Erectile dysfunction after kidney transplantation: our 22 years of experience.

AIM: To evaluate the results of treatment of erectile dysfunction (ED) in kidney transplant recipients before and after the advent of sildenafil. MATERIALS AND METHODS: From 1981 through 2002, 971 male patients of mean age 53.4 years received a renal graft. Erectile dysfunction (ED) was investigated in all patients at the first urologic visit posttransplantation. Psycho-sexual support was offered to all patients. Before sildenafil use (1998), our diagnostic approach was complex. From 1998 we tested: serum levels of testosterone, prolactin, and glucose with penile duplex ultrasonography and NPT reserved for selected cases. RESULTS: From 1981 through 1998, 365 male kidney transplant recipients (45%) reported ED. Only 169 patients chose to be treated: 27 responded to psycho-sexual therapy; 3 received testosterone with benefit; 133 had a good results from intracavernosal injection of vasoactive drugs; and 6 received a penile prosthesis. Since 1998, 126 patients reported ED (78.3%). Only 78 chose treatment: 24 patients had a satisfactory response to sildenafil (65% with 50 mg and 35% with 100 mg). PGE1 alone or in combination with papaverine and phentolamine produced a good response in 37 patients; 17 patients did not respond to pharmacotherapy; and 5 received a tricomponent penile prosthesis without complications. The side effects of sildenafil and PGE1 therapy were similar to those reported in the literature. CONCLUSIONS: ED is an important problem in male renal transplant recipients. Cultural resistance to treatment is common. However, treatment with sildenafil citrate and intracavernosal self-injection of PGE1 are well accepted, and prosthetic devices may help in resistant cases.

[Diverticuli of the female urethra. Our experience and long-term clinico-instrumental evaluation]. / Diverticoli dell'uretra femminile. Nostra esperienza e valutazione clinico-strumentale a distanza.

Since 1978, in our Division, we treated for this pathology 11 patients aged between 18 and 60 (average 45). We always performed a transvaginal diverticulectomy, in one case with intradiverticular stone removal: while in no case did we associate a colposuspension because we never found concomitant stress incontinence, nor we discovered the presence of neoplasm in the diverticulum as reported by other authors. We did not report any complication in the postoperative period: the clinical results proved quite satisfactory; in the late follow-up, also including radiologic and profilometric investigation, no relapses occurred and no morphological or manometric alterations were observed.

[Treatment of prostatic carcinoma in an advanced stage. Our experience]. / Il trattamento del carcinoma prostatico in stadio avanzato. Nostra esperienza.

The authors report the results of a retrospective study regarding 214 patients (mean age 73, smallest follow-up 6 months, greatest 70 months, average 42 months) affected by advanced prostatic cancer histologically demonstrated, observed from January 1983 to December 1990 and subject to hormonal treatment. They particular compared so-called "total androgenic suppression" (Gn-RH analogous or orchiectomy plus antiandrogen) with the "partial androgenic suppression" (Gn-RH analogous or orchiectomy). The authors report the results of the treatment regarding the subjective and the objective response, evaluated with NPCP criteria. Moreover the actuarial aspects of response and survival curves of two groups of patients are compared. The authors conclude that total compared to partial androgenic suppression does not offer significant advantages as regards to objective response and present their current treatment of advanced prostatic cancer.

[Conservative surgical therapy in the treatment of renal carcinoma]. / Terapia chirurgica conservativa nel trattameno del carcinoma renale.

The authors report results in 10 patients (5 with renal neoplasms in a single kidney, 4 with healthy contralateral kidney, and one with a pathological opposite kidney following conservative surgery: 4 surgical enucleations and 6 partial nephrectomies.

[2 cases of unexpected anatomopathological discovery of a leiomyoma of the urogenital system]. / Due casi di inaspettato riscontro anatomopatologico di leiomioma dell'apparato urogenitale.

The authors report their recent experience in two cases of leiomyoma of the genitourinary tract not only because of relatively low incidence of this neoplasm in such sites, but especially since in the first case a previous urothelial lesion had led to the performance of a cystectomy and bilateral uretero-ileo-cutaneostomy, which led us to attribute the later urethral lesion also to a transitional-type neoplastic site; in the second case, symptomatologic evolution, palpation and scrotal echography aroused suspicion of testicular neoplasm and only the observation during surgical operation made it possible to decide for a testis-preserving therapy enabled by the reassuring extemporaneous histological report.

[Priapism: our experience in 9 cases]. / Priapismo: nostra esperienza in 9 casi.

We report our experience with 9 cases of priapism treated with decompressive puncture of the corpora cavernosa or with spongiosum-cavernosum shunt. No significant difference in result between these two surgical approaches was found: we conclude that early treatment is decisive for the preservation of potency.

[Nephron-sparing treatment of kidney neoplasms in transplanted kidney. Our experience]. / Trattamento "nephron-sparing" delle neoplasie renali in rene trapiantato. Nostra esperienza.

BACKGROUND: To evaluate survival rate, follow-up and renal function in patients treated with "nephron-sparing" approach due to cancer in a transplanted kidney. METHODS: During the 18 years' activity of our Transplantation Centre 3 renal carcinomas in transplanted kidneys (0.24%) have been found. Diagnoses were made in one case during transplantation procedures and, in the remaining two, 1 month and 10 years after. All tumours were unifocal, small (10, 12 and 18 mm of diameter), capsulated and low stage (T1). The resection of the mass ("nephron-sparing" surgery) and of a layer (1 cm thick) of the tissue surrounding the tumour was performed. The histological exam showed in all cases low grade (G2) renal cell carcinoma and negative surgical margins. RESULTS: 138, 94 and 15 months after transplant all patients are alive, without disease recurrence and with good renal function. In all cases the doses of immune-suppressive therapy were reduced. CONCLUSIONS: Renal cancer in transplanted kidneys is generally treated with nephrectomy. On the contrary, we decided to apply the same criteria which are accepted for the treatment of renal neoplasms in general and then to perform a "nephron-sparing" surgery when the tumour is small, capsulated and with negative surgical margins at the intraoperative histological exam. In personal experience good results from the oncologic and nephrologic point of view have been accomplished.

The use of the small caliber JJ stent with anti-reflux valve in double kidney transplant. Personal experience.

BACKGROUND: In the experience of other authors, double kidney transplant have a higher complication rate (30%) if compared with single renal graft. In personal experience the use of small calibre ureteral stents with antireflux valve can reduce this complication rate. METHODS: From November 1999 to April 2001, at the A.S.O. S. Giovanni Battista in Turin, we performed 29 double kidney transplantations with the application of small calibre stents in 20 male and 9 female patients, aged 50-74 years. The uretero-neocystostomies were carried out according to Lich-Gregoire technique, and the JJ stents used were pediatric ones, 12 cm long and 4.8 Ch, with antireflux valve. RESULTS: We complained only 2 urological complications out of 58 anastomoses (distal unilateral ureteral necrosis in 1 case and total ureteral necrosis in the other). CONCLUSIONS: Complication rate is lower than in the literature: the authors suggest that the use of small calibre JJ stents can keep the complication rate low in double kidney transplant.

Use of small calibre JJ ureteral stent with anti-reflux valve in uretero-vesical anastomosis during renal transplantation.

BACKGROUND: We report our experience in transplantation proceedings with the use of small caliber JJ ureteral stent with antireflux valve during uretero-vesical anastomosis. METHODS: During renal transplantations we usually perform an uretero-cystoneostomy with antireflux technique according to Lich Gregoir. In the past we used to intubate the uretero-vesical anastomosis only in particular cases; since April 1998 we performed 112 single and 8 double transplants and in all cases we positioned a 12 cm long paediatric 4.8 Ch JJ ureteral stent with antireflux valve, in order to reduce urologic complications. The vesical catheter was usually removed in 6o-7o day and the ureteral stent 40-60 days after transplantation. RESULTS: We have performed 129 uretero-vesical anastomoses and we complained only one case of early dehiscence of the anastomosis (unilateral in a double transplant) and two cases of late stents' displacement. We noticed no stenosis of the anastomosis and no dysfunction in urine outflow from the upper urinary ways. CONCLUSIONS: The routinary use of paediatric JJ ureteral stents with antireflux valve was decisive in drastically reducing early urologic complications after renal transplantation. Furthermore, the risk of vesico-ureteral reflux is almost completely reduced, thanks to the technique adopted for the anastomosis which allows a physiologic-like antireflux mechanism, to the presence of the antireflux valve and to the early recovery of the physiologic ureteral peristalsis, which is promoted by the small calibre of the stent. These factors lead to a faster recovery of the renal function, with excellent results from the nephrologic and urologic points of view.

[Bladder augmentation and urinary diversions in kidney transplants].

There is some controversy about the safety of kidney transplant in patients with augmented or diverted urinary system: they are considered higher risk recipients in view of increased technical problems and infective complications leading to pyelonephritis and graft loss. The ureter of a transplanted kidney should be anastomosed into a reservoir with an adequate capacity, with low bladder pressure, with good compliance, and efficient voluntary empting. Ileal and sigmoid bladder augmentation, usually associated with clean intermittent catheterization, has become a well-accepted part of the urological practice and has been used for implantation of the transplant ureter. During the last years, the interest in new biomaterials for reconstructive surgery has increased. Experimental studies showed how these requests can be satisfied by porcine small intestinal submucosa SIS (Stratasis™): this can be degraded by the host and substituted by "new tissue". In four recent cases we have used SIS to obtain an augmented, normalpressure and good compliance bladder reservoir, with three (epithelial, muscular and adventitial) layers normally represented.

[Penile prosthesis implantation in kidney-transplanted patients].

Most kidney transplantations are performed on middle-aged men for whom problems of sexual potency are still of great importance. Although a functional renal graft improves the problem in some patients and others resolve with oral or intracavernous therapy, about 20% of patients do not have a good response. In non-responders, tricomponent penile prosthesis implantation is possible. In the last 10 years we have implanted with no complications 7 tricomponent AMS 700 prostheses in patients not otherwise responding. Our good results confirm that patients with kidney transplantation should be considered good candidates to the penile prosthesis if the erectile dysfunction persists after different therapies.

Inverted urothelial papilloma: a lesion with malignant potential.

Two cases of inverted urothelial papilloma are presented. In the first case the inverted papilloma was in the ureter and varying degrees of cellular atypia were demonstrated on histology: 7 years later, a single bladder lesion consisting of papillary transitional cell carcinoma and inverted papilloma developed in the same patient. In the second case a bladder tumor consisting of inverted papilloma mixed with papillary infiltrating transitional cell carcinoma was detected. The peculiar morphological findings, histogenesis and biological behavior of inverted urothelial lesions are discussed.