The neurosurgical outpatient clinic: comparison between accesses in public and private activities

BACKGROUND

Neurosurgical clinic assesses presence and extent of pathologies of central and peripheral nervous system or disorders affecting the spine, to identify most effective treatment and possible recourse to surgery. The aim of the study is to evaluate the appropriateness of request for a neurosurgical consult both in private and in public outpatient clinics.

MATERIALS AND METHODS

We collected and analyzed all the reports of outpatient visits of public and private clinic over a period between January and December 2018.

RESULTS

There were 0.62% real urgent visits in the public sector and 1.19% in the private sector (p = 0.05). Peripheral pathologies represented 12.53% and 6.21% of pathologies evaluated in public and private sector respectively (p < 0.00001). In addition, 15.76% of visits in public lead to surgery, while they represented 11.45% in private (p = 0.0003).

CONCLUSIONS

No study is available comparing accesses of patients in neurosurgical outpatient clinics. In public clinic, visits are booked as urgent on the prescription of the general practitioner: in reality, only 5% of these visits were really confirmed as urgent by the specialist. Peripheral pathologies are more frequent in public clinic, while cranial pathologies are more frequent in private one. Patients with cranial pathologies prefer to choose their surgeon by accessing private clinic.

Bleeding risk evaluation in cerebral cavernous malformation, the role of medications, and hemorrhagic factors: a case-control study

OBJECTIVE

Cerebral cavernous malformations (CCMs) are vascular lesions with an overall risk of rupture from 2% to 6% per year, which is associated with significant morbidity and mortality. The diagnostic incidence is increasing, so it is of paramount importance to stratify patients based on their risk of rupture. Data in the literature seem to suggest that specific medications, particularly antithrombotic and cardiovascular agents, are associated with a reduced risk of bleeding. However, the effect of the patient coagulative status on the cumulative bleeding risk remains unclear. The aim of this study was to assess the impact of different radiological, clinical, and pharmacological factors on the bleeding risk of CCMs and to assess the predictive power of an already validated scale for general bleeding risk, the HAS-BLED (hypertension, abnormal renal/liver function, stroke, bleeding history or predisposition, labile international normalized ratio, elderly, drugs/alcohol concomitantly).

METHOD

This was a multicenter retrospective observational study. The authors collected imaging, clinical status, and therapy data on patients with bleeding and nonbleeding CCMs. Univariate analysis and subsequent multivariate logistic regression were performed between the considered variables and bleeding or nonbleeding status to identify potential independent predictors of bleeding.

RESULTS

The authors collected data on 257 patients (46.7% male, 25.3% with bleeding CCMs). Compared with patients with nonbleeding lesions, those with bleeding CCMs were younger, less frequently had hypertension, and less frequently required antiplatelet drugs and beta-blockers (all p < 0.05). Bleeding lesions, however, had significantly higher median volumes (1050 mm3 vs 523 mm3 , p < 0.001). On multivariate analyses, after adjusting for age, history of hypertension and diabetes, and use of antiplatelet drugs or beta-blockers, lesion volume ≥ 300 mm3 was the only significant predictor of bleeding (adjusted OR 3.11, 95% CI 1.09-8.86). When the diagnostic accuracy of different volume thresholds was explored, volume ≥ 300 mm3 showed a limited sensitivity (36.7%, 95% CI 24.6%-50.0%), but a high specificity 78.2% (95% CI 71.3%-84.2%), with an area under the curve of 0.57 (95% CI 0.51-0.64).

CONCLUSIONS

This study supports previous findings that the CCM volume is the only factor influencing the bleeding risk. Antithrombotic agents and propranolol seem to have a protective role against the bleeding events. A high HAS-BLED score was not associated with an increased bleeding risk. Further studies are needed to confirm these results.

Patient specific Polymethyl methacrylate customised cranioplasty using 3D printed silicone moulds: Technical note

INTRODUCTION

Cranioplasty after decompressive craniectomy can be performed with several techniques and materials. With the common use of 3D printing, custom cranioplasty can be produced at affordable cost. Aim of this technical note is to describe our technique for producing patient specific Polymethyl methacrylate (PMMA) cranioplasty using 3D printed silicone moulds.

MATERIALS AND METHODS

We enrolled seven patients from January 2020 to June 2021 who required surgery for cranioplasty. The 3D printing was used to produce silicone moulds for defining the exact shape of the PMMA cranioplasty, according to the CT scan of the patient.

RESULTS

We performed seven procedures. The mean time of the surgery was 80 min. All cranioplasties perfectly matched the patient specific anatomy. No complications occurred.

CONCLUSIONS

Using 3D printed patient specific silicone moulds and PMMA resulted to be effective, with affordable costs and ensuring a good cosmetic result.

Automatic lung segmentation in COVID-19 patients: Impact on quantitative computed tomography analysis

Purpose

To assess the impact of lung segmentation accuracy in an automatic pipeline for quantitative analysis of CT images.

Methods

Four different platforms for automatic lung segmentation based on convolutional neural network (CNN), region-growing technique and atlas-based algorithm were considered. The platforms were tested using CT images of 55 COVID-19 patients with severe lung impairment. Four radiologists assessed the segmentations using a 5-point qualitative score (QS). For each CT series, a manually revised reference segmentation (RS) was obtained. Histogram-based quantitative metrics (QM) were calculated from CT histogram using lung segmentationsfrom all platforms and RS. Dice index (DI) and differences of QMs (ΔQMs) were calculated between RS and other segmentations.

Results

Highest QS and lower ΔQMs values were associated to the CNN algorithm. However, only 45% CNN segmentations were judged to need no or only minimal corrections, and in only 17 cases (31%), automatic segmentations provided RS without manual corrections. Median values of the DI for the four algorithms ranged from 0.993 to 0.904. Significant differences for all QMs calculated between automatic segmentations and RS were found both when data were pooled together and stratified according to QS, indicating a relationship between qualitative and quantitative measurements. The most unstable QM was the histogram 90th percentile, with median ΔQMs values ranging from 10HU and 158HU between different algorithms.

Conclusions

None of tested algorithms provided fully reliable segmentation. Segmentation accuracy impacts differently on different quantitative metrics, and each of them should be individually evaluated according to the purpose of subsequent analyses.

Giant Stone in Enterocystoplasty

A giant stone in enterocystoplasty is a very rare condition; only 5 cases have been reported in the literature. A 50-year-old female with an enterocystoplasty due to congenital myelomeningocele presented at our institution for an asymptomatic 10-cm bladder stone, incidentally detected during an imaging procedure for uterine fibroma. The patient was treated with a laparoscopic hysterectomy with bilateral annexectomy, neocystotomy and stone removal under general anesthesia. The case report and an accurate literature review are reported. The incidence, risk factors, pathophysiology and treatment options are analyzed.

Epidemiology and risk factors in urolithiasis

Stone formation in the urinary tract affects about 5-10% of the population in industrialized countries, although it is very rare in other countries such as Greenland or Japan. The high incidence and recurrence rate contribute to making the urolithiasis a serious social problem. Nowadays, urolithiasis must be considered a 'disease in evolution' for several reasons, such as epidemiological changes, evolution of the methods used for diagnosis, and the treatment and prophylaxis of the population considered 'at risk' of stone disease. Some features of stone disease have changed over the last few years due to many social, economical and cultural factors that are described here. The increased prevalence of small urinary calculi has brought about a change in clinical symptoms, with frequent episodes of renal-ureteral colic, persistent pain and hydronephrosis. Similarly, the presence of residual fragments after extracorporeal shock wave lithotripsy has induced a radical change in the management of small calculi through the use of mini-invasive surgical techniques.

MRI Post-vertebroplasty

PURPOSE

Percutaneous vertebroplasty (PVP), first described by Hervè Deramond in 1984, is an interventional procedure for the treatment of aggressive vertebral angioma. The aim of this study was to evaluate magnetic resonance imaging (MRI) patterns in the affected vertebrae before and after vertebroplasty by determining changes in signal intensity and size and distribution of bone cement within the vertebra at follow-up carried out at 1 week, 6 months and 12 months.

MATERIALS AND METHODS

Fourteen patients were examined using MRI, for a total of 41 treated vertebrae; MRI was performed with a 0.5-Tesla (T) superconductive magnet (SIGNA GE).

RESULTS

MRI patterns following vertebroplasty are mainly characterised by the signal produced by the areas surrounding the cement and by the cement itself. There is little effect on the size of the treated vertebra. Acrylic cement appears as an intraspongy focal area of T1 and T2 hypointensity that is mostly oval (34%) or rounded (26.8%); this appearance tends to become stable 6 months after treatment. The area surrounding the cement appears hypointense on T1 and hyperintense on T2, a likely expression of bone marrow oedema; this signal alteration tends to disappear gradually.

CONCLUSIONS

In pre- and post-vertebroplasty imaging, MRI is regarded as the reference standard for correct evaluation of both container and content. Awareness of cement changes over time and of the reaction of the surrounding bone tissue is crucial for correct assessment of post-vertebroplasty images.

Pathophysiology of Reno-Ureteral Colic

INTRODUCTION

Reno-ureteral colic presents with a complex of acute symptoms that usually indicate the presence of a stone in the collecting system, The aim of any treatment is pain relief, stone removal and preservation of kidney function. We focused our review on the pathophysiological aspects of reno-ureteral colic and, briefly, on its treatment.

MATERIALS AND METHODS

A complete overview of contemporary literature regarding reno-ureteral colic was performed by using MEDLINE and website on-line publications like EAU Guidelines.

RESULTS

Clinical presentation of reno-ureteral colic, of mechanisms of ureteral peristalsis and pathophysiology of renal colic is described. An overview of the available medical treatments is presented.

CONCLUSIONS

An accurate comprehension of the pathophysiology of reno-ureteral colic allows the physician to tailor the best treatment for each patient.

Prevalence, diagnosis and treatment of prostatitis in Italy: a prospective urology outpatient practice study

OBJECTIVE

To report a prospective, multicentre descriptive study designed to determine the prevalence of the diagnosis of prostatitis in male outpatients examined by urologists in Italy, and to further examine the diagnostic evaluation and treatment of patients identified with a clinical diagnosis of prostatitis.

PATIENTS AND METHODS

Between July 2001 and October 2001, 70 urologists, representing a cross-section of urological centres in Italy, counted and recorded the overall total of men reported in the clinic and that of patients diagnosed with prostatitis over a 5-week period. Data on demographics, previous diagnoses, symptoms, physical examination, laboratory data and therapy instituted were collected. Patients with a diagnosis of prostatitis completed questionnaires on symptom frequency and severity, and quality of life.

RESULTS

In all, 8503 patients were included in the primary outcome analysis; 1148 were identified with prostatitis (12.8%; mean age 47.1 years, range 16-83) with all age ranges equally represented, and 68% had had their first symptom within the last year. The most common presenting symptoms were severe, bothersome urinary frequency, obstructive voiding symptoms, perineal, suprapubic and penile pain or discomfort. The self-administered questionnaire confirmed that the most frequently reported and most severe symptoms at the time of evaluation were irritative voiding symptoms, perineal and suprapubic pain and discomfort. Over three-quarters of the patients were dissatisfied with their quality of life. While 98% of the patients had a digital rectal examination and expressed prostatic secretion was successfully recovered in 44%, < 3% of the patients had the traditional Meares-Stamey four-glass test. The most common treatment prescribed was drug therapy (not antibiotic).

CONCLUSION

The prevalence of a clinical diagnosis of prostatitis in urology outpatient practice in Italy was 12.8%. The prevalence, diagnosis, evaluation and treatment of prostatitis reported in this prospective study was very similar to that reported in other retrospective series from other countries.

Giant stone in a complete duplex ureter with ureterocele. A case report

We describe a case of a monolateral duplex system and a ureterocele containing a gigantic stone in a 65-year-old woman who presented with pyelonephritis without any previous history of urinary tract infections or stone disease. Stone removal and double left ureteroneocystostomy with plastic widening of a narrowed obstructive side were performed. The ureteral stone measured 10.5 cm in greatest diameter, weighed 85 g and contained calcium oxalates and phosphates. Three months after surgery, radiology (intravenous urography and cystography) showed left unobstructed upper and lower urinary tracts and the absence of vesicoureteral reflux. Urine culture was negative 3, 6 and 9 months after surgery.

Verrucous scrotal carcinoma in a patient with hypospadias: is there a possible association?

We report a case of a locally advanced verrucous scrotal cancer in a patient with hypospadias. Surgical excision was performed and no recurrence was noted with 14 months of follow-up. To our knowledge, this association has not been reported. Historically, scrotal carcinoma is occupation related, but none of the occupational predisposing factors was identified in this patient. This observation suggests that hypospadias and secondary chronic inflammation of the scrotal skin, caused by prolonged contact with urine, may contribute to an increased risk of verrucous carcinoma.

Cystic leiomyosarcoma of the kidney: an unusual clinical presentation

Primary sarcomas of the kidney are rare, accounting for 1-3% of all renal malignancies. We describe an unusual case of renal leiomyosarcoma in a 41-year-old white woman who presented with a large smooth mass, which was mobile to the overlying structures and which occupied the right hypochondria and flank. Radical nephrectomy was carried out and the patient is well, without symptoms of relapse, 1 year after surgery. Leiomyosarcomas of the kidney have an aggressive and rapidly progressive natural history, with 5-year survival rates of 29-36%. Size <5 cm, low histological grade, absence of lymph node metastases and radical surgical treatment are all associated with a better prognosis. Irradiation and chemotherapy do not appear to alter the clinical course.

The role of lomefloxacin in the treatment of chronic prostatitis

The choice of antimicrobial agents for treatment of prostatitis should be based on two factors: in vitro sensitivity of isolated pathogens and potential intraprostatic penetration of the molecule. Unfortunately, only a few antibiotic agents penetrate prostatic fluid which is the primary site of infection. Lomefloxacin, a once-daily difluoroquinolone, could play a central role in the therapy of prostatitis because it has sufficient liposolubility, low ionization (pKa), low protein binding, small molecular size, long serum elimination half-life and it can pass from interstital fluid across prostatic cells into the lumen. This study was carried out on 12 patients (mean age 65 years) with normal hepatic and renal function, divided into two groups of 6 subjects each. Lomefloxacin was administered for perioperative antisepsis at the dose of 400 mg orally once a day for 4 days. Serum and tissue were sampled in the two groups of patients 4 h (Group A) and 8 h (Group B) respectively after the last drug administration. Tissue penetration was higher than serum, with a T/S >2 in the prostatic capsule and seminal blister, and a T/S >1.6 in the adenomatous tissue, in both groups of patients. In addition, the prostatic tissue concentrations exceeded the MIC for the main pathogens usually involved in urogenital infections. Therefore, because of its pharmacokineitic and pharmacodynamic characteristics, lomefloxacin is proposed as an efficacious therapeutic option, even for the treatment of chronic prostatitis.

Molecular genetic alterations of c-myc oncogene in superficial and locally advanced bladder cancer

OBJECTIVE

Gene activation and altered expression of cellular proto-oncogene are important mechanisms implicated in initiation and development processes of human cancer. It has already been shown that c-myc oncogene is implicated in the control of cell proliferation, apoptosis and differentiation.

METHODS

We have determined the methylation status, the presence of genetic amplification and the presence of m-RNA overexpression of c-myc gene in 31 samples from patients with bladder carcinomas.

RESULTS

Our data demonstrated the presence of c-myc gene amplification only in 5 of 15 superficial bladder carcinomas (p < 0.05). On the other hand, we did not find statistical significant correlation between the methylation, expression of c-myc gene and the clinical-histopathological parameters. A significant correlation (p < 0.05) was found between the methylation pattern and m-RNA overexpression of c-myc oncogene.

CONCLUSION

We demonstrate aberrant c-myc gene status in human bladder cancer. This oncogene is altered at different levels in bladder carcinoma genesis and progression.

Intravesical migration of AMS 800 artificial urinary sphincter and stone formation in a patient who underwent radical prostatectomy

A patient who underwent placement of AMS 800 urinary sphincter for incontinence after salvage prostatectomy after radiation therapy failure, experienced urethral erosion of the cuff after 54 months. He was treated with cuff removal and prosthesis deactivation. Thirteen months later, a large bladder stone was removed transvesically, and it contained the reservoir. The remaining sphincter components were also removed. Patients with previous radiotherapy are particularly at risk for sphincter erosion, but intravesical displacement of the reservoir is a very uncommon complication.

Microsatellite alterations in superficial and locally advanced transitional cell carcinoma of the bladder

Recent studies described the existence of genetic instability associated with bladder carcinogenesis. Alterations at microsatellite loci constitute a recognized tumor marker of genome instability. A series of 21 transitional cell carcinomas of the bladder (10 superficial and 11 invasive carcinomas) was analyzed for the presence of alteration in 12 microsatellite loci, in order to detect the role of microsatellite instability in genesis and progression of human bladder cancer. Our preliminary results indicate a trend to presence of microsatellite instability (MI) in invasive and undifferentiated tumors compared to superficial and differentiated forms. Eight out of 11 T2-T4 tumors presented a number of altered microsatellite >/=2 compared to one out of 10 Ta-T1 bladder carcinomas (p=0.008). Moreover, 9 out of 15 (60%) G2-G3 tumors had significantly more unstable microsatellites than those differentiated (0 out of 6) (p=0.019). Our results provide an insight into the potential usefulness of microsatellite analysis of bladder carcinoma to better understand which neoplastic forms will evolve to invasive progression and indicate that pronounced MI may be associated with more aggressive bladder carcinomas.

New urethroplasty for treating anterior urethral stenosis

– Urethroplasties with free or pedicle preputial flaps are widely used in strictures of the spongy urethra. These techniques involve application of the preputial flap on the ventral surface of the urethra, with collapse of the spongy body and the frequent development of pseudodiverticula or urethroceles which are responsible for post-micturitional dribbling. The authors suggest a new urethroplasty for treating anterior urethral strictures, in which the free flap is applied dorsally and not ventrally, mechanically supported by the overlying spongy body and the underlying corpora cavernosa, and thus avoiding collapse of the flap. Thirty male patients with stenosis of the penile or bulbar urethra were treated with 2 different techniques using a free dorsal flap. Long-term results, with a mean follow-up of 34.5 months, were satisfying.

Retrospective evaluation of c-erbB-2 oncogene amplification using competitive PCR in collecting duct carcinoma of the kidney

PURPOSE

To evaluate retrospectively c-erbB-2 oncogene amplification in paraffin embedded specimens of collecting duct carcinoma of the kidney (CDC) with competitive polymerase chain reaction (PCR).

MATERIALS AND METHODS

Eleven CDC specimens were evaluated with a novel PCR procedure for oncogene amplification measurement, which provides sensitive and accurate results even in presence of low-quality DNA, unsuitable for Southern blot techniques.

RESULTS

c-erbB-2 oncogene amplification was present in 5 out of 11 cases (45%) with a number of copies ranging from 4 to 12. All patients presenting oncogene amplification decreased within one year, while 50% (3/6) of those without amplification are alive with a mean follow-up of 42 months.

CONCLUSIONS

The high incidence of c-erbB-2 oncogene amplification in CDC further characterizes this tumor as a separate entity from renal cell carcinoma, and shows some genetic characteristics in common with transitional cell carcinoma.

Cowper's gland duct cyst in an adult male. Radiological and clinical aspects

A 48-year-old man presenting with perineal pain, weak stream and dysuria was found to have a Cowper's gland duct cyst measuring 1.8 x 3.5 cm, which was investigated with retrograde and voiding urethrography, cavernosography and perineal MRI, which was the single most useful imaging technique. Treatment consisted in complete surgical excision, which allowed an anatomical reconstruction of the urethra. This condition is typical of the pediatric age group, and seldom diagnosed in adults.

Surgical treatment of bilateral large seminal vesicle cysts associated with unilateral renoureteral agenesis

A 26-year-old man presented bilateral cysts of the vesicles, larger on the right side, associated with agenesis of right kidney and ureter. Surgical treatment consisted of removal of the right cyst and volume reduction of the left one. The embryological aspects are discussed, together with the clinical findings and the treatment options.

Natural history of untreated idiopathic scoliosis after skeletal maturity

A total of 187 random cases of untreated idiopathic scoliosis, seen from a minimum of 15 to a maximum of 47 years after the end of growth, were reviewed. All curves increased after skeletal maturity (average progression: 0.4 degrees per year). Thoracic curves tend to progress more than lumbar, lumbar more than thoracolumbar, and thoracolumbar more than double major curves. Pain was present in 114 cases (61%) and appeared more frequently in women, after pregnancies, and with fatigue. Cardiopulmonary symptoms were present in 42 patients (22%), especially those with thoracic and thoracolumbar curves greater than 40 degrees. Psychologic disturbances were found in 35 cases (19%), mostly female patients with thoracic curves greater than 40 degrees. The cosmetic appearance of these patients at long-term follow-up was better compared with that at the end of growth, even though the curves progressed. Patients with decompensation of the trunk at the end of growth seemed to improve with time. In an unselected group of patients with severe curves a mortality rate of 17% was found, twice as much as in the Italian general population.

Removal of Harrington's distraction apparatus after vertebral arthrodesis

The author reviews 13 cases of vertebral arthrodesis for scoliosis, during the five years from 1977 to 1981, in which the Harrington distraction apparatus was removed. Contrary to opinions expressed in the literature, there were no technical difficulties or allied complications. Only in 4 cases was the arthrodesis area fully inspected, and then only to check the condition of the graft. In 9 cases the distraction apparatus was removed by a limited exposure of the extremities of the initial operation area.

Lumbar spondylolisthesis. Surgical reduction and stabilization by Harrington's technique

The author discusses the reduction and stabilization of lumbar spondylolisthesis by the posterior route according to Harrington's technique based on ten years experience since his first communication. The case histories, technique, and results are reported in eighteen cases treated during the ten years 1968-1977 at the Istituto Ortopedico Toscano, Florence, with some illustrative examples.

Multiple primary idiopathic scoliosis

This paper deals with a type of idiopathic scoliosis with more than two primary curves (three, four or five). These can be classified, together with double primary curves, under the general term "multiple primary idiopathic scoliosis", and should therefore replace "combined or double primary curves" in Schulthess' traditional classification. The author contends that the apparent rarity of multiple primary curves is due to inadequate observation, and discusses their etiology, clinical features, diagnostic criteria, natural history, prognosis and treatment.