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   Table of Contents - Current issue
October-December 2017
Volume 9 | Issue 4
Page Nos. 305-409

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Adult testicular cancer: Two decades of Saudi national data p. 305
Mohammed Abomelha
There is a paucity of data regarding testicular cancer among Saudis as well as the nonexistent of published national data. Furthermore, a substantial increase of the incidence of testicular cancer among Saudis was lately noted. The aim of the study is to determine the trends and patterns of testicular cancer among adult Saudis using national data over a period of 20 years. The national database of the Saudi Cancer Registry (SCR) on testicular cancer over the last two decades was studied including epidemiological and histological patterns. The 1004 cases of testicular cancer among adult Saudis reported by the SCR will be the subject of this study. From 1994 to 2013, 1004 cases of testicular cancer among adult Saudis were reported to the SCR, with a steadily significant increase in incidence rate reaching an annual rate of 94 cases in 2013. Age of the patients ranged 15–93 years with a mean of 34.5 years. The most affected age group was 20–34 years, where 51% of all testicular cancer accumulated. Around 85% of testicular cancer is germ cell tumors, while paratesticular and gonadal stromal tumors represent 15%. Of all testicular cancer, seminomas were seen in 40.7%, nonseminomas in 44.6%. Notably, 70.4% of the cases in the first decade were seminomas, while in the second decade 65.9% of the cases were nonseminomas. The subtypes of the nonseminomas were a mixed tumor in 51.6%, embryonal carcinoma in 19.9%, yolk sac tumor in 12.3%, germinomas in 6.7%, teratomas in 6%, and choriocarcinomas in 3.6%. Lymphomas (34.7%) and rhabdomyosarcomas (23.6%) are on the top of the paratesticular tumor group. The Surveillance Epidemiology and End Results summary stage of seminomas was localized in 61.6%, regional in 19.8%, and distant in 12.6%, while of nonseminomas was 48%, 15.5%, and 28.5%, respectively. Localized and distant status of seminomas improved over the studied period by 12% and 4% respectively, while this trend was not seen in nonseminomas. The incidence rate is on rising with doubling observed during the last decade. The most affected age group was 20–34 years. Noteworthy was the dominance of the seminomas in the first decade and of the nonseminomas in the second decade. Paratesticular tumors rate is high, third of which were lymphomas. Compared to data from Western countries, notably, there is a high rate of yolk sac tumors and germinomas and a low incidence of choriocarcinomas and embryonal carcinomas. In general, late presentation of all testicular cancer was noted, although a modest stage improvement over the studied period was observed in seminomas, not in nonseminomas.
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Pediatric testicular cancer: Two decades of Saudi national data p. 310
Mohammed Abomelha
Pediatric testicular cancer is exceedingly rare. There are no data available touching Saudi children. The aim of the study is to determine the trends and patterns of testicular cancer among Saudi children over a period of 20 years. The national database of the Saudi Cancer Registry (SCR) on pediatric testicular cancer over the last two decades was examined including epidemiological and histological patterns. From 1994 to 2013, 82 cases of testicular cancer among Saudi children aged 1–14 years were accumulated at the SCR. The annual percentage change rate was 3.3%. Of all cases, 62% appeared within the first 2 years of life. Seminomas were seen in 39%, nonseminomas in 40.3%, and paratesticular tumors in 20.7%. No gonadal stromal tumors observed. About 91% of the seminomas accrued in the first decade (1994–2003), while all nonseminomas fell in the last decade (2004–2013). The most common subtypes of the nonseminomas were yolk sac tumors and mixed tumors. More than 80% of the paratesticular tumors were rhabdomyosarcomas and lymphomas. The SEER summary stage of seminomas was localized in 56%, regional in 22%, and distant in 16%, while of nonseminomas was 56%, 16%, and 28%, respectively, and no stage improvement over the studied period was noted. No temporal trend in incidence rate was observed. The most affected age group was the first 2 years of life. Noteworthy was the high incidence of seminoma and the low rate of teratomas and stromal tumors, when compared to Western data. Notable was the dominance of the seminomas in the first decade and of the nonseminomas in the second decade. At the time of diagnosis, nonseminomas were more advanced than seminomas. No stage improvement noted over the studied period.
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Prognostic impact of Bacillus Calmette-Guérin interruption at the time of induction and consolidation p. 315
M Mofarej Alhogbani, J Aude Picard, M Hakim Fassi-Fehri, J Lionel Badet, C Marc Colombel
Context: Intravesical Bacillus Calmette-Guérin (BCG) is a cause of bladder and systemic toxicity that is difficult to prevent and is responsible for treatment drop out in bladder cancer patients. More recently, BCG shortage has become the main cause of incomplete treatment. Aims: The aim of this study was to examine the impact on long-term prognosis of bladder cancer patients following discontinuation of BCG instillations. Settings and Design: In this retrospective study, data were examined from 333 consecutive nonmuscle invasive bladder cancer patients treated from 2005 to 2015 by transurethral resection (TUR) and had undergone adjuvant BCG therapy after TUR. Subjects and Methods: Rate of complete cure, the reason for the interruption, toxicity, and the associations between discontinuance of BCG therapy, tumor characteristics, association with carcinoma in situ and tumor recurrence or progression were analyzed. Statistical Analysis Used: Recurrence and progression-free survival rate curves were estimated using the Kaplan-Meier method and were compared using the log-rank test. Univariate and multivariate analyses were performed using the Cox proportional hazards model. Differences among groups were considered as statistically significant when P < 0.05. Results: Overall, 303 patients were eligible for analysis. Median follow up was 36 (confidence interval: 7–120) months. A total of 55 (18.1%) had <6 installations (Group I); 87 (28.7%) completed induction and 1-year maintenance (Group III); and 161 (53.1%) completed the induction course, but not the 1-year maintenance (Group II). Grade III–IV toxicity rates were significantly higher in Group I than Group II and III. Interruption for BCG shortage was the main cause of interrupting BCG in Group II. Multivariate analysis showed that discontinuation of BCG induction therapy was an independent predictor for tumor recurrence (P < 0.001) and 1-year BCG maintenance therapy for tumor progression (P = 0.005). Conclusions: Discontinuation of BCG therapy has a significantly deleterious effect on tumor recurrence and progression rates. Although BCG toxicity is a major cause of drop out, BCG shortage became a major cause of discontinuation. All effort must be done today to restore normal production of BCG worldwide.
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Preliminary report on the effect of urethral diverticulum magnetic resonance imaging configuration on the incidence of new onset urodynamic stress urinary incontinence following excision p. 321
Sachin Malde, Sahar Naaseri, Rajesh Kavia, Mahreen Pakzad, Rizwan Hamid, Jeremy Ockrim, Tamsin J Greenwell
Context: Excision of urethral diverticulum in females has been reported to be associated with new onset urodynamic stress urinary incontinence (USUI) in up to 49%. Aims: We have assessed the incidence of new onset USUI in all patients having urethral diverticulum excision with Martius fat pad interposition under the care of a single surgeon between May 1, 2007, and December 1, 2011. The incidence of new onset USUI has been correlated with the preoperative magnetic resonance imaging (MRI) appearance of the urethral diverticulum. Patients and Methods: All 33 patients (mean age 42) having urethral diverticulum with Martius fat pad interposition had prospective data tabulated on demographics, preoperative MRI appearance, and pre- and post-operative videocystometrogram. Statistical Analysis Used: Statistical analysis was performed by Chi-squared and Fisher's exact. Results: Of the 33 patients, 10 (30%) had preoperative USUI and have been excluded from this study. Other preoperative urodynamic findings included idiopathic detrusor overactivity in ten (30%) and bladder outflow obstruction in five (16%). Two (10%) of the patients had a simple diverticulum, 16 (73%) had a horseshoe diverticulum, and 5 (17%) had a circumferential diverticulum. The rate of new onset USUI was 0% for simple, 6% for saddle, and 20% for circumferential. Conclusions: New onset USUI occurs in 9% of patients having excision of urethral diverticulum with Martius fat pad interposition. The incidence appears to increase with increasing complexity of urethral diverticulum on preoperative MRI – rising from 0% following simple urethral diverticulum excision to 20% following circumferential diverticulum excision.
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Transperitoneal laparoscopic repair of retrocaval ureter: Our experience and review of literature p. 324
Ashwin S Tamhankar, Abhishek J Savalia, Ajit S Sawant, Prakash W Pawar, Gaurav V Kasat, Sunil R Patil
Context and Aim: Retrocaval ureter (RCU), also known as circumcaval ureter, occurs due to anomalous development of inferior vena cava (IVC) and not ureter. The surgical approach for this entity has shifted from open to laparoscopic and robotic surgery. This is a relatively new line of management with very few case reports. Herein, we describe the etiopathology, our experience with six cases of transperitoneal laparoscopic repair of RCU operated at tertiary care center in India and have reviewed different management options. Methods: From 2013 to 2016, we operated total six cases of transperitoneal laparoscopic repair of RCU. All were male patients with average age of 29.6 years (14–50). Pain was their only complaint with normal renal function and no complications. After diagnosis with CT Urography, they underwent radionuclide scan and were operated on. Postoperative follow-up was done with ultrasonography every 3 months and repeat radionuclide scan at 6 months. The maximum follow-up was for 2.5 years. Results: All cases were completed laparoscopically. Average operating time was 163.2 min. Blood loss varied from 50 to 100 cc. Ureteroureterostomy was done in all patients. None developed urinary leak or recurrent obstruction postoperatively. Maximum time for the requirement of external drainage was for 4 days (2-4 days). Average postoperative time for hospitalization was 3.8 days. Follow-up ultrasound and renal scan showed unobstructed drainage. Conclusions: Transperitoneal or retroperitoneal approach can be considered equivalent as parameters like operative time, results are comparable for these two modalities. We preferred transperitoneal approach as it provides good working space for intracorporeal suturing.
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Pathological nature of renal tumors - does size matter? p. 330
Lutfi Ali S Kurban, Alireza Vosough, Preman Jacob, Deepak Prasad, Thomas Lam, Neil Scott, Bhaskar K Somani
Introduction: We examined the relationship between the size and nature of renal masses in term of malignant potential, histological grading, pathological staging and presence of necrosis and sarcomatoid changes. Materials and Methods: Retrospectively, we reviewed 323 consecutive nephrectomies between 2000 and 2010. Final pathology was correlated with tumour size. The renal tumours were stratified into three groups according to the largest diameter, defined as 4 cm or smaller, greater than 4 cm to 7 cm, and greater than 7 cm. We recorded the proportion of benign tumours, tumour grade and stage, presence of necrosis and sarcomatoid change. Results: Small renal masses ≤4 cm (SRMs) were more likely to be localised to the kidney (90%) and of lower histological grade (75%). The proportion of benign tumours in SRMs (15%) was higher than other two groups with the majority of benign tumours being oncocytomas. There was a statistically significant trend with greater necrosis and sarcomatoid change for the large size group. Conclusions: SRMs are likely to be low grade and organ confined with little or no adverse pathological features. There is increased likelihood of benignity in SRTs with the majority of benign tumours being oncocytomas.
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Pure retroperitoneoscopic donor nephrectomy in duplication of inferior vena cava: A series of four cases p. 335
Bipin Chandra Pal, Pranjal R Modi, Syed Jamal Rizvi, Rohit Chauhan, Suresh Kumar, Shruti P Gandhi, Vivek B Kute, Hargovind L Trivedi
Aim: Complex vascular anatomy poses a major challenge to the donor surgeon. Here, we have described the technical nuances in retroperitoneoscopic living donor nephrectomy for the left kidney in the situations of a rare vascular anomaly of duplication of inferior vena. Materials and Methods: Between September 2005 and June 2016, 1460 retroperitoneoscopic living donor nephrectomy were carried out in single surgical unit of our institution. Out of these four donors were found to have duplication of inferior vena cava (IVC). We retrospectively analyzed the prospectively collected data of these donors and studied the operative details for managing the duplicated limb of the IVC. Results: The mean age of the donors was 42.5 (range 30–54) years. Mean body mass index was 26.9 (range 25.2–28.6) kg/m2. Mean operative time (defined as between giving skin incision to the skin closure [O. T]), was 230 (range 185–310 min). Mean Warm ischemia time (defined from clamping of the renal artery to the starting of the cold HTK perfusion, [WIT]) was 136 s (range 105–178 s). In two cases, the renal vein could be controlled distal to the duplicated limb. In one case, the duplicated limb was clipped while in another a stapler was used to take a cuff of IVC. Conclusion: Retroperitoneoscopic donor nephrectomy can be performed safely in cases of duplication of IVC. Preoperative computerized tomography angiography with vascular reconstruction and surgical expertise is desirable in carrying out the procedure.
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Rapid versus gradual bladder decompression in acute urinary retention p. 339
Mohamed H Etafy, Fatma H Saleh, Cervando Ortiz-Vanderdys, Alaa Hamada, Alaa M Refaat, Mohamed Abdel Aal, Hazem Deif, Maher Gawish, Ashraf H Abdellatif, Khaled Gadalla
Objective: To demonstrate a benefit in diminished adverse events such as hypotension and hematuria with gradual drainage of the bladder when compared to rapid decompression in patients with acute urinary retention (AUR) due to benign prostatic hyperplasia in a case–control study. Methods: Sixty-two patients matched our selection criteria presenting with AUR. They were divided into two groups – the first was managed by rapid drainage of the bladder, the second was managed by gradual drainage through a urethral catheter (The first 100 mL immediately evacuated, then the rest evacuated gradually over 2 h). Results: The mean age was 64.4 and 63.2 years in the first and second group, respectively. Diagnosed cause was benign hyperplasia of the prostate. Hematuria occurred in two patients in the first group and none in the second group. The two cases of hematuria were mild and treated conservatively. After the relief of the obstruction, the mean blood pressure was noticed to decrease by 15 mmHg and 10 mmHg in the first and second group, respectively, however, no one developed significant hypotension. Pain relief was achieved after complete drainage in the first group and after the evacuation of 100 mL in the second group. Conclusions: We conclude that there is no significant difference between rapid and gradual decompression of the bladder in patients with AUR. Hematuria and hypotension may occur after rapid decompression of the obstructed urinary bladder, but these complications are rarely clinically significant.
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Characteristics of bladder neoplasms in the young population of Saudi Arabia p. 343
Abdulrahman I Alabdulkareem, Fares H Al-Jahdali, Ahmed I Nazers, Sultan S Alkhateeb
Context: Bladder neoplasms are a well-studied subject in medicine. However, the evidence of bladder neoplasms in children and the young adult population (≤40 years), particularly in Saudi Arabia, is lacking. Aims: The aims of this study were to identify histopathological characteristics as well as clinical features, prognosis, and treatment of bladder neoplasms in this age group in a single tertiary referral center, Riyadh, Saudi Arabia. Settings and Design: A retrospective cohort study. Materials and Methods: Children and young adults (≤40 years) diagnosed with epithelial and mesenchymal bladder neoplasms from 1994 to 2017. Statistical Analysis Used: Descriptive data are presented as mean (standard deviation) or median (interquartile range) for continuous variables and n (%) for categorical variables. Statistical Package for Social Sciences version 23 was used. Results: Thirty-eight cases were identified. The majority, 71.1% (n = 27) were male. The median age of diagnosis was 33 years ranging from 1 to 40 years. Nearly 45% (n = 17) were smokers. Macroscopic hematuria was present in 57.8% (n = 22). The most common histopathology was papillary urothelial carcinoma (n = 18, 58%). All mesenchymal neoplasms accounted for 18.4% (n = 7). Of all malignancies, 63.2% (n = 24) and 44.7% (n = 17) were low stage and low grade, respectively. Transurethral resection of bladder tumor (TURBT) was conducted for 81.6% (n = 31). The mean length of follow-up was 36.05 months (±39.4 months). Recurrence occurred in 15.8% (n = 6) and 7.9% (n = 3) had progression. Distant metastasis was reported in 5.3% (n = 2). Nearly 8% (n = 3) died during their follow-up. Conclusions: Bladder malignancies at the early fourth decade of life tend to be a low stage and low grade. The most common histopathology was papillary urothelial carcinoma. Management should be based on the clinical and histopathological features. However, most of the patient underwent TURBT.
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Choosing an ideal vascular cover for Snodgrass repair p. 348
Mamatha Basavaraju, Dhiraj K Balaji
Aim: The aim of this study is to compare tunica vaginalis (TV), dorsal dartos, and ventral dartos flap as a second layer vascular cover during Snodgrass repair. Materials and Methods: Data of 83 patients who underwent primary hypospadias repair with Snodgrass technique (age range: 1.6–12 years) were retrospectively collected and compared. They were divided into three groups. Group A (26 patients) included cases using TV flap, Group B (36 patients) included those where dorsal dartos from prepuce was used as second cover, and Group C (21 patients) included those with ventral dartos as cover. Results: In Group A, no complications recorded. Mild scrotal edema was present in 5 patients which was conservatively managed. In Group B, there were 8 fistulas, 2 glans breakdown, and 1 meatal stenosis. In Group C, there were 3 fistulas and 1 glans breakdown. Conclusion: TV flap is better than dorsal dartos and ventral dartos as vascular cover for primary hypospadias repair with Snodgrass technique.
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Utilization of penile prosthesis and male incontinence prosthetics in Saudi Arabia p. 353
Amjad Alwaal, Ahmad J Al-Sayyad
Background: Erectile dysfunction is a prevalent disease affecting over 50% of men between the ages of 40 and 70 years. Penile prosthesis represents the end of the line treatment when other less invasive therapies fail or are contraindicated. Male stress urinary incontinence can significantly diminish quality of life and lead to embarrassment and social withdrawal. Surgical therapies, such as male urethral slings and artificial urinary sphincters (AUS), are considered effective and safe treatments for male stress incontinence. No data exist on the utilization of penile prosthesis or male incontinence surgical treatment in Saudi Arabia. Generally, urological prosthetic surgery is performed either in private hospitals or in government hospitals. Our aim was to assess the trend of penile prosthesis and male incontinence device utilization in Saudi Arabia. Materials and Methods: We utilized sales' data of penile prosthetics, male slings, and AUS from the only two companies selling these devices in Saudi Arabia (AMS® and Coloplast®), from January 2013 to December 2016. Results: There were 2599 penile prosthesis implantation procedures done in the study period, with 67% of them performed in private institutions. There was a progressively increased use of penile prosthetics which nearly doubled from 2013 to 2016. The main type of prosthesis utilized was the semirigid type 70% versus 11% of the 2-piece inflatable and 17% of the 3-piece inflatable device. Only 10 slings and 31 AUS were inserted during the same study period. Conclusions: There is an increased utilization of penile prosthetics in Saudi Arabia. The private sector performs the majority of penile prosthesis procedures, and most of them are of the semirigid type. The governmental sector is more likely to perform inflatable penile prosthesis and male incontinence device procedures. Male incontinence prosthetics' use is very limited in Saudi Arabia.
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Laparoscopic heminephrectomy in horseshoe kidneys: A single center experience p. 357
Santosh Agrawal, Jaisukh Kalathia, Saurabh Sudhir Chipde, Udit Mishra, Anurag Tyagi, Sanjay Parashar
Introduction: Laparoscopic approach in horseshoe kidney (HSK) is a challenge because of the aberrant vessels, the renal isthmus and the renal ectopia are all unique features of this anomaly encountered during the surgery. We report our single center experience with this technique in managing three patients with HSK. Methods: A total of 15 cases (9 males and 6 females) were operated between June 2011 and December 2016 for various indications. Of these four patients were managed laparoscopically, two patients with HSK had non-functioning renal moiety underwent transperitoneal heminephrectomy. The third patient with a mass in right moiety with thin fibrous isthmus was successfully managed with laparoscopic heminephrectomy. Fourth patient with pelvi-ureteric junction obstruction with multiple renal calculi was managed with pyeloplasty and complete clearance of all calyceal the stones. Result: Mean operating time was 140 ± 1.8 (100–180) min, and estimated blood loss was 131 ± 12.6 (30–320) ml. The mean hospital stay was 2.3 ± 1.4 (1–5) days. There were no major intra- and post-operative complications except minimal postoperative discomfort. Conclusion: Laparoscopic nephrectomy is technically feasible, safe, and reliable for benign and malignant diseases in a HK with mainly three factors posing challenges during the surgery are the abnormal vasculature, division of the isthmus, and lower location of the kidney.
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Total endoscopic and anal irrigation management approach to noncompliant neuropathic bladder and bowel in children: A long-term follow-up p. 362
Naif Alqarni, Hamdan Alhazmi, Ossamah Alsowayan, Tamer Eweda, Khalid Fouda Neel
Purpose: To evaluate the long-term efficacy and durability of combined intradetrusor botulinum-A toxin (BTX-A), endoscopic treatment of vesicouerteral reflux and anal irrigation for stool incontinence (SI) via a total endoscopic and anal irrigation management (TEAM®) approach in patients with myelomeningocele and neuropathic bladder and bowel who did not respond to conservative measures. Materials and Methods: Fourteen myelomeningocele patients with at least 3 years follow-up were included in the study. All patients have urinary and SI not responded to conservative management. All patients received a cystoscopic intradetrusor injection of 12 U/kg (maximum 300 U) BTX-A. There was vesicoureteral reflux in 22 ureters, and a Deflux® injection was completed during the same procedure. SI was managed using trans-anal irrigation, either with a fleet enema or Peristeen® system regularly. Results: After at least 3 years of follow-up, mean maximum bladder capacity increased significantly from 78 ± 36 ml to 200 ± 76 ml (P < 0.0001) and the maximum detrusor pressure decreased from 56 ± 12 cm H2O to 29 ± 7 cm H2O (P < 0.001). Twenty-one refluxing ureters (95%) showed complete resolution and one persisted. Ten patients (72%) achieved complete dryness between catheterizations. Four patients (28%) went for augmentation cystoplasty, due to progressive hydronephrosis and/or persistent urinary incontinence. Thirteen patients achieved complete stool continence. Conclusions: Over long-term follow-up, major reconstruction surgery can be avoidable or delayable; the TEAM® approach is a minimally invasive, safe, simple, and effective way to achieve upper urinary tract protection and provide urinary and stool continence.
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Hypospadias repair during adulthood: Case series p. 366
Waleed M AlTaweel, Raouf M Seyam
Purpose: We report our complications and success rate in adult hypospadias repair. Patients and Methods: This was a retrospective study of patients aged ≥17 years who underwent hypospadias repair during 2006–2014. We analyzed two groups, one with primary repair and the other that had secondary repair after failed childhood hypospadias surgery. Outcome was compared between the two groups and among different surgical procedures. Descriptive statistics and Fisher's exact test were used and significance level was set at P < 0.05. Results: Forty patients were included, of which 26 presented for a secondary repair and 14 for primary repair. The meatus was distal in 15 patients, mid-penile in 16, and penoscrotal in 9. The median age of patients at the time of surgery was 21 years (standard deviation [SD] =4, range 17–30). The median follow-up period was 37 months (SD = 8, range 5–75). In the primary repair group, the success rate was 71% (10/14), whereas in the secondary repair group, the success rate was 55% (14/26). The overall complication rate was 60%. Following a subsequent repair, the overall success rate reached 95% (38/40). There was no significant difference in success or complications between patients who presented with primary or secondary hypospadias or between methods of repair. Conclusion: Delayed hypospadias repair in adults is associated with a high success rate of 95% with no difference between primary and secondary repair. Secondary repair however may require more than one procedure most of the time.
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The role of the endothelin axis in promoting epithelial to mesenchymal transition and lymph node metastasis in prostate adenocarcinoma p. 372
Sophia Papanikolaou, Vasiliki Bravou, Helen Papadaki, Kostis Gyftopoulos
Introduction: Aberrant activation of endothelin (ET) axis has been identified as a key player in tumor growth and metastasis in several tumor types. However, little is known about the possible interaction of the ET with epithelial to mesenchymal transition (EMT), a process that transforms tumor cells in a motile, resistant to apoptosis phenotype prone to invasion and metastasis. The aim of this study was to investigate the activation of the ET axis in prostate adenocarcinoma and examine possible associations with EMT markers, lymph node (LN) metastasis, and other clinicopathological parameters. Materials and Methods: We immunohistochemically evaluated the expression of ET-1 and its receptors A and B (ET-A, ET-B) in 64 N0 and 23 N1 prostate adenocarcinoma cases. EMT markers E-cadherin, N-cadherin, and β-catenin and the transcriptional factor SNAIL were evaluated. We examined possible correlations of ET pathway members with EMT markers, LN status, Gleason grade, and T stage. Results: Our results revealed increased expression of ET-1 and ET-A (but not ET-B) in prostate carcinoma; both ET-1 and ET-A were associated with lymph metastasis and T stage but not with Gleason grade. We observed E-cadherin and β-catenin decrease/relocalization and increased N-cadherin expression. SNAIL also showed increased expression in tumor tissue and was associated with LN metastasis (Mann–Whitney test, P = 0.0032). Expression of ET-1 and ET-A correlated well with SNAIL expression (Spearman r, P = 0.0002 and P = 0.0176, respectively). Conclusions: These findings indicate that activation of the ET pathway may induce EMT through SNAIL activation and correlates with increased metastatic potential.
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Laser-induced synlabia, cryptomenorrhea, and urine retention: A case report and literature review p. 380
Thoraya Fadul-Elahi, Nusrat Batool Janjua
Cosmetic laser use has many pros and cons. The worldwide use of laser for body hair removal has led to many medical complications. Unsupervised use of the laser for hair removal in vulva may result in many problems and can merely damage the vulva, although rarely, affecting the body image. This rare and novel case report is a 21 year old virgin who presented with acute urinary retention and cryptomenorrhea due to complete synlabia secondary to unsupervised vulval laser hair removal. The urinary retention was relieved by suprapubic catheterization initially. During examination under anesthesia, the fused labia were separated by a surgical incision with drainage of hematocolpos and then, a Foley's urethral catheter was inserted. She had an uneventful recovery. We report this case to emphasize on the supervised use of laser by trained and qualified personnel for hair removal in vulva to minimize its complications.
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The rarest phenomenon of flexible ureterolithotripsy: Kidney stone in supernumerary type combination with a horseshoe kidney p. 384
Musab Ilgi, Cemil Kutsal, Cumhur Yesildal, Ayhan Dalkilinc, Sinan Levent Kirecci
The horseshoe kidney (HSK) is common and supernumerary kidney is the rarest developmental anomaly of the urogenital system. The supernumerary kidney in a HSK conjunction is extremely rare, and prevalence of it is unknown. A review of literature, there have been a few case reports about the supernumerary and HSK combination, however, none of which also had a concomitant kidney stone and obstructive pathology. Our case indicated that patient referred to flank pain and visible hematuria to our clinic, and further investigations demonstrate supernumerary kidney in a horseshoe configuration and kidney stone. Kidney stone could not be found at the first attempt because of the anatomical malformation. Retrograde pyelography showed ureteral branching and helps to define the placement of stone. This stone was fragmented with flexible ureteroscopy in the lower pole of the middle kidney in the second session. There was no stone fragments absence at the 1st-month control. This exceedingly rare type case should be evaluated meticulously on preoperative duration otherwise can be a challenge for surgeons. Visualize pelvicalyceal system under the fluoroscope is a vital step in this regard to being guidance during the procedure.
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Imaging modalities for an uncommon inguinal scrotal pathology: A case report and literature review p. 387
Koo Hao Chun, Fam Xeng Inn, Erica Yee Hing, Goh Eng Hong
Inguinal scrotal swelling is a common presentation to surgical clinic with various differential diagnoses. In most circumstances, a good clinical assessment is sufficient to identify the diagnosis. Imaging is necessary when diagnostic difficulty was encountered. The choice of imaging study could affect the management and outcome. A 60-year-old male presented with an enlarging right inguinal scrotal swelling for 5 years. Clinical examination showed a swelling extended from the right inguinal region down to the right scrotum, firm, not reducible, and not separable from the right testis. Differential diagnoses range from the malignant testicular tumor, irreducible inguinal hernia to the soft-tissue tumor. Ultrasonography and computed tomography scan were unable to conclude the origin of the tumor and involvement of the right testis. Inguinal exploration with potential radical orchiectomy was planned and caused much distress to the patient, resulted in delay in surgery. Intraoperatively, the mass was separated from the testis and spermatic cord, and thus, excision biopsy was performed sparing the testis and spermatic cord. Histopathological examination showed cellular angiofibroma. The right choice of imaging modality is important to provide a precise diagnosis and better treatment plan. This could avoid the unnecessary distress to the patient for potential organ lost. A review through the literature showed the ability of magnetic resonance imaging to better delineate the anatomy of inguinal scrotal soft-tissue mass and thus should have been the imaging modality of choice.
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Migration of malleable penile prosthesis p. 390
Abdelrahman Yahya Mohamed, Hatem Althubiany, Salem Bahdilh
Penile prosthesis migration is rare. Most reported cases are migration of inflatable penile prosthesis reservoirs. We reported a case of rectal migration of malleable penile prosthesis passed out as hard bowel motion without patient recognition.
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Benign testicular neoplasm in a human immunodeficiency virus-positive patient masquerading as testicular cancer Highly accessed article p. 393
Mansi Oberoi, Thanmaya Reddy, Jennifer B Gordetsky, John V Thomas, Soroush Rais-Bahrami
Inflammatory myofibroblastic tumor (IMT) is a rare, benign neoplasm comprising spindle myoepithelial cells in the background of inflammatory cells. It can involve multiple anatomic sites in the body but rarely involves the testis. We report a case of 52-year-old male patient with a history of human immunodeficiency virus who presented with a painless, testicular mass for 2 months. Despite being treated with prolonged antibiotics and nonsteroidal anti-inflammatory drugs, scrotal ultrasound demonstrated an increase in the size of the lesion. With a presumed diagnosis of testicular germ cell tumor, a right radical inguinal orchiectomy was performed. Microscopic and immunohistochemical features were consistent with testicular IMT, a benign neoplastic process.
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Epithelioid hemangioma of penis mimicking malignancy: A rare case p. 397
Manjari Kishore, Minakshi Bhardwaj, Arvind Ahuja
Penile epithelioid hemangioma (EH) is a rare vascular neoplasm with no definite etiology. Herein, we report a case of EH of the penis in a 64-year-old man presenting with painless, bleeding mass on the glans penis. The patient underwent local excision, and on histopathological examination, a diagnosis of EH was made. Immunohistochemistry revealed positivity for CD31, smooth muscle antigen, and negative expression of cytokeratin. The present case highlights the importance of histopathology in conjunction with immunohistochemistry to reach a definitive diagnosis of this rare benign entity and differentiating it from the close malignant mimics, thereby avoiding aggressive management of the patients.
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Bladder endocervicosis – A rare diagnosis with a silent presentation p. 400
Sofia Santos-Lopes, Ana Cebola, Ana Afonso, Fernando Ferrito
Bladder endocervicosis is a benign disease, characterized by the presence of ectopic endocervical tissue in the bladder wall, with few cases described in the literature. A case of bladder endocervicosis in a 35-year-old female, with the previous history of cesarean section, subtotal hysterectomy, and right oophorectomy is reported here. The patient was asymptomatic and the bladder lesion was detected on pelvic ultrasonography. Transurethral bladder resection was performed and the histopathological analysis revealed bladder endocervicosis. 12 months of follow-up have passed without evidence of clinical or radiological recurrence. Clinical presentation, pathological features, and treatment are discussed.
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“Horrendoplasty” – A case of total perineal destruction by agricultural implement p. 403
Pedro Simoes de Oliveira, Tiago Ribeiro de Oliveira, David Martinho, Francisco Martins
Although posterior urethral injury occurs almost always in association with pelvic fracture, it may result from severe trauma to the perineum with its associated potential lethality and severe morbidity. Early primary endoscopic realignment over a urethral catheter can be attempted, although an immediate suprapubic tube placement remains the standard of care. Definitive treatment consists of elective open posterior anastomotic urethroplasty through a perineal approach. The authors present a 53-year-old man who sustained total, massive perineal destruction resulting from work accident with an agricultural implement. Immediate suprapubic tube placement was performed followed by delayed elective transperineal anastomotic posterior urethroplasty. A major multidisciplinary approach was necessary in the management strategy, including orthopedic, general, plastic, vascular surgeries, and reconstructive urology teams. At a later stage, with the patient stabilized and recovered from major, life-threatening lesions dealt with by a multidisciplinary team, urethral reconstruction can be undertaken with ultimate good functional outcomes.
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Importance of lower pole nephrectomy during ureterocalicostomy p. 407
Anubhav Raj, Sharmad Kudchadker, Varun Mittal, Sandeep Nunia, Anil Mandhani
Ureterocalicostomy is usually a salvage procedure for recurrent pelvi-ureteric junction (PUJ) stricture or upper ureteric injury. It requires meticulous dissection of the upper ureter, and lower pole nephrectomy is considered an essential step to achieve a wide funneled and dependent ureterocaliceal anastomosis. We, hereby, highlight the importance of guillotine lower pole nephrectomy through a case report of recurrent PUJ stricture managed with ureterocalicostomy that failed due to the omission of lower pole nephrectomy.
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