G. Vespasiani

Autonomic dysreflexia during urodynamics

Autonomic dysreflexia (AD) is an acute syndrome characterised by inappropriate and massive autonomic response that occurs in patients with spinal cord injury above the T6 level. Aims:u2003to evaluate the incidence of AD during cystometry and the relationships with clinical and urodynamic features. Patients and methods:u2003Forty-eight spinal cord injury patients were studied by neurological and urological examination and urodynamic evaluation with concurrent recording of blood pressure, heart rate and symptoms and signs of AD. Patients were considered to have AD if blood pressure reached values higher than 150/100u2009mmHg. Results:u2003All the patients showed a significant increase of both systolic and diastolic blood pressure, although only 20 showed pressure values higher than 150/100u2009mmHg (in seven of them without AD symptoms). AD was more frequent in cervical patients (P=0.034), but did not correlate with any other clinical features: sex ratio, age, disease duration, completeness of lesion, incidence of detrusor hyperreflexia/areflexia and detrusor-sphincter dyssynergia, voiding modalities, usage of anticholinergic drugs. In three patients blood pressure increase began when uninhibited contraction started, in 11 it was coincident with unhibited contraction peak and in the other six it appeared at maximum bladder capacity. Conclusions:u2003(1) during urodynamic evaluation all the patients with lesion level above T6 showed signs of sympathetic stimulation, although only some showed dangerous blood pressure values; (2) the relationship between urodynamic data and dysreflexia crisis shows that both the presence of detrusor uninhibited contractions and bladder distension are able to stimulate the crisis; (3) treatment with anticholinergic drugs is not sufficient to prevent autonomic dysreflexia starting from the bladder, unless it induces detrusor areflexia. These patients are at risk of developing autonomic dysreflexia following bladder distension.

Transdermal electromotive administration of verapamil and dexamethasone for Peyronie's disease

Peyronies disease continues to be a fascinating topic for urologists, and two papers in this section, one from Rome and one from Los Angeles, describe new insights into this disease.

INTRAVESICAL ELECTROMOTIVE ADMINISTRATION OF OXYBUTYNIN IN PATIENTS WITH DETRUSOR HYPERREFLEXIA UNRESPONSIVE TO STANDARD ANTICHOLINERGIC REGIMENS

PURPOSEnAbout 15% to 20% of patients with detrusor hyperreflexia do not benefit from oral oxybutynin regimens, frequently because of unpleasant side effects. Several reports indicate that intravesical oxybutynin is effective in many of these patients but there are some who still fail to respond.nnnMATERIALS AND METHODSnA select group of 10 adults with detrusor hyperreflexia unresponsive to standard oral and intravesical oxybutynin regimens were treated at weekly intervals with 5 mg. oxybutynin orally, or 5 mg. oxybutynin in 100 ml. intravesically for 60 minutes of passive diffusion and for 30 minutes with 5 mA. electrical current. Each treatment (plus oral placebo and 2 intravesical controls) was associated with an 8-hour, full urodynamic monitoring session, and periodic blood and bladder content sampling.nnnRESULTSnThere was no significant objective improvement with oral or intravesical passive diffusion oxybutynin. Conversely there was significant improvement in 5 of 6 objective urodynamic measurements with intravesical electromotive oxybutynin. Plasma profiles were a single peak and decay following oral oxybutynin and 2 distinct peaks with intravesical passive diffusion and electromotive oxybutynin. Area under the curve for intravesical passive diffusion were 709 ng. per 8 hours versus oral 1,485 (p <0.05) versus intravesical electromotive 2,781 (p <0.001). Bladder content samples confirmed oxybutynin absorption. Oral oxybutynin caused anticholinergic side effects in 7 of 10 patients. There were no side effects with intravesical passive diffusion or electromotive administrations.nnnCONCLUSIONSnAccelerated intravesical administration results in greater bioavailability and increased objective benefits without side effects in previously unresponsive patients compared with oral and intravesical passive diffusion oxybutynin administration.

Real-time transrectal sonographic voiding cystourethrography

Transrectal linear array transducer makes possible a sagittal view of the bladder base-plate, prostatic urethra, and membranous urethra yielding an image similar to that obtained with voiding cystourethrogram. This permits lack of time limitation, such as imposed by the use of fluoroscopy, and the possibility of visualizing not only the lumen of the bladder neck and urethra but also the surrounding soft tissue. Using ultrasonographic urodynamics in neuromuscular dysfunctions of the bladder and urinary voiding obstructions we obtained excellent results in patients with detrusor-sphincter dyssynergia and in those with posterior ledge at the bladder neck. Both conditions are clearly visualized, particularly the existence of the posterior ledge which is responsible for the failure of the sphincterotomy in patients with periurethral striated sphincter spasm.

Successful management of retroperitoneal malignant fibrous histiocytoma involving both kidneys.

We report a rare case of a retroperitoneal inflammatory variant of malignant fibrous histiocytoma (MFH) involving both kidneys. The best treatment for MFHs is surgery with radical excision of the tumor. In this case the need to save at least one kidney meant tumorectomy was incomplete. The patient underwent adjuvant chemotherapy and 4 years later survives in a fairly good condition.

Ureteral endometriosis: An endoscopic diagnosis

A case of ureteral endometriosis is reported. This is the first case diagnosed during a ureteropyeloscopic examination.

Voiding Dysfunction in Patients With Spinal Cord Lesions at the Thoraco-Lumbar Vertebral Junction

F Pesce, V Castellano, E Finazzi Agro`, A Giannantoni, F Tamburro, G VespasianiDepartment of Urology, University Tor Vergata and S. Lucia Rehabilitation Hospital IRCCS, Rome, ItalyNeurogenic voiding dysfunction invariably follows a complete spinal cord lesion. With spinalshock urodynamic investigation will show an areflexic bladder if the sacral spinal cord hasbeen damaged, otherwise, if the lesion involves the suprasacral cord, an overactive bladder willresult. There are some exceptions to this rule, particularly in those with lesions of the thoraco-lumbar vertebral junction, where the sacral cord is located, it may be di†cult to predicturodynamic dysfunction merely on the basis of the vertebral body involved. 46 patients with acomplete SCI neurological lesion at the thoraco-lumbar vertebral junction underwent a neuro-urological evaluation including multi-channel urodynamic studies. Overall in 20 to 36% of thepatients the urodynamic pattern was di•erent from what one would have expected consideringthe anatomical level of the vertebral body involved. Urodynamic study is confirmed as anessential tool in the correct diagnostic and therapeutic approach to the voiding dysfunction inthese type of patients.Keywords: Spinal cord injury; neurogenic voiding dysfunction; Urodynamics; upper and lowermotor neuron lesions

Urological Dysfunctions and Upper Urinary Tract Involvement in Multiple Sclerosis Patients

The goal of the present study was to investigate the involvement of the upper urinary tract (UUT) in patients with multiple sclerosis and its relationship with other neurological and urological features of the disease. One hundred sixteen patients underwent complete neurological and urological assessments, urodynamic investigation, and morphofunctional study of the urinary tract by ultrasonography, voiding cistourethrography, and/or intravenous excretory pyelography. The most remarkable relationships were observed among disease duration, pyramidal system score, amplitude of uninhibited detrusor contractions and the presence of bladder morphological abnormalities (P = 0.03, 0.0008, and 0.018, respectively) and the relationship between pyramidal system score or the presence of bladder pathology and UUT abnormalities (P = 0.03 and 0.0006, respectively). A significant relationship was found between the maximum amplitude of uninhibited contractions and UUT involvement (P = 0.002). No other significant relationship was observed between UUT involvement and any other urodynamic or urological features of the disease (type of progression and progression rate, Expanded Disability Status Scale, and other functional system scores). The relationship among disease duration, high vesical pressures, and the lack of reliable clinical indices of risk to the UUT stress the importance for patients with multiple sclerosis to adhere to a strict follow-up program with urodynamic assessment and urinary tract imaging and to maintain detrusor relaxation with anticholinergic medications.

Sequential Bacillus Calmette Guèrin and electromotive mitomycin-C versus Bacillus Calmette Guèrin alone for high-risk superficial bladder cancer: A prospective controlled study

4539 Background: Intravesical bacillus Calmette-Guèrin (BCG) and mitomycin C (MMC) are a theoretically attractive combination for the treatment of high risk superficial bladder cancer. We conducted a prospective, controlled study comparing BCG with sequential BCG + electromotive delivery MMC in patients with T1 bladder cancer.nnnMETHODSnFollowing transurethral resection and multiple biopsies we randomized 175 patients with T1 bladder cancer into 2 groups. Group I received BCG 81 mg; 6 weekly instillations. Group II received sequential BCG and electromotive (intravesical electric current; 20 mA for 30 min.) MMC at weekly intervals thus: (BCG, BCG, MMC) x 3, totaling 6 BCG and 3 MMC instillations. Non responders received repeat courses at 3 months. All complete responders underwent maintenance regimens of monthly instillations. Group I: 10 BCG treatments. Group II: (MMC, MMC, BCG) x 3, treatments.nnnRESULTSnGroup I vs Group II: median (IQR or 95% CI). Follow up (months): 64 (38-82) vs 71 (49-87); p = 0.054 Recurrence: 47% (36-58) vs 28% (19-39); p = 0.013 Months to Recurrence: 11 (6-19) vs 20 (16-33); p = 0.001 Progression: 20% (12-30) vs 14% (7-22); p = 0.312 Months to Progression: 17 (10-21) vs 46 (21-58); p = 0.002 % 5-years mortality by any cause: 11.6 (5.7-20.3) vs 4.5 (1.2-11.1); p = 0.099 % 5-years mortality by bladder cancer: 9.3 (4.1-17.5) vs 1.1 (0.02-6.1); p = 0.017 Side effects were numerous but mainly localized to the bladder. There were no treatment related deaths nor episodes of serious illness nor bladder contractures.nnnCONCLUSIONSnIntravesical sequential BCG/electromotive MMC is superior to BCG alone in the treatment of high risk bladder cancer. [Table: see text].

153 O - In vitro electromotive administration of mitomycin C in human bladder wall

Adjuvant intravesical mitomycin C (MMC) therapy for superficial bladder cancer has been shown to decrease the one-year recurrence rate by 2–43% and Ta tumours appear to respond more favorably than T1 (Herr, J. Urol., 1987). Experimental studies showed that inhibitory MMC concentrations are achieved in the urothelium (Ta tumours) in 100% of cases, in the lamina propria (TI tumours) in 20% and in the muscle layer (T2 tumours) in about 17% (Wientjes, Cancer Res., 1991). The aim of these investigations is to establish the tissue concentrations of MMC following passive diffusion (PD) and electromotive administration (EMDA) into human bladder wall samples. Sections of human bladder were inserted into a two chamber diffusion cell. The urothelium was exposed to the donor compartment (MMC 10 mg in 100 ml 0.24% saline) containing an anode and the serosa to the receptor compartment (100 ml 0.9% saline) containing a cathode. EMDA experiments were performed with pulsed current of 5 mA for 15 min. No electric current was applied in PD control experiments. MMC in samples was measured by HPLC analysis. The concentrations of MMC were determined in 15 paired experiments (30 bladder samples). The total (71,075 ng) and the mean (4,738 ng) quantities of MMC transported into tissue samples by EMDA significantly exceed the respective amounts (30,763 ng and 2,051 ng) administered by PD and similarly with wet tissue concentrations (22,923 ng/g and 1,528 ng/g versus 9,271 ng/g and 618 ng/g). In conclusion, EMDA enhances MMC penetration into the bladder wall and the method can be utilized generally for intravescical pharmacological studies.