Antonino Leto

A multistep approach to manage Fournier’s gangrene in a patient with unknown type II diabetes: surgery, hyperbaric oxygen, and vacuum-assisted closure therapy: a case report

IntroductionFournier’s gangrene is an infectious necrotizing fasciitis of the perineum and genital regions and has a high mortality rate. It is a synergistic infection caused by a mixture of aerobic and anaerobic organisms and predisposing factors, including diabetes mellitus, alcoholism, malnutrition, and low socioeconomic status. We report a case of Fournier’s gangrene in a patient with unknown type II diabetes submitted to 24-hour catheterization 15 days before gangrene onset.Case presentationThe patient, a 60-year-old Caucasian man, presented with a swollen, edematous, emphysematous scrotum with a crepitant skin and a small circle of necrosis. A lack of resistance along the dartos fascia of the scrotum and Scarpa’s lower abdominal wall fascia combined with the presence of gas and pus during the first surgical debridement also supported the diagnosis of Fournier’s gangrene. On the basis of the microbiological culture, the patient was given multiple antibiotic therapy, combined hypoglycemic treatment, hyperbaric oxygen therapy, and several surgical debridements. After five days the infection was not completely controlled and a vacuum-assisted closure device therapy was started.ConclusionsThis report describes the successful multistep approach of an immediate surgical debridement combined with hyperbaric oxygen and negative pressure wound therapy. The vacuum-assisted closure is a well-known method used to treat complex wounds. In this case study, vacuum-assisted closure treatment was effective and the patient did not require reconstructive surgery. Our report shows that bladder catheterization, a minimally invasive maneuver, may also cause severe infective consequences in high-risk patients, such as patients with diabetes.

Prospective Randomized Study of Radiofrequency Versus Ultrasound Scalpels on Functional Outcomes of Laparoscopic Radical Prostatectomy

BACKGROUND AND PURPOSE Surgical treatment of patients with prostate cancer currently involves laparoscopic radical prostatectomy (LRP) or robot-assisted LRP. Continence and nerve-sparing procedures in these techniques are supported by dissection and hemostatic surgical devices powered by different types of energy. The aim of this study was to assess recovery of continence and erectile function after laparoscopic extraperitoneal radical prostatectomy comparing two surgical devices for dissection and hemostasis-radiofrequency (RF) and ultrasound (US) scalpels. PATIENTS AND METHODS A total of 132 men with localized prostate cancer were prospectively enrolled and scheduled for extraperitoneal LRP. Patients were randomly assigned to the RF group (LigaSure; n=66) or the US group (UltraCision; n=66). Outcomes were measured by the self-administered questionnaires (International Consultation on Incontinence Questionnaire-Urinary Incontinence [ICIQ-UI] and International Index of Erectile Function 5 [IIEF 5]) 15 days before surgery, 90 and 180 days after prostatectomy to assess recovery of urinary continence and erectile function. RESULTS No significant difference was found between the two groups regarding operative time, intra- and perioperative complications, or time of hospital stay. At 180 days after surgery, patients in the RF-treated group showed better recovery in terms of continence and erectile function compared with patients in the US group (ICIQ-UI: p=0.0016; IIEF 5: p=0.0352). CONCLUSIONS The use of the RF scalpel provided better functional outcomes compared with the US scalpel in patients undergoing extraperitoneal LRP. This might be attributed to the low contiguous damage of those tissues, which are not directly involved in dissection and hemostasis, achieved using the RF device.

Synchronous primary neoplasms of the bladder, skin and breast in a male patient: a case report

The incidence of multiple primary malignant neoplasms increases with age, reflecting an increase in overall cancer risk in older patients. Cases of two or more concurrent primary cancers are still rare, although its incidence is increasing. Here, we report the case of a 57-year-old man who was referred to our institution with synchronous squamous cell carcinoma of the skin on the forehead, infiltrating ductal carcinoma of the breast, and transitional cell carcinoma of the urinary bladder. To the best of our knowledge, this is the first reported case in literature of this combination of primary neoplasms.

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi: long-term follow-up results from a case series

Purpose: Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes. Methods: From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2–9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar. Results: The average operative time was 140 min (range, 90–190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5–0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2–6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence. Conclusions: Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75–100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons.

PD23-03 PROSPECTIVE RANDOMIZED STUDY COMPARING MONOPOLAR WITH BIPOLAR TRANSURETHRAL RESECTION OF PROSTATE ON A LARGE COHORT OF PATIENTS WITH BENIGN PROSTATIC OBSTRUCTION: LONG TERM OUTCOMES

INTRODUCTION AND OBJECTIVES: Monopolar transurethral resection of the prostate (TURP) is the gold standard surgical treatment for bothersome moderate to severe lower urinary tract symptoms (LUTS) secondary to benign prostate obstruction with enlarged prostates. The aim of the study is to compare monopolar vs. bipolar TURP focusing on operative and functional outcomes with a long term follow-up. METHODS: From January 2007 to July 2013 a total of 379 patients were randomized and prospectively scheduled to undergo bipolar (202) or monopolar (177) TURP. International prostate symptom score (IPSS), IPSS-Quality of life (QoL), post-void residual and maximum flow rate were assessed preoperatively and postoperatively at 3, 12, 24 and 36 months. Operative time, length of catheterization and length of hospitalization were all recorded. Rates of urethral strictures and bladder neck contractures were also reported. RESULTS: Perioperative results showed no statistical significance between the two groups in terms of catheterization days, postvoid residual, IPSS, IPSS-QoL score, blood transfusion and TUR syndrome. The operative time was proved to be statistically significant in the monopolar group while the hospitalization days was found statistically significant in the bipolar group. The 3, 12, 24 and 36 months follow up showed significant and equal improvements in LUTS related to BPO in the 2 treatment groups. CONCLUSIONS: Monopolar and bipolar TURP are safe and effective techniques for BPH. The 2 significant differences between them were operative time in favour of the monopolar group and hospitalization days in favour of the bipolar group. Bipolar TURP has the principle advantage in preventing TUR syndrome that was reported in 2 monopolar TURP patients.

MP85-14 PERISTEEN TRANSANAL IRRIGATION SYSTEM FOR THE TREATMENT OF NEUROPATHIC BOWEL DYSFUNCTION AND ABDOMINAL PAIN

INTRODUCTION AND OBJECTIVES: Lower urinary tract symptoms, while common, are under reported in patients with multiple sclerosis. It is unclear what the impact of lower urinary tract symptoms due to MS is on the overall quality of life. We aim to define the incidence of lower urinary tract symptoms in patients with MS and their effect on neurologic quality of life. METHODS: We identified patients presenting to neurology clinic for routine follow up for multiple sclerosis. Each patient responded to validated questionnaires regarding urinary quality of life (MSQLI) and overall neurologic quality of life (NeuroQOL). Medical records were reviewed to assess for the presence of lower urinary tract symptoms. Overall neurologic quality of life was measured in the presence and absence of lower urinary tract symptoms and p-values were calculated using student0s t-test. Urinary quality of life score was correlated to overall neurologic quality of life score by calculating the Spearman0s rank correlation coefficient. RESULTS: 91 patients were included in the study. All 91 patients completed the validated questionnaires. 85 patients (93%) described the presence of at least one lower urinary tract symptom. The most common urinary tract symptoms were urgency (84%), frequency (69%), incontinence (54%), and retention (38%). 72 patients reported urologic symptoms negatively impacted urinary quality of life. Presence of lower urinary tract symptoms negatively impacted overall neurologic quality of life (Figure 1). Urinary quality of life was predictive of the overall neurologic quality of life (-0.24, p1⁄40.02). CONCLUSIONS: Lower urinary tract symptoms are very common in patients with multiple sclerosis. These symptoms greatly impact and importantly predict the overall neurologic quality of life in patients with multiple sclerosis.

M2 muscarinic receptors inhibit cell proliferation and migration in urothelial bladder cancer cells

The role of muscarinic receptors in several diseases including cancer has recently emerged. To evaluate the hypothesis that muscarinic acetylcholine receptors may play a role in bladder cancer as well as in other tumor types, we investigated their expression in bladder tumor specimens. All examined samples expressed the M1, M2 and M3 receptor subtypes. We also found that the level of M2 transcripts, but not those of M1 or M3, significantly increased with the tumor histologic grade. In view of these results, we proceeded to investigate whether the M2 agonist Arecaidine had any effect on in vitro cell growth and migration of T24 cells, a bladder tumor cell line expressing the muscarinic receptors, including the M2 subtype. We observed that Arecaidine significantly reduced T24 and 5637 cell proliferation and migration in a concentration dependent manner. The silencing of M2 receptor by siRNA in T24 and 5637 cell lines showed the inability of Arecaidine (100 mM) to inhibit cell proliferation after 48 hours, whereas the use of M1 and M3 antagonists in T24 appeared not to counteract the Arecaidine effect, suggesting that the inhibition of cell proliferation was directly dependent on M2 receptor activation. These data suggest that M2 muscarinic receptors may play a relevant role in bladder cancer and represent a new attractive therapeutic target.

Laparoscopic radical prostatectomy after previous transurethral resection of prostate using a catheter balloon inflated in prostatic urethra: Oncological and functional outcomes from a matched pair analysis

To explore the surgical, oncological and functional outcomes of laparoscopic radical prostatectomy in patients who have undergone transurethral resection of the prostate, using a catheter balloon inflated in the prostatic urethra.

Incidental diagnosis of a retroperitoneal schwannoma in a patient with chronic leukemia undergoing prostatic biopsy

We present a case of retroperitoneal schwannoma incidentally diagnosed in a patient undergoing surgical drainage of a pelvic abscess as a complication of a prostatic biopsy. A 50-year-old male, suffering from lymphatic leukemia, came to our observation due to lichen ruber planus and ejaculatory pain. The patient underwent a trans-perineal ultrasound-guided biopsy of the right seminal vesicle and of a hypoechoic area documented by ultrasonography. 48 hours after the procedure, the patient had developed: cold sores, shortness of breath with dyspnea, and high fever (40°C). The patient was hospitalized, underwent an emergency CT which documented a right presacral and pararectal liquid mass (abscess). The patient underwent emergency laparotomy and drainage of the abscess. The lesion histological examination revealed a retroperitoneal schwannoma with inflammatory phenomena and hyperplasic lymphadenitis. The retroperitoneal schwannoma is a silent disease whose only clinical manifestation coincides with the compression of adjacent anatomical structures. In many cases, the symptoms, even if present, as in this case (ejaculatory pain with compression of the seminal vesicle), are non-specific, thus delaying diagnosis and the therapeutic approach.