Prostate cancer testicular metastasis: Are they underestimated? Case report and analysis of the literature.

INTRODUCTION: We aim to present a rare case of a patient who developed a late testicular metastasis of PCa after radical prostatectomy. CASE DESCRIPTION: A 78 years old man presenting for left testicular swelling slowly increasing of size over the last 2 months. He underwent a retropubic radical prostatectomy and extended bilateral lymphadenectomy in 2007 for prostatic adenocarcinoma. At the time of the presentation the last PSA was 0.91 ng/mL. The patient underwent a standard left orchifunicolectomy in April 2019 without intra- or perioperative complications. The pathological analysis showed a testicular metastasis of acinar adenocarcinoma. CONCLUSIONS: In conclusion, testicular metastasis from PCa are uncommon conditions. PSA evaluation and physical examination of all sites of metastasis and accurate evaluation of all signs/symptoms during the clinical visit remains crucial to the diagnosis of recurrence.

Ectopic adrenal tissue in the kidney: A systematic review.

INTRODUCTION: Ectopic adrenal tissue in the kidney, including "Ectopic adrenal tissue" and "Adrenal-renal fusion", is a rare event with a specific behavior which may be difficult to distinguish clinically from renal neoplasms. We performed a systematic review on ectopic adrenal tissue variants reported in the literature underlining its clinical aspects. METHODS: Manuscripts which presented a case report or case series of ectopic adrenal tissue in the kidney were included even if published in original articles, reviews, or letters to the editor. A specific search on SCOPUS®, PubMed®, and Web of Science® database was performed. Only English language papers published in a period ranging between August 1991 and April 2020 were considered. Additionally, a case we had at our institution is described, and its characteristics are included. Data on clinical presentation, type of adrenal anomaly, location, anatomopathological and immune-histotype characteristics were collected. RESULTS: We identified 888 manuscripts. Among these 29 were included in this systematic review. Overall, 39 patients with renal adrenal fusion or adrenal ectopia were considered. In most cases, the diagnosis was made incidentally, or following investigation for flank pain, abdominal pain, or endocrinological disorders. CT scan frequently identified a solid vascularized lesion that was difficult to distinguish from renal neoplasm. Adrenal fusion was mostly located at the level of the upper pole. Adrenal rest was found in the renal parenchyma, renal hilum, or retroperitoneum in close proximity to the renal peduncle. Often these ectopic adrenal tissue lesions follow a benign behavior and can be classified as functioning or non-functioning adenomas. Rarely, they may experience neoplastic degeneration. The most frequently positive markers were inhibin, vimentin, melan-A, synaptophysin and anti-p450 scc. CONCLUSIONS: Ectopic adrenal tissue in the kidney is a rare event with specific clinical characteristics that need to be identified in order to arrive at a correct diagnosis and carry out appropriate treatment management.

Hospital care in Departments defined as COVID-free: A proposal for a safe hospitalization protecting healthcare professionals and patients not affected by COVID-19.

The COVID-19 pandemic influenced the normal course of clinical practice leading to significant delays in the delivery of healthcare services for patients non affected by COVID-19. In the near future, it will be crucial to identify facilities capable of providing health care in compliance with the safety of healthcare professionals, administrative staff and patients. All the staff involved in the project of a Covid-free hospital should be subjected to a diagnostic swab for COVID-19 before the beginning of healthcare activity and then periodically in order to avoid the risk of contamination of patients during the process of care. The modifications of various activities involved in the process of care are described: outpatient care, reception of inpatients, inpatient ward and operating room. For outpatient care, modality of appointment procedure, characteristics of waiting room and personal protective equipment (PPE) for healthcare professionals and administrative staff are presented. Reception of inpatients shall be conditional on a negative swab for COVID-19 obtained with a drive-in procedure. The management of the operating room represents the most crucial step of the patient's care process. The surgical team should be restricted and monitored with periodic swabs; surgical procedures should be performed by experienced surgeons according to standard procedures; surgical training experimental treatments and research protocols should be suspended. Adequate personal protective equipment and measures to reduce aerosolization in the operating room (closed circuits, continuous cycle insufflators, fume extraction) should be adopted. Prevention of possible transmission of the virus during procedures in open, laparoscopic and endoscopic surgery is to use a multi-tactic approach, which includes correct filtration and ventilation of the operating room, the use of appropriate PPE (FFP3 plus surgical mask and protective visor for all the staff working in the operating room) and smoke evacuation devices with a suction and filter system.   on behalf of the UrOP Executive Committee Giuseppe Ludovico, Angelo Cafarelli, Ottavio De Cobelli, Ferdinando De Marco, Giovanni Ferrari, Stefano Pecoraro, Angelo Porreca, Domenico Tuzzolo.

Robotic-assisted laparoscopic pyeloplasty with the use of the Contour™ stent: description of the technique and analysis of outcomes after the first 30 cases.

INTRODUCTION: We present a technical variation of robot-assisted pyeloplasty (RAP) using the Contour™ stent that allows a minimal incision of the retroperitoneum. MATERIAL AND METHODS: The main difference from the standard robot-assisted pyeloplasty (RAP) is the preventive retrograde insertion of a Contour™ stent, which is a single J stent subsequently easily convertible in a double J stent. RESULTS: The mean operative time was 141.2 minutes. Blood losses were negligible, median length of stay was 4 days. CONCLUSIONS: The use of a Contour™ stent showed to be a safe and feasible technical variation while performing a RAP.

Robotic surgery in patients with achondroplastic dwarfism: evaluation of risks and issues in an anatomical challenging bilateral partial nephrectomy.

The reports on the performance of robotic surgery in patients with dwarfism are anecdotal; anesthesiological issues and a challenging anatomy are the main factors that lead most of surgeons to prefer a more traditional approach. We present a case of bilateral robotic partial nephrectomy in a patient affected by achondroplastic dwarfism and aim to evaluate risks and issues in this type of surgery.

Robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with daVinci Single-Site® platform. Concept and evolution of the technique following an IDEAL phase 1.

To describe the evolution of robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) performed with the daVinci Single-Site Platform® and a home-made multiport aimed to overcome classical drawbacks of LESS, still present with this platform. Between 09/2015 and 06/2017 12 patients underwent R-LESS RP for clinical localized prostate cancer. Following a "phase 1 (development-stage)" innovation, development, exploration, assessment, long-term study (IDEAL) framework, different solutions were drawn to overcome drawbacks of daVinci Single-Site Platform®, included 3 (A, B, and C) multi-ports developed and evaluated in term of advantages/drawbacks concerning ergonomy. The end points of this study were: feasibility, safety, efficacy, by reporting rational description of multiports configuration, demographics, perioperative variables, functional and oncological results. Semi-flexible robotic 5-mm needle-holder instead of Maryland forceps, 30° lenses up and barbed-suture allowed overcoming limits of robotic-platform. Multiport-C (GelPOINT Advanced-Access® and an extra 8-mm robotic trocar outside the multiport) showed the best compromise to ensure both surgeon and bed-side assistant to reproduce a standard robotic procedure. No conversion to either standard robotic or open technique or intraoperative complications occur in any case. Two patients experienced "high-grade" Clavien-Dindo complications. After 12.4 months follow-up, all patients were continent without any sign of biochemical relapse and among 5 preoperative potent patients submitted to nerve-sparing dissection, 4 reported good erectile-function. R-LESS-RP is feasible and safe in the hands of experienced minimally-invasive surgeons. Do date, we recommend a hybrid solution with a home-made multiport and use of an additional standard robotic trocar which allows the use endowrist® technology instruments.

Developing a five-step training model for transperineal prostate biopsies in a naïve residents' group: a prospective observational randomised study of two different techniques.

PURPOSE: To evaluate a five-step training model for transperineal prostate biopsies (TPPB) and the differences in terms of the detection rate (DR) and the ease of execution when using either the "fan technique" (FT) or the use of a Free Hand technique (FH). METHODS: A prospective observational randomised study was conducted from September 2015 to November 2017. Six naïve residents, who underwent the same five-steps training model, were randomly subdivided into two different groups of three residents based on the selected TPPB technique: A (FT) and B (FH). Patient characteristics (age, PSA, prostatic volume, DRE, MRI), intraoperative (operative time, number of samples) and postoperative parameters (histologic, pain) were evaluated in the 2 groups. The overall and stratified DR for PSA ranges and prostate volume (PV), operative time and complications were compared. RESULTS: The overall detection rate was very high in both groups (FT 58.2% vs FH 59.6%) and not statistically different between the two techniques. There were no differences in terms of complication rates and pain. The FH showed a better detection rate in prostates smaller than 40 cc (p = 0.023) and a faster operative time (p = 0.025) compared to FT. CONCLUSIONS: Within the TPPB, FH is associated with a higher detection rate in patients with prostate < 40 cc compared to an FT when performed by inexperienced trainees. Standardised training organised in consecutive steps seems to contribute to the achievement of overall high detection rates with both methods.

Massive hematuria due to ruptured iatrogenic aortic pseudoaneurysm: a case report.

We report an interesting case of massive haematuria secondary to a rupture of a pseudoa- neurysm of the abdominal aorta below the renal vessels. A 65-year-old woman present- ed at our institution with a painful massive haematuria and anaemia. Two months before, she undergone a pelvic surgery complicated by an accidental injury of the right ureter sutured with a end-to-end anastomosis. An abdominal computed tomography (CT) scan with intravenous contrast showed a right-sided hydronephrosis with clots in the lumen of the right pelvis with a massive retroperitoneal hematoma due to a rupture of a iatrogenic pseudoaneurysm of the abdominal aorta below the origin of the renal arteries.

Inguinal canal tumors of adulthood.

AIM: To review benign and malignant paratesticular lesions. MATERIALS AND METHODS: A non-systematic review of the English literature in the National Library of Medicine Database (MEDLINE) was performed using the key words "spermatic cord", "inguinal canal", "neoplasms" (focusing on soft tissue sarcomas). The 74 most significant contributions were selected. RESULTS: Although generally benign (lipoma is the most frequent), paratesticular tumors have a high incidence of malignancy (30%). Ultrasonography, computed tomography and magnetic resonance imaging represent the main tools in the evaluation of a solid paratesticular mass. Most malignant tumors are sarcomas and commonly spread via local invasion to adjacent structures. The definitive diagnosis is made postoperatively. Surgical excision in the form of radical orchiectomy and wide local resection of tumor margins is mandatory and represents the mainstay of treatment options. CONCLUSION: Surgical treatment of paratesticular tumors is fundamental in order to determine the histology so as to define the correct follow-up for each patient.

Perioperative complications and mortality after radical cystectomy when using a standardized reporting methodology.

PURPOSE: To evaluate, by using a standardized reporting methodology, the perioperative complications and mortality in patients who underwent radical cystectomy. MATERIALS AND METHODS: We retrospectively reviewed all data of 404 consecutive patients who underwent radical cystectomy from 1995 to 2009 for nonmetastatic bladder cancer at the same academic center. Perioperative complications and perioperative mortality were defined as any adverse event or death from any cause within 90 days of surgery. All perioperative complications were reported according to the Martin criteria and were graded according to the Clavien system (grade 1-5). Univariate and multivariate analyses for the clinical and pathologic characteristics were used to evaluate predictors of complications. RESULTS: A total of 296 complications occurred in 209 (51.7%) patients. Among them, 139 (34.4% of the entire population) had only a '"minor"' (grade 1-2) complication, whereas 70 (17.3%) had a "major" (grade 3-5) complication. Eighteen (4.5%) patients died within 90 days after surgery. At univariate analysis, age ≥75 years (2P = .018), serum creatinine level ≥1.4 mg/dL (2P = .025), American Society of Anesthesiologists (ASA) score of 3 to 4 (2P < .001) were significant predictors of complications after 30 days from surgery; conversely, the ASA score was the only significant predictor of complications after 90 days. At multivariate analysis, only the ASA score was independently correlated with the development of complications at 30 and 90 days of follow-up (2P < .001). CONCLUSIONS: Radical cystectomy is one of the most complex procedures in urology, with a high rate of complications and mortality. The use of a standardized methodology is the only way to estimate the actual rate and the severity of complications.

Epithelioid sarcoma of the penis: a case report.

INTRODUCTION: Epithelioid sarcoma of the penis is a slowly growing soft tissue neoplasm that rarely arises from the penis. AIM: The aim of this case is to describe this rare pathology and to underline the importance of differential diagnosis with benign diseases such as Peyronie's disease. METHOD: We report the case of a 20-year-old man who referred the onset of a progressive left dorsolateral penile curvature (about 60°) started 3 years before. The patient was evaluated with two US examinations that revealed two sites of tunical thickening with normal hemodynamic evaluation. The physical examination demonstrated a dorsal fibrotic plaque of about 2.5 cm. RESULTS: A juvenile form of Peyronie's Disease was diagnosed, and the patient was scheduled for surgical treatment (plaque's incision/excision and grafting). Intraoperative appearance showed that the great part of the left cavernous body was substituted by a very tough tissue which deeply involved the erectile tissue; intraoperative frozen section was suspicious for mesenchymal epithelioid neoplasm. In order to obtain definitive histological analysis and collect proper informed consent, we preferred to proceed with our original project, applying a dual graft (buccal mucosa and allograft dermal matrix) to cover the wide excised area. The final histological report confirmed the diagnosis of epithelioid sarcoma. Postoperative CT and MRI, at 3 and 6 months from surgery, were negative for metastases. The patient underwent radical intervention after 6 months. CONCLUSIONS: Epithelioid sarcoma of the penis and Peyronie's Disease can present with similar clinical findings although they obviously entail a different clinical progress. Since the diagnosis of neoplasm can be established only by the pathologist on biopsy specimen, in cases of unusual clinical presentation of Peyronie's disease (especially in young men suffering from a fast-growing penile induration), an early histological assessment should be performed to avoid the possibility of misdiagnosis in case of this poor-prognosis disease and to assure the definitive diagnosis.

Testicular sclerosing Sertoli cell tumor: an additional case and review of the literature.

Sertoli cell tumours are very rare testicular tumours accounting for 0.4-1.5% of all testicular neoplasms. In the current report, we present a case of sclerosing Sertoli cell tumour. The histology and clinical features were compared to those of other Sertoli cell tumour subtypes in order to assess if the different subtypes really represent distinct clinical and prognostic entities. The current literature was also reviewed. Only 20 cases of sclerosing Sertoli cell tumours have been encountered. Our case, a 38-year-old man represents the 21st case. Distinction among Sertoli cell tumours is important not only histologically; sclerosing Sertoli cell tumours have a distinct clinical behaviour and prognosis, different from those of classic and large-cell calcifying Sertoli cell tumours. Pathologists and urologists should know and understand all the types of Sertoli cell tumours in order to be able to choose the correct therapeutical approach when they encounter these tumours.

Molecular diagnostic tools for the detection of nodal micrometastases in prostate cancer patients undergoing radical prostatectomy with extended pelvic lymph node dissection: a prospective study.

BACKGROUND: Routine pathological examination can miss micro-metastatic tumor foci in the lymph nodes (LN) of patients with prostate cancer (PCa) that undergo radical prostatectomy and pelvic lymph node dissection (PLND). The aim of the present prospective study was to evaluate the impact of micrometastases assessed by serial section (SS), immunohistochemistry (IHC), and Real-time Polymerase Chain Reaction (RT-PCR) in patients undergoing radical prostatectomy with extended PLND. MATERIALS AND METHODS: 32 consecutive patients who underwent radical prostatectomy with extended PLND (obturator, internal/external and distal 2 cm common iliac lymph-nodes (LN)) for intermediate (clinical T1c-T2 and PSA:10-20 ng/mL and clinical Gleason Score = 7) or high (clinical stage T3 or PSA>20 or clinical Gleason Score = 8-10) PCa were enrolled. The nodes were processed by the one uropathologist, both according to the routine pathological examination (analysis of the central section for 4 mm nodes or every 2 mm for LN>4 mm), which served as comparative method, both according to SS, IHC with antibodies against PSA and broad-spectrum Cytokeratins (BSCK), and quantitative RT-PCR targeting PSA, PSMA (PS Membrane Antigen), and Glucuronidase-S-Beta (GUSB) mRNA, that are over-expressed in prostatic cancer cells. RESULTS: A total of 628 LN were analyzed, with a mean number of LN removed of 19.6 (SD = 7.2). Applying the routine pathological examination, 10 (31.2%) patients and 23 (3.9%) LN resulted positive for nodal involvement, with mean positive LN of 2.2 (SD = 1.4). After applying the SS and the molecular method of analysis (IHC and RT-PCR), micrometastases were found in 7 LN (SS showed micrometastases in 3 of them, IHC in 6 of them and RT-PCR in 7 of them); a total of 3 (9.3%) node-negative patients showed micrometastases at routine pathological examination (in 2 patients with RT-PCR and in 1 with IHC). CONCLUSIONS: The significance of micrometastases in PCa and the potential therapeutic role of PLND is not yet clarified, but the molecular analysis of the LN can detect a significant percentage of patients who harbor micro-metastatic PCa missed at routine pathological examination, and can enhance the accuracy of lymphadenectomy as a staging method.