Issues n.3 - 2012


n.3 - 2012


Urological complications following inguinal hernioplasty

Gaetano Gulino, Michele antonucci, Giuseppe Palermo, F. Sasso, D. Tienforti, Alessandro D’Addessi, Pier Francesco Bassi

Clinica Urologica, Università Cattolica del Sacro Cuore, Roma, Italy.

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Aim of this paper is to report a systematic review of the literature about the incidence and putative mechanisms of genital tract injuries following open and laparoscopic herniorraphy and their effects on sexual function and fertility and to point out the measures of prevention and of treatment.The most frequently described events have been intraoperative complications as bladder or spermatic cord structure damage, immediate postoperative complications as ischaemic orchitis, urinary retention, urinary tract infection, hydrocele or scrotal haematoma and bacterial orchitis, or long-term complications as chronic orchialgia, testis atrophy, sexual dysfunction and infertility.The evidence of literature shows that urological complication after hernioplasty are under-reported. Only a small number of studies to date have essentially dealt with sexual quality of life after inguinal hernia surgical repair. The sexual needs of patients with groin hernias are rarely discussed.Extensive laparoscopic procedures, due to the need of learning curve, have increased the risk of vas  damage and infertility in young patients candidate to hernioplasty. Early diagnosis prevents urological complication as well as possible legal claims after hernia repair: it should be include careful history, objective and subjective symptoms and signs of uro-genital pathologies, lab data when necessary, immediate eco-color-doppler imaging and urgent urological consultation. Despite the lack of prospective randomized trials, there is a growing evidence in literature about positive impact of hernioplasty on sexual function, encouraging future studies on this issue.


Prostate cancer: What are the news in hormonal therapy? The role of GnRH antagonists

Filiberto Zattoni

Clinica Urologica, Azienda Ospedaliera Universitaria di Padova, Italy.

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The latest EAU guidelines on the evidence based-management of prostate cancer (P.Ca.), with regard to pharmacological androgen deprivation therapy (ADT), reiterate that the primary objective of hormonal therapy is to slow down the progression of the disease to the greatest possible extent. Degarelix a new product for the treatment of hormone-dependent P.Ca. has recently become available in Italy. This product is classified as a GnRH antagonist and provides safe and effective ADT. It completely blocks the synthesis and release of gonadotropins (LH and FSH), thus rapidly reducing the testosterone levels without causing clinical flare. The results of the clinical trials (36 months) demonstrate that degarelix, compared to high-dose leuprorelin (7.5 mg), suppresses levels of testosterone and PSA (Prostate-Specific Antigen) more rapidly and reduces levels of FSH and musculoskeletal events associated with treatment (pain, muscle weakness, spasms, oedema/joint stiffness, arthralgia, osteoporosis and osteopoenia) to a greater extent. In addition, these results demonstrate a significant increase in the probability of PSA progression-free survival, suggesting a possible delay in the onset of the "castration-resistant" stage. The information available to date supports the use of this new molecule as a valid alternative to GnRH agonists in the treatment of hormone-sensitive P.Ca.



Observational Database Serenoa Repens (DOSSER): Overview, analysis and results

A multicentric SIUrO (Italian Society of Oncological Urology) Project

Alessandro Bertaccini 1, Marco Giampaoli 1, Riccardo Cividini 1, Gian Luca Gattoni 2, Roberto Sanseverino 3, Tommaso Realfonso 3, Giorgio Napodano 3, Andrea Fandella 4, Elisa Guidoni 4, Domenico Prezioso 5, Raffaele Galasso 5, Carmine Cicalese 5, Vincenzo Scattoni 6, Angelo Armenio 7, Giario Conti 8, Matteo Corinti 8, Roberta Spasciani 8, Giovanni Liguori 9, Nikolitsa Lampropoulou 9, Giuseppe Martorana 1

1 Clinica Urologica, Policlinico Sant’Orsola-Malpighi, Università di Bologna; 2 Web-Master SIUrO;

3 UOC-Urologia  Ospedale "Umberto 1°" Nocera Inferiore; 4 Casa di Cura Giovanni XXIII - Monastier di Treviso; 5 Dipartimento di Scienze Ginecologiche, Ostetriche, Urologiche e Medicina della Riproduzione Università degli studi di Napoli; 6 Div. Urologia, Istituto Scientifico H. San Raffaele, Milano;

7 Ospedale Buccheri La Ferla, Palermo; 8 Ospedale S. Anna, Como; 9 Clinica Urologica Università degli Studi di Trieste - Ospedale di Cattinara, Italy.

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Objective: Men affected with Benign Prostate Hyperplasia (BPH) and Lower Urinary Tract Symptoms (LUTS) are demonstrating to require an increasing amount of attention from Urologists and Primary-care Physicians. Over the years, common urological medications were based on either α-blockers and/or 5α-reductase inhibitors.During the last decade the phytotherapeutic drugs are gaining a more often central role in the BPH and LUTS managements. In particular, clinical usage of the extract of the dried ripe fruit of serenoa repens with a dosage of 320 mg per day, has shown its clinical efficacy and its superiority. Purpose of this multicentric observational retrospective study was to evaluate all the urological aspects (clinical, biochemical, instrumental and pathological) of patients affected by BPH and LUTS, with a PSA < 10 ng/ml, a previous negative prostatic biopsy and in therapy with a daily dose of  320/640 mg of serenoa repens.

Patients and Methods: The study was conducted in 8 different centers throughout Italy from September 2010 to November 2011. Data and information of 298 men with an average of 63 years (mean PSA of 5.4 ng/ml and mean prostate gland volume of 57 cc), affected by non-acute urinary symptoms caused by BPH, a dosed PSA level inferior to 10 ng/ml, a previous negative prostate biopsy and in therapy with serenoa repens alone or associated to an α-blocker, were retrospectively inserted in an extensive on-line SIUrO Database. Comprehensive questionnaires were filled in for each patient at 3 and 6 months of follow-up. Each questionnaire contained various sections, each of them composed by several items: dosed PSA levels, uroflowmetry, International Prostate Symptoms Score (IPSS), International Index of Erectile Function (IIEF-5), trans-rectal ultrasound (TRUS) patterns, digital rectal examinations (DRE) aspects, previous prostate bioptical results (histology) and side effects.

Results: PSA levels weren’t subjected to an increase, revealing a stabilizing or downward trend. Percentage of patients with PSA below the level of 4 ng/mL was lower at the end of the study. The overall changes in the uroflowmetry were similar and parallel both in the group with only serenoa repens intake and in the group with serenoa repens plus α-blocker. The mean medium flow and the mean maximum flow had a slightly increase along the observation time. There was a substantial decreasing in the amount of patients presenting severe prostatic symptoms. Patients reported through the IIEF-5 score a sexual activity substantially unchanged after 6 months of follow-up. The serenoa repens intake resulted in an improvement of the “inflammatory-like reports”, in terms of ultrasound patterns, DRE and bioptical features.

Conclusions: serenoa repens demonstrated its efficacy reducing dysuria with minimal side effects. Further prospective studies might confirm its stabilization or lowering role on PSA levels in this cohort of patients and its possible clinical anti-inflammatory action.


Problematics of open prostatectomy in an Ivorian District Hospital setting

Anthony Chukwura Mgbakor

Department of Surgery, Anambra State University Teaching Hospital, Amaku, Awka, Nigeria

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Objective: Benign prostatic hypertrophy forms the bulk of urology workload in many sub-Saharan African hospitals. However, its management in secondary hospitals encounters specific problems that are rarely seen in the bigger tertiary institutions. We have tried to describe these difficulties across an account of open prostatectomy in regional secondary referral hospitals in the Côte d’Ivoire.

Material and methods: This is a retrospective account of the specific difficulties encountered in the management of 327 consecutive cases of open prostatectomy carried out between August 1991 and September 2007 mainly in two secondary referral hospitals in the Côte d’Ivoire.

Results: The difficulties were at different levels: late presentation with 309 (94.5%) of the patients having experienced at least an episode of acute retention of urine, surgery while most patients were still carrying a catheter, minimal investigations carried out, scoring the patients in the IPSS scale, shortage of funds in the course of the management, and surveillance in the immediate postoperative period. The overall results were relatively satisfactory given our conditions of work. The most frequent complications were wound infection (14.7%), bleeding requiring transfusion (8.6%) and re-operation for clot retention (4.3%). We had a case (0.3%) of the rare prostato-rectal fistula which was managed conservatively. There were 4 deaths (1.2%).

Conclusions: Open prostatectomy is the only surgical option for the management of benign prostatic hypertrophy in most of the urology centers of sub-Saharan Africa. Concerning its management away from the Tertiary Institutes, the surgery team is faced with specific problems which demand precise adaptations. Despite difficult working conditions, the results are sufficiently encouraging and gratifying to justify its pursuit while Urologists await the availability of equipments for transurethral resection of the prostate and other novel techniques.


Comparison of TVT, TVT-O/TOT and mini slings for the treatment of female stress urinary incontinence: 30 months follow up in 531 patients

Charalambous Stavros 1, Vouros Ioannis 1, Sakalis I. Vasileios 1, Anastasia Ch. Gkotsi 2, Salpiggidis Georgios 1, Athanasios Papathanasiou 1, Vasileios Rombis 1

1 Department of Urology, Hippokrateio General Hospital of Thessaloniki, Greece;

2 Department of Experimental Physiology, Aristotele University of Thessaloniki, Greece.

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Introduction: Although mid-urethral slings (MUS), have been extensively used for the treatment of female stress urinary incontinence (SUI), no published data exists for the efficiency and the complications of these methods in large patient series.

Methods: This is a retrospective analysis on patients who underwent MUS surgery since 1999. 531 patients were studied and the results of preoperative assessment, perioperative, early postoperatively and each follow up were registered. Patients were classified in three groups according to the MUS used. Efficacy of each method was evaluated in terms of early postoperative course, late complications and patient’s symptoms improvement based questioners, pad test, uroflowmetry, filling cystometry and ultrasonography. Evaluation took place at 7th and 30th postoperative day, 3rd and 12th month and then annually. Each patient was characterized as cured, improved or failed.

Results: Trans Obturator (TO) group prevailed in efficiency with no significant differences between trans obturator route with inside-out (TVT-O) and outside-in (TOT). Success rate at 30th month evaluation, was higher in the TO group than in Tension-free Vaginal Tape (TVT) or Single-Incision Mini Slings (SIMS) group (93.4% vs 89.5%, 93.4% vs. 91.7). None TVT patient required reoperation for remaining/reoccurring SUI, while 1.04% of TO group and 5.48% of SIMS group did. Patients of TVT group underwent reoperation for tape related complications in 2.25%, while 2.07% of TO group and none of SIMS group did. The potential limitation of the study is its retrospective character.

Conclusions: Even though TO tapes and SIMS seem more efficient than TVT, they carry a risk of SUI re-occurrence that must be weighted towards the risk of potential complications after TVT.


Prospective open-label study on the efficacy and tolerability of a combination of nutritional supplements in primary infertile patients with idiopathic astenoteratozoospermia

Gian Maria Busetto1, Aleardo Koverech2, Masa Messano2, Gabriele Antonini1, Ettore De Berardinis1, Vincenzo Gentile1

1 Sapienza Rome University, Policlinico Umberto I, Rome, Italy

2 Sigma Tau, Innovation and Development Department Corporate Nutraceutici, Cosmeceutici e Sviluppo Carnitine, Rome, Italy

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Aim of the study: To evaluate with an open-label study the efficacy and safety of a complex of nutritional supplements with antioxidant activity (L-carnitine, acetyl-L-carnitine, fructose, citric acid, selenium, coenzyme Q10, zinc, ascorbic acid, cyanocobalamin, folic acid) in primary infertile patients with idiopathic astenoteratozoospermia.

Methods: The study was conducted in a population of 114 infertile men (96 completed the study) diagnosed with idiopathic astenoteratozoospermia since at least 18 months.

Patients orally received a formulation (Proxeed - Sigma-Tau) containing L-carnitine 145 mg, acetyl-L-carnitine 64 mg, fructose 250 mg, citric acid 50 mg, selenium 50 mcg, coenzyme Q10 20 mg, zinc 10 mg, ascorbic acid 90 mg, cyanocobalamin 1.5 mcg, folic acid 200 mcg in combination once a day for 4 months.

Results: At the end of study, the mean sperm progressive motility showed a statistically significant increase from 18.3 ± 3.8 to 42.1 ± 5.5. Sixteen patients achieved pregnancy during the study. No significant improvement were observed for sperm density and rate of morphologically normal forms. The treatment was well tolerated.

Conclusions: Carnitines in association with others functional substances can improve the most important parameters of sperm quality.



Pre-treatment and post-treatment fertility in young male patients affected by Hodgkin and non-Hodgkin lymphoma

Nicolò de Luyk, Gabriele Pozzato1, Giuseppe Ricci2, Paolo Tamaro3, Massimo Manno4, Francesco Tomei4, Carlo Trombetta5

1 Department of Internal Medicine and Haematology, Maggiore General Hospital, University of Trieste, Trieste, Italy

2 Assisted Reproduction Unit, Department of Obstetrics and Gynaecology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", University of Trieste, Trieste, Italy

3 Pediatric Oncohaematology, Institute for Maternal and Child Health, IRCCS "Burlo Garofolo", University of Trieste, Trieste, Italy

4 Pathophysiology Unit of Human Reproduction and Sperm Bank, Mother and Child Department, Pordenone Hospital, Azienda S. Maria degli Angeli, Pordenone, Italy

5 Department of Urology, University of Trieste, Trieste, Italy

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Objectives: The aim of this study is to evaluate the fertility in young patients affected by Hodgkin and non-Hodgkin lymphoma, before and after chemotherapy and/or radiotherapy. We conducted a retrospective study to analyse how treatment affects male fertility and a perspective study to assess pre-treatment sperm quality.

Materials and Methods: 28 patients, treated in our center or referred to our Medically Assisted Procreation Center, from 2002 to 2011, were selected for the retrospective study and asked if interested in their fertility assessment. Semen samples were taken from 11 patients (mean age 31.55: range 20-45); other possible causes of impaired fertility were excluded. We analyzed pretreatment semen samples of 61 patients (mean age 29.08 ± 9.5) affected by leukaemia or lymphoma that were selected for the perspective study and referred to the Sperm Bank of Pordenone. All semen samples were analysed accordingly to 1999 World Health Organization guidelines.

Results: In the retrospective study all semen samples of the 11 patients selected were altered. Six patients treated with high dose alkylating agents and abdominal/pelvic radiotherapy were found azoospermic, 3 with severe oligoasthenozoospermic, 1 oligoteratozoospermic and 1 asthenozoospermic. In the perspective study pretreatment semen quality was poor in most of the samples of the 61 patients selected. Normozoospermia was observed in 14% of patients affected by Hodgkin lymphoma and in 25% affected by non-Hodgkin lymphoma.

Conclusion: Chemotherapy, radiotherapy or their combination are followed by a temporary but sometimes irreversible reduction of fertility potential. Pre-treatment semen quality is acceptable to proceed with cyopreservation techniques. Sperm cryopreservation should be offered to all post puberal male patients who have not yet conceived before treatment with gonado-toxic agents.


Nephron-sparing surgery for giant angiomyolipomas of kidney
Giampaolo Siena, Andrea Minervini, Agostino Tuccio, Gianni Vittori, Matteo Salvi, Arcangelo Sebastianelli, Omar Saleh, Alberto Lapini, Sergio Serni, Marco Carini

Department of Urology, University of Florence, Careggi Hospital, Florence, Italy

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Aims: To investigate the potential role of tumor enucleation (TE) for the treatment of giant angiomyolipomas (AML).

Methods: We retrospectively analyzed a prospectively derived database of 707 patients with kidney tumor, who were treated with conservative surgery, between January 1995 and September 2009. Overall, 31 patients had a histopathologic diagnosis of renal AML and of those, 3 patients had a diagnosis of unilateral or bilateral renal mass, with at least one clinically suggestive of giant AML (maximal tumor diameter ≥ 9 cm), either central or perihilar. These patients were the subjects of the analysis. Nephron sparing surgery (NSS) was performed as tumor enucleation (TE), carried out by a blunt dissection, using the natural cleavage plane between the tumor and the normal parenchyma.

Results: Preoperative tumor size ranged between 9.0 and 15.0 centimetres. At surgery, after kidney capsule incision, TE was done in all cases. In critical surgical steps, in case of difficult visualization of the correct enucleation plane, a sharp dissection a few millimetres away from the tumor was adopted. Warm ischemia time (WIT) was always below 20 minutes. Intraoperative blood loss was negligible. Unsignificant postoperative creatinine variation was recorded in all cases. No intra- and post-operative complications occurred. At last follow up visit, no tumor recurrence at the enucleation site was reported .

Conclusions: TE technique can be considered a viable and effective treatment option for this very rare pathologic condition, since it provides a maximal glomerular preservation and minimizes WIT and intra- and postoperative complications.


The role of the elastography in the diagnosis of prostate cancer: A retrospective study on 460 patients

Emilio Pozzi1, Guglielmo Mantica1, Christian Gastaldi1, Marco Berardinelli2, Dimitrios Choussos2, Carlo Maria Bianchi2, Alberto Roggia1

1 U.O. Urologia, Ospedale Sant’Antonio Abate, Gallarate, Italy

2 Scuola di Specializzazione in Urologia, Università degli Studi di Pavia, Italy

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Objective: Prostate cancer is one of the most common cancer among men in industrialized countries. Its diagnosis is based on Digital Rectal Examination (DRE), the evaluation of total Prostatic Specific Antigen (PSA) and PSA ratio, Trans Rectal Ultrasound Scan (TRUS) and prostate biopsy, which is the gold standard for tumoral diagnosis. The poor sensibility of TRUS, when DRE and/or PSA are abnormal, requires prostate biopsy for diagnostic confirmation. The aim of this study was to evaluate the sensibility and the specificity of real time elastography (SE) with and without the association of TRUS for cancer diagnosis.
Material and Methods: We retrospectively evaluated 460 patients who underwent TRUS-guided prostate biopsy. The mean age of patients was 66.4 years, the mean PSA was 7,96 ng/ml and the mean PSA ratio was 17.19%. We compared histopathological findings of prostate biopsies with the results of TRUS and elastography.
Results:32,17% of all patients were positive for prostate cancer.TRUS showed a sensitivity of 76,35% with a low specificity (43,59%), a Positive Predictive Value (PPV) of 39,1% and a Negative Predictive Value (NPV) of 79,53%. SE showed a lower sensitivity (61,49%), but better specificity (75%), PPV(53,85%) and NPV(80,41%). The association of TRUS + SE showed an increase in the sensitivity (79,79%) and in the NPV(86,71%). We separately evaluated the results of the two urologists with a greater experience in the use of these diagnostic methods who got an excellent sensitivity (91,42%) and an high NPV (92,68%).
Conclusions: SE is certainly an useful diagnostic method for the detection of prostate cancer, especially in association with TRUS. A great experience of the sonographist and an adequate training are indispensable to make, in the future, elastography a “structural marker”.


Role of urethral constrictor in male urinary incontinence after surgery

Luciano De Giovanni, Marco Stefanucci, Paolo Menchinelli

Divisione di Chirurgia Urologica, Università Cattolica del Sacro Cuore, Complesso Integrato Columbus, Roma, Italy.

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Aim of the study: To report  clinical experience and economical aspects concerning the use of a  peri-urethral constrictor for the treatment of male urinary incontinence after surgery.
Materials and Methods: Twelve patients  were treated with  the periurethral constrictor Vedise. They previously underwent prostate surgery and reported persistent urinary incontinence, subjectively judged  as disabling. In all the cases at least 18 months had elapsed from the date of the previous operation to the date of observation.
Results: No complications were observed during the application of the device, nor during the first postoperative period; the patients were discharged on the first postoperative day. In two patients the failure of the device was observed with immediate reappearance of urinary losses due to damage of the balloon during the activation procedure. In these cases it was necessary to replace the balloon with subsequent reactivation  of the device. In a third  patient  the detachment of the tubing connecting the cup with the balloon was reported and finally in a fourth patient a tight recurrent urethral stricture requested the removal of the device. The remaining patients, followed up for  about 12 months after the implantation, considered the application of the device as a positive experience, would recommend it to other patients and would repeat the implantation, if required.        
Conclusions: The relevance  of the preliminary selection of the patients and the need for meticulous attention during installation an activation of the device is stressed and possible modification of the device are suggested  to increase both  effectiveness and ease of use.



Hemangiopericytoma of kidney: Case report and review of the literature

Muhsin Balaban, Cihangir Cetinel, Rahim Horuz, Cemal Goktas, Onder Canguven

Kartal Teaching and Research Hospital, Kartal/Istanbul, Turkey.

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Hemangiopericytoma, which is derived from pericytes, is rarely seen in the kidney and radical nephrectomy with or without chemotherapy is the treatment of choice in most of the cases. We report a fifty-year-old male patient presenting with gross hematuria that radiologic evaluation confirmed due to a solid mass in the right kidney. Its clinical manifestations and radiologic tests were similar to renal cell carcinoma. Radical nephrectomy was performed and the pathological examination revealed the specimen as hemangiopericytoma. No additional treatment was added and the patient remained disease free at the end of the first year follow up after radical nephrectomy.


Diagnosis or recurrence detection in bladder cancer. Report of two cases

Andrea Fabiani 1, Alessandra Filosa 2, Mara Piergallina 1, Lucilla Servi 1, Gabriele Mammana 1

1 Unit of Urology, Surgical Department, 2 Section of Pathological Anatomy, Department of Clinical Pathology, Macerata Hospital, Area Vasta 3, ASUR Marche, Italy

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Objective. To demonstrate the potential role of transrectal ultrasound (TRUS) as a tool for diagnosis or recurrence detection in bladder cancer.

Material and methods. We report two cases of a primary lesion of bladder neck and trigone misdiagnosed by conventional sonographic abdominal evaluation and a case of bladder cancer recurrence diagnosed by TRUS performed before cystoscopy.

Results. The first patient presented at the Emergency Room of our Hospital for a flank pain with concurrent haematuria. The abdominal ultrasonography showed a right hydronephrosis and a thickened bladder wall without endoluminal projections. The end-fire probe with a longitudinal approach clearly showed a thickening of the bladder wall extended from the bladder neck to the posterior area. The patient was submitted to a transrectal prostate biopsy and to a urethrocystoscopy with a transurethral resection. The second patient was admitted to the Urology Unit for haematuria. Abdominal ultrasonography was unremarkable and urine cytology negative. The TRUS with an end-fire probe showed a 5 mm area of irregular thickening of the mucosa at the bladder neck. The uretrocystoscopy confirmed the presence of a perimeatal papillary lesion.

Conclusion. We recommend the use of TRUS for bladder cancer detection in selected patients, as an easy, accurate and inexpensive tool. We need further study to validate the role of TRUS in the diagnosis and follow-up of bladder urothelial carcinoma.


A case of angiomyolipoma of the spermatic cord and testicle

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

Villa Tiberia Clinic, Urology Department, Rome, Italy

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Angiomyolipomas (AML) are mesenchymal tumors of the kidney consisting of varying proportions of vascular, immature smooth muscle and mature fat cells. A rare case of testicular AML is described. A 53 year old male with a history of congenital motor defects, mental retardation, and hypertension, presented to the emergency room with sudden onset, severe left testicular pain. Scrotal sonography demonstrated an hypoechoic mass in the patient’s left testicle.

The patient was offered and underwent a trans-inguinal exploration of the left testicle which ended in a left inguinal orchiectomy. Pathologic examination of the mass revealed medium to large calibre thick-walled blood vessels with ectatic lumina, surround by sclerotic, fibrous smooth muscle bundles in a fatty milieu. Immunohistochemistry of the lesion demonstrated positive staining for smooth muscle actin (SMA+) and endothelial marker CD34. The lesion did not, however, stain positively for smooth muscle antigen S100 or melanocytic antigen HMB-45.


Neoadjuvant chemotherapy for invasive bladder cancer: An interesting case report

Davide Abed El Rahman, Victor Matei Deliu, Gennaro Musi, Danilo Bottero, Antonio Brescia, Giacomo Galasso, Federica Mazzoleni, Ottavio De Cobelli

Department of Urology, European Institute of Oncology IEO – Università degli Studi di Milano, Milano Italy

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We report the case of a 66 years old woman with histological diagnosis of muscle-invasive high grade transitional cell carcinoma and clinical diagnosis (TC) of metastatic disease treated with a platinum based combination chemotherapy obtaining a pathologic complete response.

Neoadjuvant chemotherapy for bladder cancer even with its limitations regarding patients selection, current development of surgical technique and current chemotherapy combination has shown to improve overall survival by 5-7% at 5 years and should be considered in muscle invasive bladder cancer, irrespective of definitive treatment.


Robot-assisted laproscopic removal of perirenal lymphangioma: A case report

Marco Finamanti, Alessandro Antonelli, Lorenzo Gatti, Angelo Peroni, Claudıo Simeone

Division and Chair of Urology, University of Brescia, Spedali Civili di Brescia, Italy

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The lymphangioma is a congenital malformation caused by abnormal development of the lymphatic vessels. The perirenal lymphangioma is extremely rare, and very few cases have been described in literature. A case of retroperitoneal perirenal lymphangioma is reported. Following recurring episodes of colic-like, right side back pain, a 16 year woman underwent an ultrasound which detected a multiloculated cystic lesion of 5 x 1 cm surrounding the lower pole of the right kidney. Subsequently a CT scan and an MRI detected, in the right perirenal space, a liquid multiloculated lesion, with no enhancement. Surgery was performed using the Da Vinci robotic system with transperitoneal access.

Once dissection was concluded it was possible to identify a lymphatic duct coming from the renal pedicle, which likely drained the lesion, and selectively close it using clips. In conclusion, the cystic lymphangioma, must be considered among the differential diagnoses of retroperitoneal cystic lesions. These rare tumours have an excellent prognosis, with full remission of the symptomatology following complete surgical excision.


Realtime-elastosonography of the penis in patients with Peyronie’s disease

Valentina Riversi 1, Valeria Tallis 2, Stefano Trovatelli 2, Arben Belba 2, Luca Volterrani 1, Francesca Iacoponi 3, Roberto Ponchietti 2

1 Imaging Department AOUS of Siena, Siena, Italy; 2 Department of Urology University of Siena, Siena, Italy; 3 Department of Biomedical Sciences, Applied Biology Section, University of Siena, Siena, Italy

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Objective: To evaluate the performance of real time elastosonography (RTE) in the identification of different types of  penile lesions in patients with Peyronie’s disease.Materials and methods:  Seventy four consecutive patients with complaints of Peyronie’s disease underwent B-Mode ultrasonography (US) and real time elastosonography (RTE) of the penis in the same sitting. In each patient all sequences of elastosonography and B-Mode ultrasonography were recorded and compared to evaluate the diagnostic performance of the new imaging technique.Results: B-Mode ultrasonography detected penile plaques in 64 patients (86.41%) and elastosonography confirmed these data. In the remaining 10 patients elastosonography documented, in five of them, areas of reducing elasticity suggesting the presence of initial fibrosis.  Cohen’s K was used to evaluate the discordances between B-Mode ultrasonography and Elastosonography scan. A p value < 0.05 (two tailed) was considered statistically significant. The penile curvature (K = 0.353; p = 0.125) and the painful erection (K = 0.500; p = 0.248) evaluations were discordant: the B-mode ultrasonography underestimated the positive cases. Instead the penile plaque and curvature >30°, and the penile plaque evaluations were completely concordant.Conclusions: Real time Elastosonography is a simple, non invasive, rapid complementary imaging technique that may improve the accuracy of B-Mode ultrasonography in detecting penile lesions in patients with Peyronie’s disease.