Urology Annals : 2012 - 4(1)

Natural orifice transluminal endoscopic surgery in urology: Review of the world literature

Wassim M Bazzi — Tue,10 Jan 2012

Wassim M Bazzi, Omer A Raheem, Seth A Cohen, Ithaar H Derweesh

Urology Annals 2012 4(1):1-5

Natural orifice transluminal endoscopic surgery (NOTES) has gained momentum in the recent urologic literature as a new surgical approach for intra-abdominal organs with scarless and painless postoperative recoveries. We sought to review the published literature concerning the safety and reproducibility of NOTES in urology. PubMed literature review of articles published in the English language was performed over a 10-year period, i.e., between 2001 and 2011; all articles were critically reviewed and analyzed. Despite its novelty, pure or hybrid surgical approaches have been adapted in performing NOTES. NOTES essentially utilizes transluminal flexible endoscopic instruments along with laparoscopic instruments to gain access to abdominal, pelvic, and/or retroperitoneal cavities. The preliminary results of NOTES in surgery and to a limited extent in urology appear promising, yet further research in animal survival and human cadaveric models is requisite prior to human applications, especially for complex surgeries. Future innovative research, particularly biomedical engineering, should be directed to improving the technicality and mechanistic application of NOTES; hence, better safety and efficacy of NOTES.

Urinary tract endometriosis: Review of 19 cases

Suresh Kumar — Tue,10 Jan 2012

Suresh Kumar, Punit Tiwari, Pramod Sharma, Amit Goel, Jitendra P Singh, Mukesh K Vijay, Sandeep Gupta, Malay K Bera, Anup K Kundu

Urology Annals 2012 4(1):6-12

Aim: The aim of our study was to evaluate the treatment outcomes of medical and surgical management of urinary tract endometriosis. Materials and Methods: Urinary tract endometriosis patients enrolled between Jan 2006 and May 2010 were retrospectively reviewed. Preoperative datas (mode of presentation, diagnosis, imaging), intraoperative findings (location and size of lesion), postoperative histopathology and follow-up were recorded and results were analyzed and the success rate of different modalities of treatment was calculated. Results: In our study, of nineteen patients, nine had vesical involvement and ten had ureteric involvement. Among the vesical group, the success rate of transurethral resection followed by injection leuproide was 60% (3/5), while among the partial cystectomy group, the success rate was 100%. Among patients with ureteric involvement, success rate of distal ureterectomy and reimplantation was 100%, laparoscopic ureterolysis with Double J stenting followed by injection leuprolide was 75% while that of Gonadotropin- releasing hormone (GnRh) analogue alone was 67%. Conclusion: One should have a high index of suspicion with irritative voiding symptoms with or without hematuria, with negative urine culture, in all premenopausal women to diagnose urinary tract endometriosis. Partial cystectomy is a better alternative to transurethral resection followed by GnRh analogue in vesical endometriosis. Approach to the ureter must be individualised depending upon the severity of disease and dilatation of the upper tract to maximise the preservation of renal function.

Commentary

Ehab Eltahawy — Tue,10 Jan 2012

Ehab Eltahawy, Sami Heshmat

Urology Annals 2012 4(1):12-13

Nonbilharzial squamous cell carcinoma and transitional cell carcinoma with squamous differentiation of the lower and upper urinary tract

Steffen Rausch — Tue,10 Jan 2012

Steffen Rausch, Rainer Hofmann, Rolf von Knobloch

Urology Annals 2012 4(1):14-18

Introduction: Urinary tract squamous cell carcinoma and transitional cell carcinoma with squamous differentiation are rare entities. To characterize tumour biology, prognosis, and therapy, we reviewed our data with squamous cell carcinoma (SCC) and transitional cell carcinoma (TCC/SCC). Materials and Methods: We performed a retrospective single-center analysis of 53 patients with SCC and TCC/SCC treated at our urology department from 30.05.1989 to 30.09.2004. Results: SCC was found in 2% (42/1573) of bladder carcinoma and 7% (11/130) of renal pelvis specimen. Stage pT3 was present in 55% of our patients, indicating a tendency to deep muscular invasion. Nodal and distant metastases appeared in 26%. The overall 5-year survival rate was 26% (tumor specific 46%), with a median survival of 10.5 months. We found that three of four patients with pT2N0 bladder carcinoma could be cured by cystectomy. Lymphnode status was identified as a significant prognostic parameter. For renal pelvis carcinoma, median survival was 7.35 months, with an overall 5-year-survival of 30%. Adjuvant therapy modalities were only performed in a minority of cases, although a therapeutic response was often noticed. Conclusions: SCC is characterized by poor prognosis and individual tumor biology. Survival is related to local tumor extension, indicating the necessity of an early radical surgery. To adequately discuss the role of adjuvant therapy on SCC and TCC/SCC further trials are needed.

Patients with a history of infection and voiding dysfunction are at risk for recurrence after successful endoscopic treatment of vesico ureteral reflux and deserve long-term follow up

R Coletta — Tue,10 Jan 2012

R Coletta, C Olivieri, V Briganti, ML Perrotta, L Oriolo, F Fabbri, A Calisti

Urology Annals 2012 4(1):19-23

Aim of the Study: Subureteral endoscopic injection of a bulking agent is an attractive alternative to open surgery or antibiotic prophylaxis for vesico ureteral reflux (VUR). Little information is available about long-term risk of recurrence after an initially successful treatment. Aim of this paper was to review short- and long-term success rate of endoscopic treatment in a single Center series after risk stratification of individual patients. Materials and Methods: The records of 126 patients who underwent Deflux injection for primary VUR were examined. Indications to treatment were an unvaried high grade VUR (IV-V) at 1 year from diagnosis and/or and recurrent urinary tract infection (UTI) on antibiotic prophylaxis even in the presence of mild grade VUR (III grade). Gender, age and mode of diagnosis, infections (UTI), voiding dysfunctions, VUR grade and side, renal function, number of treatments were correlated to outcome. Long-term evaluation was planned at a minimum of 1 year from the last negative post-injection cystogram (MCUG). A new MCUG and DMSA scan were also offered to those complaining new UTI episodes. Late recurrences were correlated to history and grade of reflux. Data were analyzed with Graph Pad Instat software; the Chi-square test was used for univariate comparisons, the Fisher's exact test for categorical variables.and multiple regression tests for factors influencing outcome. Results: M/F ratio was 62 to 64; median age at diagnosis was 28 months. VUR affected 198 renal units. Preinjection VUR grade was I in 1, II in 27, III in 107, IV in 59, and V in 4 units. Reduced DMSA uptake was evidenced in 51 units and scarring in 24. Median age at treatment was 34.5 months, for persistent high grade VUR (IV-V) in 55 patients and recurrent IVU in 92. Two hundred sixty seven injections were performed on 198 ureters. Complete resolution was documented by MCUG at 3-5 months in 68%, low grading < II in 20%, persistence or unsignificant reduction in 11%. Preoperative recurrent UTI, higher grade VUR, and bilaterality were correlated to a poorer surgical outcome. Among 80 successfully treated cases, 12 complained of persistent UTI. Recurrence of VUR was demonstrated in 31% of them. Deteriorated uptake or additional scarring in 25% was independent from VUR recurrence. Preoperative recurrent UTI and voiding dysfunction correlated significantly to late outcome. Conclusions: Preoperative recurrent IVU, together with high-grade reflux, seem to correlate to lower success rate of Deflux injection for primary VUR. Even after successful endoscopic treatment, long-term surveillance may be needed among these cases, mainly if voiding dysfunction is also recorded. Late recurring VUR must be actively excluded in case of new IVU episodes.

Is tumor size a reliable predictor of histopathological characteristics of renal cell carcinoma?

Song Turun — Tue,10 Jan 2012

Song Turun, Liao Banghua, Shuo Zheng, Qiang Wei

Urology Annals 2012 4(1):24-28

Objectives: To determine whether smaller tumor size is associated with less-aggressiveness in renal cell carcinoma (RCC). Materials and Methods: Series records of 505 patients diagnosed with RCC were retrospectively reviewed and the data concerning tumor size and pathological information were extracted and analyzed. Results: Five hundred and eight RCCs were identified. The mean tumor size was 5.02 ± 2.70 cm. No correlation was detected between the size of tumor and the histological subtype. The overall nuclear grade distribution was 57.1% and 42.9% for low-grade and high-grade disease, respectively. Each 1 cm increase in tumor size was associated with a significant increase in the odds ratio of high-grade disease by 1.46. 91.1% were found low-stage lesions and the odds ratio for the association of high-stage disease with each 1 cm increase in tumor size was 1.67. Multinomial models revealed that each 1 cm increase in the tumor size was associated with a 35% increase in renal capsule involvement and 66% renal vascular invasion. The cut-off point of tumor size in renal vascular invasion was 5.6 cm. Conclusion: Tumor size is not an independent predictor for the histological subtype of RCC. However, it is closely correlated to histopathological features, with the indications that the greater the tumor size, the more aggressive potential the RCC is.

Management of nephrolithiasis in autosomal dominant polycystic kidney disease - A single center experience

Ramen Baishya — Tue,10 Jan 2012

Ramen Baishya, Divya R Dhawan, Abraham Kurien, Arvind Ganpule, Ravindra B Sabnis, Mahesh R Desai

Urology Annals 2012 4(1):29-33

Purpose: To evaluate available options for the management of nephrolithiasis in patients with autosomal dominant polycystic kidney disease (ADPKD). Materials and Methods: Case files of all the patients with ADPKD treated in our hospital in the last 18 years were evaluated. Their demographic details, clinical presentations, investigations, treatments, and outcomes were critically analyzed. Results: There were a total of 19 patients (23 renal units) with nephrolithiasis among 452 consecutive cases of ADPKD. Male-to-female ratio was 3.75:1. The mean age of the patients was 43.3 years (range 23 to 60 years). The most common presentations were pain and hematuria (27.7% each). Mean serum creatinine was 7.2 mg/ dl (range 0.8-18.1 mg/dl) at presentation. The mean stone size was 115 mm 2 (range 36 to 980 mm 2 ). The majority of the stones were calyceal (n = 10). Ten renal units (nine patients) required intervention, while the rest were treated conservatively. Treatment offered included open nephrectomy for non-functioning infected kidney (n = 1), extracorporeal shock wave lithotripsy (ESWL, n = 3), ureterorenoscopy (URS, n = 3), and percutaneous nephrolithotomy (PCNL, n = 3). All patients undergoing URS and PCNL had complete clearance, while those undergoing ESWL had a residual stone. Two failed ESWL patients required an auxiliary procedure (retrograde intrarenal surgery, RIRS) and the other was kept under observation. Mean follow-up after treatment was 4.2 years (one month to six years). None of the patients had major complications. Conclusion: Careful selection of the endourological procedure can give good results in patients of ADPKD with nephrolithiasis.

Laparoscopic transperitoneal ureterolithotomy for large ureteric stones

Ahmed Al-Sayyad — Tue,10 Jan 2012

Ahmed Al-Sayyad

Urology Annals 2012 4(1):34-37

Objectives: To evaluate the efficacy and safety of laparoscopic transperitoneal ureterolithotomy for management of large proximal ureteric stones. Materials and Methods: Medical records of patients who underwent laparoscopic transperitoneal ureterolithotomy for proximal ureteral stones ≥2 cm were reviewed retrospectively. Patients' characteristics, stone characteristics, perioperative and follow-up data were studied. Patients with stones <2 cm in size, previous transperitoneal surgical procedure, or follow-up duration <6 months were excluded from the study. Results: Twelve patients (mean age = 52.9 ± 12 years) with large upper ureteric stones (mean stone largest diameter = 39 ± 13 mm) were included. Nine patients had single stone, 2 patients had two stones, and 1 patient had large impacted stone with 2 small stones floating above. Mean operative time was 107 ± 49.5 min with mean blood loss of 60.5 ± 19.2 cc. Mean total pain score was 38.4 ± 5.5 (100 point scale) and mean time till resuming oral intake was 3.6 ± 0.5 h. Mean duration of hospital stay was 2.6 ± 1.4 days and mean duration of stenting was 7.3 ± 2 weeks. Throughout a mean duration of follow-up of 14.8 ± 7.6 months, 100% stone clearance rate was achieved with no recurrence. One patient developed a ureteric stricture treated by laser endoureterotomy and stenting for 6 weeks and responded without re-stricture formation. Conclusion: Laparoscopic transperitoneal ureterolithotomy is a safe and effective approach for selected patients with large proximal ureteric stones with reduced postoperative pain and short hospital stay, and should be considered as a treatment option for such stones.

Cystoscopic enucleation of bladder leiomyoma

Ghassan A Barayan — Tue,10 Jan 2012

Ghassan A Barayan, Anmar M Nassir

Urology Annals 2012 4(1):38-40

We are presenting a rare case of bladder leiomyoma. A 61-year-old female patient was found to have a bladder mass during a work up of lower urinary tract symptoms. After full investigation, she underwent transurethral excision of the mass. The histopathology revealed typical feature of bladder leiomyoma. No recurrence was seen after a follow-up period of 12 months.

Post percutaneous nephrolithotripsy nephrostomy site tuberculosis: A report of six cases

Rahul Gupta — Tue,10 Jan 2012

Rahul Gupta, Arti Mahajan, Chaman Gupta

Urology Annals 2012 4(1):41-44

With the increase in endoscopic surgery, there is a growing concern about the effectiveness of sterilizing reusable equipment by immersion in 2% glutaraldehyde. Although reports of port site tuberculosis (post laparoscopy) are there in the literature, those of nephrostomy site post percutaneous nephrolithotripsy are not available. We describe the clinical features and treatment of six patients who presented with biopsy-proven skin tuberculosis at the nephrostomy-site for non-healing wound.

Lymphoepithelioma-like carcinoma of the urinary bladder: A case report and review of systemic treatment options

Nicholas M Pantelides — Tue,10 Jan 2012

Nicholas M Pantelides, Stella L Ivaz, Alison Falconer, Steven Hazell, Mathias Winkler, David Hrouda, Erik K Mayer

Urology Annals 2012 4(1):45-47

Lymphoepithelioma-like carcinoma (LELC) of the urinary bladder is a rare variant, which can occur in a pure form or in conjunction with transitional cell carcinoma. Owing to the scarcity of reported cases, the optimum treatment is yet to be defined, although the benefits of chemotherapy are increasingly recognised. We present a case of a 64-year-old man with pure LELC, treated with trans-urethral resection of the bladder tumor (TURBT) and primary gemcitabine and platinum-based chemotherapy. He remained free of disease at six-month follow-up cystoscopy. The case adds to the growing evidence for the efficacy of chemotherapy, coupled with TUR, as part of a bladder-preserving treatment option for LELC.

Primary renal leiomyosarcoma: A diagnostic challenge

Shashi Dhawan — Tue,10 Jan 2012

Shashi Dhawan, Prem Chopra, Sanjay Dhawan

Urology Annals 2012 4(1):48-50

Primary leiomyosarcoma is an extremely rare entity constituting only 0.5-1% of all invasive renal tumors. It is frequently diagnosed on histological examination because it does not have any specific diagnostic features clinically and radiologically. At times, it is difficult to differentiate leiomyosarcoma from the sarcomatoid renal cell carcinoma even in histopathology as both the tumors have spindle-shaped atypical cells. Moreover, some epithelial markers can be present in pure smooth muscle sarcomas, while some smooth muscle markers are positive in carcinomas. Hence, a diagnosis of primary renal leiomyosarcoma should be made with caution. Since the prognosis for a renal sarcoma is particularly poor, differentiation from sarcomatoid renal cell carcinoma is necessary. The diagnostic challenge of one such tumor is discussed.

Xanthogranulomatous pyelonephritis presenting with thrombocytopenia and renal mass

Majid Malaki — Tue,10 Jan 2012

Majid Malaki, Masood Jamshidi, Farzad Ilkhchooyi

Urology Annals 2012 4(1):51-54

Xanthogranulomatous pyelonephritis (XGP) is a rare event in children without any predisposing factor like calculi, obstruction or vesicoureteral reflux. In this case we report a four-year-old girl who presented with a renal mass, hematuria, flank pain, anemia and thrombocytopenia-these signs and symptoms misled us to Wilms tumor. Thrombocytopenia which is a strange event in XGP resolved after nephrectomy. Normal contra lateral kidney was infected four months after right nephrectomy. This suggests that these patients should be under strict surveillance and antibiotic prophylaxis as they are a high-risk group for urinary tract infection, and thrombocytopenia should be considered as a laboratory test finding in XGP.

Symptomatic giant adrenal myelolipoma associated with cholelithiasis: Two case reports

Shahina Bano — Tue,10 Jan 2012

Shahina Bano, Sachchida Nand Yadav, Vikas Chaudhary, Umesh Chandra Garga

Urology Annals 2012 4(1):55-60

In this article, we have discussed about two cases of adrenal myelolipoma and aim to discuss the role of imaging in their diagnosis and their management. Different imaging techniques such as ultrasound, computed tomography and magnetic resonance imaging were used to aid in diagnosis in each of the cases. The findings have been highlighted here. In each of the cases, the diagnosis could be confirmed by imaging, and there was cholelithiasis seen associated with unilateral adrenal myelolipoma. Adrenal myelolipomas are rare, benign, non-functional tumors of adrenal gland. Most tumors are unilateral and small; bilateral, giant myelolipomas are extremely rare. The association of adrenal myelolipoma with gallstones is uncommon. To our knowledge only two cases of such an association have been reported in the literature. However, the possibility does exist and steps should be taken to ensure a complete diagnosis. Also, it is important to understand the key points which help us in diagnosing adrenal myelolipomas by imaging.

A typical category in the voided urine samples

Viroj Wiwanitkit — Tue,10 Jan 2012

Viroj Wiwanitkit

Urology Annals 2012 4(1):61-61