Do sclero-embolization procedures have advantages over surgical ligature in treating varicocele in children, adolescents and adults? Results from a systematic review and meta-analysis.

We aimed to systematically review complications, and recurrence rate of varicocele treatment by comparing the surgical ligature versus sclero-embolization techniques in children, adolescents and adults. The secondary outcomes were the evaluation of semen parameters and spontaneous pregnancy rate in adults. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Continuous variables were pooled using the inverse variance of the mean difference (MD) with a fixed effect, and 95% confidence interval (CI). The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method with the random effect model and reported as Odds Ratio (OR), and 95% CI. Statistical significance was set two-tail p-value < 0.05. Twenty studies were included. Incidence of postoperative hydrocele was significantly higher in the surgical ligation group (OR 3.06 95% CI 1.06-8.88, p = 0.04). Incidence of postoperative orchiepidydimitys was significantly higher in sclero-embolization group (OR 0.26 95% CI 0.08-0.85, p = 0.02). Presence of normal spermatozoa was significantly higher sclero-embolization group compared with the surgical ligature group (MD 2.54% 95% CI 0.43-4.65, p = 0.02). No difference was found in overall complications, wound infection, testis pain, surgical site hematoma, total sperm count, sperm motility, pregnancy and recurrence rate. This review confirms that current data does still not support the superiority of one type of treatment over other ones.

Feasibility study for interspecialistic collaboration in active research of urothelial neoplasms of professional origin.

INTRODUCTION: In Italy only a small fraction of cancer is reported to the supervisory body and recognised as professional by the insurance institution. Among the causes of this sub-notification, especially for lowgrade etiologic fractional cancers such as bladder cancers are the lack of knowledge of carcinogenicity in the occupational field and the consequent incomplete medical history collections. OBJECTIVES: Diagnosis of occupational bladder neoplasms and activation of systematic surveillance of tumors of professional origin through an "active research" program. METHODS: From July 2010 to July 2017, all patients diagnosed with Bladder Cancer in the departments of Urology of Area Vasta 3 ASUR Marche underwent a first interview and a further anamnestic study in selected cases.When an occupational exposure was recognised, more information for preventive, social security and criminal justice has been acquired. RESULTS: The study highlighted 18 cases of bladder tumors due to occupational exposure to aromatic amines and polycyclic aromatic hydrocarbons, which are the most important risk factor for BC after tobacco smoking. CONCLUSIONS: Our study confirmed that active research is an useful tool both for the activation of epidemiological surveillance and for the regional registration of professional tumors. In addition active research of occupational exposure allow obtaining information that can be used for preventive purposes, for criminal justice and for the initiation of medico-legal actions and improvement of working conditions aimed at guaranteeing workers' rights.

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.

The eternal enigma in prostatic biopsy access route.

Dear Editors,We read with interest the article by Di Franco and co-workers (1). The introduction of prostatic magnetic resonance and the relative fusion-biopsy have not yet allowed the expected improvements in prostate biopsy. To our knowledge, there are no works that demonstrate the superiority of fusion techniques on the remaining ultrasound guided prostate biopsies that are still the widely used in the diagnosis of prostate cancer. Furthemore, these technologies are expensive exams and they are not yet available in all centers, especially in those minors. We work at a "minor" center and we always keep in mind that the goal of  prostatic biopsy is the diagnosis and the staging of prostatic neoplasms.. However, it remains uncertain which of the two techniques, transperineal (TP) or transrectal (TR), is superior in terms of detection rate during first biopsy setting. Several studies have compared the prostate cancer detection rate but TR and TP access route in prostatic gland sampling seems to be equivalent in terms of efficiency and complications, as reported by Shen PF et al. (2), despite several methodological limitations recognized in their work. The results reported by Di Franco CA et al. represent the real life experience of most urologists that perform the PB based on their own training experience and available technical devices. From an historical viewpoint, the TP route has been the first one to be used to reach the prostate, both for diagnostic and therapeutic purposes. To date, because it seems to be more invasive and difficult, the TP route is less used worldwide than the TR one (2). Theoretically, the TP approach should detect more prostate cancer than the TR way  because the cores of the TP approach are directed longitudinally to the peripheral zone and the anterior part of the prostate (4). The results reported by Di Franco et al. seems to confirm these considerations. However, our real life experience differ from the conclusions reached in their work. We recently conducted a prospective evaluation of 352 patients who underwent their first prostate biopsy because of a suspicious of prostate cancer (elevated prostate specific antigen (PSA) and/or abnormal digital rectal examination and/or abnormal findings on transrectal prostatic ultrasound). Patients was randomized as following. A total of 187 patients (Group A) underwent a prostatic biopsy with a transperineal approach in a lithotomic position,  using a biplane probe (8818 BK Medical, Denmark) and a fan technique with a single perineal median access (5). The remnants 165 patients (Group B) underwent a transrectal ultrasound guided prostate biopsy in a left lateral position, using a end fire probe configuration (8818 BK Medical, Denmark) and a sagittal technique. The bioptic prostatic mapping was performed with a 12-core scheme sec. Gore (3) by a single experienced operator and the histopathologic evaluation was performed by a single dedicated uro-pathologist. Statistical evaluations were made with a T Student test  (p<0,005). Group A and Group B was similar in term of mean patient age (67,9 years and 67 years respectively), mean total PSA (12,1 ng/ml vs 12 ng/ml) and digital rectal examination positivity (22% vs 29%).  The global cancer detection rate was 33,69% (63/187) in the transperineal prostate biopsy group and 48,48 % (80/165) in the transrectal approach (p=0.0047).  No significant statistical differences were found in the complications rates between the two groups. Statistical evaluation of site of tumor localization reveal only a trend to statistical significance in apical site tumors diagnosed with the TR approach versus the TP technique. The TR approach had a better diagnostic accuracy than TP technique in case of PSA<4 ng/ml, intermediate prostate volume (30 and 50 ml), normal digital rectal examination without any relationship with the patient age. In our experience, two aspect may explain the difference between the two group in term of global detection rate. First, we usually perform transrectal biopsy with a sagittal technique that simulates the transperineal way of needle incidence with the prostatic gland. The lateral and anterior gland portions may be sampled more accurately. Second, our transperineal approach consists in a single perineal median access that can make more difficult the gland sampling between the two lobes. However, there was no significant difference in core positivity rate at the peripheral zone, medium gland, apex or any other site such as reported in many randomized clinical trials (2). Unlike the conclusions reported by Di Franco et al., in our experience we found a statistically significant difference between the TR and TP approach, at the first biopsy setting, in term of global cancer detection rate. No differences were found in terms of complications. Moreover, our data suggest that TR approach had a better diagnostic accuracy than TP technique in case of  PSA<4 ng/ml, prostate volume 30-50 ml, normal digital rectal examination without any relationship with the patient age. The further step of the statistical evaluation of our data will be the definition of the possibility that the TR biopsy determine a better staging of prostate cancer than TP approach as first procedure.    REFERENCES 1)      Di Franco CA, Jallous H., Porru D. et al. A retrospective comparison between transrectal and transperineal prostate biopsy in the detection of prostate cancer Arch Ital Urol Androl 2017; 89(1), 55-92)      Shen FP, Zhu YC, Wei WR et al. The results of transperineal vs transrectal prostate biopsy: a systematic review and meta-analysis. Asian Journal of Androl 2012; 14: 310-15.3)      Gore JL., Shariat SF, Miles BJ., et al. Optimal combinations of systematic sextant and laterally directed biopsies for the detection of prostate cancer. J Urol 2001; 165: 1554-59.  4)      Abdollah F., Novara G., Briganti A. et al. Trasrectal versus transperineal saturation re biopsy of the prostate: is there a difference in cancer detection rate? Urology 2011; 77:9215)      Novella G, Ficarra V, Galfano A, et al. Pain assessment after original transperineal prostate biopsy using a coaxial needle. Urology. 2003; 62 : 689-92.

We really need a classification of prostatic abscess?

Not available.

Painful ultrasound detected lesion in the proximal part of the corpus cavernosum: A case of so called "partial priapism"?

Partial priapism is a rare disorder generally described in literature as related to an idiopathic etiology leading to the thrombosis of the corpus cavernosum. Despite his rarity, this condition has been described in the last years with an increased frequency. It is characterized by thrombosis of the proximal segment of one corpus cavernosum with perineal pain as the more frequent clinical manifestation. Few cases were associated with perineal trauma. Instrumental appearance suggests for an hematoma in the interstitium of the proximal part of corpus cavernosum. Therapy is still controversial. We report a case of a 52-years old man referred to our Section of Urology suffering from a perineal pain occurred without trauma, sexual arousal or sexual intercourse, during the working office time. Laboratory revealed a slightly elevated white blood cells count. The full blood count, protein C reactive, electrolytes, international normalized ratio, activated partial thromboplastin time and urinalysis were within normal range. Tunica albuginea was normal. The partial thrombosis of the right corpus cavernosum was hypothesized. Treatment was conservative with non steroidal anti-inflammatory drug. Only the clinical presentation of symptoms and perineal ultrasound scan performed with color sonography leaded to the diagnosis. Eleven days later, at the clinical and ultrasonographic follow-up visit, the patient was asymptomatic with a total clinical and instrumental disappearance of signs of the corpus cavernosum involvement previously described. Considering the rarity of the condition, we performed a literature review.

Adenomatous hyperplasia of the rete testis: A rare intrascrotal lesion managed with limited testicular excision.

INTRODUCTION: Testicular cancer is one of the most frequent in young men and its incidence is increasing in recent years because of incidental finding during routine ultrasound exams. Adenomatous hyperplasia of the rete testis is one of the benign and rare pathological types incidentally detected and very few cases are described in the literature. CASE REPORT: A 40 years old man come to our attention for a balanoposthitis without testicular pain. During andrological examination we performed palpation of the testes and we noticed a palpable nodule of hard consistency in the left testicle. We then performed an ultrasound exam of the testis which highlighted the presence of an intra-didymus neoformation with diameters of 1.2 x 1.6 cm and with the presence of cysts inside. We also performed blood tests to check tumor markers alpha fetoprotein, beta hCG and LDH which resulted inside the normal range. We then conducted a chest and abdomen CT scan that showed no pathological elements. Therefore, as we suspected that this tumor was benign, we performed an enucleation of the neoplasm. The definitive histological examination revealed the presence of dilated ducts lined with epithelial cubic-columnar cells with clear cytoplasm rich in glycogen and the pathologist so concluded that the tumor could be classified as adenomatous hyperplasia of the rete testis. At three months of follow up, the patient doesn't have any recurrent lesion to either testicles. DISCUSSION: Adenomatous hyperplasia of the rete testis is a very rare intrascrotal lesion. This histological type is the most frequent between benign lesion of the ovary, but few works in literature reported this histological type in the male gonad and, in most of these works, authors described these lesion at epididymis. CONCLUSION: We believe that a conservative approach must be considered mandatory in case of testicular lesions 1.5 cm in diameter. A radical approach might have alterate fertility of the patient and also have caused psychological trauma more than an enucleation. However a longer follow up is needed to understand if this was the right decision for the oncological point of view.

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.

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.

Testicular sparing surgery in small testis masses: A multinstitutional experience.

INTRODUCTION: The incidence of benign testicular tumors is increasing in particular in small lesion incidentally found at scrotal ultrasonography. Primary aim of this study was to perform radical surgery in malignant tumor. Secondary aim was to verify the efficacy of the diagnostic-therapeutic pathway recently adopted in management of small masses with testis sparing surgery in benign lesions. MATERIALS AND METHODS: In this multicenter study, we reviewed all patients with single testis lesion less than 15 mm at ultrasound as main diameter. We applied the diagnostic-therapeutic pathway described by Sbrollini et al. (Arch Ital Urol Androl 2014; 86:397) which comprises: 1) testicular tumor markers, 2) repeated scrotal ultrasound at the tertiary center, 3) surgical exploration with inguinal approach, intraoperative ultrasound, and intraoperative pathological examination. Definitive histology was reviewed by a dedicated uro-pathologist. RESULTS: Twenty-eight patients completed this clinical flowchart. The mean lesion size was 9.3 mm (range 2.5-15). Testicular tumor markers were normal except in a case. Intraoperative ultrasound was necessary in 8/28 cases. We treated 11/28 (39.3%) with immediate radical orchiectomy and 17/28 (60.7%) with testis-sparing surgery. Definitive pathological results were: malignant tumor in 6 cases (seminoma), benign tumor in 10 cases (5 Leydig tumors, 2 Sertoli tumors, 1 epidermoid cyst, 1 adenomatoid tumor, 1 angiofibroma), benign disease in 11 (8 inflammation with haemorragic infiltration, 2 tubular atrophy, 1 fibrosis), and normal parenchyma in 1 case. We observed a good concordance between frozen section examination and definitive histology. Any malignant tumor was treated conservatively. Any delayed orchiectomy was necessary based on definitive histology. CONCLUSIONS: The incidence of benign lesions in 60% of small testis lesions with normal tumor markers makes orchiectomy an overtreatment. Testicular sparing surgery of single testicular nodules below 15 mm is a safe option, but requires a standardized pathway in diagnosis. Our pathway has shown good reliability and security profile to be applied in a multicenter management for small scrotal masses. Our study has shown the reliability of the diagnostic-therapeutic pathway in the management of single testicular masses. The higher incidence of benign lesions in 60% of patients makes often orchiectomy an overtreatment.

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.

Penile plaque as predictor of an advanced anorectal carcinoma: A case report.

The secondary involvement of the penis by tumors from others organs is a rare event representing only 0.8% of overall metastasis in the genitourinary tract. The most frequent clinical findings is priapism, but occasionally, solitary metastases to the penile skin, mucosa of the glans, corpus spongiosum or lesions of the albuginea mimicking an induratio penis have been reported. We report a case of penile plaque predicting the relapse of an anorectal carcinoma. The precise etiology of this particular manifestation is not well understood and the prognosis is poor. There are no individual treatments with curative intent.

Patch bulging after plaque incision and grafting procedure for Peyronie's disease. Surgical repair with a collagen fleece.

The incision/excision and grafting techniques (PIG) for surgical therapy of Peyronie's disease (PD) have gained popularity in recent years. Several different graft materials have been used but the ideal graft has yet to be established. The use of grafting materials could cause complications. In the daily clinical practice it will always be more frequent to manage complications arising from their use. We present herein the case of a patch bulging repaired with a ready-to-use collagen fleece (Tachosil®, Takeda, Linz, Austria, Europe) in a 61 years old man subjected to intervention of geometric corporoplasty with Paulo Egydio technique using an acellular collagen material (Xenform® patch, Boston Scientific, Natick, MA, USA) as graft. We also discuss the possible implications of PIG procedure.

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.

Variation of inflammatory indexes in patients with chronic abacterial prostatitis treated with an herbal compound/extract.

INTRODUCTION: Inflammation is a highly prevalent finding in the prostate. Men with inflammation have higher IPSS score and increased prostate size. For men with prostatic inflammation, there is a significantly increased risk of developing acute urinary retention and the need of a surgical approach to the disease. Some laboratory tests (i.e. fibrinogen, C-reactive protein), can play a role in identifying patients at greatest risk of complications and adverse outcomes after surgery. There have been several experiences exploring the role of nutraceutical approach to the prostate inflammation. Aim of our study were to describe the variation in symptoms and inflammatory indexes in men affected by chronic abacterial prostatitis, treated with an herbal extract containing Curcuma Longa 500 mg, Boswellia 300 mg, Urtica dioica 240 mg, Pinus pinaster 200 mg and glycine max 70 mg. MATERIALS AND METHODS: A prospective multicenter study was conducted from February 2021 and March 2022. One hundred patients, with a diagnosis of Chronic Prostatitis were enrolled in a multicentric phase III observational study. They were treated with the herbal extract, one capsule per day, for 60 days. No placebo arm was included. In each patient, inflammatory indexes, PSA, prostate volume, IIEF-5, PUF, uroflowmetry (Qmax), IPSS-QoL, NIH-CPPS were registered and statistically compared at baseline and at the follow up visit. RESULTS: The variation obtained on the inflammation indexes showed a global improvement after treatment, including the PSA reduction. We also recorded a significant improvement on IPSS-QoL, NIH-CPPS, PUF and Qmax scores. CONCLUSIONS: The herbal extract considered in our study may represent a promising and safe therapeutic agent leading to a reduction of inflammation markers, and could be used in the treatment of prostatitis and benign prostatic hyperplasia.

The potential role of transrectal ultrasound as a tool for diagnosis or recurrence detection in bladder cancer. Two cases report.

OBJECTIVES: To demonstrate the potential role of transrectal ultrasound (TRUS) as a tool for diagnosis or recurrence detection in bladder cancer. MATERIAL AND METHODS: We report two cases of a primary lesion of bladder neck and trigone misdiagnosed by conventional sonographic abdominal evaluation and a case of bladder cancer recurrence diagnosed by TRUS performed before cystoscopy. RESULTS: The first patient presented at the Emergency Room of our Hospital for a flank pain with concurrent haematuria. The abdominal ultrasonography showed a right hydronephrosis and a thickened bladder wall without endoluminal projections. The end-fire probe with a longitudinal approach clearly showed a thickening of the bladder wall extended from the bladder neck to the posterior area. The patient was submitted to a transrectal prostate biopsy and to a urethrocystoscopy with a transurethral resection. The second patient was admitted to the Urology Unit for haematuria. Abdominal ultrasonography was unremarkable and urine cytology negative. The TRUS with an end-fire probe showed a 5 mm area of irregular thickening of the mucosa at the bladder neck. The uretrocystoscopy confirmed the presence of a perimeatal papillary lesion. CONCLUSION: We recommend the use of TRUS for bladder cancer detection in selected patients, as an easy, accurate and inexpensive tool. We need further study to validate the role of TRUS in the diagnosis and follow-up of bladder urothelial carcinoma.

COVID-19 vaccination and penile Mondor disease. There is any relationship?

Dear Editor, the pandemic spread of Coronavirus 2 infection (SARS-CoV-2), determining the coronavirus disease 2019 (Covid-19), had devastating consequences globally with several waves affecting social and economic life. The use of masks, physical distancing, testing of exposed or symptomatic persons, contact tracing and isolation have helped limit the transmission where they have been rigorously applied; however, these actions have proved not sufficient to limit the virus spread [...].