Giuseppe Di Fino

TachoSil® Sealed Tubeless Percutaneous Nephrolithotomy to Reduce Urine Leakage and Bleeding: Outcome of a Randomized Controlled Study

PURPOSE We determined the efficacy and safety of TachoSil(®) in sealing the tract after percutaneous nephrolithotomy compared to nephrostomy tube placement. MATERIALS AND METHODS A total of 100 consecutive patients scheduled for percutaneous nephrolithotomy were randomized 1:1 to receive a 16Fr nephrostomy tube (group 1) or TachoSil in the tract (group 2). All patients received a mono-J ureteral catheter. The primary study end points were bleeding and urinary leakage rates. The secondary end points were pain as assessed by the 0 to 10-point visual analog scale, analgesic requirement and hospital stay. RESULTS The groups were comparable for preoperative and operative variables. In group 1, 3 patients were excluded intraoperatively because of relevant bleeding, and in group 2, 1 patient was excluded intraoperatively because of hydrothorax. Tract complications were significantly more frequent in group 1 than in group 2 (25.5% vs 2%, p <0.001). However, the difference in urinary leakage reached statistical significance (19.1% vs 2%, p = 0.007), whereas that in perirenal hematoma formation did not (6.4% vs 0%, p = 0.113). There was no difference between the groups in mean ± SD number of analgesic doses (1.17 ± 1.56 vs 1.20 ± 1.69, p = 0.791) and visual analogue scale scores (4.77 ± 2.28 vs 4.24 ± 2.32, p = 0.270). Postoperative hospital stay was significantly shorter in group 2 than in group 1 (5.15 ± 1.74 vs 2.75 ± 1.78 days, p <0.0001). CONCLUSIONS Although failing to reduce pain and analgesic requirement, TachoSil provided better tract control and a shorter hospital stay than nephrostomy tube placement, thus allowing the extension of indications for tubeless percutaneous nephrolithotomy to most procedures.

Pentraxin 3: A Novel Biomarker for Predicting Progression from Prostatic Inflammation to Prostate Cancer

Pentraxin-3 (PTX3) is a member of the pentraxin family of innate immune regulators, which includes C-reactive protein (CRP). PTX3 has been implicated in angiogenesis, proliferation, and immune escape in cancer. In the present study, we evaluated PTX3 tissue expression and serum concentration as a biomarker to discriminate prostatic inflammation and benign prostatic hyperplasia (BPH) from prostate cancer, and to determine whether PTX3 status may predict progression from BPH to prostate cancer. We analyzed 40 patients with biopsy-proven BPH who underwent a second prostate biopsy 12 to 36 months later when they were diagnosed with prostate cancer or inflammation/BPH (n = 20 patients each group). Furthermore, we evaluated PTX3 serum concentrations in an independent set of patients with biopsy-proven inflammation/BPH (n = 61) and prostate cancer (n = 56). We found reduced PTX3 tissue expression in patients with prostatic inflammation/BPH compared with patients who developed prostate cancer. In the latter group, there was an increase in PTX3 tissue expression between the first and second prostate biopsy. PTX3 serum levels were also higher in patients with prostate cancer than in patients with inflammation/BPH. In contrast, there was no difference in serum PSA or CRP levels in these two groups. ROC curve analysis confirmed the reliability of PTX3 serum levels in predicting prostate cancer development, identifying a cutoff value of 3.25 ng/mL with a sensitivity and a specificity of 89.3% and 88.5%, respectively. In summary, our results encourage further evaluation of PTX3 as a tissue biopsy and blood-borne biomarker to discriminate BPH from prostate cancer.

Asymptomatic Bladder Metastasis from Breast Cancer

Introduction. Breast cancer is the most common nondermatologic cancer in women. Common metastatic sites include lymph nodes, lung, liver, and bone. Metastases to the bladder are extremely rare, with all reported cases presenting with urinary symptoms. Case Report. Herein, we report the first case of completely asymptomatic bladder metastasis from breast cancer, occasionally revealed, 98 months after the initial diagnosis of lobular breast carcinoma, by a follow-up computed tomography scanning showing thickening of left bladder wall and grade II left hydronephrosis. A positive staining for estrogen and progesterone receptors was confirmed by immunohistochemistry. Discussion. The reported case confirms that bladder metastases from breast cancer tend to occur late after the diagnosis of the primary tumor and, for the first time, points out they can be asymptomatic. Conclusion. Such data support the need for careful follow-up and early intervention whenever such clinical situation is suspected.

Transurethral Distal Ureter Balloon Occlusion and Detachment: A Simple Means of Managing the Distal Ureter During Radical Nephroureterectomy

Distal ureter bladder cuff (DUBC) excision is an essential part of radical nephroureterectomy (RNU), but the technique to accomplish it remains controversial. We describe a novel technique of transurethral distal ureter balloon occlusion before detachment (TUDUBOD) whereby the affected ureter is occluded with a 5F Fogarty balloon catheter and circumferentially incised until the perivesical fat to detach it from the bladder. In the 13 patients who were treated between May 2005 and May 2010, mean surgical time for TUDUBOD was 21.3 minutes. Results for surgical margins were always negative; at mean follow-up of 39.8 months (range 16-74 mos), 4 (30.1%) patients had bladder recurrences but none occurred at the DUBC excision site or perivesical space. TUDUBOD seems to be a simple, cheap, and effective mean of managing the distal ureter during RNU that keeps with the oncologic principle of preventing tumor cell spillage outside the bladder.

Absence of Bladder Outlet Obstruction Is an Independent Risk Factor for Prostate Cancer in Men Undergoing Prostate Biopsy.

AbstractThe purpose of this study was to investigate the relationship between bladder outlet obstruction (BOO) and the risk of being diagnosed with prostate cancer (PCa).Study population consisted of 2673 patients scheduled for the first prostate biopsy (PBx). All patients underwent uroflowmetry before PBx; those with a peak flow rate (PFR) <10 mL/s were considered to have BOO.The incidence of PCa was 41.3% (1104/2673) in the overall population and 34.1% (659/1905) in patients with serum prostate-specific antigen (PSA) ⩽ 10 ng/mL. Univariate and multivariate logistic regression analyses showed that patients with BOO had a significantly (P < 0.0001) lower risk than those without BOO of being diagnosed with PCa (33.1% vs 66.9% in the overall population; 30% vs 70% in patients with PSA ⩽ 10 ng/mL). As the presence of BOO was significantly correlated to a large prostate volume, another independent predictor of PBx outcome, we tested whether these parameters could be used to identify, in the subset of patients with PSA⩽10 ng/mL, those who could potentially be spared from a PBx. If we would have not biopsied patients with BOO and prostate volume ≥60 mL, 14.5% of biopsies could have been avoided while missing only 6% of tumors. Only 10% of the tumors that would have been missed were high-risk cancers.In conclusion, in men undergoing PBx, the absence of BOO, as determined by a PFR ≥10 mL/s, is an independent risk factor for PCa. Our study provides ground for this simple, noninvasive, objective parameter being used, alone or in combination with prostate volume, in the decision-making process of men potentially facing a PBx.

Magnetic resonance imaging of penile paraffinoma: case report

BackgroundPenile paraffinoma is a well-known delayed complication of paraffin oil injection into the penis for penile girth augmentation but its MRI features have not been previously described.Case presentationA 35-year-old Ukraine man presented with erectile dysfunction, voiding difficulty and an irregular, hard and painful penile mass that had progressively grown over the last year. He reported having received, seven years before, several penile injections of paraffin oil for penile girth augmentation. On physical examination, the mass was tender, poorly delimited, and involved the whole penile shaft and the cranial part of the scrotum. Preoperative MRI, performed to determine the extent of tissue to be removed and the possibilities of penile reconstruction, showed a newly-formed homogeneous tissue, compressing but not infiltrating Buck’s fascia, iso-hypointense relative to muscle on T1-weighted sequences, and with a low signal intensity at T2-weighted sequences. On T1-weighted fat suppressed sequences, it did not enhance with contrast administration. MRI data were confirmed by surgical findings, as the newly-formed scar tissue did not infiltrate Buck’s fascia. Pathology confirmed the diagnosis of penile paraffinoma.ConclusionMRI seems to provide an adequate imaging of the histological events occurring after injection of paraffin oil in the subcutaneous tissues. Penile paraffinoma remains a clinical diagnosis, but MRI features may be helpful in planning an adequate surgical strategy and, in selected cases, establishing the differential diagnosis with other penile diseases, including cancer.

Bladder metastasis from lung adenocarcinoma: a difficult differential diagnosis with primary bladder adenocarcinoma

BackgroundBladder metastases from lung adenocarcinoma are extremely rare; in the seven previously reported cases, the finding of an intact epithelium overlying the bladder tumour was considered suggestive of a secondary lesion. We describe the first case of bladder metastasis from lung adenocarcinoma whereby endoscopic appearance was strongly consistent with primary bladder cancer, thus complicating the differential diagnosis with primary bladder adenocarcinoma.Case reportA 65-year-old woman with a 13-year history of clean intermittent catheterization was diagnosed with a right lung adenocarcinoma metastatic to mediastinal and right supraclavicular nodes, as well as to the left lung, and treated with six cycles of cisplatin/pemetrexed, followed by six cycles of pemetrexed only. The 18-month follow-up computed tomography revealed several solid lesions of the bladder wall and she was scheduled for transurethral resection of bladder tumours. Endoscopic appearance was strongly consistent with primary bladder cancer but a thorough pathologic evaluation allowed the diagnosis of bladder metastasis from lung adenocarcinoma.ConclusionsDifferentiating primary bladder adenocarcinoma from metastatic adenocarcinoma lesions can be difficult. An endoscopic appearance consistent with primary bladder cancer further complicates the differential diagnosis, which heavily relies on pathologic evaluation and specific immunohistochemical staining.

Prognostic Factors for Anastomotic Urinary Leakage Following Retropubic Radical Prostatectomy and Correlation With Voiding Outcomes.

AbstractThis study aimed to determine the occurrence and grade of cystographically detected urinary leakage (UL) in a contemporary series of open retropubic radical prostatectomy (RP), whether patients’ clinical variables predict occurrence of UL, and whether occurrence of UL correlates with patients’ voiding outcomes in terms of urinary continence and anastomotic stricture (AS).Enrolled patients underwent cystography 7 days after retropubic RP; in case of UL, the catheter was left in situ and cystography repeated at 7 days intervals until demonstrating absence of UL. Leakage was classified as grade I = extraperitoneal leak <6 cm, grade II = extraperitoneal leak >6 cm, grade III = leak freely extending in the small pelvis. Voiding was evaluated at 3, 6, and 12 months after RP using the 24-hour pad test and uroflowmetry; in cases of maximum flow rate <10 mL/s, urethrocystoscopy was carried out to determine presence and location of an AS.The first postoperative cystogram showed UL in 52.6% of patients (grade I in 48.1%, grade II in 21.5%, and grade III in 30.4% of the cases). Multivariate analysis demonstrated that patients with UL had significantly greater prostate volume (64.5 vs 34.8 cc, P < 0.001), loss of serum hemoglobin (4.77 vs 4.19 g/dL, P < 0.001), lower postoperative serum total proteins (4.85 vs 5.4 g/dL, P < 0.001), and higher rate of AS (20.6% vs. 2.8%, p < 0.001) than those without UL. Continence rate at 3, 6, and 12 months postoperatively was 34.2%, 76%, and 90%, respectively, in patients with UL compared with 77.5%, 80.3%, and 93% in patients without UL; such difference was statistically significant (P < 0.001) only at 3 months follow-up. ROC curve analysis showed that prostate volume and postoperative serum total proteins had the best AUC (0.821 and 0.822, respectively) and when combined, their positive and negative predictive values for UL were 90% and 93%, respectively.In conclusion, half of the patients undergoing open retropubic RP may present, 7 days postoperatively, some degree of cystographically detected UL; prostate volume, loss of serum hemoglobin, and postoperative serum total proteins could be used to predict it. UL delayed return to urinary continence without affecting long-term results, but led to a significantly higher rate of AS.

Noninvasive electromagnetic detection of bladder cancer.

Objectives. Normal and neoplastic human tissues have different electromagnetic properties. This study aimed to determine the diagnostic accuracy of noninvasive electromagnetic detection of bladder cancer (BC) by the tissue-resonance interaction method (TRIM-prob). Patients and Methods. Consecutive patients were referred for cystoscopy because of (i) microscopic or gross hematuria and/or irritative voiding symptoms and (ii) bladder ultrasounds and urinary cytology findings negative or just suspicious of malignancy. Patients were first submitted to TRIM-prob bladder scanning by a single investigator and then to cystoscopy by another investigator blind to TRIM-prob data. Results. In 125 evaluated patients cystoscopy was positive for BC in 47 and negative in the remaining 78; conversely, TRIM-prob bladder scanning was positive for BC in 53 and negative in 72. In particular, TRIM-prob scanning yielded 7 false positives and only one false negative; therefore, its overall sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 97.9%, 89.9%, 86.8%, 98.6%, and 93.6%, respectively. Conclusions. TRIM-prob bladder scanning was a simple and quite accurate method for non-invasive electromagnetic detection of BC. If the elevated positive and negative predictive values will be replicated in further well-designed studies, it could be used to screen asymptomatic patients at high risk of BC.

Pilonidal Cyst of the Penis Mimicking Carcinoma

Pilonidal sinus is a long-standing chronic inflammatory condition consisting of a sinus tract from the skin-lined orifice extending into subcutaneous tissue, with hairs attached to the wall of the tract and projecting outside of the opening. Penile location is rare, and differential diagnosis with severe balanoposthitis, epidermal cysts, and neoplasms can be difficult. We report a rare case of pilonidal cyst located between coronal sulcus and prepuce which, due to its ulcerated aspect and absence of a tract with projecting hairs, simulated a penile carcinoma.