A Family History of Lethal Prostate Cancer and Risk of Aggressive Prostate Cancer in Patients Undergoing Radical Prostatectomy

We investigated whether a family history of lethal prostate cancer (PCa) was associated with high-risk disease or biochemical recurrence in patients undergoing radical prostatectomy. A cohort of radical prostatectomy patients was stratified into men with no family history of PCa (NFH); a first-degree relative with PCa (FH); and those with a first-degree relative who had died of PCa (FHD). Demographic, operative and pathologic outcomes were analyzed. Freedom from biochemical recurrence was examined using Kaplan-Meier log rank. A multivariate Cox logistic regression analysis was also performed. We analyzed 471 men who underwent radical prostatectomy at our institution with known family history. The three groups had: 355 patients (75%) in NFH; 97 patients (21%) in FH; and 19 patients (4%) in FHD. The prevalence of a Gleason score ≥8, higher pathologic T stage, and biochemical recurrence (BCR) rates did not significantly differ between groups. On Kaplan-Meier analysis there were no differences in short-term BCR rates (p = 0.212). In this cohort of patients undergoing radical prostatectomy, those with first-degree relatives who died of PCa did not have an increased likelihood of high-risk or aggressive PCa or shorter-term risk of BCR than those who did not.

Does Listening to Music During Office-Based Flexible Cystoscopy Decrease Anxiety in Patients: A Prospective Randomized Trial

PURPOSE

To validate the effect of listening to music on perceived anxiety and pain during office-based flexible cystoscopy using the State-Trait Anxiety Inventory (STAI) and the Visual Analog Scale (VAS), in a well-matched North American veteran patient population in a prospective, randomized fashion.

PATIENTS AND METHODS

A total of 137 veteran patients receiving routine urologic care in a North American Veterans Affairs (VA) healthcare system were recruited over a 2-year period (June 2011 to June 2013). All patients were prospectively randomized to undergo office-based flexible cystoscopy with or without music. The music group consisted of 73 patients who listened to the same excerpt of classical music at the time of flexible cystoscopy; the nonmusic group consisted of 64 patients.

RESULTS

The median postprocedural STAI anxiety scores between the music and nonmusic groups were statistically significantly different: 30 (range 23-39) and 35 (range 28-49), respectively (P=0.0017). The median postprocedural pain VAS score between the music and nonmusic groups reached statistical significance: 0 (range 0-1) and 2 (range 1-2), respectively (P<0.0001). The median delta STAI anxiety score was statistically significantly different between the music and nonmusic groups: 0 (range -3-0) and 2 (range 0-4), respectively (P<0.0001).

CONCLUSIONS

This study demonstrates that listening to music decreases anxiety and pain associated with flexible cystoscopy in a North American VA patient population. We recommend incorporating music as an effective adjunct to other maneuvers used at the time of flexible cystoscopy to reduce anxiety and pain.

Modern advances in reducing anxiety and pain associated with cystoscopy: Systematic review

AIM: To investigate if music reduces anxiety and pain in the Veterans Affairs population undergoing flexible cystoscopy.

METHODS: This study was reviewed and approved by the University of California, San Diego Human Research Protections Program Institutional Review Board. Patients were prospectively randomized to undergo flexible cystoscopy with or without music. Thirty-eight patients were randomized into either the No Music group (n = 24) or the Music group (n = 14). We used the state-trait anxiety inventory and the visual analog pain scale, respectively. Statistics were generated and compared using an independent t-test and chi-squared tests. P values < 0.05 were considered statistically significant. Outpatient cystoscopy is a safe and useful procedure employed frequently in Urology for diagnosis and evaluation of genitourinary pathologies. However, cystoscopy-related distress cannot be ignored. Three components of outpatient cystoscopy have been evaluated to improve the cystoscopic experience: local anesthetic control, cystoscopic equipment redesign and environmental modification. We reviewed the literature pertaining to these modifications.

RESULTS: The mean age was 65.3 and 67.1 years for men in the No Music and Music groups, respectively. Although, the majority of patients in each group self-identified as Caucasians (66%), African American, Hispanic and other ethnicities represented 13%, 8% and 13% respectively. The majority of patients (68%) reported experiencing hematuria. Thirty-four percent had a history of bladder cancer, and eighteen percent had a history of prostate cancer. Ten patients (26%) admitted to taking antidepressants. Physiologic parameters that correlated to pain and anxiety (systolic blood pressure, diastolic blood pressure, and heart rate) were statistically similar in both groups prior to and after flexible cystoscopy. The median delta anxiety between the No Music and Music groups were not significantly different (0.78 vs -1.46), and the pain scores between the No Music and Music groups (1.5 vs 1.6) were not statistically different (P = 0.28 and P = 0.92, respectively).

CONCLUSION: Preliminary results demonstrate that music does not reduce anxiety or pain associated with flexible cystoscopy.

Surgical management of traumatic penile amputation: a case report and review of the world literature

INTRODUCTION

There is paucity of case reports that describe the successful reimplantation of a penis after amputation. We sought to report on self-inflicted penile amputation and comment on its surgical management and review current literature.

AIM

To report on self-inflicted penile amputation and comment on its surgical management and review current literature.

METHODS

A 19-year-old male with no prior medical history presented to our university-affiliated trauma center following sustaining a self-inflicted amputation of shaft penis secondary to severe methamphetamine-induced psychosis. He immediately underwent extensive reconstructive reimplantation of the penis performed jointly by plastics and urology teams reattaching all visible neurovascular bundles, urethra, and corporal and fascial layers. The patient was discharged with a suprapubic tube in place and a Foley catheter in place with well-healing tissue.

MAIN OUTCOME MEASURES

To review the current published literature and case reports on the management of penile amputation with particular emphasis its etiology, surgical repairs, potential complications and functional outcomes.

RESULTS

We report herein a case of a traumatic penile amputation and successful outcome of microscopic reimplantation and review of the published literature with particular comments on surgical managements.

CONCLUSION

We review the literature and case reports on penile amputation and its etiology, surgical management, variables effecting outcomes, and its complications. Raheem OA, Mirheydar HS, Patel ND, Patel SH, Suliman A, and Buckley JC. Surgical management of traumatic penile amputation: A case report and review of the world literature. Sex Med 2015;3:49-53.

Development of penile hydrocele following placement of inflatable penile prosthesis: a rare entity

INTRODUCTION

The development of a penile hydrocele following the placement of an inflatable penile prosthesis (IPP) for erectile dysfunction has never been documented. We herein report an unusual complication of penile hydrocele formation that developed following placement of an IPP for erectile dysfunction.

METHODS

The penile hydrocele was successfully repaired by excision of the hydrocele sac.

RESULTS

Successful surgical repair of a penile hydrocele was accomplished following placement of an IPP without removal of any implant components. The penile implant was functional at the end of the procedure as well as at all scheduled follow-up appointments.

CONCLUSIONS

With advances in both surgical techniques and improved devise technology, high volume penile implanters encounter fewer IPP-related complications such as infectious or mechanical complications. We herein report for the first time a rare complication of penile hydrocele development after IPP placement that was treated successfully with surgical excision of the hydrocele sac. Urologists who perform these types of procedures should be aware of this unusual complication and know that it is curable with prompt diagnosis and meticulous surgical repair.

Unclassified mucinous renal cell carcinoma: a rare histopathological entity

Renal cell carcinoma (RCC) with mucin production is extremely rare. We present the case of a previously healthy 76-year-old woman who underwent a robotic-assisted laparoscopic right nephrectomy for a 5-cm heterogeneously enhancing right renal mass. Pathology revealed mucin-producing epithelial RCC. We discuss the presentation and pathological features of this case and comment on its definitive treatment.

Adjunctive maneuvers to treat urethral stricture: a review of the world literature

The development of urethral stricture (US) or bladder neck contracture is a relatively uncommon but well described condition observed primarily in men. Despite familiarity with US disease, management remains challenging for urologists. Risk factors for the development of USs or bladder neck contracture include primary treatment modality, tobacco smoking, coronary artery disease and poorly controlled diabetes mellitus. Numerous treatment options exist for this condition that vary in procedural complexity, including intermittent self catheterization (CIC), serial urethral dilation, endoscopic techniques and open reconstructive repairs. Repetitive procedures for this condition may carry increased failure rates and morbidities. For the treatment of refractory or recalcitrant bladder neck contracture, newer intralesional anti-proliferative, anti-scar agents have been used in combination with transurethral bladder neck incisions to augment outcome and long-term effect. The primary focus of this systematic review of the published literature is to streamline and summarize various and newer therapeutic modalities available to manage patients with US or bladder neck contracture.

Clinical predictors of nocturia in the sleep apnea population

OBJECTIVES

This study aims to evaluate clinical predictors of nocturia in patients with obstructive sleep apnea (OSA).

MATERIALS AND METHODS

In retrospective manner, a total of 200 patients with OSA were randomly included. Group I contained 100 patients with OSA and no nocturia, and Group II included 100 patients with OSA and nocturia. Bivariate logistic analyses were used to identify variables most likely to contribute to nocturia. Multivariate logistic regression of age, waist circumference, STOP score (Snore, Tired, Obstruction and Pressure), and Apnea-Hypopnea Index (AHI) was performed to evaluate predictors of nocturia. Statistical significance was defined as P < 0.05.

RESULTS

Median nocturia episodes were 2.2 in Group II. Patients were younger in Group I, with a mean age of 45 vs 50 years (P = 0.008). Mean BMI of 30 was similar in both groups, but there were more overweight patients in Group II (28% vs 18%). AHI approached significance between groups-18 vs 23 in group I and II, respectively (P = 0.071). In multivariate analysis, age over 70 years and moderate AHI were statistically significant predictors of nocturia (coefficients 0.6 and -0.2 with P = 0.003 and 0.03, respectively).

CONCLUSIONS

This study identifies age and AHI score as predictors of nocturia in patients with OSA. This may indicate the usefulness of incorporating nocturia in the screening of patients with OSA. Future studies are needed to further evaluate mechanism of action, clinical significance, and effect of treatment for nocturia in patients with OSA.

Surgical management of adolescent varicocele: Systematic review of the world literature

Historically, idiopathic varicocele is the most commonly diagnosed pre-pubertal andrological condition. The clinical presentation of varicocele may vary from dull and dragging unilateral or bilateral testicular pain to visible varicose veins lying over the hemiscrotum. Over the last decade, significant strides were made in managing symptomatic varicoceles, particularly minimal invasive procedures and surgeries. We sought to review the published literature in a systematic manner to gain an overview and streamline the presentations and main treatment modalities.

Surgical management of bladder transitional cell carcinoma in a vesicular diverticulum: case report

We report a case of primary transitional cell carcinoma (TCC) ofa bladder diverticum along with a literature review. A 55-year-oldmale presented with painless gross hematuria. A histological diagnosisof TCC within a bladder diverticulum was made followingcystoscopical examination. Initially transurethral resection of bladdertumour with subsequent intravesical chemotherapy followed.As a result of recurrence and in view of bladder-sparing therapy, adistal partial cystectomy was performed. This report demonstratesthat conservative bladder-sparing treatment can be achieved andsubsequently followed by vigilant cystoscopy.

Renal cell carcinoma with IVC and atrial thrombus: a single centre's 10 year surgical experience

Renal cell carcinoma (RCC) propagates into the IVC in 4% of cases with 1% extending into the right atrium. Radical surgical resection remains the definitive curative/palliative treatment in those without significant metastases. The aim was to review our experience in patients with different levels of IVC involvement, cardiopulmonary bypass (CPB) and perioperative/long term outcomes.

PATIENTS AND METHODS

From 2001 to 2012, 24 radical nephrectomies with IVC thrombectomy were performed. A retrospective chart review was undertaken to record demographics, presenting symptoms, duration of surgery, peri-operative transfusion, CPB and peri-operative complications, tumour grade/stage, and patient survival.

RESULTS

We identified 24 patients (18 male, Age median 59 range 35-78). The commonest presenting symptoms were weight loss, pain and haematuria. The majority of tumours were right sided (n = 17) with 8 having lung metastases at presentation. Thrombus level was 16 (infradiaphragmatic), 2 (supradiaphragmatic), 6 (intra-atrial). 15 patients required sternotomy for vascular control and 9 required CPB both with a significantly longer operative time compared (6.1 ± 3.5 vs. 7.2 ± 1.2 vs. 3.5 ± 1.1 h, respectively). Peri-operative complications (n = 21) included cardiopulmonary, renal, gastrointestinal and septic problems. There were 2 peri-operative deaths. Blood transfusion was significantly less in those not requiring sternotomy or CPB using the "Cell Saver" device. The majority were Fuhrman grade 3 (n = 16) and clear cell type (n = 14). Overall 3-year survival was 100% (Laparotomy only), 40% (sternotomy + cross-clamp), and 20% (CPB).

CONCLUSIONS

IVC thrombectomy has significant morbidity and requires careful patient selection and a multi-disciplinary approach to optimise patient outcomes. In this series, the level of IVC thrombus and requirement for CPB directly affects patient morbidity and outcome.

Does timing of cytoreductive nephrectomy impact patient survival with metastatic renal cell carcinoma in the tyrosine kinase inhibitor era? A multi-institutional study

OBJECTIVE

To compare outcomes of metastatic renal cell carcinoma (mRCC) patients who underwent primary cytoreductive nephrectomy (CRN), followed by adjuvant sunitinib therapy, vs those who underwent primary sunitinib therapy before planned CRN.

METHODS

This was a multi-institutional retrospective analysis of 35 mRCC patients from June 2005 to August 2009 (median follow-up, 28.5 months): 17 underwent primary CRN, followed by adjuvant sunitinib (group 1); 18 underwent primary sunitinib therapy, followed by planned CRN (group 2). Response to therapy was determined using Response Evaluation Criteria in Solid Tumors. Group 2 patients who had partial response (PR)/stable disease (SD) proceeded to CRN (group 2 +CRN). Group 2 patients who progressed were treated with salvage systemic therapy (group 2 no-CRN). Primary and secondary outcomes were disease-specific survival (DSS) and overall survival (OS).

RESULTS

Patient demographic and tumor characteristics were similar. The groups had similar rates of DSS and OS on univariate analysis (P = .318 and P = .181). In group 2, 11 (61%) had PR/DS; 7 (39%) progressed. Mean times to disease-specific death in group 1, group 2 (+CRN), and group 2 (no-CRN) were 29.2, 4.6, and 28.7 months, respectively (P = .025). Kaplan-Meier analysis of DSS and OS demonstrated significant improvement in group 2 (+CRN) vs group 1 vs group 2 (no-CRN; P <.001), which remained significant on multivariate regression.

CONCLUSION

Nonresponders to primary sunitinib therapy had a poor prognosis. Offering CRN, if safely feasible, combined with sunitinib, was associated with improved disease-specific outcome in mRCC. Responders to primary sunitinib who underwent CRN had better DSS and OS than patients who underwent primary CRN, followed by sunitinib. Further investigation is required to assess the role, timing, and sequencing of targeted therapy and CRN in treatment of mRCC.

Treatment of hepatitis B virus reactivation in a cadaveric renal transplant recipient with entecavir

INTRODUCTION

Risk of reactivation of Hepatitis B virus (HBV) infection and other liver related complications continues to be a major cause of concern in HBV carriers undergoing cadaveric renal transplantation. Antiviral medications have been recommended post renal transplantation in patients who are chronic HBV carriers.

CASE REPORT

Here we present the case of a 15-year-old girl known to have kidney failure and chronic active HBV infection indicated by positivity of both HBsAg and HBeAg. She was treated with interferon alpha for six months resulting in clearance of HBeAg and reduction of HBV-DNA titer to 32.15 copies/ml. She underwent successful cadaveric renal transplantation and was maintained on cyclosporine, azathioprine and prednisolone. Two years post transplant, the patient developed elevated liver enzymes, positive HBeAg and high HBV-DNA titers. She was treated with lamivudin resulting in normalization of liver function tests. Lamivudine was discontinued after nine months due to poor compliance resulting from psychological problems. Three years post transplant, the patient was started on Entecavir 0.5 mg oral, daily. At follow up clinic visits till present time, the patient is tolerating Entecavir treatment with no reported side effects. Liver enzymes remained stable, but the effect on viral load and viral markers was unremarkable.

CONCLUSION

The role of various antiviral agents in treating HBV infection among kidney transplant recipients requires further evaluation.

Management of pelvic lymphoceles following robot-assisted laparoscopic radical prostatectomy

Pelvic lymphocele is a potential complication of radical prostatectomy. Although lymphoceles often regress spontaneously, many may progress, precipitate clinical symptoms, and ultimately require intervention. To date, the best treatment of pelvic lymphoceles has not yet been fully defined. However, laparoscopic marsupialization is a definitive and efficacious surgical alternative to percutaneous drainage. It is effective, results in minimal patient morbidity, and allows for rapid recovery. We report our experience with management of clinically symptomatic pelvic lymphoceles following robotic-assisted prostatectomy using laparoscopic marsupialization.

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

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.

Gene expression and epigenetic discovery screen reveal methylation of SFRP2 in prostate cancer

Aberrant activation of Wnts is common in human cancers, including prostate. Hypermethylation associated transcriptional silencing of Wnt antagonist genes SFRPs (Secreted Frizzled-Related Proteins) is a frequent oncogenic event. The significance of this is not known in prostate cancer. The objectives of our study were to (i) profile Wnt signaling related gene expression and (ii) investigate methylation of Wnt antagonist genes in prostate cancer. Using TaqMan Low Density Arrays, we identified 15 Wnt signaling related genes with significantly altered expression in prostate cancer; the majority of which were upregulated in tumors. Notably, histologically benign tissue from men with prostate cancer appeared more similar to tumor (r = 0.76) than to benign prostatic hyperplasia (BPH; r = 0.57, p < 0.001). Overall, the expression profile was highly similar between tumors of high (≥ 7) and low (≤ 6) Gleason scores. Pharmacological demethylation of PC-3 cells with 5-Aza-CdR reactivated 39 genes (≥ 2-fold); 40% of which inhibit Wnt signaling. Methylation frequencies in prostate cancer were 10% (2/20) (SFRP1), 64.86% (48/74) (SFRP2), 0% (0/20) (SFRP4) and 60% (12/20) (SFRP5). SFRP2 methylation was detected at significantly lower frequencies in high-grade prostatic intraepithelial neoplasia (HGPIN; 30%, (6/20), p = 0.0096), tumor adjacent benign areas (8.82%, (7/69), p < 0.0001) and BPH (11.43% (4/35), p < 0.0001). The quantitative level of SFRP2 methylation (normalized index of methylation) was also significantly higher in tumors (116) than in the other samples (HGPIN = 7.45, HB = 0.47, and BPH = 0.12). We show that SFRP2 hypermethylation is a common event in prostate cancer. SFRP2 methylation in combination with other epigenetic markers may be a useful biomarker of prostate cancer.

Discontinuation of anticoagulant or antiplatelet therapy for transrectal ultrasound-guided prostate biopsies: a single-center experience

Purpose

Historically, it was thought that hemorrhagic complications were increased with transrectal ultrasound-guided prostate biopsies (TRUS biopsy) of patients receiving anticoagulation/antiplatelet therapy. However, the current literature supports the continuation of anticoagulation/antiplatelet therapy without additional morbidity. We assessed our experience regarding the continuation of anticoagulation/antiplatelet therapy during TRUS biopsy.

Materials and Methods

A total of 91 and 98 patients were included in the anticoagulation/antiplatelet (group I) and control (group II) groups, respectively. Group I subgroups consisted of patients on monotherapy or dual therapy of aspirin, warfarin, clopidogrel, or low molecular weight heparin. The TRUS biopsy technique was standardized to 12 cores from the peripheral zones. Patients completed a questionnaire over the 7 days following TRUS biopsy. The questionnaire was designed to assess the presence of hematuria, rectal bleeding, and hematospermia. Development of rectal pain, fever, and emergency hospital admissions following TRUS biopsy were also recorded.

Results

The patients' mean age was 65 years (range, 52 to 74 years) and 63.5 years (range, 54 to 74 years) in groups I and II, respectively. The overall incidence of hematuria was 46% in group I compared with 63% in group II (p=0.018). The incidence of hematospermia was 6% and 10% in groups I and II, respectively. The incidence of rectal bleeding was similar in group I (40%) and group II (39%). Statistical analysis was conducted by using Fisher exact test.

Conclusions

There were fewer hematuria episodes in anticoagulation/antiplatelet patients. This study suggests that it is not necessary to discontinue anticoagulation/antiplatelet treatment before TRUS biopsy.

Prevalence of nephrolithiasis in human immunodeficiency virus infected patients on the highly active antiretroviral therapy

BACKGROUND AND PURPOSE

Protease inhibitors, specifically indinavir, have historically been implicated as a cause of nephrolithiasis in the human immunodeficiency virus (HIV) infected patients. There is a paucity of data, however, on stone disease with nonindinavir etiologies since the introduction of highly active antiretroviral therapy (HAART). We sought to describe the prevalence of nephrolithiasis in the HIV population since the use of HAART.

PATIENTS AND METHODS

We retrospectively reviewed HIV-positive patients currently receiving HAART treatment in whom image proven kidney and/or ureteral urolithiasis developed, between 1998 and 2010. A detailed analysis of patients' current treatment, surgical intervention, and metabolic studies was performed.

RESULTS

A total of 436 HIV-positive patients were included and 46 (11%) patients had nephrolithiasis. Each patient included in this study was receiving nonindinavir-based antiretroviral therapy. There were 41 men of whom 36 were Caucasian. Eleven (24%) patients underwent 24-hour urine collections with 11 metabolic abnormalities identified. Stone analysis was available for seven patients (four calcium oxalate monohydrate, one cystine, one uric acid, and one atazanavir).

CONCLUSIONS

We report the largest series of nephrolithiasis in an HIV population since the introduction of HAART and highlight not only the similar prevalence of nephrolithiasis to the non-HIV population but also the lack of consistent comprehensive metabolic evaluations in HIV patients with recurrent nephrolithiasis.

Surgical management of bladder transitional cell carcinoma in a vesicular diverticulum: case report

We report a case of primary transitional cell carcinoma (TCC) of a bladder diverticum along with a literature review. A 55-year-old male presented with painless gross hematuria. A histological diagnosis of TCC within a bladder diverticulum was made following cystoscopical examination. Initially transurethral resection of bladder tumour with subsequent intravesical chemotherapy followed. As a result of recurrence and in view of bladder-sparing therapy, a distal partial cystectomy was performed. This report demonstrates that conservative bladder-sparing treatment can be achieved and subsequently followed by vigilant cystoscopy.

Partial orchiectomy and testis intratubular germ cell neoplasia: World literature review

Approximately 5% of all patients diagnosed with testicular cancer may have contralateral intratubular germ cell neoplasia (ITGCN) and may develop contralateral germ cell tumor. Here, we present a historical review and current literature regarding ITGCN and partial orchiectomy. The PubMed world literature search was performed for articles written in the English language. Search terms used were: Partial orchiectomy and ITGCN, with a return of 322 articles. Articles obtained were from the United States, Germany, Denmark and the Netherlands as well as a few case reports from Australia, France, Turkey and Spain. A critical review of the literature was performed. Partial orchiectomy is an option for the management of testicular malignancy in a select group of patients in whom radical orchiectomy is not desirable, including those with a solitary testicle, bilateral concurrent malignancies and a desire for paternity or being independent from androgen supplementation. Reports have demonstrated the feasibility of partial orchiectomy, but there are strict surgical criteria; tumor less than 2 cm in size, maintenance of cold ischemia, meticulous dissection to maintain testicular blood supply and biopsying of adjacent testicular parenchyma to ensure negative margins and absence of concurrent ITGCN. Partial orchiectomy is followed by testicular irradiation of 18-20 Gy; this radiation dose reduces fertility but maintains leydig cell function with androgen independence. Patients with a history of testicular carcinoma have a 5% chance of developing a metachronous contralateral tumor. Partial orchiectomy is a technically challenging procedure that requires close follow-up, but may represent a reasonable management option in selected patients.

Intraperitoneally placed Foley catheter via verumontanum initially presenting as a bladder rupture

Since urethral Foley catheterization is usually easy and safe, serious complications related to this procedure have been rarely reported. Herein, we describe a case of intraperitoneally placed urethral catheter via verumontanum presenting as intraperitoneal bladder perforation in a chronically debilitated elderly patient. A 82-yr-old male patient was admitted with symptoms of hematuria, lower abdominal pain after traumatic Foley catheterization. The retrograde cystography showed findings of intraperitoneal bladder perforation, but emergency laparotomy with intraoperative urethrocystoscopy revealed a tunnel-like false passage extending from the verumontanum into the rectovesical pouch between the posterior wall of the bladder and the anterior wall of the rectum with no bladder injury. The patient was treated with simple closure of the perforated rectovesical pouch and a placement of suprapubic cystostomy tube.

Mycophenolate mofetil in low-risk renal transplantation in patients receiving no cyclosporine: a single-centre experience

BACKGROUND

We assess our long-term experience with regards the safety and efficacy of Mycophenolate Mofetil (MMF) in our low risk renal transplant population and compared it retrospectively to Azathioprine (AZA) immunosuppressive regimen. Patients and methods. Between January 1999 and December 2005, 240 renal transplants received MMF as part of their immunosuppressive protocol (MMF group). AZA group of 135 renal transplants was included for comparative analysis (AZA group). Patients received Cyclosporine was excluded from this study.

RESULTS

The incidence of biopsy proven 3-month acute rejections was 30 (12.5%) in MMF group and 22 (16%) in AZA group respectively (P = 0.307). Patient survival rates at 1 and 5 years for the MMF group were 97 and 94%, respectively, compared to 100% and 91% at 1 and 5 years respectively for the AZA group (P = 0.61). Graft survival rates at 1 and 5 years for the MMF group were 95 and 83%, respectively, compared to 97 and 84% at 1 and 5 years, respectively for the AZA group (P = 0.62).

CONCLUSION

There was no difference in acute rejection episodes between MMF and AZA based immunotherapy. Additionally, we observed no significant difference concerning graft survival in the MMF group when compared to AZA group.

Anatomical review of the lateral collateral ligaments of the ankle: a cadaveric study

Arrangements of the lateral collateral ligaments of the ankle are complex. Injuries to these ligaments can occur in the inverted planter flexed position of the ankle. Traditionally, the anterior talofibular ligament (ATFL) is the first ligament involved in such ankle injuries. We reviewed the anatomical arrangements of the lateral ankle. Twenty ankles from ten Caucasian cadavers were carefully dissected. Length and width of each ligament were measured in neutral, dorsiflexion and plantar flexion. The angle between the ATFL and other ligaments was also recorded. ATFL was present in 95% of ankles dissected. Five ankles showed two slip configuration of the ATFL. One ATFL was noted as being significantly thicker and another one was significantly narrow. Mean length of the ATFL in neutral was 15.5 mm (range 10-21 mm), which increased in plantar flexion to 18 mm (range 11-25 mm) and decreased slightly in dorsiflexion to 14.5 mm (range 10-19 mm). The calcaneofibular ligament was present in all dissections and had a mean measurement of 18.5 mm in neutral (range 14-23 mm) decreasing to 17 mm in planter flexion and 15.5 mm in dorsiflexion. Treating ligamentous ankle injuries can be very costly, thus creating a large economic burden to both patients and health institutions. Understanding the anatomical characteristics of the lateral collateral ligament complex of the ankle provides the basic foundation for understanding injuries and helps to clinically manage such injuries appropriately.

Mycophenolate mofetil in pediatric renal transplantation: a single center experience

We assessed our long-term experience with regards to the safety and efficacy of MMF in our pediatric renal transplant population and compared it retrospectively to our previous non-MMF immunosuppressive regimen. Forty-seven pediatric renal transplants received MMF as part of their immunosuppressive protocol in the period from January 1997 till October 2006 (MMF group). A previously reported non-MMF group of 59 pediatric renal transplants was included for comparative analysis (non-MMF group). The MMF group comprised 29 boys and 18 girls, whereas the non-MMF group comprised 34 boys and 25 girls. Mean age was 11.7 and 12 yr in the MMF and non-MMF groups, respectively. The incidence of acute rejection episodes was 11 (23.4%) and 14 (24%) in the MMF and non-MMF group, respectively. Two (3.3%) grafts were lost in the non-MMF group compared with one (2.1%) in the MMF group. Twenty-one (44.68%) patients in the MMF group developed post-transplant infections compared with 12 (20.33%) in the non-MMF group (p < 0.0001). In conclusion, the use of MMF in pediatric renal transplantation was not associated with a lower rejection rate or immunological graft loss. It did, however, result in a significantly higher rate of viral infections.

Postirradiation lumbosacral radiculopathy following seminoma treatment presenting as flaccid neuropathic bladder: a case report

Introduction

Postirradiation lumbosacral syndrome is a radiculopathy induced by radiation injury to the spinal cord. Its usual presentation is motor deficit and or sensory loss involving the lower limbs. Visceral involvement has not been reported previously.

Case presentation

We describe a case of severe hypotonic bladder caused by radiation-induced spinal cord injury following treatment of stage Ι testicular seminoma in a 38-year-old Caucasian man who had undergone radical orchidectomy and prophylactic paraaortic lymph node irradiation for stage Ι seminoma. Three years later he had clinical and urodynamic findings of hypotonic bladder. The magnetic resonance imaging results suggested a radiation-induced injury.

Conclusion

Such an unusual presentation of the syndrome of postirradiation lumbosacral radiculopathy can impose a clinical challenge to practicing clinicians. Future studies are required to further delineate the mechanism of injury and further management plans.

Abstract 4904: Epigenetic discovery screen identifies SFRP2 as a novel biomarker of high grade prostate cancer

Prostate cancer (CaP) is the most common noncutaneous malignancy and 3rd leading cause of cancer related deaths in men in the Western world. We urgently require CaP-specific biomarkers to distinguish between indolent and aggressive disease and avoid over-treatment. Hyperactivity of Wnt/ β-catenin signaling is an important mechanism of cancer progression, linked to androgen independent growth, development of bone metastases and self-renewal of CaP stem cells. Our aims were to (1) profile Wnt-related gene expression in benign and malignant prostates, (2) investigate hypermethylation of Wnt antagonists and (3) select a novel Wnt-related target for evaluation in low versus high grade CaP.

TaqMan Low Density Arrays revealed 14 genes with significantly altered expression between cancer and benign tissue; 12/14 were upregulated in tumors. Only 6/19 human WNT genes were expressed in CaP (WNT3A, WNT4, WNT5B, WNT7B, WNT10A, WNT11); only WNT4 was significantly upregulated in tumors. Overall, the expression profile was highly similar between tumors of high (≥7) and low (≤6) Gleason scores. However, significant differences were observed for DACT1, BTRC, AXIN1 and DLL4. Pharmacological demethylation of PC-3 cells with 5-Aza-CdR reactivated 38 targets (≥2-fold) relative to untreated cells; 40% of these genes inhibit Wnt signalling. Pyrosequencing and QMSP evaluated hypermethylation of Wnt antagonist SFRPs (secreted frizzled related proteins), revealing frequent methylation of SFRP2 in 65% of tumors (48/74; Normalized Index of Methylation (NIM) = 116). Significantly lower frequencies and quantitative levels of methylation were found in benign tissue 9% (7/69; NIM = 0.47, P &lt; 0.0001) and in preinvasive High Grade Prostatic Intraepithelial Neoplasia 30% (6/20, NIM = 7.45, P &lt; 0.0001).

Immunohistochemical analysis of tissue microarrays revealed moderate/strong SFRP2 protein expression in the cytoplasm of 84% (172/205) of benign epithelia; while negative/weak SFRP2 staining was noted in most tumor epithelia, particularly Gleason grades 3 & 4, where only 12% (21/171) and 23% (29/124) of cases stained positive, respectively. In contrast, almost half (24/57) of Gleason grade 5 tumors showed moderate/strong SFRP2 expression (P &lt; 0.0001). Microscopic evaluation of these tumors revealed different morphological patterns, corresponding with differential SFRP2 expression. Moderate/strong grade 5 tumors (designated Type A) appeared morphologically solid while negative/weak grade 5 tumors (designated Type B) appeared more diffuse. Furthermore, 80% (4/5 patients) of Type A patients experienced biochemical recurrence, compared with 0% (0/6 patients) of Type B patients (P = 0.015).

This is the first report of epigenetic control of Wnt signaling antagonist SFRP2 in CaP. Our data suggest that SFRP2 may be a useful prognostic biomarker in sub-stratifying patients with high grade tumors at increased risk of recurrence.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4904.

Fistulization in a locally advanced case of squamous cell carcinoma of the prostate

Squamous cell carcinoma of the prostate gland is very rare, constituting 0.5%-1% of all prostatic malignancies. Though it has a similar clinical presentation to prostate cancer, the tumor is more aggressive, spreading to bone, liver and lung. The median survival time is approximately 14 months. Diagnosis is exclusively by histology. Therapeutic options may include radical surgery, radiotherapy, chemotherapy, hormonal therapy or a combination of these treatments. We present a case of locally advanced squamous cell carcinoma of the prostate and comment on its management and subsequent disease related complication.