Sustained-release alfuzosin, finasteride and the combination of both in the treatment of benign prostatic hyperplasia. European ALFIN Study Group.

OBJECTIVES: To assess the additive benefit of combining an alpha1-blocker and a 5alpha-reductase inhibitor. METHODS: This European, randomized, double-blind, multicenter trial involved 1.051 patients with lower urinary tract symptoms related to benign prostatic hyperplasia. Patients received sustained release (SR) alfuzosin (n = 358), a selective alpha1-blocker given at a dose of 5 mg twice daily without dose titration; finasteride (n = 344), 5 mg once daily, or both drugs (n = 349), for 6 months. Primary efficacy criteria were symptomatic improvement (International Prostate Symptom Score: I-PSS) and maximum flow rate (Qmax). Safety was assessed by monitoring adverse events. RESULTS: Symptomatic improvement was significantly higher from the 1st month of treatment with SR alfuzosin, alone or in combination; mean changes in I-PSS versus baseline at end-point were -6.3 and -6.1, respectively, compared with -5.2 with finasteride alone (SR alfuzosin vs. finasteride, p = 0.01; combination vs. finasteride, p = 0.03). The percentages of patients with a decrease in I-PSS of at least 50% were 43, 42 and 33% for SR alfuzosin, the combination and finasteride, respectively (SR alfuzosin vs. finasteride, p = 0.008; combination vs. finasteride, p = 0.009). In the overall population, increases in Qmax were greater with SR alfuzosin and the combination, compared with finasteride alone after 1 month of therapy, but changes at end-point were similar in the three treatment groups. In those 47% of patients likely to be obstructed (baseline Qmax <10 ml/s), however, mean increases in Qmax were significantly higher with SR alfuzosin, alone or in combination, whatever the visit. Finasteride, alone or in combination, significantly impaired sexual function. The incidence of postural symptoms was low and similar in the three treatment groups. CONCLUSION: In this 6-month trial, SR alfuzosin was more effective than finasteride, with no additional benefit in combining both drugs.

Detection of apoptosis by the TUNEL technique in clinically localised prostatic cancer before and after combined endocrine therapy.

AIMS: Apoptosis in prostate cancer was evaluated after three months of combined endocrine therapy to investigate the association with tumour grade, tumour stage, and the immunohistochemical detection of p53 and bcl-2 in tumour cells before and after therapy. METHODS: Twenty six formalin fixed, paraffin wax embedded core biopsies and corresponding prostatectomy specimens, excised after three months of combined endocrine therapy, were analysed for the presence of apoptotic cells by the terminal deoxynucleotidyl transferase mediated dUTP-biotin nick end labelling (TUNEL) method, and for p53 and bcl-2 overexpression by immunohistochemistry. RESULTS: All 26 adenocarcinomas were clinically localised at diagnosis. In biopsies performed before combined endocrine therapy, the apoptotic indices varied between 0.09% and 1.73%, while the tumour grade fell between Gleason score 1 and 8. The mean (SD) apoptotic count pretherapy was 0.71% (0.50). There was a significant association between elevated apoptotic counts and higher Gleason scores in the biopsies (p = 0.005). After three months of therapy, the percentage of apoptotic tumour cells increased independently of tumour stage, while a significant association with Gleason grade was found (p = 0.0018) and all the tumours had Gleason scores of < 7. In eight cases the apoptotic index was more than twice its pretherapy value. The remaining tumours showed less of an increase in the apoptotic index (five cases) or a reduction in the percentage of apoptotic cells. The overall moderate increase in apoptotic index after combined endocrine therapy was not statistically significant (p = 0.8). Immunoreactivity to p53 was absent in all cases, before and after therapy, while a slight increase in the number of cells overexpressing bcl-2 was observed in five of the 13 tumours (38.1%) with reduced apoptotic indices after therapy. CONCLUSIONS: After three months of combined endocrine treatment a minority of clinically localised prostate neoplasms showed regressive epithelial alterations, associated with an increase in apoptotic tumour cells; an increase in cells overexpressing bcl-2 was observed in five of the 13 tumours with reduced apoptotic indices.

[Our experience with prostatic incision (TUIP) with local anesthesia]. / La nostra esperienza sull'incisione prostatica (TUIP) in anestesia locale.

The Authors present their experience in the treatment of prostatic obstruction with bladder neck incision (TUIP) performed under local anesthesia. An Hulbert 6 Fr endoscopic needle is used to infiltrate the prostatic area submitted to TUIP with 200 mg of Lidocaine 2%. The TUIP was done with a single deep incision at 7 hours using a 24 Fr Iglesias resector with Collins device. 28 patients with an age range from 69 to 85 years (mean 74) affected by IPB in an obstructed fase were submitted to this procedure. Various parameters were achieved for the selection of the patients: urodynamic diagnosis of low urinary tract obstruction, prostatic volume less than 50 ml without important prostatic median lobe, high anesthesiological risk, absence of correlated vesical complications. A clinical follow up was done at 1-6 and 12 months. The results obtained showed a good compliance of the patients treated with satisfactory urodynamic patterns. The Authors conclude that this less invasive approach, in selected cases, is the treatment of choice not only for low invasivity and morbidity rate but also for the reduced time of catheterization, hospitalization and costs.

[Our experience concerning scrotal traumatology]. / La nostra esperienza sulla traumatologia scrotale.

The Authors present their experience on 24 blunt scrotal traumas observed since January 1991. They underline the importance of an ecographic scanning that enables a precise evaluation of the traumatic event. Patients that present positive ultrasonic findings are promptly operated thus permitting bleeding and infection control. In this way gonadic function is restored and hospital care reduced. The diagnostic approach is presented, cases reported and results discussed. After a review of the literature on the topic they stress the role of Eco-Color-Doppler examination in scrotal blunt trauma for the intrinsic characteristics of precision, rapidity and non invasivity. This permits a nosologic evaluation of all types of blunt trauma and selects, for surgery, only those patients with a well definied diagnosis.

[Our technique in orthotopic neobladder]. / La nostra tecnica di neovescica ortotopica.

The strive in the field of orthotopic neobladders derives from the need to improve their morphofunctional aspects and to simplify the surgical procedures. The Authors propose their experience on a new method of orthotopic neobladder in 8 patients submitted to radical cystectomy for advanced bladder neoplasia from march 91 until june 93. The surgical technique was to prepare a reservoir with a simile Camey 2 type procedure modified by them using 50 cm of ileus, 30 of which detubularized and reconfigured into a simile spheric shape with Polygia 75 staplers. The remaining length was left intact for the ureteral anastomosis performing the Wallace 1 type procedure. The advantages of this technique are that: the neobladder is prepared rapidly using staplers, thus reducing operating time the presence of an isoperistaltic segment of ileus for ureteral anastomosis permits an reduced ureteral mobilization with a low probability of reflux a simple reconversion in ileal conduit in case of reservoir failure or neoplastic urethral recurrence is possible. The criteria for selecting the patients are reported and the diagnostic algorithm regarding the follow-up presented. The latter is done with biochemical, echographic, radiological and pressure studies, every 4-6 or 12 months. Particular attention has been focused on the quality of life in relation to the diurnal/nocturnal continence and micturation interval. They conclude that this technique is surgically simple and rapid with satisfactory clinical and urodynamic results.

[Transperitoneal nephrectomy of crossed ectopic kidney without fusion associated with stenosis of the pyeloureteral junction and pyelocaliceal staghorn calculi]. / Nefrectomia transperitoneale di rene ectopico crociato senza fusione con stenosi del giunto pielouretrale e calcolosi a stampo completa secondaria.

The authors report their experience on a case of crossed ectopic kidney without fusion associated with stenosis of the pyeloureteral junction and secondary pyelocaliceal staghorn calculosis. After a brief summary of the various types of kidney ectopia and related principles of operation they describe their case report underlying the rarity of their case and the surgical approach. They consider the anterior transperitoneal approach as the most indicated for this type of malformation as it permits a better surgical view of the kidney and of the vascular structures.

[The combination of extracorporeal lithotripsy and percutaneous nephrostomy in the treatment of obstructive ureteral urate calculi]. / Associazione della litotrissia extracorporea e della nefrostomia percutanea nel trattamento della calcolosi ureterale ostruente uratica.

The authors report their experience with combined percutaneous nephrostomy and extracorporeal shock-wave lithotripsy to treat obstructive uratic ureteral stones. The role of nephrostomy is stressed as a diagnosis and treatment method before, during and after lithotripsy. Thus, the method proved especially useful to drain obstructed kidneys and restore peristalsis, to evacuate septic urine, to facilitate the elimination of lithiasic fragments, to perform anterograde pyelography before, during and after lithotripsy and finally to allow pharmacological litholysis. Fourteen patients were successfully treated with combined extracorporeal lithotripsy and percutaneous nephrostomy and the results compared with those obtained with other techniques--e.g., ureteroscopy, whose value appears lower because the method requires general anesthesia and is more traumatic to the ureter. The authors conclude that combined extracorporeal lithotripsy and percutaneous nephrostomy make the best technique to treat obstructive uric acid stones thanks to their positive results, low invasiveness and to patients compliance.

[Ultrasound-color Doppler in the study of sexual impotence]. / L'eco-color Doppler nello studio dell'impotenza sessuale.

Male impotence is a relatively frequency disease. To define the correct aetiology of this disorder is important to plan a right diagnosis to difference organic, psychological and psycho-organic causes. From June 90 to June 91 fifty-four patients with male impotence of different degree were observed and went through diagnostic investigations. The patients were classified in four groups (A, B, C, D) as clinical results of the pharmacological test (intracavernous injection of PGE1 alpha 15 micrograms). A and B groups showed normal and nearly normal hemogenic finding. C group showed either low arterial flow increase after FIC or venous leakage. D group showed very low haemodynamic increase. The analysis of Eco-doppler studies was performed 5'-10'-20' after intracavernous injection of PGE1 alpha obtaining three haemodynamic markers: the systolic top flow (Vs) the diastolic ending flow (Vd) resistance flow index. The Authors discuss the results obtained considering the Eco-color-doppler the most important stage in the haemodynamic evaluation of sexual impotence.

[Gonadal involvement in the Schonlein-Henoch syndrome]. / Interessamento gonadico nella sindrome di Schönlein-Henoch.

The authors report a case of testicular involvement in the Henoch-Schönlein's purpura, in order to call attention on the problem of an affection which has sometimes an acute onset and may therefore undergo a useless explorative surgical intervention. With the help of the existing literature, they define the pathological feature and point out the feasibility of a differential diagnosis when looking for the usually observed involvements (skin, joints, kidney, ecc.), associated with H.S. syndrome, in an accentuated or just slightly evident way, as in the presently described case.

Haemostasis during transvesical prostatic adenomectomy. A controlled trial on the effect of drugs with antifibrinolytic and thrombin-like activities.

Blood loss, plasma fibrinolytic activity, prothrombin, P.T.T., and fibrinogen plasma levels were measured in 30 patients subjected to transvesical adenomectomy. These parameters were evaluated during 7 consecutive days after the operation. Ten patients received the antifibrinolytic substance (AMCHA), ten patients received Bothrops Jararaca venom extract, and ten patients served as controls. The results show that the coagulating fraction of Bothrops Jararaca snake venom reduces intraoperative bleeding without influencing the haemostatic balance. Postoperative haematuria could be reduced by antifibrinolytic agents.