Extracorporeal shock wave lithotripsy in an elderly population: how to prevent complications and make the treatment safe and effective.

INTRODUCTION: The aim of our study is to consider the feasibility and the results of shock wave lithotripsy (SWL) in an elderly cohort of patients, considering different diseases and concomitant morbidity. MATERIALS AND METHODS: From January 2003 up to July 2006, a total of 1100 SWL treatments were performed in our Stone Centre with Dornier Lithotripter S device. We retrospectively analyzed all the treatments carried out in patients older than 70 years of age, collecting a total of 130 patients. The average age was 75.1 years (range: 70-89). Stone location was renal in 95 and ureteral in 45 patients. Information about SWL outcomes and complications were collected as well as patient's characteristics and treatment modalities. RESULTS: Average stone size was 10.2+/-3.4 and 8.7+/-3.1 for the renal and ureteral location, respectively. 73 out of 140 patients (52.1%) were stone free after a single treatment; 49 patients (35%) required an adjunctive session, whereas SWL was unsuccessful in 18 (12.8%) patients. We observed 64, 24, 21, 10, 31 cases of concomitant arterial hypertension, diabetes mellitus, chronic renal failure, solitary kidney condition and previous neoplastic pathologies. A total of 8 and 6 subjects had previous cardiac surgery and atrial fibrillation respectively, thus requiring a warfarin scheduled conversion to low molecular weight heparin. Five patients had a pace maker implant and three patients an abdominal aortic aneurism. No SWL-related complications were found in this series considering both urological and systemic features. CONCLUSION: SWL represents the treatment of choice for urolithiasis, and it has to be recommended especially to geriatric patients. In those subjects, SWL complications can be avoided with a proper and personalized preparation, together with an ECG and ultrasound continuously monitored procedure.

Urological concerns: Should trans-urethral catheter be located over or under the thigh?

INTRODUCTION: Bladder catheterization is a common practice after several surgical procedures; a wrong trans-urethral catheter position can affect the outcomes of some urological maneuvers. We assess with a physical model the variation of intra-vesical pressures due to different locations of the catheter. MATERIALS AND METHODS: Using a plastic bag fulfilled with 5l of normal saline, we try to reproduce bladder condition assessing pressures in case of catheter located over or under the thigh. RESULTS: In case of catheter over the thigh, the flow of liquid is not allowed, and only a pressure of 23 cm of water induces the passage of fluid. CONCLUSION: A wrong catheter position may adversely affect intravesical pressures; this finding has to be taken into consideration, especially when dealing with post-urological surgery catheterization.

Knotted urethral catheter in an 80-year-old woman: prevention and management of this unusual complication.

Intravesical catheter knotting represents a rare event, especially described in paediatric literature. We report a case of a catheter knot, occurring in an 80-year-old woman, managed by means of sustained traction.

Noninvasive management of obstructing ureteral stones using electromagnetic extracorporeal shock wave lithotripsy.

BACKGROUND: Extracorporeal shock wave lithotripsy (ESWL) represents noninvasive management of urolithiasis. Since the first HM3 model, technological progress has improved the efficacy and safety of this treatment. The current study aimed to evaluate the role of ESWL as a first-line emergency therapy of renal colic due to ureteral stone with impaired renal function. METHODS: This prospective study enrolled all the patients admitted from the emergency room with acute renal colic meeting the following criteria: serum creatinine level ranging from 1.5 to 2.5 mg/dl, hydronephrosis, ureteral stones 6 to 15 mm in size, body mass index less than 30, normal renal function at baseline, and no evidence of urinary tract infection. The patients were submitted to a single-session emergency treatment using Dornier Litothripter S. Follow-up assessment, performed at 24 and 72 h, included radiologic and ultrasound examinations with renal function serum assessment. The end points were a decrease in creatinine level and a stone-free condition. RESULTS: A total of 40 patients were eligible for the study. The mean creatinine level at admission was 1.93 +/- 0.26 mg/dl. After the treatment, renal function recovery occurred for 34 subjects (85%), with a significant global decrease in creatinine levels (p = 0.00). The global stone-free rate 72 h after SWL was 67.5% (27/40). The patients with residual fragments were managed using re-SWL (n = 7) and endoscopic technique (n = 6). CONCLUSIONS: Emergency SWL represents an effective tool in the treatment of ureteral stones with hydronephrosis and slight renal impairment. Although complete stone clearance after one treatment still remains a difficult target, the actual role of SWL in the management of acute obstruction is to obtain ureteral canalization and renal function recovery.

Indwelling ureteral stents and sexual health: a prospective, multivariate analysis.

PURPOSE: Ureteral stents are common devices in urological practice. However, a stent may provoke lower urinary tract symptoms that severely affect quality of life. We evaluated the relationship between ureteral stents and male erection/female sexuality. MATERIALS AND METHODS: A total of 30 men and 20 women undergoing ureteral stent positioning were considered. Patients affected by risk factors for erectile dysfunction or hormonal and metabolic alterations were excluded. Hystero-ovariectomy and menopause were considered exclusion criteria. Three questionnaires were administered before stenting and 45 to 60 days after stent positioning, including the International Prostate Symptom Score, the International Index of Erectile Function-5 for men and the Female Sexual Function Index for women. RESULTS: Mean age was 45 years in men and 39 years in women. The mean+/-SD International Index of Erectile Function-5 score was 23.2+/-1.27 and the mean Female Sexual Function Index score was 32.15+/-2.71 before stent positioning. No lower urinary tract symptoms were reported before the procedure. After the ureteral stent was indwelling the mean International Index of Erectile Function-5 score was 13.5+/-4.01 and the mean Female Sexual Function Index score was 23.6+/-14.66 (p=0.000 and 0.007, respectively). Of 30 men 25 reported a pathological International Index of Erectile Function-5 score and 6 of 20 women denied any sexual activity due to stent related anxiety, resulting in the minimum Female Sexual Function Index score. In the remaining 14 women sexual life was not significantly impaired by the ureteral stent (p=0.08). CONCLUSIONS: Ureteral stents impaired the quality of sexual life in male and female subjects. In men the most important distress was in regard to erectile function, probably related to lower urinary tract symptoms. Conversely female sexuality appeared to be severely impaired due to stent related psychological concerns.

Bacille Calmette-Guérin intravesical instillation and erectile function: is there a concern?

The aim of our study was to evaluate the effect of bacille Calmette-Guérin (BCG) therapy on erectile function in a cohort of male patients affected by non-muscle invasive bladder cancer. Thirty male patients undergoing BCG treatment for non-muscle invasive bladder cancer were enrolled in the study. Their mean age was 60.4 years. None of the patients had risk factors for erectile dysfunction (ED). All subjects underwent a BCG standard schedule therapy (once weekly instillation for 6 weeks). International Index of Erectile Function (IIEF-5) and International Prostate Symptom score (I-PSS) were addressed to the patients during the treatment schedule (at fourth or fifth instillation) and 1 month after the last instillation. The mean IIEF-5 score was 17.6 +/- 6.7 during therapy and 21.7 +/- 2.92 a month after the last instillation (P=0.008). Baseline ED and the association with lower urinary tract symptoms are variables significantly connected with post-treatment results (P=0.016 and 0.00 respectively) whereas the age seems not to be related to ED (P=0.256). No major side effects were recorded. It is concluded that BCG treatment is effective for prophylaxis of non-muscle invasive bladder cancer; however, it may induce a high incidence of ED. Although this effect is transient and reversible, erectile failure is another source of psychological distress that adversely affects the quality of life of men undergoing BCG treatment.

Immediate improvement in penile hemodynamics after cessation of smoking: previous results.

OBJECTIVES: To assess the chronologic relationship between the cessation of smoking and the restoration of erectile function. Smoking is associated with an increased risk of erectile dysfunction. METHODS: Twenty active smokers (20 to 40 cigarettes/day) affected by erectile dysfunction (International Index of Erectile Function 5-item score less than 21) were enrolled in the study. The mean age was 40 years. All the patients underwent penile color Doppler ultrasonography during the basic and dynamic phases (10 microg prostaglandin E1). A second Doppler evaluation was performed 24 to 36 hours after cessation of smoking. The peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded. The PSV and EDV cutoff value was 30 cm/s and 5 cm/s, respectively. RESULTS: Of the 20 patients, 10 (50%) had normal PSV values but only 5 (25%) had normal EDV values at the baseline Doppler evaluation. All the patients (100%) had normal PSV values at the second penile Doppler evaluation after smoking withdrawal, and 17 (85%) also had normal EDV values. The average PSV was 40.1 and 50.3 cm/s (P = 0.09) and the mean EDV was 6.8 and 2.4 cm/s (P <0.01) at the baseline penile Doppler examination and after smoking withdrawal, respectively. CONCLUSIONS: Within 24 to 36 hours of the cessation of cigarette smoking, the color Doppler parameters demonstrated a significant improvement in EDV and a trend toward an increase in PSV. Additional clinical evaluation is required to further characterize the expeditious improvement in erectile function after the cessation of smoking.

Changes in peak systolic velocity induced by chronic therapy with phosphodiesterase type-5 inhibitor.

The aim of this study was to assess the influence of chronic therapy with phosphodiesterase type-5 inhibitor on penile haemodynamics at colour Doppler ultrasound. Thirty patients affected by erectile dysfunction (ED) of different aetiology tested with the International Index of Erectile Function (IIEF-5) were evaluated with penile colour Doppler ultrasound during basic and dynamic phases (10 microg PGE1) before and after chronic self-administration of sildenafil citrate (dosage: 100 mg as required, two to three times a week) for a period of 5-20 months (mean: 12.3). Treatment was interrupted 14-21 days before the second ultrasound evaluation. Peak systolic velocity (PSV) and end-diastolic velocity (EDV) were recorded by means of colour Doppler; cut off values were 25 and 5 cm s(-1) respectively. Data were compared by nonparametric tests. Twenty-two of the 30 patients showed normal pre-treatment PSV, while eight of 30 had an insufficient arterial flow. Mean pre-treatment EDV was 4.7 +/- 0.5. After chronic therapy with sildenafil, a global improvement of 10.5% on PSV was seen (P < 0.001), without any statistical difference between patients with normal pre-treatment peak and those with a borderline one. No statistically significant changes were found for EDV (P = 0.98). It is concluded that chronic therapy with phosphodiesterase-5 inhibitor results in a significant improvement in PSV values, probably due to a penile chronic vasoactive enhancement.

Transrectal contrast-enhanced (Levovist) ultrasonography in evaluation of urinary leakage after radical prostatectomy: a preliminary report.

Quick postoperative catheter removal remains one of the main goals of radical prostatectomy, but it leads to a greater risk of urinary leakage. Transrectal ultrasonography with enhancing contrast medium (Levovist) is a simple, effective, and minimally invasive examination to evaluate vesicourethral integrity.

Experimental varicocele in the rat: early evaluation of the nitric oxide levels and histological alterations in the testicular tissue.

The relationship between varicocele and male infertility remains to be explained. Oxidative damage because of the testicular venous backflow may represent one of the causes of gonad injury and seems to precede the histological alteration. Therefore measuring the values of spermatic or intratesticular nitric oxide (NO) could be useful in evaluating this oxidative distress. The aim of this study is to assess the role of testicular NO in early detection of the damages induced by an experimental varicocele in the Wistar rat. A left varicocele was induced in 10 animals (group A). A control group of 10 rats was performed (group B). Animals were killed 3 months after the operation. Both testicles were harvested, weighed and sectioned in two equal parts: one for the evaluation of the NO level and the other one for histological examination. All the rats in group A showed a conspicuous dilatation of the left spermatic vein. The histopathological analysis was normal in both the groups. Biochemistry showed a meaningful statistical difference (P < 0.001) in the concentrations of NO among the specimens of the left and right gonads in group A but no difference was found in group B. The increase in NO values and the presence of other oxidant agents represent the first sign of testicular distress and it seems to anticipate histopathological changes. As it is well known that a great difference exist between human and animal sperm, NO could therefore in the future be taken into consideration together with others parameters for the evaluation of patient who is affected by varicocele.

A knotted multi-length ureteral stent: a rare complication.

Ureteral catheters represent essential devices in the management of upper urinary tract obstruction; complications are unusual. Knotting of the stent at its proximal coiled end is a very rare but potentially dangerous event that should be promptly recognized.

An outbreak of hepatitis C virus in a haemodialysis unit: molecular evidence of patient-to-patient transmission.

Hepatitis C virus (HCV) infection remains a major problem in haemodialysis units despite the risk decrease provided by anti-HCV screening of blood. The exact mode of transmission of HCV in the dialysis units remains unclear. To identify the route of the virus and the mechanisms of transmission an investigation into the outbreak of HCV infection in a haemodialysis unit on a molecular level was held: 12 newly infected patients and 14 already infected were investigated by sequencing the 5' untranslated region of the viral genome. The results showed that 3 strains infected new cases and these strains matched those sequenced in already infected patients. Transmission occurred between patients treated on the same shift and also between different rooms. Console and blood or blood product contamination was excluded. Our study gave molecular evidence of patient-to-patient transmission of HCV in a haemodialysis unit. Our data underline the importance of the strict enforcement of standard precautions to prevent HCV transmission and failure of the isolation of anti-HCV positive patients as preventive measure.

[Comparison of the quality of life of patients treated by surgery or radiotherapy in epidermoid cancer of the penis]. / Comparaison de la qualité de vie des patients traités pour cancer épidermoïde de la verge par chirurgie ou radiothérapie.

OBJECTIVE: The purpose of our work is to examine how partially or totally radical surgery and radiotherapy can weigh on quality of life in patients with squamous carcinoma of the penis, considering whether quality of life can be a good criterion in treatment options. MATERIAL AND METHODS: We have interviewed 17 patients alive and disease-free (average follow-up 69.43 months) after surgical treatment or radiotherapy for cancer of the penis (emasculation, 2; total amputation of the penis, 2; partial penectomy, 11; radiotherapy, 2). Tests used: General Health Questionnaire (G.H.Q.-12 by D. Goldberg); Hospital Anxiety and Depression Scale (H.A.D.S.); Social Problem Questionnaire (S.P.Q.); Overall Sexual Functioning Questionnaire (O.S.F.Q); Family APGAR Questionnaire (F.A.Q.); Performance Status ECOG. RESULTS: Thirty-five per cent of the patients presented limitations in their state of health and social problems. Anxiety was evident in 29.5% of the patients and depression in 6%. The global sexual function was compromised in 76.5%. CONCLUSION: The profile of quality of life resulted compromised in the patients who had undergone radical surgical treatment. The sexual function was the most altered component. The impact of the pathology and its treatment on the other domains of quality of life proved less significant.

Surgical treatment of penile carcinoma: our experience from 1976 to 1997.

OBJECTIVE: The purpose of this work is to evaluate our experience with the surgical treatment of penile squamous carcinoma, analyzing the therapeutic results in terms of local recurrence rates, survival and mortality rates. MATERIAL AND METHODS: From 1976 to 1997, 47 patients were treated at our institution for carcinoma of penis. Treatment of primary tumor was conservative in 8 patients (17%). Partial penectomy was performed in 30 patients (63.8%); total penectomy in 5 (10.7%) and emasculation in 4 (8.5%). Pathological stage was pTis in 2 cases (4.2%), pT1 in 20 (42.6%), pT2 in 21 (44. 7%) and pT3 in 4 (8.5%). The tumor was clinically overstaged in 13 patients (27.7%) and understaged in 4 (8.5%). Bilateral inguinal lymphadenectomy was performed only in 4 patients clinically N+ (pN2) and in 3 clinically N0 (pN0). RESULTS: Local recurrence rate was 43% in the patients with pT1 stage tumor treated conservatively. No local recurrence was observed after penectomy. 19 patients (40.4%) are alive and disease-free; 17 patients (36.2%) died of the tumor and 11 patients (23.4%) died of other causes but disease-free. Mean follow-up is 69.43 months. The overall 5-year survival rate was 34%. CONCLUSION: Partial penectomy gives better results than conservative treatment in the local management of the T1 stage tumor. Survival and mortality rates are related to both pathological and histological stages. The high mortality rate observed in the pT2 stage tumors in our experience might be related to the fact that in this stage an inguinal lymphadenectomy was not performed as a rule.

Penetrating trauma to the scrotum and the corpora cavernosa caused by gunshot.

The authors describe a case of gunshot wound of the male genitalia by two low-velocity bullets. The first bullet caused a lesion of the right testicle and came out of the right hemiscrotum; the second one had penetrated the left gluteal region with no exit wound. The penile ultrasound confirmed the presence of the bullet at the root of the right corpus cavernosum. The patient underwent exploratory surgery, drainage of the voluminous bilateral scrotal hematoma, and suture of a laceration of the right-testicle cranial portion. Due to the absence of active bleeding, voluminous hematoma and serious injuries in the corpus cavernosum, no surgical removal of the bullet in the right corpus cavernosum was required. The patient regained a normal sexual function 1 month after the operation.

[Percutaneous, laparoscopic, and surgical treatment of idiopathic varicocele: analysis of costs]. / Il trattamento percutaneo, laparoscopico e chirurgico del varicocele idiopatico: analisi dei costi.

Idiopathic varicocele can compromise the spermatogenetic function of the testicle and associate with alterations of the semen quality. The treatment of varicocele stops the progress of testicular damage and improves spermatogenesis and semen parameters. These are the main alternatives to the traditional surgical treatment of varicocele retrograde percutaneous occlusion of the internal spermatic vein using sclerosing agents and embolizing devices (either separately or in combination), microsurgical ligation via inguinal or sub-inguinal approach, laparoscopic ligation and, more recently, antegrade scrotal sclerotherapy. None of these techniques can be considered the "gold standard" therapy. Literature does not point out any significant difference between them, either considering the absence of reflux percentage, or the improvement of semen quality, or the pregnance rate. Therefore cost comparison may be a valid criterion in the choice of treatment for varicocele correction. The total cost of the surgical retroperitoneal unilateral ligation of the internal spermatic vein is 968,805 Lire, while for the bilateral ligation it is 1,118,285 Lire. The costs of sclerotherapy and percutaneous embolization are respectively of 698,750 Lire and 1,708,950 Lire. The combination of the two techniques amounts to 1,918,230 Lire. Laparoscopic bilateral ligation costs 2,437,935 Lire. Antegrade scrotal sclerotherapy costs 191,035 Lire if unilateral, 216,580 Lire if bilateral. After considering these data we can say that antegrade scrotal sclerotherapy is the first choice economically in the treatment of both unilateral and bilateral varicocele.

[Laparoscopic unilateral retroperitoneal lymphadenectomy in non-seminomatous neoplasms of the testis in clinical stage I]. / La linfadenectomia retroperitoneale monolaterale laparoscopica nelle neoplasie non seminomatose del testicolo in stadio clinic I.

Since June 1993, unilateral laparoscopic retroperitoneal lymph node dissection (LRPLND) was performed in 6 patients diagnosed with clinical stage I nonseminomatous germ cell tumors (NSGCT). All of the patients had undergone prior radical orchiectomy. The testicular cancer was left-sided in three cases and right-sided in three cases. Preoperative staging by means of tumor markers assessment, computerized tomography scan (CT) of the chest and abdomen and chest X-ray was unremarkable for metastatic disease. All procedures were accomplished without any complications in a mean time of 325 min (275 to 420 min). The estimated peri- and postoperative blood loss was minimal. Of note, the comparison between the hematocrit and hemoglobin decrease of LRPLND and RPLND showed a statistically significant reduction (3.1 vs 11.1% P < 0.01 and 1.1 vs 3.2 g/dl P < 0.01). None of the patients required blood transfusion. In the case of the first patient the hospital stay was 18 days due to a widespread subcutaneous emphysema. In the remaining five cases the average hospitalization was 4.8 days ranging between 4 and 6 days. The patients resumed normal activities within 12 to 27 days (mean 16.2 days) postoperatively. Mean number of lymph nodes removed was 6.8, ranging between 5 and 9. Histologic examination of the dissected lymph nodes revealed microscopic metastases from embryonal carcinoma in two patients. Both of these patients were subject to adjuvant chemotherapy. The mean follow-up period is 33.3 months, ranging between 18 and 48 months. To date, no relapses have been observed. In accordance with other reports, we believe that LRPLND is both feasible and effective. However, larger and more comprehensive studies with long-term follow-up are required to determine whether this approach is reliable and definitely superior to standard open surgery in the management of clinical stage I NSGCT.