Endovascular therapy for erectile dysfunction: current knowledge and future perspectives.

Erectile dysfunction (ED) is defined as the inability to attain or maintain penile erection sufficient for successful sexual intercourse. ED carries a notable influence on quality of life, with significant implications for family and social relationships. Because atherosclerosis of penile arteries represents one of the most frequent causes of ED, patients presenting with it should always be investigated for potential coexistent coronary or peripheral disease. Up to 75% of patients with ED have a stenosis of the iliac-pudendal-penile arteries, supplying perfusion of the male genital organ. Recently the potential treatment of this pathological condition by percutaneous approaches has emerged with good angiographic results and with a significant improvement in symptoms and quality of life. This review will focus on the normal anatomy and physiology of erection, the pathophysiology of ED, the relation between ED and cardiovascular diseases and, lastly, on new treatment modalities aimed at restoration of normal erectile function.

Multiple chromophobe and clear cell renal cancer in a patient affected by Birt-Hogg-Dubè syndrome: a case report.

OBJECTIVES: Birt-Hogg-Dubé syndrome (BHDS) is a rare autosomal dominant characterized by the presence of fibrofolliculomas and/or trichodiscomas, pulmonary cysts, spontaneous pneumothorax, and renal tumors. The syndrome is linked to mutations in the FLCN gene, which is preferentially expressed in the skin, kidney, and lung. The aim of our paper is to describe a case of multiple bilateral renal cancer in a patient affected by BHDS. CASE PRESENTATION: Patient subjected to enucleoresection seven kidney tumors discovered right after ultrasound performed for other reasons. Definitive histologic examination were as follows: multifocal type chromophobe renal cell carcinoma and clear cell. After 1 month, the patient was readmitted for spontaneous pneumothorax. After about a year, the patient was again subjected to resection of multiple renal tumors left. Histological examination proved that it was multifocal renal cell carcinoma, clear cell varieties. The genome analysis highlighted positive for mutation c. 1379_1380 of FLCN gene, BHDS gene. Currently, the patient is under close follow-up. After 1 year, the chest computed tomography (CT) confirmed the presence of minute air bubbles scattered on both sides. Instead, the abdominal CT was positive for a small round lesion 6 mm exophytic. CONCLUSIONS: The BHDS is a rare syndrome whose management is extremely complex both in terms of oncological and functional. Kidney tumors associated with BHDS usually have a favorable clinical course. Present evidence suggests a close follow-up of the carriers of the genetic mutation patients whether or not they have expressed the lesions of disease given the high rate of recurrence of renal lesions.

Holmium laser enucleation of the prostate combined with mechanical morcellation: two years of experience with 196 patients.

BACKGROUND AND PURPOSE: For 2 years, we followed a cohort of consecutive men who underwent holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation to relieve bladder outlet obstruction with the goal of determining the safety, efficacy, and durability of this procedure. PATIENTS AND METHODS: From January 2000 to June 2001, 196 men with symptomatic bladder outlet obstruction were treated with HoLEP at our institution. A pulsed high-power 80 W holmium laser was used, with the enucleated tissue being removed with a transurethral mechanical morcellator. All patients underwent volume evaluation, peak urinary flow rate estimation (Qmax), postvoiding residual urine volume measurement, International Prostate Symptom Score determination, and a single-question quality of life (QoL) score. Immediate and long-term complications were assessed. RESULTS: The total operative time averaged 83.2 +/- 42.5 minutes, and the average resected weight was 36 +/- 26 g. The morcellation efficiency was 2.8 +/- 1.0 g/min. The mean catheter time was 19 +/- 13 hours, and the hospital stay averaged 1.5 +/- 1.0 days. The mean hemoglobin value and serum sodium concentration did not change, and no patient needed a blood transfusion or experienced hyponatremia. With a mean follow-up of 12.6 +/- 4.9 months (range 6-24 months), significant improvement has been seen in all voiding measures, with a 148% increase in Qmax and a 60% improvement in the symptom score at 1 year postoperatively. Overall, 89% of the patients noticed an improvement in QoL. The complications have been irritative urinary symptoms in 23%, bladder mucosal injury in 6.6%, and transient stress incontinence in 7.1%. Eight patients (4.0%) have required reoperation. CONCLUSION: The HoLEP procedure is an efficacious surgical intervention for symptomatic bladder outlet obstruction with minimal associated morbidity. Wider application and technical refinement will allow the surgeon to reduce the operative time and to render mechanical morcellation safer.

[Nephron sparing surgery in renal cell carcinoma: our experience of a 20-year clinical practice]. / Nephron sparing surgery nei tumori del rene: nostra esperienza relativa a 20 anni di pratica clinica.

OBJECTIVES: Nephron sparing surgery (NSS) is now considered the standard of care in the treatment of renal cell carcinoma (RCC) in stage T1. We retrospectively evaluated our results related to the use of NSS in over twenty years of clinical practice. METHODS: We reviewed our database relating to the use of NSS in the last twenty years of clinical practice, from 1988 to July 2012, in 549 patients. The pre- and post-operative parameters recorded are the evaluation of the site and size of the renal lesion obtained from radiological investigations, the need for clamping the renal pedicle, open or laparoscopic surgical approach, blood loss, histology and intra- and postoperative complications. We also evaluated the parameters related to renal function before and after surgery. RESULTS: The mean follow-up was 95 months (7.6 years). The average diameter of the lesion at CT abdomen was 4.8 cm (1-8 cm). The warm ischemia was required in 317 patients, cold in 18 patients, no need for ischemia in 214 patients. The total duration of surgery was 122.56 ± 52.76 min. 15 procedures were performed laparoscopically. Ischemia time: 3'-25'; bleeding: 50-1000 cc. The lesion was benign in 115 of the 549 patients enrolled; it was a RCC in the remaining cases except for three, which were papillary carcinomas. At 5 years, the cancer free survival rate was 97.5%. CONCLUSIONS: Our data show that the implementation of NSS offers long-term benefits in terms of functional results and a good cancer control.

[A renal cell carcinoma with metastasis to the urinary bladder]. / Carcinoma a cellule renali (RCC) con metastasi vescicali.

We report the case of a renal cell carcinoma with solitary metastasis to the urinary bladder, occurring 3 years after radical nephrectomy in a 68-year-old patient. The cystoscopy revealed a solid and rounded bladder lesion with a fine footstalk. Transurethral resection was performed and the pathological diagnosis was of eosinophil cell and clear cell carcinoma. The patient also presented secondary lesions in under- and upper-diaphragmatic lymph node area, brain and lung; therefore, he received treatment with several systemic therapies (Sorafenib, Sutent, Everolimus, IFN-alpha, Oxaliplatin and Gemcitabine).

Three-year outcome following holmium laser enucleation of the prostate combined with mechanical morcellation in 330 consecutive patients.

OBJECTIVES: A prospective study to assess safety, efficacy, and medium-term durability of holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of bladder outlet obstruction (BOO) due to benign prostate enlargement (BPE). METHODS: Between January 2000 and July 2003, 330 consecutive patients underwent HoLEP at our institution. All patients were pre-operatively assessed with transrectal ultrasound gland volume evaluation, maximum urinary flow rate (Q(max)), international prostate symptoms score (IPSS), and the single-question quality of life (QoL). Intra-, peri-, and postoperative parameters were evaluated and the patients were reassessed at 1-, 3-, 6-, 12-, 18-, 24-, and 36-mo follow-up with the same examinations. RESULTS: Patients' mean age was 66+/-8.1 yr; prostate volume was 62+/-34 cc. Enucleation time was 45.4+/-22.9 min and morcellation time 17.3+/-14 min, whilst resected weight was 40+/-27.5 g. Catheter time was 23+/-14.7h and hospital stay was 48+/-26 h. Mean serum hemoglobin and sodium did not drop significantly from baseline after the procedure (p=013). A significant improvement occurred in Q(max) (25.1+/-10.7 ml/s), IPSS (0.7+/-1.3), and QoL (0.2+/-0.5) at the 3-yr follow-up compared with baseline (p<0.05). Twenty-eight percent of patients complained of irritative urinary symptoms, typically self-limiting after 3 mo; transient stress incontinence was reported in 7.3% of patients. Nine patients (2.7%) had persistent BOO, requiring reoperation. CONCLUSIONS: HoLEP represents an effective and safe surgical intervention. The relief from BOO also proved to be durable after 3-yr follow-up. The present report adds to the evidence that HoLEP could be the standard "size-independent" surgical treatment for symptomatic BPE-related BOO.

Holmium laser enucleation of the prostate combined with mechanical morcellation in 155 patients with benign prostatic hyperplasia.

OBJECTIVES: To report our experience with holmium laser enucleation of the prostate (HoLEP) combined with mechanical morcellation for the treatment of symptomatic benign prostatic hyperplasia (BPH). METHODS: From January 2000 to May 2001, 155 consecutive patients with BPH underwent HoLEP combined with mechanical morcellation and were followed up for at least 6 months. A pulsed high-powered 80-W holmium-neodymium:yttrium-aluminum-garnet laser was used (power setting 2.0 J/pulse, 35 pulses/s, and 70 W). The enucleated tissue was removed by a transurethral mechanical morcellator. RESULTS: The preoperative mean prostate volume was 53 +/- 39 cm3; 38.7% of patients had an estimated gland volume greater than 50 cm3; 30.8% had BPH complicated by urinary retention, bladder calculi, bladder diverticula, or urethral stricture. The total mean operative time was 87 +/- 44 minutes, the resected weight was 37 +/- 26 g, and the morcellation efficiency was 1.9 +/- 1.6 g/min. The catheter time was 18 +/- 13.5 hours and the hospital stay 1.5 +/- 1.0 days. No patient needed a blood transfusion or experienced hyponatremia. The patients were followed up for a mean of 13 +/- 5 months (range 6 to 24). The International Prostate Symptom Score, quality-of-life score, and peak urinary flow rate had improved significantly 1 month after HoLEP and continued to improve in the next few months, regardless of whether the gland volume was more or less than 50 cm3. CONCLUSIONS: HoLEP combined with mechanical morcellation is an efficient surgical intervention for BPH, regardless of gland size.