Conservative management of an early abdominal complication during a Tullio percutaneous endoscopic excision of renal pelvis urothelial carcinoma: A case report

BACKGROUND

Upper tract urothelial carcinoma (UTUC) representing only a small fraction of all urothelial tumors. It predominantly affects the renal pelvis in men, often coexisting with bladder carcinoma. UTUC displays a more aggressive genetic profile compared to bladder neoplasms, with the majority of patients presenting with advanced disease. Histologically, about a quarter of UTUC cases exhibit high-grade subtypes, associated with a worse prognosis. Tobacco use and past exposure to aromatic amines are significant risk factors for UTUC. Imaging modalities such as Uro-computed tomography and magnetic resonance imaging play crucial roles in diagnosis. Ureterorenoscopy is vital for direct visualization and biopsy sampling, but its limited sampling capacity presents challenges in determining tumor depth and staging. Traditionally, nephroureterectomy with bladder cuff excision has been the gold-standard treatment for UTUC. Endoscopic conservative treatment has recently emerged as a viable option for selected patients, offering comparable oncological outcomes to radical surgery. Percutaneous access is also feasible for larger intrarenal tumors.

CASE SUMMARY

We present a case of an 84-year-old woman who underwent percutaneous endoscopic excision of a renal pelvis neoplasm using the Tullio laser. Despite successful tumor removal, the patient experienced a postoperative complication with abdominal fluid leakage. Conservative management effectively resolved the complication. Given the patient's age and refusal for radical surgery, the conservative approach proved to be a valid therapeutic choice.

CONCLUSION

Overall, UTUC remains a diagnostic and therapeutic challenge due to its rarity. However, advances in endoscopic and percutaneous techniques provide valuable alternatives for selected patients, warranting further exploration in this evolving field.

Phallic rubber band application to prevent enuresis unusual cause of urethral stricture in a child: A case report

BACKGROUND

Urethral stricture is the abnormal narrowing of the urethra due to spongiofibrosis. The established aetiological factors for urethral stricture abound in our environment. However, the application of a penile rubber band to prevent enuresis thereby causing this pathology is not a familiar occurrence. Patients with enuresis can suffer psycho-social challenges and trauma, especially for a child due to peer stigmatization. This has a great impact on the child's psyche and may affect even his performance at school. The aim of this paper is to highlight the psychosocial impact and management challenges of a child with enuresis (nocturnal urinary incontinence).

CASE SUMMARY

This is the case of a 10-year-old boy who presented with a history of nocturnal urinary incontinence since birth and lower urinary tract symptoms (LUTS) for 3 years culminating in chronic urinary retention. He maintained a normal urge to micturate and continent of urine during the daytime before the onset of LUTS. He had an antecedent longstanding history of tying a rubber band to the penile shaft mostly before going to the bed at night to prevent enuresis due to his peer stigmatization. He was acutely ill-looking, with distended suprapubic region. The phallus and scrotum were enlarged and oedematous with a circumferential proximal penile shaft scar and ventral penile shaft urethrocutaneous fistula. He was diagnosed to have complete short segment bulbopenile stricture and right ectopic ureter. He subsequent had augmented anastomotic urethroplasty and bilateral non-refluxing ureteroneocystostomy at different sitting.

CONCLUSION

The adherence to surgical principles of urethral stricture and enuresis management where surgically correctable in a child is associated with the resolution of enuresis and social reintegration.

Top 50 most cited articles on prostatic artery embolization for benign prostatic hyperplasia: A bibliometric review

BACKGROUND

Bibliometric analysis can be used to assess the current state of the literature and publication trends on a given topic. There has not been a review of this kind on prostatic artery embolization (PAE) for benign prostatic hyperplasia (BPH). PAE is a relatively new and somewhat controversial treatment option for BPH. Given the novelty and controversy, there has been much research published on the topic recently.

AIM

To survey the current state of research on PAE for BPH by using bibliometric analysis to analyze the top 50 most highly cited articles.

METHODS

A cross-sectional study was performed using the Web of Science database to identify the most cited articles published on PAE for BPH as of June 2022. Articles that did not primarily focus on PAE or BPH as an indication were eliminated. The 50 most cited articles were carried forward for analysis.

RESULTS

All but 6 articles were published in the last decade with contributions from 15 countries. Fifty-two percent of the studies had a C level of evidence. The majority were published in the Journal of Vascular and Interventional Radiology and Cardiovascular and Interventional Radiology. Twenty percent (n = 10) of the articles were published in urologic journals. On average, articles published in urologic journals tended to be more recent. The mean year of publication for an article in a urological journal was 2016.6 compared to 2013.9 in a non-urologic journal (P = 0.02). Seventy percent of the articles focused on clinical outcomes, while only 2% focused on practice guidelines. Self-citations accounted for 11.4 citations per article on average, corresponding to 14.7% of all citations analyzed.

CONCLUSION

The most influential papers on this topic represent a fairly recent body of work with contributions from a wide variety of countries and journals. The fact that articles in urologic journals were published significantly more recently than articles on the list in non-urologic journals may suggest that the field of urology is starting to accept PAE for a wider range of indications. Finally, while there has been much high-quality research published, more influential studies on practice guidelines and technique may be beneficial.

Scrotal strangulation in the differential diagnosis of acute scrotum: A case report

BACKGROUND

Acute scrotal pain and swelling are common presentations in the emergency department. Urgent surgical intervention is justified in up to one-third of cases, whereas two-thirds of them should be treated conservatively.

CASE SUMMARY

We report a case of scrotal only strangulation in a child and review the available literature.

CONCLUSION

Due to its rarity, scrotal strangulation can be a diagnostic challenge. Skin ulceration and edema may well indicate the presence of a strangulation object. A high index of suspicion and appropriate physical examination, especially in patients with a mental disability or behavioral disorder, are key to early diagnosis and treatment.

Perinephric urinoma, an unusual upper tract presentation of a lower tract injury following retroperitoneoscopy: A case report

BACKGROUND

A 66-year-old lady was referred to urology for a suspected urinoma after retroperioneoscopy done for debridement of a retroperitoneal abscess that developed following a duodenal perforation.

CASE SUMMARY

Serous contents of the drain sent for fluid creatinine were elevated confirming this and computed tomography urography findings suggested an upper tract injury with urinoma around the kidney. However, the antegrade nephrostogram suggested otherwise and on flexible cystoscopy and cystogram, an extraperitoneal bladder perforation was instead identified, with tip of retroperitoneal drain sitting inside the bladder.

CONCLUSION

This case identifies a limitation in the usual diagnostic approach for such injuries and emphasizes the need to exercise caution when managing them especially when they occur after several surgical procedures and in the presence of multiple surgical drains.

Estimation of successful capping with complete aspiration of bladder via nephroureterostomy tube

BACKGROUND

Ureteral stent and nephroureterostomy tube (NUT) are treatments of ureteral obstruction. Ureteral stent provides better quality of life. Internalization of NUT is desired whenever possible.

AIM

To assess outcomes of capping trial among cancer patients with complete aspiration of retained contrast from bladder via NUT.

METHODS

Our Institutional Review Board approved retrospective review of all NUT placement, NUT exchange and conversion of nephrostomy catheter into NUT performed during June 2013 to June 2015 (n = 578). Cases were excluded due to lack of imaging of bladder (n = 37), incomplete aspiration of bladder (n = 324), no attempt at capping NUT (n = 166), and patients with confounding factors interfering with results of capping trial including non-compliant bladder, bladder outlet obstruction and catheter malposition (n = 14). Study group consisted of 37 procedures in 34 patients (male 19, female 15, age 2-83 years, average 58, median 61) most with cancer (prostate 8, endometrial 5, bladder 4, colorectal 4, breast 2, gastric 2, neuroblastoma 2, cervical 1, ovarian 1, renal 1, sarcoma 1, urothelial 1 and testicular 1) and one with Crohn’s disease. Medical records were reviewed to assess outcomes of capping trial. Exact 95% confidence intervals (95%CI) were calculated.

RESULTS

Among patients with complete aspiration of retained contrast, 30 (81%, 95%CI: 0.65-0.92) catheters were successfully capped (range 12-94 d, average 40, median 24.5) until planned conversion to internal stent (23), routine exchange (5), removal (1) or death unrelated to catheter (1). Seven capping trials (19%, 95%CI: 0.08-0.35) were unsuccessful (range 2-22 d, average 12, median 10) due to leakage (3), elevated creatinine (2), fever/hematuria (1) and nausea/vomiting (1).

CONCLUSION

Capping trial success among patients with complete aspiration of retained contrast/urine from bladder via NUT appears high.

Evaluation of patient reported outcome measures post urethroplasty: Piloting a “Trifecta” approach

BACKGROUND

Buccal mucosal graft urethroplasty is the gold standard treatment for urethral stricture disease. Toowoomba has obtained a fellowship trained urethroplasty surgeon who has been performing urethroplasties for the last two years. Patient reported outcome measure (PROM) questionnaires allow for a detailed and standardized analysis of success and morbidity post urethroplasty and can be used as a reference point against which urethral surgeons can benchmark their performance.

AIM

To assess whether patient compliance rates improved with the use of an abridged PROM questionnaire.

METHODS

Our database of urethroplasty patients was searched to identify patients who had completed the original PROM. This is routinely requested to be completed at the 3-, 6- and 12-mo mark. All patients are asked to complete the questionnaire and to bring it back to their next appointment. Our original PROM consists of the international prostate symptom score, the sexual health index measure and the Global Response Assessment. An abridged version of the questionnaire was derived focusing on urinary flow, sexual function and overall quality of life and consisted of three questions.

RESULTS

Sixty-six patients were included in our study. Fifty-four patients had been invited to complete the original PROM with an overall compliance rate of 30%. Compliance rates improved to 91% with the introduction of the modified PROM. No correlation between non-compliance and patient factors were found. There was also no significant difference in patient reported quality of life when comparing urinary flow and sexual function.

CONCLUSION

We recommend the use of PROMs pre- and post-operatively to accurately determine the level of patient satisfaction. We acknowledge the aversion of patients in completing PROMs due to the length of these questionnaires. We propose a simplistic version aimed at the “Trifecta” of urethroplasty comprising of three questions focusing each on urinary flow, sexual function and quality of life. Our modified PROM demonstrated markedly improved compliance rates and can be used as a screening tool to identify patients who might have had a poor outcome and who require a more in-depth assessment.

Prostate resection speed: A key factor for training and broad outcomes?

BACKGROUND

Trans-urethral resection of prostate (TURP) is one of the most commonly performed operations in urology to treat bladder outflow obstruction (BOO) in men. TURP surgery is also a key for endo-urological training in the British National Health Service (NHS) for training junior urologists. The working hypothesis is that prostate resection speed (PRS) in the context of bipolar TURP surgery, is not a key factor in major complication rates or broad patient outcomes at 3 mo after surgery, and therefore supervising consultants should not focus primarily on resection speed when teaching TURP.

AIM

To investigate objective differences in consultants vs trainees PRS and whether PRS affected complication rates/outcomes after TURP.

METHODS

Retrospective descriptive study analyzing patient case-notes, operative and electronic records, study undertaken at Burton Queen’s Hospital NHS Foundation Trust, United Kingdom, a secondary care centre in the public sector of the NHS. Participants included: all Bipolar TURPs undertaken between 13/04/2016 and 27/06/2017. Exclusions: patients undergoing concomitant operations or where intra-operative equipment problems occurred. Resected prostate (g), operative time, post-operative complications and outcomes at 3-mo were obtained from electronic records. Clavien-Dindo Grade II complications or above considered significant. Binary successful yes/no outcome at 3-mo after surgery included both patients who reported moderate to significant symptom improvement, or being catheter-free for those catheterized before TURP.

RESULTS

157 patients were identified. After exclusion a total of 125 patients were included from analysis. The mean PRS for trainees (0.34 g/min) was found to be lower than the mean PRS for consultants (0.41 g/min). The operating urologist’s PRS was not observed to be related to the number of TURPs that they performed during the period of the study. The trainee vs consultant means post-operative success rates (86.5% vs 90.5%) were comparable. The Trainees’ patients did not suffer any significant complications as defined by the study. There was no clear relationship observed between PRS and the rate of significant post-operative complications or patients’ 3-mo binary successful outcome. PRS was noted to increase with increasing intra-operative experience for both Trainees 1 and 2 when comparing the first half of their TURPs to their latter half.

CONCLUSION

Consultants have a higher PRS in comparison to trainees. There is no trend between PRS and significant post-operative complication rates or 3-mo outcomes.

Neutrophil-lymphocyte ratio in the management and prediction of outcomes in renal cell carcinoma

Renal cell carcinoma (RCC) is one of the ten most common malignancies. The prognosis of RCC is poor when the disease is in advanced stages, with five-year survival of less than 10%. However current assessment approaches are limited in their ability to prognosticate and guide therapeutic decision-making. Cellular-mediated inflammatory response is increasingly being recognised to have an important role in carcinogenesis of RCC. Various inflammatory markers have been found to identify patients with RCC at high risk of recurrence and predict survival. Neutrophil-lymphocyte ratio (NLR) is a simple and inexpensive inflammatory marker that has been shown to be of value in the assessment of patients with RCC. An elevated pretreatment NLR has been found to be associated with reduced overall survival, recurrence-free survival and progress-free survival and risk of recurrence in localized RCC. In addition, lower pretreatment NLR has been demonstrated to be associated with better clinical response to systemic therapy including vascular endothelial growth factor inhibitors, among patients with metastatic RCC. However, NLR has not been found to differentiate whether small renal masses of less than 40 mm are benign or malignant. Further research is needed to determine the cut-offs for NLR to predict different clinical outcomes and how post-treatment NLR can be used. In addition, more work is also needed to evaluate combining NLR with other biomarkers in a model to predict patients’ clinical outcome or response to treatment for RCC.

Urinary supersaturation as a diagnostic measure in urolithiasis

AIM

To demonstrate that urinary supersaturation per se is not a reliable diagnostic measure of the risk for stone formation.

METHODS

Available physical and chemical data for calcium oxalate monohydrate (COM) and calcium hydrogen phosphate dihydrate (brushite, BRU), and urinary supersaturations with respect to COM and BRU in healthy individuals and stone formers, were obtained from the literature. Classical theory of nucleation was used for calculations.

RESULTS

It was found that the rate of homogeneous nucleation (unaided by substrates) of COM and BRU is nil at all conceivable supersaturations of urine. Consequently spontaneous formation of crystals in urine requires the presence of nucleation substrates for (heteronuclei).

CONCLUSION

Urinary supersaturation with respect to lithiatic compounds is a necessary, but not a sufficient condition for nephrolithiasis. The absence of crystallization inhibitors and the presence of efficient nucleation promoters (heteronuclei) in urine are further necessary conditions of urolithiasis occurrence. Urinary supersaturation per se is not a reliable diagnostic measure of the risk of kidney stone formation.

Recirculating chemohyperthermia as a treatment for non-muscle invasive bladder cancer: Current and future perspectives

About 75% of all bladder cancer diagnosed are non-muscle invasive bladder cancer (NMIBC), recurring over 50% of them after transurethral resection of the bladder tumor. In order to prevent recurrences, adjuvant intravesical chemotherapy with mitomycin C and immunotherapy with bacillus Calmette-Guérin (BCG) is traditionally used. Unfortunately, many patients relapse after receiving these treatments and a significant proportion of them require surgery. After a one-to-three years BCG maintenance, the risk for progression at 5 years was 19.3% for T1G3 tumors. Many new treatment approaches are being investigated to increase the effectiveness of adjuvant intravesical therapy. One of the developing treatments for intermediate and high-risk NMIBC is the combination of intravesical chemotherapy and hyperthermia, called chemohyperthermia. This article provides a review of the mechanism of action, current status and indications, results and future perspectives.

Combined urethral and suprapubic catheter drainage improves post operative management after open simple prostatectomy without bladder irrigation

AIM

To compare outcomes after open simple prostatectomy without bladder irrigation, in subjects drained by combined 2-way urethral catheter and suprapubic catheter (SPC) vs those drained by 2-way urethral catheter only.

METHODS

A total of 84 participants undergoing Freyer’s simple prostatectomy over an 18-mo period were randomized into 2 groups (n = 42). Subjects in group 1 were managed with 2-way urethral catheter and in situ 2-way SPC while subjects in group 2 had a 2-way urethral catheter drainage only. In group 1 subjects, the SPC was spigotted and only used for drainage if there was clot retention. The primary outcomes were number of clot retention episodes, and number of clot retention episodes requiring bladder syringe evacuation. Other secondary outcomes evaluated were blood loss, requirement of extra analgesics, duration of surgery, hospital stay and presence or absence of post-op complications.

RESULTS

The mean age in the groups was 65.7 (± 7.6) in group 1 vs 64.8 (± 6.8) in group 2. The groups were similar with respect to age, prostate specific antigen, prostate volume, blood loss, duration of surgery, blood transfusion and overall complication rate. However statistically significant differences were observed in clot retention episodes between group 1 and 2: 0.8 (± 1.5) vs 3.5 (± 4.4), P < 0.000, clot retention episodes requiring evacuation with bladder syringe 0.4 (± 0.9) vs 2.6 (± 3.8), P = 0.001, requirement of extra analgesics 0.4 (± 0.5) vs 4.0 (± 1.5), P < 0.000 and duration of admission 8.6 d (± 1.2) vs 7.3 d (± 0.6), P < 0.000.

CONCLUSION

Subjects drained with a combination of urethral and SPCs have fewer clot retention episodes and reduced requirement of extra analgesics but slightly longer hospital stay.

Radical cystectomy and en-bloc resection of enterovesical fistula from bladder cancer

Enterovesical fistulae secondary to benign or malignant bowel disease are not uncommonly reported in the literature. However, bladder malignancy as the primary pathology is exceedingly rare. We report a case of muscle invasive urothelial carcinoma of bladder with an enterovesical fistula to a loop of small bowel. The patient first presented with signs and symptoms of per rectal bleeding, haematuria, pneumaturia, faecaluria and rectal micturition. Her initial biochemistry test revealed significant metabolic acidosis with normal anion gap and hypokalemia. A computed tomography abdomen/pelvis with rectal contrast demonstrated an enterovesical fistula from the dome of bladder to a loop of small bowel. The patient underwent radical cystectomy with en-bloc resection of a loop of involved ileum and sigmoid colon due to the intraoperative findings of the sigmoid colon adherent to the tumour. The published literature is reviewed, focusing on the incidence, diagnostic modality and treatment strategies available for this rare condition.

Chronic kidney disease after radical nephrectomy for suspected renal cancers

Nephrectomy is the treatment of choice for early stage renal cell carcinoma. However, radical nephrectomy is consistently associated with higher rates of new-onset chronic kidney disease (CKD) than the general population, regardless of the method used in measuring renal function. The higher rates of CKD are associated with worsened survival because of increased risk of cardiovascular diseases and mortality. Comorbidities and adjacent non-neoplastic kidney diseases are important risk factors for the development of CKD after nephrectomy. Partial nephrectomy has become the standard of care for patients with stage 1a tumours (diameter < 4 cm) and an attractive option for those with stage 1b (diameter 4-7 cm). Therefore stratifying the risk of postoperative CKD before surgery is important and ongoing monitoring of kidney function after radical nephrectomy is needed in addition to oncological surveillance. More research is needed to better understand the risk of CKD after radical nephrectomy and develop effective strategies to optimize kidney function after such surgery.

Urine chemokine levels correlate with treatment response to phosphodiesterase 4 inhibitor in prostatitis

AIM

To investigate the association of urinary chemokines with the treatment response in chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) patients.

METHODS

Between 2007-2011, 18 out of 21 male CP/CPPS patients met the exclusion/inclusion criteria of the 16 wk longitudinal study on twice daily oral treatment with Phosphodiesterase 4 inhibitor called Apremilast for 12 wk. Symptom scores and urine specimen were collected at baseline and every visit at 4 wk interval from CP/CPPS patients who completed at least 8 wk of drug treatment. Urine collected at each visit was frozen and then analyzed together after thawing for chemokines and growth factors using MILLIPLEX™ MAP immunoassay. Cross sectional association of Chronic Prostatitis Symptom Index (CPSI) and visual analog scale (VAS) with chemokine levels in urine collected at baseline was assessed in 18 CP/CPPS patients relative to 10 asymptomatic male subjects. Longitudinal association between urine chemokine levels and symptom scores was assessed in 8 treatment-adherent CP/CPPS patients at baseline and at 4, 8, 12 and 16 wk.

RESULTS

Urine chemokines levels of CXCL-1 (GRO-a), CXCL-8 (IL-8), CXCL-10 (IP-10) and CCL5 (RANTES) in CP/CPPS patients at baseline were significantly elevated relative to asymptomatic subjects, whereas levels of sIL-1RA in CP/CPPS were significantly lower compared to controls (P < 0.05). Quantitatively, urine levels of CXCL-10 were higher than other chemokines in CP/CPPS, but its 5 fold change relative to controls was lower than the 20 fold change noted for CXCL-8. The mean age of enrolled patients who completed at least 8 wk of treatment (n = 8) was 46.5 ± 9.4 years and analysis found that elevation of CXCL-8 and CCL5 increased the odds for higher score of CPSI by 54% and 25%, respectively (F test, P = 0.00007). Urine levels of CCL2 (MCP-1) and CXCL-10 together explained approximately 85% of variance in longitudinal data on multivariate analysis. Bivariate analysis of 5 patients who fully complied and completed the assigned dose regimen, showed strong linear correlation of reduced urine levels of CXCL-10, CXCL-8, CCL5, CCL2 and PDGF with improvement in clinical activity as measured by pain VAS and CPSI (Pearson r = 0.83-0.97; P < 0.05).

CONCLUSION

Urine levels of CXCL-10, CCL2 and PDGF can be sensitive, objective and non-invasive markers of response to new therapeutic intervention in CP/CPPS patients.

Contemporary management of upper tract urothelial cell carcinoma

Upper tract urothelial cell carcinoma (UTUCC), formerly known as transitional cell carcinoma of the upper urinary tract, is a rare oncologic disease in Western countries. Thus its disease process and its management are not as well defined as other urologic cancers. We are reviewing the current evidence based literature available to develop a plan for the treatment of UTUCC. A PubMed search was completed using the key words “upper tract urothelial cell carcinoma”, “epidemiology”, “risk factor”, “treatment” and “prognosis”. Six hundred fifty two articles were found. We narrowed our search to articles published between January 2004 and June 2016 for a more contemporary review of the topic. Four hundred seventy articles were then available for review. Further detailed search was performed for relevance on the topic and hundred one articles were selected for the review. Many risk factors have been found to be associated with the development of UTUCC, including tobacco use. Patients are often asymptomatic and may only present with microscopic or gross hematuria. Tumor grade and stage are pivotal in determining the treatment options for UTUCC. Advancements in endoscopic techniques have aided in the diagnosis, grading and treatment of this disease. Treatment options include topical therapy, with combinations of methotrexate, vinblastine, doxorubicin and cisplatin or gemcitibine or cisplatin, endoscopic resection, segmental ureterectomy and ureteral implantation, and nephroureterectomy, including bladder cuff. Treatment recommendations depend on tumor grade and stage, renal function, tumor location and the patient’s prognosis. There are currently no tissue or blood-based biomarkers available to accurately monitor the disease. Further studies of gene expression and biomarkers may hopefully improve the management of this disease. Although rare in many countries, UTUCC is becoming more prevalent due to exposure to carcinogenic herbal remedies and other identifiable risk factors. Numerous treatment modalities, both surgical and chemotherapeutic, have been utilized to treat both low and high grade UTUCC tumors. Additional clinical trials are necessary to further develop methods for screening, treatment, and surveillance to improve management.

Classical seminoma in a 92-year-old patient

Seminoma is a germ cell tumour which primarily affects the testes. Seminomas are treated by orchidectomy with usually excellent outcomes. We report the occurrence of a classical seminoma in a 92-year-old man, who is currently the oldest patient with this histology reported in literature. He presented with a painful, swollen testis. Scrotal ultrasound scan revealed a testicular mass. A left inguinal orchidectomy was carried out and histological examination confirmed the diagnosis of a classical seminoma. Further staging by computerised tomography revealed pulmonary lesions suspicious of metastases. The patient declined further treatment in view of his age and co-morbidities.

Enuresis and sleep disordered breathing: An old and new link

The causes of nocturnal enuresis (NE) are likely multifactorial. It has been related to several (urological-nephrological-hormonal) reasons but clear and univocal pathogenesis remains mostly undetermined. Sleep disordered breathing (SDB) is a syndrome of upper airway dysfunction that occurs during sleep and is characterized by snoring and/or increased respiratory effort secondary to increased upper airway resistance and pharyngeal collapsibility. Adenotonsillar hypertrophy is the main cause of SDB in children. To date, several studies have associated childhood NE with coexistent SDB. Adenotonsillectomy was successful for both SDB and NE in about half of patients. Unfortunately, practical consensus guidelines for the management of primary NE do not mention, or marginally concern, SDB in these children, particularly in those who have treatment resistance and comorbidities. The concerns regard the concomitant presence of two relatively frequent sleep disorders, raising the question whether they are really coincidental problems of childhood.

Splenunculi mimicking metastases in a patient with locally advanced prostate cancer

A 61-year-old man with locally advanced prostate cancer was found to have multiple solid intra-abdominal solid lesions during staging investigations. While some were in the pelvis, they were not located in the common landing sites for prostate cancer metastases, and his prostate specific antigen was not significantly elevated to suggest a high burden of metastatic disease. He reported a history of a blunt abdominal trauma due to a motor vehicle accident more than forty years ago which had been conservatively managed. His staging imaging revealed a lack of a discrete spleen in his left upper abdomen and this raised the suspicion that these solid lesions may represent ectopic splenic tissue. Imaging with nuclear medicine scintigraphy confirmed the lesions in his upper abdomen and pelvis to be splenunculi. He proceeded with a combination of androgen deprivation therapy and external beam radiotherapy for locally advanced, non-metastatic prostate cancer. Although it has been described in patients with low risk prostate cancer, this is the first case report of splenunculi mimicking metastases in a patient with locally advanced prostate cancer.

Does the molecular classification of breast cancer point the way for biomarker identification in prostate cancer?

There is significant variation in clinical outcome between patients diagnosed with prostate cancer (CaP). Although useful, statistical nomograms and risk stratification tools alone do not always accurately predict an individual’s need for and response to treatment. The factors that determine this variation are not fully elucidated. In particular, cellular response to androgen ablation and subsequent paracrine/autocrine adaptation is poorly understood and despite best therapies, median survival in castrate resistant patients is only approximately 35 mo. We propose that one way of understanding this is to look for correlates in other comparable malignancies, such as breast cancer, where markers of at least 4 distinct gene clusters coding for 4 different phenotypic subtypes have been identified. These subtypes have been shown to demonstrate prognostic significance and successfully guide appropriate treatment regimens. In this paper we assess and review the evidence demonstrating parallels in the biology and treatment approach between breast and CaP, and consider the feasibility of patients with CaP being stratified into different molecular classes that could be used to complement prostate specific antigen and histological grading for clinical decision making. We show that there are significant correlations between the molecular classification of breast and CaP and explain how techniques used successfully to predict response to treatment in breast cancer can be applied to the prostate. Molecular phenotyping is possible in CaP and identification of distinct subtypes may allow personalised risk stratification way beyond that currently available.

Efficacy and safety of onabotulinum toxin A for overactive bladder

Overactive bladder (OAB) syndrome is a condition which affects 16.9% of women and 16.2% of men with a significant negative impact on quality of life. It is a condition characterized by urgency, with or without urge incontinence, frequency and nocturia. Behavioral modifications and oral anti-muscurinic medications are first and second-line therapies for OAB but are frequently ineffective or poorly tolerated. For refractory cases of OAB, onabotulinum toxin can be offered and this therapy was approved by the Food and Drug Administration in January of 2013. In this editorial, we will review the indications, usage, efficacy and safety data for intradetrusor injection of onabotulinum toxin A.

Cost effectiveness of robot-assisted urologic oncological surgery in the United States

Urology has been on the forefront of technological advances in minimally invasive surgery, from laparoscopy to robot-assisted surgeries. As with all new technological advances in medicine, the results of new advances are compared to previously established gold standards. When it comes to robot-assisted urology, morbidity, oncological outcomes, and cost between the same surgeries performed in an open fashion vs with robot-assistance should be assessed. Because healthcare spending is increasingly under more scrutiny, there is debate on the cost effectiveness of robot-assisted surgeries given the high acquisition and maintenance cost of robotic systems. This articles aims to critically evaluate the cost effectiveness of robot-assisted surgeries for prostatectomies, cystectomies, and partial nephrectomies in the United States.

Use of synthetic grafts in pelvic reconstruction: A path of continued discovery

Since the 1990s, mesh has been used in pelvic reconstruction to augment repairs for stress urinary incontinence and pelvic organ prolapse (POP). In 2008 and 2011, the United States Food and Drug Administration (FDA) issued Public Health Notifications ultimately informing providers and the public that complications associated with the use of synthetic mesh in the transvaginal repair of POP are not rare. In this review, we (1) examine literature characterizing surgical practice-patterns subsequent to the FDA announcements; (2) describe presentation of mesh-associated complications and outcomes of management; (3) discuss the most recent materials science research; and (4) seek to characterize whether or not mesh has lived up to the long-term efficacy promise of a permanent implant. Durability of mesh-augmented anatomical outcomes do not consistently translate into improved patient satisfaction and subjective outcomes. This, when coupled with the possibility of mesh-associated complications, emphasizes the need for continued innovation beyond the status quo of current synthetic grafts.

Chylous ascites in laparoscopic renal surgery: Where do we stand?

Postoperative chylous ascites, which is caused by the disruption of lymphatic channels and persistent lymphatic leakage, was a rare complication in the urologic field before laparoscopic surgery was introduced. Now that laparoscopic urologic surgery, especially laparoscopic nephrectomy, is widely performed, chylous ascites as a complication of laparoscopic renal surgery has been reported more frequently. With these accumulated experiences and data comes knowledge about the proper diagnosis and management of chylous ascites, although there is still some debate regarding the correct protocol for diagnosis and management. Therefore, we performed a systematic review of the current literature regarding the etiology, incidence, diagnosis, management, and prognosis of chylous ascites after laparoscopic renal surgery, as well as strategies used to prevent it, and discuss current perspectives on overcoming this complication in the laparoscopic age.

Adjuvant radiotherapy for pathologically advanced prostate cancer improves biochemical recurrence free survival compared to salvage radiotherapy

AIM: To evaluate the long-term outcomes of patients receiving adjuvant and salvage radiotherapy following prostatectomy with adverse pathologic features and an undetectable prostate specific antigen (PSA).

METHODS: A retrospective review was performed of patients who received post-prostatectomy radiation at Loyola University Medical Center between 1992 and 2013. Adverse pathologic features (Gleason score ≥ 8, seminal vesicle invasion, extracapsular extension, pathologic T4 disease, and/or positive surgical margins) and an undetectable PSA following prostatectomy were required for inclusion. Adjuvant patients received therapy with an undetectable PSA, salvage patients following biochemical recurrence (BCR). Post-radiation BCR, overall survival, bone metastases, and initiation of hormonal therapy were assessed. Kaplan-Meier time-to-event analyses and stepwise Cox proportional hazards regression (HR) were performed.

RESULTS: Post-prostatectomy patients (n = 134) received either adjuvant (n = 47) or salvage (n = 87) radiation. Median age at radiotherapy (RT) was 63 years, and median follow-up was 53 mo. Five-year post-radiation BCR-free survival was 78% for adjuvant vs 50% salvage radiotherapy (SRT) (Logrank P = 0.001). Patients with radiation administered following a detectable PSA had an increased risk of BCR compared to undetectable: PSA > 0.0-0.2: HR = 4.1 (95%CI: 1.5-11.2; P = 0.005); PSA > 0.2-1.0: HR = 4.4 (95%CI: 1.6-11.9; P = 0.003); and PSA > 1.0: HR = 52 (95%CI: 12.9-210; P < 0.001). There was no demonstrable difference in rates of overall survival, bone metastases or utilization of hormonal therapy between adjuvant and SRT patients.

CONCLUSION: Adjuvant RT improves BCR-free survival compared to SRT in patients with adverse pathologic features and an undetectable post-prostatectomy PSA.