Il trattamento endourologico retrogrado della calcolosi cistinica multirecidivante: caso clinico paradigmatico

Presentiamo un caso clinico di calcolosi cistinica multirecidivante paradigmatico. Il paziente giungeva alla nostra osservazione dopo multipli trattamenti endourologici in altra sede con una situazione litiasica complessa: portatore di nefrostomie bilaterali e di stent ureterale destro venivano evidenziati calcoli multipli renali bilaterali e grosse calicificazioni ureterali, a destra a ridosso dello stent e a sinistra per un tratto di oltre 5 cm. Il trattamento endourologico retrogrado eseguito in più tempi, associato a una adeguata terapia medica per la cistinuria, ha portato a una bonifica completa. Riteniamo che il trattamento endourologico retrogrado rappresenti la modalità più adeguata per risolvere la calcolosi cistinica multirecidivante, al quale deve necessariamente essere associata la terapia farmacologica della cistinuria. Risulta altresi mandatario un trattamento in tempi brevi e una permanenza di eventuali endoprotesi ureterali per il tempo strettamente necessario, allo scopo di evitare calcificazioni degli stessi anche con formazioni litiasiche di ossalato di calcio. Ottenuta la bonifica, è consigliabile che anche i controlli vengano effettuati inizialmente secondo scadenze ravvicinate per poter risolvere eventuali recidive prima che raggiungano dimensioni tali da richiedere trattamenti più complessi

La calcolosi molle e le potenzialità del trattamento endourologico

Abstract non disponibil

Renal colic, where is it headed? An observational study

Aim: In the last thirty years, the treatment for renal and ureteral calculi has undergone profound variations. The objective of this study has been to evaluate the existence of parameters which can affect the spontaneous expulsion of a symptomatic ureteral stone in a reasonably brief period of time and to identify whether certain parameters such as sex, age, the location and dimension of the stone, the presence of dilation in the urinary tract together with the administered therapy, can be used for a correct clinical management of the patient. Methods: In a period of 9 months, 486 cases of renal colic were registered at emergency department. Results: The cases of renal colic due to ureteral calculus were 188 (38.7%). The patients' charts, complete of all data and therefore, valid for this research, resulted to be 120 (64%). In the presence of a symptomatic ureteral stone, the correct approach must first of all, focalize on the dimension of the calculus itself; less importance instead, is given to the location, as reported in other studies, the presence of hydroureteronephrosis, sex and the side. Conclusion: In the cases when the pain symptoms cannot be solved by means of the administration of analgesics, it is then reasonable to take into consideration an immediate endourological treatment. If the pain symptoms are promptly solved, an attentive wait of 4 weeks should be considered reasonable in order to allow spontaneous expulsion of the calculus

An unusual pathological finding of chronic lymphocitic leukemia and adenocarcinoma of the prostate after transurethral resection for complete urinary retention: case report

BACKGROUND: We describe a patient who underwent transurethral resection of the prostate for urinary obstructive symptoms and had histological findings of adenocarcinoma of the prostate with prostatic localization of chronic lymphocitic leukemia (CLL).The contemporary presence of CLL, adenocarcinoma of the prostate and residual prostatic gland after transurethral resection has never been reported before and the authors illustrate how they managed this unusual patient. CASE PRESENTATION: A 79-years-old white man, presented with acute urinary retention, had a peripheral blood count with an elevated lymphocytosis (21.250/mL) with a differential of 65.3% lymphocytes and the prostate-specific antigen (PSA) value was 3.38 ng/mL with a percent free PSA of 8.28%. The transrectal ultrasound (TRUS) indicated an isoechonic and homogenic enlarged prostate of 42 cm(3 )and the abdomen ultrasound found a modest splenomegaly and no peripheral lymphadenophaty. The patient underwent transurethral resection of the prostate and had a pathological finding of adenocarcinoma in the prostate with a Gleason Score 4 (2+2) of less than 5% of the material (clinical stage T1a), associated with a diffused infiltration of chronic lymphocitic leukemia elements. CONCLUSIONS: The incidental finding of a prostatic localization of a low-grade non-Hodgkin's lymphoma does not modify eventually further treatments for neither prostate cancer nor lymphoma. The presence of a low-grade and low-stage lymphoma, confirmed by a hematological evaluation, and the simultaneous evidence of an adenocarcinoma after transurethral resection of the prostate for acute urinary retention do not require any immediate treatment due to its long-term survival rate and the follow-up remains based on periodical PSA evaluation and complete blood count

Post-operative acute urinary retention after greenlight laser. Analysis of risk factors from a multicentric database

Purpose: Greenlight laser is a mini-invasive technique used to treat Benign Prostatic Obstruction (BPO). Some of the advantages of GreenLight photoselective vaporization (PVP) are shorter catheterization time and hospital stay compared to TURP. Post-operative acute urinary retention (pAUR) leads to patients' discomfort, prolonged hospital stay and increased health care costs. We analyzed risk factors for urinary retention after GreenLight laser PVP. Materials and methods: In a multicenter experience, we retrospectively analyzed the onset of early and late post-operative acute urinary retention in patients undergoing standard or anatomical PVP. The pre-, intra- and post-operative characteristics were compared betweene patients who started to void and the patients who developed post-operative urinary retention. Results: The study included 434 patients suitable for the study. Post-operative acute urinary retention occurred in 39 (9%). Patients with a lower prostate volume (P < .001), an adenoma volume lower than 40 mL (P < .001), and lower lasing time (P = .013) had a higher probability to develop pAUR at the univariate analysis. The multivariate logistic regression confirmed that lower lasing time (95% CI: 0.86-0.99, OR = 0.93, P = .046) and adenoma volume (95% CI: 0.89-0.98, OR = 0.94, P = .006) are correlated to pAUR. Furthermore IPSS ≥ 19 (95% CI: 1.19- 10.75, OR = 2.27, P = .023) and treatment with 5-ARI (95% CI: 1.05-15.03, OR = 3.98, P = .042) are risk factors for pAUR. Conclusion: In our series, post-operative acute urinary retention was related to low adenoma volume and lasing time, pre-operative IPSS ≥ 19 and 5-ARI intake. These data should be considered in deciding the best timing for urethral catheters removal

Sviluppo e sperimentazione clinica di nuovi laser per il trattamento mininvasivo della nefrolitiasi, delle neoplasie uroteliali e dell\u2019ostruzione cervico-uretrale.

Il laser (acronimo inglese di \u201cLight Amplification by Stimulated Emission of Radiation\u201d) \ue8 rappresentato da un sistema fisico ed ottico sofisticato in grado di amplificare ed emettere una radiazione elettromagnetica coerente, collimata e monocromatica. Conseguentemente, il fascio laser, caratterizzato da una minima divergenza, \ue8 unidirezionale e produce un intenso fascio di energia orientabile con precisione sul bersaglio. Dalle prime sperimentazioni su vesciche canine ad opera di Parson nel 1966, l\u2019applicazione del laser in ambito urologico ha subito continui e significativi miglioramenti inerenti il tipo di sorgente e lunghezza d\u2019onda del laser, la tipologia delle fibre ottiche e la precisione dell\u2019applicazione della radiazione, la riduzione dei costi di acquisizione e manutenzione, estendendone le potenziali applicazioni cliniche. Nell\u2019ultimo decennio le procedure chirurgiche con impiego del laser si sono imposte come gold standard in molti campi del panorama urologico. Se, infatti, nella pratica clinica attuale il laser \ue8 soprattutto utilizzato nel trattamento della nefrolitiasi, molteplici altre patologie possono essere trattate con successo utilizzando l\u2019energia laser: le stenosi uretrali, ureterali e pielo-ureterali, l\u2019ostruzione cervico-uretrale e le neoplasie uroteliali dell\u2019alta via escretrice. Attualmente, l\u2019Holmium:Yttrium\u2013Aluminium\u2013Garnet (Ho:YAG) rappresenta il laser maggiormente utilizzato in ambito urologico: sorgenti laser a ridotta energia di esercizio (fino a 20 W) sono state recentemente impiegate nel trattamento dei calcoli urinari, delle neoplasie uroteliali e delle patologie benigne dei tessuti molli, mentre rimangono tuttora necessarie sorgenti energetiche ad elevata potenza (80-100 W) per il trattamento dell\u2019ostruzione cervico-uretrale secondaria ad ipertrofia prostatica. Analogamente all\u2019Ho:YAG laser, anche la radiazione continua generata da una sorgente laser a diodi con lunghezza d\u2019onda di 1470 nm \ue8 caratterizzata da un\u2019elevata capacit\ue0 di assorbimento da parte dell\u2019acqua, rendendo quindi ipotizzabile la generazione all\u2019estremit\ue0 della fibra di una bolla di plasma ad alta energia, con potenziali effetti fototermici e di cavitazione. Scopo del primo studio \ue8 stata la sperimentazione e la valutazione del grado di efficacia e sicurezza di una nuova sorgente Ho:YAG laser a ridotta potenza di esercizio (max 10 W), l\u2019Ho:YAG laser CalculaseTM prodotto dalla Karl Storz (Tuttlingen, Germany), utilizzata nel trattamento ureterorenoscopico della calcolosi reno-ureterale cos\uec come delle neoplasie delle alte vie escretrici. Nel secondo studio \ue8 stata effettuata una sperimentazione \u201cin vitro\u201d utilizzando una sorgente laser a diodi con lunghezza d\u2019onda di 1470 nm, allo scopo di comprendere con precisione la tipologia delle interazioni tra tale lunghezza d\u2019onda e l\u2019acqua ed i tessuti biologici e di valutare il suo possibile impiego in litotrissia. L\u2019esistenza di una sorgente laser a diodi con lunghezza d\u2019onda di 980 nm, caratterizzata da un\u2019elevato assorbimento nel sangue e da un ridotto assorbimento nell\u2019acqua (utilizzata nella cosiddetta \u201cSelective Light Vaporization\u201d della prostata), ha inoltre portato alla ideazione di una nuova \u201cpiattaforma\u201d laser a diodi, in grado di erogare contemporaneamente le due lunghezze d\u2019onda, 1470 e 980 nm. Un prototipo di tale laser, prodotto dalla Biolitec AG (Bonn, Germany), \ue8 stato utilizzato sia in studi in vitro che in vivo, allo scopo di testare l\u2019efficacia e sicurezza di questa nuova sorgente laser combinata nella fotovaporizzazione della prostata. Nel corso del primo studio, la nuova sorgente Ho:YAG, operante con basse energie e ridotte frequenza di ripetizione degli impulsi, si \ue8 dimostrata efficace nella litotrissia reno-ureterale, indipendentemente dalla composizione chimica dei calcoli, cos\uec come nella fotoablazione delle neoplasie dell\u2019alta via escretrice. Nel secondo studio, \ue8 stato dimostrato come il laser a diodi a 1470 nm rappresenti fino ad ora il primo ed unico laser in continua in grado di generare una bolla di plasma ad alta energia a livello della punta della fibra, quando questa \ue8 immersa in acqua. Tale bolla di plasma si \ue8 inoltre dimostrata efficace nella frantumazione di calcoli urinari di diversa composizione. Combinando le due lunghezze d\u2019onda del laser a diodi in un\u2019unica piattaforma, \ue8 stato inoltre possibile sfruttare contemporaneamente l\u2019elevata efficacia coagulativa del laser a 980 nm con il potere termoablativo della radiazione a 1470 nm, garantendo un\u2019efficacie e sicura fotovaporizzazione della prostata e suggerendo un promettente ruolo di questa sorgente a doppia lunghezza d\u2019onda sia nel trattamento della nefrolitiasi cos\uec come della ostruzione cervico-uretrale.Laser, acronym for \u201cLight Amplification by Stimulated Emission of Radiation\u201d, represents a monochromatic light with a narrow wavelength bandwidth, and with the properties of coherence and collimation. Consequently, the laser beams have minimal divergence, are directional, and produce intense beams of energy that may be targeted with precision. Since Parson in 1966 used a pulsed-ruby laser in a dog\u2019s bladder, the use of laser technology in Urology has undergone significant advances with regard to different types of lasers, wavelength of energy and optical fibers used, precision of laser application and cost reduction, further improving laser technology and extending its potential applications. During the last decade some laser technologies have become established as standard modalities widely available to urologists. In the current urological practice, laser is predominantly applied to the treatment of urinary stones. However, a number of diseases other than stones can be successfully managed, including urethral, ureteral and ureteropelvic junction strictures, benign prostate hyperplasia (BPH) and upper urinary tract (UUT) transitional cell carcinomas (TCCs). Nowadays, Holmium:Yttrium\u2013Aluminium\u2013Garnet (Ho:YAG) laser is the most widespread, versatile, available laser. Recently, low-power versions of Ho:YAG laser, that yield up to 20 W of power, allowed successfully treating urinary stones, urethral, ureteral and ureteropelvic junction strictures, and TCCs. In contrast, high-power holmium laser devices (80-100 W) are still necessary for benign prostate hyperplasia treatment. Similar to Ho:YAG laser, the continuous wave radiation at 1470 nm delivered by diode laser has a high absorption in water; therefore, the radiation could produce, with a fiber tip immersed in water, high energy plasma bubbles, with photothermal and cavitation effects. Aim of the first study was the evaluation of efficacy and safety of a new low-power Ho:YAG laser with a maximum power limited to 10 W (Ho:YAG laser CalculaseTM, built by Karl Storz, Tuttlingen, Germany) in the transureteral retrograde treatments of both urinary stones and UUT TCCs. Aim of the second experiment was to test the 1470 nm diode laser in order to better understand the inter-action modalities of this wavelength with water and biological matter, evaluating its capacity to function as a lithotripter. Moreover, as 980 nm diode laser used in the selective light vaporization of the prostate has a low absorption in water and a high absorption in blood, with an optimal haemostatic effect, our idea was to create a high power multi-diode laser source, capable of delivering two simultaneous diode wavelengths (980 nm and 1470 nm) through the same optical fiber (laser unit built by Biolitec AG, Bonn, Germany). The goal of this study was to test this new diode laser in the photo-vaporization of the prostatic tissues, both in vitro and in vivo. In the first study, the new employed low-power Ho:YAG laser, that operates using low repetition frequencies and energy levels, would seem to provide excellent stone free rates, regardless of the stone hardness. Likewise, the CalculaseTM Ho:YAG laser, proved to be safe and effective in the treatment of the UUT neoplasms, allowing for a fine and complete tumor photoablation. In the second study, the 1470 nm diode laser proved to be the first continuous wave source capable of producing a high energy plasma bubble with a high thermoablation effect, confirming its capacity to function as a lithotripter, capable of shattering calculi of medium hardness. Moreover, combining the 980 nm with the 1470 nm radiation, it was possible to merge the optimal haemostatic effect with the 980 nm wavelength and the fast thermoablative effect of the 1470 nm radiation, thus guaranteeing, in our initial in vivo experiments, an efficient and safe photovaporization of the prostate. In conclusion, our preliminary data suggest a promising role of the multi-wavelength diode laser in the treatment of renal stones as far as of BPH