Total laparoscopic bladder resection in the management of deep endometriosis: "take it or leave it." Radicality versus persistence.

BACKGROUND: Bladder endometriosis (BE) is the most common external site of deep-infiltrating endometriosis (DIE) affecting the urinary tract. Frequently associated with other DIE lesions, it can be strongly related to a ventral spread of adenomyosis. Possible symptoms are urinary frequency, tenesmus and hematuria, and they are frequently related to DIE of the posterior and lateral compartment. Hormonal therapy can be used in non-symptomatic patients; conversely, in other cases surgical treatment is the management of choice. METHODS: Retrospective cohort study of a series of consecutive patients treated between September 2004 and December 2017 in a tertiary care referral center. Only full-thickness detrusor involvement was considered as BE. All patients underwent laparoscopic bladder resection with concomitant radical excision of DIE. RESULTS: BE was found in 264 patients and was associated with simultaneous bowel DIE requiring bowel resection in 140 patients (53%). Twenty-five patients (9.5%) had associated obstructive ureteral signs requiring ureteroneocystostomy. Mean hospital stay and time of catheter removal were 9.7 and 9.1 days, respectively. Postoperative major complications (< 28 days) were observed in 19 patients (7.2%). Follow-up was performed at 1, 6 and 12 months after surgery, with a 2.3% recurrence rate observed. CONCLUSIONS: Laparoscopic partial cystectomy for BE is a feasible and safe technique, and experienced laparoscopic surgeons should consider it the gold standard treatment. Surgical eradication leads to excellent surgical outcomes in terms of reduction of symptoms and recurrence rates, considering the need to maintain an adenomyotic uterus for fertility purposes.

Study of the Compression Behaviour of Ti6Al4V Trabecular Structures Produced by Additive Laser Manufacturing.

The aim of this paper was to investigate the compression properties of several trabecular structures produced by additive laser manufacturing of a Ti6Al4V, having different densities and unit cells. Filling space structures were investigated, with different unit cells characterized by both bending-dominated and stretching-dominated behaviour. The stiffness and yield strength were correlated to relative density according to the Gibson and Ashby model. For a constant porosity, the stiffness and the yield strength varied between two extremes represented by the cubic structure (stretching-dominated deformation) and the cross structure (bending-dominated deformation). The properties of the deformed structures did not differ substantially from those of the regular structures. Only in the cubic structure did distortion enhance the contribution of bending to deformation and both stiffness and strength decreased. Cross structures displayed the highest strength at constant stiffness than the others, since they are characterized by the most favourable orientation of the struts.

Total Laparoscopic Ureteroneocystostomy for Ureteral Endometriosis: A Single-Center Experience of 160 Consecutive Patients.

STUDY OBJECTIVE: To investigate the efficacy of laparoscopic ureteroneocystostomy in patients with deep infiltrating endometriosis (DIE) with ureteral, parametrial, and bowel involvement. DESIGN: Prospective study (Canadian Task Force classification II-2). SETTING: Tertiary referral center for endometriosis care. PATIENTS: One hundred sixty patients with DIE underwent laparoscopic radical eradication and ureteroneocystostomy between January 2009 and December 2016. INTERVENTIONS: Laparoscopic nerve-sparing radical treatment with ureteroneocystostomy, parametrectomy, and, if necessary, segmental bowel resection. MEASUREMENTS AND MAIN RESULTS: Surgical eradication was radical, and ureteral endometriosis was histologically confirmed in all patients (45.6% intrinsic and 54.4% extrinsic). In 58.7% of patients ureteroneocystostomy was performed with the psoas hitch technique. Bowel resection was performed in 121 patients (75.6%), and 115 of them had a concomitant ileostomy (71.9%). Unilateral parametrectomy was performed on the left side in 61.9% of patients and on the right side in 30% of patients, respectively, whereas bilateral parametrectomy was completed in 33 patients (20.6%). Postoperative complications were infrequent: 7 patients underwent reoperation (4.4%), 8 patients experienced fever (5%), 4 patients required blood transfusion (2.5%), 3 patients had intestinal fistulas (1.9%), and 24 patients experienced impaired bladder voiding (15%) after 6 months. Mean follow-up time was 20.5 months (range, 1-60). The study reported good clinical and surgical results, with a regression of symptoms (p < .001) and recurrence of parametrial endometriosis of 1.2% that required opposite-side ureteroneocystostomy. CONCLUSION: This is the largest documented series of patients with DIE undergoing laparoscopic radical eradication and ureteroneocystostomy. The collected data show that in patients with ureteral endometriosis, this technique is feasible, effective, and safe and provides good results in terms of relapses and symptoms' control.

Robotic-assisted radical prostatectomy is less stressful than the open approach: results of a contemporary prospective study evaluating pathophysiology of cortisol stress-related kinetics in prostate cancer surgery.

The objective of this study was to investigate the effects of prostate cancer (PCA) surgery on the stress system and to identify potential independent factors associating with stress recovery. The design of the study was prospective and PCA surgery included robot-assisted radical prostatectomy (RARP) or retro pubic radical prostatectomy. Between February and December 2013, 151 consecutive patients were evaluated. The effects of PCA surgery on the stress system were measured by cortisol serum levels before and after surgery on post-operative day (POD) 0, 1, 3, 5 and 45. Statistical methods were applied. RARP was performed in 71% of cases. PCA surgery triggered the stress system which immediately (POD 0) responded by cortisol overproduction which induced the negative feedback mechanism that started on POD 1, continued on POD.

Thyroid surgery performed on an overnight basis: a 17 years of experience

Objective This study aimed to evaluate the results of thyroid surgeries with hospitalization periods shorter than 18 hours performed in a surgical endocrinology service, correlating these results with type of procedure, the definitive diagnosis and complications associated with the procedure.Subjects and methods The procedures performed, complications associated, hospitalization period, and relationships among these variables were assessed in consecutive patients subjected to different types of thyroid surgeries from January 1997 to March 2014 by the same group of surgeons. Data were analyzed by frequency, and the associations between the hospitalization period and other variables were analyzed using the Pearson chi-square test and Fisher’s exact test, using a multiple comparisons test with Bonferroni correction.Results Among the 3,411 surgeries performed, 799 of them were malignant neoplasia, 2,505 were benign tumors and 107 were Graves’ disease. The following procedures were performed: total thyroidectomy (1597 patients); total thyroidectomy with neck exploration (369 patients); lobectomy plus isthmectomy (1084 patients); total thyroidectomy complementation (145 patients); total thyroidectomy with neck dissection (84 patients); modified radical total thyroidectomy (13 patients); nodulectomy (11 patients); unresectable (9 patients); central neck dissection (48 patients); lateral neck dissection (38 patients); and others (13 patients). The following surgical complications, characteristic of the procedure: hemorrhage in 41 (1.2%) patients, hypoparathyroidism in 10 (0.3%) patients and recurrent laryngeal nerve (RLN) injury in 23 (0.7%) patients. Hospitalization shorter than 18 hours was observed in 97% of patients.Conclusion Thyroid surgery can be safely performed in virtually all patients on an overnight basis in specialized services.

Thyroid surgery performed on an overnight basis: a 17 years of experience.

OBJECTIVE: This study aimed to evaluate the results of thyroid surgeries with hospitalization periods shorter than 18 hours performed in a surgical endocrinology service, correlating these results with type of procedure, the definitive diagnosis and complications associated with the procedure. SUBJECTS AND METHODS: The procedures performed, complications associated, hospitalization period, and relationships among these variables were assessed in consecutive patients subjected to different types of thyroid surgeries from January 1997 to March 2014 by the same group of surgeons. Data were analyzed by frequency, and the associations between the hospitalization period and other variables were analyzed using the Pearson chi-square test and Fisher's exact test, using a multiple comparisons test with Bonferroni correction. RESULTS: Among the 3,411 surgeries performed, 799 of them were malignant neoplasia, 2,505 were benign tumors and 107 were Graves' disease. The following procedures were performed: total thyroidectomy (1597 patients); total thyroidectomy with neck exploration (369 patients); lobectomy plus isthmectomy (1084 patients); total thyroidectomy complementation (145 patients); total thyroidectomy with neck dissection (84 patients); modified radical total thyroidectomy (13 patients); nodulectomy (11 patients); unresectable (9 patients); central neck dissection (48 patients); lateral neck dissection (38 patients); and others (13 patients). The following surgical complications, characteristic of the procedure: hemorrhage in 41 (1.2%) patients, hypoparathyroidism in 10 (0.3%) patients and recurrent laryngeal nerve (RLN) injury in 23 (0.7%) patients. Hospitalization shorter than 18 hours was observed in 97% of patients. CONCLUSION: Thyroid surgery can be safely performed in virtually all patients on an overnight basis in specialized services.

Unusual case of locally advanced and metastatic paratesticular liposarcoma: a case report and review of the literature.

Liposarcoma accounts for 20% of all sarcomas and is a rare occurrence in the paratesticular region. We present the case of a 66-year-old man with a massive liposarcoma of the right scrotum invading the lower limb and the abdominal wall skin. The case concerns an unusually large and aggressive liposarcoma (25 cm), presenting with multiple lung and nodal metastases. The patient had an unfavourable evolution with rapid progression of metastases, although there were no signs of local disease. In this case, a wide local excision was performed in order to obtain local control of the disease. Even though paratesticular sarcomas might have a more favourable evolution, the association with lung involvement carries an ominous prognosis. Diagnosis of paratesticular sarcoma should be kept in mind in case of irregular necrotic masses in the inguinal and scrotal region.

Prostate volume index and chronic inflammation of the prostate type IV with respect to the risk of prostate cancer.

BACKGROUND: Benign prostatic hyperplasia and prostate cancer (PCA) alter the normal growth patterns of zonal anatomy with changes of prostate volume (PV). Chronic inflammatory infiltrates (CII) type IV are the most common non-cancer diagnosis of the prostate after biopsy. OBJECTIVE: To evaluate associations of both PV index (PVI), i.e. the ratio of transitional zone volume (TZV) to peripheral zone volume (PZV), and CII with PCA in patients undergoing biopsy. SUBJECTS AND METHODS: Between January 2007 and December 2008, 268 consecutive patients who underwent prostate biopsy were retrospectively evaluated. PV and TZV were measured by transrectal ultrasound. PZV was computed by subtracting the PV from the TZV. CII were evaluated according to standard criteria. Significant associations of PVI and the presence of CII (CII+) with PCA risk were assessed by statistical methods. RESULTS AND LIMITATIONS: We evaluated 251 patients after excluding cases with painful rectal examinations, prostate-specific antigen (PSA) >20 µg/ml and metastases. The PCA detection rate was 41.1%. PVI was a negative independent predictor of PCA. A PVI ≤1.0 was directly [odds ratio (OR) = 2.36] associated with PCA, which was detected more frequently in patients with a PVI ≤1.0 (29.1%) than in those with a PVI >1.0 (11.9%). CII+ was inversely (OR = 0.57) and independently associated with PCA, which was detected less frequently in cases with CII (9.9%) than in those without CII (21.1%). Potential study limitations might relate to the fact that PV was not measured by prostatectomy specimens and there was PSA confounding for CII and PCA. CONCLUSIONS: Low values of PVI are directly associated with risk of PCA, which was almost 2.5 times higher in patients with a PVI ≤1.0. The PVI might be an effective parameter for clustering patients at risk of PCA. CII+ was inversely associated with risk of PCA and decreased the probability of detecting PCA by 43%. The role of the PVI and CII in PCA carcinogenesis needs further research.

Is ureteral stent placement by the transurethral approach during robot-assisted radical prostatectomy an effective option to preoperative technique?

Ureteral stent placement may be needed in patients undergoing robot-assisted radical prostatectomy (RARP) in cases of a large median lobe or previous transurethral surgery to prevent damage to the ureteral orifices. Unpredictable anatomic variants or technical difficulties in bladder neck section may necessitate intraoperative stent placement. We describe our original, simple, and feasible transurethral stent placement technique during RARP, which could be a valid option to preoperative technique.

Portal vein thrombosis with renal cell carcinoma: a case report.

Portal vein thrombosis refers to an obstruction of blood flow in the portal vein; this rare disease can be both local and systemic. Local risk factors, accounting for about 70% of cases, can be abdominal cancers, inflammatory of infective diseases, surgical procedures or cirrhosis. A 62-year-old man, affected by hypertension and taking acetylsalicylic acid after a myocardial infarction in 1994, developed deep venous thrombosis on the right leg. Six months later the patient was admitted to the emergency unit due to abdominal pain. A CT scan revealed the presence of a complete splanchnic vein thrombosis and a primary tumor on the right kidney. The patient was treated with total parenteral nutrition and intravenous solution of heparin sodium first and then, because of occurrence of allergy, fondaparinux, with improvement of the abdominal pain. Subsequently he underwent right radical nephrectomy.

Animal experimental model of Peyronie's disease: a pilot study.

OBJECTIVE: The Peyronie's disease (PD) is an idiopathic disorder of connective tissue of the penis, that involves the tunica albuginea of the corpora cavernosa and the adjacent areolar space. It is a growing clinical evidence to support the therapeutic potential of mesenchymal stem cells and histological findings has assumed a possible application of lipofilling technique in patients with PD. The objective of this experimental study is the creation of a murine experimental model of PD, evaluating with MRI the penis of the rats (feasibility study), in order to plane the application of lipofilling technique in an animal model. METHODS: Four male Wistar rats were anesthetized, fixed in prone position and subjected to MRI. The animals underwent, subsequently, an injection of thrombin in the tunica albuginea and MRI images were acquired at 7 and 21 days after injection with incision of the dartos. RESULTS: The MRI acquisitions, both in coronal and axial projection, showed an adequate visibility of the anatomical structures. At 7 days after thrombin injection with the dartos incision it was evident an oedematous portion, visible as a hyperintense area, located at the injection area. At 21 days after injection, oedema was partially resolved: the injection part of the hyperintense area remains unchanged, while the remaining area appears to be part of a re-absorption and re-organization process. CONCLUSIONS: Since none of the various treatment modalities currently available for the management of PD is able to bring healing, the researchers' attention is increasingly directed towards innovative treatment programs, such as the use of stem cells of mesenchymal origin. At the present time, the research in PD is hampered by the lack of universally accepted animal model and this is likely attributed to the limited insight into PD mechanisms and the difficulties faced by current animal models to truly represent the complexity.

Primary osteosarcoma of the thyroid gland: report of a rare neoplasm / Osteossarcoma primário da glândula tireoide: relato de uma neoplasia rara

Primary mesenchymal tumors of the thyroid gland are extremely rare. The authors report a case of primary thyroid osteosarcoma in a male patient presenting a tumoral mass in the neck. CT scan demonstrated a large tumor in the right thyroid lobe with areas of calcification. The surgical specimen consisted of a hard brown-gray tumor, measuring 13 × 11 × 7.5 cm. Microscopy revealed a high-grade malignant neoplasm composed of polygonal cells of intermediate size, chondroid pattern in some areas and osteoid formation. The process was immunonegative for AE1/AE3, glial fibrillary acidic protein (GFAP), epithelial membrane antigen (EMA), p53 and thyroid transcription factor-1 (TTF-1), and immunopositive for CD99 and S100. Thus the diagnosis of primary osteosarcoma of the thyroid gland was established.

Tumores mesenquimais da glândula tireoide são extremamente raros. Os autores relatam um caso de osteossarcoma primário de tireoide em um paciente masculino que apresentou massa tumoral na região cervical. A tomografia computadorizada demonstrou um grande tumor no lobo tireoideano direito, com zonas de calcificação. A peça cirúrgica consistia de um tumor marrom-acinzentado e firme, medindo 13 × 11 × 7,5 cm. À microscopia, foi encontrada neoplasia maligna de alto grau composta por células poligonais de tamanho intermédio, com um padrão condroide em algumas áreas e formação de osteoide. O processo revelou imunoexpressão negativa para AE1/AE3, proteína glial fibrilar ácida (GFAP), antígeno da membrana epitelial (EMA), p53 e fator de transcrição da tireoide (TTF-1) e imunopositividade para CD99 e S100. O diagnóstico de osteossarcoma primário da glândula tireoide foi, então, estabelecido.

Plasmocitoma da glândula tireoide: relato de caso de uma rara neoplasia / Primary plasmacytoma of the thyroid gland: a case report of a rare neoplasia

Extramedullary plasmacytoma comprises 3%-5% of all plasma cell neoplasms, and approximately 80% of the cases occur in the upper respiratory tract. Primary thyroid plasmacytomas (PTP) are rare tumors. The authors report a case of PTP in a male patient with dyspnea and dysphagia. Physical examination and computerized tomography (CT) scan revealed a solid tumor affecting the thyroid gland, measuring 12 cm in its greatest dimension. Surgical biopsy was performed. Microscopy revealed a hypercellular malignant neoplasm composed of round plasmacytoid cells arranged in solid nests, which showed a positive immunoexpression for CD138, epithelial membrane antigen (AME), kappa light chains and multiple myeloma oncogene 1 (MUM1). The diagnosis of PTP was accordingly established.

O plasmocitoma extramedular constitui 3%-5% de todas as neoplasias de plasmócitos e aproximadamente 80% dos casos ocorrem no trato respiratório superior. Plasmocitomas primários da tireoide (TPP) são tumores raros. Os autores relatam um caso de TPP em um paciente masculino referindo dispneia e disfagia. O exame físico e a tomografia computadorizada revelaram tumor sólido comprometendo a glândula tireoide, medindo 12 cm na maior dimensão, o qual foi submetido à biópsia cirúrgica. À microscopia, foi identificada neoplasia maligna hipercelular constituída por células redondas/plasmocitoides dispostas em ninhos sólidos, as quais exibiam imunoexpressão positiva para CD138, antígeno da membrana epitelial (AME), cadeias leves kappa e oncogene mieloma múltiplo 1 (MUM1). O diagnóstico de TPP foi, então, estabelecido.

Critical points in understanding the Italian version of the IIEF 5 questionnaire.

PURPOSE: The aim of these study is to assess the understanding of the Italian version of the IIEF-5 questionnaire (International Index of Erectile Function) and the impact of patient's demographic and clinical characteristics on it. MATERIALS AND METHODS: Each patient was asked to self complete the Italian version of the IIEF-5 questionnaire and to self report demographic information and any difficulties to complete the questionnaire and which question was considered more difficult to understand. RESULTS: A total of 89 patients were included in this study. Patients mean age was 61.2 +/- 15.4 (standard deviation = SD) years. The mean IIEF score at the time of the visit was 13.5 +/- 8.5 (SD). The questions considered more difficult to understand were number 5 (26%), number 4 (20%) and number 1 (20%). Statistically significant differences between patients with and without problems in completing the questionnaire were found in terms of education level (p = 0.0026). CONCLUSIONS: Patients with a lower educational level have more difficulties in understanding the questionnaire and the most difficult questions are items number 5, 4 and 1.

A relação entre o tamanho tumoral e fatores prognósticos em 241 casos de carcinoma papilar da tireóide / The relation between tumoral size and prognostic factors in241 cases of thyroid papillary carcinoma

Introdução: O carcinoma papilar é a neoplasia mais frequente da tireoide. Em geral, corresponde a lesões indolentes, com excelente prognóstico em longo prazo. Os fatores prognósticos associados ao carcinoma papilar incluem idade, invasão neoplásica extratireoidiana e presença de metástases à distância. Os autores avaliam 241 casos de carcinoma papilífero da tireoide com o objetivo de estimar a relação entre o tamanho tumoral e fatores prognósticos nesta neoplasia. Métodos: No presente estudo, foram analisadas as seguintes variáveis: idade, sexo, topografia, tamanho tumoral, grau de diferenciação, variante histológica, multicentricidade, margens cirúrgicas, invasão angiolinfática, capsular e extratireoidiana, estadiamento e presença de metástases nodais. Foi utilizado o teste de Mann-Whitney para verificar a associação entre o tamanho tumoral e as variáveis. Resultados: A idade média correspondeu a 53,22 anos, sendo encontrados 211 casos no sexo feminino (87,6%). O tamanho tumoral esteve associado a idade (p<0,001), sexo (p<0,001), invasão capsular (p<0,01), extensão neoplásica extratireoidiana (p<0,001), invasão neoplásica angiolinfática (p<0,02) e presença de metástases em linfonodos regionais (p<0,001), não existindo relação com grau e variante histológica (p>0,05). A presença concomitante de tireoidite de Hashimoto e hiperplasia nodular exibiu associação significante (p<0,001). Conclusão: No carcinoma papilífero, o tamanho tumoral representa um dos principais fatores morfológicos relacionados à invasão neoplásica capsular e angiolinfática, extensão extratireoidiana e metástases em linfonodos.

Introduction: Papillary carcinoma is the most common cancer of the thyroid gland. In general the lesions are indolent with an excellent long-term prognosis. The prognostic factors associated with papillary carcinoma include age, extra-thyroid neoplastic invasion, and presence of distant metastases. Here the authors studied 241 cases of papillary thyroid carcinoma in order to estimate the relationship between tumor size and prognostic factors in this malignancy. Methods: The following variables were considered in this study: age; sex; topography; tumor size; differentiation grade; histological variant; multicentricity; surgical margins; angiolymphatic, capsular and extra-thyroid invasion; taging; and nodal metastasis. The Mann-Whitney test was used to determine the association between tumor size and the variables. Results: The mean age was 53.22 years, and 211 cases occurred in females (87.6%). Tumor size was associated with age (p <0.001), gender (p <0.001), capsular invasion (p <0.01), extra-thyroid neoplastic extension (p <0.001), angiolymphatic neoplastic invasion (p <0.02), and presence of regional lymph node metastases (p <0.001), with no relationship to grade and histological variant (p> 0.05). The concomitant presence of Hashimoto’s thyroiditis and nodular hyperplasia were significantly associated (p <0.001). Conclusion: In papillary carcinoma, tumor size represents one of the main morphological factors related to capsular and angiolymphatic invasion, extra-thyroid extension, and lymph nodes metástases.

Peliose hepática associada a contraceptivos orais: relato de um caso e revisäo da literatura / Peliosis hepatis associated with oral contraceptives: report of a case and review of the literature

Peliose hepática é um distúrbio raro, caracterizado pela existência de múltiplas cavidades cheias de sangue, distribuídas irregularmente pelo parênquima hepático. Os autores relatam sua experiência no diagnóstico e tratamento de uma mulher de 30 anos portadora da referida patologia, na qual o único fator etiológico identificado foi o uso crônico de anticoncepcionais orais. É realizada revisäo da literatura