Issues n.4 - 2012


n.4 - 2012

Narrow-Band Imaging (NBI) and White Light (WLI) transurethral resection of the bladder in the treatment of non-muscle-invasive bladder cancer

Emanuele Montanari1, Jean de la Rosette2, Fabrizio Longo1, Alberto Del Nero1, Pilar Laguna2

1Urological Department - Medical School of Medicine University of Milan DISS A.O. S. Paolo - Milano, Italy;

2Urological department - Academic Medical Centre Amsterdam - Amsterdam - The Netherlands.

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Objective: Narrow-Band Imaging (NBI) is an optical image enhancement technology  that narrows the bandwidth of the light output from the endoscopy system to 415 nm and 540 nm. The aim of the present study is to evaluate the feasibility of NBI transurethral resection of the bladder (TURB NBI) compared to in White Light (TURB WLI) (Feasibility study) and the recurrence rate at the 1-year follow-up in patients treated for non-muscle-invasive bladder cancer (NMIBC) (Recurrence study).

Methods: A total of 92 patients with a suspicion of primary or recurrent bladder cancer were prospectively enrolled in our study. Forty-five were consecutively enrolled to undergo WLI TURB and 47 consecutively to undergo NBI TURB. All patients underwent routine follow-up with flexible WLI cystoscopy every 3 months during the first year and every 6 months during the second year, supplemented by urine examination, urine culture, and bladder washout cytology.

Results: Type I-II complications were reported in 12 patients in the NBI group (25%) and in 10 patients in the WLI group (22%). Patients with High Grade NMIBC who underwent a second look WLI TURB had residual disease in 33% of NBI group and in 43% of WLI group.The recurrence rate at one year follow-up was 35% in NBI group and 50% in WLI group. No statistic significance can be issued for the clinical differences observed.

Conclusions: TURB performed entirely by the NBI technique is feasible and safe. It guarantees a complete and rapid resection of good quality from a pathological point of view. Moreover, the technique is relatively inexpensive with respect to other methods proposed to enhance the detection rate, for which data on operative endoscopy are lacking. In our clinical experience, even if not statistically significant, NBI TURB reduces at one year follow up the recurrence rate of bladder NMI tumours when compared to WLI TURB (35% vs. 50%). Other larger, randomized, prospective trials with longer follow-up periods are required to confirm our outcomes.

Effects of ankle position on pelvic floor muscle electromyographic activity in female stress urinary incontinence: Preliminary results from a pilot study

Maria Angela Cerruto1, Ermes Vedovi2, William Mantovani3, Carolina D’Elia1, Walter Artibani1

1Department of Surgery Urology Clinic, University of Verona, Italy;

2Rehabilitation Unit, Policlinic Hospital, Verona, Italy;

3Department of Medicine and Public Health, University of Verona, Italy.

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Objectives: A standing posture including various ankle positions might effectively facilitate pelvic floor muscle activity (PFMa) in incontinent women, and an ankle dorsiflexion (DS) at 15° was identified as the best position able to increase PFMa. Nevertheless, this ankle inclination is very uncomfortable. We carried out this study aiming at identifying smaller ankle inclinations able to significantly affect PFMa in incontinent women reducing patient discomfort.

Methods: Twenty women, not yet entered menopause and with mild-moderate uncomplicated stress urinary incontinence, were enrolled. An electromyographic (EMG) biofeedback instrument using surface electrodes was employed to measure changes in PFMa while each patient assumed the following different ankle inclinations in upright position: horizontal standing (HS); DS at 5° (5DS), 10° (10DS) and 15° (15DS); and ankle plantar flexion (PS) at 5° (5PS), 10° (10PS) and 15° (15PS).

Results: No EMG differences were found between HS and PS. PFM tension in DS, at whatever angle, was significantly greater than in both HS (P < 0.020) and PS (P < 0.040). No differences were found between 10DS and 15DS in terms of resting PFMa. Concerning maximal PFMa, it was higher in 10DS than in 15DS (P = 0.010), and in 5PS than in both 5DS (P = 0.006) and 15DS (P = 0.010); no EMG differences were found between 5PS and 10DS.

Conclusions: These preliminary results showed that 10DS in upright standing had comparable effects on resting PFMa than 15DS with same effectiveness and less patient’s discomfort, facilitating a better maximal contraction. Moreover a slight PS might effectively facilitate maximal PFMa.


Urinary apparatus tumours and asbestos: The Ramazzini Institute caseload

Michelina Lauriola1, Luciano Bua1, Daniela Chiozzotto1, Fabiana Manservisi1, Achille Panetta2, Giuseppe Martorana3, Fiorella Belpoggi1

1Cesare Maltoni Cancer Research Center, Ramazzini Institute, Bentivoglio, Bologna, Italy;

2Departmental Operative Unit in the Oncology Department, Palliative Care, Bentivoglio Hospital,

Bentivoglio, Bologna, Italy.

3Professor and Chief, Department of Urology, University of Bologna, Italy.

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Many studies have drawn attention to the possible association between occupational exposure to asbestos and tumours of the urinary apparatus. Besides the main etiological agents recognised today – such as smoking, obesity and hypertension – experimental and epidemiological evidence converges on the view that tumours of the kidney and bladder are largely due to occupational exposure to industrial agents: these and their transformation products linger in the body and are eventually eliminated by those organs. That one such agent targeting the urinary system is asbestos has found confirmation in the discovery of asbestos fibres in the urine of populations at risk. We here present 23 cases of work exposure to asbestos in a range of exposure scenarios where the workers developed tumours of the kidney and bladder. The cases came to the attention of the Ramazzini Institute casually.


Critical points in understanding the italian version of the IIEF 5 questionnaire

Carolina D’Elia, Maria Angela Cerruto, Francesca Maria Cavicchioli, Sofia Cardarelli, Alberto Molinari, Walter Artibani

Dept. of Urology, Urology Clinic, A.O.U.I. Verona, Italy.

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Purpose: The aim of these study is to assess the understanding of the Italian version of the IIEF-5 questionnaire (International Index of Erectile Function) and the impact of patient’s demographic and clinical characteristics on it.

Materials and Methods: Each patient was asked to self complete the Italian version of the IIEF-5 questionnaire and to self report demographic information and any difficulties to complete the questionnaire and which question was considered more difficult to understand.

Results: A total of 89 patients were included in this study. Patients mean age was 61.2 ± 15.4 (standard deviation = SD) years. The mean IIEF score at the time of the visit was 13.5 ± 8.5 (SD). The questions considered more difficult to understand were number 5 (26%), number 4 (20%) and number 1 (20%). Statistically significant differences between patients with and without problems in completing the questionnaire were found in terms of education level (p = 0.0026).

Conclusions: Patients with a lower educational level have more difficulties in understanding the questionnaire and the most difficult questions are items number 5, 4 and 1.

Laparoscopic-endoscopic single-site surgery retroperitoneal ureterolithotomy: Technique and initial experience

Volkan Tugcu1, Bircan Mutlu2, Volkan Yollu2, Mehmet Yucel3, Ali Ihsan Tasci4

1Associate Professor, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Department of Urology,

Istanbul, Turkey;

2Assistant Dr., Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Department of Urology,

Istanbul, Turkey;

3Assistant Professor, Dumlupinar University Faculty of Medicine, Department of Urology, Kutahya, Turkey;

4Professor, Bakırkoy Dr.Sadi Konuk Training and Research Hospital, Department of Urology,

Istanbul, Turkey.

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Objective: Laparoscopic-endoscopic single-site surgery (LESS) is a nearly scarless surgical technique. The aim was to assess the results of our initial LESS retroperitoneal ureterolithotomy (LESS-RU) experience and our technique.

Material and methods: Primary indication for LESS-RU procedure in this study was obstructive or impacted ureteral stone(s) larger than 15 mm and located in the middle or upper part of the ureter in those patients in whom prior interventions have failed. Eighteen patients underwent LESS-RU for upper or middle ureteric stone by one experienced laparoscopist, between December 2008 and December 2009. Patient characteristics, operative details, complications, use of analgesic medication and time to return to work were recorded.

Results: Eighteen cases were successfully accomplished. The mean patient age was 40.1 yr (19-60 yr), and median BMI was 27.7 kg/m2 (21-32). The mean operative time was 69.9 min (50-150 min), and the mean blood loss was 31.9 ml (20-70 ml). Mean stone size was 18.1 mm (range: 16-22). No patient required morphine for pain relief and the main use of oral analgesics was for two days. In postoperative follow-up there was a minimally scar and good cosmetic results were detected.

Conclusions: LESS-RU proved to be safe and feasible. We think that LESS-RU will take place of laparoscopic ureterolithotomy in the near future with better cosmetic results. Further clinical investigation in comparison to the established techniques should take place to evaluate the outcome of LESS-RU .


Solitary lung metastasis after radical prostatectomy in presence of undetectable PSA

Pietro Pepe1, Filippo Fraggetta2, Francesco Tornabene3, Maurizio Nicolosi3, Francesco Aragona1

1Urology Unit - Cannizzaro Hospital, Catania, Italy;

2Pathology Unit - Cannizzaro Hospital, Catania, Italy;

3Thoracic Unit - Cannizzaro Hospital, Catania, Italy.

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Clinical recurrence in the absence of biochemical PSA failure is uncommon and accounts for less than 1%; we report a rare case of solitary lung metastasis in a patient with undetectable PSA level (<0.1 ng/mL) after radical prostatectomy (RP) for prostate cancer (PCa). An asymptomatic 75-year-old man nine years after RP showed a solitary lung mass (about 2 cm) at chest radiography; the 18-FDG-PET/CT confirmed the presence of an isolated mass suspicious for primitive pulmonary cancer. The initial histological specimen after RP showed a mixed acinar and ductal PCa (Gleason score 7, pT3aN0 stage, negative surgical margins). A segmental pulmonary resection was performed and definitive specimen demonstrated a single ductal PCa metastasis; after six months from surgery the patient was free from recurrence. In conclusion, in patients with atypical PCa variants imaging studies may be considered in the follow up even in presence of undetectable PSA because they could benefit from early salvage therapy.


Robotic malfunction during live robotic urologic surgery: Live surprise in a robotic surgery congress

Volkan Tugcu1, Bircan Mutlu1, Abdullah Erdem Canda2, Erkan Sonmezay1, Ali Ihsan Tasci1

1Bakirkoy Dr. Sadi Konuk Training and Research Hospital, Urology Clinic, Istanbul, Turkey;

2Ankara Ataturk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey.

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Background: Robotic-assisted laparoscopic radical prostatectomy (RARP) has increasingly become a preferred treatment of choice. Since it is a device dependant surgery, robotic surgery may be a challenging procedure due to failure.

Methods: We report how we managed to complete successfully a case of RARP with laparoscopic approach in spite of right robotic arm failure during live surgery.

Results: A 56-year-old male patient diagnosed with localized prostate cancer (PCa) (Gleason score 3 + 3 = 6) with a serum prostate specific antigen (PSA) level of 7.6 ng/mL was elected for a live RARP case during the 1st Turkish National Robotic Surgery Congress in 2011. Following 120 minutes from starting the RARP procedure, the right robotic arm failed surprisingly with a “recoverable fault” message appeared on the screen. Pressing “recover fault” button did not work and the right arm operated for few seconds more but the fault repeated again. We replaced the robotic instruments, shut down and restarted the system again that were all useless. Finally, all of the arms were out of order and we were not able to use the robot anymore. Therefore, we laparoscopically completed the procedure successfully without converting to open surgery.

Conclusions: Although da Vinci surgical system failure rarely occurs, surgical team should be prepared to convert to open or complete the procedure laparoscopically. Having previous laparoscopic experience seems to be an advantage in order to complete the procedure without converting to open. Patients should be informed about the possibility of robotic failure and about its consequences before the surgery.


Spontaneous postmenopausal urethral prolapse: A case report and review of literature

Ugur Yucetas1, Muhsin Balaban2, Alper Aktas2, Bulut Guc3

1Istanbul Training and Research Hospital, Urology Clinic, Istanbul, Turkey;

2Kartal Training and Research Hospital, Urology Clinic, Istanbul, Turkey;

3Marmara University School of Medicine, Istanbul, Turkey.

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Urethral prolapse is a circular protrusion of the distal urethra through the external meatus. It is very rare condition seen mostly in black premenercheal black girl and occasionally in postmenopausal white women. We present a case of spontaneous urethral prolapse in 63-year-old postmenopousal white women with succesful management with estrogen treatment.

TURP and PVP treatments are really similar?
From subjective feeling to objective data. Pilot study (proof of concept) prospective randomized trial 

Giuseppe Albino, Ettore Cirillo Marucco 

U.O. di Urologia, Ospedale “L. Bonomo”, Andria, ASL BAT, Italy 

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Transurethral resection of the prostate (TURP) is the gold standard of surgical treatment of the BPH. Alternative surgical techniques have been developed for patients with blood coagulation disorders secondary to anticoagulants or antiplatelet intake. The photoselective vaporization of the prostate (PVP) by Green Laser is a technique used with the aim of obtaining tissue ablation with instantaneous hemostasis. In our experience we sensed the feeling of some differences between the two technologies. For each patient, we calculated the difference (∆) between Qmax, Qmed, PMR to 6 months after surgery compared with preoperative measurements (∆Qmax, ∆Qmed, ∆PMR). In the comparison between PVP and TURP the differences between the results, in terms of ∆Qmax (11.04 vs. 8.9 ml/sec), ∆Qmed (5.87 vs. 3.64 ml/sec), ∆PMR, are not statistically significant, therefore it is clear that if we consider the average of the results, significant differences do not come out between the two techniques. Instead, the real differences emerge from consideration of standard deviations: the higher standard deviations of Qmax and Qmed of PVP compared to TURP (8.29 vs 5.01; 5,51 vs 1.64) indicate that the final result of an intervention being performed by TURP is nearest to the expected preoperatively result; on the contrary the final result of an operation being performed by PVP shows a significantly higher variability. As regards for our clinical decision it follows that the proposal of a surgical procedure which shows the "risk" of a higher variability of the final result is justified only in cases of high cardiovascular or blood coagulation "risk". 


Spontaneous rupture of urinary bladder: A case report and review 

Giuseppe Albino1, Francesco Bilardi2, Domenico Gattulli2, Pietro Maggi3, Antonio Corvasce1, Ettore Cirillo Marucco1 

1U.O. di Urologia; 2U.O. di Chirurgia generale; 3U.O. di Diagnostica per Immagini, Ospedale “L. Bonomo”, Andria, ASL BAT, Italy 

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Spontaneous rupture of the bladder is a rare event. The clinical presentation shows the signs and symptoms of peritonitis, but the diagnosis is made at the operating table. This event is burdened with a high mortality rate. We present a case report of a 73 year old man whocame to our observation. He was a chronic carrier of urinary catheter, at least 7 times removed traumatically by himself. At the time of admission he showed drastic reduction in urine output, absence of hydronephrosis, normal functioning of the catheter, a tense and widely meteoric abdomen, the presence of air-fluid levels, normal kidneys, absence of free fluid in the abdomen. The CT showed a fluid collection of about 7cm diameter between the bladder and rectum. The explorative laparotomy found a small fissuration of the posterior wall of the bladder. For his severe conditions, the patient died a few hours after surgery, in intensive care unit. Although it is a rare event, since 1980, 177 cases of spontaneous rupture of the bladder are reported in the literature. Their causes may be essentially divided into two groups: for increase of intravesical pressure; or for weakening of the bladder wall. In most cases, the spontaneous rupture of the bladder takes place in presence of a urothelial neoplasm or after radiation therapy of the pelvic organs. The etiology of spontaneous rupture of the bladder in our case does not relate to a bladder tumor or radiotherapy. It may have been caused by repeated episodes of acute retention of urine with extreme bladder distension up to 3 liters. It is not easy to think of a bladder perforation in patients presenting signs of peritonitis without a history of bladder cancer or pelvic radiotherapy. A CT with intravesical contrast medium could help the diagnostic orientation.


PCA3 score accuracy in diagnosing prostate cancer at repeat biopsy:
Our experience in 177 patients 

Michele Barbera1, Pietro Pepe2, Quintino Paola1, Francesco Aragona2 

1Urology Unit - Giovanni Paolo II Hospital, Sciacca, Italy; 2Urology Unit - Cannizzaro Hospital, Catania, Italy. 

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Introduction: To evaluate PCA3 score accuracy in prostate cancer (PCa) diagnosis in patients undergoing repeat saturation prostate biopsy (SPBx).

Material and methods: From January 2010 to March 2012, 177 patients (median 64 years) with primary negative extended biopsy underwent a SPBx (median 28 cores) for persistent suspicion of PCa. The indications for repeat biopsy were: PSA > 10 ng/mL, PSA values between 4.1-10 or 2.6-4 ng/mL with free/total PSA < 25% and < 20%, respectively; moreover, before performing SPBx PCA3 score was evaluated.

Results: Median PSA was 9.5 ng/mL (range: 3.7-28 ng/mL): in 74 (41.8%) cases PSA was > 10 ng/mL, in 99 (56%) and 4 (2.2%) was included between 4-10 and 2.6-4 ng/mL, respectively. Median PCA3 score was equal to 52 (range 3-273); 140 (79%) and 100 (56.5%) patients had a PCA3 score greater than 20 and 35, respectively. A T1c PCa was found in 48 patients (27.1%); PCA3 score was 60 (median; range: 7-208) in the presence of PCa and 34 (median; range: 3-268) in the absence of cancer (p < 0.05). Diagnostic accuracy, sensitivity, specificity, PPV and NPV of PCA3 score cut-off of 20 vs 35 in PCa diagnosis were 43.5 vs 50.2%, 91.7 vs 73%, 25.6 vs 41.8%, 31.5 vs 35% and 89.5 vs 80.6%, respectively. 

Conclusions: PCA3 score reduce number of unnecessary repeat SPBx; using a PCA3 cut-off of 20 vs 35 would have avoided 21% vs 37.8% of biopsies while missing 8.4% (4 cases) vs 27% (13 cases) of significant PCa, respectively. 


Incidence of abdominal aortic aneurysm
during diagnostic ultrasound for urologic disease: Our experience 

Lucio Dell’Atti 

Urology Unit, Arcispedale “S. Anna”, Ferrara, Italy. 

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Background: The prevalence of abdominal aortic aneurysms (AAA) is increasing because of increased life expectancy. There are none or few symptoms related to abdominal aortic aneurysm until rupture. After rupture, mortality rates are 60-80%, but with an elective operation. 

Methods: We performed an observational study on 140 consecutive patients of age over 50 years (range 50-82), presented to our clinic to perform a routine ultrasound examination of the urinary tract. We consecutively evaluated in these patients the possible detection of abdomi- nal aortic aneurysm.

Results: Ultrasonography of the abdomen is the test of choice for the detection of the disease, it is an examination of low-cost and non-invasive. It has a high diagnostic sensitivity 80%, in our study (result slightly less than the range reported by the literature 82-99%) and a specificity of 100%.

Conclusions: Because of its safety, low cost, ease of use, and wide availability, ultrasonography is the most commonly used clinical imaging modality. Ultrasonography is the standard method for screening and monitoring AAAs that have not ruptured. With the advance in 3-dimensional (3D) imaging, 3D ultrasonography has provided a new opportunity to acquire fast and reliable AAA measurements, which can not only shorten the time for a ultrasound exam but also reduce the workload of AAA surveillance. 


Role of ultrasound in management of long-term complications after to radical cystectomy
and orthotopic neobladder construction: Case report 

Anna Mudoni1, Francesco Caccetta1, Maurizio Caroppo1, Fernando Musio1, Antonella Accogli1, Annalisa Noce2, Emiliana Ferramosca3, Vitale Nuzzo1 

1Nephrology and Dialysis, Hospital “Cardinale G. Panico”, Tricase, Lecce, Italy;  

2Department of Internal Medicine, Nephrology and Hypertension Unit, “Tor Vergata” University Hospital, Rome, Italy;

3Department of Internal Medicine, Ageing and Renal Diseases, Division of Nephrology, Dialysis and Hypertension, “S. Orsola-Malpighi University Hospital”, Bologna, Italy.

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Radical cystectomy with urinary diversion is considered the gold standard treatment for bladder cancer.
We report a case of 66 years old male with long term complications, after radical cys- tectomy and an ileal neobladder according to Hautmann. He developed uroseptic episodes, stones, post-void residual, stenosis of the uretero-neobladder anastomosis, metabolic acidosis and progressive deterioration of renal function.
Renal ultrasound helped us to identify the dilation of the urinary tract, the grade of hydronephrosis and the presence of stones. During the follow-up, it is very important the collaboration between urologist and nephrologist and the role of ultrasound for an early correction of the hydronephrosis and the elective replacement of the stents in order to preserve the renal function. 


Nephrotic syndrome and abdominal arterial bruits in a young hypertensive patient: A case report 

Maria Paola Canale1, Valentina Rovella1, Emiliano Staffolani1, Natascia Miani1, Maria Silvia Borzacchi1, Konstantinos Giannakakis2, Annalisa Noce1, Nicola Di Daniele1 

1Department of Internal Medicine - Nephrology and Hypertension Unit; University of Rome “Tor Vergata”, Rome; Italy; 

2Department of Radiology, Oncology and Pathology, University of Rome “La Sapienza”, Rome; Italy. 

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We report the case of a 34-year old black African hypertensive woman who presented with nephrotic proteinuria, mild renal failure and abdominal bruits on physical examination. The renal Doppler ultrasound revealed bilateral artery stenosis. Thoraco-abdominal aortic nuclear magnetic resonance showed a restriction of proximal descending aorta with post-stenotic spindle dilation while abdominal aorta and iliac vessels appeared diffusely stenotic with atherosclerotic plaques and infrequent spindle dilations and right ostial renal artery stenosis. Renal angiography failed to reveal renal artery stenosis. Right renal biopsy showed type 1 membrano-proliferative glomerulonephritis in sclerotic evolution and severe arteriolosclerosis. The particularly early onset of the disease suggests that the pathogenesis of the membrano-proliferative glomerulonephritis may be multifactorial and related to vascular hypoplasia and chronic renal hypoperfusion leading to renin angiotensin system activation. Hyperlipidemia secondary to nephrotic syndrome may have accelerated systemic atherosclerosis and progression of renal disease.


Ultrasound diagnosis of renal infarction: Case report and review of the literature 

Lucio Dell’Atti1, Roberto Galeotti2, Gian Rosario Russo1 

1Urology Unit, Arcispedale “S. Anna”, Ferrara, Italy;
2Vascular and Interventional Radiology Unit, Arcispedale “S. Anna”, Ferrara, Italy.

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Renal infarction secondary to thromboembolism is usually a sequela of cardiac disease, the heart being the source of systemic arterial emboli in up to 94% of cases; the three major causes are: atrial fibrillation, myocardial infarction and rheumatic mitral stenosis. Renal infarction is often confused with other conditions due to similar presenting symptoms. This leads to delay in initiating treatment and significantly decreases the chances of renal salvage.
We report a sonographic diagnosis in 39-year-old man, with risk factors for thrombosis, without a prior history of thromboembolism.


Ultrasonographic findings in dual kidney transplantation 

Stefano Vittorio Impedovo, Pasquale Martino, Silvano Palazzo, Pasquale Ditonno, Michele Tedeschi, Fabrizio Palumbo, Ardit Tafa, Matteo Matera,
Francesco Paolo Selvaggi, Michele Battaglia 

Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy 

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Introduction: Organ shortage has led to using grafts from expanded criteria donors (ECD). Double kidney transplantation is an accepted strategy to increase the donor pool, using organs from an ECD which are not acceptable for single kidney transplantation (SKT). Aim of this retrospective study was to analyse the role of colour Doppler ultrasound (CDUS) in the diagnosis of major surgical complications in DKT, performed with unilateral or bilateral placement.

Materials and Methods: From 2000 to 2011 we performed 54 DKT. Unilateral placement of both kidneys was done in 26 patients and bilateral DKT in 28, through two separate Gibson incisions (18) or one midline incision (10). Each patient underwent at least 3 CDUS before hospital discharge. The main surgical complications, discovered initially thanks to ultrasound (US), were hydronephrosis from ureteral obstruction, lymphocele and deep venous thrombosis (DVT).

Results: Mean follow-up was 42.7 months. Good postoperative renal function was demonstrat- ed in 25 patients (46.3%), while delayed graft function occurred in 29 (53.7%). US showed ureteral obstruction requiring surgery in 5 unilateral DKT while no patient subjected to bilat- eral DKT developed severe hydronephrosis. Lymphoocele, surgically drained, was demonstrat- ed in 6 bilateral DKT with a midline incision, 2 bilateral DKT with two separate incisions and 3 unilateral DKT. CDUS also enabled diagnosis of 2 cases of DVT in ipsilateral DKTs.

Conclusions: CDUS provides useful information in patients with DKT, allowing the detection of clinically unsuspected unilateral diseases. US study of our patients demonstrated that unilateral DKTs are more susceptible to the development of DVT and ureteral stricture, while the incidence of voluminous lymphocele is more frequent in bilateral DKT through a single midline incision. In this scenario, all patients undergoing DKT should be carefully monitored by US after surgery.


Refractory hypertension and rapidly progressive renal failure due to bilateral renal artery stenosis: Case report 

Annalisa Noce1,2, Maria Paola Canale1, Olga Durante1,2,
Simone Manca di Villahermosa1, Valentina Rovella1, Fulvio Fiorini2, 3, Claudia Parolini1, Nicola Di Daniele1 

1Department of Internal Medicine - Nephrology and Hypertension Unit, University of Rome “Tor Vergata”, Rome, Italy; 

2Kidney Ultrasound Study Group - Italian Society of Nephrology (SIN-GSER);

3Department of Nephrology and Dialysis, “S. Maria della Misericordia” Hospital, Rovigo, Italy.

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Introduction: We report a case of refractory hypertension and acute renal failure with mild proteinuria due to an unreported bilateral Renal Artery Stenosis, who underwent renal biopsy in the suspicion of rapidly progressive glomerulonephritis.

Case presentation: A 51 year-old Caucasian male was admitted with refractory hypertension of recent onset and acute renal failure. Duplex Doppler Ultrasonography was performed and provided images highly suggestive for bilateral renal artery stenosis. The patient was referred to the department of interventional radiology, where bilateral selective renal angiography and percutaneous endovascular angioplasty and stenting were performed successfully.

Conclusion: Duplex Doppler Ultrasonography is thus suggested in patients presenting with refractory hypertension and acute renal failure, especially if atherosclerotic disease and clinical clues of RAS are present. Renal revascularisation with bilateral angioplasty and stenting may play a key role in the treatment of bilateral Renal Artery Stenosis, especially in patients unable to maintain renal function as systemic blood pressure is lowered.


Bilateral native kidney neoplasia detected
by ultrasound in functionning renal allograft recipient 

Annalisa Noce1, Giuseppe Iaria2, Olga Durante1, Daniele Sforza2, Maria Paola Canale1, Simone Manca Di Villahermosa1, Veronica Castagnola1, Giuseppe Tisone2, Nicola Di Daniele1 

1Department of Internal Medicine - Nephrology and Hypertension Unit; University of Rome “Tor Vergata”, Rome, Italy; 

2Department of Surgery, Transplant Surgery Unit - University of Rome “Tor Vergata”, Rome, Italy. 

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We report the case of bilateral renal clear cell carcinoma in the native kidney, occurring four years after renal transplantation. Renal Doppler Duplex sonography revealed large solid bilateral neoformation. Total-body computed tomography confirmed the presence of bilateral kidney lesions and also showed the presence of concomitant gross dyscariocinetic lesion of left hemotorax. The patient underwent bilateral native nephrectomy and the histological diagnosis was renal cell carcinoma. Subsequent left upper lobectomy revealed necrotic keratinizing squamous cell carcinoma.
Then, the patients was switched tacrolimus to everolimus treatment and mycophenolate mofetil was reduced.


Torsion of a neoplastic intrascrotal testis: When the torsion reveals the mass. A case report and review 

Giuseppe Albino1, Rosanna Nenna2, Antonio Corvasce1, Ettore Cirillo Marucco1 

1U.O. di Urologia, Ospedale “L. Bonomo”, Andria, ASL BAT, Italy;

2U.O. di Anatomia ed Istologia Patologica, Ospedale “L. Bonomo”, Andria, ASL BAT, Italy.

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Cases of torsion of the spermatic cord are rare in men over 30 years old. Testicular tumors manifest themselves rarely with symptoms of acute scrotum. We report the case of a 38 years old patient who presented for a suspected left testis torsion. On examination, the testicle was markedly increased in size and painful. The manual derotation made pain dramatically disappear. He came to our attention after about a month asking for an orchidopexy. During the surgery a biopsy was performed. The diagnosis was a Yolk Sac Tumor. A radical inguinal orchiectomy was performed with left hemiscrotal excision, “in block”. He performed four cycles of chemotherapy and with no recurrence after 12 months of follow-up. In literature only seven cases of torsion of an intrascrotal testicle with cancer are reported. Our case is the eighth one.


Comparison between ultrasound-guided and digital-guided anesthesia before prostatic biopsy 

Giuseppe D’Eramo, Daniela Fasanella, Francesca Di Quilio, Peter Molnar, Stefano Salciccia, Alessandro Sciarra, Vincenzo Gentile 

Department of Urology “U. Bracci”, University Sapienza, Rome, Italy 

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Objective: Our target in this study is to evaluate the efficacy of ultrasound (US)-guided anesthesia in comparison it to the digital-guided one, considering pain and discomfort reduction, during prostate biopsy.

Materials and methods: We analyzed 150 patients that underwent prostate biopsy between March 2011 and January 2012; conditions to enter the sample were: elevated PSA levels and/or psa ratio free/total less than 15% and/or detection of alteration via ultrasound examination and/or a positive outcome of a digital rectal examination. Patients were randomized into two groups. In 75 patients (Group A) was performed local US-guided anesthesia with a dose of 10 ml of mepivacaine 1%, in the other 75 patients (Group B) a local digital-guided anesthesia was performed, again with an equal dose of 10 ml of mepivacaine 1%. After the biopsy patients were kept under observation for two hours, afterthat they were asked to provide description of the pain experienced during biopsy, using a 10-point visual analog scale (Visual Analogue Scale; 0 for no pain, 10 for excruciating pain). 

Results: In Group A, 49 patients scored a VAS value of zero, 23 a value of 1 and 2 a value of 3. On the other side, in Group B, 9 patients scored a VAS value of 1, 36 a value of 2, 28 a value of 3 and 2 a value of 4. In comparison patients in Group A scored VAS values statistically lower than patients in Group B (t Student Test, p < 0,01). 

Conclusions: The ultrasound-guided prostatic anesthesia is preferable to the digital-guided, because it considerably reduce the pain related to this procedure.


Modifications of the bladder wall (organ damage) in patients with bladder outlet obstruction: Ultrasound parameters 

Andrea Benedetto Galosi1, Daniele Mazzaferro2, Vito Lacetera2, Giovanni Muzzonigro2, Pasquale Martino3, Giacomo Tucci4 

1Division of Urology, Area Vasta 4, ASUR Marche, “Augusto Murri” General Hospital, Fermo;

2Institute of Urology, Polytechnic University of Marche, Azienda OU Ospedali Riuniti, Ancona;
3Institute of Urology, Dept. DETO, University of Bari, Italy;

4Urinary Incontinence Unit, Division of Urology, “Murri” General Hospital, Fermo, Italy.

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Introduction: Progressive changes in the bladder wall are observed in men with lower urinary tract obstruction secondary to benign prostatic enlargement (BPE). The high pressure voiding causes initially an increase in the proportion of smooth muscle (hyperplasia/hypertrophy of the detrusor) that develops to major changes in the advanced stages of bladder decompensation (fibrosis), hyperactivity and decreased functional capacity. Early identification of bladder changes by noninvasive transabdominal ultrasound can suggest therapeutic choices that can prevent further organ damage in the bladder wall. Aim of our study is to review ultrasound (US) parameters, that could be considered reliable and reproducible, in order to demonstrate the damage of the bladder wall. 

Methods: We performed a literature review to detect reported US parameters according to our aims. Our clinical experience was evaluated in retrospective manner to detect feasibility and limitations of the evaluation of these parameters in men with different degrees of bladder damage secondary to BPE. 

Results: Measurement of the Bladder Wall Thickness (BWT) or Detrusor Wall Thickness (DWT) by US is reliable, with at least 3 measurements of the anterior bladder wall taken at a filling volume of 250 ml. In particular, the DWT [thickness of the hypoechoic muscle between two hyperechoic layers corresponding to serosa and mucosa] is considered the best diagnostic tool to measure detrusor hypertrophy using cut-off value > 2.9 mm in men. US derived measurements of bladder weight (Estimated Bladder Weight, EBW) is another noninvasive tool for assessing bladder modifications in patients with Bladder Outlet Obstruction (BOO) with a cut-off value of 35 gr. Technique for measuring the BWT and EBW relies on conventional US 7.5-4 MHz using the automatic system of computation (BVM 6500 3.7 MHz). The variability of intra-operator (4.6 to 5.1%) and inter-operator measurements (12.3%) is acceptable. Also conventional US detects established signs of bladder damage: diverticulosis, trabecolations in the bladder wall (pseudo-diverticula), calculi and post-void residual urine (PVR) (> 50cc). Furthermore the Intravescical Prostate Protrusion (IPP), easy measured by transabdominal ultrasound, is strongly correlated to obstruction in men with BPE (cut-off 12 mm). Measurement, scoring and monitoring of the cervico-urethral obstruction in men with symptomatic BPE is possible by the non-invasive US of the bladder wall. Early identification by measuring DWTand EBW in addition to established US paremeters has the advantage of suggest the adoption of therapeutic measures sufficient to prevent progression of bladder damage. Conclusions: US derived measurements of DWT and EBW are reproducible and reliable. Transabdominal US also detect established bladder damage such as diverticula, stones and PVR, while IPP measurement seems to be correlated to BOO. US bladder parameters are considered potential noninvasive clinical tools for baseline assessment of patients with BOO. In particular noninvasive US parameters could be useful for longitudinal studies monitoring men with lower urinary tract obstruction secondary to BPE.


Comparison of ESWL outcome between
Wolf Piezolith 3000 vs Storz Modulith SLK.
It is the man who makes efficient the machine 

Giuseppe Albino, Ettore Cirillo Marucco 

U.O.C. di Urologia, Ospedale “L. Bonomo”, Andria, ASL BAT 

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Aim of the Study: The choice of an extracorporeal lithotripter for extracorporeal shock wave lithotripsy (ESWL) of urinary stones must be done with efficacy criteria. It is easy to demonstrate the advantages of the third-generation lithotripters compared to previous generations of lithotripters. This study has the purpose of evaluate whether it is possible to establish differences in effectiveness between two third generation lithotripters. 

Methods and Results: We report about the last 100 ESWL treatments carried out with the Wolf Piezolith 3000 and the last 100 with the Storz Modulith SLK, performed by the same single operator. Stones were stratified by site and size. Comparison was made considering the number of shock waves per session and the number of sessions and the outcomes. The results showed no statistically significant differences. In fact, the cumulative stone-free rate was 93% for the Wolf Piezolith and 91% for the Storz Modulith. 

Conclusions: The technical differences between lithotripters concern the energy delivered, the shape of the acoustic focus, the depth of focus, the coupling surface, the mobility of the head, the alignment mode and the simultaneous use of ultrasonography and radiological pointing. These differences are never obtained from published series. Furthermore data of patients and stones that have not been treated for the difficulty of stone targeting due to the depth of acoustic focus (high BMI), the limited inclination of the head or to the patient intolerance to shock waves are not usually reported. 

The results obtained by the same operator are comparable even when are obtained with different machines of the same generation. The real differences could arise if we would take into account also the patients which were excluded from evaluation because, for the same generation of lithotripters, the results depend on the operator, while the eligibility to treatment of the patient depends on thecharacteristics of the machine.


Transrectal ultrasound (TRUS) and TRUS-biopsy accuracy in potential candidates for PRIAS active surveillance protocol 

Vito Lacetera1, Andrea Benedetto Galosi2, Ubaldo Cantoro1, Francesco Catanzariti1, Daniele Mazzaferro1, Daniele Cantoro1, Luigi Quaresima1, Alessandro Conti1, Rami Raquban1, Rodolfo Montironi3, Giovanni Muzzonigro1 

1Institute of Urology, Polytechnic University of Marche, Azienda O.U. Ospedali Riuniti, Ancona;
2Division of Urology, Area Vasta 4, ASUR Marche, “Augusto Murri” General Hospital, Fermo;

3Institute of Pathology, Polytechnic University of Marche, Azienda O.U. Ospedali Riuniti, Ancona, Italy.

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Aim: Evaluate the transrectal ultrasound (TRUS) and TRUS-guided Biopsy (TRUS-Bx) accuracy in patients with low risk prostate cancer (PCA) that were potential candidate for PRIAS active surveillance (AS) protocol but underwent to immediate radical prostatectomy (RP). 

Methods: 616 men were extracted from our institutional RP database. We selected the patients who met PRIAS inclusion criteria. The primary outcome was to evaluate the positive pre- dictive value (PPV) and the specificity of suspected lesions at TRUS. The secondary outcome was to evaluate the TRUS-Bx accuracy in term of pathological upstaging and pathological upgrading with respect of RP specimen pathology report.

Results: 147 men of 616 (23,8%) in our RP database met PRIAS criteria; in this group we found 66 suspected lesions at TRUS examination (66/147: PPV 44,8%). Prostate cancer was really present in the biopsy specimen in only 32/66 of suspected lesions; in 28/66 the suspect lesion at TRUS was in the same position of the index lesion at final pathology. TRUS/biopsy specificity was 48% and TRUS/surgical specimen specificity 39%. TRUS-Bx staging accuracy: upgrading between biopsy and RP was recorded in 57/147 (38%) whereas 30/147 (20%) were upstaged on final pathology up to N1.

Conclusions: TRUS and TRUS-Bx are insufficient tools to detect the grade, the location and the extent of PCA. New emerging techniques, such as US-MRI fusion biopsy and 3D template-guided transperineal saturation biopsy are promising to minimize the risk of misclassification and therefore to better select the best option of treatment (radical treatments or focal therapies or active surveillance) in each patient with low risk prostate cancer.


Pancake polycystic kidney: Case report 

Marco Heidempergher, Nicoletta Landriani, Cristina Airaghi, Monique Buskermolen, Maria Teresa Barone, Daniele Scorza, Paola Cuoccio, Francesco Genderini,
Luciana Scandiani, Augusto Genderini 

Nefrologia - Dialisi Ospedale “L. Sacco”, Milano, Italy 

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Pancake kidney is a very rare fusion abnormality, characterised by the presence of a renal parenchymal mass located in pelvic site, generally with two pelvies and two ureters and without an intervening fibrous septum. The case here reported describes a condition of “pancake kidney”, eventually associated with polycystic disease and abnormous vascular supply. Hypertension and microscopic hematuria were the only clinical signs.


Value of the resistive index in patient and graft survival after kidney transplant
Stefano Vittorio Impedovo, Pasquale Martino, Silvano Palazzo, Pasquale Ditonno, Michele Tedeschi, Floriana Giangrande, Carlos Miacola, Saverio Forte,
Francesco Paolo Selvaggi, Michele Battaglia

Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy 

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Introduction: The Resistive Index (RI) obtained by performing doppler sonography is a hemodynamic index commonly used to measure flow resistance within an organ to assess if there is a vascular disease associated with that organ. It is a well-known predictor of kidney transplant outcome. The purpose of this study was to analyze the impact of RI values on patient and graft survival, as well as kidney graft function during 5-year follow-up.

Materials and Methods: We retrospectively investigated 761 kidney transplant recipients from cadaveric donors performed between 1998 to 2011. RI was measured at hospital discharge after the kidney transplant. All the patients were divided into tertiles, according to the baseline RI value (Group 1: RI < 0.70, Group 2: RI between 0.70 and 0.79 and Group 3: RI > 0.80). 

Results: Patients with a low RI (<0.70) showed the lowest incidence of delayed graft function (DGF) compared to the other two groups (20.2% vs 32.2% vs 33%). Recipients with low RI values displayed significantly better creatinine clearance (70 vs 55 vs 35ml/min, respectively) than those with medium or high RI values at 5-year follow-up. Kaplan-Meier estimates of cumulative graft survival were significantly worse in patients who had a RI of 0.70 or more than in patients with a RI of less than 0.70 (p = 0.02). Cumulative patient survival showed the same behavior (0.01) 

Conclusions: Low RI values measured in segmental arteries in the very early post-transplant period predict better kidney graft function and reduce the risk of all-cause graft loss, including patient death in a 5-year follow-up period.


Indication to renal biopsy in DM2 patients: potential role of intrarenal resistive index 

Monica Insalaco1, Pasquale Zamboli2, Fulvio Floccari3, Fulvio Marrocco3, Simeone Andrulli4, Francesco Logias5, Luca Di Lullo6, Fulvio Fiorini7, Antonio Granata1 

1Nephrology and Dialysis Unit - “San Giovanni di Dio” Hospital, Agrigento, Italy;
2Nephrology and Dialysis Unit - Second University, Napoli, Italy;

3Nephrology and Dialysis Unit - “San Paolo Hospital, Civitavecchia, Italy;

4Nephrology and Dialysis Unit - “A. Manzoni” Hospital, Lecco, Italy;

5Nephrology and Dialysis Unit - “San Francesco” Hospital, Nuoro, Italy;

6Nephrology and Dialysis Unit - “Parodi Delfino” Hospital, Colleferro, Italy;

7Nephrology and Dialysis Unit - “S. Maria della Misericordia” Hospital, Rovigo, Italy.

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Diagnosis of diabetic nephropathy is generally based, rather than on histological confir- mation, on clinical criteria (long history of diabetes, presence of proteinuria, diabetic retinopathy or peripheral neuropathy). This clinical approach has perhaps limited utility in DM2 patients, because only 50% of them show microvascular complications in presence of nephropathy. Eco-colour-Doppler sampling of interlobular renal arteries and determination of their resistance indices (RI), was proposed in the differential diagnosis of numerous nephropathies. Aim of this study was to evaluate whether RI can be useful in discerning non-diabetic renal disease (NDRD), in order to better define indications to perform renal biopsy among proteinuric DM2 patients. All patients were submitted to: echo-colour-Doppler study of renal vessels; systematic screening for diabetic retinopathy; needle renal biopsy. RI resulted to be significantly higher in diabetic glomerulosclerosis (GSD) group as compared with NDRD group, while no significant difference was found with respect to NDRDs overlapping GSD (overlapping group). The last one showed however median RI significantly higher than isolated NDRD group. Normalized chi square Pearson for the hypothesis that RI can predict GSD resulted 0.73, while it resulted 0.43 for the hypothesis that diabetic retinopathy can predict GSD. Echo-colour-Doppler can significantly contribute, more than the other parameters proposed (nephritic or nephrotic syndrome, hematuria, diabetic retinopathy), to the identification of underlying nephropathy in DM2 subjects. In the light of our experience, it seems that the detection of RI values > 0.72 suggests the diagnosis of GSD or mixed forms, reducing the indications to renal biopsy only in presence of values < 0.72.


Ureteral strictures after kidney transplantation: Risk factors 

Pasquale Martino, Stefano Vittorio Impedovo, Silvano Palazzo, Pasquale Ditonno, Vito Ricapito, Gabriele Alberto Saracino, Giuseppe Lucarelli, Michele Tedeschi, Carlo Bettocchi, Michele Battaglia 

Urology, Andrology and Kidney Transplantation Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy 

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Introduction: Ureteral obstruction is one of the most commonly reported urological complications after kidney transplantation often occurring within the first 3 months after surgery. Ischemia is the most frequent cause of ureteral stenosis and is the result of excessive hilar dissection and a poor anastomotic technique. Aim of this study was to identify the main risk factors for ureteral stenosis after kidney transplantation from cadaveric donors and to assess their impact on both graft survival and patient.

Materials and Methods: We retrospectively investigated 761 kidney transplants from cadaveric donors performed between 1998 to 2011. In all the patients, the ureteroneocystostomy was stented with a double J stent 4.7Ch x 12 cm held in place for an average time of 4-6 weeks post-operatively. Each patient underwent at least 3 ultrasound scans during hospital stay and subsequently during follow-up. All patients with severe hydronephrosis were followed by sequential renal scintigraphy with MAG3 and diuretic stimulus.

Results: After a mean follow-up of 60.1 (± 38.5) months, severe ureteral stenosis was discovered in 21 patients (2.76%), with exclusive involvement of the vesicoureteral junction. No statistically significant correlation was found with donor age and the incidence of delayed graft function, whereas a significant correlation between ureteral obstruction and unilateral placement of both grafts in dual kidney transplantation (DKT) (p < 0.001) was found. These patients had a longer mean hospital stay than the control group, but there was no influence on survival of the organ or patient.

Conclusions: ureteral obstruction after renal transplantation often features subtle and late symp- toms. Early ultrasound monitoring is therefore essential and in the presence of severe hydronephrosis, scintigraphic confirmation of the obstruction. In fact. early resolution of the stenosis appears to provide optimal graft and patient survival.