Stefano Zecchini Antoniolli

Short-term outcome after high-intensity focused ultrasound in the treatment of patients with high-risk prostate cancer

To assess the short‐term outcome in patients with high‐risk prostate cancer treated by transrectal high‐intensity focused ultrasound (HIFU).

Vesicouterine fistulas following cesarean section: Report on a case, review and update of the literature

Herein we report on 1 more case of vesicouterine fistula followingcesarean section with review and update of the literature concerningthis unusual topic. The disease presented with vaginal urinary leakage,cyclic hematuria and amenorrhea. The fistula was successfully repairedby delayed surgery. Actually, all over the world the prevalence of thedisease is increasing for the frequent use of the cesarean section.Fistulas may develop immediately after a cesarean section, manifest inthe late puerperium or occur after repeated procedures. Spontaneoushealing is reported in 5% of cases. Vesicouterine fistulaspresent with vaginal urinary leakage, cyclic hematuira (menouria),amenorrhea, infertility, and first trimester abortions. The diagnosis isruled out by showing the fistulous track between bladder and uterus aswell as by excluding other more frequent urogenital fistulas. Thedisease treatment options include conservative treatment as well assurgical repair. Rarely, patients refuse any kind of treatment becauseof the benignity of symptoms and prognosis of the disease. Conservativemanagement by bladder catheterization for at least 4–8 weeks isindicated when the fistula is discovered just after delivery since thereis good chance for spontaneous closure of the fistulous track. Hormonalmanagement should be tried in women presenting with Youssefs syndrome.Surgery is the maninstay and definitive treatment of vesicouterinefistulas after cesarean section. Patients scheduled for surgery shouldundergo pretreatment of urinary tract infections. Surgical repair ofvesico-uterine fistulas are performed by different approaches whichinclude the vaginal, transvesical-retroperitoneal and transperitonealaccess which is considered the most effective with the lowest relapserate. Recently, laparoscopy has been proposed as a valid option forrepairing vesicouterine fistulas. The endoscopic treatment may beeffective in treating small vesicouterine fistulas. The pregnancy rateafter repair is 31.25% with a rate of term deliveries of25%. The disease may be prevented by emptying the bladder as wellas by carefully dissecting the lower uterine segment. It is advisablethat after vesicouterine fistula repair delivery should be performed byrepeating a cesarean section since the risk of fistula recurrence.Usually, vesicouterine fistulas are diagnosed postoperatively. As aresult, at least 95% of patients will undergo another operationfor repairing the fistula. In the meantime they are bothered by relatedsymptoms which impair their quality of life. As far as we are concernedintraoperative diagnosis is the gold standard in detecting vesicouterinefistulas for allowing immediate repair. We propose intraoperativesonography by the transvaginal (or transrectal) route for the Foleytransurethral catheter producing bloody urine, for suspecting bladderinjury while dissecting the uterine lower segment and for monitoringpatients who already had had vesicouterine fistula repair. As a resultpatients will avoid the familial and social problems related to thedisease as well another operation. Moreover, ultrasound Dopplerexamination may help in better investigating and understanding thepathophysiology of vesicouterine fistulas.

Primary lymphoepithelioma-like carcinoma of the urinary bladder: report of one case with review and update of the literature after a pooled analysis of 43 patients.

Background and objectives:Lymphoepithelioma-like carcinoma (LELC) is anundifferentiated epithelial tumor with a denseinflammatory infiltrate that resembles thelymphoepithelioma of the nasopharinx occurringin other sites. Primary LELC of the bladder(LELCB) was first reported by Zukerberg et alin 1991. The incidence of LELCB is 0.4%–1.3% of all bladder carcinomas. The mean ageat diagnosis is 69 years. Of the patientpopulation 69% are men. Herein we report onone more case of primary predominant LELCB andreview all the English literature concerningthis subject after performing a pooled analysisof the cases recorded in the Eglish literatureincluding the present one.Materials and methods: The reports of 43patients including the present case of primaryLELCB from the English literature werecollected from 1991 to 2002. Patients wereevaluated for age, sex, primary and adjuvanttreatments, clinical staging, follow-up andoutcome, and disease related survival. Theoverall patient population was separated into 3groups according to the LELCB classification ofAmin. Results: The overall patientpopulation included 31 males and 12 females.Average age was 68.4 years (range 52–84). LELCBhistological subtypes resulted pure in 17cases(40%), predominant in 16 (37%) and focal in10 (23%). Mean follow-up was 37.7 months(range 0–216). Outcome resulted as follows: 26patients (62%) did not show evidence ofdiasease (62%), 11 (26%) died of disease, 1(2%) was alive with metastases, and 4 (10%)died for causes unrelated to the primarydisease. Survival rate related to specificdisease resulted 71%. Mean follow-up was 48.1in the first group (pure LELCB), 32 in thesecond (predominant LELCB), and 30.3 in thethird one (focal LELCB). Patients with notevidence of disease were 13 (81%) in group 1,13 (82%) in group 2, and 0 in group 3.Patients who died of their disease resulted 1(6%) in the first group, 1 (6%) in thesecond, and 9 (90%) in the third one. Patientswho died for disease not related to the primarytumor were 2 (13%) in the first group, 1 (6%)in the second, and 1 (10%) in the third one.One patient (6%) was alive with metastases ingroup 2. Survival rate related to specificdisease resulted 93% in the first group, 93%in the second one, and 0% in the third one.Conclusions:To date, there are no clear guide lines for the treatment of LELCB. Treatments performedinclude both deep transurethral resection ofthe tumor (TUR-B) as well as partial or radicalcystectomy, with or without adjuvant treatmentsincluding systemic chemotherapy andradiotherapy. The prognosis is favorable forpatients presenting with the pure andpredominant forms with a diploid DNA patternand very poor for patients presenting withfocal LELCB. Bladder salvage therapy byperforming both TUR-B alone or combined withadjuvant systemic chemotherapy may be areasonable option for patients with pure orpredominant LELCB, while radical surgery withadjuvant systemic therapy may be indicated forfocal muscle invasive LELCB.

Intraparenchymal renal artery aneurysms. Case report with review and update of the literature.

Increased interest in aneurysms involving therenal artery and its branches has occurredduring the past 3 decades. The prevalence ofrenal artery aneurysms is approximately 0.01%–1% in the general population as well as2.5% in hypertensive patients undergoingangiography. Intraparenchymal renal arteryaneurysms (IPRAAs) are rare since beingdetected in less than 10% of patients withrenal artery aneurysms. The Authorsreport an unusual case of multiple smallintrarenal artery aneurysms associatedwith a large IPRAA located in the mid portionof the right kidney. Usually, IPRAAs aresecondary to diseases or injuries of the kidneyvascular network. They are classified as true,false, saccular, fusiform, dissecting, andmicroaneurysms. Potential complications ofIPRAAs include peripheral dissection,thrombosis, hypertension, renal infarction andrupture. IRAAs may be detected incidentally aswell as present with urologic symptoms andsigns related to complications. Actually, IRAAsare investigated by non invasive modalitiesincluding duplex ultrasound, magnetic resonanceangiography, spiral three-dimensional computedtomography angiography, and three-dimensionalreconstructed rotational digital substractionangiography of the segmental and distantbranches of the renal artery. Angiography withintrarterial injection of contrast material isthe gold standard in diagnosing IPRAAs.Treatment options for IPRAAs includeobservation, aneurysmectomy with surgicalrepair, endovascular procedures, nephrectomy orpartial nephrectomy. Observation is indicatedfor asymptomatic intraparenchymal renal arteryaneurysms measuring less than 2 cm in diameter.Surgical repair of IPRAAs includesaneurysmectomy and reconstruction of the renalartery by in vivo or ex vivo technique. Theprocedure is indicated for IPRAAs causingrenovascular hypertension, dissection, urologicsymptoms, embolization, local expansion andwomen of childbearing age with a potential forpregnancy. In recent years, transcatheterarterial embolization has emerged as a simple,useful and effective technique in managingIRAAs. The procedure is performed bytransfemoral catheterization as well as bysuperselective catheterization and embolizationof interlobar arteries with 3F microcatheters.Endovascular occlusion is obtained by usinggelatin sponge, steel coils, detachablebaloons, and conventional non-detachablemicrocoils delivered through a microcatheter.Nephrectomy or partial nephrectomy are reservedfor conditions precluding renalrevascularization which include overt RAArupture, covert RAA rupture, artery-to-veinfistula, renal cell carcinoma, end stagenephropaty, renal infarction, severe ischemicrenal atrophy or complex intrarenal aneurysms.Recently, partial nephrectomy by thelaparoscopic approach has been proposed formanaging IPRAAs and the procedure is consideredfeasible and safe.

Adrenal extramedullary hematopoiesis: report on a pediatric case and update of the literature.

The authors report on a rare pediatric case of adrenal extramedullary hematopoiesis in a patient with beta-thalassemia disease. The lesion was clinically discovered as incidentaloma of the right adrenal gland and treated by surgery. Adrenal extramedullary hematopoiesis may clinically be detected as incidentaloma. Adrenal incidentalomas presenting with hematologic disorders, such as agnogenic myeloid aplasia and beta-thalassemia, need careful imaging as well as adrenal hormonal investigation in order to exclude malignancy and sublinical hypersecretory syndromes. Ultrasound or CT-FNA of the lesion are effective in finding out the disease.

Investigative clinical study on prostate cancer part II: on the role of the pretreatment total PSA to free testosterone ratio as a marker assessing prostate cancer prognostic groups after radical retropubic prostatectomy.

Objectives: To explore the significance of the pretreatment total prostate-specific antigen (PSA) to free testosterone (FT) ratio (PSA/FT) as a marker for assessing the pathologic Gleason sum (pGS) and levels of tumor extension (pT) in prostatectomy specimens. Patients and Methods: 128 of 135 consecutive patients diagnosed with prostate cancer underwent radical prostatectomy. Simultaneous pretreatment serum samples were obtained to measure serum total testosterone, FT and total PSA levels. The statistical design of the study included 2 sections: the first part trying to explore the role of the PSA/FT ratio in clustering patients with different pathologic prognostic factors, and the second to investigate the PSA/FT ratio distribution in different groups of patients according to the pathologic stage and pGS of the specimen after radical prostatectomy. Results: The average age was 65.80 (range 51.21–77.26) years, mean PSA was 8.88 (range 1.22–44.27) µg/l, mean FT was 35.32 (range 13.70–69.30) pmol/l, and the mean PSA/FT ratio was 0.27 (range 0.04–1.48). The PSA/FT ratio significantly clustered both the pT and pGS groups. Analysis of variance for the distribution of the PSA/FT ratio was significant for the pT model groups. The mean PSA/FT ratio increased as the tumor extended and grew through the prostate gland (high-stage disease). Analysis of variance for the different distributions of the PSA/FT ratio was significant for all model pGS groups. In our investigation we also found (data not shown) that a PSA/FT ratio of ≧0.40 was strongly correlated with large extensive (pT3b+pT4) and high-grade cancers (pGS8+pGS9). Conclusions: Prostate cancer patients may be classified into 3 different pathologic prognostic groups according to the PSA/FT ratio: low risk (PSA/FT ≤0.20), intermediate risk (PSA/FT >0.20 and ≤0.40), and high risk (PSA/FT >0.40 and ≤1.5). The PSA/FT ratio may be considered as the marker expressing different biology groups of prostate cancer patients, and it is strongly associated with pT and pGS.

Chronic inflammation of the prostate type IV with respect to risk of prostate cancer

BACKGROUND Chronic inflammatory infiltrate (CII) might be involved in prostate cancer (PCA) and benign hyperplasia (BPH); however, its significance is controversial. Chronic inflammatory prostatitis type IV is the most common non cancer diagnosis in men undergoing biopsy because of suspected PCA. OBJECTIVE To evaluate potential associations of coexistent CII and PCA in biopsy specimens after prostate assessment. DESIGN, SETTING, AND PARTICIPANTS Between January 2007 and December 2008, 415 consecutive patients who underwent prostate biopsy were retrospectively evaluated. The investigated variables included Age (years) and PSA (ug/l); moreover, CII+, glandular atrophy (GA+), glandular hyperplasia (GH+), prostate Intraepithelial neoplasm (PIN+), atypical small acinar cell proliferation (ASAP+) and PCA positive cores (P+) were evaluated as categorical and continuous (proportion of positive cores). OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Associations of CII+ and PCA risk were assessed by statistical methods. RESULTS AND LIMITATIONS In the patient population, a biopsy core positive for PCA was detected in 34.2% of cases and the rate of high grade PCA (HGPCA: bGS ! 8) resulted 4.82%. CII+ significantly and inversely associated with a positive biopsy core P+ (P < 0.0001; OR = 0.26) and HGPCA (P = 0.0005; OR = 0.05). Moreover, the associations indicated that patients with coexistent CII+ on needle biopsy were 74% less likely to have coexistent PCA than men without CII+ as well as 95% less likely to have HGPCA in the biopsy core than men without coexistent CII+. There were limits in our study which was single centre and included only one dedicated pathologist. CONCLUSIONS There was an inverse association of chronic inflammation of the prostate type IV and risk of PCA; moreover, HGPCA was less likely to be detected in cancers associated with coexistent CII. In prostate microenvironment, prostate chronic inflammation may be protective; however, its role in PCA carcinogenesis remains controversial and needs further research.

Case report: Primary retroperitoneal pelvic hydatid disease

A 38-year-old man complaining hypertension, 4 months in duration, underwent ultrasound examination that discovered a cystic pelvic mass. Physical examination showed a spherical, smooth and firm mass on the left iliac pit. Erithrocyte sedimentation rate was 35 mm/h. Total leukocyte count was 8490/mmc with 5.6% eosinophilia. Chest x-ray was normal. Computed tomography (CT) detected 2 cystic masses arising from the left retroperitoneal space of the pelvis. The cysts measure 4 and 7 cm in diameter, displaced the bladder on the right side and showed a complex laminated architecture with many septs and calcifications. Magnetic resonance imaging (MRI) confirmed CT findings. Intravenous pyelography showed compression of the bladder wall on the left side. Cystoscopy showed a small yellowish lesion localized on the left lateral wall and biopsy revealed cystic cystitis. Digit rectal bimanual palpation under general anaestesia detected a spherical, smooth and firm mass on the left side of the pelvis. The hemoagglutination test for echinococcus was positive to a dilution of 1:5120. A preoperative diagnosis of primary pelvic hydatid disease was made. Administration of albendazole (600 mg/day) was started and continued for 4 weeks before operation. Surgical exploration, via a suprapubic extra-peritoneal approach after placing a left ureteral 4 Fr catheter, revealed a large cystic mass measuring 12 cm in diameter in the left side of the pelvis. The mass displaced bladder and bowel loops on the right side. The cyst was dissected from peritoneum, bladder, pelvic vessels, psoas, ureter and left vas deferens that had to be isolated and excised since being closely connected to the wall of the cyst. The mass could not be excised intact since being closely adherent to the adjacent organs. The fluid of the cyst was drained and the cavity was irrigated with 40% saline hypertonic and povidone-iodine solution. Then the cyst wall was completely removed in a stepwise manner. Two drains were placed in the left pelvic cavity and the incision was closed. The left uretheral catheter was removed on the second day. The drains in the pelvis were extracted on the fourth and fifth day. Convalescens was uneventful. Histology of the wall of the cyst showed a laminated structure with daughter cysts containing scolices of Echinococcus granulosus. Administration of albendazole (800 mg/die) was continued for 6 weeks after operation. The patient had no complaints when last seen 15 months after operation. Ultrasound examination and immunological tests for Echinococcus granulosus were negative.

Adult primary teratoma of the testis – report on 5 cases in clinical stage I disease

Objectives:Testis pure teratoma accounts for 2.7% to 3% of all germcell tumors in adult where it behaves as a malignant neoplasm. Pureteratoma of the testis presents in clinicalstage I disease in 44% of thepatients whose risk of having pathologicalstage II disease is 16.7% to19.2%. Herein we report on 5 casesof adult pure teratoma of the testispresenting itself in clinical stage I disease.Materials and methods: From September 1976 to February 2000, 75patients underwent orchidectomy for clinical stage I nonseminomatous germcell cancer of the testis. Testis pure teratoma was detected in 5 patients(7%). Testis tumor markers wereevaluated in all cases. Patients underwentimaging examination to detect the clinical stage of the disease. Treatmentoptions after orchidectomy included retroperitoneal lymph node dissection(RPLND) in 4 patients and surveillance in 1.Results: The average age of the patients was 31 years (range 24–45).The tumor was on the left sided in 3 cases(60%) and right in 2 (40%).Tumor average size was 3.2 cm (rang 1–6).Histopathology detected thefollowing subtypes: mature teratoma in3 cases (60%), immature teratomain 1 (20%) and teratoma with malignanttransformation in (20%). Allpatients were at clinical stage I disease. Germ cell cancer microscopicmetastatic disease including embryonal carcinoma was detected in 1dissected lymph node of 1/4 patients (25%).Average follow up was 166months (range 93–249). All patients werealive and disease free and norelapses were detected during the follow up period.Conclusions: Primary pure teratoma of the testis does not respond tochemotherapy nor does it to radiation therapy. The disease treatmentoptions after orchidectomy for patients withclinical stage I disease includeRPLND or surveillance with their relativerisks and benefits. RPLND is thechosen treatment because it is both staging and treating. A close a longterm follow up is required since pure teratoma metastatic disease mayclinically develop after more than 10 years.

The preoperative serum ratio of total prostate specific antigen (PSA) to free testosterone (FT), PSA/FT index ratio, and prostate cancer. Results in 220 patients undergoing radical prostatectomy

OBJECTIVES To evaluate associations of preoperative total prostate specific antigen (PSA) to free testosterone (FT), the PSA/FT index ratio, with features of pathology prostate cancer (PCA) and to investigate its prognostic potential in clustering the PCA population. PATIENTS AND METHODS After excluding criteria, the records of 220 patients who underwent radical prostatectomy (RP) were retrospectively reviewed. Serum samples of PSA, total testosterone (TT) and FT were collected at 8.00 A.M., one month after biopsies and before RP. The PSA/FT ratio was computed in the population of patients who were clustered in groups according to ranking intervals of the PSA/FT ratio which identified at least 4 clusters which were coded as A, B, C, and D. The independent associations of the PSA/FT index ratio were assessed by statistical methods and a two-sided P < 0.05 was considered to indicate statistical significance. RESULTS TT correlated to FT which was a significant predictor of PSA in the population of patients who were subsequently clustered, according to increasing interval values of the PSA/FT index ratio, in groups that showed a stronger linear association of FT with PSA. The PSA/FT index ratio significantly associated with pathology features of prostate cancer such as pathology Gleason score (pGS), invasion of the seminal vesicles (pT3b), proportion of positive cores (P+) and proportion of cancer involving the volume of the prostate. In the population of patients, TT, PSA/FT index ratio and P+ independently associated with pGS ≥ 7 and pT3b; moreover, the odds ratio (OR) of the PSA/FT index ratio resulted 9.11 which was stronger than TT (OR = 1.11) and P+ (OR = 8.84). In the PCA population, TT, PSA/FT index ratio and P+ also independently associated with pT3b PCA; interestingly, the OR of PSA/FT index resulted 54.91 which was stronger than TT (OR = 1.31) and P+ (26.43). CONCLUSIONS Preoperative PSA/FT index ratio is an independent strong factor which directly associates with aggressive features of pathology PCA; moreover, it might express prognostic potential for clustering the patient population in risk classes. Confirmatory studies are required.