Prospective study of post-ESWL infections of the urinary tract

Throughout the world ESWL is nowadays the treatment of choice in renoureteral stones and ever smaller stones can be treated. We have undertaken the present study to evaluate post treatment infective complications in low-risk patients. A prospective study has been performed on 150 non-infected patients before ESWL treated for renal stones whose maximum diameter was less than 15 mm. None out of this group underwent pretreatment manoeuvres. Urinecultures were checked before and after treatment (3 days – 30 days). Out of 150 third day urine cultures 11 were positive but only 5 patients presented a symptomatic infection. All patients whose urineculture was positive received antibiotic treatment. All urinecultures were negative at the 30 days follow-up. The low incidence of urinary symptomatic and asymptomatic infections in our series and the rapid cure by antibiotic therapy suggest performing ESWL treatment in selected patients without any antibiotic prophylaxis. Antibiotic therapy will be set up just in symptomatic or asymptomatic post-treatment infections.

Laboratory laparoscopy: Nephroureterectomy, pelvic lymphadenectomy and orchiectomy

Recent developments in technology have resulted in the application of laparoscopy in several areas of urology. To develop the technique different procedures were performed in 22 male pigs weighing 25–30 kilograms. The types of procedure included: pelvic lymphadenectomy, nephroureterectomy, orchiectomy of cryptorchid testicle.

Prognostic significance of prostate-specific antigen in endocrine treatment for prostatic carcinoma

We have studied the prognostic significance of prostate-specific antigen (PSA), monitored monthly, in 24 patients with prostatic cancer (5 D1, 19 D2) on endocrine therapy. The pretreatment levels of PSA were high in all patients (mean value 41 ng/ml). It was found that PSA levels at the end of the first and sixth months of treatment were reliable prognostic indicators. At the first month evaluation PSA had decreased more than 50% from the initial values in the 16 patients with stable disease, while it had decreased less than 50% in those with progressing disease. At the end of 6 months, patients with stable disease had PSA levels within the normal range, while 8 of the patients who had progressing disease had levels higher than 10 ng/ml. Respectively 6 and 2 patients had also had increases in PSA levels at 3 and 6 months before scintigraphic demonstration of increased bone metastases.

Clinical urological laparoscopy: Renal cyst resection, spermatic vein ligation and pelvic lymphadenectomy

The recent expansion and acceptance of laparoscopic surgery have led us to perform urological laparoscopic procedures. We describe our experience with large renal cyst resection, spermatic vein ligation for varicocele and staging pelvic lymph node dissection for localized prostate cancer. We performed renal cyst resection in 4 patients, spermatic vein ligation for varicocele in 6 patients and pelvic lymphadenectomy in 6 patients. The procedures are effective and decrease postoperative morbility.

[Treatment of ureteral calculi with extracorporeal lithotripsy. Comparison between the original Dornier HM3 and the modified lithotriptor]

From January 1985 till June 1989, 222 patients with ureteral stones, underwent ESWL treatment. 109 patients were treated with the original Dornier HM3 under general or epidural anaesthesia and 113 patients were treated with the modified Dornier HM3 under anglosedation. 156 stones were in the upper ureter, 15 in the middle ureter, 51 in the lower ureter. We performed a total of 269 ESWL treatments. Out of 109 patients treated with the original HM3 and 113 patients treated by the modified HM3 12 (11%) and 28 (24.7%) needed, respectively, two or more ESWL sessions. In 89.9% and 88.5% of the patients, respectively, has been performed an ureteral manipulation before the treatment to push up or to localize the stone. The treatment was unsuccessful in 10 patients of whom 3 underwent anterograde lithotripsy by percutaneous access, 4 transureteral lithotripsy and 3 surgery. At three months the percentage of patients stone free was as follows: original HM3 patients 88% modified HM3 patients 92.9%. The extracorporeal lithotripsy is now-day the treatment of choice for the ureteral stone without any limitation, due to the stone localisation. The clinical use of modified HM3 on ureteral stones didn't low our success rate, but increased the shock wave out of session.

Urinary NAG excretion after anesthesia-free extracorporeal lithotripsy of renal stones: a marker of early tubular damage

Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biological side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lithotripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments.

[An overview of extracorporeal lithotriptors in current clinical use: technical notes]

ASWL ten years ago opened a new era for kidney stone treatment and recently it's showing a new therapeutical approach to biliary stones. Dornier HM3 is since 1983 the first lithotripter with a wide clinical employment. Actually we know about twenty extracorporeal lithotripter in clinical use. Our review try to classify old and new extracorporeal lithotripsy devices looking at technical aspects and lithotripsy center organization.

[Urinary excretion of N-acetyl-glucosaminidase after extracorporeal shockwave lithotripsy: a marker of renal tubule injury]

The major complications of extracorporeal shock wave lithotripsy (ESWL) are perirenal hematomas for an incidence of less than 1 per cent. However in animal experiments histopathological effects of focused electrohydraulic shock waves on renal parenchyma have been reported, the most significant of which are hemorrhagic foci healing rapidly by cicatrization. Furthermore imaging studies have demonstrated morphological changes limited to the area of the kidney exposed to shock waves. Liver, skeletal muscle and pancreatic enzyme changes have been documented after ESWL. In our experience the urinary ratio of NAG (N-acetyl-glucosaminidase) to creatinine, a good marker of renal tubular damage, increased after treatment with both the original and the modified spark gap Dornier HM3 lithotripters and with the piezoelectric Wolf Piezolith 2200. Particularly the threshold of pathological urinary NAG excretion were 2,000 and 2,600 shocks respectively using the original and the modified Dornier HM3 and 7,000 shocks using the Wolf Piezolith 2200. The functional significance of the changes is not known, however in clinical practice it would seem prudent to avoid excessive exposure to shock waves.

[Enoxacin in the treatment of bacterial prostato-cystitis]

Thirty-three patients suffering from acute, subacute or chronic prostatovesiculitis were admitted to an open, non comparative trial. Enoxacin was administered at the daily dosage of 400 mg every 12 hours for 10 days starting from the enrollment. A second cycle of treatment was performed if cure was not obtained with the first cycle. Treatment efficacy was established by assessing patient symptoms related to the infection, such as pollakiuria and dysuria, consistency and volume of prostate and spermatic vesicles (evaluated by rectal examination and transrectal ultra-sonography); bacterioscopical and bacteriological evaluations of prostate/vesicles secretion with sensitivity testing were also carried out. All observations were collected at baseline, 5 and 30 days after the end of the first cycle and 5 days after the end of the 2nd cycle of treatment. After the first cycle of treatment, cure was obtained in 22 subjects (67%) and clinical improvement in 24 (73%). All but one patients still infected at the end of the first treatment period, showed improvement (5; 45.5%) or cure (6; 54.5%). The end of the second cycle None of the 22 patients cured with one cycle of treatment relapsed within 30 days after the end of treatment, confirming they really achieved cure. Side effects were observed only in 1 case (mild vertigo); no drop outs were observed. These results suggest that enoxacin may be successfully used in the treatment of prostato-vesiculitis.

[Extracorporeal lithotripsy with low pressure shockwaves using a modified Dornier HM3 lithotriptor: preliminary results]

Extracorporeal shock wave lithotripsy is a well established procedure for the treatment of the renal and ureteral calculi. The technical innovations of the low-pressure generator with a modified ellipsoid installed into the Dornier HM3 lithotripter leads to decrease the pressure in the second focus F2 lowering the painful sensation linked to the treatment and allowing to perform lithotripsy without general or epidural anae sthesia. From January to March 1988 132 patients underwent 144 treatment by modified Dornier Lithotripter HM3, we performed the treatments under a combination of anxiolytic and analgesic drugs in 125 patients (94.6%), only 7 patients needed the general or epidural anaesthesia, because of complex endoscopic pretreatment instrumentations. An average of 2150 Shock waves was applied with a range of 500 to 3800, the shock wave energy was administered at an average 20 Kvolts (16-26 Kv). Stone fragmentation had a success rate of 94.6%. The average postoperative stay was 4.5 days. After a month of follow-up 50.9% of the patients was free of stones, 27.8% had sand or spontaneously passable fragments and 11.1% had residual fragments larger than 4 mm. The treatment was judged as free of pain or with tolerable pain in 60% of the patients, 40% of the patients needed additional medication. The number of secondary treatment was, in our review, 9% but it could increase because we observed after a month of follow-up that 11% of the patients treated presents fragments larger than 4 mm.

[Dissection of the internal carotid artery. Personal case reports and a review of the literature]

The clinical and angiographic features of 20 patients affected by internal carotid artery dissection are reported. In one patient the neurological signs were related to a traumatic event, in two cases the symptoms presented after hyperextension of the neck during athletic events, while their onset was apparently spontaneous in the remaining 17 patients. Plain CT was normal in 14 cases and positive for ischemic necrosis in 6 patients. Angiography demonstrated extensive/segmental stenosis of the internal carotid lumen in 12 cases (60%), pseudoaneurysmal dilatation in 3 cases (15%), and complete carotid occlusion in 5 patients (25%). The "double lumen" feature was seen in 3 cases at the origin of the dissection. One patient died, surgical ligature of the internal carotid artery was performed in two cases, while the other patients received medical treatment with platelet inhibitors, except for the young patient affected by post-traumatic artery dissection. Complete recovery was observed in 82% of the patients. Follow-up angiograms demonstrated normal recanalization of the internal carotid artery in 4 out of 6 patients; one of them had two false aneurysms which following angiograms demonstrated to be completely resolved. Regression of stenosis was observed in 6 of the remaining patients by Doppler US. On the whole, the recanalization of the internal carotid artery was observed in 59% of cases. Angiographic findings seemed not to play a decisive role in the prognosis of carotid dissections, which largely depends on the overall patient's condition and on the presence/absence of ischemic cerebral damages.