Clinical and biochemical markers of visceral adipose tissue activity: Body mass index, visceral adiposity index, leptin, adiponectin, and matrix metalloproteinase-3. Correlation with Gleason patterns 4 and 5 at prostate biopsy

Context:

The correlation between aggressive prostate cancer and obesity mainly based on body mass index (BMI) and pathology after surgery remains controversial.

Aims:

The aim of the study was to correlate BMI, visceral adiposity index (VAI), and the plasmatic levels of leptin, adiponectin, and matrix metalloproteinase-3 (MMP-3), and biomarkers of adipose tissue function, with the detection of Gleason patterns 4 and 5 at biopsy.

Subjects and Methods:

Consecutive patients with prostate cancer at 12-core transrectal biopsy were enrolled. BMI, waist circumference (WC), blood samples to evaluate the plasmatic levels of triglycerides (TG) and high-density lipoproteins (HDL), adiponectin, leptin, and MMP-3 were obtained immediately before biopsy. The VAI was calculated according to the formula: WC/(39.68 + [1.88 × BMI]) × TG/1.03 × 1.31/HDL.

Results:

One hundred and forty-nine patients were entered. The median PSA, BMI, and VAI were 10.0 ng/ml, 27.6 kg/m², and 4.6, respectively. Gleason patterns 4 or 5 were detected in 68 (45.6%) patients; in 15 (41.7%), 31 (44.9%), and 22 (50.0%) among normal weight, overweight, and obese patients, respectively (P = 0.55). The statistical analysis did not show any significant correlation between BMI, VAI, the plasmatic levels of leptin, adiponectin, MMP-3, and the detection of Gleason patterns 4 and 5 at biopsy. A statistically significant association emerged with older age (P = 0.017) and higher PSA values (P = 0.02).

Conclusion:

We did not find any association between BMI, VAI, the plasmatic levels of adiponectin, leptin, and MMP-3 and the detection of Gleason patterns 4 and 5 at prostate biopsy.

A new training model for robot-assisted urethrovesical anastomosis and posterior muscle-fascial reconstruction: the Verona training technique

A training model is usually needed to teach robotic surgical technique successfully. In this way, an ideal training model should mimic as much as possible the "in vivo" procedure and allow several consecutive surgical simulations. The goal of this study was to create a "wet lab" model suitable for RARP training programs, providing the simulation of the posterior fascial reconstruction. The second aim was to compare the original "Venezuelan" chicken model described by Sotelo to our training model. Our training model consists of performing an anastomosis, reproducing the surgical procedure in "vivo" as in RARP, between proventriculus and the proximal portion of the esophagus. A posterior fascial reconstruction simulating Rocco's stitch is performed between the tissues located under the posterior surface of the esophagus and the tissue represented by the serosa of the proventriculus. From 2014 to 2015, during 6 different full-immersion training courses, thirty-four surgeons performed the urethrovesical anastomosis using our model and the Sotelo's one. After the training period, each surgeon was asked to fill out a non-validated questionnaire to perform an evaluation of the differences between the two training models. Our model was judged the best model, in terms of similarity with urethral tissue and similarity with the anatomic unit urethra-pelvic wall. Our training model as reported by all trainees is easily reproducible and anatomically comparable with the urethrovesical anastomosis as performed during radical prostatectomy in humans. It is suitable for performing posterior fascial reconstruction reported by Rocco. In this context, our surgical training model could be routinely proposed in all robotic training courses to develop specific expertise in urethrovesical anastomosis with the reproducibility of the Rocco stitch.

The clinical use of statistical permutation test methodology: a tool for identifying predictive variables of outcome

OBJECTIVES

To identify the predictive variables affecting the outcome after radical surgery for bladder cancer by a newer statistical methodology, i.e. nonparametric combination (NPC).

METHODS

A multicenter study enrolled 1,312 patients who had undergone radical cystectomy for bladder cancer in 11 Italian oncological centers from January 1982 to December 2002. A statistical analysis of their medical history and diagnostic, pathological and postoperative variables was performed using a NPC test. The patients were included in a comprehensive database with medical history and clinical and pathological data. Five-year survival was used as the dependent variable, and p values were corrected for multiplicity using a closed testing procedure. The newer nonparametric approach was used to evaluate the prognostic importance of the variables. All of the analyses were performed using routines developed in MATLAB© and the significance level was set at α = 0.05.

RESULTS

A significant prognostic predictive value (p < 0.01) for tumor clinical staging, hydronephrosis, tumor pathological staging, grading, presence of concomitant carcinoma in situ, regional lymph node involvement, corpora cavernosa invasion, microvascular invasion, lymphatic invasion and prostatic stroma involvement was found.

CONCLUSIONS

The NPC test could handle any type of variable (categorical and quantitative) and take into account the multivariate relation among variables. This newer methodology offers a significant contribution in biomedical studies with several endpoints and is recommended in presence of non-normal data and missing values, as well as solving high-dimensional data and problems relating to small sample sizes.

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.

Dissecting the expression of EEF1A1/2 genes in human prostate cancer cells: the potential of EEF1A2 as a hallmark for prostate transformation and progression

BACKGROUND

In prostate adenocarcinoma, the dissection of the expression behaviour of the eukaryotic elongation factors (eEF1A1/2) has not yet fully elucidated.

METHODS

The EEF1A1/A2 expressions were investigated by real-time PCR, western blotting (cytoplasmic and cytoskeletal/nuclear-enriched fractions) and immunofluorescence in the androgen-responsive LNCaP and the non-responsive DU-145 and PC-3 cells, displaying a low, moderate and high aggressive phenotype, respectively. Targeted experiments were also conducted in the androgen-responsive 22Rv1, a cell line marking the progression towards androgen-refractory tumour. The non-tumourigenic prostate PZHPV-7 cell line was the control.

RESULTS

Compared with PZHPV-7, cancer cells showed no major variations in EEF1A1 mRNA; eEF1A1 protein increased only in cytoskeletal/nuclear fraction. On the contrary, a significant rise of EEF1A2 mRNA and protein were found, with the highest levels detected in LNCaP. Eukaryotic elongation factor 1A2 immunostaining confirmed the western blotting results. Pilot evaluation in archive prostate tissues showed the presence of EEF1A2 mRNA in near all neoplastic and perineoplastic but not in normal samples or in benign adenoma; in contrast, EEF1A1 mRNA was everywhere detectable.

CONCLUSION

Eukaryotic elongation factor 1A2 switch-on, observed in cultured tumour prostate cells and in human prostate tumour samples, may represent a feature of prostate cancer; in contrast, a minor involvement is assigned to EEF1A1. These observations suggest to consider EEF1A2 as a marker for prostate cell transformation and/or possibly as a hallmark of cancer progression.

Is antibiotic prophylaxis in invasive urodynamics a useful procedure in postmenopausal subjects?

Objectives.

To define the incidence rate of urinary tract infections (UTI) and the usefulness of antibiotic prophylaxis in postmenopausal female undergoing invasive urodynamics (IU).

Methods.

262 postmenopausal females underwent IU, being previously double-blindly randomized in 2 homogenous age-matched groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400 mg dose of norfloxacin. Group 2 (132 patients) was given placebo. The statistical analysis was performed using a Chi-Square test, in order to evaluate any difference between groups for UTI incidence rate.

Results.

54 patients out of 262 (20.6%) developed a UTI [24 out of 130 subjects who received antibiotic prophylaxis (18.4%), and 30 out of 132 subjects who received placebo (22.7%)]. As per the UTI incidence rate, no statically significant difference (p>.05) was shown between patients receiving and those not receiving the antibiotic prophylaxis.

Conclusions.

The UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by the administration of antibiotic prophylax.

Is antibiotic prophylaxis in invasive urodynamics a useful procedure in postmenopausal subjects?

OBJECTIVES. To define the incidence rate of urinary tract infections (UTI) and the usefulness of antibiotic prophylaxis in postmenopausal female undergoing invasive urodynamics (IU). METHODS. 262 postmenopausal females underwent IU, being previously double-blindly randomized in 2 homogenous age-matched groups. Group 1 (130 patients) received oral antibiotic prophylaxis with a single 400 mg dose of norfloxacin. Group 2 (132 patients) was given placebo. The statistical analysis was performed using a Chi-Square test, in order to evaluate any difference between groups for UTI incidence rate. RESULTS. 54 patients out of 262 (20.6%) developed a UTI [24 out of 130 subjects who received antibiotic prophylaxis (18.4%), and 30 out of 132 subjects who received placebo (22.7%)]. As per the UTI incidence rate, no statically significant difference (p>.05) was shown between patients receiving and those not receiving the antibiotic prophylaxis. CONCLUSIONS. The UTI incidence rate in postmenopausal women undergoing urodynamics is not affected by the administration of antibiotic prophylax.

Urgency degree and bladder contraction velocity: Sequential changes in women with idiopathic detrusor overactivity

AIMS

In patients with idiopathic detrusor overactivity (DO) who showed storage symptoms worsening with time, we checked whether and which urodynamic parameter changes are associated with an increased urgency degree.

MATERIALS AND METHODS

We analyzed retrospectively the urodynamic findings in 54 women -27 with storage symptoms (Group A, mean age 32 +/- 7 years) and 27 controls (Group B, mean age 30 +/- 9 years). These latter had a history of recurrent UTIs (urinary tract infections), but when seen by us had no UTI, DO, lower urinary tract symptoms, or any other pathological finding. Group A had a first urodynamic examination when first referred (time 1) and were re-assessed a mean of 16 months later (time 2) for worsened storage symptoms.

RESULTS

In Group A, an idiopathic DO was shown at both times 1 and 2; urgency of voiding could be delayed during cystometry for >or=2 min (= moderate urgency) at time 1 and for <2 min (= severe urgency) at time 2; detrusor contraction strength or contractility proved higher than in Group B (P < 0.001) and increased from time 1 to time 2 (P < 0.001), detrusor shortening velocity being always the major component of the higher contractility levels.

CONCLUSIONS

A DO-related increase in bladder contractility may have been further enhanced by severe urgency through a positive feedback mechanism. The urgency degree proved closely associated in DO patients with the level of detrusor shortening velocity rather than with detrusor pressure.

Transverse Retubularized Ileal Vaginoplasty: A New Application of the Monti Principle—Preliminary Report

OBJECTIVE

The surgical management of the absence of the vagina is a complex problem and constitutes a significant technical challenge. Herein we present our successful experience with vaginal reconstruction by the use of a modified ileal segment according to the Monti principle.

METHODS

Six patients aged from 23 to 41 years (mean 33 years) were referred to our institution for vaginal stenosis. In our series, ileum has been used to create the neovagina: the isolated segment has been longitudinally detubularized and transversally retubularized in order to configure the roof of the neovagina.

RESULTS

The mean operating time was 220 min. No intra-operative complication occurred. The mean follow-up of this series was 16 months. At the latest follow-up, all patients had patent moist neovaginas, but excessive vaginal mucous was not a problem in any patient in our series.

CONCLUSIONS

Neovaginal creation using isolated ileal segments according to the Monti channel principle provide excellent tissue for vaginal replacement, providing excellent patient satisfaction and relatively low morbidity. Cosmetic, functional and anatomical results were encouraging. In our opinion our technique may be indicated for all cases of vaginal absence: congenital abnormalities in the pediatric population, vaginal stenosis after treatment of pelvic tumors, severe vaginal scarring secondary to chronic inflammatory disease or in case of secondary correction after failure gender surgery.

Laparoscopic mobilization of neovagina to assist secondary ileal vaginoplasty in male-to-female transsexuals

OBJECTIVES

To describe 3 cases of successful laparoscopically assisted vaginal reconstruction using an ileal segment in patients with complete neovaginal stenosis.

METHODS

We evaluated 5 male-to-female transsexual patients who required laparoscopic-assisted vaginal replacement for complete neovaginal stenosis after sex reassignment surgery. We performed complete laparoscopic vaginal isolation and mobilization, external configuration of the vagina, and laparoscopic-assisted vaginal anastomosis.

RESULTS

No intraoperative complications occurred, and laparotomy conversion was not necessary. The mean length of the neovagina at the first postoperative visit was 13 cm. At a mean follow-up of 14 months, all patients were sexually active and completely satisfied with the operation.

CONCLUSIONS

Our results have confirmed the feasibility of laparoscopic perineal neovagina construction by ileal colpoplasty. The cosmetic, functional, and anatomic results were encouraging. Isolated ileal segments provided excellent tissue for vaginal replacement, resulting in excellent patient satisfaction and relatively low morbidity. Furthermore, we report a modified surgical approach to conventional ileal vaginoplasty according to the Monti channel principle.

An unusual use of AMS 800 artificial urinary sphincter cuff in the treatment of sphincteric neurogenic incontinence: case report

STUDY DESIGN

Case report of an unusual use of AMS 800 (American Medical Systems, Inc., Minnetonka, Minnesota) artificial urinary sphincter cuff in a female patient affected by neurogenic urinary incontinence.

OBJECTIVE

To describe this rare surgical solution.

SETTING

Department of Urology in Italy.

METHODS

A 43-year-old woman affected by flaccid paraplegia, acontractile bladder and incompetent bladder neck, underwent an implantation of an artificial urinary sphincter AMS 800. After 7 years, a mechanical failure of the device occurred and pubovaginal sling (PVS) utilizing the cuff of the sphincter was employed due to the poor quality of rectus fascia and the development of previous allergy for some heterologous materials.

RESULTS

At 17 months follow-up, the patient is content and able to empty the bladder by clean intermittent self-catheterization (CIC).

CONCLUSION

The risk of developing an allergy reaction due to the employment of heterologous materials and the impossibility to use the rectus fascia obliged us to adopt the pre-existent cuff of the artificial urinary sphincter AMS 800.

Voiding urgency and detrusor contractility in women with overactive bladders

AIMS

To check whether the contractility of overactive bladders would be affected by voiding urgency.

METHODS

We urodynamically studied 100 women: 20 normal controls (group 1), 60 patients with idiopathic detrusor overactivity (DO), and 20 with neurogenic DO from intracerebral lesions. The idiopathic DO groups 2A (n = 20), 2B (n = 20), and 3 (n = 20) had moderate, severe, and no voiding urgency, respectively. The neurogenic DO group 4 had severe urgency. The delay time of urgent void at cystometry (2 minutes or more or, respectively, less than 2 minutes) defined moderate or severe urgency. Detrusor contractility was defined by the maximum bladder external voiding power (WF(max)).

RESULTS

WF(max) was higher in the idiopathic DO patients than in the controls, had the highest values in group 2B, and did not differ significantly between groups 1-4 and 2A-3.

CONCLUSIONS

We inferred from our data that idiopathic DO suggests a facilitation of voiding contractions and that such facilitation might be centrally amplified by severe urgency. This amplifying effect would probably be impaired in cases of neurogenic DO from intracerebral lesions.

Acute generalized exanthematous pustulosis in cystic echinococcosis: immunological characterization

We report the first case, to the best of our knowledge, of a woman suffering from cystic echinococcosis of the liver, who consequently developed urticaria and acute generalized exanthematous pustolosis (AGEP). Serum immunoglobulin (Ig)E and IgG4 specific to Echinococcus granulosus antigens were detected by immunoblotting. Furthermore, the intracellular cytokine analysis revealed a prevalent T-helper 2 polarization. It can be reasoned that, while the presence of IgE specific to various E. granulosus allergens may be responsible for the chronic urticarial manifestations, the detection of IgG4 specific for E. granulosus antigens, forming immunocomplexes, may be related to the development of the AGEP.

Urgency of voiding and abdominal pressure transmission in women with mixed urinary incontinence

AIMS

To ascertain whether abdominal pressure transmission (a.p.t.) to the urethra would be affected by urgency of voiding in women with mixed urinary incontinence.

METHODS

We urodynamically assessed 80 consecutive women. Group 1 (n = 40), with stress incontinence, had stable bladders and no urgency. Group 2 (n = 40), with mixed (stress + urge) incontinence and overactive bladders, were split into Groups 2A (n = 20) and 2B (n = 20) according to the delay time of urgent void at cystometry (CMG) equating at least 2 min (taken as an index of moderate urgency) or, respectively, less than 2 min (taken as an index of severe urgency). Nonparametric statistics checked for significant differences in a.p.t. and in pelvic floor (peri-urethral) muscle strength level. We defined a.p.t. at stress (cough) urethral pressure profilometry (UPP) by the pressure transmission ratio (PTR). Pelvic floor muscle strength was defined at "holding" UPP by the maximum urethral pressure developed during attempts "to hold urine" (hMUP).

RESULTS

PTR was reduced in all women, but PTR (and hMUP) proved relatively higher in Group 2, though nonsignificantly different values of PTR (and hMUP) were seen in Groups 2B and 1.

CONCLUSIONS

Transmission of abdominal pressure to the urethra was reduced in all of the incontinent women. The mixed incontinence group, however, had a relatively less reduced (active component of) a.p.t., most likely dependent on a greater pelvic floor (peri-urethral) muscle strength level secondary to frequent contractions in response to urgency. Yet, of the same mixed incontinence patients, those with the most severe urgency degrees had relatively low pelvic floor (peri-urethral) muscle strength levels (eventually resulting from muscle fatigue? or primarily due to peri-urethral tissue atrophy?), which prevented (the active component of) a.p.t. from increasing.

The feasibility of urethral color ultrasound imaging in the diagnosis of female intrinsic sphincter deficiency: preliminary results

STUDY DESIGN

Prospective study.

OBJECTIVES

To evaluate the feasibility of color ultrasound imaging of the urethra in association with UPP to diagnose intrinsic sphincter deficiency (ISD).

SETTING

Italy.

METHODS

We studied a group of 13 normal female volunteers (mean age 29 years) during the estrogenic phase and a group of 15 patients (mean age 63.9 years) with ISD. All patients and normal volunteers underwent color ultrasound imaging using a 4-7 MHz convex broad band transducer. Translabial sagittal scans of the urethra were obtained. The color ultrasound parameters were optimized for detection of parenchymal slow flows. A subjective score of the degree of vascularization along the entire urethra was established as follows: (a) minimal or absent (1), (b) poor (2), (c) moderate (3), (d) good (4). Statistical analysis, using the non-parametric Mann-Whitney rank sum test, was carried out to determine differences of ultrasound scores between volunteers and patients.

RESULTS

The statistical evaluation showed that the differences between the ultrasound scores in the two groups was statistically significant (P<0.001).

CONCLUSION

We affirm that color ultrasound imaging of the urethra seems to be feasible and useful in association with UPP in the diagnosis of ISD even if this echographic investigation needs further observations.

The effect of acute bladder filling on plasmatic antidiuretic hormone production in healthy adult volunteers

OBJECTIVE

To assess the existence of a vesical hypothalamic reflex by evaluating the changes of plasmatic ADH levels during acute bladder filling in healthy adult volunteers.

MATERIALS AND METHODS

Twenty normal male subjects aged between 19 and 40 years (average age 31.6 years) were evaluated. All subjects signed informed consent. The subjects had no pathologic blood and urine examination, no cardiovascular, hepatic, renal disease, they were no smokers and they did not take drugs which may interfere with plasmatic ADH levels. A blood sampling at rest condition (time 0) and successively during cystometry in the presence of first sensation, normal and strong desire was carried out. Plasmatic ADH was measured on extracted samples by radioimmunoassay. A one-factor repeated measures analysis of variance was employed to verify the effect of time on ADH levels. The Greenhouse-Geisser and Huynh-Feldt adjustments were adopted to protect against the case of violation of homogeneity of covariance.

RESULTS

Statistical analysis did not show significant differences of plasmatic ADH levels between rest condition and bladder filling.

CONCLUSIONS

We exclude the existence of a vesical hypothalamic reflex and we suppose that extravesical factors may interfere with the plasmatic ADH production during the night.

Decreased nocturnal urinary antidiuretic hormone excretion in enuresis is increased by imipramine

OBJECTIVE

To assess the role of integrated nocturnal antidiuretic hormone (ADH) secretion in children with enuresis, and possible modifications induced by treatment with imipramine.

PATIENTS AND METHODS

The morning plasma ADH and nocturnal urinary ADH integrated concentrations were measured in 18 consecutive enuretic children (patients) and 21 age- and sex-matched controls admitted for minor treatment. Diurnal and nocturnal urine production, and plasma and urinary osmolality were also determined; lumbosacral radiography and uroflowmetry were undertaken in the patients. The assessments were repeated after 14 days of treatment with imipramine hydrochloride (orally, 20 mg/night).

RESULTS

Half the patients had occult spinal malformations but the uroflowmetry results were all within the normal range. The median (95% confidence interval, CI) urinary ADH integrated concentrations were markedly lower in patients, at 29.7 (22.1-37.3) vs 63.0 (35.1-90.8) pg/mL/h (P = 0.03) than in controls. Plasma ADH levels were significantly increased by imipramine (0.64 to 1.47 pg/mL, 95% CI, 0.40-0.89 vs -0.26-3.2; P < 0.001), as were nocturnal urinary ADH integrated concentrations, at 29.7 (22.1-37.3) vs 59.0 (37.3-80.6) pg/mL/h (P < 0.001), and morning plasma osmolality decreased, from 298.5 (294.5-302.5) to 294.9 (292.4-297.3) mosmol/kg (P = 0.003), as was the 24-h fluid intake, from 983 (721-1245) to 666 (435-897) mL (P = 0.004).

CONCLUSIONS

We conclude that enuretic children have a lower nocturnal ADH excretion; imipramine restores nocturnal ADH excretion, increases morning plasma ADH levels, and causes consistent changes in other biochemical variables.

Colour Doppler ultrasonography of female urethral vascularization in normal young volunteers: a preliminary report

OBJECTIVE

To assess urethral vascularization in healthy young women, using colour Doppler ultrasonography.

SUBJECTS AND METHODS

Eleven healthy young women volunteers (mean age 33.6 years, range 24-46) with no pelvic floor disorders and no history of incontinence were assessed. The subjects underwent colour Doppler ultrasonography using a 4-7 MHz convex broadband transducer. Translabial sagittal scans of the urethra were taken when the subjects had a full bladder, both during the oestrogenic and progestogenic phases. The colour Doppler ultrasonography parameters were optimized to detect slow flows in the anterior and posterior distal, middle and proximal urethra. A rank-sum nonparametric test was used to assess differences between the resistive indices.

RESULTS

The statistical evaluation showed a significant difference in the resistive index only in the anterior urethra, between the distal and middle plus proximal urethra, in both the progestogenic (P = 0.002) and oestrogenic (P = 0.0127) phases.

CONCLUSIONS

This study confirmed that the vascularization of the urethra plays an important role in the 'seal' effect, which is considered one of the most important factors in urethral closure. There was a significantly greater resistive index in the anterior proximal urethra than in the middle and distal urethra. These findings suggest that the seal effect is related to the existence of a rich venous urethral vascularization, involved in the mechanism of urethral closure. Colour Doppler ultrasonography of the urethra seems to be feasible and useful for understanding the mechanism of the vascular component in female continence.

Modified Ghoneim's technique using a single serous-lined extramural tunnel in detubularized orthotopic ileal W-bladder

OBJECTIVES

We report our preliminary clinical experience with a modification of Ghoneim's original technique involving reimplantation of ureters in a single tunnel on the right part of the neobladder forming a 'W' shape.

METHODS

From 1997 to 1999, we performed radical cystectomy with double 'W' orthotopic neobladder construction and uretero-ileal reimplantation using our modified Ghoneim's technique on 11 male patients, aged 40-74 (mean 65.5) years, affected by invasive bladder cancer.

RESULTS

No postoperative complications were observed. After a mean follow-up of 12.5 months all patients are free of recurrences.

CONCLUSIONS

In our hands the modified Ghoneim's technique seems to reduce the mean operating time required to tailor the uretero-ileal anastomosis and guarantee greater stability of the anastomosis itself.

Correction of complex penile deformities by modified nesbit procedure asymmetric tunica albuginea excision

PURPOSE

Penile angulation combined with penile torsion is an uncommon finding in case of congenital or acquired penile curvature. We describe our technique for treatment of complex penile curvature by the excision of asymmetric ellipses of tunica albuginea.

MATERIALS AND METHODS

During the last 4 years, 4 patients with complex penile curvature underwent surgical correction by the excision of asymmetric ellipses of tunica albuginea. 3 patients had Peyronie's disease and 1 had congenital penile deviation. They ranged in age from 27 to 63 years.

RESULTS

Convalescence was uneventful with good cosmetic correction of the penile torsion and lateral curvature in all patients. 1 patient reported shortening of the penis of about 2 cm, postoperatively. 2 patients reported decreased penile sensation, which resolved after 3 months. Erectile failure did not occur postoperatively in any case.

CONCLUSIONS

During the last years many Authors have modified the original surgical procedure in an attempt to correct penile deformity. Unfortunately there are very few reports about correction of penile deformities combined with penile torsion. Our modified Nesbit surgical technique for complex deformities differs from the others with regard to the shape of the incision. In this manner, by shortening the longer corporeal body and creating a torque on the penis, it is possible to correct both problems: penile angulation and torsion. The technique is simple, bloodless, safe and reliable. In our experience good cosmetic and functional results have been achieved without complicated surgical interventions.

Laparoscopic bladder auto-augmentation in an incomplete traumatic spinal cord injury

OBJECTIVES

To assess the urodynamic and clinical outcome of a laparoscopic auto-augmentated bladder.

METHODS

Laparoscopic bladder autoaugmentation in a 27-year-old woman with an incomplete spinal cord injury at T12 level with urge incontinence caused by a hyperreflexic bladder.

RESULTS

Six months later the patient voids by Valsalva's manoeuvre every 3 h and remains dry day and night. The radio-urodynamic study, performed 2 months later, revealed an intact bladder with a diverticulum of anterior wall and a capacity of 510 ml with filling rate of 100 ml/min without evidence of leakage of infusion water.

CONCLUSION

Laparoscopic retropubic auto-augmentation allows a brief hospital stay and minor postoperative discomfort. Moreover the laparoscopic approach should not complicate or preclude subsequent enterocystoplasty if necessary.

Congenital mesoblastic nephroma (CMN) with an unusual immunohistochemical feature

OBJECTIVES

To describe a case of congenital mesoblastic nephroma (CMN) treated by radical nephrectomy with no evidence of relapses after five years in spite of an unusual positivity for proliferating cellular nuclear antigen (PCNA).

METHODS

A three-month-old child presented a right renal mass with compression of the inferior vena cava. Excretory urography showed an intrarenal mass with distortion of the calyceal system. There was no evidence of metastasis. Radical nephrectomy was carried out; no adjuvant therapy was given. Histological and immunohistochemical studies were performed.

RESULTS

The tumor was a 6 x 6 x 5 cm solitary mass extending into perirenal tissue, involving the hilar vessels but not the ureter. Histologically, it has been classified as a congenital mesoblastic nephroma of the classic variant. Positive reaction for vimentin and actin was observed. Strong positivity for PCNA and negativity for P53 were revealed.

CONCLUSIONS

PCNA is considered to be a reliable marker of potential malignancy. This, however, contrasts with the biological behavior of our case. Further evaluation is required for correct interpretation of this additional information and to avoid inappropriate aggressive therapy.

Baroreceptor-heart rate reflex sensitivity enhancement after urinary bladder distention in essential hypertensives

Our objective was to determine if urinary bladder distention modifies the sensitivity of the baroreceptor-heart rate reflex in hypertensive and control subjects. The baroreceptor-heart rate reflex sensitivity was measured in 15 male patients (mean age 37+/-8 years) with mild untreated hypertension (mean 163+/-8/ 95+/-12 mmHg) and 17 age- and sex-matched control subjects before and after urinary bladder distention. Bladder filling was performed infusing saline heated to 37 degrees C via a urinary catheter; the volume infused in each patient corresponded to that which caused the urge to void without reaching the pain threshold. The baroreceptor-heart rate reflex sensitivity was determined correlating the variations of the systolic pressure and of the peak blood flow velocity in the common carotid artery with the variations of the ECG RR' interval of the following heart beat, both during spontaneous and phenylephrine-induced fluctuations of the haemodynamic variables. After bladder distention the diastolic pressure of the hypertensive subjects increased significantly (95+/-12 vs. 100+/-12 mmHg: P < 0.02), whereas the heart rate decreased (RR= 873+/-70 vs. 926+/-80 ms; P < 0.005). These parameters were unchanged in the normotensive subjects (84+/-9 vs. 83+/-8 mmHg and 914+/-158 vs. 913+/-140 ms, respectively). The baroreceptor-heart rate reflex sensitivity, measured on the basis of spontaneous pressure and carotid blood flow velocity fluctuations in relationship to RR changes, decreased in the normotensive subjects after bladder distention (10.7+/-4.6 vs. 9.4+/-2.7 ms/mmHg; P < 0.05 and 423+/-99 vs. 356+/-102 ms/kHz; P < 0.01, respectively), whereas it increased in the hypertensive patients (6.9 +/- 3.6 vs. 8.3 +/- 2.8 ms/mmHg; P < 0.03, and 332 +/- 86 vs. 381+/-97 ms/kHz; P < 0.03 respectively). After bladder distention and phenylephrine administration the baroreceptor-heart rate reflex sensitivity, measured by the correlation between systolic pressure and RR interval, increased only in the hypertensive group (10.2+/-5.4 vs. 15.2+/-7.7 ms/mmHg; P < 0.005). In conclusion urinary bladder distention provokes in hypertensives but not normotensive controls a brisk parasympathetic response of the component of the baroreceptor-heart rate reflex which controls heart rate.

The usefulness of the somatosensory evoked potentials of the pudendal nerve in diagnosis of probable multiple sclerosis

STUDY DESIGN

The aim of the study was to evaluate the sensitivity of pSEP in patients affected by probable MS.

OBJECTIVES

Bladder dysfunction is the presenting symptom in 2% of patients affected by multiple sclerosis (MS) and may be present in up to 78% of them. Abnormalities of somatosensory evoked potentials of the pudendal nerve (pSEP) have been found by many authors in patients affected by clinically defined MS, but little is known of diagnostic reliability of pSEP in early stage of MS.

METHODS

Sixteen patients, eleven females and five males, aged between 18 and 45 years old (mean age 28.9), affected by clinically probable MS, were studied. Six of them reported retention or urge incontinence. pSEP with P1 (P40) scalp wave was analyzed. All patients also underwent visual evoked potentials (VEP), SEP of median and tibial nerves (mSEP, tSEP), brainstem acoustic evoked potentials (BAEPs), MRI of the brain and cerebrospinal fluid (CSF) evaluation. Urodynamic study with simultaneous measurement of intravesical, intraurethral and abdominal pressures with external sphincter electromyography was performed.

RESULTS

Abnormalities of the evoked potentials were found in all patients. Abnormalities of the pSEP were observed in all the symptomatic cases and in eight of the remaining ten patients; ten showed no responses from the scalp and four showed P1 increased latency. Urodynamic abnormalities were found in 12 patients and MRI showed demyelinating lesions in 13 patients and oligoclonal bands were found in eight of them.

CONCLUSION

pSEP can be worthwhile as part of the initial diagnostic evaluation in patients affected by MS. It provides information of diagnostic relevance and plays a role in screening patients for urodynamic testing, which, however, is more specific for detecting urethrovesical dysfunctions and preventing urological complications.

Rare association of renal angiomyolipoma and oncocytoma

The association of renal angiomyolipoma and renal oncocytoma in the same kidney is rare, only 7 cases having been previously reported. We report a 69-year-old woman affected by the simultaneous presence of renal angiomyolipoma and oncocytoma in the right side with a decrease of renal function on the left side due to a stenosis of the superior polar branch that was successfully treated preoperatively by angioplasty. An enucleation of renal masses on the right side was performed with renal function preservation after 2 years.

Una Soluzione Economica per il Trattamento Della Trombosi Cavale Intraepatica Nell'anziano: Intrahepatic Tumour Trombectomy: An Economic Therapeutic Option in Elderly Patients

Radical excision of renal cancer with propagation into the intrahepatic and intrapericardial inferior vena cava (IVC) has become an accepted surgical approach. We present a case of left radical nephrectomy for renal cancer with IVC sovrahepatic involvement, in which we verified the possibility of approaching the intrapericardial IVC through a limited diaphragmatic incision, thereby avoiding the more invasive sternotomy. The advantages of this approach are: lesser invasiveness, simpler control of the upper extension of the thrombus and decreased blood loss.

Embryonal adenoma of the kidney. A rare embryonal adenoma of the kidney

We report the case of a 47-year-old man who underwent partial nephrectomy for an embryonal adenoma which was characterized by a monomorphous appearance. No adjuvant therapy was given and at the 5-year follow-up the patient is in perfect health and no relapse has been observed.