Efficacy of spermatic vein ligation in patients affected by high grade left varicocele.

PURPOSE: To study the effect of high grade varicocele treatment in infertile patients. MATERIALS AND METHODS: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject's partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. RESULTS: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10(6)/mL compared to 19.7x10(6)/mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). CONCLUSION: Surgical treatment of high grade varicocele proved to effectively treat associa¬ted infertility by improving seminal parameters and pregnancy rate in our patient cohort.

Efficacy of spermatic vein ligation in patients affected by high grade left varicocele

Purpose: To study the effect of high grade varicocele treatment in infertile patients. Materials and Methods: Seventy-five patients were selected by the following criteria: infertility persisting for more than 1 year; abnormal semen parameters; no other infertility-related disease; no obvious causes of infertility in the subject’s partner; basal eco-color Doppler ultrasound demonstrating continuous reflux in the spermatic vein. All patients considered for the study had at least a six months period from the diagnosis to the surgery due to waiting list, choice of the patient or time needed to complete diagnostic evaluation of the couple. The surgical procedure was performed through an inguinal approach. All enrolled patients were counseled to have unprotected intercourse during the ovulation period in order to maximize the probability of pregnancy within the 6-month preoperative period. The achievement of pregnancy and semen parameters were recorded during the preoperative and postoperative period. Results: Two of the seventy-five patients were excluded because of persistent varicocele after surgery. The preoperative pregnancy rate was 1.3% (1 couple). The postoperative pregnancy rate was 42.5%. The stratification of pregnancies by semester showed a significantly higher rate in the first postoperative period (p = 0.0012). Mean time to conception was 13.5 months. Mean preoperative sperm count was 17.6x10 6 /mL compared to 19.7x10 6 /mL in the postoperative period (p < 0.0001). Mean percentage of progressive sperm motility was 13.7%, compared to 17.6% in the postoperative period (p < 0.0001). Mean percentage of normal sperm morphology was 7.6%, compared to 15.2% postoperatively (p < 0.0001). Conclusion: Surgical treatment of high grade varicocele proved to effectively treat associated infertility by improving seminal parameters and pregnancy rate in our patient cohort. .

[Transrectal ultrasound assessment of anastomosis after videolaparoscopic radical prostatectomy: our experience]. / Il controllo ecografico transrettale dell'anastomosi dopo VLRP. La nostra esperienza.

BACKGROUND: Trans-Rectal UltraSound (TRUS) has proved to be an accurate procedure comparable to that of Fluoro-cystography (FC) to assess vesicourethral anastomosis after radical prostatectomy, with the advantages of lower costs, no radiation exposure and no dependence on the radiology department. METHODS: 60 Video Laparoscopic Radical Prostactomies (VLRP) were performed at our institution between September 2008 and January 2010. All patients underwent anatomosis assessment on postoperative day 6 with TRUS (Aloka A7 US machine with endorectal end-fire probe). 200 ml of sterile saline was manually instilled into the bladder by an assistant, while TRUS visualization of anastomosis was carried out by an urologist. The test was considered positive if any expanding anechoic shadow developed beside the anastomosis. In case of negative test the catheter was removed. In case of positive test the catheter was left in place and reassessment was performed every 5-7 days with both TRUS and FC, until negative result. RESULTS: At the initial TRUS assessment we had 4 positive and 56 negative tests. Three out of the four patients with a positive test had a second assessment on p.o. day 14, which gave a negative result. The 4th positive case had a positive second assessment on p.o. day 14 and a third negative one on p.o. day 21. In a total of 20 assessments both TRUS and FC were performed. The results of the two procedures were always in accordance. CONCLUSIONS: We have introduced TRUS assessment of vescicourethral anastomosis after laparoscopic radical prostatectomy as a routine procedure in our department. We are planning a comparative study, using FC as the gold standard, for validation purposes.

Preoperative blood donation program and postoperative low molecular weight heparine (LMWH) prophylaxis in patients undergoing radical prostatectomy.

OBJECTIVE: The need and timing of perioperative heparin prophylaxis is matter of debate. The aim of our work is to review the incidence of venous thromboembolism (VTE) after radical retro pubic prostatectomy (RRP) in patients undergoing preoperative blood donation, compressive stockings, haemodilution, surgical prevention of lymphocoele and postoperative low molecular weight heparin therapy as prophylaxis for thrombotic events. METHODS: This is a retrospective analysis considering a series of 500 RRP performed between 1999 and 2006 by the same Surgeon (MG) at the Urological Unit, Desio, Hospital, Milan, Italy. All the patients were enrolled in an auto transfusion program and were subjected to autologous blood donation. Low molecular weight heparin (.04 ml of Calcic Nadroparin 3800 UI s.c. daily) was administrated within 24 hours following surgery until the 11th post-operative. Age, PSA, basal, preoperative and postoperative haemoglobin values were assessed in each patient. The incidence of venous thromboembolism was calculated taking into consideration occurrences of both pulmonary embolism and deep venous thrombosis. RESULTS: In this retrospective analysis we did not observe any major event including intra- or peri-operative deaths. There was one occurrence of pulmonary microembolism and one sural phlebitis that were treated with prolonged heparin and dicumarol therapy. Two significant haemorrhagic events occurred in the postoperative period requiring surgical revision. CONCLUSION: These data suggest that low weight heparin prophylaxis starting with 24 hours following radical prostatectomy, associated with preoperative blood donation, intra-operative haemodilution, compression stockings, surgical care to avoid lymphocoele and early mobilization in preventing venous thromboembolism.

Programa de donación de sangre preoperatoria y profilaxis postoperatoria con heparina de bajo peso molecular en pacientes sometidos a nefrectomia radical / Preoperative blood donation program and postoperative low molecular weight heparine (LMWH) prophylaxis in patients undergoing radical prostatectomy

OBJECTIVES: The need and timing of perioperative heparin prophylaxis is matter of debate. The aim of our work is to review the incidence of venous thromboembolism (VTE) after radical retro pubic prostatectomy (RRP) in patients undergoing preoperative blood donation, compressive stockings, haemodilution, surgical prevention of lymphocoele and postoperative low molecular weight heparin therapy as prophylaxis for thrombotic events.METHODS: This is a retrospective analysis considering a series of 500 RRP performed between1999 and 2006 by the same Surgeon (MG) at the Urological Unit, Desio Hospital, Milan, Italy.All the patients were enrolled in an auto transfusion program and were subjected to autologous blood donation. Low molecular weight heparin (0.4 ml of Calcic Nadroparin 3800 UI s.c. daily) was administrated within 24 hours following surgery until the 11th post-operative. Age, PSA, basal, preoperative and postoperative haemoglobin values were assessed in each patient. The incidence of venous thromboembolism was calculated taking into consideration occurrences of both pulmonary embolism and deep venous thrombosis.RESULTS: In this retrospective analysis we did not observe any major event including intra- or peri-operative deaths. There was one occurrence of pulmonary microembolism and one sural phlebitis that were treated with prolonged heparin and dicumarol therapy.Two significant haemorrhagic events occurred in the postoperative period requiring surgical revision.CONCLUSIONS: These data suggest that low weight heparin prophylaxis starting within 24 hours following radical prostatectomy, associated with preoperative blood donation, intra-operative haemodilution, compression stockings, surgical care to avoid lymphocoele and early mobilization is effective in preventing venous thromboembolism (AU)

OBJETIVO: La necesidad y el tiempo de la profilaxis perioperatoria con heparina es una cuestión discutida. El objetivo de este trabajo es revisar la incidencia de tromboembolismo venoso después de prostatectomía retropúbica en pacientes sometidos a donación de sangre preoperatoria, sistemas comprensivos intermitentes, hemodilucion, prevención quirúrgica del linfocele y terapia postoperatoria con heparina de bajo peso molecular como profilaxis para los eventos trombóticos. MÉTODOS: Análisis retrospectivo considerando una serie de 500 prostatectomías radicales retropúbicas realizadas entre 1999 y 2006 por el mismo cirujano (MG) en la unidad de urología del Hospital Desio de Milán, Italia. Todos los pacientes fueron enrolados en un programa de autotrasfusión y sometidos a donaciones sanguíneas autólogas. Se administró heparina de bajo peso molecular (Nandroparina cálcica 3800 UI subcutaneas al día) dentro de las 24 horas posteriores a la cirugía y hasta el décimoprimer día posoperatorio. La edad, el PSA, la hemoglobina basal, preoperatoria y postoperatoria fueron evaluados en cada paciente. La incidencia de tromboembolismo venoso fue calculada teniendo en consideración la aparición de embolismo pulmonar y trombosis venosa profunda. RESULTADOS: En este análisis retrospectivo no observamos ningún evento importante incluyendo muertes intra o perioperatorias. Hubo un caso de microembolismo pulmonar y otro de flebitis sural que fueron tratados con heparina y dicumarol a largo plazo. Hubo dos eventos hemorrágicos significativos en el periodo posoperatorio que requirieron resección quirúrgica. CONCLUSIONES: Estos datos sugieren que la profilaxis con heparina de bajo peso molecular iniciada dentro de las primeras 24 horas después de la prostatectomías radical, asociada con donación de sangre preoperatoria, hemodilucion intraoperatoria, dispositivos de compresión intermitente, cuidado quirúrgico para evitar linfocele, inmovilización precoz es eficaz previniendo el tromboembolismo venoso (AU)

Percutaneous therapy of low stage and grade urothelial neoplasia: long-term follow up.

Nephroureterectomy with the excision of the ipsilateral ureteral orifice and bladder cuff has been considered the standard treatment of the urinary upper transitional cell carcinoma. With the advent of sophisticated techniques for the endo-urologic management of many benign urologic diseases of the upper tract, there has been growing enthusiasm for the application of these same techniques in the management of upper tract TCC, which is also supported by recent advances in the development of small calibre telescopes with improved optics and the development of small calibre adjunctive instruments and laser fibers. A large number of cases published in the literature has confirmed the safety and efficacy of percutaneous treatment in selected patients with upper tract TCC of low grade and stage. Between 1997 and 2005 we treated 62 pts (37 pelvic transitional cell carcinoma and 25 ureteral). 4 pts (5 renal units: 4 T1G2 and 1 TaG1) underwent percutaneous resection for a tumor in a solitary kidney (2 cases), one case for bilateral neoplasm, and in the other case the lesion was unilateral with chronic renal failure. After preoperative evaluation, (excretory urography, computerized tomography and ureteroscopy with biopsy to confirm the low stage and grade of the lesion) the tumor was resected using an Amplatz sheat of 26-30 Fr and a 24 Fr resectoscope to keep a low intra-caliceal pressure. The tumor base was biopsied and fulgurated After 48 h, contrastography to assure integrity of the urinary system was performed and Mitomycin C was infused over 24 h. Second-look nephroscopy with multiple biopsies was performed in all cases 7 days later and 8 Ch nephrostomy was placed. If the biopsies resulted negative the patient was submitted to 6 weekly endocavitary instillation of BCG through the nephrostomy tube. All pts at a mean follow up of 71 months were tumor free. One patient presented a bladder relapse after 83 months. No complication of percutaneous resection was observed. The endocavitary instillations were well tolerated. In our experience the percutaneous approach is safe and useful in neoplastic lesions of low grade and stage and should be considered as first line therapy in selected patients. Adjuvant topical therapy appears efficacious and some complications may be avoided by maintaining low intracavitary pressures during administration.

Metanephric adenoma: case report and review of the literature.

Metanephric adenomas are benign tumors frequently found post-mortem (from 7% to 22% of autopsies) which originate from distal tubules; they are generally small in dimensions (smaller than 1 cm) and located in the renal cortex. Etiology is unknown, even though they could be associated with smoke, tubular nephrosclerosis, dialysis. An endocrinal relationship was proposed, because of its more frequent incidence in female (2:1). Metanephric adenoma is an uncommon kind of renal adenoma with no malignant potentiality: from the clinical and diagnostic viewpoint its own greater importance depends on the probability of diagnostic misunderstanding with Wilms' tumor; furthermore its echographic, tomographic and arteriographic characteristics are often similar to small renal adenocarcinoma ones (100). Polycytemia is frequently associated to metanephric adenoma as paraneoplastic syndrome and, more rarely, abdominal mass, abdominal pain, hematuria and hypertension (140). The most important study on metanephric adenoma is the one realized by E.K. Mostofi, including 50 cases from the Department of Genitourinary Pathology, Armed Forces Institute of Pathology, Washington, D.C., published in 1995; in this study half of findings was incidental; mean dimension of tumor about 5,5 cm and in 50% it could be seen a distinct capsule sourrounding the tumor (in the remaining cases the capsule was discontinuos or absent) (210). An important radiological characteristic is that metanephric adenomas are more frequent calcificated than other histotypes and, from the pathological viewpoint, the most important differential element seems to be the smaller dimensions of its cells with hyperchromatic nuclei in the absence or lack in mitotic activity and in the absence of chromosome aberrations. In the case of difficult histological diagnosis, cytogenetic and immunohistochemical analysis can be useful. In conclusion, because it is impossible to distinguish in the preoperatory between the metaneprhic adenomas and the other tumoral types on the bases of the symptoms, dimensions or radiographic appearance, it is mandatory to treat it as malignant eteroformations in a therapeutical strategy, when it is possible.

[Reconstructive urethroplasty using porcine acellular matrix: preliminary results]. / Uretroplastica ricostruttiva con matrice acellulare suina: risultati preliminari.

OBJECTIVE: The use of "porcine acellular matrix", obtained from small intestine submucosa, could simplify the repair of long urethral strictures, whereas single stage techniques can be carried out only by means of grafts, as buccal mucosa; or flaps, as prepucial skin. To our knowledge we report the first use of porcine intestine submucosa in urethroplastic surgery. MATERIALS AND METHODS: From May 2001 to December 2001, five urethral reconstructions were completed using "porcine acellular matrix". Four male patients had urethral strictures longer than 10 cm. After circumcision and penile degloving, we extended the surgical approach to the perineum-scrotal region by a midline longitudinal incision. The urethra was exposed, dissected from corpora cavernosa, then rotated of 180 degrees and on this side longitudinally incised throughout all the stenotic length. Urethroplasty was accomplished with matrix tissue modelled according to the length of the stenosis and grafted by a 5-0 polyglycolic acid running suture. The enlarged urethra was then derotated, laying the graft dorsally, closed to corpora cavernosa, to prevent pouching. A further graft was accomplished in a female patient with a 3 cm long urethral stricture. All urethroplasties were stented for 14 days. No complication developed. RESULTS: After 1 month urethral patency was satisfactory compared with preoperatory images and the urinary flow was normal. After 2 months the urethra was endoscopically verified: it was easy to appreciate the homogeneous transformation of the graft into the native tissue. At 6-month follow-up radiological and urodynamic outcome is still satisfactory in all patients. CONCLUSIONS: According to our preliminary experience "porcine acellular matrix" is a promising approach for the repair of long urethral strictures. Its safety and effectiveness encourage us to treat more cases in male and female patients.