Matteo Giulio Spinelli

Pelvic endometriosis and hydroureteronephrosis

OBJECTIVE To assess whether routine renal ultrasonography may be recommended in all patients with pelvic endometriosis, in order to avoid silent ureteral involvement of the disease. DESIGN Retrospective descriptive study. SETTINGS Tertiary center for the treatment of endometriosis at the Department of Obstetrics and Gynecology of the State University of Milan, Milan, Italy. PATIENT(S) Seven-hundred-fifty patients with a primary diagnosis of endometriosis, between January 2005 and July 2007. INTERVENTION(S) Routine urinary ultrasound; recording of patient history, signs, and symptoms; gynecologic examination; blood and urinary analyses; magnetic resonance imaging; spiral multislice computerized tomography. MAIN OUTCOME MEASURE(S) Symptoms and signs of ureterohydronephrosis; diagnosis of ureterohydronephrosis. RESULT(S) Twenty-three patients (3%) of all 750 patients with endometriosis had associated ureterohydronephrosis diagnosed at renal ultrasound. Symptoms secondary to ureteral and renal involvement were present in 10 patients (43.5%); 6 reported lumbar pain (26.1%) and 4 patients (17.4%) had renal colic. CONCLUSION(S) In our study, the high number (56.5%) of asymptomatic ureteral involvement in patients with known pelvic endometriosis seems to warrant the need for further investigations regarding the possibility to avoid the high percentage of silent renal losses. Unfortunately there appears to be no specific risk factor to allow for early suspicion nor a validated preventive diagnostic and therapeutic program. It remains to be evaluated whether urinary ultrasound ensures a beneficial cost-benefit ratio if employed on a routine basis.

Recent advances in the surgical treatment of benign prostatic hyperplasia

TURP for many years has been considered the gold standard for surgical treatment of BPH. Symptoms relief, improvement in Maximum flow rate and reduction of post void residual urine have been reported in several experiences. Notwithstanding a satisfactory efficacy, concerns have been reported in terms of safety outcomes:intracapsular perforation, TUR syndrome, bleeding with a higher risk of transfusion particularly in larger prostates have been extensivelyreported in the literature. In the recent years the use of new forms of energy and devices suchas bipolar resector, Ho: YAG and potassium-titanyl-phosphate laserare challenging the role of traditional TURP for BPH surgical treatment. In 1999 TURP represented the 81% of surgical treatment for BPHversus 39% of 2005. Is this a marketing driven change or is there areal advantage in new technologies? We analyzed guidelines and higher evidence studies to evaluate therole of the most relevant new surgical approaches compared to TURPfor the treatment of BPH. In case of prostates of very large size the challenge is ongoing, withminimally invasive laparoscopic approach and most recently roboticapproach. We will evaluate the most recent literature on thisemerging field.

Bullous Wells' syndrome associated with non-Hodgkin's lymphocytic lymphoma.

3/µl; eosinophils 14.3% neutrophils 48%, lymphocytes 31.2%, monocytes 6.5%, basophils 0.2%), total immunoglobulin E (IgE) = 751 IU/ml, C-reactive protein (CRP) 1.25 mg/dl, erythrocyte sedimentation rate (ESR) in the first hour 60 mm; viral markers (Epstein Barr virus, cytomegalovirus, hepatitis A, B and C virus), cryoglobulin, ANCA, LAC, ANA, ENA and anti-DNA antibodies were all negative. Histopathological examination of the lesion on the left leg showed an epidermis characterized by multiple, sometimes confluent vesicles containing serum and eosinophil granulocytes. The underlying papillary dermis was markedly oedematous, with focal and minimal erythrocytic extravasations and an interstitial eosinophil granulocytic infiltrate. The reticular dermis was infiltrated by a large number of prevalently perivascular lymphocytic elements and numerous perivascular and interstitial eosinophil granulocytes, which also extended along the interlobular hypodermal septa and, to a lesser extent, the hypodermic lobules. The reticular dermis also showed some small and isolated flame figures (Fig. 2). The diagnosis of Wells’ syndrome was made on the basis of the clinical picture and the histological findings, together with a negative direct immunofluorescence test (5). Having excluded pharmacological, infective, vasculitic and inflammatory causes, the subsequent instrumental and laboratory investigations were aimed at identifying a possible relapse of the patient’s previous neoplastic disease. Complete abdominal ultrasonography, chest radiography and colonoscopy were negative, as was a search for tumour markers. The physical examination findings of numerous swollen inguinal and axillary lymph nodes therefore drew our attention to a possible underlying lymphoproliferative disease, and a subsequent lymph node biopsy revealed a picture compatible with a diffuse, small-cell non-Hodgkin’s B lymphoma/ B-cell CLL, which was confirmed by a bone marrow biopsy.

Progesterone receptor +331G/A polymorphism in endometriosis and deep-infiltrating endometriosis.

In this study, we sought to examine the association between P receptor +331G/A polymorphism and endometriosis. We excluded any relationship between endometriosis in general and the P receptor +331G/A polymorphism but found a significant association with deep-infiltrating endometriosis, supporting a potential role of this variant in the P receptor-dependent invasive behavior of endometrial cells.

Reconstructive urethroplasty using porcine acellular matrix (SIS): evolution of the grafting technique and results of 10-year experience

Introduction. Long tract urethral reconstruction still has no other resolution than two-stage techniques or graft and flap procedures, that are neither simple nor trouble-free. Tissue engineering simplifies this surgery using porcine acellular matrix, obtained from small intestine submucosa (SIS): thin but strong, ready for grafting, it is not immunogenic, being deprived of cells. It is a biological bridge for reconstruction, promoting the regeneration of surrounding tissue. We report our experience using SIS for urethroplasty. Materials and Methods. After coronal or perineal-scrotal incision and penile degloving, the urethra is rotated of 180° and opened through the entire restricted tract. The graft is sutured dorsally and reinforced by the contact with the cavernous bodies to prevent pouching. From 1999 to 2005 we performed this grafting procedure in 36 men and 4 women. Afterwards, 16 more surgeries performed were with direct ventral graft procedure, without urethra isolation and rotation, with worthy simplification. RESULTS. A 10–year follow-up shows satisfactory urodynamic and subjective outcomes for both procedures, assessed by voiding urethrography, uroflowmetry International Prostate Symptom Score, and Quality of Life perception. At urethroscopy the graft appears completely homogeneous to the native tissue, as confirmed by the histological examination. The ventral direct graft represents the more consistent innovation: we did not observe pouching and the results remained effective. For penile urethra, in a few patients, periodic dilatations were necessary. Conclusions. SIS can be considered as an alternative to more difficult grafting procedures, which are probably no more indispensable in urethral enlargement, even for critical strictures.

Massive recurring angiomyxoma of the scrotum in a obese man.

Aggressive angiomyxoma (AAM) is a rare mesenchymal benign myxoid tumor, characterized by locally infiltrative nature and high recurrence rate. AAM occurs almost exclusively in adult females, arising from the soft tissue of the pelvic region: to our knowledge, only 43 cases occurring in men have been reported. We report a case of massive recurrence of scrotal AAM in a 46-year-old obese man, who already underwent surgery for the same disease in 2004 and 2005. The mass had a circumference of 106 cm and weighted 30 kg. It was impossible to appreciate the testes and to find the penis. The patient underwent scrotal resection, bilateral orchidopexia and transposition of the penis, by means of a preputial flap. Residual scrotal skin was modeled in order to create a neoscrotum, where the testes were placed and secured with interrupted sutures. Histologic examination showed diffuse angiomyxoma-like lipomatosis. After three months, the patient presented with local relapse which also involved the external urethral orifice.

Ralp & Rocco Stitch: Original Technique:

Incontinence and impotence are the two chief drawbacks of radical prostatectomy (RP). Incontinence is the most relevant for most of the patients, even if there is high variability in terms of prevalence and definition of continence. Incontinence seems the result of several factors, the most important being the surgical injury of some structures and the biomechanical instability associated with vesicourethral anastomosis. In the posterior urethra, which guarantees the continence mechanism, two functionally independent regions can be recognized: the proximal and the distal. The proximal region can be identified with the bladder neck, while the distal region is the rhabdosphincter urethrae. Concerning the distal functional region, two kinds of strategy can be applied: the preservation of puboprostatic ligaments and urethral attachments, or the reconstruction of the urethral rhabdosphincter, which can be anterior, posterior or total. We describe our technique of choice for posterior reconstruction, first described by Rocco and then modified by Patel et al.L’incontinenza urinaria e l’impotenza sono le due principali complicanze postoperatorie della prostatectomia radicale (RP) (1).L’incontinenza sembra essere il problema che assilla mag -giormente i pazienti, anche se la sua incidenza e inferiore a quella dell’impotenza.A seconda delle varie statistiche, dei metodi usati per il ri-levamento e della definizione che gli autori ne danno, della lunghezza del follow-up e dell’esperienza del chirurgo, l’in -continenza e riportata in percentuali che variano in modo molto considerevole.Considerando per semplicita le linee guida delle due prin-cipali associazioni di Urologia,la percentuale di incontinen -

Sclerotherapy of the Pampiniform Plexus with Modified Marmar Technique in Children and Adolescents

Aims: Treatment of varicocele in children is a debated problem for which no validated guidelines exist. Several techniques have been proposed to solve this problem. The aim of this study was to evaluate the effectiveness and applicability of a modified Marmar technique in the treatment of varicocele in children and adolescents. Methods:From April 2004 to September 2005, we evaluated 25 patients between the ages of 9 and 18 (mean 14.4) years, who suffered from left-sided varicocele with concomitant testicular hypotrophy. The diagnosis was ascertained clinically and with scrotal color Doppler ultrasound using the Dubin and Amelar classification. In 2 cases phimosis was also present. The operation was performed according to a modified Marmar technique, using embolization of the pampiniform plexus with 2 ml of 3% polidocanol. Patients underwent clinical evaluation and scrotal color Doppler ultrasound at 1 week and 3 and 6 months. Results: The mean duration of the operation was 42 min. At 1 week after surgery no persistence of varicocele was found. In 1 patient, edema of the spermatic cord occurred for about 2 months with spontaneous regression, in 1 patient homolateral hydrocele was observed. At 6 months no other complications were reported. No case of testicular atrophy was observed. Conclusions: The technique described has already been validated in the adult population, and although we present only a small number of cases, the operation proved easy to perform, safe, of low cost and can be considered a valid alternative to the microsurgical technique in children and adolescents.

Successful Cyclosporine Treatment in a Case of Amicrobial Pustulosis Associated with Immunological Abnormalities

Amicrobial pustulosis associated with autoimmune diseases (APAD) is a clinical entity which was described only recently and few cases are reported in the literature. This condition is characterized by recurrent acute onset with pustular lesions predominantly involving skin folds, genitals, scalp and external auditory canals of young women. The etiopathogenesis of APAD is unknown and the most effective therapeutic treatment seems to be systemic corticosteroids. We describe the case of a 16-year old female patient suffering from APAD successfully treated with cyclosporine A.

Glans penis necrosis following paraphimosis: A rare case with brief literature review

A 83-year-old man presented to the urology department with a painful swelling of the glans penis. The patient was admitted from the emergency department for pneumonia and urinary tract infection two days before, and a urethral catheter was placed. Physical examination showed preputial edema and a swollen glans penis associated with an ischemia-related hemorrhagic mucosal suffusion (Fig. 1). A diagnosis of glans penis necrosis caused by paraphimosis was made.