AbstractFournier’s gangrene is a potentially fatal emergency condition characterized by necrotizing fasciitis and supported by an infection of the external genital, perineal and perianal region, with a rapid and progressive spread from subcutaneous fat tissue to fascial planes.In this case report, a 52-year-old man, with a history of hepatitis C-virus (HCV)-related chronic liver disease and cocaine use disorder for which he was receiving methadone maintenance therapy, was admitted to the Emergency Department with necrotic tissue involving the external genitalia.Fournier’s gangrene is usually due to compromised host immunity, without a precise cause of bacterial infection; here it is linked to a loco-regional intravenous injection of cocaine. A multimodal approach, including a wide surgical debridement and a postponed skin graft, was needed. Here we report this case, with a narrative review of the literature.

The Paraganglioma is the most common extra-adrenal pheochromocytoma arising from neural crest (1) (It will better to write: The paraganglioma is an extra-adrenal pheocromocytoma arising from the neural crest. 10% of pheocromocytomas are extra-adrenal and can arise form chromaffin tissue derived from primitive neuroectoderm). Minimally invasive techniques allow surgeons to perform the procedure without wide exposure and mobilization of intra abdominal organs. To our knowledge we present the third case of robotic excision of a retroperitoneal paraganglioma (2,3). MAteRiAL And MetHodsA 31 years old male with incidental 3 x 3 cm retroperitoneal mass located between the left renal vein and aorta. Even if serum Neuron-Specific Enolase and chromogranine-A were negative an anti-hypertensive prophylaxis was administered. (Will be worthwhile to add if cathecolamines E.g. metanephrines where measured in urine as part of the most common lab tests used when pheocromocytoma is suspected. Also if possible the type of anti-hypertensive drug used). We preferred a retroperitoneal approach. The ureter and the spermatic vessels were identified and not resected. The peritoneum was incised at the level of the tumor and the mass was carefully dissected. The maneuver was difficult because the paraganglioma was characterized by many small vessels leading to the lesion, unlike adrenal pheochromocytoma where a definite pedicle may be identified. Robotic surgery allowed to identify the vascular branches and to clip them with 5mm Hem-o-Lok. The manipulation of the mass caused some hypertensive peaks up to 240/130mmHg. For this reason, we were forced to perform a step by step dissection. Finally, the tumor was inserted into an EndoBag and retrieved from the optical trocar. ResULtsOperative time was 120 minutes; estimated blood loss was less than 50cc. No complications occurred. After surgery the blood pressure was normal. Patient was discharged on postoperative day 2. Final histopathological exam showed paraganglioma (a short pathology description would be helpful to add a little more information to the video case report). concLUsionsThe robotic excision of paraganglioma is a safe (a comment on the extremely high blood pressure during surgery should be added in order to show that this could be a high risk surgery when precautions prior to surgery are not made) and efficacious surgical strategy.

No abstract

Enterovesical fistula is a rare disease. The standard treatment of colovesical fistula is removal of the fistula, suture of the bladder wall, and colic resection with or without temporary colostomy. The usual approach is open because the laparoscopic one has high conversion rates and morbidity. We report the first laparoscopic conservative treatment of colovesical fistula in our knowledge and its long-term results. A 69-year-old man was affected by colovesical fistula due to endoscopic exeresis of a 2 cm adenomatous polyp in the sigmoid diverticulum. We performed a laparoscopic conservative treatment of the fistula without colic resection. Operative time was 210 min and estimated blood loss was 300 ml. The catheter was removed after 10 days. Time to first flatus was 2 days and the hospital stay was 8 days. No peri- or post-operative complications occurred. At 48-month follow-up fistula did not recur. Laparoscopic conservative surgery for colovesical fistula is safe and feasible. It could be a therapeutic option in selected cases, especially if diverticular disease and inflammation are slight.

AbstractPurposeAngiosarcoma (AS) is an aggressive malignant tumour of endothelial origin, most frequently compelling the skin. The kidney is a rare site of primary occurrence of AS with a quite challenging diagnosis and poor prognosis, mainly due to its raw metastasising power. We described our first case of AS treatment. A comprehensive literature review in this field is also carried out.Patients and methodsWe report the case of a 56-years-old man with radiological appearance of an 11 cm poor vascularised left renal mass. The pre-operative imaging ruled out distant metastases and inferior vena cava thrombosis. Thus, after radioembolization, we performed a transperitoneal open radical nephrectomy with regional lymphadenectomy with the removal of the middle portion of the ileo-psoas muscle, followed by two lines of adjuvant chemotherapy. We analysed all the papers concerning primary kidney AS until December 2018.ResultsEstimated intraoperative blood loss was 200 mL with an operative time of 100 minutes. No postoperative complications were recorded, with the patient discharge in the 8th postoperative day. The pathological assessment showed a pT3a N0, M0 tumour compatible with AS of the kidney. An immune-histochemical study showed a vascular positive for CD31, CD34, Fli-1 with a Ki-67/Mib 1 of 50%. One month after surgery the patient began adjuvant chemotherapy with gemcitabine. After 45 days from surgery, a Computed Tomography scan showed lung and liver metastases with disease relapse in the left kidney lodge. The response to the first-line treatment was excellent, unlike the second-line, encountering a chemo-refractory disease. The cancer-specific survival was of 15 months. We included 66 cases in our review.ConclusionThis is the first case of treatment of kidney AS performed at our Institute. Our findings added new information about the unclear biology and progression of this subset of tumours, demonstrating an abysmal prognosis.