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Robotic partial adrenalectomy for symptomatic aldosterone-secreting adenomas: technique and outcomes

==inizio abstract==

Partial adrenalectomy for functioning adrenal masses is significantly underused.
We describe surgical technique and present perioperative and functional outcomes of a two center series including nine symptomatic aldosterone-secreting adenomas treated with robotic partial adrenalectomy (RPA) from June 2014 to October 2016
Surgical steps include: Incision of Gerota’ s fascia at the level of the upper pole of the kidney and exposure of the adrenal gland; careful dissection of the medial aspect of the gland, preserving adrenal vessels with a selective control of vessels feeding the adrenal mass; progressive dissection of the mass with a pure enucleation technique in order to maximize the amount of adrenal parenchyma spared; specimen retrieval into an endocatch bag; hemostasis and closure of adrenal defect with a sliding clip technique.
Two cases are demonstrated in the video.
Baseline, perioperative and early functional outcomes data are reported.
All cases were completed robotically. Intraoperative blood loss was negligible, postoperative course was uneventful in all cases, except for 1 patient who required antibiotic therapy for post-operative fever (Clavien grade 2 complication). Median hospital stay was 3 days (IQR: 2-3).
Patients became normotensive immediately after surgery. Aldosterone and plasmatic renin activity levels returned within the normal range as well.
Robotic Partial Adrenalectomy is a safe and feasible technique.

==fine abstract==

Our surgical experience in bilateral benign testicular tumors. Is the conservative surgery an easy and safe approach?

==inizio objective==

Bilateral testicular tumors are a very rare event and represent the 2.7% of all testicular masses. 15% of the bilateral testicular tumors occurs simultaneously, but in 85% of cases the second tumor appears in the remaining testicles after a variable period. Epidermoid cysts of the testis are rare and benign lesions. The incidence of bilateral cysts is around 0,5%. Granulosa cell tumor of the testis is an infrequent stromal cell tumor and is a rare pathologic finding, accounting for 1.2%-3.9% of prepuberal testicular tumors. Although radical surgery was previously considered the treatment of choice, we evaluated the role of partial orchiectomy in presence of bilateral benign lesions in terms of preservation of testicular function (1). The aim of this study was to describe our experience in testicular tumors, focusing on their diagnosis and conservative surgical treatment.

==fine objective==

==inizio methodsresults==

231 patients with testicular tumors whose underwent testicular surgery for testicular masses at our department from January 2010 to June 2016 were retrospectively analysed. Baseline ultrasonography (US) and an hormone panel test were performed to all patients. Contrast-enhanced ultrasound (CEUS) was performed in the patients with no clear diagnosis of malignant lesion. Semen analysis was performed before of the testicular surgery and at the 6 month follow-up. Mean values with standard deviations (±SD) were computed and reported for all items. Statistical significance was achieved if p-value was ≤0.05 (two-sides).

==fine methodsresults==

==inizio results==

The patients with simultaneously occurring bilateral benign testicular tumors were 6 (2,6%). The average age is 23,8 years (range 16 – 34). Overall, 16 benign lesions are removed. 3 out of 16 patients had only 2 tumors (1 on the left testicle and 1 on the right), 2 out of 16 patients had 3 tumors (2 on the left testicle and 1 on the right) and only 1 patient had 4 tumors (2 on the left testicle and 2 on the right). The average diameter was 0,78cm (range 0,3 – 1,8cm). Preoperative average value of testosterone was 624,3±225,08 ng/dl (range 351 – 946 ng/dl). Preoperative average values of spermiogram were: global sperm cells count 45±17,34 millions (range 35 – 80 millions), sperm progressive motility 35,83±3,77% (range 29 – 40), normal forms 6±2,37% (range 3-9).
Postoperative average value of testosterone was 587,5 ± 188,16 ng/dl (range 400 – 861 ng/dl) (p=0,7648). Postoperative average values of spermiogram were: global sperm cells count 42,5 millions ± 21,14 (range 25 – 82 millions) (p=0,8273),sperm progressive motility 31,83±7,26% (range 23 – 45) (p=0,2582), normal forms 5,1±1,47% (range 3-7) (p=0,4476). No recurrences were seen at a median follow-up of 24,3 months. PGI-I (Patient Global Impression of Improvement) test average score was 2 (1 – 4).

==fine results==

==inizio discussions==

History, physical examination and tumor markers don’t always allow to distinguish between benign and malignant lesions.
Ultrasonography has a sensitivity of 96% and a specificity of 44% for the diagnosis of the testicular masses (2).
CEUS allows seeing the distribution of the microcirculation, which is homogeneous in benign lesions and anarchic in malignant lesions. We used histograms that enable to identify the anticipation of vascularization that is typical of malignant lesions.
In our experience, no significant differences were seen for serum testosterone levels and no significant differences were seen in global sperm cells count, sperm progressive motility and normal forms after the conservative surgery.
In addiction, PGI-I score indicates an higher degree of satisfaction of the patients treated with conservative technique.

==fine discussions==

==inizio conclusion==

Bilateral simultaneously occurring testicular masses are extremely rare. Some of these are benign and, in this case, the radical orchiectomy can represent an overtreatment. In these patients partial orchiectomy could be an option (in particular for young patients), allowing to maximize the advantages related to the maintenance of testicular parenchyma (3). The exocrine and the endocrine function are both preserved. In addiction, we should consider the psychological and cosmetic benefits of receiving a conservative treatment.
Despite the radical orchiectomy remains the gold standard for all testicular masses, the inclusion criteria are not clear and the discussion of informed consent with the patient is mandatory. We agree with EGCCCG (European Germ Cell Cancer Consensus Group) guidelines (4) that partial orchiectomy should be proposed for simultaneously occurring bilateral benign lesions.

==fine conclusion==

==inizio reference==

1-Tavolini IM, Oliva G, Nigro F, Dal Moro F, Zuliani G, Norcen M, Mazzariol C, Pagano F. Synchronous and metachronous bilateral tumors of the testis: a single institution experience of 11 cases and review of the literature. Arch Ital Urol Androl. 1999 Jun;71(3):155-64

2-Loberant N, Bhatt S, Messing E, Dogra VS. Bilateral testicular epidermoid cysts. J Clin Imaging Sci. 2011;1:4. doi: 10.4103/2156-7514.73502. Epub 2011 Jan 1.

3-Cosentino M1, Algaba F2, Saldaña L3, Bujons A4, Caffaratti J4, Garat JM4, Villavicencio H4. Juvenile granulosa cell tumor of the testis: a bilateral and synchronous case. Should testis-sparing surgery be mandatory? Urology. 2014 Sep;84(3):694-6.

4-Zuniga A, Lawrentschuk N, Jewett MA. Organ-sparing approaches for testicular masses. Nat Rev Urol. 2010 Aug;7(8):454-64.

==fine reference==

Neuroendocrine Carcinoma of the Bladder

==inizio objective==

Primary neuroendocrine cancer of the bladder is a rare histological occurrence, constituting 0.48–1% of all bladder cancers. The 5-year survival rate is around 8% and the prognosis is extremely unfavorable. Due to the morphology of the tumor, treatments based on small cell lung cancer have been performed. In this study, we treated a case in which chemotherapy was performed with cisplatin (CDDP) and etoposide (VP-16) forneuroendocrine cancer that occurred in the bladder; here, we report the results.

==fine objective==

==inizio methodsresults==

Our patient was a 49 year old male. His previous history included hypertension. He had no family history in particular. In June 2014, the patient visited our department because of voiding obstructive and irritative symptoms. He was evaluated by ultrasound examination, thoracic and pelvic CT scan, urinary cytology and cystoscopy without evidence of bladder pathology. He was treated with alpha lytic therapy because of his obstructive symptoms. Nine months later he returned with intensive irritative voiding symptoms and haematuria. An ultrasound examination revealed a thickening on the right bladder wall. A thoracic and pelvic CT scan revealed a flat lesion of 4 cm on the right bladder wall and metastasis to right external iliac lymph nodes with a diameter of 2.5 cm, resulting in a diagnosis of clinical stage T3bN1M0. No obvious distal metastasis was detected by bone scintigraphy and thoracic pelvic CT. In April 2015 the patient was hospitalized for the purpose of undergoing a transurethral resection of the bladder tumor (TUR-Bt). In the histopathological findings, there were a number of large and small solid alveoli of atypical cells accompanied by infiltrative growth into the interstitium. The atypical cells had a high N/C ratio and rough chromatin, and the neoplastic alveoli also suggested differentiation into the neuroendocrine system. When immunohistological staining was performed, the tumor cells were partially positive for CD56 and chromogranin A and negative for synaptophysin. Based on the morphology and the results of immunohistological staining, the patient was diagnosed with neuroendocrine cancer. Radical cystectomy was performed in June 2015 with bilateral ureterocutaneostomy.

==fine methodsresults==

==inizio results==

In September 2015 a positron emission tomography-computed tomography (PETCT) performed before chemotherapy revealed no distal metastasis. Based on the protocol for small cell lung cancer, chemotherapy with cisplatin (CDDP) and etoposide (VP-16) was performed along with PE therapy (P: 80 mg/body, E: 100 mg/body). Two other PETCT in March 2016 and November 2016 revealed no recurrence.

==fine results==

==inizio discussions==

Since first being reported by Cramer et al. in 1981, neuroendocrine bladder cancer has often been reported as primary small cell cancer of the bladder. Histologically, it is believed that this condition exhibits a similar histological appearance as small cell lung cancer, where the tumor cells are small, the nuclei are rich in chromatin and are circular or spindle-shaped, and tumor cells with scarce cytoplasm solidly proliferate. For immunostaining, CD56, synaptophysin, and chromogranin A are used. In this study, CD56 and chromogranin A were shown to be partially positive. The case in this study involved a high-grade neuroendocrine cancer according to the World Health Organization classification, and using the classifications of lung cancer, many parts had morphologies equivalent to those of small cell cancer, while some parts exhibited morphologies of large cell cancer. Blomjous et al. have reported that primary neuroendocrine cancer of the bladder constitutes approximately 0.48% of all bladder tumors in autopsy cases. At the time of diagnosis, primary neuroendocrine cancer of the bladder is detected as an advanced cancer occurring in T3 and T4 in 70% and 16.3% of cases, respectively. In addition, the 5-year survival rate has been reported to be 8.1–19%, and the prognosis is extremely unfavorable. Regarding treatment, multimodality therapy combining surgical therapy and chemotherapy/radiation therapy is often implemented; however, this is not yet an established therapy. Based on cases of small cell lung cancer, chemotherapy is mainly performed with PE therapy using a combination of cisplatin (CDDP) and etoposide (VP-16), and there are reports in which the prognosis was improved.

==fine discussions==

==inizio conclusion==

Primary neuroendocrine cancer of the bladder is a rare histological occurrence, constituting 0.48–1% of all bladder cancers. The 5-year survival rate is around 8% and the prognosis is extremely unfavorable. This case is to be signaled because of the age of the patient and the rapid evolution of pathology.

==fine conclusion==

==inizio reference==

1 Cramer SF, Aikawa M, Cebelin M: Neurosecretory granules in small cell invasive carcinoma of the urinary bladder. Cancer 1981;47:724–730.
2 Blomjous CE, Vos W, Schipper NW, et al: Morphometric and flow cytometric analysis of small cell undifferentiated carcinoma of the bladder. J Clin Path 1989;42:1032–1039.
3 Abbas F, Civantos F, Benedetto P, et al: Small cell carcinoma of the bladder andprostate.
Urology 1995;46:617–630.
4 Mackey JR, Au HJ, Venner P, et al: Genetourinary small cell carcinoma of the bladder: a report of 25 cases. J Urol 1998;153:1820–1822.

==fine reference==

Robotic partial adrenalectomy: initial report from two tertiary referral centers

==inizio objective==

In the era of minimally invasive surgery, partial adrenalectomy has been certainly underused. We aimed to report on postoperative and early functional outcomes of a two-center robotic partial adrenalectomy (RPA) series.

==fine objective==

==inizio methodsresults==

From June 2014 to October 2016 RPA was performed on 13 consecutive patients affected by non-functioning adenomas, aldosterone-secreting adenomas and pheochromocytoma (3, 9 and 1, respectively). Preoperative, postoperative and early functional outcomes data were prospectively collected and reported.

==fine methodsresults==

==inizio results==

All cases were completed robotically. Median nodule size was 29 mm (range 20-40) for non-functioning adenomas, and 17.6 mm (range 10-30) for functioning adrenal masses. Intraoperative blood loss was negligible, postoperative course was uneventful in 12 cases; a single (7.7%) postoperative Clavien grade 2 complication occurred (fever requiring antibiotics); median hospital stay was 3 days (IQR 2-3.5). Patients with hyperaldosteronism became normotensive immediately after surgery (mean preoperative blood pressure: 154/93 mmHg; mean postoperative blood pressure: 120/71 mmHg, respectively). None of the patients required further hypotensive treatment.
Aldosterone and plasmatic renin activity (PRA) levels decreased and returned within the normal range after surgery (mean post-operative aldosterone: 150 pg/ml [ normal range: 17.6-232] and mean post-operative PRA:2.4 ng/ml h [range: 0.2–2.8], respectively).
Postoperative urinary metanephrines of the patient with pheochromocytoma decreased within normal range as well.

==fine results==

==inizio discussions==

==fine discussions==

==inizio conclusion==

RPA is a safe, feasible and minimally invasive surgical approach. The excellent perioperative and early functional outcomes suggest an increasing adoption of this technique in the near future.

==fine conclusion==

==inizio reference==

-Current trends in partial adrenalectomy.
Colleselli D1, Janetschek G.
Curr Opin Urol. 2015 Mar;25(2):89-94. doi: 10.1097/MOU.0000000000000147.

==fine reference==

Malignant mesothelioma of tunica vaginalis testis: a case report

==inizio objective==

Mesothelioma of the tunica vaginalis testis is a extremely rare tumor and the most unusual type of mesothelioma with only a limited number of reported cases (less than 300 cases published in the literature) [1]. Because of his low incidence and nonspecific clinical presentation, it’s almost diagnosed accidentally during surgery for other reasons and the prognosis is usually poor. We present a case of a patient with a mesothelioma of tunica vaginalis testis, diagnosed secondarily during hydrocele surgery, with long-term survival after radical surgery.

==fine objective==

==inizio methodsresults==

we describe a case of a 40 years old patient, who was admitted to our department for routine left hydrocele surgery. The patient reported progressive scrotal enlargement without pain and the ultrasonography showed a simple left hydrocele with 350 ml in volume and normal testis. During the operation an anatomopathological analysis was request because of the strange nodular thickening of tunica vaginalis: the examination revealed a malignant mesothelioma with epithelioid structure and tubule-papillary proliferation.

==fine methodsresults==

==inizio results==

The patient agreed with a radical operation and a left hemiscrotectomy with left inguinal lymph node dissection was performed. The definitive histology confirmed the previous report of malignant mesothelioma with angioinvasion but normal testicle findings and negative lymph node. The immunoistochemical study showed positivity for calretinin, cytocheratin 5/6 and WT1 while carcinoembryonic antigen was negative. The patient underwent further examinations: computed tomography (CT) showed absence of lymph node enlargement or distant metastases. Chemotherapy and radiotherapy were not indicated. For the first 2 years a CT was repeated every 4 months, and then every 6 months for 3 years. Five years after surgery the patient has well done and show no signs of residual disease.

==fine results==

==inizio discussions==

Mesothelioma is a rare malignant tumor, that develops from the internal surface of the pleura, pericardium, peritoneum and tunica vaginalis testis. Less then 5% of cases of malignant mesothelioma occur in the tunica vaginalis [2]. The first case was described by Barbera and Rubino in 1957 [3]. Due to his low incidence, it is unknown whether asbestos exposure plays a role in his etiology: less than half of reported mesothelioma of tunica vaginalis testis are associated with asbestos exposure. Other suspected causes are scrotal trauma, log-term hydrocele, herniorraphy and exposition to radiation during radiotherapy. The diagnosis occurs often secondarily during surgery for other reasons (hydrocele, testicular tumor or inguinal hernia). Approximately one third of tumors is locally invasive when diagnosed and more of 50% of patients develop a local recurrence with most recurrences within the first 2 years [4]. Because radiotherapy and chemotherapy have failed to provide significant results, a radical resection with hemiscrotectomy, even with local lymphadenectomy, appears to be the preferred treatment, associated with better prognosis and should be proposed when possible. Our case shows the importance of a correct diagnosis, if possible preoperative otherwise intraoperatively in case of fibrotic thickening of the tunica vaginalis or hemorrhagic hydrocele fluid. A mesothelioma of tunica vaginalis testis should be suspected always in all patients with asbestos exposure and rapid enlargement of hemiscrotum.

==fine discussions==

==inizio conclusion==

malignant mesothelioma of the tunica vaginalis testis is a rare entity, often initially thought to be a hydrocele or an epididymal cyst. An aggressive approach with hemiscrotectomy with or without regional lymphadenectomy can reduce the risk of recurrence.

==fine conclusion==

==inizio reference==

1) Jankovichova T, Jankovich M, Ondrus D et al. Extremely rare tumor – malignant mesothelioma of tunica vaginalis testis. Bratisl Med J 2015; 116 (9): 574-576
2) Spiess PE, Tomasz T, Kassouf W et al. Malignant mesothelioma of the tunica vaginalis. Urology 2005; 66: 397-401
3) Barbera V. Rubino M. Papillary mesothelioma of the tunica vaginalis. Cancer 1957; 10: 183-189
4) Plas E, Riedl CR, Pflueger H. Malignant mesothelioma of the tunica vaginalis: review of the literature and assessment of prognostic parameters. Cancer 1998; 83: 2437-2446

==fine reference==