Primary Mucosal Melanoma Presenting with a Unilateral Nasal Obstruction of the Left Inferior Turbinate.

We report the case of a primitive nasal melanoma in an 82-year-old patient, showing how this rare malignancy, with non-specific signs and symptoms, can represent a challenging diagnosis for the physician. A 82-year-old Caucasian patient presented for unilateral nasal obstruction and occasional epistaxis. Computerized tomography (CT) and magnetic resonance imaging (MRI) of the facial massif revealed turbinate hypertrophy and a polypoid phlogistic tissue isointense in T1 with an intermediate signal in T2 and Short-TI Inversion Recovery (STIR)-T2, occupying the middle meatus and the anterior upper and lower left meatus with partial obliteration of the ostium and the infundibulum of the maxillary sinus. The Positron emission tomography (PET) exam was negative for metastases. Conservatory surgery in the left anterior video rhinoscopy was performed, allowing a radical 4-cm tumor excision. Histology reported epithelioid cell melanoma, PanK-, CD45-, and PanMelanoma+. Adjuvant radiotherapy was suggested, even considering a complete resection as the result of surgery. No local or systemic relapse was noticed at the 2-month follow-up visit. Although mucosal melanoma is a rare and aggressive malignancy characterized by a poor prognosis, early diagnosis allows a more conservative approach, with little surgical difficulty and no aesthetic effect. Our case raises awareness of the importance of early intervention even in those cases where the clinic symptoms and diagnostic images show uncertain severity.

The digital era of pediatric urological clinical care: telemedicine for management of lower urinary tract symptoms and nocturnal enuresis - a comprehensive tertiary center insight.

BACKGROUND: Lower urinary tract symptoms (LUTS) and nocturnal enuresis (NE) are complex conditions requiring a long-term follow-up. Telemedicine is an emerging technological tool in the surgical field, and its availability exponentially grew during the COVID-19 pandemic, expanding its application fields, optimizing technical aspects, reducing costs, and ensuring high-quality standards. This work describes our experience with telemedicine in a Division of Pediatric Urology for the follow-up of enuresis and LUTS. METHODS: A retrospective analysis of our telemedicine preliminary experience was conducted at Regina Margherita Children's Hospital in Turin, Italy. This study included all the patients aged <18 years who were monitored for enuresis and LUTS through telemedicine between September 1, 2021 and July 31, 2023. Clinical data and outcomes were analyzed, and patients and families were asked to voluntary fill an evaluation questionnaire on their satisfaction. Additionally, we focused on the post COVID-19 period, between September 2022 and July 2023, analyzing the data of two different patients' populations: the first one (G1) of patients choosing telemedicine outpatients visits (TOVs) and the second one (G2) of those choosing a face-to-face visit. RESULTS: One hundred five patients were enrolled. One hundred sixty-two TOVs were performed. The median age at first visit was 9.7±0.66 years (range 7-16 years). Diagnosis were: 77/105 (67%) NE and 28/105 (33%) LUTS. The average referred distance between the patients' residence and the hospital was 46.35±129.37 km (range 2-1300 kilometers) and the time taken to overcome it was 44.21±77.29 minutes (range 10-780 minutes). In 64/105 cases (61%) the follow-up was interrupted for total healing or symptoms resumption. Only two cases (2%) required the conversion to an in-person ambulatory consult, due to a social-linguistic barrier. 146/162 families (90%) filled the survey questionnaire at the end of each TOV, reporting in 94% of cases a high satisfaction level. In the comparative statistical analysis of the two patient groups, G1 (52 telemedicine office visits, [TOVs]) vs. G2 (25 face-to-face visits), the average referred distance was 17.78±7.98 km (range: 5-35 km) for G1, contrasting with 7.04±3.35 km (range: 2.5-14 km) for G2 (P=0.00001). Additionally, the waiting time before the visit was 3.96±2.90 minutes (range: 0-10 minutes) for G1, in contrast to 26.52±11.22 minutes (range: 5-44 minutes) for G2 (P=0.00001). Furthermore, a higher compliance with behavioral or pharmacological indications was observed in the G1 group, exhibiting lower adherence in only 12 out of 52 cases compared to 14 out of 25 cases in G2 (P=0.0091). CONCLUSIONS: Telemedicine is a proper solution and an effective tool to manage the therapeutic follow-up of NE and LUTS, ensuring suitable quality standards and reducing social costs, such as the loss of working days and transport costs. The implementation and complete integration of its use into the healthcare system should be the goals to pursue in order to take full advantage of all its potentials.

Retrograde Intrarenal Surgery for Renal Stones: Is It a Safe and Effective Option in Preschool Children?

INTRODUCTION: Few studies in the literature describe the Retrograde Intra-Renal Surgery (RIRS) outcome in preschool children. We evaluated the feasibility, stone-free rate and complications of RIRS in preschool children at two European tertiary care centres of Pediatric Urology. MATERIAL AND METHODS: The retrospective study includes all children undergone RIRS for stones <25 mm from 2017 to 2022. Patients were divided into Group 1 <5 years (G1) and Group 2 >5 years (G2). Semirigid ureterorenoscope 4.5-6.5 Ch and a 7.5 Fr flexible ureteroscope with a 9.5/11 Ch ureteral access sheath (UAS) were used. Stone-free rate (SFR) was evaluated at 3 months. Fischer/Chi-square test for qualitative data and Mann-Whitney for quantitative data were used for statistical analysis. RESULTS: 63 patients underwent RIRS, 19 G1-patients, median age 3.55 ± 1.06 years (range 1.5-5 years), and 44 G2-patients, median age 11.25 ± 2.95 (range 6-17 years) (p < 0.00001). Intraoperative complications occurred in 1 case in G1(5%) and 3 in G2(7%) (p = 1): two minor ureteric injuries in G2 were treated by a prolonged JJ-stent. Postoperative fever was reported in 3 cases in G1 (16%) and 4 in G2(9%) (p = 0.42), while post-operative hematuria in 4 G1-patients (21%) and in 7 G2-patients (16%) (p = 0.72). SFR was 84.2% in G1 and 88.6% in G2. At an average follow-up of 15.05 ± 4.83 months in G1 and 19.95 ± 10.36 months in G2, reintervention for residual stones was necessary in 3 cases in G1(16%) and in 6 cases in G2(14%) (p = 1). CONCLUSIONS: In a European country with low-volume pediatric stone centers, RIRS is a promising therapeutic option in young children as it offers acceptable stone-free rate and a low incidence of high-grade complications. LEVEL OF EVIDENCE: III.

JJ stent dislodgement in the distal ureter: how to recover it in preschool children?

Double-J ureteral stents are usually placed after various urological procedures. The dislodgement of their distal ringlet is a rare complication, whose retrieval is arduous in younger children, due to the small ureteral caliber. We propose our innovative endoscopic approach to recover the dislodged JJ stent. Under 8-9.8 Ch cystoscopy, the ureteral meatus is gently cannulated with a 00.18″ guidewire, then a balloon catheter Passeo 18 3-4 mm (Biotronik, Lake Oswego, OR, USA) is coaxially inserted. A pneumatic dilatation of the vesical-ureteral junction is performed up to 8 atmospheres for 5 minutes under direct vision. Consequently, the ureteral meatus allows the cystoscope passage, and the JJ-stent can be recovered thanks to endoscopic grasping forceps. A mono-J stent is then left in place for 24 hours. Four patients aged 8 months - 4 years have been successfully treated with this approach after that JJ migration was found intraoperatively or during ultrasonography. No intra- or postoperative complications occurred. Postoperative hospital stay was prolonged for one day. During 29.5 medium follow-up no clinical or ultrasonographic signs of vesical-ureteral reflux ensued. Our cystoscopic approach is effective and safe to ensure a prompt endoscopic JJ retrieval without changing neither surgical approach nor the anesthesiological support. We believe that all the pediatric urology centers should know the procedure and have small size balloon catheter available.

Obstructive or non-obstructive megacystis: a prenatal dilemma.

Introduction: Diagnosis of prenatal megacystis has a significant impact on the pregnancy, as it can have severe adverse effects on fetal and neonatal survival and renal and pulmonary function. The study aims to investigate the natural history of fetal megacystis, to try to differentiate in utero congenital lower urinary tract obstruction (LUTO) from non-obstructive megacystis, and, possibly, to predict postnatal outcome. Materials and methods: A retrospective single-center observational study was conducted from July 2015 to November 2023. The inclusion criteria were a longitudinal bladder diameter (LBD) >7 mm in the first trimester or an overdistended/thickened-walled bladder failing to empty in the second and third trimesters. Close ultrasound follow-up, multidisciplinary prenatal counseling, and invasive and non-invasive genetic tests were offered. Informed consent for fetal autopsy was obtained in cases of termination of pregnancy or intrauterine fetal demise (IUFD). Following birth, neonates were followed up at the same center. Patients were stratified based on diagnosis: LUTO (G1), urogenital anomalies other than LUTO ("non-LUTO") (G2), and normal urinary tract (G3). Results: This study included 27 fetuses, of whom 26 were males. Megacystis was diagnosed during the second and third trimesters in 92% of the fetuses. Of the 27 fetuses, 3 (11.1%) underwent an abortion, and 1 had IUFD. Twenty-three newborns were live births (85%) at a mean gestational age (GA) of 34 ± 2 weeks. Two patients (neonates) died postnatally due to severe associated malformations. Several prenatal parameters were evaluated to differentiate patients with LUTO from those with non-LUTO, including the severity of upper tract dilatation, keyhole sign, oligohydramnios, LBD, and GA at diagnosis. However, none proved predictive of the postnatal diagnosis. Similarly, none of the prenatal parameters evaluated were predictive of postnatal renal function. Discussion: The diagnosis of megacystis in the second and third trimesters was associated with live births in up to 85% of cases, with LUTO identified as the main cause of fetal megacystis. This potentially more favorable outcome, compared to the majority reported in literature, should be taken into account in prenatal counseling. Megacystis is an often misinterpreted antennal sign that may hide a wide range of diagnoses with different prognoses, beyond an increased risk of adverse renal and respiratory outcomes.

Urinary PSA-ZINC biomarker outperforms standard of care in early detection of prostate cancer.

BACKGROUND: Urine is a promising biological fluid for prostate cancer (PCa) diagnostics due to its non-invasive collection and wide range of biomarkers. The aim of this study was to assess the role of urinary PSA (uPSA) and urinary Zinc (uZinc) as biomarkers for the diagnosis of PCa in combination with routine parameters of standard of care (SOC - blood PSA, abnormal DRE, age) and MRI in patients candidates for prostate biopsy. METHODS: Urine samples after prostatic massages were collected from men with suspected PCa scheduled for prostate biopsy. Quantification of uPSA was performed by ECLIA platform and confirmed by ELISA assay, while uZinc measurement was evaluated by ICP-MS and confirmed by colorimetric in vitro assay. Six multivariate logistic regression analysis were performed to assess diagnostic performance of uPSA and uZinc (urine), SOC and MRI alone, and combination of MRI+SOC, MRI+urine and SOC+MRI+urine. The discriminative power of the logistic models was assessed by calculating the area under the receiver operating characteristic (ROC) curves (AUC). RESULTS: Two hundred thirty-eight patients were included in the analysis; 145 of them were diagnosed with PCa. Urine test showed a better discrimination of HS from CP, in respect of uPSA and uZinc alone, both for PCa of any grade and Gleason Score ≥7 (4+3) (AUC 0.804 and 0.823 respectively). ROC curve combining SOC+MRI+urine showed an AUC=0.882, that is statistically different from SOC or MRI alone, or MRI+SOC (P=0.0001, P=0.0001, and P=0.008 respectively). PCa risk algorithm designed considering SOC+MRI+urine results in potential reduction of 57% of unnecessary biopsies compared to the current standard parameters. CONCLUSIONS: The loss of uPSA and Zinc production and secretion during neoplastic transformation of the prostate could potentially represent a hallmark of PCa. Its combination with age, PSA and DRE, as well as with mpMRI could represent an interesting approach to improve the diagnostic accuracy of PCa.

3D virtual models and augmented reality for radical prostatectomy: a narrative review.

BACKGROUND AND OBJECTIVE: The increasing popularity of three-dimensional (3D) virtual reconstructions of two-dimensional (2D) imaging in urology has led to significant technological advancements, resulting in the creation of highly accurate 3D virtual models (3DVMs) that faithfully replicate individual anatomical details. This technology enhances surgical reality, providing surgeons with hyper-accurate insights into instantaneous subjective surgical anatomy and improving preoperative surgical planning. In the uro-oncologic field, the utility of 3D virtual reconstruction has been demonstrated in nephron-sparing surgery, impacting surgical strategy and postoperative outcomes in prostate cancer (PCa). The aim of this study is to offer a thorough narrative review of the current state and application of 3D reconstructions and augmented reality (AR) in radical prostatectomy (RP). METHODS: A non-systematic literature review was conducted using Medline, PubMed, the Cochrane Database, and Embase to gather information on clinical trials, randomized controlled trials, review articles, and prospective and retrospective studies related to 3DVMs and AR in RP. The search strategy followed the PICOS (Patients, Intervention, Comparison, Outcome, Study design) criteria and was performed in January 2024. KEY CONTENT AND FINDINGS: The adoption of 3D visualization has become widespread, with applications ranging from preoperative planning to intraoperative consultations. The urological community's interest in intraoperative surgical navigation using cognitive, virtual, mixed, and AR during RP is evident in a substantial body of literature, including 16 noteworthy investigations. These studies highlight the varied experiences and benefits of incorporating 3D reconstructions and AR into RP, showcasing improvements in preoperative planning, intraoperative navigation, and real-time decision-making. CONCLUSIONS: The integration of 3DVMs and AR technologies in urological oncology, particularly in the context of RP, has shown promising advancements. These technologies provide crucial support in preoperative planning, intraoperative navigation, and real-time decision-making, significantly improving the visualization of complex anatomical structures helping in the nerve sparing (NS) approach modulation and reducing positive surgical margin (PSM) rate. Despite positive outcomes, challenges such as small patient cohorts, lack of standardized methodologies, and concerns about costs and technology adoption persist.

Prechemotherapy Transperitoneal Robotic-Assisted Partial Nephrectomy (RAPN) for a Wilms Tumor: Surgical and Oncological Outcomes in a Four-Year-Old Patient.

BACKGROUND: Wilms tumor (WT) is the most frequent renal tumor in children. The SIOP-UMBRELLA Guidelines allow for nephron-sparing surgery (NSS) in syndromic patients, as well as in cases of small (<300 mL) non-syndromic unilateral WTs, without lymph node involvement, and with a substantial expected remnant renal function, following neoadjuvant chemotherapy. We present a case of prechemotherapy transperitoneal robot-assisted partial nephrectomy (RAPN) for a unilateral, non-syndromic Wilms tumor. METHODS: A four-year-old child presented with a solid mass measuring 3.6 cm in diameter involving the upper right renal pole, incidentally detected during an abdominal echotomography. CT scan and abdominal MRI revealed no local infiltration or lymph node involvement, suggesting that the exophytic mass could be easily resected via an NSS robotic approach. Preoperative imaging did not strongly suggest WT. A virtual 3D reconstruction of the tumor was performed. RESULTS: After the oncologic board approval, a robot-assisted partial nephrectomy with an intraperitoneal approach was performed. Histopathological analysis confirmed the diagnosis of WT. The patient subsequently received 10 doses of vincristine as adjuvant chemotherapy. A 28-month follow-up showed no tumor recurrence. CONCLUSIONS: Intraperitoneal RAPN may be an option for selected WT and warrants consideration as a challenging but advantageous approach.

Comparison Study between Artificial Urinary Sphincter and Adjustable Male Sling: A Propensity-Score-Matched Analysis.

AIMS: This study aimed to compare the outcomes of the AUS and an adjustable male sling (ATOMSTM). METHODS: It was a retrospective observational cohort study with two arms. Propensity score matching (PSM) was performed in order to limit selection bias and, consequently, a comparison between groups in terms of functional outcomes (24 h pad test and perception of improvement questionnaires), complications (overall complications, high-grade complications, reinterventions and explantations) and device survival was performed. RESULTS: 49 patients in both arms were included. The baseline characteristics were similar between the groups. The mean follow up was 43 ± 35 months. Dryness was achieved in 22 patients (44.9%) in the AUS group and 11 (22.5%) in the sling group (p = 0.03). A total of 40 patients declared themselves well improved in the sling group (81%), while 35 (71%) declared the same in the AUS group (p = 0.78). The AUS was associated with more high-grade complications, reinterventions and explantations than the ATOMSTM. Survival at 60 months was 82 ± 9% in the sling group and 67 ± 7% in the AUS group (p = 0.03). CONCLUSIONS: While the AUS may be characterized by a higher dry rate, it has an increased risk of high-grade complications and reinterventions. It is proposed that the ATOMS prosthesis can be successfully used for patients who require a less invasive procedure that maintains good functional outcomes.

Prophylaxis of Ocular Infection in the Setting of Intraocular Surgery: Implications for Clinical Practice and Risk Management.

In this review we discuss the role of intraocular surgery preoperative prophylaxis. The correct choice of antimicrobial drug is variable in each surgical setting, according to the available strengths of evidence, the anatomical district involved, and the type of procedure. In the ophthalmic surgical field, there has been a progressive shift from antibiotic formulations, which are known to cause antibiotic resistance, to a new class of antiseptic compounds, which proved to be effective not only against bacteria, but also against fungi, protozoa, and viruses. Among these, povidone-iodine (PVI) is a water-soluble polymer that can form a complex with iodine, and the perioperative application of PVI 5-10% eye drop for 3 min is the gold standard for infection prophylaxis. A new formulation of 0.6% PVI eye drop is a new option for infection prophylaxis in the days before surgery. Chlorhexidine is a biguanide compound, which is a valid alternative with a good safety and efficacy profile and is the antiseptic of choice in patients with iodine allergy. New compounds that are currently being studied include polyhexamethylene biguanide (PHMB), picloxydine, ozone, hypochlorous acid (HOCl), and Biosecur. PHMB is a biguanide polymer that was found to be more effective than PVI in in vitro studies for reducing microorganisms and extending the duration of antisepsis, but to date, there are no formulations available on the market for preoperative ocular surgery in which it is present as main ingredient. Ozone is a molecule with oxidizing effect, which showed interesting preliminary results but is not effective against virus, Staphylococcus aureus and Candida albicans. HOCl has a natural bactericidal propriety but its applicability to prophylaxis of ocular infection in the setting of ocular surgery is not established. Biosecur is a non-toxic organic alcohol-free compound that exhibited bactericidal and fungicidal effect versus all common microorganisms and is currently available as an ocular spray.

Intravesical Agents in the Treatment of Bladder Clots in Children.

Bladder blood clots represent an infrequent urinary condition in children. They usually result from hematuria with many underlying causes, such as urinary tract infections and urethral/bladder traumas. Treatment options for clot removal include trans-urethral or suprapubic bladder irrigation and, if unsuccessful, endoscopic management under general anesthesia with a resectoscope. In younger male children, however, the repeated passage of a trans-urethral resectoscope may be challenging and traumatic, due to the small lumen diameter. Eventually, an open surgical approach can be required in many patients. Few anecdotal non-surgical approaches have been proposed for the management of bladder blood clots in children. This review aims to summarize the conservative techniques described in the literature with the instillation of intravesical agents, analyzing the different strategies and their advantages.

Intravitreal Injection Planning during COVID-19 Pandemic: A Retrospective Study of Two Tertiary University Centers in Italy.

The COVID-19 pandemic has hampered the optimum management of retinal diseases. This study examined the impact of the pandemic on the intravitreal-injection practice in two academic centers in Italy along with the related medico-legal implications. A retrospective analysis of electronic medical records from 16 March 2020 to 14 March 2021 at the ophthalmological departments of University of Cagliari (SGD) and University Magna Græcia of Catanzaro (UMG) was conducted. The data collected between 16 March 2020 and 14 June 2020 (lockdown), 15 June 2020 and 13 September 2020 (unlock), and 14 September 2020 and 14 March 2021 (second wave) were compared with those of the same period of the previous year. Weekly data on the administered drug and the number and type of treated disease were collected and analyzed. During the lockdown, a drop of 59% at SGD (p < 0.00001) and 77% at UMG (p < 0.00001) in intravitreal injections was found. In the first year of the pandemic, the reduction in injections was approximately of 27% (p < 0.0008) and 38% (p < 0.0001) at SGD and UMG, respectively. The COVID-19-related containment measures and the health resources redistribution have led to a delay in the treatment of chronic diseases of the retina, prioritizing the undeferrable ones. The lack of management guidelines has conceived relevant ethical and medico-legal issues that need to be considered in future measures planning.

Applications and Current Medico-Legal Challenges of Telemedicine in Ophthalmology.

BACKGROUND: The digital revolution is redesigning the healthcare model, and telemedicine offers a good example of the best cost-effectiveness ratio. The COVID-19 pandemic has catalysed the use of the telemedicine. The aim of this review is to describe and discuss the role and the main applications of telemedicine in the ophthalmic clinical practice as well as the related medico-legal aspects. METHODS: 45 original articles and 5 reviews focused on this topic and published in English language from 1997 and 2021 were searched on the online databases of Pubmed, Scopus, Web of Sciences and Embase, by using the following key words: "telemedicine", "privacy", "ophthalmology", "COVID-19" and "informed consent". RESULTS: Telemedicine is able to guarantee patient care using information and communication technologies. Technology creates an opportunity to link doctors with the aim of assessing clinical cases and maintaining high standards of care while performing and saving time as well. Ophthalmology is one of the fields in which telemedicine is most commonly used for patient management. CONCLUSIONS: Telemedicine offers benefits to patients in terms of saving time and costs and avoiding physical contact; however, it is necessary to point out significant limitations such as the absence of physical examinations, the possibility of transmission failure and potential violations of privacy and confidentiality.

Gastric perforation in blunt abdominal trauma. Report of two cases and review of literature.

Gastric perforations as a result of blunt abdominal traumas are rare, with a reported incidence of less than 2%. Usually associated with other solid visceral injuries, isolated gastric ruptures following a blunt abdominal injury are extremely uncommon. The severity of injury, timing of presentation, time elapsed since the last meal, as well as the presence of concomitant injuries are important prognostic factors. Contrast-enhanced CT scan is the gold-standard diagnostic tool in haemodinamically stable patients and allows to detect or raise suspicion of injuries to hollow viscera in about 87% of cases. The authors report two cases of patients suffering from gastric injury following a blunt abdominal trauma. The first one with a double gastric laceration treated with suture repair. The second one with a wide laceration and tissue loss along the greater gastric curvature requiring a wedge resection. Both patients had an uneventful recovery. Authors present a brief review of the literature; a search on PubMed using the key words "blunt abdominal trauma" and "gastric injury" was performed, including all studies published in the last 20 years. Finally, the main data extracted from four reviews were examinated. KEY WORDS: Abdominal trauma, Gastric injury, Hollow viscus perforation.

Real-life effects of benralizumab on allergic chronic rhinosinusitis and nasal polyposis associated with severe asthma.

The aim of this study has been to evaluate the efficacy of the IL-5 receptor blocker benralizumab on chronic rhinosinusitis with nasal polyposis (CRSwNP), associated with severe eosinophilic allergic asthma. Ten patients with severe eosinophilic allergic asthma and CRSwNP were enrolled. Sino-nasal outcome test (SNOT-22), numerical rating scale (NRS), endoscopic nasal polyp score, Lund Mackey CT (computed tomography) score, and blood eosinophil count were measured at baseline and after 24 weeks of treatment with benralizumab. All the above clinical, endoscopic, imaging, and hematological parameters significantly improved after 24 weeks of treatment with benralizumab. In particular, SNOT-22 decreased from 61.10 ± 17.20 to 26.30 ± 19.74 (P < 0.001), NRS decreased from 7.20 ± 1.55 to 3.40 ± 2.22 (P < 0.001), the endoscopic polyp nasal score decreased from 4.20 ± 1.32 to 2.50 ± 1.78 (P < 0.001), the Lund-Mackay CT score decreased from 16.60 ± 5.50 to 6.90 ± 5.99 (P < 0.001), and blood eosinophil count decreased from 807.3 ± 271.1 cells/µL to 0 cells/µL (P < 0.0001). These results strongly suggest that benralizumab exerted a very effective therapeutic action on CRSwNP associated with severe asthma, thus improving nasal symptoms and decreasing polyp size.