[BPH: state of the art in the surgical treatment]. / IPB: stato dell'arte sul trattamento chirurgico.

TURP has been considered the gold standard for surgical treatment of BPH for many years. Symptoms relief, improvement in maximum flow rate and reduction of post void residual urine have been reported in several experiences. Nevertheless, concerns have been reported in terms of safety outcomes: intracapsular perforation, TUR syndrome, bleeding. In the recent years the use of new forms of energy and devices such as bipolar resector, Ho: YAG and potassium-titanyl-phosphate laser are challenging the role of traditional TURP for BPH surgical treatment. In 1999 TURP represented 81% of surgical treatment for BPH versus 39% in 2005. We have analyzed guidelines and recent literature to evaluate the role of the most relevant new surgical approaches compared to TURP for the treatment of BPH.

Emphysematous pyelonephritis in decompensated diabetes: a case report and review of the literature.

Emphysematous pyelonephritis is a rare and severe renal parenchyma necrotizing infection visible just in diabetic patients which results in gas presence--probably produced through the glucose fermentation process--in the collecting system, renal parenchyma and perirenal tissue. We present a case of a not known diabetic female patient with emphysematous pyelonephritis of the left kidney and emphysematous pyelitis of the controlateral kidney.

High burden stones: the role of SWL.

Percutaneous nephrolithotomy (PCNL), PCNL and Shock Wave Lithotripsy (SWL), SWL monotherapy and open surgery are nowadays the potential treatment alternatives for patients with staghorn stones. Several groups have proposed classification schemes to better define staghorn calculi dimensions taking into account size, morphology and composition of the stones. More recently the use of a CT imaging with three-dimensional reconstruction or of a coronal reconstruction of axial CT images was reported to obtain an accurate stone volume calculation. The difficulty in accurately assessing stone burden explains the wide range of reported stone-free rates for SWL monotherapy from 22 to 85%. A recent AUA guideline of the management of staghorn calculi stated that stone free rate is 78% for PCNL and 54% for SWL monotherapy and these values are similar to those reported in Segura guideline but the rate for combination treatment (PNL + SWL) is now lower (66% versus 81%) than in the previous guideline. This reduction is probably due to the fact that in the recent meta-analysis SWL was the last procedure and in the previous generally a sandwich therapy was performed with PCNL followed by a SWL and a secondary PCNL. Improved PCNL techniques with use offlexible nephroscopy and multitract PCNL allow to achieve complete stone clearance by PCNL alone. Complete removal of stone is crucial to eradicate infection and prevent further stone regrowth. Residual fragments may perpetuate postreatment infection and stone regrowth has been reported up to 78% in such patients after SWL monotherapy. In our previous experience (prior to 2000) we observed 45 pts with high burden stones: 31/45 pts (68%) underwent combined therapy PCNL and SWL with a successful rate of 65% (stone free and fragments < 4 mm). In our more recent experience ('03-'08) we treated 34 patients with high burden stones: we performed combined therapy PCNL and SWL in 11 pts (32%) with an overall success rate of 63%. PCNL was undertaken initially with the attempt to remove as much stone as possible with the aid offlexible nephroscopy and SWL was used only for residual stones because the passage, even of fragments < 4 mm, does not always occur in dilated renal cavities. SWL monotherapy should not be used for most patients and may be considered only in patients with small volume staghorn stones with normal collecting system.

[Single session cystolitholapaxy and PCNL for encrusted DJ stent with large associated stone burden]. / Stent DJ calcifico con litiasi multipla calicopielica e vescicale associata: trattamento con litotrissia vescicale e PCNL in una singola seduta.

INTRODUCTION: Ureteral stent use is commonplace in urology to prevent or relieve ureteral obstruction. If ureteral stents are neglected, they can cause severe morbidity due to migration, occlusion, encrustation, breakage, stone formation, and even death, due to life-threatening urosepsis or complications related to operative intervention. Extracorporeal shockwave lithotripsy, ureterorenoscopy, electrohydraulic lithotripsy, laser lithotripsy, and percutaneous nephrolitholapaxy (PCNL) have been reported for forgotten ureteral stent management, but currently there are no guidelines for this challenging situation and only few algorithms have been introduced by some studies. METHODS: We present a case of a man presenting with an encrusted left double J (DJ) stent, inserted two years before, and bulky radiolucent lithiasis at both ends of the stent. The patient was studied with intravenous pyelogram and non contrast-enhanced computed tomography, and then treated with cystolithotripsy and PCNL in a single session. RESULTS: Complete clearance of the stones was obtained and the DJ stent was removed without breaking from the percutaneous access. CONCLUSIONS: Neglected stents still represent a challenge in urology: while endourology remains the best option for treatment, the management of ureteral stents should be based on follow-up and prevention, using for example a computerized warning and stent retrieval software system.

Sensitivity and detection rate of a 12-core trans-perineal prostate biopsy: preliminary report.

OBJECTIVES: The various prostate biopsy methods are usually compared in terms of the diagnosis rate of prostate cancer. However, the prevalence of cancer in patients with a negative prostatic biopsy is not usually known. We determined the sensitivity and detection rate of 12-core transperineal biopsies in patients not previously investigated for prostate cancer. METHODS: We performed prostate biopsy in 63 patients (median age 67 years) before radical cystoprostatectomy for high-grade bladder cancer. We then assessed the relationships between biopsy result, prostate cancer in the surgical specimen, and other variables. RESULTS: 17.2% of patients had a positive biopsy and 54% had prostate cancer on definitive histology. Biopsy sensitivity was 32.3% overall, 75% for clinically significant cancers, and 11% for non-significant cancers. Median PSA was 1.2ng/ml, PSA levels did not correlate with the presence of prostate cancer, the presence of clinically significant cancer, bioptic diagnosis, or prostate volume. Age correlated with risk of cancer. CONCLUSIONS: According to autopsy series, the prevalence of prostate cancer is greater than 50% in males older than 60, yet low PSA levels do not reliably indicate disease absence. The sensitivity of double sextant biopsy is unsatisfactory overall (32%), but acceptable (75%) for diagnosing clinically significant cancer.

High incidence of benign testicular neoplasms diagnosed by ultrasound.

PURPOSE: We evaluated the clinical and histological significance of incidental ultrasonographic focal testicular lesions and assessed whether a conservative surgical approach may put the patient at higher oncological risk due to insufficient surgical eradication. MATERIALS AND METHODS: From October 2000 to May 2002 all patients with infertility, scrotal swelling, scrotal pain, varicocele, scrotal trauma or erectile dysfunction underwent scrotal ultrasonography. A total of 1,320 patients were investigated. Focal testicular lesions were found in 27 patients (2%), palpable nodules were present in 17 (63%) and nonpalpable incidental lesions were diagnosed in 10. Nodule diameter was 3 to 24 mm. All patients underwent explorative surgery via inguinotomy and preventive clamping of the spermatic cord. The nodules were completely removed with biopsy of the resection margins. Nonpalpable lesions were removed under ultrasonographic guidance. The testicle was only preserved when frozen section revealed a benign lesion and margins were negative. RESULTS: Of the 17 cases of palpable lesions (diameter 3 to 24 mm) conservative surgery was performed in 8 (47%). Definitive histological diagnosis showed Leydig cell tumor in 2 (25%), and large cell calcifying Sertoli's cell tumor, adenomatoid tumor, pseudofibrotic tumor of the tunica albuginea, epidermoid cyst, tubular fibrosis and non-Hodgkin's lymphoma in each 1 (12.5%). The remaining 9 patients (53%) underwent orchidectomy. Definitive histological examination revealed pure seminoma in 4 patients (44%), embryonal carcinoma in 4 (44%) and diffuse Leydig cell hyperplasia in 1 (12%). Seven of the 10 pts (70%) with nonpalpable nodules (diameter 4 to 16 mm) underwent conservative surgery. Histological study revealed focal Leydig cell hyperplasia in 1 case (10%), fibrosis in 3 (30%), infarction in 2 (20%) and mesothelial hyperplasia in 1 (10%). Orchiectomy was performed in the remaining 3 pts. Histology showed diffuse Leydig cell tumor in 2 pts (20%) and adenomatoid tumor with abscessed areas in 1 (10%). Neither atrophy nor local relapse was observed in pts who underwent conservative treatment during followup (mean: 1 month, range 19 to 9). CONCLUSIONS: The incidental diagnosis of testicular ultrasound alterations is increasing and 80% show a benign histology. In these cases a conservative surgical approach is the best option and it does not expose the patient to the risk of relapse.