Single setting 3D MRI-US guided frozen section and focal cryoablation of the index lesion in low/intermediate risk prostate cancer

Objectives: To explore the reliability of frozen sections to diagnose prostate cancer (PCa) and to describe surgical steps of a 3D magnetic resonance imaging (MRI)– ultrasound (US)-guided prostate biopsy (PB) and focal cryoablation of the index lesion in a single setting procedure. Patients and Methods: Patients with suspicious PCa, based on prostatic specific antigen (PSA) value and on a PIRADS 4 or 5 single lesion, as well as the steadfastness of avoiding any kind of radical treatment, were considered for enrolment. IRB and written informed consent were obtained from the patients. The entire procedure was performed transperineally, in two consecutive surgical phases: 3D MRI–US-guided plus systematic template PB and real-time TRUS-guided focal cryoablation. Three cores were taken from the index lesion (one for frozen section and two for final pathology), three cores from the surrounding area and systematic sampling was performed for the rest of the gland. Focal cryoablation of the index lesion was performed once confirmation of PCa was obtained by means of frozen sections. Follow-up schedule included PSA test at 3-mo interval, MRI 3-mo and 1-yr postoperatively and prostate biopsy of the treated area at 1-yr. 31 Results: This report includes 14 patients with a minimum follow up time of 12 months. All patients were potent before treatment, complained no severe low urinary tract symptoms and denied consent to any radical treatment. PCa diagnosis was histologically confirmed in all patients by frozen sections. All other cores were negative. At final histology, there was a Gleason score upgrade in three patients, from 3+3 to 3+4. The postoperative course was uneventful and all patients were discharged on the first postoperative day. Mean PSA value decreased from 6.37 (baseline) to 0.83 ng/mL at 3-mo evaluation. Three-mo postoperative MRI images showed complete ablation of the index lesion in all patients. Urinary continence and erectile function were preserved in all patients, without clinically meaningful changes at EPIC questionnaire. At one-yr follow-up, eleven patients showed no signs of persistent or recurrent disease at MRI imaging and treated area biopsies; three patients had a suspicious area at MRI and they needed treatment for confirmed disease at biopsy. Conclusion: Single setting 3D MRI–US-guided frozen section and focal cryoablation of the index lesion could represent a step forward towards a “patient-tailored” minimally invasive approach to diagnosis and cure of low and intermediate risk PCa

Valutazione angiografica della perfusione miocardica mediante myocardial blush in soggetti con coronarie indenni e confronto con valutazione funzionale mediante Coronary Flow Reserve.

Il blush (Myocardial Blush Grade, MBG) è una semplice misura angiografica della perfusione miocardica a livello capillare. E’ stato finora utilizzato per valutare il grado di integrità del microcircolo dopo angioplastica primaria nello STEMI e, molto recentemente, nelle sindromi coronariche acute senza sopraslivellamento del tratto ST. Non esistono evidenze in letteratura della utilità del blush nel valutare la perfusione miocardica in pazienti con coronarie indenni da stenosi epicardiche critiche. La valutazione del blush sarà effettuata, in pazienti con coronarie indenni, sia mediante visualizzazione soggettiva da parte degli operatori, sia mediante analisi oggettiva con software “QuBE” (J. Am. Coll. Cardiol. 2010;56;B88), ritenendo valida quest’ultima analisi oggettiva ai fini dello studio. Sarà quindi possibile, tra l’altro, verificare la eventuale differenza tra analisi soggettiva del blush e calcolo del blush mediante software validato. Le cineangiografie registrate per il blush saranno ottenute in RAO cranializzata, iniettando in coronaria sinistra, a ingrandimento 17. A questo punto, dopo eventuale ulteriore bolo di eparina 40-60UI/kg in base ad ACT, si effettuerà l’analisi della CFVR mediante flow wire posizionata nell’IVA, e successivamente nella circonflessa, dopo bolo i.c. di adenosina (90-120 mcg), in modo da poter confrontare il metodo angiografico di valutazione della perfusione del microcircolo con il gold standard funzionale per lo studio della riserva coronarica. Scopo principale dello studio non è di proporre interpretazioni fisiopatologiche, ma di valutare se il blush può essere adottato come metodo semplice e virtualmente privo di rischi (e di costi) rispetto alla misura della riserva coronarica mediante guida di flusso in pazienti con coronarie indenni

An uncommon clinical condition: chronic thrombosis of the inferior vena cava. A case report and review of literature

The lifetime incidence of deep vein thrombosis (DVT) is approximately 0.1% in general population and even more uncommon in subjects below 40 years of age. Thrombosis of the inferior vena cava (IVC) is an exceptionally rare clinical condition, with etiological factors similar to lower limb DVT. We present a case of post-traumatic chronic obstruction of the IVC in 41 years-old man, caused by a prolonged squatted position, while he was working as a bricklayer. We visited the patient fifteen years after the onset of the first clinical setting showing a severe post thrombotic syndrome, as a consequence of the already diagnosticated thrombosis, involving predominantly the right inferior leg. Thrombophilia screening tests showed patient to be a heterozygous carrier of methylenetetrahydrofolate reductase (MTHFR) gene mutation. Computed tomography (CT) scan confirmed the thrombotic obstruction of the infrahepatic IVC, both common iliac veins, right external and internal iliac veins, with multiple collateral pathways. Because of thrombosis extension, inherited prothrombotic condition and the young age of the patient, we decided to continue life-long oral anticoagulant therapy

Late complications of robot-assisted radical cystectomy with totally intracorporeal urinary diversion

Introduction and objectives: To evaluate late complications in a large cohort of patients undergoing robot-assisted radical cystectomy (RARC) with totally intracorporeal urinary diversion (ICUD). Materials and methods: We prospectively enrolled patients who underwent RARC and ICUD between August 2012 and June 2019. We excluded patients with Ejection fraction < 36%, retinal vasculopathy, ventriculoperitoneal shunts, and those treated without curative intent. All complications and their onset date have been recorded, defined, and graded according to Clavien classification adapted for radical cystectomy. Results: 210 patients were included, 76% of whom were men, with a mean age of 62 years. Urinary diversions used were Padua Ileal Bladder (PIB) in 80% of cases, and ileal conduit (IC) in 20% of patients (generally older and with more comorbidity). The mean follow-up was 30 ± 22 months. The stenosis rate of uretero-ileal anastomosis was 14%, while a reduction in eGFR (≥ 20%) was observed in about half of the cases. UTIs occurred in 37% of the patients, especially in the first 12 months. Only 2% of patients had bowel occlusion, whereas incisional hernia, lymphocele, and systemic events (metabolic acidosis and major cardiovascular events) occurred respectively in 20%, 10%, and 1% of cases. Conclusions: Our study evaluates first late complications in a cohort of patients who underwent RARC with ICUD. These data are encouraging and in line with findings from a historical series of open radical cystectomy (ORC). This study is a further step in supporting RARC as a safe and effective surgical option for the treatment of muscle-invasive bladder cancer (MIBC) in tertiary referral centers

Coronary artery anomalies and their clinical relevance

Coronary artery anomalies (CAAs) represent one of the most confusing topic in cardiology and affect approximately 1% of the general population. Altough some anomalies seem to be only anatomical curiosities, others may sometimes have fatal consequences. This review describes the anatomical characteristics of main CAAs and focuses on the pathophysiological mechanisms by which CAAs may cause a pathological state. The last section describes these therapeutical options of this congenital disorders

Robotic simple prostatectomy vs HOLEP, a 'multi single-center' experiences comparison

Introduction: The aim of this study was to compare peri-operative and mid-term outcomes of patients who underwent robot-assisted simple prostatectomy (RASP) vs holmium laser enucleation of the prostate (HOLEP). RASP and HOLEP are the treatments of choice for men with symptomatic benign prostatic obstruction (BPO) and a prostate ≥80 g, achieving comparable short and mid-term efficacy. No randomized controlled studies have proved the superiority of one technique over the other. Material and methods: The prospectively maintained databases of the participating institutions were queried for patients with a prostate volume (PV) ≥80 g, who underwent surgery for BPO between 2011 and 2021. The study population was divided into two subgroups based on surgical approach. Demographics, baseline characteristics, and 12 months outcomes were compared between groups: χ2 and Student t-tests were used for categorical and continuous variables, respectively. The Trifecta composite outcome (post-operative Q-max >15 ml/sec, International Prostate Symptom Score (IPSS) <8 and absence of complications) was used to define surgical quality and the two groups were compared accordingly. Logistic regression analyses investigated predictors of Trifecta achievement. Results: We included 97 patients with comparable pre-operative features (all p >0.30): 43 underwent RASP, 54 HOLEP. Median PV was 102 g (IQR 89-120) and Q-max was 7.2 ml/s (IQR 5.4-9.0). The Trifecta rate was 43% overall, higher in the RASP subgroup (56% vs 33%; p = 0.02). The endoscopic approach was its only independent predictor (OR 0.5; 95% CI 0.28-0.88; p = 0.016). Conclusions: At univariable regression analysis, surgical approach was the only independent predictor of Trifecta achievement, which was significantly higher in the RASP group compared to HOLEP

Insight from an Italian Delphi Consensus on EVAR feasibility outside the instruction for use: the SAFE EVAR Study

BACKGROUND: The SAfety and FEasibility of standard EVAR outside the instruction for use (SAFE-EVAR) Study was designed to define the attitude of Italian vascular surgeons towards the use of standard endovascular repair (EVAR) for infrarenal abdominal aortic aneurysm (AAA) outside the instruction for use (IFU) through a Delphi consensus endorsed by the Italian Society of Vascular and Endovascular Surgery (Societa Italiana di Chirurgia Vascolare ed Endovascolare - SICVE). METHODS: A questionnaire consisting of 26 statements was developed, validated by an 18 -member Advisory Board, and then sent to 600 Italian vascular surgeons. The Delphi process was structured in three subsequent rounds which took place between April and June 2023. In the first two rounds, respondents could indicate one of the following five degrees of agreement: 1) strongly agree; 2) partially agree; 3) neither agree nor disagree; 4) partially disagree; 5) strongly disagree; while in the third round only three different choices were proposed: 1) agree; 2) neither agree nor disagree; 3) disagree. We considered the consensus reached when >70% of respondents agreed on one of the options. After the conclusion of each round, a report describing the percentage distribution of the answers was sent to all the participants. RESULTS: Two -hundred -forty-four (40.6%) Italian Vascular Surgeons agreed to participate the first round of the Delphi Consensus; the second and the third rounds of the Delphi collected 230 responders (94.3% of the first -round responders). Four statements (15.4%) reached a consensus in the first rounds. Among the 22 remaining statements, one more consensus (3.8%) was achieved in the second round. Finally, seven more statements (26.9%) reached a consensus in the simplified last round. Globally, a consensus was reached for almost half of the proposed statements (46.1%). CONCLUSIONS: The relatively low consensus rate obtained in this Delphi seems to confirm the discrepancy between Guideline recommendations and daily clinical practice. The data collected could represent the source for a possible guidelines' revision and the proposal of specific Good Practice Points in all those aspects with only little evidence available

The role of immune suppression in COVID-19 hospitalization: clinical and epidemiological trends over three years of SARS-CoV-2 epidemic

Specific immune suppression types have been associated with a greater risk of severe COVID-19 disease and death. We analyzed data from patients >17 years that were hospitalized for COVID-19 at the “Fondazione IRCCS Ca′ Granda Ospedale Maggiore Policlinico” in Milan (Lombardy, Northern Italy). The study included 1727 SARS-CoV-2-positive patients (1,131 males, median age of 65 years) hospitalized between February 2020 and November 2022. Of these, 321 (18.6%, CI: 16.8–20.4%) had at least one condition defining immune suppression. Immune suppressed subjects were more likely to have other co-morbidities (80.4% vs. 69.8%, p < 0.001) and be vaccinated (37% vs. 12.7%, p < 0.001). We evaluated the contribution of immune suppression to hospitalization during the various stages of the epidemic and investigated whether immune suppression contributed to severe outcomes and death, also considering the vaccination status of the patients. The proportion of immune suppressed patients among all hospitalizations (initially stable at <20%) started to increase around December 2021, and remained high (30–50%). This change coincided with an increase in the proportions of older patients and patients with co-morbidities and with a decrease in the proportion of patients with severe outcomes. Vaccinated patients showed a lower proportion of severe outcomes; among non-vaccinated patients, severe outcomes were more common in immune suppressed individuals. Immune suppression was a significant predictor of severe outcomes, after adjusting for age, sex, co-morbidities, period of hospitalization, and vaccination status (OR: 1.64; 95% CI: 1.23–2.19), while vaccination was a protective factor (OR: 0.31; 95% IC: 0.20–0.47). However, after November 2021, differences in disease outcomes between vaccinated and non-vaccinated groups (for both immune suppressed and immune competent subjects) disappeared. Since December 2021, the spread of the less virulent Omicron variant and an overall higher level of induced and/or natural immunity likely contributed to the observed shift in hospitalized patient characteristics. Nonetheless, vaccination against SARS-CoV-2, likely in combination with naturally acquired immunity, effectively reduced severe outcomes in both immune competent (73.9% vs. 48.2%, p < 0.001) and immune suppressed (66.4% vs. 35.2%, p < 0.001) patients, confirming previous observations about the value of the vaccine in preventing serious disease

Severe spasm of the left main and spontaneous intramural haematoma: A serial optical coherence tomography study

No abstract availabl

Current State of Symptomatic Aortic Valve Stenosis in the Elderly Patient

BACKGROUND: There have been few reports regarding treatment selection and prognosis of symptomatic aortic valve stenosis (AS) in the elderly in Japan. METHODS AND RESULTS: Sixty-one patients hospitalized between January 2000 and December 2007 for symptomatic severe AS were investigated. The average observation period was 27 months. Thirty-seven patients (61%) were diagnosed with AS for the first time on hospitalization. Thirty-six patients had onset of symptoms within 1 month before admission. Thirty-six patients received aortic valve replacement (group S) and 25 received medical therapy (group M). The patients in group M were older than those in group S (84.1 ± 5.3 years vs. 74.2 ± 4.6 years, P<0.001). Maximum flow velocity measured by echocardiography was lower in group M (4.5 ± 0.3 m/s vs. 4.9 ± 0.5 m/s, P<0 .01), but there was no difference in valve area between the 2 groups (0.62 ± 0.19 cm2 vs. 0.57 ± 0.15 cm2, P=0.12). One-year mortality rate derived from the Kaplan-Meier curve was higher in group M than group S (53.1% vs. 6.4%, respectively). On multivariate analysis, the only independent favorable prognostic factor was aortic valve replacement (HR: 0.02, 95%CI: 0.01-0.15, P<0.01). CONCLUSIONS: Medical therapy is often selected for treatment of symptomatic AS in the elderly, but the prognosis is very poor. Symptomatic severe aortic stenosis should be treated surgically, or with transcatheter aortic valve implantation in cases with high surgical risk