Transcatheter embolization of an isolated lumbar arterial bleeding complicating radical nephrectomy for renal infarction with infected perirenal haematoma

Lumbar arterial bleedings are rare but potentially life threatening. We report a case of an isolated right lumbar arterial bleeding after radical nephrectomy for renal infarction with infected perirenal haematoma. The diagnosis was suggested by computed tomography and confirmed with angiography. Definitive treatment of this vascular injury was obtained after percutaneous transcatheter embolization of the fourth right lumbar artery. General anaesthesia, further blood loss due to difficult surgical dissection, or even failure to find and ligate the injured artery, especially in redo-operations, can be avoided by this minimal invasive procedure. Endovascular embolization of a lumbar artery injured after radical nephrectomy might be a valuable treatment alternative in patients with postoperative retroperitoneal bleeding.

Effect of nutritional supplement challenge in patients with isolated high-grade prostatic intraepithelial neoplasia

OBJECTIVES

To investigate, through a prospective follow-up study, the effects of a dietary supplementation challenge in men with isolated high-grade prostatic intraepithelial neoplasia (HGPIN).

METHODS

The effects of a 6-month supplementation challenge with selenium, vitamin E, and soy isoflavonoids in men diagnosed with isolated HGPIN on biopsy were evaluated. A total of 100 patients entered the study. Of the 100 men, 29 were excluded because they refused additional biopsies or were noncompliant with the protocol, 71 underwent repeat biopsies at 3 months, and 58 underwent a third set at 6 months. The prostate-specific antigen (PSA) level was recorded at inclusion and before each set of biopsies. The study endpoint was defined as the diagnosis of PCa at 3 months or the histopathologic status at 6 months.

RESULTS

At the study endpoint, PCa had been found in 24 men (33.8%), HGPIN in 34 (47.9%), and no HGPIN or carcinoma in 13 (18.3%). The PCa risk throughout the study period was 25.0% in the group with a stable or decreasing PSA level (n = 48, 67.6%) and 52.2% in the group with an increasing PSA level (n = 23, 32.4%). This difference was statistically significant (P = 0.0458). Isolated HGPIN remaining at the first repeat biopsy and the percentage of initial cores with HGPIN were significant predictors of PCa at additional biopsies.

CONCLUSIONS

The results of our study have shown that a decrease in the PSA level while taking a selenium, vitamin E, and soy isoflavonoids supplement predicts for a significantly lower risk of PCa in future biopsies. The percentage of initial biopsy cores with HGPIN and isolated HGPIN remaining at the first repeat biopsy are significant predictors of PCa in future biopsies.

Transrectal ultrasound in the staging of clinical T3a prostate cancer

INTRODUCTION

The clinical staging of T3a prostate cancer is usually based on digital rectal examination (DRE). Overstaging of clinical T3a prostate cancer is present in 13-27% of the cases presented and understaging is in the range of 30%. The value of transrectal ultrasound (TRUS) as a staging tool is not generally accepted. The purpose of this study is to determine whether TRUS can refine the local staging in unilateral clinical T3a (cT3a) prostate cancer.

PATIENTS AND METHODS

Between 1987 and 2004, 200 patients were staged as unilateral cT3a prostate cancer by DRE. All patients underwent radical prostatectomy and bilateral pelvic lymphadenectomy. Preoperative TRUS staging was performed for all patients. Final histopathological staging was compared with DRE and TRUS staging. The operable group (OG) was defined as T2 to unilateral T3a, and the advanced group (AG) was defined as bilateral T3a to T4.

RESULTS

All DRE patients were assumed operable. However, in this group histopathology showed 27.0% of the patients had advanced disease. TRUS confirmed 184 patients to be operable (140 having unilateral cT3a, 44 patients having cT1c to cT2). Sixteen patients were considered to have advanced disease by TRUS. Importantly, in this group, 68.7% of the cases were indeed confirmed to have advanced disease by histopathology.

CONCLUSION

TRUS can be used to refine clinical staging in unilateral cT3a prostate cancer. In cases where TRUS indicates advanced disease, it might be wise to trust the TRUS staging, rather than the DRE.

Alkaline encrusted pyelitis

Alkaline encrusted pyelitis is an infectious disease characterised by encrustations in the wall of the upper urinary tract, surrounded by severe inflammation. Destruction of native kidneys and kidney grafts may occur, resulting in end stage renal failure. Corynebacterium group D2, an urea splitting microorganism, is nearly exclusively associated with this disease. The most important predisposing factors are previous urological procedures and an immunosuppressed state. In a suggestive clinical context, diagnosis should be made with unenhanced computed tomography findings and bacteriologic isolation of the responsible microorganism. The treatment is threefold: appropriate antibiotic therapy, by preference with glycopeptides, acidification of urine and chemolysis, and if needed, surgical removal of encrustations. We report the case of a patient who was diagnosed with this rare condition and could escape maintenance dialysis after correct diagnosis was made and conservative treatment was started using antibiotics and combined oral and local acidification.

Adrenocortical carcinoma with fat inclusion: case report

Adrenocortical carcinoma is a rare tumor that arises from the adrenal cortex, with an estimated incidence of 0.5% to 2% per 1 million patients yearly. Although some fat content can be expected in hormonally active adrenocortical carcinomas, areas of 100% fat are extremely rare. We present a case of an adrenocortical carcinoma with a small focus of pure fat depicted on magnetic resonance imaging.

FDG-PET for preoperative staging of bladder cancer

PURPOSE

The presence of lymph node involvement (N) and distant metastasis (M) in patients with invasive bladder carcinoma is a major determinant of survival and, therefore, a pivotal element in the therapeutic management. The aim of this prospective study was to evaluate the use of( 18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in this indication.

METHODS

Whole-body FDG-PET and computed tomography (CT) were performed in 55 patients with non-metastatic invasive bladder cancer for preoperative staging. Correlative imaging of PET with CT was performed, leading to a PET(CT) result. The imaging results were compared with the gold standard, consisting of histopathology (lymphadenectomy, guided biopsy) or clinical follow-up for 12 months, and related to overall survival using the Kaplan-Meier method.

RESULTS

The gold standard was available in 40 patients and indicated NM-positive disease in 15 patients (12 N lesions, 8 M lesions), and NM-negative disease in 25 patients. For the diagnosis of NM-positive disease, the sensitivity, specificity and accuracy of PET(CT) were 60%, 88% and 78%, respectively. Diagnostic discordances between PET(CT) and CT alone were found in 9/40 patients, among whom PET was correct in six (15%): three with true-positive and one with true-negative distant metastases, and two with true-negative lymph nodes. Median survival time of patients in whom PET(CT) indicated NM-positive disease was 13.5 months, compared with 32.0 months in the patients with a NM-negative PET(CT) (p=0.003).

CONCLUSION

Addition of metabolism-based information provided by FDG-PET to CT in the preoperative staging of invasive bladder carcinoma yields a high diagnostic and prognostic accuracy.

Ureteral ectopy in the seminal vesicle associated with cyst formation and renal dysplasia: contribution of 3D-MRI

A case of a congenital anomaly of the urinary tract in a 25-year-old Caucasian male is presented. Preoperative and pathologic findings demonstrated an ectopic ureter which terminated in a seminal vesicle cyst. Both structures formed an abortive common duct at the bladder base. The ipsilateral kidney was dysplastic. Findings on voiding cytourethrography, spiral CT, and MRI are discussed and correlated with pathologic findings. The authors suggest that MRI, especially with the use of 3D sequences, is the examination of choice in the evaluation of a complex congenital urogenital anomaly as presented.

Magnetic resonance imaging in the detection and characterization of renal diseases

Over the last decade, state-of-the-art magnetic resonance MRI has become a valuable partner in the clinical imaging arena to tackle a wide variety of kidney diseases in a non-invasive manner, mainly due to its high tissue contrast and multiplanar imaging capabilities. Paramagnetic contrast agents have further improved the performance of MRI of the kidney since their administration seems to be applicable in virtually all patients, irrespective of their age, renal function and their ability to cooperate. Moreover, MRI is particularly helpful for further differentiation of lesions that are equivocal on CT and/or ultrasound. Further technical developments of applied MR-techniques and further improvements in spatial resolution will expand the imaging possibilities and create new tracts and challenges in the MRI evaluation of kidney disease. An overview of the current status of MRI in the diagnosis of renal abnormalities, which includes description of technique and normal anatomy and congenital variants, is given. The benefits of MRI in diagnosing diseases of renal parenchyma mass lesions such as cysts, renal cystic diseases, and benign and malignant tumors is reviewed. Furthermore, the MRI diagnosis of vascular diseases, diffuse renal parenchymal diseases, renal infectious diseases and the pathology of the renal collecting system will be discussed.

Is low-grade prostatic intraepithelial neoplasia a risk factor for cancer?

INTRODUCTION

High-grade prostatic intraepithelial neoplasia (HGPIN) is generally accepted to be a precursor lesion of prostate cancer. The likely outcome of isolated low-grade PIN (LGPIN) lesions in prostate biopsies remains unclear. A follow-up study of 106 patients with LGPIN- and HGPIN lesions was performed.

MATERIALS AND METHODS

In a 2-y period, 207 men were diagnosed with isolated PIN on standard systematic sextant biopsy of the prostate. In total, 104 patients had LGPIN and 103 had HGPIN. No patients had ever received androgen deprivation therapy, chemotherapy or radiation therapy. In all, 106 patients who underwent repeat second or third sextant biopsies were analysed in the study; 30% of these patients received a selenium-vitamin E supplement for at least 6 months.

RESULTS

In total, 43 had LGPIN and 63 HGPIN on the first biopsy. The mean age was 63.5 y (range 46-77) in the LGPIN group and 64.9 y in the HGPIN group. The mean total PSA was 6.96 ng/ml (range 0.59-34.13) in the LGPIN group and 8.44 ng/ml (range 0.59-35.3) in the HGPIN group. In the LGPIN group, 30% of the patients had cancer in at least one of the repeat biopsy cores. In the HGPIN group, 27% had cancer in at least one of the repeat biopsy cores. The mean total PSA of patients who had cancer in repeat biopsies with LGPIN was 7.84 ng/ml (range 2.92-34.13). The mean total PSA of the patients who had cancer in repeat biopsy in the HGPIN was 6.73 ng/ml (range 0.56-25). There was no significant difference in PSA and pathological stage between those patients who did and those who did not receive selenium-vitamin E supplements.

CONCLUSIONS

These data are intriguing since the risk of finding prostate carcinoma on repeat sextant biopsy in the LGPIN group is 30%. This is higher than commonly reported. The importance of recognising and re-biopsying HGPIN was confirmed. If chemoprevention could be shown to be effective, it might be beneficial not only in HGPIN but also in LGPIN. The possible activity of chemopreventive agents and their combination with iso-flavonoids needs further investigation.