Patients' perceptions of quality of care delivery by urology residents: A nationwide study.

OBJECTIVE: To present the results of a nationwide survey among urological patients to evaluate their perception of the quality of care provided by residents. METHODS: An anonymous survey was distributed to patients who were referred to 22 Italian academic institutions. The survey aimed to investigate the professional figure of the urology resident as perceived by the patient. RESULTS: A total of 2587 patients were enrolled in this study. In all, 51.6% of patients were able to correctly identify a urology resident; however, almost 40% of respondents discriminated residents from fully trained urologists based exclusively on their young age. Overall, 98.2% patients rated the service provided by the resident as at least sufficient. Urology trainees were considered by more than 50% of the patients interviewed to have good communication skills, expertise and willingness. Overall, patients showed an excellent willingness to be managed by urology residents. The percentage of patients not available for this purpose showed an increasing trend that directly correlated with the difficulty of the procedure. Approximately 5-10% of patients were not willing to be managed by residents for simple procedures such as clinical visits, cystoscopy or sonography, and up to a third of patients were not prepared to undergo any surgical procedure performed by residents during steps in major surgery, even if the residents were adequately tutored. CONCLUSIONS: Our data showed that patients have a good willingness to be managed by residents during their training, especially for medium- to low-difficulty procedures. Furthermore, the majority of patients interviewed rated the residents' care delivery as sufficient. Urology trainees were considered to have good communication skills, expertise and willingness.

Autologous fascial slings remain viable at long-term follow-up: a post cystectomy case report.

BACKGROUND: Autologous fascial slings (AFS) have been used for a very long time in the treatment of female stress urinary incontinence, but the introduction of synthetic mesh slings placed either retropubicallyor trans-obturator has decreased the need to harvest the autologous rectus muscle fascia, thus reducing invasiveness and operative time. However AFS are still indicated in complicated cases and re-interventions, and the FDA has underlined safety concerns over the use of surgical meshes for the transvaginal repair of prolapsed pelvic organs. CASE PRESENTATION: A 76-year-old woman with muscle-invasivebladder cancer underwent radical cystectomy 16 years after retropubic positioning of an autologous rectus muscle fascial sling for SUI, with complete symptom resolution. The sling was easily identified and removed en bloc with the bladder and urethra, providing an opportunity to histologicallyevaluate the autologous fascial graft after its long permanence in the new position. Histopathological examination demonstrated increased fibroblastic proliferation and formation of capillaries. A slight separation and an increased waviness of the connective fibers were both evident. An increased vascularity was also apparent, including transverse vessels, with clusters of vessels. A relative inflammatory reaction was present in over 300 cells/10 HPF. All these characteristics indicated viable connective tissue. CONCLUSIONS: AFS remain a valuable surgical option for both primary and recurrent SUI in women, showing high cure rates and low complications in the long-term. The present case, to the best of our knowledge, presents the longest follow-up period of an autologous rectus muscle fascia placed retropubically and its histological evaluation documents characteristics which support its mechanical strength and viability.

Unusual Case of Pancreatic Adenocarcinoma with Bladder Metastasis.

Background: The pancreas can be the site of neoplasms of several histogenetic origins; in most cases, tumors derive from the exocrine component, and ductal adenocarcinoma certainly prevails over the others. This tumor displays remarkably aggressive behavior, and it is often diagnosed at a late stage of disease. Case presentation: We discuss the rare case of a 76-year-old male with locally advanced pancreatic head adenocarcinoma who developed uncommon metastatic disease. The bladder constitutes a very rare site of metastases, mostly deriving from melanoma, gastric, lung and breast cancers. The bladder's secondary involvement in pancreatic malignancies represents an extremely unusual occurrence, and there are very few cases described in the literature to date. Conclusions: The finding of pancreatic adenocarcinoma metastases leads to a poor prognosis, and patients who are diagnosed at this stage constitute 53% of cases, with a 5-year survival of 3%. Although rare, therefore, the diagnostic hypothesis of pancreatic ductal adenocarcinoma (DAC) metastases to the bladder must, in some cases, be considered, especially if accompanied by a clinical picture that may suggest it.

Robotically assisted removal of pelvic splenosis fifty-six years after splenectomy: A case report.

BACKGROUND: 'Splenosis' is defined as the autotransplantation of splenic tissue following trauma or surgery, usually in the form of intraperitoneal nodules. The proliferation of imaging techniques has resulted in increased unexpected discoveries of splenosis nodules, and achieving a differential diagnosis can be challenging. Nuclear medicine studies have been playing an increasingly important role in this process, but the clinical significance of asymptomatic nodules remains uncertain. CASE SUMMARY: We present a case of pelvic splenosis in a 73-year-old man diagnosed 56 years after a splenectomy during a computed tomography (CT) follow-up for B-cell lymphoma, presenting intense contrast enhancement of an 18 mm nodule in the right recto-vesical space. 18F-fluorodeoxyglucose demonstrated weak metabolic activity. Since histological diagnosis was deemed necessary, the nodule was easily removed with robotically assisted laparoscopy, together with another 6 mm left a paracolic lesion. The latter was previously undiagnosed but retrospectively visible on the CT scan. CONCLUSION: In a patient requiring differential diagnosis of splenosis nodules from lymphoma recurrence, the robotic approach provided a safe en bloc removal with short hospitalization. The Da Vinci Xi robot was particularly helpful because its optics can be introduced from all ports, facilitating visualization and lysis of multiple intra-abdominal adhesions.

Bioelectric Impedance Analysis Test Improves the Detection of Prostate Cancer in Biopsy Candidates: A Multifeature Decision Support System.

Prostate cancer (PCa) gold-standard diagnosis relies on prostate biopsy, which is currently overly recommended since other available noninvasive tools such as prostate-specific antigen (PSA) multiparametric MRI (mMRI) showed low diagnostic accuracy or high costs, respectively. The aim of the study was to determine the accuracy of a novel Bioelectric Impedance Analysis (BIA) test endorectal probe for the selection of patients candidate to prostate biopsy and in particular the clinical value of three different parameters such as resistance (R), reactance (Xc), and phase angle (PA) degree. One-hundred twenty-three consecutive candidates to prostate biopsy and 40 healthy volunteers were enrolled. PSA and PSA density (PSAD) determinations, Digital Rectal Examination (DRE), and the novel BIA test were analyzed in patients and controls. A 16-core prostate biopsy was performed after a mMRI test. The study endpoints were to determine accuracy of BIA test in comparison with PSA, PSAD levels, and mMRI and obtain prostate cancer (PCa) prediction by BIA test. The Mann-Whitney U-test, the Wilkoxon rank test, and the Holm-Bonferroni's method were adopted for statistical analyses, and a computational approach was also applied to differentiate patients with PCa from those with benign disease. Combined PSA, PSAD, DRE, and trans-rectal ultrasound test failed to discern patients with PCa from those with benign disease (62.86% accuracy). mMRI PIRADS ≥3 showed a sensitivity of 83% and a specificity of 59%. The accuracy in discerning PCa increased up to 75% by BIA test (sensitivity 63.33% and specificity 83.75%). The novel finger probe BIA test is a cheap and reliable test that may help to improve clinical multifeature noninvasive diagnosis for PCa and reduce unnecessary biopsies.

Pumpkin seeds, Centella asiatica, Boswellia, Helichrysum, acetate vitamin E, Melaleuca alternifolia and hyaluronic acid phytocomplex monotherapy effects in patients with chronic pelvic pain syndrome.

BACKGROUND: Proxelan® and antibiotics combined therapy was successfully previously used in the treatment of symptoms of patients with chronic prostatitis. Aim of the present study was to investigate the effects of Proxelan® monotherapy on pain symptoms of patients with chronic prostatitis (CP) or chronic pelvic pain syndrome (CPPS) in a prospective pilot study. METHODS: Thirty consecutive patients with CP/CPPS symptoms younger than 50, without urinary obstruction, total prostate-specific antigen (PSA) <4 ng/mL, negative microbiology testing on prostate fluid and urethral swab, naïve from other treatments during the previous three months were enrolled in a pilot study. IPSS and NIH-CPSI questionnaires were administered to all the patients. Patients could choose to be investigated regarding semen quality and IL6/IL8 seminal markers for inflammatory disease prior and after the therapy course. Proxelan® suppositories were prescribed for each patient for a month with a daily dosage of 1 suppository at bed-time. The primary endpoint of the study included at least a 30% reduction of pain symptoms because similar results can be obtained in each previously investigated placebo group. Effects on semen parameters such as leukocytospermia, spermatozoa concentration and motility, cytokine levels were considered as secondary endpoints. RESULTS: Subjective pain relief was obtained in all the patients with significant decrease of NIH-CPSI pain items (P=0.04). Urinary symptoms, investigated by IPSS questionnaire, decreased significantly (P=0.04) as well as quality of life items (P=0.04). Leukocytospermia was found in 5/15 patients available for further investigations. IL6 decreased by 11.55% one month after the treatment while sperm motility resulted increased by 17.3%. CONCLUSIONS: Proxelan® monotherapy may represents a promising valid alternative to combined treatment with antibiotics in patients with CP/CPPS symptoms although the results obtained should be investigated in randomized controlled trials.

Human papilloma virus and genitourinary cancers: a narrative review.

INTRODUCTION: Human papilloma virus (HPV) is the most common sexually transmitted pathogen and its potential role in the genesis of several diseases such as cervical, head and neck, anal and penile cancers, is now largely recognized. Aim of this review article was to evaluate and summarize the state of the art of HPV-related urogenital cancers, focusing on the potentially innovative methods for the diagnosis of infection that should be used to improve viral causative detection and prevent its diffusion through sexual intercourses. EVIDENCE ACQUISITION: The initial search was carried out by using the Medline and the Google Scholar computerized databases through the selected key-words to identify the more recent literature on HPV epidemiology and its relationship with the main relevant urinary tract cancers. Studies were selected, extracted, analyzed and summarized. The PRISMA statement criteria were adopted and reported. EVIDENCE SYNTHESIS: Polymerase chain reaction assay (HPV test) represents the best option for the diagnosis of HPV infection. Difficulties for the diagnosis in male are due to the site of investigation (glans, sub coronal sulcus, scrotum, urine, sperm) and the method adopted to take the sample (brushing, tissue biopsy). Due to these reasons several studies analyzed seemed to be incomparable. HPV infection is generally found in about 20% of heterosexual men. Its connection with cervical, anal, head and neck and penile cancer has been previously evidenced in 90%, 60%, 68% and 40% of cases respectively. In particular, HPV infection differed significantly among penile squamous cell carcinoma (SCC) subtypes ranging from 22.4% in verrucous subtype to 66.3% for the basaloid/warty subtype. Although the connection between prostate cancer and HPV infection has never been previously confirmed, forest plot analysis relative to a series of nine studies done during the last ten years, demonstrated a 7.7 objective risk (OR) for subjects with HPV infection to develop subsequent prostate cancer. On the other hand, some authors found comparable results in subjects with prostate cancer, benign prostate hyperplasia and prostate inflammation, thus demonstrating that this link still remains questionable. Similarly, the connection between HPV infection and urothelial, testicular and renal cancer continue to be hotly debated although HPV has been found in the urine, semen and renal tissue of patients respectively. CONCLUSIONS: Integrated parts of HPV (E6 and E7 fractions) have been previously found in cervical, head and neck, anal and penile cancers. Conversely, although the evidence of concomitant HPV infection, integrated viral genome in cancer cells DNA had never been demonstrated in all the other genito-urinary tract cancers, and its role in the tumor genesis remain still largely debated. This is the reason why HPV infection should be tested in all patients with genitourinary cancer to better investigate about its potential role in the tumor genesis and development. Moreover, HPV infection option should be kept in mind when considering possible viral transmission to sexual partners.

Clinical reappraisal and state of the art of nephropexy.

The diffusion of minimally invasive techniques for renal surgery has prompted a renewed interest in nephropexy which is indicated to prevent nephroptosis in symptomatic patients and to mobilize the upper ureter downward in order to bridge a ureteral defect. Recent publications have been reviewed to present the state of the art of the diagnosis and management of these two challenging conditions and to try to foresee the next steps. The evaluation of patients with mobile kidney can be made relying on diagnostic criteria such as ultrasound with color Doppler and measurement of resistive index, conventional upright X-ray frames after a supine uro-computerized tomography scan and both static and dynamic nuclear medicine scans, always with evaluation in the sitting or erect position. Laparoscopic nephropexy emerges as the current treatment option combining both objectively controlled repositioning of the kidney and resolution of symptoms with minimal invasiveness, low morbidity, and short hospital stay. The use of robotics is presently limited by its higher cost, but may increase in the future. Downward renal mobilization and nephropexy is a safe and versatile technique which has been adopted as a unique strategy or more often in combination with other surgical maneuvers in order to cope with complex ureteral reconstruction.

Erectile dysfunction and diabetes: Association with the impairment of lipid metabolism and oxidative stress.

OBJECTIVES: To test the hypothesis that exists an association of non-diabetic and diabetic patients suffering from erectile dysfunction (ED) with lipid metabolism and oxidative stress. DESIGN AND METHODS: Clinical and laboratory characteristics in non-diabetic (n = 30, middle age range: 41­55.5 years; n = 25, old age range: 55.5­73), diabetic ED patients (n = 30, age range: 55.5­75 years) and diabetic patients (n = 25, age range: 56­73.25), were investigated. Proteomic analysis was performed to identify differentially expressed plasma proteins and to evaluate their oxidative posttranslational modifications. RESULTS: A decreased level of high-density lipoproteins in all ED patients (P < 0.001, C.I. 0.046­0.10), was detected by routine laboratory tests. Proteomic analysis showed a significant decreased expression (P < 0.05) of 5 apolipoproteins (i.e. apolipoprotein H, apolipoprotein A4, apolipoprotein J, apolipoprotein E and apolipoprotein A1) and zinc-alpha-2-glycoprotein, 50% of which are more oxidized proteins. Exclusively for diabetic ED patients, oxidative posttranslational modifications for prealbumin, serum albumin, serum transferrin and haptoglobin markedly increased. CONCLUSIONS: Showing evidence for decreased expression of apolipoproteins in ED and the remarkable enhancement of oxidative posttranslational modifications in diabetes-associated ED, considering type 2 diabetes mellitus and age as independent risk factors involved in the ED pathogenesis, lipid metabolism and oxidative stress appear to exert a complex interplay in the disease.