Article

A 25-year-old man from Bangla Desh with acute right scrotal pain was subjected to scrotal surgical exploration because of the suspicion of testicular torsion. The testicle appeared normally positioned; an epididymal nodule was removed, and pathology showed the presence of the filaria worm.

Filariasis is a tropical disease which has been estimated to affect 120 millions people throughout the world. Lymphadenitis and lymphangitis are the more common clinical settings; in men, there is a frequent scrotal involvement. In some cases, acute scrotal pain may lead to the suspicion of testicular torsion.

The observation of patients with genital filariasis is likely to become more frequent in an era of massive immigration from different countries; nowadays, the disease should always be taken into consideration in the differential diagnosis in patients with acute scrotal pain coming from tropical areas.

Sexual Dysfunctions in Female with Neurological Disorders

Female sexuality is a controversial issue due to its embarrassment and to paucity of literature publications. The neuroanatomy and neuromediators involved in female sexuality are important but not so fundamental as in men. There are three sexual female dysfunctions (SFD): primary, secondary, tertiary. In the primary one, the sexual dysfunction (SD) is correlated to the neurological disease, in the secondary the SD derives from the symptoms of the neurological disease, in the tertiary the SD is the psychological reaction to the effects of the disease. We analyse the FSD in neurological diseases, as the outcome of medulla trauma, multiple sclerosis, epilepsy, Alzheimer, Parkinson, diabetes, outcome of pelvic surgery. Female sexuality (FS) is difficult and complex compared to male sexuality. Women with medulla lesion feel some discomfort when having to go and speak to their doctor: they are afraid of pregnancy, sexual intercourses, bladder and rectal functions. In women with newly diagnosed multiple sclerosis, there is a tertiary sexual dysfunction. Medical therapy worsens female sexuality as in case of epilepsy. Emotional and behavioural disorders involve sexual dysfunctions in women with Alzheimer. In Parkinson, reduction of sexual desire involves break of sexual intercourses. SD are more frequent in complicated diabetes. In pelvic surgery, pelvic autonomic dysfunction and depression correlated to the oncology disease, contribute to the FSD. Sexual counselling, especially in young women with medulla lesion or multiple sclerosis, is the best therapy, and learning erotic extragenital areas able to make sensations similar to the orgasms.

Free DNA in Urine: A New Marker for Bladder Cancer? Preliminary Data

The aim of the present preliminary study was to investigate the presence of free DNA (FDNA) in urine as a possible marker for the diagnosis of bladder cancer. Naturally voided morning urine specimens were collected from 57 patients with suspected bladder cancer before cystoscopy. A standard urine test was performed; the specimens were then processed in order to obtain a quantitative evaluation of the presence of free DNA in the urine. Twenty-two patients were excluded from the study because they had leukocyturia and/or bacteriuria. Free DNA concentrations higher than 250 ng/mL were found in all 16 patients showing bladder cancer at cystoscopy and in seven (36.8%) of the 19 patients with negative cystoscopy. Urinary FDNA seems to have an excellent sensitivity: we observed no false negative cases and 36.8% false positive cases. By contrast, only 6.25% of the bladder cancer patients had positive urine cytology. Our results seem promising, although further studies and larger numbers are needed to define urinary free DNA as a reliable marker of bladder cancer.

Morphological changes on the intestinal mucosa in orthotopic neobladder

INTRODUCTION

The intestinal mucosa undergoes significant atrophic changes when it is used to reconstruct the urinary tract. We analyzed the ultrastructural changes of intestinal mucosa in the orthotopic neobladder on the basis of our clinical experience.

PATIENTS AND METHODS

Fifteen male patients with an ileal neobladder underwent endoscopic biopsy at different postoperative intervals.

RESULTS

No significant changes were observed 3 months after surgery. After 6 and 12 months, the structure of the microvilli was modified significantly. No other substantial changes after 24 months were observed.

CONCLUSIONS

Progressive modifications occur in the cytoplasmic structures involved in the absorptive process. They do not seem to begin before 3 months and are almost totally completed after 1 year.

Filariasis: an emergent cause of acute scrotal pain

A 25-year-old man from Bangla Desh with acute right scrotal pain was subjected to scrotal surgical exploration because of the suspicion of testicular torsion. The testicle appeared normally positioned; an epididymal nodule was removed, and pathology showed the presence of the filaria worm. Filariasis is a tropical disease which has been estimated to affect 120 millions people throughout the world. Lymphadenitis and lymphangitis are the more common clinical settings; in men, there is a frequent scrotal involvement. In some cases, acute scrotal pain may lead to the suspicion of testicular torsion. The observation of patients with genital filariasis is likely to become more frequent in an era of massive immigration from different countries; nowadays, the disease should always be taken into consideration in the differential diagnosis in patients with acute scrotal pain coming from tropical areas.

[Sexual dysfunctions in female with neurological disorders]

Female sexuality is a controversial issue due to its embarrassment and to paucity of literature publications. The neuroanatomy and neuromediators involved in female sexuality are important but not so fundamental as in men. There are three sexual female dysfunctions (SFD): primary, secondary, tertiary. In the primary one, the sexual dysfunction (SD) is correlated to the neurological disease, in the secondary the SD derives from the symptoms of the neurological disease, in the tertiary the SD is the psychological reaction to the effects of the disease. We analyse the FSD in neurological diseases, as the outcome of medulla trauma, multiple sclerosis, epilepsy, Alzheimer, Parkinson, diabetes, outcome of pelvic surgery. Female sexuality (FS) is difficult and complex compared to male sexuality. Women with medulla lesion feel some discomfort when having to go and speak to their doctor: they are afraid of pregnancy, sexual intercourses, bladder and rectal functions. In women with newly diagnosed multiple sclerosis, there is a tertiary sexual dysfunction. Medical therapy worsens female sexuality as in case of epilepsy. Emotional and behavioural disorders involve sexual dysfunctions in women with Alzheimer. In Parkinson, reduction of sexual desire involves break of sexual intercourses. SD are more frequent in complicated diabetes. In pelvic surgery, pelvic autonomic dysfunction and depression correlated to the oncology disease, contribute to the FSD. Sexual counselling, especially in young women with medulla lesion or multiple sclerosis, is the best therapy, and learning erotic extragenital areas able to make sensations similar to the orgasms.

Effects on Sexual Function by the Drugs used in the Treatment of Benign Prostatic Hyperplasia and Prostate Cancer. A Practical Guide for the Urologist

The effects on sexual function (SF) by the drugs commonly used in the treatment of benign prostatic hyperplasia (BPH) and prostate cancer (PC) have been analyzed. BPH therapy: alpha-blockers have no adverse effects on SF; the only one without significant hypotensive effect, Tamsulosin, can cause retrograde ejaculation in 4–8% of cases. 5-Alpha-reductase (Finasteride and Dutasteride) inhibitors could have detrimental effects on erectile function, libido and ejaculation in a small percentage of cases rarely exceeding 10%; these effects are reversible and their incidence reduces after 1 yr. Phytotherapy (extracts from pygeum africanum and serenoa repens) and mepartricin have no unfavorable action on SF. PC therapy: Loss of erectile function and libido are the norm with the use of LH-RH analogues, estrogens and steroidal antiandrogens (cyproterone acetate). Non-steroidal antiandrogens (Flutamide, Bicalutamide and Nilutamide) allow the preservation of SF in two-thirds of cases.

Radical Perineal Prostatectomy: Initial Experience of a Single Center and Comparison with the Retopubic Technique

The Authors present a comparison between the first 13 radical perineal prostatectomies performed in their Center and 14 retropubic radical prostatectomies, in order to describe the experience of a group adopting a new technique besides an already acquired one. The age of the patients ranged from 56 to 74 years (mean 67), the mean follow-up was 12 months. Both technique provided a disease-specific survival of 100% and absence of technique-related complicances. The perineal technique implies, at the beginning, worse –- although acceptable –- results as regards continence and erectile function and better results as regards duration of the hospital stay of the patient.

Colonic metaplasia in the long-term follow-up of the ileal neobladder

OBJECTIVE

To look for the presence of colonic metaplasia (CM), the shifting from sialomucins (SIs) to sulfomucins (SUs), considered as a probably premalignant lesion in the stomach in the mucosa of the ileal neobladder (IN).

METHODS

19 patients with IN were subjected to endoscopic biopsy; the samples were analyzed by means of histochemistry with high iron diamine, a test indicated to identify SIs and SUs.

RESULTS

CM was never observed earlier than 1 year after the operation, was absent in 9/19 patients (mean follow-up 14 months) and present in 10/19 (mean follow-up 59 months).

CONCLUSION

Time-dependent phenotypic changes, already described in the stomach as being premalignant, take place after constant contact with urine in the mucosa of the IN. It is at present unclear whether they may be defíned as only metaplastic or frankly preneoplastic; anyway, a careful follow-up remains indicated in all patients with íntestinal urinary diversions.

[Phenotypic changes in mucin-secreting cells in the ileal neobladder mucosa: a metaplastic or precancerous lesion?]

Colonic metaplasia with shifting from sialo-to sulfomucins was observed in 10/18 patients with ileal orthotopic neobladder; their median follow-up was 59 months. There is a significant statistical relationship (p = 0.002) between Colonic Metaplasia and a follow-up longer than 14 months. Diversion Cancer is nowadays a practical problem and probably urologists will be confronted with it in the future more than at present. A modification of established attitudes as regards urinary diversion in standard situations (i.e., 60 over years old patients with invasive bladder cancer) don't seems, at present, justified, although our study confirms the suspicion that ileal neobladder could be considered theoretically at risk for cancer onset.

Ultrastructural mucosal appearance in the ileal neobladder

METHODS

15 patients with ileal neobladder underwent endoscopic biopsy at different postoperative intervals. The specimens were analyzed by electron microscopy in order to evaluate the evolution of the mucosal changes ultrastructurally.

RESULTS

No significant change was observed 3 months after the operation. After 6 months, the number and height of the microvilli were reduced, the cell borders crooked and the terminal web upset. After 12 months disappearance of the glycocalyx, increased lysosomal features, increased activity of the muciparous cells, rounded mitochondria and loss of the polarized disposition of the cytoplasmic organelles were detected in the enterocytes. We observed no other substantial change after 24 months and more.

CONCLUSIONS

Progressive modifications occur in the cytoplasmic structures involved in the absorptive process. They do not seem to begin before 3 months and are almost totally completed after 1 year.

Role of retroperitoneal lymph node dissection in clinical stage I Leydig cell tumours

Leydig Cell Tumours (LCT) account for 3% of all testicular tumours; 10% are malignant and are refractory to radio- and chemotherapy. The role of Retroperitoneal Lymph Node Dissection in clinical stage I LCT is therefore a particularly debated one. From March ‘83 to December ‘95, 10 patients with LCT were subjected to orchiectomy (1 of them bilaterally because of a metachronous tumour). In 10 out of 11 specimens the following pathological features – a) size larger than 50 mm, b) infiltration of spermatic cord, c) lymphatics and veins, d) capsule, e) necrosis, f) cellular pleomorphism, g) numerous mitoses, h) nuclear atypia – were absent. The only patient in which b) and d) were present was subjected to RPLND. After a follow-up ranging from 17 to 157 months all patients are disease-free. Abstention from RPLND in clinical stage I LCT therefore seems the more rational choice when the above- listed pathologic features are absent.

Rottura spontanea dell'uretere: Due casi: Spontaneous rupture of the ureter: Two cases

Spontaneous rupture of the ureter is rare, usually ending in a periureteral abscess. Two cases of spontaneous rupture of the ureter secondary to calculosis in patients with ureterosigmoidostomy are described. Surgical management includes immediate drainage of the urinoma with urinary reconstruction (if necessary and possible) or radical surgery.

Mielolipoma non surrenalico associato ad adenocarcinoma renale: Extra-adrenal myelolipoma and renal cell carcinoma

Extra-adrenal myelolipomas are rare benign tumours composed of hematopoietic and adipose tissue. We report a case of retroperitoneal myelolipoma and renal cell carcinoma.

Favourable results of a therapeutical scheme in idiopathic retroperitoneal fibrosis: Suggested protocol

— The Authors describe the favourable results obtained in 3 patients with Idiopathic Retroperitoneal Fibrosis (IRF) using a therapeutic protocol based on the association of prednisolone and cyclophosphamide. In 2 patients this therapy obtained a partial radiologic and total clinical remission; in the third case it guaranteed a stabilization of the results obtained by previous surgery. Given the absence of significant side effects, the protocol may be taken into consideration for practically all patients with TRF.

[Imposing "calcium milk" lithiasis in giant hydronephrosis]

The authors report a quite unusual case of "milk of calcium renal Stone" in unilateral giant Hydronephrosis. Radiographic, sonographic, intravenous urographic and TC aspects are described and prominence il given to morphostructural information obtained through digital image techniques of pyeloureteral zone junction and of "milk of calcium renal Stone". The authors discuss the pathogenesis of the renal Stone type and emphasize the convenience of investigative acts to clear up the ethio-pathogenetic role of pyeloureteral infections.

Self-introduction of foreign bodies into the urethra: a multidisciplinary problem

A 36-year-old man was hospitalized for self-insertion of a metallic body into the urethra. The self-inserted foreign body (SFB) was removed by endoscopic means; psychiatric evaluation of the patient showed a disturbed schizoid personality. After a review of the current literature, including clinical features, diagnostic manoeuvres and methods of treatment of SFB, the authors suggest that a psychiatric evaluation is always recommended in order to discover mental underlying disorders, thus reducing the risk of recurrence.

Urinary diversion: Anatomo-physiological assumptions

The basic anatomical and physiological conditions needed for preparation of a good functioning urinary reservoir are analyzed according to current literature and personal experience. Owing to the need for a schematic and concise exposition, the text has been subdivided under five headings: (I) Metabolic considerations: a) the segment used; b) the duration of contact between intestinal mucosa and urine; c) the size of the exposed intestinal surface. (II) Renal function. (Ill) Physical properties of the reservoir: a) contractility; b) configuration; c) accommodation; d) viscoelasticity. (IV) Carcinogenesis: a) statistical considerations; b) ethiopathogenesis. (V) Clinical consequences of the removal of a normally functioning intestinal segment.

Ureterosigmoidostomy

After a brief review of the main ureterosigmoidostomy techniques, the Authors evaluate their own experience based on 116 patients operated between 1969 and 1987. The early and late complications of this procedure have been analyzed, in particular those regarding the state of the upper urinary tracts, hyperchloremic acidosis, colonic neoplasms, renal stones and proctitis. The Authors conclude that ureterosigmoidostomy still seems to have a well-defined role among urinary diversion possibilities that may be offered to patients (in particular women).

Urodynamic Aspects Compared

The aim of this study is to compare urodynamic and clinical (in particular night and daytime “dry” interval) parameters in patients subjected to urinary diversion with ileal orthotopic neobladder after cystectomy. Experiences with the techniques of Carney, Reddy II, Carney II and VIP have been compared. The progressive improvements obtained through these techniques, taken in chronological order, are clear, particularly from the urodynamic point of view.

Bladder Orthotopic Substitution

The Authors have briefly reviewed current literature regarding orthotopic bladder substitution. On the grounds of these preliminary considerations, the experience progressively acquired in our Department during the last three years has been reevaluated. The following techniques have been performed: Carney (without ileal detubularization), Reddy II (with partial detubularization), Carney II (with total detubularization) and VIP (with reconfiguration associated with total ileal detubularization). Our data show that the association of detubularization and reconfiguration seems to be the most suitable measure to guarantee construction of a continent, high-capacity, low-pressure reservoir.

Leydig cell tumors: Prognostic factors

Leydig Cell Tumors (LCT) are uncommon testicular neoplasms that account for 1 to 3% of all testicular tumors. Only about 10% of LCT are malignant and generally refractory to radiotherapy and conventional chemotherapy. Therefore, there is some debate about the value of Retroperitoneal Lymphadenectomy (RPLND) in Stage I disease. Indeed, although surgery is the only available therapy which is able to cure and prevent tumor spread, RPLND is a challenging invasive surgery and may be useless in 90% of the cases. The Authors observed 5 cases of patients in clinical Stage I disease with benign behaviour demonstrated after an adequate follow-up. Pathological analysis showed absence of signs of malignancy. Starting from these experiences, it is suggested that RPLND may be avoided in selected cases when definite pathological signs of malignancy are absent.

Focal xanthogranulomatous pyelonephritis: diagnostic and therapeutic aspects

The authors report 2 cases of localized xanthogranulomatous pyelonephritis (XGP) in which computed tomography (CT) permitted to raise a motivated clinical suspicion of inflammatory disease: the surgical exploration documented absence of neoplasm and allowed a conservative therapy implying only the removal of the mass. A literature review confirms that some CT signs in XGP permit differentiation from carcinoma. If they are present, in unifocal cases of disease, the authors suggest a limited surgical approach and a therapeutic strategy as conservative as possible.

Congenital polyp of the prostatic urethra: report on 2 cases

Congenital polyps of the prostatic urethra are an uncommon cause of obstructive uropathy, infection and/or hematuria in male children. A filling defect localized in the posterior urethra on the voiding cystourethrogram represents the peculiar diagnostic finding. Transurethral resection is the treatment of choice, according to the size of the polyp. Two cases of congenital posterior urethral polyps are reported and the main clinical and radiological features are discussed. This lesion has to be considered in the differential diagnosis of the voiding dysfunction in young boys.