Multisensory perception constrains the formation of object categories: a review of evidence from sensory-driven and predictive processes on categorical decisions.

Although object categorization is a fundamental cognitive ability, it is also a complex process going beyond the perception and organization of sensory stimulation. Here we review existing evidence about how the human brain acquires and organizes multisensory inputs into object representations that may lead to conceptual knowledge in memory. We first focus on evidence for two processes on object perception, multisensory integration of redundant information (e.g. seeing and feeling a shape) and crossmodal, statistical learning of complementary information (e.g. the 'moo' sound of a cow and its visual shape). For both processes, the importance attributed to each sensory input in constructing a multisensory representation of an object depends on the working range of the specific sensory modality, the relative reliability or distinctiveness of the encoded information and top-down predictions. Moreover, apart from sensory-driven influences on perception, the acquisition of featural information across modalities can affect semantic memory and, in turn, influence category decisions. In sum, we argue that both multisensory processes independently constrain the formation of object categories across the lifespan, possibly through early and late integration mechanisms, respectively, to allow us to efficiently achieve the everyday, but remarkable, ability of recognizing objects. This article is part of the theme issue 'Decision and control processes in multisensory perception'.

Surgical correction of Peyronie's disease via tunica albuginea plication: long-term follow-up.

Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea with fibrosis and inflammation that lead to palpable plaques formation, penile curvature, and pain during erection. Patients report negative effects on main domains such as physical appearance and self-image, sexual function, and performance. The aim of this study was to evaluate plication of the albuginea outcomes after a long-term follow-up period. Between 1998 and 2006, a total of 204 patients with PD underwent surgical correction with albuginea plication technique. We obtained complete long-term follow-up data in 187 cases. The follow-up data included evaluation of curvature correction, penile shortening, sexual function, complications, and patient satisfaction. After a mean follow-up of 141 months, the most common postoperative complications were: loss of length (150 patients had a minimal penile shortening ≤1.5 cm, 37 patient between 1.5, and 3 cm, none >3 cm), recurrent or residual penile curvature (15 patients, without impairing sexual intercourse), erectile dysfunction (15 patients had IIEF-5 < 10 at 5 years of follow-up vs. 28 patients at 10 years), change in penile sensation (37 patients experienced paresthesia of the glans 1 year after surgery, 28 at 5 years, and 15 at 10 years); painful or palpable suture knots (in 20 cases) spontaneously healed in 3 months. Overall, 77% of the patients and partners were completely satisfied, 14% partially satisfied, and 9% unsatisfied. Plication procedure is safe and simple to be performed compared with the classical Nesbit's procedure. It has a shorter surgical time, lower costs, and could be successfully performed by less experienced surgeons too. It has a minimal risk of de novo erectile dysfunction, injury to the dorsal neurovascular bundle. Results are good in terms of patient satisfaction according to anatomical outcome and functional correction.

Does site of specimen extraction affect incisional hernia rate after robot assisted laparoscopic radical prostatectomy?

BACKGROUND: Robot assisted laparoscopic radical prostatectomy (RALP) spread in the last decade as a minimally invasive alternative to open radical prostatectomy for men with localized prostate cancer. It is associated with excellent surgical, functional and oncological results with less postoperative pain and shorter convalescence. Anyway, the development of an incisional hernia (IH), may negate known benefits as it can lead not only to bothersome symptoms but also to severe complications, such as bowel obstruction, strangulation and perforation. Port-site or extraction site hernias, whose incidence rate is underdiagnosed, have become more commonly after minimally invasive surgery; but IH rate after robot-assisted radical prostatectomy has not been well characterized. This study aimed to evaluate the impact of extraction-site location (vertical supra-umbilical incision versus an off-midline incision) on incisional hernia rates in robotic prostatectomy. MATERIALS AND METHODS: We included in the study 800 patients undergone RALP, 400 with a supra-umbilical incision for specimen extraction and 400 with off-midline incision. All were followed up for at least 3 years. The main study end point was IH occurrence at the extraction site (midline versus off-midline). RESULTS: IH rate for the entire series was 4.75%, in particular 5% for the midline group and 4.5% for the off-midline group. The hernias were diagnosed at a mean of 20.2 and 18.2 months after surgery, respectively in the two groups. There was no statistically significant differences in baseline characteristics; anyway larger prostate weight, wound infection and history of prior cholecystectomy were associated with higher proportion of IH. CONCLUSION: Extraction site hernias are a rare but a potentially serious complication following RALP. In our series, the midline extraction doesn't result in a significantly higher IH rate in comparison with the off-midline extraction site.

Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos / Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes

Objetivo: Comparar los resultados clínicos intra y postoperatorios tempranos entre la enucleación transuretral con láser de tulio de la próstata (ThuLEP) y la resección bipolar transuretral de la próstata (TURis) para el tratamiento de la hiperplasia prostática benigna (HBP) en un ensayo prospectivo aleatorizado. Métodos: El estudio aleatorizó a 208 pacientes consecutivos con HBP a ThuLEP (n = 102) o TURis (n = 106). Para todos los pacientes se evaluaron preoperatoriamente en cuanto a pérdida de sangre, tiempo de cateterización, volumen de irrigación, estancia hospitalaria y tiempo operatorio. A los 3 meses después de la cirugía también fueron evaluados por la International Prostate Symptom Score (IPSS) el flujo máximo (Qmáx) y el volumen de residuo posmiccional (RPM). Resultados: Los pacientes en cada brazo de estudio no mostraron diferencias significativas en los parámetros preoperatorios. En comparación con TURis, ThuLEP tuvo el mismo tiempo quirúrgico (53,69±31,44 vs 61,66±18,70min; p = 0,123), pero resultó en menos disminución de la hemoglobina (0,45 vs 2,83g/dl, p = 0,005). ThuLEP también necesitó menos tiempo de cateterización (1,3 vs 4,8 días, p = 0,011), volumen de irrigación (29,4 vs 69,2l; p = 0,002) y estancia hospitalaria (1,7 vs 5,2 días, p = 0,016). Durante los 3 meses de seguimiento, los procedimientos no demostraron una diferencia significativa en Qmáx, IPSS, RPM y ECDV. Conclusión: ThuLEP y TURis alivian los síntomas del tracto urinario inferior igualmente, con alta eficacia y seguridad. ThuLEP fue estadísticamente superior a TURis en la pérdida de sangre, el tiempo de cateterización, el volumen de irrigación y la estancia hospitalaria. Sin embargo, los procedimientos no difirieron significativamente en Qmáx, IPSS, RPM y ECDV a través de 3 meses de seguimiento

Objective: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. Methods: The study randomized 208 consecutive patients with BPH to ThuLEP (n = 102) or TURis (n = 106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). Results: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70 minutes, P = .123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P = .005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P = .011), irrigation volume (29.4 vs 69.2 L, P = .002), and hospital stay (1.7 vs 5.2 days, P = .016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. Conclusion: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up

Thulium laser enucleation (ThuLEP) versus transurethral resection of the prostate in saline (TURis): A randomized prospective trial to compare intra and early postoperative outcomes. / Enucleación con láser de tulio (ThuLEP) frente a resección transuretral de la próstata en solución salina (TURis): un ensayo prospectivo aleatorizado para comparar resultados intra y postoperatorios tempranos.

OBJECTIVE: To compare clinical intra and early postoperative outcomes between thulium laser transurethral enucleation of the prostate (ThuLEP) and transurethral bipolar resection of the prostate (TURis) for treating benign prostatic hyperplasia (BPH) in a prospective randomized trial. METHODS: The study randomized 208 consecutive patients with BPH to ThuLEP (n=102) or TURis (n=106). For all patients were evaluated preoperatively with regards to blood loss, catheterization time, irrigation volume, hospital stay and operative time. At 3 months after surgery they were also evaluated by International Prostate Symptom Score (IPSS), maximum flow rate (Qmax), and postvoid residual urine volume (PVR). RESULTS: The patients in each study arm each showed no significant difference in preoperative parameters. Compared with TURIS, ThuLEP had same operative time (53.69±31.44 vs 61.66±18.70minutes, P=.123) but resulted in less hemoglobin decrease (0.45 vs 2.83g/dL, P=.005). ThuLEP also needed less catheterization time (1.3 vs 4.8 days, P=.011), irrigation volume (29.4 vs 69.2 L, P=.002), and hospital stay (1.7 vs 5.2 days, P=.016). During the 3 months of follow-up, the procedures did not demonstrate a significant difference in Qmax, IPSS, PVR, and QOLS. CONCLUSION: ThuLEP and TURis both relieve lower urinary tract symptoms equally, with high efficacy and safety. ThuLEP was statistically superior to TURis in blood loss, catheterization time, irrigation volume, and hospital stay. However, procedures did not differ significantly in Qmax, IPSS, PVR, and QOLS through 3 months of follow-up.

Immediate and Catastrophic Antibody-Mediated Rejection in a Lung Transplant Recipient With Anti-Angiotensin II Receptor Type 1 and Anti-Endothelin-1 Receptor Type A Antibodies.

Preexisting donor-specific anti-HLA antibodies (DSAs) have been associated with reduced survival of lung allografts. However, antibodies with specificities other than HLA may have a detrimental role on the lung transplant outcome. A young man with cystic fibrosis underwent lung transplantation with organs from a suitable deceased donor. At the time of transplantation, there were no anti-HLA DSAs. During surgery, the patient developed a severe and intractable pulmonary hypertension associated with right ventriular dysfunction, which required arteriovenous extracorporeal membrane oxygenation. After a brief period of clinical improvement, a rapid deterioration in hemodynamics led to the patient's death on postoperative day 5. Postmortem studies showed that lung specimens taken at the end of surgery were compatible with antibody-mediated rejection (AMR), while terminal samples evidenced diffuse capillaritis, blood extravasation, edema, and microthrombi, with foci of acute cellular rejection (A3). Immunological investigations demonstrated the presence of preexisting antibodies against the endothelin-1 receptor type A (ETA R) and the angiotensin II receptor type 1 (AT1 R), two of the most potent vasoconstrictors reported to date, whose levels slightly rose after transplantation. These data suggest that preexisting anti-ETA R and anti-AT1 R antibodies may have contributed to the onset of AMR and to the catastrophic clinical course of this patient.

Glomerular c4d immunoreactivity in acute rejection biopsies of renal transplant patients.

In renal transplant patients, glomerulitis may be present in all types of acute rejection, often accompanied by diffuse C4d staining of peritubular capillaries: C4d3 positivity in more than 50% of peritubular capillaries. It may progress to chronic transplant glomerulopathy, characterized by capillary basement membrane multilayering, proteinuria, and progressive loss of renal function. While C4d3 is a recognized marker of an antibody-mediated reaction, the significance of glomerular C4d (GlC4d) staining is unknown. The aim of this study was to evaluate GlC4d immunoreactivity and its correlation with C4d3 in acute rejection biopsies. Paraffin-embedded acute rejection biopsies from 90 renal transplant patients were evaluated according to the Banff classification. Biopsies showing C4d-positive endothelial cells in more than 50% of glomeruli were considered GlC4d-positive. C4d3-positive staining prevalence was 23%. GlC4d-positive staining showed an 89% concordance rate (r = 0.81, P < .0001; Cohen's k = 0.80, P < .0001). GlC4d detection sensitivity was 0.80 and specificity 0.97. C4d3 and GlC4d immunoreactivity was significantly associated with glomerulitis (P < .006 and P < .03, respectively) and with proteinuria at the time of biopsy (P < .03 and P < .01, respectively). Interestingly, GlC4d positivity correlated better than C4d3 positivity with the presence of posttransplant circulating anti-human leukocyte antigen alloantibodies (P < .04 and P = .7, respectively). Patients with C4d3- or GlC4d-positive acute rejections underwent graft loss due to interstitial fibrosis and tubular atrophy more frequently than those with C4d0- or GlC4d-negative rejections (P < .0001 and P < .005, respectively), whereas no differences were observed in graft loss due to death. In conclusion, C4d3 and GlC4d stains showed a high correlation rate. Compared with C4d3, GlC4d staining demonstrated good sensitivity and excellent specificity. Our results suggested that GlC4d staining may indicate glomerular endothelial damage and be of prognostic value.

Promoting epidural analgesia for labor: 2005-2007 diffusion in Lombardia, Italy.

BACKGROUND: Since January 2005 the Regional Government of Lombardia, a large Italian region with over 1/5 of all Italian births, allocated public funds for 3 consecutive years to help provide epidural analgesia (EA) for women in labor. The aim of the present study was to evaluate the trend of diffusion of EA in the triennium 2005-2007. METHODS: Data obtained from regional Obstetric Departments, recognized by the National Health Care System, were elaborated by the Epidemiological Service of Regione Lombardia. The software looked for specific codes for vaginal deliveries, with or without EA, and Cesarean sections included in the administrative patient records. RESULTS: A substantial increase in epidurals administered in comparison to total vaginal deliveries was recorded after assignment of regional financing: from 8.2% in 2005, to 10.4% in 2006 and 12.9% in 2007 (P<0.0001). More than 60% of epidurals were performed in 8 hospitals with >2 000 births per year. The rate of EAs in these hospitals was 18% in 2005, 22% in 2006 and 24.9% in 2007. In the 69 hospitals with <2000 births per year, the rate of EAs was markedly lower: 4% in 2005, 5.5% in 2006 and 7.8% in 2007. In both cases, the increase was statistically significant (P<0.0001). At the three-year time-point, the rate of Cesarean sections did not change. CONCLUSIONS: The continuous increase of EA for labor after regional financings suggests that the low rate of pain relief procedures in Lombardia was mainly due to economic and organizational issues, rather than to cultural and psychological factors.

An update on xenotransplantation.

Xenotransplantation is one of the possible avenues currently being explored to address the shortage problem of human organs. With this in mind, this article will briefly review the current situation with respect to the immunological, physiological and biosafety aspects related to the transplantation of pig organs into primates. Acute humoral xenograft rejection (AHXR) currently remains the central immunological obstacle and the development of strategies for both a better control of the elicited anti-pig humoral immune response or the prevention of the onset of coagulation disorders that accompany AHXR are the two primary focuses of research. To date, porcine xenografts have been shown to sustain the life of nonhuman primates for several months. Such preclinical studies have also demonstrated the absence of insurmountable physiological incompatibilities between pig and primate. In addition, reassuring findings regarding biosafety aspects have been generated and pro-active research aimed at the identification of an organ source with a higher safety profile is also underway. These advancements, in conjunction with ongoing research in pig genetic engineering, immunosuppression and tolerance are expected to further extend the survival of porcine xenografts transplanted into primates. However, until further physiological, efficacy and safety data are generated in relevant primate models, clinical xenotransplantation should not be considered.

Expression of CTLA-4 in nonhuman primate lymphocytes and its use as a potential target for specific immunotoxin-mediated apoptosis: results of in vitro studies.

T-cell-mediated immunoregulation is one of the main mechanisms implicated in induction and maintenance of transplantation tolerance. In this regard, deletion or modulation of xeno/alloantigen-specific T cells, as well as blocking of their interactions with other cell populations, are currently being pursued for tolerance induction in humans as well as nonhuman primates. In order to investigate whether cytotoxic T-lymphocyte antigen-4 (CTLA-4) may represent a suitable target for a T cell depletion approach in nonhuman primate models, we analysed CTLA-4 expression in peripheral blood mononuclear cells (PBMCs) from nonhuman primates and the potential role of two anti-CTLA-4 saporin-conjugated immunotoxins. The analysis was performed in PBMCs from 8 cynomolgus monkeys from Philippines and from Mauritius both at protein level by flow cytometry and at transcriptional level by RT-PCR. In addition, the apoptotic role of the immunotoxins was investigated. The results showed that CTLA-4 was expressed at variable levels depending on the origin of the cynomolgus monkeys and the resting or activated cell condition. CTLA-4 was not expressed on resting Mauritius PBMCs and showed a lower up-regulation upon PMA/PHA activation compared to the Philippines PBMCs that expressed CTLA-4 also before activation. Two CTLA-4 RNA transcripts (672 and 550 bp) were detected with levels variations after cell stimulation. Two anti-CTLA-4 immunotoxins induced in vitro apoptosis of activated PBMCs from both sources of cynomolgus monkeys. This is the first report that documents CTLA-4 expression both at protein and transcriptional level by nonhuman primate PBMCs and provides novel perspectives of xeno/allograft rejection immunotherapy based on CTLA-4 targeting.

Tetanus and botulinum neurotoxins: turning bad guys into good by research.

The neuroparalytic syndromes of tetanus and botulism are caused by neurotoxins produced by bacteria of the genus Clostridium. They are 150 kDa proteins consisting of three-domains, endowed with different functions: neurospecific binding, membrane translocation and specific proteolysis of three key components of the neuroexocytosis apparatus. After binding to the presynaptic membrane of motoneurons, tetanus neurotoxin (TeNT) is internalized and transported retroaxonally to the spinal cord, where it blocks neurotransmitter release from spinal inhibitory interneurons. In contrast, the seven botulinum neurotoxins (BoNT) act at the periphery and inhibit acetylcholine release from peripheral cholinergic nerve terminals. TeNT and BoNT-B, -D, -F and -G cleave specifically at single but different peptide bonds, VAMP/synaptobrevin, a membrane protein of small synaptic vesicles. BoNT types -A, -C and -E cleave SNAP-25 at different sites within the COOH-terminus, whereas BoNT-C also cleaves syntaxin. BoNTs are increasingly used in medicine for the treatment of human diseases characterized by hyperfunction of cholinergic terminals.

[Recovery of urinary incontinence after retropubic radical prostatectomy. Results in 100 patients]. / Ripresa della continenza urinaria dopo prostatectomia radicale retropubica. Risultati in 100 pazienti.

AIM OF THE STUDY: To shorten the time to recovery of full urinary continence after radical retropubic prostatectomy and to increase the postoperative continence rate. MATERIALS AND METHODS: One hundred and five consecutive patients were submitted to radical retropubic prostatectomy for prostate cancer, with curative intent, focusing our attention on three steps of the operation. First, to achieve a complete control of bleeding from the dorsal vein complex and to perform a minimal touch dissection of the urethral stump; second, to perform a conservative dissection of the bladder neck, and, third, to implement a vascular type, watertight, vesico urethral anastomosis. Continence was assessed 24 hours after catheter removal and at monthly follow up visits until full recovery and graded as dry if no dropping was visible and the patient was able to interrupt the urinary stream during micturition; stress incontinence, if any dropping was observed during abdominal strain between micturitions; and wet, if uncontrollable dropping occurred, and the number of pads needed per day recorded. RESULTS: At a median follow-up time of 18 months, range 6 to 30, a total of 87 of 100 evaluable patients (87%) resulted as dry; 10 patients (10%) resulted as having a variable degree of stress incontinence needing one to three pads per day, and 3 patients (3%) resulted as wet. In 41 of the 87 dry patients (47.1%) continence was achieved within the first day from catheter removal, and in a median time of 4 weeks, range 2 to 16 in the remaining 46 patients (52.9%). CONCLUSIONS: The results of total continence rate of the present study seem to compare to the recent literature except for the time to full recovery which is shorter; it is difficult to identify the contribution of each single surgical step.

[Study of the diuretic efficacy and tolerability of therapy with Rocchetta mineral water in patients with recurrent calcium kidney stones]. / Studio sulla tollerabilità e l'efficacia diuretica della idropinoterapia con acqua oligominerale Rocchetta in pazienti con nefrolitiasi calcica recidivante.

The diluition of urine decreases the risk of stone formation by lowering the concentration of calcium, oxalate and uric acid, but involves a simultaneous decrease of the concentration of the inhibitors of crystallization. On the other hand the ion content of the drinking water used for stone prevention could by itself modify urine composition. We tested the effect of the administration of a mild-calcium high-bicarbonate content water on urine composition of a group of calcium renal stone formers. A group of 40 calcium renal stone formers was instructed to drink 3 l/day of a mild-calcium (57 mg/l) and high-bicarbonate (180 mg/l) content water (Rocchetta) for a 7 day period. A 24-h collection was obtained before and after water administration for analyses of calcium, magnesium, oxalate and citrate. Urine volume was significantly increased after water administration (1601 +/- 357 vs 1878 +/- 339). Daily urinary calcium, magnesium and citrate were significantly increased, whereas daily urinary oxalate was unchanged after water administration. In conclusion the mild-calcium high-bicarbonate content water administration seems suitable for stone prevention because of the increased excretion of urinary inhibitors counterbalancing increased urinary calcium excretion.

Renal stone fragments following shock wave lithotripsy.

PURPOSE: We describe a select group of asymptomatic patients with fragments and dust 3 months after extracorporeal treatment, who were followed to evaluate the long-term outcome and therapeutic implications. MATERIALS AND METHODS: A total of 129 patients with dust and residual fragments (less than 4 mm.) at 3 months was re-examined at 12 months, and 95 were also evaluated at 24 months. Followup examinations consisted of radiographic studies, renal ultrasonography and urine culture. Dust and residual fragments were sought, and patients were defined as free or as having persistent lithiasis or stone regrowth. At 24 months recurrences in the patients stone-free at 12 months also were considered. RESULTS: At the 12-month followup 60 patients (46.5%) were stone-free and 56 (43.5%) still had dust or residual fragments. The localization of the stones or fragments at 3 months and their sizes did not have a significant influence on the stone-free rate but regrowth was greater in patients with stones larger than 10 mm. (11 of 40 patients, 27.5% versus 2 of 89, 2.2%, p = 0.001). The probability of eliminating residual lithiasis at 12 months was significantly greater in patients with dust than in those with residual fragments (42 of 79 patients, 58% versus 18 of 50, 36%, p = 0.026). Regrowth of residual lithiasis was observed in 13 patients (10%). CONCLUSIONS: Based on our results, we do not believe that patients with fragments require systematic re-treatment in the short term but they may be followed long term and re-treated if symptoms persist or stones recur.

[Seminal obstructions of the inflammatory origin]. / Ostruzioni seminali di origine flogistica.

Presence of bacteria in the sperm is often associated to a reduction of fertility in relationship with a decrease in number and motility of spermatozoa and with an augmentation of the abnormal spermatic cells. In the most severe cases, chronic and complicated phlogosis may lead to obstruction of seminal pathways with consequent azoospermia. Clinical features of seminal phlogosis are extremely variable both in acute and chronic evolutions. In every case the first diagnostical step is sperm count and seminal complete analysis which can give evidence of phlogistic alteration in quantity and quality of spermatic cells with a typical presence of an excess in white blood cells (leukospermia) as consequence of infection. The great variety in clinical and bacteriological aspects and the particular biological features of the organs involved, as the prostate, makes treatment a difficult problem to solve with particular regard to the choice of an effective antibiotic which pharmacokinetic has to result suitable for the microorganism as well as for the tissue of the infection site. All those efforts are indispensable to reduce the too frequent therapeutical failures in the management of seminal phlogistic pathology with complications of organic but also physiological relevancy for the patient and the partner too, such as azoospermia.

Extracorporeal shock wave lithotripsy.

The first clinical application of extracorporeal SWL dates back to 1980. Since then the use of this method has spread widely and its indications have been extended progressively so that it way now be considered the treatment of choice in 80-90% of cases of ureterorenal lithiasis. Treatments without anesthesia or analgesics have been associated with an increase of retreatments from 5-14% (original HM3) to 45-60% (lithotripters not requiring anesthesia or analgesia). However, almost all lithotripter succeed in fragmenting stones sufficiently. The stone free rate varies with different lithotripters in the different series: 90-56% for stones of maximum diameter < 1 cm, 78-30% for stones of maximum diameter of 1-2 cm. and 52.5-10% for stones of maximum diameter of 2-3 cm. (the last figure was obtained with a piezoelectric lithotripter). Extracorporeal lithotripsy as monotherapy of staghorn stones has yelded a stone free rate varying between 31% and 55% with high percentages of residual fragments in about 50% of case of the various series. The stone free rate after treatment varies according to stone site: it is between 75% and 84% of caliceal stones for upper caliceal calculi and falls to under 60% for lower caliceal ones. The frequency of recurrences, that is, of new stones in patients stone free after SWL, is between 4% and 10% annually. Adding the percentage of true recurrences reported by the various authors at 19 to 42 months of follow-up (6.2-13.8%) to the fragment regrowth rate (17.2-22.3%) gives a total new stone rate of 23.4% and 36%. These figures are not greatly different from those reported in a population of untreated stone formers (10-15% per year). Extracorporeal lithotripsy seems thus not to influence lithiasis recurrence significantly.

Extracorporeal shock wave lithotripsy in the treatment of ureteral lithiasis: methodological controversies and therapeutic efficacy.

The treatment of ureteral stones has undergone a radical change in the last 15 years. First, the increased use of endoscopic procedures and then the introduction of extracorporeal lithotripsy relegated traditional surgery to a marginal role for this type of disorder. The best available treatment modality for ureteral lithiasis, particularly distal ureteral stones, is still a matter of great controversy among urologist. With the introduction in clinical use of second- and third generation lithotripters, which are even less invasive and require no anesthesia, interest has increased in treating patients by extracorporeal lithotripsy, reducing endoscopic monoeuvres to a minimum. The absolute contraindications to extracorporeal lithotripsy for ureteral stones are the same as those for renal stones: intractable hemostatic alterations, pregnancy, physical structure that limits positioning and altered patency of the urinary tract. From June 1990 to December 1994, 270 patients with ureteral stones were treated by extracorporeal lithotripsy at our center. The Dornier MPL 9000 lithotripter was used in 68 cases (25%) and the modified HM3 Dornier in 202 (75%). Pretreatment manoeuvres were performed in 130 patients (48%). Endoscopic manoeuvres were not performed in 140 patients treated in situ. 18 patients (13%) treated initially in situ subsequently underwent post-treatment manoeuvres which were required only in 3 patients who had undergone pretreatment. All patients were examined as outpatients 3 months after the treatment. A total of 241 patients (89%) were stone free, 121 who had undergone pretreatment manoeuvres and 119 who had been treated in situ. 29 patients (11%) were not stone free: 23 patients subsequently underwent endoscopic lithotripsy, 2 surgery and 4 stone removal by Dormia probe. The possibility of performing treatment without anesthesia, the absence of complications and the high proportion of successes make extracorporeal lithotripsy, particularly the in situ procedure, the treatment of choice for ureteral stones. Ureterorenoscopy has been proposed by some authors as the first treatment for mid and pelvic ureteral stones which are difficult to localize with the lithotripter. However, although this method is very efficacious and less expensive, the percentage of complications is greater and patient compliance is less.

IL-12 synergizes with IL-2 and other stimuli in inducing IL-10 production by human T cells.

IL-12, a potent inducer of IFN-gamma production by T cells and NK cells, has been recently reported to exacerbate an established Th2 response in vivo. However, the effect of IL-12 on Th2-lymphokine production remains unclear. Since IL-10 is a lymphokine associated with Th2 responses which decreases both IL-12-induced IFN-gamma production and IL-12 production by macrophages, we have analyzed here, in an APC-free system, the ability of IL-12 to modulate the production of human IL-10 by established Th0, Th1, and Th2 T cell clones (TCC), T cell lines, and purified peripheral blood T cells. IL-12 synergized with anti-CD3 mAb, Con A, or IL-2 in inducing IL-10 production by Th0, Th1, and Th2 TCC and by T cell lines. This effect was dose dependent (from 0.1 to 50 U/ml) and associated with an increase of IL-10 mRNA transcription. As previously reported, IL-12 also enhanced IFN-gamma production by stimulated Th1 and Th0 TCC and, to a lesser extent, IL-4 production by stimulated Th0 and Th2 TCC. These observations were extended to peripheral blood T cells stimulated in the presence of exogenous IL-2. Moreover, using neutralizing anti-IL-2 Ab, we report that endogenous IL-2 produced by stimulated Th0 TCC could in part contribute to the effect of IL-12 on IL-10 and IL-4 production. In conclusion, IL-12 synergizes with IL-2 and other stimuli in inducing IL-4 and IL-10 production by T cells. This property may help to explain why IL-12 does not efficiently down-regulate an established Th2 response.

[pT1G3 bladder carcinoma: parameters of a correct therapy]. / Carcinoma vescicale pT1G3: parametri per una corretta terapia.

Between 13.8% and 27% of all superficial bladder cancers are represented by pT1G3 neoplasm. In the Department of Urology of Policlinico S. Marco-Zingonia, between February 1988 and June 1994, we treated 22 patients suffering for pT1G3 bladder tumor. TUR-B has demonstrated to be a good approach for treatment of superficial bladder cancer, with low morbility; on the opposite side, we have to underline the high rate of recurrence and of progression of the urothelium disease. Now a day our best approach for the treatment of pT1G3 bladder tumor is represented by radical cystectomy supplied by chemotherapy.

[Extracorporeal lithotripsy in patients with acquired or congenital coagulopathies]. / Lithotripsie extra-corporelle chez des patients atteints de coagulopathies acquises ou congénitales.

Post ESWL haemorragic complications are frequent and most patients experience temporary haematuria and focal intrarenal bleeding or perirenal haematoma are detected by NMR or US imaging. By tradition coagulation troubles have been a contraindication for ESWL but literature describes cases of coagulopathic patients treated with ESWL. From January 1992 to July 1993, 4 of our patients with severe haemostatis troubles (severe haemophilia A in two cases, acquired deficit of coagulation factors and mild thrombocytopenia secondary to post-necrotic hepatitis in 1 case and Glanzmann's thrombasthenia in 1 case) underwent ESWL using Dornier HM3 mod. or MPL 9000. An extensive haematological and clinical evaluation pre and post-ESWL with an adequate haematological prophylaxis (transfusion of blood derivatives) has been performed depending on the coagulation disorder. In our patients we did not observe any haemorragic complication and we propose a reappraisal of the contraindications of ESWL in subjects with coagulation disorders: careful evaluation of haemorragic risk factors, by suitable correction measures and close clinical and instrumental monitoring, allows a reduction of the risk of haemorragic complications in coagulopathic patients who undergo ESWL treatment.