Parotid metastasis from renal cell carcinoma: a case report and review of the literature

Renal cell carcinoma metastasis to the parotid gland after tumour nephrectomy is extremely rare. Herewith a review of the literature on this topic is discussed and a case report is presented of a 69-year-old man affected by parotid localization of renal clear cell carcinoma with neck lymph node metastases and involvement of the masseter muscle 2 years after nephrectomy. When an otolaryngologist encounters a parotid mass, diverse differential diagnoses have to be considered. A high level of suspicion of metastatic disease from the specific primary site will help in achieving correct diagnosis and evaluation of the extension of the disease. Surgical resection, even enlarged parotidectomy with neck dissection, should be considered as a therapeutic option for exclusive location of the disease in the head and neck.

Inclusion body myopathy, Paget's disease of the bone and frontotemporal dementia: recurrence of the VCP R155H mutation in an Italian family and implications for genetic counselling

The acronym IBMPFD denotes a syndrome including inclusion body myopathy, Paget's disease of the bone (PDB) and frontotemporal dementia (FTD) as cardinal features, which is caused by missense mutations in the VCP gene. We studied the clinical characteristics and the histopathological features in two siblings and their mother who presented with adult-onset myopathy and presenile, rapidly progressive FTD. One sibling also showed PDB. Light and electron microscopy performed on muscle biopsies demonstrated degenerative changes with inclusion bodies and abnormal aggregates. Mutation analysis of the VCP gene on affected siblings revealed a heterozygous missense mutation (R155H) in a hot spot. This is the first Italian family with multiple individuals diagnosed as having IBMPFD and carrying the recurrent R155H mutation. The implications for genetic counselling were also discussed, with regard to the procedures that may be offered to families suffering from a multisystem disorder with high risk of cognitive decline.

Use of Haemostatic Agents and Glues during Laparoscopic Partial Nephrectomy: A Multi-Institutional Survey from the United States and Europe of 1347 Cases

OBJECTIVES

Laparoscopic partial nephrectomy (LPN) is a technically challenging procedure for the management of renal tumours. Major complications of LPN include bleeding and urine leakage. Haemostatic agents (HAs) and/or glues may reduce haemorrhage and urine leakage. We sought to examine the current practice patterns for urologists performing LPN with regard to HA use and its relationship with bleeding and urine leakage.

MATERIALS AND METHODS

A survey was sent via e-mail to urologists currently performing LPN in centres in the United States and Europe. We queried the indications for HA/glue usage, type of HAs/glues used, and whether concomitant suturing/bolstering was performed. In addition, the total number of LPNs performed, laparoscopic tools used to resect the tumour, tumour size, and tumour position were queried.

RESULTS

Surveys suitable for analysis were received from 18 centres (n=1347 cases). HAs and/or glues were used in 1042 (77.4%) cases. Mean tumour size was 2.8cm, with 79% of the tumours being defined as exophytic and 21% deep. The HAs and glues used included gelatin matrix thrombin (FloSeal), fibrin gel (Tisseel), bovine serum albumin (BioGlue), cyanoacrylate glue (Glubran), oxidized regenerated cellulose (Surgicel), or combinations of these. Sixteen centres performed concomitant suturing/bolstering. The overall postoperative bleeding requiring transfusion and urine leakage rates were 2.7% and 1.9%, respectively.

CONCLUSIONS

The use of HAs and/or glues is routine in most centres performing LPN. The overall haemorrhage and urine leakage rates are low following LPN. More studies are needed to assess the potential role of HAs and/or glues in LPN.

Diagnosis of Medullary Sponge Kidney by Computed Tomographic Urography

The diagnosis of medullary sponge kidney traditionally was established by means of intravenous pyelography. Beginning in the mid-1990s, intravenous pyelography rapidly was supplanted by computed axial tomography as the preferred imaging study for evaluating patients with renal stone disease. Conventional computed tomographic imaging has not been satisfactory for diagnosing medullary sponge kidney. The introduction of multidetector-row computed tomography in 1999 allowed radiologists to acquire images composed of elements allowing the creation of high-resolution 3-dimensional displays. Computed tomographic urography is an imaging technique that provides both cross-sectional displays and images of the contrast-filled renal collecting systems, ureters, and urinary bladder that are the equivalent of intravenous pyelography. We report a case of medullary sponge kidney diagnosed by means of 3-dimensional multidetector-row computed tomographic urography.

Positive margins in laparoscopic partial nephrectomy in 855 cases: a multi-institutional survey from the United States and Europe

PURPOSE

Open partial nephrectomy has emerged as the standard of care in the management of renal tumors smaller than 4 cm. While laparoscopic radical nephrectomy has been shown to be comparable to open radical nephrectomy with respect to long-term outcomes, important questions remain unanswered regarding the oncological efficacy of laparoscopic partial nephrectomy. We examined the practice patterns and pathological outcomes following laparoscopic partial nephrectomy.

MATERIALS AND METHODS

A survey was sent to academic medical centers in the United States and in Europe performing laparoscopic partial nephrectomy. The total number of laparoscopic partial nephrectomies, positive margins, indications for intraoperative frozen biopsy as well as tumor size and position were queried.

RESULTS

Surveys suitable for analysis were received from 17 centers with a total of 855 laparoscopic partial nephrectomy cases. Mean tumor size was 2.7 cm (+/-0.6). There were 21 cases with positive margins on final pathology, giving an overall positive margin rate of 2.4%. Intraoperative frozen sections were performed selectively at 10 centers based on clinical suspicion of positive margins on excised tumor. Random biopsies were routinely performed on the resection bed at 5 centers. Frozen sections were never performed at 2 centers. Of the 21 cases with positive margins 14 underwent immediate radical nephrectomy based on the frozen section and 7 were followed expectantly.

CONCLUSIONS

Early experience with laparoscopic partial nephrectomy in this multicenter study demonstrates oncological efficacy comparable to that of open partial nephrectomy with respect to the incidence of positive margins. The practice of intraoperative frozen sections varied among centers and is not definitive in guiding the optimal surgical treatment.

Atherosclerotic adult Moya-Moya disease in a patient with hyperhomocysteinaemia

Moya-Moya is a rare cerebrovascular occlusive disease characterized by bilateral stenosis or occlusion at the terminal portion of the internal carotid artery and abnormal vascular network at the base of the brain, named "moya-moya". In children, Moya-Moya disease usually presents with ischemic cerebrovascular events, mainly TIA or lacunar stroke, leading to mental deterioration. In adults, especially in females, it presents with intracranial haemorrhages. We describe the case of an adult patient with an atherosclerotic Moya-Moya disease which presented with a cerebral borderzone infarction.

Advanced Ureteroscopy: Wireless and Sheathless

BACKGROUND

The introduction of a new generation of flexible ureteroscopes significantly advanced the therapeutic and diagnostic efficacy of the instrument, allowing greater access to all aspects of the upper urinary tract and facilitating wireless ureteroscopy.

PATIENTS AND METHODS

Four hundred sixty consecutive upper urinary-tract procedures were performed utilizing the 7.5F actively deflectable, flexible ureteroscope. A prospective database of these procedures was maintained. The indications, access technique, complications, success rate of stone treatment, and access to lower-pole calices were evaluated. The accumulated clinical data were compared with a published database of 1000 consecutive flexible ureteroscopies.

RESULTS

A stent was in place or had recently been in place in 108 of the procedures (24%). Of the remaining 352 flexible ureteroscopic procedures, only 11% (52) required any form of ureteral dilation to facilitate ureteral access. Two hundred twenty seven procedures were performed in which no guidewire was required to place the flexible endoscope in the upper urinary tract (i.e., "wireless" ureteroscopy).

CONCLUSION

Wireless no-touch flexible ureteroscopy with the new flexible instruments is a feasible and safe technique for diagnostic and therapeutic procedures in most patients, irrespective of the location of the pathology, including the distal ureter. These ureteroscopes, with their exaggerated deflection, are ushering in a new era of endoscopic treatment of the upper urinary tract. Greater instrument deflectability and control can lead to shorter procedures and fewer treatment failures.

Open epididymal sperm aspiration (OESA): minimally invasive surgical technique for sperm retrieval

OBJECTIVES

Male infertility caused by irreparable obstructive azoospermia is widely treated with MESA (Microsurgical Epididymal Sperm Aspiration) or TESE (Testicular Sperm Extraction) or PESA (Percutaneous Epididymal Sperm Aspiration) followed by an Intracytoplasmatic Spermatozoa Injection (ICSI). For each procedures are claimed advantages and disadvantages. Aim of this work is to describe our technique (OESA) for sperm retrieval reporting the results.

METHODS

From 1998 to 2003 153 sperm retrieval procedures in azoospermic patients were performed. The technique consists in a small (1 cm.) surgical incision of scrotal wall under local or spinal anaesthesia. After inspecting the intrascrotal component to record the status of the epididymis and of the testicle, epididymal sperm aspiration was performed in the most appropriate site with 18 gauge needle. The aspirated spermatozoa were used immediately after aspiration not being permitted in our Institute cryopreservation. When no sperms were found TESE was performed.

RESULTS

In 78 cases aspiration from epididymis was successful (OESA). In the other patients (75) TESE was performed. Higher count of spermatozoa were retrieved in all cases of OESA. Pregnancy rate was 26.6% for OESA and 6.4% for TESE. No complications occurred.

CONCLUSIONS

This technique is very simple and easy allowing to obtain the advantages of microsurgical techniques (mainly choice of the most appropriate site of aspiration and immediate haemostasis if needed) with minimal invasivity (avoiding epididymal surgical incision). Moreover if OESA does not allow sperm extraction is possible to perform immediately TESE.