Vincenzo Li Marzi

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.

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.

The Female Sexual Function Index (FSFI): Linguistic Validation of the Italian Version

INTRODUCTION Although several new measurements for female sexual dysfunction (FSD) have recently been developed, the Female Sexual Function Index (FSFI) remains the gold standard for screening and one of the most widely used questionnaires. The Italian translation of the FSFI has been used in several studies conducted in Italy, but a linguistic validation of the Italian version does not exist. AIM The aim of this study was to perform a linguistic validation of the Italian version of the FSFI. METHODS A multicenter cross-sectional study conducted in 14 urological and gynecological clinics, uniformly distributed over Italian territory. We performed all steps necessary to determine the reliability and the test-retest reliability of the Italian version of the FSFI. The study population was a convenience sample of 409 Italian women. MAIN OUTCOME MEASURES The reliability of the questionnaire was calculated using Cronbachs alpha, which was considered weak, moderate, or high if its value was found less than 0.6, between 0.6 and 0.8, or equal to or greater than 0.8, respectively. The test-retest reliability was assessed for all women in the sample by calculating Pearsons concordance correlation coefficient for each domain and for the total score, both at baseline and after 15 days (r range between -1.00 to +1.00, where +1.00 indicates the strongest positive association). RESULTS Cronbachs alpha coefficients for total and domain score were sufficiently high, ranging from 0.92 to 0.97 for the total sample. The test-retest procedure revealed that the concordance correlation coefficient was very high both for FSFI-I total score (Pearsons P = 0.93) and for each domain (Pearsons P always >0.92). CONCLUSION For the first time in the literature, our study has produced a validated and reliable Italian version of the FSFI questionnaire. Consequently, the Italian FSFI can be used as a reliable tool for preliminary screening for female sexual dysfunction for Italian women.

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.

Management of sexual dysfunction due to central nervous system disorders: a systematic review

To systematically review the management of sexual dysfunction due to central nervous system (CNS) disorders.

Hemangioma of the Clitoris Presenting as Clitoromegaly: A Case Report

A 20-year-old woman with massive clitoral enlargement is presented to discuss the differential diagnosis and the treatment of this condition.

Urodynamics useless before surgery for female stress urinary incontinence: Are you sure? Results from a multicenter single nation database

The role of urodynamics (UDS) before surgery for stress urinary incontinence (SUI) remains a debated issue in female urology as well as in urogynaecology and it has been recently questioned on the basis of data coming from selected population of patients defined as “uncomplicated.” The aim of this study was to investigate the percentage of “uncomplicated” patients undergoing urodynamic evaluations in six referral Italian centers. The secondary aim was to assess the prevalence of women, for whom the urodynamic evaluation could add new information to the pre‐urodynamic picture and in how many cases these findings had a significant impact on patient management.

Role of Clinical and Surgical Factors for the Prediction of Immediate, Early and Late Functional Results, and its Relationship with Cardiovascular Outcome after Partial Nephrectomy: Results from the Prospective Multicenter RECORd 1 Project

Purpose: We sought to determine the predictors of short‐term and long‐term renal function impairment after partial nephrectomy. Materials and Methods: Clinical data on 769 consecutive patients who underwent partial nephrectomy were prospectively recorded at a total of 19 urological Italian centers from 2009 to 2012 in the RECORd 1 (Italian Registry of Conservative Renal Surgery) Project. We extracted clinical data on 708 of these patients who were alive, free of recurrent disease and with a minimum 2‐year functional followup. Results: Of the patients 47.3% underwent open, 36.6% underwent laparoscopic and 16.1% underwent robot‐assisted partial nephrectomy. The median baseline estimated glomerular filtration rate was 84.5 ml/minute/1.73 m2 (IQR 69.9–99.1). Immediate (day 3 postoperatively), early (month 1) and late (month 24) renal function impairment greater than 25% from baseline was identified in 25.3%, 21.6% and 14.8% of cases, respectively. Female gender and the baseline estimated glomerular filtration rate were independent predictors of immediate, early and late renal function impairment. Age at diagnosis was an independent predictor of immediate and late impairment. Uncontrolled diabetes was an independent predictor of late impairment only. Open and laparoscopic approaches, and pedicle clamping were independent predictors of immediate and early renal function impairment. Overall 58 of 529 patients (11%) experienced postoperative cardiovascular events. Body mass index and late renal function impairment were independent predictors of those events. Conclusions: Surgically modifiable factors were significantly associated with worse immediate and early functional outcomes after partial nephrectomy while clinically unmodifiable factors affected renal function during the entire followup. Late renal function impairment is an independent predictor of postoperative cardiovascular events.

Radical retropubic prostatectomy for prostate cancer with microscopic bladder neck involvement: survival and prognostic implications

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

Do Preoperative Urodynamics Still Have a Role in Female Stress Urinary Incontinence

The interesting randomized controlled trial by van Leijsen et al. concerns one of the most relevant and actually debated issue in urogynecology, the role of urodynamics in the preoperative evaluation of women with stress urinary incontinence (SUI). Some articles, also very recently published, seem to show that preoperative urodynamics do not improve the effectiveness of surgery in patients treated with midurethral slings placements for SUI. However, the last recommendations of the International Consultation on Incontinence suggest to perform urodynamic assessment before SUI surgery. The article by Van Leijsen et al. could be an important intellectual and clinical impact in the preoperative management of SUI. However, this trial presents some relevant limitations that could partially invalidate the obtained finding. The authors included in their study population also women with mixed urinary incontinence and they did not specify how they determined predominant stress incontinence. In spite of this potentially biasing enlargement of the patients recruitment and of the involvement of 10 different hospital, the authors enrolled in their trial only 59 women with SUI; this is a very small subset of patients, thus resulting in a very low statistical power for a minimal clinically relevant difference. Moreover, the study did not include or describe the women that more likely could benefit from urodynamics, patients with low leak point pressure, low MUCP, pelvic organ prolapse, previous failed incontinence or prolapse surgery or voiding dysfunction. Several papers identified new and classical urodynamic parameters to predict the sling outcomes (MUCPP, VLPP, open vesical pressure) and to offer to the patients a more accurate preoperative counselling. Moreover it is well-demonstrated that in incontinent women with pelvic organ prolapse, the urinary symptoms are not at all reliable and accurate. In addition, the role of preoperative risk factor to predict voiding dysfunction after SUI surgery is still debated and controversial. Some authors did not find any urodynamic parameter significantly related to post-surgical voiding disorders; on the contrary other research articles showed an important rate of postoperative voiding dysfunction, mostly asymptomatic, and identified preoperative maximal peak flow rate as independent preoperative risk factor. Finally, the first aim of every surgeon should be ‘‘primum non nocere’’; therefore it is mandatory, as much as possible, to avoid useless or damaging surgical procedures. Digesu et al. demonstrated that urodynamic investigations provide useful information in the assessment of women with a history of pure SUI, because as many as 20% of them might not need surgery as the first line of treatment. Furthermore, in 2008, Ward et al. reported that the overall probability to change management in incontinent women after urodynamic evaluation was 26.9% for medical treatment and 45.5% for surgical treatment. Van Leijsen et al. should be praised on the relevance and the topical interest of this issue, however, it is very difficult that this study could really conclude the debate on the preoperative role of urodynamics and further large-scale well-designed randomized controlled trials on this topic are strongly desirable.