Unusual clinical scenarios in Urology and Andrology.

This collection includes some unusual cases and how they were diagnosed and treated. Case 1: A case of a patient with primary hyperthyroidism presenting with a submucosal ureteral stone after endoscopic lithotripsy was described. After multiple endoscopic treatment, the stone was successfully removed by open ureterolithotomy recovering ureteral patency and normal renal function. Case 2: A case of burned-out testicular cancer with atypical lymphatic spread (stage II A) was presented. After right orchiectomy and complete remission of tumor markers, due to atypical metastases location and uncertain histology, the patient was treated with systemic therapy based on bleomycin, etoposide and cisplatin (PEB). At re-staging after chemotherapy computed tomography showed reduction of all node metastases and an observation protocol was proposed. Case 3: A patient was readmitted to hospital after 12 days from an uneventful Robot-Assisted Radical Prostatectomy (RARP) for prostate cancer due to lower abdominal pain plus abdominal distension, nausea and constipation not responsive to medical therapy. Computed Tomography showed colon and small bowel dilatation without any evidence of anatomical or mechanical obstruction. Laparoscopic abdominal exploration confirmed bowel distension without evidence of obstructing lesions. Ogilvie's Syndrome or acute colonic pseudo-obstruction (ACPO) was diagnosed. The patient fully recovered and was discharged six days after the procedure. Case 4: A case of recurrent Acute Idiopathic Scrotal Edema (AISE) was diagnosed on clinical signs together with the decisive help of pathognomonic ultrasound findings as the "fountain sign". Case 5: Small bilateral testicular nodules were diagnosed in a 30-years old patient undergoing scrotal ultrasound in follow up of acute lymphoblastic leukemia. Ultrasound guided testis sparing surgery was performed demonstrating Leydig cell tumors.

Effect on prostatic specific antigen by a short time treatment with a Curcuma extract: A real life experience and implications for prostate biopsy.

INTRODUCTION AND OBJECTIVES: PSA elevation is associated with prostate cancer and it is used in screening programs for its diagnosis. It is one of the most common indications for referral to an urologist. There's no consensus about what to do in PSA elevation management. Antibiotics, nutraceuticals or anti-inflammatories are commonly prescribed in daily practice. Our objective was to verify the effect on the PSA value of a short 30-day trial of a curcuma extract, than to discuss the implications in terms of reducing the number of prostate biopsies performed. PATIENTS AND METHODS: We enrolled 50 consecutive patients admitted at our attention for a first PSA over the level of 4 ng/ml or for a suspected PSA rising defined as PSA velocity (PSAv) > 0.75 ng/ml/years. They received treatment with curcuma extract, 2 tablets per day for 30 day. All patients received a second PSA measurement and TRUS within 6 days from the end of the therapy. In case of PSA reduction below 4 ng/ml, patients were reassured and invited to repeat a PSA control over the time. When PSA level were persistently high over 4 ng/ml or in case of any rising, patients underwent a transrectal ultrasound guided 12-core prostatic biopsy (TRUSbx). RESULTS: Mean age of the patients was 64.56 ± 8.88 (range, 42- 81 years). Prostate volume was 48.34 ± 15,77 ml (range, 18-80 ml). At visit 1, PSA value was in mean 6,84 ± 3.79 ng/ml (range 2.93-21ng/ml). Consequently, mean PSA density value was 0.16 ± 0.16 (range 0.05-1.11). PSA free and PSA total ratio at baseline was 16.85 ± 3.9% (range 8-26%). At visit 2, the prostate volume did not change. Total PSA was 4.65 ± 2,67 ng/ml (range 1-16.82 ng/ml). PSA free and PSA total ratio (PSAF/T) after treatment was 19.68 ± 5.35 % (range 7.8-29%). The differences of total PSA and PSAF/T between visit 1 and visit 2 were < 0.0001 and p < 0.0036, respectively. We performed 26 TRUSbx. Prostate cancer was diagnosed in 6 cases, PIN HG in 2 cases and non neoplastic findings in the remnants 18 patients. CONCLUSIONS: Use of the Curcuma extract is able to lower the PSA value after a 30-day intake period. We are not able to state that the reduction of PSA after intake of this Curcuma extract may exclude a prostate cancer. We need further studies to evaluate that.

Explorative surgery for acute scrotal pain: The importance of patient age, side affected, time to surgery and surgeon.

INTRODUCTION AND OBJECTIVE: Testicular torsion must be diagnosed quickly and accurately. The delay of the diagnosis and the subsequent delay of surgery may lead to loss testicular viability and orchidectomy. Aim of our retrospective evaluation was to define which element should be considered as major support to the clinician in distinguishing spermatic cord torsion from the other diseases mimicking this clinical emergency requiring surgical exploration. MATERIAL AND METHODS: We retrospectively reviewed all clinical and instrumental data of emergency scrotal exploration performed for acute scrotal pain at two different Urological Department in a 10 year period. Results of surgical exploration represented the four diagnostic categories in which patients were divided for statistical evaluation. We evaluated the relationship between diagnosis performed by testicular surgical exploration and the all clinical data available including surgeon involved in the procedures. RESULTS: A total of 220 explorative scrotal surgery were considered. We divided the cases in 4 categories according to the diagnostic results of each surgical procedure. Of all, spermatic cord torsion was diagnosed in 45% (99/220). The total testis salvage rate was of 78.8%. The patients with a diagnosis of spermatic cord torsion were older than patients with appendix torsion (15 vs 11 years in mean). When the affected side was the left, the probability to have a diagnosis of spermatic cord torsion was higher than the right side [χ2 (2, N = 218) = 11.77, p < 0.01]. Time elapsing between onset of symptoms and testicular salvagewas significantly lower even than in case of appendix torsion/necrosis (p < .0001), and of others pathologies diagnosed (p = .0383). CONCLUSION: In case of spermatic cord torsion, in addition to the clinical data, patient age and left side affected may represent an independent diagnostic predicting factor. The time elapsing between onset of symptoms and explorative surgery remain the only still prognostic factor for testicular viability.

May ultrasound probe size influence pain perception of needle piercing during transrectal prostate biopsy? A prospective evaluation.

INTRODUCTION AND OBJECTIVE: Transrectal ultrasound guided prostate biopsy (TRUS-Bx) is the definitive step in the diagnosis of prostate cancer (CaP). Patients (pts) generally experience significant pain during the procedure at the point that biopsy should be accompanied by some form of anesthesia. Several different factors influence pain perception (PP) during TRUS-Bx. In our study we want to assess that the use of an ergonomic smaller sized probe reduces PP during the procedure independently from the administration of local anesthesia or pain relieving drugs. MATERIALS AND METHODS: This was a prospective, randomized study in which 114 pts who underwent TRUS-Bx due to abnormal PSA and/or to digital rectal examination (DRE) suspicious findings were considered eligible. Pts were split in two TRUS-Bx groups into which we used two different sized ultrasound probes. In group 1, 61 pts underwent TRUS-Bx with ALOKA end fire probe (size 74 mm). In group 2, 53 pts underwent TRUS-Bx with B-K Type 8818 probe (size 58 mm). Both groups were treated with no local anesthesia or pain relieving drugs. Pain was evaluated three times using a 10-point visual analogue scale (VAS), during the DRE (VAS 1), during the insertion of the probe (VAS 2) and during the needle piercing (VAS 3). RESULTS: Mean age of pts was 68.03 (SD 8.51); mean tPSA and mean prostate volume was 7.75 (SD 4.83) and 45.17cc (SD 17.7), respectively. The two groups were homogeneous respect to tPSA (p = 0.675) and to prostate volume (p = 0.296); age was significantly different (p = 0.04) between Group 1 (65.93) and Group 2 (70.43), whereas no statistically significant correlation between VAS 3 and age was observed (p = 0.179). Analyzing pain perception, we found no statistically significant difference between the two groups in DRE (VAS 1; p = 0.839); on the contrary, patients in Group 1 experienced on average more pain than other in Group 2 both during the insertion of the probe (VAS 2 3.49 vs 1.09; p < 0.001) and during the needle piercing VAS 3 (2.8 vs 2.00; p < 0.05). The discomfort during probe insertion and manipulation was perceived as very high (VAS 2 > 5) in 42.6% of patients in Group 1 and in 9.4% in Group 2. Globally, the procedure was well tolerated (mean VAS score < 3) in 77% of patients in Group 1 and in 90% in Group 2. The proportion of patients who experienced more than moderate pain (VAS > 5) during needle piercing ranged 24.6 % in Group 1 to 18.9 % in Group 2. CONCLUSIONS: Patients who underwent a TRUS-Bx with the 58-mm circumference probe were found to experience lower degree of pain not only during the insertion of the probe through the anal sphincter, but also in the moment of needle piercing.

Buccal mucosa is a promising graft in Peyronie's disease surgery. Our experience and a brief literature review on autologous grafting materials.

AIM: Peyronie's Disease (PD) is an under reported acquired benign condition that, at the moment, is not curable with medical therapy. Surgery represent the gold standard of treatment. Surgical approaches are several and they consist in "plication techniques" or plaque incision/excision with grafting of resulting albuginea defect. Among grafting procedures, albuginea defect substitution with autologous materials demonstrated over the years not inferior results respect to heterologous grafts. Buccal mucosa graft (BMG) is not usually emphasized in many review articles and clinical series are yet limited. METHODS: We present our experience with seventeen plaque incision procedures and BMG in surgical correction of complex penile curvatures due to PD performed in a period of 30 months. Our analyses was focused on buccal mucosa graft characteristics as major determinant of the surgical success. We also conducted a brief literature review on autologous grafting materials used in reconstructive penile surgery for PD. RESULTS: Our cosmetics and functional results consists in a 100% of functional penile straightening with no relapses and 5,8% of de novo erectile dysfunction. Mean age was 56.4 years, mean follow-up of 22.5 (6-36) months. No complications graft related were observed. Operative time was 115.3 minutes in mean. Over 94% of patients referred they were "really much better" and "much better" satisfied based on PGI-I questionnaire administrated at the last follow- up visit. CONCLUSION: BMG is revealing as an optimal choice for reconstructive surgery in PD. Anatomical characteristics consisting in the great elasticity, the quick integration time and the easy harvesting technique lead to high cosmetics and functional success rate, without omitting economical and invasiveness aspects.

An unusual case of primary intrascrotal lipoma.

In daily clinical practice, intrascrotal lesion are commonly detected, both by clinical examination either by ultrasound scan. While 95% of testicular lesions are malignant, most paratesticular lesions are benign. Among these, intrascrotal lipomas must be take into account in differential diagnosis. When they originate from scrotal wall, they named "primary scrotal lipoma". We describe a case of a primary intrascrotal lipoma diagnosed after surgical excision in a young man presented at our Urological Department complaining a painful left scrotal mass.

Ultrasound features of a metastatic seminal vesicle melanoma: A case report.

In this report we describe what we consider to be the second case of seminal vescicle (SV) metastasis from an unknown primary melanoma. only presenting symptom was a palpable firm nodule of the right prostate base on digital rectal examination (DRE). The diagnosis, after prostatic transrectal ultrasound examination (TRUS), was performed by ultrasound guided biopsy. We underline that prostatic TRUS evaluation is mandatory in case of abnormal digital rectal examination. Seminal vesicle must be always evaluated.

Could hyaluronic acid (HA) reduce Bacillus Calmette-Guérin (BCG) local side effects? Results of a pilot study.

BACKGROUND: Bacillus Calmette-Guérin (BCG) is considered the most effective treatment to reduce recurrence and progression of non-muscle invasive bladder cancer (NMIBC) but can induce local side effects leading to treatment discontinuation or interruption. Aim of this exploratory study is to investigate if the sequential administration of Hyaluronic acid (HA) may reduce local side effects of BCG. METHODS: 30 consecutive subjects undergoing BCG intravesical administration for high risk NMIBC were randomized to receive BCG only (Group A) or BCG and HA (Group B). A 1 to 10 Visual Analog Scale (VAS) for bladder pain, International Prostate Symptom Score (IPSS) and number of micturitions per day were evaluated in the two groups before and after six weekly BCG instillations. Patients were also evaluated at 3 and 6 months by means of cystostopy and urine cytology. RESULTS: One out of 30 (3,3%) patients in group A dropped out from the protocol, for local side effects. Mean VAS for pain was significantly lower in group B after BCG treatment (4.2 vs. 5.8, p = 0.04). Post vs. pre treatment differences in VAS for pain, IPSS and number of daily micturitions were all significantly lower in group B. Three patients in group A and 4 in group B presented with recurrent pathology at 6 month follow up. CONCLUSIONS: These preliminary data suggest a possible role of HA in reducing BCG local side effects and could be used to design larger randomized controlled trials, assessing safety and efficacy of sequential BCG and HA administration. TRIAL REGISTRATION: NCT02207608 (ClinicalTrials.gov) 01/08/2014. Policlinico Tor Vergata Ethics Committee, resolution n 69-2011.

Diagnostic and therapeutic utility of transrectal ultrasound in urological office prostatic abscess management: a short report from a single urologic center.

OBJECTIVES: Prostatic abscess (PA) is an infrequent condition in the modern antibiotic era. The everyday use of transrectal ultrasound (TRUS) during diagnostic work-up and the widespread recurrence to prostatic biopsies may lead to an increase of PA diagnosis. In this short report we analyze the patients characteristics and the management of seven recent cases of PA diagnosed in our institution. MATERIALS AND METHODS: The records of 7 patients admitted to our Center for LUTS associated to septic fever or acute urinary retention, was prospectively collected. Suspect of PA was done on digital rectal examination (DRE) and confirmed by TRUS performed after urinary system ultrasound (UUS) evaluation. Patients were admitted to hospital only in case of septic signs. A sovrapubic (SPC) or urethral catheter (UC) was placed depending on symptoms. A TRUS-guided aspiration of PA was performed with patient in lithotomic position, using a 18 gauge two-part needle, side/end fire needle access. Patient was discharged with antibiotic therapy and followed up until complete resolution of the PA and symptoms. RESULTS: Mean age was 62 years (range 24-82). Two patients were diabetics and one was affected by the immunodeficiency acquired syndrome (HIV). In one case, PA was detected after a persistent fever post TRUS guided prostate biopsy. Average prostate volume was 69 ml (range 19-118 ml). DRE was able to diagnose PA only in 2 cases (29%), UUS evaluation in 1 case (14%). All cases were confirmed by TRUS as hypo-anechoic areas with or without internal echoes in all patients. Mean PA dimension was 3.64 cm (range 1.5-8). SPC was placed in 3 cases (43%), UC in 3 patients (43%). Only 1 patient refused catheterization. Side fire needle aspiration was performed in all cases and in combination with end fire access in case of particular location of abscess cavities. Second look was needed in 2 cases (29%). Antibiotics were administered in all cases. The aspirated pus showed a positive culture for Escherichia coli (43%), Klebsiella pneumoniae (29%), Pseudomonas aeruginosa (14%) and Enterococcus faecalis (14%). PA resolution time mean was 9 days (range 3-24). CONCLUSIONS: TRUS evaluation in case of persistent LUTS associated with fever or acute urinary retention is determinant in the diagnosis of PA. Office or institutional management with TRUS needle aspiration is a good option in these cases.

Diagnostic ultrasound-guided excisional testicular biopsy for small (< 1 cm) incidental nodules. A single institution experience.

INTRODUCTION AND OBJECTIVES: The widespread use of scrotal ultrasound (SUS) has led to a marked increase in the number of incidentally detected testicular lesions. A small incidental nodule (STN) has defined as a non palpable (< 10 mm), asymptomatic solid lesion with normal levels of oncological testicular markers. Nowadays the lack of agreement on the topic causes managing problems to andrologists. We present our experience consisting in 8 cases of STN discovered by SUS performed for different clinical indications. MATHERIAL AND METHODS: We retrieved from our ultrasonographic files the clinical information about 717 patients evaluated for andrological problems. Patients with STN underwent to a complete clinical history and physical examination as well as oncological testicular markers measurement and ormonal assessment and then received a diagnostic ultrasound guided excisional biopsy (DEB). Surgical approach was performed through an inguinal incision. Using the coordinates previously obtained from preoperative SUS, STN was localized by intraoperative SUS. The lesion was enucleated and sent to the Pathology department for frozen section examination (FSE). Biopsies of affected testis (TB) were also performed. Post-excision ultrasound has been used to confirm the complete removal of the nodule. Whether pathological findings were benign, testis sparing surgery (TSS) was performed. Immediate radical orchidectomy (IRO) was performed if FSE and TB findings suggested a malignant lesion. RESULTS: STNs were discovered in 8 patients (1,1%). Very small lesions (< 5 mm) were detected in 50% of cases. We performed four IRO and four DEB with consequent TSS. In one case we performed a delayed radical orchidectomy (DRO). At FSE pathologist reported 3 Leydig cell tumor and 3 seminoma and an inflammatory regressive lesion in one case. FSE on TB reported intratesticular neoplasia (TIN) in three cases. In one case nodule wasn't sent to FSE. We observed a concordance between FSE and definitive pathologic report in six cases (75%). CONCLUSIONS: The management of STN is still a challenge for the surgical andrologist. A correct diagnosis has a crucial role in making the best treatment and patients outcome. Ultrasound guided excisional biopsy and the close collaboration with a dedicated pathologist are very useful in reducing errors.

[What to do if percutaneous tibial nerve stimulation (PTNS) works? A pilot study on home-based transcutaneous tibial nerve stimulation]. / Che fare se l'elettrostimolazione percutanea del nervo tibiale funziona? Studio pilota sull'elettrostimolazione trans- dermica domiciliare del nervo tibiale.

INTRODUCTION: Aim of this pilot study was to assess the feasibility of a home-based transcutaneous tibial nerve stimulation (TTNS) protocol in patients responding to percutaneous tibial nerve stimulation (PTNS ). MATERIALS AND METHODS: 16 overactive bladder syndrome (OAB) patients, responding to PTNS, were included. Patients performed a flexible home protocol of TTNS. Satisfied patients were considered "subjective responders"; patients not showing a ≥10% increase of urgency/urgency incontinence episodes/day were considered "objective responders". RESULTS: 14/16 patients were followed up for a mean of 19.7 months. All patients were considered subjective responders; 13 were considered objective responders. The mean number of stimulations/week was 1.6 (1-3). CONCLUSIONS: After this pilot study, it is possible to conclude that home-based TTNS is feasible. Nevertheless, further randomized trials are needed before drawing any conclusions.