A conservative treatment for eosinophilic cystitis

Introduction: Eosinophilic cystitis is a rare condition which causes common symptoms and may mimic other conditions. Eosinophilic cystitis has several causes such as hypereosinophilic syndrome, inflammatory diseases, neoplasia, parasites or fungal infection, IgE-related diseases, Drug Reaction and Eosinophilia and Systemic Symptoms (DRESS) syndrome, or Churg-Strauss syndrome. Therefore, differential diagnosis is difficult. Case presentation: We report the case of a middle-aged man affected by eosinophilic cystitis with persistent hematuria and other peculiar symptoms that may be brought back to hypereosinophilic crisis. Conclusion: Conservative approach is preferred, avoiding radical cystectomy rather than corticosteroid, antihistaminic and second line therapy. Hyperbaric therapy is an innovative approach for severe relapsing gross hematuria without specific literature and should be studied for further indications

Circumcision and Sexually Transmitted Disease Prevention: Evidence and Reticence

Circumcision is one of the oldest surgical procedures and the most common surgical procedure performed on males. It is practiced for three main reasons: ritual or religious meanings, prophylactic hygienic purposes, and therapeutic indications. Male circumcision is advocated as an efficacious prevention strategy against sexually transmitted diseases. One of the main biological mechanisms responsible for the lower human immunodeficiency virus (HIV) infection rate in heterosexual circumcised men is the protective effect of keratinization of the glans. Moreover, male circumcision removes the inner part of the prepuce containing Langerhans cells that are targeted by HIV. Several observational studies showed a protective effect of male circumcision regarding the HIV acquisition in heterosexual men, in women with circumcised partners, and in men who have sex with men with an insertive anal role. Circumcision reduced the infection rate of other sexually transmitted diseases like human papillomavirus (HPV), mycoplasma, and genital ulcer disease. It seems now evident that circumcision has no negative effects on sexual function, sensitivity, sexual sensation, and satisfaction. When performed freely after informed consent, male circumcision is a lawful practice in adults. In children, the lack of an informed consent is overcome by the favorable risk/benefit ratio and the decision whether to circumcise or not pertains to the parents

Use of Solovov - Badenoch principle in treating severe and recurrent vesico-urethral anastomosis stricture after radical retropubic prostatectomy: Technique and long-term results

OBJECTIVE: • To report our experience in the management of patients with combined urinary incontinence and stricture after radical prostatectomy with a two-step approach: urethroplasty with a ' pullthrough ' technique after the Solovov - Badenoch principle; and artificial urinary sphincter (AUS) insertion after 8 - 10 months. PATIENTS AND METHODS: • We retrospectively evaluated a cohort of 11 patients treated between September 2001 and January 2010. RESULTS: • There were no intraoperative complications in either procedure. • After urethroplasty one patient was unable to empty the bladder with complete urine retention without urethral stricture (treatment failure). • At 6 months after the urethroplasty 10 patients were completely incontinent and received AUS. • One previously irradiated patient developed urethral erosion 6 months after AUS implantation and underwent complete removal of the device. • After a mean (range) follow-up of 65 (19 - 119) months, nine patients (81.8%) were continent with no post-void residual urine and a perfectly functioning AUS. CONCLUSION: • Our experience with a two-step approach (combined suprapubic/ transperineal redo anastomosis and AUS placement) shows that redo vesico-urethral anastomosis is easier than pure transperineal approaches with good results in restoring patency and that the transperineal step provides a dedicated operative field for AUS implantation with reduced risks of perioperative complications. © 2012 The Authors

EGFR CELL EXPRESSION IN BLADDER WASHINGS AS A RISK MARKER TOOL IN NON MUSCLE-INVASIVE BLADDER CANCER. PRELIMINARY EXPERIENCE

INTRODUCTION AND OBJECTIVES: Up to day, EGFR expression has been determined mainly in tissue specimens of muscleinvasive bladder cancer and its overexpression has been associated with worse prognosis and shorter survival. Urothelial EGFR status after NMIBC transurethral resection (TUR) could indicate the risk of recurrence and progression. We investigated the feasibility of EGFR measurement in bladder washings of patients undergoing intravesical adjuvant therapy for NMIBC and its usefulness in identifying risk subgroups. METHODS: Our prospective study included patients after TUR of NMIBC and healthy controls. A cellular pellet was obtained from bladder washing, and RNA extraction performed by miRNeasy Mini Kit (Qiagen). Good quality of RNA was checked. The cDNA obtained from RNA was used to perform a gene expression analysis by a Real Time PCR, according to the method of the comparative quantification (DDCt) with an endogenous control (Cyclophilin). Every reaction was set in triplicate as a guarantee of quality. Patients were grouped for EAU risk class and maintained in follow-up. The EGFR expressions were statistically analyzed according to EAU risk groups and to patients0 outcome. EGFR gene expression values were expressed in FOLDs of change compared to healthy controls (EGFR¼1). RESULTS: Fifty-eight patients and 21 healthy age-matched controls were entered. An adequate cellular pellet was obtained in 50 patients (86.2%) showing a median EGFR expression of 2.0 folds (IQR 0.6-4.3, p¼0.0004). After TUR and adjuvant intravesical therapy, 22 (55%) out of 40 high-risk patients, showed EGFR decrease to 1.3 folds (IQR 0.9-1.5), while 18 (45%) showed elevated EGFR, median 4.7 (IQR 4.1-11.6). At 25 months median follow-up (IQR 19.0-34.8), 20 (40%) patients recurred and 6 (12%) progressed. Among patients with or without EGFR gene increase, 9 (22.5%) and 5 (12.5%) recurred and 5 (12.5%) and 1 (2.5%) progressed, respectively. CONCLUSIONS: In our experience EGFR expression measurement was feasible in more than 85% of patients and resulted related to EAU risk classes for recurrence and progression, showing different behavior during intravesical therapy. It was possible to identify a subgroup of high risk patients overexpressing EGFR in spite of intravesical adjuvant therapy. EGFR evaluation in bladder washing could represent a repeatable and useful tool to identify a subgroup of patients at risk for progression unresponsive to intravesical adjuvant therapy and candidate to early radical cystectom

LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR

LOWER RESPONSE TO INTRAVESICAL ADJUVANT THERAPY IN HIGH-RISK BLADDER CANCER COULD BE RELATED TO THE UROTHELIAL EXPRESSION OF EGFR Cristina Scalici Gesolfo1, Sebastiano Billone1, Alessio Guarneri1, Marco Vella1, Alessandro Perez2, Graziella Cangemi2, Antonio Russo2, Alchiede Simonato1,Vincenzo Serretta1 and GSTU Foundation3 1Section of Urology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Palermo, Italy; 2Section of Medical Oncology, Department of Surgical, Oncological and Stomatological Sciences, University of Palermo, Palermo, Italy; 3Palermo, Italy Introduction: Studies on the role of EGFR in non-muscleinvasive bladder cancer (non-MIBC) are lacking. EGFR expression has been determined mainly in tissue specimens of MIBC and its overexpression has been associated with worse prognosis and shorter survival. Urothelial EGFR status after transurethral resection (TUR) of non-MIBC could indicate the risk of recurrence and progression. We investigated the feasibility of EGFR measurement in bladder washings of patients undergoing intravesical adjuvant therapy for non-MIBC and its usefulness in identifying risk subgroups. Patients and Methods: Our prospective study included patients after TUR of non-MIBC and healthy controls. Samples of bladder washings were centrifuged at 4˚C for 10 minutes at 1500 rpm, washed in cold phosphate buffer saline solution and centrifuged again obtaining a cellular pellet stored at −80˚C until RNA extraction was performed by miRNeasy Mini Kit (QiagenR). A Nanodrop ND-2000 spectrophotometer was used to check for good quality of RNA. RNA criteria to proceed with reverse transcription to cDNA: minimum 500 ng/ml, protein (260/280) solvents and organic compounds (260/230), contamination ratio 1.7-2.5. The cDNA obtained from RNA by High Capacity cDNA Reverse Transcription Kit (Life TechnologiesR) was used to perform a gene expression analysis by a real-time PCR, according to the method of the comparative quantification (ΔΔCt) with an endogenous control (cyclophilin). Every reaction was set in triplicate as a further guarantee of quality. The patients were grouped for EAU risk class and maintained in follow-up. EGFR expressions were statistically analyzed according to EAU risk groups and to patients’ outcomes. EGFR gene expression values were expressed in folds of change compared to healthy controls (EGFR=1). Results: Fifty-eight patients and 21 healthy age-matched controls were entered. An adequate cellular pellet was obtained in 50 patients (86.2%) showing a median EGFR expression of 2.0-fold (IQR=0.6-4.3-fold, p=0.0004). The median level of EGFR varied considerably among the EAU risk classes. After TUR and adjuvant intravesical therapy, in 22 (55%) out of 40 high-risk patients, EGFR decreased to 1.3-fold (IQR=0.9-1.5-fold), while 18 (45%) showed elevated EGFR, median=4.7-fold (IQR=4.1-11.6-fold). At 25 months median follow-up (IQR=19.0-34.8 months), 20 (40%) patients experienced recurrence and six (12%) progression. Among patients with and those without EGFR gene increase, disease in nine (22.5%) and five (12.5%) recurred and in five (12.5%) and one (2.5%) progressed, respectively. Conclusion: In our experience EGFR expression measurement was feasible in more than 85% of patients and was related to EAU risk classes for recurrence and progression, showing different behavior during intravesical therapy. It was possible to identify a subgroup of high-risk patients overexpressing EGFR in spite of intravesical adjuvant therapy. EGFR evaluation in bladder washing could represent a repeatable and useful tool to identify a subgroup of patients at risk for progression predicted as not being responsive to intravesical adjuvant therapy and candidates for early radical cystectomy. We wish to thank GSTU Foundation for data and statistical management

Analysis of Bacterial Stent Colonization: The Role of Urine and Device Microbiological Cultures

In this study, we explored the incidence of double J (JJ) contamination of patients who underwent an endourological procedure for urinary stones and ureteral stenosis. We developed a prospective study between January 2019 and December 2021. Ninety-seven patients, 54 male and 43 female, were enrolled. Urine culture was taken during four steps: before stent insertion, a sample from selective renal pelvis catheterization, a sample two days after the JJ insertion and finally, after the stent removal procedure. At the time of the stent removal, 1 cm of proximal and distal ends were cut off and placed in the culture for bacterial evaluation. Cohen's kappa coefficient value (k) and concordance rates of microbiological culture results were evaluated. The study group comprised 56% of male patients. Proximal and distal stent cultures were positive in 81 and 78 patients. The concordance rate of microbiological cultures between proximal and distal double J stent is 88% (k 0.6). The most common pathogens isolated from urine and stent cultures were Enterococcus spp. in 52 cases and Klebsiella spp. in 27 cases

Double-Layered Hand-Sewn versus Stapled Intestinal Anastomosis in Patients Who Underwent Ileal Urinary Diversion in Radical Cystectomy: A Comparative and Cost Effective Study

Introduction: Intestinal anastomosis can be performed by hand suturing (single layer or double layer) or by a mechanical suturing machine. The aim of the study was to compare complications, operative time, and costs of the intestinal anastomosis techniques. Methods: A retrospective comparative study was conducted including patients who underwent radical cystectomy and uretero-ileo-cutaneostomy or vescica ileale Padovana orthotopic neobladder. Double-layered hand-sewn intestinal anastomosis (HS-IA) were performed using Vicryl stitches. Mechanical-stapled intestinal anastomosis (MS-IA) were performed with a mechanical stapler. Results: Data of 195 patients who underwent were collected. 100 (51.3%) patients underwent HS-IA and 95 (48.7%) patients underwent MS-IA. Considering the complications classified according to Clavien-Dindo, a statistical difference with higher incidence for grade one in the HS-IA both in the ileal conduit group and in the neobladder one than the MS-IA (15.8% and 8.7%, respectively, in HS-IA vs. 1.7% and none in MS-IA). There is not a significant difference in time to flatus and time to defecation. Difference is recorded in the ileal conduit groups for the length of stay (10 days, range 9-12 with HS-IA vs. 13 days range 12-16 days with MS-IA (p < 0.001). The cost of the suture thread used for a single operation was 0.40 euros, whereas the overall cost of a disposable mechanical stapler and one refill was 350.00 euro. Conclusion: Both HS-IA and MS-IA are safe and effective for patients. The cost for the stapling device is 350 euro, in contrast, the cost for Vicryl sutures is negligible

Adherence to Guidelines among Italian Urologists on Imaging Preoperative Staging of Low-Risk Prostate Cancer: Results from the MIRROR (Multicenter Italian Report on Radical Prostatectomy Outcomes and Research) Study

Objective. A number of evidence-based guidelines for diagnosis and management of prostate cancer have been published. The aim of this study is to evaluate the adherence of Italian urologists to the guidelines concerning the preoperative imaging staging of prostate cancer. Methods. In October 2007 a multicentric observational perspective study called Multicentric Italian Report on Radical prostatectomy Outcome and Research (MIRROR) was started in 135 Italian urology centers. Recruitment was closed in December 2008 and 2,408 cases were collected. In this paper we have taken into consideration all examinations carried out for preoperative imaging staging, evaluating compliance with the recommendations in the American Urological Association (AUA) and European Association of Urology (EAU) guidelines. Results. Five hundred sixty-seven (53.34%) patients were not managed according to the EAU guidelines concerning T-staging, 545 (51.27%) concerning N-staging and 757 (71.21%) concerning M-staging. According to AUA guidelines, we also analyzed patients with a Gleason grade of biopsy specimens of 7: 238 (57.35%) of these patients had undergone testing for T staging, 244 (57.35%) for N-staging and 322 (77.60%) for M-staging. Conclusions. The compliance of Italian urologists with the guidelines is low, leading to an inappropriate increase in cost of care and unnecessary anxiety for the patients

Preliminary Results of ERAS Protocol in a Single Surgeon Prospective Case Series

Background and Objectives: The aim was to compare the intra and postoperative outcomes between the Enhanced Recovery After Surgery (ERAS) protocol versus the standard of care protocol (SCP) in patients who underwent radical cystectomy performed by a single surgeon. Materials and Methods: A retrospective comparative study was conducted including patients who underwent radical cystectomy from 2017 to 2020. Length of stay (LOS), incidence of ileus, early postoperative complications, and number of re-hospitalizations within 30 days were considered as primary comparative outcomes of the study. Results: Data were collected for 91 patients who underwent cystectomy, and 70 and 21 patients followed the SCP and ERAS protocol, respectively. The mean age of the patients was 70.6 (SD 9.5) years. Although there was a statistically significant difference in time to flatus (TTF) [3 (2.7-3) vs. 1 (1-2 IQR) days, p &lt; 0.001, in the SC hospital and in the ERAS center respectively], no difference was reported in time to first defecation (TTD) [5 (4-6) vs. 4 (3-5.8), p = 0.086 respectively]. The median LOS in the SCP group was 12 (IQR 11-13) days vs. 9 (IQR 8-13 p = 0.024). In the postoperative period, patients reported 22 complications (37% in SCP and 42.8% in ERAS group, p = 0.48). Conclusions: The study reveals how even partial adherence to the ERAS protocols leads to similar outcomes when compared to SCP. As a single surgeon series, our study confirmed the role of surgeons in reducing complications and improving surgical outcomes