Stefano Bucci

Efficacy and Safety of Combined Oral Therapy with Tadalafil and Alfuzosin: An Integrated Approach to the Management of Patients with Lower Urinary Tract Symptoms and Erectile Dysfunction. Preliminary Report

INTRODUCTION Alpha1-blockers (AB) are the first-line monotherapy for lower urinary tract symptoms (LUTS). Phosphodiesterase type 5 (PDE5) inhibitors are the first-line treatment for erectile dysfunction (ED). Numerous studies have supposed a significant association between ED and LUTS, but a causal relationship cannot be established. AIM The aim was to evaluate the efficacy of a combined therapy with an AB (alfuzosin) and PDE5 inhibitors (tadalafil) in patients with LUTS and ED. METHODS This was a randomized, open-label, three-arm study. A total of 66 men complaining of ED and LUTS were included in the study. Patients were assessed at baseline and after 12 weeks of study treatment, and then underwent randomized allocation to either alfuzosin 10 mg once a day (22 patients) or tadalafil 20 mg on alternative days (21 patients), or a combination of both (23 patients). MAIN OUTCOME MEASURES All participants completed the erectile function domain of the International Index of Erectile Function (IIEF-EF) and the International Prostatic Symptom Score (IPSS). Other efficacy variables included maximum urinary flow rate (Qmax) and medium urinary flow rate (Qave). RESULTS IIEF-EF tended to improve with alfuzosin alone (+15%), while it was clearly improved with tadalafil alone (+36.3%). The greatest improvement was experienced with the combination therapy (+37.6%). Improvement in Qmax was observed in all groups, but patients receiving combination therapy had greater improvement (29.6%) than patients receiving either only alfuzosin (21.7%) or only tadalafil (9.5%). IPSS was significantly improved in alfuzosin group (27.2%), was more marked with the combination therapy (41.6%), and a small increase, although not significant, was also observed with tadalafil (8.4%). CONCLUSIONS Combined therapy improved ED and LUTS as demonstrated by the significant improvement in uroflowmetry measures and in IPSS and IIEF-EF scores. A significant improvement was also observed in quality of life assessments. The beneficial effects of tadalafil on LUTS similar to the benefits of alfuzosin on ED, although present, were smaller.

Color Doppler ultrasound investigation of varicocele

Varicocele, whose association with male infertility has been clearly documented in the literature, is a common finding in adolescents and adult men, being diagnosed in 20–40% of infertile patients. A correct and early diagnosis of this affliction is of great importance because, in most cases, a timely correction, usually performed using percutaneous sclerotherapy, leads to an improvement in semen quality. Currently, physical examination in a warm room is the mainstay of diagnosis, but this is affected by a low sensibility and specificity, especially in cases of low grade varicocele. Colour Doppler ultrasound (CDU) is a new, reliable and non-invasive diagnostic method for the evaluation of varicocele testes which allows the detection of even subclinical varicocele thanks to its capacity for measuring the size of the pampiniformis plexus and blood flow parameters of the spermatic veins. At present, there is a lack of completely standardised diagnostic criteria, but when this problem is solved, clinical examination and CDU will certainly become the “gold standard” in the investigation of varicocele.

Percutaneous Management of Renal Artery Aneurysm With a Stent-Graft

A 53-year-old woman presented with systemic hypertension that was not responsive to medical treatment with lacidipine 4 mg. daily. The patient had no risk factors for atherosclerosis. Laboratory results were normal. Abdominal color Doppler ultrasound and selective renal angiography showed fibromuscular dysplasia of the main right renal artery consisting of multiple stenoses and 1 cm. saccular aneurysm (fig. 1). The left renal artery was normal. Various therapeutic options were discussed with the patient, and she elected to undergo an endovascular stent-graft procedure to avoid surgery. The procedure was performed percutaneously via the left axillary artery, in order to obtain a better angle while positioning the stent, through a 7Fr introducer sheath. Heparin 5,000 IU was administered. After renal artery selective catheterization with a multipurpose catheter, the lesion was crossed with a 0.014-inch guide wire. The wire was exchanged via the same catheter with a 0.035-inch Amplatz Super Stiff Guide Wire (Boston, Scientific Corp., Natick, Massachusetts). A 28 mm. Jostent Periphel Stent Graft (JOMED, Helsingborg, Sweden) was then mounted on a 5 40 mm. balloon catheter and advanced through the guide wire. The stent was delivered across the lesion and inflated at 8 atm. for 15 seconds. A final right renal arteriogram showed excellent graft position, aneurysmal exclusion and no sign of residual stenosis (fig. 2). There were no complications, and the patient was discharged home on postoperative day 2 on a regimen of aspirin 100 mg. daily for 3 months. The patient remained normotensive for 10 months. At 24month followup blood pressure was observed in the normal range with amlodipine 5 mg. daily, and serum creatinine was 1.2 mg./dl. (normal 0.4 to 1.3). Color Doppler ultrasound showed wide patency of the renal artery, normal renal perfusion and aneurysmal exclusion.

Role of US in acute scrotal pain

BackgroundThe acute scrotum is a common emergency department (ED) presentation and can be defined as any condition of the scrotum or intrascrotal contents requiring emergent medical or surgical intervention. Although rarely fatal, acute scrotal pathology can result in testicle infarction and necrosis, testicular atrophy, infertility, and significant morbidity.MethodsScrotal US is best performed with a linear 7.5- to 12-MHz transducer. In addition to imaging in the longitudinal and transverse planes, it is helpful to obtain simultaneous images of both testes for comparison. Color Doppler is used to evaluate for abnormalities of flow and to differentiate vascular from nonvascular lesions. Attention to appropriate color Doppler settings to optimize detection of slow flow is critical.ResultsThe evaluation of acute scrotal pain can be challenging for the clinician initially examining and triaging the patient. Acute scrotal conditions due to traumatic, infectious, vascular, or neoplastic etiologies can all present with pain as the initial complaint. Additionally, the laboratory and physical examination findings in such conditions may overlap; this, coupled with potential patient guarding and lack of collaboration, may result in a limited, non-specific physical examination. Therefore, scrotal ultrasound has emerged to play a central role in the evaluation of the patient presenting with acute scrotal pain.ConclusionsIn conclusion, we are firmly convinced that a scrotal ultrasound should always be performed in the presence of acute scrotal pain. Moreover, urologist should be able to perform a scrotal ultrasound but, if imaging does not supply a clear diagnosis, surgical exploration is still mandatory.

Comparative experimental evaluation of guidewire use in urology.

OBJECTIVES To evaluate the characteristics and mechanical properties of five different guidewires principally used in urology to provide a guide to the best choice in every situation. This objective was achieved by performing mechanical tests on each guidewire and on the same guidewire in relationship to a real human ureter. Finally, the mechanical properties of a real human ureter were evaluated experimentally. METHODS Five different guidewires with a 0.035-in. external diameter were studied to determine their mechanical properties of interest: tip buckling, shaft permanent deformation, guide friction on the human ureter, and the force at which the tip perforated a real human ureter. RESULTS Nitinol guidewires with hydrophilic coating had the least dangerous tip in the tip buckling and tip piercing force tests and the lowest friction values on the friction guide test. The shaft of the polytetrafluoroethylene-coated guidewires was stiffer on the bending resistance and plastic deformation tests. CONCLUSIONS The ideal endourologic guidewire should be sufficiently flexible and lubricated to negotiate a tortuous ureter and pass possible obstructions. However, high strength against bending is also required when we need to pass a stent or catheter over a guidewire.

Condylomata acuminata of the Neovagina in a HIV-Seropositive Male-to-Female Transsexual

We present an unusual case of condylomata acuminata arising in the transplanted skin of a neovagina in a male-to-female transsexual. The neovagina had been constructed using a penile and a scrotal skin flap. Resection of the larger condylomata was performed; then all visible lesions were ablated by electrovaporization. Microsocpic examination and DNA hybridization revealed condylomata acuminata due to human papillomavirus type 16, 31, and 33 infection.

Bilateral Testicular Carcinoma In Patient With The Persistent MüLlerian Duct Syndrome

The persistent mullerian duct syndrome is a rare form of male intersex disorder in which a phenotypically normal male subject has fallopian tubes and a uterus along with testes and wolffian duct derivatives. This internal male pseudohermaphroditism is caused by a deficiency of mullerian duct inhibitory factor.1 A genetic mutation of chromosome 19 seems to be implicated in this condition.2 Like other undescended testes these gonads are at increased risk of malignant transformation, and a variety of germ cell tumors have been reported in association with this syndrome.3 These patients often present with cryptorchidism or an inguinal hernia with fallopian tubes and a uterus. We report a case of bilateral synchronous germ cell tumor in a patient with the persistent mullerian duct syndrome.

Reversible acute renal failure after unilateral extracorporeal shock-wave lithotripsy

Extracorporeal shock-wave lithotripsy (ESWL) is the treatment of choice for the majority of patients with renal or proximal ureteral stones. We describe an unusual case of anuric renal failure following ESWL, in absence of obstruction or myoglobinuria, in the presence of unilateral nephrolithiasis and two normally functioning kidneys. A mechanism for this patient’s acute renal failure (ARF) is postulated. Although the frequency of ARF after ESWL is extremely rare and the mechanism responsible for ARF is not understood, the appearance of ARF, when ureteral obstruction or hematoma are absent, should be included among complications following EWSL. Attention should be paid to older patients.

Evaluation of tumor thrombi in the inferior vena cava with intraoperative ultrasound

To report and discuss four cases of renal cell carcinoma (RCC) in which preoperative investigations yielded contradictory results regarding the cranial extension of propagation of the tumor thrombus into the vena cava. An intraoperative ultrasound scan (IOU) was performed in all cases to identify the exact level of the tumor thrombus. We have performed an IOU of the vena cava in four patients with RCC propagation into the inferior vena cava. Preoperative investigations were performed in all patients and consisted of abdominal Ultrasound scan (USS), contrast enhanced CT scan and gadolinium enhanced MRI scan. Intraoperative ultrasound has identified correctly the cranial extension and the absence of tumor thrombus infiltration in all patients. The thrombus reached the suprahepatic vena cava in two cases and was confined to the infrahepatic vena cava in the remainder. Preoperative imaging investigation had failed to determine the correct cranial extension of the tumor thrombus in two patients.IOU is a very useful tool to accurately assess the precise extent of tumor thrombus and eventually the presence of vein wall infiltration. These data are of paramount importance to plan the optimal surgical approach. According to our experience this type of investigation identifies the cranial extent of a tumor thrombus inside the vena cava better than standard imaging techniques.

Value of magnetic resonance imaging in the evaluation of sex-reassignment surgery in male-to-female transsexuals*

Background: We investigated the value of magnetic resonance imaging (MRI) in the evaluation of sex-reassignment surgery in male-to-female transsexual patients.Methods: Ten male-to-female transsexual patients who underwent sex-reassignment surgery with inversion of combined penile and scrotal skin flaps for vaginoplasty were examined after surgery with MRI. Turbo spin-echo T2-weighted and spin-echo T1-weighted images were obtained in sagittal, coronal, and axial planes with a 1.5-T superconductive magnet. Images were acquired with and without an inflatable silicon vaginal tutor. The following parameters were evaluated: neovaginal depth, neovaginal inclination in the sagittal plane, presence of remnants of the corpus spongiosum and corpora cavernosa, and thickness of the rectovaginal septum.Results: The average neovaginal depth was 7.9 cm (range = 5–10 cm). The neovagina had a correct oblique inclination in the sagittal plane in four patients, no inclination in five, and an incorrect inclination in one. In seven patients, MRI showed remnants of the corpora cavernosa and/or of the corpus spongiosum; in three patients, no remnants were detected. The average thickness of the rectovaginal septum was 4 mm (range = 3–6 mm).Conclusion: MRI allows a detailed assessment of the pelvic anatomy after genital reconfiguration and provides information that can help the surgeon to adopt the most correct surgical approach.