Nicola Pavan

Penile fracture: Retrospective analysis of our case history with long-term assessment of the erectile and sexological outcome

OBJECTIVES To review the cases of patients with suspected penile fracture and asses erectile and sexological outcomes. MATERIALS AND METHODS from 1987 to 2013 presented to the Urology Clinic of Trieste and at the AIED of Pordenone a total of 41 cases that were divided into two groups according to the timing of treatment: 18 patients with anamnestic diagnosis of penile fracture treated nonimmediately and 23 patients treated immediately after the trauma. For all patients we evaluated the type of treatment adopted, the occurrence of complications and reoperations and the follow-up. The erectile function was also evaluated through the IIEF, as well as the psychological impact of the trauma on social and sex life, using a psycho- sexological questionnaire. RESULTS Among patients treated immediately after the trauma 14 were subjected to surgery. About a year after surgery, penile curvature was reported in 1 patient, pain in 3 patients, urinary disorders in 1 patient, while none reported erectile dysfunction (ED). Out of these, only 3 patients underwent reoperation. Among those treated conservatively 1 patient reported curvature, 1 patient reported pain and none reported ED. Among patients who were admitted at a later date, 14 reported curvature and 4 reported pain whereas urinary disorders were reported in 1 and ED in 4 patients. From a psychological point of view, the trauma caused in most cases a fear of new trauma and of repercussions on erectile function and sensitivity. CONCLUSIONS The diagnosis is mainly clinical; however, radiological investigation is essential to confirm the diagnosis, assess the site and extent of the trauma and possible urethral involvement, so as to plan the most appropriate treatment. In addition, immediate treatment leads to better long-term results, with a lower incidence of ED and penile curvature. Psychologically, penile trauma intensifies the fear of reoccurrence; it decreases, however, with the passage of time.

Is there a place for nutritional supplements in the treatment of idiopathic male infertility

OBJECTIVE Infertility affects 15% of couples in fertile age. Male factor is a cause of infertility in almost half of cases, mainly due to oligoasthenoteratozoospermia (OAT). The purpose of this study is to review the effects of nutritional supplements as medical treatment for idiopathic male infertility. MATERIAL AND METHODS A Pub Med and Medline review of the published studies utilizing nutritional supplements for the treatment of male infertility has been performed. RESULTS Clinical trials on Vitamin E, Vitamin A, Vitamin C. Arginine, Carnitine, N-Acetyl-Carnitine, Glutathione, Coenzyme Q10, Selenium and Zinc were reviewed. Although there is a wide variability in selected population, dose regimen and final outcomes, nutritional supplements both alone and in combination seems to be able to improve semen parameters (sperm count, sperm motility and morphology) and pregnancy rate in infertile men. CONCLUSIONS There are rising evidences from published randomized trials and systematic review suggesting that nutritional supplementation may improve semen parameters and the likelihood of pregnancy in men affected by OAT. This improvement, however, is not consistent and there is a wide variation in the treatment regimens used. Well designed and adequately powered RCTs are needed to better clarify the role of nutritional supplements as treatment for male infertility.

Re-examining Prostate-specific Antigen (PSA) Density: Defining the Optimal PSA Range and Patients for Using PSA Density to Predict Prostate Cancer Using Extended Template Biopsy

OBJECTIVE To compare the predictive accuracy of prostate-specific antigen (PSA) density vs PSA across different PSA ranges and by prior biopsy status in a prospective cohort undergoing prostate biopsy. MATERIALS AND METHODS Men from a prospective trial underwent an extended template biopsy to evaluate for prostate cancer at 26 sites throughout the United States. The area under the receiver operating curve assessed the predictive accuracy of PSA density vs PSA across 3 PSA ranges (<4 ng/mL, 4-10 ng/mL, >10 ng/mL). We also investigated the effect of varying the PSA density cutoffs on the detection of cancer and assessed the performance of PSA density vs PSA in men with or without a prior negative biopsy. RESULTS Among 1290 patients, 585 (45%) and 284 (22%) men had prostate cancer and significant prostate cancer, respectively. PSA density performed better than PSA in detecting any prostate cancer within a PSA of 4-10 ng/mL (area under the receiver operating characteristic curve [AUC]: 0.70 vs 0.53, P < .0001) and within a PSA >10 mg/mL (AUC: 0.84 vs 0.65, P < .0001). PSA density was significantly more predictive than PSA in detecting any prostate cancer in men without (AUC: 0.73 vs 0.67, P < .0001) and with (AUC: 0.69 vs 0.55, P < .0001) a previous biopsy; however, the incremental difference in AUC was higher among men with a previous negative biopsy. Similar inferences were seen for significant cancer across all analyses. CONCLUSION As PSA increases, PSA density becomes a better marker for predicting prostate cancer compared with PSA alone. Additionally, PSA density performed better than PSA in men with a prior negative biopsy.

Primary renal MALToma: A rare differential diagnosis for a recurrent renal mass after primary ablative therapy

We report a case of primary renal lymphoma of mucosa-associated lymphoid tissue in an 82-year-old woman. She presented with a history of renal mass previously treated with kidney percutaneous cryoablation at another centre.

Neovaginal prolapse in male-to-female transsexuals: an 18-year-long experience.

Neovaginal prolapse is a rare and distressing complication after male-to-female sexual reassignment surgery. We retrospectively analysed the prevalence of partial and total neo-vaginal prolapses after sexual reassignment surgery in our institute. During the years, two different techniques have been adopted with the aim of fixing the neovaginal cylinder. In the first, two absorbable sutures are placed at the top of the penoscrotal cylinder and fixed to the Denonvilliers fascia. In the second, two additional sutures are added from the posterior/midpoint of the flap to the prerectal fascia. We enrolled 282 consecutive transsexual patients. 65 (23.04%) out of the 282 were treated with the first technique and the following 217 (76.96%) with the last technique. In the first technique, 1 case (1.53%) of total prolapse and 7 cases (10.76%) of partial prolapse were observed, while in the other 217 patients treated with the second technique only 9 cases of partial prolapse were observed (4.14%) and no cases of total prolapse. All prolapses occurred within 6 months from the procedure. In our experience, the use of 4 stitches and a more proximal positioning of the sutures to fix the penoscrotal apex with the Denonvilliers fascia guarantees a lower risk of prolapse.

Practical recommendations for performing ultrasound scanning in the urological and andrological fields

AIM US scanning has been defined as the urologists stethoscope. These recommendations have been drawn up with the aim of ensuring minimum standards of excellence for ultrasound imaging in urological and andrological practice. A series of essential recommendations are made, to be followed during ultrasound investigations in kidney, prostate, bladder, scrotal and penile diseases. METHODS Members of the Imaging Working Group of the Italian Society of Urology (SIU) in collaboration with the Italian Society of Ultrasound in Urology, Andrology and Nephrology (SIEUN) identified expert Urologists, Andrologists, Nephrologists and Radiologists. The recommendations are based on review of the literature, previously published recommendations, books and the opinions of the experts. The final document was reviewed by national experts, including members of the Italian Society of Radiology. RESULTS Recommendations are listed in 5 chapters, focused on: kidney, bladder, prostate and seminal vesicles, scrotum and testis, penis, including penile echo-doppler. In each chapter clear definitions are made of: indications, technological standards of the devices, the method of performance of the investigation. The findings to be reported are described and discussed, and examples of final reports for each organ are included. In the tables, the ultrasound features of the principal male uro-genital diseases are summarized. Diagnostic accuracy and second level investigations are considered. CONCLUSIONS Ultrasound is an integral part of the diagnosis and follow-up of diseases of the urinary system and male genitals in patients of all ages, in both the hospital and outpatient setting. These recommendations are dedicated to enhancing communication and evidence-based medicine in an inter- and multi-disciplinary approach. The ability to perform and interpret ultrasound imaging correctly has become an integral part of clinical practice in uro-andrology, but intra and inter-observer variability is a well known limitation. These recommendations will help to improve reliability and reproducibility in uro-andrological ultrasound scanning.

Prevalence of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infections Among Transgender Persons Referred to an Italian Center for Total Sex Reassignment Surgery

Introduction The burden of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in transgender population is an underestimated issue. We performed a study to evaluate the prevalence of such infections in transgender persons addressed our center for total sex reassignment surgery (SRS). Materials and Methods All transgender persons undergoing SRS from 2000 to 2014 were evaluated retrospectively. Participant characteristics and results of HIV, HBV, and HCV testing were collected. Exact Fisher test, Cochran-Armitage tests for trend and correct prevalence ratios were estimated. Results Among 498 transgender persons, 243 had confirmed serological data. Of them, 25 were female-to-male and 218 male-to-female (MtF) subjects. The prevalence of HIV, HBV and HCV infections was 0%, 4.0%, and 8.0% in female-to-male, and 12.1%, 4.6%, and 3.7% in MtF. Among MtF, younger age and earlier year of SRS were associated with lower HIV prevalence. From the multivariate model, the mutually adjustment prevalence ratios were 1.9 (95% confidence interval [95% CI], 1.2–3.1) for SRS in 2005–2010 and 3.6 (95% CI, 1.3–9.4) in 2010–2014, as compared with SRS in 2000–2004; and 4.7 (95% CI, 2.4–9.4) for South Americans as compared with others. Among the HCV-positive MtF, 57.1% were also HIV-positive. Regarding HBV, the immunity was 38.5% and, after mutual adjustment, the prevalence ratios were 2.1 (95% CI, 1.3–3.4) for South Americans versus others and 2.2 (95% CI, 1.6–3.1) for year of birth ≥ 1980. Discussion The prevalence of HBV and HCV infections among our transgender persons overlaps that reported in the general population, but HCV prevalence was much higher in HIV-infected MtF. The high burden of HIV infection among MtF and its recent incremented prevalence points out that social and medical support should be strongly promoted in such population.

Role of Penile Doppler US in the Preoperative Assessment of Penile Squamous Cell Carcinoma Patients: Results From a Large Prospective Multicenter European Study.

OBJECTIVE To determine the role of penile Doppler ultrasound (PDU) compared with magnetic resonance imaging (MRI) in preoperative diagnostic evaluation of patients with penile squamous cell carcinoma. MATERIALS AND METHODS A prospective analysis on patients presenting with clinical diagnosis of penile squamous cell carcinoma from 6 different European hospitals between 2012 and 2014 was carried out. Each patient who had planned an organ sparing approach underwent an MRI and PDU both with an artificial erection with prostaglandin E 1. Age, evidence of MRI or PDU corpora cavernosa infiltration, frozen section examination report, definitive pathological report, and surgical approach used per patient were recorded. Accuracy, precision, negative predictive value, sensitivity, and specificity were calculated. Outcomes were statistically evaluated. RESULTS Two hundred patients were enrolled in the study. The mean age of the patients was 67.35 ± 15.45 (range 51-82). All of the patients were treated surgically. Of the 200 patients, 135 (67.5%) underwent a corpora sparing approach, whereas 65 had a partial penectomy because of the frozen section outcome. About corpora cavernosa infiltration, the definitive outcome confirmed the frozen section examination. PDU vs MRI accuracy was 96.5% vs 90.5%; precision was 92.6% vs 96%; sensitivity was 96.9% vs 73.8%, specificity was 96.2% vs 98.5%. Despite sensitivity (P <.05) no statistical evidence was found between ultrasound and MRI. CONCLUSION PDU has a statistical similar outcome on detecting infiltration of corpora cavernosa and could be used as a less expensive tool to drive surgical strategy in patient with a diagnosis of penile squamous cell carcinoma.

MR imaging in patients with male-to-female sex reassignment surgery: postoperative anatomy and complications

OBJECTIVE To investigate the role of MRI in the evaluation of both the new female anatomy and complications in male-to-female sex reassignment surgery (MtF-SRS). METHODS 71 consecutive patients with MtF-SRS had 74 MRI [age range, 21-63 years; mean (±standard deviation) age, 36 ± 10 years; median age, 37 years]. In 47 patients, MRI was performed to rule out early post-operative complications after gender conversion (n = 40), vaginoplasty (n = 6) or remodelling of the labia majora (n = 1). In 27 patients, MRI was performed 1-20 years after MtF-SRS for late post-operative complications, pain or dysuria, inflammatory changes or poor cosmetic outcome. Three patients had MRI both before and after the operation. RESULTS MRI allowed investigation of the new female anatomy in all cases. Soon after MtF-SRS, a small amount of blood was identified in all patients around the neoclitoris, urethral plaque and labia. Post-operative complications were clinically significant fluid collections (n = 5), labial abscesses (n = 2), severe cellulitis (n = 3), partial neovaginal prolapse (n = 3), focal necrosis and dehiscence of the vaginal wall (n = 2) and hypovascularization of the neoclitoris (n = 1). After ileal vaginoplasty, three patients developed clinically insignificant haematomas, one a large rectovaginal fistula with dehiscence of the intestinal anastomosis and bowel perforation (n = 1). In the 27 patients investigated 1-20 years after MfF-SRS, MRI demonstrated cavernosal remnants (n = 10), spared testis (n = 1) neovaginal strictures (n = 8), fistulas and abscesses (n = 3) and prolapse (n = 2). Three of these patients also had fibrotic changes. In the remaining three patients, no pathological features were identified. CONCLUSION After genital reconfiguration, MRI allows assessment of the post-operative anatomy and of post-operative complications. Advances in knowledge: Imaging features of the new anatomy and of surgical complications after SRS are discussed and illustrated.

Contemporary minimally invasive surgery for adrenal masses: it's not all about (pure) laparoscopy.

adrenal masses: it’s not all about (pure) laparoscopy Nicola Pavan*, Ithaar Derweesh, Jens Rassweiler, Benjamin Challacombe, Homayoun Zargar, James Porter**, Evangelos Liatsikos, Jihad Kaouk, Francesco Porpiglia and Riccardo Autorino *Urology Clinic, Department of Medical, Surgical and Health Science, University of Trieste, Trieste, Italy, Department of Urology, UC San Diego Health System, La Jolla, CA, USA, Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Heidelberg, Germany, Guy’s and St Thomas’ Hospitals, London, UK, Departments of Urology and Surgery, Royal Melbourne Hospital, Melbourne, Vic., Australia, **Swedish Urology Group, Seattle, WA, USA, Department of Urology, Medical School, University of Patras, Patras, Greece, Glickaman Urological Institute, Cleveland Clinic, Cleveland, OH, USA, Division of Urology, Department of Oncology, University of Turin ‘San Luigi’ Hospital, Orbassano, Italy, and Urology Institute, University Hospitals, Case Western Reserve University, Cleveland, OH, USA