Issues n.3 - 2010


n.3 - 2010

Paediatric urolithiasis in central coast region of Tunisia: Changes in stone composition according to age and gender

Akram Alaya, Abdellatif Nouri, Mohamed Fadhel Najjar


Objective: Studies evaluating the influence of age and gender on the distribution of the various types of paediatric urinary calculi are scarce. Aim of our study was to highlight the modification of epidemiological characteristics of this pathology depending on patients’ age and gender.

Patients and methods We present the results of a study based on 205 calculi (from 122 boys and 83 girls) analyzed by infrared spectroscopy between 1993 and 2007. 54.6% of the patients were under 5 years.

Results: Calcium oxalate (CaOx) was the predominant constituent in 54.7% of stones, followed by calcium phosphate and ammonium urate (14.6% each). We found a male preponderance for struvite stones (12.3% vs 1.2%), and an increasing prevalence of calcium oxalate stones with age (42.9% in infants vs 59.3% in older children). Purines stones were observed in 20% of cases, but their prevalence decreases with age (28.6% in infants vs 18.5% in old children).

Conclusion: the increase of calcium oxalate stone rate in school age children and the decrease of purines stones confirm the change on the etiology of urolithiasis according to age.

Calcium oxalate nephrolithiasis: Urinary “medium size peptides”analysis using MALDI-TOF mass spectrometry

Alessandro D'Addessi, Luca Bongiovanni, Matteo Vittori, Chiara Fanali, Nazario Foschi, Massimo Castagnola, Pier Francesco Bassi


Objective: Urinary lithiasis is one of the most common benign urological diseases. The pathogenic mechanisms of renal stone formation are complex and not clearly defined. We have studied the urinary protein composition of patients affected by calcium oxalate (CaOx) nephrolithiasis in a range of molecular weight between 1 and 5 kDa (medium size peptides). These molecules seem to have a double role in limiting the crystal adhesion to renal cells and at the same time in facilitating the degradation of crystals once internalised in cells. Their daily excretion is high, approximately 2-7 mg/die, even if studies have reported higher values. Our aim in surveying the urinary peptides was to look for qualitative difference in the medium size range, possible indication of the presence of a biomarker or any predisposing factors in patients affected by calcium oxalate nephrolithiasis.

Materials and methods: The urinary protein composition of 17 patients (11 male, 6 female; mean age 45 yrs ± 14SD) affected by CaOx nephrolithiasis was assessed in comparison with 17 healthy subjects. It was performed a qualitative assay using MALDI-TOF mass spectrometry (MS) in a range of molecular weight between 1 and 5kDa (medium size peptides).

Results: No differences were detected in the mass spectrums between patients and control subjects: all peaks overlapped. In addition, the values of peak intensity were comparable in both patient and control subject mass spectrums.

Conclusions: In the range of molecular weight between 1 and 5 kDa, we have not detected significant differences in the urinary composition between stone former patients and healthy subjects. Our results warrant further research in different molecular size peptides.

Urinary alkalization for the treatment of uric acid nephrolithiasis

Elisa Cicerello, Franco Merlo, Luigi Maccatrozzo


Three major conditions control the potential for uric acid stones: the quantitative excretion of uric acid, the volume of urine as it affects the urinary concentration of uric acid and the urinary pH. However, the most important factor for uric acid stone formation is acid urinary pH that is a prerequisite for uric acidic stone formation. Indeed the goal standard of urinary alkalization is to achieve a pH of 6-6.5. Administration of alkali should be titrated appropriately by pH paper to record urinary pH until a steady state is achieved. Alkali therapy such as sodium bicarbonate and potassium citrate has been advocated on the basis of established clinical experience, although potassium citrate should be preferred because it may avoid the complication of calcium salt precipitation. Recently it has been reported the clinical efficacy of therapy with potassium citrate/potassium bicarbonate for dissolution of radiolucent stones respect to control study period (only water daily intake of 1500 ml). Furthemore, mean urinary pH was significantly continuously higher during the alkali treatment study in comparison to the control study period, even though the mean of urinary volumes were similar in the two periods. In conclusion urinary alkalization with maintaining continuously high urinary pH values, could be the treatment of choice for stone dissolution and prevention of uric acid stones.

30 minutes high energy transurethral microwave thermotherapy (30 minutes TUMT) for the treatment of chronic urinary retention in patients with ASA II-III-IV

Mauro Dicuio, Stepan Vesely, Tomas Knutson, Jan-Erik Damber, Diego Ettore Cuzzocrea, Christer Dahlstrand


Objective: to investigate if 30-Minutes-TUMT was useful and safe in the treatment of chronic urinary retention due to BOO in patients with ASA II-III-IV.

Material and methods: 19 patients with chronic urinary retention (mean age 73.5 years) were scheduled for TUMT treatment because of absolute or relative contraindications to surgery. According to ASA classification there were 8 patients ASA II, 9 ASA III and 2 ASA IV. Routinely parameters were studied before and after treatment. Pain and patient's discomfort before, during and after TUMT treatment were registered using the VAS score (visual analogue scale: 0 = no pain and 10 = maximal pain). Urgency, irritation, and “how they feel” were registered at 2 days, 1, 2 and 4 weeks after TUMT using VAS technique.

Results: mean follow-up was 31,6 months (range 24-47), among the 9 responders patients (47,4%) who void normally without need of catheterisation, one patient died 12 months after the treatment for reasons not connected to the TUMT. Six patients (21.6%) failed the treatment and underwent TURP one or two years later (5 were ASA II and one ASA III). Among the 4 of 19 (21.0%) who had intermittent catheterisation after the treatment two died 1 and 2 years later, one has detrusor instability and one continued intermittent catheterisation. VAS during treatment was: 0 minute= 0.0; 5’ = 3.1; 15’ = 2.9; 25’ = 2.8; 2 h after the treatment = 0.3. At 3 years follow up IPSS, QoL and Qmax were still acceptable. No major complication occurred.

Conclusions: 47.4% of the patients responded positively to the new 30 minutes TUMT removing the urethral catheter, without needing surgical procedure avoiding the operation risk. 68.4% also improved their QoL. Local anaesthesia and oral/intravenous analgesia were sufficient during treatment. TUMT seems to have no anesthesiological risk. It is an option in patients with high risk of operation.

Can Sonovue® targeted biopsy replace extended or saturation biopsy in prostate cancer diagnosis? Our experience at primary and repeat biopsy

Pietro Pepe, Giuseppe Candiano, Michele Pennisi, Francesco Aragona


Objective: To evaluate the detection rate of prostate cancer (PCa) at initial and repeat biopsy in patients submitted to Sonovue® targeted biopsy vs extended or saturation prostate biopsy (SPBx).

Material and Methods: From November 2007 to April 2008 60 patients aged 64 years (median) underwent extended TRUS-guided transperineal prostate biopsy. Indications to biopsy were: abnormal DRE, PSA > 10 ng/mL; PSA included between 2.6 and 4.0 and 4.1 and 10 ng/mL with %free/total PSA ≤ 20% and ≤ 25%, respectively. In 45 and 15 men prostate biopsy was performed as primary and repeated procedure respectively; median PSA was 8.3 ng/mL vs 11.8 ng/mL and digital rectal examination was positive in 9 vs 3 patients, respectively. Before performing extended or SPBx scheme in case of primary (19 cores) and repeated (28 cores) procedure, prostate areas characterized by absence of enhancement after Sonovue® (2.4 mg) administration on gray scale during continuous harmonic imaging (HI) contrast-enhanced ultrasound (CEUS) were considered suspicious for PCa and submitted to targeted biopsy.

Results: 3.5 (median) targeted biopsies were performed in the peripheral zone of 22 men. In patients who underwent primary and repeated biopsy PCa was detected in 20/45 (44.5%) and 3/15 (20%) cases, but Sonovue® detected only 6/20 (30%) and 1/3 (33.4%) of cancers, respectively. Sensitivity and specificity of Sonovue® in diagnosing PCa was equal to 30.0% and 61.5% (primary biopsy) vs 33.4% and 54.5% (repeated biopsy).

Conclusions: Based on its low diagnostic accuracy, Sonovue® CEUS HI targeted biopsy can not replace extended or SPBx in diagnosing PCa.

Elasto-sonography of the testis: Preliminary experience

Marco Grasso, Salvatore Blanco, Marco Raber, Luca Nespoli


Objectives: We report our experience in elastosonography, a new developed ultrasonographic diagnostic dynamic technique used to provide an estimation about tissue stiffness.

Methods: 41 patients who presented with scrotal pain, painless enlargement of the scrotum or testicular nodules and infertility were submitted to ultrasound examination (US), color doppler ultrasonography (CDU), elastosonography examination (E). During ultrasonography examination we obtained conventional B-mode images. Lesion size was defined by the major diameter. The color doppler examination was performed to evaluate the vascular pattern. Subsequently we obtained elasticity images, with the patient in supine position. We used Hi Vision™ 8500 (Hitachi-Tokyo, Japan) ultrasonographyc machine with SonoElastography imaging option and we scanned with 7,5 MHz linear probe. To obtain images that were appropriate for analysis, we applied the probe with only light pressure, which we defined as a level of pressure that maintained contact with the skin and permitted imaging conditions for which the association between pressure and strain was essentially proportional.

Results: In 38 cases elastosonography confirmed the US and CDU findings. In the remaining 3 cases it allowed a better characterization of 2 small benign tumors and of an intratesticular haematoma.

Conclusion: In our preliminary experience elastosonography can provide additional informations by an higher definition in those cases where there are solid testicular lesions smaller than 10 mm. Infact elastosonography resulted helpful in the determination of 2 small lesions diagnosticated after surgery as Sertoli tumor and adenomatoid tumor of the testis, respectively in a third case the elastosonography identified an intraparenchimal hematoma (confirmed after surgical exploration )in the differential diagnosis with a solid tumor. Further systematic experience is needed for better characterization of testicular lesions with this newly developed technique

Corporoplasty by plication: Out patient surgery for the correction of penile curvature

Mauro Seveso, Gianluigi Taverna, Guido Giusti, Alessio Benetti, Orazio Maugeri, Alessandro Piccinelli, Pierpaolo Graziotti


Objective: Corporoplasty using plication of the albuginea is a simple technique but considered by many Authors at high risk for recurrence in respect to other corrective techniques using excision of the albuginea tunica. The aim of this study was to assess long term functional and cosmetic results of this approach done in an outpatient environment.

Material and methods: From January 1997 to December 2008 we submitted 217 patients presenting induratio penis plastica (183) or congenital curvature (34) to corporoplasty with albuginea plication. All patients were assessed preoperatively with history, physical examination and photographic documention of the erectile penis. These patients, all with vaginal penetration problems, were submitted to corporoplication with 2-4 sutures 2/0 (polyglycolic) contralateral to the curvature, using local anaesthesia on outpatient basis. Follow-up included functional and cosmetic results, eventual complications and level of patient satisfaction.

Results: Median follow-up of our study was 44 months (range 2-58). Complete correction of curvature was achieved in 206 patients (95%) whereas 87% reported good erectile function (IIEF-5 > 21). 145 patients (67%) reported penis shortening and 41% complained of palpating the sutures. Two patients required reoperation for recurring curvature. No perioperative complications or altered sensitivity of the glans were reported.

Conclusions: Simple plication of the corpora cavernosa can be done on an outpatient basis using local anaesthesia with optimal functional and cosmetic results. The success of this minimally invasive approach makes it a valid alternative to standard excision of the tunica albuginea procedure. Detailed preoperative information concerning procedure expectations and treatment course are extremely important in obtaining complete functional and cosmetic patient satisfaction.

Effect of aging on urinary incontinence in woman

Carlo Vecchioli-Scaldazza, Carolina Morosetti


Objective: The aim of the study was to evaluate, in a group of female patients with urinary incontinence (UI), the effect of aging on: a) urodynamic findings; b) incidence of detrusor overactivity; c) types of urinary incontinence; d) pelvic organ prolapse; e) body mass index; f) anorectal disorders.

Material and Methods: Eighty four consecutive patients with urinary incontinence were enrolled in this study. Patients were divided into two groups according to their age: group A: patients with age ≤ 65 years, group B: patients with age > 65 years. Patients underwent a full urogynaecological workup with a clinical evaluation and urodynamic study.

Results: In older patients urge and mixed urinary incontinence were the most prevalent type of (UI). In these patients an increase of the bladder sensation with a decrease of the bladder capacity, an increase of detrusor overactivity and a reduction of the maximum urethral closure pressure were found. Furthermore, a higher body mass index was observed in older patients.

Conclusions: The results of this study show an age-associated correlation of types of urinary incontinence, urodynamic findings, body mass index and incidence of detrusor overactivity.

Risk of prostate cancer at first saturation re-biopsy in a patient with previous diagnosis of HGPIN.

Roberto Giulianelli, Stefano Brunori, Barbara Cristina Gentile, Giorgio Vincenti, Stefano Nardoni, Teuta Shestani, Luca Mavilla, Luca Albanesi, Francesco Attisani, Francesco Pisanti


Introduction: It is advisable to submit a patient with isolated HGPIN to re-biopsy every 3-6 months, performing an increasing number of samples in order to increase the detection rate. The aim of this study is to evaluate if the use of saturation needle biopsy technique may increase this rate.

Materials and methods: From January 2004 to June 2006, 780 patients with hypoecogenic nodule at TRUS and/or PSA values between 2.5 and 10 ng/ml, underwent TRUS 10-core prostate needle biopsy, performed by the same operator. Isolated HGPIN was detected in 26 cases (3.3%). Within a year all these patients underwent saturation needle re-biopsy. This procedure consisted of 24 samples obtained using a tru-cut needle 18 G under soft anesthesia by a major opiate. All the patients received a single dose of Levofloxacin per os before the biopsy and for the following 2 days.

Results: Prostate cancer was found in 8 (33.3%) of the 24 eligible patients: 40% showed a Gleason Score 6 and 60% > 7. Concerning PSA, we observed 35% of neoplasms for values between 2.5 and 3.9 ng/ml and the remaining 65.0% for values between 4.0 and 9.9 ng/ml.

Conclusions: The use of saturation needle biopsy allowed to detect 30.8% of prostatic cancer performing the first re-biopsy within a year. This result does not differ from others obtained with 8- 10 cores techniques, therefore the indication of the 24-cores procedure should be limited to carefully selected patients with a high risk of developing cancer after that other techniques had not been successful.

Laparascopic heminephrectomy in horseshoe kidney: A case report

Dario Del Biondo, Antonio Celia, Guglielmo Zeccolini, Guglielmo Breda


We present a case of laparoscopic transperitoneal heminephrectomy involving a large renal cell carcinoma of 7 cm centrally located on the left side of a horseshoe kidney in a 48 years old male patient detected by ultrasound scan and CT scan.

Fibrous pseudotumor originating from tunica albuginea testis: A case report.

Yusuf Özlem Ilbey, Emin Özbek, Emre Can Polat, Abdulmuttalip Simsek, Adnan Somay


We report the case of 33 year-old man who presented a rare benign paratesticular mass identified as fibrous pseudotumor. Because of its rarity, the clinical, diagnostic and therapeutic aspects as well as the possibilities of organ-sparing surgery are discussed.

Management of large prostatic abscess associated with urethral stenosis and penile cancer recurrence

Andrea Benedetto Galosi, Gianni Parri, Vito Lacetera, Giovanni Muzzonigro


Introduction: The purpose of this report was to analyze the management of a large prostatic abscess in a patient with urethral stenosis and recurrence of penile cancer, who had presented with acute urinary retention.

Methods: The clinical diagnosis was based on the end-fire transrectal ultrasound (TRUS) findings and later confirmed by CT. The patient had several surgical scars and radiationinduced effects in the lower abdomen, therefore the placement of a percutaneous sovrapubic catheter was considered hazardous. The placement of a transurethral catheter was impossible because of firm meatal stenosis due to previous penile partial amputation and growing tissue that suggested local recurrence of penile cancer.

Results: Transurethral placement of a 8 Fr catheter was possible under radiologic/ultrasound control using a hydrophilic glidewire. The definitive treatment also included percutaneous transperineal drainage and placement of a 8 Fr pig-tail drain under TRUS. Subsequent surgical treatment of the penis showed low grade superficial squamous cell carcinoma. Management and follow-up of prostatic abscess is based on TRUS imaging. After 4 years of follow-up, abscess recurrence was observed and treated with a urethral catheter and antibiotics.

Conlusion: Urethral stenosis due to penile cancer is a predisposing factor in the development of prostatic abscesses. Placement of a bladder catheter and percutaneous drainage of the abscess are the mainstays of treatment. In malignant urethral stenosis, the conservative management of a prostatic abscess is safe and efficacious in a long term follow-up. Transrectal US is a key instrument to guide intervention and to check results.

Chylous ascites following laparoscopic adrenalectomy: Case report and literature review

Galanakis Joanny, Antonio Celia, Guglielmo Zeccolini, Dario Del Biondo, Guglielmo Breda


We report a case of chylous ascites developing the first post-operative day after laparoscopic adrenalectomy. The early initiation of treatment with total parenteral nutrition and somatostatin analog led to rapid resolution of the ascites. To the best of our knowledge, this is the first case of chylous ascites after laparoscopic adrenalectomy and we report it to stress the need for greater awareness and attention (meticulous dissection, permanent use of hemoclips and/or suture ligatures instead of electrocautery) even for simpler laparoscopic urologic procedures.

Kidney hibernoma: Case report and literature review

Alessandro Delsignore, Stefania Ranzoni, Matteo Arancio, Carlo Marchetti, Giuseppe Landi, Alessandro Mina, Maurizio Marcato, Carlo Martinengo


Objectives: Hibernomas are rare benign tumours originating from the brown adipose tissue. They occur generally in adults with a peak incidence in the third decade and with a slightly predominance in women. They are benign tumor that does not recur with complete excision. CT and RM images should not be misdiagnosed with atypical lipomas or well-differentiated liposarcoma. We report a case of incidental renal hibernoma discovered in a 51 years old women during open surgery for kidney pielic stone.

Case report: A 51-year-old woman presenting with recurrent left flank pain was diagnosed with left kidney stone. Abdomen ultrasound and i.v. pyelografy showed pyelic stone of 2 cm without other pathologies of the urinary tract. Patient underwent left percutaneus lithitripsy complicated by severe bleeding. We converted into open surgery and incidentally we observed a brown, well-defined, encapsulated, and mobile mass of 1 cm that resulted to adhere to kidney capsule. We removed this lesion respecting surgical borders. Intraoperative histological examination revealed cells with eosinofil cytoplasm and no evidence of mitosis or cellular atypia. Definitive histological examination show a well-circumscribed, encapsulated tumor, with large cells with central nuclei and multivacuolated granular cytoplasm. A rich vascular network was present absence of mitosis or atypia was confirmed. Histological diagnosis presumed hibernoma.

Conclusion: Our case report results one of the few cases of renal localisation of hibernoma that howewer need a surgical treatment.

Primary obstructive megaureter in adults: Management strategy in a young woman

Andrea Solinas, Antoncarlo Pau, Mohammed Ayyoub, Mauro Frongia


Objective: Primary obstructive megaureter is an uncommon disease in adults. We describe a case in a thirty years old woman affected by monolateral megaureter complicated by ureteric calculi.

Material and method: The clinical presentation, renal function, radiologic data, complications and treatment were studied.

Results: The patient, with a history of recurrent right flank pain in the last ten years, had a right primary obstructive megaureter radiologically revealed complicated by ureteric calculi. Omolateral kidney result malrotate. Extensive ureteral tailoring with an extravesical ureteral reimplantation was performed. The calculi were removed at the time of ureteroneocystostomy.

Conclusion: Adult and adolescent primary obstructive megaureter is a congenital abnormality that do not regress. Complications such us stone formation and altered function of the affected kidney are common and when associated to recurrent urinary tract infections require surgical intervention. Conservative management probably has a role only in the uncomplicated primary megaureter patients with normal creatinine clearance and who have possibility of a regular lifelong follow-up.