Three Dimensional (3D) Laparoscopic Nephron-sparing Treatment of a Huge Cystic Nephroma: A Case Report and Literature Review

Background/Aim

Cystic nephroma (CN) is a very rare, benign, renal cystic lesion, which is characterized by a usually unilateral, multicystic kidney mass. In adults it is seen more frequently in females (1:8 male-to-female ratio). The peak incidence of CN is between 50 and 60 years of age. Median age at diagnosis is 55 years for females and 44 years for men and it is a rare entity in adults under 30 years of age.

Case Report

We report the case of a 52-year-old female patient with chronic right-flank pain, who was treated at our hospital. A multiloculated 10×8.6 cm Bosniak IV renal cyst tumor was depicted on retroperitoneal computed tomography. After a three-dimensional laparoscopic partial nephrectomy, the histopathological specimen examination revealed: a multilocular cystic nephroma.

Conclusion

CNs are rare benign tumors that should be included in the differential diagnosis when treating large multiloculated complex renal cysts.

Record and Appraisal of Endophytic Tumor Localization Techniques in Minimally Invasive Kidney-Sparing Procedures. A Systematic Review

PURPOSE

Review and efficacy assessment of techniques used for intraprocedural endophytic renal mass localization.

MATERIALS AND METHODS

Advanced search was carried out on PubMed, Cochrane Library, Web of Science and Google Scholar databases up to August 2020. Eligibility criteria were set, according to PRISMA statement. OR (95 % CI) for identification or technical success, positive margins and recurrence, were calculated for completely endophytic tumors. Risk of Bias was evaluated using ROBVIS tool.

RESULTS

77 studies used for result synthesis, including 1,317 endophytic tumors, with 758 of them completely endophytic. 356 endophytic tumors treated laparoscopically and 598 robotically, using ultrasound-based methods, transarterial embolization, dual-source CT, invasive signage, 3D printing, and augmented reality variations. Identification success was 97.8-100%, positive margins 0-12.5 %  (completely endophytic: 95 % CI; 0.255-1.971, OR 0.709 in laparoscopic, 95 % CI ; 0.379-3.109, OR 0.086 in robotic partial nephrectomy), recurrences 0-3.9 % (completely endophytic: 0 recurrences in laparoscopic, 95 % CI ; 0.0917-2.25, OR 0.454, in robotic partial nephrectomy), and complications 0-60 % . 363 were treated with ablation techniques using CT-based methods, thermal monitoring, transarterial embolization, ultrasound guidance and invasive signage. Technical success was 33.4-100 % (completely endophytic: 95 % CI ; 0.00157-2.060, OR 0.0569 for invasive and 95 % CI ; 0.598-13.152, OR 2.804 for non-invasive localization techniques) and recurrences were 0-20%.

CONCLUSION

Ultrasound-based techniques showed acceptable identification success and oncologic outcomes in laparoscopic or robotic setting. Augmented reality, showed no superiority over conventional techniques. Near infrared fluoroscopy with intravenous indocyanine green, was incapable of endophytic tumor tracking, although when administered angiographic, results were promising, along with other embolization techniques. Percutaneous hook-wire or embolization coil signage, aided in safe and successful tracking of parenchymal isoechoic masses, but data are inadequate to assess efficacy.  CT-guidance, combined with ultrasound or thermal monitoring, showed increased technical success during thermal ablation, unlike ultrasound guidance that showed poor outcomes.

Hook-wire assisted localization of a completely endophytic renal mass during three-dimensional laparoscopic partial nephrectomy: Presentation of our technique

INTRODUCTION

Totally endophytic renal masses may be invisible during laparoscopic partial nephrectomy, posing challenge to surgeons regarding tumor's identification and resection.

CASE PRESENTATION

A 22-year-old male was incidentally diagnosed with a completely endophytic, cT1a renal mass. Percutaneous Computed Tomography-guided insertion of a hook-wire was performed prior to laparoscopic partial nephrectomy. The hook-wire anchored centrally into the tumor and its extra-renal part was easily identified intraoperatively, contributing to tumor's identification and surgical excision. Total operative time was 185 min, warm ischemia time was 21.5 min, tumor excision time was 10 min, and total renorraphy time was 31 min. No complications were encountered perioperatively. The patient was discharged on the fourth postoperative day. Histology revealed a pT1a, clear-cell renal cell carcinoma, with negative surgical margins.

CONCLUSIONS

Our first experience indicates that hook-wire guided excision of a completely endophytic renal mass during laparoscopic partial nephrectomy is feasible, safe, and cost-effective.

Transperitoneal and retroperitoneal approach in laparoscopic partial nephrectomy for posterior cT1 renal tumors: A retrospective, two-centers, comparative study

OBJECTIVES

To compare perioperative, oncological and functional outcomes of Laparoscopic Transperitoneal Partial Nephrectomy (LTPN) and Retroperitoneal Laparoscopic Partial Nephrectomy (LRPN) for posterior, cT1 renal masses (RMs).

MATERIALS AND METHODS

Databases of two urologic institutions applying different laparoscopic surgical approaches on posterior cT1 RMs between June 2016 and November 2018 were retrospectively evaluated. Data on patient demographics, perioperative data and tumor histology were collected and further analyzed statistically.

RESULTS

Each group consisted of 15 patients. Baseline characteristics were comparable in each group. When compared to LTPN, LRPN was associated with significantly shorter operative time (OT) (115 min versus 199 min, p < 0.05). No significant differences were detected in the other outcomes.

CONCLUSIONS

LRPN is associated with a significantly shorter OT compared to LTPN for posterior cT1 RMs. Both surgical approaches are safe, feasible and credible, demonstrating optimal results.

Laparoscopic Resection of a Non-functional, Extra-adrenal Paraganglioma: A Case Report and Literature Review

Non-functional, extra-adrenal, retroperitoneal paraganglioma is a rare, neuroendocrine, and potentially malignant tumor. Its diagnosis and treatment may be challenging. A 69-year-old female patient was admitted because of a left para-aortic, solid, 4.4-cm mass, incidentally discovered during abdominal ultrasonography for screening purposes. Her clinical examination was unremarkable. Preoperative differential diagnosis based on cross-sectional imaging included tumor of neuroendocrine or mesenchymal origin. Hormonal investigation with 24-hour urinary catecholamines and metanephrines and plasma-fractionated metanephrines was in the normal range. Following consultation with the endocrinologist and anesthesiologist, the tumor was removed by using the three-dimensional (3D) laparoscopic transperitoneal surgical approach. The perioperative course was uneventful and the patient was discharged on the third postoperative day. Histopathologic findings were consistent with the diagnosis of retroperitoneal extra-adrenal paraganglioma of 5 cm in maximum diameter.

Macroscopic Appearance of Giant Adrenal Myelolipoma During Laparoscopy: An Adjunct in Differential Diagnosis

Giant adrenal myelolipoma is a rare, benign, sizable, mesenchymal tumor. Preoperative differential diagnosis from retroperitoneal liposarcoma may be challenging. A 66-year-old female patient was admitted because of a sizable tumor at the right retroperitoneal space, incidentally discovered during abdominal ultrasonography for screening purpose. Preoperative imaging studies were indicative for the diagnosis of a giant adrenal myelolipoma (11.7 × 12.9 cm in size); however, a retroperitoneal liposarcoma could not be excluded. We decided to proceed with tumor's surgical removal by using laparoscopic transperitoneal approach and three-dimensional high-definition camera. Intraoperatively, the tumor did not infiltrate surrounding tissues and was surrounded by a thin capsule under which there were sparse, orange-colored spots that resembled adrenal cortex. This finding reinforced the initial and most possible diagnosis of adrenal myelolipoma and we easily enucleated the mass. Postoperative course was uneventful, and the patient demonstrated no recurrence on imaging six months postoperatively. Histology confirmed the diagnosis of giant adrenal myelolipoma, measuring 16.5 x 15 x 6.5 cm.

Mini percutaneous nephrolithotomy in the treatment of renal and upper ureteral stones: Lessons learned from a review of the literature

The aim of this review is to present the most recent data regarding the indications of mini percutaneous nephrolithotomy (PCNL), the results and the complications of the method. Medline was searched from 1997 to January 2014, restricted to English language. The Medline search used a strategy including medical subject headings and free-text protocols. PCNL is a well-established treatment option for patients with large and complex renal calculi. In order to decrease morbidity associated with larger instruments like blood loss, postoperative pain and potential renal damage, a modification of the technique of standard PCNL has been developed. This is performed with a miniature endoscope via a small percutaneous tract (11–20 F) and was named as minimally invasive or mini-PCNL. This method was initially described as an alternative percutaneous approach to large renal stones in a pediatric patient population. Furthermore, it has become a treatment option for adults as well, and it is used as a treatment for calculi of various sizes and locations. However, the terminology has not been standardized yet, and the procedure lacks a clear definition. Nevertheless, mini-PCNL can achieve comparable stone-free rates to the conventional method, even for large stones. It is a safe procedure, and no major complications are reported. Although less invasiveness has not been clearly demonstrated so far, mini-PCNL is usually related to less blood loss and shorter hospital stay than the standard method.

Long-term results after computed-tomography-guided percutaneous radiofrequency ablation for small renal tumors

PURPOSE

To present the long-term results and to identify possible risk factors for recurrence after radiofrequency ablation (RFA) for renal tumors.

PATIENTS AND METHODS

Thirty-one patients with a total of 39 renal tumors ranging from 1.3 to 7.5 cm (mean size 3.1 cm) were treated with RFA using a Rita Medical System model 1500 RF generator attached to a 15-gauge Starburst XL probe under percutaneous CT scan guidance. The average patient age was 61.4 years (range 37-86 y). Indications for RFA were bilateral tumors, presence of serious comorbidities, a high risk of development of additional renal-cell carcinomas, marginal renal function, and patient preference. No tumor was biopsied before treatment; therefore, only local control success rates could be provided. Recurrence was defined as enhancement or lesion enlargement on follow-up CT scan. Statistical analysis was performed to identify possible risk factors for recurrence. Parameters tested were age, sex, and number of ablation sessions, tumor size, location, multiplicity, body mass index, and American Society of Anesthesiologists score.

RESULTS

Initial ablation success rate was 90% and with repeated treatment, a success rate of complete ablation reached 97%. Average follow-up was 61.2 months (range 36-84 mos). Recurrence was seen in four tumors. The risk factor associated with recurrence was tumor size exceeding 4 cm (P < 0.01, relative risk [RR] = 3.31). Overall 3- and 5-year tumor control rate was 92% and 89%, respectively. Tumor size was also predictive for recurrence in the subgroup of 17 patients followed for more than 5 years (P = 0.02, RR = 3.15). Tumor control rate for this subgroup was 90%.

CONCLUSIONS

According to our results, larger tumor size was prognostic for recurrence after RFA for renal tumors. This treatment seems to demonstrate excellent tumor control long-term results, comparable to those achieved by nephron-sparing surgery in a selected group of patients.

Treatment Characteristics and Inherent Prostatic Features Do Not Predict Patient Outcome after High-Energy Transurethral Thermotherapy: A Prospective Study of ProstaLund Feedback Treatment™

PURPOSE

To determine whether treatment characteristics, intrinsic prostatic factors, and clinical parameters predict the outcome in patients treated with high-energy transurethral microwave thermotherapy (HE-TUMT).

PATIENTS AND METHODS

A series of 48 consecutive patients, 28 with an indwelling catheter, underwent ProstaLund Feedback Treatment (PLFT). The 12-month International Prostate Symptom Score response rate (IPSS < or = 7 or > or =50% improvement), peak flow rate response rate (Q(max) > or = 15 mL/sec or > or =50% improvement), and bladder outflow obstruction index response rate (BOOI <40) were correlated with treatment characteristics such as duration, average intraprostatic temperature, time with therapeutic intraprostatic temperatures (>45 degrees C), average intraprostatic blood flow, consumed energy, and recorded prostate mass destruction. Baseline parameters such as age, serum prostate specific antigen concentration, prostate volume, and pretreatment IPSS, quality of life (QOL), Q(max), postvoiding residual urine volume (PVR), and BOOI were included in the logistic regression analysis.

RESULTS

Treatment characteristics did not discriminate responders and nonresponders to HE-TUMT. For the patients without a catheter, the IPSS response (75%) was predicted by higher pretreatment IPSS (P = 0.041; relative risk [RR] = 3.4) and higher pretreatment PVR (P = 0.026; RR = 1.1). The Q(max) response (85%) was predicted by higher grades of pretreatment obstruction (P = 0.009; RR = 1.02). The BOOI response (60%) was not related to any of the factors tested. For the patients with a catheter, no outcome predictors could be identified.

CONCLUSIONS

According to our results, the intraprostatic temperature, the duration of intraprostatic temperatures in the therapeutic range, and the pattern of blood flow did not predict HE-TUMT outcome. Treatment duration, consumed energy, and the magnitude of tissue necrosis did not translate into clinical efficacy. Clinical parameters were important predictors of outcome in patients not in retention.

Induction of spermatogenesis in men with azoospermia or severe oligoteratoasthenospermia after antegrade internal spermatic vein sclerotherapy for the treatment of varicocele

AIM

To evaluate the treatment outcome of antegrade internal spermatic vein sclerotherapy in men with non-obstructive azoospermia or severe oligoteratoasthenospermia (OTA) as a result of varicocele.

METHODS

Between September 1995 and January 2004, 47 patients (mean age 33.8 +/- 6.3 years) underwent antegrade internal spermatic vein sclerotherapy for the treatment of varicocele with azoospermia (14 patients) or severe OTA (33 patients). Testicular core biopsy was also performed in complete azoospermic patients who provided informed consent. The outcome was assessed in terms of improvement in semen parameters and conception rate.

RESULTS

Forty-two (89.4%) of 47 patients had bilateral varicocele. Serum follicle stimulating hormone (FSH) did not differ between patients with azoospermia and severe OTA. After the follow-up of 24.8 +/- 9.2 months, significant improvement was noted in mean sperm concentration, motility and morphology in 35 patients (74.5%). Comparison between groups during the follow-up revealed significantly higher values of sperm concentration, motility and normal morphology in the severe OTA group. Pregnancy was achieved in 14 cases (29.8%). Testicular histopathology of the azoospermic patients with postoperative induction of spermatogenesis revealed maturation arrest at spermatid stage, Sertoli-cell-only (SCO) with focal spermatogenesis or hypospermatogenesis. None of the patients with pure SCO pattern or maturation arrest at spermatocyte stage achieved spermatogenesis after the treatment. Preoperative serum FSH levels didn't relate to treatment outcome.

CONCLUSION

Antegrade internal spermatic vein sclerotherapy is an easy and effective treatment for symptomatic varicocele. It can significantly reverse testicular dysfunction and improve spermatogenesis in men with severe OTA, as well as induce sperm production in men with azoospermia, improving pregnancy rates in subfertile couples.

Extracorporeal shockwave therapy for Peyronie's disease: an alternative treatment?

AIM

To determine retrospectively the safety and efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease.

METHODS

Fifty-three patients with stable Peyronie's disease underwent ESWT (group 1). Fifteen patients matched with the baseline characteristic of the patients in group 1, who received no treatment, were used as the control (group 2). The patients' erectile function (International Index of Erectile Function [IIEF-5] score), pain severity (visual analog scale), plaque size and degree of penile angulation were assessed before and after the treatment in group 1 and during the follow-up in group 2.

RESULTS

The mean follow-up time was 32 months (range: 6-64 months) in group 1 and 35 months (range: 9-48 months) in group 2. All the patients were available for the follow-up. Considering erectile function and plaque size, no significant changes (P > 0.05) were observed in group 1 before or after the ESWT. A total of 39 patients (74%) reported a significant effect in pain relief in group 1 after ESWT. However, regarding improvement in pain, IIEF-5 score and plaque size, no significant differences were observed between the two groups. In 21 patients (40%) of group 1, the deviation angle was decreased more than 10 degrees with a mean reduction in all patients of 11 degrees (range: 6-20 degrees). No serious complications were noted considering ESWT procedure.

CONCLUSION

ESWT is a minimally invasive and safe alternative procedure for the treatment of Peyronie's disease. However, the effect of ESWT on penile pain, sexual function and plaque size remains questionable.

Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: A comparison study

OBJECTIVES

To compare the postoperative quality of life (QOL) and reconvalescence in patients with clinical Stage I nonseminomatous germ cell tumor (NSGCT) after laparoscopic retroperitoneal lymph node dissection (L-RPLND) and the open procedure (O-RPLND).

METHODS

Twenty-one patients with NSGCT who underwent transperitoneal L-RPLND were matched and compared with 29 patients who underwent O-RPLND. The operative, QOL, and recovery data and complications and cure rates were analyzed for both groups.

RESULTS

The mean follow-up time for the L-RPLND and O-RPLND groups was 14 months (range 6 to 20) and 26 months (range 8 to 38), respectively. No major complication requiring open surgical revision or prolongation of hospitalization was observed intraoperatively or postoperatively in either group. However, the early and late minor postoperative complications were significantly greater in the O-RPLND group than in the L-RPLND group (P <0.001). The L-RPLND patients had a significantly shorter hospitalization, greater QOL scores, and a faster return to normal activities than did the O-RPLND patients (all P <0.001).

CONCLUSIONS

L-RPLND for patients with clinical Stage I NSGCT is a safe and efficacious procedure, with a faster reconvalescence and greater postoperative QOL than after O-RPLND.

Treatment of Renal-Vascular Injury by Transcatheter Embolization: Immediate and Long-Term Effects on Renal Function

PURPOSE

To evaluate the impact of superselective embolization for treatment of renal-vascular injuries on renal function.

PATIENTS AND METHODS

Between 1995 and 2004, four male patients and one female patient with a mean age of 45.4 years underwent embolization to control bleeding from renal-vascular injuries resulting from iatrogenic interventions (N = 4) or blunt abdominal trauma (N = 1). Angiography depicted a pseudoaneurysm in all patients, together with an arteriovenous fistula in one. Superselective embolization was achieved with 0.035- or 0.018-inch coils combined with a mixture of Histoacryl and Lipiodol in one patient.

RESULTS

Bleeding was controlled in all patients and did not recur. No complications occurred after the procedure. Hematuria ceased within 3 days. The serum creatinine concentration returned to pre-injury values within 10 days. Embolization caused an immediate parenchymal ischemic area of 0 to 20% (mean 9%). The contrast-enhanced CT scan 6 months after the procedure revealed a parenchymal perfusion deficit of 0 to 10% (mean 5%).

CONCLUSIONS

Superselective embolization resulted in permanent cessation of bleeding. Renal function was preserved in all the patients, and serum creatinine concentrations returned to the pre-injury values. Transcatheter embolization should be considered the treatment of choice in the management of renal-vascular injuries.

Erectile dysfunction after transurethral prostatectomy for lower urinary tract symptoms: results from a center with over 500 patients

AIM

To identify possible risk factors for erectile dysfunction (ED) after transurethral resection of prostate (TURP) for benign prostatic hyperplasia (BPH).

METHODS

Between March 1999 and March 2004, 629 patients underwent TURP in our department for the treatment of symptomatic BPH. All patients underwent transrectal ultrasound examination. In addition, the flow rate, urine residue, International Prostate Symptom Score (IPSS) and quality of life (QOL) were recorded for those who presented without a catheter. Finally, the erectile function of the patient was evaluated according to the International Index of Erectile Function Instrument (IIEF-5) questionnaire. It was determined that ED existed where there was a total score of less than 21. The flow rate, IPSS and QOL assessment were performed at 3 and 6 months post-treatment. The IIEF-5 assessment was repeated at a 6-month follow-up. A logistic regression analysis was used to identify potential risk factors for ED.

RESULTS

At baseline, 522 (83%) patients answered the IIEF-5 questionnaire. The mean patient age was (63.7+/-9.7) years. The ED rate was 65%. After 6 months, 459 (88%) out of the 522 patients returned the IIEF questionnaire. The rest of the group was excluded from the statistical analysis. Six months after TURP, the rate of patients reporting ED increased to 77%. Statistical analysis revealed that the only important factors associated with newly reported ED after TURP were diabetes mellitus (P = 0.003, r = 3.67) and observed intraoperative capsular perforation (P = 0.02, r = 1.12).

CONCLUSION

The incidence of postoperative, newly reported ED after TURP was 12%. Risk factors for its occurrence were diabetes mellitus and intraoperative capsular perforation.

Laparoscopic Radical Prostatectomy Using an Extraperitoneal Approach: Nordwest Hospital Technique and Initial Experience in 255 Cases

PURPOSE

We report on our modifications in technique and initial experience with 255 extraperitoneal laparoscopic radical prostatectomy (eLRP).

PATIENTS AND METHODS

Using significant surgical modifications, our laparoscopic method replicates the steps of the retropubic descending RP. We evaluated 255 consecutive patients who underwent an eLRP with pelvic lymph-node dissection.

RESULTS

The mean operative time was 136 minutes (range 84-266 minutes). Because of technical difficulty, the first three patients were converted to open surgery. One major complication, myocardial infarction, and one surgical reintervention in a case of secondary rectourethral fistula after open surgical repair of a laparoscopic rectal injury were observed. The blood transfusion rate was 1.2%. The pathologic stage was pT2a in 56 patients (22%), pT2b in 50 (20%), pT2c in 74 (29%), pT3a in 42 (16%), pT3b in 29 (11%), and pT4 in 3 (2%). Positive margins were found in 7% of patients (13/180) with pT2 tumors and 27% of patients (19/71) with pT3 tumors. The mean catheterization time was 7 days. The continence rates (no pads at all) at 3, 6, and 12 months were 73.7% (146/198), 89.6% (112/125), and 92.7% (38/41), respectively. After a nerve-sparing procedure, the total potency rates at 3 and 6 months were 37.5% (21/56) and 48.8% (21/43), respectively.

CONCLUSION

The eLRP seems to be safe with short-term oncologic and functional results at least as favorable as those of open radical prostatectomy and classical transperitoneal LRP. The operative times are shorter, and the complication rate appears to be lower.

Retroperitoneoscopic versus open surgical radical nephrectomy for large renal cell carcinoma in clinical stage cT2 or cT3a: quality of life, pain and reconvalescence

OBJECTIVES

To determine whether retroperitoneoscopic radical nephrectomy for large renal cell carcinoma in stage cT2 or cT3a is a feasible, safe and effective therapy option and if it shows any advantage regarding quality of life in comparison to open procedure.

METHODS

23 patients who underwent RPNx for tumor size greater than 7 cm (group 1) were matched and compared with 25 patients, who underwent ONx (group 2) for tumor with similar size characteristics. Patient and surgical data, QoL variables and complications were statistically analyzed.

RESULTS

The median followup was 12 (range: 6-18) months for both groups. Group 1 had significantly (p < 0.001) less blood loss, shorter hospital stay, and shorter postoperative analgesic requirements. No conversion to open surgery was necessary, and no major complications requiring an invasive intervention occurred. Retroperitoneoscopic patients had significantly better QoL and pain scores postoperatively to 6 months (p < 0.001) and they return to baseline QoL status faster (p < 0.001).

CONCLUSIONS

RPNx for large RCC in stage cT2 or cT3a is a safe and efficacious procedure with good short-term outcome results and significantly shorter recovery of QoL variables.

Bcl-2 protein and DNA ploidy in renal cell carcinoma: do they affect patient prognosis?

AIM

The aim of the present study was to correlate bcl-2 protein expression and DNA-ploidy status with established prognostic parameters in renal cell carcinoma (RCC) and to examine their impact on disease progression and patient survival.

METHODS

Both parameters were prospectively measured in 50 consecutive radical nephrectomy specimens using flow cytometry. They were correlated with the tumor grade, stage and histological type. Kaplan-Meier survival analysis for all parameters was performed.

RESULTS

Bcl-2 protein expression was higher in RCC compared to normal renal tissue (P < 0.0001). Aneuploid tumors had higher bcl-2 expression compared to diploid tumors (P = 0.015). Bcl-2 expression and DNA content were not correlated with tumor histological types (P = 0.277/P = 0.419), grades (P = 0.690/P = 0.449), T categories (P = 0.637/P = 0.585) or stages (P = 0.726/P = 0.800). Median follow-up time was 46 months (range, 5-84) with a mean overall survival of 61.8 months (95% confidence interval, 53.7-69.9). Tumor stage was the only statistically important prognostic factor (P = 0.0045).

CONCLUSION

Although Bcl-2 expression was correlated with tumor DNA content, the prognostic value of these two parameters following radical nephrectomy was not established.

Splenogonadal fusion: report of a case and review of the literature

We report a case of splenogonadal fusion masquerading as a testicular tumor and review the etiology, the pathogenesis and the management of this rare disease. A 20-year-old male patient presented with clinical and radiological findings of a left testicular mass for which he underwent a left radical inguinal orchidectomy. Histopathology of the removed testicle revealed no tumor. The gonad was fused to ectopic splenic tissue, the later forming a distinct encapsulated mass attached to the lower pole of the testicle inside the tunica vaginalis. Splenogonadal fusion, although a rare condition, may account for a non-malignant testicular mass and should be suspected in young patients with other congenital anomalies.

Feedback microwave thermotherapy with the ProstaLund Compact Device for obstructive benign prostatic hyperplasia: 12-month response rates and complications

PURPOSE

To evaluate the effectiveness of the ProstaLund Compact Device in the treatment of benign prostatic hyperplasia (BPH).

PATIENTS AND METHODS

A series of 38 consecutive patients with a mean age of 72.6+/-8.2 years, 19 with an indwelling catheter, underwent transurethral microwave thermotherapy (TUMT) with the ProstaLund Compact Device. Pretreatment evaluation included transrectal ultrasonography (TRUS), urodynamics, and cystoscopy for all patients and flow rate (Qmax), postvoiding residual urine volume (PVR), International Prostate Symptom Score (IPSS), and quality-of-life (QoL) assessment for those without a catheter. The mean prostate volume was 63.5+/-30 cc. The Qmax, IPSS, and QoL studies were repeated at 3, 6, and 12 months, while urodynamics, cystoscopy, and TRUS were repeated at 6 and 12 months.

RESULTS

The treatment lasted a mean of 43.1+/-17.1 minutes, achieved a maximal intraprostatic temperature of 58.7+/-7.2 degrees C, and destroyed 18.4+/-14.3 g of prostatic tissue. Twelve months post-treatment, for the patients without a catheter preoperatively, the IPSS was improved from 21.5+/-6.3 to 6.5+/-3.1 (P<0.001), Qmax from 7.2+/-3.1 mL/sec to 18.1+/-7.4 mL/sec (P<0.001), detrusor pressure at Qmax from 87.5+/-15 cm H2O to 48.4+/-16.4 cm H2O (P<0.001), and PVR from 113.2+/-78.2 mL to 34.6+/-36.7 mL (P<0.01). The good-response rates for IPSS (<or=7 or >or=50% improvement), Qmax (>or=15 mL/sec or >or=50% improvement), PVR (<50 mL or >or=50% decrease), and QoL (<or=2) were 73.7%, 84.2%, 73.7%, and 94.7%, respectively. For the patients with a catheter preoperatively, the IPSS improved from 9.5+/-6 at 3 months to 5.1+/-5.3 (P<0.05) at the end of the follow-up period. The Qmax was 13.2+/-6.4 mL/sec at 3 months and remained stable throughout the follow-up period. Patient good-response rates for IPSS (<or=7), PVR (<150 mL), and QoL (<or=2) were 75%, 87.5% and 75%, respectively. Only two patients were unable to void after the treatment. Complications were similar to those presented in the literature, and bladder stone formation was noted as well (five patients).

CONCLUSIONS

ProstaLund thermotherapy is a highly promising alternative treatment for BPH, improving substantially both objective and subjective measures of bladder outflow obstruction.

DOES THE MANAGEMENT OF BLADDER PERFORATION DURING TRANSURETHRAL RESECTION OF SUPERFICIAL BLADDER TUMORS PREDISPOSE TO EXTRAVESICAL TUMOR RECURRENCE?

PURPOSE

We evaluated the impact of a bladder perforation during transurethral resection of superficial bladder tumor on extravesical tumor recurrence and patient prognosis. We also defined potential risk factors for extravesical recurrence prospectively giving emphasis to the management of the perforation.

MATERIALS AND METHODS

The medical records of 3,410 patients were reviewed. Parameters recorded included patient age and sex, tumor stage, grade, number, size and location at the time of perforation, the type of bladder perforation (extraperitoneal vs intraperitoneal) and the way the perforation was managed (open surgical repair vs conservative treatment). Logistic regression analysis was used to identify risk factors for extravesical recurrence. Cox regression analysis was used to compare cancer specific survival.

RESULTS

A total of 34 cases of bladder perforation were recorded, 4 patients were treated with open surgery and 30 treated conservatively. The 4 patients who underwent open surgery presented with extravesical recurrence after a mean followup of 7.5 months. The remaining 30 patients had no evidence of extravesical recurrence after a mean followup of 60 months (p <0.001). Of the patients with extravesical relapse 3 died of disease. The surgical management of bladder perforation was the best predictor of extravesical recurrence (p <0.001, r = 1.13), followed by an intraperitoneal localization of the perforation (p =0.0003, r = 0.67) and tumor size (p =0.01, r = 0.42).

CONCLUSIONS

Surgical repair of a bladder perforation during transurethral resection of bladder tumor increases the risk of extravesical tumor cell recurrence and negatively affects patient prognosis.

Modified ileal neobladder for continent urinary diversion: functional results after 9 years of experience

PURPOSE

We report the continence status and urodynamic findings in 59 patients who underwent radical cystectomy and orthotopic bladder reconstruction using a modified S-ileal neobladder technique between January 1993 and July 2002.

MATERIALS AND METHODS

Continence status was assessed using patient interview, frequency-volume charts and the need for protective devices. Reservoir sensation, compliance, capacity and activity were assessed by enterocystometry. Post-void residual urine volume greater than 100 ml was the indication for clean intermittent self-catheterization.

RESULTS

Daytime continence was reported by 95.5% and 100% of our patients at 1 and 5 years, respectively. Overall, 77.7% of patients reported nighttime continence at 1 year and 96.5% at 5 years. The need for a protective device decreased with time and most of the patients would have undergone the operation again. Enterocystometric capacity and maximum reservoir pressure remained remarkably stable at 391.6 versus 440 ml, and 30 versus 20 cm H2O, 6 months and 5 years after surgery, respectively. Nevertheless, median post-void residual urine volume increased from 35 ml at 6 months to 55 ml at 5 years with an increase in prevalence of patients requiring intermittent self-catheterization due to post-void residual urine greater than 100 ml from 1.8% at 6 months to 10% at 5 years.

CONCLUSIONS

Orthotopic bladder substitution with the modified S-ileal neobladder technique has an excellent functional outcome over time, resulting in high daytime and nighttime continence levels as well as high acceptability rates from our patients.