R. Migliari

Tension-free vaginal mesh repair for anterior vaginal wall prolapse.

Objectives: We determined the efficacy of the use of a tension free prolene mesh to correct a grade III anterior vaginal wall prolapse recurrence.Methods: Twelve women (mean age 65.6 years) with stress urinary incontinence (SUI) (4 type II and 1 type III) and bladder prolapse entered the study. After vaginal incision a pretailored polypropylene mesh was fixed to its four angles by absorbable sutures to the urethropelvic ligaments and pubocervical fascia anteriorly and to the cardinal ligaments and pubocervical fascia posteriorly. When present, a posterior descensus was corrected during the same procedure. SUI was treated with the tension–free vaginal tape procedure (TVT) through a separate vaginal incision over the mid–urethra.Results: All patients were available for postoperative pelvic examination at 3–month intervals, for a mean follow–up of 20.5 months (range 15–32). Nine patients were considered cured (no cystocele recurrence) while in 3 patients a grade 1 asymptomatic cystocele was present postoperatively (asymptomatic). No significant postoperative pain was reported by the patients.Conclusions: This study confirms that in patients with moderate cystocele a tension–free mesh to support bladder base and neck effectively treats the cystocele. It is particularly recommended in the treatment of previous failure with traditional techniques and when the quality of suspending tissue is poor or defective. A long–term study on a large number of patients is still warranted to confirm and validate its clinical use.

Treatment results using a mixed fiber mesh in patients with grade IV cystocele.

PURPOSE We determined the efficacy of a modification of the 4-corner bladder and bladder neck suspension procedure using mixed fiber mesh to correct grade IV cystocele. MATERIALS AND METHODS We evaluated 15 women with a mean age of 67 years who had severe anterior vaginal wall prolapse, of whom 3 had concurrent enterorectocele. Previously 5 patients had undergone repair of anterior vaginal wall prolapse and 2 had undergone procedures for stress urinary incontinence. In 10 patients type II stress urinary incontinence was diagnosed with urethral hypermobility and abdominal leak point pressure greater than 90 cm. water. No patients with intrinsic sphincter deficiency were enrolled in the study. A mixed fiber mesh was positioned using a modification of the 4-corner bladder and bladder neck suspension technique. Patients with concurrent enterorectocele underwent simultaneous formal repair of the posterior descensus. RESULTS All patients were available for postoperative pelvic examination at 3-month intervals. Mean followup was 23.4 months (range 18 to 39). Of the 15 women 13 were continent (dry) at followup. No recurrent cystocele was evident, except in 1 patient who presented with segmental posterior bladder prolapse. In 2 patients new onset enterorectocele developed 6 months after mesh implantation. CONCLUSIONS Our study confirms that the addition of mesh to the classic 4-corner bladder base and neck suspension procedure effectively treats incontinence and cystocele. We recommend this method for cases in which traditional techniques have previously failed and when the quality of suspending tissue is poor or defective, as in connective tissue disease. However, the risk of worsening enterorectocele or its new onset must be considered.

Effect of casodex on sleep-related erections in patients with advanced prostate cancer

Sleep-related erections in 5 patients with stage T3N0M0 prostate cancer treated with a new nonsteroidal antiandrogen, Casodex, were evaluated with continuous monitoring of penile tumescence and rigidity on multiple nights. Mean serum luteinizing hormone levels were 7.2 +/- 1.2 IU/l. before therapy and increased to 14 +/- 3.6 IU/l. after 6 months of therapy. Serum testosterone and estradiol levels also increased from a basal level of 5.05 +/- 1.9 ng./ml. and 102 +/- 18 pmol./l., respectively, to 8.04 +/- 1.32 ng./ml. and 175 +/- 20 pmol./l., respectively, after 6 months of therapy. No significant modifications in regard to number of nocturnal penile tumescence episodes, maximum penile circumference and total rigidity time were found before and after therapy. Only 1 patient reported a decrease in sexual drive and libido. All patients presented with stable disease (National Prostatic Cancer Treatment Group criteria) and an unmodified performance status (Eastern Cooperative Oncology Group) after 6 months. Pure antiandrogen therapy did not seem to interfere significantly with the erectile capability of men with prostate cancer.

Laparoscopic Microwave Ablation and Enucleation of Small Renal Masses: Preliminary Experience

Advancements in imaging and laparoscopy have led to the expansion of minimally invasive techniques in the ablation of small renal masses (SRMs). We report the results of a study aimed at assessing the efficacy of thermoablative microwave (MW) effects on SRMs and the haemostatic as well as necrotic MW effects on the parenchyma surrounding the neoplasm. From November 2008 to October 2010, 10 patients with SRMs underwent laparoscopy-guided Tru-Cut biopsy, MW tumour ablation, and enucleation. Mean age was 66 yr (range: 46-84 yr). Mean renal tumour diameter was 2.75 cm (range: 1.3-4.2 cm). MW antennas were applied one to three times depending on tumour volume, location, and shape. After MW thermoablation, laparoscopic enucleation was performed to evaluate the histopathologic and haemostatic effects of MW. The mean MW antenna application time was 14.1 min (range: 4-30 min). Enucleation did not require renal pedicle clamping in any of the cases because no significant bleeding took place. Preablation pathology revealed clear cell renal carcinoma of Fuhrman grade I-II in all cases. Postablation pathology showed extensive coagulative necrosis without skipped tumour areas. No intra- or postoperative complications were reported. Histopathologic effects on SRMs provide consistent proof of principle for future studies.

The effect of flutamide on basal and ACTH-stimulated plasma levels of adrenal androgens in patients with advanced prostate cancer

The effect of flutamide on basal and ACTH-stimulated plasma levels of adrenal androgens was investigated in 6 patients with untreated advanced prostate cancer, aged 52–75 yr. Flutamide was administered (250 mg three times daily) for 10 days; before and after treatment, a synthetic ACTH1 -24 stimulation test (250 µg im, with blood sampling immediately before and 60 min after the stimulus) was performed. Basal plasma 170H-pregnenolone (Δ5-170HP), 170H-progesterone (A4-170HP), androstenedione (A), dehydroepiandrosterone (DHEA) and its sulphate (DHEAS) were unchanged by flutamide treatment. In contrast, basal plasma testosterone (T) concentrations significantly increased (p < 0.05). The response of Cortisol Δ 4-170HP, Δ 5-170HP, A and DHEA to ACTH, as well as the ACTH-stimulated Δ5-170HP/Δ4-170HP, Δ5-170HP/DHEA, Δ4-170HP/A and DHEA/A ratios, were unchanged by flutamide treatment. These findings indicate that: a) Short-term flutamide administration enhances testicular steroidogenesis, via augmented LH pulse frequency; b) Adrenal steroidogenesis seems to be not affected by the drug, since ACTH-stimulated plasma levels of adrenal androgens and precursors/products ratios were unchanged.

THE EFFECT OF ANDROGEN BLOCKADE ON PULSATILE GONADOTROPHIN RELEASE AND LH RESPONSE TO NALOXONE

In order to clarify the effects of androgen blockade on the hypothalamic‐pituitary‐testicular axis in man, four patients with advanced prostate cancer, not previously treated, were given oral flutamide, 250 mg three times daily for 9 days. Before, and 7, 8 and 9 days after starting flutamide treatment, on separate days, the following tests were performed: a gonadotrophin pulsatility study, with 20 min interval blood sampling for 12 h, a naloxone test and a GnRH test. Flutamide induced a significant increase in both LH and FSH pulse frequency, while pulse amplitudes and plasma integrated concentrations (IC) of LH and FSH were unaffected. Plasma integrated concentrations of testosterone and oestradiol rose significantly, while that of prolactin was unaffected. The increase in plasma LH concentration induced by naloxone injection was abolished by flutamide treatment. On the other hand, the small FSH response to naloxone was unaffected by flutamide treatment. Response to GnRH was unaffected by flutamide. These results suggest that flutamide exerts effective androgen blockade at the hypothalamic level, since, despite increased plasma testosterone concentrations, gonadotrophin pulse frequency increased and the LH response to naloxone was abolished.

Metastatic Renal Cell Cancer Treated with Recombinant Alpha 2a Interferon and Vinblastine

42 patients with advanced renal cell carcinoma were treated with a combination therapy with interferon alpha 2a (mean dosage 16 x 10(6) U i.m. 3 times/week) and vinblastine (0.1 mg/Kg every 21 days). 12 patients (28.5%) had a positive response. Of them 1 presented a complete response (2.38%), 5 a partial response (11.9%) and 6 a stable disease (14.2%). No significant side effects were observed apart from the flu-like syndrome (all patients) and a moderate leukopenia (45.2%). The median duration of responses was 10+ months (range 3-37 months). At 4-year follow-up the median survival time was 16.0 months (range 4-37 months).

ABH and Lewis Antigens in Human Male Accessory Sex Glands

Antigenic properties of human semen are due to sperm surface antigens produced by germinal cells during spermatogenesis (intrinsic antigens) and to those of seminal plasma. The latter are in part serum proteins, in part substances common to semen and other body fluids, and in part seminal plasma-specific antigens [15]. They are supplied by the male accessory sex organs and can be absorbed on the sperm surface (sperm-coating antigens). An example of sperm-coating antigens is ABH antigens, first found on spermatozoa by Landsteiner and Levine [14] and in seminal plasma by Edwards et al. [6]. ABH antigens are expressed in erythrocytes and in the cell membranes of endothelia and of a variety of tissues, and enter in the composition of several secretions such as saliva, milk, tears, and digestive juices [22]. Their antigenic determinants consist of a few sugars linked to a precursor molecule by distinct glycosyltransferases coded by the ABO, H, and Se genes [19].

URETEROSCOPIC REMOVAL OF URETERAL CALCULI IN BILATERAL URETERAL DUPLICATIONS

Two rare cases of ureteroscopic removal of impacted ureteral calculi in patients with partial and complete ureteral duplication are described. The procedural steps and problems encountered are discussed. Successful ureteroscopic stone extraction was obtained in the 2 patients.

Short Term Effects of Flutamide Administration on Hypothalamic-Pituitary-Testicular Axis in Man

The effect of short term administration of flutamide on the hypothalamic-pituitary-gonadal axis was studied in six patients with advanced prostate cancer (C2 stage). Flutamide significantly increased LH pulse frequency in all patients (p less than 0.05 by Wilcoxons test). The FSH pulse analysis disclosed a similar pattern of LH. Plasma IC-T clearly increased following flutamide therapy; mean IC-T values were 2.67 +/- 0.47 ng./ml. and 4.67 +/- 0.62 ng./ml. before and after flutamide administration, respectively (p less than 0.05 by paired Students t test). Our study demonstrates that flutamide acts in humans as a selective and specific antiandrogen compound.