Girolamo Morelli

Regional lymph node dissection in the treatment of renal cell carcinoma : is it useful in patients with no suspected adenopathy before or during surgery?

Objectives To evaluate the role of regional lymph node dissection (LND) in a series of patients with renal cell carcinoma (RCC) with no suspicion of nodal metastases before or during surgery.

Combination of Perianal-Intrarectal Lidocaine-Prilocaine Cream and Periprostatic Nerve Block for Pain Control During Transrectal Ultrasound Guided Prostate Biopsy: A Randomized, Controlled Trial

PURPOSE To our knowledge the optimal analgesia during prostate biopsy remains undetermined. We tested the efficacy and safety of combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block during transrectal ultrasound guided prostate biopsy. MATERIALS AND METHODS A total of 280 patients were randomized to receive combined perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block (group 1), perianal-intrarectal lidocaine-prilocaine cream alone (group 2), periprostatic nerve block alone (group 3) or no anesthesia (group 4) before transrectal ultrasound guided prostate biopsy. Pain was evaluated with a 10-point visual analog scale at subsequent procedural steps, including perianal-intrarectal substance administration, prostate transrectal ultrasound, periprostatic nerve block and sampling. Complications were assessed by self-administered questionnaire and telephone interview. RESULTS The groups were comparable in patient age, prostate volume, pathology results and visual analog scale perianal-intrarectal substance administration. Visual analog scale results for transrectal ultrasound were lower in groups 1 and 2 vs 3 and 4 (mean 1.5 and 1.41 vs 5.37 and 5.31, p <0.001) and results for periprostatic nerve block were lower in group 1 vs 3 (mean 1.03 vs 3.74, p <0.001). Results for sampling were lower in groups 1 to 3 vs 4 (mean 0.77, 1.27 and 1.27 vs 4.33, p <0.001) and in group 1 vs 2 and 3 (p <0.001). Stratified analysis showed that visual analog scale sampling was lower in group 1 vs 2 and 3 in patients 65 years old or younger, those with a prostate greater than 49 cc and those with lower anorectal compliance (visual analog scale results for perianal-intrarectal substance administration greater than 2) (p = 0.006, <0.001 and 0.003, respectively). The overall complication rate was similar in all 4 groups (p = 0.87). CONCLUSIONS Our findings suggest that the combination of perianal-intrarectal lidocaine-prilocaine cream and periprostatic nerve block provides better pain control than the 2 modalities alone during the sampling part of transrectal ultrasound guided prostate biopsy with no increase in the complication rate. The magnitude of this effect is higher in younger men, men with a larger prostate and men with lower anorectal compliance.

Glansectomy with split-thickness skin graft for the treatment of penile carcinoma

Using our prospectively derived database, we identified 17 patients with squamous-cell carcinoma involving the glans penis, who were treated using organ-sparing surgery between March 2003 and January 2008. Of them, two were treated with partial glansectomy with primary glans closure, and 15 underwent total glans amputation and reconstruction of a new glans using a split-thickness skin graft (STSG). These 15 patients represent the subject of our study (mean age 51 years, range 42 to 59 years). Overall, two patients had early partial loss of the graft and of them, one required surgical regrafting. Two late complications occurred, consisting of one meatal stenosis and one postoperative phimosis. At a mean follow-up of 36 months, functional results were extremely satisfactory. All patients maintained their erectile function with good vaginal penetration starting from 3 months after surgery, with a range between 2 and 6 months. Orgasm and ejaculation were preserved in all patients, although reduced glans sensitivity was reported by all patients. No local recurrences were reported.

Primitive Neuroectodermal Tumor (PNET) of the kidney: a case report

BackgroundA case of Primitive Neuroectodermal Tumor (PNET) of the kidney in a 27-year-old woman is presented. Few cases are reported in the literature with a variable, nonspecific presentation and an aggressive behaviour. In our case, a radical nephrectomy with lymphadenectomy was performed and there was no residual or recurrent tumour at 24-month follow-up.MethodsThe surgical specimens were formalin-fixed and paraffin embedded. The sections were stained with routinary H&E. Immunohistochemistry was performed.ResultsThe immunohistochemical evaluation revealed a diffuse CD99 positivity in the cytoplasm of the neoplastic cells. Pankeratin, cytokeratin AE1/AE3, vimentin, desmin, S100, cromogranin were negative. The clinical presentation and the macroscopic aspect, together with the histological pattern, the cytological characteristic and the cellular immunophenotype addressed the diagnosis towards primary PNET of kidney.ConclusionsSince sometimes it is difficult to discriminate between PNET and Ewings tumour, we reviewed the difficulties in differential diagnosis. These tumors have a common precursor but the stage of differentiation in which it is blocked is probably different. This could also explain their different biological behaviour and prognosis.

Endorectal coil MR imaging findings in hemospermia

The purpose of this study was to illustrate the spectrum of abnormalities found at endorectal coil magnetic resonance (MR) imaging in patients with hemospermia. Ninety patients aged between 23 and 71 years (mean age 41 years) presenting with hemospermia underwent evaluation with endorectal coil MR imaging at 1.5 T. Duration of hemospermia ranged between 5 days and 4 years (mean 15 months). MR examination protocol included T1-weighted spin-echo (SE) and T2-weighted fast SE MR images obtained in the sagittal, coronal, and axial planes. Abnormalities were observed on endorectal-coil MR images in 49 of 90 patients (54%). Blood within the seminal vesicle or the ejaculatory duct was recognized in 23 of 90 patients (25%). Dilatation of the seminal vesicles or the ejaculatory duct was observed in 31 of 90 patients (34%). Cystic lesions were identified in 14 cases, eight of which involved the utriculus and six the ejaculatory duct. Calculi within the seminal vesicles were depicted in seven patients. No malignant disease was demonstrated. In conclusion, despite the evidence that hemospermia is most often a benign and self-limiting condition, we found that endorectal coil MR imaging can detect abnormal findings in more than half of the patients, and may be helpful in assessing the level at which hemorrhage occurred and in defining the cause of the disease.

Prulifloxacin versus levofloxacin in the treatment of chronic bacterial prostatitis: a prospective, randomized, double-blind trial.

Abstract Ninety-six patients with chronic bacterial prostatitis (CBP) and evidence of infection were randomized to receive a 4-week oral course of either prulifloxacin (a new fluoroquinolone) 600 mg or levofloxacin 500 mg once daily. They were evaluated with the Meares-Stamey test and the National Institutes of Health Chronic Prostatitis Symptom Index (NIH-CPSI) at baseline and one week after therapy completion. Patients with microbiological eradication were evaluated again with the Meares-Stamey test 6 months after therapy completion. The microbiological eradication rate was 72.73% for prulifloxacin and 71.11% for levofloxacin (p=0.86) and the reduction in the NIH-CPSI was 10.75 and 10.73, respectively (p=0.98). Safety was comparable, with 18.18% adverse events for prulifloxacin and 22.22% for levofloxacin (p=0.79). Thus, a 4-week course of prulifloxacin 600 mg once daily is at least as effective and safe as levofloxacin 500 mg once daily in the treatment of CBP.

Results of Vardenafil Mediated Power Doppler Ultrasound, Contrast Enhanced Ultrasound and Systematic Random Biopsies to Detect Prostate Cancer

PURPOSE We evaluated the ability of the phosphodiesterase-5 inhibitor vardenafil to increase prostate microcirculation during power Doppler ultrasound. We also evaluated the results of contrast and vardenafil enhanced targeted biopsies compared to those of standard 12-core random biopsies to detect cancer. MATERIALS AND METHODS Between May 2008 and January 2010, 150 consecutive patients with prostate specific antigen more than 4 ng/ml at first diagnosis with negative digital rectal examination and transrectal ultrasound, and no clinical history of prostatitis underwent contrast enhanced power Doppler ultrasound (bolus injection of 2.4 ml SonoVue® contrast agent), followed by vardenafil enhanced power Doppler ultrasound (1 hour after oral administration of vardenafil 20 mg). All patients underwent standard 12-core transrectal ultrasound guided random prostate biopsy plus 1 further sampling from each suspected hypervascular lesion detected by contrast and vardenafil enhanced power Doppler ultrasound. RESULTS Prostate cancer was detected in 44 patients (29.3%). Contrast and vardenafil enhanced power Doppler ultrasound detected suspicious, contrast enhanced and vardenafil enhanced areas in 112 (74.6%) and 110 patients (73.3%), and was diagnostic for cancer in 32 (28.5%) and 42 (38%), respectively. Analysis of standard technique, and contrast and vardenafil enhanced power Doppler ultrasound findings by biopsy core showed significantly higher detection using vardenafil vs contrast enhanced power Doppler ultrasound and standard technique (41.2% vs 22.7% and 8.1%, p <0.005 and <0.001, respectively). The detection rate of standard plus contrast or vardenafil enhanced power Doppler ultrasound was 10% and 11.7% (p not significant). CONCLUSIONS Vardenafil enhanced power Doppler ultrasound enables excellent visualization of the microvasculature associated with cancer and can improve the detection rate compared to contrast enhanced power Doppler ultrasound and the random technique.

Mixed Germ Cell Tumor after Bilateral Orchidopexy in Persistent Müllerian Duct Syndrome with Transverse Testicular Ectopia

The persistent müllerian duct syndrome is characterized by the retention of müllerian derivatives (fallopian tubes, uterus) in patients otherwise normally virilized, usually with cryptorchidism or an inguinal hernia. Very rarely, this syndrome is associated with transverse testicular ectopia , which designates the condition when both testes descend through the same inguinal canal into the same scrotal sac. We report on a patient with both conditions, who had T1N2M0 scrotal mixed germ cell tumor of the testis (teratoma and embryonal carcinoma), 18 years after bilateral orchidopexy. The literature concerning this uncommon association is reviewed.

Functional Evaluation of Different Ileal Neobladders and Ureteral Reimplantation Techniques

Objectives: To compare and assess the function of ileal neobladders with different reconfiguration and with several types of ureteral reimplantation. Methods: Forty-five male patients underwent radical cystectomy and detubularized ileal neobladder. In 20 patients an ileal neobladder was carried out according to Studer’s technique, in 12 a ‘W’- and in 13 a ‘U’-shaped neobladder. In the Studer’s patients 60 cm of ileum was used, in the ‘W’ 40 and in the ‘U’ 30 cm. For the uretero-ileal anastomosis Nesbit’s technique was utilized in the Studer’s, in the ‘W’ and ‘U’ neobladders Camey Le Duc’s technique was performed instead. Four patients underwent a serous-lined extramural tunnel reimplantation. Follow-up included a functional and morphological study of the urinary system and a urodynamic study. Results: All Nesbit’s uretero-ileum anastomoses resulted refluent when the reservoir was filled up, 15 of 50 ureteral reimplantations according to the Camey Le Duc technique showed reflux at full filling. At 3, 6 and 12 months follow-up, the double reconfiguration reservoirs (Studer’s and ‘W’) showed a larger capacity and a lower maximum pressure than neobladders with a single bending. At 12 months, continence and the voiding interval time was significantly higher in the double reconfiguration than in the ‘U’ neobladders. Conclusion: The double reconfiguration of the reservoir (‘W’) might be preferable to that with a single one. As for the type of ureteral anastomosis to select, the problem is still debatable even if in our case-control study we have had better results in terms of reflux and stenosis with the uretero-enteric anastomosis with Nesbit’s and associated afferent long tubular ileal limb than with Studer’s technique.

Bladder Involvement in Systemic Sclerosis: Urodynamic and Histological Evaluation in 23 Patients

Lower tract involvement of systemic sclerosis is an uncommon manifestation. In this study we have evaluated the functional and morphologic vesical changes in 23 female patients with systemic sclerosis to investigate if bladder dysfunction was correlated with an extended skin slerosis and/or a more serious organ involvement. Urodynamic alterations were observed in only 3 cases. Urinary symptoms and urodynamic features were correlated neither with severity of vesical fibrosis nor with visceral involvement. Autonomic dysfunction was detected in 13 patients.