A conservative approach to perineal Fournier's gangrene.

Fournier's gangrene (FG) is a disease involving necrosis of perineum and external genitalia; in 95% of cases it is possible to diagnose the Fournier's gangrene just by physical examination. The clinical presentation of FG varies from an initial localized infection to large areas with necrotizing infection. The disease typically affect elderly men (6°-7° decade) with important systemic comorbidities; women are less frequently affected. Despite improvements in diagnosis and management, the mortality rate nowadays is between 20% and 43%. The severity and mortality of the disease is dependent upon the general condition of the patient at presentation and upon the rate of spread of the infection. Treatment involves a multidisciplinary approach: intensive systematic management, broad-spectrum antibiotic therapy, early surgical debridement (wide abscission of necrotic tissues and surgical drainage of peritoneum, scrotum, penis, and inguinal areas), hyperbaric oxygen therapy; surgery can eventually be repeated if necessary; reconstructive surgery has an important role in the final treatment of the disease. The technical difficulties frequently encountered and the inability to make a complete removal of the necrotizing tissues at the time of surgery in some cases has led to the application of combined techniques, in view of the enhancement effect of specific advanced medications, targeted antibiotic therapy and hyperbaric medicine. We have considered 6 patients affected by Fournier's gangrene treated at our institution; all the patients received treatment with the help of plastic surgeons of the same institution. After debridement, all the patients were treated with advanced specific dressings consisting of plates and strips made of calcium alginate, hydrogels and polyurethane and twodimensional cavity foams. Reconstructive surgery was necessary in one case. Hyperbaric oxygen therapy (HBO) has been performed in all cases. The multidisciplinary approach, the combined use of HBO therapy and the adoption of advanced specific dressings, have made possible the complete healing of the lesions in a shorter period, avoiding further surgery in 5 out of 6 patients.

Sacral neuromodulation in patients with multiple sclerosis.

PURPOSE: We present a case series of patients with multiple sclerosis (MS) and neurogenic lower urinary tract dysfunction treated by sacral neuromodulation (SNM). METHODS: We reviewed charts of 25 patients who were treated for refractory lower urinary tract symptoms; during the SNM testing phase, patient management included evaluation of number of daily voiding, number of episodes of incontinence, residual urine and quality of life score. Patients who experienced greater than 50% improvement in symptoms of frequency and incontinence episodes and/or a greater than 50% decrease in the number of catheterizations and a greater than 50% increase in voided volumes were offered placement of the permanent InterStim(TM) . RESULTS: Fifteen patients were implanted with InterStim(TM); mean duration of MS was 13.66 years; mean follow-up of patients was 49.4 months. Nine patients were on clean intermittent catheterization, and in all of them, a significant decrease in residual volume with increase in voided volume and number of voiding per day; in 6 patients, the main problem was incontinence, and in them incontinence, episodes decreased and voided volume increased. Sixty-six per cent of patients have a functioning device after a mean follow-up of 61.2 months. CONCLUSIONS: SNM is a good option in the treatment of voiding dysfunction in patients with MS in a medium to long-term follow-up. Urinary retention due to detrusor underactivity is not a good indication for SNM; it should be offered to MS patients with refractory urgency urinary incontinence and MS patients with urinary retention due to detrusor-sphincter dyssynergia (DSD).

The role of uroflowmetry biofeedback and biofeedback training of the pelvic floor muscles in the treatment of recurrent urinary tract infections in women with dysfunctional voiding: a randomized controlled prospective study.

OBJECTIVES: To evaluate the efficacy of a training program with uroflowmetry biofeedback and pelvic floor relaxation biofeedback on urodynamic and voiding parameters in women with dysfunctional voiding. METHODS: Eighty-six women with recurrent urinary tract infections (UTIs) and dysfunctional voiding were randomly assigned to receive a treatment schedule as follows: uroflowmetry biofeedback (group 1), biofeedback training of the pelvic floor muscles (group 2), uroflowmetry biofeedback combined to biofeedback training of the pelvic floor muscles (group 3), no treatment (group 4). Patients were regularly evaluated by American Urological Association Symptom Index and urodynamics during the study period. All the patients were followed up for 1 year with monthly urine cultures. A further evaluation was done at month 24 by American Urological Association Symptom Index and free uroflowmetry with measurement of residual urine. RESULTS: The prevalence of storage and emptying symptoms decreased significantly at 3, 6, and 12 months in the groups 1, 2, and 3, and remained stable during the study period. Mean flow rate, flow time, voiding volume increased significantly, whereas postvoid residual urine decreased. The prevalence of UTI decreased significantly in groups 1, 2, and 3. At month 24, storage and emptying symptoms and voiding patterns were similar to the baseline values in all the patients. The incidence of UTIs was similar to baseline values in groups 1, 2, and 3. CONCLUSIONS: Training the voluntary control of the pelvic floor seems essential in obtaining control over the bladder function. These results reinforce the importance of pelvic floor therapy in the resolution of UTIs.

BMAP-28 improves the efficacy of vancomycin in rat models of gram-positive cocci ureteral stent infection.

An experimental study was performed to evaluate the efficacy of BMAP-28 alone and in combination with vancomycin in animal models ureteral stent infection due to Enterococcus faecalis and Staphylococcus aureus. Study included a control group without bacterial challenge to evaluate the sterility of surgical procedure, a challenged control group that did not receive any antibiotic prophylaxis and for each bacterial strain three challenged groups that received (a) 10 mg/kg vancomycin intraperitoneally, immediately after stent implantation, (b) BMAP-28-coated ureteral stents where 0.2-cm(2) sterile ureteral stents were incubated in 1mg/l BMAP-28 solution for 30 min immediately before implantation and (c) intraperitoneal vancomycin plus BMAP-28-coated ureteral stent at the above concentrations. Experiments were performed in duplicate. Ureteral stents were explanted at day 5 following implantation and biofilm bacteria enumerated. Our data showed that rats that received intraperitoneal vancomycin showed the lowest bacterial numbers. BMAP-28 combined with vancomycin showed efficacies higher than that of each single compound. These results highlight the potential usefulness of this combination in preventing ureteral stent-associated in gram-positive infections.

Tolerability of prostate transrectal biopsies using gel and local anesthetics: results of a randomized clinical trial.

PURPOSE: To evaluate the role of intrarectal EMLA, a new topical anesthetic cream, and lidocaine gel as local anesthesia during transrectal prostate biopsy and to observe whether gel temperature can improve pain control. PATIENTS AND METHODS: A series of 210 consecutive patients were randomized. Group 1 (N = 60) underwent intrarectal instillation of EMLA cream, group 2 (N = 50) 2.5% lidocaine gel, group 3 (N = 40) placebo, and group 4 (N = 60) no treatment. Patients in groups 2 and 3 were subdivided into subgroups according to instillation of warm or cooled gel. Pain control was assessed by a 10-point visual analog scale. RESULTS: The median pain scores were 2.6 in group 1, 3.8 in group 2, 3.9 in group 3, and 3.6 in group 4. In 16 patients (7.6%), the procedure was suspended because of pain: none group 1, 6.0% in group 2, 10% in group 3, and 15% ing group 4. The temperature of the lidocaine gel did not affect tolerability. CONCLUSION: Intrarectal instillation of EMLA cream is a simple, safe, and effective method of local anesthesia during transrectal prostate biopsy, superior to lidocaine gel, placebo, and no treatment.

Safety and efficacy of transurethral resection of prostate glands up to 150 ml: a prospective comparative study with 1 year of followup.

PURPOSE: We investigated the safety and efficacy of transurethral resection of the prostate (TURP) for prostate glands between 70 and 150 ml. MATERIALS AND METHODS: We prospectively evaluated 113 patients treated with TURP for benign prostatic hyperplasia. A total of 57 patients with a prostate volume of less than 70 ml were assigned to group 1, while 56 with a prostate volume of between 70 and 150 ml were assigned to group 2. Preoperative parameters considered in each patient were prostate volume, International Prostate Symptom Score (I-PSS), urinary flow rate measurement (Qmax) and post-void residual urine volume (PVR). Operative time, resected tissue weight and all complications were recorded. All patients were evaluated 3 months and 1 year postoperatively. Preoperative, perioperative and postoperative data on the 2 groups were compared. RESULTS: Each group achieved significant improvement in I-PSS, Qmax and PVR. Operative time was significantly longer in group 2 but the complication rate was similar in the 2 groups. Group 2 resulted in better improvements in Qmax and I-PSS. At 1 year of followup PVR was significantly lower in group 1 than in group 2. Multivariate analysis revealed that only age was a significant independent predictor of complications, and only age and initial Qmax were independent predictive variables of outcome. CONCLUSIONS: TURP for large prostate glands is a safe procedure without showing a different complication rate compared with TURP for recommended volumes. Patients with a baseline prostate volume of greater than 70 ml seem to achieve better improvement in obstruction and symptoms.

Transurethral resection versus minimally invasive treatments of benign prostatic hyperplasia: results of treatments. Our experience.

OBJECTIVE: In this non-randomized prospective study the results of standard TURP (Transurethral Resection of the Prostate) versus other minimally invasive treatments were compared. MATERIALS AND METHODS: Among all the patients treated at our Institution for bladder outlet obstruction due to BPH (Benign Prostatic Hyperplasia) from January 1995 to June 1998, 212 patients have been evaluated; 90 patients underwent to TURP, 13 patients to TVP (Transurethral ElectroVaporization), 24 patients to TUNA (TransUrethral Needle Ablation), 71 patients to ILC (Interstitial Laser Coagulation), and 13 patients to WIT (Water-Induced Thermotherapy). RESULTS: TURP achieves the highest decrease of prostate volume (48.8%), the best increase of maximum flow rate (75.3%) and the highest decrease of residual volume (89.8%) in comparison to other methods; these results are substantially stable 24 months after treatment; on the other hand, after WIT a reduction of prostatic volume of 5.2%, an increase of maximum flow rate of 16.7% and a decrease of residual volume of 25.2% can be observed. The relief of bladder outlet obstruction is indicated by the decrease of detrusor pressure at maximum flow rate in comparison to baseline values; it decreases of 27.5% for WIT, of 34.8% for TUNA, of 38.3% for ILC, of 48.4% for TUR, and of 53.3% for T.P The recorded results are substantially stable 24 months after treatment. A marked decrease of IPSS and QL score can be observed for all the procedures after 6 months, ranging from 40.2% for WIT to 76.7% for TUNA; however, these parameters undergo to a slight worsening 24 months after treatment for TURP, TVP and TUNA, while remain substantially stable for ILC and WIT. CONCLUSION: From the analysis of our results, it appears that TURP is still the golden standard treatment for BPH; TURP remains the most effective and definitive way of treatment, but it could be less attractive from the patients' perspective, especially after minimally invasive treatments with good tolerability have become available. It is therefore evident that the choice of each method should be performed in consideration of patients' general performance status, of symptoms and of indications and contraindications of each method.

Acupuncture reflexotherapy in the treatment of sensory urgency that persists after transurethral resection of the prostate: a preliminary report.

AIMS: In this study, we wanted to evaluate whether acupuncture reflexotherapy is able to treat the sensory irritative components of LUTS (lower urinary tract symptoms) that persist after transurethral resection of the prostate. METHODS: We have evaluated 42 patients, randomly selected into three groups: 14 patients received placebo, 15 patients received oxybutynin, and 13 patient were treated with electrostimulation by acupuncture reflexotherapy. RESULTS: Before treatment, the mean maximum flow rate (Qmax) was 21.0 +/- 3.2 mL/sec, the mean International Prostate Symptom Score (I-PSS) score was 12.9 +/- 4.2, the mean I-PSS Quality of Life (IPSS QoL) score was 3.6 +/- 1.2. At the first check-up performed after 3 months, we could observe that the I-PSS and QoL scores were 12.6 +/- 4.3 and 3.8 +/- 1.3 in the group who received placebo; the scores decreased to 11.1 +/- 3.2 and to 3.1 +/- 1.0, respectively, in the 15 patients treated with oxybutynin and decreased to 6.1 +/- 2.6 and 1.3 +/- 1.1, respectively, in the 13 patients who underwent acupuncture reflexotherapy. At 1-year follow-up, these parameters were practically similar. The voiding diaries allowed us to deduce that the average number of daytime voidings decreased by 8% in patients who received oxybutynin and decreased by 20% in 13 patients who underwent reflexotherapy; the average number of nocturnal micturitions decreased by approximately 20% and 60%, respectively, in patients who received oxybutynin and reflexotherapy. CONCLUSIONS: This study has pointed out that acupuncture reflexotherapy has a real benefit in patients with sensory urgency that persists after transurethral resection of the prostate.

Acupunctural reflexotherapy as anaesthesia in day-surgery cases. Our experience in left internal vein ligature for symptomatic varicocele and in circumcision.

Acupunctural reflexotherapy has been performed in patients during minimally invasive treatments for benign prostatic hyperplasia and in patients with lower urinary tract symptoms. We report two cases of left internal spermatic vein ligature for varicocele and a case of circumcision using acupunctural reflexotherapy, a procedure, to our knowledge, never applied before in open surgery. A 38 and a 24 years old male patients came to our observation for a 2nd degree symptomatic left varicocele and a 40 years old patient came to have a circumcision; they requested alternative anaesthesia for the operation and acupunctural reflexotherapy has been performed. This technique for analgesia can be useful and can be applied in selected cases, i.e. minor surgery in patients who do not wish or cannot have a general anaesthesia; it can be associated to other techniques of anaesthesia as peri- and post-operative analgesia. No contraindications nor collateral effects exist. The limits of this methods are represented by the length of time required for preparation of the patient and the existence of patients non-responder to electrostimulation.