Who "apparently" more spends, "in reality" spends less. Spending "a little" more for the rental of the extracorporeal lithotripter can save "a lot" about the days of hospitalization for urinary stones.

OBJECTIVE: The right to health (according to the Article 32 of the Italian Republic Constitution) is financially conditioned; for this reason the National Health System (NHS) has the objective of rationalize health expenditure according to the criteria of efficiency, effectiveness and economy. This paper is an example of rationalization concerning the extracorporeal shock wave lithotripsy (ESWL). MATERIALS AND METHODS: Hospital admissions for urinary stones were taken into account. "Edotto", the database of the Puglia region has identified 23 inpatient admissions during which was performed ESWL. A single operator performed ESWLs with a Storz lithotripter, Modulith SLK. RESULTS: The average hospital stay is conditioned by days "to wait" lithotripsy. In 2014 the hospitalization days "waiting for" lithotripsy were 100. The results were subjected to SWOT analysis and discussed with the Boston Consulting Group Matrix. DISCUSSION: Constant availability of the lithotripter would spare 100 days of hospitalization, amounting to € 88,200.00. This waste of resources corresponds to an additional cost equal to 98.3% on the cost for the rental of the lithotripter. Instead, reducing "unnecessary" hospitalization days would get a saving of 79.3% on the rental cost. It is as if for 46 days of the lithotripter rent were paid 46 days, while for 365 days of the lithotripter rent were paid only 11.8 sessions per year. CONCLUSIONS: Rationalization of resources is not necessarily a synonym of "reduction" of resources, but of reduction of waste in the NHS. A good plan is the most important rational basis to get more resources. About the process taken into account it is seen as an investment of € 21,450.00 would keep unchanged the effectiveness of lithotripsy service but would add efficiency and economy (increase of sessions/year, increase in the active mobility, increase in orthopedic treatments) and would drastically reduce the number hospital days (a waste).

Once-a-day Tadalafil administration improves the spermogram parameters in fertile patients.

OBJECTIVES: We explored the safety of Tadalafil once-daily treatment for 12 week and its effects on semen quality in a clinical subpopulation of men with psychogenic erectile dysfunction (ED). PATIENTS AND METHODS: Twenty-seven men, between 19 and 35 years, unaware of their fertility status, suffering from psychogenic ED were enrolled. The examination of the seminal fluid was performed twice before administration of Tadalafil and twice after three months of continuous daily administration of Tadalafil 5 mg. The volume of the seminal fluid, the concentration of sperm, the concentration of sperm with type "a+b" motility, the concentration of sperm with type "a" motility, the concentration of normal sperm were taken into consideration. The results before treatment with Tadalafil (T0) and after 3 months of treatment (T3m) were compared. RESULTS: The administration of once-daily Tadalafil 5mg, brings to an average increase of the total number of sperm cells, both total and fast motility (type a) and the percentage of nemasperms, and to an average increase of semen volume of only 0.41 ml. These quantitative and qualitative improvements of the seminal fluid resulted statistically significant as regard motility, nemasperm percentage and seminal fluid volume. No unespected safety findings were observed. CONCLUSIONS: Tadalafil administration improves the quality of sperm cells and seminal fluid: in particular motility, percentage of nemasperms and volume of seminal fluid. We emphasize the safety of the once-daily treatment with tadalafil 5mg and the positive effects on spermatogenesis.

PCA3 score of 20 could improve prostate cancer detection: results obtained on 734 Italian individuals.

BACKGROUND: The role of PCa3 score in the diagnostics of prostate cancer (PCa) is still under debate, mainly due to the lack of a univocal cut-off useful alone or within nomograms proposed by Urologists. Aim of present study is to compare different PCA3 score cut-off values (20, 25, 35 and 50) observed in 734 patients with suspected PCa who were monitored for about three years with single or multiple biopsies. METHODS: 734 patients who underwent first prostate biopsy for suspected PCa were enrolled. One month later the first biopsy result was obtained, both negative and positive PCa patients were investigated by means of PCA3 score, in order to establish risk of PCa presence on repeated biopsies. RESULTS: PCA3 score was significantly higher (p<0.001) in PCa patients to the PCa negative ones, while tPSA did not significantly vary. The best negative predictive value (NPV 97.5%) and sensitivity (95.4%) result were obtained when a PCA3 score of 20 was used. At cut-off value of 50, the 75% of patients resulted as false positive. CONCLUSIONS: PCA3 score of 20 could be safely introduced in the prostate cancer screening diagnostic flow chart, since it provides important information regarding the outcome of re-biopsy.

Evaluation of the diagnostic and predictive power of PCA3 in the prostate cancer. A different best cut-off in each different scenario. Preliminary results.

INTRODUCTION: Aim of this study is to evaluate the diagnostic performance of PCA3 in patients with indication to perform a new biopsy, according to the histological doubt such as High Grade Prostatic Intraepithelial Neoplasia (HGPIN) or Atypical Small Gland Proliferation (ASAP) or the clinical suspicion. MATERIALS AND METHODS: One hundred men were enrolled. We used the PCA3 - PROGENSA™ procedure. After the PCA3 test a repeated prostate biopsy was proposed. The histological findings were correlated to the PCA3 scores. We calculated the positive predictive value (PPV), the sensibility, the specificity, the Youden's index, the ROC curves, the area under the curve (AUC) for each cut-off value of PCA3 score. RESULTS: These results are preliminary, because at present only 50 of the 100 enlisted men were subjected to rebiopsy. We calculated the best cut-off PCA3 score 20 at the first diagnosis; for patients with HGPIN or ASAP at first biopsy the best sensitivity cut-off is 45; the best cutoff is 45 when you already have a diagnosis of HGPIN, and 35 for ASAP. If we normalize the PCA3 score to the prostate volume, the best cut-off would be 20, with 100% sensitivity with a prostate volume of 65 ml. All results are statistically significant. The real problem, also present in literature, is the constant presence of not diagnosed prostate cancers, for any cut-off value. CONCLUSIONS: Our preliminary results suggest that, to get the best diagnostic performance, it would be wrong to maintain a single cut-off, but it should be chosen according to the scenario of the patients subgroup. It is to explore the possibility to search for the PCA3 in the serum to bridge the gap of the aggressive PCa missed by the urinary test.

Quick Prostate Test (QPT): motion for a tool for the active contribution of the general pratictioner to the diagnosis and follow up of benign prostatic hyperplasia.

INTRODUCTION: Less than 40% of men with LUTS consult their doctor. Patients consider the LUTS as physiological and are resigned to endure them. It is necessary to foster awareness of the micturition disorders, to monitor their development and to assess the effectiveness of therapies. At present the only validated test is the IPSS-Q8, but in Italy it is used by only 4% of General Practitioners (GPs). Because the IPSS is complex and not easy to handle, we need a more simple test but nevertheless efficient. The Italian Society of Urology (SIU) and the Italian Society for Interdisciplinary Primary Care (SIICP) presented the "Quick Prostate Test" (QPT) in November 2012. We aimed to evaluate the efficiency of QPT versus the IPSSQ8 and its suitability in primary care. MATERIALS AND METHODS: The QPT is composed of 3 questions to be answered "yes" or "no." The answer "yes" just to one question makes "positive" the test. We enrolled 64 men, ≥ 50 years old, suffering from BPH, extracted from the database of five GPs. The patients were randomized into two arms: to the arm 1 only QPT was administered, to verify efficiency of the test; to the arm 2 both the QPT that the IPSS-Q8 were administered. RESULTS: Into the arm 1, the 96.4% has tested positive for QPT. Into the arm 2, the 89% of patients with one or two positive responses to the QPT showed a moderate IPSSQ8 score; the 75% of the patients with three positive responses to the QPT had a serious IPSS-Q8 score. The GPs (80%) have expressed the highest level of satisfaction for the QPT for the "time of administration" and for the "simplicity" of the test. CONCLUSIONS: The experience with the QPT has shown that the test is efficient and suitable in the primary care setting. We want to encourage the GPs to use the QPT for the monitoring of patients with lower urinary tract symptoms (LUTS) and to contribute to the validation of the test.

Potential usefulness of CTC detection in follow up of prostate cancer patients. A preliminary report obtained by using Adnagene platform.

OBJECTIVE: Prostate cancer (PCa) represents one of the most important medical problems for males, being the second major cause of cancer death. Routinely, PCa patients are followed up with both periodic evaluation of serum PSA levels and imaging. Recently, alternative laboratory methods were proposed for PCa patients' monitoring, with contrasting results. Aim of the present study was to evaluate the usefulness of a new commercially CE-IVD kit for detection of prostate circulating tumour cells. Our intention was to verify the Adnagene platform usefulness to identify patients with disease progression, whatever treatment ongoing, in order to modify the therapeutic process even before treatment failure is evident with imaging methods. MATERIALS AND METHODS: Twenty-one patients were enrolled and subdivided into three groups: n = 10 high risk tumor PCa patients; n = 6 low risk PCa patients; n = 5 sbjects without any signs of PCa. AdnaTest Prostate Cancer kit was used for enrichment and molecular characterization of prostate circulating tumour cells. RESULTS: Healthy subjects (with BPH) and patients without metastases resulted as negative, while 3 out of 10 high risk PCa patients were positive at least for one molecular marker like PSA, while only two showed positivity for PSMA mRNA. Our results indicate that the test specificity is 100% and the sensitivity is 100%; of course the sample is too small to give it statistical validity. In detail we verified that only the "not responder" patients resulted positive for AdnaTest. CONCLUSIONS: The present preliminary report provides evidence that isolation and detection of circulating tumour cells (CTCs) is feasible and it may be useful in the follow-up of patients with advanced prostate cancer. If the results of this preliminary study would be confirmed by a large prospective cohort study, it could be demonstrated that this test is a rapid diagnostic method, based on the analysis of a blood sample and useful to the clinician to decide when to change therapy for patients resistant to castration or able to confirm that, at that time, the therapy is effective.

TURP and PVP treatments are really similar? From subjective feeling to objective data. Pilot study (proof of concept) prospective randomized trial.

Transurethral resection of the prostate (TURP) is the gold standard of surgical treatment of the BPH. Alternative surgical techniques have been developed for patients with blood coagulation disorders secondary to anticoagulants or antiplatelet intake. The photoselective vaporization of the prostate (PVP) by Green Laser is a technique used with the aim of obtaining tissue ablation with instantaneous hemostasis. In our experience we sensed the feeling of some differences between the two technologies. For each patient, we calculated the difference (delta) between Qmax, Qmed, PMR to 6 months after surgery compared with preoperative measurements (deltaQmax, deltaQmed, deltaPMR). In the comparison between PVP and TURP the differences between the results, in terms of deltaQmax (11.04 vs. 8.9 ml/sec), deltaQmed (5.87 vs. 3.64 ml/sec), deltaPMR, are not statistically significant, therefore it is clear that if we consider the average of the results, significant differences do not come out between the two techniques. Instead, the real differences emerge from consideration of standard deviations: the higher standard deviations of Qmax and Qmed of PVP compared to TURP (8.29 vs 5.01; 5,51 vs 1.64) indicate that the final result of an intervention being performed by TURP is nearest to the expected preoperatively result; on the contrary the final result of an operation being performed by PVP shows a significantly higher variability. As regards for our clinical decision it follows that the proposal of a surgical procedure which shows the "risk" of a higher variability of the final result is justified only in cases of high cardiovascular or blood coagulation "risk".

Spontaneous rupture of urinary bladder: a case report and review.

Spontaneous rupture of the bladder is a rare event. The clinical presentation shows the signs and symptoms of peritonitis, but the diagnosis is made at the operating table. This event is burdened with a high mortality rate. We present a case report of a 73-year-old man who came to our observation. He was a chronic carrier of urinary catheter, at least 7 times removed traumatically by himself. At the time of admission he showed drastic reduction in urine output, absence of hydronephrosis, normal functioning of the catheter, a tense and widely meteoric abdomen, the presence of air-fluid levels, normal kidneys, absence of free fluid in the abdomen. The CT showed a fluid collection of about 7 cm diameter between the bladder and rectum. The explorative laparotomy found a small fissuration of the posterior wall of the bladder. For his severe conditions, the patient died a few hours after surgery, in intensive care unit. Although it is a rare event, since 1980, 177 cases of spontaneous rupture of the bladder are reported in the literature. Their causes may be essentially divided into two groups: for increase of intravesical pressure; or for weakening of the bladder wall. In most cases, the spontaneous rupture of the bladder takes place in presence of a urothelial neoplasm or after radiation therapy of the pelvic organs. The etiology of spontaneous rupture of the bladder in our case does not relate to a bladder tumor or radiotherapy. It may have been caused by repeated episodes of acute retention of urine with extreme bladder distension up to 3 liters. It is not easy to think of a bladder perforation in patients presenting signs of peritonitis without a history of bladder cancer or pelvic radiotherapy. A CT with intravesical contrast medium could help the diagnostic orientation.

Torsion of a neoplastic intrascrotal testis: when the torsion reveals the mass. A case report and review.

Cases of torsion of the spermatic cord are rare in men over 30-years-old. Testicular tumors manifest themselves rarely with symptoms of acute scrotum. We report the case of a 38-years-old patient who presented for a suspected left testis torsion. On examination, the testicle was markedly increased in size and painful. The manual derotation made pain dramatically disappear. He came to our attention after about a month asking for an orchidopexy. During the surgery a biopsy was performed. The diagnosis was a Yolk Sac Tumor. A radical inguinal orchiectomy was performed with left hemiscrotal excision, "in block". He performed four cycles of chemotherapy and with no recurrence after 12 months of follow-up. In literature only seven cases of torsion of an intrascrotal testicle with cancer are reported. Our case is the eighth one.

Comparison of ESWL outcome between Wolf Piezolith 3000 vs. storz Modulith Slk. it is the man who makes efficient the machine.

AIM OF THE STUDY: The choice of an extracorporeal lithotripter for extracorporeal shock wave lithotripsy (ESWL) of urinary stones must be done with efficacy criteria. It is easy to demonstrate the advantages of the third-generation lithotripters compared to previous generations of lithotripters. This study has the purpose of evaluate whether it is possible to establish differences in effectiveness between two third generation lithotripters. METHODS AND RESULTS: We report about the last 100 ESWL treatments carried out with the Wolf Piezolith 3000 and the last 100 with the Storz Modulith SLK, performed by the same single operator. Stones were stratified by site and size. Comparison was made considering the number of shock waves per session and the number of sessions and the outcomes. The results showed no statistically significant differences. In fact, the cumulative stone-free rate was 93% for the Wolf Piezolith and 91% for the Storz Modulith. CONCLUSIONS: The technical differences between lithotripters concern the energy delivered, the shape of the acoustic focus, the depth of focus, the coupling surface, the mobility of the head, the alignment mode and the simultaneous use of ultrasonography and radiological pointing. These differences are never obtained from published series. Furthermore data of patients and stones that have not been treated for the difficulty of stone targeting due to the depth of acoustic focus (high BMI), the limited inclination of the head or to the patient intolerance to shock waves are not usually reported. The results obtained by the same operator are comparable even when are obtained with different machines of the same generation. The real differences could arise if we would take into account also the patients which were excluded from evaluation because, for the same generation of lithotripters, the results depend on the operator, while the eligibility to treatment of the patient depends on the characteristics of the machine.

"And if a one night a renal colic..." the strange case of renal vein thrombosis without renal cancer.

INTRODUCTION: It is common experience to all urologists to manage many patients admitted at night from the casualty ward with a diagnosis of "therapy-resistant renal colic". However not all the patients with flank pain really suffer for renal colic, although painful somatic irradiation refers to the same areas. CASE REPORT: A seventy years old male patient was admitted from the casualty ward for left renal colic. Laboratory tests showed normal creatinine, mild reduction of albuminemia, elevated triglycerides and cholesterol at the upper limit of normal. The pain had risen sharply a few hours before. For some years the patient suffered nocturia, but he never made an urologic consultation. Ultrasonography performed in the casualty ward demonstrated normal findings with no hydronephrosis but the presence of left perirenal extravasation with "casting-like" aspect and extending to the pelvis. Contrast-enhanced computed tomography (CT) revealed the presence of left renal vein thrombosis and acute segmental pulmonary embolism. The left kidney, apart from increased volume and reduced parenchymal impregnation, showed no neoplastic nodule. The case presented as unusual according to the opinion of consulted nephrologists, vascular surgeons and urologists (also from others hospitals and universities). After informed consent of the patient (stressing seriousness and singularity of his condition), we decided to treat him as a deep vein thrombosis. We administered an heparin bolus (80UI/kg), followed by the infusion of heparin (18UI/kg/h) using a peristaltic pump for 14 days. RESULTS: CT performed after 14 days of treatment showed the full resolution of renal vein thrombus and of pulmonary embolism. Thereafter a nephrotic syndrome was diagnosed and the patient was took in care by the nephrologist. Nephrotic syndrome preceded the hospital admission of the patient and was the etiological cause of renal vein thrombosis. DISCUSSION: The well known causes of acute flank pain reported in textbooks include renal and perirenal inflammatory processes, renal cell or transitional cell cancers of the kidney or of the urinary tract, obstruction of the urinary tract by stones or stenosis, hydronephrosis of different etiology whereas vascular causes are not often mentioned. CONCLUSIONS: After the diagnosis of left renal vein thrombosis, the more probable associated urological is a renal cell carcinoma. Excluding renal cancer other possible causes of thrombosis are medical conditions such as amyloidosis, multiple myeloma, nephrotic syndrome, thrombophlebitis.

Hydrocele with surprise. Case report and review of literature.

INTRODUCTION: Hydrocele is a fluid collection between tunica vaginalis and testis. Approximately 10% of testicular cancers occurs with a reactive hydrocele. CASE REPORT: A 64 year old male presented with a 30 year history of left hydrocele, progressively increasing. Physical examination demonstrated a left large hydrocele, transilluminable, not under pressure. Ultrasonography showed a "corpusculated hydrocele with vaginal hypertrophy jutting out near the head of the epididymis, perhaps caused by an inflammatory reaction [...]" As the patient showed only a minimal discomfort due to the groin swelling, without pain, surgical excision was planned without priority (Class C < 180 days). RESULTS: The surgical exploration showed a paratesticular papillary neoplasm of 3 cm. Intraoperative pathologic examination of a frozen sample demonstrated a "borderline papillary cystadenoma". The Left orchifunicolectomy was performed. The definitive histological examination showed a "left paratesticular Papillary Serous Tumor of Low Malignant Potential (PSTLMP) with morfoimmunoistochemical features of Mullerian origin of neoplasm". Computed tomography (CT) was negative for lymph nodes and metastasis. In agreement with the oncologist we decide for atchful waiting. DISCUSSION: Despite of rich personal experience of resections and eversions of the vaginal tunic, an urologist rarely observes a case of paratesticular cancer. A PubMed search found 28 citations between 1985 and 2010 with 42 reported cases of paratesticolar neoplasm, including 27 with malignancy features. Rhabdomyosarcoma is the most common, followed by mesothelioma, adenocarcinoma and neuroblastoma. This case report consists of a "borderline" neoplasm for which in the literature, after orchiectomy, it is reported no case of recurrence or metastasis (with a follow up of up to 18 years). CONCLUSION: The banality of the disease never must underestimate the possibility of an undetected cancer.

Liver harvesting surgical technique for the treatment of retro-hepatic caval thrombosis concomitant to renal cell carcinoma: perioperative and long-term results in 15 patients without mortality.

OBJECTIVE: Radical surgical treatment improves the prognosis of patients affected by Inferior Vena Cava (IVC) thrombosis concomitant to renal carcinoma. However, thrombus extension above the infrahepatic IVC represents a major technical topic for surgeons because of the possible occurrence of uncontrollable haemorrhages and tumor fragmentation. We report the results of an innovative surgical approach to caval thrombosis including the isolation of the IVC from the liver as routinely performed during liver harvesting. In the presence of retro-hepatic IVC thrombosis, this technique improves vascular control and allows to perform a large cavotomy with an en-bloc removal of the thrombus and the tumor. METHODS: From January 1995 through June 2003, 15 patients with renal cancer and caval thrombosis were treated at our Institution. Four, ten and one patients were respectively affected by an infrahepatic (Level I), retro-hepatic (Level II) and atrial (Level III) IVC thrombosis. RESULTS: All patients underwent radical surgical treatment. In presence of Level II caval thrombosis, the patients underwent the above reported surgical technique. Perioperative mortality was absent; major morbidity occurred in one patient (6.7%). The thrombus was radically removed in all cases. After a mean follow-up of 53.9 months (5-100 months) all patients but one are still alive. One patient died 9 months after surgery with multiple bilateral pulmonary metastases. CONCLUSIONS: Isolation of the retro-hepatic IVC is a safe and effective manoeuvre to significantly reduce perioperative mortality and morbidity in patients affected by Level II caval thrombosis concomitant to renal carcinoma.