We relate our experience about ureteritis, especially non specific ureteritis. The traumatic, radiation ureteritis will be discussed in others chapters. Most cases of ureteritis are infective, and may be due to any of the organism normally found in urinary tract infections, particularly Escherichia Coli, staphylococci, streptococci, enterococci, proteus and pyocyaneus. It is really primary, but it usually ascending from an associated cystitis, descending from pyelonephritis, or due to direct spread from and adjacent inflammatory lesion such as appendicitis or salpingitis. The infection may also reach the ureter by lymphatic spread, particularly from the prostate and seminal vesicles. Any associated abnormalities of the ureter, such as stricture, megaloureter, ureterocele, and so on, will naturally predispose to infective ureteritis. As ureteritis is rarely primary, the first step in treatment must be toward the elucidation and cure of any underlying lesion. Thus calculi, cystitis, pyelitis, and so on, will need appropriate therapy, and this in itself will considerably improve or cure the ureteritis, and specially in the more acute cases. In the chronic cases with stricture formation, dilation or even excision of the stenosed portion may be required. For the treatment of the strictures we want emphasize the role of the ureteral stenting thinking its use is necessary to preserve the renal function.
Ureteral injuries are an uncommon complication after gynecological procedures. The Authors consider separately direct lesions during surgery and those following radiotherapy. For both these situations preventive criteria, which permit a lower incidence in ureteral injuries, are considered. Early diagnosis and intraoperative repair are the most important tool for surgical lesions while the exact stage of neoplasm and N.E.D. status are fundamental for lesions resulting from radiation therapy. In our opinion, best treatment of stable lesions is surgery, while endourology is not usually a definitive treatment and has only a temporary and palliative role.
Ureteral malformations that concern adults are very few. The aim of this review is to value the real clinical incidence and to illustrate etiology, diagnosis and therapeutical management advised in the literature.
The ureteral complications after renal transplantation are urine leakage, stenosis and vesicoureteral reflux. The treatment is influenced by immunosuppression and difficult surgery (for bleeding and fibrosis). We report 8 cases with ureteral complication after renal transplantation. Stenosis were present in 5 cases: we performed ureterocystoneostomy by Politano-Leadbetter technique in 4 and pyelocystoanastomosis in 1. Vesicoureteral reflux were present in 3 cases: we preformed ureterocystoneostomy by Politano-Leadbetter technique in 2 and endoscopic infiltration with teflon of ureterovesical junction in 1. At present all patients have a normal renal function and absence of urinary tract infection.
The function of the ureter is to transport urine from the renal pelvis toward the bladder and to protect the renal parenchyma from distally generated backflow and back pressure. The ureter manifests peristaltic activity and can adapt its mechanical characteristics to diuresis amount. The changes in ureteral function resulting from obstruction are dependent on the degree and duration of obstruction. Even the rate of urine flow, the mechanical and anatomic properties of the ureter, the nature of disease process and the age of the patient influence the response of the ureter to obstruction. It is the purpose of this report to correlate the anatomic and physiologic properties of the ureter with normal and pathologic clinical situations.
From 1983 to 1992, 29 patients with primitive ureteral tumors have been recovered in our department. All the tumors were urothelial. Urography, spontaneous and selective urinary cytology, retrograde ureteropyelography permitted a correct diagnosis in 86% of them. Ureteroscopy is not performed routinely but only when conventional radiology is doubtful or a conservative treatment can be proposed. Controlled trials on endoscopic therapy of ureteral tumours are very few and even if our results are encouraging we believe that this therapeutic option is effective and safe only in selected case and nephroureterectomy is the treatment of choice.
We relate our experience about ureteritis, especially non specific ureteritis. The traumatic, radiation ureteritis will be discussed in others chapters. Most cases of ureteritis are infective, and may be due to any of the organism normally found in urinary tract infections, particularly Escherichia Coli, staphylococci, streptococci, enterococci, proteus and pyocyaneus. It is really primary, but it usually ascending from an associated cystitis, descending from pyelonephritis, or due to direct spread from and adjacent inflammatory lesion such as appendicitis or salpingitis. The infection may also reach the ureter by lymphatic spread, particularly from the prostate and seminal vesicles. Any associated abnormalities of the ureter, such as stricture, megaloureter, ureterocele, and so on, will naturally predispose to infective ureteritis. As ureteritis is rarely primary, the first step in treatment must be toward the elucidation and cure of any underlying lesion. Thus calculi, cystitis, pyelitis, and so on, will need appropriate therapy, and this in itself will considerably improve or cure the ureteritis, and specially in the more acute cases. In the chronic cases with stricture formation, dilation or even excision of the stenosed portion may be required. For the treatment of the strictures we want emphasize the role of the ureteral stenting thinking its use is necessary to preserve the renal function.
The injuries to the ureter, whether from external trauma or iatrogenic, are rare. Some problems are common to this type of pathology, independently from the causes of injuries. It is necessary a prompt diagnosis of the lesion to avoid the urinar leakage, the infection and the fibrosis of the ureteral's stumps. If the diagnosis is not prompt, the clinical pattern may be silent for some days; after, many complications will arise up: sepsis, urinomas and fistulas. When the lesion is incomplete, and there is no devascularization, the urine drainage alone, positioned above the level of the lesion, is indicated for spontaneous repairing. When the ureteral tissue loss is extensive, it is not enough a simple anastomosis between the ureteral's stumps; in these cases is necessary a more complex repair surgery or ureteral substitution.
Idiopathic retroperitoneal fibrosis is generally held to be uncommon. Its etiology is unknown. The disease continues to present with early bilateral ureteric involvement. Nowadays imaging techniques permit so a timely diagnosis to preserve and reduce renal damage. The optimum method of management is still controversial. Controversies on pharmacological, endourological and surgical treatment are debated. The advantages of various types of surgery are reviewed. In the urological department of the Civic Hospital in Brescia from February 1984 to June 1992, 87 patients (6 females and 2 males) with IRP were observed. Surgical treatment was combined with corticosteroids in 6 patients. Ureterolysis was performed with omental wrapping in 5 patients, with ureteric intraperitonealisation in 2 other ones. In the last case an ileal loop replacement was performed. In 5 out of 8 patients the ureteral stricture was resected and a termino-terminal anastomosis was necessary. Long-term follow-up is satisfactory. The authors conclude that omental wrapping is the safest method of choice.
Ureteral pathology is reviewed in 297 urinary diversions, which were performed consecutively in our Department, in the last 9 years. Either cutaneous or intestinal anastomosis stricture was the most common complication. Our attempts to cure definitely this problem by endourological techniques were unsatisfactory. So the Authors conclude that surgery is usually the best option.
The authors underline the diagnostic accuracy of transurethral bladder ultrasonography in the estimation of local infiltration of bladder tumors. The study was conducted on 21 patients who underwent either endoscopic resection or cystectomy. The clinical staging obtained by transurethral echography was compared with the pathological one. The results obtained by either method were comparable in all cases.
Seventeen patients submitted to radical cystectomy and orthotopic bladder replacement according to Reddy's technique were studied at the 1, 3, 6 and 12-month, then annually follow-up by physical examination, intravenous pyelogram, cystourethrography, suprapubic and transrectal ultrasonography and complete urodynamics. Sixteen patients (94%) reported day-time urinary continence and twelve patients (70%) day-time and nocturnal continence. Cysto-manometry showed a mean bladder capacity of 450 cc with a maximal endocavitary pressure of 40 cm. H2O and satisfactory peak flow rate. Vesico-ureteral reflux was never detected at roentgenography. Ultrasonography may be useful in the study of a possible reflux or stenosis of the neovesico-ureteral junction by detecting renal scars or dilatation of the renal cavities. Sovrapubic ultrasonography can quantify the capacity of the neo-bladder (300-600 cc), study its shape, walls and contractions that do not cause the involuntary opening of the neo-bladder neck. Transrectal ultrasonography studies the bladder neck shape and its dynamic function. Residual urine volume never exceeded 50 cc. Ultrasonography demonstrated its effectiveness and reliability and limited the application of more invasive roentgenographic procedures.
Until now, patients with a progressive prostatic cancer, in whom all therapies failed and the disease spread locally and distally, was considered "a lost patient"; because it did not exist an effective therapy easily to be used. The skeletal pain control is a serious problem and it is a great responsibility also for the Urologists especially if the patient has not a short survival time and the quality of life is very poor. Physicians feel the need for a systemic, well tolerated and effective therapy also for a long time, uniform and repeatable, able to be efficient for these patients. Strontium 89 chloride seems to offer all these possibilities and to be the best procedure for Urologist, Radiotherapists and Nuclear Specialists in order to satisfy the patients requirements. International research has shown Sr-849 Chloride is a powerful new therapy. Sr-89 Chloride is a radiopharmaceutical product for the treatment of painful metastases from prostatic cancer. It is a new treatment but its effectiveness is well documented and results are reported in the most important international literature. In our Department a clinical research has started and our purpose is to produce more data for a clinical and biological evaluation of the results, hoping that a similar research will extend as a multicenter study.
Metastases in the central nervous system (C.N.S.) from urological tumors can be spinal or craniocerebral. The experience of 30 patients with spinal and craniocerebral metastases from urological tumors admitted to Neurosurgical Clinic of the University of Milan, is reported. They were 7.5% of the all number of metastases admitted at the Neurosurgical Department, during the same period. The brain metastases constitute 10% of brain metastases diagnosed in this period. Only patients with solitary (to CT scan and NMR) metastasis, and with a general prognosis that allow to an adequate and useful period of survival, are submitted to surgical treatment. 23 patients (76.6%) are surgical treated. The mean survival from the discovery of the C.N.S. metastases was 9 months (9.4 months among surgically treated patients and 7.8 months among those were not operated). Surgical mortality was 13%. Out of patients with survival until 5 months, patients submitted to surgical treatment showed a better quality of life. Our results allow us to affirm that in selected patients surgical removal of solitary metastases, could improve the quality of survival, but is not able to prolong substantially the period of survival.
The present contribution considers the diagnostic possibilities of radiological imaging procedures in the evaluation of the lymphatic and bloodborne metastases in urological tumors. As regards the evaluation of the lymph node chains the presently available imaging modalities are discussed. For each of them, diagnostic accuracy and the percentage of false positive and false negative readings are presented. For the evaluation of the bloodborne metastases, the available imaging procedures for each organ and site are reported and a diagnostic flow chart is suggested.
The treatment of the prostatic carcinoma is an open problem. Nowadays the medical and/or endoscopic therapy combines with the surgical therapy by means of the radical prostatectomy. This work presents the experience of the team of Desenzano (BS) and their position, which, in accordance with many authors, underlines the validity of the radical prostatectomy, in those cases of tumor at stage D 1, in order to reduce the progression of the disease and to prolong the survival.
The authors briefly illustrate some biological and epidemiologic characteristics of the malignant urologic tumors; then they describe the modalities of metastasizing underlining that this process is determined not only by hematic and lymphatic dissemination but also by sequential and complex events "metastatic fall", involving multiple guest-tumor intersections to the organotropism of the neoplastic cells and to their intrinsic aggressiveness and to the histological type of tumor. Afterwards the authors analytically analyze the most important malignant neoplasms of the urogenital apparatus either as clinical importance or as statistic incidence.
Antiblastic chemotherapy of the urological tumors proves to be effective in germ-cell testicular tumor, in bladder cancer and in penis cancer, while a real effective anti-cancer therapy for prostatic and renal cell cancer has not found yet. There is not a significant difference between BVP and BEP regimens as first-line treatments of the good risk germ-cell testicular tumors. On the contrary BEP showed a lower toxicity and an higher efficacy in the treatment of the poor risk patients. Considering salvage therapies, PEI regimen proves to be as the most effective, also in the management of patients pretreated with BEP; high dose chemotherapy with autologous bone marrow transplant is currently examined as third-line therapy. In the treatment of bladder cancer the most effective drugs are Methotrexate, Adriamycin, Vinblastine and Cyclophosphamide, that, when combined, are sensitively more efficacious. The different chemotherapies achieved elevated percentage of Complete and Partial Responses (CR+PR): however these results are maintained in only 10% of the cases. So far the aim of the last studies is to improve the results both with a modification of posology and of the schedule of administration, and with the employ of growth-factors to reduce toxicity. An appreciable improvement in the treatment of locally advanced penis cancer has been achieved employing VBM regimen as adjuvant therapy, especially for patients with extrinsic lymph-nodal metastases, who underwent bilateral inguinal and iliac lymphadenectomy.(ABSTRACT TRUNCATED AT 250 WORDS)
The best knowledge of the biological and genetic mechanism involved in the process of metastasizing must determine the attempt of elaborating new therapeutical modalities. The authors show the sequential events of the metastasizing process based on the most recent theories, underlining the way the organotropism of the neoplastic cells can be the explanation of the otherwise inexplicable metastases.
