The prevalence of TTR cardiac amyloidosis among patients undergoing bone scintigraphy

BACKGROUND

Radiolabeled bisphosphonates bone scintigraphy is highly sensitive in detecting transthyretin (TTR) cardiac amyloidosis; data on the true prevalence of cardiac involvement in TTR amyloidosis are lacking.

METHODS AND RESULTS

This retrospective observational, monocentric study aims to estimate the prevalence of positive bone scan suspect for TTR cardiac amyloidosis among an all-comers population who underwent a bone scintigraphy. ECG, echocardiography and clinical status of patients with unexpected cardiac uptake (Perugini score 2-3) who underwent bone scintigraphy with [99mTc]-HDP or [99mTc]-DPD at San Luigi Gonzaga University Hospital between January 2015 and May 2020 have been collected. The prevalence of bone scintigraphy suspect for cardiac involvement was 0.54% (23/4,228). The bone scintigraphy was mainly performed using [99mTc]-HDP (82.9%) and the dominant indication for the test was oncology in the 47.9% of cases. 8 Subjects had a history of neuropathy (34.8%) and 5 of carpal tunnel syndrome (21.7%). 11 Patients suffered a previous episode of heart failure (48%) while 5 patients (21.7%) were totally asymptomatic, without any sign or symptom before the bone scintigraphy making the nuclear examination crucial for an early diagnosis of TTR amyloidosis.

CONCLUSION

Bone scintigraphy allows suspecting TTR amyloidosis in a pre-clinical stage of the disease in an all-comers population of patients undergoing bone scintigraphy mainly for oncology reasons.

COVID-19 therapies and their impact on QT interval prolongation: A multicentre retrospective study on 196 patients

Background

SARS-CoV-2 infection has caused a global pandemic. Many of the medications identified to treat COVID-19 could be connected with QTc prolongation and its consequences.

Methods

Non-ICU hospitalized patients of the three centres involved in the study from the 19th of March to the 1st of May were included in this retrospective multicentre study. Relevant clinical data were digitally collected. The primary outcome was the incidence of QTc prolongation ≥ 500 ms, the main secondary outcomes were the Tisdale score ability to predict QTc prolongation and the incidence of ventricular arrhythmias and sudden deaths.

Results

196 patients were analysed. 20 patients (10.2%) reached a QTc ≥ 500 ms. Patients with QTc ≥ 500 ms were significantly older (66.7 ± 14.65 vs 76.6 ± 8.77 years p: 0.004), with higher Tisdale score (low 56 (31.8%) vs 0; intermediate 95 (54.0%) vs 14 (70.0%); high 25 (14.2%) vs 6 (30.0%); p: 0.007) and with higher prognostic lab values (d-dimer 1819 ± 2815 vs 11486 ± 38554 ng/ml p: 0.010; BNP 212.5 ± 288.4 vs 951.3 ± 816.7 pg/ml p < 0.001; procalcitonin 0.27 ± 0.74 vs 1.33 ± 4.04 ng/ml p: 0.003). After a multivariate analysis the Tisdale score was able to predict a QTc prolongation ≥ 500 ms (OR 1,358 95% CI 1,076–1,714p: 0,010). 27 patients died because of COVID-19 (13.7%), none experienced ventricular arrhythmias, and 2 (1.02%) patients with concomitant cardiovascular condition died of sudden death.

Conclusions

In our population, a QTc prolongation ≥ 500 ms was observed in a minority of patients, no suspected fatal arrhythmias have been observed. Tisdale score can help in predicting QTc prolongation.

Riparazione Trans-Vaginale di Fistola Neovescico-Vaginale

Introduction

Neobladder vaginal fistula is a known complication after cystectomy and orthotopic neobladder in women. The exact incidence is still unknown, even if in some of the largest series is reported in about 5% of female patients. We present our personal experience with a case of neobladder vaginal fistula.

Methods

A fifty-year old woman affected by T2G3 bladder cancer underwent radical cystectomy and orthotopic neobladder in December 2007. Definitive pathological examination revealed pT3aN0G3 urothelial cancer with squamous aspects. Two cycles of neoadjuvant chemotherapy were administered before cystectomy. Three weeks after cystectomy, a retrograde cystography revealed a fistula between vagina and neobladder. At first, the patient was treated conservatively, keeping the urethral catheter for two months. Cystographies, repeated every month, recorded a reduction in size of the fistula but not the complete closure. A surgical correction was planned. Preoperative cystoscopy showed the neobladder opening of the fistula on the posterior wall. Then a transvaginal approach with fistula excision and a two layer cross suture were performed.

Results

At the cystography performed 1 month after surgical repair no fistula was detected, and the patient was completely dry. At 3 months follow-up the patient was completely dry.

Conclusion

The development of a neobladder-vaginal fistula is a significant, even if infrequent, complication after cystectomy. In our case, we performed a transvaginal approach without tissue interposition, with good results. Such procedure is easy and effective and, in our opinion, can be tempted as first line surgical treatment.

A high-throughput assay for the detection of Tyr-phosphorylated proteins in urine of bladder cancer patients

BACKGROUND

Bladder cancer has the peculiarity of shedding neoplastic cells and their components in urine representing a valuable opportunity to detect diagnostic markers. Using a semi-quantitative method we previously demonstrated that the levels of Tyr-phosphorylated proteins (TPPs) are highly increased in bladder cancer tissues and that soluble TPPs can also be detected in patient's urine samples. Although the preliminary evaluation showed very promising specificity and sensitivity, insufficient accuracy and very low throughput of the method halted the diagnostic evaluation of the new marker. To overcome this problem we developed a quantitative methodology with high sensitivity and accuracy to measure TPPs in urine.

METHODS

The Immobilized Metal Affinity Chromatography (IMAC) was miniaturized in a 96 well format. Luminescence, visible and infrared fluorescence antibody-based detection methods were comparatively evaluated.

RESULTS

Due to their low abundance we evidenced that both phosphoprotein enrichment step and very sensitive detection methods are required to detect TPPs in urine samples. To pursue high throughput, reproducibility and cost containment, which are required for bladder cancer screening programs, we coupled the pre-analytical IMAC procedure with high sensitive detection phases (infrared fluorescence or chemiluminescence) in an automated platform.

CONCLUSIONS

A high throughput method for measuring with high sensitivity TPP levels in urine samples is now available for large clinical trial for the establishment of the diagnostic and predictive power of TPPs as bladder cancer marker.

GENERAL SIGNIFICANCE

The new assay represents the first quantitative and high throughput method for the measurement of TPPs in urine.

[Retroperitoneoscopic nephropexy]

INTRODUCTION

Nephroptosis has been defined as renal descent of 5 or more cm on orthostasis. This disease is more frequent in young and slim women. The patient complains pain in upright position,that regress lying down. The therapy consists of surgical treatment. We report the case of a woman treated with retroperitoneoscopic nephropexy.

METHODS

We present the case of a 25-years old woman, affected by lumbar pain in upright position for about 1 year. Ultrasound scan of the abdomen and RX-KUB did not show hydronephrosis nor stones. Both an orthopedic examination and a spinal MRI excluded bone or muscular diseases. Intravenous pyelography and diuretic isotope renography in upright position revealed a renal descent of more than 5 cm, without obstruction of upper urinary tract. The patient underwent a renal color doppler imaging, that showed reduction of right kidney resistive index in upright position. The patient underwent a right retroperitoneoscopic nephropexy. After complete dissection of the perirenal fat from the kidney, three nonabsorbable sutures were placed between the posterior renal capsule and the psoas muscle.

RESULTS

No blood loss nor peri-operative complications have been observed. One month after the procedure, the patient did not complain any pain. Renal color doppler, performed one month after the nephropexy, showed a normalization of resistive index.

CONCLUSIONS

Symptomatic nephroptosis is a disease that has been questioned in the past. Nowadays, the modern imaging and functional examination available allow to identify the “true”cases of symptomatic nephroptosis. The treatment with retroperitoneoscopic nephropexy is an easy and effective procedure.

[Avulsion of the penile skin: a conservative approach]

INTRODUCTION

Skin avulsion of male genital is a rare urological emergency. Although not life-threatening such lesions are both physically and psychologically traumatic. If poorly managed in the acute setting, these injuries may result in long-term problems or permanent disabilities.

METHODS

A 58 year-old male patient was admitted to the Emergency Department of our hospital with a traumatic injury of the penis, caused by a bike trauma. At the inspection, a rather complete degloving of penis and a tear in scrotal skin with no involvement of testes were observed. The skin was completely detached, out of the penis, but for a small flap at the peno-scrotal angle. After a careful cleaning, the penis was covered again with the skin attached to peno-scrotal angle through multiple circumferential sutures.

RESULTS

A complete cover of the defects was obtained with one-step surgery. The patient was treated with broad spectrum of antibiotics for 1 month. No infections occurred. The patient was discharged from hospital after 5 days. After 3 months from trauma, the patient is able to achieve sexual intercourse, with normal erectile function, no painful erections and no penile recurvatum.

CONCLUSIONS

Traumatic skin avulsion of penis is a rare condition; the best aesthetic and functional results depends on the choice of the proper treatment. Conservative approach in selected cases can provide good results both aesthetically and functionally.

Proposta di Follow-Up del Paziente con Neovescica Ortotopica

Today, the most widely employed “solution” after radical cystectomy is bladder substitution through the creation of an othotopic neobladder. Many kind of othotopic neobladders have been proposed and employed and, during the last 20 years, we have observed a continuous improvement of such techniques. Nevertheless, notwithstanding these technical improvements, patients with orthotopic neobladder can still report many various complications. Thus, a specific “functional” follow-up is mandatory; “functional” follow-up should be associated and integrated to oncological follow-up that these patients usually undergo. Functional follow-up should be lifelong.

[Proposal for a follow-up of patients with orthotopic neobladder]

Today, the most widely employed “solution” after radical cystectomy is bladder substitution through the creation of an orthotopic neobladder. Many kind of orthotopic neobladders have been proposed and employed and, during the last 20 years, we have observed a continuous improvement of such techniques. Nevertheless, notwithstanding these technical improvements, patients with orthotopic neobladder can still report many various complications. Thus, a specific “functional” follow-up is mandatory; “functional” follow-up should be associated and integrated to oncological follow-up that these patients usually undergo. Functional follow-up should be lifelong.

Avulsione della Cute Peniena: Un Approccio Conservativo

Introduction

Skin avulsion of male genital is a rare urological emergency. Although not life-threatening such lesions are both physically and psychologically traumatic. If poorly managed in the acute setting, these injuries may result in long-term problems or permanent disabilities.

Methods

A 58 year-old male patient was admitted to the Emergency Department of our hospital with a traumatic injury of the penis, caused by a bike trauma. At the inspection, a rather complete degloving of penis and a tear in scrotal skin with no involvement of testes were observed. The skin was completely detached, out of the penis, but for a small flap at the penoscrotal angle. After a careful cleaning, the penis was covered again with the skin attached to penoscrotal angle through multiple circumferential sutures.

Results

A complete cover of the defects was obtained with one-step surgery. The patients was treated with broad spectrum of antibiotics for 1 month. No infections occurred. The patient was discharged from hospital after 5 days. After 3 months from trauma, the patient is able to achieve a sexual intercourse, with normal erectile function, no painful erections and no penile recurvatum.

Conclusions

Traumatic skin avulsion of penis is a rare condition; the best aesthetic and functional results depends on the choice of the proper treatment. Conservative approach in selected cases can provide good results both aesthetically and functionally.

Re-Biopsies of the Prostate after Endo-Magnetic Resonance Imaging (MRI) and Spectroscopy (MRS) in Patients with ASAP: Preliminary Results

Introduction e Objectives

There are some evidences that the combination of EndoMRI and MRS might be able to limit the number of iterative biopsies in patients with negative biopsies of the prostate and a still rising PSA. The aim of this study is to evaluate the possible role of EndoMRI/MRS in patients with ASAP.

Methods

From November 2005 to September 2008 we enrolled 28 consecutive patients diagnosed with ASAP at a TRUS-guided needle prostate biopsy. All patients underwent prostatic EndoMRI and MRS. A prostatic zone was classified as: suspicious for prostate cancer if low intensity signal was present on T2-weighted images and/or if the choline + creatine / citrate ratio was >0.86; equivocal or negative otherwise. A subsequent 12-core needle prostate biopsy was performed and supplementary biopsies were added in the suspicious zones. The results of MRI/MRS were then compared with histological findings.

Results

The combination of EndoMRI and MRS was suspicious for cancer in 70% of patients, equivocal in 23% and negative in 7%. Histological findings at re-biopsy included: prostate cancer in 35%, ASAP in 23%, BPH or prostatitis in 42%. In 78% of patients diagnosed with prostate cancer the combination MRI/MRS was suspicious and in 22% equivocal. In all patients the cancer was found in suspicious zones at MRI/MRS where targeted biopsies were performed.

Conclusions

The combination of EndoMRI and MRS proved to have a good sensitivity but a poor specificity in identifying a concurrent prostate cancer among patients with ASAP. The location of positive cores for prostate cancer was consistent with the suspicious zones at MRI/MRS.

Testis Sparing Microsurgery

The unexpected detection of non palpable hypoechoic testicular lesions has become more frequent thanks to the increased use of trans-scrotal ultrasound (US): patients are often asymptomatic and the objective examination reveals no palpable masses. The different diagnostic, therapeutic approaches vary from radical orchifunicolectomy to simple US follow-up, although the guidelines on the management of these lesions are not defined, yet. The article shows our series of patients with hypoechoic testicular lesions who underwent surgical exploration, with the aid of the operating microscope and histologic test.

Materials and Methods

6 patients in total underwent microsurgical exploration of non palpable hypoechoic testicular lesions, from April 2003 to December 2004.

Results

4 out of the 6 cases were a left-sided testicular lesion, whereas the 2 remaining cases revealed a right-sided lesion [hypoechoic areas mean size = 3.9 mm (range 2.5 – 16)]. The lesions in all patients could be easily identified and successfully excised thanks to the microsurgical technique. The intraoperative frozen section examination (FSE) showed a benign lesion in 5 cases and an intratubular germ cell neoplasia (ITGCN) in one. Patient with ITGCN underwent radical orchiectomy. The final histological analysis confirmed the frozen section examination report for all the 6 cases. Patients were clinically and ultrasonographically evaluated with a mean follow-up of 15 months. No complication occurred.

Conclusion

Microsurgical exploration of the testis combined with FSE represents a safe, effective and reliable technique in case of non palpable hypoechoic testicular lesions. This approach leads to significant advantages and should be considered especially in patients with a solitary testis or presenting bilateral lesions, and wishing to father a child.

Modified Nesbit Procedure: An Easy and Effective Technique

This paper reports the results of a modified Nesbit procedure, designed to increase precision and to simplify the correction of penile congenital or acquired curvatures.

Materials and Methods

58 patients in total were considered candidates for surgical treatment of penile curvature, and underwent a modified corporoplasty procedure involving plication suture on the convex aspect of the penis before tunica albuginea resection. Hospital records and follow-up data were retrospectively reviewed.

Results

37 patients were affected by congenital penile curvature (mean angle: 48 degrees - range 40 to 90); they reported difficult vaginal penetration. Another 21 patients suffered from Peyronie's disease, with mean angle penile deformity of 48 degrees (range 40 to 60), but no hourglass deformity or hinge effects. All patients had spontaneous and full erections. Mean operative time ±SD was 62±15 minutes. No intra-operative complications were reported. Penile curvature was completely corrected in all cases. Neither residual curvatures nor hypercorrections were recorded. Regarding erectile function, which was evaluated in the Peyronie's disease group, pre-operative average International Index of Erectile Function-5 score was 17.83±4.17, whereas post-operatively it was 19±4.63 (p >0.036). With regard to overall satisfaction, 3 patients (5%) with Peyronie's disease were unsatisfied.

Conclusions

This modified corporoplasty procedure has resulted in an improved straightening outcome thanks to the possibility of performing tunica albuginea excision only after the surgeon has made and verified the exact correction in real time. A slight but statistically significant improvement in erectile function was observed in patients with Peyronie's disease.

Predictive model for reduction of Escherichia coli during acetic acid decontamination of chicken skin

AIMS

The response surface methodology was used to evaluate the effect of operating variables (acetic acid concentration, spraying time and temperature) on the reduction of Escherichia coli populations on poultry breast skin in a laboratory showering process, as well as to identify the best conditions that are required to develop this operation.

METHODS AND RESULTS

Skin samples were inoculated with a 24-h E. coli culture and afterwards treated according to experimental design under selected acetic acid concentration, spraying time, and solution temperature. The E. coli reduction model was significantly affected by the acetic acid concentration and spraying time (P < or = 0.05 and < or =0.01), while temperature did not show a significant effect (P > 0.05).

CONCLUSION

The predictive model obtained was validated through additional confirmatory experiments and showed to be adequate, and it could be used as an approach to optimize the acetic acid spray washes during poultry carcasses processing.

SIGNIFICANCE AND IMPACT OF THE STUDY

The use of acetic acid washes in the processing of poultry does not have the capability of eliminating E. coli populations from carcasses. However, significant reductions in the initial load could be achieved.

Detection of Circulating Prostate Cancer Cells Using Real Time Rt – Pcr: Our Experience

PCR (Polymerase Chain Reaction) has revolutionized molecular genetics and continues to be applied to many fields of medicine and biology. We used nested real time RT – PCR to detect circulating prostate cells in patients affected by prostate cancer, in order to evaluate a possible clinical role of this technique. We present our initial experience.

Bilateral adrenalectomy for Cushing's syndrome: a comparison between laparoscopy and open surgery

We report our experience with bilateral adrenalectomy for treatment of Cushing's syndrome and we compare the outcome of laparoscopy with open surgery in terms of effectiveness and safety. A series of 23 patients underwent bilateral adrenalectomy for treatment of Cushing's syndrome [Cushing's disease in 16, ectopic ACTH syndrome in 2, and ACTH-independent macronodular adrenal hyperplasia (AIMAH) in 5 cases]. From 1993 to 1996, all patients were treated using an open approach (Group A), while from 1997 all patients were treated using a transperitoneal laparoscopic approach (Group B). The comparison between the 2 groups was performed considering patients characteristics, operative times, blood losses, intraoperative and post-operative complications, analgesic consumption, post-operative hospital stay and recovery. Open surgery was performed in 10 patients and laparoscopy in 13 patients. No significant difference was recorded between the two groups as to patients' characteristics and complications. Mean operative time was significantly increased in Group B, while post-operative hospital stay was significantly longer in Group A. Laparoscopic bilateral adrenalectomy can be safely and effectively employed to treat Cushing's syndrome. However, long operatives times may represent a limitation especially in high risk patients.

Y-neobladder: an easy, fast, and reliable procedure

OBJECTIVES

To describe the operative technique of a new, Y-shaped, ileal neobladder and report the clinical and functional outcomes to add a contribution to the most discussed issues about orthotopic neobladders, in particular related to the problem of the prevention of strictures of ureteral-neobladder anastomoses.

METHODS

Between January 1999 and June 2002, 50 patients (41 men and 9 women) underwent radical cystectomy and Y-shaped orthotopic neobladder reconstruction. The following parameters were considered: operative time, complications, and functional outcomes (evaluated with voiding chart and a questionnaire analyzing continence). Urodynamic studies were performed in the first 20 patients.

RESULTS

The operative time for neobladder reconstruction was 15 to 20 minutes. No severe complications or significant metabolic complications were recorded. Only 1 case of unilateral stricture of the ureteral-neobladder anastomosis was recorded (1% of renal units); the stricture was easily treated with a retrograde endoscopic approach. Daytime and nighttime continence was good or satisfactory in 90% and 85% of patients, respectively. One year after surgery, the average maximal neobladder capacity was 390 mL, and the average pressure at maximal capacity was 15 cm H2O.

CONCLUSIONS

The ileal Y-shaped orthotopic neobladder had good functional outcomes comparable to most popular orthotopic neobladders. Moreover, the surgical technique of the Y-neobladder is easy, rapid, and reliable. In particular, the Y-neobladder seemed to reduce, in our experience, the occurrence of strictures at the ureteral-neobladder anastomosis, because it permits a perfectly aligned anastomosis without mobilization of the ureters.

Renal Cell Cancer in Presacral Ectopic Kidney: Preoperative Diagnostic Imaging Compared to Surgical Findings

The occurrence of renal cell carcinoma is an exceptional phenomenon in an ectopic kidney. We describe a patient with renal cell cancer of the pelvic kidney who underwent radical nephrectomy at our institute. Preoperatively the patient underwent paramagnetic medium-enhanced magnetic resonance that provided an accurate description of the ectopic renal vessels. During surgery the anatomy of the vessels appeared exactly as described by the MR examination. Histological examination revealed a pT2N0GIV renal cell cancer. Nine months later the patient underwent control examinations, and no delayed complications had occurred. In our experience magnetic resonance provided an exact description of the ectopic kidney vascularization as confirmed by the surgical findings. Preoperative knowledge is important both for the surgeon during the dissection of the vessels and to plan correct lymphadenectomy on the basis of the vessel source identified at imaging.

Early Prostate Cancer: Watchful Waiting

Prostate cancer is, today, the most frequent cancer and the second most frequent cause of death for cancer in USA. The watchful waiting approach, that has been traditionally proposed by urological communities in Northern Europe, is still matter of debate. The following review will consider the clinical studies published in Literature and will discuss the most controversial issues.

Evolving standard in the treatment of coronary artery disease. Drug-eluting stents

Coronary stent implantation is the predominant method of percutaneous coronary interventions (PCI). This is to be attributed to the ease of use beside the better short and long term clinical outcome as compared to balloon angioplasty. Nevertheless, improvements in operator skill and stent technology together with better use of adjunctive pharmacological therapy have contributed to the improvement in clinical outcome. However, the main limitation of coronary stenting is still represented by in-stent restenosis (ISR) with an estimated rate of 17-32%. Thus, compared to coronary bypass surgery, the major adverse cardiac events following stent implantation are still higher and mainly represented by the need for re-intervention. The advent of drug eluting stents (DES) has led the experts to predict that with DES there will be little or no difference between PCI and coronary bypass surgery in terms of long-term outcome leading to a further expansion of indications. The clinical trial programs of the 2 available DES for clinical use (sirolimus-eluting stent, SES - Cypher and paclitaxol-eluting stent - Taxus) have been able to demonstrate the safety and clinical efficacy of both. Nevertheless, off-label use in patients on high risk for restenosis confirmed these data. At least for SES as was demonstrated by 2 "real world" registries. Thus, the introduction of DES represents a remarkable evolution for new standards in coronary artery disease treatment and offers hope to those patients considered to be "high risk" such as diabetics, patients with ISR, diffuse disease in whom surgery was previously the only therapeutic option. This paper will discuss the main results of the clinical trial programs of the DES (mentioned above) available for clinical use in the present time and analyze technical and procedural aspects which could affect long term outcome.

Sequential transurethral resection of the prostate and laparoscopic bladder diverticulectomy: comparison with open surgery

OBJECTIVES

To compare our experience with transurethral resection of the prostate and sequential laparoscopic bladder diverticulectomy with a previous series of combined open bladder diverticulectomy and transvesical prostatectomy.

METHODS

We compared the data of 10 consecutive patients (group 1) who underwent sequential transurethral resection of the prostate and transperitoneal laparoscopic bladder diverticulectomy and 13 consecutive patients (group 2) who underwent traditional combined open bladder diverticulectomy and transvesical prostatectomy. The following parameters were considered: size and position of the diverticulum, transrectal ultrasound adenoma volume, operative time, postoperative hemoglobin variations, analgesic requirement, complications, postoperative hospital stay, and urinary flowmetry.

RESULTS

No statistically significant differences existed between the two groups either for diverticulum size (6.8 versus 7.2 cm) or diverticula position. A significant difference was observed in the operative time (247 minutes for group 1 versus 136 minutes for group 2, P <0.0001), mean postoperative hemoglobin decrease (2.6 g/dL for group 1 and 3.9 g/dL for group 2, P = 0.001), analgesic requirement (1.3 ampoules of buprenorphine cloritrate for group 1 versus 1.8 ampoules for group 2, P = 0.45), and postoperative hospital stay (3 days for group 1 versus 9.6 days for group 2, P <0.0001). No statistically significant difference was recorded for control flowmetry. No intraoperative complications were recorded for the two groups.

CONCLUSIONS

In our series, sequential transurethral resection of the prostate and transperitoneal laparoscopic diverticulectomy for large diverticula proved to be a safe, effective, and minimally invasive procedure, despite the longer operative times compared with transvesical prostatectomy and open bladder diverticulectomy.

Does adrenal mass size really affect safety and effectiveness of laparoscopic adrenalectomy?

OBJECTIVES

To evaluate the effectiveness and safety of laparoscopic adrenalectomy with regard to adrenal mass size, as well as to consider its clinical and pathologic patterns. Laparoscopy is today considered the first-choice treatment of many adrenal diseases, although its use is still controversial for large adrenal masses and incidentally found adrenal cortical carcinoma.

METHODS

A total of 125 patients underwent lateral transperitoneal laparoscopic adrenalectomy. The indications were either functioning or nonfunctioning adrenal masses, without any radiologic evidence of involvement of the surrounding structures. The correlation between the size and the operative times, estimated blood loss, incidence of intraoperative and postoperative complications, and length of hospital stay were studied with Pearson's correlation coefficient, Fisher's exact test, and the chi-square test. The analysis of variance test was used to evaluate any possible correlation between the size and clinicopathologic features and the results.

RESULTS

A slight correlation was observed between the size and operative time (P = 0.004), but no correlation was observed between the size and the other parameters. Statistical analysis showed a significant correlation between the clinicopathologic patterns (nonfunctioning benign adrenal masses, Conn's adenoma, Cushing's adenoma, pheochromocytoma, adrenal cortical cancer, and other tumor metastasis) and the operative time (P = 0.011), but not with the other parameters.

CONCLUSIONS

Laparoscopic adrenalectomy is also effective and safe for large lesions. The results of our series confirms that the risk of encountering an incidental adrenal cortical cancer is significantly increased for large lesions, and therefore, in these cases, additional attention is required to observe oncologic surgical principles.

Cortical-sparing laparoscopic adrenalectomy in a patient with multiple endocrine neoplasia type IIA

We describe the case of a patient affected by multiple endocrine neoplasia type IIA with a new diagnosis of an asymptomatic right pheochromocytoma. The patient underwent laparoscopic adrenalectomy with adrenal sparing. The removal of the tumor was successful with preservation of about one third of the adrenal gland. At the time of the last follow-up, the patient is well with partial hypoadrenalism without replacement therapy. The limitations to cortical-sparing adrenalectomy imposed by traditional open surgery (small tumor with peripheral location) can be reconsidered using the laparoscopic approach. Laparoscopic cortical-sparing adrenalectomy should become the gold standard for treatment of bilateral pheochromocytoma. The advantages of this technique are its efficacy and its reduced invasiveness with a low rate of complications either during the operation or in the postoperative period. Moreover, the preservation of a portion of the adrenal cortex may prevent the need for a life-long steroid replacement therapy.

Drug-eluting stent: the emerging technique for the prevention of restenosis

Percutaneous coronary interventions (PCI) have surpassed coronary artery bypass grafting as the most common means for treating coronary artery disease, because of materials improvement, the use of stent and pharmacotherapy. However, despite the variety of mechanical techniques such as dilatation, debulking or conventional stent implantation, the incidence of restenosis on short and mid-term follow-up is still representing an important limitation to PCI. Restenosis is mainly due to elastic recoil, negative vessel remodelling and neointimal proliferation, as a response to vessel injury induced by angioplasty devices. The use of conventional stents has provided an efficient method to avoid elastic recoil and negative vessel remodelling, thus partially reducing restenosis as compared to conventional balloon dilatation. However, neointimal proliferation (biological vessel response to injury caused by stent implantation) is not affected by stenting technique. Thus, the extensive use of coronary stent, even in complex lesions, have produced again a "new" disease: the in-stent restenosis especially in some patients' subset (diabetics) or in some lesion subset (bifurcations, long lesions, small vessels, total occlusions, diffuse disease). Therefore, the main target of today's interventional cardiologists is to resolve this problem. The combination between mechanical control of elastic recoil and negative remodelling (stent) and the control of neointimal proliferation - biological response to vessel injury - (antiproliferative drugs) is the emerging approach against restenosis. This emerging approach consists in using the stent as drug carrier to the target site. Local delivery of antiproliferative or immunosuppressive agents using a drug-coated stent is supposed to inhibit in stent restenosis. The first antiproliferative agents being used successfully in clinical trials are sirolimus and paclitaxel and, so far, the data available of these trials demonstrated a marked reduction of restenosis using sirolimus- and paclitaxel-coated stents as compared to conventional stents. However, many questions are still to be answered and several other clinical trials with drug-eluting stents are ongoing, evaluating safety and efficacy of sirolimus and paclitaxel in a larger number of patients and in different subset of coronary lesions type and morphology. Based on the very impressive results available at the present time, we can expect, in the very near future, remarkable changes in our clinical practice and the beginning of a new "era" of interventional cardiology.

Role of adjunctive medical therapy with nifedipine and deflazacort after extracorporeal shock wave lithotripsy of ureteral stones

OBJECTIVES

To increase the success rate of the first treatment of ureteral stones through extracorporeal shock wave lithotripsy (ESWL), we tested the efficacy of a medical therapy with nifedipine and deflazacort administered to patients who had undergone ESWL for ureteral stones.

METHODS

This prospective study lasted from October 1998 to September 2000 and involved 80 patients. All the patients underwent ESWL with Sonolith 4000+. The patients were randomly divided into two groups: 40 patients (group 1) received an "adjunctive" treatment with oral medical therapy (nifedipine and deflazacort); the other 40 patients (group 2) were used as the control group.

RESULTS

Complete fragment expulsion occurred in 30 (75%) of the 40 patients of group 1 and in 20 (50%) of the 40 patients of group 2 at the endpoint. A statistically significant difference was observed in the stone-free rate (P = 0.02). Concerning the symptomatic therapy, the average diclofenac use was 37.5 mg per patient in group 1 and 86.25 mg per patient in group 2 (P = 0.02).

CONCLUSIONS

The results of this study have shown the role that adjunctive medical therapy with nifedipine and deflazacort given after an ESWL procedure can play in increasing the success rate of ureteral stone treatment. Furthermore, these results would suggest that adjunctive medical therapy can reduce total analgesic consumption after the ESWL procedure.

Transperitoneal laparoscopic adrenalectomy: experience in 72 procedures

PURPOSE

To evaluate the safety and effectiveness of transperitoneal laparoscopic adrenalectomy for a variety of adrenal diseases.

PATIENTS AND METHODS

Seventy-two patients underwent laparoscopic adrenalectomy from January 1995 until March 1999. The indications for the treatment were limited to either functioning or nonfunctioning adrenal masses without radiologic evidence of involvement of the surrounding tissues. The indication for bilateral adrenalectomy was Cushing's disease after the failure of other therapies or Cushing's syndrome secondary to ectopic ACTH secretion without the discovery of a primary neoplasm.

RESULTS

Thirty-five of the adrenalectomies were performed on the left side and 33 on the right side, and 4 were performed bilaterally. The right-sided procedures required a mean operating time of 130 minutes (range 85-200 minutes), the left-sided procedures required a mean operating time of 140 minutes (range 95-200 minutes), and the bilateral procedures required a mean operating time of 240 minutes (range 210-290 minutes). A conversion from laparoscopy to laparotomy was necessary for 3 patients (4%). Intraoperative complications were reported in 6 patients (8%). Postoperative complications likewise occurred in six patients.

CONCLUSIONS

These procedures proved to be safe and able to remove the majority of either functioning or nonfunctioning benign adrenal masses. Some controversy remains regarding the safety of laparoscopic adrenalectomy for large lesions and the safety of bilateral laparoscopic adrenalectomy because of bleeding risks, anesthetic risks, and long operative times. The effectiveness of laparoscopic adrenalectomy for nonfunctioning adrenal masses with histologic findings of carcinoma has not yet been proved.

[Pelvic ultrasound monitoring of lymphocele in patients treated with radical prostatectomy]

Pelvic lymphoceles, occurred in patients undergone radical retropubic prostatectomy, are believed to increase the risk of deep venous thrombosis and so thromboembolic complications. The authors' aim is to evaluate the usefulness of pelvic ultrasonography in the diagnosis and in the possible early treatment of pelvic lymphoceles. Fifty-eight patients undergone radical prostatectomy and pelvic lymphadenectomy, between January '98 and December '99, underwent a pelvic ultrasonography in VII post-operative day. When a symptomatic or large (over 5 cm) lymphocele was found, it was treated with ultrasound (US) guided drainage. In the study, the following parameters were considered: lymphocele occurrence, size, location and treatment and thromboembolic complication. Statistical analysis was carried out with Fisher's exact test. Pelvic US showed a lymphocele in 23 out of 58 (40%) patients. Mean size was 5 cm. Deep venous thrombosis occurred in 4 patients, all with pelvic lymphoceles. No thromboembolic complications were recorded. In our experience, pelvic ultrasound has shown to be an easy e reliable tool for diagnosis and percutaneous treatment of pelvic lymphoceles.

Effectiveness of nifedipine and deflazacort in the management of distal ureter stones

OBJECTIVES

To evaluate the effectiveness of medical therapy during watchful waiting in patients with distal ureter stones.

METHODS

Ninety-six patients with radiopaque stones located in the distal tract of the ureter and with stone sizes of 1 cm or smaller were involved in the study. The patients were randomly divided into two groups. Group A (n = 48) received oral treatment with 30 mg of deflazacort daily (maximum 10 days) plus 30 mg of slow-release nifedipine daily (maximum 4 weeks). Group B (n = 48) underwent a wait-and-watch approach. Both groups of patients were allowed to use diclofenac on demand. Statistical analyses were carried out using Student's t test, the chi-square test, and Fisher's exact test.

RESULTS

The average stone size was 5.8 +/- 1.8 mm for group A and 5. 5 +/- 1.4 mm for group B. No statistically significant difference was found in stone size. Stone expulsion was observed in 38 (79%) of 48 patients in group A and in 17 (35%) of 48 patients in group B. The average expulsion time was 7 days (range 2 to 10) for group A and 20 days (range 10 to 28) for group B. A statistically significant difference was observed in both the expulsion rate and the expulsion time (P <0.05). The mean amount of sodium diclofenac used was 15 mg per patient for group A and 105 mg per patient for group B (P <0.05).

CONCLUSIONS

The medical treatment proved to be effective and safe, as demonstrated by the increased stone expulsion rate, decreased expulsion time, and reduced need for analgesic therapy.

What is the role of ultrasonography in the follow-up of adrenal incidentalomas? The Gruppo Piemontese Incidentalomi Surrenalici

OBJECTIVES

The incidental discovery of an adrenal mass has become a frequent finding because of the increased use and technical improvement of computed tomography (CT) and magnetic resonance imaging. The approach to the investigation of these masses is ill-defined, and unequivocal guidelines for their management are lacking. The first problem concerns the distinction between malignant masses requiring surgery and the more frequent benign masses. In the case of a benign mass, an additional problem is the method of follow-up, considering cost, discomfort to the patient, and the consequences of false-positive results. The aim of this study was to evaluate the possible role of ultrasonography (US) in the follow-up of incidentally discovered adrenal masses.

METHODS

Two hundred eight cases of adrenal incidentalomas consecutively diagnosed in Piedmont, Italy from 1989 to 1996 and collected for a retrospective multicenter analysis were used. The US and CT characteristics of the adrenal masses were compared in patients who underwent surgery.

RESULTS

Most patients were 50 to 69 years of age; women were predominantly affected. CT was more reliable than US in detecting the malignant nature of an adrenal lesion. The mass diameter measured by US and CT was clearly correlated.

CONCLUSIONS

At diagnosis, US was not sufficiently reliable in evaluating adrenal mass characteristics. Considering the high correlation between US and CT size estimation, in the case of a presumably benign lesion, US could be considered a simple, economic, and effective method of follow-up, with CT limited to evaluating masses growing over time (CT remains mandatory at diagnosis).

Treatment of simple renal cysts by percutaneous drainage with three repeated alcohol injection

OBJECTIVES

This study sought to show the effectiveness and safety of three repeated alcohol injections for the treatment of simple large renal cysts.

METHODS

From September 1991 to December 1997 we treated 72 renal cysts. The cyst was drained with an 8F mono J stent. Ninety-five percent sterile ethanol was injected into the cyst and left in place for 20 minutes. Two repeat alcohol injections were performed every 24 hours. After the third alcohol injection, the catheter was removed. To avoid pain in the last 39 patients, 20 mL of 2% lidocaine hydrochloride was injected into the cyst for 15 minutes before the alcohol injections.

RESULTS

The follow-up period ranged from 8 to 83 months (mean 48). One patient underwent surgical intervention because of considerable bleeding in the cystic cavity that occurred after percutaneous drainage. In 1 patient in whom the cystic cavity communicated with the urinary tract, no alcohol injections were performed. After the repeated alcohol injections, the cystic cavity completely disappeared in 68 of the 70 treated cysts at first ultrasound examination. This result, observed at the first ultrasound control observation, remained unchanged during follow-up.

CONCLUSIONS

In our experience, percutaneous drainage with three repeated alcohol injections offers a high rate of success without the cost and morbidity associated with other procedures, such as operation or laparoscopy.

Transvaginal ultrasonography in the assessment of organic diseases of female urethra

The current investigation aimed to check the effectiveness of transvaginal ultrasonography in the diagnosis of organic urethral diseases, comparing its results with those of conventional examinations (physical examination, voiding cystourethrography, pelvic ultrasonography, cystourethroscopy). Transvaginal ultrasonography was performed in 560 female patients with recurrent cystitis, dysuria, or palpable masses and diagnosed the following urethral diseases: 25 diverticula, seven stenoses, three carcinomas, two leiomyomas of periurethral tissue, and one incomplete duplex urethra. In our study transvaginal ultrasonography proved to be the most reliable diagnostic tool among imaging methods used.

Clinical features of urinary tuberculosis today

Over the last few years an increase of tuberculosis in the urogenital forms has also been noted. The authors decided to investigate whether the clinical features of the disease have changed in time. Data taken from literature were compared with the case histories of the San Luigi Hospital from the last 5 years. At onset, symptoms have remained practically the same. Some data emerged, however, which have given food for thought: diagnosis was made on average 6–8 months after the first symptoms appeared and the lesions were often found in the advanced stage, thus requiring a greater number of radical and reconstructive operations.

Advances in bacteriological diagnosis

Microbiological diagnosis of urogenital tuberculosis, traditionally based on the results from bacterioscopy and cultures, may sometimes be insufficient apart from requiring a particularly long time (4–8 weeks). In an attempt to reduce the times of response and to improve sensitivity, new methods have been put forward using DNA probes in culture media (fast methods) and nucleic acid amplification systems (ultra-fast methods). The authors describe the various methods and report their experience using the fast (AccuProbe) and the ultra-fast methods (MTBDA). They still consider the culture examination as the gold standard, but times of response may be reduced (10–15 days) using the AccuProbe test. The ultra-fast methods MTBDA may be put to good use when there is a clinical and/or radiological suspicion of tuberculosis with a negative culture or in cases where a rapid differential diagnosis is necessary.

Tuberculosis epidemiology

A gradual return of tuberculosis has been noted in industrialised countries since the late eighties. The real world-wide trend of the disease is, however, still widely underrated, as shown by the discrepancy between the number of cases reported to the WHO and those estimated by the same on the basis of the annual risk of tuberculotic infections (ARTI). According to these calculations, it is forecast that by the year 2000 approx. 13,000,000 persons world-wide will have the disease. Also in Italy the disease has been on the increase since the late eighties and in 1995 the incidence rate estimated by the WHO was 18/100,000. In the last decade, however, the increase has been different for the various forms: 13% and 35% for pulmonary and extrapulmonary tuberculosis respectively. The causes contributing to this increase in western countries may be attributed to the decline in control programmes, migration from areas of high incidence and the spread of AIDS.

The effect of neonatal pinealectomy on the inhibitory actions of food restriction on vaginal opening and collagen aging in the rat

Long-term food restriction is known to inhibit development and aging in the rat. These actions may be mediated by the pineal hormone, melatonin, whose secretion is increased by food restriction. This mechanism was investigated by studying the effects of pinealectomy in ad libitum fed and food restricted rats of both sexes living under normal conditions of temperature (23 degrees C) and lighting 12 h light:12 h dark cycle) over a period of 400 days. Pinealectomies were performed at the age of 5 days. Pinealectomy did not affect the amount of food eaten per day. Vaginal opening occurred at age 35 days in ad libitum fed female rats and was delayed to 49 days (P < 0.001) in rats whose food intake was restricted by 35%, but only to 41 days (P < 0.001) if food restricted (FR) rats were pinealectomized (Px). The inhibitory effect of food restriction on body growth and tail tendon collagen fibre aging was the same in both intact and pinealectomized rats. At the conclusion of the study in middle age at 400 days, plasma melatonin levels 4 h into the dark cycle were higher in food restricted than in ad libitum fed rats (P = 0.015). This study provides evidence for a role of the pineal in mediating the inhibitory action of food restriction on vaginal opening, but not on body growth or collagen aging in tail tendon up to middle age.