Umberto Maestroni

Primary bilateral seminal vesicle carcinoma: description of a case and literature review.

With no more than 60 reported cases, tumors of the seminal vesicles are rare. Because of poor and nonspecific symptoms diagnosis is often very difficult. This report presents a case of a 56-year-old man with right renal agenesis and intermittent hematospermia and bilateral cystic masses of the seminal vesicles. Transrectal biopsies of the cystic lesion revealed a papillary clear cell adenocarcinoma. The patient underwent radical prostatectomy and pelvic lymphoadenectomy. Lymph node metastases were found on histological examination. The patient received 4 cycles of chemotherapy and pelvic radiotherapy. He remains disease free 21 months after surgery. Radiological imaging in patients with hematospermia and hematuria will allow disease detection at earlier stages. Immunohistochemistry and histomorphology can be used for differential diagnosis. Surgery with clear margins offers the best chance to cure. Hormonal and radio-chemotherapy have a role as adjuvant and palliative treatment.

Laparoscopic removal of an intrauterine contraceptive device migrated into the bladder: a case report.

Dear Editor Intrauterine Contraceptive Devices (IUDs) are a form of long-term, reversible, and safe contraception, which are commonly used worldwide. A regular medical check-up is necessary to determine its position within the uterus, up to six months after IUD insertion. The complications of translocation have a wide range from displacement of IUD in myometrium to uterine perforation. Predisposing factors which are considered to be associated with dislocation include postpartum insertion, inexperienced operator insertion technique, and position of the uterus (1). Clinical history, physical examination, and transvaginal ultrasonography (US) are common procedures for the evaluation of IUDs and related complications. Although two-dimensional (2D) US (2DUS) is a routine modality in practice, it has a limited role for verifying two arms of IUD within the same plane; therefore, it may fail to detect IUD displacement (2). Furthermore, the most currently introduced hormonal IUDs can be demonstrated only by a vague shadow and might be remained unnoticed in 2DUS due to their low echogenicity (3). Recently, the availability of advanced US modalities has changed the management of IUDs by optimal evaluation of entire uterine cavity. Coronal view on three-dimensional (3D) US (3DUS) is particularly helpful to visualize the shaft and both horizontal arms in a single plane. In symptomatic patients with pelvic pain or abnormal bleeding, many IUDs, which appeared to be placed correctly or low on 2DUS, were confirmed to be imbedded, at least in part, within the myometrium with further investigations using hysteroscopy or 3DUS (4). The 3DUS is extremely useful in the management of IUDs by coronal views of the uterus and 3D-reconstructed views of the endometrium and adjacent myometrium. Many studies demonstrated the overall outstanding effectiveness of 3DUS in determining IUDs’ location, particularly for symptomatic patients with complications or patients with hormonal IUDs. Valsky et al. reported that 3DUS has a great value in symptomatic patients when the location of IUD cannot be correctly identified with traditional 2DUS (5). Bonilla-Musoles et al. designed a comparative study for the identification and location of IUDs in 66 asymptomatic women by 2DUS and 3DUS. While position of all IUDs were identified accurately with 3DUS, 2DUS failed to identify the type of IUD in 9% as well as the position of IUDs in 3%, and misidentified IUDs in 12% of patients, which was later confirmed on 3DUS (2). Lee et al. claimed the complete visualization of IUDs in 95% of patients on 3DUS vs 64% on 2DUS (6). Figure 3. In third patient, descended t-shaped intrauterine device IUD was located in the with its left arm in the cervical substance of the intrauterine device in the cervical substance (A, B). In this paper, we present 2D and 3D images of three patients with a history of IUD, placed one to three years earlier, with complaints of abdominal pain or spotting. Low positioned IUDs were identified on 2DUS. Further investigation by 3DUS was required in these symptomatic patients in order to determine the exact location of IUDs. The 3DUS was performed using 3DXI (ACCUVIX XQ, Medison, South Korea) US device with a 6.5 MHz transvaginal probe. The 2DUS and 3DUS images of patients are compared in Figures 1 - ​-33. Figure 1. In first patient, t-shaped intrauterine device (IUD) was revealed with a vertical body and flexible arms clearly not protruding beyond the confines of the endometrial echo (A, B). Figure 2. A, A low-lying of intrauterine device (IUD) in the lower uterine segment using standard two-dimensional imaging in second patient; B, The results of three-dimensional ultrasonography revealed t-shaped intrauterine device dislocated in endometrial cavity ... Comparing two images of 2DUS and 3DUS demonstrated the additional information helping in identifying the cause of abdominal pain or spotting. Sites of IUD translocation vary in terms of their clinical significance and selection of subsequent therapeutic plan. Although menorrhagia and intermenstrual bleeding have been considered as a common adverse effect of IUD placement, pelvic pain and bleeding should raise the possibility of dislodgement, perforation, or passage. The 3DUS has a crucial role in the management of both asymptomatic patients and those with suspected complications, whilst IUDs location may remain unnoticed on physical examination and 2DUS.

Is laparoscopy contraindicated in giant adrenal masses

The first laparoscopic adrenalectomy was performed and described by Gagner in 1992. Since then, this technique has become more and more widespread and there is common agreement in the literature that it is the gold standard for adrenalectomy. Laparoscopic adrenalectomy is indicated in benign adrenal masses, and it is routinely performed in masses smaller than 5 to 7 cm. The laparoscopic procedure in masses larger than this cut-off is discussed, although many investigators agree about its feasibility, safety and effectiveness. We present this case: man, 39 years old, large palpable mass in the right hypochondrium. Computed tomography scan (CT) suggested the diagnosis of giant adrenal myelolipoma (15×12×7 cm). Complete adrenal endoclinologic evaluation showed that the lesion was not a secreting tumor. Laparoscopic adrenalectomy was performed with good results.

Recurrent apocrine carcinoma of the scrotum: a case report.

Apocrine carcinoma is a rare tumor of the skin that typically arises in areas rich in apocrine glands, such as axilla and perineum. The main differential diagnosis is a metastasis from a primary apocrine carcinoma of the breast. Several authors have attempted to define morphological and immunohistochemical parameters to differentiate metastasis from primary apocrine carcinoma of the skin, but none of these had been demonstrated to be reliable markers. Here, we report a case of primary apocrine carcinoma of the scrotum that relapsed three times within a few years, without any clinical or radiological evidence of any other tumor of breast or other sites.

A novel algorithm for the prediction of prostate cancer in clinically suspected patients.

BACKGROUND Prostate cancer (PCa) represents the most common solid tumor affecting men and its early detection remains the best approach to improve survival rates. The assessment of serum levels of PSA is currently used for PCa screening but the low specificity of the test results in a high number of false positives. Other forms of PSA may be detected in the bloodstream including PSA associated with immunoglobulin M (PSA-IgM) which, alone or combined with PSA, has shown diagnostic accuracy for PCa. OBJECTIVES The aim of the study is to improve the diagnostic accuracy of PSA-IgM by developing a multivariable model which includes serum biomarkers and routine diagnostic parameters to obtain a predictive index useful in the post-screening clinical practice. PATIENTS AND METHODS One hundred sixty male patients with clinical suspect of PCa underwent a trans-rectal ultrasound guided first prostate biopsy with a standardized sampling scheme. To generate the model, we assessed the presence of PSA and PSA-IgM complexes in sera of patients and the prostate volume of each patient. A novel predictive probability for PCa (iXip) was obtained combining non-overlapping biomarkers normalized with diagnostic parameters. RESULTS The study population included 49 patients with PCa diagnosed at biopsy and 111 controls in which prostate biopsy showed the presence of benign prostatic hyperplasia, inflammation, atypical small acinar proliferation or high-grade prostatic intraepithelial neoplasia. The iXip values for patients with PCa (mean ± SD=0.467 ± 0.160) were significantly higher (p-value < 0.001) than control subjects (mean ± SD=0.314 ± 0.098) and the iXip AUC (0.787) was significantly greater (p-value < 0.001) than the AUCs of each biomarker. CONCLUSIONS iXip shows a significant increase in diagnostic performance compared to PSA and PSA-IgM and its post-screening use may facilitate decision-making in recommending for biopsy clinically suspected patients.

Laparoscopic adrenalectomy in giant masses

Background Laparoscopic adrenalectomy is considered the treatment of choice in the surgical management of the most majority of the adrenal diseases. Nevertheless, one of the much discussed topics is the dimensional cut-off for the laparoscopic treatment and it is not clear if laparoscopy should be used in large adrenal masses. Introduction Laparoscopic adrenalectomy is the goal standard in benign adrenal masses smaller than 6 cm, while its advantages in masses larger than this cut-off and in malignant lesions is still discussed. Materials and Methods We present six cases of laparoscopic adrenalectomy since November 2008 for masses between 7 and 15 cm; 4 men and 2 women. 3 right and 3 left. A complete adrenal endocrinological evaluation demonstrated that the lesions were not secreting tumors. All patients were studied with CT scan. The technique was performed using a flank approach with a 45° tilt. We used 5 trocars in patients who had the masses on the right side, and 4 in those who had the lesions on the left side. After creating an adequate pneumoperitoneum through an open access, the posterior peritoneum cutting, mobilization of the colon, medial dissection of the adrenal gland, and ligation of the main adrenal vein were performed. The adrenal gland was carefully dissected by Ultracision. The mass was extracted by endobag through an additional subcostal port. The mean operative time was 120 minutes. Blood loss was about 50 cc. The drainage was removed on day 2 after surgery and the patient was discharged on day 3. No post-operative complication occurred. The anatomopathologic exam gave evidence of myelolipoma and hemorrhagic cyst. Discussion The benefits of the laparoscopic approach are widely demonstrated and consist of a shorter hospital stay, reduced morbility decreased analgesic requirement, and reduced intraoperative blood loss. One of the most discussed topics is the dimensional cut-off and it is not clear if the laparoscopy approach should be used in large adrenal masses (considering the longer operative time and increasing blood loss). Many surgeons performed laparoscopic adrenalectomy for masses of up to 13 cm, thus demonstrating that this procedure is safe and effective. A limitation of laparoscopic approach for adrenal giant masses is the increased risk to treat an adrenal cortical carcinoma. Conclusions Our experience, supported by the literature, demonstrates that the laparoscopic adrenalectomy is a feasible and effective surgical technique also in the case of giant masses. Preoperative diagnosis has a predominant role to determine the contraindication of this technique (invasive adrenal carcinoma).

A challenging case of laparoscopic synchronous bilateral adrenalectomy for Cushing’s disease. Case report

Introduction Laparoscopic adrenalectomy is a treatment option in patients with Cushings syndrome. Preoperative comorbities as well as surgical and anesthesiological difficulties can make the procedure challenging. Presentation of the case We present the case of a 53-year-old obese man diagnosed with Cushings syndrome, also suffering from other endocrine pathologies, neurofibromatosis type 2, cardiomiopathy with severe hypertrophy and diastolic dysfunction, deep vein thrombosis (DVT) and obstructive sleep apnea syndrome (OSAS). After multidisciplinary team discussion of the case, the patient underwent laparoscopic synchronous bilateral adrenalectomy. The laparoscopic approach was a part of a balanced enhanced recovery program which resulted in uneventful discharge in 4 days. Conclusion Laparoscopic synchronous bilateral adrenalectomy is feasible and effective and should be considered also in patients with wide preoperative comorbidities and challenging intraoperative management, as long as the patient is meticulously studied preoperatively. An approach including a multidisciplinary team discussion is recommended.

Recurrence of prostate cancer after HIFU. Proposal of a novel predictive index

Background and aim of the work: Prostate cancer is one of the most common cancers in men over 50 years of age. Surgery, radiotherapy and hormonal manipulation represent its typical treatment. High-Intensity Focused Ultrasound (HIFU) is an alternative choice in localized prostate cancer. To date, an index for prediction of recurrence in patients treated with HIFU is not availabe. Our study proposes a novel index for the predition of recurrence able to determine if a candidate is fit for this tratment. methods: 107 patients underwent HIFU fram 2010 to 2015. A total of 12 variables were considered for the analysis. The final predictive model was obtained through a stepwise forward selection method. Results: The final model used a total of 6 variables, all correlated to the response variable. The Index is able to predict the recurrence after HIFU tratment in the most majority of candidates to treatment. The index may be used to make a more scientific decision with regard to choosing optimal candidates for HIFU. (www.actabiomedica.it)

Are Nephroenteric Fistulas Only a Surgical Trouble

Nephroenteric fistulas can be secondary to different etiologies, the most common of which are pyelocolic fistulas. The absence of pathognomonic symptoms and the heterogeneity of presentation can sometimes result in a delay in diagnosis. We report on three cases: a pyelo-duodenal fistula secondary to kidney stones and subsequent pyonephrosis, a pyelocolic fistula due to inveterate ureteral stones with hydropyonephrosis, and a rare case of posttraumatic pyelocolic fistula. All patients were treated with radical nephrectomy and resection of the involved intestinal tract. Fistulas of the kidney with the gastrointestinal tract are complex not only for the surgical treatment, which is mandatory in the majority of cases, but also for clinical and instrumental diagnosis. Severe infection is a major concern due to the admixture of the enteric bacterial flora with the urinary tract. Nephroenteric fistulas require skilled surgical procedures, close control of the septic risk, management of patients overall medical condition, and balance between invasive and conservative approach.

The Oncological Outcome of HIFU for the Treatment of Localized Prostate Cancer

Introduction : Prostate cancer is considered one of the most important health problems. Due to the increased number of diagnosed patients and the inability to distinguish aggressive tumors, minimally-invasive procedures have become increasingly interesting. High-intensity focused ultrasound (HIFU) is an alternative option to radical surgery to treat prostate cancer. To date, however, no data are available on the efficacy of this technique in comparison to standard treatment. Methods and Results : We reviewed the literature to concentrate on the oncological outcome of HIFU treatment of prostate cancer with the following key words: hifu, high intensity focused ultrasound, ultrasonic therapy, transrectal hifu, prostate ablation. MedLine and Embase via Ovid database were searched. Selection criteria were: English language, articles published between 2006 and 2013, case series including more than 150 participants and reported data on oncological outcome. Thirteen uncontrolled studies were identified. No randomized controlled trials (RCT) were found in the literature comparing HIFU to other routine approaches to prostate cancer treatment. Conclusion : HIFU seems to be a promising minimally-invasive treatment for low- and intermediate-risk prostate cancer, especially for patients who are unfit for radical surgery. Prospective studies with longer follow-up periods and RCT are required to properly assess the benefits of HIFU and to compare this treatment with standard treatment.