Gianpaolo R Zanetti

Abstract: Primary cell cultures from renal cell carcinoma (RCC) and normal renal cortex tissue of 60 patients have been established, with high efficiency (more than 70%) and reproducibility, and extensively characterized. These cultures composed of more than 90% of normal or tumor tubular cells have been instrumental for molecular characterization of Annexin A3 (AnxA3), never extensively studied before in RCC cells although AnxA3 has a prognostic relevance in some cancer and it has been suggested to be involved in the hypoxia-inducible factor-1 pathway. Western blot analysis of 20 matched cortex/RCC culture lysates showed two AnxA3 protein bands of 36 and 33 kDa, and two-dimensional Western blot evidenced several specific protein spots. In RCC cultures the 36-kDa isoform was significantly down-regulated and the 33-kDa isoform up-regulated. Furthermore, the inversion of the quantitative expression pattern of two AnxA3 isoforms in tumor cultures correlate with hypoxia-inducible factor-1alpha expression. The total AnxA3 protein is down-regulated in RCC cultures as confirmed also in tissues by tissue microarray. Two AnxA3 transcripts that differ for alternative splicing of exon III have been also detected. Real-time PCR quantification in 19 matched cortex/RCC cultures confirms the down-regulation of longer isoform in RCC cells. The characteristic expression pattern of AnxA3 in normal and tumor renal cells, documented in our primary cultures, may open new insight in RCC management.

Abstract: OBJECTIVE: To report our experience with extracorporeal shock wave treatment for pper urinary tract stones in transplanted kidneys. PATIENTS AND METHODS: A total of eight patients underwent extracorporeal shock wave lithotripsy (SWL) in prone position under analgosedation with the Dornier MPL 9000 lithotripter or the Storz Modulith SLX lithotripter employing ultrasound targeting. The stones had overall diameter ranging 7-12 mm and were located in the renal calices in 5 cases and in the ureter in 3 cases. Five stones were radiopaque and 3 radiolucent. RESULTS: Stone fragmentation was obtained in 87% of the patients and 75% became stone free within 90 days. Serum creatinine values and creatinine clearances remained stable within 30 days post-operatively in all the treated patients. CONCLUSIONS: SWL in transplanted kidney is feasible and simple to perform when the patient is treated in prone position with ultrasound targeting and without any complication or deterioration of renal function. Results similar to those achievable in native kidneys can be obtained also in graft kidneys with limited endourological antero-retrograde ancillary manouvres.

Abstract: Urinary tract infections and urosepsis are complications which can precede or follow a kidney stone treatment. Often the stones themselves are the source of infection, whether they are infection stones or not. Systemic infections are difficult to foresee, and neither a pre-operative negative urine culture nor an antibiotic prophylaxis avoid infectious complications for certain. The primary predictive risk factors of urosepsis are: patient conditions, urinary tract infection or a history of recurrent infections, characteristics of the stone, and anatomy of the urinary tract. Infection stones are still a matter of debate, concerning both the aetiology of the disease and its treatment. Positive cultures are not only found with struvite stones, but also with apatite and calcium oxalate stones. Currently, a long-term antibiotic therapy is advised in patients affected by infection stones. Antibiotic therapy should prevent not only septic complications but also recurrence or re-growth of stones after treatment. Different antibiotic modalities are recommended, sometimes together with urease inhibitors. Mid-stream urine culture is the easiest available pre-treatment parameter notwithstanding its poor predictive value. In case of suspected or proven urinary infection, an appropriate antibiotic therapy should always be administered prior to surgical procedure. There is, however, controversy regarding the antibiotic use, its role, expediency, and duration of prophylaxis in relation to the various surgical procedures, and the way infectious complications are considered and classified. When antibiotic prophylaxis is considered, its duration should be clearly established prior to surgery; duration may vary depending on the type of surgery or the type of antibiotic. Furthermore, prophylaxis should be administered only for a limited amount of time. In infection stones, in immuno-compromised patients or in patients with anatomical anomalies or diabetes, the risk of post-treatment infection and sepsis is higher Hence there is agreement on the need for prophylaxis and antibiotic therapy The most recent literature has shown excellent results with fluoroquinolones both in prophylaxis and therapy, concerning post-operative infection control after percutaneous as well as ureteroscopic removal of stones. No agreement has yet been reached on antibiotic prophylaxis modalities prior to percutaneous or ureteroscopic removal and its usefulness for SWL.

Abstract: Treatment of renal and ureteral stones by SWL has been proved safe and effective in the last 25 years. We reviewed our twenty-four year experience, which began in January 1985 with an original HM3 Dornier lithotripter and has continued along the years with second and multifunctional third generation lithotripters. Dysrhythmias occurred almost exclusively in stone kidney treatments and never in distal ureteral ones. No significant correlation was found between the side of the treated kidney, the number and strength of shockwaves, or the administration of analgesics and the occurrence of dysrhythmia. SWL without ECG triggering was not associated with the occurrence of dysrhythmic episodes of any particular clinical significance. We followed for an average of 42 months patients treated with SWL for different types of stones. At discharge, 31.5% of the patients were stone free, whereas 65.3% had stone dust or passable fragments. At three-month follow-up, 64.8% were stone free and 33.6% had dust or passable fragments. After a follow-up of over 24 months, 55% of the patients were still stone free, recurrence was observed in 13.8% and regrowth of fragments in 22.3% of the patients. Small fragments less than 5 mm are defined as clinically insignificant residual fragments (CIRF); although they are likely to pass spontaneously and remain asymptomatic, they are considered by some authors a factor that favours regrowth and an increased risk for symptomatic episodes. Patients with fragments in our experience do not require systematic retreatment but they could be followed and treated if necessary if stones recur or symptoms persist. Most of the CIRF pass spontaneously after treatment without any complication, but since about 20% of patients become symptomatic or require intervention, a close follow-up is required. Extracorporeal shock wave lithotripsy is the first choice treatment today for most renal and ureteral stones, however adequate evaluation of the patient and of the stone is required, and all possible treatment options should be considered.

Abstract: Cystinuric patients frequently require stone removing procedures because of their high tendency to have recurrent urinary calculi. In the last 20 years the morbidity of stone treatment has been reduced by the introduction of endourologic procedures and shock wave lithotripsy (SWL), but cystine stones are not amenable to all minimally invasive procedures. The aim of our study was to assess the impact of new technology in the treatment of cystine stones. The records of patients observed at our institutions from 1978 to 2005 were reviewed. We retrospectively analysed the previous stone histories of all the patients who presented at our institutions for stone treatment who resulted to be cystinuric at our metabolic work up. Patients were divided in two groups according to the date of our first observation: group A comprised patients observed from 1978 to 1989 who mainly experienced traditional stone treatment and group B patients observed from 1990 to present who were preferentially treated with minimally invasive therapeutic modalities. A total of 48 cystinuric patients were observed (31 in group A and 17 in group B). The mean age (38 +/- 15 vs. 36 +/- 13 years), the age at stone onset (21 +/- 11 vs. 21 +/- 12) and the annual recurrence rate (1.34 +/- 2.38 vs. 1.16 +/- 1.11 stones/year/pt) were not significantly different in the two groups. The male/female ratio was 18/13 and 8/9, respectively, in group A and B. In group A 16 patients underwent open surgical treatment for a total of 29 procedures (0.93 for patient) and four of them had nephrectomy; in group B only eight underwent open surgery but other seven had percutaneous surgery (0.47 + 0.41 procedure/patient). In group B 37 SWL treatments were performed (2.17 for patient) whereas patients in group A underwent only four SWLs. Renal function was impaired in six patients (19%) in group A with a patient requiring haemodyalitic treatment and in one patient (6%) in group B. Compared to the traditional stone treatment, after 1990 fewer cystinuric patients required open surgery and none underwent nephrectomy or developed severe renal failure. Our results indicate that the actual care of patients with cystine stones should still be improved requiring a comprehensive approach in order to avoid inappropriate SWL treatments and more attention to early diagnosis and preventive measures.

Abstract: The aim of this study was to investigate the influence of the potential renal acid load (PRAL) of the diet on the urinary risk factors for renal stone formation. The present series comprises 187 consecutive renal calcium stone patients (114 males, 73 females) who were studied in our stone clinic. Each patient was subjected to an investigation including a 24-h dietary record and 24-h urine sample taken over the same period. Nutrients and calories were calculated by means of food composition tables using a computerized procedure. Daily PRAL was calculated considering the mineral and protein composition of foods, the mean intestinal absorption rate for each nutrient and the metabolism of sulfur-containing amino acids. Sodium, potassium, calcium, magnesium, phosphate, oxalate, urate, citrate, and creatinine levels were measured in the urine. The mean daily PRAL was higher in male than in female patients (24.1+/-24.0 vs 16.1+/-20.1 mEq/day, P=0.000). A significantly (P=0.01) negative correlation (R=-0.18) was found between daily PRAL and daily urinary citrate, but no correlation between PRAL and urinary calcium, oxalate, and urate was shown. Daily urinary calcium (R=0.186, P=0.011) and uric acid (R=0.157, P=0.033) were significantly related to the dietary intake of protein. Daily urinary citrate was significantly related to the intakes of copper (R=0.178, P=0.015), riboflavin (R=0.20, P=0.006), piridoxine (R=0.169, P=0.021) and biotin (R=0.196, P=0.007). The regression analysis by stepwise selection confirmed the significant negative correlation between PRAL and urinary citrate (P=0.002) and the significant positive correlation between riboflavin and urinary citrate (P=0.000). Urinary citrate excretion of renal stone formers (RSFs) is highly dependent from dietary acid load. The computation of the renal acid load is advisable to investigate the role of diet in the pathogenesis of calcium stone disease and it is also a useful tool to evaluate the lithogenic potential of the diet of the individual patient.

Abstract: In calcium renal stones, calcium oxalate and calcium phosphate in various crystal forms and states of hydration can be identified. Calcium oxalate monohydrate (COM) or whewellite and calcium oxalate dihydrate (COD) or weddellite are the commonest constituents of calcium stones. Calcium oxalate stones may be pure or mixed, usually with calcium phosphate or sometimes with uric acid or ammonium urate. The aim of this study was to compare the clinical and urinary patterns of patients forming calcium stones of different composition according to infrared spectroscopic analysis in order to obtain an insight into their etiology. The stones of 84 consecutive calcium renal stone formers were examined by infrared spectroscopy. In each patient, a blood sample was drawn and analysed for serum biochemistry and a 24-h urine sample was collected and analysed for calcium, phosphate, oxalate, citrate and other electrolytes. We classified 49 patients as calcium oxalate monohydrate (COM) stone formers, 32 as calcium oxalate dihydrate (COD) stone formers and three as apatite stone formers according to the main component of their stones. Patients with COM stones were significantly older than patients with COD stones (P < 0.002). Mean daily urinary calcium and urinary saturation with respect to calcium oxalate were significantly lower in patients with COM than in those with COD stones (P < 0.000). Patients with calcium oxalate stones containing a urate component (< or = 10%) presented with higher saturation (P < 0.012) with respect to uric acid in their urine (and lower with respect to calcium oxalate and calcium phosphate, respectively P < 0.024 and P < 0.003) in comparison with patients without a urate component in the stone. Patients with calcium oxalate stones with a calcium phosphate component (> or = 15%) showed higher (P < 0.0016) urinary saturation levels with respect to calcium phosphate (and lower with respect to uric acid (P < 0.009), compared with patients forming stones without calcium phosphate or with a low calcium phosphate component. Patients with calcium stones mixed with urate had a significantly lower urinary pH (P < 0.002) and urinary calcium (P < 0.000), and patients with calcium phosphate >15%, higher urinary pH (P < 0.004) and urinary calcium (P < 0.000). In conclusion, in the evaluation of the individual stone patient, an accurate analysis of the stone showing its exact composition and the eventual presence of minor components of the stone is mandatory in order to plan the correct prophylactic treatment. Patients with "calcium stones" could require various approaches dependent on the form and hydration of the calcium crystals in their stones, and on the presence of "minor" crystalline components that could have acted as epitaxial factors.

Abstract: Cystinuria ia an inheritable autosomal recessive disorder of amino acids transport affecting the epithelial cells of the renal tubules and gastrointestinal tract. It is characterized by abnormal concentrations of cystine and the other dibasic amino acids in the urine, resulting in a risk of renal stone formation because of the low solubility of cystine in urine. According to the recent advances in molecular genetics, two genes have been identified as responsible for this disease (SLC3A1 and SLC7A9), but other unknown genes may be involved in cystinuria. We assessed the presence of cystinuria in 2086 consecutive patients with renal stones by using cyanide-nitroprusside test (Brand's test). According to our experience, this screening test should be performed in all patients at the onset of renal stone disease in order to avoid a delay in the possible diagnosis of cystinuria. In fact cystinuric patients often have mixed calculi composed of substances other than cystine that can disguise the presence of cystininuria that is so diagnosed many years after the onset of the initial symptoms. Patients with positive cyanide-nitroprusside test were further studied for identification of urine amino acids by quantitative ion-exchange chromatography. Pathological cystinuria was confirmed in 39 (1.9%) out of 41 patients with positive Brand test. The mean age of cystine stone patients was 38.1 +/- 15.8 years, whereas the age at stone onset was 21.8 +/- 12.4. Renal stones were recurrent in 85% of cases, while other 6 patients were observed at their first stone. The male to female ratio was 1:0.62. The mean number of stone episodes for patient was 18.5 +/- 35.8 and the mean interval to first recurrence was 4.1 +/- 4.3 years. The recurrence rate 5 years after the first renal stone was 83%. Furthermore we studied 85 members from 24 families of patients with cystine stones. Twenty-four family members excreted excessive amounts of cystine, but only 5 of them (21%) had cystine calculi. Twenty-two patients were treated with 1-1.5 g alpha-mercaptopropionylglycine daily. Treatment reduced stone formation from 0.93 to 0.46 stones/patient/year. Only six patients had side effects of sufficient severity to require withdrawal.

Abstract: Primary tumors of seminal vesicles are rare. We report on a benign tumor of the seminal vesicle with fibroepithelial and cystic features. We performed a laparoscopic transperitoneal approach. The mass, not fixed to any anatomical structures except to the prostate, was isolated and removed. Histological examination of tumor revealed two distinct components: epithelial and stromal. We consider the term fibroadenoma more appropriate than cystoadenoma, because the stroma is not reactive but a distinct neoplastic component.

Abstract: OBJECTIVE: The aim of this study was to analyze the frequency of renal stone patients with chronic inflammatory bowel disease and their urinary patterns. METHODS: During a 20-year period, 1941 consecutive patients with renal stone disease underwent routine laboratory procedures including a fasting blood sample for chemistry profile and a 24-hour urine collection for analyses of electrolytes. Thorough histories including chronic inflammatory disease or ileal resection were obtained. Patients with inflammatory bowel disease together with a control group comprising 47 idiopathic renal calcium stone formers were submitted to a xylose absorption test for evaluation of intestinal absorption. RESULTS: We observed 10 patients with Crohn's disease, 12 with ulcerative colitis and one patient with ileal bypass for obesity. Six patients underwent ileal resection and 10 patients total colectomy. Urinary oxalate excretion was significantly higher and urinary citrate lower in stone patients with ileal disease (Ox 60 +/- 23, Cit 113 + 7-118 mg/day) than in idiopathic stone formers (Ox 28.2 +/- 11.5, Cit 381 +/- 205) and stone patients with ulcerative colitis (Ox 20.3 +/- 14.8, Cit 369 +/- 247). Urinary volume was significantly lower in patients with ulcerative colitis. A significant inverse correlation (-0.38, p < 0.01) between oxalate urinary excretion and blood xylose level was found 2 hours after ingestion of xylose. No significant reduction of xylose absorption was demonstrated in both normoxaluric and hyperoxaluric idiopathic stone patients. CONCLUSIONS: Crohn's disease and ulcerative colitis are characterized by recurrent inflammatory involvement of different intestinal segments involving distinctive urinary patterns. Malabosorption associated with ileal disease causes increased oxalate absorption by increasing oxalate solubility in the intestinal lumen and permeability of the colonic mucosa; a reduced citrate excretion is associated in relation to mild acidosis due to the loss of bicarbonate in the liquid stool. In ulcerative colitis, especially if an ileostomy is present, urine are scanty and concentrated, and urine pH falls, leading to uric acid or mixed stones. Mild hyperoxaluria of idiopathic renal stone formers is not related to subtle intestinal malabsorption.

Abstract: Beginning in the 1980s, a series of anatomical discoveries were introduced to modify the classic retropubic radical prostatectomy proposed by Millin in 1942 in an effort to reduce intra and postoperative complications such as intraoperative bleeding and postoperative erectile dysfunction and incontinence. Urinary incontinence post retropubic "anatomical" radical prostatectomy remains a distressing problem for the patient and the physician rating from 6 to 20% even in the hands of experienced surgeons from high volume Academic Centers. The reason for the discrepancy in results is unclear and should be searched in surgical experience of the surgeon, volume of surgical activity of the Center, and selection of the patients undergoing the radical retropubic procedure. In the Literature we identified methodological factors which can bias the data on post radical retropubic prostatectomy such as 1) Consensus is lacking on definition of continence and/or incontinence following radical retropubic prostatectomy 2) Different surgical techniques are compared: sphincter damaging, versus repairing, versus preserving; bladder neck sparing versus non sparing; nerve sparing versus non sparing 3) Patients with preoperative urinary incontinence are included in the series and the preoperative continence status is not known. 4) Different timing in registration of incontinence. 5) Different methods in data collection. This latter seems to be the most important reason for discrepancy in the collection of the data. Self administered questionnaires oriented to evaluate incontinence analyzed by a third party seem to be the most powerful and objective tool for post prostatectomy incontinence rating. Post prostatectomy incontinence may be attributed to sphincter dysfunction as a result of surgical injury during prostatic surgery and/or to bladder dysfunction including detrusor instability and decreased compliance resulting in stress or urge or mixed stress/urge postoperative incontinence. In the Literature bladder dysfunction is considered to be responsible or jointly responsible for post RRP incontinence in a rate as high as 93%. More recently, a major role is considered to be played in post RRP incontinence pathophysiology by intrinsic sphincter insufficiency. Rarely bladder dysfunction is an isolated cause of incontinence. Moreover the symptom of stress incontinence accurately predicts the finding of intrinsic sphincter deficiency. The apical dissection and the preservation of the intrinsic sphincter remain the most complex parts of RRP and the keys to the maintenance of postoperative urinary continence.

Abstract: PATIENTS AND METHODS: Between January 1996 and December 1999, 749 patients underwent electromagnetic SWL. Among them, 23 patients, 19 with renal and 4 with ureteral stones, were receiving antithrombotic drugs (aspirin, ticlopidine, dipyridamole). According to the cardiologist and hematologist, we divided these patients into two groups: Group 1 had a low thromboembolic risk (previous myocardial infarction), and Group 2 had a high thromboembolic risk (aortocoronary bypass, atrial fibrillation, cerebrovascular disease, peripheral occlusive arterial disease). Group 1 patients discontinued their antiplatelet therapy 8 days prior to SWL to permit a sufficient number of functioning platelets to remain. Group 2 patients suspended antiplatelet therapy, and unfractioned heparin 5000 IU tid (8 a.m., 4 p.m., and 12 p.m.) was administered for the 8 days prior to SWL. On the ninth day of withdrawal, SWL was performed in all patients. Close follow-up was performed during the postoperative period (hemoglobin, hematocrit, kidney ultrasonography, plain abdominal film). The antithrombotic therapy was restored in all patients within 10 to 14 days of withdrawal. RESULTS: Hematomas and thromboembolic events were not observed. At 3 months' follow-up, 14 patients (61%) were stone free, 3 (13%) had <4-mm fragments, and 6 (26%) had >4-mm residual fragments. CONCLUSION: Our schedules for the suspension or substitution of antithrombotic therapy, although tested in a small number of patients, allowed us to perform SWL without hemorrhagic or thromboembolic complications.

Abstract: OBJECTIVES: Diet has been proposed as a causative factor of hypercalciuria in patients with calcium stones. The aim of this study was to investigate the influence of diet on calcium metabolism of renal stone formers. METHODS: Thirty-five renal calcium stone formers were entered in this study. A 2-day recall of dietary intake was obtained from each subject. The food records were coded and computer analyzed for total energy, protein, fat, carbohydrate, sodium, potassium, calcium, magnesium, phosphate, oxalate, vitamin C and fiber. Daily potential renal acid load (PRAL) of the diet was calculated considering the mineral and protein composition of foods, the mean intestinal absorption rate for each nutrient and the metabolism of sulfur-containing amino acids. A fasting blood sample was drawn and a 24-hour urine collection were obtained for analyses of calcium, phosphate and creatinine. Serum osteocalcin was also analyzed. A fasting 2-hour urine sample was collected in the morning for hydroxyproline, pyridinium cross-links and creatinine. RESULTS: The mean daily dietary PRAL of renal stone formers was 22.4 +/- 15.7 (range 4.2-65.8) mEq/day. Regression analysis demonstrated that urinary calcium excretion is dependent on daily protein intake and dietary PRAL, whereas the urinary pyridinium cross-links/creatinine ratio is inversely dependent on daily calcium intake. The urinary pyridinium cross-links/creatinine ratio was significantly lower in patients on a low calcium diet (< 600 mg/day) than in other patients (19.5 +/- 7.8 vs. 27.3 +/- 7.5 nM/mM, p = 0.008). No significant difference was observed between the 2 groups for daily urinary calcium (254 +/- 109 vs. 258 +/- 140 mg/day), serum osteocalcin (8.2 +/- 3.3 vs. 6.2 +/- 2.4 ng/ml) and urinary hydroxyproline/creatinine (14.1 +/- 7.4 vs. 10.3 +/- 4 mg/g). CONCLUSIONS: The urinary calcium excretion of renal stone formers seems to be dependent on dietary acid load rather than dietary calcium intake. In patients consuming an acidifying diet a restriction of calcium intake could increase bone resorption leading to a progressive bone loss.

Abstract: PURPOSE: In industrialized countries the prevalence of upper urinary tract stones has continually increased during the 20th century, but there are considerable differences between countries and also within the same country. To study whether there is still an increase in the frequency of renal stones, an investigation was undertaken to determine the prevalence of stone formers in a village near Milan, Italy, during two time periods, with an interval of 12 years. MATERIALS AND METHODS: Questionnaires were administered in 1986 and 1998 to all adult (age >25 years) occupants of two random samples of households in the village. Participants were asked whether they had experienced a kidney stone during their lifetime. RESULTS: The overall prevalence of stone formers among males was 6.8% in 1986 and 10.1% in 1998; that among females was 4.9% in 1986 and 5.8% in 1998. In all age classes, the respondents in the 1998 survey more frequently reported a history of stones than in 1986, but the prevalence of renal stones was significantly higher in 1998 than in 1986 only among males aged 31-40 and 51-60 years. The yearly incidence was estimated at 0.4%, with 0.6 and 0.18% in men and women, respectively. CONCLUSIONS: This marked increase in renal stones could be the result of environmental factors such as dietary habits and lifestyle, in particular the influence of an increased consumption of animal protein should be considered.

Abstract: BACKGROUND: In the present study we compared the clinical value of two new specific tests for transitional cell carcinoma, urinary nuclear matrix protein (NMP22) levels and bladder tumor antigen (BTA) test, with that of urinary cytology in the follow-up of patients with superficial bladder cancer. MATERIALS AND METHODS: Hundred and five bladder cancer patients were recruited: 30 stage pTa and 45 stage pT1 (group A), and 30 with a history of bladder cancer but no recurrence at the time of the study (group B). Urine samples were collected before any instrumental manipulation of the genitourinary tract. All patients were negative for urinary tract infections at conventional urine analysis. RESULTS: NMP22 at a cutoff value of 6 U/ml showed a sensitivity of 83.3% in pTa cases and 97.7% in pT1 cases, with a false-positive rate of 23.3%. The BTA test was positive in 26.6% of patients with cancer stage pTa and in 66.6% of pT1 stage, with 30% false-positives in the non-neoplastic group. Urinary cytology, performed on three consecutive samples, was positive in 20% of patients with cancer stage pTa and in 64.4% of pT1 stage and did not show any false-positive cases. Stratifying the neoplastic patients according to lesion grade, NMP22 (at a cutoff value of 6 U/ml) was positive in 86.2% of G1, 97.2% of G2 and 90% of G3. BTA was positive in 37.9, 52.7 and 70% of G1, G2 and G3, respectively, while urinary cytology was positive in 37.9, 44.4 and 80%.

Abstract: PURPOSE: We investigate further the recurrence rate and risk factors for recurrence in 300 consecutive patients who presented to our stone clinic after a first stone episode 7 to 17 years ago. MATERIALS AND METHODS: The medical records of the patients who presented consecutively with a first stone episode from 1980 to 1990 were studied and supplemented by a followup mail questionnaire and telephone interviews. At first visit serum samples were taken from all patients and 24-hour urine samples were collected for metabolic testing. RESULTS: A total of 195 patients were followed successfully, of whom 52 (27%) experienced symptomatic stone recurrence after a mean plus or minus standard deviation of 7.5+/-5.9 years. However, ultrasound examination of 36 symptom-free patients showed recurrent stones in 28%. Comparison of patients with or without recurrence confirmed that recurrence was not influenced by sex, family history of stones and urinary risk factors. However, age at onset of the disease was lower for patients who had 2 or more stones during followup than those who had only 1 stone or no recurrence. CONCLUSIONS: Stones can recur as long as 10 years after the first episode, although the rate is lower than previously reported. The metabolic evaluation after a first stone episode needs to be reappraised in terms of its cost-effectiveness, since recurrences do not seem to be predictable from standard laboratory tests.

Abstract: PATIENTS AND METHODS: We evaluated in 269 consecutive patients the incidence and gravity of dysrhythmic complications during nonsynchronized extracorporeal shockwave lithotripsy (SWL) using an electromagnetic lithotripter. RESULTS: Dysrhythmia occurred during treatment in 22 patients (8.8%) with no previous cardiac dysrhythmia. Ventricular extrasystoles occurred in 14 patients, atrial extrasystoles in 7 patients, and sinus bradycardia in 1 patient. It was not necessary to terminate treatment because of the occurrence of dysrhythmia in any of the patients. For 13 of the 22 patients (59%), it was sufficient to interrupt the treatment momentarily to obtain resumption of the normal rhythm. For 8 patients (36%), treatment was continued after triggering the release of the shockwaves with the refractory phase of the heart cycle. For one case of bradycardia (42 beats/min), it was possible to continue with the treatment after intravenous administration of atropine 0.5 mg. Pretreatment dysrhythmias were revealed by the electrocardiographic examination in 16 of the patients studied (6.3%). CONCLUSIONS: Extracorporeal shockwave lithotripsy without ECG triggering has been found to be fast and efficient and not correlated with the occurrence of dysrhythmic episodes of any particular clinical significance. No significant correlation was found between the occurrence of dysrhythmia, the side treated, the number and strength of the shockwaves, or the administration of analgesics. It was found, however, that dysrhythmia occurred almost exclusively in treatments involving the kidneys. The ECG-triggering option was indispensable in some patients in order to complete the lithotripsy without complications.

Abstract: Transurethral resection of the prostate (TURP) is still the standard treatment of benign prostatic hypertrophy (BPH) but the surgical lasers recently introduced seem to offer the patient a very low perioperative complication rate, a short learning curve, the reduced operating time and the health care system a very low cost/benefit ratio. We report our personal experience with contact vaporizing laser ablation of the prostate (CLAP) paying attention to efficacy, safety and costs. Between December 94 and March 97, 67 pts (mean age 62.8 +/- 9 years) underwent CLAP for BPH (mean prostate volume 40.4 +/- 17.1 cc). Five pts presented coagulation disorders, five were renal transplant recipients and one had chronic renal failure requiring peritoneal dialysis. All patients were preoperatively submitted to digital rectal examination, transrectal prostatic ultrasound, dosage of serum PSA, determination of the International Prostatic Symptom Score (IPSS), the post voiding residual urine and maximum flow rate. All these exams were repeated at 1, 3, 6, 12 and 24 months after CLAP. The bladder pressure at maximum flow (Pdet-Qmax) was preoperatively determined in 23 patients and repeated at the six months follow up. For CLAP we used an SLT neodynium-YAG laser or diode laser with maximum potency 60 W. For statistical analysis we used Student's t-test for paired data. The mean operating time was 47.9 +/- 12.5 min (range 18-75 min) and the laser energy averaged 17.707 +/- 11.239 J (range 3000-58,000 J). The mean catheter time after CLAP was 2.5 days and the mean hospital stay was 4.8 days. No intraoperative complications occurred. Two patients 48/72 h after surgery presented macrohematuria requiring laser revision, three patients presented an acute urinary retention post catheter removal and one patient had acute prostatis. At the follow up, the IPSS score, Q max, Pdet-Qmax and PVU showed a significant statistical difference respect to baseline values. The prostate volume at the 180-day follow up was not significantly different from baseline values (42.1 +/- 16.8 cc vs 40.4 +/- 17.1 cc). Contact laser ablation of the prostate has been demonstrated to be efficacious and comparable to TURP in relieving BPH obstruction however the higher costs exceeding the TURP ones by 13%, the longer operative times and the lower durability of laser disobstruction impede to replace TURP with the CLAP.

Abstract: Numerous authors have reported successful results with both antegrade or retrograde endopyelotomy. Both procedures have proved to be efficient in primary as in secondary obstructions. Some additional etiological factors, such as crossing vessels high-grade hidronephrosis and poorly functioning kidney, may decrease the success rate of these minimally invasive techniques. The development of a cutting balloon catheter used under fluoroscopic control simplified the retrograde technique. This technique proved to be easier to perform than antegrade or retrograde endoscopic incision and did not require specialized instrumentation. In our experience 6 patients from 30 to 65 years old (average age 52) with an ureteropelvic-junction obstruction secondary to open surgery underwent endopyelotomy with the cutting balloon device. At the three month followup 4 patients had renographic patent ureteropelvic junction and no modifications were seen at one year follow up The retrograde endopyelotomy under fluoroscopic control seems to offer a rapid and effective treatment of UPJO. It is indicated for all primary and secondary UPJO obstruction apart forpatients with a concomitant renal stone or with high-insertion ureteropelvic junction.

Abstract: Permanent metallic stents have found wide application for use in the vascular and biliary systems and currently devices are also available for use in the urinary tract. Permanent stenting of the ureter has proven to be an useful option in the management of obstruction caused by external compression due to malignancy whereas the efficacy of permanent stenting in the treatment of benign ureteral strictures is still controversial. We treated three patients with benign ureteral strictures by implantation of a self-expanding endoluminal stent that resulted in ureteral patency persisting up to 24 months.

Abstract: The access to the collecting system can be performed under fluoroscopy computerized tomography, ultrasonographic, mixed ultrasonographic and fluoroscopic guidance. In this paper the creation of a percutaneous transparenchymal ultrasound-fluoroscopy guided access to the intrarenal collecting system completely performed by urologist for different purposes is presented. In five years 297 patients underwent 330 percutaneous kidney accesses to perform derivative nephrostomies (217 pts), percutaneous nephrolithotomies (37 pts), antegrade ureteral manoeuvres (34 pts), antegrade endopyelotomies (7 pts), transitional cell carcinoma of the upper tract resection (2 pts). 11 patients out of these had a percutaneous kidney access in a transplanted kidney. The percutaneous access was successful in 98% of the attemps. A posterior calyx of the lower group (74%), of the medium group (25%) or of the upper group (1%) was accessed. In 73 accesses the mean target calyx diameter was 12.8 mm (range 5-45 mm), the mean operative time 5.4 minutes and the mean fluoroscopy time 5.1 seconds. In 84.5% of the patients the access was performed under local anesthesia when a dilation of the tract was not required. Gross haematuria was observed in 3.9% of the accesses and an arterial lesion treated by embolization in 0.9% of the accesses. Blood transfusion was required in 0.3% of the patients. The ultrasound-fluoroscopy guided access is at least as precise as the fluoroscopy guided one moreover it makes the procedure less invasive and it makes more precise the surgical planning.

Abstract: PURPOSE: Patients with calcium renal stone are reported to have lower bone mineral density. The state of bone density in patients with renal stones have different explanations but the role of nutritional factors seems to be crucial. A group of 48 consecutive male calcium renal stone formers was studied to investigate the relationship between bone density and dietary intake. MATERIALS AND METHODS: Patients completed a dietary diary for a 3-day period during normal diet. Nutrients and calories were calculated by food composition tables using a computerized procedure. Bone densitometry was assessed at the lumbar spine and femoral neck, and expressed as Z score. A blood sample was collected and was analyzed for serum biochemistry including alkaline phosphatase, parathyroid hormone and 1,25 vitamin D. A 24-hour urine sample was analyzed for calcium, phosphate, oxalate, citrate and other electrolytes. RESULTS: Dietary calcium intake was significantly lower (p < 0.01) in patients with low than in those with normal bone mineral density. There was no difference in serum parathyroid hormone levels, phosphate and alkaline phosphatase between the 2 groups. The results suggest that some renal stone formers seem to be unable to decrease renal excretion of calcium on a low calcium diet leading to a negative calcium balance. CONCLUSIONS: A primary abnormality of bone metabolism could be a reasonable explanation of reduced bone density observed in renal stone formers on a low calcium diet since serum parathyroid hormone levels are in the normal range. From a therapeutic point of view these data confirm that restriction of dairy products in renal stone formers should be avoided.

Abstract: Incontinence isn't itself a disease but the feature of possible urinary tract alterations or outside of it. Incontinence is frequent above all in the elderly but it can be on charge of both sexes at every age. In Italy, according to recent evaluations, people affected with this disease would be more than 4 millions. Incontinence is therefore an important failure for its health aspects but also for economic and social ones. The problem is to evaluate if incontinence can't be prevented and as consequence needs only an assistance management, or it can be considered a preventable disease able to be cured, as we deeply believe, suggested also by the positive results of new therapeutical procedures, in association with traditional surgery and rehabilitation such as injectables or mini-invasive quick operations such as colpocleisis or percutaneous vaginal colposuspension (PVC), matters of this presentation and always performed according to correct diagnosis and indication. Bovine dermal collagen highly purified, poorly viscous and easily injectable, despite traditional rehabilitation and surgery, is a further procedure, endoscopic and minimally invasive to treat stress incontinence. Collagen is employed to perform a bladder neck plasty, increasing urethrosphincterial competence, to obtain continence without the creation of an obstruction. Genital prolapse, that is hysterocolpocele or simple vaginal vault prolapse, has course in high proportion (37%) in elderly (after 80 years). Surgical management of severe failures of continence and often also of the voiding function, such as: hyscuria with vesicoureteral reflux, obstinate constipation related to severe genital prolapse with allied rectocele is often hardly performed in elderly owing to the age and general health conditions: colpoclesis is a vaginal surgical approach that can be easily performed by the urologist too, it is an effective alternative to permanent catheterization or maxipad to be offered to the patient to improve her quality of life. In between the above maintained procedures takes place the percutaneous vaginal colposuspension (PVC). It is an original technique made up in our Institute to treat incontinence by the bladder neck resuspension to Cooper ligament according to a complete miniinvasive retropubic tension free transvaginal colposuspension, in local anaesthesia and complementary light narcosis in Day Surgery. Urinary incontinence is today a disturbance easy to be cured thanks to injectables and to miniinvasive surgical procedures as reported in this presentation concerning the most advanced approaches to its management.

Abstract: Eighteen years after the first clinical shock wave lithotripsy (SWL), no doubt remains as to its therapeutic efficacy in ureterorenal lithiasis. The advent of lithotriptors with a large shock wave energy range and integration of both ultrasound and radiologic imaging equipment at the shock wave source has meant that outpatients treatment of urolithiasis is now feasible in a good proportion of cases. In our lithotripsy center, from January 1995 to August 1996, 208 out of 310 patients who underwent SWL treatment for renal and ureteral stones, were outpatients. Pretreatment manoeuvres were performed in 10.6% of the patients. No major complications occurred during the treatment. Only three patients (1.4%) were admitted to hospital because of fever, colics or perirenal haematoma in the first two days after SWL therapy. The stone free rate was 67 and 84% respectively one and three months after treatment. In our experience, the possibility of performing SWL treatments without anesthesia and even analgosedation, the absence of complications and the high success rate, make outpatient treatment of urolithiasis safe and suitable in a large number of patients.

Abstract: We studied 476 patients with idiopathic renal calcium stone disease (286 M, 190 F) while they ate their customary diets. Each subject collected a 24-hour urine sample and completed a dietary diary for a 3-day period. Daily urinary oxalate excretion (M 0.24 +/- 0.15 mg/dl, F 0.23 +/- 0.15 mg/dl) and nutrient intake values were calculated and multiple regression analyses were performed. Daily urinary oxalate excretion was significantly (p < 0.001) related to urinary volume (R = 0.24), vitamin C intake (R = 0.33) and body mass index (R = 0.37) and inversely related to calcium intake (R = -0.35). We conclude that urinary oxalate reflects endogenous oxalate production, presumably related to body size, but also intestinal absorption of oxalate, related to dietary intake and to the effect of dietary calcium intake which reduces intestinal oxalate absorption.

Abstract: Recent interest in nephron sparing surgery for renal cell carcinoma has been stimulated by advances in diagnostic imaging, following an increasing number of incidentally discovered low stage renal cell carcinoma and good long term survival in patients undergoing this form of treatment. Tosaka et al reported a 5-years survival of 94.7% in patients with incidental renal cell carcinoma compared with 60.9% in diagnosed because symptomatic. Along with a diagnosis of carcinoma more and more premature, a whole string of little lesions is present, not easily identifiable by the recent diagnostic imaging. Tosaka and others examined renal lesions going by the ultrasonography as a check-up or as a first frame in patients suffering from microscopic hematuria; they proved that neoplastic lesions represent 5.4% of all the masses identifiable by diagnostic imaging. The frequent discovery of limited carcinoma, the difficulty in the diagnostic attribution and demonstration of the good survival of patients who were treated by a nephron sparing surgery, added to the one of patients undergone to radical nephrectomy, caused an interest in nephron-sparing surgery for incidental renal carcinoma also for patients with normal controlateral kidney and not very extended tumors, usually in peripheral sites. At the moment record of cases concerning nephron sparing surgery is quite limited, any way it shows a survival equal to 90% with only two local recurrences, reported only in one experience and caused by an incomplete resection or by multicentric neoplastic lesions.

Abstract: 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.

Abstract: 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.

Abstract: 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.

Abstract: In the female patient with transitional cell carcinoma the risk of urethral recurrence is very low, when the bladder neck is histologically free of tumour. On the other hand urinary continence can be maintained if the lower half of the urethra together with the nerve supply is preserved. On this basis orthotopic bladder reconstruction was applied also in a female patient. In order to preserve urinary continence minimal dissection was performed anterior to the proximal urethra; in addition pubourethral ligaments were left intact. On the other hand to prevent chronic urinary retention arising from downward displacement of the reservoir a colposacropexy was performed. At 3 weeks the filling cystogram demonstrated a well shaped and compliant reservoir. No downward displacement of the reservoir was observed in upright position. Neither reflux nor residual urine could be demonstrated by voiding cystourethrogram. The woman achieved diurnal and nocturnal continence at 3 month.

Abstract: We subjected to a functional and metabolic evaluation (urodynamic examination + cystography) 10 patients underwent to radical cystectomy with a ileal orthotopic reservoir (VIP) for bladder cancer. At the moment patients have a minimum 3-years follow-up and they are out of disease. The medium capacity of the reservoir is about 447 ml, with a low pressure flow, a medium pressure of ureteral closing of 62.5 cm of H2O. At the cystography neither ureteral reflux nor post miction residuum have been proved. All the patients are continent, with the exception of one patient suffering from episodes of nocturnal enuresis. The metabolic evaluation hasn't proved substantial changes except the presence of hypocitraturia in the only patient in metabolic acidosis. In conclusion the ileal orthotopic reservoir showed a good long-term functionality without considerable complication of metabolism.

Abstract: The laparoscopic technique has well defined indications for some andrological procedures such as the diagnosis and the treatment of cryptorchidism, but its role remains controversial in varix ligation for which laparoscopy is however the newest development. At the Institute of Urology of the University of Milan from January 1992 to June 1994 five adults patients with undescended and unpalpable testis underwent laparoscopy. In 4 cases laparoscopic orchiopexy (2 direct and 2 staged procedures) and in one case laparoscopic orchiectomy have been performed. In the same period 20 cases of varicocele (6 bilateral) have been observed and treated by laparoscopic varix ligation. For cryptorchidism after the identification of the testis we decide on the basis of parenchimal trophism wheter to perform orchidopexy or orchiectomy. A single step laparoscopic orchiopexy can be performed if the undescended testis is located proximal to the internal inguinal ring and if the mobilization of the spermatic vessels allows it. A Fowler-Stephens staged orchiopexy is indicated for intra abdominal testicle with short spermatic vessels. In the first stage the spermatic vessels are isolated and divided relying on the compensation offered by the deferential and extrafunicular vessels. After six months, once the testis trophism has been ascertained, the testis can be placed in the scrotum. For varicocelectomy the peritoneum is incised at the projection of the spermatic cord from the internal inguinal ring. A blunt and gentle dissection prepares the spermatic vascular bundle, the spermatic artery is identified and isolated and the vein are clipped and divided.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract: In order to achieve an appropriate technical experience and explore clinical feasibility of laparoscopic urinary diversion, the authors planned a laboratory experiment. In ten male pigs weighing about 25 kilograms cystoprostatectomy was performed. Ureterocutaneostomy or ureterosigmoidostomy were carried out next. For ureterocutaneostomy a channel was bluntly dissected through the abdominal wall. The ureter was grasped by a clamp passed through the stroma, drawn outside and anstomosed to the skin. Operative time was about 30 minutes. For ureterosigmoidostomy a longitudinal incision of approximately 1 cm was made through the wall of the sigmoid colon in order to reach the mucosa. A very small opening in the angle of the incision was made. A suture was placed in the ureteral tip and secured to the colon wall. Finally, the ureter was covered in its bed with antireflux technique. Operative time was about 180 minutes. Laparoscopic ureterocutaneostomy was also successfully applied in a compromised patient to resolve a particular clinical situation.

Abstract: Diseases of the kidney and of the adrenal gland can be managed surgically by the laparoscopic approach. Laparoscopic nephrectomy, nephroureterectomy, renal cyst resection and adrenalectomy have been reported. This paper describes our early experience with the laparoscopic approach for the treatment of diseases of the kidney and of the adrenal gland. Since June we have performed 4 nephrectomies, 14 renal cyst excisions and one adrenalectomy. Postoperative recovery and need for pain medication were reduced. Complications have been rare. At the present time laparoscopic nephrectomy for benign renal diseases, laparoscopic excision of recurrent renal cysts and laparoscopic adrenalectomy for functioning renal tumours should be considered. The role of laparoscopic approach for treatment of malignant diseases of the kidney and of the adrenal gland is still debatable.

Abstract: 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.

Abstract: Today we may consider radical perineal prostatectomy as an example of mild invasive surgery compared with the retropubic. Technique is found less traumatic account of the precision of the approach, the accuracy of hemostasis and urethral bladder suture and the speed of postoperative handling. The only disadvantage related with the impossibility of transperineal pathological lymph node staging can today be satisfactory overcome after the advent of laparoscopic lymph node methods which permits safe non invasive preoperative hystological examination. The authors show the technique of laparoscopic and surgical therapy, concluding that perineal prostatectomy is a better approach toward retropubic radical prostatectomy, if combined with preoperative laparoscopic pelvic lymphadenectomy.

Abstract: 22 pts treated by radical perineal prostatectomy have been submitted to pelvic floor training soon after catheter removal, in order to assess faster continence reappraisal than that normally described in literature. 18 pts resulted dry within 4 months from surgical care. 2 pts resulted with stabilized mild stress incontinence due to daytime activity within 6 months from prostatectomy. 2 pts complained strong stress urinary incontinence over a period of more 9 months from surgery, but none resulted affected from continuous leakage. In this pts we observed a maximum time of continence reappraisal of 6 months with a minimum of 1 and an average of 4. An high perineal test has been found statistically correlated in the first three months from surgery with nocturnal continence reappraisal and the begging of diurnal micturion events (p < 0.005). Pelvic floor exercises has been found useful in the treatment of post radical perineal prostatectomy stress urinary incontinence.

Abstract: The advances made in laparoscopic surgery during the last five years have made possible the performance of a variety of bladder level procedures as suspension of the bladder neck, removal of bladder diverticulum and cystectomy. Laparoscopic bladder-neck suspension is purposed by different Authors as a minimally invasive procedure that can be provide efficacious results as like as open surgery, reducing post-operative disconfort. All different laparoscopic technique provide good results at short-term follow-up. A longer follow-up period is required for the evaluation of the effective efficacy of this treatment. In according with other authors, our experience with laparoscopic bladder diverticulectomy demonstrates the feasibility and the potentiality of this technique. Up to now this procedure has been employed in the treatment of diverticula involved in urinary infection or residual urine. At the beginning, laparoscopic cystectomy has been purposed in patients with begin disease; more recently, laparoscopy has been disease; more recently, laparoscopy has been employed for cystectomy in case of bladder cancer. The few cases described demonstrate that the technique is feasible but, until now, laparoscopic cystectomy has been reported just in female patients.

Abstract: Laparoscopic surgery admits the retroperitoneal approach: the main restriction is the tight manoeuvring space that can be obtained with insufflation. The use of a dilatator balloon in the retroperitoneal cavity offers a solution to this problem. A cutaneous access and a dull parietal path is created, with blind positioning of the apex of the dihedron between the inferior renal pole and the ureter. Peroperative ultrasound control makes it possible to identify the inferior renal pole, to control the position of the apex of the catheter with the balloon and the movements of the retroperitoneal organs in real time. The possibility of following the procedure by ultrasonography have proven usefull in our experience.

Abstract: The main post uretero-sigmoidostomy complications are stricture of the anastomosis, chronic infection and urolithiasis. In our institution the patients with ureterosigmodostomy undergo a follow-up protocol in which blood chemistry, ultrasonography, intravenous pyelography and C.T. are periodically performed. The aim of the present paper is to compare the accuracy of kidney sonography after diuretic stimulation with intravenous pyelography in the diagnosis of ureteral stenosis. Out of 91 patient with ureterosigmoidostomy 18 patients (34 kidneys) underwent intravenous pyelography, a basal U.S. and then a dynamic one at 5, 10, 15, 30, 45, 60, 90, 120 minutes after administration of furosemide 20 mg i.v. At basal U.S. 27 kidneys were normal and 7 showed a dilations. After diuretic stimulation we observed 16 normal kidneys, 16 dilated units and 2 intermittent hydronephrosis. Out of 16 dilated kidneys 6 became normal in 60 minutes. Out of 10 dilated units 3 were normal in 90 minutes (hipotonic), 2 were normal before 120 minutes (low grade obstruction) and 5 were dilated after 120 minutes (high grade obstruction). With intravenous pyelography we observed 27 normal kidneys and seven dilated units. Dynamic sonography have shown high sensibility (100%), specificity (88.8%) and accuracy (91%) in diagnosis of ureteral obstruction in to I.V.P. in the follow-up of this kind of divesion.

Abstract: Six patients with inferior and middle polar renal cysts of 8-15 centimeters of diameter, underwent the resection of the cyst by laparoscopic technique. The operation required an average time of execution of two hours and the positioning of four trochars to consent an adequate access. The absence of important complications during and after the operation has allowed a quick dismission of the patients. The laparoscopic treatment of renal cysts represent a valid choice to traditional surgery and percutaneous needle aspiration.

Abstract: Surgical treatment of varicocele can be carried out using different techniques. The laparoscopic approach [1-2] represent a new trend that we used to ligate and dissect the spermatic vein in 10 patients, 8 with monolateral left varicocele and 2 with bilateral varicocele. The average time for laparoscopic surgery has been 45 minutes for monolateral varicocele and 65 minutes in the bilateral one. The absence of important complications during and after the operation has allowed to dismiss all patients 48 hours after the surgical treatment. The preferential direction of laparoscopic approach to varicocele is represented by the bilateral form.

Abstract: 7 patients, suffering by prostatic adenocarcinoma in clinical stage B, were undergone to laparoscopic pelvic lymphadenectomy, to obtain a complete staging. The average time of execution of the operation was 180 minutes. The absence of important complications during and after surgical time, within low surgical trauma, has allowed the dismission of patients 48 hours after the operation. The low morbility demonstrated for this technique has allowed the dissection of a number of lymph node to consent an adequate staging.

Abstract: The Authors illustrate their experience in the treatment of a case of left criptorchidism using laparoscopic technique associated with traditional surgery (Fowler-Stephens technique) without important complications during and after the procedure. The non palpable testis was located in the peritoneal cavity. The first step consists in a laparoscopic clip ligation of the spermatic vessels with the intent of improve the vasal collateral blood flow. After a 6 months interval, the patient underwent laparoscopic orchidopexy.

Abstract: During our experimental trial we achieved laparoscopic cistectomies with urinary diversion to prove our manual capability with the reconstructive surgery. We executed, on male pigs, 10 cistectomies with urinary diversion using laparoscopic technique. We performed 5 ureterocutaneostomies on 5 pigs and, in the other ones, 5 ureterosigmoidostomies. During UCS the pigs laid in lateral position, and during USS in supine position. The average time of the operation is going to reduce in consideration of the overcoming of the initial techno-instrumental difficulties and is 60 minutes for cistectomy, 30 minutes for ureterocutaneostomy and 120 minutes for ureterosigmoidostomy.

Abstract: Laparoscopic nephrectomy is a new procedure in which the entire kidney is removed introducing it in an Endopouch and, after morcellation pulled out through a 12 mm port. After an initial experimental experience, in our Institute we have performed one laparoscopic nephrectomy for left pyelonephritic kidney and ureteral reflux. The operation required the positioning of 5 trocars and 4 hours for its execution. The discharge of the patient was possible four days after.

Abstract: This paper describes the case of a recurrent post-partum urethrovaginal fistula. The extent of the vaginal tissues loss and the perilesional scarring made the direct closure of the defect non practicable. After suturing the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Nineteen months after surgery the flap healed well without peri urethral suffusion.

Abstract: Extracorporeal shock-wave lithotripsy (ESWL) is now applied as the treatment of choice in most cases of urinary stones. Its acceptance in pediatry, however has been only gradual despite numerous positive studies. We report on fourteen young patients (mean age: 9.7 years) who were all treated by ESWL with the MPL9000 lithotriptor for renal stones. Each patient received an average of 1440 shocks with generator energy set at 14.4 Kv. Six of these patients required either analgosedation or anesthesia. No observable complications of treatment occurred. At one-month follow up, the kidneys of twelve patients were found to be stone-free, while two still presented fragments that could pass spontaneously. At three-month follow-up, thirteen patients were stone-free and a single patient retained some fragments. From this data we infer that ESWL with the MPL9000 lithotriptor may be used safety and efficiently to treat urolithiasis in younger patients.

Abstract: From the beginning of urological applications of laparoscopy, this technique has found many clinical indications. In our center, after an experimental training in animals, we performed 48 operations using laparoscopy: 18 pelvic lymphadenectomies (15 for prostate cancer, 2 for bladder tumor and 1 for penis carcinoma), 11 ligatures of the spermatic vein (3 bilateral), 4 orchidopexies, 10 excisions of renal cysts, 4 nephrectomies and 1 adrenalectomy. For cryptorchidism, laparoscopy is a less invasive alternative to surgical exploration; in case of prostate cancer, laparoscopic pelvic node dissection has a lower incidence of complications and requires few days of hospitalisation. The excision of renal cysts by laparoscopy, in case of large symptomatic pathology, is an efficacious operation with low morbidity. In case of nephrectomy for small wrinkled kidneys or severe hydronephrosis, long execution time makes cost/benefit ratio somewhat debatable; adrenalectomy, instead, is easier than nephrectomy and offers many advantages in comparison with traditional surgical approach. All indications will be better evaluated at a later date, with the indispensable learning period and the continuous progress of technical equipment.

Abstract: Bladder endoscopy and videolaparoscopy, both outcomes of human intelligence applied to technology, allow in association, to evaluate bladder proliferent alterations in the depth, providing the possibility to perform a radical treatment, including perithoneum, without risks of ileum injuries. Aim of the method is to increase diagnostic and operative effectiveness of the simple cystoscopy by the adding of the endoperithoneal control of the bladder just by the videolaparoscopy. By this new technique at least two main advantages may be achieved: the check at full thickness of the bladder wall by translightening; the transurethral resection with laparoscopic assistance.

Abstract: This paper describes a case of recurrent postpartum urethrovaginal fistula. The extent of the vaginal tissue loss and the perilesional scarring made direct closure of the defect not practicable. After suturing of the urethra, the anterior vaginal wall was reconstructed with an island bulbocavernous musculocutaneous flap raised from the left labium majus. Seven months after surgery, the flap healed well, and cystography showed a regular voiding without periurethral suffusions. Healing of thedonor site also was aesthetically satisfactory.

Abstract: A potential complication of prostatic adenomectomy and TURP is urinary incontinence. The incidence of this problem ranges from 0.1 to 1%. we reviewed our experience with 15 patients who were incontinent between 10 to 24 months after prostatectomy. We treated these patients with bladder training. At first, patients were evaluated for the type and extent of incontinence. Perineal exercise were taught in detail, tested for their correct use via simultaneous and abdominal examination. Patients were evaluated weekly for compliance. No pharmaceutical agents were used. All the 15 patients improved in the number of incontinence episodes 5 patients achieved total continence, while only one showed a little change. We conclude that patients who are incontinent after prostatectomy can improve with a well-done behavioral training program.

Abstract: Perineal floor training and perineal biofeedback allow to reach a good improvement of clinical discomfort in the treatment of stress and urge urinary incontinence. The aim of this study is the real evaluation of the benefit due to a 6 week perineal biofeedback and pelvic floor training (PFT) versus PFT alone. 8 female patients have been treated with a 6 week trial with perineal biofeedback plus PFT trial and 22 with a 3 month PFT alone one. PFT alone, permits a good improvement but 10% less than if associated to perineal biofeedback.

Abstract: A therapeutical trial based on pelvic floor training, reduced evening fluid intake and a 3 hour nocturnal awakening has been performed by 12 adult primary enuretics. The aim of this study is to verify if diurnal pelvic floor training is useful to gain a nocturnal micturition control.

Abstract: We have studied the prognostic significance of prostate-specific antigen (PSA), monitored monthly, in 24 patients with prostatic cancer (5 D1, 19 D2) on endocrine therapy. The pretreatment levels of PSA were high in all patients (mean value 41 ng/ml). It was found that PSA levels at the end of the first and sixth months of treatment were reliable prognostic indicators. At the first month evaluation PSA had decreased more than 50% from the initial values in the 16 patients with stable disease, while it had decreased less than 50% in those with progressing disease. At the end of 6 months, patients with stable disease had PSA levels within the normal range, while 8 of the patients who had progressing disease had levels higher than 10 ng/ml. Respectively 6 and 2 patients had also had increases in PSA levels at 3 and 6 months before scintigraphic demonstration of increased bone metastases.

Abstract: Tumor markers are antigens which can be associated with certain malignancies. A variety of markers have been demonstrated in genitourinary tumors. The best known examples are human chorionic gonadotropin (bHCG) and alpha-fetoprotein (AFP) for testicular tumors, prostatic acid phosphatase (PAP) and prostatic specific antigen (PSA) for prostatic cancer. The plasma levels of these substances are influenced by the tumor mass and therefore by the tumor stage. Markedly elevated plasma levels can be demonstrated when metastases are present, although a few patients without metastases may elaborate abnormal amount of markers. The removal of the primary tumor leads to a fall to normal levels: a still increased level indicates residual primary tumor or the presence of metastases. Measurements of markers are also of value in estimating the effects of medical treatment and in detecting local or distant recurrences.

Abstract: We evaluated the usefulness of percutaneous nephrostomy in 1700 patients treated for reno-ureteral stones by extracorporeal shock wave lithotripsy (SWL). Out of this group 81 patients (5.8%) underwent echo-guided percutaneous nephrostomy (EPCN): the procedure has been performed in local anesthesia in 38% of the cases (31 pts) before SWL and in 62% (50 pts) after. The majority of EPCN were carried out for the presence of acute or chronic ureteral obstruction with echographic evaluable dilation of pyelocaliceal system when retrograde ureteral manipulations failed or were considered unsuitable. EPCN before SWL was performed because of ureteral stone and uncomplicated pyelocalyceal dilation (19 pts); ureteral stone, pyelocaliceal dilation and fever > 38 degrees C (3 pts); ureteral stone, pyelocalyceal dilation and functional IVP exclusion (5 pts); pyelic stone in solitary kidney (1 pts); ureteral stones in pregnancy (2 pts). EPCN after SWL was performed because of uncomplicated, persistent pile-up (31 pts); ureteral pile-up complicated by fever and colics (9 pts); ureteral obstructing fragments (2 pts); double J obstruction by stone dust (3 pts); persistent ureteral pile-up around double J (3 pts); anuria in solitary kidney (1 pt). Out of the patients who underwent EPCN before SWL 13% were stone free and without drainage at discharge, 77% had passable stone fragments at discharge and drainage has been taken out at 15-30 days check up, 10% had unbroken stone and underwent with drainage to ureterolithotripsy.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract: The safety and short-term effectiveness of percutaneous nephrolithotomy (PCNL) and extracorporeal shock wave lithotripsy (ESWL) have already been well established. However, long-term follow-up studies are essential to prove that the recurrence rate after PCNL and/or ESWL is equal or even better than that of surgery. We reviewed 57 patients treated with ESWL monotherapy, 45 patients treated by PCNL (or by PCNL combined with ESWL for complete staghorn stones) and 59 patients treated by open surgery who all had at least three years of follow-up. The overall recurrence rate for ESWL was 37% for PCNL and for open surgery 39%. ESWL, PCNL and open surgery all showed a higher rate of recurrence and persistent bacteriuria when associated with residual stones. Therefore every effort should be made to remove residual fragments following stone treatment. We conclude that because of its efficacy and low morbidity ESWL should be the treatment of choice for most of renal calculi. Complete staghorn calculi are best treated with open surgery because the complete elimination of all calculous material and the eradication of infection are achieved at a higher rate than by PCNL and ESWL.

Abstract: Increasing interest has developed in recent years about the preservation of sexual function after urological surgery. The pelvic plexus which is formed by parasympathetic visceral efferent preganglionic fibers that arise from the sacral center provides autonomic innervation to the corpora cavernosa. The cavernous nerves emerge from the pelvic plexus and then travel along the posterolateral portion of the seminal vesicle and prostate and then along the membranous urethra. The preservation of the nerve supply of the corpora during urological and pelvic procedures is of vital importance to preserve potency.

Abstract: A total of 64 treatments by the Dornier HM3 lithotriptor was performed on 52 solitary kidneys with stones. A slight increase but no significant variations in serum creatinine was noted in 15 patients without obstruction just after treatment (p greater than 0.05). No significant increases in serum creatinine were found even at the short-term, mid-term and long-term followup. After 12 to 56 months hypertension developed in only 1 previously normotensive patient. Of 37 patients at mid-term followup (12 to 24 months) 62% were stone-free, 24% had passable fragments, 8% had recurrent stones and 5% had regrowth of the residual fragments. At long-term followup (24 to 56 months) 50% of 26 patients were stone-free, 19% had dust or passable fragments, 19% had recurrences and 11% had regrowth of the residual fragments. The demonstrated effectiveness, small number of complications at the short-term followup, lack of sequelae at the long-term followup and relatively small number of recurrences confirm that extracorporeal lithotripsy is not only effective but also safe. It can be proposed as the treatment of first choice even when the stone is in a single remaining kidney.

Abstract: From January 1985 till June 1989, 222 patients with ureteral stones, underwent ESWL treatment. 109 patients were treated with the original Dornier HM3 under general or epidural anaesthesia and 113 patients were treated with the modified Dornier HM3 under anglosedation. 156 stones were in the upper ureter, 15 in the middle ureter, 51 in the lower ureter. We performed a total of 269 ESWL treatments. Out of 109 patients treated with the original HM3 and 113 patients treated by the modified HM3 12 (11%) and 28 (24.7%) needed, respectively, two or more ESWL sessions. In 89.9% and 88.5% of the patients, respectively, has been performed an ureteral manipulation before the treatment to push up or to localize the stone. The treatment was unsuccessful in 10 patients of whom 3 underwent anterograde lithotripsy by percutaneous access, 4 transureteral lithotripsy and 3 surgery. At three months the percentage of patients stone free was as follows: original HM3 patients 88% modified HM3 patients 92.9%. The extracorporeal lithotripsy is now-day the treatment of choice for the ureteral stone without any limitation, due to the stone localisation. The clinical use of modified HM3 on ureteral stones didn't low our success rate, but increased the shock wave out of session.

Abstract: Second generation lithotripters require a higher number of shocks per session as well as an increased rate of secondary treatments for complete stone disintegration compared to the original spark gap lithotripter. The clinical relevance of biological side effects caused by such treatment are less known. We evaluated urinary excretion of N-acetyl-glucosaminidase (NAG) before and after lithotripsy in 50 patients treated with a low pressure spark gap lithotripter (Dornier HM3) and in 36 patients treated with a piezoelectric lithotripter (Wolf Piezolith 2200) in an attempt to evaluate their side effects on renal tissue. The urinary excretion of NAG increased after both spark gap lithotripsy using the modified HM3 and piezoelectric lithotripsy. These changes may be associated with slight tubular damage that would occur after anesthesia-free lithotripsy in patients subjected both to a high number of shocks and to secondary treatments.

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Abstract: Extracorporeal shock waves lithotripsy is a well established procedure for the treatment of renal and ureteral calculi. From January 1985 to December 1987, 1034 patients underwent 1152 treatments with the Dornier HM3 lithotripter; from January 1988 and December 1988, 466 patients underwent 566 treatments with the modified Dornier HM3. Treatments with the original HM3 were performed mainly under general anaesthesia (97%). Only 2.4% of modified Dornier HM3 treatments have been performed under general anaesthesia; the 97.6% were treated under a combination of anxiolytic and analgesic drugs. An average of 1900 and 2300 shock waves was applied with the original HM3 and the modified one, respectively. The rate of secondary treatment increased from 10.3% to 17.4% respectively. At three month follow-up the 85.6% of the patients treated with the original HM3 and the 76.7% of those treated with the modified Dornier were free from stones. Low energy lithotripsy with the modified semi ellipsoid has proved to be equally effective as the older generators working with high shock wave pressure.

Abstract: The major complications of extracorporeal shock wave lithotripsy (ESWL) are perirenal hematomas for an incidence of less than 1 per cent. However in animal experiments histopathological effects of focused electrohydraulic shock waves on renal parenchyma have been reported, the most significant of which are hemorrhagic foci healing rapidly by cicatrization. Furthermore imaging studies have demonstrated morphological changes limited to the area of the kidney exposed to shock waves. Liver, skeletal muscle and pancreatic enzyme changes have been documented after ESWL. In our experience the urinary ratio of NAG (N-acetyl-glucosaminidase) to creatinine, a good marker of renal tubular damage, increased after treatment with both the original and the modified spark gap Dornier HM3 lithotripters and with the piezoelectric Wolf Piezolith 2200. Particularly the threshold of pathological urinary NAG excretion were 2,000 and 2,600 shocks respectively using the original and the modified Dornier HM3 and 7,000 shocks using the Wolf Piezolith 2200. The functional significance of the changes is not known, however in clinical practice it would seem prudent to avoid excessive exposure to shock waves.

Abstract: ASWL ten years ago opened a new era for kidney stone treatment and recently it's showing a new therapeutical approach to biliary stones. Dornier HM3 is since 1983 the first lithotripter with a wide clinical employment. Actually we know about twenty extracorporeal lithotripter in clinical use. Our review try to classify old and new extracorporeal lithotripsy devices looking at technical aspects and lithotripsy center organization.

Abstract: Extracorporeal shock wave lithotripsy is a well established procedure for the treatment of the renal and ureteral calculi. The technical innovations of the low-pressure generator with a modified ellipsoid installed into the Dornier HM3 lithotripter leads to decrease the pressure in the second focus F2 lowering the painful sensation linked to the treatment and allowing to perform lithotripsy without general or epidural anae sthesia. From January to March 1988 132 patients underwent 144 treatment by modified Dornier Lithotripter HM3, we performed the treatments under a combination of anxiolytic and analgesic drugs in 125 patients (94.6%), only 7 patients needed the general or epidural anaesthesia, because of complex endoscopic pretreatment instrumentations. An average of 2150 Shock waves was applied with a range of 500 to 3800, the shock wave energy was administered at an average 20 Kvolts (16-26 Kv). Stone fragmentation had a success rate of 94.6%. The average postoperative stay was 4.5 days. After a month of follow-up 50.9% of the patients was free of stones, 27.8% had sand or spontaneously passable fragments and 11.1% had residual fragments larger than 4 mm. The treatment was judged as free of pain or with tolerable pain in 60% of the patients, 40% of the patients needed additional medication. The number of secondary treatment was, in our review, 9% but it could increase because we observed after a month of follow-up that 11% of the patients treated presents fragments larger than 4 mm.

Abstract: 50 patients were studied with respect to renal tubular damage related to open operative, percutaneous and extracorporeal shock wave treatment of renal stones. Preoperative and postoperative urinary N-acetyl-glucosaminidase (NAG) levels were measured as a marker of renal damage. There was no significant evidence of renal tubular damage in patients who underwent a conventional or percutaneous nephrolithotomy; urinary NAG excretion was significantly increased after ischaemic surgery. After extracorporeal shock wave lithotripsy (ESWL) serum NAG levels increased, probably because a damage of the white blood cells in cutaneous and renal circulation, but a slight increase of urinary NAG excretion could suggest a mild renal tubular damage especially in case of more than 2,000 shocks.

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