Malakoplakia of the urinary bladder: A review of the literature.

OBJECTIVE: The aim of the study is to make a review of the literature about bladder malakoplakia. MATERIAL AND METHODS: We searched articles on the PUBMED web-literature database with the following keywords: "vesical malakoplakia" and "bladder malakoplakia". In the literature we found 254 articles. At final we have excluded 219 articles, including in our study only 35 articles. RESULTS: The overall average age found was 50.85 years. The average age of men was 43.22 years, while that of women was 53.37 years. 75% of the patient cases were women and 25% were men. Regarding comorbidities, in 5.55% of the cases were missing whereas 47.22% of the patients suffered from recurrent urinary tract infection (UTI) and 19.44% from immune system disorders. Urine culture was positive in 69.44% with E.coli being isolated in 92% of cases. Hydroureteronephrosis was present in 44.44% of the cases: left in 6.25% of cases, right in 18.75% and bilateral in 75%. The mean serum creatinine of patients with hydroureteronephrosis was 5.11 (1-21) mg/dl. The most frequent site of the lesion was the vesicoureteral junction (VUJ) (42.31%), followed by the trigone (38.46%). 30.56% of patients were treated with antibiotic and surgery (transurethral resection of bladder, partial or radical cystectomy), less frequent options were antibiotics alone and surgery alone. The recurrence rate was 15%. CONCLUSIONS: Malakoplakia is a disorder usually related to other affections, like UTI and immunodepression, and it seem to be caused by an abnormal macrophage function. In almost half of the described cases of isolated bladder malakoplakia, hydroureteronephrosis and renal failure were present.Treatment is not standardized, but both medical and surgical therapies are effective to avoid recurrence.

Prolonged antibiotic therapy increases risk of infection after transrectal prostate biopsy: a case report after pancreasectomy and review of the literature.

Infection due to prostate biopsy afflicted more than 5% of patients and is the most common reason for hospitalization. A large series from US SEER-Medicare reported that men undergoing biopsy were 2.26 times more likely to be hospitalized for infectious complications within 30 days compared with randomly selected controls. The factors predicting a higher susceptibility to infection remain largely unknown but some authors have higlighted in the etiopathogenesis the importance of the augmented prevalence of ciprofloxacin resistant variant of bacteria in the rectum flora. We present one case of sepsis after transrectal prostate biopsy in a patient with history of pancreatic surgery. Based on our experience patients candidated to prostate biopsy with transrectal technique with history of recent major surgery represent an high risk category for infective complication. Also major pancreatic surgery should be consider an high risk category for infection. A transperineal approach and preventive measures (such as rectal swab) should be adopted to reduce biopsy driven infection.

Diagnostic-therapeutic pathway for small lesions of the testis.

Objective of our study was to define a diagnostic-therapeutic pathway for proper treatment of not-palpable testicular masses, that may be benign in 38% of cases. Since the intraoperative diagnosis is difficult to reach in particular in small lesion (< 8 mm) and the risk of tissue loss in frozen section analysis occurs frequently, we propose a diagnostic flow chart for the best management of small testis lesions. This proposed protocol has to be shown in details to physicians and patients, who must understand the clinical implications and the risk to undergo a second radical surgery.

Modifications of the bladder wall (organ damage) in patients with bladder outlet obstruction: ultrasound parameters.

INTRODUCTION: Progressive changes in the bladder wall are observed in men with lower urinary tract obstruction secondary to benign prostatic enlargement (BPE). The high pressure voiding causes initially an increase in the proportion of smooth muscle (hyperplasia/hypertrophy of the detrusor) that develops to major changes in the advanced stages of bladder decompensationi (fibrosis), hyperactivity and decreased functional capacity. Early identification of bladder changes by noninvasive transabdominal ultrasound can suggest therapeutic choices that can prevent further organ damage in the bladder wall. Aim of our study is to review ultrasound (US) parameters, that could be considered reliable and reproducible, in order to demonstrate the damage of the bladder wall. METHODS: We performed a literature review to detect reported US parameters according to our aims. Our clinical experience was evaluated in retrospective manner to detect feasibility and limitations of the evaluation of these parameters in men with different degrees of bladder damage secondary to BPE. RESULTS: Measurement of the bladder wall thickness (BWT) or detrusor wall thickness (DWT) by US is reliable, with at least 3 measurements of the anterior bladder wall taken at a filling volume of 250 ml. In particular, the DWT [thickness of the hypoechoic muscle between two hyperechoic layers corresponding to serosa and mucosa] is considered the best diagnostic tool to measure detrusor hypertrophy using cut-off value > 2.9 mm in men. US derived measurements of bladder weight (Estimated Bladder Weight, EBW) is another noninvasive tool for assessing bladder modifications in patients with bladder outlet obstruction (BOO) with a cut-off value of 35 gr. Technique for measuring the BWT and EBW relies on conventional US 7.5-4 MHz using the automatic system of computation (BVM 6500 3.7 MHz). The variability of intra-operator (4.6 to 5.1%) and interoperator measurements (12.3%) is acceptable. Also conventional US detects established signs of bladder damage: diverticulosis, trabecolations in the bladder wall (pseudo-diverticula), calculi and post-void residual urine (PVR) (> 50 cc). Furthermore the Intravescical Prostate Protrusion (IPP), easy measured by transabdominal ultrasound, is strongly correlated to obstruction in men with BPE (cut-off 12 mm). Measurement, scoring and monitoring of the cervico-urethral obstruction in men with symptomatic BPE is possible by the non-invasive US of the bladder wall. Early identification by measuring DWTand EBW in addition to established US paremeters has the advantage of suggest the adoption of therapeutic measures sufficient to prevent progression of bladder damage. CONCLUSIONS: US derived measurements of DWT and EBW are reproducible and reliable. Transabdominal US also detect established bladder damage such as diverticula, stones and PVR, while IPP measurement seems to be correlated to BOO. US bladder parameters are considered potential noninvasive clinical tools for baseline assessment of patients with BOO. In particular noninvasive US parameters could be useful for longitudinal studies monitoring men with lower urinary tract obstruction secondary to BPE.

Transrectal ultrasound (TRUS) and TRUS-biopsy accuracy in potential candidates for PRIAS active surveillance protocol.

AIM: Evaluate the transrectal ultrasound (TRUS) and TRUS-guided Biopsy (TRUS-Bx) accuracy in patients with low risk prostate cancer (PCA) that were potential candidate for PRIAS active surveillance (AS) protocol but underwent to immediate radical prostatectomy (RP). METHODS: 616 men were extracted from our institutional RP database. We selected the patients who met PRIAS inclusion criteria. The primary outcome was to evaluate the positive predictive value (PPV) and the specificity of suspected lesions at TRUS. The secondary outcome was to evaluate the TRUS-Bx accuracy in term of pathological upstaging and pathological upgrading with respect of RP specimen pathology report. RESULTS: 147 men of 616 (23.8%) in our RP database met PRIAS criteria; in this group we found 66 suspected lesions at TRUS examination (66/147: PPV 44.8%). Prostate cancer was really present in the biopsy specimen in only 32/66 of suspected lesions; in 28/66 the suspect lesion at TRUS was in the same position of the index lesion at final pathology. TRUS/biopsy specificity was 48% and TRUS/surgical specimen specificity 39%. TRUS-Bx staging accuracy: upgrading between biopsy and RP was recorded in 57/147 (38%) whereas 30/147 (20%) were upstaged on final pathology up to N1. CONCLUSIONS: TRUS and TRUS-Bx are insufficient tools to detect the grade, the location and the extent of PCA. New emerging techniques, such as US-MRI fusion biopsy and 3D template-guided transperineal saturation biopsy are promising to minimize the risk of misclassification and therefore to better select the best option of treatment (radical treatments or focal therapies or active surveillance) in each patient with low risk prostate cancer.