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Objectives The aim of this study was to evaluate the use of mechanical thresholds (MT), measured with the SMALGO (Small Animal ALGOmeter), and to determine whether there was a correlation between MT and Glasgow Feline Composite Measure Pain Scale (CMPS–Feline) scores in cats undergoing ovariohysterectomy. Methods Client-owned cats undergoing flank ovariohysterectomy were recruited. Pain scores for the pre- and postoperative periods were obtained using the CMPS-Feline in each cat by two independent investigators (A and B). Following CMPS–Feline scoring, MT were measured with the SMALGO, in the surgical area, pre- and postoperatively, only by investigator A. Each cat served as its own control for the comparison of pre- and postoperative variables. Reliability statistics were used to assess the level of inter-observer agreement (A vs B) with respect to pre- and postoperative CMPS–Feline scores, while Spearman’s correlation statistics were used to analyse the relationship between MT and CMPS–Feline scores. Results Twenty-nine cats completed the study. Preoperative MT (340 g [range 108–691]) were significantly higher than postoperatively (233 g [range 19–549]; P = 0.001). CMPS–Feline scores were not found to differ significantly between the preoperative period (2 [range 0–7] for investigator A and 3.2 ± 2.3 for investigator B) and postoperative period (2 [range 0–10] for investigator A and 3 [range 0–8] for investigator B) for either investigator. Reliability statistics revealed that the level of inter-observer agreement with respect to CMPS–Feline was fair for the preoperative assessments but poor for the postoperative evaluations. There was no correlation between MT and CMPS-Feline scores. Conclusions and relevance Although there was no correlation with CMPS–Feline scores performed at the same timepoint, MT increased postoperatively vs baseline. Assuming that, despite analgesia, susceptibility of the surgical area to mechanical stimulation would increase after surgery, this finding suggests that MT might be useful to assess feline surgical pain. The poor level of inter-observer agreement with respect to postoperative CMPS–Feline scores highlights the potential limitations of this scale.

Objective:To identify histopathological and immunophenotypical features with potential predictive or prognostic value in patients undergoing pulmonary metastasectomy from renal cell carcinoma (RCC).Methods:We retrospectively collected all consecutive patients undergoing pulmonary metastasectomy from RCC after prior nephrectomy. Paired samples of primary tumors and corresponding pulmonary metastases were analyzed, revising histopathological features and testing C-MET, mTOR, and PD-L1 by immunohistochemistry.Results:A total of 25 patients were included. Median overall survival (mOS) from metastasectomy was 5.5 years (95% CI = 1.9–9.1). The laterality of metastases had a significant predictive value, with median relapse-free survival (mRFS) from metastasectomy not reached (NR) at mean follow-up (FU) of 60.8 months for left lung involvement, mRFS of 52.9 months (95% CI = 0–145.5) for the right lung and 6.4 months (95% CI = 1.7–11) for bilateral metastases ( p = 0.028). Primary RCC with positive expression of mTOR had higher mOS after metastasectomy than negative cases ( p < 0.001), NR at mean FU of 4.3 years versus mOS of 2 years (95% CI = 0.7–3.3), respectively. PD-L1 positivity on intra-tumor (TILs) and peri-tumor (RILs) infiltrating lymphocytes of metastases was related to higher OS, NR versus 2 years (95% CI = 1.2–2.7, p = 0.003), and NR versus 1.4 years (95% CI = 0.2–2.6, p = 0.012), respectively. The shorter was the surgical interval, the more probably the metastases had high c-MET expression (>70%) ( p = 0.007) and PD-L1 expression >10% on TILs ( p = 0.024).Conclusions:mTOR positivity on primary RCC could be a favorable prognostic factor to select patients for pulmonary metastasectomy. The positive impact of PD-L1 expression on immune cells is opposite to the well-known negative prognostic value of PD-L1 on tumor cells in RCC.

Background In Italy medical cannabis is a prescription drug since 1998. Even though it could not be considered a therapy as such, it is indicated as a symptomatic treatment also in cancer patients, to cure iatrogenic nausea/vomiting and chronic pain. Patients and methods We conducted a knowledge survey about medical cannabis among cancer patients referred to two outpatient cancer care centers and a home care service. Results From February to April 2018, 232 patient were enrolled; 210 patients were on active disease-oriented treatment (90.5%), while 22 (9.5%) not. Eighty-one percent of the patients have heard about medical cannabis, but only 2% from healthcare professionals. Thirty-four percent of responders thought about using cannabis to treat one or more of their own health problems, especially pain (55%). Despite that, 18% of the participants believe that medical cannabis could have negative effects on their own symptoms. Patients with high educational level better knew cannabis (odds ratio = 3.52; 95% confidence interval: 1.07–11.53), and medical cannabis (odds ratio = 3.21; 95% confidence interval: 1.48–6.98), when compared to patient with low educational level. Patients who were on active disease-oriented treatment better knew medical cannabis (odds ratio = 3.91; 95% confidence interval: 1.26–12.11) compared to “out of treatment” patients. Metastatic patients were less informed about medical cannabis compared to patients on adjuvant treatment. Conclusions Our survey shows that most of Italian cancer patients know medical cannabis and a third of them have considered using cannabis to treat one (or more) of their own health problems. In the same time, they are poorly informed and do not tend to ask for information about medical cannabis to healthcare professionals.

Purpose: Age-related non-communicable chronic diseases (ArCDs) are the leading cause of mortality. The major metabolic risk factor for their development is the metabolic syndrome (MetS), defined as a clustering of risk factors of metabolic origin such as abdominal obesity, high blood pressure, dyslipidemia and high fasting glycemia. There is increasing observational and experimental evidence that improving diet and the use of metformin (a calorie-restriction mimetic drug) may modify the risk of developing MetS and ArCD. We designed a phase III randomized controlled trial (the Me.Me.Me trial) to evaluate the effect of a comprehensive lifestyle intervention (including moderate physical activity and a Mediterranean-macrobiotic diet) and the effect of treatment with metformin in the prevention of ArCDs in healthy people with MetS. This report describes the scientific protocol of this trial. Methods: The design of the study is 2 × 2 factorial with 2,000 volunteers to be randomized into 4 equal groups of 500 each, which are allocated to the following treatments: metformin (1,700 mg/day) + active lifestyle intervention, placebo + active lifestyle intervention, metformin (1,700 mg/day) alone, and placebo alone. The metformin/placebo component of the study is double blind. The study is planned for a term of 5 years. Results: The Me.Me.Me. trial is ongoing and recruitment of participants is underway. No patient has completed the 5 years of follow-up. Conclusions: We believe that the results of the trial will clarify the importance of lifestyle for primary prevention and the role of metformin as a potential chemopreventive agent. The trial is registred on ClinicalTrials.gov with the identification NCT02960711.

Objectives The objective of this study was to identify the renal ultrasonographic (US) findings most strongly associated with azotaemia in cats. Methods US findings in 238 cats with (serum creatinine >180 μmol/l) and 270 cats without azotaemia were compared in a retrospective case-control study. Cats with pre-renal azotaemia or urethral obstruction were excluded. Data extracted from the medical records included age, body weight and body condition score (BCS). Quantitative and subjective US findings were extracted from archived ultrasound images and contemporaneous reports. Results In non-azotaemic cats, mean ± SD renal length was 40.1 ± 5.5 mm. Male cats had larger kidneys than female cats (mean difference 5.2 mm; P = 0.001) and, on average, the right kidney was slightly larger than the left (mean difference 1.6 mm; P = 0.01). Azotaemic cats had significantly lower mean body weight and BCS, and greater mean age and renal pelvic diameter. Renal pelvic diameter was negatively correlated with urine specific gravity (ρ –0.44, P Conclusions and relevance Perinephric fluid was the US finding most strongly associated with azotaemia in this study and may merit more emphasis than it has received to date. Bias in radiologists’ subjective assessments of renal size suggests that other subjective findings will also be biased.

Background Urolithiasis is a frequent complication in a heterotopic reservoir and the surgical management could be a difficult problem. Open surgery is not recommended in patients with multiple previous surgeries. A less invasive technique, such as the endourologic procedures, would allow high stone-free rate and low surgical morbidity. Introduction Stone formation in the reservoir is a well-known complication of urinary diversion. The incidence of lithiasis in patients with continent urinary diversion is reported as 12–52.5%. Most patients will have multiple physical factors, such as immobility, need for self-catheterization and poor urine drainage, so that it is not certain that an intestinal reservoir is the cause of stones on its own. The management of urolithiasis in continent urinary diversion can be challenging and could be a difficult problem to solve. A less invasive technique, such as the endourologic procedures, is desiderable, especially in patients with kidney transplant and low immune defence. Materials and Methods We present the case of a 59-year-old woman with previous history of spina bifida and with neurogenic bladder. At a pediatric age, she underwent incontinent urinary diversion using a sigmo-colic conduit. For several years she had been suffering from kidney stones and recurrent urinary infections, which led to a left nephrectomy for pyonephrosis, subsequent deterioration of renal function and dialysis. In 2004, we performed an atypical continent and self-catheterizable reservoir using the previous colic conduit detubularized and ileum-cecal tract with Mitrofanoff system conduit of 14 Fr size. Finally, kidney transplant was carried out as last surgical procedure. Recently she has come to our attention for multiple and large reservoir stones. Surgical Technique preliminary exploration of the continent pouch with flexible cystoscope. Percutaneous access with Endovision° direct control through the afferent conduit with 8 Fr flexible ureteroscope. Dilation of percutaneous tract with pneumatic baloon and positioning 30 Fr Amplats sheet. Lithotripsy, with ultrasound and ballistic sources, was performed and the residual fragments were removed with grasping. At the end of the procedure, after controlling the complete clearance with flexible nephroscope and X-ray a percutanous 12 Fr catheter and a 12 Fr Foley in the Mitrofanoff conduit were inserted. Results No fever or increase serum creatinine were observed in the post-operative time. On day 3, we removed the percutaneous foley and after 7 days we performed a cystography with a normal pouch configuration; no leakage or residual fragments were observed. The woman was discarge and returned to usual self-catheterization. The first 3-month post-operative control was regular; no infections or pain were reported. Conclusions In special cases, like this one, the percutaneous procedure is preferred to open surgery for a best control of the pouch and a simple complete clearence of the fragments.

BackgroundThe endourological technique is a safe and effective approach in the treatment of large stones in the pediatric population with congenital malformations.IntroductionThe VACTERL association is a group of congenital malformations that include vertebral defects, anal atresia, cardiac defects, tracheoesophageal fistula with atresia, renal defects, and radial upper limb dysplasia. Renal anomalies are found in approximately 90% of patients.Materials and MethodsWe present a case of a 7-year-old girl with VACTERL association and cloacal malformations, undergoing multiple surgeries with subsequent Mitrofanoff continent appendico-vesicostomy. She presented at our attention for centimetric left ureteral and inferior pyelo-calyceal stones. She underwent flexible ureteroscopy with laser lithotripsy of both stones. A ureteral catheter and a nephrostomy tube have been left at the end of the procedure.ResultsThe ureteral catheter was removed in the 2nd post-operative day, the tubes were removed after a nephrostogram in the 8th post-operative day. The patient is stone-free. No complications were observed in the post-operative time.ConclusionsEndoscopy is the method of choice for the management of pediatric urolithiasis with complex renal calculi, due to its low incidence of major complications and a high stone-free rate.

Background Laparoscopic adrenalectomy is considered the treatment of choice in the surgical management of the most majority of the adrenal diseases. Nevertheless, one of the much discussed topics is the dimensional cut-off for the laparoscopic treatment and it is not clear if laparoscopy should be used in large adrenal masses. Introduction Laparoscopic adrenalectomy is the goal standard in benign adrenal masses smaller than 6 cm, while its advantages in masses larger than this cut-off and in malignant lesions is still discussed. Materials and Methods We present six cases of laparoscopic adrenalectomy since November 2008 for masses between 7 and 15 cm; 4 men and 2 women. 3 right and 3 left. A complete adrenal endocrinological evaluation demonstrated that the lesions were not secreting tumors. All patients were studied with CT scan. The technique was performed using a flank approach with a 45° tilt. We used 5 trocars in patients who had the masses on the right side, and 4 in those who had the lesions on the left side. After creating an adequate pneumoperitoneum through an open access, the posterior peritoneum cutting, mobilization of the colon, medial dissection of the adrenal gland, and ligation of the main adrenal vein were performed. The adrenal gland was carefully dissected by Ultracision. The mass was extracted by endobag through an additional subcostal port. The mean operative time was 120 minutes. Blood loss was about 50 cc. The drainage was removed on day 2 after surgery and the patient was discharged on day 3. No post-operative complication occurred. The anatomopathologic exam gave evidence of myelolipoma and hemorrhagic cyst. Discussion The benefits of the laparoscopic approach are widely demonstrated and consist of a shorter hospital stay, reduced morbility decreased analgesic requirement, and reduced intraoperative blood loss. One of the most discussed topics is the dimensional cut-off and it is not clear if the laparoscopy approach should be used in large adrenal masses (considering the longer operative time and increasing blood loss). Many surgeons performed laparoscopic adrenalectomy for masses of up to 13 cm, thus demonstrating that this procedure is safe and effective. A limitation of laparoscopic approach for adrenal giant masses is the increased risk to treat an adrenal cortical carcinoma. Conclusions Our experience, supported by the literature, demonstrates that the laparoscopic adrenalectomy is a feasible and effective surgical technique also in the case of giant masses. Preoperative diagnosis has a predominant role to determine the contraindication of this technique (invasive adrenal carcinoma).

Introduction and Objectives Ureteral stenosis and vesicocoureteral reflux after renal transplantation represent a key concern because of their incidence and the associated morbidity. Prompt diagnosis and minimally invasive treatment are mandatory in immunosuppressed patients with single kidney. The aim of this study is to evaluate the success rate of the endourological techniques in the management of such complications. Materials and Methods Between January 1996 and December 2006, 647 kidney transplants were performed. Urinary tract continuity was re-established by ureteroneocystostomy according to Gregoir-Lich technique. We observed 13 cases of ureteral stenosis (2%) and 11 cases of symptomatic vesicoureteric reflux (1.7%). The endourogical procedure was performed in 13 patients: 5 cases of II-III grade vesicoureteric reflux, 4 early ureteral stenosis and 4 late ureteral stenosis. Patients with vesicoureteric reflux underwent endoscopic injection of macroplastique in 4 cases and Durasphere in 1. Early ureteral stenoses were treated using balloon dilation in 2 cases, balloon dilation and laser endoureterotomy in 3, ureteral stent placement in the other. Recipients with late stenosis underwent laser incision and balloon dilation in 2 cases, balloon dilation in 1 and a laser incision only in the last case. Combined antegrade and retrograde endoscopic approach was performed in 7 patients, whereas retrograde access in 1. Results Endourologic treatment was successful in 9 cases (69.2%); 2 patients required open reconstructive surgery due to endourological technique failure (early ureteropelvic junction stricture, late ureterovesical anastomotic stricture). Vesicoureteric reflux was corrected in 3 patients (60%), 2 patients underwent uretero-ureterostomy for recurrent reflux. No technique-related morbidity was observed. With a mean follow-up of 81.6 months, 8 patients show normal renal function, 5 patients have returned to haemodialysis (4 for chronic rejection, 1 for carcinoma in the graft). Conclusions Considering their low morbidity and the satisfactory success rate, we claim that endourological procedures should be considered the preferred treatment for ureteral stenosis and vesicoureteric reflux in selected patients.

We present a new device, SPARC Sling System, designed for the placement of a pubo-urethral sling for the correction of female stress urinary incontinence due to urethral hypermobility. Twenty patients (medium age 53.4), affected by SUI resulting from urethral hypermobility (range of Q-tip test 30°-70°, VLPP > of 70 cmH2O and POP grade < II according to Baden and Walker classification) are underwent to this surgical procedure. 85% of them, after a medium follow-up of 10.5 months (range 3–21) show a complete correction of SUI. Three patients, in which SUI persists, refer a significant improvement of the incontinence. We think that the high rate of success (85%), the swiftness of the execution and the versatility of the SPARC Sling System put this surgical procedure between the mini-invasive selected methods to correct female stress urinary incontinence due to urethral hypermobility.

We have considered the aspects and the differences of quality of life and erectile function of 32 consecutive patients underwent to surgical operation of radical cistectomy and urinary diversion (11 patients with ileoureteralcutanous sec. Bricker and 21 patients with orthotopic neobladder). Medical Outcomes Study - Short Form - SF36 TEST and International Index of Erectile Function - IIEF-5, TEST have been administered to the patients, to know the Quality of Life assessment and the erectile dysfunction. The evaluation and analysis of the answers show no statistical significant differences between the two groups of patients about quality of life and sexual aspects.

With no more than 60 reported cases, tumors of the seminal vesicles are rare. Because of poor and nonspecific symptoms diagnosis is often very difficult. This report presents a case of a 56-year-old man with right renal agenesis and intermittent hematospermia and bilateral cystic masses of the seminal vesicles. Transrectal biopsies of the cystic lesion revealed a papillary clear cell adenocarcinoma. The patient underwent radical prostatectomy and pelvic lymphoadenectomy. Lymph node metastases were found on histological examination. The patient received 4 cycles of chemotherapy and pelvic radiotherapy. He remains disease free 21 months after surgery. Radiological imaging in patients with hematospermia and hematuria will allow disease detection at earlier stages. Immunohistochemistry and histomorphology can be used for differential diagnosis. Surgery with clear margins offers the best chance to cure. Hormonal and radio-chemotherapy have a role as adjuvant and palliative treatment.

– Histological specimens from 95 RCCs were immunostained for p53 protein, E-cadherin and Ki-67 antigen. Results, as well as stage and grade, were correlated to overall survival and disease-free interval. Markers were also correlated to each other. Statistically significant correlations were observed between stage, grade and Ki-67 versus both overall survival and disease-free interval and between Ki-67 and grade. The authors conclude that the analysis of cell proliferation by Ki-67 immunostaining may help improve understanding of the RCC prognosis.

The Authors review their own surgical series about retropubic and perineal radical prostatectomy performed in 1993–2002 ys, with particular attention for risk factors of biochemical recurrence of disease.

We report a case of Churg-Strauss syndrome, with bilateral ureteral involvement. We describe the endourological approach to the disease and we also discuss the literature about this argument.

Autotransfusion and hemodiluition before surgery reduce the risk of infection and alloimmunisation and allow a considerable saving of homologous blood. The Authors describe their personal experience on the use of preoperative hemodiluition over the last two years in 59 patients who underwent prostatectomy. The blood was taken in the early post-operative period. Only three patients (5.1%), were submitted to homologous blood transfusion. As far as the results are concerned, the hematocrit (which indicates the degree of E.D.) never fell below 28%. All patients showed normal post-surgery development. We stress the safety of this method particularly in urological surgery in peripheral hospitals where the quick availability of blood is essential and where there is a high risk of thromboembolism.

The management of major renal trauma is still controversial and there are few studies about preservation of renal function after surgical reconstruction. We report our results on 10 patients who underwent renal reconstruction and quantitative assessment of differential renal function by radionuclide scintigraphy (99m-TC DMSA); mean follow-up was 6.6 years. Function was 25% or more in 9 reconstructed kidneys: this value is considered an adequate preservation of renal function. We consider reconstructive surgery an appropriate method to manage major renal injuries.

Spinocellular carcinoma of the penis is rare and potentially fatal, especially when there are lymph node metastases. From January 1992 to December 1995 we treated 6 stage T3 N1 M0 tumours of the penis. Six to eight weeks after total penectomy, bilateral inguinal lymphadenectomy and pelvic lymphadenectomy were carried out. These patients also underwent 8 cycles of chemotherapy with vincristine, bleomycin and methotrexate. At an average follow-up of 36 months, all the patients are disease-free with no signs of recurrence either in the lymph nodes or in any organ.

We report the case of a 56-year-old male suffering from acute urine retention after a period of increasing dysuria. Physical examination, TRUS and CT showed the presence of a multilocular cystic mass in the space above the prostate and behind the bladder. Pathological findings following surgical exploration indicated a Müllerian duct cyst, few cases of which have been reported in literature. We performed surgery because malignancy was suspected and it was impossible to drain off all the cystic fluid due to the multilocular nature of the cyst. Moreover, cystic adenocarcinomas originating from Müllerian duct remnants have been reported. We agree with other authors that a percutaneous approach should be standard treatment in these cases, leaving open surgery for more complex cases.

Retroperitoneal fibrosis (RF) often presents with characteristic clinical and urographic findings that may hide lymphoma. A case of RF with bioptic confirmation is reported. On CT examination the variations in enhancement were not useful in distinguishing RF from lymphoma. Although on sagittal and coronal images MR accurately depicted the extent of the abnormal retroperitoneal mass as found at surgery, it was not able to correlate heterogeneous low intensity T2-weighted signals with definitive histological features.

Twelve patients were submitted to orthotopic ileal neobladder, performed using staplers. All patients underwent clinical and urodynamic evaluations at 3, 6 and 12 months after surgery (mean follow-up 6 months). They reported complete daytime continence and 2 pts/4 night-time continence too. At one year, post-voiding volume was absent, mean neobladder capacity was 450 cc and mean pressure at maximum capacity was 30-40 cc. These preliminary results indicate that this technique guarantees low-pressure reservoir with good capacity and compliance.

Gonadal stromal tumor is a rare neoplasm of the testis. 10% of these tumors are malignant, but malignant histological criteria are not established. The principal therapy is orchidofuniculectomy while lynphadenectomy is for uncertain malignant neoplasm. Radiotherapy and antiblastic therapy sensitivity is poor.

Clinically, it is difficult to distinguish prostatic malacoplakia from carcinoma. Two cases of prostatic malacoplakia are described, highlighting the ultrasound aspects of the lesion.

Papillary renal cell carcinoma (RCC) is known by the tendency to avascularity shown by angiography. More uncommon is the cystic variant of papillary RCC called cystoadenocarcinoma. The majority of papillary tumors are in stage I. The survival for papillary RCC is significantly higher than that for non-papillary RCC. CT-scan MNR, although non diagnostic, enhance the suspicion of a heterologous process in so called “complicated cysts”. US-guided percutaneous needle aspiration may be helpful to diagnose these tumours. We report 2 cases of cystodenocarcinoma and our considerations.