[Scrotal masses: considerations on two cases of epididymal tumors].

The scrotum is a fibromuscular sac that contains the testis, epididymis, spermatic cord and the associated fibrous coatings. All these components can be affected by different variety of pathologic phenomena, including congenital, inflammatory and neoplastic events. When a scrotal mass is observed, there are two basic questions to be answered, i.e. if the mass is intratesticular or extratesticular, and if it is of cystic or solid nature. Apart from a few rare exceptions, intratesticular solid masses should be considered malignant, while extratesticular masses with liquid content are generally benign. CASE REPORTS. Two cases of tumor are hereby presented: they originated from the epididymis, and their clinical presentations did not allow making a differential diagnosis between benign and malignant tumor during the preoperative examinations. After presenting the diagnostic doubts to patients, and once obtained their informed consent, surgeries were performed allowing for a precise histological diagnosis, and at the same time, proving to be also valid therapeutic tools.

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.

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.

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.

Magnetic resonance imaging of the patellar tendon after harvesting its central third: a comparison between traditional and subcutaneous harvesting techniques.

The aim of this study was to compare the 2-year results after anterior cruciate ligament reconstruction using patellar tendon autografts harvested through a paratenon-splitting, traditional technique (group A) with the results of a subcutaneous technique aiming at protecting the infrapatellar nerves and the paratenon (group B). Special emphasis was placed on evaluating the donor site. Magnetic resonance imaging (MRI) of the patellar tendon was performed to evaluate the reconstitution after harvesting its central third. Examinations of knee-walking ability and assessments of anterior knee sensitivity were made in order to evaluate donor-site discomfort and the function of infrapatellar nerves. Seventy-two consecutive patients were included in the study; group A comprised 35 patients and group B, 37 patients. At the 2-year follow-up, the Tegner activity level, the Lysholm score, and the IKDC evaluation system showed no significant differences between groups A and B. The median loss of normal anterior knee sensitivity was 16 cm2 (range, 0 to 200 cm2) in group A and 0 cm2 (range, 0 to 285 cm2) in group B (P = .20). In group A 20% of the patients and in group B 58% had normal sensitivity (P < .01). MRI showed that the donor-site gap (area corresponding to non-tendinous-like tissue signal) was 5 mm (range, 0 to 9 mm) in group A and 2 mm (range, 0 to 5 mm) in group B (P < .0001). At 2-year follow-up, the subcutaneous graft-harvesting technique resulted in less disturbance of anterior knee sensitivity and a smaller donor-site gap than the traditional technique.

Analysis of subjective, objective and functional examination tests after anterior cruciate ligament reconstruction. A follow-up of 527 patients.

This study included 527 patients (178 female and 349 male) with unilateral anterior cruciate ligament (ACL) rupture who underwent arthroscopic ACL reconstruction using bone-patellar tendon-bone autograft and interference screw fixation. The follow-up examination was performed by independent observers at a median of 38 (21-68) months after the index operation. At the follow-up, the Lysholm score was 86 (14-100) points, the Lysholm instability subscore was 22 (0-25) points and the Lysholm pain subscore was 19 (0-25) points. The Tegner activity level was 6 (1-10). The one-leg-hop test was 91 (0-167)% of the non-injured knee. The difference in the anterior side-to-side laxity as measured with the KT-1000 arthrometer at 89 Newton (N) was 1.5 (-5-13) mm and the total KT-1000 side-to-side difference at 89 N was 2 (-7-11) mm. Using the International Knee Documentation Committee (IKDC) evaluation system, 177 (33.6%) patients were classified as normal (group A), 211 (40%) as nearly normal (group B), 109 (20.7%) as abnormal (group C) and 30 (5.7%) as severely abnormal (group D). The highest correlation coefficients were recorded between the IKDC evaluation system and the Lysholm score (p = 0.66), the patients' subjective evaluation (p = 0.53), the Tegner activity level (p = 0.34), all the laxity tests (p > or = 0.34) and the one-leg-hop test (p = 0.28). The resumption of sporting activities and work as evaluated by the Tegner activity level correlated with the patients' subjective evaluation (p = 0.34) but did not correlate with the laxity tests, i.e., the manual Lachman test (p = -0.06) and the total and anterior KT-1000 tests (p = -0.06). Furthermore, none of the laxity tests correlated with the functional tests or the patients' subjective evaluation. We conclude that the IKDC evaluation system is a reliable and useful tool for evaluating the post-operative outcome after an ACL reconstruction.

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.

Complications following arthroscopic anterior cruciate ligament reconstruction. A 2-5-year follow-up of 604 patients with special emphasis on anterior knee pain.

The aim of the study was to assess knee function after arthroscopic anterior cruciate ligament reconstruction and to analyse complications impeding rehabilitation, additional surgery until the final follow-up, as well as residual patellofemoral pain and donor-site problems. Between 1991 and 1994, 635 patients were operated on using patellar tendon autografts and interference screw fixation. Of these, 604 (95.1%) patients (403 male and 201 female) were re-examined by independent observers at the final follow-up 38 (range 21-68) months post-operatively. The Lysholm score was 85 (range 14-100) points and the Tegner activity level was 6 (range 1-10). Using the IKDC score, 206 patients (34.1%) were classified as normal, 244 (40.4%) as nearly normal, 122 (20.2%) as abnormal and 32 (5.3%) as severely abnormal. In patients with an uninjured contralateral knee (n = 527), the KT-1000 revealed a total side-to-side difference of 1.5 (range -7-11) mm, and 384/527 (72.9%) had a side-to-side difference of < or = 3 mm. The one-leg-hop test was 95% (range 0%-167%). One or more complications impeding rehabilitation were recorded in 184/604 patients (30.5%). The most common was an extension deficit (> 5 degrees), in 81 patients (13.4%). During the period until the final follow-up, 196 re-operations were performed in 161/604 (26.7%) patients. More than one re-operation was required in 27 patients. Shaving and anterior scar resection due to extension deficit were the most common procedures performed (on 65 occasions). Moderate to severe subjective anterior knee pain related to activity, walking up and down stairs, and sitting with the knee flexed was found in 203/604 patients (33.6%). The median loss of anterior knee sensitivity was 16 (range 0-288) cm2. Patients with a full range of motion had less anterior knee pain than patients with isolated flexion or extension deficits, or combined flexion and extension deficits (P < 0.05, P = 0.08 and P < 0.001, respectively). Patients with a full range of motion had less anterior knee pain than patients with extension deficits (with and without flexion deficits) (P < 0.001). Patients with a full range of motion and a minimal loss (< or = 4 cm2) of anterior knee sensitivity had significantly (P < 0.01) less subjective anterior knee pain than patients who did not fulfil these criteria. A considerable number of complications hindering the rehabilitation and conditions requiring additional surgery until the final follow-up were recorded. Anterior knee pain and problems with knee-walking were correlated with the loss of range of motion and anterior knee sensitivity.

Bone mineral assessments in the calcaneus after anterior cruciate ligament injury. An investigation of 92 male patients before and two years after reconstruction or revision surgery.

The aim of this study was to assess the Bone Mineral Areal mass (BMA) in the calcaneus of male patients with unilateral anterior cruciate ligament (ACL) injury before and after reconstruction and to assess whether the BMA ratio or the BMA of the injured and uninjured side correlated with the level of activity, functional performance or the time period between the injury and the reconstruction. Ninety-two male patients with unilateral ACL injury were included in the study. The BMA was analysed immediately prior to surgery: a median of 11 (2-192) months after the injury in 30 patients aged 26 (15-41) years scheduled for primary ACL reconstruction (Group A). Forty-nine patients aged 29 (18-49) years had their BMA analysed a median of 24 (23-29) months after the primary ACL reconstruction (Group B). Thirteen patients aged 27 (21-39) years had their BMA analysed a median of 24 (20-45) months after ACL revision surgery (Group C). The median BMA ratio (injured side/uninjured side) was 96 (88-105)% in Group A, 96 (86-118)% in Group B and 95 (83-111)% in Group C. In all three groups, the median BMA value in the calcaneus was significantly lower on the injured side compared with the uninjured side (P=0.001, P=0.0003, P=0.01 in Groups A, B and C, respectively). The time period between the injury and the reconstruction neither correlated with the BMA ratio nor the BMA of the injured or the uninjured side in Group A. The level of activity as measured by the Tegner activity level and the functional performance as measured by the one-leg-hop quotient did not correlate with the BMA ratio in any of the groups. In the 49 patients with a primary ACL reconstruction (Group B), the post-operative Tegner activity level correlated with the BMA, on both the injured and uninjured side (P=0.0003, P=0.0005, respectively), when the BMA was assessed two years after the index operation. Male patients with unilateral ACL injury had a significantly lower BMA in the calcaneus on the injured side compared with the uninjured side before primary reconstruction, two years after primary reconstruction and two years after revision surgery. The time period between the injury and the index operation did not correlate with the BMA. A high level of activity correlated with the BMA on both the injured and the uninjured side two years after primary reconstruction.

Ipsi- or contralateral patellar tendon graft in anterior cruciate ligament revision surgery. A comparison of two methods.

Twenty-four patients who underwent anterior cruciate ligament revision surgery were studied postoperatively (12 with reharvested ipsilateral patellar tendon grafts and 12 with contralateral patellar tendon grafts). For comparison purposes, 12 matched patients with primary anterior cruciate ligament reconstruction, who had been operated on using the same technique by the same surgeons, were chosen. The median time since the first reconstruction was 57 months (range, 15 to 132) in the ipsilateral tendon group and 54 months (range, 20 to 108) in the contralateral tendon group. Follow-up examination showed that there were no significant differences in total KT-1000 arthrometer side-to-side measurements between the groups, but the Lysholm score was higher for patients with contralateral tendon grafts than for patients with ipsilateral grafts. Only two patients with ipsilateral grafts were classified as having excellent or good results. Functional testing outcomes were similar for all groups, and magnetic resonance imaging screening showed no differences between the reharvest and primary harvest groups in terms of length, width, thickness, or donor site gap of the patellar tendon. However, there were two major complications in the group with revision surgery with the ipsilateral reharvested patellar tendon. Reharvesting the ipsilateral patellar tendon resulted in lower functional scores and a higher rate of complications than revision with the contralateral patellar tendon or primary anterior cruciate ligament reconstruction.

Factors affecting donor-site morbidity after anterior cruciate ligament reconstruction using bone-patellar tendon-bone autografts.

The objective of this study was to assess knee function after anterior cruciate ligament reconstruction focusing on residual donor-site problems. Ninety consecutive patients with chronic unilateral anterior cruciate ligament rupture were operated on by the same surgeon using patellar tendon autografts, the all-inside arthroscopic technique, and interference screw fixation. At the follow-up examination 24 (range 22-32) months after the index operation, the median total anterior-posterior KT-1000 side-to-side difference was 2.5 (-7 to 11) mm. The median Lysholm score was 86 (range 37-100) points and the median Tegner activity level was 6 (range 1-9). Using the IKDC evaluation system, 62 of 90 (69%) were classified as normal or nearly normal. The median one-leg-hop quotient was 93 (range 0-167)% of the uninjured leg. Of 90 patients, 44 (49%) had minor or no discomfort when asked to walk on their knees (kneewalkers) and 46 of 90 (51%) patients had severe problems or found it impossible to perform the test (non-kneewalkers). The 'kneewalkers' had a median loss of anterior knee sensitivity of 10 (range 0-120) cm2. The corresponding value for the 'non-kneewalkers' was 25 (range 0-200) cm2 (P = 0.0001). Palpatory donor-site tenderness was registered in 19 of 44 (43%) of the 'kneewalkers' and 37 of 46 (80%) of the 'non-kneewalkers' (P < 0.001). Full hyperextension was not regained by 9 of 44 (20%) of the 'kneewalkers' and 19 of 46 (41%) of the 'non-kneewalkers' (P < 0.05). Additional surgery during the follow-up period was required by 6 of 44 (14%) of the 'kneewalkers' and 19 of 46 (41%) of the 'non-kneewalkers' (P < 0.01). Magnetic resonance imaging focusing on the donor site was performed on 31 randomly selected patients and revealed no difference between the 'kneewalkers' and the 'non-kneewalkers' in terms of patellar tendon width, thickness, length, and residual donor-site gap size. The kneewalking test was found to be a functional and reliable test for detecting donor-site morbidity. It appears that donor-site morbidity was related to problems requiring additional surgery during the follow-up period, such as extension deficit and pain near the metal implant on the tibial side, as well as the loss of anterior knee sensitivity. It appears to be important to attempt to preserve the sensitivity in the operated area during surgery and to regain full hyperextension in the postoperative period to minimize donor-site morbidity.

Is bracing after anterior cruciate ligament reconstruction necessary? A 2-year follow-up of 78 consecutive patients rehabilitated with or without a brace.

The aim of this study was to evaluate the effect of a standard postoperative rehabilitation knee brace on function, stability and postoperative complications at the 2-year follow-up after anterior cruciate ligament (ACL) reconstructive surgery. Seventy-eight consecutive patients with a unilateral chronic ACL rupture reconstructed by the same surgeon using the endoscopic "all-inside" technique, patellar tendon autograft and interference screw fixation were included in the study. The rehabilitation followed a standard protocol. Group A included 39 patients who were supplied postoperatively with a knee brace for 4 (range 3-6) weeks. Group B included 39 patients for whom a brace was not used. The median age was 27 (range 16-48) years in group A and 26 (range 14-51) years in group B. The median time period between the injury and the index operation was 24 (range 3-150) months in group A and 18 (range 3-360) months in group B. All 78 patients were re-examined by two independent observers after a median follow-up period of 25 (range 23-28) months in group A and 24 (range 22-27) months in group B. The median KT-1000 total side-to-side difference between the reconstructed and the uninjured knees at 89 N was 3 (range -5.5-11) mm in group A and 3 (range -7-10) mm in group B (NS). When the anterior translation was tested separately at 89 N, the corresponding values were 3 (range -4-13) mm in group A and 3 (range -5-10) mm in group B (NS). The median one-leg hop quotient was 95% (range 50%-167%) of the uninjured leg in group A and 92% (range 64%-119%) in group B (NS). The median Lysholm score was 89 (range 39-100) points in group A and 85 (range 37-100) points in group B (NS). In group A, 27/39 (69%) patients and in group B 21/39 (54%) patients were classified as excellent or good (NS). The median Tegner activity level was 7 (range 3-9) in group A and 6 (range 3-9) in group B (NS). Using the IKDC scale, 27/39 (69%) in group A and 24/39 (62%) in group B were classified as normal or nearly normal (NS). The median sick leave in group A was 62 (range 0-357) days and 59 (range 0-243) days in group B (NS). No serious complications occurred during the first 6 postoperative weeks. Two serious complications were, however, registered after the 6th postoperative week. One patient in group A sustained a rupture of the reconstructed ACL 8 weeks postoperatively (3 weeks after removing the brace), and one patient in group B sustained an undislocated patellar fracture during the 7th postoperative week after a fall. This study indicates that the use of a postoperative rehabilitation brace after an arthroscopic ACL reconstruction did not appear to influence either objective stability or subjective function by the 2-year follow-up.