[Multidetector CT urography: diagnostic role in the evaluation of patients with non-traumatic hematuria]. / Urografia-TC multidetettore: ruolo diagnostico nella valutazione del paziente con ematuria non traumatica.

Blood in the urine (hematuria) can originate from any site along the urinary tract and may be the only sign of renal or vesical malignancy. Therefore, literature recommends for the evaluation of any case of macroscopic or microscopic hematuria. Our aim was to define the diagnostic role of multidetector CT urography (MDCTu) in the evaluation of this symptom through the analysis of 181 consecutive patients from January 2003 to March 2006.

Papillary carcinoma of the thyroid: low expression of NCAM (CD56) is associated with downregulation of VEGF-D production by tumour cells.

The expression of NCAM was investigated in tissue sections of 61 cases of papillary carcinoma and in 14 lymph node metastases using immunohistochemistry. Tumour cells of 18 primary tumours were not stained, whereas in the remaining 43 cases, NCAM was expressed in less than 5% tumour cells. Similar results were obtained when NCAM expression was evaluated at the RNA level. Reduced expression of NCAM is an early event since 6/15 cases (40%) of micro-carcinoma were NCAM-negative. NCAM-positive tumour cells were more often located at the invasion front of the tumour. It has been reported that NCAM expression may affect lymphangiogenesis. In tissue sections immunostained for podoplanin, it was found that lymphatic vessels were extremely rare inside the body of the tumour, and were mostly associated with foci of chronic inflammation and/or of reparative fibrosis. Lymphangiogenesis is sustained by VEGF-C, VEGF-D, and FGF2. Analysis of micro-dissected samples of the tumour and of the paired normal thyroid tissue revealed that RNA transcripts for VEGF-D were significantly less numerous in the tumour tissue (p = 0.001). The potential role of NCAM in tumour cell biology was investigated by silencing the NCAM gene in the TPC1 thyroid papillary carcinoma cell line. It was found that NCAM down-regulation caused a significant reduction (p < 0.05) in the expression of both VEGF-C and VEGF-D mRNAs. In addition, NCAM-silenced TPC-1 cells were more adhesive to different extracellular matrix components, and were less efficient in cell migration (59% reduction; p < 0.05) and invasiveness (68% reduction). These latter results confirm that modifications of NCAM expression cause profound alterations in the adhesive and migratory properties of tumour cells, but are in apparent discrepancy with the observation that loss of NCAM is usually associated with increased tumour invasiveness in vivo.

[The actual role of bilateral neck exploration in the treatment of primary hyperparathyroidism]. / Il ruolo attuale della esplorazione bilaterale del collo nel trattamento dell'iperparatiroidismo primario.

Surgery is the only curative treatment for primary hyperparathyroidism (pHPT). Surgical exploration is recommended for all patients with biochemically documented pHPT and signs or symptoms of the disease. Some patients are asymptomatic, others have subtle symptoms that disappear after parathyroid surgery. Felix Mandl successfully performed the first parathyroidectomy in 1925, using a bilateral neck exploration (BNE) with examination of all four glands and this remained the procedure of choice for pHPT into the 1990s. As over 80% of pHPT cases are due to a single parathyroid adenoma, many authors have questioned the need of BNE and have proposed directed unilateral approaches, termed "mini-invasive parathyroidectomies". The aim of this report is to define which is the actual role of the conventional surgical approach to pHPT.

[Intraoperative quick parathyroid hormone assay in thyroid surgery: preliminary experience on 36 cases]. / Dosaggio intraoperatorio dell'ormone paratiroideo in chirurgia tiroidea: esperienza preliminare su 36 casi.

Through the analysis of our preliminary experience on 36 consecutive cases of thyroid surgery, we assessed the feasibility of the rapid intraoperative assay of the intact parathyroid hormone (iPTH) as predictive risk factor of hypocalcemia versus seric calcium level on the first post-operative day to select the patients eligible to an early discharge. Furthermore, we managed to determine if iPTH level during thyroid surgery could point out the cases in which parathyroid autotransplantation is necessary, as the macroscopic evaluation of the parathyroid gland's viability is inadequate.

[Renal giant angiomyolipoma in tuberous sclerosis complex: case report and literature review]. / Angiomiolipoma renale gigante in paziente con sclerosi tuberosa: descrizione di un caso e revisione della letteratura.

The aim of this paper is to describe a typical clinical case of tuberous sclerosis complex (Bourneville disease) and discuss controversial issues about the management of this rare condition, with a short revision of the literature. Particularly, we define which is the role of the surgeon in the treatment of this very rare condition, that should be primary approached conservatively.

[The Bochdalek hernia in the adult: case report and review of the literature]. / L'ernia di Bochdalek nell'adulto: caso clinico e revisione della letteratura.

The Bochdalek hernia, the most common diaphragmatic hernia, except the hiatus hernia, is located on the posterolateral side of this muscle. This pathology is generally diagnosed in children; in fact only 105 such cases occurring in adults have been described in the literature. In these cases, surgical intervention is made necessary by the severity of potential complications. The Author's attention was drawn to a woman of 60 years of age, affected by pituitary nanism, who suffered from a left hand Bochdalek hernia. The symptomatology, characterised by abdominal pains and constipation had been presented for about one year. The computerised tomography confirmed the hernia of abdominal viscera in the thorax cavity. The intervention was conduced via the abdomen: the hernia were reduced, the hernial hole were closed with a double strata and the muscular plane reinforced with a synthetic prosthesis (dual mesh). The postoperative process was regular and the patient dismissed on 11th postoperative day.

[Benign cicatricial stenosis of colorectal anastomosis: considerations on 2 cases]. / La stenosi cicatriziale benigna dell'anastomosi colorettale: considerazioni su due casi di nostra osservazione.

During the surgical treatment of two patients with benign anastomotic colorectal stenosis, the Authors registered the presence of concomitant tenacious adherence of the anastomotic line to the sacral bone. Such event, according to the Authors, could represent one of the causes of failure and greater risk of perforation during the treatment with the different endoscopic therapies that, nevertheless, ought to be considered the gold standard in the therapy of benign structures. The Authors developed their hypothesis physiopathologic on the basis of personal experience and of the search a diagnostic procedure able to highlight the presence of a tenacious adherence with solid structures during the operative evaluation. If further studies focused on this subject will bring to satisfactory results, this would represent a further aid for the evaluation of the best therapeutic approach of the benign post anastomotic stenosis.

[Inflammatory tumors of the cecum in emergencies: surgical considerations and case report]. / I tumori infiammatori del cieco in urgenza: considerazioni di terapia chirurgica e caso clinico.

A cecal mass of uncertain etiology encountered during surgery for presumed appendicitis is a dilemma for the surgeon. The differential diagnosis of an unsuspected ileocecal mass must include neoplasm, diverticular disease, inflammatory bowel disease and severe appendicitis involving the ileocecal region. Right hemicolectomy is the gold standard for the treatment of the unsuspected ileocecal mass. The Authors report a case of inflammatory tumour of caecum secondary to appendicitis in a young adult.

[Abdominal approach to the treatment of the vestigial retrorectal tumors: our experience]. / L'approccio addominale per i tumori vestigiali retrorettali: nostra esperienza.

Although the vestigial retrorectal cysts are still rare, the number of the observed ones is destined to increase, as methods by imaging become routinely used in the clinical practice. Once diagnosed, the removal of retrorectal lesions should be mandatory. Therefore, by reporting three clinical cases, the Authors propose notes of technique above the abdominal approach used for the surgical treatment of these retrorectal congenital neoformations. In their experience, the anterior route had no postoperative complications, short stay, no neurological consequences and good long-term results.

[Principles of surgical technique of the anterior access to the thoraco-lumbar spine]. / Principi di tecnica chirurgica per l'accesso anteriore alla colonna vertebrale toraco-lombare.

General surgeons are more and more frequently requested to prepare an operative exposure of the spine, in order to perform anterior maneuvers of removal and stabilization of the vertebral bodies. Since 1989 to date, in collaboration with the neurosurgical équipe of Prof. G. Cantore, Neurological Sciences Department, La Sapienza University of Rome, the Authors have collected 116 cases of vertebral diseases: among them, 48 involved the thoraco-lumbar junction of the spine (D12-L2). In this paper, Authors' aim is to state precisely the surgical technique of the anterior access to the thoraco-lumbar junction: attention has been focused on this tract of the column stating its anatomical complexity and the high invasivity of the procedures requested for its exposure. Therefore, such notes of technique have been elaborated to make safer the neurosurgical demolitive and reconstructive procedures and, most of all, to reduce the surgical trauma whenever it is possible.

[Diaphragmatic eventration in the adult: repair with Gore-Tex surgical mesh]. / L'eventratio diaframmatica nell'adulto: riparazione con mesh in Gore-Tex.

The Authors report the case of a fifty-nine-year-old patient, affected by complete eventration of the left diaphragm and cranial stomach dislocation with axial volvulus, associated with an upward movement of part of the left colon and some jejunal loops. The subclinical condition had been occasionally discovered during a routine chest X-ray at the age of eighteen and the patient remained without symptoms up to five years ago, when he began to show significant digestive and cardiorespiratory symptoms. The patient has been successfully treated via thoracotomy with phrenic alloplastic using Gore-Tex patch and has obtained an immediate remission of the symptoms. Left diaphragmatic eventration of the adult is a rare pathology, either congenital or acquired, with few and definite surgical indications such as severe digestive and cardiorespiratory symptoms. Different surgical techniques including the use of patches are herein illustrated.

Total removal of an intramedullary cavernous angioma by transthoracic approach.

Intramedullary cavernous angiomas are rare vascular malformations; all published cases have been surgically approached posteriorly by standard laminectomy. We describe the case of a 63-year-old man with an intramedullary cavernous angioma, anteriorly located in the thoracic spinal cord. The angioma was operated on by transthoracic approach and totally removed.

[Endoscopic palliative treatment of a neoplastic esophageal fistula: report of a case]. / Palliazione endoscopica di una fistola neoplastica esofagea: caso clinico.

Oesophago-respiratory neoplastic fistulas present serious problems of management, because of the severe status of the patient. Therefore, a palliative treatment, to allow for a gradual respiratory and digestive function recovery with clinical improvements is needed. Surgical palliation has a mortality rate of 40% and a long post-operative hospitalization. Endoscopic palliation, on the other hand, has the same percentage of success of surgical palliation, but has the advantage to be performed in those patients with severe health conditions immediately improving the symptomatology and not excluding a subsequent surgical approach. The Authors present the case of a 70-year-old patient with a neoplastic relapse on the oesophago-gastric anastomosis, associated to an oesophago-respiratory fistula manifesting as severe dysphagia and dyspnoea. An endoscopic palliative treatment of the fistula was performed introducing a metallic coated prosthesis into the oesophagus. Severe clinical conditions regressed immediately and after 3 months they are unchanged. The Authors suggest endoscopic palliation with oesophageal prosthesis as the best therapeutic choice in those cases not amenable to surgery.

Ureteral anastomosis in the orthotopic ileal neobladder: comparison of 2 techniques.

PURPOSE: The functional results and complications of 2 different ureteroileal anastomoses were evaluated in patients with bladder cancer undergoing radical cystectomy and orthotopic ileal bladder substitution. MATERIALS AND METHODS: Between 1989 and 1995, 102 patients underwent creation of a low pressure neobladder. In the first 50 cases the ureteroileal anastomosis was created with a split-cuff nipple technique as an additional antireflux mechanism. In the next 52 cases the ureteroileal anastomoses were constructed via the direct end-to-side technique counting on the antireflux protection of the afferent tubular limb. RESULTS: Stenosis occurred in 7 of the 100 ureters (6 patients) treated with the split-cuff nipple technique and 7 of 104 treated with a direct end-to-side anastomosis. This complication occurred more commonly in the left ureter (11 of 14 patients). Reflux was noted at cystography in 10 cases with the split-cuff nipple method and 12 with end-to-side anastomoses, and was symptomatic in only 3 patients. Four ureteral strictures were treated successfully with primary open repair. Percutaneous dilation and stenting were performed for 8 ureteral strictures: 2 cases were successful, 3 failed and 3 are unresolved. CONCLUSIONS: We observed no differences between the antireflux split-cuff and end-to-side anastomoses with regard to stricture formation or ureteral reflux. Therefore, we do not believe that there is a need to create antireflux ureteral anastomoses due to the tubular afferent ileal segment and given that the reflux is asymptomatic in most patients. Strictures may be treated with percutaneous balloon dilation and stenting but open repair appeared to be more effective.

[Orthotopic replacement of the bladder in the female]. / La sostituzione ortotopica della vescica nella donna.

Orthotopic substitution of the bladder in females is a procedure which is increasing worldwide. Patients with tumours of the bladder neck or the trigon, or with multifocal tumours, expanded carcinomas in situ or massive pelvic adenopathies are not eligible for the procedure. The main consideration should be the risk of urinary incontinence or hypercontinence. Our experience relates to 8 patients, the neobladder being constructed using the Studer technique. Six months postoperatively daytime continence was 100% and night-time continence 75%.

[Postoperative sacrocele: prevention and surgical considerations]. / Sacrocele post-operatorio: prevenzione e considerazioni chirurgiche.

In the Authors experience with surgical management of sacral chordomas, an unusual complication represented by posterior herniation of the rectum was observed. Weakness of the posterior pelvic floor is at the basis of this complication, which the Authors defined "sacrocele". Posterior herniation of the rectum highly impairs the patient quality of life and may contraindicate radiation therapy. Therefore, the Authors routinely reconstruct the posterior pelvic floor by using a polyglactin mesh following any sacrectomy. This technique is simple and safe. Authors' experience on a limited series is presently reported.

[Blind-ending branch of bifid ureter: apropos of a case]. / L'uretere bifido a branca cieca: a proposito di un caso.

The Authors report on a case of blind-ending ureter. A young woman (29 years old) underwent surgery because of recurrent urinary tract infections and left loin pain. The operation consisted in a radical resection of the blind branch together with Coen's operation for the coexistence of vesicoureteral reflux. Authors' goal was to review the international Literature on this rare pathology pointing out their opinion on the existing terminology which is still far from being clear and definite.

Lower urinary tract reconstruction following cystectomy: experience and results in 96 patients using the orthotopic ileal bladder substitution of Studer et al.

Between 1989 and 1993 96 patients (89 males and 7 females) affected with invasive neoplasms of the bladder underwent surgery consisting of the creation of an orthotopic ileal neobladder according to Studer et al., after radical cystectomy. Patient selection and details of the surgical procedure are described. An accurate follow-up of 3-60 months (mean: 28 months) is presented. There have been 6 perioperative deaths (6.2%) and 11 early complications, all directly related to the neobladder and requiring reoperation in 6 cases (6.2%). Late complications required rehospitalization in 23 cases (23.9%) and a second reoperation was necessary in 10 (10.4%). The urodynamic tests show that the neobladder assumes an average capacity at about 330 cm3 after 1 year. Pressure at maximum capacity decreases in time and ranges from 10 to 20 cm H2O at 2 years. After 1 year, the complete urinary continence rate by day is 97% and the stress incontinence rate is 22%. Night-time continence, instead, increases to 74% after 1 year and to 83% after 2 years. In female patients, the functional results were satisfactory thanks to careful patient selection and to the surgical procedure adopted. Twenty-four patients had disease progression; 17 of these patients with locally advanced neoplasms died. The authors believe that the orthotopic ileal continent reservoir can be a satisfactory solution after cystectomy for bladder cancer, offering the patients a better quality of life compared to other urinary diversions both in male and female patients.

Orthotopic ileal neobladder in female patients after radical cystectomy: 2-year experience.

We describe a surgical technique to conserve urinary continence in 7 women who underwent radical cystectomy with construction of an orthotopic ileal neobladder for infiltrating bladder carcinoma. The selection of the patients and the surgical procedure to preserve the anatomical and functional integrity of the female urethra are described. Followup ranged from 7 to 28 months. There were no postoperative deaths or serious clinical complications. The urinary continence rate was 100% during the day and 71% at night with micturition at regular 3-hour intervals. The vesical capacity varied from 250 to 400 cc and pressure at maximum capacity from 10 to 25 cm. water. Urinary flow was satisfactory and the urethral pressure profile showed a normal sphincteric mechanism at rest. Two patients died of metastases at 14 and 8 months postoperatively, and 5 are alive and disease-free. We believe that these results confirm the possibility of obtaining micturition in women via the urethra following radical cystectomy.

Sequential subcutaneous thymopentin, interferon alpha-2a and interleukin-2 in metastatic renal cell cancer.

To determine the activity of sequential administration of thymopentin (TP-5), interferon alpha-2a (IFN) and interleukin-2 (IL-2) in metastatic renal cell cancer (RCC), 17 patients with RCC were treated with TP-5 50 mg/d on days 1 to 14, IFN 3 MIU/d on days 14, 15, 21, 22 and IL-2 18 MIU/d on days 16 to 20, and 23 to 27. Treatment was given subcutaneously and cycles were repeated every 6 weeks. All patients were assessed for toxicity and response. No objective responses were observed. Two patients had a short-lived disease stabilization. Median survival was 9 months. Toxicity was generally moderate. The most important side-effects were related to IL-2 administration. In view of the lack of antitumor activity, the combination of TP-5 + IFN + IL-2 in the doses and schedule used in this trial cannot be recommended. The investigation of chemotherapeutic and immunological agents that can effectively synergize with IFN or IL-2 is essential.