular floor is innervated by the somatic component (pudendal nerve) derived from the sacral branches (S2-S4). Bladder neck and smooth muscle urethral sphincter innervation is given mostly by the orthosympathetic component. The rhabdosphincter innervation comes from the pudendal nerve and from the pelvic plexus; its role in the continence mechanism is probably to give steady tonic urethral compression. Levator ani muscle takes part in the sphincteric complex with its anteromedial pubococcygeal portion. It plays its role strengthening the sphincteric tone during increase of the abdominal pressure or during active quick stop cessation of the urinary stream.

[Anatomy of the urethral sphincteric vesico-prostatic complex]

As 27 different names have been proposed for the components of the urethral sphincter, it is difficult to build a clear anatomical model of it. Starting from a review of the literature and from some personal observations of surgical anatomy, our aim is to draw a vision as much organic as possible of the anatomy of the urethral sphincter. The components of the urethral sphincter are: the bladder neck (preprostatic sphincter), the smooth muscle urethral sphincter, the rhabdosphincter and levator ani muscle. Recently the rhabdosphincter has been proposed as a vertical structure that extends from the pelvic cavity (bladder base) to the perineal cavity. It can be round-shaped or omega-shaped. The anterior insertions are along the anterolateral aspect of the prostate (superiorly) and on the perineal fascia (inferiorly). The posterior insertions are on the Denonvilliers fascia and posterior aspect of the prostatic apex (superiorly) and on the central perineal tendon (inferiorly). The rhabdosphincter has strong means of fixations: anteriorly it is fixed to the pubis by the pubo-urethral ligaments, posteriorly it is supported by the medial fibrous raphe of the perineum. The anteromedial fibres of levator ani muscle are involved in the continence mechanism by their strong relation with the rhabdosphincter and the prostate.

[Personal research: reconstruction of the urethral striated sphincter]

OBJECTIVE

Incontinence is one of the drawbacks of radical prostatectomy. The causes of post-operative incontinence are sphincter deficiency (SD) and bladder dysfunction (BD). SD seems to be the main cause of incontinence and long time to continence. We present a surgical modification of the anatomical radical retropubic prostatectomy consisting in the reconstruction of the posterior aspect of the striated urethral sphincter in order to obtain a quick recovery of continence postoperatively.

MATERIALS AND METHODS

Caudal retraction of the urethro-sphincteric complex after apical dissection of the prostate often occurs. Furthermore posterior fibrous raphe interruption can cause shortening of anatomical and functional urethral length and affect continence. In order to avoid caudal retraction of the sphincteric complex, after completing vesico-urethral anastomosis, the posterior emicircumference of the striated sphincter is fixed to the posterior aspect of the bladder one centimeter cranially and posteriorly to the urethro-vesical anastomosis. The rabdosphincter is sutured separately from the urethro-vesical suturing. This technical modification makes it possible to obtain an anatomical length of the urethra of about a centimeter more than with the standard technique, replacing it in a more anatomical position. Furthermore, this technique provides the new posterior platform for the urethro-sphincteric complex. Twenty-four patients with clinical organ confined disease and age range 54-74 years (mean 64 years) underwent Walsh's anatomical radical retropubic prostatectomy with reconstruction of the rabdosphincter (group A). Catheter was removed 7 to 11 days postoperatively. Early continence was assessed objectively with the number of pads per day as follows: 0-1 mini pad = continent; 1-2 pads per day = mild incontinence; 2 or more pads per day = severe incontinence. Continence was evaluated at 3 days and one month after catheter removal. Group A compared to 21 patients (group B) who underwent standard anatomical RPP (historical control group).

RESULTS

In group A 16/24 patients (66.7%) and 19/24 patients (79.2%) were continent respectively at three days after removal of the catheter and after one month; mild incontinence (1-2 pads/day) was present in 6/24 patients (25%) and 3/24 (12.5%) respectively, 2/24 patients (8.3%) suffered from severe incontinence after 3 days and one month. In group B 7/21 patients (33%) were continent at hospital discharge, 11/21 (52%) after one month.

CONCLUSIONS

Careful reconstruction of the posterior aspects of the rabdosphincter shortens time to continence after RRP.

[Neural network based detection of pulmonary nodules on chest radiographs]

PURPOSE

We investigated the capabilities of an artificial neural network-based Computer-Aided Diagnosis (CAD) system in improving early detection of pulmonary nodules on chest radiographs.

MATERIAL AND METHODS

We used a data-set of 145 digitized chest films. Two different radiologists read the radiographs to detect the sites of possible nodules. The system uses two neural networks trained on a training-set of 100 radiographs selected from the data-set. The first network is used to focus attention on the sites of potential nodules while the second calculates the likeliness of nodule presence in ROIs. The clinical test was performed on 45 more radiographs from the training-set, but different from those in the data-set, which were positive for both benign and malignant nodules. These latter plain films showed 65 nodular lesions which differed by shape and acquisition technique.

RESULTS

Sensitivity was 89% in all radiographs while specificity, evaluated by ROI, and accuracy, were 98%.

CONCLUSIONS

There are potential limitations in nodule detection on plain radiographs. Some of them are operator-dependent, such as nonsystematic investigation, lesion underestimation, and poor reading, and some are technique-dependent, such as X-ray beam/tube, low voltage, patient positioning, focus-film distance and development process. CADs may contribute to improving detection of pulmonary nodules because the false-negative rate is decreased and sensitivity consequently increased. The high sensitivity and specificity rates of neural networks encourage further trials on wider data-sets to help the radiologist in the early detection of pulmonary nodules.

[Interventional radiology in the palliative treatment of pancreatic cancer]

AIMS AND BACKGROUND

Pancreatic carcinoma often involves the head of the pancreas and obstructive jaundice is its earliest sign. It sometimes extends to celiac plexus and duodenum causing pain and bowel obstruction respectively. Only 20% of cases are totally resectable (stage I) at the time of diagnosis. Palliative treatment is the only available therapeutic option when the tumor extends surrounding organs or has given lymphatic metastases (stage II, III, IV). The aim of this study is to evaluate effectiveness of interventional radiology procedures on unresectable cancer palliative treatment.

METHODS

Between Jan 90 and Sep 98, 195 patients with unresectable pancreatic carcinoma received percutaneous treatments. They were 104 males and 91 females with mean age of 74 years (range, 48-95). One hundred eighty four patients underwent biliary drainage, six patients underwent celiac plexus block, two patients were treated by bowel stenting. Two patients received both biliary and bowel stents, one patient underwent biliary drainage and celiac plexus block.

RESULTS

Jaundice treatment was performed by placement of drainage catheters in 48 patients, polymeric endoprostheses in 58 and metallic stents in 77 (67 Wallstents). Biliary drainage was successful in all cases obtaining appreciable bilirubin serum levels reduction and jaundice regression in 175 patients (95%). In 44 patients Wallstents were placed during a single PTC session time ("one step" technique). In 21 cases (11%) peri-procedural complications occurred. Follow-up related to 85 patients shows survival rate covered between 30 and 570 days (mean, 142). Best survival values occurred in patients who underwent "one step" technique. Celiac plexus block was successful in 5/7 cases (71%) with no complications, total pain relief and withdrawal of pharmacological treatment. Bowel stenting achieved complete recanalization of intestinal loop in 2 cases but showed troubles related to management of these patients.

CONCLUSIONS

In patients with unresectable pancreatic carcinoma palliation is the only therapeutic option and has the purpose to achieve biliary tree decompression and eliminate jaundice associated symptoms, improving quality of life and reducing hospitalization. Jaundice relief is reachable by surgical, endoscopic or percutaneous approach. Surgical palliation is characterized by disadvantageous cost-effectiveness rate. Endoscopic and percutaneous palliations are alternative, although, in selected patients, percutaneous Wallstents placement by one step technique is perhaps the most successful procedure, showing high rate of technical outcome with low complications and short time spent in hospital. Celiac plexus block under CT guidance constitutes a reliable method for management of pain. At present bowel stricture treatment is surgical.

Long-term results of intrarenal surgery for branched calculi: is such surgery still valid?

OBJECTIVE

To evaluate whether intrarenal surgery for branched calculi remains valid in the light of current new techniques, e.g. percutaneous nephrolithotomy and extracorporeal shockwave lithotripsy.

PATIENTS AND METHODS

Between January 1978 and October 1984, 44 patients (24 male and 20 female, mean age 42.5 years, range 14-66) underwent complex surgery for large stones, requiring opening of the renal pelvis and a transparenchymal approach to the calices; 47 renal units were operated in 49 procedures. The evaluation before surgery included creatinine and blood nitrogen levels, blood pressure measurement, urine culture, abdominal plain X-ray (44 patients), intravenous urography (42) and isotopic renography with renal scintigraphy (five). Renal lithiasis was categorized and all patients underwent extended pyelolithotomy with a transparenchymal approach, achieved by partial nephrectomy (six patients), radial paravascular nephrotomy (10), posterior lower nephrolithotomy (29), resection of the posterior segment (two), and posterior segmentotomy and reconstruction (2); 16 operations were performed under ischaemia. In October 1996, the patients were clinically evaluated by serum creatinine levels (42), urine cultures (42), abdominal plain X-ray (42), IVU (34), isotopic renography (eight), renal ultrasonography (eight) and blood pressure measurement (44). The mean follow-up was 14.8 years.

RESULTS

The major postoperative complications were; residual stones (six patients), fistula with ureteric stenosis (one, with a permanent nephrostomy), toxic temporary hepatic failure (one), femoral arterial embolism (one, resolved using a Fogarty catheter) and recurrent large stones (two, operated 1 and 5 years later). From 1984 to 1996, 19 patients had recurrent stones and two underwent dialysis. In October 1996, the renal function of 47 renal units was stable or normal in 36 (77%), reduced in seven (15%) and lost in four (8%); 24 patients were hypertensive (12 preoperatively), nine have urinary tract infection, three are positive for hepatitis B or C virus, and lithiasis has recurred in 15 renal units.

CONCLUSIONS

Intrarenal surgery, conducted using modern anatomical guidelines, was an effective treatment for renal branched stones. The long-term results are satisfactory after appropriate correction of the urinary tract, with the consequent prevention of stasis and chronic infection. The definitive comparison between surgical and combined endoscopic/extracorporeal methods will only become clear when there is a comparable follow-up. Currently, surgery remains preferable in patients with giant calculi, a small pelvis and prevalent calyceal development.

Original Digital Technique to Isolate Santorini'S Plexus and Membranous Urethra during Radical Retropubic Prostatectomy and Radical Cystectomy

The authors give the results obtained with their digital technique for isolating Santorini's plexus during radical retropubic cystectomy or radical prostatectomy. Objectives: to reduce bleeding during surgery; to respect anatomic structures; greater safety during resection of the urethra; to respect the neurovascular erectile bundles; to assess post-operative erection. This technique was used in 46 operations (32 cystectomies and 14 radical prostatectomies) between January 1997 and February 1998. Blood loss from the plexus was 150 ml max. Operating time was reduced by about 15 minutes. Although the number of cases is still small, this digital isolation technique can be considered safe, almost bloodless and should preserve erection in a higher percentage of patients compared to the “classic” nerve-sparing technique.

Extracorporeal lithotripsy in ureteral stones: Our experience with Dornier HM3, EDAP LT02, Piezolith 2300 lithotripters

We present our experience with three different lithotriptors: Dornier HM3, EDAP LT02 and Piezolith 2300. Materials and methods: 1876 patients with ureteral stones were treated between 1 January 1988 and 1 January 1996. The above 3 lithotriptors were used. In 925 patients the stones were located in the upper ureter, in 182 in the middle ureter and in 769 in the pelvic ureter. Auxiliary procedures were performed in 37% of patients. A DJ stent was used to catheterise 299 (16%) patients and a nephrostomy was performed in 19 (1%). Catheterisation was carried out in 247 (13.1%) ureters to localise the stones, plus 83 (4.4%) push ups and 52 (2.7%) Dormia baskets. Results: one treatment was sufficient in 1395 (74.3%) patients, 2 treatments in 335 (29.1%), 3 in 114 (6%), 4 in 21 (1.1%), 5 in 10 (0.5%) and 6 in 1 (0.05%). Patients were considered stone-free when they had negative X-ray and sonography two months after treatment; stones smaller than 3 mm, capable of being spontaneously eliminated without retrograde dilatation, were considered as fragments. The results were 1475 (78.6%) stone-free patients, 246 (13.1%) with fragments and 117 (6.2%) failures. 38 patients failed to appear at follow-up. Complications: complications were considered as hyperpyrexia and colics. There was very little hematuria, which regressed spontaneously in any case within the first 24 hours. Conclusion: side effects were few and required no treatment, so in our experience lithotripsy is the first choice treatment for ureteral stones. Particular attention, however, must be paid to the size of the stone in predicting the number of treatments.

[Orthotopic ileal neobladders in men and women: techniques and comparison]

PURPOSE

evaluation of results and complications of ileal orthotopic neobladders in men and women with transitional cell carcinoma.

MATERIALS AND METHODS

between 12-89 and 12-95 we performed 146 radical cystectomy for bladder neoplasm, in 32 patients we can perform ileal orthotopic neobladder, 29 were male and 3 were female. Oncologic indications to this kind of operation were: clinical stage T2, T3a, T3b, T1G3 multicentric and or recurrence, absence of metastasis absence of nodal metastasis, negativity of urethral biopsy. General contraindications were urethral stenosis and incontinence. Oncological contraindications, in woman, were bladder neck neoplasm or urethral neoplasm. In 4 patients we use Camey II technique, in 19 pts we performed the paduan ileal neobladder, in 9 pts we use Hautmann technique. 7 patients performed neoadjuvant chemotherapy with 4 circles of MVAC, 4 pts underwent adjuvant chemotherapy, and 2 pts salvage chemotherapy. In woman we take care during cystectomy to dissect cardinal ligament very close to cervix uteri, to resect the uterosacral ligament far to the sacrum. We did not dissect under the ureter and we cut the urethra 0.5-1 cm far from the bladder neck.

RESULTS

follow up was between 6 and 66 months. 24 patients are now alive and disease free, 2 patients are alive with disease progression, 1 have a pelvic recurrence and 1 have pulmonary recurrence. 4 pts died for disease progression and 2 for non oncological cause, quality of life was considered as regard to continence and sexual activity. 1 pts was completely incontinent and 1 pts has nocturnal incontinence with a daily micturation every 1 hour. We can evaluate only 18 patients for sexual activity and 4 reported normal erection.

COMPLICATIONS

in three cases we had to reoperate for early complications due to mechanical bowel obstruction, ileocutaneous fistula and wound dehiscence. In three cases we had the formation of stones, in two patients ureteroileal stenosis, in two cases urethro-ileal stenosis and 1 reflux from the neobladder. Orthotopic ileal neobladder allows a very good quality of life and is the first choice derivation after radical cystectomy.

Echo-guided transperineal prostatic biopsy vs transrectal prostatic biopsy in the diagnosis of prostatic cancer. Our experience

From January 1992 to May 1996, we performed 526 prostatic biopsies for suspected carcinoma after digital rectal examination (DRE), transrectal ultrasonography (TRUS) and PSA. 288 patients underwent transperineal echo-guided biopsy (TP) and 238 transrectal biopsy (TR). Diagnosis of prostatic cancer was made in 133 cases: 69 in the TP group and 64 in the TR group. We evaluated the reliability, sensitivity, specificity and complications of the two methods. TR biopsy is simple to do and well-tolerated by the patient, but has a greater number of complications.

[Terazosin in the treatment of benign prostatic hypertrophy]

Benign prostatic hypertrophy provokes clinical manifestations correlated on one hand to a static obstructive component, due to the increase in glandular size, and on the other hand to a dynamic component, controlled by the alpha adrenergic autonomic system which gives the smooth muscular tonus of the prostatic adenoma. The alpha adrenergic receptor block reduces the dynamic component, improves the clinical and urodynamic parameters determined by the infra-bladder obstruction in patients with BPH. The selective alpha 1, long acting antagonists especially, such as terazosin, offer a safe and efficient therapy for selected patients suffering from BPH. They also have the indisputable benefit of mono-administration. In this study the basic concepts of BPH treatment with terazosin are discussed.

Predictability of duration and severity of congenital hydronephrosis as a cause of smooth muscle deterioration in pyelo-ureteral junction obstruction

Between 1989 and 1990, 31 new unilateral PUJO, prenatally diagnosed (16th-37th week of gestational age), underwent pyeloplasty between 19 and 105 days of age. The correlation between severity (V) (volume of hydronephrotic kidney) and duration (dT) of congenital hydronephrosis from its first detection in utero to surgery and histological findings were prospectively evaluated in this series. A dT longer than 70 days and a V larger than 50 ml., were considered as predictable for hypotrophy with fibrosis of the upper urinary tract smooth musculature. In conclusion, time seems to play an important role in the increase of the volume of the obstructed urinary tract to the extent of a large-scale hydronephrosis.

[A new classification of reno-ureteral lithiasis]

The Authors suggest a change in their surgical classification of renal calculi to conform the description to the new techniques in the treatment of renal calculosis. Category "C" describes the morphology and topography of renal stones in five degrees (C1-C5); small letters "p, s, m, i" indicate the pelvis, superior, middle, inferior calyces; "n" and "a" symbolize stone having a size similar to or exceeding normal shaped renal cavities. "Cu" indicates ureteral calculi; small letters "l, i, p" indicate lumbar, iliac, pelvic ureteral stones. "N" describes the nature of the calculi. Category "E" stands for the excretory tract; "+" and "-" indicate the presence or absence of dilatation, the small letters "e, i" show the extra or intrarenal position of renal cavities; "no" and "o" indicate absence or presence of intrinsic obstruction of the excretory tract. "R" points out the number of surgical recurrences. Category "P" indicates the function of the parenchyma; numbers 1, 2, 3, refer to normal renal function, moderate or serious insufficiency. "U" stands for unique functional or anatomical kidney; "I" indicates the presence of infection.

[The EDAP LT and the M.P.L. 9000. Results of the treatment of reno-ureteral lithiasis]

The advantages and disadvantages of piezoelectric lithotripsy are discussed with specific analysis of the EDAP LT 01. A description of the EDAP LT 01 is included. Installation, accommodation, and maintenance features are discussed. The Dornier M.P.L. 9000 represents a third-generation lithotripter for both kidney and gallbladder stones with an ultrasound localization system tubules shock-wave coupling. The use of TH M.P.L. 9000 was limited by ultrasound-guided localization of kidney stones, upper ureteral calculi causing obstruction, and intramural lower ureteral stones.

[Prognostic parameters in extracorporeal lithotripsy]

Extracorporeal lithotripsy consists of applying shock waves (electrohydraulic and piezoelectric) from outside the human body, which pass through the body tissues without damaging them breaking down the urinary calculi into particles which can then be automatically expulsed through the excretory tract. The object of this study is to analysis some of the important parameters which affect the success of the extracorporeal lithotripsy. These factors are as follows: 1) type of shock wave: electrohydraulic or piezoelectric, their action mechanism, methods of fragmenting the urolites; 2) the chemical composition of the calculi and its consequential resistance to the fragmented shock waves; 3) Patency, tone and peristalsis of the intra and extrarenal excretory tract for expulsing the urolite particles; 4) general conditions of the urinary apparatus. From the interaction of these 4 variables arise different clinical situations which must be evaluated before operating in order to develop the proper therapeutic subscription for a renal-urethral lithiasis. The current therapeutic procedures for renal-urethral lithiasis are as follows: electrohydraulic and piezoelectric extracorporeal lithotripsy; electrohydraulic waves or ultrasound percutaneous litholapaxy; operative urethroscope; traditional surgery; chemolysis.