Morphological changes of bladder mucosa in patients who underwent instillation with combined sodium hyaluronic acid-chondroitin sulphate (Ialuril®).

OBJECTIVE: To investigate what changes are endoscopically evident after glycosaminoglycans (GAGs) therapy by hyaluronic acid (HA) and chondroitin sulphate (CS) (Ialuril®) in female patients affected by bladder pain syndrome(BPS)/ interstitial cystitis (IC) or recurrent urinary tract infections (rUTIs). PATIENTS AND METHODS: 21 female patients over 18 years affected by rUTIs or BPS/IC received intravesical instillation of HA and CS (4 weekly instillations followed by 2 instillations every 2 weeks and 2 instillation monthly). Post-treatment evaluation included cystoscopy and patient assessment of improvement in symptoms and satisfaction on a visual analogue scale (VAS) from 0 to 10. RESULTS: The post-treatment endoscopy showed a positive effect on bladder mucosa morphology. In 2 cases, treatment did not change endoscopic findings and clinical symptoms. In the other patients, when macroscopic features of the bladder mucosa normalized, the clinical picture improved. CONCLUSIONS: GAGs therapy by HA and CS (Ialuril) improves the morphology of bladder mucosa in patients with rUTI or BPS/IC.

Botulinum toxin A modulates afferent fibers in neurogenic detrusor overactivity.

BACKGROUND: Although botulinum toxin (BoNT/A) injected into the detrusor muscle improves overactive bladder symptoms in patients with neurogenic detrusor overactivity, how it does so remains unclear. In this study, we investigated whether BoNT/A improves detrusor overactivity by modulating bladder afferent activity. METHODS: To do so, during urodynamic assessment, we tested the soleus muscle Hoffmann (H) reflex during bladder filling before and after intradetrusor BoNT/A in patients with Parkinson's disease (PD) and in patients with complete chronic spinal cord lesion (SCI) and detrusor overactivity refractory to conventional therapy. Healthy subjects underwent H reflex studies during urodynamic assessment and acted as controls. RESULTS: Our findings show that BoNT/A injected into the detrusor muscle effectively reduces clinical overactive bladder symptoms in patients with PD and SCI. In healthy subjects and patients with PD, bladder filling [at maximum cystometric capacity, (MCC)] significantly decreased the H reflex size, whereas in patients with SCI, it slightly facilitated the H reflex size. At MCC, in patients with PD, BoNT/A significantly reduced the expected H reflex inhibition, whereas in those with SCI, BoNT/A turned the H reflex facilitation at maximum bladder filling into a slight inhibition. CONCLUSIONS: These findings show that BoNT/A injected into the detrusor muscle in patients with PD and SCI modulates bladder afferent activity. Modulation of bladder afferents possibly explains why BoNT/A improves detrusor overactivity.

The management of pelvic organ prolapse: a review.

The increase of the prevalence of pelvic organ prolapse (POP) and urinary incontinence (UI), associated to changes in longevity, population demographics, and lifestyle expectation, is leading to a different set of urogynecological surgical challenges for 21st century women The objective of this review is to determine the characteristics and the effects of the different surgical technique in the management of POP. Here, we reviewed traditional techniques as well as we are going to take in consideration the introduction of several new procedures involving the use of different meshes or grafts, with or without introducer kits. Finally the laparoscopic approaches and the rapidly evolving robotic surgery will be discussed. Waiting for studies with high level of evidence, due to the plethora of techniques, mesh or graft material, absorbable (synthetic and biological) and non-absorbable, at present, there seems to be no final evidences about the best management.

Mini-invasive techniques for the treatment of female stress urinary incontinence.

AIM: The aim of this study was to review recent literature on mini-invasive surgical technique for the treatment of female stress urinary incontinence (SUI). Surgical aspects, intraoperative and perioperative complications and objective and subjective outcomes were analyzed and compared. METHODS: The PubMed databank from 2000 to February 2007 was searched for original prospective and randomized studies in English, on surgical treatment of female SUI, which avoided a laparotomic access to the female pelvis. Studies had to investigate at least 40 women with a minimum follow-up of 12 months. RESULTS: A total of 38 prospective studies were found: 27 of them were on mid-urethral slings; 8 assessed urethral injections; and 3 radiofrequency treatment. Fifteen studies were randomized. Follow-ups ranged from 12 to 60 months, except for sexual function which had a 6-month follow-up. Ten out of 38 studies assessed patients who did not refer pelvic organ prolapse or detrusor overactivity and had not undergone any previous anti-incontinence procedure. CONCLUSION: Mid-urethral slings showed good outcomes and are safe and brief to perform and have a relatively short learning curve. Urethral injections showed discouraging results, as they have poor outcomes and repetitive treatments are frequently necessary. Injections can be used in women with contraindications to major surgical procedures, with intrinsic sphincter deficiency as the main cause of incontinence. Radiofrequency showed worse results than mid-urethral slings and is a valuable choice in women who refuse more invasive procedures. The development of studies with longer follow-ups on mini-invasive surgical techniques are encouraged.

Recovery of sexual function after nerve-sparing radical retropubic prostatectomy: is cavernous nitric oxide level a prognostic index?

The preservation of NANC nerve fibers (producing nitric oxide, NO) is necessary for erection recovery after retropubic radical prostatectomy (RRP). Yet, it is impossible to establish when and if a patient will recover erections; therefore, we investigate the prognostic value of cavernous blood NO levels on this parameter. Nerve-sparing RRP was performed on 14 patients for localized prostate cancer. We evaluated all patients 3 months after surgery by IIEF score: no patients had erections. A cavernous blood sample was also taken to determine NO levels (as nitrite). Patients were evaluated again 18 months after surgery. In six cases, erectile function was compromised, whereas in seven cases, potency was restored. Statistical analysis showed a relationship between nitrite levels in cavernous blood 3 months after surgery and the recovery or erectile function at 18 months. We propose that cavernous NO blood levels are a prognostic index of erection recovery.

Differing expression of enzymes of the glyoxalase system in superficial and invasive bladder carcinomas.

This work aimed to study the activities of the glyoxalase system enzymes (glyoxalase I (GI) and glyoxalase II (GII) and their gene expression in human bladder carcinomas compared with the corresponding normal mucosa. Samples of these tissues were collected from 26 patients with superficial (SBC) or invasive bladder cancer (IBC) and used to evaluate enzyme activity and gene expression by northern blot analysis. In keeping with the electrophoretic pattern and the expression level of the respective genes, GI activity significantly increased in SBC samples, while it remained unchanged in IBC samples compared with the normal mucosa. In contrast, GII showed a higher activity in the tumour (either SBC or IBC samples) versus normal tissues. These results confirm the role of the glyoxalases in detoxifying cytotoxic methylglyoxal (MG) in bladder cancer. The differing levels of GI activity level and gene expression of GI between the SBC and IBC samples could help in their differential diagnosis.

Ureteral endometriosis: an endoscopic diagnosis.

A case of ureteral endometriosis is reported. This is the first case diagnosed during a ureteropyeloscopic examination.

Real-time transrectal sonographic voiding cystourethrography.

Transrectal linear array transducer makes possible a sagittal view of the bladder base-plate, prostatic urethra, and membranous urethra yielding an image similar to that obtained with voiding cystourethrogram. This permits lack of time limitation, such as imposed by the use of fluoroscopy, and the possibility of visualizing not only the lumen of the bladder neck and urethra but also the surrounding soft tissue. Using ultrasonographic urodynamics in neuromuscular dysfunctions of the bladder and urinary voiding obstructions we obtained excellent results in patients with detrusor-sphincter dyssynergia and in those with posterior ledge at the bladder neck. Both conditions are clearly visualized, particularly the existence of the posterior ledge which is responsible for the failure of the sphincterotomy in patients with periurethral striated sphincter spasm.

Extracorporeal piezoelectric shockwave lithotripsy of ureteral stones: are second-generation lithotripters obsolete?

BACKGROUND: The role of extracorporeal shockwave lithotripsy (SWL) for ureteral calculi is still being debated. We evaluated our results in a large series to clarify the role of this modality. PATIENTS AND METHODS: A total of 478 patients with solitary ureteral stones were treated by in situ piezoelectric extracorporeal shockwave lithotripsy (SWL) using a Wolf Piezolith 2300 ultrasound-guided lithotripter. Two hundred fifty stones (52.3%) were located in the upper ureter and 228 (47.7%) in the distal ureter. Seventy of the upper ureteral stones were located in the ureteropelvic junction and 180 in the lumbar ureter. The diameter of the stones ranged from 5 to 30 mm. Four hundred sixty-seven patients were followed up for a mean of 4 months. RESULTS: Four hundred forty patients (94.2%) were stone free after in situ SWL alone. Complete removal of all stone fragments was achieved in 95.4% of the 216 patients with calculi of 5 to 10 mm in diameter, in 94.3% of the 229 with stones of 11 to 20 mm, and in 81.8% of the 22 with calculi of 21 to 30 mm. In situ treatment completely removed 61 of 69 ureteropelvic junction stones (88.4%), 166 of 175 lumbar stones (94.8%), and 213 of 223 distal ureteral stones (95.5%). In situ treatment failed in 27 stones (5.8%). After 4 months, 12 stone fragments and 15 unfragmented stones persisted despite retreatments and required endoscopic procedures. The mean number of sessions and shockwaves per patient was 1.8 and 4884, respectively. Morbidity was low. Renal colic in 57 patients (11.9%) was managed successfully by analgesics. In 36 patients, stone fragments obstructed the ureter; in 28 of these 36 (78%), the obstruction was resolved and the patients were stone free after in situ retreatments alone. All these results were achieved on an outpatient basis without sedation or local or general anesthesia. CONCLUSION: Piezoelectric SWL is an effective and noninvasive method for eliminating ureteral stones. Second-generation ultrasound-guided lithotripters are not yet obsolete.

Prostate cancer: correlation between local and systemic disease.

BACKGROUND: Prostate cancer is in Italian men the second neoplasm for incidence. Transrectal ultrasonography (TRUS) is still today a cheap test, not very invasive, well accepted by the motivated patient and sufficiently accurate for the valuation of the local status disease. We proposed our data to verify if a careful local ultrasonographic study of prostatic carcinoma could or not predict its systemic course. METHODS: We have valued 136 out patients affected by prostate cancer and treated with either palliative medical therapy or radiotherapy. The follow-up varies from 12 to 132 months. The local, evaluation of the disease done through TRUS in longitudinal and/or axial scan (the dimension of the gland, the volume and ultrasonographic characteristics of the lesion, capsular involvement and estimation of the surrounding structures: seminal vesicles, vesica, rectum). RESULTS: In the long run, considering the local and systemic course of the disease, we have noticed accordance globally in 116 patients (85.3%); 13 patients showed only systematic progression (9.5%) while in 7 patients, we have noticed a local but not a systemic variation. CONCLUSIONS: We can deduce that periodical carrying-out of the TRUS (twice a year) constitute a reliable index not only of local procedure of the pt. but also predicting the systemic course of the disease, making the routine carrying out of the other check-up unnecessary, that could be reserved for cases with precise clinical indication.

New therapeutic options for refractory neurogenic detrusor overactivity.

AIM: Current pharmacologic treatment of detrusor overactivity relies on anticholinergic drugs. However, they often have untolerable side effects so that they are administered in doses insufficient to restore urinary continence. Recently, intravesical instillations and injections into the detrusor muscle of new pharmacological agents have been developed. The present study report our own experience in the treatment of detrusor overactivity with intravesical administrations of vanilloid agents and with botulinum-A toxin injections into the detrusor muscle in a group of spinal cord injured patients. In particular, we compared the clinical and urodynamic effects of the 2 drugs in an attempt to find a new and valid therapeutic option in those cases unresponsive to conventional treatment. METHODS: Seventy-five patients with spinal cord injury and refractory detrusor overactivity were included in the study: 35 patients received repeated intravesical instillations of resiniferatoxin (RTX) dissolved in normal saline; 40 patients received repeated injections of 300 units botulinum A-toxin diluted in 30 ml normal saline. Clinical assessment and urodynamics were performed at baseline and 6, 12 and 24 months after treatment. RESULTS: With both treatments there was a significant reduction in mean catheterization and episodes of incontinence and a significant increase in mean first involuntary detrusor contraction and in mean maximum bladder capacity at 6, 12 and 24 months after therapy. We did not detect any local side effects with either treatment. Botulinum-A toxin significantly reduced also the maximum pressure of uninhibited detrusor contractions more than RTX at all follow-up time points. CONCLUSION: In patients with spinal cord injury and refractory detrusor overactivity intravesical RTX and botulinum-A toxin injections into the detrusor muscle provided beneficial clinical and urodynamic results with reduction of detrusor overactivity and restoration of urinary continence in most patients. Botulinum-A toxin injection provided better clinical and urodynamic benefits than intravesical RTX.

Feminine urinary incontinence and urodynamic examination.

The Authors performed urodynamic examinations on all patients affected by urinary incontinence. This examination enabled them to classify incontinence precisely, from the etiopathogenetic point of view. Incontinence may be due to an altered transmission of the abdominal pressure, to sphincteral lesions or insufficiency, or to stimuli. This classification provides clear indications for the choice of the most suitable therapy (surgical, medical, instrumental). It thereby contributes to improving the outcome and decreasing the number of relapses so far reported by all Authors using any of the suggested surgical techniques.

Vaginal metastasis from unsuspected renal cell carcinoma.

The Authors report on a case of renal cell carcinoma with vaginal metastasis, which appeared on clinical examination as a primary vaginal disease without urinary symptoms.

[Uro-gynecologic protocol for studying urinary stress incontinence]. / Protocollo uroginecologico per lo studio della IUS.

Regarding the difficulty in using a common and standardised language in the diagnosis of Stress Urinary Incontinence (SUI) the authors developed a research protocol based on anamnestic, clinical, urodynamic and imaging forms, in order to have a numerous elements for the evaluation of this pathology. The preliminary study had to identify the most meaningful and common parameters, encoded according to broadly approved literature or the classification proposed by International Continence Society (ICS). One of the fundamental purposes was to clarify the role of ultrasonography technique applied to the field of Stress Incontinence. In this article the authors explain the choices they make, the technique employed for such a study and the ultrasonic images that are pathognomonic of the specific anatomo-functional disorders.

[The clinician's need in renovascular hypertension]. / Le esigenze del clinico nell'ipertensione reno-vascolare.

Clinician questions in nephrovascular hypertension are: 1) Is hypertension secondary to nephrovascular disease? 2) Is vascular obstruction susceptible of surgical management? 3) Which is the best technical approach? In this review of recent international literature we have focused diagnostic value of echo-color Doppler in the screening of patients with secondary hypertension. The sensibility and specificity of this diagnostic test reach 89% and 99.5%. Respectively when the stenosis is over 70%. Anyway when the stenosis is under 70% the accuracy of this examination is lower. Angiography remains the gold standard test in patient eligible for surgery, although its invasiveness. Diagnostic tests of the renin-angiotensin axis (e.g. Captopril test) are useful too, but morphologic evidence is not provided. Surgical approach is the best choice in elective patients.

[Ultrasonography and Doppler color ultrasonography in kidney neoplasms: the demands of the clinician]. / Ecografia ed eco-color Doppler nella patologia neoplastica del rene: le esigenze del clinico.

The high number of diagnostic methods for images (ultrasound, computer tomography--CT, magnetic nuclear resonance--MNR) has allowed the urologist diagnosis more precocious of renal masses contributing to increase the survival rate and quality of life of patients affected by renal carcinoma. Although many are the advantages that the ultrasound scan gives to the urologist, still today in presence of ultrasound scan results showing expansive renal masses, probably malignant, many perform a CT or MNR for diagnostic confirmation and tumor extension.

[Role of Doppler color ultrasonography in the diagnosis of renovascular abnormalities associated with stenosis of the pyeloureteral junction]. / Ruolo dell'eco-color Doppler nella diagnosi di anomalie vascolari renali associate a stenosi della giunzione pieloureterale.

The obstruction of the pielo-ureteral junction, in most of the cases, recognizes an intrinsic etiopathogenesis, the presence of a segment ureteral aperistaltic and alteration of the ureteral musculature. The association of GPU stenosis and the presence of vascular anomalous shanks are frequent. The knowledge of this anatomical situation is important for choosing the therapeutic strategy and the surgical technique. The pre-operative diagnosis of the anomalous vase could condition the choice of the technique (endoscopic technique, laparoscopic), opting for open surgery to have a better control of the vascular shank. We have examined the use of the echo-color Doppler to diagnose the presence of anomalous vase. We have studied 13 patients (6 men and 7 women) between 18 and 62 years of age (average 35 years); the side interested by the obstruction was in 8 cases the right and in 5 cases the left. During surgery in 4 cases out of 13 examined anomalous vases were present. The pre-operative color Doppler found 3 anomalous shanks with a negative false, a positive false and 8 negative trues, showing a sensibility of 75%, a specificity of 88% with a global diagnostic ability of the 84%. We therefore believe that the echo-color Doppler is reliable enough in the pre-operative diagnosis of vascular anomalies associated to stenosis of the GPU and that could be used for pre-operative diagnosis of this urological affection.

[Ultrasonographic study of urethral sphincter in vesico-sphincter dyssynergia]. / Lo studio ecografico dello sfintere uretrale nella dissinergia vescico-sfinterica.

The ultrasound study of bladder neck and urethral sphincter in men could be performed by means of transrectal ultrasound scan in longitudinal scanning or by probing the surface in transperineal scanning. The endocavitary ultrasound scan study gives the best indications in the evaluation of the bladder neck in men. The neuromuscular bladder dysfunctions' (neurologic bladder), which can be studied by ultrasound scan are dyssinergia, striped detrusor, detrusor-bladder-neck dyssinergia, detrusorial iper-reflexy bladder instability. In paraplegic subjects the exam should be performed in gynecological position or in side decubitus, and micturition is obtained by means of sovrapubic percussion and compression or with prevailing action of the abdominal press. The detrusor-striped dyssinergia is the dysfunction of the bladder where the ultrasound scan results are more meaningful and give the best elements. In these cases, already in basal conditions, could be present a bladder neck half-opened. During micturition there is an ample opening of the bladder neck and of the prostatic urethra, but scarce relaxation of the membranous urethra; sometimes a protrusion of the back lip of the bladder neck could be present too. In iper-reflexy (unstable bladders) and in detrusorial ipo-reflexy, ultrasound scans could result poorly specific and non-significative.

[Color Doppler echography of the cavernous bodies after F.I.C. in the study of erectile impotence of vascular origin]. / L'eco-color Doppler dei corpi cavernosi dopo "F.I.C." nello studio dell'impotenza erettile su base vascolare.

Study with the Doppler method has been associated with "cavernometrics" and "cavernography" in erection pathologies for some time. But this enquiry is burdened not only be technical inaccuracies such as the lack of knowledge of the angle of incidence of the doppler wave and the diameter of the explored vessel etc, but also by intrinsic difficulty method itself. Therefore, the authors have used a color Doppler to individuate and study the cavernous arteries, and present the results obtained from a group of 21 patients, all affected by erectile deficits, who were selected on the basis of anamnestica and clinical criteria. They individualized 21 patients in whom the vasculogenic nature of their affection appeared probable, out of the 125 who were under their observation for their sexual inadequacy. In three patients the clinical suspicion of a venous incompetency was confirmed by dynamic "cavernometrics with cavernography". The study of the four phases of erection (flaccidity, tumescence, erection, detumescence) was carried out after an intracavernous injection of 20 micrograms of PGE/1. The parameters considered were: systolic velocity of the hematic wave, diastolic speed, the index of resistance and range. In cases of vasculogenic impotence with an arterial base the systolic wave in the 2nd and 3rd phases presented a speed inferior to the norm of standard values, the resistance index altered by the lacking of physiological increment due in the erectile beyond the closing of venous "polsters", also to the rigidity of the albuginea.(ABSTRACT TRUNCATED AT 250 WORDS)

[Echographic study of the bladder neck and prostate region after Nd-Yag laser treatment]. / Studio ecografico del collo vescicale e della loggia prostatica dopo trattamento con Nd Yag Laser.

The authors describe the ultrasonic images they obtained in the follow up of three groups of patients who were divided according to basic pathology and treated with Nd: Yag Laser with contact (CLAP) and side firing (VLAP) fibers. Next the great differences noted between the results achieved with ultrasonic investigation and those obtained with flowmeter controls and IPSS are presented. The authors discuss the possible causes of these dissonances and hypothesize a new way to evaluate cervico-urethral de-obstruction: no longer an anatomical technique but a functional one.