Treating anterior vaginal wall prolapse with polypropylene mesh via the transoburator route minimizing the complications with the use of preventing measures. A prospective study with 2-year follow-up.

AIM: Our objectives were to evaluate the efficacy of the Perigee™ transoburator (TOT) mesh kit (American Medical Systems [AMS]-Minnetonka, MN, USA) in the treatment of ≥ stage 2 symptomatic AVP following a 2-year follow-up and to discuss the role of the pre-, peri- and postoperative measures taken to prevent complications METHODS: A total of 50 patients were eligible and were subjected to AVP surgical treatment with the use of the Perigee™ system. All patients were followed-up at 4 weeks, 2, 6, 12 and 24 months. Our primary objective was treatment success and efficacy after anatomical examination of the patient at the 24-month follow-up. Efficacy was defined as ≤ stage I AVP. All patients completed the 24-month follow-up. Our secondary objective was to examine the complication rates in relation to the use of preventative measures. RESULTS: The proportion of patients with II to III stage significantly decreased postoperatively (P<0.001). A significantly improvement was found in all POP-Q measures (P<0.05) while mean vaginal length was similar to the preoperative values. At 24-month follow-up, 45 women were defined as ≤ stage I, indicating a 90% objective success rate (95% CI: 81.4-98.6%). Two patients had vaginal mesh extrusion (4.0%) both treated with conservative measures. No erosions occurred at any point postoperatively. De novo dyspareunia was reported in two of the 17 cases (11.8%) who reported being sexually active at follow-up. One of the two had also mesh extrusion and with appliance of the vaginal estrogen and the office excision of the exposed mesh the symptoms were resolved, while the other was treated with vaginal estrogen. Two cases (4.0%) reported de novo incontinence and both were treated with a TOT sling (monarc AMS) procedure three months after the cystocele repair. Three cases (6.0%) reported pain vaginal pain postoperatively and again our treatment of choice was vaginal estrogen cream for 4 weeks with the addition of antinflammatories for 10 days and their symptoms resolved. CONCLUSIONS: The treatment of AVP with the use of Perigee™ TOT system can be both effective and safe. The goal is the improvement of the quality of life of the patients and is important to avoid or to keep as minimum as possible the complications. Main complications that the surgeon should bear in mind are the vaginal erosion, vaginal mesh extrusion, de novo dyspareunia, de novo incontinence and vaginal pain. Proper patient selection, the appliance vaginal estrogen cream pre- and postoperatively and following strict surgical principles are the mainstay of the success of the TOT operation. It is crucial for POP procedures to be performed by high-volume surgeons in this field, with extensive knowledge of the pelvic floor anatomy and the mesh's characteristics. Of course this is a small study and further clinical studies with larger number of patients are needed in order to further scientific evaluate the TOT operation.

Solitary fibrous tumor of the kidney with massive retroperitoneal recurrence. A case presentation.

Solitary fibrous tumor is an unusual spindle cell neoplasm that usually occurs in the pleura but has also been described in other sites. Renal presentation is rare and only 38 cases of SFT of the kidney have been described until now. Up to 90% of the tumors have benign characteristics. Local retroperitoneal recurrence is extremely rare. We report a case of a large malignant solitary fibrous tumor recurrence after the surgical excision of the primary tumor. Histological examination of the specimen confirmed the diagnosis by revealing highly positive reaction of the neoplasmatic cells for vimentin, CD34, bcl-2 and moderately positive for actin. The rate of Ki67 lied between 2-7%. No adjuvant therapy was given to the patient and he is disease-free with no imaging findings of recurrence or metastasis 9 months after the re-operation.

Implication of high grade intraepithelial neoplasia in adverse pathology after radical prostatectomy.

The implication of high grade prostatic intraepithelial neoplasia (HGPIN) to prostate cancer aggressiveness and prognosis is conflicted. The aim of the present study was to evaluate the role of HGPIN in prediction of adverse pathology in patients undergoing a radical prostatectomy. We retrospectively analysed patients who underwent a radical prostatectomy between January 2005 and December 2010. The relationship between HGPIN and the presence of upgrade, positive surgical margins (PSM), extracapsular disease (ECD), seminal vesicle invasion (SVI) and lymph node invasion (LNI) was analysed. HGPIN predictive ability was estimated by using receiver operating characteristic curves. HGPIN was found in 160 (53.3%) specimens. A statistically significant correlation was found between HGPIN and preoperative prostate specific antigen (p=0.020) and patients' age (p=0.025). No significant differences were found, regarding the presence of adverse pathological findings, between the patients with or without HGPIN, irrespective of the preoperative risk stratification. HGPIN did not reach significance for the prediction of upgrade, PSM, ECD, SVI and LNI. The presence of concomitant HGPIN and prostate cancer found not to be related with tumor aggressiveness in patients undergoing a radical prostatectomy and should not be considered as a parameter for the operative outcome prediction.

Clinical and pathological parameters predicting extracapsular disease in patients undergoing a radical prostatectomy for clinically localized prostate cancer.

To determine the epidemiological, clinical and pathological factors that can potentially predict extracapsular extension of prostate cancer in patients undergoing radical prostatectomy for clinically localized disease. We retrospectively analyzed the medical records of patients who undergone radical prostatectomy from January 2001 until November 2010. Patients age, prostate volume, PSA, PSA density, percent of cancer in prostate biopsy material, presence of cancer in biopsy cores of the right lobe or the left lobe or both lobes, Gleason summary, 1st Gleason pattern and 2nd Gleason pattern were analyzed for their predictive ability. From 187 studied patients, 44 of them (23.5%) had extracapsular disease. Multivariate analyses revealed that smaller prostate volumes and the presence of malignancy in both lobes after prostate biopsy were significant predictors for non-organ confined disease in the total population and in patients with Gleason score ≥ 7. Presence of malignancy in both lobes was the only significant predictive factor in patients with PSA ≤ 10 and in those with Gleason score ≤ 6. Prostate volume and positive cores for malignancy from both lobes after prostate biopsy are preoperative data that can be used for prediction of extracapsular disease. This information can be valuable in cases a nerve sparing radical prostatectomy is planned.

Preoperative prostate specific antigen and prostate volume are significant predictors of seminal vesicle invasion in patients with prostate cancer.

To evaluate the potential role of several clinical and pathological parameters in prediction of seminal vesicle invasion in patients with clinically localized prostate cancer undergoing radical prostatectomy. We retrospectively analyzed the medical records of patients who undergone radical prostatectomy from January 2005 until November 2010. Patients age, prostate volume, PSA, PSA density, percent of cancer in prostate biopsy material, Gleason summary, 1st Gleason pattern, 2nd Gleason pattern and the presence of high grade prostatic intraepithelial neoplasia were studied for their predictive ability. Two hundred and seventeen patients analyzed and 13.8% of them had seminal vesicle invasion in the final histopathological examination of the surgical specimen. A significant difference in PSA values, PSA density, percentage of cancer in biopsy material, biopsy Gleason score and 1st Gleason pattern was noticed between patients with and without seminal vesicle invasion. In univariate analysis, PSA, PSA density, prostate volume, percentage of cancer in biopsy material, biopsy Gleason score and 1st Gleason pattern found significant. However, in multivariate analysis, only PSA (p=0.008) and prostate volume (p=0.027) were found to be significant predictors. PSA ≥ 10 ng/ml and prostate volume ≤ 41 ml was shown to be the optimal cut-off values for seminal vesicle invasion in receiver operating curve analysis. PSA and prostate volume should be considered significant predictors for adverse pathology of the seminal vesicles in patients planned for surgical treatment of prostate cancer. This is of great concern especially in cases that a seminal vesicle sparing technique is planned.

Laparoscopic mesh repair of parastomal hernia. Is it a sufficient and free of complication technique? a case presentation and review of the literature.

Parastomal hernia is a complication of stoma formation. It is accompanied by high morbidity. It affects stoma's function and patient's quality of life. There several alternative treatment options including stoma relocation, primary prophylactic repair during the stoma construction and open or laparoscopic mesh repair. We describe the case of a young woman with Crohn's disease that presented a parastomal hernia at the site of an ileostomy. We performed a laparoscopic mesh placement and repair of the hernia. After 28 months of follow-up, the patient remains complications and recurrence-free. The laparoscopic mesh repair is a challenging way to treat parastomal hernias. In the studies have been done so far comparing this approach with the other alternative treatments, the laparoscopic way seems to offer remarkable therapeutic results with minor complication and recurrence rates. Our department's experience is suggesting that laparoscopic repair is an effective and sufficient treatment option.

A comparative analysis of primary and secondary Gleason pattern predictive ability for positive surgical margins after radical prostatectomy.

To compare the predictive ability of primary and secondary Gleason pattern for positive surgical margins in patients with clinically localized prostate cancer and a preoperative Gleason score ≤ 6. A retrospective analysis of the medical records of patients undergone a radical prostatectomy between January 2005 and October 2010 was conducted. Patients' age, prostate volume, preoperative PSA, biopsy Gleason score, the 1st and 2nd Gleason pattern were entered a univariate and multivariate analysis. The 1st and 2nd pattern were tested for their ability to predict positive surgical margins using receiver operating characteristic curves. Positive surgical margins were noticed in 56 cases (38.1%) out of 147 studied patients. The 2nd pattern was significantly greater in those with positive surgical margins while the 1st pattern was not significantly different between the 2 groups of patients. ROC analysis revealed that area under the curve was 0.53 (p=0.538) for the 1st pattern and 0.60 (p=0.048) for the 2nd pattern. Concerning the cases with PSA <10 ng/ml, it was also found that only the 2nd pattern had a predictive ability (p=0.050). When multiple logistic regression analysis was conducted it was found that the 2nd pattern was the only independent predictor. The second Gleason pattern was found to be of higher value than the 1st one for the prediction of positive surgical margins in patients with preoperative Gleason score ≤ 6 and this should be considered especially when a neurovascular bundle sparing radical prostatectomy is planned, in order not to harm the oncological outcome.

Schwannoma of the kidney with magnetic resonance images of non-homogenous renal mass--a case presentation.

Schwannomas are rare tumours that originate from the neural sheath and are usually located in the head and neck, extremities, and posterior mediastinum. Although 3% of schwannomas occur in the retroperitoneum, involvement of visceral organs is extremely uncommon. Schwannomas of the kidney are rare, with only a few reported cases. A 55-year-old woman was referred to our hospital with an abdominal sonography showing a spherical lesion in the upper pole of the left kidney that did not have the characteristics of a cortical cyst. The ultrasound had been recommended from her family doctor, due to a non specific pain in the hypogastrium in the previous 10 days. The final pathologic diagnosis was intrarenal benign schwannoma. Schwannomas are rare renal tumours with usually benign behaviour. Due to nonspecific symptoms and limited radiologic features for the diagnosis and assessment of the benign or malignant character of the tumour, the therapeutic approach is similar to other renal tumours. The definitive diagnosis is achieved with the help of immunohistochemistry.