Development and internal validation of a nomogram predicting significant prostate cancer: Is it clinically applicable in low prevalent prostate cancer countries? A multicenter study

BACKGROUND

Accurately identifying aggressive prostate tumors and studying them as a separate outcome are urgently needed. Nomogram is a predictive tool using an algorithm, it has been widely applied in clinical practice to predict prognosis. We aimed to develop and internally validate a nomogram predicting clinically significant prostate cancer (csPCa).

METHODS

Data were retrieved from the records of the two main hospitals in Riyadh, during the period 2019-2022. Significant variables associated with csPCa cases were used to develop and internally validate a novel nomogram, utilizing the C index, and calibration curves. Decision curve analysis (DCA) was used to assess its clinical utility.

RESULTS

Prostate imaging reporting and data system (PI-RADS), smaller prostate volume, and prostate-specific antigen (PSA) > 10 ng/mL were significantly associated with the risk csPCa, respectively. The model developed by the nomogram showed an excellent accuracy for csPCa discrimination, as indicated by area under the curve (0.83), and calibration curves. DCA showed that our model was superior and surpassed all other models with a larger net benefit for various threshold probabilities. Based on our model, at a probability threshold of 30%, biopsying patients is the equivalent of a strategy that led to an absolute 5% reduction in the number of biopsies without missing any csPCa.

CONCLUSION

The developed nomogram consisting of PI-RAD, total PSA, and prostate volume showed a robust predictive capacity for csPCa before prostate biopsy that may be valuable for clinical judgment to prevent needless biopsy. Yet, the small percentage (5%) of yielded unnecessary biopsies that could be saved by using such a model, cast an important question on its merit and clinical applicability.

Prostate-specific Antigen Density as a Proxy for Predicting Prostate Cancer Severity: Is There Any Difference between Systematic and Targeted Biopsy?

Background

Prostate cancer screening with prostate-specific antigen (PSA) can result in unnecessary biopsies and overdiagnosis. Alternately, PSA density (PSAD) calculation may help support biopsy decisions; however, evidence of its usefulness is not concrete.

Objective

To evaluate the predictive value of PSAD for clinically significant prostate cancer detection by systematic and MRI-targeted biopsies.

Methods

This prospective study was conducted at two tertiary hospitals in Riyadh, Saudi Arabia, between December 2018 and November 2021. Patients suspected of prostate cancer were subjected to multi-parametric MRI, and for those with positive findings, systematic and targeted biopsies were performed. Clinically non-significant and significant prostate cancer cases were classified based on histopathology-defined ISUP grade or Gleason score. The PSAD was measured using the prostate volume determined by the MRI and categorized into ≤0.15, 0.16-0.20, and >0.20 ng/ml2 subgroups.

Results

Systematic and targeted biopsies were carried out for 284 patients. The discriminant ability of PSAD is higher in MRI-targeted biopsy compared with systematic biopsy (AUC: 0.77 vs. 0.73). The highest sensitivity (97%) and specificity (87%) were detected at 0.07 ng/ml2 in targeted biopsy. More than half of the clinically significant cases were detected in the >0.2 ng/ml2 PSAD category (systematic: 52.4%; targeted: 51.1%). The CHAID methodology found that the probability of having clinically significant cancer (CSC) in patients with PSAD >0.15 ng/ml2 was more than threefold than that in patients with PSAD ≤0.15 ng/ml2 (64% vs. 20.2%). When considered by age, in PSAD ≤0.15 ng/ml2 subgroup, the percentage of CSC detection rate increased from 20.2% to 24.6% in patients aged ≥60 years.

Conclusion

PSAD has good discriminant power for predicting clinically significant prostate cancer. A cutoff of 0.07 ng/ml2 should be adopted, but should be interpreted with caution and by considering other parameters such as age.

Studies on the radiation dose, image quality and low contrast detectability from MSCT abdomen by using low tube voltage

Background

To study radiation dose, image quality and low-contrast cylinder detectability from multislice CT (MSCT) abdomen by using low tube voltage using the American College of Radiology (ACR) phantom. The ACR phantom (low-contrast module) was scanned with 64 MSCT scanner (Brilliance, Philips Medical System, Eindhoven, Netherlands) with 80 and 120 KVP, utilizing different tube current time product (mAs) range from 50 to 380 mAs. The image noise (SD), signal to noise ratio, contrast-to-noise ratio (CNR), and scores of low contrast detectability were assessed for every image respectively.

Results

From images analyses, the noise essentially increased with the use of low tube voltage. The CNR was 0.94 ± 0.27 at 120 KVP, and CNR was 0.43 ± 0.22 at 80 KVP. However, with the same dose, there were no differences of statistical significance in scores of low-contrast detectability between 120 KVP at 300mAs and 80 KVP at (200–380) mAs (p > 0.05). At 300 mAs, the CTDIvol obtained at 80 KVP was about 29% of that at 120 KVP. The CTDIvol obtained at 80 KVP were decreased from 5% at 50 mAs, to 37% at 380 mAs.

Conclusions

There is a possibility to decrease exposure of radiation virtually by reducing KVP from 120 to 80 KVP in examination of abdominal CT when the high tube current is used, though increasing image noise at low tube voltage.

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy

OBJECTIVES

To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions.

METHODS

A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded.

RESULTS

Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001).

CONCLUSION

No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.

Screening for diabetes among tuberculosis patients: a nationwide population-based study in Egypt

Background

The prevalence of type 2 diabetes mellitus (DM) is increasing rapidly in Egypt and considered one of the major health problems in the Eastern Mediterranean region.

Objectives

To measure the prevalence of diabetes and detect the undiagnosed cases of diabetes mellitus among patient with tuberculosis.

Methods

Study Design: Nationwide population-based study. To diagnose DM among TB patients, we used a fasting blood sugar level of ≥ 126 mg/dl and a post-prandial blood glucose test result of ≥ 200 mg/dl.

Results

Screening for DM among 1435 TB patients' with no history of DM detected 30 new cases of DM, with a case detection rate of 2.09%. The highest screening yields were among TB patients aged ≥ 40 years, females and those with pulmonary TB. The number needed to screen (NNS) TB patients for detecting one new case of DM was 48 while the lowest values were for older age (NNS=27) and females (NNS=29).

Conclusion

Older age and being females and those with pulmonary type of TB were more prone to the double burden of TB and DM. Identifying cases with double burden of diseases will improve the proper management of both diseases and prevent complications.

Is survival after radical cystectomy for bladder cancer in Saudi patients different from that of Western patients?

BACKGROUND

Although radical cystectomy (RC) is considered the gold standard treatment of muscle invasive bladder cancer, nearly half of patients develop metastases and ultimately die within 2 years.

OBJECTIVE

To assess survival, evaluate different prognostic factors that may affect disease-free survival (DFS) in Saudi patients after RC for carcinoma of the bladder and to compare our results with those of Western countries.

DESIGN

Retrospective chart review.

SETTING

A tertiary care center in Saudi Arabia.

PATIENTS AND METHODS

We collected data on patients who underwent RC for bladder cancer in the period between 1979 and 2014. Demographic, clinical and pathological variables and the application of perioperative chemotherapy were reviewed. Univariate and multivariate analyses were done with DFS as the end point.

MAIN OUTCOME MEASURE

Disease-specific survival.

RESULTS

On 328 patients for whom data was available, the median follow up was 23 months (range, 2 month-28 years) and median age was 58 years (range, 21-90). Of these patients, 268 were males (81.7%), 235 (71.7%) had urothelial carcinoma (UC), 79 (24.1%) had squamous cell carcinoma (SCC), and 208 (63.4%) had pathological tumor stage 3 or more. The 5-year overall survival (OS) and DFS were 52% and 48%, respectively. There was no statistically significant difference in DFS of patients with UC and pure SCC. On univariate analysis, lymph node status and pathological tumor stage were significant predictors of DFS. Both variables sustained statistical significance in a multivariate analysis.

CONCLUSION

Survival following RC is almost the same as others. Moreover, pathological tumor stage and lymph node metastasis were the only independent predictors for survival following RC. Future cooperative prospective studies are required to gain data on our region.

LIMITATIONS

Relatively small sample size and retrospective.

Qualitative interviews with non-national tuberculosis patients in Cairo, Egypt: understanding the financial and social cost of treatment adherence

Limited data are available about the challenges of non-national TB patients undergoing long-term treatment courses in an urban setting. This study aimed to understand the financial and social cost of adherence of non-national TB patients in Cairo, Egypt as a means to inform the development of context-specific interventions to support treatment adherence. In 2011, 22 in-depth interviews were conducted with TB patients from Sudan, Ethiopia, Eritrea, Somalia and Djibouti to obtain qualitative data. Analysis was based on thematic analysis that aimed to identify recurrent themes and codes from the narratives. The study identified a number of factors that influence TB treatment adherence. Uncertain financial status due to limited or no employment was frequently discussed in interviews, which resulted in fear of not being able to support family, loss of pride, dependence on family and friends, fear of losing housing, food insecurity and limited food options. Respondents also feared infecting other household members and longed for opportunities to discuss their illness and treatment experiences with other individuals but their social networks were often limited. TB-related stigma was driven by shame and blame of infection. Respondents also believed stigma was based on their foreign origin. Stigma manifested in distancing and exclusion in various ways, resulting in isolation, psychological distress and reluctance to disclose TB status to others. Poverty-related factors and social context with a special focus on stigma should be considered when developing strategies for supporting long-term treatment courses for non-national patients in Cairo and other similar urban settings.

Prognostic factors of treatment among patients with multidrug-resistant tuberculosis in Egypt

BACKGROUND/PURPOSE

Multidrug-resistant tuberculosis (MDR-TB) represents 5% of TB cases globally. In Egypt, it represents 11.4% of TB cases (2.2% of new and 38.2% of previously treated). Our objectives were to evaluate the treatment outcomes and determine the associated prognostic factors among the first national treatment cohort of MDR-TB from 2006 to 2010.

METHODS

All patients diagnosed with MDR-TB from July 2006 to December 2010 who were admitted to Abbassia Chest Hospital, the first Egyptian national center established for MDR-TB treatment, were included. They were followed up clinically, radiologically, and bacteriologically by sputum smear, culture, and drug-susceptibility testing at regular intervals. Individualized treatment regimens were prescribed according to each patient's drug-susceptibility testing and the drug treatment history. Patients received at least five effective drugs. Outcome rates, and crude and adjusted odds ratios of unsuccessful outcomes were calculated.

RESULTS

The number of bacteriologically proven MDR-TB patients was 228, of which 225 were pulmonary cases. Half of the cases showed moderate or extensive lung lesions, and 15.8% were diabetics. A total of 158 (119 cured and 39 completed treatment) patients achieved successful outcome (69.3%), 16 (7.1%) failed treatment, 27 (11.8%) were lost to follow up, and 27 (11.8%) died. Predictors of unsuccessful outcome were delay in sputum culture conversion to 2 months or more, moderate or extensive lung lesions, and a history of diabetes.

CONCLUSION

A treatment success rate of approximately 69% was achieved with the first national treatment cohort of MDR-TB under the Egyptian program. Predictors of unsuccessful treatment were delayed culture conversion, moderate or extensive lung affection, and diabetes.

First insight into the genetic population structure of Mycobacterium tuberculosis isolated from pulmonary tuberculosis patients in Egypt

The present study aimed to assess the population structure of Mycobacterium tuberculosis (MTB) isolates from Egypt. A total of 230 MTB isolates were analysed using spoligotyping, large sequence polymorphism (LSPs), mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing and multi-locus sequence typing (MLST). The majority of isolates (93.0%) belonged to lineage 4, including 44.3, 13.4 and 10.8% of the ill-defined T clade, LAM and Haarlem families, respectively, and lineage 3 was identified in 7.0% of the isolates. MIRU-VNTRs typing allowed efficient discrimination of the spoligotype-defined clusters, including spoligo-international types (SIT) 53, 34, and 4, into 56 patterns, including 13 clusters and 43 unique patterns. A new SNP at position 311614 was identified in all six isolates to form the biggest MIRU-VNTR cluster, which suggested a recent clonal expansion. This SNP could possibly be used as a genetic marker for robust discriminations of Egyptian MTB isolates belonging to SIT53. The combination of spoligotyping, 12 MIRU-VNTRs loci and MLST provided insight into the genetic diversity and transmission dynamics of the Egyptian MTB genotypes and could be a key to implementation of effective control measures by public health authorities.

Predictors of viable germ cell tumor in postchemotherapeutic residual retroperitoneal masses

OBJECTIVE

The aim of this study was to identify predictors of viable germ cell tumor (GCT) in postchemotherapeutic residual retroperitoneal masses.

MATERIALS AND METHODS

The pertinent clinical and pathologic data of 16 male patients who underwent postchemotherapeutic retroperitoneal lymph node dissection (PC-RPLND) at King Faisal Specialist Hospital and Research Centre between 1994 and 2005 were reviewed retrospectively. It was found that all patients received cisplatin-based chemotherapy for advanced testicular GCT.

RESULTS

Out of the 16 male patients, 2 (13%), 8 (50%), and 6 (37%) had viable GCT, fibrosis, and teratoma, respectively. Ten (10) of the patients with prechemotherapeutic S1 tumor markers did not have viable GCT, and two of the six patients who had prechemotherapeutic S2 tumor markers have viable GCT. All tumor marker levels normalized after chemotherapy even in patients with viable GCT. Four patients had vascular invasion without viable GCT. Furthermore, four patients had more than 60% embryonal elements in the original pathology, but only 1 had viable GCT at PC-RPLND. Four of the five patients with immature teratoma had teratoma at PC-RPLND but no viable GCT; however, out of the four patients with mature teratoma, one had viable GCT and two had teratoma at PC-RPLND. Of the two patients with viable GCT, one had 100% embryonal cancer in the original pathology, prechemotherapeutic S2 tumor markers, history of orchiopexy, and no vascular invasion; the other patient had yolk sac tumor with 25% embryonal elements and 40% teratoma in the original pathology, and prechemotherapeutic S2 tumor markers.

CONCLUSION

None of the clinical or pathological parameters showed a strong correlation with the presence of viable GCT in PC-RPLND. However, patients with ≥S2 may be at higher risk to have viable GCT. Further studies are needed to clarify this.

Isolated ureteric endometriosis presenting as a ureteric tumor

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Prospective randomized trial of 100u vs 200u botox in the treatment of idiopathic overactive bladder

Aim:

To evaluate the clinical outcomes of two different doses of BTX-A in patients with refractory idiopathic overactive bladder.

Patients and Methods:

Thirty nine patients with refractory idiopathic overactive bladder from 1/1/2008 till 30/3/2009 were evaluated in a tertiary care hospital. Patients were evaluated using urodynamic studies, voiding diary, UDI-6 and IIQ-7 questionnaires prior to being prospectively randomized (alternate randomization) to the BTX-A applications and three months after treatment. Voiding diary and residual volume were followed two weeks later. All patients received intradetrusorial injections of BTX-A (Botox, Allergan, Irvine, CA) of 100u or 200u under cystoscopic control on an outpatient basis. The primary endpoint was assessed for the improvement of urodynamic parameters and adverse events at three months after the initial treatment. Secondary end points included urinary frequency, urgency and UUI episodes as assessed by voiding diary and QoL.

Results:

Eleven patients were enrolled to each arm of the study. There were no significant differences in demographic characteristics between the two groups. Urodynamic assessment at the end of the third month showed significant improvement in urodynamic variables in both groups. There was no statistically significant difference in urodynamic parameters and in the voiding diary between the two groups. QOL was significantly improved in both groups with no statistically significant difference between the different doses. Only three patients developed acute urinary retention.

Conclusion:

BTX-A at 100u and 200u appears to improve symptoms, urodynamic parameters and QoL with no statistical significance between the two groups.

The outcome of the seminal fluid parameters collected via coitus interruptus versus masturbation

A one year study was carried out to determine the outcome of the seminal fluid parameters collected via masturbation and coitus interruptus in 151 patients who were undergoing intrauterine insemination (IUI) and patients who came for seminal analysis. There were no statistically significant differences in terms of volume, concentration, progressive motility and normal morphology from specimens collected via coitus interruptus compared to specimens collected via masturbation. Pregnancy outcomes were also comparable.

Blood lead levels in Egyptian children from high and low lead-polluted areas: impact on cognitive function

OBJECTIVES

Many children are harmed by low-level lead exposure which impairs cognitive development with subsequent poor scholastic achievement. We investigated blood lead levels in children in relation to cognitive function.

MATERIALS AND METHODS

Blood lead levels were measured in 100 children recruited from high (n = 50) and low (n = 50) lead-polluted areas.

RESULTS

Blood lead levels ranged between 3 and 28 microg/dl (median 9, interquartile range 6 microg/dl). In addition, 43% of children had levels > or =10 microg/dl, of whom 90.1% were living in high-risk areas for lead pollution. Cognitive dysfunction was found in 37% of children. Children with cognitive dysfunction had significantly higher blood lead and lower hemoglobin than those without (P < 0.001).

CONCLUSIONS

Increased blood lead level in many children is one of the health problems in Egypt which may be the reason, at least in part, for cognitive dysfunction with subsequent poor scholastic achievement. Thus, interventions to control lead exposure are mandatory.

Diet, nutritional knowledge and health status of urban middle-aged Malaysian women

The objective of the study was to assess nutritional and health status as well as nutritional knowledge in urban middle-aged Malaysian women. The impact of menopause on diet and health indices was also studied. The study included 360 disease free women, non users of HRT,aged > or =45 years with an intact uterus recruited from November 1999 to October 2001. Personal characteristics, anthropometric measurements and blood sample were acquired followed by clinical examination. Nutrient intake and nutritional knowledge was determined by a quantitative FFQ and KAP. The findings showed that urban middle-aged women, aged 51.65+/-5.40 years had energy intakes (EI) 11% below RDA, consisting of 53% carbohydrates, 15% protein and a 32% fat which declined with age. The sample which comprised of 42.5% postmenopausal women had a satisfactory diet and healthy lifestyle practices. Premenopausal women consumed more dietary fat (6%) with other aspects of diet comparable to the postmenopausal women. Iron intake was deficient in premenopausal women, amounting to 56% RDA contributing to a 26% prevalence of anaemia. Overall, calcium intake reached 440 mg daily but dairy products were not the main source. The postmenopaused had a more artherogenic lipid profile with significantly higher total cholesterol (TC) and LDL-C, but more premenopausal women were overweight/obese (49% versus 35%). EI was the strongest predictor for BMI and waist circumference (WC), with WC itself an independent predictor of fasting blood sugar and TC with BMI strongly affecting glucose tolerance. High nutritional knowledge was seen in 39% whereas 20% had poor knowledge. Newspapers and magazines, followed by the subject's social circle, were the main sources of nutritional information. Nutritional knowledge was positively associated with education, household income, vitamin/ mineral supplementation and regular physical activity but inversely related to TC. In conclusion, middle-aged urban women had an adequate diet with low iron and calcium intakes. Nutritional knowledge was positively associated to healthier lifestyle practices and lower TC. A comparable nutrient intake and lifestyle between pre and postmenopausal women suggested that health changes associated with menopause was largely independent of diet.

Bone health in urban midlife Malaysian women: risk factors and prevention

The aim of this study was to identify risk factors associated with osteoporosis in urban midlife Malaysian women and to assess the effectiveness of lifestyle intervention in bone loss prevention with hormone replacement therapy (HRT) as a positive control. A total of 514 disease-free, uterus-intact, non-HRT-using women aged 45 years and older were recruited into the study. After initial bone mineral density (BMD) assessments, they were randomized into three groups: GI (control), G2 (lifestyle intervention), and G3 (lifestyle intervention with HRT). The study group was composed of 67.5% Chinese, 27.8% Malay, and 4.2% Indians with a mean age of 51.07+/-5.28 years. Two-fifths were postmenopausal, and the prevalence of osteoporosis was 24.1%, seen predominantly at the hip. Postmenopausal women had significantly lower mean BMD and a higher incidence of osteoporosis compared with the premenopausal women, 42.1% vs. 11.1% (p<0.0005). A lower incidence of osteoporosis was found in women who took calcium supplementation regularly as opposed to those who do not, 18.7% vs. 29.3% (p=0.036). Age and a greater postmenopausal duration showed a significant negative association with BMD, whereas higher family income, weight, body mass index, and waist and hip circumference were positively correlated. After 18-20 months, the effect of intervention was assessed based on BMD values of 279 women at baseline and after intervention. Lifestyle intervention alone was effective in premenopausal women, preventing over 90% of spinal bone loss compared with the controls, who lost 11.6% (0.046 g/cm2) bone mass with similar losses of hip bone, 2.0% (0.026 g/cm2) vs. 1.5% (0.020 g/cm2). Premenopausal women on HRT also showed a substantial decrease in spine and hip BMD, 18.6% (0.081 g/cm2) and 9.0% (0.122 g/cm2), respectively. The lifestyle intervention program retarded postmenopausal bone loss by 21% and 37% compared with controls, who lost 9.6% (0.141 g/cm2) and 6.0% (0.138 g/cm2) bone mass at the spine and hip. In comparison, lifestyle intervention with HRT increased postmenopausal BMD by 12.7% (0.216 g/cm2) at the spine and 1.9% (0.042 g/cm2) at the hip. The changes in hip BMD were influenced by current age, ethnicity, and income, while intervention had the strongest effect on spine BMD changes. In conclusion, lifestyle intervention prevented spinal bone loss in premenopausal women and retarded postmenopausal spine and hip bone loss compared with controls. The benefits of physical activity on spine and hip BMD highlight its potential as a safe and cost-effective alternative to HRT, which is not advocated because of its potential adverse effects.

Living Related Liver Transplantation for Hepatocellular Carcinoma in Egypt

BACKGROUND

Living related liver transplantation (LRLT) for hepatocellular carcinoma (HCC) in cirrhotic patients has emerged as a rewarding therapy for a cure. Extensions of the Milan criteria have been proposed with encouraging results.

PATIENTS AND METHODS

From October 2001 to June 2004, 47 adult patients with end-stage liver disease (ESLD) have been treated using LRLT, including 11 (9 males and 2 females) with HCC superimposed on hepatitis C virus (HCV)-related (n = 10) or hepatitis B virus-related (n = 1) cirrhosis. Their mean age was 50 years (range, 40-61). HCC was confirmed preoperatively in 9 subjects whereas it was an incidental finding in 2 cases. Alpha fetoprotein (AFP) levels were elevated in 5 of them. Radiologically, tumor number and sizes ranged from 1 to 2 nodules and from 1.5 to 7 cm, respectively. Five of the 11 subjects underwent pretransplantation tumor control therapy.

RESULTS

Nine patients are alive, all of them being disease free during follow-up periods ranging from 6 to 30 months. Two subjects died: one of HCC recurrence at 1 year posttransplantation, and another of a pulmonary embolism on day 7. AFP levels decreased to normal values in 4 cases. Excluding the 2 incidental tumors, pathological examination of the explants revealed a higher number and larger size of the nodules in 3 and 5 cases, respectively. Microvascular invasion was documented in 3 explants, 1 of which experienced HCC recurrence and the other 2 received 6 cycles of Doxorubicin following normalization of their liver profile. Postoperative complications included the following: recurrent HCC (n = 1), recurrent HCV (n = 2), acute cellular rejection (n = 3), anastomotic biliary stricture (n = 1), and subphrenic collection (n = 1).

CONCLUSION

Our current data confirm the efficacy of LRLT for treatment of HCC superimposed on liver cirrhosis.

Squamous cell carcinoma of the bilharzial and non-bilharzial urinary bladder: a review of etiological features, natural history, and management

Squamous cell carcinoma of the urinary bladder, though uncommon in Europe and the United States, is the most common variety of bladder tumor in countries where urinary bilharziasis prevails. A great controversy still exists regarding its natural history and management. Here, we review the literature of bilharzial and nonbilharzial squamous cell carcinoma of the urinary bladder, focusing on large series. Our aim was to gather most of the published data about this disease entity, report it in a systematic comparative review, and attempt to identify the adverse features and variables behind its dismal outcome. The conclusions are that squamous cell carcinoma, whether bilharzial or nonbilharzial, has distinctive clinicopathological features, different from those of the transitional cell variety. These tumors usually present in advanced (muscle-invasive) stages. Pelvic nodal metastases are not common, and the incidence of distant metastases is less than that reported with transitional cell carcinoma. Local treatment, including cystectomy and adjunctive radiotherapy, is the most acceptable way of treating such tumors.

Percutaneous nephrolithotomy in treatment of large stones within horseshoe kidneys

OBJECTIVES

To present our experience with percutaneous nephrolithotomy (PCNL) in the treatment of large stones within horseshoe kidneys.

METHODS

The study included 34 patients with 45 stone-bearing horseshoe kidneys treated by PCNL in one center. The indications for PCNL were large stone burden (greater than 2 cm) in 10 kidneys (22.2%), multiple complex stones in 22 (48.9%), staghorn stones in 3 (6.7%), and failed extracorporeal shock wave lithotripsy (ESWL) in 10 kidneys (22.2%). All PCNL procedures were performed in a standard one-session technique with fluoroscopic guidance. Procedures were evaluated for intraoperative and postoperative complications, use of auxiliary procedures (second-look PCNL, ureteroscopy, and ESWL), and length of hospital stay. Moreover, the stone-free rate was calculated at discharge from the hospital and 3 months later. In addition, we assessed the need for secondary intervention during a mean follow-up of 75 +/- 16 months (range 6 to 108).

RESULTS

The stone burden ranged from 264 to 2408 mm(2) (mean 664 +/- 153). Access to the horseshoe kidneys was supracostal in 10 (22.2%) and subcostal in 35 kidneys (77.8%). A single tract was used in 37 (82%), and two tracts were created in the remaining 8 kidneys (18%). Major complications were seen in six PCNL procedures (13.3%) and included significant hematuria requiring blood transfusion in three, septicemia in one, ureteral obstruction in one, and colonic injury in one. All complications were successfully treated. Auxiliary procedures were required in 12 patients (35.3%) and included ureteroscopy in 1, second-look PCNL in 3, and ESWL to fragment residual caliceal stones in 8 patients. The mean hospital stay was 4 +/- 1.9 days (range 3 to 12). The stone-free rate was 82% at discharge and 89% at 3 months. During the course of follow-up, 19 patients (56%) developed stone recurrence and were successfully treated with ESWL in 8 and PCNL in 11.

CONCLUSIONS

PCNL is a safe and effective procedure in the treatment of large stones within horseshoe kidneys.

Percutaneous nephrolithotomy in children: early and late anatomical and functional results

PURPOSE

We report our experience with percutaneous nephrolithotomy (PCNL) in children, and evaluate its early and late anatomical and functional results.

MATERIALS AND METHODS

A total of 65 children with renal calculi were treated with PCNL. Patient age at operation ranged from 9 months to 16 years (mean +/- SD of 5.9 +/- 0.9 years), and 27 (41.5%) were younger than 5 years. Seven patients had bilateral renal stones and, therefore, the number of kidneys treated by PCNL was 72. The patients were followed regularly every 3 months during year 1 and every 6 months thereafter. Renal scans using technetium dimercapto-succinic acid for detection of renal scarring and technetium diethylenetetramine-pentaacetic acid for determination of selective glomerular filtration rate (GFR) were performed in all patients at least once during followup, which ranged from 6 to 72 months (mean +/- SD 40 +/- 10).

RESULTS

Early complications included significant intraoperative bleeding in 1 case, renal pelvis perforation in 1 and transient fever in 2. Mean hospital stay +/- SD was 3 +/- 1.2 days (range 2 to 21). Of the renal units 62 (86%) were stone-free after a single PCNL, and the remaining 10 with residual stones were treated with a second look PCNL (4) and shock wave lithotripsy (6). Stone-free rates at hospital discharge and at 3 months were 93% and 100%, respectively. During followup 6 patients (9%) had recurrence of small renal stones and were successfully treated with shock wave lithotripsy. None of the kidneys had scarring on dimercapto-succinic acid renal scan. All of the kidneys except 1 showed improvement or stabilization of the corresponding GFR determined by diethylenetetraminepentaacetic acid renal scan. Comparison of the mean preoperative GFR of the corresponding kidney (28.8 +/- 11.2 ml per minute) with mean value at followup (36.1 +/- 9.9) showed an increase of statistical significance (p <0.01).

CONCLUSIONS

PCNL is a safe and effective procedure for the treatment of children with renal calculi. At long-term followup the procedure improves renal function without renal scarring.

Laparoscopic Ablation of Giant Renal Cyst

We report a case of a symptomatic giant (18 x 10 x 8-cm) renal cyst in a 40-year-old woman that was marsupialized laparoscopically and excised. The surgical technique, based on progressive decompression of the cyst, is fully described. Excellent results were achieved. The recent application of laparoscopic ablation of different types of renal cysts is reviewed. This minimally invasive technique, when properly mastered, is highly effective and offers results similar to those of open surgery. It is associated with definitive postoperative advantages and is the treatment of choice for very large renal cysts, especially those located anteriorly, when sclerotherapy is ineffective or is contraindicated.

Serum nickel concentration in normal menstrual cycle and after combined contraceptive pill

Serum nickel concentration in the different phases of the menstrual cycle and after use of a combined contraceptive pill (Anovlar) was determined by atomic absorption spectrophotometry. Twenty ovulating females had their serum nickel level measured on day 5 and on day 27 of their cycle. Forty females using Anovlar for 6 months and 40 females using it for more than 3 years had their serum nickel determined. The serum nickel concentration of the non-pill users was higher on day 5 (2.52 +/- 0.46 micrograms/L) than on day 27 (2.21 +/- 0.37 micrograms/L p less than 0.05). In long-term users, the serum nickel (0.98 +/- 0.38 microgram/L) was less than the short-term users (2.38 +/- 0.35 micrograms/L, p less than 0.01) and the non-users (p less than 0.01). There was a negative correlation between the duration of pill use and the serum nickel level (r = -0.44, p less than 0.01). The significance of the decreased serum nickel level with long-term pill use remains to be determined.

The perineal groove and canal in males and females--a third look

We present 5 uncommon cases: One case of perineal canal in a female; two cases of perineal groove in females, one with normal anus and another with ectopic perineal anus. Two cases of perineal canal in males. The canal is deep in the perineum, runs forward above the root of scrotum, close to the floor of the urethra (which is normal), and opens on the undersurface of the penis. One of them is associated with covered anus incomplete with anocutaneous fistula as well opening on the scrotal raphe. In all 5 cases the perineal canal or gutter opens posteriorly in the ectodermal anal canal, immediately below the line of anal valves. A third look to the origin of these conditions will be discussed versus the 1st and 2nd looks of Stephens and Chatterjee. Embryological and histopathological studies will support our point of view.

Chemical Examination of Local Plants. XIII. Elucidation of the Structure of a New Glycoside From the Leaves of Egyptian Hibiscus sabdariffa

The ether as well as the methanol extracts of the defatted leaves of Hibiscus sabdariffa yielded a new glycoside, the structure of which has been determined, by mass and N.M.R. spectra and by synthesis, as β- sitosteryl β-D-galactoside.