Issues n.2 - 2011


n.2 - 2011

Is microsurgical technique really necessary in inguinal or sub-inguinal surgical treatment of varicocele?

Gaetano Gulino, Alfonso D’Onofrio, Giuseppe Palermo, Michele Antonucci, Fabrizio Presicce, Marco Racioppi, Pier Francesco Bassi


The ideal method for treatment of varicocele is still controversial. The techniques of inguinal and sub-inguinal ligation, although less invasive than “high” abdominal ligations (Palomo, Ivanissevich), have been less popular than the former ones. Up to now most authors have considered as mandatory microsurgical techniques for the ligation of spermatic veins at inguinal or sub-inguinal level, or at least instruments of optical magnification in order to preserve testicular arterial supply of the spermatic and cremasteric artery at groin and to prevent testicular atrophia or gonadic ischemia. The aim of this study was to assess clinical outcomes of open surgical tecnique of varicocele repair compared to results derived from microsurgical series. A retrospective study included 45 patients of mean age 31 years (range 18-39) that underwent open surgical technique of inguinal ligation of spermatic veins in the period 2004-2009; clinical results of this series were compared with those obtained in five relevant studies derived from systematic review of the literature on microsurgical techniques. The pre-operatory evaluation in our series included a physical examination, a minimum of two semen analysis and scrotal color Doppler ultrasound. Post-operative pain, complication rates, days of hospitalization and time to return to work were considered as main outcomes. All patients were evaluated at 1 week, at 3 and 6 months after the operation by means of a physical examination, scrotal Doppler ultrasound and sperm analysis. Most patients (39/45) presented no pain in the first week, 6/45 mild to moderate pain (mean VAS score 2). None of the patients reported pain in the weeks thereafter. The hospitalization (1.8 +/- 0.7 days) and the time for return to work (7.2 +/- 3.2 days) were not significantly different in microsurgical and open groups. During follow-up no complications like hydrocele or testicular atrophy were observed. Doppler ultrasound carried out 3 and 6 months after surgery, pointed out no reflux in testicular veins in 41/45 cases while in 4/45 it showed a persistence of reflux grade I, less than the grade before the treatment. Comparing pre-and post-operatory sperm analysis allowed us to observe a significant improvement either in spermatozoa concentration (22 +/- 4 40_+/- 6 millions/ml, p < 0.01), either in motility (33 +/- 4% and 48 +/- 4%, p < 0.05), without significant changes in morphology. No significant differences were recorded comparing these data with those coming from microsurgical series. Our study reported positive clinical outcomes using the technique of sub-inguinal surgical ligature of varicocele without using microsurgical techniques or instruments of optical magnification. The operative time, complication and relapse rates, Doppler flow parameters and semen parameters were not significantly different from those reported in the literature of microsurgical techniques, with the advantage of such a simple surgical technique combined with cost savings and patient’s comfort.

Blood donors: An ideal population to study the PSA value and the incidence of prostate cancer in healthy population

Andrea Fandella, Marco Borghesi, Alessandro Bertaccini


Population screening for prostatic carcinoma (CP) is a debated topic, and its real utility is still unknown. Nowadays only surveys on little groups or clinical randomized studies are recommended. In this study the male population of blood donors of our hospital aged between 45 and 65 years underwent a complete evaluation for CP. The objectives of the study were: a) early diagnosis of CP, b) exclusion of carriers of neoplastic pathology from blood donations (theoretic risk of transmission of neoplastic cells in immunodepressed patients); c) evaluation of the feasibility of a model to be exported to other Transfusion Centres if successful with an high adhesion rate to the screening. A total of 1387 PSA dosages were obtained on 605 patients. In the 45 to 49 years group PSA value ranged from 0.26 to 2.86 ng/mL (mean and median value were 0.85 and 0.68 respectively), in the 50-59 years group PSA range was 0.6 to 7.96 (mean and median value 1.21 and 0.87respectively) and in the 60 to 69 years group PSA ranged from 0.7 to 293.67 (mean and median 3.6 and 1.29 respectively). A total of 32 biopsies for high PSA values and/or for suspect digital rectal finding were performed allowing diagnosis of prostate adenocarcinoma in 15 subjects (2.4%). Out of them,14 underwent radical prostatectomy (9 pT2 - 5 pT3), and one was placed on hormonal therapy.

Residual prostatic tumour in the surgical bed following radical prostatectomy in organ-confined prostate cancer: Possible prognostic significance

Claudio Valotto, Giovanni Falconieri, Stefano Pizzolitto, Maria Angela Cerruto  Giovanni Brondani, Alberto De Gobbi, Filiberto Zattoni


Introduction and objectives: The aim of our study was to verify the impact of benign and malignant residual glandular tissue on surgical bed after radical prostatectomy, in terms of both biochemical and clinical disease progression, in a group of patients with pathologically organ-confined cancer of the prostate (PCa).

Material and methods: Files from 70 consecutive patients who undergone radical retropubic prostatectomy (RRP) for organ-confined PCa were retrospectively evaluated. During each intervention, after prostate removal, biopsies of the surgical bed were obtained from the following sites: urethral/periapical section margin, basal, left and right postero-lateral and under/retrotrigonal regions. No patient was been previously treated with either radiation or hormone therapy. We evaluated the relationship between the presence of either benign or malignant prostatic cells at surgical bed biopsies and the following parameters: postoperative serum PSA levels, definitive Gleason score, tumour staging, margin status.

Results: In all cases pathological stage was pT2N0M0, an immediate postoperative PSA zeroing occurred and surgical margins were negative. Surgical bed biopsies after prostate removal were positive for malignant cells in 5/70 cases (7.1%) and for benign prostatic cells in 16/70 patients (22.9%). Overall a biochemical disease progression was observed in 13/70 cases (18.6%): 1 case with surgical bed biopsies positive for cancer; 3 cases with biopsies positive for benign prostatic tissue; 9 patients with biopsies negative for prostatic tissue residuals. In this latter group 2 cases of disease progression were observed. Stratifying patients according to biopsy features, we did not find any significant difference between groups concerning preoperative PSA (p = 0.319), prostate weight (p = 0.158), pathological staging (p = 0.371), Gleason score (p = 0.457), follow-up (p = 0.144), biochemical progression rates (p = 0.553). At logistic regression model the only statistically significant association was between disease progression and preoperative PSA (p = 0.026). Stratifying patients with no malignant biopsies in two subgroups (presence and absence of residual benign prostate tissue) no statistically significant differences were detected in terms of disease relapse (p = 0.158).

Conclusions: In patients with pathologically organ-confined PCa, minimal neoplastic tissue residuals might not significantly affect medium-long-term prognosis: 80% of patients with positive biopsy showed undetectable serum PSA levels after a median follow-up over 5 years. In contrast, surgical margins positive for benign prostatic glands was not significantly related to a possible disease relapse/progression.

High energy microwave thermotherapy for symptomatic benign prostatic enlargment: Predictive parameters of long term outcome

Giuseppe Lucarelli, Michele Battaglia, Carlo Bettocchi, Roberto Peschechera, Gaetano Valerio Palella, Pasquale Martino, Silvano Palazzo, Gabriele Alberto Saracino, Francesco Paolo Selvaggi, Pasquale Ditonno


Objectives: High-energy transurethral microwave thermotherapy (HE-TUMT) has become one of the most preferred minimally invasive procedure for the treatment of benign prostatic enlargment (BPE). In this study we report the long term results in a subset of patients treated with the 30-minute high energy protocol.

Patients and methods: A total of 135 patients were treated with TUMT Prostasoft 3.5. The International Prostate Symptom Score (IPSS), Madsen Symptom Score (MSS), Quality of Life (QoL) score, peak urinary flow rate (Qmax) and post-voiding residual urine volume (PVR) were assessed at baseline and at 12, 24, 36, 48 and 60 months after treatment.

Results: The mean follow-up period was 46.1 months. The mean IPSS at baseline was 17.8 and decreased to 5.6 at 60 months (p < 0.001). The MSS decreased from 12.6 at baseline to 4.3 at 5 years (p < 0.0001). The QoL score improved from 4.1 to 2.2 at 5 years (p < 0.001). The mean Qmax value at baseline was 9.4 ml/sec and it improved to 15.7 ml/sec at 60 months (p = 0.001), whereas PVR decreased from 97 to 24 ml at 5 years (p = 0.001). Retreatment was required for 47 patients (34.8%). Univariate and multivariate analysis showed that the only baseline parameters able to predict the long-term efficacy were a IPSS < 18 and a Qmax > 10 ml/sec (p = 0.04).

Conclusions: These data shows a high response rate obtained with 30-minute TUMT protocol and a durability of response up to 5 years after treatment, making this procedure a safe and effective alternative to TURP in selected patients.

Comparative randomized study on the efficaciousness of treatment of BOO due to BPH in patients with prostate up to 100 gr by endoscopic Gyrus prostate resection versus open prostatectomy. Preliminary data

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


Obiectives: With the advent of medical management and minimally techniques for benign prostate hypeplasia (BPH), invasive surgical procedures such open prostatectomy (OPSU) have become less common, altough selected patients may still benefit from open prostatectomy. Aim of this study was to evaluate efficacy and safety of Bipolar TURP (Gyrus electro surgical system) versus standard open prostatectomy in patients with lower urinary tract symptoms (LUTS) due to bladder outlet obstruction (BOO) with markedly enlarged glands refractory to medical therapy.

Methods: From January 2003 to January 2004, 140 patients affected by mild-severe LUTS, secondary to BOO from BPH, refractory to medical therapy, with markedly enlarged glands, were randomized in two groups (1:1), and subjected to open prostatectomy (OPSU) carried out with traditional method (Bracci Thecnique) versus transurethral resection of the prostate (TURP) utilizing the bipolar methodology. Preoperative work-up included IPSS, IIEF-5 and Qol questionnaires. All patients were submitted to uroflowmetry, transrectal ultrasound (TRUS), measurament of postvoidal residual urine and PSA determination. IPSS, IIEF-5 and Qol, uroflowmetry, TRUS, measurament of post-voidal residual urine , PSA determination and number of reoperations were evaluated at 1, 3, 6, 12, 18, 24, 30 and 36 months. Operative time, resected tissue weight and perioperative complications were also registered. Total post-operative catheter time, total postoperative hospital stay, haemoglobin loss were recorded in the 2 groups.

Results: Comparative data on IPSS symptom score, IIEF-5 and Qol, PSA, peak urinary flow rates and post-void residual urine volume in the 2 groups were similar but showed a significative improvement with respect to baseline value. Postoperative haemoglobin levels, postoperative catheterization, hospital stay and 3-yr overall surgical re-treatment-free rate were significantly better in the Bipolar group.

Conclusions: In the treatment of LUTS due to bladder outlet obstruction (BOO) with markedly enlarged glands refractory to medical therapy, Bipolar TURP has a comparable outcome to open prostatectomy at short and medium term according to both subjective and objective outcome measures.

Giant scrotal lymphedema as unique onset sign of muscle-invasive bladder cancer. The risk of a misdiagnosis

Rafael Boscolo-Berto, Guido Viel, Claudio Lamon, Andrea Agostini, Roberto Vezzaro, Marina Gardiman, Massimo Montisci, Daniela I. Raduazzo


A 78-year-old male presented complaining voiding low urinary tract symptoms associated to genital weightiness over the past few years. Grossly the lesion was only interesting the scrotum, for an about 7.5 kg mass. The scrotum was minimally tender, with an intact skin bereft of erythema or inflammation, lower limb lymphedema, inguinal/crural lymphadenopathy. Despite repeated urinary cytologies were negative, an abdominal CT and urethrocystoscopy confirmed a muscle-invasive transitional cell carcinoma affecting the bladder. The surgical strategy included a direct excision of the giant scrotum with local tissue reconstruction and a radical cystectomy with ileal conduit. This is the first time it's noted a giant scrotal lymphedema as the unique onset sign of a muscle invasive transitional cell carcinoma of the bladder otherwise clinically silent. In this clinical setting, a differential diagnosis has always to be carried out, as bladder cancer is a life-threatening disease requiring an aggressive approach.

Ureterectomy and ureteral reimplatation for low-grade transitional cell carcinoma: Is the laparoscopic approach feasible and effective?

Umberto Maestroni, Stefania Ferretti, Francesco Dinale, Samanta Fornia, Francesco Ziglioli


As it is well known, the gold-standard to treat ureteric and pelvi-caliceal Transitional Cell Carcinoma (TCC) is nephroureterectomy. Nevertheless, in particular circumstances, such as solitary kidney, a more conservative treatment is needed. Conservative treatment has been reported for low-grade TCC, also. In this paper we discuss the laparoscopic approach to low-grade ureteric TCC in patients with otherwise normal urinary tract. After reporting a case of a patient treated with this approach, we deal with some technical aspect of the surgical procedure and with the pre-operative and post-operative management of the patient.

Rupture of superficial dorsal vein of penis

Abdulmuttalip Simsek, Omer Kurt, Levent Verim, Sinasi Yavuz Onol


Penile fracture is a remarkable but under reported urologic injury. Coitus and penile manipulations are common predisposing factors. Rupture of the superficial vein of penis is an uncommon situation that makes differential diagnosis with other penile lesions. The diagnosis in such cases is mostly after exploration. We report the cases of 34 and 49 year old male patients with a painless hematoma after intercourse. Conservative or surgery intervention are the alternative mode of treatment.

Benign intrascrotal lesion: Fibrous pseudotumor of testis

Hüseyin Tarhan, Rauf Taner Divrik, İlker Akarken, Muammer Altok, Ferruh Zorlu


Fibrous pseudotumors of the tunica vaginalis, epididymis, and spermatic cord are uncommon benign paratesticular masses. We report the case of a 27 year old man who presented with grossly abnormal testicular examination. Scrotal Doppler ultrasound scan showed normal testicles bilaterally and solid, round, multiple 15-40 mm hypoechoic lesions adjacent to the right testis. Tumoral markers were within normal limits. Uncomplicated right radical orchiectomy was performed. After a follow-up of 12 months, no relapse occurred. We discuss about rare benign paratesticular masses identified as fibrous pseudotumors.

Emphysematous pyelonephritis in decompensated diabetes: A case report and review of the literature

Davide Abed El Rahman, Gianpaolo Zanetti, Mario Ferruti, Pietro Acquati, Augusto Maggioni, Isabella Oliva, Elisabetta Finkelberg, Sami Abed El Rahman, Massimo Zilocchi, Marco Filizzolo, Francesco Rocco


Emphysematous pyelonephritis is a rare and severe renal parenchyma necrotizing infection visible just in diabetic patients which results in gas presence – probably produced through the glucose fermentation process – in the collecting system, renal parenchyma and perirenal tissue (1-3). We present a case of a not known diabetic female patient with emphysematous pyelonephritis of the left kidney and emphysematous pyelitis of the controlateral kidney.

Caring for bladder dysfunctions in patients with Parkinson’s disease

Tatiana Bolgeo


Parkinson’s disease and parkinson-like syndromes are frequently associated with disautonomic disorders, particularly urinary symptoms, with various degrees of severity. Urinary symptoms can represent the debut of an extrapiramidal syndrome and in most cases are urgency and incontinence due to detrusor hyperreflexia. Urodynamic studies allow to understand the causes of urinary symptoms, and thus makes possible a rational nursing and therapeutic approach.