Bladder Pneumatosis: an inusual case report

==inizio objective==

Emphysematous cystitis (EC) or bladder pneumatosis is a very rare condition characterized by air within the wall of the bladder as a result of infection by gas‐forming organisms. Predisposing factors include diabetes mellitus, a neurogenic bladder, bladder‐outlet obstruction, in‐dwelling urethral catheters and recurrent urinary tract infections The major risk factor is diabetes mellitus (1). There are reported cases in literature of bladder pneumatosis without urinary tract infection (2). The amassing of gas within the wall of the bladder in this cases is not clear, a similar process of intestinal pneumatosis was proposed (2,4). Here we present a case of Bladder pneumatosis in an elderly woman affected by diabetes.

==fine objective==

==inizio methodsresults==

A female patiste 75 years old presented with asthenia, hyporexia cachexia, was affected by lung cancer with metastasis, BPCO and 24 hour oxygen therapy, hearth failure, hyperthyroidism , DM, Bartolini’s gland abscess. The patients presented in acute urinary retention, so an indwelling catheter was placed with drainage of 800 cc of clear urine. A computed contrasted tomography scan of the abdomen and thorax showed the presence of a lung cancer with multiple liver and lymph nodal metastasis and multiple air‐filled cysts within the wall of the bladder.

==fine methodsresults==

==inizio results==

Work‐up failed to show an infectious etiology, results of the urine analysis did not show pyuria, hematuria or bacteriuria, and no organisms were isolated from urine and blood cultures carried out before the administration of antibiotics. Antibiotic therapy was administered for Bartolini’s gland infection. No therapy was administered ether for lung cancer nor metastasis, the patients was addressed to palliative therapies.

==fine results==

==inizio discussions==

EC is a rare disorder characterized by the amassing of gas in the wall of the bladder. The disease is most common in female than in male (64% vs 36%) and more frequent in middle‐aged diabetic women (mean age 66 years) (3,6,7). There are several theories on the pathogenesis of these gas‐forming infections, but the combination of the presence of gas‐producing organisms, high glucose concentration in tissues and impaired tissue perfusion all favor the development of emphysematous infections of the urinary tract (1). Clinical presentation varies with abdominal pain, outlet irritative symptoms, pneumaturia and acute abdomen are are the most frequent symptoms (3). This is not a typical emphysematous cystitis case. Bladder ischemia could allow bacterial to enter in the bladder wall as happens in intestinal ischemia (5). The most common bacterial etiology are Escherichia coli and Klebsiella pneumoniae (80%) (6). None of the theories proposed to explain EC can fully account for the characteristic features of this case.

==fine discussions==

==inizio conclusion==

Bladder penumatosis is a rare condition not fully understood not always associated to UTI. Il Conservative treatment, urinary tract decompression with indwelling catheter and antibiotic treatment are preferred.

==fine conclusion==

==inizio reference==

1. M. Amano, T. Shimizu Emphysematous cystitis: a review of the literature. Intern Med, 53 (2014), pp. 79-82.
2. J. Medina-Polo, J.A. Nunez-Sobrino, R. Diaz-Gonzalez An unusual case of air within the bladder wall: bladder pneumatosis? Int J Urol, 18 (2011), pp. 375-377.
3. A.A. Thomas, B.R. Lane, A.Z. Thomas, et al. Emphysematous cystitis: a review of 135 cases. BJU Int, 100 (2007), pp. 17-20.
4. A.J. Aschoff, G. Stuber, B.W. Becker, et al. Evaluation of acute mesenteric ischemia: accuracy of biphasic mesenteric multi-detector CT angiography. Abdom Imaging, 34 (2009), pp. 345-357.
5. P. Renner, K. Kienle, M.H. Dahlke, et al. Intestinal ischemia: current treatment concepts. Langenbecks Arch Surg, 396 (2011), pp. 3-11.
6. E.P. Oñate, M.E. Sanhueza, R. Torres, E. Segovia. Emphysematous cystitis: report of one case. Rev Med Chil. 2014 Jan;142(1):114-7.
7. I.J. Cooke, L.M. Okorji, R.S. Matulewicz, D.T. Oberlin, B.T. Helfand. Bladder Pneumatosis From a Catastrophic Vascular Event. Urol Case Rep. 2016 Aug 4;8:58-60.

==fine reference==

Combined assessment of main outcomes of partial or total adrenalectomy for functioning adrenal masses: a novel trifecta

==inizio objective==

There is lack of validated tools to evaluate surgical and functional outcomes of partial (PA) and total adrenalectomy (TA) for unilateral benign disease. The aim of this study was to assess the impact of a novel trifecta for the evaluation of outcomes of patients with a solitary, functioning adrenal mass, treated with either minimally-invasive PA (MIPA) or TA (MITA) at four different institutions.

==fine objective==

==inizio methodsresults==

From March 2011 to October 2019, we analyzed a multicentric dataset of 109 consecutive patients who underwent MIPA (n=32) or MITA (N=77) for unilateral Conn’s syndrome (n=92) or pheochromocitoma (n=17). Trifecta was defined as “no clinical symptoms at 1 year follow-up”; “no major complications (Clavien 3-5)”; “no use of any speficic drug treatment at 1-year follow-up”. Baseline demographic, perioperative and functional data were collected and reported. Trifecta outcomes were assessed for MIPA and MITA. A descriptive analysis was used.

==fine methodsresults==

==inizio results==

Baseline, demographic and perioperative data are reported in Table 1. At a mean follow-up of 42,4 months (IQR 30-53) overall trifecta outcomes were achieved by 59 patients (54.1%). The trifecta rates for MIPA and TAPA were 65.6% and 49.4, respectively (p=0.12) (Fig.1).. No perioperative complications were observed in the PA group while the perioperative complications rate in the TA series was 13%.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

We described a novel and reproducible clinical tool as an indicator of both surgical quality and clinical outcomes of minimally-invasive adrenalectomy for benign disease. In experienced centres, trifecta outcomes may be achieved approximately by half of the patients independently of the surgical approach chosen. In our series the quest for trifecta seems to be better accomplished by an adrenal-sparing approach, which is likely to become an established treatment in the urological armamentarium.

==fine conclusion==

==inizio reference==

==fine reference==

Linfoadenectomia Retroperitoneale Robot-assistita per massa residua post chemioterapia in paziente trattato per neoplasia germinale mista (carcinoma embrionale + teratoma post-puberale) del testicolo sinistro

==inizio abstract==

Il video descrive la tecnica utilizzata presso il nostro Istituto per il trattamento chirurgico Robot-assistito per masse residue post-chemioterapia per tumore a cellule germinali del testicolo. Il caso rappresentato riguarda un uomo di 23 anni sottoposto a ottobre 2018 a orchifunicolectomia sinistra diagnosi istologica di neoplasia germinale mista (carcinoma embrionale 50% e teratoma maturo post-puberale 50%) con presenza di invasione linfovascolare. TAC e PET-FDG post-operatorie negative.
Sottoposto a tre cicli di PEB.
Al follow-up esibisce FDG PET/TC con evidenza di due lesioni ipodense a contenuto colliquativo necrotico in sede paraortica sinistra entrambe di circa 3 x 2 cm di diametro. Markers negativi.
Il paziente è stato sottoposto il 7 novembre 2019 a Linfoadenectomia Retroperitoneale Robot-assistita attraverso il Sistema Robotico Davinci Xi secondo il template dello Weissbach study che include, a sinistra, l’asportazione dei linfonodi pre-aortici, para-portici e retro-aortici, interaorto-cavali. Il limite craniale è rappresentato dalla vena renale di sinistra, quello caudale dall’arteria mesenterica inferiore, il limite laterale dall’uretere. La linfoadenectomia comprende anche i linfonodi iliaci comuni di sinistra.
Il tempo di console è stato di 76′.
Le perdite ematiche: 100 cc. Il paziente è stato dimesso in seconda giornata.
In attesa di esito istologico.

==fine abstract==

Hydronephrosis as an unusual presentation for metastatic lobular breast cancer

==inizio abstract==

We present here the first-reported case of tubal metastasis from lobular breast cancer diagnosed by the incidental finding of hydronephrosis.
A 61-year-old woman suffering from left hydronephrosis was referred to us 4 years after she underwent a right radical mastectomy and subsequent radiotherapy for lobular breast carcinoma.
The CT scan revealed a left hydronephrosis with dilated ureter up to the proximal third, where thickening of the walls was not excluded.

An exploratory laparoscopy was performed and the definitive histopathology examination showed a recurrence of the initial carcinoma with a right tubal metastasis and peritoneal carcinosis.
The eventuality of such an unusual site of metastasis should be remembered.

==fine abstract==

ICG-guided robotic-assisted Partial Adrenalectomy

==inizio abstract==

We present a case of a 54-year old female patient with a 1 cm left adrenal aldosterone-secreting lesion. Patient was symptomatic and required hypotensive treatment. Serum aldosteron levels were increased. Patient was placed in extended flank position and side docking. A transperitoneal five-port access was performed using a 30° scope. Once the adrenal gland was identified, under NIFI, the adrenal nodule appeared hyperintense compared to the adrenal parenchyma.
The lesion was progressively mobilized following the pseudocapsule plane. A blunt and sharp dissection using monopolar scissors was employed to maximize adrenal parenchyma preservation. Blood pressure was carefully monitored intraoperatively to ensure hemodynamic stability during the procedure. The dissection was carried out without any isolation of adrenal vessels, in order to avoid accident or injury to adrenal vessels. The remnant adrenal margins were approximated with a sliding-clip running suture (3/0 Monocryl).

ICG-guided RPA is a safe and feasible procedure, providing excellent functional outcomes. The real time feed-back of ICG technology is best suited for small lesions to improve visualization of resection margins and to minimize unintended resection of healthy parenchyma.

==fine abstract==