Quality of life assessment in patients who undergo sacral neuromodulation implantation for urge incontinence: an additional tool for evaluating outcome.

PURPOSE: We investigated the impact of sacral neuromodulation on quality of life and assessed the importance of quality of life for determining the success of sacral neuromodulation in patients with detrusor hyperactivity, including instability and hyperreflexia. We also compared it with parameters documented in a voiding diary. MATERIALS AND METHODS: From May 1998 to December 2000, 82 female and 31 male patients 17 to 79 years old (mean age 51.1) with urge incontinence (63), urgency/frequency (5), voiding disturbance (41) and pelvic pain (4) resistant to conservative treatment were enrolled in a national prospective registry after showing a positive response to percutaneous nerve evaluation testing. Of the patients 47 who were 32 to 79 years old (mean age 59.2) with urge incontinence due to detrusor instability and 16 who were 27 to 51 years old (mean age 51.5) with hyperreflexia were asked to complete a validated self-reporting incontinence domain specific quality of life questionnaire before, and 3, 6, 9, 12, 18, 24 and 36 months after implantation. RESULTS: Compared with baseline the quality of life index significantly improved at each followup, which strongly correlated with the decrease in the number of incontinence episodes. CONCLUSIONS: Evaluating quality of life may be an additional useful tool for assessing the results of sacral neuromodulation for urge incontinence. Our study confirms that sacral neuromodulation is effective therapy for urge incontinence that can have a positive effect on patient quality of life.

Chronic sacral neuromodulation in patients with lower urinary tract symptoms: results from a national register.

PURPOSE: The Italian Register was created in February 1997 to collect the national results of sacral neuromodulation. All Italian centers at which sacral neuromodulation is performed were invited to participate in our study. We present the results from retrospective and prospective registers. MATERIALS AND METHODS: A total of 196 patients underwent permanent implantation of sacral neuromodulation and were enrolled in the Italian register. There were 18 males and 75 females in the retrospective, and 28 males and 75 females in the prospective studies. Student's t test was used to compare paired values, and the Wilcoxon rank sum and nonparametric tests were used when necessary. RESULTS: Mean incontinent episodes daily plus or minus standard deviation for patients with detrusor instability went from 5.4 +/- 3.9 to 1.1 +/- 1.6 (median 5 and 0, respectively) at 12-month followup (p <0.001). For idiopathic retention average residual volume decreased from 277 to 108 cc (median 287 and 80, respectively), and 50% of patients stopped catheterization and another 13% catheterized once daily at 1-year after implantation. With neurogenic voiding disturbances, the results fluctuated with time from a minimum of 33% to a maximum 66% of patients who did not catheterize at 6-month followup and 12 months after implantation, respectively. At 12-month followup, 50% of patients with hyperreflexia had less than 1 incontinent episode daily. The problem was completely solved in 66% of patients in the retention group. Of patients in the urge incontinent population 39% were completely dry and 23% had less than 1 incontinent episode daily. CONCLUSIONS: Sacral neuromodulation is effective therapy for treating lower urinary tract symptoms resistant to less invasive therapy.

Modified expression of plasma glutathione peroxidase and manganese superoxide dismutase in human renal cell carcinoma.

Two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) is a powerful tool to separate thousands of polypeptides and to highlight the modification of protein expression in malignant diseases. By applying 2-D PAGE to ten normal human kidney and ten homologous renal cell carcinoma (RCC) tissues, we found two peptides in all ten normal tissues but not in RCCs and, conversely, two peptides were detected in all RCCs but not in normal tissues. Using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF-MS) and internal sequence analysis, the two first peptides were identified as two isoforms of plasma glutathione peroxidase (GPxP). The two other peptides isolated in all RCCs but not in normal tissues were identified by N-terminal sequence analysis as multimeric forms of manganese superoxide dismutase (Mn-SOD). No multimeric Mn-SODs and only two monomeric forms were detected in normal tissues. GPxP and Mn-SOD are metallo-enzymes encoded on chromosome 5q32 and on chromosome 6p25, respectively. Their regions are within the locus 5q21-->qter and 6q21-6q27 on which deletions and translocations are described in some cytogenetic studies of RCC transformation. Therefore, our results might suggest a correlation between the modified expression of GPxP and Mn-SOD in tumor tissues and chromosomal modifications, and that the two proteins may be putative markers for diagnosis of RCC.

[Ethical aspects]. / Aspetti etici.

The relation is considered between ethical choices, morals and deontology in plastic surgery of the male external genitals. Ethics dictates the behavioural model applied by an individual or group in their actions. Professional ethics--deontology--is the collection of duties governing the exercise of a certain profession. Morals are the set of rules governing an individual's life in society. Ethics, deontology and morals do not always convey the same message, since environmental, racial and religious situations, custom, and even fashion can influence a patient's demands, reflecting his desire to improve his quality of life, even only from the purely hedonistic viewpoint, and the specialist's attitude. Surgeons are increasingly tending to bend to these demands or--much worse--even encourage and foster them, with a view to financial considerations. The attitude and ethical choices available are examined in relation to surgery to lengthen or enlarge the penis.

Renal cell carcinoma and normal kidney protein expression.

Renal cell carcinoma (RCC), a human kidney cancer from the proximal tubular epithelium, accounts for about 3% of adult malignancies. Molecular and cytogenetic analysis have highlighted deletions, translocations, or loss of heterozygosity in the 3p21-p26, a putative RCC locus, as well as in 6q, 8p, 9pq, and 14pq. Studies on phenotypic expression of human kidney tissue and on post-translational modifications in RCC have not yet provided a marker for early renal cell carcinoma diagnosis. Current diagnostic methods do not help to detect the tumor before advanced stages. We therefore used two-dimensional polyacrylamide gel electrophoresis (2-D PAGE) to study normal and tumor kidney tissues in ten patients suffering from RCC. A human kidney protein map in the SWISS-2DPAGE database accessible through the ExPASy WWW Molecular Biology Server was established. Of 2789 separated polypeptides, 43 were identified by gel comparison, amino acid analysis, N-terminal sequencing, and/or immunodetection. The comparison between normal and tumor kidney tissues showed four polypeptides to be absent in RCC. One of them was identified as ubiquinol cytochrome c reductase (UQCR), whose locus has elsewhere been tentatively assigned to chromosome 19p12 or chromosome 22. A second polypeptide was identified as mitochondrial NADH-ubiquinone oxido-reductase complex I whose locus is located on chromosome 18p11.2 and chromosome 19q13.3. These result suggest that the lack of UQCR and of mitochondrial NADH-ubiquinone oxidoreductase complex I expression in RCC may be caused by unknown deletions, or by changes in gene transcription or translation. It might indicate that mitochondrial disfunction plays a major role in RCC genesis or evolution.

Management of recurrent stricture of appendicostomy in continent neobladder (Indiana pouch) with Memotherm ureteral stent: case report.

The authors report their experience in the treatment of recurrent stricture of the appendiceal stump in continent diversion (Indiana pouch) after cystectomy by means of the Memotherm ureteral stent. The patient presented was treated successfully with this device after failure of repeat cold-knife incisions of the stricture. At 9-months' follow-up from positioning, the stent is in place, covered by mucosa. Self-catheterization of the pouch is easily performed five or six times a day with a 12F catheter.

[Stents in the treatment of stenosis of the entero-urethral junction in continent diversion: case reports]. / Gli stents nel trattamento delle stenosi della giunzione entero-uretrale nelle derivazioni continenti: casi clinici.

Strictures of entero-urethral anastomosis in orthotopic neobladder and of the catheterizable conduit in continent diversion after cystectomy are seldom encountered; they are usually treated with dilation, TUR or cold incision. 3 cases that came to our observation are presented. The first was treated with TUR after neo-bladder neck stricture in orthotopic neobladder; total incontinence occurred after this procedure. The patient at present is waiting for AS800 artificial sphincter implant. The second patient had similar features. After repeat TUR a prostacoil removable stent was placed through the stricture and removed after 5 months. At 12 months from removal the patient is continent and doesn't present clinical evidence of restriction. The third patient underwent cystectomy with Indiana continent pouch. After 4 months increasing problems in self catheterization occurred due to stricture of the catheterization conduit (appendix). He was treated twice with cold incision with early recurrence of the stricture. A permanent Memotherm stent (indicated for urethral strictures) was placed inside the appendix. After one month self catheterization was started again. At a 2 months follow up there is no evidence of stricture. In our experience, even if anecdotal, we have verified that treatment of this kind of strictures with TUR can cause incontinence or expose to further recurrences. 2 of the cases presented were treated with different kind of stents; the outcome is good even if the follow up is still short. We believe that this kind of treatment can be considered in selected cases.

[Role and current significance of EDVG (epididymography plus vasography) in obstructive azoospermia]. / Ruolo e significato attuale della EDVG (epididimovesciculodeferentografia) nelle azoospermie ostruttive.

The Authors present their 20 years experience about 612 EDVG (epididymography plus vasography). We will here discuss indications, complications and future prospects of EDVG and refer data arising from 55 andrology units: we can appreciate as this methodic is up to date in selected cases, i.e. obstructive azoospermia associated with normal FSH levels and lower or absent fructose, in presence of clearly pathological TRUS.EDVG is also indicated when on obstructive pathology is suspected to be the cause of an oligospermia or before vaso-vasostomy.

[Conservative treatment of high-risk (T1G3) transitional carcinoma]. / Il trattamento conservativo nel carcinoma transizionale ad alto rischio (T1G3).

OBJECTIVE: This study evaluates the outcome of patients (pts) with primary T1G3 bladder cancer treated by transurethral resection (TUR) alone or followed by intravesical prophylaxis (BCG/Doxorubicin). Cistectomy was considered at disease progression. METHODS: Between 1/89 and 5/95 thirty-one pts with primary T1G3 bladder cancer were treated by TUR, in 24 followed by intravesical prophylaxis (13 with BCG, 11 with Doxorubicin). 7 pts had only TUR. RESULTS: At 42 months median follow up 45.2% pts (14/31) are disease free. The recurrence rate was 25.8% (8/31) and progression of disease was seen in 29.0% (9/31); mortality rate was 22.6% (7/31). In 13/31 pts treated by TUR + BCG 53.8% pts (7/13) are disease free. The recurrance rate was 23.1% (3/13) and progression of disease was seen in 23.1% (3/13) of cases; mortality rate was 23.1% (3/13). In 11/31 pts treated by TUR+Doxorubicin 54.5% pts (6/11) are disease free. The recurrance rate was 18.2% (2/11), progression of disease was seen in 27.3% (3/11) of cases of mortality rate of 9.1% (1/11). In 7/31 pts treated by TUR alone 14.3% pts (1/7) are disease free. The recurrance rate was 42.9% (3/7) and progression of disease was seen in 42.9% (3/7) of cases and mortality rate of 42.9% (3/7). Cistectomy was considered in 4 pts (3 for disease progression and 1 because of no disease free interval). The other pts with progression were not treated surgically because of their poor performance status. CONCLUSION: At a 42 months median follow up 77.4% pts (24/31) are alive (83.3% pts treated by TUR+intravesical prophylaxis). 64.5% pts (20/31) still have their bladder (66.6% pts treated by TUR+intravesical prophylaxis (16/24). We did not find a significative difference between prophylaxis with immunotherapy or chemotherapy. In conclusion we believe that the conservative management of high risk bladder transitional cell carcinoma T1G3 is feasible and allow us to plan cistectomy only in pts with progression or recurrance with no free interval without losing survival.

[Impotence: non-hormonal drug therapy. Old and new drugs]. / Impotenza: farmacoterapia non ormonale. Vecchi e nuovi farmaci.

The treatment for male impotence has undergone a radical change during these last years. This change is due mainly to the use of vasoactive drugs and more and more sophisticated prosthesis. The Authors discuss old and new drugs used, considering that often pharmacotherapy for impotence doesn't require the giving of a drug, but its suspension. The Authors mention, among the most active drugs, trazodone, yohimbine, pentoxifylline and L-arginine hydrochloride. However these pharmacological agents found only application to well defined and unfortunately limited cases. To day the ideal therapeutic agent is still not available. There is a need for continued research in this field; the initial results, like the ones on the erective mechanisms NO-dependents, give hope for the future.

[Prostatic prosthesis in the treatment of prostatic hypertrophy: our experience]. / Le protesi prostatiche nel trattamento dell'ostruzione cervico uretrale; nostra esperienza.

Prostatic stenting is a therapeutic option in the management of obstruction in patients unfit for surgical treatment. At present different devices are available, permanent or temporary, the former being covered by epithelium. The Authors report their experience on 40 patients, 27 of which treated with Fabian spiral. They conclude considering that permanent stenting is likely to be a better solution; temporary spirals, however, give good results and can be the first choice in some situations.

[Current role of echography, of PSA and of PSAD in the diagnosis of prostatic carcinoma]. / Ruolo attuale dell'ecografia, del PSA e della PSAD nella diagnosi del carcinoma prostatico.

The Authors report their experience in the diagnosis of prostatic carcinoma by means of DRE, TRUS and PSA. They emphasize the improvement of diagnosis given by these exams when used in association, despite a high rate of false positives. In the years 92-93, 182 patients underwent ecoguided prostatic biopsy after DRE and PSA evaluation. PSA density value was calculated as proposed by Benson (PSAD = PSA/V); this parameter should screen between PSA elevation due to BPH and those due to prostatic carcinoma. After their experience, even if limited, they conclude that TRUS should not be used as a "first-line test" but only in patients with abnormal findings in DRE and/or PSA. PSAD may be useful to improve specificity of PSA even if a precise cut-off can not be determined.

HER-2/neu oncogene expression and DNA ploidy in normal human kidney and renal cell carcinoma.

Using flow cytometry (FCM), we have investigated both the DNA content (stained with propidium iodide) and HER-2/neu oncogene expression (revealed by means of an anti-HER-2/neu monoclonal antibody) in neoplastic and non-neoplastic kidney samples from 20 patients with renal cell carcinoma. All the non-neoplastic samples and 15/20 (75%) renal cell cancers showed diploid modal DNA content while the remaining 5 neoplastic sample (25%) showed both diploid and hyperdiploid cell populations. In normal kidney the level of HER-2/neu oncoprotein was low (median fluorescence values in arbitrary units = 7.5 AU, range: 4-10 AU). In diploid renal cancers the level of HER-2/neu was slightly increased (median fluorescence values = 20 AU, range: 9.5-30 AU) (p < .005). The relationship of HER-2/neu expression to the cell cycle in these tumor samples is not clear since most of the cells express the antigen in all phases of the cell cycle. On the other hand, there is an association between HER-2/neu expression and abnormal DNA content suggesting that aneuploid pattern may be biologically related to overexpression of the HER-2/neu gene.