Improving pre-operative planning of robot assisted nephron sparing surgery using three-dimensional anatomical model

Introduction Despite the introduction of robot-assisted surgery in daily clinical practice, complex renal masses are still challenging even for expert surgeon. In this scenario 3D anatomical models and augmented reality represent valuable tools for the surgeon. Materials and methods We present a challenging case where PN was mandatory to preserve the overall renal function. The patient was 69 years old, with indwelling catheter for BPH and Parkinson disease. After a single episode of hematuria with negative cystoscopy, a cT1N0M0 renal cancer was diagnosed (38 mm maximum diameter). Pre-operative three-dimensional (3D) model was obtained. After multidisciplinary discussion robot-assisted partial nephrectomy was proposed. The surgery was planned according to the anatomical model. Results Before the procedure a 7Ch single loop ureteral stent was placed. The surgery was carried out in 220 minutes. Selective ischaemia was perfomed for 24 minutes. Estimated blood loss was 400cc. No post-operative complications were observed. Ureteral stent was removed 4 days after the surgery. Definitive histological examination described a pG2-3 T1a Nx R0 clear cell renal carcinoma. Conclusion In selected cases 3D model result to be a useful tool for the pre-operative planning of the surgery

Earthquake rupture forecasts for the mps19 seismic hazard model of Italy

In recent years, new approaches for developing earthquake rupture forecasts (ERFs) have been proposed to be used as an input for probabilistic seismic hazard assessment (PSHA). Zone-based approaches with seismicity rates derived from earthquake catalogs are commonly used in many countries as the standard for national seismic hazard models. In Italy, a single zone-based ERF is currently the basis for the official seismic hazard model. In this contribution, we present eleven new ERFs, including five zone-based, two smoothed seismicity-based, two fault-based, and two geodetic-based, used for a new PSH model in Italy. The ERFs were tested against observed seismicity and were subject to an elicitation procedure by a panel of PSHA experts to verify the scientific robustness and consistency of the forecasts with respect to the observations. Tests and elicitation were finalized to weight the ERFs. The results show a good response to the new inputs to observed seismicity in the last few centuries. The entire approach was a first attempt to build a community-based set of ERFs for an Italian PSHA model. The project involved a large number of seismic hazard practitioners, with their knowledge and experience, and the development of different models to capture and explore a large range of epistemic uncertainties in building ERFs, and represents an important step forward for the new national seismic hazard model

The role of preoperative cart score as predictor of renal functional decline after partial nephrectomy

Introduction: Partial nephrectomy (PN) may be associated with a decreased risk of functional loss compared to radical nephrectomy (RN), but a significant functional decline may still occur. CART score is a novel scoring system able to predict functional decline after PN. Aim of this study was to assess the validity of CART score in an internal cohort of patients. Materials and methods: We enrolled 67 patients with pre-operative estimated glomerular filtration rate (eGFR) >60 ml/min/1.73 m2 by CKD-EPI who underwent PN in a single institution. Data were prospectively collected and retrospectively analyzed. For each patient CART score was determined considering the value of pre-operative CRP, age at surgery, race and tumor size and patients were divided into 3 categories: low (4\u20136), intermediate (7\u20139) and high (>10) score. Statistical analysis were conducted using Fisher exact test, T test, and Mann-Whitney U test. Univariate and multivariate analyses were performed. Results: Patients were assigned as follows: 46 to low-CART, 20 to intermediate-CART and 5 to high-CART score. Comparing to low CART, high CART patientswere at higher risk of developing post-operative CKD stage worst than IIIb (p = 0.0045); median age and clamping time were significantly higher in this group (p = 0.008; p = 0.005). No differences were observed for ischaemia (warm vs. cold), presence of diabetis mellitus or hypertension, BMI, Charlson score and mean follow-up. ROC analysis revealed AUC of 0.9. At multivariate analysis high CART score resulted as the only independent predictor of post-operative eGFR <45 ml/min/1.73 m2 (OR 14.01, 1.32\u201322.9 CI 95%; p = 0.04). Conclusions: CART score is a a low time-consuming and a good costeffective tool. In our cohort of study a high CART score represented a strong predictor of post-operative CKD stage worst than IIIb. CART score may play an adjunctive role in pre-operative counselling and clinical decision making of patients eligible for PN

Salvage extracapsular re-implantation for penile prosthesis impending erosion

Aim of the study: Post-operative erosion of prosthesis components is an uncommon but devastating complication worth noting. Distal cylinder and scrotal pump erosion is usually related to infection but isolated erosion has been described in the literature. If the prosthetic material is not exposed to the exterior, impending erosion is present. Patients complain of pain over the end of the cylinder and worry that it will wear through the skin. and the prosthesis components may be evident with physical examination and can be confirmed if necessary through magnetic resonance imaging. Distal cylindrical erosion through the corpus cavernosum with extrusion affecting the urethra, glans, or corporeal shaft can be managed through multiple methods. Options include reseating the cylinders and using fibrotic tissue to support the containment of the cylinders, utilization of alloplastic materials such as Gortex polytetrafluoroethylene polypropylene mesh to create a \u201cwindsock\u201d or utilization of prefabricated autologous fascial grafts. Herein we describe the technique of salvage extracapsular re- implantation for penile prosthesis impending erosion with the use of a distal corporoplasty by reseating the cylinder in a new cavity of spongy erectile tissue more dorsal or lateral to the extrusion site. Materials and methods: Circumcising incision is made and the distal corpora are exposed. A lateral longitudinal corporotomy of about 4 cm is made over the cylinder in the area of impending erosion and the inflatable cylinder is retracted proximally using a suture inserted through the hole in the end. At this point, the posterior wall of the fibrotic capsula containing the cylinder is incised transversely about 3\u20134 cm proximal to the glans. Subsequently The space is developed for a short distance by sharp dissection initially, then fully by inserting a metal dilator.In this manner a new cavity in the distal end of the corpus cavernosum is created. Using a Keith needle and introducer the inflatable cylinder is introduced into this new cavity. The corporotomy is closed using long-term absorbable suture. The cylinder is now secured in its proper location by 2 tough layers comprising the back wall of the original sheath and the corporotomy closure. Results: Routine post-operative care is followed. This technique ensured that the cylinder remained in the newly created, appropriately positioned channel. Discussion: We propose that, on salvage for implant distal extrusion or impending erosion, the replacement implant can be inserted into the cavernous tissue surrounding the capsule, between the capsule and tunica albuginea (extracapsular reimplantation), rather than intra- capsular. Using this technique, the cylinder can be replaced in a more medial and secure position under the glans penis by creating a new cavity for the cylinder behind the back wall of the fibrotic sheath Moreover, this may reduce contact between the replacement implan

Giorgio Nicolich, father of Urology in Trieste

Aim of the study: Until 1918 Trieste was part of the Habsburgic Empire. In this period the city was in full economic and demographic growth. In this context, among the medical and surgical society raised the figure of Giorgio Nicolich senior, brilliant surgeon and researcher. He was initially chief of the Surgical Division and gave birth lately to the Urological Division in 1887, in which he practiced until 1925, year of retirement and death. Materials and methods: Giorgio Nicolich was born in Venice in 1852. He graduated in 1875 at the University of Padua, and became trainee of Tito Vanzetti (1809\u20131888), a surgeon particularly versed in urinary tract surgery and known for both routine surgical capacity and exceptional operations, that gave throughout his activity new and advanced boundaries to the uro-nephrology field. His activity was open to novelties like the use of radio needles for prostate cancer, the use of nephrectomy, mercurial care of the syphilis. After moving to Trieste, the year after his graduation, he entered the Trieste Civic Hospital as a secondary physician of the Division for chronic syphilitic and surgical diseases and became its chief in 1886. From 1887 he obtained the urological characterization of the Division, and the other surgical specialties were transferred to the pre-existing Surgical Division and to the new 10th Division. At the end of the Great War, in 1919 he became professor of Urology, retired in 1925, after an extension for merit of 5 years. In these last years he was joined by Carlo Ravasini, who succeeded him. Nicolich died in the same year. Results: He carried out a wide activity. He attended the Parisian school of Urology with Gujon and Albarran and, in 1921, he founded the Italian Society of Urology. He was an authority in the field of urology in the national and international landscape (he was a pupil in Vienna of Theodor Billroth) and was coauthor of the \u201cManual of Urology\u201d and President of the Italian Society of Urology. He became also honorary member of the Urological Society of Berlin, of the Belgian Society and member of the Academy of Medicine of Constantinople. In 1924, the year before his death, he founded the Italian Archives of Urology. Discussion: Apart from his extraordinary ability as a surgeon, Giorgio Nicolich was a member of that small number of doctors born in Trieste or came to Trieste, who created a cohesive environment of remarkable level, between the various Divisions of the City Hospital. He is credited and reminded not only for have given life to the Urology of Trieste, but for have practiced avant-garde medicine and surgery, forming a new generation of specialist surgeons