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Restricted accessOtherFirst published April, 2015pp. 74-74
Restricted accessReview articleFirst published April, 2015pp. 75-83Sepsis represents a clinical syndrome following an infection and it is characterized by classical signs of systemic inflammatory response syndrome (SIRS): fever or ipothermia, tachycardia, tachipnea, leucocytosis or leucopenia. There may also be symptoms related to a specific infection such as a cough in pneumonia or burning with urination in a kidney infection, and abdominal pain in an intraabdominal sepsis.
Common locations for the primary infection include lungs, brain, urinary tract, skin and soft tissues, and mainly abdominal organs.
Patients who develop sepsis have an increased risk of complications and death and face higher healthcare costs and longer treatment.
The infection is caused most commonly by bacteria, but can also be by fungi, viruses, or parasites.
Severe sepsis is sepsis causing poor organ function or insufficient blood flow; septic shock is the situation with ipotension and/or need for high dosage of inotropes or vasopressors and multiple organ failure syndrome is when multiple organ dysfunction or failure is present.
Outcomes depend on the severity of disease with the risk of death from sepsis being as high as 30%, severe sepsis as high as 50%, and septic shock as high as 80%.
Prevention, early diagnosis, and treatment, both medical (antibiotics) and surgical (source control), together with the prompt intensive care and organ support are crucial to increase survival rate.
Open accessReview articleFirst published April, 2015pp. 84-92Erectile dysfunction (ED) is a very common disorder with a deep impact on patients and their partners. Several options are now available for treating ED; oral pharmacotherapy with phosphodiesterase-5 (PDE5) inhibitors currently represents the first-line option for many ED patients. Vitaros©/Virirec© is new topical, non-invasive treatment for ED that offers the combination of an active drug (alprostadil, a synthetic PGE1) with a skin enhancer that improves its local absorption directly at the site of action. Vitaros©/Virirec© has a favorable pharmacodynamic profile and is poorly absorbed in systemic circulation. This makes it suitable in any circumstances and results in a reduced risk of adverse events (AEs), being systemic AEs reported in only 3% of the treated population. Its clinical efficacy has been demonstrated in both phase II and III trials, showing a global efficacy up to 83% with the 300 μg dose in patients with severe ED significantly better than placebo. Its fast onset of action together with its favorable toxicity profile and lack of interactions with other drugs makes Vitaros©/Virirec© a first-line therapeutic option for patients with ED, particularly for individuals who are reluctant to take systemic treatments or with AEs. It may also have an important role in patients not responding to PDE5 inhibitors, particularly those with ED after radical prostatectomy.
Restricted accessResearch articleFirst published April, 2015pp. 93-97The objective of this study is to evaluate whether performing an ileal conduit (IC) versus a neobladder (NB) during radical cystectomy (RC) can play a role on the morbidity of the surgical procedure.
At our institution since 2001, a database collecting the data of more than 450 patients who have undergone RC is perspectively maintained.
The records of 246 patients submitted to RC and IC and 120 to RC and NB have been reviewed for the present study. By a binary logistic regression model, a propensity score was generated joining these factors: gender, age, smoking habit, Charlson' comorbidity score, platelet antiaggregants or oral anticoagulant therapy, ASA (American Society of Anesthesiologists) score, hydronephrosis, pathologic T stage, and lymphadenectomy. A group of patients submitted to IC and another to NB having the closer propensity score were created with a matching ratio of 1:1. The following features were compared between the two groups: operative time, blood loss, intraoperative complication rate, and postoperative complications rate (overall, clavien 1–2, clavien ≥3, related to RC, relate to urinary reconstruction).
One hundred thirty-four patients were selected, 67 submitted to NB, 67 to IC, well matched according to the desired features. No differences were noted for all the compared features.
The morbidity of RC does not seem to be dependent on the choice to perform IC versus NB.
Restricted accessResearch articleFirst published April, 2015pp. 98-101Laparoscopic partial nephrectomy is still one of the more challenging procedures in urology. Minimizing warm ischemia time (WIT) and bleeding requires efficient intracorporeal suturing. In addition, achieving negative surgical margins requires complete excision of the tumor. Robotic-assisted partial nephrectomy (RALPN) adds the advantages offered by the “Da Vinci system” to laparoscopy, such as the 3-D vision, and the better degree of freedom of surgical instruments.
The objective of this study is to report our experience with RALPN.
From August 2009 to October 2012, 60 patients underwent RALPN for kidney cancer. The average age of the patients (35 female, 25 male) was 63 (range 48–80) years. Average BMI was 25 (range 21.8–29.7) kg/m2. Average tumor size was 3.2 cm (range 2-6.7 cm). All the procedures were performed by a transperitoneal approach, liar clamping was used in all cases: in 47 patients by one intracorporeal tourniquet for the artery and one for the vein; in three cases, ilar clamping was “en block” by Satinsky.
Mean operative time was 167.2 min (140–250) with a WIT of 23.8 min (15–28). The mean estimated blood loss was 260 mL (50–300). In one case, nephrectomy was necessary because the tumor involved the renal pedicle. One patient had pulmonary embolism and one urinary leakage conservatively managed.
Pathologic examination revealed clear cell renal cell carcinoma in 58 patients, oncocytoma in one patient, and angiomyolipoma in one patient. All resection margins were free from tumor.
Partial nephrectomy, facilitated by robotic technology, is more and more frequently performed as a safe and effective minimally invasive procedure.
Restricted accessResearch articleFirst published April, 2015pp. 102-105The flank-suspended position was adopted in percutaneous nephrolithotomy (PCNL), and haemodynamics, blood gas variables and subjective feelings were examined with an attempt to explore the effect of the operative position in PCNL on the body's inner environment and patient comfort.
The influence of the flank-suspended and prone position on haemodynamics, arterial blood gases and subjective feelings in patients receiving PCNL was examined.
A total of 100 patients with kidney stones who underwent PCNL during January 2010 to January 2011 were divided into flank-suspended groups (
Paired
The blood pressure was decreased within and after the operation in both groups, substantially in the prone group, significantly lower than that before the operation (p<0.05). No significant differences in the heart rate, respiratory frequency and oxyhaemoglobin saturation were noted among the different time points in the same group. Blood gas analysis showed that pH value and base excess were profoundly reduced within and after the operation in the two groups, significantly lower than those before the operation, and the decrease was most manifest in the prone group. There was no difference in the blood sodium and potassium among the different time points in each group. The flank-suspended group was superior to the prone group with regard to posture comfort and dyspnoea degree but not puncture-site pain 24 h postoperation.
Flank-suspended and prone PCNL affects the haemodynamics, blood gas variables and subjective feelings of patients to a varying degree. The flank-suspended PCNL possesses advantages over prone PCNL such as little influence on haemodynamics and blood gas variables, satisfactory posture comfort, less dyspnoea and easy access to vital sign observation.
Restricted accessCase reportFirst published April, 2015pp. 106-108Angiomyolipoma (AML) is the most common benign tumour of the kidney and is composed of smooth muscle cells, blood vessels and fat elements. AMLs are usually casually discovered when the kidneys are imaged for other reasons. Their first presentation is often a spontaneous retroperitoneal haemorrhage or bleeding into the urinary collection system, which can be life-threatening. The bleeding tendency is related to the irregular, aneurysmal, tortuous blood vessels that compose the tumor. The greatest risks for bleeding are tumour size and grade of the vascular component of the tumour. Moreover, the risk of bleeding is proportional to the size of the lesion (it is higher in AMLs with a diameter more than 4 cm). Shock due to a grave haemorrhage from AML rupture is called Wunderlich syndrome that is clinically characterized by the Lenk's triad: acute flank pain, a flank mass and hypovolemic shock. Other symptoms and signs may be present: haematuria, palpable mass, flank pain, urinary tract infections, renal failure or hypertension. Small AMLs usually require no therapy, although follow-up is recommended in order to follow its growth. Larger or symptomatic lesions can be electively embolized and/or resected with a partial nephrectomy. AMLs that present with retroperitoneal haemorrhage frequently require emergency embolization. We describe a case of an actively bleeding small renal AML, with a rapid growth, without any evidence for big aneurysmal vessels, who underwent an emergency embolization at our hospital.
Restricted accessCase reportFirst published April, 2015pp. 109-113Sunitinib therapy showed an improvement in survival of patients with metastatic renal cell carcinoma.
A 51-year-old man, with Eastern Cooperative Oncology Group Score (ECOG) of 0, presented at our Institute in March 2012 for macrohematuria and urinary retention. A computed tomography (CT) scan of the abdomen showed a right renal lesion. The lesion had a diameter of 15 cm and was developing towards the liver, in the absence of cleavage planes between the liver and kidney. A 12 mm finding, suspected as secondary lesion, was detected at the level of the VII hepatic segment. Neoadjuvant chemotherapy with Sunitinib was proposed.
The patient underwent a ultrasound-guided biopsy, which confirmed the presence of Clear Cell Carcinoma. The patient began chemotherapy treatment in May 2012 according to the scheme SUNITINIB 50 mg daily for 4 weeks every 6 weeks. After four courses of treatment, according to RECIST criteria for solid tumors, 40% (9 cm vs 15 cm) regression of the primary tumor and 33% (8 mm vs 12 mm) regression of the secondary lesion were observed at a CT scan of the abdomen. In February 2013, Laparoscopic Adrenal-Sparing Radical Nephrectomy was performed. At a follow-up of 3 months, performed with a thorax and abdomen CT scans, there was a complete remission of hepatic secondary lesion and no areas of secondary localization of disease.
This case report showed the effectiveness of neoadjuvant chemotherapy with Sunitinib. The use of this chemotherapy agent can change the approach to the management of cRCC.
Restricted accessCase reportFirst published April, 2015pp. 114-117The adrenal glands are among the target metastatic organs due to the potential of systemic metastasis from renal cell carcinoma (RCC). The number of cases with bilateral metachronous metastases from RCC is about twenty.
A sixty-one-year-old man presented for routine checks due to an operated left renal tumor (clear cell carcinoma, PT2N0M0, Fuhrman grade III). The patient underwent 18FDG-PET/CT in order to restage the disease upon observation of bilateral adrenal masses on ultrasound and CT. A bilateral metachronous metastasis was found, whose SUVmax was 6.7 × 50 × 38 × 20 cm on the left adrenal gland, and another metastasis whose SUVmax was 5.5 40 × 29 × 20 on the right adrenal gland.
The patient underwent a CT-guided biopsy and diagnosis of adrenal metastasis was made by pathological and immunohistochemical examination. The laparoscopic treatment was performed.
There is no standard approach for the treatment of these patients in the literature. But metastasectomy is the most realistic part of the treatment. Making definitive diagnosis with biopsy, following hormonal examination and treatment with minimally invasive adrenal sparing surgical procedure containing frozen-section are strongly recommended. Cancer specific survival significantly increases with metastasectomy.
Restricted accessCase reportFirst published April, 2015pp. 118-119Prostatic fluid collection is not uncommon in urological practice. Prostatic abscess is the most frequent finding in this clinical setting. Spontaneous prostatic hematoma is rare, and may be related to prostatic cancer. Every case of prostatic collection must be considered with attention, and further evaluation is needed when the diagnosis is not clear. Here we report the case of a spontaneous prostatic hematoma, which was eventually found to be due to prostatic cancer, describing in detail the clinical features, differential diagnosis and treatment options.
Restricted accessCase reportFirst published April, 2015pp. 120-123Perivascular epithelioid cell tumors (PEComa) are a very uncommon mesenchymal cancer with uncertain malignant potential.
A computerized research on Pub Med was performed regarding bladder PEComa. We evaluated the literature cases and described a case of bladder PEComa.
PEComa of the bladder is a very rare neoplasm and only 15 cases have been reported so far.
Bladder PEComa involves young subjects of both genders, mostly under 40 years of age. Surgical treatment (partial or radical cystectomy) is the most common management.
A long-term follow-up and larger series are required to better understand the best clinical approach to bladder PEComa.
Restricted accessCase reportFirst published April, 2015pp. 124-126Renal medullary carcinoma (RMC) is a rare tumor, originating in the epithelial papillary cells, that primarily affects young black men with sickle cell trait. We report the case of a 29-year-old Caucasian woman, who at ultrasound showed a cystic mass at the right kidney, with a vascular pattern at the level of the cystic wall. A CT-guided biopsy of the lesion was performed, revealing the presence of unspecified tumor cells. A total nephrectomy was then performed. Microscopically, a tumor resulting from the epithelial papillary cells was observed; several areas of lymphoplasmacytic infiltrates were seen at the junction between the normal kidney tissue and the tumor, and a renal medullary carcinoma was diagnosed. Six months later, the patient developed multiple pulmonary metastases and started chemotherapy with Carboplatin, Paclitaxel and Gemcitabine. The patient died after 27 months of follow-up.
RMC is a tumor that usually occurs in young black men, at an average age of 25 years with extremes of 11 and 39 years. Sickle-cell disease or sickle-cell trait is often present. The longest documented survival (until now) for RMC was 16 months. The best treatment is surgery with enlarged nephrectomy. There are still no appropriate chemotherapy protocols.
Restricted accessCase reportFirst published April, 2015pp. 127-129Hemangiopericytoma (HPC) is an uncommon perivascular tumor, first described in 1942, occurring most frequently in the extremities (pelvis, meninges, head and neck), and rarely affecting the urogenital system. In 1870, Wagner published the first histological description of a Solitary Fibrous Tumor (SFT) of the pleura. It is now thought that the majority of lesions previously called hemangiopericytomas (HPCs) are essentially indistinguishable from solitary fibrous tumors (SFTs). Nowadays, the new WHO classification of soft tissue tumors categorizes most HPCs as SFTs. We report the first case of penile SFT-HPC in a 44-year-old man, presenting with a 3-year history of slow-growing penile mass. The patient underwent a tumor excision. Six months after surgery he is free of local recurrence and distant metastasis.
Restricted accessOtherFirst published April, 2015pp. 130-136Within medical research, a useful statistical tool is based on hypotheses testing in terms of the so-called null, that is the treatment has no effect, and alternative hypotheses, that is the treatment has some effects. By controlling the risks of wrong decisions, empirical data are used in order to possibly reject the null hypotheses in favour of the alternative, so that demonstrating the efficacy of a treatment of interest. The multivariate permutation tests, based on the nonparametric combination – NPC method, provide an innovative, robust and effective hypotheses testing solution to many real problems that are commonly encountered in medical research when multiple end-points are observed. This paper discusses the various approaches to hypothesis testing and the main advantages of NPC tests, which consist in the fact that they require much less stringent assumptions than traditional statistical tests. Moreover, the related results may be extended to the reference population even in case of selection-bias, that is non-random sampling. In this work, we review and discuss some basic testing procedures along with the theoretical and practical relevance of NPC tests showing their effectiveness in medical research. Within the non-parametric methods, NPC tests represent the current “frontier” of statistical research, but already widely available in the practice of analysis of clinical data.