[Bladder augmentation and urinary diversions in kidney transplants].

There is some controversy about the safety of kidney transplant in patients with augmented or diverted urinary system: they are considered higher risk recipients in view of increased technical problems and infective complications leading to pyelonephritis and graft loss. The ureter of a transplanted kidney should be anastomosed into a reservoir with an adequate capacity, with low bladder pressure, with good compliance, and efficient voluntary empting. Ileal and sigmoid bladder augmentation, usually associated with clean intermittent catheterization, has become a well-accepted part of the urological practice and has been used for implantation of the transplant ureter. During the last years, the interest in new biomaterials for reconstructive surgery has increased. Experimental studies showed how these requests can be satisfied by porcine small intestinal submucosa SIS (Stratasis™): this can be degraded by the host and substituted by "new tissue". In four recent cases we have used SIS to obtain an augmented, normalpressure and good compliance bladder reservoir, with three (epithelial, muscular and adventitial) layers normally represented.

[Penile prosthesis implantation in kidney-transplanted patients].

Most kidney transplantations are performed on middle-aged men for whom problems of sexual potency are still of great importance. Although a functional renal graft improves the problem in some patients and others resolve with oral or intracavernous therapy, about 20% of patients do not have a good response. In non-responders, tricomponent penile prosthesis implantation is possible. In the last 10 years we have implanted with no complications 7 tricomponent AMS 700 prostheses in patients not otherwise responding. Our good results confirm that patients with kidney transplantation should be considered good candidates to the penile prosthesis if the erectile dysfunction persists after different therapies.

[Prostate cancer: transrectal high-intensity focused ultrasound for the treatment of local recurrence after radical prostatectomy or radiotherapy].

OBJECTIVES. To evaluate the efficacy and safety of transrectal high-intensity focused ultrasound (HIFU) as salvage therapy for locally recurrent prostate cancer after external beam radiotherapy or recurrences located in the region of vesicourethral anastomosis after radical prostatectomy. METHODS. Transrectal biopsy of the prostate (recurrence after radiotherapy) or in the region of vesicourethral anastomosis (recurrence after prostatectomy) was performed in all cases at the time of biochemical relapse. Only patients with positive biopsy were treated. Systemic disease was excluded by PET-CT and bone scan. All treatments were carried out under spinal anesthesia. The device used was Ablatherm (EDAP, Lion, France). The patients were followed with PSA measurement every 3 months and clinical examination every 6 months. In case of biochemical relapse we performed re-biopsy. RESULTS. From 2002 to 2008 we treated 19 patients with local recurrence after radiotherapy. The mean follow-up was 30 months for each patient (range 6-72 months). 9 patients (47%) are disease-free at last followup, with PSA < 1 ng/mL. 9 patients experienced biochemical failure: 8 were treated with androgen deprivation, 1 with salvage prostatectomy. 2 patients died of the disease. Adverse events related to HIFU included 1 rectourethral fistula (observed before the use of specific parameters dedicated to this patient population) and mild incontinence (2-3 pads/die) in 4 patients. From 2002 to 2008 we treated 27 patients with a local recurrence after radical prostatectomy. Mean pre-HIFU PSA was 2.17 ng/mL (range 0.5-8 ng/ml); the Gleason score ranged from 5 to 8. All patients reached a minimum follow-up of 20 months (range 20-80 months). Median PSA nadir was 0.2 ng/ml. The disease-free rate was 51% (14/27); these patients have a median PSA of 0.2 ng/ml at last follow-up. 81% (22/27) of control biopsies were negative. There were no intra-operative or post-operative complications. CONCLUSIONS. The small number of patients in our series limits our ability to draw any definitive conclusions. We believe that HIFU may be a potentially useful treatment option for patients who develop prostate cancer recurrence after external beam radiotherapy or in the region of vesicourethral anastomosis after radical prostatectomy. The procedure is safe, side effects are acceptable and do not add significant morbidity to the previous radical treatment. HIFU lesions are targeted only to the area of recurrence. It is important to remember that, in case of failure, the patient can undertake any other therapies.

Value of endorectal MRI and MRS in patients with elevated prostate-specific antigen levels and previous negative biopsies to localize peripheral zone tumours.

AIM: To evaluate prospectively the role of endorectal magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS) in detecting peripheral zone tumour in patients with total prostate-specific antigen (PSA) values>or=4 ng/ml and one or more negative transrectal ultrasound (TRUS) biopsy rounds. MATERIAL AND METHODS: Fifty-four consecutive men (mean age 65.4+/-5.2 years, mean total PSA 10.8+/-7.5 ng/ml), underwent a combined MRI-MRS examination with endorectal coil. MRI included transverse, coronal, and sagittal T2-weighted and transverse T1-weighted fast spin-echo sequences. MRS data were acquired using a double spin-echo point resolved spectroscopy (PRESS) sequence. A 10-site scheme was adopted to evaluate the prostate peripheral zone. A peripheral prostatic site was classified as suspicious if low intensity signal was present on T2-weighted images and/or if the choline+creatine/citrate ratio was >0.86. Following MRI-MRS all patients were submitted to a standard 10-core biopsy scheme to which from one to three supplementary samples were added from suspicious MRI and/or MRS sites. In per-patient analysis findings were considered true-positive if biopsy positive patients were classified as suspicious, irrespectively of lesion site indication. RESULTS: Prostate cancer (PC) was detected in 17 of 54 patients (31.5%); median Gleason score was 6 (range 4-8). On a per-patient basis sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy were respectively 100, 64.9, 56.7, 100, and 75.9% for MRI; 82.2, 70.3, 57.7, 92.9, and 75.9% for MRS; and 100, 51.4, 48.6, 100, and 66.7% for combined MRI-MRS. In all the 17 PC patients, combined MRI-MRS correctly indicated the sites harbouring cancer, whereas both MRI and MRS gave erroneous indications in two patients. CONCLUSION: The results of the present study show that MRI alone might be able to select negative patients in whom further biopsies are unnecessary. The combination of MRI and MRS might be able to drive biopsies in suspicious sites and increase the cancer detection rate. Further studies are required to confirm these data.

Erectile dysfunction after kidney transplantation: our 22 years of experience.

AIM: To evaluate the results of treatment of erectile dysfunction (ED) in kidney transplant recipients before and after the advent of sildenafil. MATERIALS AND METHODS: From 1981 through 2002, 971 male patients of mean age 53.4 years received a renal graft. Erectile dysfunction (ED) was investigated in all patients at the first urologic visit posttransplantation. Psycho-sexual support was offered to all patients. Before sildenafil use (1998), our diagnostic approach was complex. From 1998 we tested: serum levels of testosterone, prolactin, and glucose with penile duplex ultrasonography and NPT reserved for selected cases. RESULTS: From 1981 through 1998, 365 male kidney transplant recipients (45%) reported ED. Only 169 patients chose to be treated: 27 responded to psycho-sexual therapy; 3 received testosterone with benefit; 133 had a good results from intracavernosal injection of vasoactive drugs; and 6 received a penile prosthesis. Since 1998, 126 patients reported ED (78.3%). Only 78 chose treatment: 24 patients had a satisfactory response to sildenafil (65% with 50 mg and 35% with 100 mg). PGE1 alone or in combination with papaverine and phentolamine produced a good response in 37 patients; 17 patients did not respond to pharmacotherapy; and 5 received a tricomponent penile prosthesis without complications. The side effects of sildenafil and PGE1 therapy were similar to those reported in the literature. CONCLUSIONS: ED is an important problem in male renal transplant recipients. Cultural resistance to treatment is common. However, treatment with sildenafil citrate and intracavernosal self-injection of PGE1 are well accepted, and prosthetic devices may help in resistant cases.

The use of the small caliber JJ stent with anti-reflux valve in double kidney transplant. Personal experience.

BACKGROUND: In the experience of other authors, double kidney transplant have a higher complication rate (30%) if compared with single renal graft. In personal experience the use of small calibre ureteral stents with antireflux valve can reduce this complication rate. METHODS: From November 1999 to April 2001, at the A.S.O. S. Giovanni Battista in Turin, we performed 29 double kidney transplantations with the application of small calibre stents in 20 male and 9 female patients, aged 50-74 years. The uretero-neocystostomies were carried out according to Lich-Gregoire technique, and the JJ stents used were pediatric ones, 12 cm long and 4.8 Ch, with antireflux valve. RESULTS: We complained only 2 urological complications out of 58 anastomoses (distal unilateral ureteral necrosis in 1 case and total ureteral necrosis in the other). CONCLUSIONS: Complication rate is lower than in the literature: the authors suggest that the use of small calibre JJ stents can keep the complication rate low in double kidney transplant.

[Nephron-sparing treatment of kidney neoplasms in transplanted kidney. Our experience]. / Trattamento "nephron-sparing" delle neoplasie renali in rene trapiantato. Nostra esperienza.

BACKGROUND: To evaluate survival rate, follow-up and renal function in patients treated with "nephron-sparing" approach due to cancer in a transplanted kidney. METHODS: During the 18 years' activity of our Transplantation Centre 3 renal carcinomas in transplanted kidneys (0.24%) have been found. Diagnoses were made in one case during transplantation procedures and, in the remaining two, 1 month and 10 years after. All tumours were unifocal, small (10, 12 and 18 mm of diameter), capsulated and low stage (T1). The resection of the mass ("nephron-sparing" surgery) and of a layer (1 cm thick) of the tissue surrounding the tumour was performed. The histological exam showed in all cases low grade (G2) renal cell carcinoma and negative surgical margins. RESULTS: 138, 94 and 15 months after transplant all patients are alive, without disease recurrence and with good renal function. In all cases the doses of immune-suppressive therapy were reduced. CONCLUSIONS: Renal cancer in transplanted kidneys is generally treated with nephrectomy. On the contrary, we decided to apply the same criteria which are accepted for the treatment of renal neoplasms in general and then to perform a "nephron-sparing" surgery when the tumour is small, capsulated and with negative surgical margins at the intraoperative histological exam. In personal experience good results from the oncologic and nephrologic point of view have been accomplished.

Use of small calibre JJ ureteral stent with anti-reflux valve in uretero-vesical anastomosis during renal transplantation.

BACKGROUND: We report our experience in transplantation proceedings with the use of small caliber JJ ureteral stent with antireflux valve during uretero-vesical anastomosis. METHODS: During renal transplantations we usually perform an uretero-cystoneostomy with antireflux technique according to Lich Gregoir. In the past we used to intubate the uretero-vesical anastomosis only in particular cases; since April 1998 we performed 112 single and 8 double transplants and in all cases we positioned a 12 cm long paediatric 4.8 Ch JJ ureteral stent with antireflux valve, in order to reduce urologic complications. The vesical catheter was usually removed in 6o-7o day and the ureteral stent 40-60 days after transplantation. RESULTS: We have performed 129 uretero-vesical anastomoses and we complained only one case of early dehiscence of the anastomosis (unilateral in a double transplant) and two cases of late stents' displacement. We noticed no stenosis of the anastomosis and no dysfunction in urine outflow from the upper urinary ways. CONCLUSIONS: The routinary use of paediatric JJ ureteral stents with antireflux valve was decisive in drastically reducing early urologic complications after renal transplantation. Furthermore, the risk of vesico-ureteral reflux is almost completely reduced, thanks to the technique adopted for the anastomosis which allows a physiologic-like antireflux mechanism, to the presence of the antireflux valve and to the early recovery of the physiologic ureteral peristalsis, which is promoted by the small calibre of the stent. These factors lead to a faster recovery of the renal function, with excellent results from the nephrologic and urologic points of view.

[Obstructive azoospermia. Instrumental diagnosis: echography and endoscopy]. / Azoospermie ostruttive. Diagnostica strumentale: ecografia ed endoscopia.

Obstructive disorders of seminal tract are mainly distinguished in Proximal and Distal Obstructive Syndrome, following typical seminal pattern. Fine localization of obstruction is very important for prognostic and therapeutic evaluation. In Proximal Obstruction the role of echography and endoscopy is today poorly defined and usefull. In Distal Obstruction a preeminent role is recognised to transrectal ultrasound and its mini-invasive applications: biopsy, evacuative puncture, direct contrastography of obstructed seminal way. At this regard is reported a case of dysmorphic congenital obstruction documented with transrectal ultrasound and contrastography. Diagnostic endoscopic indications mainly refer to therapeutic procedures.

[The percutaneous treatment of the urological complications following kidney transplantation]. / Trattamento percutaneo delle complicanze urologiche dopo trapianto renale.

Renal transplantation is considered the treatment of choice in most cases of renal failure; the urologic complication rate ranges 1 to 10% in different surveys. This work was aimed at evaluating the application and results of interventional radiology in these cases. Since 1983, 24 patients (20 males and 4 females) whose age ranged from 18 to 63 years (mean age: 42 years) have been submitted to percutaneous maneuvers in our department. Thirty-four complications were treated: 14 stenoses, 11 fistulas, 7 urinomas and 2 transient obstructions. Complete success was obtained in 15/24 patients (62.5%), while 7/24 patients (29.16%) underwent reoperation and in 2/24 cases (8.34%) a definitive pyelostomy catheter was inserted. In 7 stenosis cases ureteroplasty was successfully performed and a double-J endoprosthesis inserted; the follow-up results (5-21 months) were satisfying in all cases. The only complication was one case of endoperitoneal hematoma. Considering the good results obtained, the low morbidity and mortality and the low cost, percutaneous maneuvers must be considered the treatment of choice in the urologic complications of renal transplants. When the percutaneous treatment of the main lesion fails, pyelostomy does nonetheless allow the drainage of urinary collections, the maintenance of renal function and the improvement of local and general conditions, which makes it easier to reoperate under elective conditions.