Congenital cysts of the lower male genitourinary tract: a disorder with various treatment approaches and pitfalls-case report.

BACKGROUND: The cysts of the male pelvic floor represent a rare clinical entity. Their origin is linked to an altered development of paramesonephric and mesonephric ducts during embryogenesis. CASE PRESENTATION: We report our experience regarding two patients presenting cysts of the ejaculatory system treated with open and mini-invasive surgery. The patients referred to our clinic with nonspecific symptoms and the diagnosis was obtained by radiological investigations. The patient treated with an open approach developed a pelvic purulent collection and a fistula of the prostatic urethra, managed with surgical drainage and prolonged bladder catheterization. On the other hand, the patient treated with laparoscopic approach did not develop any complications. No sexual or ejaculatory disorders were reported. CONCLUSIONS: Patients with congenital cysts of the pelvic floor must be adequately informed about the risks and benefits of surgery and a careful counseling is mandatory before surgery. Treatment is recommended for symptomatic patients and an endoscopic approach is associated with a high rate of recurrence. A laparoscopic approach, when possible, is desirable.

The use of endoscopic combined intrarenal surgery as an additional approach to upper urinary tract urothelial carcinoma: Our Experience.

INTRODUCTION: With increasing experience and advancing technology, endoscopy for UTUC has become more common. Endoscopic Combined Intrarenal Surgery (ECIRS) could be an option for patients with low-grade and large-volume UTUC that could be either anatomically or technically challenging to manage by retrograde flexible ureterorenoscopy. MATERIALS AND METHODS: In this video, we describe, step by step, our ECIRS technique as applied to two selected clinical cases of UTUC. CONCLUSION: ECIRS could represent a useful approach to UTUC in selected cases. The advantage of the "endovision" puncture and dilation technique is in the avoidance of entering the renal calyx at the level of the tumor. In addition, the combined approach, compared to the purely percutaneous approach, allows access to, and treatment of, neoplasms located in all renal calyces.

A conceptual model for evaluating eco-efficiency of thermal spraying processes.

Thermal spraying (TS) is one of the main processes for obtaining surfaces with the desired protective properties in various industrial applications. TS is an energy-intensive treatment required to heat the application material and consumes different resources. To assess the environmental impact of TS, it becomes necessary to integrate an approach that jointly analyses and evaluates the economic and environmental variables influencing the system. The concept of eco-efficiency (EE) added to the TS process allows for assessing the environmental and economic condition through the survey and application of eco-indicators. The lack of an EE evaluation model for TS processes was identified based on literature searches. Thus, the overall objective of this work is to propose a conceptual model to evaluate the EE of TS treatment, selecting environmental and economic indicators considered more impactful in the process. The model developed consists of three main steps: (i) the input and output indicators (environmental and economic) are identified by applying the Analytic Hierarchy Process (AHP) method; (ii) the structure to be employed in the model is defined; and (iii) the Data Envelopment Analysis (DEA) model is applied to define the EE evaluation form. The proposed model consists of clear and easy-to-follow steps for evaluating the EE of spraying processes, filling the gap found in the literature. The use of DEA allowed the integration of the environmental and economic indicators obtained from the TS processes to generate important insights for evaluating EE. The results prove the model's effectiveness in identifying the EE results for each analysed unit of the TS process. The model has provided an evaluation consistent with the existing studies, and the EE scores were assessed according to twenty-one decision-making units (DMUs) allowing the identification of the most eco-efficient DMUs concerning TS processes.

Safety profile of treatment with greenlight versus Thulium Laser for benign prostatic hyperplasia.

OBJECTIVE: The major strengths of surgical treatment of benign prostatic hyperplasia with laser are reduced morbidity compared to endoscopic resection. No studies analysed the different risk of intra/peri-operative events between patients undergoing Thulium and GreenLight procedures. MATERIALS AND METHODS: We retrospectively reviewed 100 consecutive cases undergoing GreenLight vaporization and Thulium procedures performed during the learning curve of two expert endoscopic surgeons. Pre-operative data, intra and post-operative events at 90 days were analysed. RESULTS: Patients on antiplatelet/anticoagulant therapy were pre-dominant in the Green group (p < 0.0001). Rates of blood transfusion (p < 0.0038), use of resectoscope (p < 0.0086), and transient stress urinary incontinence were statistically higher in the Thulium group. On the contrary conversions to TURP (p < 0.023) were more frequent in GreenLight patients. Readmissions were more frequently necessary in GreenLight group (24%) vs. Thulium group (26.6%). The overall complication rate in GreenLight and Thulium groups were 31% and 53% respectively; Clavien 3b complications were 13% in Thulium patients versus 1% in GreenLight patients. CONCLUSIONS: GreenLight and Thulium treatments show similar safety profiles. Randomized controlled trial are needed to better clarify the rate of major complications in Thulium group, and the incidence of post-operative storage symptoms in these patients' populations.

Risk assessment of upper limbs repetitive movements in a fish industry.

OBJECTIVE: Work-related Musculoskeletal Disorders (WMSDs) have a multifactorial origin: work-related risk factors and individual factors (age, sex, anthropometric characteristics). The purpose of the current study was the risk assessment of upper limb-WMSDs of workers engaged in tasks of anchovies filleting and packaging in a fish industry considering the ergonomic evaluation and the painful symptomatology complained by employees of different age. The activities were analysed by the American Conference Governmental Industrial Hygienists (ACGIH) method, the Strain Index (SI) method, the Rapid Upper Limb Assessment (RULA) method as well as the Occupational Rapid Assessment (OCRA) checklist. Workers answered the Italian version of the Nordic Musculoskeletal Questionnaire (NMQ). RESULTS: The ACGIH method showed that packaging needs greater protection, while filleting requires ergonomic interventions. The SI showed a significant increasing risk for both tasks. The final score identified by RULA, for tasks of fish filleting and packaging, suggested a medium level of action, therefore were required additional observations. By OCRA checklist the final score for both tasks denoted a high risk.

Low grade epithelial stromal tumour of the seminal vesicle.

BACKGROUND: The mixed epithelial stromal tumour is morphologically characterised by a mixture of solid and cystic areas consisting of a biphasic proliferation of glands admixed with solid areas of spindle cells with variable cellularity and growth patterns. In previous reports the seminal vesicle cystoadenoma was either considered a synonym of or misdiagnosed as mixed epithelial stromal tumour. The recent World Health Organisation Classification of Tumours considered the two lesions as two distinct neoplasms. This work is aimed to present the low-grade epithelial stromal tumour case and the review of the literature to the extent of establishing the true frequency of the neoplasm. CASE PRESENTATION: We describe a low-grade epithelial stromal tumour of the seminal vesicle in a 50-year-old man. Computed tomography showed a 9 x 4.5 cm pelvic mass in the side of the seminal vesicle displacing the prostate and the urinary bladder. Magnetic resonance was able to define tissue planes between the lesion and the adjacent structures and provided useful information for an accurate conservative laparotomic surgical approach. The histology revealed biphasic proliferation of benign glands admixed with stromal cellularity, with focal atypia. After 26 months after the excision the patient is still alive with no evidence of disease. CONCLUSION: Cystoadenoma and mixed epithelial stromal tumour of seminal vesicle are two distinct pathological entities with different histological features and clinical outcome. Due to the unavailability of accurate prognostic parameters, the prediction of the potential biological evolution of mixed epithelial stromal tumour is still difficult. In our case magnetic resonance imaging was able to avoid an exploratory laparotomy and to establish an accurate conservative surgical treatment of the tumour.

Subcapsular renal hematoma after retrograde ureterorenoscopic lithotripsy: our experience.

BACKGROUND: Ureterorenoscopy is the current standard treatment for ureteral and kidney stones, also stones greater than 2 cm can be removed. Complications linked to infectious processes or ureteral damage are the most frequently reported. Subcapsular renal hematoma is an extremely rare complication following this procedure. METHODS: We report the retrospective experience of two urological referral units for stones disease by analyzing incidence, risk factors and management of subcapsular renal hematoma. RESULTS: Between May 2011 and December 2017, 2497 consecutive ureteroscopies for urolithiasis were performed by 8 skilled endourologists. A subcapsular renal hematoma was diagnosed in four cases (0.12%). Symptoms appeared few hours after intervention in two patients and after 14 postoperative days in the remaining two. In all cases CT scan revealed a subcapsular renal hematoma without signs of active bleeding. Conservative treatment was successful. Two patients required blood transfusion. One patient developed renal hypotrophy. CONCLUSIONS: Subcapsular renal hematoma represents a rare but potentially serious complication after ureterorenoscopic lithotripsy. Its real incidence and etiology still need to be clarified. The elevated intrarenal pressures play an important role. Persistent hematuria, flank pain and hemoglobin drop should guide prompt investigation to reach an early diagnosis. In most cases a conservative management is sufficient.

Prediction of the Vickers Microhardness and Ultimate Tensile Strength of AA5754 H111 Friction Stir Welding Butt Joints Using Artificial Neural Network.

A simulation model was developed for the monitoring, controlling and optimization of the Friction Stir Welding (FSW) process. This approach, using the FSW technique, allows identifying the correlation between the process parameters (input variable) and the mechanical properties (output responses) of the welded AA5754 H111 aluminum plates. The optimization of technological parameters is a basic requirement for increasing the seam quality, since it promotes a stable and defect-free process. Both the tool rotation and the travel speed, the position of the samples extracted from the weld bead and the thermal data, detected with thermographic techniques for on-line control of the joints, were varied to build the experimental plans. The quality of joints was evaluated through destructive and non-destructive tests (visual tests, macro graphic analysis, tensile tests, indentation Vickers hardness tests and t thermographic controls). The simulation model was based on the adoption of the Artificial Neural Networks (ANNs) characterized by back-propagation learning algorithm with different types of architecture, which were able to predict with good reliability the FSW process parameters for the welding of the AA5754 H111 aluminum plates in Butt-Joint configuration.

A low-iron-available, polyphenol-enriched, carbohydrate-restricted diet to slow progression of diabetic nephropathy.

Diabetic nephropathy has become the leading cause of uremia. Several lines of evidence suggest dietary factors other than protein intake have a substantial role in the progression of diabetic nephropathy to end-stage renal disease. The present investigation was initiated to evaluate whether a carbohydrate-restricted, low-iron-available, polyphenol-enriched (CR-LIPE) diet may delay and improve the outcome of diabetic nephropathy to a greater extent than standard protein restriction. To this aim, 191 diabetic patients, all with type 2 diabetes, were randomized to either CR-LIPE or standard protein restriction and the following outcomes monitored: doubling of serum creatinine, cumulative incidence of end-stage renal disease, and all cause mortality. Over a mean follow-up interval of 3.9 +/- 1.8 years, serum creatinine concentration doubled in 19 patients on CR-LIPE (21%) and in 31 control subjects (39%) (P < 0.01). Renal replacement therapy or death occurred in 18 patients on CR-LIPE (20%) and in 31 control subjects (39%) (P < 0.01). These differences were independent from follow-up interval, sex, mean arterial blood pressure, HbA(1c), initial renal dysfunction, and angiotensin system inhibitor use. In conclusion, CR-LIPE was 40-50% more effective than standard protein restriction in improving renal and overall survival rates.

A case of medullary sponge kidney (Cacchi-Ricci disease) mimicking a renal mass.

Medullary sponge kidney (MSK) is an uncommon benign congenital disorder, generally asymptomatic. In symptomatic patients the diagnosis is usually made by excretory urography performed in the most frequent complications such as renal stones, urinary tract infections and haematuria. Excretory urography can be very characteristic, showing cystic collections of ectatic collecting ducts like "bunches of grapes" or "bouquet of flowers". When haematuria represents the only symptom, and radiographic findings are not characteristic of MSK, the differential diagnosis with a renal tumor can be very difficult. We report a case of MSK that underwent nephrectomy since clinical and radiological features mimicked a renal tumor.

Effect of iron depletion on cardiovascular risk factors: studies in carbohydrate-intolerant patients.

Controversy surrounds the role of iron (Fe) in atherosclerosis (ASCVD), mainly due to the inaccuracy of assessing body Fe stores with serum ferritin and transferrin saturation. Quantitative phlebotomy was used to test whether or not (a) Fe stores are increased in individuals at high risk for ASCVD and (b) Fe depletion to near-deficiency (NID) levels is associated with reduction of risk factors for ASCVD. Thirty-one carbohydrate-intolerant subjects completed the study. Fe stores were within normal limits (1.5 +/- 0.1 g). At NID, a significant increase of HDL-cholesterol (p < 0.001) and reductions of blood pressure (p < 0.001), total and LDL-cholesterol (p < 0.001), triglyceride (p < 0.001), fibrinogen (p < 0.001) and glucose and insulin responses to oral glucose loading (p < 0.001) were noted, while homocysteine plasma concentration remained unchanged. These effects were largely reversed by a 6-month period of Fe repletion with reinstitution of Fe sufficiency. Thus, although individuals at high risk for ASCVD are not Fe-overloaded, they seem to benefit, metabolically and hemodynamically, from lowering of body Fe to levels commonly seen in premenopausal females.

[Ejaculatory system cysts: a case report]. / Raro caso di cisti del sistema eiaculatore.

INTRODUCTION: Male pelvic floor cysts are a rare clinical entity that include: Wolffian duct remnants, Müllerian duct remnants, cysts of the seminal vesicles, prostate and ejaculatory duct/vas deferens cysts.
 CASE REPORT: We report the clinical case of a 21-year-old male patient with a history of previous surgery in childhood and more precisely: partial colectomy for congenital megacolon, removal of dysplastic right kidney and subsequent surgical adhesiolysis for bowel obstruction.
 At 17, the patient was submitted to MRI for groin pain with an incidental finding of a cystic mass at the level of the right seminal vesicle. Consequently, a TUR-ED was performed at another urology unit, for a suspected seminal vesicle ectasia, without resolution of pain symptoms. The patient was referred to us for persistent genitourinary infections, ejaculation disorder and episodes of gross hematuria. An additional MRI confirmed the presence of a cystic mass of 5,5 cm with a suspected opening into prostatic urethra. Urethrocystoscopy and urethrocystography retrograde confirmed this anatomical communication. For the persistence of the symptoms we performed retropubic surgical exeresis of the mass, with a histopathological finding of benign cyst of the vas deferens.
 Two major postoperative complications were reported: a pelvic hematoma that required surgical exploration and a urinary extravasation at the level of prostatic urethra, which resolved with prolonged urethral catheterization.
 CONCLUSIONS: Male pelvic floor cysts are a rare disease with a complex clinical and therapeutic management. A correct diagnosis is based on clinical signs and symptoms together with imaging studies of the pelvic region. The high risk of erectile dysfunction and ejaculatory disorders correlated to a surgical approach, recommend a treatment of these lesions only for symptomatic cases.

[History of laser in BPH therapy]. / Storia del Laser nella terapia dell'IPB.

Laser technology has been used in the treatment of BPH for more than 15-20 years in order to challenge transurethral resection of the prostate. The aim of this review article is to analyze the evolution of laser in BPH therapy, from early coagulative techniques - progressively abandoned for their elevated postoperative morbidity and unfavorable outcomes - to the newer techniques of vaporization, resection and enucleation of the prostate. A better comprehension of tissue-laser interactions, the improvement of laser technology and a growing clinical experience have lead to the development of different laser systems (Holmium, KTP, Thulium laser) that challenge TURP. Today, HoLEP and, secondarily, PVP are the laser techniques supported by more clinical evidences and represent valid alternatives to TURP.

Near-iron deficiency-induced remission of gouty arthritis.

OBJECTIVES: Previous evidence supports a role for iron in the pathogenesis of gout. For example, iron, when added to media containing urate crystals, stimulated oxidative stress with subsequent complement and neutrophil activation. Conversely, iron removal inhibited these responses as well as urate-crystal-induced foot pad inflammation in rats in-vivo. The objective of the present study was to investigate whether or not iron removal may improve the outcome of gouty arthritis in humans as well. METHODS: Quantitative phlebotomy was used to remove iron in 12 hyperuricaemic patients with gouty arthritis and maintain their body iron at near-iron deficiency (NID) level (i.e. the lowest body iron store compatible with normal erythropoiesis and therefore absence of anaemia). RESULTS: During maintenance of NID for 28 months, gouty attacks markedly diminished in every patient, from a cumulative amount of 48 and 53 attacks per year before (year -2, -1), to 32, 11 and 7 during induction (year 0) and maintenance (year +1, +2) of NID, respectively. During NID, attacks were also more often of milder severity. CONCLUSIONS: During a 28-month follow-up, maintenance of NID was found to be safe and beneficial in all patients, with effects ranging from a complete remission to a marked reduction of incidence and severity of gouty attacks.

Effect of iron depletion in carbohydrate-intolerant patients with clinical evidence of nonalcoholic fatty liver disease.

BACKGROUND & AIMS: Increased body iron, genetic hemochromatosis (GH) mutations, and nonalcoholic fatty liver disease (NAFLD) tend to cluster in carbohydrate-intolerant patients. In an attempt to further clarify the interrelationships among these conditions, we studied 42 carbohydrate-intolerant patients who were free of the common GH mutations C282Y and H63D, and had a serum iron saturation lower than 50%. METHODS: We measured body iron stores, and induced iron depletion to a level of near-iron deficiency (NID) by quantitative phlebotomy. RESULTS: In the 17 patients with clinical evidence of NAFLD, we could not demonstrate supranormal levels of body iron (1.6 +/- 0.2 vs. 1.4 +/- 0.2 g; P = 0.06). However, at NID, there was a 40%-55% improvement (P = 0.05-0.0001) of both fasting and glucose-stimulated plasma insulin concentrations, and near-normalization of serum alanine aminotransferase activity (from 61 +/- 5 to 32 +/- 2 IU/L; P < 0.001). CONCLUSIONS: These results reflect the insulin-sparing effect of iron depletion and indicate a key role of iron and hyperinsulinemia in the pathogenesis of NAFLD.