Fournier's gangrene and intravenous drug abuse. An unusual case report and review of the literature

Fournier's gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes.In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia.Fournier's gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature

Renal artery embolization before radical nephrectomy for complex renal tumour: Which are the true advantages?

Introduction: Renal artery embolization is performed before radical nephrectomy (RN) for renal mass in order to induce preoperative infarction and to facilitate surgical intervention through decrease of intraoperative bleeding. Moreover, in metastatic renal cancer it seems to stimulate tumour-specific antibodies, even if no established benefits in clinical response or survival have been reported. The role of preoperative renal artery embolization (PRAE) in management of renal masses has been often debated and its real benefits are still unclear. Nevertheless, in huge and complex renal masses, which are often characterized by a high and anarchic blood supply and rapid local invasion, radical nephrectomy can be challenging even for skilled surgeons. The aim of this prospective randomized study was to evaluate the effectiveness and safety of PRAE in complex masses by comparing perioperative outcomes of RN with and without PRAE.Materials and methods: From December 2015 to May 2018 we enrolled prospectively 64 patients who underwent RN for localized (T2a-b) or locally advanced (T3 and T4) or advanced (N+, M+) renal cancers. Patients were divided in two groups. The first group included 30 patients who underwent PRAE; in the second group we enrolled 34 patients who did not undergo RN without PRAE. Perioperative outcomes in terms of operative time, blood loss, transfusion rate and length of hospitalization were evaluated. Statistical analysis was performed using GraphPad Prism 6.0 software.Results: Median blood loss was 250 ml (50-500) and 400 ml (50-1000) in the first and second group, respectively, with a statistically significant difference (p=0.0066). Median surgical time was 200 min (90-390) and 240 min (130-390) in PRAE and No-PRAE group (p=0.06), respectively. No major complications occurred after embolization. Overall complication rate in Group 1 and 2 was 46.7% (14/30) and 50% (17/34), respectively (p=0.34). No major complications occurred in both groups. The mean follow up was 21,5 months.Conclusions: Our results prove PRAE to be a safe procedure with low complications rate. To our experience, PRAE seems to be a useful tool in surgical management of a large mass and advanced disease

Desmopressin in the treatment of nocturia in patients affected by neurogenic bladder

The efficacy and safety of desmopressin in the treatment of adults with nocturia have been assessed in several randomized trials, but few information exist on its application in patients affected by Parkinson's disease (PD) or Multiple Sclerosis (MS). The aim of the present study was to investigate the efficacy and safety of desmopressin administration in PD and MS patients affected by nocturia, in a medium term follow up

Clinical outcomes of second-line Treatments cycling in refractory wet OAB patients before switching to intradetrusor injections of onabotulinumtoxin/A: a real world observational study

Introduction: Persistence and adherence rates assessed for various drugs for Overactive Bladder (OAB) in real-world settings are dramatically poor, with almost 70% to 90% of patients discontinuing treatment within 1 year. We investigated the clinical outcomes of second-line treatments in a group of patients with wet-OAB, who then switched to Onabotulinumtoxin A (Onabot/A) intradetrusorial injections. Patients’ discontinuation to treatment and the reasons why patients stopped their oral medications were also investigated. Comparisons with the clinical outcomes and satisfaction to treatment obtained with Onabot/A intradetrusor injections in the same patients were also assessed. Patients and Methods: The outpatient visits charts of 125 wet OAB patients treated with secondline oral agents, who then switched to Onabotulinum toxin A intradetrusor injections, were retrospectively reviewed. We assessed the number and types (immediate or long-acting formulations) of anticholinergics (ACHs) cycled, the use of Mirabegron oral therapy, and persistence to these pharmacological agents since the beginning of treatment until patients switched to Onabot/A intradetrusor injections. Patients were classified as having tried 1, 2, or ≥3 anticholinergics, alone or in combination with Mirabegron, or Mirabegron oral treatment alone. Daily frequency of Urinary Incontinence (UI), as recorded by the 3-day voiding diary and satisfaction to treatment, as scored by a Visual Analog Scale (VAS), both obtained at the last evaluation before being included in the neurotoxin treatment regimen, were retrospectively analyzed. Any eventual side effect due to ACHs and/or Mirabegron treatment was also noted. Daily frequency of urinary incontinence episodes and satisfaction to treatment, as well as rates of discontinuation and side effects, has been investigated in the same patients following Onabot/A intravesical treatment. Results: From January 2000 to October 2015, 125 patients affected by refractory wet OAB have been treated with ACHs and Mirabegron. Twenty-six (31%) patients assumed 2 ACHs and then Mirabegron, 21 (25%) patients cycled 3 ACHs and then Mirabegron, 13 (15%) patients cycled 4 ACHs and then Mirabegron, 15 (18%) cycled 5 ACHs and 9 (11%) patients cycled 6 ACHs. Types of ACHs used were propiverine, trospium, solifenacine, fesoterodine, oxybutynin IR and ER. Fortyone patients, more recently evaluated for their wet-OAB, have been treated only with 1 ACH before switching to Onabot/A intradetrusor injections. Overall duration of treatment increased according to the number of ACHs cycled. The median/IRQ frequency of UI episodes/day and the median (IRQ) VAS score were similarly poor across all the subgroups of patients, regardless of the number of ACHs cycled. Poor efficacy of treatment was reported by 52 (41.6%) of patients, intolerable side effects by 38 (30.4%) patients, and poor efficacy with unpleasant adverse effects in 35 (28%). After discontinuing second-line treatments the 125 patients switched to a third-line therapy represented by Onabot/A intradetrusor injections, 100 U diluted in 10 ml normal saline. Fifty-four patients received from 1 to 4 repeat injections, 36 from 5 to 9 repeat treatments and 16 patients received ≥ 10 repeat injections. For eACH sub-group of patients with different No. of injections, the median/ IQR frequency of daily UI episodes as well as satisfaction to treatment, appeared to be significantly improved as compared to those obtained with ACHs and Mirabegron, as evaluated at the last follow up visit. Improvements remained constant regardless of the number of repeat injections and of the length of follow up, in the majority of cases. Conclusion: The majority of patients affected by wet OAB cycled at least 2 antimuscarinics before switching to a third line-therapy, with a consistent group cycling 5 and 6 different anticholinergic drugs. After switching to Onabot/A intradetrusor injections, the same patients found a prompt improvement in daily UI episodes and satisfaction to treatment. Thus, there is the urgent need to identify pharmacological agents with a better efficacy and safety profile in order to improve adherence and persistence to OAB second-line therapies

Holmium:YAG Laser for the Treatment of Genital and urethral Warts: Multicentre Prospective Evaluation of Safety and Efficacy

Introduction: Genital condylomatosis is a highly contagious disease caused by the human papilloma virus (HPV). The aim of this prospective multicentre study was to evaluate the safety and efficacy of the Holmium:YAG (yttrium-aluminium-garnet) laser in the treatment of genital and intra-urethral warts; the secondary aim was to assess the patients' postoperative satisfaction and cosmetic results. Methods: From December 2016 to March 2019, patients with genital warts were prospectively enrolled in three hospitals. The inclusion criteria were male gender, age over 18 years-old and treatment-naïve. External and urethral genitalia warts were treated by the Holmium YAG laser. The follow-up analysis consisted of physical examination, flexible urethro-cystoscopy in case of meatal lesions, and administration of Dermatology Quality of Life Index (DLQI) and Patient Global Impression of Improvement (PGI-I) questionnaires at 1, 3, 6 and 12 months after surgery and subsequently yearly. Results: Sixty patients were enrolled. The single treatment was effective in 57/60 patients (95%). At a mean follow-up of 26 months, recurrences occurred in 8 patients (13.3%). No peri- or postoperative complication occurred. An improvement in pre-operative condition was highlighted with PGI-I and DLQI questionnaires. Conclusion: Our prospective multicentre study showed that holmium laser surgery seems to be a safe and effective treatment for external genital and urethral warts. Good dermatological outcomes aid to further improve patient satisfaction

Fournier's gangrene secondary to locally advanced prostate cancer: case report and review of the Literature

Fournier's gangrene is a rare and potentially lethal condition. Previously described as an idiopathic process, this necrotising fasciitis is secondary to infection and in 95% of cases the cause arises from ano-rectum (30-50%), uro-genitalia (20-40%) or genital skin (20%). Cancer could lead to a Fournier's gangrene thanks a compromised host immunity condition. In the past the rate of death was high ranging from 20% to 80%, while currently mortality is decreasing to 10%. We report a case of a 76-years-old man with Fournier’s Gangrene due to locally advanced prostate cancer. The multimodal therapeutic management included broad-spectrum antibiotic therapy, intravenous fluid resuscitation and surgical debridement that was delayed by the will of the patient. To our knowledge, this is the first case of Fournier's gangrene caused by prostate cancer without common predisposing factors. In order to improve the knowledge about this rare disease, we performed a narrative review of the literature

Role of miRNAs in prostate cancer: Do we really know everything?

Many different genetic alterations, as well as complex epigenetic interactions, are the basis of the genesis and progression of prostate cancer (CaP). This is the reason why until now the molecular pathways related to development of this cancer were only partly known, and even less those that determine aggressive or indolent tumour behaviour. MicroRNAs (miRNAs) represent a class of about 22 nucleotides long, small non-coding RNAs, which are involved in gene expression regulation at the post-transcriptional level. MiRNAs play a crucial role in regulating several biological functions and preserving homeostasis, as they carry out a wide modulatory activity on various molecular signalling pathways. MiRNA genes are placed in cancer-related genomic regions or in fragile sites, and they have been proven to be involved in the main steps of carcinogenesis as oncogenes or oncosuppressors in many types of cancer, including CaP. We performed a narrative review to describe the relationship between miRNAs and the crucial steps of development and progression of CaP. The aims of this study were to improve the knowledge regarding the mechanisms underlying miRNA expression and their target genes, and to contribute to understanding the relationship between miRNA expression profiles and CaP