Laparoscopic renal tumour ablation by means of the Tissuelink floating-ball radiofrequency device

The Tissuelink floating ball, a new radiofrequency monopolar device, allows us to remove small renal parenchimal tumours during a laparoscopic procedure in a safe, simple way. It applies radiofrequency energy with low volume saline irrigation for simultaneous blunt dissection of the renal mass and haemostatic sealing and coagulation of the renal parenchyma without the need of a preventive occlusion of the major renal vessels.

Materials and Methods.

From November 2001 to November 2003, we performed 5 laparoscopic enucleoresections of renal parenchimal tumours using the Tissuelink technology. Four were in the right kidney, 1 was in the left kidney. The patients were male in 3 and female in 2 cases. Mean patient's age was 61.2 years (range 33–71). All the tumors were small in size (range 10–40 mm) and had a peripheral location. None of them was in close proximity to the collecting system. This was the reason why we never inserted a stent in the urinary tract before the laparoscopic procedure. No patients required blood transfusion. The histology revealed a renal clear cell carcinoma in 4 cases (grade 1 in two, grade 2 in two) while the remaining was an old haematoma.

Overall we had 2 complications.

The haematoma broke during the procedure, because of its softness. Another patient suffered of a burning of the skin, just on the place of an ECG electrode.

Conclusions.

The laparoscopic enucleoresection of small, peripheral renal tumours by mean of the Tissuelink floating ball devise seems to be, even in an initial experience, simple and effective, even without the need of the preventive occlusion of the renal artery and vein. No relapse occurred after 12 months follow-up.

Primary lymphoma of the epididymis: case report and review of the literature

OBJECTIVE

To report an extremely rare clinical pathological observation of a case of primary lymphoma of the epididymis, without testicular or systemic involvement, and to update the relevant literature.

MATERIALS AND METHODS

A 25-year-old white male patient complaining of right scrotal pain was referred to our department. Clinical examination detected a hard painful mass at the right epididymal head. Epididymitis was diagnosed and conservative therapy with antibiotics and anti-inflammatory drugs was given. After 2 months of therapy the patient was admitted to our department because a tumor was suspected. Tumor markers were normal. Right scrotal exploration was performed through a standard inguinal incision. The epididymal head was completely replaced by a hard white mass. Fresh frozen sections indicated a malignant tumor. Right radical orchiectomy was performed.

RESULTS

High-grade primary epididymal non-Hodgkin's lymphoma with diffuse large cells (group G according to the Working Formulation) was diagnosed. Clinical pathological staging detected stage IE (extranodal) primary epididymal lymphoma. The patient was referred to the Hematologic Unit for combined chemotherapy, according to the VACOP-B protocol. After an 18-month follow-up the patient is well and disease free.

CONCLUSIONS

When an epididymal mass does not benefit from medical treatment, scrotal exploration and fresh frozen sections of the lesion should be done. The possible bilateral involvement by primary epididymal lymphoma has to be kept in mind. Radical orchiectomy is the treatment of choice for primary lymphoma of the epididymis. Adjuvant chemotherapy is indicated in high-grade malignant lymphoma. Prognostic parameters of the disease may be the grade of malignancy and the size of the tumor.

[Histopathologic risk factors in patients with non-seminomatous germ tumors of the testis in clinical stage 1. Retrospective study of 75 patients]

OBJECTIVES

This retrospective study was performed to evaluate histopathologic prognostic risk factors in 75 patients on clinical stage 1 nonseminomatous germ cell cancer of the testis (NSGCTT).

METHODS

From September 1976 to February 2000 we operated on 75 patients for NSGCTT on clinical stage 1 disease. Average age was 29.5 years (range 16-71). After orchiectomy, therapeutic options included retroperitoneal lymph node dissection (RLND) for 44 patients (58.6%), surveillance for 26 (34.6%) and neoadjuvant chemotherapy for 5 (6.6%). Testis primary tumor samples were assessed for studying prognostic risk factors that included vascular and/or lymphatic invasion (IV/IL+), percentage of embryonal carcinoma (%EC) and absence of yolk sac tumor (YS-).

RESULTS

All patients were alive and disease-free. The average age follow-up was 84.5 months (range 1-254). Relapses occurred in 11 (14.6%) patients after an average follow-up of 9.09 months (range 3-24). Prognostic risk factors were detected as follows: IV/IL+ in 17 cases (22.7%), (50-80%) EC in 23 (30.6%), CE% > 80 in 23 (30.6%), YS- in 55 (72%). In 8 (10.6%) patients there was not any prognostic risk factor. Disease relapse related to prognostic risk factors was detected as follows: 18.1% for VI/LI, 90.9% for EC% > 50 (27.2% for 50-80% EC and 63.6% for CE% > 80) and 90.9% for YS-. Relapsing rates between patients with EC% > 80 and 50-80% EC resulted statistically significant (p = 0.02, odds ratio = 12.25). Relapsing rates between patients on surveillance and those who underwent RLND was next to be significant (p = 0.05, odds ratio 3.68).

CONCLUSIONS

EC% > 80 is a prognostic risk factor for disease relapse in patients with clinical stage 1 NSGCT who are selected in a high risk group requiring RPLND or neoadjuvant chemotherapy as therapeutical option.

The pathophysiology, diagnosis and therapy of the transurethral resection of the prostate syndrome

In this article, the authors analyze a syndrome first described by Creevy in the 1940s, which may occur during a transurethral resection of the prostate (TURP). The syndrome is characterized by cardiocirculatory and neurological problems due to rapid changes in intravascular volume and plasma solute concentrations caused by excess irrigating fluid absorption. This article reviews the available literature and reports on the experience of our clinic, a specialist department in the physiopathology, diagnosis, therapy and prevention of TURP syndrome.

The TURP syndrome: importance of expiratory ethanol measurement and high serum levels of glycine

OBJECTIVE

In a prospective study it was our intention to evaluate the reliability and the predictive value of expiratory ethanol for the early detection of the occurrence of TURP syndrome and emphasize the role of the serum levels of glycine in clinical manifestation.

METHODS

We studied 30 patients scheduled for elective traditional transuretral resection of the prostate performed with subarachnoid anesthesia. Serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were monitored at scheduled intervals. Continuous heart rate and blood pressure monitoring was performed during the perioperative period in the operativing room and, later, in the recovery room. Occurrence of cardiocirculatory, respiratory and neurologic symptoms were recorded. Statistics included Bonferroni's t-test and Fisher's exact test. A decision level plot for end-expiratory ethanol level was performed for the choice of predictivity criterion.

RESULTS

In our population we identified three groups of patients: Group I (15 patients) in which no symptom was recorded; Group II (6 patients) in which non-specific anesthesia-related symptoms occurred; Group III (9 patients) in which TURP syndrome of various degree of severity was observed. In this group of patients changes in serum sodium and glycine concentrations, serum osmolality and end-expiratory ethanol levels were significantly different compared with the other two groups. In regard to end-expiratory ethanol levels, we identified a cut-off point at 0.05 mg/ml. In Group III two patients developed transient blindness. These patients had the highest serum glycine concentrations (> 4000 mumol/ml). Mortality was nil.

CONCLUSIONS

Our data show the reliability and accuracy of end-expiratory ethanol levels as a predictive test of the occurrence of TURP syndrome. Further, we emphasize the role of serum glycine concentration in the occurrence of neurologic symptoms related to the transurethral resection of the prostate.

Unilateral laparoscopic retroperitoneal lymph node dissection for clinical stage I nonseminomatous germ cell testicular neoplasm

OBJECTIVE

The aim of this study is to evaluate the reliability of laparoscopic retroperitoneal lymph node dissection (LRPLND) in the management of clinical stage I nonseminomatous germ cell tumors (NSGCT).

METHODS

Since June 1993, unilateral LRPLND was performed in 6 patients diagnosed with clinical stage I NSGCT. All patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in 3 cases and right-sided in the other 3 cases. Preoperative staging by means of tumor marker assessment, computerized tomography scan of the chest and abdomen and chest X-ray was unremarkable for metastatic disease.

RESULTS

All procedures were accomplished without any complications in a mean time of 325 min (275-420 min). The estimated perioperative blood loss was minimal (< 50 ml), and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining 5 cases, the average hospitalization was 4.8 days, ranging from 4 to 6 days. The patients resumed normal activities within 12-27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8, ranging from 5 to 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in 2 patients. Both of these patients received adjuvant chemotherapy. The mean follow-up period is 21.3 months, ranging from 6 to 36 months. To date, no relapses have been observed.

CONCLUSION

In accordance with other reports, we believe that LRPLND is both feasible and effective. However, the definitive assessment of the efficacy and morbidity of this diagnostic procedure requires a larger and more comprehensive series as well as longer follow-up.

Modern imaging methods and preoperative management of pheochromocytoma: review of the literature and case report

OBJECTIVES

To discuss the modern imaging techniques and preoperative management of pheochromocytoma and to report on one additional case.

METHODS

A 66-year-old male with an incidentally discovered left adrenal mass is described. The adrenal medulla strongly accumulate 131 I-metaiodobenzylguanidine (MIBG). The patient underwent left adrenalectomy after preoperative therapy with alpha and beta-blockers. The recent literature on pheochromocytoma modern imaging techniques and preoperative management is reviewed.

RESULTS

MIBG scintigraphy diagnosed a benign functioning adrenal pheochromocytoma, allowing preoperative medical management. Postoperative workup was unremarkable. Diagnosis of pheochromocytoma was confirmed by immunohistopathology. At 18 months follow-up, the patient is alive and disease-free.

CONCLUSIONS

Incidentally discovered adrenal masses have to be investigated to detect malignancy and subtle hormonal overproduction. MIBG scintigraphy has a high specificity (100%) in detecting pheochromocytoma, metastasis, surgical residual tumor, local relapse and other adrenal crest tumors. Positive results of octreotide scintigraphy in detecting malignant pheochromocytoma have been reported. Currently, pheochromocytoma removal is a safe operation with mortality rates ranging from 0 to less than 3%. Preoperative alpha adrenergic blockage with phenoxybenzamine or prazosin is important in decreasing the operative risk. Beta-blockers may be necessary for cardiac arrhythmia. Intraoperative invasive monitoring of hemodynamic variables may be both diagnostic and therapeutic of inadequate preoperative management. Lifelong follow-up for patients with pheochromocytoma is important.

Experience in the surgical treatment of Fraley's syndrome

OBJECTIVE

To report our 20-year experience with nephron-sparing surgery in the treatment of Fraley's syndrome.

MATERIALS AND METHODS

From September 1976 to July 1996, 6 women, 18-43 years old, underwent surgical treatment. All patients had been suffering debilitating right flank pain for at least 6 months before the operation. Diagnosis was in call cases made with the use of intravenous pyelography and renal arteriography, which showed a vascular impression on the superior infundibulum with secondary dilatation of the upper pole calyx. This was localized only on the right side in 5 cases, while in 1 it was bilateral though more severe on the right. Ipsilateral nephroptosis was observed in 2 of the patients. In 2 cases in whom the superior infundibulum was sufficiently long, an infundibulo-infundibulostomy with everted flaps was performed. In a case in whom a short infundibulum was compressed between a venous and an arterial branch, Fraley's infundibulopyelostomy was carried out. In 1 patient in whom the infundibulum was compressed by the anterior-superior segmental artery, a Heineke-Mikulicz-type infundibulorrhaphy was combined to vasopexy. In the remaining 2 cases, the infundibulum was not cut: in one case, a simple vasopexy of two vascular branches was carried out, while in the other, a minor arterial branch was ligated and divided. In 4 patients, nephropexy was also performed.

RESULTS

No significant intra- or postoperative complications were observed. Follow-up averaged 102.5 months. Pain relief was complete in 5 cases, in whom disappearance of the vascular impression was also radiologically demonstrated. Only 1 patient, who underwent infundibulorrhaphy and vasopexy, experienced occasional flank pain and urinary infection after the operation, with just a slight improvement in the excretory urogram.

CONCLUSIONS

Surgical treatment of Fraley's syndrome is indicated only in symptomatic and/or complicated cases; in relation to the type of obstruction and the anatomy of the intrarenal structures, whether excretory or vascular, several effective nephron-sparing techniques can be selected.

Incidental renal cell carcinoma-age and stage characterization and clinical implications: study of 1092 patients (1982-1997)

OBJECTIVES

To compare the epidemiologic, clinical, and pathologic characteristics of incidental and symptomatic renal cell carcinoma in a large series of patients, with emphasis on age distribution and its potential impact in defining groups of patients that may benefit from early detection programs.

METHODS

Records of 1092 patients with renal tumors from 1982 to 1997 were reviewed. Age, clinical presentation, and pathologic stage and grade were analyzed. Special attention was given to the age distribution and its relationship to the incidental or symptomatic diagnosis.

RESULTS

The overall mean age and proportion of patients older than 65 gradually increased (from 57 to 62.6 years and from 24.7% to 48.7%, respectively) from 1982 to 1997. The mean age in the incidental group rose steadily higher than in the symptomatic group. A progressive increase of incidental tumors from 13.0% in 1982 to 1983 to 59.2% in 1996 to 1997 was observed. A lower stage (74.3% versus 49.1%), grade (75.5% versus 56.9%), and percentage of metastases at presentation (10.4% versus 19.6%) were registered in the incidentally found neoplasms than in the symptomatic neoplasms. Eighty-two (80.4%) of 102 patients who underwent conservative surgery had incidental renal cell carcinoma.

CONCLUSIONS

Our data confirm a rapid and dramatic change in the epidemiologic and clinical characteristics of renal cancer, with an increasing number of incidentally found tumors presenting with lower stage, grade, and percentage of metastases. An unexpected but significantly higher rate of renal neoplasms was observed in older patients. The stage, grade, and patient age observed in our series of incidentally found tumors raises the question of whether to leave the current diagnostic approach unaltered, thus benefiting a subgroup of patients with clinically unrecognized and possibly indolent renal cell carcinoma, or to extend early detection programs to younger patients with potentially more aggressive tumors.

[Our experience in the treatment of retroperitoneal fibrosis]

To discuss retroperitoneal fibrosis (RPF) etiopathogenesis and to report on our experience in the treatment of the disease. From 1977 to 1998 26 RPF patients, 15 idiopathic (I group) and 11 secondary (II group), entered our clinic. Vascular risk factors of the I group were cigarette smoking (73.3%) and arterial hypertension (46.6%). Etiologic factors of the II group were aorta abdominal aneurysm (four cases), radiation therapy for female genital tract cancer (four case), aorto-bifemoral bypass for aorta aneurysm (two cases), retroperitoneal non-Hodgkin lymphoma (one case). Treatment performed for idiopathic disease was medical in eight cases (alone in two, with endourologic measures in six) using corticosteroids in five and tamoxifen in three; only endourological in three and surgical in four (nephrectomy in two patients, ureterolysis and ureteroneocystostomy in one, pyeloureterolysis in one) with perioperative corticosteroid treatment in three cases. Treatments performed in patients with secondary disease were endourologic in five surgical in three (ureteroureterostomy, ureteroneocystostomy, pyeloureterolysis and pyeloreduction), medical with corticosteroids in two; one patient affected by perianeurysmatic fibrosis did not require any treatment because of disease's spontaneous recovery. Medical treatment induced symptom remission and plaque reduction in all patients. Surgery determined complete recovery in all patients except for one in whom the disease relapsed with controlateral urinary tract involvement. Medical RPF treatment for idiopathic or secondary disease is effective in the first stage. Disease management with tamoxifen is easy to perform, safe and effective. In the steady state of RPF the best results are obtained by surgery and perioperative glucocorticoid therapy reduced significantly fibrosis' relapse.

Treatment of retroperitoneal fibrosis with tamoxifen: case report and review of literature

OBJECTIVE

To evaluate the efficacy of tamoxifen in the treatment of idiopathic retroperitoneal fibrosis in one patient and to review the results reported in the literature.

METHODS

A 68-year-old man with idiopathic retroperitoneal fibrosis and obstructive acute renal failure was admitted to our department. Bilateral ureteral stents were placed and tamoxifen 20 mg daily p.o. was started.

RESULTS

The ureteral stents were removed five months after tamoxifen therapy. IVP demonstrated normal appearance of the ureters nine months after medical treatment. An MRI scan showed an important decrease of the fibrotic periaortic mass at 12 months and then we stopped tamoxifen.

CONCLUSIONS

Actually tamoxifen represents an attractive and safe choice of medical treatment for retroperitonea fibrosis, particularly in the acute stages. Nevertheless, the duration of treatment, the effectiveness and the persistence of the results are still uncertain because few cases have been reported in the literature.

Penetrating trauma to the scrotum and the corpora cavernosa caused by gunshot

The authors describe a case of gunshot wound of the male genitalia by two low-velocity bullets. The first bullet caused a lesion of the right testicle and came out of the right hemiscrotum; the second one had penetrated the left gluteal region with no exit wound. The penile ultrasound confirmed the presence of the bullet at the root of the right corpus cavernosum. The patient underwent exploratory surgery, drainage of the voluminous bilateral scrotal hematoma, and suture of a laceration of the right-testicle cranial portion. Due to the absence of active bleeding, voluminous hematoma and serious injuries in the corpus cavernosum, no surgical removal of the bullet in the right corpus cavernosum was required. The patient regained a normal sexual function 1 month after the operation.

[Fournier's gangrene: report of 2 cases and review of the literature]

Fournier's gangrene is an extensive fulminant infection of the genitals, perineum or the abdominal wall. Since the first description by Jean Alfred Fournier in 1883 about 700 cases have been reported in the literature. The main aetiological factors are: perianal, perirectal or periurethral infections, diabetes mellitus and chronic alcoholism. Many aerobic and anaerobic organisms may be involved. Mortality rates range from 30-50%. The dramatic course of Fournier's gangrene requires early recognition, surgical drainage, extensive surgical debridment, antimicrobial therapy, hyperbaric oxygen therapy, as well as intensive care treatment in order to prevent irreversible endotoxic shock. We report two cases of Fournier's gangrene. In both cases symptoms were fever, pain and extensive cutaneous necrosis in the scroto-perineal region.

Unilateral laparoscopic retroperitoneal lymphadenectomy for clinical stage I nonseminomatous testicular cancer

Since June 1993, unilateral laparoscopic retroperitoneal lymph-node dissection (LRPLND) has been performed in six patients with clinical Stage I nonseminomatous germ-cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor marker assessment, CT scan of the chest and abdomen, and chest radiography was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 minutes (275-420 minutes). The estimated perioperative and postoperative blood loss was minimal, and none of the patients required blood transfusion. In the case of the first patient, the hospital stay was 18 days because of a widespread subcutaneous emphysema. In the remaining five cases, the average hospitalization was 4.8 days (range 4-6 days). The patients resumed normal activities within 12 to 27 days (mean 16.16 days) postoperatively. The mean number of lymph nodes removed was 6.8 (range 5-9). Histologic examination of these nodes revealed microscopic metastases from embryonal carcinoma in two patients, both of whom were subjected to adjuvant chemotherapy. The mean follow-up period is 27.1 months (range 12-42 months). To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical Stage I NSGCT.

La chirurgia conservativa renale nell'anziano: Kidney preserving surgery in the elderly

Conservative renal surgery has recently been extended to elderly patients who have decreased renal function and reduced survival rates in the case of dialytic treatment. Furthermore, age is no longer a limiting factor despite the increased anethesiological risk. Fifteen cases of renal neoplasm in patients over 70, who had undergone conservative surgery, were reviewed: 14 are alive and disease-free after 14-135 months and 1 died from unrelated causes. It is concluded that conservative renal surgery has a role even in the elderly.

[Percutaneous, laparoscopic, and surgical treatment of idiopathic varicocele: analysis of costs]

Idiopathic varicocele can compromise the spermatogenetic function of the testicle and associate with alterations of the semen quality. The treatment of varicocele stops the progress of testicular damage and improves spermatogenesis and semen parameters. These are the main alternatives to the traditional surgical treatment of varicocele retrograde percutaneous occlusion of the internal spermatic vein using sclerosing agents and embolizing devices (either separately or in combination), microsurgical ligation via inguinal or sub-inguinal approach, laparoscopic ligation and, more recently, antegrade scrotal sclerotherapy. None of these techniques can be considered the "gold standard" therapy. Literature does not point out any significant difference between them, either considering the absence of reflux percentage, or the improvement of semen quality, or the pregnance rate. Therefore cost comparison may be a valid criterion in the choice of treatment for varicocele correction. The total cost of the surgical retroperitoneal unilateral ligation of the internal spermatic vein is 968,805 Lire, while for the bilateral ligation it is 1,118,285 Lire. The costs of sclerotherapy and percutaneous embolization are respectively of 698,750 Lire and 1,708,950 Lire. The combination of the two techniques amounts to 1,918,230 Lire. Laparoscopic bilateral ligation costs 2,437,935 Lire. Antegrade scrotal sclerotherapy costs 191,035 Lire if unilateral, 216,580 Lire if bilateral. After considering these data we can say that antegrade scrotal sclerotherapy is the first choice economically in the treatment of both unilateral and bilateral varicocele.

L'eziopatogenesi della fibrosi retroperitoneale: Etiopathogenesis of retroperitoneal fibrosis

The etiopathogenesis of retroperitoneal fibrosis is still obscure and probably multifactorial. Among the secondary forms due to demonstrable causes, the one caused by aorto-iliac atherosclerosis has recently been recognised. Its pathogenesis is linked to the low density oxidised lipoproteins of the atheromatous plaque, which are responsible for a local immunologic reaction. The most common form is still idiopathic or primitive, hypothetically related to genetic, environmental, vascular and/or immunologic factors. Idiopathic retroperitoneal fibrosis is sometimes associated with other sclerosing syndromes and/or systemic diseases. In such cases a common pathogenesis, probably immunologic may be postulated. After having illustrated the different categories of retroperitoneal fibrosis, the authors report their experience with 25 patients of whom 14 had idiopathic fibrosis and 11 secondary fibrosis. In the former group 11 patients (78.5%) smoked more than 10 cigarettes a day, while there was a history of prolonged professional exposure to asbestos in one case. The following associated pathologies were observed: hypertension in 7 cases (50%), ischemic cardiopathy in 2 (14.3%), diabetes mellitus in 2 (14.3%), multiple myeloma in 1 (7.1%) and juvenile rheumatoid arthritis in 1 (7.1%). The disease was also associated with other sclerosing pathologies in 3 cases: sclerosing cholangitis in 2 and Dupuytren's contracture in 1. The location of the fibrosis was typically periaortic in 13 cases (92.8%), as shown by CT. Lastly, 10 patients underwent immunosuppressive therapy with a favourable response, suggesting the probable immunologic pathogenesis of the disease.

La fibrosi retroperitoneale idiopatica. Terapia medica: Idiopathic retroperitoneal fibrosis. Medical treatment

Medicai treatment of both idiopathic and secondary retroperitoneal fibrosis (RPF) aims at stopping the inflammatory process in the early stage of the disease. Glucocorticoids and non-steroidal antiestrogen drugs are used. Methylprednisolone, the most commonly used glucocorticoid, is successfully employed with different therapeutic protocols. Although based on a few cases, results of treatment with tamoxifen are also satisfactory. The authors report 25 cases of RPF, idiopathic in 14 and secondary in 11. Twelve patients underwent medical therapy, corticosteroids being used in 10 and tamoxifen in 2. All patients recovered from the fibrotic disease. Only 1 patient stopped steroid therapy due to worsening diabetes. Easy administration and the lack of side effects make tamoxifen a valid alternative to corticosteroids.

[Laparoscopic unilateral retroperitoneal lymphadenectomy in non-seminomatous neoplasms of the testis in clinical stage I]

Since June 1993, unilateral laparoscopic retroperitoneal lymph node dissection (LRPLND) was performed in 6 patients diagnosed with clinical stage I nonseminomatous germ cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor markers assessment, computerized tomography scan (CT) of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 min (275 to 420 min). The estimated peri- and postoperative blood loss was minimal. Of note, the comparison between the hematocrit and hemoglobin decrease of LRPLND and RPLND showed a statistically significant reduction (3.1 vs 11.1% P < 0.01 and 1.1 vs 3.2 g/dl P < 0.01). None of the patients required blood transfusion. In the case of the first patient the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining five cases the average hospitalization was 4.8 days ranging between 4 and 6 days. The patients resumed normal activities within 12 to 27 days (mean 16.2 days) postoperatively. Mean number of lymph nodes removed was 6.8, ranging between 5 and 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in two patients. Both of these patients were subject to adjuvant chemotherapy. The mean follow-up period is 33.3 months, ranging between 18 and 48 months. To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical stage I NSGCT.

[Endoscopic treatment of bladder diverticula]

Since February 1993 six patients with bladder diverticula have undergone resection of the diverticular neck and fulguration of the diverticular mucosa at the time of transurethral resection of the prostate in 5 cases and urethral dilation in one case. The mean dimension of the diverticular was 5.2 cm. After a mean follow-up of 20 months the diverticulum has largely shrunk in one case and has completely disappeared in 5 cases. Our paper demonstrates the effectiveness of this technique in the treatment of bladder diverticular. In our opinion endoscopic fulguration represents a valid alternative to open surgery for the treatment of small bladder diverticular.

Bilateral Testis Germ Cell Tumours: Two Case Reports

The authors present 2 cases of bilateral testicular germ cell tumours occuring metachronously and synchronously. The usefulness of testicular contralateral biopsy at the time of inguinal orchiectomy is discussed. Advantages and problems concerning the new therapeutic approach of organ-sparing surgery for testicular bilateral germ cell tumours are reported.

Bladder hernias: Report of 4 cases and literature review

– Bladder hernia is a rare pathology found in men over 50 years old in particular and almost always associated with bladder neck obstruction. The authors report 4 cases of bladder hernia treated surgically between April 1984 and November 1995. The average age of patients was 67.5 years (range: 61–75), who presented with non-specific voiding disturbances associated with an inguinal mass which increased in volume during voiding. Diagnosis was made on the basis of pyelographic results. Conservative surgery (reduction of the hernia and reconstruction of the inguinal channel) was carried out in 3 cases, while the hernia was excised in the remaining patient due to its large size, the narrow neck of the sac and the severe damage to the herniated bladder wall. Prostatic adenomectomy was carried out at the same time in all patients, by transvesical approach in 3 cases and transurethral in one. The histological exam showed adenofibroleiomuscular hyperplasia of the prostate in all cases, in one being associated with a prostatic adenocarcinoma. After an average follow-up of 93.75 months (range 20–170), results were good in all patients.

Due casi di fibrosi retroperitoneale con risposta favorevole alla terapia corticosteroidea

Retroperitoneal fibrosis is rare and is usually treated with exploratory laparotomy. Satisfactory response to corticosteroid therapy has been shown, however, in cases with early retroperitoneal disease, while those with late disease show no improvement. Two cases are reported of patients with retroperitoneal fibrosis treated successfully with long-term corticosteroid therapy.

Idiopathic chronic urinary retention in the female: Case report

Female urinary retention may present various etiological aspects. From reports in literature, the most frequent cause appears to be a neurological lesion (60%), while there is no clearly identifiable cause in the remaining 40%. The Authors report the case of a young woman who, following slight retention immediately after a gynaecological operation, returned after 5 months requiring first of all indwelling vesical catheterisation followed by clean intermittent authocatheterisation. Checks and clinical assessments produced negative results and the real cause of urinary retention was not clear. Clean intermittent autocatheterisation was the only feasible therapy, also allowing functional recovery of the vesico-sphincteric apparatus.

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

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

[Leydig cell tumor of the testis]

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

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

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

Testicular neoplasms and tumoral markers

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

Flow cytometric DNA analysis in conservatively treated renal tumours

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

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

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

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

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

Laparoscopic treatment of varicocele

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

Vesicovaginal fistulas: our experience and review of literature

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

Role of PSA on Diagnosis and Clinical Stadiation of Prostatic Cancer

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

Flow Cytometry Role of DNA Analysis

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

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

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

Surgical Procedure for Treatment of Urinary Stress Incontinence

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

Neurophysiology in Lower Urinary Tract Dysfunction

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

Bladder Instability

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

Diagnostic and therapeutic problems in multicentric renal angiomyolipoma

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

Laparoscopic pelvic lymphadenectomy

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

[Conservative surgical treatment of bilateral renal neoplasms]

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

Considerations regarding a case of leiomyoma of the urinary bladder

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