EDITOR IN CHIEF Andrea B. Galosi CO-EDITOR Pasquale Martino
Un’opera nuova e completa sul microbiota, il complesso consorzio di batteri che abita il nostro organismo e ne influenza lo status di salute o malattia. Centinaia di illustrazioni a colori, contenuti multimediali, aggiornati in progress continuo ed accessibili mediante QR code. Un Trattato imprescindibile per chi si occupa di salute interpretando i referti sul microbiota.
Costo di copertina €120,00, IVA e spese di spedizione incluse. Per informazioni ed eventuali ordini, scrivere a: info@edizioniscriptamanent.eu
EDITOR in CHIEF
Andrea B. Galosi, Ancona (IT)
CO-EDITOR
Pasquale Martino, Bari (IT)
ASSISTANT EDITOR
Lucio Dell’Atti, Ancona (IT)
ASSISTANT EDITOR JUNIOR Carlo Giulioni, Ancona (IT)
EDITOR
Luigi Napolitano, Napoli (IT)
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)
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)
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)
Barozzi Libero, Bologna (IT), Bertolotto Michele, Trieste (IT) Giuseppetti Gian Marco, Ancona (IT) Giovagnoni Andrea, Ancona (IT), Valentino Massimo, Tolmezzo (IT)
Beltran Antonio Lopez, Lisbon (PT), Fiorentino Michelangelo, Bologna (IT) Liang Cheng, Indianapolis (USA), Montironi Rodolfo, Ancona (IT)
Wijkstra Hessel, Eindhoven (NL)
“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.
AUDI is Open Access at www.issuu.com
Why Open Access? Because it shares science at your finger tips with no payment. It is a new approach to medical literature, offering accessible information to all readers, becoming a fundamental tool, improving innovation, efficiency and interaction among scientists.
Papers are accepted for publication with the understanding that no substantial part has been, or will be published elsewhere. By submitting a manuscript, the authors agree that the copyright is transferred to the publisher if and when the article is accepted for publication. The copyright covers the exclusive rights to reproduce and distribute the article, including reprints, photographic reproduction and translation. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior written permission of the Publisher.
For details on media opportunities within this journal please contact Mrs. Donatella Tedeschi, MD at +39 0270608060
23
A traumatic ureteral catheterization
Giordano Polisini, Matteo Mantovan, Leonard Perpepaj, Andrea Benedetto Galosi
25 Penile cancer in 26-years old men
Francesco Passaro, Francesco Di Bello, Giovanni Grimaldi, Alessandro Izzo, Giuseppe Quarto, Luigi Castaldo, Raffaele Muscariello, Dario Franzese, Antonio Tesone, Luigi Napolitano, Sisto Perdonà
27 Muscle invasive bladder cancer at the time of COVID-19: a retrospective monocentric study Giuseppe Romeo, Luigi De Luca, Francesco Trama, Marco Fabiano, Maurizio Fedelini, Clemente Meccariello, Nunzio Alberto Langella, Francesco Bottone, Luigi Cirillo, Giovanni Maria Fusco, Luigi Napolitano, Biagio Barone, Riccardo Giannella, Luigi Pucci, Paolo Fedelini
29 ESUT 2022 Updates New techniques for Benign Prostatic Obstruction Carlo Giulioni
33 SIU 2022 Updates Muscle-invasive bladder cancer in elder patient Carlo Giulioni
Edizioni Scripta Manent s.n.c.
Via Melchiorre Gioia 41/A - 20124 Milano, Italy Tel. +39 0270608060
Registrazione: Tribunale di Milano n. 19 del 17/01/2018 e-mail: info@edizioniscriptamanent.eu web: www.edizioniscriptamanent.it
Direttore Responsabile: Pietro Cazzola
Direzione Marketing e PR: Donatella Tedeschi
Comunicazione e Media: Ruben Cazzola
Grafica e Impaginazione: Cinzia Levati
Affari Legali: Avv. Loredana Talia (MI)
Stampa: Àncora s.r.l. (MI)
The total or partial reproduction, by any means, is forbidden without the written authorization of the Publisher.
The Publisher is not liable for the opinion expressed by the Authors of the articles and for images used by them.
Advances in Urological Diagnosis and Imaging - 2022; 5, 2
Division of Urology, Azienda Ospedaliero-Universitaria delle Marche, Faculty of Medicine, School of Urology, Department of Clinical, Special and Dental Sciences, Università Politecnica delle Marche, Ancona, Italy.
Urethral catheterization is commonly a safe and simple procedure. Urinary tract infection, bleeding or genitourinary trauma are common complications (1, 2). The risk of complication is increased in patients with an indwelling catheter and in patients who perform daily intermittent catheterization (2). Accidental ureter catheterization is an exceptional complication, only reported in about ten cases in the literature. We report a case of left ureter catheterization associated with ureteral rupture.
KEY WORDS: Case report, ureteral catheterization, traumatic catheterization.
A 77 years old woman was referred to the Emergency Department for haematuria, anemization, and acute renal failure. She was institutionalized in a nursing home. She suffered from fronto-temporal dementia with severe cognitive-motor impairment, epilepsy, type II diabetes mellitus, major depression, gallbladder stones, SARS COV2 pneumonia in January 2021 complicated by pulmonary embolism, severe dysphagia requiring PEG placement, chronic immobilization syndrome with indwelling catheter, and history of urinary tract infection. She had no history of urological surgery.
At physical examination, the patient was on acute urinary retention despite the presence of a bladder catheter in situ. She had a CT scan which showed a voluminous fecaloma, that displaced the bladder, the bladder catheter was placed in the pelvic tract of the left ureter with suspicion of ureteral rupture and bilateral hydronephrosis (Figure 1).
For that reason, the catheter was removed and replaced in the bladder with spill of 500 mL of clear urine. A left percutaneous nephrostomy was placed and anterograde and retrograde pyelography showed
Figure 1. A-C coronal section and D-F sagittal section. The CT scan shows a voluminous fecaloma and a catheter with inflated balloon placed in the pelvic tract of the left ureter (red circle).
extravasation of the contrast medium in the middle part of the left ureter. The catheter was in the bladder but with its tip in the ureter (Figure 2). So, under fluoroscopic guidance, the bladder catheter was repositioned correctly. Unfortunately, the patient died a few days later from cardiac failure.
Figure
Urethral catheterization is a safe and simple procedure but not exempt from complications. The most frequent complications procedure-related are early balloon inflation in the urethra, inability to place the catheter into the bladder (5), urinary tract infections, bleeding, and genitourinary trauma. Bladder perforation, peritonitis, and recto-vesical fistula are rare but have been reported in the literature (13, 6). The risk of complication is increased in patients with an indwelling catheter and in patients who perform daily intermittent catheterization (2).
Accidental ureteral catheterization is a rare complication, only reported in about ten cases in the literature. Neurogenic bladder dysfunction, empty bladder, and history of re-implantation of the ureter into the bladder are
specific risk factors for accidental ureteral catheterization (1, 2).
If ureteral catheterization is suspected, the diagnosis can be made with CT (spherical hypodense structure filled with water attenuation in the ureter with or without hydronephrosis) or ultrasound (a spherical hypo-anechoic Foley balloon may be seen in the abdomen with or without hydronephrosis) (4).
When ureteral catheterization is confirmed, deflation of the catheter balloon and manual removal or replacement of the catheter should be attempted (2, 4).
If a ureteral injury is present, management requires anterograde or retrograde stent placement, percutaneous nephrostomy (in case of abscess formation, urinary tract infection, or urinary fistula formation), or surgery (depending on the type of injury and the comorbidities of the patient) (4).
In our case, the patient had an indwelling catheter, she had not performed urological surgery previously and the ureteral orifice was in its natural location. At first, we repositioned the catheter in the bladder. At final, due to ureteral rupture with the presence of urinoma, we also decided to place a percutaneous nephrostomy for urine drainage. Although there is not univocal consensus for the execution of the procedure correctly, to prevent the risk of injuries always it is advisable to check urine return before inflation of the catheter balloon, verify if the length of the catheter outside of the urethra is suitable and readapt the balloon position if sudden pain occurred.
1. Oehler E, Le Guern A. An unusual complication of urethral catheterization: hydronephrosis with pyelonephritis after ureteral catheterization. J Visc Surg. 2015; 152(2):141-2.
2. Anderson BW, Greenlund AC. Ureteral cannulation as a complication of urethral catheterization. Korean J Urol. 2014; 55(11):768-71.
3. Kim MK, Park K. Unusual complication of urethral catheterization: a case report. J Korean Med Sci. 2008; 23(1):161-2.
4. Baker KS, Dane B, Edelstein Y, et al. Ureteral rupture from aberrant Foley catheter placement: a case report. J Radiol Case Rep. 2013; 7(1):33-40.
5. Hale N, Baugh D, Womack G. Mid-ureteral rupture: a rare complication of urethral catheterization. Urology. 2012; 80(5):e65-6.
6. Ishikawa T, Araki M, Hirata T, et al. A rare complication: misdirection of an indwelling urethral catheter into the ureter. Acta Med Okayama. 2014; 68(1):47-51.
Giordano Polisini
Division of Urology, Azienda Ospedaliero-Universitaria delle Marche, Faculty of Medicine, School of Urology, Department of Clinical, Special and Dental Sciences, Università Politecnica delle Marche, Ancona, Italy
E-mail: gio.pol.93@gmail.com
Advances in Urological Diagnosis and Imaging - 2022; 5,2
Francesco Passaro 1, Francesco Di Bello 1, Giovanni Grimaldi 2, Alessandro Izzo 2, Giuseppe Quarto 2, Luigi Castaldo 2 , Raffaele Muscariello 2, Dario Franzese 2, Antonio Tesone 2, Luigi Napolitano 1, Sisto Perdonà 2 .
1 Unit of Urology, Department of Neurosciences, Reproductive Sciences, and Odontostomatology, University of Naples “Federico II”, Naples, Italy;
2 Department of Urology, National Cancer Institute, Pascale Foundation, Naples, Italy.
Background: Penile squamous cell carcinoma (SCC) is rare in Europe. The age group affected is between the sixth and eight decades of life, with two-thirds of cases occurring in patients aged over 65 years. The main risk of factor for the development of penile SCC is human papillomavirus (HPV) infection.
Case report: This case report presents an uncommon case of a 26-year-old man with a penile SCC HPV 16 correlated. The patient underwent excisional biopsy of the glans in a suspicious lesion. The biopsy was positive for SCC of the penis in situ with focal interruption of the lamina propria associated with HPV. He was subsequently treated for widening of the excision with extemporaneous histological examination of the margins and sentinel lymph node.
Conclusion: After three years of follow-up the patient is fully satisfied with the cosmetic and functional results.
KEY WORDS: Penile cancer, case report, young men.
Penile squamous cell carcinoma (SCC) is rare in Europe. The age group affected is between the sixth and eight decades of life, with two-thirds of cases occurring in patients aged over 65 years (1, 2). The main risk of factor for the development of penile SCC is human papillomavirus (HPV) infection. However, the disease could be misdiagnosed and up to 50% of patients can be symptomatic for more than 1 year before the diagnosis (1). We report a case of penile cancer in a 26 years-old Caucasian male with a suspect of lymph node involvement.
At age of 26, a young and healthy Caucasian male, presented to his primary care physician with a lesion on his uncircumcised penis. The naive lesion, clinically compatible with Bowen disease, appeared as a centimetric verrucous scar surrounded by erythematosus margin, close to urethral meatus on the gland apex. Patient history was negative for
immunodepressive disorders and other major comorbidities, but he was sexually active. Firstly, the HPV-DNA test after a cytobrushing of the suspicious lesion was performed and resulted positive for HPV 16 and HPV 56. Secondly, the gland punch biopsy confirmed the suspect: intraepidermal carcinomatous neoplastic lesion compatible with clinic diagnosis of Bowen disease. Moreover, the inguinal ultrasound (US), performed after a month, showed iperplastic lymph nodes (14 mm of diameter on the right and 11 mm of diameter on the left) with ovul shape, wavy edges, inhomogeneous structure, hypoechoic with preserved ilo and vascularization. The patient underwent to penile rod biopsy. The histological examination showed SCC of the penis in situ with focal interruption of the lamina propria associated with HPV concurrent with severe dyskeratosis. The patient received the diagnosis of penis SCC and opted for a stringent follow-up. After 2 months from surgery, the patient performed the scintigraphy exam with 99mTc-NANOCOLL for the detecting of sentinel lymph node (Figure 1). The imaging showed a suspect focus of uptake on the left inguinal region. Moreover, a not-clear spot of uptake was measured in
Advances in Urological Diagnosis and Imaging - 2022;
paramedian zone of suprapubic region. The following decision was clear: the patient received a widening of resection margins with sentinel lymph nodes dissection. In addition, a meatoplasty was performed for aesthetic and functional outcomes. Fortunately, the histological examination resulted negative for lymph nodal invasion. After three years of follow-up the patient is alive, fully satisfied with the cosmetic and functional results.
Early diagnosis and treatment was essential for long-term cure in SCC of the penis. Several studies had shown that the 6-year survival drops from 65% to 15% with development of nodal metastasis (3). As noted, up to half the men with this disease had symptoms for more than 1 year before presentation. The primary care physicians were required to an early-diagnosis. Furthermore, this disease is rare in the young Caucasian population. As evidenced by our patient, the correct diagnosis, the sudden treatment, and the strict follow-up represented the gold key for the
Figure 1. The scintigraphy exam of suspicious sentinel lymph nodes.
SCC patient management. We presented this case to alert physicians of the possibility of penile cancer in young Caucasian males and to share our approach to the current available information.
SCC is a rare tumor worldwide, despite this it should be better investigated mostly in young men.
1. Narasimharao KL, Chatterjee H, Veliath AJ. Penile carcinoma in the first decade of life. Br J Urol. 1985; 57(3):358.
2. Hakenberg OW, Dräger DL, Erbersdobler A, et al. The Diagnosis and Treatment of Penile Cancer. Dtsch Arztebl Int. 2018; 115(39):646-52.
3. Culkin DJ, Beer TM. Advanced penile carcinoma. J Urol. 2003; 170(2 Pt 1):359-65.
Advances in Urological Diagnosis and Imaging - 2022; 5,2
Luigi Napolitano, MD
Department of Neurosciences, Reproductive Sciences and Odontostomatology, Urology Unit, University of Naples “Federico II”, Naples, Italy
Via Sergio Pansini n 5, 80131 - Naples (NA), Italy E-mail: dr.luiginapolitano@gmail.com Phone: +390817462611 - Fax: +390815452959
Giuseppe Romeo 1, Luigi De Luca 2, Francesco Trama 3, Marco Fabiano 1, Maurizio Fedelini 1 , Clemente Meccariello 1, Nunzio Alberto Langella 1, Francesco Bottone 1, Luigi Cirillo 2, Giovanni Maria Fusco 2 , Luigi Napolitano 2, Biagio Barone 2, Riccardo Giannella 1, Luigi Pucci 1, Paolo Fedelini 1
1 AORN “A. Cardarelli”, Napoli;
2 Department of Neuroscience and Reproductive and Odontostomatological Sciences of University of Naples "Federico II", Naples, Italy;
3 Uroginecology and Andrology Clinic University of Perugia.
To the Editor,
The suspension of most elective surgeries during the COVID-19 pandemic has led to an extension of the waiting list for urological surgery (1). The purpose of this study is to evaluate the impact of the COVID-19 pandemic on the bladder cancer in large hospitals.
A retrospective study was designed. Radical Cystectomy (RC) between December 2019 and March 2020 were analyzed (group A). In addition, we analyzed patients who performed RC between December 2018 and March 2019 in the pre - covid era (group B). Medical records of our single-center bladder cancer database, including demographic and histopathologic data were collected. All surgical procedures were performed by a single expert equipe, and a single anatomic pathologist was recruited for histologic diagnosis. We excluded: patients in whom the muscle tunic was not present on final histological examination, patients in whom demographic and clinical data were not collected or patients with a previous diagnosis of bladder cancer. Tumor Nodal Metastasis (TNM) 7th edition classification was used for pathological staging and WHO 2016 classification for histological grading.
Thirty-six patients were enrolled. Group A consisted of 13 subjects while group B consisted of 23 subjects. The two groups did not differ statistically in age (71±8.3 Vs 69±7.8) and BMI (22.1±5.9 Vs 21.7±6.7) (p=0.532). Analysis of the histologic study of the pieces indicated that there was a statically significant increase in diagnosis of pT3a stage in group A compared with group B (p=0.045). There were no statically significant differences in pT2b stage (p=0.762). In addition, there was a statically significant increase of T4 diagnosis in group A compared Group B (p=0.037).
There were no statistically significant differences in length of hospitalization (p=0.667), peri-operative complications (p=0.091), and bleeding (p=0.058) in the two groups). There was a statistically significant difference regarding the urinary diversion. In fact, there was a higher incidence of ureterocutaneostomy diversion in group A (74% Vs 47%) than in group B (p=0.021)(Table 1).
Table 1. Perioperative outcomes.
Group A (n=13) Group B (n=23) p pT2b 30.7% 34.8% 0.762 pT3 38.4% 30.4% 0.045 pT4 30.8% 17.4% 0.037
Time of hospitalization 10±4 8±7 0.667 Hemotransfusion 49% 54% 0.058
Peri-operative complications 24% 32% 0.091 UCS diversion 74% 47% 0.021
Our findings report that patients who underwent RC during the pandemic had a more advanced disease stage than subjects who underwent RC in the pre-pandemic period. This is probably due to the delays to treatment of patients awaiting urologic surgery during COVID-19 pandemic (2, 3).
Further studies, with higher number of cases are needed to assess a more accurate correlation between disease stage and time to surgery in COVID-19 pandemic years.
Advances in Urological Diagnosis and Imaging - 2022; 5,2
1. Creta M, Sagnelli C, Celentano G, et al. SARS-CoV-2 infection affects the lower urinary tract and male genital system: A systematic review. J Med Virol. 2021; 93(5):3133-3142.
2. Leow JJ, Tan WS, Tan WP, et al. A systematic review and meta-analysis on delaying surgery for urothelial carcinoma of bladder and upper tract urothelial carcinoma: Implications for the COVID19 pandemic and beyond. Front Surg. 2022; 9:879774.
3. Esperto F, Pang KH, Albisinni S, et al. Bladder Cancer at the time of COVID-19 Outbreak. Int Braz J Urol. 2020; 46(suppl.1):62-68.
Advances in Urological Diagnosis and Imaging - 2022; 5,2
Giovanni Maria Fusco Department of Neuroscience and Reproductive and Odontostomatological Sciences of University of Naples "Federico II", 80131 Naples, Italy e-mail: giom.fusco@gmail.com Phone: +39 0817462611
Carlo Giulioni
New techniques for prostatic hypertrophy have emerged, in recent years, for prostatic hypertrophy. The aim of the development of these innovations is multiple:
• Ensure the preservation of ejaculation, especially in the younger population.
• Have an alternative to medical therapy for patients who cannot tolerate medical therapy.
• Patients who are not candidates for endoscopic electrical energy or laser therapy.
Therefore, these techniques were developed to perform this procedure in outpatient or day-hospital settings without general or spinal anaesthesia needed.
Thermal and pressure energy has been implemented in surgical practice, obtaining promising outcomes. Water Vapor Treatment (WVT) is a new way in the field of minimally invasive surgical treatments to use radiofrequency to create thermal energy in the form of water vapour and apply thermal energy for BPO. During the treatment, 103˚C water vapour is convectively delivered into 37˚C prostate tissue, increasing the temperature of tissue within each treatment area to approximately 70˚C over the course of each 9-second treatment, resulting in instantaneous cell death. This system is intended to relieve symptoms, and obstruction and reduce prostate tissue associat-
ed with BPH. The condensation of water vapour releases stored thermal energy. Cell membranes are gently denatured, thereby causing immediate cell death, the vasculature is closed, and there is denervation of the alpha-adrenergic nerves within the treatment zone. Water vapour cannot penetrate the zonal boundaries and therefore stays within the zone it is injected. For the evaluation of WVT efficacy, Mynderse et al. reported lesion volumes after treatment through magnetic resonance imaging: at 3 and 6 months, the prostate volume had reduced by 91.8% and 96.5%, respectively (1). Moreover, in a 4-Year randomized trial overview on the safety and efficacy of the procedure, this procedure guaranteed significant symptom relief and improved quality of life that remained durable throughout 4 years, with a minimal physician learning curve (2).
In summary, WVT has shown promising results for prostate volume 30-80 cc in the long term with a low retreatment rate and minimal sustained erectile dysfunction or retrograde ejaculation.
Aquabeam® System is a novel technology that integrates real-time ultrasonic imaging with robotically executed surgeon-guided high-velocity waterjet ablation to precisely resect prostatic tissue. Aquablation therapy combines cystoscopic visualization, ultrasound imaging, and advanced planning software to provide the surgeon with a multidimensional view of the treatment area.
As for the technique, in the lithotomy position, the 22F handpiece is inserted under direct vision into the prostatic urethra and it is advanced up to the bladder. The handpiece is placed at the 12 o’clock position of the bladder neck. Thus, the prostate is compressed, allowing the anterior tissue to fall below the range of motion of the water jet. Under real-time TRUS guidance, the target anatomic resection contour was defined to preserve the anatomy of the bladder neck, verumontanum area, ejaculatory ducts, and external urinary sphincter. Once the treatment map is complete, prostate tissue is precisely removed using a robotically controlled high-velocity heat-free waterjet that can move from the bladder neck to the apical part of the prostate. The robotic and waterjet technologies enable targeted and controlled tissue removal with rapid resection times that are highly consistent across all prostate sizes and shapes, and surgeon experience levels.
The bladder was thoroughly irrigated to remove the residual floating tissue particles and blood clots.
A Double-blind randomized clinical trial compared the efficacy of the Aquablation compared to 5-year postoperative outcomes of the Aquablation with TURP for men with medium-volume prostates (30-80 ml) (3). At 5 years, IPSS scores improved by 15.1 points for Aquablation and 13.2 points in TURP, with an improvement in peak urinary flow rate was 12.5% and 8.9% compared to baseline for Aquablation and TURP, respectively. Furthermore, procedure-related ejaculatory dysfunction was lower for Aquablation (7% vs. 25%). As for large-volume prostates, Desai et al. reported 2-year postoperative outcomes of the Aquablation for men with adenoma volume comprised between 80 and 150 ml: mean IPSS and IPSS quality of life improved from 23.2 to 5.8 and from 4.6 to 1.1,
respectively, at 2 years (4). Antegrade ejaculation was also maintained in 98% of sexually active men after 2 years. In a systematic review including 9 studies, an improvement in terms of Qmax, QoL, IPSS, and PVR, evaluated after water jet dissection, was shown concerning the baseline in all the selected articles with a statistical not inferiority compared to TURP. Primarily bleeding (range 2.4–19%) urethral stricture (0.99%), and urinary retention (7.7%) were the most frequent complications, with a similar rate of the overall adverse event than in the endoscopic surgery (5). Moreover, in the sexually active subjects, appearance reduction in the International Index of Erectile Function (IIEF-5) for the aquablation arm was higher or comparable to the TURP arm with the maintenance of ejaculatory function after surgery. Given the high rate of postAquablation bleeding, the focal bladder neck cautery may be performed after the procedure. In a Multicentric uncontrolled clinical trial with 2,089 consecutive Aquablation procedures, postoperative bleeding requiring transfusion occurred in 17 cases (0.8%) and take-back to the operating room for fulguration occurred in 12 cases (0.6%) (6).
In patients with high anaesthetic risks, various devices have been devised to widen the lumen without affecting the prostate adenoma. The prostatic urethral lift (PUL) represents a novel minimally invasive approach that uses permanent implants which are cystoscopically deployed through obstructing prostatic tissue. It is one of the best techniques for the preservation of ejaculatory function. The PUL system consists of two main components: a transurethral delivery device with an integrated cystoscope and permanent nitinol and stainless steel implants. Once the surgeon positions the transurethral delivery device at the desired location, the implants are inserted and subsequently compress and retract the prostatic adenomatous tissue. The number of implants a patient requires depends on the length of the prostatic urethra, the amount of prostatic tissue and the presence of a median lobe, generally 4. Tissue remodelling is induced by localized compression between the capsular tab and the urethral end piece (7). PUL demonstrated satisfactory efficacy in the literature.
A Multicenter randomizing clinical trial, reporting 3-years its postoperative outcomes, showed an improvement from baseline in total IPSS at 3 years was 41.1% and a significant increase in terms of Qmax (53%) and quality of life (48.8%) during the follow-up, with no sustained ejaculatory or erectile dysfunction events (8). However, any concerns about its reintervention rate occur. In the literature, the surgical reintervention rate for urethral lift has been estimated at 2% to 3% per year in the first studies. In a meta-analysis involving 11 studies with overall 2016 patients undergoing surgery endoscopy for BPO, 153 men needed surgical reintervention (9). Among them, 51% was transurethral resection of the prostate/laser (51.0%), 32.7% repeat prostatic urethral lift
and 19.6% device explant. The annual rate of surgical reintervention after urethral lift resulted in 6.0% per year (9).
The temporary implanted nitinol device (TND) is deployed in the prostatic urethra and bladder neck. This process expands and reshapes the bladder neck and prostatic urethra, creating an open channel for the flow of urine. The device is made up of three elongated nitinol struts connected at the distal end, an antimigration anchoring leaflet, and a polyester retrieval suture.
The technique: In the lithotomy position, using a standard 19 to 22 Fr cystoscope, the surgeon inserts the enclosed device through the cystoscope sheath and into the bladder. The device is then deployed and retracted so that the anchoring leaflet is under the bladder neck at the 6 o’clock position and the 3 struts are in the 12, 5, and 7 o’clock positions within the prostatic urethra.
Once inserted, the bladder is drained, and the patient is discharged with simple analgesia. After a week, the patient has the device removed by using the retrieval suture and a special open-ended silicone catheter that allows the device to be collapsed and removed safely without a cystoscope or anaesthesia. Currently, no meta-analysis nor systematic review were published. A Multicenter singlearm clinical trial reported 36-month postoperative outcomes of men with prostate volumes less than 75 ml. Over 3 years, 81 men with reported sustained improvements in IPSS (20.7–8.55), IPSS Quality of life (3.96–1.76), and Qmax (7.71 mL/s to 15.2 mL/s) (10). Therefore, further investigation to evaluate the safety and efficacy of TND is needed.
The Temporary Prostatic Stent (TPS) is a useful tool for immediate and efficacy control after insertion determining no urine leak, immediate voiding, and clear urine. It guarantees a peak flow of 12- 15 ml/sec according to bladder contractility, driven by stent the standard length and diameter of the prostatic tube. It is not ballooned, as vesical catheters do and, therefore, surface in contact with urine is 5 times lower than in a Foley catheter. It is a safe procedure due to the impossible passage through the sphincter without any risk of urethral injury or urethral bleeding. It is indicated also for the large bulbous urethra, and hypertonic sphincter (patient anxiety or neurologic origin).
Describing the technique, the urethra is calibrated through a Bougie CH 22 or 24. The surgeon inserts to the same depth as the one noted with the Bougie and until the perception of the abutment of the device against the posterior wall of the bulbous urethra. Then the patient is required to contract his sphincter, unlocking the Luer connection between the stylet and pusher tube and allowing to retrieve the stylet by 5 cm. Afterwards, the pink bumper of the flattener tube is taken and the urologist should retrieve the pink bumper of the flattener tube to remove at once the flattener tube, stylet, and pusher tube. The retrieval suture is cut 3 mm beyond the meatus. Several advantages occur of this procedure:
• Silicone composition: low risk of encrustation and bacterial colonization.
• Single model: a unique length and a single diameter CH 20 for all prostates with a distance bladder neck-apex < 7cm or prostate volume <150 cc.
• No migration: anti-migration wings and length of the bulbar tube.
• Excellent tolerance: no balloon in contact with the trigone, no bladder spasms.
• Immediate efficacy control after insertion: no leak, satisfactory bladder emptying.
• Low risk of bacterial contamination: bacteria are flushed out by each voiding.
• Sexual activity preserved: possible retrograde ejaculation.
However, data need to be validated by prospective studies or randomized trials.
Prostatic artery embolization (PAE) is a minimally invasive treatment that is performed by an interventional radiologist, with a lower risk of urinary incontinence and sexual side effects compared to invasive surgical procedures such as TURP.
The technique: A Foley catheter may be inserted to provide a reference point for the surrounding anatomy. PAE is performed through a small catheter under local anaesthesia with access through the femoral or radial arteries. The interventional radiologist will then guide the catheter into the vessels that supply blood to the prostate. An arteriogram is done to map the blood vessels. Non-spherical or spherical PVA particles or Polyzene-coated hydrogel microspheres are injected through the catheter to reduce prostate blood supply on both sides. Following this procedure, the prostate will begin to shrink, relieving and improving symptoms usually within days of the procedure. In an overview regarding 630 consecutive patients with BPH and moderate-to-severe LUTS, PAE was technically successful in 618 (98.10%) patients, with a discharge before 24 hours in all cases (11). Moreover, a significant change from baseline to last FU in IPSS, QOLS, Prostate Vol, PSA, Qmax, Residual Vol, and IIEF occurred, with only 2 major complications. Finally, a meta-analysis of clinical trials comparing the efficacy and safety of PAE versus established surgical therapies, with 5 studies and overall 708 patients included (12). The mean reduction in the IIEF-5 was lower after PAE compared with standard surgical therapies (3.80). All of the functional outcomes assessed were significantly superior after surgical standard treatments in terms of Qmax (3.62 ml/s), prostate volume (11.51 ml), PVR (11.86 ml), and PSA (1.02 ng/ml).
Dr. Carlo Giulioni has no conflict of interests.
1. Mynderse LA, Hanson D, Robb R, et al. Rezūm System Water Vapor Treatment for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia: Validation of Convective Thermal Energy Transfer and Characterization with Magnetic Resonance Imaging and 3D Rendering. UROLOGY. 2015; 86:122-127.
2. McVary KT, Rogers T, Roehrborn CG. Rezūm Water Vapor Thermal Therapy for Lower Urinary Tract Symptoms Associated With Benign Prostatic Hyperplasia: 4-Year Results From Randomized Controlled Study. Urology. 2019; 126:171-179.
3. Desai M, Bidair M, Bhojani N, et al. Aquablation for benign prostatic hyperplasia in large prostates (80-150 cc): 2-year results. Can J Urol. 2020; 27(2):10147-10153.
4. Gilling PJ, Barber N, Bidair M, et al. Five-year outcomes for Aquablation therapy compared to TURP: results from a double-blind, randomized trial in men with LUTS due to BPH. Can J Urol. 2022; 29(1):10960-10968.
5. Reale G, Cimino S, Bruno G, et al. “Aquabeam® System” for benign prostatic hyperplasia and LUTS: birth of a new era. A systematic review of functional and sexual outcome and adverse events of the technique. Int J Impot Res. 2019; 31(6):392-399.
6. Elterman Ds, Foller S, Ubrig B, et al. Focal bladder neck cautery associated with low rate of post-Aquablation bleeding. Can J Urol 2021; 28(2):10610-10613.
7. Roehrborn CG, Chin PT, Woo HH. The UroLift implant: mechanism behind rapid and durable relief from prostatic obstruction. Prostate Cancer Prostatic Dis. 2022; 25(1):79-85.
8. Roehrborn CG, Rukstalis DB, Barkin J, et al. Three year results of the prostatic urethral L.I.F.T. study. Can J Urol. 2015; 22(3):7772-82.
9. Miller LE, Chughtai B, Dornbier RA, McVary KT. Surgical Reintervention Rate after Prostatic Urethral Lift: Systematic Review and Meta-Analysis Involving over 2,000 Patients. J Urol. 2020; 204(5):1019-1026.
10. Amparore D, Fiori C, Valerio M, et al. 3-Year results following treatment with the second generation of the temporary implantable nitinol device in men with LUTS secondary to benign prostatic obstruction. Prostate Cancer Prostatic Dis. 2021;24(2):349-357.
11. Pisco JM, Bilhim T, Pinheiro LC, et al. Medium- and Long-Term Outcome of Prostate Artery Embolization for Patients with Benign Prostatic Hyperplasia: Results in 630 Patients. J Vasc Interv Radiol. 2016; 27(8):1115-22
12. Zumstein V, Betschart P, Vetterlein MW, et al. Prostatic Artery Embolization versus Standard Surgical Treatment for Lower Urinary Tract Symptoms Secondary to Benign Prostatic Hyperplasia: A Systematic Review and Meta-analysis. Eur Urol Focus. 2019; 5(6):1091-1100.
Advances in Urological Diagnosis and Imaging - 2022; 5,2
Carlo Giulioni
Department of Urology, Polytechnic University of Marche 71 Conca Street, 60126, Ancona – Italy
E-mail: carlo.giulioni9@gmail.com Phone: +39 320/7011978 ORCID: 0000-0001-9934-4011
Trimodality treatment is determined by maximal debulking transurethral resection of bladder tumour (TURBT) Combined with radiotherapy (RT) and platinum-based chemotherapy (CT). All cases are discussed at a multidisciplinary urologic tumour board and are dedicated to Highly selected patients, corresponding to 10-15% of current radical cystectomy patients (1). There are several criteria to consider in patient selection:
• Radicality of TURBT
• Tumor stage: negative lymph nodes are required
• Hydronephrosis: significantly increased risk of distant metastasis
• Multifocality and CIS are considered exclusion criteria
• Good bladder function l Finality: to preserve normal function of the bladder
• Highly motivated patients: patients must be aware of all options and agree with the possibility of salvage cystectomy
• Discussion at multidisciplinary urologic tumour board.
Therefore, the ideal patients have T2 MIBC, with no hydronephrosis nor CIS, TURBT was visibly complete, the tumour was unifocal, with a necessary good bladder function and capacity.
In a retrospective analysis of 475 patients with Т2-T4a
MIBC treated at the Massachusetts General Hospital with transurethral resection of bladder tumour followed by concurrent CT-RT, rates of CR improved from 66% to 88% and 5-yr disease-specific survival from 60% to 84% over treatment eras, with the 5-yr risk of salvage radical cystectomy rate decreasing from 42% to 16% (2). According to the evidence, TMT is mini-invasive therapy with low morbidity (sexual, urinary), leaving an intact bladder and guaranteeing satisfactory oncologic results. In an editorial commentary regarding stereotaxic radiotherapy (SBRT) (3), it targeting macroscopic bladder tumours could differ from the conventional palliative treatment of the whole bladder in three critical ways:
• The treatment course is shortened;
• The target volume is reduced and the daily dose is typically hypofractionated.
• The intent is the symptoms (and tumour growth) management minimizing bowel and urinary toxicities, especially reducing OTT treatment and augmenting patients' compliance to RT.
In summary, the TMT approach might be considered a valid and feasible option in fit patients who refuse radical cystectomy (80% intact-bladder disease-free survival at 5 years). Patients' selection and a multidisciplinary discussion remain fundamental elements for proposing every approach in bladder cancer, even for elderly patients who are optimal candidates for TMT or palliative RT.
Bladder cancer is a potential killer of the elderly, as cancerspecific mortality was higher in older individuals than in their younger counterparts (4). In pre-treatment decisionmaking, frailty is a determining factor as it correlates with mortality and side effects of cancer treatment and is more important than chronological age. According to the EAU guidelines, the decision on bladder-sparing treatment or radical cystectomy in older / frail patients with invasive bladder cancer must consider tumour stage and frailty (5). Therefore, one of the decision-making points is whether our approach has palliative or curative intent. Although an endoscopic procedure alone is not recommendable, performing a complete TURBT in the elderly is essential, as it may be curative in selected cases, cystectomy may not be feasible / refused, bladder sparing is more effective if no / low residual volume and re-tur may add morbidity. Partial cystectomy is a less challenging alternative for the elderly patient, although this procedure is contraindicated in the case of positive pelvic lymph nodes, prior history of urothelial carcinoma and ureteral reimplantation (6). Some factors can be relevant to improve partial cystectomy outcomes:
• N-acetyl cysteine: Reduction on PSM & local recurrence.
• PLND: CSM reduced from 40% to 30% when PLND was performed.
• Advance in technology for positive margins rate:
approximately 19% of PSM, no difference between robotic, lap. and open partial cystectomy.
Afterwards, the literature does not indicate a preference for radical cystectomy in the elderly. In a series of 34 elderly patients who underwent radical cystectomy and ureterocutaneostomy derivation, complications of grade III or greater, according to the Clavien-Dindo classification, were in about 5% of cases.
There are no studies with large sample sizes on minimally invasive radical cystectomy in elderly patients, although they are promising. Yanagihara et al. reported a non-significant major postoperative complication rate compared to young patients, with similar outcomes for Cancer-specific survival and Recurrence Free Survival (7). Moreover, no case series regarding robot-assisted radical cystectomy was published, although the UAE guidelines recommend informing the patient about the pros and cons of this procedure (5). Nevertheless, regardless of the choice of surgical technique, current literature confirms that outcomes of cystectomy are better in centres performing over 20 surgeries per year. Therefore, elderly patients should be recommended to undergo cystectomy in high-volume centres, both for RARC and ORC.
In summary, elderly patients with BC are more likely to die of bladder cancer than their younger counterparts and should not be denied RC just because of age/comorbidities. Nonetheless, these are fundamental determinants of postoperative morbidity and mortality.
Radical cystectomy with urinary derivation is the most complex surgical procedure in the urological field, with postoperative surgical morbidity up to 20 years after surgery. The type of urinary derivation is the most impacting factor on postoperative morbidity and quality of life in these patients (8). In a retrospective review of 117 patients over 80 years, there is a reduced probability of receiving continent derivation compared to young people (3% vs 40%), with a higher rate of entering the ICU (4% vs 11%) (9). Age> 80 years is often considered the threshold after which neobladder reconstruction is not recommendable, although in carefully selected elderly patients, all other forms of wet and dry urinary diversions, including orthotopic bladder substitutions, are possible. However, according to Tan et al., age is an independent predictor of high-grade complications beyond previous abdominal surgery, an ASA score> 2, and intraoperative blood loss (10). Then there are the late complications depending on the position and length of the segment intestinal used for urinary diversion.
Bricker's Ileal Conduit is the preferred choice in patients with neurological and psychiatric disease, limited life expectancy, renal or hepatic failure, cancer extended to prostatic urethra/bladder neck, or complicated urethral stricture. Furthermore, due to the shorter contact time of urine with the intestinal mucosa, metabolic complications in patients with ileal duct are less frequent than in patients
with an orthotopic neobladder. Nevertheless, early (such as gastrointestinal or uretero-ileal anastomosis dehiscence) or late (such as bowel, renal, stomal complication or urolithiasis) may occur in approximately 30% of patients (11). Cutaneous ureterostomy may be equally valid in high-risk patients with previous intestinal surgery or radiotherapy aiming for an oncological debulking strategy or a palliative intent. According to a retrospective study comparing the outcomes of urinary diversions, UCS with a single stoma can represent a valid alternative to IC in elderly patients with relevant comorbidities, reducing peri-operative complications without significant impairment of quality of life (12). In conclusion, a radical cystectomy may be proposed for the older adult (> 75-80 yo), and several urinary diversions can be offered in the well selected patients, with acceptable complication rates and overall survival.
1. Mathieu R, Lucca I, Klatte T, et al. Trimodal therapy for invasive bladder cancer: is it really equal to radical cystectomy? Curr Opin Urol. 2015; 25(5):476-82.
2. Giacalone NJ, Shipley WU, Clayman RH, et al. Long-term Outcomes After Bladder-preserving Tri-modality Therapy for Patients with Muscle-invasive Bladder Cancer: An Updated Analysis of the Massachusetts General Hospital Experience. Eur Urol. 2017; 71(6):952-960.
SIU 2022 Updates - Muscle-invasive bladder cancer in elder patient
3. Jereczek-Fossa BA, Marvaso G. Palliative radiation therapy in bladder cancer: a matter of dose, techniques and patients' selection. Ann Palliat Med. 2019; 8(5):786-789.
4. Lughezzani G, Sun M, Shariat SF, et al. A population-based competing-risks analysis of the survival of patients treated with radical cystectomy for bladder cancer. Cancer. 2011; 117(1):103-9.
5. EAU Guidelines. Edn. presented at the EAU Annual Congress Amsterdam 2022. ISBN 978-94-92671-16-5
6. Ma B, Li H, Zhang C, et al. Lymphovascular invasion, ureteral reimplantation and prior history of urothelial carcinoma are associated with poor prognosis after partial cystectomy for muscle-invasive bladder cancer with negative pelvic lymph nodes. Eur J Surg Oncol. 2013; 39(10):1150-6.
7. Yanagihara Y, Nishida K, Watanabe R, et al. Feasibility of Laparoscopic Radical Cystectomy in Elderly Patients: A Comparative Analysis of Clinical Outcomes in a Single Institution. Acta Med Okayama. 2019; 73(5):417-418.
8. Hautmann RE, Hautmann SH, Hautmann O. Complications associated with urinary diversion. Nat Rev Urol. 2011; 8(12):667-77.
9. Donat SM, Siegrist T, Cronin A, et al. Radical cystectomy in octogenarians--does morbidity outweigh the potential survival benefits? J Urol. 2010; 183(6):2171-7.
10. Tan WS, Lamb BW, Kelly JD. Complications of Radical Cystectomy and Orthotopic Reconstruction. Adv Urol. 2015; 2015:323157.
11. Shimko MS, Tollefson MK, Umbreit EC, et al. Long-term complications of conduit urinary diversion. J Urol. 2011; 185(2):562-7.
12 Longo N, Imbimbo C, Fusco F, et al. Complications and quality of life in elderly patients with several comorbidities undergoing cutaneous ureterostomy with single stoma or ileal conduit after radical cystectomy. BJU Int. 2016; 118(4):521-6.
Carlo Giulioni
Department of Urology, University Hospital “Ospedali Riuniti”.
71 Conca Street, 60126, Ancona – Italy
E-mail: carlo.giulioni9@gmail.com Phone: +39 320/7011978
ORCID: 0000-0001-9934-4011
Advances in Urological Diagnosis and Imaging is a free open access journal. The Journal has the purpose of promote, spread and favorite the scientific knowledge and research in diagnosis and imaging in Urology, Andrology and Nephrology.
Advances in Urological Diagnosis and Imaging publishes every 4 months original articles, reviews, case reports, position papers, guidelines, editorials, abstracts and congress proceedings.
To publish in Advances in Urological Diagnosis and Imaging is free
The official language of the journal is English
For papers with national interest because of local contents, in the “Italian Corner” it’s accepted their publication in Italian. The abstract must be in English. The editing of these papers follows the instructions below described.
All accepted paper will be published after a peer reviewed process.
Manuscripts are accepted with the understanding that they have not been published or submitted for publication in any other journal.
Authors must submit the results of clinical and experimental studies conducted according to the Helsinki Declaration on clinical research and to the Ethical Code on animal research set forth by WHO (WHO Chronicle 1985; 39:51).
The Authors must obtain permission to reproduce figures, tables and text from previously published material. Written permission must be obtained from the original copyright holder (generally the Publisher).
Manuscripts must be written in English language in accordance with the “Uniform Requirements for Manuscripts submitted to biomedical journals” defined by The International Committee of Medical Journal Editors (http://www.ICMJE.org).
Manuscripts in Italian language can be published only after translation (expenses will be charged to the Authors). Manuscripts should be typed double spaced with wide margins.
They must be subdivided into the following sections: Title page
It must contain: a) title; b) a short (no more than 40 characters) running head title;
c) first, middle and last name of each Author without abbreviations; d) University or Hospital, and Department of each Author; e) last name, address and e-mail of all the Authors; f) corresponding Author; g) phone and/or fax number to facilitate communication; h) acknowledgement of financial support; i) list of abbreviations.
The Authors must submit a long English summary (300 words, 2000 characters). Subheadings are needed as follows: Objective(s), Material and method(s), Result(s), Conclusion(s). After the Summary, three to ten key words must appear, taken from the standard Index Medicus terminology.
For original articles concerning experimental or clinical studies, the following standard scheme must be followed: Summary - Key Words - Introduction - Material and Methods - Results - Discussion - Conclusions - References - Tables - Legends - Figures.
Case Report should be divided into: SummaryIntroduction (optional) - Case report(s) - ConclusionsReferences (Discussion and Supplementary Figures, Tables and References can be submitted for publication in Supplementary Materials).
Literature reviews, Editorials and Original articles concerning experimental or clinical studies should not exceed 3500 words with 3-5 figures or tables, and no more than 30 references.
Case reports, Notes on surgical technique, and Letters to the Editors should not exceed 1000 words (Summary included) with only one table or figure, and no more than three references. No more than five Authors are permitted.
References must be sorted in order of quotation and numbered with arabic digits between parentheses. Only the references quoted in the text can be listed. Journal titles must be abbreviated as in the Index Medicus. Only studies published on easily retrieved sources can be quoted. Unpublished studies cannot be quoted, however articles “in press” can be listed with the proper indication of the journal title, year and possibly volume. References must be listed as follows:
•
All Authors if there are six or fewer, otherwise the first three, followed by “et al.”. Complete names for Work Groups or Committees. Complete title in the original language. Title of the journal following Index Medicus
rules. Year of publication; Volume number: First page.
Example: Starzl T, Iwatsuki S, Shaw BW, et al. Left hepatic trisegmentectomy. Surg Gynecol Obstet. 1982; 155:21.
• Books
Authors - Complete title in the original language. Edition number (if later than the first). City of publication: Publisher, Year of publication.
Example: Bergel DIA. Cardiovascular dynamics. 2nd ed. London: Academic Press Inc., 1974.
ary 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.
•
Authors of the chapters - Complete chapter title. In: Book Editor, complete Book Title, Edition number. City of publication: Publisher, Publication year: first page of chapter in the book.
Example: Sagawa K. The use of central theory and system analysis. In: Bergel DH (Ed), Cardiovascular dynamics. 2nd ed. London: Academic Press Inc., 1964; 115.
Tables must be aimed to make comprehension of the written text easier. They must be numbered in Arabic digits and referred to in the text by progressive numbers. Every table must be accompanied by a brief title. The meaning of any abbreviations must be explained at the bottom of the table itself.
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.
Authors must submit their manuscripts (MAC and WINDOWS Microsoft Word are accepted) to the Assistant Editor (dellatti@hotmail.com).
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.
ON : MEDICAL AND SURGICAL DEVICES, DIAGNOSTIC INSTRUMENTS, REGISTERED DRUGS , DIET SUPPLEMENTS , NUTRACEUTICALS
S.I.E.U.N. guarantees the Authors the publication of the article for scientific purposes completely free of charge. Each of the Authors is required to declare at the bottom of their article if they have received funding or grants from Sponsors for publication / study.
Papers that contain references to devices (medical and surgical), diagnostic instruments, registered drugs, diet supplements, nutraceuticals must not be used for commercial purposes without the authorization of Edizioni Scripta Manent.
The Authors are required to declare in the Copyright Assignment Form which possible Sponsors could be interested in a commercial use of the reprints.
Sponsor are requested to buy a minimum amount of 100 reprints at a cost of € 1.500 (1 to 4 pages) or € 2.000 (5 to 8 pages).
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 liter-
Prices for the purchase of number of reprints greater than 100 can be negotiated with Edizioni Scripta Manent. Edizioni Scripta Manent retains copyright for republishing and the distribution rights for commercial purpose.
Translation of manuscripts in Italian language is offered on payment.
Translation and reprints can be requested to Edizioni Scripta Manent by e-mail to info@edizioniscriptamanent.eu
