Advances in Urological Diagnosis and Imaging - AUDI (Vol. 2 - n. 3 - 2019)

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ISSN 2612-7601

ADVANCES IN UROLOGICAL DIAGNOSIS AND IMAGING EDITOR IN CHIEF Andrea B. Galosi CO-EDITOR Pasquale Martino

OFFICIAL JOURNAL of

S.I.E.U.N. Italian Society of Integrated Diagnostic in Urology, Andrology, Nephrology

Vol. 2 - n. 3 - 2019

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ADVANCES

IN

UROLOGICAL DIAGNOSIS AND IMAGING

Official Journal of S.I.E.U.N. EDITOR in CHIEF Andrea B. Galosi, Ancona (IT)

CO-EDITOR Pasquale Martino, Bari (IT)

ASSISTANT EDITOR Lucio Dell’Atti, Ancona (IT)

EDITORIAL BOARD Urology Ahmed Hashim, London (GB), Artibani Walter, Verona (IT) Battaglia Michele, Bari (IT), Bucci Stefano, Trieste (IT) Carini Marco, Firenze (IT), Carrieri Giuseppe, Foggia (IT) De Nunzio Cosimo, Roma (IT), Fandella Andrea, Treviso (IT) Ficarra Vincenzo, Messina (IT), Finazzi Agrò Enrico, Roma (IT) Franzese Corrado, Nola (IT), Gunelli Roberta, Forlì (IT) Kastner Christof, Cambridge (GB), Lapini Alberto, Firenze (IT) Miano Roberto, Roma (IT), Mirone Vincenzo, Napoli (IT) Montorsi Francesco, Milano (IT), Morgia Giuseppe, Catania (IT) Muller Stefan, Bonn (GE), Palazzo Silvano, Bari (IT) Pavlovich Christian, Baltimore, Maryland (USA) Pepe Pietro, Catania (IT), Rocco Bernardo, Modena (IT) Salomon George, Hamburg (GE) Schiavina Riccardo, Bologna (IT), Scattoni Vincenzo, Milano (IT) Volpe Alessandro, Novara (IT), Waltz Joachen, Marseille (FR)

Andrology Bettocchi Carlo, Bari (IT), Bitelli Marco, Roma (IT) Cai Tommaso, Trento (IT), Cormio Luigi, Foggia (IT) Fusco Ferdinando, Napoli (IT), Gontero Paolo, Torino (IT) Liguori Giovanni, Trieste (IT), Lotti Francesco, Firenze (IT) Pizzocaro Alessandro, Milano (IT), Trombetta Carlo, Trieste (IT)

Nephrology Boscutti Giuliano, Trieste (IT), D’Amelio Alessandro, Lecce (IT), Fiorini Fulvio, Rovigo (IT), Gesualdo Loreto, Bari (IT), Granata Antonio, Agrigento (IT), Ranghino Andrea, Ancona (IT)

Radiology Barozzi Libero, Bologna (IT), Bertolotto Michele, Trieste (IT) Giuseppetti Gian Marco, Ancona (IT), Giovagnoni Andrea, Ancona (IT), Valentino Massimo, Tolmezzo (IT)

Pathology Beltran Antonio Lopez, Lisbon (PT) Fiorentino Michelangelo, Bologna (IT) Liang Cheng, Indianapolis (USA), Montironi Rodolfo, Ancona (IT)

Bio-Medical Engineering Wijkstra Hessel, Eindhoven (NL) Advances in Urological Diagnosis and Imaging - 2019; 2, 3

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Official Journal of S.I.E.U.N.

General Information

Contents

AIMS and SCOPE

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“Advances in Urological Diagnosis and Imaging” (AUDI) has the purpose of promoting, sharing and favorite technical-scientific research on echography and imaging diagnosis, in diagnostic and terapeutical field of Urology, Andrology and Nefrology. AUDI publishes original articles, reviews, case reports, position papers, guidelines, editorials, abstracts and meeting proceedings.

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Simone Scarcella, Edoardo Agostini, Erika Palagonia, Carlo Giulioni, Luciano Ola, Lucia Pitoni, Giordano Polisini, Giuseppe Chiacchio, Sergio Brischetto, Lucio Dell’Atti, Massimo Polito, Lorenzo Montesi, Giulia Sbrollini, Marco Tiroli, Giulio Milanese, Andrea Benedetto Galosi.

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Rare complication of urinoma: Hydrocele resolved with ureteral stenting Guevar Maselli,Valentina Fioravanti, Angela Piccirilli, Pietro Saldutto, Federico Romantini, Carlo Vicentini

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Imaging findings in rare diseases: Emphysematous cystitis

Imaging findings and surgical management of autosomal dominant polycystic kidney disease (ADPKD) Edoardo Agostini, Simone Scarcella, Giulio Milanese, Lucio Dell’Atti, Andrea Ranghino, Andrea Benedetto Galosi

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ORIGINAL

PAPER

Imaging findings in rare diseases: Emphysematous cystitis

Simone Scarcella, Edoardo Agostini, Erika Palagonia, Carlo Giulioni, Luciano Ola, Lucia Pitoni, Giordano Polisini, Giuseppe Chiacchio, Sergio Brischetto, Lucio Dell’Atti, Massimo Polito, Lorenzo Montesi, Giulia Sbrollini, Marco Tiroli, Giulio Milanese, Andrea Benedetto Galosi.

Department of Urology, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy.

Emphysematous cystitis (EC) is a rarely reported urinary tract infection characterized by the presence of gas-producing bacteria within the bladder wall and lumen. This disease usually affects elderly diabetic women and presents a vast plethora of clinical symptoms making the diagnosis challenging even for an experienced urologist. Imaging studies are mandatory to obtain the definitive diagnosis allowing an early treatment with conservative medical therapy.

Whereas, surgical management should be reserved for advanced cases of necrotizing infections.

SUMMARY

KEY WORDS: Emphysematous cystitis, review, urinary tract infection, diabetes mellitus.

INTRODUCTION Emphysematous cystitis (EC) is a rare condition due to the presence of gas within the bladder wall and lumen. It belongs to the family of complicated urinary tract infection (UTI) and was described for the first time in 1961 by Bailey et al. (1). Although EC is an unusual condition, it has been increasingly reported in recent years thanks to the broad use of different imaging techniques for the diagnosis of urological diseases. Likewise other emphysematous conditions of the urinary tract, it is a potentially life-threatening pathology requiring proper diagnosis and targeted treatment (2).

EPIDEMIOLOGY AND

ETIOLOGY

Emphysematous cystitis is an uncommon condition caused by gas-forming microbes usually diagnosed in woman between 55 to 70 years of age and it represents the less severe condition among other emphysematous infections of the urinary tract (3). Diabetes mellitus is the main risk factor for developing the disease and this association is

reported in 70% of EC cases found in literature with a 2:1 female to male predominance (4). Other known risks factors are: recurrent urinary tract infections, chronic indwelling bladder catheters, anatomical abnormalities, immune deficiency, neurogenic bladder or urinary stasis secondary to bladder outlet obstruction (BOO) (5).

Different hypothesis were proposed regarding the pathogenesis of urinary emphysematous infections. It is believed that the synergy of high glucose concentration with the presence of gas-producing bacteria in combination with an uncontrolled diabetes mellitus reduces tissue perfusion, this leads to the development of the condition (6).

Different microbes were isolated in EC patients. The most common were Escherichia coli and Klebsiella pneumoniae, reported respectively in 60% and 20% of cases. Other reported pathogens were Enterobacter aerogenes, Proteus mirabilis and Streptococcus Spp accounting for 15% of cases while the finding of Pseudomonas aeruginosa, Candida albicans, Clostridium perfrigens, Enterococcus faecalis and Staphylococcus aureus has been rarely reported accounting only for 5% of the cases (7).

CLINICAL

PRESENTATION

Clinical features of EC can vary, ranging from asymptomatic patients to pnematuria associated with lower urinary tract symptoms (LUTS) or presenting with acute abdomen and severe sepsis. Abdominal pain is reported by 80% of patients alongside with gross hematuria. Pneumaturia in observed in 70% of patients with bladder catheterization and it is a highly specific symptom. In approximately 30% to 50% of patients, symptoms are associated with fever and LUTS such as dysuria, high urinary frequency and urgency but, when reported, these manifestations are usually of mild entity and nonspecific (8). If misdiagnosed, EC could lead to the development of an ascending emphysematous infection resulting in associated Emphysematous Pyelonephritis (EP) which is known to have a higher mortalAdvances in Urological Diagnosis and Imaging - 2019; 2,3

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S. Scarcella, E. Agostini, E. Palagonia, C. Giulioni, L. Ola, L. Pitoni, G. Polisini, G. Chiacchio, S. Brischetto, L. Dell’Atti, M. Polito, L. Montesi, G. Sbrollini, M. Tiroli, G. Milanese, A.B. Galosi.

ity rate (14%) compared to EC alone (7%). A delayed diagnosis can also lead to bladder rupture with sepsis and subsequent death (9). In this context it is mandatory to provide an early diagnosis and manage the patient properly.

DIAGNOSIS According to the wide range of different symptoms that could be associated with EC the diagnosis in most cases is challenging even for experienced urologists. An accurate Figure Series 1. Conventional Abdominal Radiography.

medical history should be taken: particular interest has to be given, investigating the presence of possible risk factors.

Routine laboratory analysis with inflammation markers (CReactive-Protein CRP, Procalcitonin PCT) and both blood and urine cultures should be performed, as it has been reported that 40% to 60% of patients with EC have bacteremia (10). Despite literature evidence reporting diagnostic findings using cystoscopy, laparotomy and pathological report on bladder biopsy. The diagnosis of EC should be decided on radiological bases.The most common imaging technique, used in 84% of reported cases, is a direct conventional abdominal radiography (X-Ray scan) that can point out an area of increased radiolucency delineating the bladder wall, with documentation of intraluminal air as a diagnostic sign (Figure Series 1). In challenging patients a computed tomography (CT scan), used in 40% of reported cases, could improve the diagnostic accuracy defining in Figure Series 2. Computed Tomography.

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Imaging findings in rare diseases: Emphysematous cystitis

a more accurate way both the severity of the condition and the disease extension to surrounding tissues (Figure Series 2).

Moreover, it is of pivot importance to exclude mimicking conditions such as vesico-intestinal or vesico-vaginal fistulas, tumors and abscesses (11).

Ultrasonography (US) is less used compared to X-Ray radiography and CT-Scan, but can confirm the suspected diagnosis showing a diffuse wall thickening with focal hyperechoic images characterized by acoustic shadows (Figure 3) (12).

TREATMENT The management has to be tailored according to the patient’s comorbidities and EC severity. Usually empiric broad-spectrum antibiotics therapy and bladder drainage through transurethral catheterization, to rest the bladder, are mandatory both in out-patients and in-patients. Most used antibiotics are fluoroquinolone, ceftriaxone, carbapenem, aminoglycoside, ampicillin or amoxicillin. If diabetes mellitus is associated glycemic control has to be taken into account with further correction of any comorbid disorders. When first line empiric antibiotics regimen is not sufficient medical therapy has to be modelled based on the sensitivities of blood and urine cultures.

Surgical management is not routinely indicated, and reserved in cases of conservative therapy failure. Partial or radical cystectomy and any of the techniques of surgical debridement have been reported in 10% of published series in case of severe necrotizing infections not manageable with medical therapy (13). In a single case report hyperbaric oxygen therapy was used to treat a patient with EC and associated gas embolism in the femoral vein (14).

Figure 3. Ultrasonography.

CONCLUSIONS Emphysematous cystitis is a rare complicated UTI due to the presence of gas producing bacteria within the bladder wall and lumen. It represent the most frequent but least morbid gas-forming infection of the urinary tract.

Established risk factors are female gender, older age and severe DM. Diagnosis remains challenging even for experienced urologists due to the heterogeneity of symptoms, commonly reported also in others urological conditions.

Moreover, EC is a potential life-threatening disease: a high level of clinical suspicion should be maintained in case of a diabetic patients affected by complicated UTI not improving with standard therapy. Imaging studies, such as CT-scan or X-Ray radiography, are mandatory to early diagnose the disease severity and extension. Subsequent prompt Advances in Urological Diagnosis and Imaging - 2019; 2,3

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S. Scarcella, E. Agostini, E. Palagonia, C. Giulioni, L. Ola, L. Pitoni, G. Polisini, G. Chiacchio, S. Brischetto, L. Dell’Atti, M. Polito, L. Montesi, G. Sbrollini, M. Tiroli, G. Milanese, A.B. Galosi.

treatment is of paramount importance to avoid potential morbidity and mortality associated with the proliferation of the infection. Conservative management trough intravenous antibiotics, bladder drainage and glycemic control is indicated for first line of management in compensated patients with few comorbidities and mild/moderate infections, whereas surgical treatment is unavoidable in the case of necrotizing infections.

6. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol. 1990; 143:960964.

REFERENCES

9. Amano M, Shimizu T. Emphysematous Cystitis: A review of the literature. Intern Med. 2014; 53:79-82.

1. Bailey H. Cystitis emphysematosa; 19 cases with intraluminal and Interstitial collections of gas. Am J Roentgenol Radium Ther Nucl Med. 1961; 86:850-62.

10. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore).

2007; 86:47-53.

2. Bjurlin MA, Hurley SD, Kim DY, et al. Clinical outcomes of nonoperative management in emphysematous urinary tract infections. Urology.

2012; 79:1281-1285.

11. Joseph RC, Amendola MA, Artze ME, et al. Genitourinary tract gas: Imaging evaluation. Radiographics. 1996; 16:295-308.

3. Patel NP, Lavengood RW, Fernandes M, et al. Gas-forming infections in genitourinary tract. Urology. 1992; 39:341-5.

4. Thomas AA, Lane BR, Thomas AZ, et al. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007; 100:17-20.

5. Quint HJ, Drach GW, Rappaport WD, Hoffmann CJ. Emphysematous Cystitis: a review of the spectrum of disease. J Urol. 1992; 147:134-7.

CORRESPONDENCE Simone Scarcella, MD Department of Urology, Polytechnic University of Marche Region University Hospital “Ospedali Riuniti” 71 Conca Street - 60126 Ancona - Italy e-mail: simoscarc@gmail.com Phone: .+39 071/5963227

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7. Kuo CY, Lin CY, Chen TC, et al. Clinical features and prognostic factors of emphysematous urinary tract infection. J Microbiol Immunol Infect.

2009; 42:393-400.

8. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics.

2002; 22:543-561.

12. Kauzlaric D, Barmeir E. Sonography of emphysematous cystitis. J Ultrasound Med. 1985; 4:319-20.

13. Stamm WE, Hooton TM. Management of urinary tract infections in adults. N Engl J Med. 1993; 329:1328-1334.

14. McCabe JB, Mc-Ginn MW, Olsson D, et al. Emphysematous cystitis: rapid resolution of symptoms with hyperbaric treatment: a case report.

Undersea Hyperb Med. 2004; 31:281-284.

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C ASE

REPORT

Rare complication of urinoma: Hydrocele resolved with ureteral stenting Guevar Maselli 1, Valentina Fioravanti 2, Angela Piccirilli 2, Pietro Saldutto 1, Federico Romantini 2, Carlo Vicentini 2.

1 2

Urology Department, ospedale civile Mazzini, Teramo, Italy; Università degli Studi di L’Aquila, L'Aquila, Italy.

Our work describes the case of a scrotal urinoma of a 44 years old male, sustained by a urinoma occurred after ureteral obstruction. The scrotal urinoma promptly healed after ureteral stenting, without complications.

In our work we try to explain the etiopathogenesis of this occurrence.

SUMMARY

KEY WORDS: Urinoma, scrotal urinoma, ureteral stone, urolithiasis, stenting, hydrocele.

INTRODUCTION Our work describes, for the first time in the literature, a case of hydrocele secondary to a urinoma linked to ureteral lithiasis. Treatment of the urinoma with ureteral stenting resulted in the resolution of the associated hydrocele.

CASE

REPORT

A 44-year-old man presented with 2 days of left abdominal pain and was admitted into our emergency room.

The patient underwent surgery for right inguinal hernia 30 years before.The evaluation with CT scan of the abdomen demonstrated left hydronephrosis sustained by a 5mm stone in the proximal ureter, with no evidence of urinary extravasation (Figure 1). We decided for a conservative approach, based on blood tests (creatininemia: 1.05 mg/dl, C-reactive protein (CRP): 0.79 mg /L, white blood cells (WBC): 9.55) and the possibility of the stone to be spontaneously expelled. After six days the patient was readmitted into the emergency room for diffuse abdominal pain.

The patient was hospitalized for poor response to pain medications and new onset of edema and swelling of the left hemiscrotum. Scrotal ultrasound scan (U.S.) showed a notable distention of the left vaginal tunic, caused by a liquid collection. Both left and right testis and epididymis

showed normal ultrasound features (Figure 2). Blood tests showed a slight increase in creatinine values (1.38 mg/dl), CRP (1.4 mg/L) and WBC (14.30). Revaluation with CT scan of the abdomen demonstrated the progression of the stone, which migrated to the distal part of the ureter, 1cm from the ureteric orifice. There was a notable increase of the edema in the left pararenal fascia with evidence of a fluid collection surrounding the urinary collecting system. Such collection drained through the spermatic funicle into the left hemiscrotum (Figure 3).

The findings suggested a possible rupture of the pelvis or of the ureter, or urinary backflow from the calyceal fornix.

Therefore, in order to drain the urine, a double pigtail ureteral stent was inserted. General condition of the patient rapidly improved with complete resolution of the scrotal swelling within two days.

A 2 months post-operative CT scan showed the absence of the urinoma and spontaneous expulsion of the stone (Figure 4). The patient was later scheduled for removal of the ureteral stent.

DISCUSSION To date, only seven research articles are found on Pubmed by searching using the keywords “urinoma” and “scrotum” following the formula (“urinoma”[MeSH Terms] OR “urinoma”[All Fields]) AND (“scrotum”[MeSH Terms] OR “scrotum”[All Fields]).

Two of these works describe cases in which the urinoma was associated with an infected hydrocele and spontaneous drainage through the scrotum. In both cases treatment of the urinoma with urinary divertion, and treatment of the scrotal infection were simultaneous. Complete reabsorption of the urinoma required up to 4 months after urinary derivation (1, 2).

Other three articles presented cases of a urinoma associated with scrotal edema as a complication of renal transplant (3-5). The remaining two articles are not related to the present case and consequently are not cited and taken into account. Our work describes, for the first time, a case Advances in Urological Diagnosis and Imaging - 2019; 2,3

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Figure 1. CT scan plane showing the ureteral stone and left kidney, with no evidence of extravasation of urine.

Figure 3. CT scan showing the urinoma draining through the spermatic funicle into the scrotum.

Figure 2. Scrotal US showing signs of hydrocele.

Figure 4. CT scan showing the absence of the urinoma and spontaneous expulsion of the stone.

of hydrocele secondary to urinoma, not complicated with infection, resolved after ureteral stenting.

The main difference with the previous cases described in the literature relates with the etiopathogenetic mechanism of urinary extravasation (6). In the presented case, the absence of a frank rupture of the urinary excretory system did not result in the creation of a true urinoma, but created instead an extravasation due to fornix urinary backflow (6). Urine leaked in the perirenal fat and drained from the retroperitoneum down to the inguinal canal and then into the scrotum. Urine, much likely, dissected through the inguinal canal along the spermatic cord. Urine collection into the scrotum is a rare occurrence, as

demonstrated by such a small number of cases reported in the literature to date. Normally, there is no direct anatomical connection between the retroperitoneum and the scrotum.The two existing cases reporting a scrotal urinoma in transplant patients, suggest that an iatrogenic anatomical alteration in the transplant site (inguinal region) can cause a scrotal urinoma. In our case, such alteration was probably an anatomical congenital condition. While the collection of urine into the scrotum is an occurrence already reported by other authors, our case is the first of its kind, as no author has ever described its resolution after ureteral stenting. In addition the administration of broadspectrum antibiotics (ceftriaxone 1gr/day for 5 days) dur-

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A rare complication of urinoma

ing the early stages of the treatment with ureteral stenting prevented bacterial superinfection. In previously described cases, instead, infective complications are directly correlated with the rupture of the urinary excretory system, whereas in our case the anatomy of the urinary excretory system was intact.

CONCLUSIONS Perirenal edema linked to urine extravasation, due to hydronephrosis, is a rare complication of ureteral obstruction. The urine could reach the scrotum through the retroperitoneum and subsequently the inguinal canal.

Treating the hydronephrosis in an early phase, can both resolve the clinical symptoms (renal colic) and the scrotal swelling.

REFERENCES 1. Ataus S, Yaycioglu O, Onder AU, et al. Giant spontaneous urinoma draining from the scrotal wall. J. of Urology. 2000; 163(6):1874-1875.

2. Altobelli E, Bove AM, Sergi F, et al. Retroperitoneal Urinoma Spontaneously Drained in the Scrotum Repaired with Gracilis Muscle Flap: A Case Report. Case Reports in Urology. 2012; vol. 2012, Article ID 597839, 3 pages.

3. MarĂ­n-Oyaga V, Tirado-Hospital JL, Cuenca-Cuenca JI, et al. Atypical localization of urinoma detected by renogram in a kidney transplanted patient with scrotal edema. Rev Esp Med Nucl Imagen Mol. 2013; 32(2):132-133.

4. Banzo I, Gomez-BarquĂ­n R, Quirce R, et al. Tc-99m MAG3 renal transplant imaging of scrotal urinoma. Clin Nucl Med. 1997; 22(6):401-402.

5. Weinberg EJ, DuCret RP, Foshager MC, et al. Scrotal urinoma as a complication of renal transplantation. Clin Nucl Med. 1994; 19(8):749-750.

6. Hinman F Jr. Peripelvic extravasation during intravenous urography, evidence for an additional route for backflow after ureteral obstruction.

J of Urology. 1961; 85:385.

CORRESPONDENCE Guevar Maselli Urology Department, ospedale civile Mazzini, Teramo, Italy E-mail: gue.maselli@gmail.com

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C ASE

REPORT

Imaging findings and surgical management of autosomal dominant polycystic kidney disease (ADPKD) Edoardo Agostini 1, Simone Scarcella 1, Giulio Milanese 1, Lucio Dell’Atti 1, Andrea Ranghino 2, Andrea Benedetto Galosi 1.

1 2

Department of Urology, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy; Department of Nephrology, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy.

Autosomal dominant polycystic kidney disease (ADPKD) is characterized by the occurrence of multiple cysts increasing over the time in both kidneys with progressive reduction of the kidney function. We report a case of ADPKD admitted for severe renal function impairment associated with recurrent urinary tract infections that led to septic shock. The life-threatening evolution of the case required proper diagnosis true imaging technique and surgical treatment was indicated.

SUMMARY

KEY WORDS: Autosomal dominant polycystic kidney disease, ADPKD, Bilateral nephrectomy, Hemodyalisis.

urinary tract infections are commonly due to the high number of infected cysts, still remaining difficult to treat with elevated failure rate. Antibiotics of choice are fluoroquinolones, metronidazole, trimethoprim-sulfamethoxazole, clindamycin and vancomycin (3). Surgical management is required only in particular conditions when medical treatment fails to prevent disease progression or when life-threatening complications occur. Most used surgical procedures associated with this disease are cysts decompression by aspiration/sclerosis/fenestration and nephrectomy (4).

We present a case of a Caucasian man affected by ADPKD, referred to our centre for sepsis, as consequence of recurrent urinary tract infections, and severe chronic renal failure.

INTRODUCTION Autosomal dominant polycystic kidney disease (ADPKD) is a multisystem condition characterised by bilateral multiple renal cysts, liver cysts, pancreatic cysts combined with an increased risk of intracranial aneurysms, aortic dissection, mitral valve prolapse, hypertension, renal pain, renal insufficiency and chronic urinary tract infections (1). The disease usually develops into a significantly clinical condition with a late-onset and 50% of the affected patients will present an end-stage renal disease-ESRD by the age of 60. The diagnosis of the disease is clinical and confirmed by renal imaging criteria; genetic testing is recommended in case of first degree relatives affected (2). The disease is characterised by high variability in both the severity of chronic renal impairment and in the extra-renal symptoms. First line of therapy is always conservative medical treatment, tailored to the individual specific symptoms. Hypertension treatment may include diet modification associated with Vasopressin V2 receptor antagonists, ACE inhibitors and angiotensin II receptor blockers in order to slow down the progression of the disease. ADPKD condition is frequently associated with nephrolithiasis and preventive measures should be adopted in these particular patients. Recurrent

CASE

REPORT

A 63-year-old man with a history of autosomal dominant polycystic kidney disease was referred to our Institute for sepsis, hypertension and severe chronic renal failure. The diagnosis of APKD was formulated when the patient was 32-year-old: he was asymptomatic, but laboratory findings reported a creatinine level of 1,41 mg/dl and contrast enhanced CT scan showed 33 cm polycystic kidneys (Figure 1). Medical history became relevant after 2012 when the patient developed hypertension, recurrent urinary tract infections (UTI) and rheumatoid arthritis. At the time of admission, the patient was referred to our Urology Unit for an emergency consultation regarding uncontrolled hypertension, pyelonephritis and septic shock, as consequences of UTI. Hyperthermia 39° and chronic renal failure stage 4 was associated with this clinical condition. Blood laboratory tests showed VFG = 23 ml/min, PCR = 39.4 mg/dL, white blood cells = 16630/mmc, creatinine = 6 mg/dL, hemoglobin = 9 mg/dL, azotemia = 180 mg/dL. Blood and urine cultures revealed an E. Coli No conflict of interest declared.

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Imaging findings and surgical management of autosomal dominant polycystic kidney disease (ADPKD) Figure 1. Contrast Enhanced CT Scan findings.

Figure 2. Surgical approach and intraoperative findings.

Figure 3. Post- Surgery Contrast Enhanced CT Scan.

preservation (Figure 2). Few cysts were broken during the kidneys isolations maneuvers: some showed purulent content, other were “chocolate cysts� and other showed a complex architecture.The surgery went uneventful and no intraoperative complications occurred. At the end of the surgical procedure the patient was transferred to the Post-Surgical Intensive Care Unit and the next day to Nephrology Unit to start the hemodialysis. No postsurgical complications occurred during recovery and the patient was discharged 10 days after the surgical procedures (Figure 3).

DISCUSSION AND

infection. Subsequently a specific intravenous antibiotic therapy with Imipenem/cilastatin 250 mg + Teicoplanin 400 mg daily was administered for 23 days.

Once the patient resulted stabilized, the case was discussed during a multidisciplinary meeting and considering the life-threatening condition a bilateral nephrectomy was indicated.

A laparotomy median xipho-pubic incision was performed and both kidneys removed with a trans-peritoneal approach: right kidney was removed firstly and then left nephrectomy was performed with unilateral adrenal gland

CONCLUSIONS

Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited kidney disease and usually it is associated with PKD1 and PKD2 mutation. The diagnosis consists of clinical findings, radiological and genetic confirmation especially in patients with familiar history. Hepatic cysts, congenital defects of heart valves and aortic aneurisms are commonly associated with this condition.

Most frequent symptoms and clinical findings are high blood pressure, hematuria, flank pain and severe renal impairment.

Conservative medical treatment represents the treatment of choice with the aim of controlling and reducing disease progression. Only in case of severe clinical conditions impairment or in case of life-threatening complications occurrence, surgical treatment is indicated. Nephrectomy can be performed before, after or simultaneously with renal transplantation. Different considerations need to be considered evaluating surgery timing and renal transplantaAdvances in Urological Diagnosis and Imaging - 2019; 2,3

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tion. If the nephrectomy is performed before transplantation, patients must undergo hemodialysis with subsequent risk of HLA antigen sensitization. On the contrary, performing nephrectomy with contextual transplantation can expose the patient to higher risk of blood loss, intraoperative and postoperative complications. The treatment algorithm for patients affected by APKD is challenging even for experienced urologists, a multidisciplinary approach is mandatory to plan the best strategy according to patient characteristics.

REFERENCES 1. Harris PC, Torres VE. Polycystic kidney disease. Annu Rev Med. 2009; 60:321-37.

2. Wilson PD. Polycystic kidney disease. N Engl J Med. 2004; 350:151-64.

3. Torres VE, Harris PC, Pirson Y. Autosomal dominant polycystic kidney disease. Lancet. 2007; 369:1287-301.

4. Mochizuki T, Tsuchiya K, Nitta K. Autosomal dominant polycystic kidney disease: recent advances in pathogenesis and potential therapies. Clin Exp Nephrol. 2013; 17(3):317-26.

CORRESPONDENCE Simone Scarcella, MD Department of Urology, Polytechnic University of Marche Region, University Hospital “Ospedali Riuniti”, 71 Conca Street - 60126 Ancona - Italy E-mail: simoscarc@gmail.com Phone. +39 071/5963227

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C ASE

REPORT

Correlation between imaging and pathological findings in isolated prostatic localization of Wegener granulomatosis Simone Scarcella 1, Lucio Dell’Atti 1, Giulio Milanese 1, Gianluca Moroncini 3, Alessia Cimadamore 4, Francesca Sternardi 2, Andrea Giovagnoni 2, Armando Gabrielli 3, Rodolfo Montironi 4, Andrea Bendetto Galosi 1.

1

Department of Urology, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy; Department of Radiology, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy; 3 Department of Internal Medicine, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy; 4 Section of Pathological Anatomy, Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy.

2

Wegener Granulomatosis (WG) is a C-ANCA antibodies associated vasculitis. The usual presentation consists of the triad of a necrotic-granulomatous vasculitis of the respiratory tract associated with a necrotizing vasculitis of the small/medium-size vessels and a segmental glomerulonephritis.

A prostatic localization is rare and accounts for only 2% of cases described in the literature. A 52-year-old man was referred to our center for suspected prostatic abscess with acute urinary retention (AUR) and diffuse pain in the pelvic area. His recent medical history was positive for recurrent LUTS, dysuria, strangury which persisted despite medical treatment. DRE revealed acute pain during exploration and soft consistency while TRUS showed an area described as prostatic abscess. A transurethral resection of the prostate (TURP) was performed and histological examination revealed widespread acute gangrenous inflammation. Purulent fluid culture was negative, as well as pre- and post-operative urine culture. After an initial remission of symptoms and within 2 months from surgery, the patient was admitted to our division for AUR with associated leukocyturia, even though urine culture resulted negative. Blood tests excluded any infectious etiology. Imaging studies (CEUS, MRI) showed an area suggestive of necro-degenerative pathology with inflammatory involvement of extra-prostatic pelvic tissues (rectum, bladder, seminal vesicles). A Re-TURP was performed due to a worsening of the clinical condition. Histological examination revealed inflammatory-necrotizing process, with neutrophils and eosinophils infiltration and small vessels impairment. Serum C-ANCA antibodies resulted positive and WG of the prostate gland was diagnosed.

Further systemic evaluation excluded any other extra-prostatic involvement. Patient was treated with corticosteroid therapy that led to a progressive improvement of the symptoms. Isolated WG of the prostate is a rare entity characterized by necrosis simulating a prostatic abscess. Prompt corticosteroid treatment is mandatory to prevent the spreading of the diseases to the adjacent organs.

We present an unusual case of isolated WG of the prostate with particular interest regarding the correlation between radiological and histological findings.

SUMMARY

KEY WORDS: Granuloma, Prostatitis, Prostate Abscess, Wegener’s Granulomatosis.

INTRODUCTION Wegener Granulomatosis (WG) is a necrotizing vasculitis of unknown ethiology incorporated in the class of antineutrophil cytoplasmatic antibodies (ANCA) – associated vasculitis, along with Churg-Strauss Syndrome and microscopic polyangiitis (1). Usually patients are diagnosed upon presentation of the classic triad that consists of focal necrotizing arteritis of small and medium sized vessels, necrotizing granulomatous vasculitis of the upper and lower respiratory tract and focal segmental glomerulonephritis (2).

Prevalence of WG is estimated to be 3:100.000 without gender differences. Kidneys are involved in over 90 percent of cases while the remaining genitourinary tract organs (ureters, bladder, urethra, seminal vesicles, epididymis, testis, perineum, cervix, vagina or penis) have been reported infrequently (3). Prostatic involvement has mostly been described as progression of systemic disease and in exceptional cases as the first manifestation of the illness (4).

CASE

REPORT

A 52-year-old male was admitted to the Urology Department of our Hospital due to hematuria, acute urinary retention (AUR) and marked diffuse pain associated with tenderness in the pelvic area. His medical history presented with controlled hypertension and a previous 6 months history of dysuria, increased urinary frequency, decreased force of urinary stream, nicturia, chronic urinary retention and documented UTIs from E. Coli and S. Anginosus. Despite appropriate medical treatment with a personalized antibiotic regimen, no improvement of symptoms was reported, even after the urine bacterial cultures resulted negative. Digito-Rectal-Examination revealed acute pain during exploration and soft consistency while Trans-rectal-Ultrasound disclosed an area described as prostatic abscess with diffuse edema in the surrounding tissues. On admission, all blood tests were performed, with

No conflict of interest declared.

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Figure 1. mp-MRI: Axial T2w characterize by transitional zone inhomogeneity, with multiple branched cystic cavities. Capsular thickening is also present.

PSA value of 1.3 ng/ml, thus within normal range, and urine cultures resulted negative. The patient was therefore submitted to a transurethral prostate resection (TURP) with associated transurethral drainage of the abscess.

Histological examination revealed a diffuse necrotizing prostatitis with intense infiltration of neutrophils and lymphocytes. Hystochemical stain (i.e. PAS, Grocott, Gram, Ziehl-Neelsen) were performed without any evidence of infectious etiological agents. Conventional bacteriologic and acid-fast bacilli cultures were conducted without documenting any growth. Purulent fluid culture was negative, as well as post-operative urine culture. The patient was discharged after five days without post-operative complications. Following an initial remission of symptoms, within 2 months from surgery, the patient needed transurethral catheterization for AUR with associated leucocyturia, even though urine culture resulted negative. Beforehand he had complained for a week of urethralgia, reduction of urinary stream and increased voiding frequency. A complete blood test analysis and cultures for infectious disease were performed resulting negative. A contrast enhanced transrectal ultrasound (CEUS) put in evidence an anechoic area of 1.4 cm with no contrast enhancement adjacent to the posterior prostatic urethra, suggestive of necrotic/degenerative pathology. Further investigation with multi-parametric MRI (mp-MRI) showed signal inhomogeneity in the transition zone of the prostate, due to the presence of multiple branched cystic cavities characterized by absence of contrast enhancement, and associated prominent parietal thickening of the seminal vesicles that appeared hypointense in T2 weight scans with alteration of the surrounding fat suggestive for necrotic and inflammatory areas (Figure 1). As a result of imaging findings and worsening of clinical symptoms a second TURP was performed.

Pathological report described extensive and irregular necrotic areas with cellular debris, neutrophils and a great number of eosinophils. Necrotic areas were surrounded by a mixed inflammatory infiltrate consisting in histiocytes and granulation tissue (Figure 2). Intense stromal and periglandular infiltrate with eosinophils was present in the prostate parenchima (Figure 3). Inflammatory infiltrate with lymphocytes and eosinophils was also found in a vessel wall which was associated to secondary lumen occlusion (Figure 4). According to histopathological findings, the main differential diagnoses were a post-surgical granu-

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Figure 2. Necrotic area with cellular debris and neutrophils surrounded by a mixed inflammatory infiltrate consisting in histiocytes and granulation tissue.

Figure 3. Intense stromal and periglandular inflammatory infiltrate with lymphocytes and eosinophils.

Figure 4. Vessel wall with lumen occlusion by intense infiltrate with lymphocytes and eosinophils.

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Correlation between imaging and pathological findings in isolated prostatic localization of Wegener granulomatosis

lomatous prostatitis that can be seen after transurethral resection or a prostatic inflammatory process with vessel involvement (Churg-Strauss syndrome, Wegener’s Granulomatosis, Immunoglobulin G4-related prostatitis).

The case was presented during a multidisciplinary genitourinary cancer meeting and the possibility of a granulomatous prostatitis was suggested. Further immunological investigations were requested and confirmed a positive titles (350,4 U/ml) of antineutrophil cytoplasmatic antibody with positive anti-proteinase 3 activity (ANCA anti PR-3).

Subsequent evaluation by the Internal Medicine and Immunology departments defined the diagnosis of Wegener’s Granulomatosis of the prostate gland. Second TURP surgery was uncomplicated and the patient started immunosuppressive treatment with glucocorticoids.

Intravenous Methylprednisolone 40 mg daily was infused during hospitalization and then switched to oral Prednisone 25 mg daily following hospital discharge.

Further evaluations excluded any other extra-prostatic involvement: sinus and chest CT scan and colonoscopy resulted both normal. Urine tests confirmed no alteration of 24 hours proteinuria from the spot urine protein-creatinine ratio. Medical corticosteroid therapy led to a progressive improvement of symptoms with normalization of urinary voiding in 2 weeks. After one month the dosage of oral Prednisone was reduced to 5mg daily without relapse of symptoms. At four months c-ANCA antibodies blood test resulted negative and corticosteroid treatment was further reduced to 2mg Methylprednisolone daily as maintenance therapy. Imaging follow-up was performed with mp-MRI of the prostate gland at three and six months which showed a 10mm peri-urethral focal lesion located in the right apex of the prostate, with parietal thickening, liquid content and with hypo-intense signal restriction in DWI scan (Figures 5-7).

These radiological findings might be explained with a granuloma that remains stable during follow-up while a reduction of parietal thickening of seminal vesicles and signal inhomogeneity of peri-prostatic fat tissue were described. After 18 months of follow-up patient remained stable and uneventful using low dose corticosteroid therapy.

Figure 5. mp-MRI performed 30 days after urinary catheter extraction showed inhomogeneity of periprostatic fat with capsular thickening, and prominent parietal thickening of the seminal vesicles appearing hypointense.

Figure 6. Axial T2w images showed a slight reduction of inhomogeneity of peri-prostatic fat and parietal thickening of the seminal vesicles.

Figure 7. Axial T2w image shows a peri-urethral focal lesion (arrowhead) with parietal thickening, liquid content, primarily characterizing a suspect granuloma lesion.

DISCUSSION WG is a disorder usually affecting the respiratory system and kidneys. The involvement of other parts of the urogenital tract is rarely reported and described as an infrequent condition (5). Prostatic localization accounts for 2% of the published case series (6). When this occurs, the clinical picture includes dysuria, acute urinary retention, gross hematuria, increased urinary frequency, chronic obstructive symptoms and recurrent documented UTIs (7). In exceptional cases prostatic involvement has been described as the first manifestation, prior to systemic diffusion of the disease (8). Physical examination in most cases reveals a prostate gland appearing firm, enlarged, painful at rectal exploration with necrotic areas that could simulate an abscess (9). Immunological blood test investigations are mandatory to establish both the diagnosis of: positive antineutrophil cytoplasmic antibody (ANCA) anti-proteinase 3 activity and monitor the worsening or therapeutic Advances in Urological Diagnosis and Imaging - 2019; 2,3

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response of Wegener’s Granulomatosis (10). ANCA titles are considered the most reliable serologic marker and can be confirmed in 75% to 90% of patients with active GW (11). Usually irritative-obstructive voiding symptoms are treated with medical treatment and can be resolved promptly with a rapid improvement. In some patients, after an initial response to pharmacological therapy, a relapse of symptoms could occur during follow-up with persistent dysuria, even after receiving immunosuppresants. A surgical procedure, with endoscopic transurethral prostate resection, should be considered. In the majority of cases, histopathological evaluation show necrotic granulomas.

Similar histological findings can be observed in others granulomatous prostatitis like tuberculosis or mycoses, sarcoidosis or after BCG intravescical treatment and in idiopathic forms (12). An accurate personal medical history, evaluation of related symptoms and comorbidities with the confirmation of ANCA titles positivity are the key points of a correct differential diagnosis and an accurate diagnosis.

Urologists should be aware of this rare entity, even if urogenital symptoms are uncommon manifestations of GW or can be underestimated for their lack of specificity. In exceptional cases, symptomatic urogenital involvement could be the first and only clinical symptom of the disease. First line therapy should always be medical, with immunosuppressive drugs. In case of relapse, during mainteinance treatment, the immunosuppressive therapy should be increased back to the previous dosage. In case of persistent symptoms or clinical worsening, despite maintenance therapy, surgical treatment is indicated. In our experience, the relapse of symptoms was associated with persistent and non-responsive dysuria and a transurethral resection of the prostate (TURP) had to be repeated. In conclusion, we believe that the treatment of WG involving the prostate gland must be tailored according to the patient characteristics and response to initial medical treatment. If no response to pharmaceutical therapy is achieved, surgical treatment is recommended and should be performed by an experienced urologist.

Primary WG of the prostate gland was diagnosed. Further systemic evaluation excluded any other extra-prostatic involvement. Patient was treated with corticosteroid therapy that led to a progressive improvement of the symp-

CORRESPONDENCE Simone Scarcella, MD Department of Urology, Polytechnic University of Marche Region, University Hospital “Ospedali Riuniti”, 71 Conca Street - 60126 Ancona - Italy E-mail: simoscarc@gmail.com Phone. +39 071/5963227

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toms. Isolated WG of the prostate is a rare entity characterized by necrosis simulating a prostatic abscess. Prompt corticosteroid treatment is mandatory to prevent the spreading of the diseases to the adjacent organs.

REFERENCES 1. Falk RJ, Gross WL, Guillevin L, et al. Granulomatosis with polyangiitis (Wegener’s): an alternative name for Wegener’s granulomatosis.

Arthritis Rheum. 2011; 63:863-864.

2. Janette JC, Falk RJ, Andrassy K, et al. Nomenclature of systemic vasculitides. Proposal of an international consensus conference. Arthritis Rheum. 1994; 37:187-192.

3. Huong DL, Papo T, Piette JC, et al. Urogenital manifestations of Wegener granulomatosis. Medicine (Baltimore). 1995; 74:152-161.

4. Dufour JF, Le Gallou T, Cordier JF, et al. Urogenital manifestations in Wegener granulomatosis. A study of 11 cases and review of the literature. Medicine. 2012; 91:67-74.

5. Stillwell TJ, DeRemee RA, McDonald TJ, et al. Prostatic involvement in Wegener’s granulomatosis. J Urol. 1987; 138:1251-1253.

6. Stillwell TJ, Engen DF, Farrow GM. The clinical spectrum of granulomatous prostatitis: a report of 200 cases. J Urol 1987; 138:320-323.

7. Middlenton G, Karp D, Lee E, Cush J. Wegener’s granulomatosis presenting as lower back pain with prostatitis and urethral obstruction. J Rheumatol. 1994; 21:566-9.

8. Gunnarsson R, Omdal R, Kjellevold KH, Ellingsen CL. Wegener’s granulomatosis of the prostate gland. Rheumatol Int. 2004; 24:120-122.

9. Hussain SF, Baker JT, De Bolla AR. Wegener’s granulomatosis presenting as granulomatous prostatitis causing urinary retention. Br J Urol. 1990; 65:104.

10. Thai Lh, Charles P, Resche-Rigon M, et al. Are anti-proteinase-3 ANCA a useful marker of granulomatosis with polyangiitis (Wegener’s) relapse?Result of a retrospective study on 126 patients.

Autoimmun Rev. 2014; 13(3):313-8.

11. Hoffman GS, Kerr GS, Leavitt RY, et al. Wegener’s granulomatosis: an analysis of 158 patients. Ann Intern Med. 1992; 116:488-498.

12. Petersen RO, Sesterhenn IA, Davis CJ. Prostate; in Urologic Pathology, ed 3. Philadelphia, Lippincott Williams & Wilkins. 2009, pp 451-560.

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LECTURE

Public health perspective on Prostate Surgery

Claudio Maria Maffei 1, Simone Scarcella 2, Eugenio Pretore 2.

1 2

Health Service Department Marche Region, Umberto I University Hospital, Ancona, Italy; Polytechnic University of the Marche Region, Umberto I University Hospital, Ancona, Italy.

This lecture was held during the section “Update on diagnostic and therapeutic novelties for prostatic pathologies” of the Urological and Andrological Association of Marche Region - AssUAM Congress that took place in Ascoli Piceno (Italy) the 23th of November 2019 (1).

The aim of the AssUAM Regional Congresses is to offer moments of training and networking among all the Urology Healthcare Professionals at a regional level.

Through the integration of different competences patients and citizens can be correctly diagnosed and treated according to their urologic condition. Recently different innovations regarding diagnosis, treatment and rehabilitation improved patients care outcomes with prostatic conditions. In this context the collaboration between different specialists such as Urologists, Oncologists and Radiotherapists represent the next step of patient care.

With this multidisciplinary approach in mind, it is possible to offer the best targeted treatment based on the specific characteristics of the single patient and disease. We are looking into proposing the most efficient integration into the Marche Regional Urological Network including all the Urology Operating Units of the territory with the objective of answering the questions:

“What is the correct information to give to urologic patients affected by prostatic conditions?” and “How can we orientate them towards the best diagnosis and treatment?”

The goal of this lecture is to discuss some aspects related to these two questions and provide some data to reflect on. First off, it is essential to define what a clinical network is and three topics need to be addressed: - What is a clinical network and how do you integrate healthcare procedures?

- Selection criteria on prostate diseases to be shared with the public in a regional network pathway.

- The apparent lack of shared diagnostic and therapeutic

algorithms towards urological field in the Marche Region with particular reference to prostatic conditions.

Clinical Network and Diagnostic Therapeutic Assistance Pathway (PDTA) In the Marche region the term clinical network entered in the health care glossary between 2013 and 2014, years in which some regional resolutions emerged on the reorganization of the hospital network, and clinical networks were mentioned as the framework of the reorganization.

A clinical network should at least be characterized by: - The identification of which hubs are part of it.

- The sharing of “rules” relating to the selection of interventions and the organization of activities (guidelines, PDTA).

- The planned distribution of activities among the hubs in the network to avoid duplication and reach economies of scale.

- The explicit definition of how connections between hubs work.

- The explicit adherence to these “rules” by all hubs.

- The continuous monitoring of network performance.

- The presence of a central coordination that takes care of making the availability of services homogeneous for all habitants of the Region.

Then, within a network, one should work in accordance with the structured PDTA. I take for granted that the definition of PDTA as a multi-professional process that accompanies a patient throughout his journey from diagnosis to treatment and rehabilitation with further monitoring of chronic conditions. It is important to mention that a PDTA can be established within a single structure, a single company or a clinical network. When it is constructed in such a way it has to cover more care settings, also integrating the territorial response defined as Integrated Care Advances in Urological Diagnosis and Imaging - 2019; 2,3

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Path (ICP). There are three levels of organization in the PDTA: Model pathway: it is the most common level of PDTA based on international scientific evidences selected by a team of experts.

Operational pathway: it is based on the evidences provided by the scientific community and adapted to local needs and resources of the Urological Territorial Department.

Assigned pathway: it is the most personalised diagnostic and treatment route based on the individual need of the patient.

The Complete pathway is defined by the activation and completion of all these three steps and it has to be constantly monitored and evaluated by both the patient and healthcare team in order to evidence additional requirements (2). This is of main importance in order to improve the PDTA levels and increase its efficiency. Moreover, it is mandatory to properly inform our patients about shared diagnostics and therapeutics algorithms commonly used in all territorial urologic networks.

Data on prostate surgery in the Marche Region: the importance of data monitoring The data presented has been extracted from the National Outcomes Program (PNE) active in Italy on the initiative of National Agency for Regional Health Services (AGENAS); (Figure 1). The PNE elaborates the data of Hospital Discharge Cards (SDOs) and calculates a series of indicators related to different conditions / interventions including

Figure 1. The National Outcomes Program (PNE).

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prostatectomy for prostate cancer and simple prostatectomy for benign hyperplasia. The main data regards: volume of hospital activity, surgical outcomes, complications, reintervention and percentages of readmissions within 30 days from discharge (3).

2018 PNE trends of indicators in Marche Region regarding simple prostatectomy trends for benign hyperplasia showed a treatment rate of 2.86/1000 inhabitants in Ancona province. Other provinces are showing rates equalling half: 1.27/1000 for Ascoli Piceno, 1.72/1000 for Fermo, 1.26/1000 for Macerata and 1.42/1000 for Pesaro and Urbino (Figure 2). The reason of this discrepancy is the presence of three major Urological Departments in the province: Villa Igea, INRCA of Ancona and Umberto I University Hospital of Ancona. Since 2015, the number of interventions carried out in the Marche has gone from 705 in 2015 to 1263 in 2017. In particular, the graph of the output of Villa Igea over the years shows a shift from just over 100 admissions in 2014 to over 400 in 2017 (Figure 3, 4).

The burden of private practice physicians in the Marche’s output of simple prostatectomy for benign hyperplasia needs two other data sets which can always be obtained from the PNE. The first regards the output of the private practice clinic Villa Anna in San Benedetto del Tronto, completely dedicated to the treatment of citizen in the Abruzzo Region. In Villa Anna 111 prostatic patients were treated in 2017. The second concerns Villa Pini in Civitanova Marche, in which 43 surgery for prostatic hyperplasia were done.

A total (45%) 564 of the 1263 recorded in 2017 in Marche region were performed by private care physicians (Figure 5). Moreover, these private practice surgeries have tripled in number between 2015 and 2017. Similarly, prostate cancer surgeries performed in private practice clinics raised from 436 in 2015 to 738 in 2017: in the last year the high-

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Public health perspective on Prostate Surgery Figure 2. 2018 PNE Simple Prostatectomy treatment rate in Marche Region.

est number of prostate cancer surgeries were perfomed in Villa Igea with 147 cases, compared to the 143 of Umberto I University Hospital (Figure 6).

Considering radical prostatectomy surgeries for prostate cancer, the private practice clinics increased the number of cases treated from 33 to 178 in the period between 2015 and 2017. PNE data for 2018 and 2019 will probably see a further imbalance in the output of prostate interventions in favour of private institutions. This trend of private practice activity in Marche Region does not correspond to the trend recorded at a national level that it is not increasing so strongly in all Italian Regions.

Public Hospitals have a strictly regulated policy regarding expenses and financial controls. All expenses have to be assessed annually with specific monetary budgets.

The medical activities taken into account in these budgets are regulated rigorously by different PDTA that are defined and approved in a Regional Network. In public Hospitals all medical activities are planned and have to follow the diagnostic and therapeutic algorithms described in the singular PDTA for the specific medical condition. This way of planning and monitoring all medical activities of a single clinic

Figure 3. Trend of BPH Surgeries performed in Umberto I Hospital.

Figure 4. Trend of BPH Surgeries performed in Villa Igea Hospital.

Figure 5. Simple Prostatectomy for prostatic hyperplasia in Marche Region.

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C.M. Maffei, S. Scarcella, E. Pretore Figure 6. Radical Prostatectomy for prostate cancer in Marche Region.

should be applied also in private practice clinics with a specific integration at a Regional Government level. Without the assimilation of the Clinical Network and Diagnostic Therapeutic Assistance Pathway in both the public and private sectors we will risk to have to face an inevitable massive transfer of resources, machinery, technical competences, skills and patients to the private sector.

same quality of medical treatment to all patients. To obtain this goal we need to share the same guidelines and PDTA between public and private hospitals dedicated to prostatic surgery.

Conclusions

1. https://www.assuam.com/

Data presented today clearly state an increasing activity of the medical private practice sector in the Marche Region.

Our aim is to monitor efficiently and to guarantee the

CORRESPONDENCE Eugenio Pretore, MD Department of Urology, Polytechnic University of Marche Region University Hospital “Ospedali Riuniti�

71 Conca Street - 60126 Ancona - Italy e-mail: eugenio.pretore@gmail.com Phone: .+39 071/5963227

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References 2. http://e-p-a.org/sito-internet-e-p-a/percorsi-diagnostici-terapeutici-eassistenziali-pdta/ 3. https://pne.agenas.it/

Istruzioni Autori AUDI.qxp_Stesura Seveso 29/11/18 10:15 Pagina 1

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The meaning of any abbreviations must be explained at the bottom of the table itself.

FIGURES

Figures are also graphics, algorithms, photographs, drawings. Figures must be numbered and quoted in the text by number. The meaning of all symbols, abbreviations or letters must be indicated. Histology photograph legends must include the enlargement ratio and the staining method.

Legends must be collected in one or more separate pages.

Please follow these instructions when preparing files: • Do not include any illustrations as part of your text file.

• Do not prepare any figures in Word as they are not workable.

• Line illustrations must be submitted at 600 DPI. • Halftones and color photos should be submitted at a minimum of 300 DPI.

MANUSCRIPT

REVIEW Only manuscript written according to the above mentioned rules will be considered. All submitted manuscripts are evaluated by the Editorial Board and/or by two referees designated by the Editors. The Authors are informed in a time as short as possible on whether the paper has been accepted, rejected or if a revision is deemed necessary.

The Editors reserve the right to make editorial and literary corrections with the goal of making the article clearer or more concise, without altering its contents.

Submission of a manuscript implies acceptation of all above rules.

MANUSCRIPT

PRESENTATION Authors must submit their manuscripts (MAC and WINDOWS Microsoft Word are accepted) to the Assistant Editor (dellatti@hotmail.com).

PROOFS

Authors are responsible for ensuring that all manuscripts are accurately typed before final submission. Galley proofs will be sent to the Corresponding Author. Proofs should be returned within seven days from receipt.

Copertina.qxp_Cop edit som 29/01/20 11:49 Pagina II

Ed _Cop+Ed+fisse 2006 04/10/18 11:28 Pagina IV