Giulio Nicita

A NEW OPERATION FOR GENITOURINARY PROLAPSE

PURPOSE A new method to support female prolapsed pelvic organs is presented, which involves use of nonabsorbable mesh cut in a hammock shape. The approach is transvaginal and the novelties are the way in which the mesh is anchored and its considerable size. MATERIALS AND METHODS The mesh is anchored transversally between the 2 arcus tendineus of the endopelvic fascia and in the anteroposterior direction between the bladder and uterine necks. The anteroposterior dimension of the mesh must completely cover the cystocele. From January 1996 to June 1997 this technique was used in 44 patients ranging in age from 43 to 86 years. The patients presented with various degrees of incontinence and combinations of cystocele, uterine or vaginal vault prolapse, rectocele and/or enterocele. Cystocele and incontinence were classified according to the SEAPI QMM scales and the other anatomical defects according to the Beecham classification. Preoperative analysis of all patients included cystography, video urodynamics, and pelvic and abdominal echography. RESULTS All patients affected by some degree of incontinence were cured. Patients with prolapse without incontinence were completely satisfied with the operation. Uterine prolapse was third degree in 6 of 20 patients and it partially recurred in 3. Cystography in all patients demonstrated excellent repair of the descensus. Sexual life and menses did not change, and no pelvic fibrosis or hydroureteronephrosis occurred. Followup ranges from 9 to 23 months (median 13.9). CONCLUSIONS This technique has broad application and is simple to perform. Longer followup will prove its merits definitively.

Sexual dysfunction in women during dialysis and after renal transplantation.

INTRODUCTION Disorders of the reproductive system and menstrual abnormalities often associated with loss of libido and inability to reach orgasm are common in adults of both sexes with an end-stage renal disease. These symptoms may significantly contribute to depression and reduce the sexual activity of women. AIM To determine if sexual function, as well as hormonal status, improves after kidney transplantation, comparing a group of pre-menopausal women during dialysis and after a successful renal transplantation. METHODS We enrolled 58 women that received kidney transplantation. Patients included were 18-45 years old, on hemodialysis for more than 6 months following a fully functioning kidney transplantation, and on a stable corticosteroids immunosuppressive regimen for at least 6 months. All women underwent a general and urogynecological examination, a hormonal profile determination, and filled out the Female Sexual Function Index (FSFI) and a Beck Depression Inventory questionnaire administered during dialysis and 12 months after transplantation. MAIN OUTCOME MEASURES We evaluated the prevalence of Female Sexual Dysfunction according to the FSFI cutoff points, sexual hormonal status, and menstrual status during dialysis and 12 months after kidney transplantation. RESULTS Nineteen out of 58 women left the study prematurely. Thirty-nine women (mean age 36 +/- 5.9 years) completed the study. A total of 74% of the patients had menstrual disturbances during dialysis, as opposed to 45% after transplantation (P < 0.001). Sixteen out of 39 (41%) patients acknowledged having an active sexual life during dialysis. Thirty-four out of 39 (88%) transplanted patients acknowledged having an active sexual life (Fischers exact test P = 0.000039). The hormonal profile and FSFI results improved significantly after transplantation. CONCLUSION This study demonstrates that a successful transplantation should improve the sexual life in women with chronic renal failure.

Vardenafil can Improve Continence Recovery after Bilateral Nerve Sparing Prostatectomy: Results of a Randomized, Double Blind, Placebo-Controlled Pilot Study

INTRODUCTION Phosphodiesterase type 5 inhibitors (PDE5-I) have acquired an established role in the treatment of post-prostatectomy erectile dysfunction (ED). Several trials in men with ED and lower urinary tract symptoms associated with benign prostatic hyperplasia suggest that PDE5-I could improve both erectile function and urinary symptoms. AIM To assess the role of vardenafil in continence recovery after bilateral nerve sparing radical prostatectomy (BNS-RP). METHODS Thirty-nine patients with prostate cancer were recruited. After BNS-RP, patients were double-blinded assigned to three arms: a) vardenafil on demand; b) vardenafil nightly; and c) placebo. MAIN OUTCOMES MEASURES Urinary function (UF) and urinary bother (UB) of University of California-Los Angeles Prostate Cancer Index questionnaire were assessed preoperatively and at 1, 3, 6, 9, 10, and 12 months. Twelve-month outcomes were compared to 1 month with a t-test. The differences in UF and UB (at 3, 6, 9, 10, and 12 months) between the three treatment arms were calculated by an analysis of variance. With ALLFIT we estimated half-maximal recovery times (ER50) and maximal recovery (R(max)) in three groups. RESULTS The improvement of UF and UB between 1 and 12 months was significant in all arms except for placebo (UF: P = 0.125; UB: P = 0.089). Nightly resulted in greater UF at 3, 6, and 9 months and greater UB at 6 months compared with placebo (P = 0.042, P = 0.044 and P = 0.039); after nightly administration, patients presented higher UB than after on-demand use, 3 and 6 months postoperatively (P = 0.036 and P = 0.017). ALLFIT demonstrated a similar ER50 in all groups (2.6 months for both UF and UB) and indicated that nightly administration induced significant improvements in R(max) compared with placebo (both <0.0001). CONCLUSIONS Vardenafil can improve continence recovery after BNS-RP compared with placebo. The daily use of vardenafil seems to provide better continence rate, although it does not seem to influence the timing needed to achieve full continence.

ENDOLUMINAL STENT PLACEMENT AFTER PERCUTANEOUS TRANSLUMINAL ANGIOPLASTY IN THE TREATMENT OF POST-TRANSPLANT RENAL ARTERY STENOSIS

PURPOSE We report our experience with endoluminal stent placement after percutaneous transluminal angioplasty for the treatment of post-transplant renal artery stenosis. MATERIALS AND METHODS From October 1992 to September 1996, 8 stents were successfully implanted in 7 patients affected by resistant transplant renal artery stenosis. All transplanted kidneys were procured from cadaver donors. The patients were routinely evaluated with duplex sonography and the median interval between transplantation and stenosis detection was 7.4 months (range 0.5 to 17). When serious renal stenosis was diagnosed (greater than 50%), selected angiography and percutaneous transluminal angioplasty were performed. In 8 cases (7 patients) an endoluminal metallic Palmaz stent was placed in the site of the restenosis. One patient received 2 stents repeatedly positioned in different stenosis sites. RESULTS No major complications occurred. Clinical outcome was positive in 5 patients (71.4%) and Stenosis recurred in 2 (28.5%) (less than 50% and less than 35%, respectively). Median followup after stent placement was 14.8 months (range 1 to 37). CONCLUSIONS Percutaneous endoluminal stent procedures after resistant transplant renal artery stenosis or for ex novo treatment for severe anastomotic stenoses appears to be promising. Longer followup periods are necessary for true evaluation of this procedure.

Factors predicting continence recovery 1 month after radical prostatectomy: Results of a multicenter survey

Objectives:  To assess the factors associated with continence recovery 1 month after radical prostatectomy (RP) and to identify the correlation between these factors.

Tankyrase-1 mRNA expression in bladder cancer and paired urine sediment: preliminary experience

Abstract Background: The enzyme tankyrase-1 (TNKS-1), a member of the growing family of poly(ADP-ribose) polymerases (PARPs), was identified as a component of the human telomeric complex. PARPs catalyze the formation of long chains of poly(ADP-ribose) onto protein acceptors using NAD+ as a substrate. TNKS-1 interacts with the telomeric DNA-binding protein TTAGGG repeat-binding factor 1 (TRF1), which is a negative regulator of telomere length. TNKS-1 is a positive regulator of telomere elongation and its activity appears to be upregulated in some human cancers. Methods: We evaluated for the first time TNKS-1 mRNA expression by real time RT-PCR in tumor tissue, paired normal mucosa and urine sediment in patients with transitional cell carcinoma (TCC) of the bladder. Samples were collected from 41 consecutive patients, 20 with non-muscle-invasive (pTa-pT1) and 21 with muscle-invasive (≥pT2) bladder TCC. Results obtained in urine sediment were compared with those from 40 healthy subjects matched for age and sex. Results: In pTa-pT1 tumor tissues, TNKS-1 mRNA levels were significantly higher than in ≥pT2 patients (p<0.0001). In urine sediment from TCC patients, independent of tumor stage, TNKS-1 mRNA levels were significantly higher than in healthy controls, with maximal levels in ≥pT2 patients. In particular, TNKS-1 mRNA levels in urine were elevated in 31/41 patients with a sensitivity of 81% in ≥pT2 tumors and 65% in pTa-pT1 TCC. Of patients with pTa-pT1 tumors, 11 had a recurrence within 18 months after initial transurethral resection. In these patients, urine levels of TNKS-1 mRNA were higher than in non-relapsing patients (p=0.038). Conclusions: In this preliminary study, TNKS-1 mRNA in urine sediment from patients with bladder TCC correlated with tumor stage, and higher preoperative levels were associated with increased risk of early recurrence. Clin Chem Lab Med 2007;45:862–6.

The Impact of Mid-Urethral Slings for the Treatment of Urodynamic Stress Incontinence on Female Sexual Function: A Multicenter Prospective Study

INTRODUCTION Urinary incontinence is a common condition that negatively impacts on female sexuality (FS). AIM To evaluate FS before and after a mid-urethral sling (MUS) procedure using the Female Sexual Function Index (FSFI). We included women that were both sexually and nonsexually active at baseline. METHODS One hundred fifty-seven women complaining of urodynamic stress incontinence underwent a MUS procedure and were enrolled in the study. All patients answered the Italian translation of FSFI, before and 12 months after surgery. To understand the real impact of the MUS on female sexual function, for the first time in the literature, we also monitored and included in the final analysis all the women who are nonsexually active at baseline. We evaluated the prevalence of female sexual dysfunction according to the FSFI cutoff point (26.55). MAIN OUTCOME MEASURES FSFI total score, pads use, and stress test presurgery and postsurgery. RESULTS One hundred thirty-three patients completed the study protocol: 105 out of 133 underwent to a trans-obturator procedure, while 28 out of 133 had a retropubic procedure. After the 12-month follow up, 115 out of 133 patients (86%) were dry, 10 improved their symptoms, and the remaining 8 were unchanged. Seventy-nine out of 133 (59%) patients reported an active sexual life before surgery. Fifty-four (41%) reported they were not sexually active before surgery. Twelve months after surgery, 22 out of 54 nonsexually active women (40%) reestablished sexual activity, whereas only 6 out of 79 (7.5%) patients, sexually active at baseline, were not sexually active 1 year after surgery (P < 0.05). After adjusting for multiple testing, only age, menopause, and storage symptoms remained significantly correlated with the FSFI total score postsurgery as independent variables. Conclusions.  Our data showed that after a MUS procedure, female sexual function improves. We also found that a very relevant percentage of nonsexually active women reported renewed sexual activity after MUS.

Renal Cell Carcinoma of Native Kidney After Renal Transplantation: Clinical Relevance of Early Detection

BACKGROUND Life expectancy after transplantation has improved, and cancer may soon be the leading cause of late death after transplantation. The guidelines of the American and European societies of nephrology and urology have not yet established the optimal frequency for screening for renal cell carcinoma (RCC) of native kidneys in patients who have undergone renal transplantation. OBJECTIVE To evaluate the prevalence, prognosis, and risk factors of RCC in a series of patients followed up for 16 years in our transplantation unit. MATERIALS AND METHODS Our study is a follow-up observational cohort study conducted in 694 consecutive renal transplant recipients admitted to our institution from July 1991 through July 2007. At our institution, ultrasound studies of the native kidneys were performed every 6 months after renal transplantation. RESULTS In the patient cohort studied, 10 patients developed a renal tumor (1.6% incidence). Three patients died of causes other than recurrence of RCC. Seven patients are alive with no evidence of RCC recurrence or metastatic disease after a mean (range) follow-up of 41 (12-96) months. Acquired cystic kidney disease and dialysis duration were positively associated with development of RCC. CONCLUSIONS The incidence of RCC in the literature varies between 0.3% and 4.8%. The variability depends on the timing of follow-up, with a higher incidence in prospective studies with strict follow-up. We advise ultrasound studies performed by specialized physicians every 6 months after transplantation. More detailed guidelines designed by the major international transplantation societies are necessary.

Selective Transcatheter Arterial Embolization of Renal Carcinoma: An Original Technique

The association of pharmaco-angiography with norepinephrine and transcatheter arterial embolization is a technique used to obstruct arteries invaded by renal carcinoma. We treated 4 patients with this method before nephrectomy and recommend its use as a complement to an operation for renal carcinoma or as definitive treatment in poor surgical candidates.

Ureteral Intussusception by a Fibroepithelial Polyp

Abstract We report a case of ureteral intussusception caused by a fibroepithelial polyp as a result of forced mucosal sliding. Renal colic was the presenting symptom. Radiologically, it appeared as a pyeloureteral junction obstruction. Pyeloureteral resection was done.