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Introduction: Lymphoid neoplasms of the urinary tract and male genital organs are relatively rare, comprising less than 5% of all primary extranodal lymphomas; only a handful of small case series and isolated case reports have been published to describe their predominant sites and subtypes.
, Materials and Methods: We searched our institution's electronic archive of pathology reports from 
2001 to 2012. We considered lymphoid neoplasms involving the kidney, bladder, testes and prostate. Patient age at diagnosis, sex, clinical history, and outcome were recorded using the relevant electronic medical records.
, Results: We identified 25 patients with lymphoid neoplasms of the urogenital tract. 11 cases out of 40 were primary genitourinary lymphomas. Mean age at diagnosis was 61.7 years (range 13-87 years). Among bladder lymphomas cases, a male predominance was noted. As regards the types of lymphoid neoplasms, the following subtypes were observed: diffuse large B-cell lymphoma (32%), chronic lymphocytic leukemia (24%), small lymphocytic lymphoma (20%), Malt lymphoma (8%), Burkitt lymphoma (4%), follicular lymphoma (4%); diffuse large B-cell ALK+ (4%) and lymphoblastic lymphoma (4%).
, Results: Genitourinary tract lymphomas most commonly occurred in the kidney. B-cell non-Hodgkin's lymphomas were predominant, with diffuse large B-cell lymphoma being the most common subtype in the entire group. Although this study confirms the predominance of diffuse large B-cell lymphoma in extranodal sites, the findings also highlight the variety of lymphomas that may occur in the genitourinary tract. This diversity of subtypes affirms the importance of fully characterizing lymphomas by immunohistochemistry and other modalities, which are indispensable for accurate diagnosis.

Introduction: We present a refinement to our original technique in MtF gender reassignment surgery. Our goal was to construct a neoclitoris, which is wet and covered with urethral neoprepuce. Since 1995 more than 300 transgender MtF patients have been operated at our institution. Our refinement has been applied to 12 cases and showed both excellent functional and cosmetic results during midterm follow-up., Patients and Methods: During 2010 several sex reassignment surgeries have been performed using our new technique that includes: bilateral orchiectomy, removal of corpora cavernosa of the penis, formation of the neourethra with neomeatus, neovaginoplasty by inversion of penoscrotal skin flaps, construction of the neoclitoris with preservation of the neurovascular bundle and exterior vulva formation. The refinement consists in creating a neoclitoris embedded in urethral mucosa using urethral flaps. These flaps are in continuity with the previously spatulated urethra. The urethral plate is further incised distally in a Y fashion. The urethral flaps are sutured around the neoclitoris to form a neo-urethroclitoris covered by urethral neoprepuce, which resembles a real female clitoris. The neoclitoris is positioned in the anatomical position of the male suspensory ligament of the penis that is also the natural anatomical position of the female clitoris., Results: With this method we are able to construct a clitoris with a normal sensitivity embedded in urethral mucosa that remains wet and hairless. It can be easily stimulated during sexual intercourse, as most of the patients reported great satisfaction and ability to reach orgasm., Discussion: We want to emphasize how both the cosmetic results and functionality of the neovagina and neoclitoris are important in this type of surgery for the quality of life of our patients. We are still far from a perfect surgical solution, but we are further improving our technique and follow our aims step by step.

Penile fracture is a serious urological condition that requires surgical repair. We report a case of a penile fracture after traumatic event where sonography was performed and demonstrated the exact site of the rupture in the tunica albuginea and the urethral integrity.

Ultrasound guided systemic sextant needle biopsy of the prostate is the procedure of choice for the diagnosis of prostate cancer. During the past 50 years, the techniques, indications, and pathologic interpretation of prostate biopsies have evolved. Moreover, the indications for prostate biopsy have become more refined. This paper provides the results of an interactive questionnaire on ultrasound guided biopsy of the prostate. 14 questions have been selected. A range of 102-109 answers have been collected for every questions at Castrocaro (Fo) during the 14th National Congress of the Italian Society of Urological, Andrological and Nephrological Ultrasound on May 3rd 2002.

The early detection of prostatic neoplasm is nowadays a primary need in the urological field. The availability of transrectal ultrasound equipment alongside with bioptic tools made possible that transrectal ultrasound-guided biopsy of the prostate became the standard procedure to achieve this goal. With this work we would like to confirm the efficacy of this method which is also associated with a good tolerance and low complications rate. 82 patients that came to our Department between 1997 and 1999 were submitted to this procedure, 25 resulted positive for prostatic adenocarcinoma. Only 2 of them did not tolerate the procedure while all the others referred only mild discomfort at the moment of the puncture; 9 patients afterwards had to be admitted to the hospital due to fever (1 patient), acute retention of urine (3 patients) and persistent macroscopic hematuria (5 patients). Transrectal ultrasound-guided biopsy of the prostate reveals to be a safe and accurate method to obtain tissue samples of the prostate along with high tolerance and low incidence of serious complications.

Prostatic cysts are rare; they are to be considered in the evaluation of obstructive azoospermia. A correct diagnosis is based on transrectal ultrasound of the prostate. Herein we describe our experience with perineal ultrasound cyst aspiration. During the last 10 years, 21 infertile patients underwent ultrasound puncture of an intraprostatic cyst. Patients were placed in the lithotomy position, a 16 G needle was adopted; by means of ultrasound was possible to follow the needle entering the cyst. The content was aspirated and, if no spermatozoa were detected in the cystic liquid, sclerosing agents were introduced. The technique was performed successfully in all patients with symptomatic cyst within the prostate. Follow-up prostatic ultrasound and semen analysis were performed in 17 patients. There was 1 recurrence that was aspirated again. In 12 cases an increase in sperms number and motility was obtained, in 3 cases oligoastenospermia remained unchanged and 2 patients are still azoospermic. In 3 cases the partners become pregnant.

All the concepts and principles commonly espoused in plastic surgery are very useful in urologic reconstructive operations too. Hypospadia's repair, neo-bladder reconstruction, microsurgery of the seminal way require as certain rules as an absolute respect for anatomy, sparing of the finest tissue vascularization and tension free sutures. Pedicled skin flaps harvesting and utilisation are techniques typical of plastic surgery but are also largely used in urologic adult and paediatric surgery. They are adopted for urethral, penile and corpora cavernosa reconstruction. Pedicled flaps are utilised for the closure of large skin defect in case of complicated wound or when an urinary fistula is present, especially after radiotherapy. A perfect knowledge of the flap nourishment and of the method of harvesting is crucial if the best results must be obtained. In our work we describe the surgical technique for the utilisation of gracilis muscle and forearm flap. Special care is taken to the anatomical description.

Varicocele, which is the most common cause of infertility in man, is detected by means physical examination and color Doppler sonography. We analyzed the results of percutaneous sclerotherapy of the spermatic veins in 76 out of 103 patients with varicocele: antegrade sclerotherapy was performed in 11 patients while 92 men underwent retrograde scleroembolization. Color Doppler sonography was performed one month later and showed persistence of varicocele in 3 patients who underwent retrograde sclerotherapy. Retrograde percutaneous sclerotherapy of the spermatic vein represents, in our opinion, the gold standard in the treatment of primitive and recurrent left varicocele, because of its efficacy and minimal invasive nature. Antegrade sclerotherapy is an effective alternative treatment when retrograde access is not possible.

Among the usual indications of intraoperative ultrasounds, we describe four infrequent applications that show how useful and powerful this technique could be for interventive urologists. The first case regards a 66 years old male who was affected by a renal metastasis from thoracic cage chondrosarcoma. The use of intraoperative ultrasounds permits to highlight atypical sonographic features of the secondary lesion that were not seen in preoperative radiologic exams and that are completely different from the usual renal lesions. The second case regards the treatment of prostatic abscess performed by echoguided transperineal puncture in which the use of transrectal ultrasound probe permits a precise and correct placement of the needle and the drainage in order to obtain a fast relief of the symptomatology. The third case shows the role of intraoperative ultrasounds in the localization of a parathyroid adenoma in a 52 years old male affected by primary hyperparathyroidism and with recurrent renal colics. In this case the blind surgical exploration of the parathyroid gland and so the possibility of iatrogenic lesions to the recurrent laryngeal nerve were avoided by the use of the intraoperative sonography for the identification of the adenoma. At the same time the operation times were reduced. The last case underlines the importance of using intraoperative ultrasounds in the real-time monitoring for the creation of the neovagina in sex reassignment surgery in male-to-female transexualism in order to avoid a dangerous postoperative complication represented by the iatrogenic lesion of the rectum during the dissection of the perineal region.

Large cell calcifying Sertoli cell tumor of the testis is an extremely rare type of sex cord tumor with low malignant potential that occurs in the first and second ecades of life. Twenty-eight cases have been reported in the literature and, to our knowledge, only 2 had an aggressive behaviour. Patient age, tumor size, histological malignant patterns such as pleomorphism and high mitotic rate seem to heavy influence the future neoplasm malignancy. Ultrasonography imaging of the large cell calcifying has described in only 6 cases. We report an experience with a large cell calcifying Seroli cell tumor of the testis and point out the unusual sonographic findings. Moreover, if histologic examination suggests no malignant features, we suggest local excision as ideal therapy for the preservation of testicular parenchyma.

Endometriosis is relatively frequent in females of menstrual age and consists in the appearance of active endometrial tissue at site other than uterine cavity. Endometrial tissue has been described to colonise the urinary system, particularly the urinary bladder. The most common clinical features of vesical endometriosis are urgency and frequency, hypogastric pain and hematuria. We report on a case of vesical endometriosis whose presenting features were dysmenorrhea, stranguria and pelvic pain. MRI and CT did not provide different or more precise information than ultrasound scan: these findings were indistinguishable from an intrauterine lesion. On the contrary endovaginal sonography was more sensitivity than MRI and CT. Cystoscopy was negative. Nondiagnostic laparoscopy was performed. Patient underwent laparotomy and partial cystectomy. Histopatological findings demonstrated an endometriosis of the muscle layer of the bladder. The rarity of this condition prompted us to report on the problems encountered in making the differential diagnosis.

The employment of ultrasonography in urology is not well established yet. On this purpose a survey of present situation in different medical setting was conducted. 200 questionnaires were filled by about 1000 physicians operating in various medical centers. The most of answers was provided by assistant head physicians (41%) and head physicians (30%), with a clear prevalence of urologists (64%) and nephrologists (32%). The number of beds reported by each centers ranged from 0 to 90, while the average doctor-patient ratio was 3.6. 72% he centers could avail of B-mode echography (22% of them owned an echo-Doppler velocimeter). The data obtained reveal the great heterogenety of present medical system and the necessity of finding a correct equilibrium between specialistic and primary care settings. It can be concluded that the correct use of ultrasonography depends both on good knowledge of its real indications and on the proper professional training of the echografist.

The impossibility to palpate organs and tissues is probably the most important drawback of the laparoscopic approach: laparoscopic sonography represent the only real alternative to manual palpation. The laparoscopic approach in the field of urology was initially limited to the identification of the undescended testes in paediatric urology and to the laparoscopic ligation of varicocele. More recently, it took into account the pelvic lymphadenectomy for staging prostatic and bladder cancer. The upper urinary tract and the retroperitoneum were approached more recently. In a preliminary phase the indications for laparoscopic nephrectomy were limited to benign diseases, such as atrophic kidney in patients with renal hypertension, and scarred pyelonephritic kidney. At present some preliminary experiences are reported about nephrectomy performed for carcinoma of the urether or of the upper collecting system and for renal masses of unknown origin. Another indication for a laparoscopic approach to the kidney is represented by symptomatic renal cysts. These cysts have been usually treated with percutaneous aspiration and/or sclerosis, but a high rate of recurrence is reported. Laparoscopy may be used to approach renal cysts with the advantage that most of the cystic wall could be excised, reducing the change of recurrence. Another possible indication for laparoscopy and laparoscopic sonography is the retroperitoneal lymphadenectomy in testes cancer with staging or therapeutic purposes. Nowadays preliminary experiences in laparoscopic adrenalectomy have been reported in a limited series of cases. In this report the Authors present their initial experience using a 7.5 MHz rigid probe having 400 crystal which can be inserted into a 10 mm trocar.(ABSTRACT TRUNCATED AT 250 WORDS)

Herein we report on the results of 171 out of 214 patients with renal cysts. In 127 cases diameter of cyst being less than < 6 cm, was monitored repeating renal ultrasound every 6 months: 78 patients underwent pecutaneous cyst echoguided puncture, while 9 patients were treated as follows: 4 by open surgery, 3 by laparoscopy and 2 by percutaneous treatment in general anaesthesia. Cysts are classified in 4 types and therapy is different according to Bosniak's classification. When the cyst is less than 6 cm in diameter and symptomatology is absent, we follow the patients up with yearly ultrasound. In our experience cyst sclerotization is carried out by injecting either ethanol or Trombovar or 50% glucose in water alone or associated with 2% Aethoxysclerol. The best results are obtained from the use of ethanol (30% of the volume of cyst). However some relapses are encountered after this kind of procedure. In these cases it is helpful to examine the cystic wall because of the presence of intracystic septa. Percutaneous treatment by means nephroscopy permits to visualize the cystic wall but it is not able to perform a biopsy of its wall. Laparoscopic treatment is performed by inserting 5 trocars with the patient under general anaesthesia. This technique is able to localize and biopsy the cystic wall without causing side-effects or complications. Open surgery was performed only in 4 patients affected with hidatid cyst. At present echoguided cyst puncture permits to approach the renal not complicated cysts, while laparoscopy constitutes a safe treatment in the case of benign recurrent and complicated cysts.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraoperative ultrasound localization of the non palpable testicular lesions allows to detect small gonadal tumors or to well study benign testicular masses. Several methods have been proposed to study non palpable testicular masses including CT and NMR. Prospective studies of the efficacy of CT vs spermatic venography in localization of cryptorchid testes have also been reported: spermatic venography proved to be the most accurate of the two modalities even if possible neoplastic degeneration of testicular tissue is very difficult to investigate with this method. Herein we describe our clinical experience and particularly four cases in which we adopted intraoperative ultrasonography of testes with different results. M.S. a 28 year old infertile patient underwent testicular ultrasound during a check-up and a little image localized at the level of right testis was found. Even if no mass was palpable we decided to operate on the patient; an intraoperative testicular ultrasound revealed the precise localization so that the little mass was excised and examined at once. Histologic study confirmed the presence of tumoral tissue and orchiectomy was performed: deeper hystological studies confirmed it was a leydigioma. D.C. 27 year old bilaterally cryptorchid patient had been already operated on twice but no testicular structure was encountered at the level of inguinal channels. Neither preoperative abdominal ultrasound nor CT revealed the presence of the testes. At abdominal exploration both testes were localized in the iliac region. Intraoperative testicular ultrasound allowed us to localize a right testicular tumor: right orchiectomy and left autotransplantation were performed.(ABSTRACT TRUNCATED AT 250 WORDS)

The occurrence of an obstruction of the ejaculatory ducts, in spite of its rarity, must be considered by the Urologists in the screening of the etiologic causes of obstructive azoospermia. Nowadays, the diagnostic approach, which includes the biochemical study of seminal plasma and prostatic ultrasound, often leads to the preoperative recognition of the site of obstruction. Various surgical and endoscopic techniques have been adopted for the treatment of ejaculatory duct obstructions in different historical periods. Herein we describe our experience that starts from 1979. 17 infertile patients with intraprostatic cysts and 2 with a stenosis of the veru montanum were treated by us following these criteria: 9 azoospermic patients underwent scrototomy and endoscopy; 10 patients with a severe oligozoospermia underwent echo-guided puncture of an intraprostatic cyst. The patients were placed in the lithotomy position, a 16 G needle was adopted and by means ultrasound was possible to follow the needle entering the cyst. When no spermatozoa was detected in the cystic liquid, sclerosing agents (Sodium-tetradecyl-sulphate 30 mg in 1 l.) was introduced. This easy procedure was carried out on outpatients in local anaesthesia. One out of ten oligozoospermic patients had to repeat the echo-guided puncture of intraprostatic cyst as the first attempt had been followed by recurrence. Eight out of ten subfertile patients who had undergone percutaneous echo-guided treatment had longer than 1 year follow-up: in seven cases an increase in sperms number and motility was obtained; in one case sperm count remained unmodified. In three cases the partners became pregnant.

Several Authors have discussed the long term efficacy of sclerotherapy; somebody supposes that percutaneous angiographic treatment of spermatic vein is not sure at all because the occlusion due to the sclerosing agents is not retained as long lasting. Studies have been done by other Authors about comparison of recurrent varicocele anatomy following surgery and percutaneous balloon occlusion: it is concluded that venous collaterals are identified easily by renal venography, and knowledge of these collaterals is helpful in planning further radiological treatment. Since 1980 we have always treated left varicocele by means of percutaneous sclerotherapy of the spermatic veins following renal phlebography: the treatment is done on an outpatient basis, in local anaesthesia. Sclerosing agents we usually adopt are: sodium-tetradecyl sulphate and alcohol. At our knowledge long-term results of this treatment have never been published; this is the reason for which long-term follow-up of 27 patients that 6 years ago underwent percutaneous sclerotherapy was done. Only 16 of them have accepted to repeat: a) physical examination; b) Doppler flowmetry; c) scrotal ultrasound. The presence of a varicocele was demonstrated in 2 out of 16 patients (12.5% of the case). These data confirms that percutaneous treatment performed following the procedures we adopted in 1986 has a long term efficacy in 87.5% of the cases.(ABSTRACT TRUNCATED AT 250 WORDS)

B. L. a 27 year old bilaterally cryptorchid patient underwent right testicular autotransplantation in the presence of a quite normal testis. After one year the patency of microsurgical anastomosis was confirmed by means of Doppler flowmetry and scrotal echography demonstrated the presence in the scrotum of a testis provided will normal echogenicity. Left laparoscopic orchiectomy was planned. A small semilunar skin incision was made just below the rim of the umbilicus. Veress needle was introduced: as soon as the needle pierced the parietal peritoneum, its spring mechanism was released allowing the sharp needle point to retract leaving only the blunt tip protruding. Carbon dioxide gas was insufflated through the side part of the Veress needle until adequate abdominal distension was achieved. After having removed the Veress needle, the laparoscope on its sharp-pointed trocar was introduced into the peritoneal cavity and left testis was easily localized. Four trocars were introduced up to proceed to laparoscopic orchiectomy. The patient was discharged two days after. In our opinion in the presence of a bilateral cryptorchism in the adult, is better to plan a monolateral autotransplantation. After having verified the long-term result of microsurgery we can decide if a contralateral orchiectomy has to be planned.

B.L. a 27 year old bilaterally cryptorchid patient underwent right testicular autotransplantation in the presence of a quite normal testis. After one year the patency of microsurgical anastomosis was confirmed by means Doppler flowmetry and scrotal echography demonstrated the presence into the scrotum of a testis provided of a normal echogenicity. Left laparoscopic orchiectomy was planned. A small semilunar skin incision was made just below the rime of the umbilicus. Veress needle was introduced: as soon as the needle pierced the parietal peritoneum, its spring mechanism was released allowing the sharp needle point to retract leaving only the blunt tip protruding. Carbon dioxide gas was insufflated through the side part of the Veress needle until adequate abdominal distension was achieved. After having removed the Veress needle, the laparoscope on its sharp-pointed trocar was introduced into the peritoneal cavity and left testis was easily localized. Four trocars were introduced up to proceed to laparoscopic orchiectomy. The patient was discharged two days after. In our opinion in the presence of a bilateral cryptorchism in the adult, is better to plan a monolateral autotransplantation. After having verified the long-term result of microsurgery we can decide if a contralateral orchiectomy has to be planned.

The presence of penile nodule, curvature, disorders in blood flow to and from the corpora cavernosa is often correlated with organic sexual impotence. Echography allows to obtain a clear imaging of penile structures: diameters of corpora cavernosa can be measured before and after injection of vasoactive drugs. In our study penile structure were evaluated using a Combison 310 and a Toshiba with 7.5 MHz probe. In a lot of cases echography was repeated after intracavernous injection of PGE 1 or papaverine. The equipment needed for this evaluation is expensive but echography is undoubtedly less invasive than other equivalent examinations like cavernosography. Although the sensitivity and specificity of penile echography have not yet been clearly established this test is generally considered to be an useful and objective one. Penile echography is particularly usefull in discriminating between echogenic and not-echogenic nodules in case of Peyronie disease.

If we define erectile impotence as the inability to achieve and maintain a firm erection we can distinguish several pathogens of impotence: psychologic disorders, neurogenic sinusoidal disorders, arterial disorders, venous & sinusoidal disorders and systemic diseases and other disorders can cause erectile impotence. An etiologic screening of impotence must be carried out by Urologists in order to adopt the best surgical approach. Especially when surgery has to be planned, a complete, often invasive screening associated with a super-specialist diagnostic study is necessary at the beginning of any procedure. Different approaches to impotence can be adopted on the basis of patient's age, etiology and failure of other devices. The main methods of surgical correction of impotence may be divided as follows: a) percutaneous transluminal angioplasty (P.T.A.); b) revascularization; c) surgical treatment of "venous leakage", d) trans-luminal veno-occlusion (T.L.V.O.); e) correction of penile curvature; f) prostheses placement. The diagnosis of arteriogenic impotence depends upon the arteriographic demonstration of bilateral hemodynamically significant obstruction. In our experience the injection of papaverine during the test has provided a better visualization of cavernous arteries and helicine branches. Reduction of luminal diameter by more than 50% suggest a hemodynamically significant stenosis. Intracavernous injection of vasoactive agents has provided an attractive alternative to surgery. We have employed papaverine alone or with phentolamine or phenoxybenzamine. After short term treatment, some patients have achieved good erections without further injections. For P.T.A. of the distal internal pudendal arteries our approach has been via the ipsilateral or contralateral femoral arteries. Under local anesthesia a penile arteriographic catheter is placed in the internal pudendal artery.(ABSTRACT TRUNCATED AT 250 WORDS)