Retro-mode imaging for the diagnosis of optic disc drusen: a case series

OBJECTIVE

We aimed to compare the detectability of optic disc drusen (ODD), using various non-invasive imaging techniques, including the novel retro-mode imaging (RMI), as well as to analyze the morphological characteristics of ODD on RMI.

METHODS

This study involved seven patients with bilateral ODD, totaling 14 eyes. Multimodal imaging techniques, including multicolor fundus photography (MC), near-infrared reflectance (NIR), green and blue light fundus autofluorescence (G-FAF and B-FAF, respectively), and RMI were used to examine the eyes. FAF was used as the primary method of identifying ODD, and each method's detection rate was compared by two observers. Quantitative measurements of ODD included the number of ODD visualized by the RMI technique, the perimeter (P) and area (A) of ODD were identified.

RESULTS

The average age of the patients included was 49.28 ± 23.16 years, with five of the seven being men. RMI was able to detect ODD in all cases, with a sensitivity of 100%, compared to MC (sensitivity 60.71%), NIR (sensitivity 60.71%), B-FAF (sensitivity 100%), G-FAF (sensitivity 100%). RMI was the only imaging technique capable of assessing ODD morphology and quantifying ODD.

CONCLUSIONS

RMI is a promising imaging modality for diagnosing superficial ODD, providing valuable information on the distribution, location, and size of ODD. We suggest the incorporation of RMI as a complementary tool for diagnosing and monitoring ODD in combination with other multimodal imaging methods.

A cystic fibrosis child with lung function decline

Respiratory infections are a major threat to cystic fibrosis patients. Besides bacteria, many fungi colonize the cystic fibrosis respiratory tract where an important fungal biota has been described. We report here the case of a 7-year-old cystic fibrosis child with pulmonary exacerbation and Arthrographis kalrae isolated from bronchoalveolar lavage fluid. To the best of our knowledge, this is the first reported case of lung infection due to Arhtrographis kalrae in a cystic fibrosis pediatric patient.

Colistin-resistant microorganisms and cystic fibrosis: microbiological surveillance in an Italian Children’s Hospital

Several advances in the medical field are often dependent on the ability to fight infections with the use of antibiotics, including joint replacements, organ transplants, and cancer therapy. The capacity of the bacteria to adapt to and escape from the mechanisms of action of antibiotics makes the antimicrobial resistance a serious public health problem worldwide. Polymyxin E colistin has rarely been used because of its nephrotoxicity and neurotoxicity. More recently, the emergence of multi-drug resistant bacteria as carbapenem-resistant Klebsiella pneumoniae, Acinetobacter baumannii and Pseudomonas aeruginosa and the re-evaluation of its pharmacokinetic properties have led to a resurgence of colistin as a treatment option, contributing to select resistant strains. Investigating the phenomenon of colistin-resistance in gram-negative bacteria, especially P. aeruginosa, is now mandatory, particularly after identification of a plasmid-mediated mechanism for the resistance to colistin (mcr) in Enterobacteriaceae strains, a mechanism transferable to other species. In this study, we investigated colistin-resistance in gram-negative bacteria isolated from respiratory secretions of cystic fibrosis patients in follow-up at Children’s Hospital Bambino Gesù of Rome.

Major discrepancies between what clinical trial registries record and paediatric randomised controlled trials publish

BACKGROUND

Whether information from clinical trial registries (CTRs) and published randomised controlled trial (RCTs) differs remains unknown. Knowing more about discrepancies should alert those who rely on RCTs for medical decision-making to possible dissemination or reporting bias. To provide help in critically appraising research relevant for clinical practice we sought possible discrepancies between what CTRs record and paediatric RCTs actually publish. For this purpose, after identifying six reporting domains including funding, design, and outcomes, we collected data from 20 consecutive RCTs published in a widely read peer-reviewed paediatric journal and cross-checked reported features with those in the corresponding CTRs.

METHODS

We collected data for 20 unselected, consecutive paediatric RCTs published in a widely read peer-reviewed journal from July to November 2013. To assess discrepancies, two reviewers identified and scored six reporting domains: funding and conflict of interests; sample size, inclusion and exclusion criteria or crossover; primary and secondary outcomes, early study completion, and main outcome reporting. After applying the Critical Appraisal Skills Programme (CASP) checklist, five reviewer pairs cross-checked CTRs and matching RCTs, then mapped and coded the reporting domains and scored combined discrepancy as low, medium and high.

RESULTS

The 20 RCTs were registered in five different CTRs. Even though the 20 RCTs fulfilled the CASP general criteria for assessing internal validity, 19 clinical trials had medium or high combined discrepancy scores for what the 20 RCTs reported and the matched five CTRs stated. All 20 RCTs selectively reported or failed to report main outcomes, 9 had discrepancies in declaring sponsorship, 8 discrepancies in the sample size, 9 failed to respect inclusion or exclusion criteria, 11 downgraded or modified primary outcome or upgraded secondary outcomes, and 13 completed early without justification. The CTRs for seven trials failed to index automatically the URL address or the RCT reference, and for 12 recorded RCT details, but the authors failed to report the results.

CONCLUSIONS

Major discrepancies between what CTRs record and paediatric RCTs publish raise concern about what clinical trials conclude. Our findings should make clinicians, who rely on RCT results for medical decision-making, aware of dissemination or reporting bias. Trialists need to bring CTR data and reported protocols into line with published data.

IL-1 receptor antagonist ameliorates inflammasome-dependent inflammation in murine and human cystic fibrosis

Dysregulated inflammasome activation contributes to respiratory infections and pathologic airway inflammation. Through basic and translational approaches involving murine models and human genetic epidemiology, we show here the importance of the different inflammasomes in regulating inflammatory responses in mice and humans with cystic fibrosis (CF), a life-threatening disorder of the lungs and digestive system. While both contributing to pathogen clearance, NLRP3 more than NLRC4 contributes to deleterious inflammatory responses in CF and correlates with defective NLRC4-dependent IL-1Ra production. Disease susceptibility in mice and microbial colonization in humans occurrs in conditions of genetic deficiency of NLRC4 or IL-1Ra and can be rescued by administration of the recombinant IL-1Ra, anakinra. These results indicate that pathogenic NLRP3 activity in CF could be negatively regulated by IL-1Ra and provide a proof-of-concept evidence that inflammasomes are potential targets to limit the pathological consequences of microbial colonization in CF.

IL-1-mediated inflammation contributes to the pathogenesis of cystic fibrosis. Here the authors show that this is largely due to NLRP3 activation, whereas NLRP4 induces IL-1Ra, limiting the overall inflammasome activity and providing a therapeutic angle to ameliorate the disease.

Hypoxia promotes danger-mediated inflammation via receptor for advanced glycation end products in cystic fibrosis

RATIONALE

Hypoxia regulates the inflammatory-antiinflammatory balance by the receptor for advanced glycation end products (RAGE), a versatile sensor of damage-associated molecular patterns. The multiligand nature of RAGE places this receptor in the midst of chronic inflammatory diseases.

OBJECTIVES

To characterize the impact of the hypoxia-RAGE pathway on pathogenic airway inflammation preventing effective pathogen clearance in cystic fibrosis (CF) and elucidate the potential role of this danger signal in pathogenesis and therapy of lung inflammation.

METHODS

We used in vivo and in vitro models to study the impact of hypoxia on RAGE expression and activity in human and murine CF, the nature of the RAGE ligand, and the impact of RAGE on lung inflammation and antimicrobial resistance in fungal and bacterial pneumonia.

MEASUREMENTS AND MAIN RESULTS

Sustained expression of RAGE and its ligand S100B was observed in murine lung and human epithelial cells and exerted a proximal role in promoting inflammation in murine and human CF, as revealed by functional studies and analysis of the genetic variability of AGER in patients with CF. Both hypoxia and infections contributed to the sustained activation of the S100B-RAGE pathway, being RAGE up-regulated by hypoxia and S100B by infection by Toll-like receptors. Inhibiting the RAGE pathway in vivo with soluble (s) RAGE reduced pathogen load and inflammation in experimental CF, whereas sRAGE production was defective in patients with CF.

CONCLUSIONS

A causal link between hyperactivation of RAGE and inflammation in CF has been observed, such that targeting pathogenic inflammation alleviated inflammation in CF and measurement of sRAGE levels could be a useful biomarker for RAGE-dependent inflammation in patients with CF.

MALDI-TOF MS proteomic phenotyping of filamentous and other fungi from clinical origin

Major changes in medical, intensive care and organ transplantation practices are drastically increasing the risk of fungal opportunistic infections. We designed and set-up a MALDI-TOF MS-based assay to identify the most isolated and emerging therapy-refractory/uncommon fungi from cystic fibrosis (CF) and immunocompromised patients. Two-hundred and thirty isolates from 10 different genera (Aspergillus, Emericella, Fusarium, Geosmithia, Neosartorya, Penicillium, Pseudallescheria, Scedosporium, Talaromyces, Fomitopsis), investigated during routine diagnostic efforts, were correlated to 22 laboratory-adapted reference MALDI-TOF MS "proteomic phenotypes". A growth time-course at 30°C on Sabouraud agar medium was performed for the 22 "phenotypes" at 48, 72, 96 and 120h points. The best peptide extraction conditions for full recovery of conidia- or asci-producing multihyphal morph structures and the highest intra- and inter-class profiling correlation were identified for the 120h point spectra dataset, from which an engineered library derived (pre-analytical phase). Fingerprinting classifiers, selected by Wilcoxon/Kruskal-Wallis algorithm, were computed by Genetic Algorithm, Support Vector Machine, Supervised Neuronal Network and Quick Classifier model construction. MS identification (ID) of clinical isolates was referred to genotyping (GT) and, retrospectively, compared to routine morphotyping (MT) IDs (analytical phase). Proteomic phenotyping is revolutionizing diagnostic mycology as fully reflecting species/morph varieties but often overcoming taxonomic hindrance.

Pseudomonas aeruginosa infection in cystic fibrosis caused by an epidemic metallo-β-lactamase-producing clone with a heterogeneous carbapenem resistance phenotype

An epidemic IMP-13 metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa clone, causing infections and even large outbreaks in Italian critical care settings, was detected in a young cystic fibrosis patient. In this patient, the chronic infection was sustained by distinct clonal sub-populations of the MBL-producing P. aeruginosa clone, either susceptible or resistant to carbapenems. These findings underscore the importance of infection prevention practices in cystic fibrosis settings and pose an important diagnostic and therapeutic challenge.

Renal Tumours, Epidemiology and Diagnostic Profile

Our understanding of the natural history of renal cell carcinoma and the possibilities of new technologies are evolving and being integrated with advances in classification and staging. In this article we reviewed the literature in order to provide an analysis of the changing epidemiology of renal cell carcinoma.

Radiological evaluation of renal masses has rapidly progressed from conventional angiography and intravenous urography to ultrasounds, CT and MRI. As more patients are imaged for many opportunities, the incidental detection has increased. This article reviews the imaging and not techniques in order to characterize these lesions accurately.

Videoendoscopically assisted transvaginal radical cystectomy

We describe our experience of anterior pelvic exenteration for bladder cancer in women using a combined transvaginal and laparoscopic approach. The feasibility of videoendoscopically assisted transvaginal cystectomy was demonstrated several years ago, but the indications have been greatly reduced by the spreading use of orthotopic neobladders in women. Moreover, nulliparous patients or patients with vaginal atresia are not suitable for this technique, even if the specimen can also be retrieved through the minilaparotomy used for performing urinary diversion. In the last 3 years, we have performed only four additional cases. Nevetheless, the results are satisfactory. We did not have any major intraoperative complication. Patients were discharged after 7 to 11 days (average 8.6 days) without any postoperative complications. The minimum survival was 13 months, and four patients are still alive. The operation itself is not easy and therefore can be offered only by centers where videoendosurgery has already entered common clinical practice.

Fatal pulmonary infection due to multidrug-resistant Mycobacterium abscessus in a patient with cystic fibrosis

We report a case of fatal pulmonary infection caused by Mycobacterium abscessus in a young patient with cystic fibrosis, who underwent bipulmonary transplantation after a 1-year history of severe lung disease. Fifteen days after surgery he developed septic fever with progressive deterioration in lung function. M. abscessus, initially isolated from a pleural fluid specimen, was then recovered from repeated blood samples, suggesting a disseminated nature of the mycobacterial disease. Drug susceptibility testing assay, performed on two sequential isolates of the microorganism, showed a pattern of multidrug resistance. Despite aggressive therapy with several antimycobacterial drugs, including clarithromycin, the infection persisted, and the patient died.

Horseshoe-shaped marlex mesh for the treatment of pelvic floor prolapse

OBJECTIVE

Pelvic prolapse results from weakness or damage to the normal pelvic-support systems. The main support for the pelvic viscera is provided by the pelvic fascia, which is naturally reinforced by urethra-pelvic ligaments, cardinal ligaments and uterosacral ligaments. A polypropylene mesh (Marlex-Bard) was used as a genitourinary and rectal support in order to substitute the damaged pelvic fascia.

METHODS

Sixteen consecutive females suffering from severe genitourinary prolapse entered the study. Using the HWS (Baden-Walker) classification 10 patients presented a grade-IV and 6 patients a grade-III cystocele, 7 patients a grade-III and 1 a grade-IV rectocele. Hysterocele of grade IV was present in 2 patients and in 5 patients grade III. No enterocele was present at the pre-operative visit. Twelve patients suffered from stress incontinence; one had obstructive urinary symptoms with postvoiding residual urine of >200 ml. All patients underwent urodynamic tests and pre-operative cystography. The primary aim was prolapse reduction and continence. The operation, under general anesthesia, consisted of insertion and fixation of a horseshoe-shaped Marlex mesh between pubis and sacrum to close the area between the pelvic viscera and inferior pelvic hiatus. Three patients underwent hysterectomy.

RESULTS AND CONCLUSIONS

The follow-up ranged between 12 and 29 months. In 15 patients the prolapse was completely resolved and 13 were dry at follow-up. One patient presented a complete recurrence at the 3-month follow-up. Nine cases of pre-operative constipation were recovered after surgery. This technique seems to give promising results in the repair of genitourinary prolapse and stress incontinence.

Primary endoscopic treatment of ureteric calculi. A review of 378 cases

AIM OF THE STUDY

In the post-ESWL period, ureteroscopy represented the solution giving a second choice in the treatment of ureteral calculi in case of failure of extracorporeal lithotripsy. The aim of this study is to review a wide series of ureteral stones in which ureteroscopy combined with endoscopic lithotripsy can be chosen as the first approach for the treatment of ureteral calculi.

METHODS

Between January 1994 and September 1997, 378 patients underwent ureteroscopy and endoscopic lithotripsy for ureteral stones with a miniscope associated with either a pneumatic or electropneumatic lithotriptor. Three different miniscopes were used: Olympus (8 Fr), Wolf (7 Fr) and Circon Acmi (7.7 Fr). 238 patients were male and 140 were female. The stones were localized in the upper tract of the ureter in 62 cases (16.4%), 96 (25.3%) in the mid ureter and 220 (58. 3%) in the lower ureter.

RESULTS

A complete stone fragmentation with spontaneous expulsion of the fragments occurred in 354 patients (93.6%). In 22 patients (5.8%) the stones were accidentally pushed up and successfully underwent ESWL. In 38 patients (10%) the fragments were completely removed by basket. A single J polyethylene catheter was placed in 21 (5.5%) and a JJ stent in 147 patients (38. 8%). The operative time ranged from 10 to 60 min, with an average time span of 32. In 22 cases (5.8%) an iterative ureteroscopy for stenosis or incomplete fragmentation was needed. Five cases (1.3%) of ureteral perforation were successfully treated by JJ stent, and only 1 case of ureteral avulsion (upper ureter) was treated by open surgery. In the attempt of overcoming an ureteral stenosis, we had 1 case (0.2%) of ureteral reimplantation. One patient (0.2%) underwent ureterolithotomy for an extremely narrow stenosis just before the ureteropelvic junction. No relevant complication was recorded in the postoperative period. Patients were dismissed after 1- 4 days (average 1.9). Up until now, no case of postoperative ureteral stricture has been observed, although we were not able to carry out a specific follow-up in all our patients.

CONCLUSIONS

Ureteroscopy with miniscopes has a high success rate (93.6%) with low morbidity and can be given as a primary approach in the management of ureteral calculi. In the lumbar ureter (especially in women) this technique can represent a good alternative to ESWL in the treatment of obstructing stones (which need stenting) or when the patient asks for a 'one-shot' treatment.

Lithotripsy with miniscope: Clinical results of 193 consecutive patients

A retrospective analysis was carried out on 193 patients who underwent ureteroscopy for ureteral stones with a miniscope associated with either an electrohydraulic or a pneumatic lithotriptor. Complete stone fragmentation with spontaneous expulsion of the fragments occurred with just one session in 89.1% of cases. Nine patients underwent ureterolithotomy. The only complications were 3 ureteral lesions without perforation. The authors consider that with these mini instruments, there is a very low rate of morbidity connected with this procedure, which can therefore be given first option in the treatment of lower ureteral stones.

Retroperitoneoscopic treatment of ureteropelvic junction obstruction

PURPOSE

To demonstrate feasibility and safety of retroperitoneoscopic treatment of ureteropelvic junction obstruction.

MATERIALS AND METHODS

11 patients with symptomatic ureteropelvic junction obstruction were selected for retroperitoneoscopic pyeloplasty. Operative time ranged between 2 h 30 min and 4 h (mean 3 h 10 min); in 5 cases we had to convert to open surgery and an open pyeloplasty was performed through a minimal (6 cm) lombotomic incision.

RESULTS

Follow-up IVPs were performed in all patients approximately 2-3 weeks after stent removal. In all patients, a reduction in the grade of hydronephrosis was observed. Significant improvement was noticed in 9 patients; in 2 patients a moderate improvement was observed.

CONCLUSIONS

Our experience with retroperitoneoscopic treatment of ureteropelvic junction obstruction demonstrates that also with this approach it is possible to perform reconstructive procedures, with minimal complications. Technical refinements will progressively reduce the conversion rate to open surgery, even if done through minilaparotomy.

Laparoscopic tumorectomy for renal cell carcinoma in a HIV-positive patient

We report on a HIV-positive patient in whom laparoscopic nephron-sparing surgery has been performed. A 47-year-old white male referred for evaluation and treatment of an asymptomatic, serendipitously discovered renal mass. The patient underwent a laparoscopic tumorectomy; indications, surgical technique and rationale are described in detail.

Videoendoscopic retroperitoneal cutaneous ureterostomy

Since January 1993, 10 patients with bilateral ureteral obstruction due to advanced pelvic cancers underwent videoendosurgical cutaneous ureterostomy. Five patients had prostate cancer, three had uterine cancer, and only two had bladder cancer. In five cases a bilateral laparoscopic transperitoneal procedure (LCU) was performed. In five cases a retroperitoneal laparoscopic technique (RLCU) was adopted, and only in one out of these five cases was the procedure done bilaterally. All the procedures were done under general anesthesia. The procedure was accomplished in all the cases without any intraoperative complication. Monolateral retroperitoneal laparoscopic cutaneous ureterostomy (RLCU) required 35-42 min, including the dilation time. Bilateral RLCU required extra time for changing the position of the patient. Postoperative pain was rather insignificant and did not require additional medication. Postdiversion hospital stay was 3-6 days depending on the general condition of the patient. The mean follow-up was 14.4 months.

Heat-expansible permanent intraurethral stents for benign prostatic hyperplasia and urethral strictures

We report our experience with the insertion of a new thermoexpansible permanent intraurethral stent, the Memotherm. We treated 49 patients, 25 with benign prostic hyperplasia (BPH), 21 with recurrent urethral strictures (2 cervicourethral and 18 bulbar and 1 of a vescicourethral anastomosis after radical prostatectomy), and 3 with sphincterotomies (2 for dyssynergia and 1 with incontinence plus stenosis). The patients' ages ranged from 24 to 84 (mean 59.7) years. In all patients, stent insertion was achieved without any operative problem. In two patients, stents were removed (one in the BPH group and one in the urethral stricture group), and at long-term follow-up, we have seen two patients with severe mucosal hyperplasia.

Videoendoscopic cutaneous ureterostomy for palliative urinary diversion in advanced pelvic cancer

Since January 1993, 9 patients with bilateral ureteral obstruction due to advanced pelvic cancers underwent videoendosurgical cutaneous ureterostomy. Five patients had prostate cancer, 3 had uterine cancer and only 1 bladder cancer. In 5 cases a bilateral laparoscopic transperitoneal procedure was performed. In 4 cases a retroperitoneal laparoscopic technique was adopted and only in 1 out of these 4 cases the procedure was done bilaterally. All the procedures were done under general anesthesia. The procedure was accomplished in all the cases without any intraoperative complication; the operative time ranged between 35 and 130 min. Postoperative pain was rather insignificant and did not require additional medication. Postdiversion hospital stay ranged from 3 to 11 days according to the general condition of the patients. The mean follow-up is 10.8 months. In conclusion, retroperitoneal laparoscopic cutaneous ureterostomy seems to be a reasonable alternative to percutaneous nephrostomy in case of bilateral ureteral obstruction due to advanced prostate or uterine cancer, provided that the clinical condition of the patient allows general anesthesia.

Laparoscopically assisted transvaginal radical cystectomy

Herein we describe 5 cases of anterior pelvic exenteration in females through a combined transvaginal and laparoscopic approach for bladder cancer. In 4 cases hysterectomy and bilateral ovariectomy were performed. As far as urinary diversion is concerned, a bilateral cutaneous ureterostomy was performed in the 1st case, and in the remaining 4 an ileal conduit was accomplished through a minilaparotomy at the stoma site. The surgical specimen was withdrawn 'en bloc' transvaginally in all cases except 1, in whom vaginal atrophy forced us to perform a midline minilaparotomy. Total operative time ranged between 6 and 9 h, and 4 patients were discharged after 7-11 days with no complications. One patient was discharged only after 18 days due to obesity and diabetic problems. A larger series is needed to confirm the advantages of the combined transvaginal and videolaparoscopic approach for anterior pelvic exenteration as compared to the conventional procedure, with special regard given to the oncological outcome. Our initial experience is surely encouraging.

Laparoscopic bilateral cutaneous ureterostomy for palliation of ureteral obstruction caused by advanced pelvic cancer

In cases of advanced urologic malignancies with impairment of renal function secondary to tumor infiltration in high-risk patients, the possibility of performing a laparoscopic instead of an open cutaneous ureterostomy should be considered. We performed laparoscopic cutaneous ureterostomy in three male patients, two with prostate cancer and one with bladder cancer, and in one female patient with uterine cancer. Five operative ports were used. The ureters were identified, dissected, severed, and passed through two 10-mm ports; and cutaneous ureterostomies were performed in the usual manner. The mean operative time was 96 minutes. Patients were discharged after 5 to 7 (mean 6) days. The two patients with prostate cancer are now in treatment with GnRH analogues with a follow-up of 3 and 7 months. The patient with bladder cancer underwent palliative radiotherapy and is well after 6 months. The patient with uterine cancer has stable disease after 3 months. Laparoscopic urinary diversion causes less discomfort and has a low complication rate and may be the first-choice diversion in patients with advanced cancer who have a life expectancy longer than 6 months.

Prostate cancer detection in BPH patients

The first problem to be solved in the evaluation of BPH patients is surely the differential diagnosis with prostate carcinoma. We evaluated the impact of a combined approach for prostate cancer detection using DRE, PSA, TRUS and ultrasound-guided biopsy, determining the sensitivity and specificity of different tools, in order to obtain a diagnostic algorithm to be used for pretreatment differential diagnosis between prostate cancer and BPH.

Urolume in urethral stenosis: Italian Club of Minimally Invasive Urology experience

A multicenter study of the patients in whom the Urolume has been implanted has been among the actions undertaken by the Italian Club of Minimally Invasive Urology (UMICLUB). For each patient, a computer information format has been prepared containing evaluation data related to the preoperative period, the endoscopic procedure, and follow-up. The collected data were computerized through unifunctional and multifunctional analysis. Of the 82 patients recruited, 76 were followed for a period ranging from 1 to 40 months. Urinoflow results dramatically improved after implantation of the endoprosthesis: peak flow rates increased by 310%, while mean flow rates increased by 294%. Incontinence and dribbling were found in 4% and 20% of the patients, respectively, and were independent of the distance between the external sphincter and the Urolume prosthesis and of the stent number and length. The cross-data elaboration seems to indicate a statistically significant relation between urethral preparation before Urolume implantation and stricture recurrence, with recurrence being more frequent after dilation. Significant correlations have not been noticed between stenosis etiology, urinary infection, type of anesthesia, and recurrence; between the type of anesthesia, stent length, and duration of hospitalization; or between stent number and position and pain. The impact of the Urolume prosthesis on sexual activity was marginal by all three measures considered (pain during erection, coitus, and ejaculation).

Laparoscopic pelvic lymphnodes dissection for prostate and bladder cancer: indication, techniques and results

Laparoscopic pelvic lymphadenectomy has been proposed for staging of prostate cancer and it might be used, in selected cases, also in bladder cancer. On a total of 31 laparoscopic lymphadenectomies (LPND), 18 for prostate cancer and 13 for bladder cancer, we found positive nodes in 8 cases (26.1%), 4 in prostate and 4 in bladder cancer group. We had no intraoperative complications and negligible postoperative complications (in 10% of cases shoulder-tip pain and in 24% subcutaneous emphysema); all these spontaneously disappeared after 24-36 hours. Patients with negative nodes underwent radical surgery except two prostate cancer patients who underwent radiotherapy, and patients with positive nodes underwent hormonal therapy (for prostate cancer) or chemoradiotherapy protocol (for bladder cancer). In conclusion, laparoscopic lymphadenectomy proved to be a feasible and safe method for staging urological malignancies, being less invasive, with shorter hospitalization and postoperative convalescence than open lymphadenectomy. It should be mainly indicated in high risk prostate cancer patients (elevated PSA and/or Gleason score). In bladder cancer patients, it could be proposed in bladder sparing investigational protocols, as the percentage of pelvic nodes metastases in T2/T3 bladder cancer is sufficiently high to justify an additional staging procedure.

Ureteroarterial fistula: a case report

Ureteroarterial fistulas are rare, with less than 20 well documented cases reported. We report a case of a fistula between the left external iliac artery and the left ureter in a patient who underwent a previous operation for bladder cancer. The diagnostic and therapeutic approaches in these rare but high risk patients are discussed.

Malignant priapism due to a huge renal carcinoma

Metastases to the penis from renal cell carcinoma producing priapism are very rare, as only 18 cases have been described since 1964. We present an additional case of priapism due to massive metastatic involvement of the corpora cavernosa in a patient with huge renal cell carcinoma, 28 cm in diameter, discussing the possible pathogenetic mechanism of such a rare condition.

Comparison between digital rectal examination, prostate-specific antigen and transrectal ultrasound in symptomatic patients. Results on 141 cases

In this study we proposed to verify sensitivity and specificity of prostate-specific antigen (PSA), digital rectal examination (DRE) and transrectal ultrasound (TRUS) in patients who referred at our institution for prostatic complaints. 141 patients, ages ranging between 55 and 86 years (mean 67.5), underwent DRE, blood PSA, TRUS and ultrasonically guided biopsy of the prostate. The comparison of the results obtained with the different diagnostic tools allowed us to draw a diagnostic algorithm for prostate cancer in symptomatic patients.

[Exploration of the intra-renal collecting system using flexible fibroscopy]

23 cases of flexible retrograde nephroscopy system for undiagnosed hematuria or filling defect are reviewed. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. The indications were merely diagnostic (filling defects and/or haematuria). The success rate was very high (22 of 23). 9 cases of papillary tumors, 4 cases of small radiolucent stones and 1 case of papillary necrosis were diagnosed. In 8 cases no pathology was found. The complication rate was extremely low and the postoperative course was uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system and transureteral nephroscopy through a 10.8 F flexible scope is a feasible and effective procedure.

[Extracorporeal lithotripsy using the Lithoring multi-one, a third generation lithotripter]

The Lithoring multi-one is a lithotripter recently developed in Italy. Its main features are: (1) spark gap generator with large ellipsoid with tunable power for treatments with or without analgesia (2) localization by fluoroscopy and ultrasounds without moving the patient (3) isocentric variation of shock wave window (4) multi-functional table. It can treat both urinary and biliary stones. Herein we described (1) the experimental in vitro studies, including those carried out by intentionally changing the direction of the blast path during the treatment (2) the experimental in vivo studies on pigs which demonstrated a rate of side effects favourably comparable with that of other spark gap lithotripters (3) the clinical experience on urinary stones which started in May, 1989. The first 50 patients were treated without anaesthesia with an average of 1700 shock waves at 19.2 Kv. 37 patients had stones larger than 1 cm. 13 patients had ureteral stones. Two patients had complete staghorn stones. The disintegration rate was 97.9 percent, the overall stone-free rate at 3 months follow-up was 83.3 percent and the retreatment rate was 1.29 treatments for patients. No complication occurred.

Percutaneous transcatheter renal angioplasty: an endourological experience

A series of 56 percutaneous transcatheter renal angioplasties, carried out in an endourological unit, is reviewed and compared with radiological series. The results were inferior for fibrosclerotic lesions (77 vs. 90%) and nonostial atherosclerosis (67.8 vs. 75%), but slightly superior for ostial lesions (33 vs. 20-30%) in the endourological series as compared with the radiological series. Conversely, morbidity was significantly inferior (8.9 vs. 18.6%). The endourological series compares well with the radiological series in the literature. Percutaneous transcatheter renal angioplasty should be considered a procedure belonging both to interventional radiology and to endourology. Owing to the technical difficulties and the complication rate, it should not be performed in outpatients and a surgical support team should be available in the event of a threatening renal complication.

Flexible antegrade and retrograde nephroscopy: review of 50 cases

50 cases of flexible instrumentation of the intrarenal collecting system are reviewed. 28 were performed by retrograde flexible ureterorenoscopy. The introduction was carried out by combining hydraulic dilation, rigid ureterorenoscopy and a working sheath. 22 cases were performed through a percutaneous route. The indications were both diagnostic (filling defects and/or hematuria) and therapeutic (caliceal stone and/or fragments). The success rate was high in the diagnostic cases (20 of 24), but lower in the therapeutic cases (13 of 26). The complication rate was extremely low and the postoperative course was always uneventful. Flexible instruments offer a very good chance to explore the intrarenal collecting system. Both transureteral and percutaneous flexible nephroscopies are feasible and effective procedures. A laser can be used well in this area.

In situ or retrograde manipulation of ureteral stones: still a controversy?

A series of 365 patients with ureteral stones is reviewed. ESWL, ureterorenoscopy, basket extraction and open surgery were alternatively used according to the stone and to the increasing experience in minimally invasive techniques. The overall success rate of in situ ESWL varied between 79 and 90% according to the localization of the stone and no difference was noted between patients treated with the original HM III Dornier lithotriptor and patients treated with the upgraded HM III with low pressure and large ellipsoid for painfree ESWL. Also the retreatment rate did not differ significantly (38 vs 42%). Ureterorenoscopy, carried out as first approach or after ESWL failure, was successful in 80.4% of the cases. Basket extraction was successful only in 32.3% of the cases. In situ ESWL, in one or two sessions, without anaesthesia and without hospital stay, is a good solution for roughly 80% of ureteral stones. Retrograde manipulation with or without ureterorenoscopy, requiring anaesthesia and hospitalization, should be reserved to failures of in situ ESWL.

Painless extracorporeal shock wave lithotripsy for outpatients: a new option

Extracorporeal shock wave lithotripsy is becoming the most common procedure for the treatment of renal and ureteral stones. The introduction of a new generator and a new hemi-ellipsoid for the Dornier HM-III lithotripter improves patient comfort and requires no general or peridural anesthesia, thus making it easier to perform this procedure on an outpatient basis.

Extracorporeal shock wave lithotripsy in the prone position for stones situated anteriorly

Stones situated anteriorly cannot be satisfactorily reached with extracorporeal shock wave lithotripsy (ESWL) in the supine position. By assuming the prone position, patients with stones in horseshoe or ectopic kidneys or in the iliac ureter can be treated by ESWL with the same success rate as patients with posterior stones. This new technique has been used in 30 patients with iliac ureteral stones, 5 patients with caliceal stones in horseshoe kidneys and 1 patient with a pyelic stone in a sacral kidney.

Percutaneous debulking of staghorn stones combined with extracorporeal shockwave lithotripsy: results and complications

The results and complications of 122 percutaneous debulking of staghorn stones are carefully reviewed, discriminating between dilated and not dilated kidneys. Percutaneous debulking can be defined as satisfactory in about 70% of the cases. In the remaining 30% of the cases (mostly not dilated kidneys) it has got little or no results. The overall complication rate is quite low and most of the common complications can be prevented. Percutaneous procedures in nondilated kidneys have an overall complication rate highly superior to that in dilated kidneys. It should be preferable to treat as many staghorn stones as possible in nondilated kidneys with staged extracorporeal shockwave lithotripsy (ESWL) monotherapy, stenting the ureter and monitoring the urinary infection. Struvite stones are best suitable for stented ESWL because of their fragility. In case of cystine or oxalate monohydrate staghorn stone open surgery might be preferable in virgin patients, but it is often refused by the patients.