Cesare Selli

Dorsal free graft urethroplasty

PURPOSE Dorsal free graft urethroplasty was performed to reduce the incidence of urethrocele. MATERIALS AND METHODS We treated 12 patients with penile and 13 with bulbous strictures. Of the 13 patients with a bulbous stricture 6 received a dorsally placed tube graft and 7 received a patch graft. RESULTS Temporary fistulas were seen on postoperative urethrography in 5 cases but they all resolved spontaneously. At a mean followup of 35.8 months clinical and radiological findings were excellent in 23 cases and good in 2. No signs of graft weakening, such as post-void dribbling or diminished ejaculation, were apparent. CONCLUSIONS The use of free skin grafts for urethral reconstruction is anatomically healthier in the dorsal than in the ventral position.

Conservative Surgical Treatment of Renal Cell Carcinoma: Clinical Experience and Reappraisal of Indications

During a 14-year period 36 patients who presented with renal cell carcinoma underwent conservative surgical treatment. The patients were divided into 3 groups according to treatment indications and condition of the contralateral kidney: group 1 included patients with a solitary kidney or bilateral tumors, group 2 patients had a damaged contralateral kidney and group 3 patients were without abnormalities of the contralateral kidney. Cumulative 6-year survival rates were 58 per cent for group 1, and 90 per cent for groups 2 and 3 combined. The over-all cumulative 6-year survival rate was 74 per cent. Based on these data extension of the indication for conservative surgical treatment seems to be justified in patients who present with low stage tumors and partial or potential damage to the contralateral organ.

Long-term results of anterior and posterior urethroplasty with actuarial evaluation of the success rates.

PURPOSE We analyzed the long-term results of different urethroplasty techniques. MATERIALS AND METHODS We performed a retrospective review of 98 patients who underwent different procedures for anterior (78) and posterior (20) urethral strictures. Mean followup was 53 months. A total of 20 patients underwent end-to-end anastomosis (group 1), 30 underwent 1-stage procedures (group 2), 28 underwent 2-stage procedures (group 3), and 20 underwent bulboprostatic anastomosis (group 4). The results were analyzed using Kaplan-Meier curves and log rank test. RESULTS The success rate was 95% for group 1, 93.4% for group 2, 78.6% for group 3, and 70% for group 4. Statistical evaluation of the actuarial success rates failed to show significant differences among the 4 groups. CONCLUSIONS The stricture recurrences were uniformly distributed over time. Urethroplasty patients must be followed for the rest of their lives.

Role of Bladder neck preservation in urinary Continence following Radical retropubic prostatectomy

Objective: To report our experience of the influence of bladder neck preservation on patient continence. Material and Methods: Radical retropubic prostatectomy with bladder neck preservation was performed in 131 patients (age range 48–73 years; mean 64.5 years). Urinary continence was evaluated using a validated questionnaire at follow‐up visits and telephone interviews. All patients reporting incontinence were studied using a pad test and urodynamics. Results: After a mean follow‐up period of 21.7 months (range 4–47 months), 115 patients were continent (87%) and 16 incontinent. According to the International Continence Society criteria, three had severe, three moderate and 10 mild incontinence. Urodynamics revealed sphincter deficiency in 15 cases, which was associated with decreased bladder compliance in four, while decreased compliance was the only abnormality in one. Continence was recovered 0–27 months after surgery (mean 3.2 months): 40% of men were continent within the first month and 74% within the third. Histopathology revealed positive margins in 30/131 patients (22%), but exclusively at the bladder neck level in only seven (5%), and two also had positive nodes. Six patients (4.5%) presented bladder neck stenosis requiring transurethral incision. No statistically significant differences were found between the ages of continent and incontinent men or between the time to continence recovery with two different techniques of retropubic hemostasis; however, use of a nerve‐sparing technique significantly reduced the time to continence recovery. Conclusions: Bladder neck preservation during radical retropubic prostatectomy does not improve the long‐term results of urinary continence but does contribute substantially to its earlier recovery, thus improving the quality of life. With proper patient selection the risk of positive margins at the bladder neck level only is reasonably low.

TELOMERASE IN UROLOGICAL MALIGNANCY

PURPOSE Telomerase is a ribonucleoprotein enzyme that compensates for the progressive erosion of chromosomal ends, called telomeres. In most somatic cells telomerase expression is repressed and telomeres progressively shorten after each cell division, causing cell senescence. Conversely telomerase is active in most human cancers, maintaining the integrity of chromosome ends and representing an important step in cell immortalization and carcinogenesis. The large and increasing interest in telomerase was motivated by the demonstration that more than 90% of human cancers are telomerase positive, whereas most normal tissues or benign tumors contained low or undetectable telomerase activity. We addressed the most recent data on telomerase detection in urological malignancy. Approaches to telomerase inhibition as a future anti-cancer therapy are also discussed. MATERIALS AND METHODS We comprehensively reviewed the most recent and significant publications in this field using current issues of specific journals and a MEDLINE search. RESULTS Telomerase is often expressed in bladder (90%), prostate (80%) and renal (69%) carcinoma. A variable but significant percent of normal tissues from tumor adjacent zones or noncancer samples are positive for telomerase. The clinical role of telomerase is still questionable in renal cancer, while important insights into the diagnostic role of telomerase in bladder and prostate carcinoma are increasing. Telomerase detection in exfoliated cells collected with urine or bladder washings seems a promising tool for the diagnosis and management of bladder cancer. CONCLUSIONS Larger perspective studies of larger groups of patients are required to discover an appropriate role for telomerase when assessing these tumors. The improvement of quantitative methods to evaluate the expression of telomerase is a cornerstone in the complete clarification of the clinical relevance of telomerase.

Predictors of morbidity in patients with indwelling ureteric stents: results of a prospective study using the validated Ureteric Stent Symptoms Questionnaire.

Study Type – Therapy (case series) Level of Evidence 4

Combination of Perianal-Intrarectal Lidocaine-Prilocaine Cream and Periprostatic Nerve Block for Pain Control During Transrectal Ultrasound Guided Prostate Biopsy: A Randomized, Controlled Trial

PURPOSE To our knowledge the optimal analgesia during prostate biopsy remains undetermined. We tested the efficacy and safety of combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS A total of 280 patients were randomized to receive combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block (group 1), perianal-intrarectal lidocaine-prilocaine cream alone (group 2), periprostatic nerve block alone (group 3) or no anesthesia (group 4) before transrectal ultrasound guided prostate biopsy. Pain was evaluated with a 10-point visual analog scale at subsequent procedural steps, including perianal-intrarectal substance administration, prostate transrectal ultrasound, periprostatic nerve block and sampling. Complications were assessed by self-administered questionnaire and telephone interview. RESULTS The groups were comparable in patient age, prostate volume, pathology results and visual analog scale perianal-intrarectal substance administration. Visual analog scale results for transrectal ultrasound were lower in groups 1 and 2 vs 3 and 4 (mean 1.5 and 1.41 vs 5.37 and 5.31, p <0.001) and results for periprostatic nerve block were lower in group 1 vs 3 (mean 1.03 vs 3.74, p <0.001). Results for sampling were lower in groups 1 to 3 vs 4 (mean 0.77, 1.27 and 1.27 vs 4.33, p <0.001) and in group 1 vs 2 and 3 (p <0.001). Stratified analysis showed that visual analog scale sampling was lower in group 1 vs 2 and 3 in patients 65 years old or younger, those with a prostate greater than 49 cc and those with lower anorectal compliance (visual analog scale results for perianal-intrarectal substance administration greater than 2) (p = 0.006, <0.001 and 0.003, respectively). The overall complication rate was similar in all 4 groups (p = 0.87). CONCLUSIONS Our findings suggest that the combination of perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block provides better pain control than the 2 modalities alone during the sampling part of transrectal ultrasound guided prostate biopsy with no increase in the complication rate. The magnitude of this effect is higher in younger men, men with a larger prostate and men with lower anorectal compliance.

Asymptomatic bacteriuria treatment is associated with a higher prevalence of antibiotic resistant strains in women with urinary tract infections.

BACKGROUND Women suffering from recurrent urinary tract infections (rUTIs) are routinely treated for asymptomatic bacteriuria (AB), but the consequences of this procedure on antibiotic resistance are not fully known. The aim of this study was to evaluate the impact of AB treatment on antibiotic resistance among women with rUTIs. METHODS The study population consisted of 2 groups of women who had previously been enrolled in a randomized clinical trial: group A was not treated, and group B was treated. All women were scheduled for follow-up visits every 6 months, or more frequently if symptoms arose. Microbiological evaluation was performed only in symptomatic women. All women were followed up for a mean of 38.8 months to analyze data from urine cultures and antibiograms. RESULTS The previous study population consisted of 673 women, but 123 did not attend the entire follow-up period. For the final analysis, 257 of the remaining 550 patients were assigned to group A, and 293 to group B. At the end of follow-up, the difference in recurrence rates was statistically significant (P < .001): 97 (37.7%) in group A versus 204 (69.6%) in group B. Isolated Escherichia coli from group B showed higher resistance to amoxicillin-clavulanic acid (P = .03), trimethoprim-sulfamethoxazole (P = .01), and ciprofloxacin (P = .03) than that from group A. CONCLUSIONS This study shows that AB treatment is associated with a higher occurrence of antibiotic-resistant bacteria, indicating that AB treatment in women with rUTIs is potentially dangerous.

Reoperative Surgery for Recurrent Strictures of the Penile and Bulbous Urethra

PURPOSE We evaluated the outcome of reoperation for anterior urethral strictures. MATERIALS AND METHODS Strictures that recurred after urethroplasty were repaired by various procedures in 20 patients (penile urethra in 8 and bulbous urethra in 12, mean followup 57 months). RESULTS Of the recurrent penile urethral strictures 3 showed excellent and 5 satisfactory results, compared to 9 and 3, respectively, for bulbous urethral strictures. Overall 60% of the cases had an excellent outcome and no failures were documented. CONCLUSIONS Any type of urethroplasty may fail even after a considerable period but reoperation with proper indications can offer a lasting solution.

Conservative surgery for renal cell carcinoma

The authors present their clinical experience in conservative surgery for renal cell carcinoma, which was performed in two cases of simultaneous bilateral tumours, in a case of neoplasm in solitary kidney, in two cases of cancers with damaged contralateral kidney and in two cases of association between cyst and small tumour. All patients are alive and without evidence of residual or recurrent malignancy with a followup ranging between 6 months and 7 years. The pros and cons of the various surgical solutions are discussed.