Urology Journal
Volume:7 Issue: 1, Winter 2010

Unresectable renal cell carcinoma (RCC) is a technically incurable condition. Historically, RCC is resistant to chemotherapy and radiotherapy. Cytokine therapy was until recently considered the mainstay of treatment. However, responses are modest. Improvement in the understanding of the biology of RCC, particularly the hereditary types, is providing the basis for novel therapeutic targets. Our aim was to review the clinical utility of various systemic agents and surgery in the management of advanced RCC and suggest practice guidelines in the light of current literature. Evidence was collected by review of current literature, guidelines of the American and European associations and the national comprehensive cancer network. Treatment of advanced RCC has recently undergone a major change with the development of targeted agents and potent angiogenesis inhibitors. Small-molecule multikinase inhibitors that target vascular endothelial growth factor receptors have a favorable toxicity profile and can prolong time to progression and preserve quality of life when used in newly diagnosed or previously treated patients; bevacizumab enhances the response rate and prolongs disease control when added to interferon-alpha. Temsirolimus, a mammalian target of rapamycin inhibitor, prolongs the survival duration of patients with poor-risk disease. All currently available agents have variable toxicity profile and they, at best, improve survival by a few months. Surgery still has a significant role in the management of stage IV RCC. Supportive care and surgery remain the mainstay of treatment even in the management of advanced and metastatic RCC. Systemic therapeutic agents are showing promising results.

Percutaneous renal procedures have become an established approach for diagnosis and treatment of a number of renal pathologic lesions. Hemorrhage and vascular lesionsare the most serious complications. The reported incidence of postoperative hemorrhage requiring selective angio-embolization for bleeding control is 1.2%.(1) Delayed bleeding after percutaneous procedures is almost always secondary to pseudoaneurysms or arteriovenous fistulas.(2) We report a case of pseudoaneurysm following percutaneous nephrolithotomy (PCNL) that caused recurrent episodes of severe hematuria after the operation, requiring embolization, but it resolved spontaneously.

Laparoscopic partial nephrectomy is increasingly practiced by urologists, and its technique isconstantly improving. Recently, Simforoosh and colleagues reported a simplified technique for performing partial nephrectomy. (1) Renal artery pseudoaneurysm is an uncommon complication after laparoscopic partial nephrectomy. (2) Few cases have been reportedso far with this problem, and all of the reported patients who had undergone successful angioembolization were free from hematuria.(3,4) We present a patient who had a massive hematuria and severe drop of the blood pressure in spite of her successful embolization of renal artery pseudoaneurysm after laparoscopic partial nephrectomy.

The present study aimed to assess the efficacy and safety of percutaneous nephrolithotomy (PCNL) in elderly patients. We retrospectively reviewed 50 PCNLs performed in the elderly patients (age > 65 years) carried out in our clinic from 2001 through 2007 and compared those with 248 PCNLs performed in younger patients (age < 40 years) during the same period. No significant difference was seen in calculus burden between thetwo groups. The success rates (stone-free patients and patients with residual calculi < 4 mm) were 85% for the elderly patients and 90% for the younger patients (P =. 45). The major composition of calculi was calcium oxalate in 58% and 66.5% of the elderly and younger groups, respectively. No significant complication was observed in the elderly group. Fever without sign and symptoms of bacteremia was seen in 3 patients of each group (8.0% versus 1.2%, P =. 004). The operative time was 75.0 ± 6.4 minutes and 76.0 ± 5.1 minutes (P =. 25), and the mean hospital stay was 3.7 ± 0.3 days and 3.8± 0.9 days (P =. 80) in the elderly and younger patients, respectively. We found that PCNL in patients over 65 years was a safe andreliable technique with a stone-free rate of 85% for all types of calculi. Wellcontrolledcomorbidities do not increase the risk of operation. It seems that despite the higher medical risk in the elderly patients, PCNL could be safe and yields a high stone-free rate.

Percutaneous nephrolithotomy (PCNL) is the treatment of choice for large kidney calculi, staghorn calculi, and calculi that are multiple or resistant to shock wave lithotripsy. In many centers, PCNL is performed under general anesthesia. However, complications under spinal anesthesia can be less frequent. We evaluated the impact of spinal anesthesia on intraoperative and postoperative outcome in patients undergoing PCNL. The intra-operative and postoperative anesthetic and surgical outcomes were evaluated in 160 consecutive patients who underwent PCNL under spinal anesthesia in the prone position. The mean age of the patients was 40.0 ±14.3 years, and the meanoperative time was 95.0 ± 37.8 minutes. The mean calculus size was 34.2 ± 9.8 mm. Ten patients had staghorn calculi (mean size, 4.2 ± 1.1 cm; mean operative time, 140 ± 40 minutes). Return of sensory and motor activity took 140.0 ± 19.7 minutes and 121.0 ± 23.8 minutes, respectively. Duringthe first part of anesthesia, 18 patients developed hypotension, which was controlled by ephedrine, 10 mg, intravenously. Ten patients (6.3%) needed blood transfusion and 6 complained of mild to moderate headache, dizziness, and mild low back pain for 2 to 4 days after the operation, which improvedwith analgesics and bed rest. Seventy percent of the patients had completeclearance of calculus or no significant residual calculi larger than 5 mm on follow-up ultrasonography. Spinal anesthesia is safe and effective for performing PCNLand is a good alternative for general anesthesia in adult patients.

Recent scientific attention has focused on the role of growthfactors in the progression of cancer. HER-2/neu is an epidermal growth factor receptor that is demonstrated to have correlation with poor prognosis of many cancers. This study evaluated the overexpression of HER-2/neu protein and its clinical importance in nonseminomatous germ cell tumors of the testis. Testis specimens of 54 patients with testicularnonseminomatous germ cell tumors, referred to Omid Hospital from 2001 to 2007, were re-evaluated and the patients’ records were reviewed. Patients’ age, tumor subtype, tumor stage, tumor markers, therapeutic response, and disease-free survival were assessed and the specimens were evaluated for the degree of HER-2/neu expression using an immunohistochemistry method. Immunohistochemical staining was performed for 54 specimens.Overexpression of HER-2/neu was seen in 33.3% of the patients with nonseminomatous germ cell tumors, especially in those with teratocarcinoma subtype compared to those with mixed germ cell tumors or embryonal cell carcinoma. However, HER-2/neu overexpression did not show any correlation with tumor stage, therapeutic response, disease-free survival, age, β-human chorionic gonadotropin, or α-fetoprotein. We observed overexpression of HER-2/neu receptor interatocarcinoma subtype of germ cell tumor. We suggest further studies toevaluate the clinical importance of this finding.

Thyroid hormones affect kidney function and may alter withchanges in kidney function, as well. We evaluated changes in serum levels of triiodothyronine (T3), thyroxin (T4), and thyroid-stimulating hormone (TSH) early after kidney transplantation and their relationship with delayed graft function (DGF). Fifty-five consecutive kidney allograft recipientswere enrolled in the study. Serum levels of T3, T4, and TSH were measured on the day before transplantation, and also on posttransplant days 1, 3, 7, 14, and 21. Results were compared between patients with a normal allograft function and those with DGF. The mean T3 level decreased from 110.41 ± 49.79 ng/dL beforetransplantation to 80.78 ± 51.42 ng/dL on the 1st day after transplantation (P =. 04), while T4 reduction reached a significant level on the 3rd day after transplantation (8.27 ± 3.27μg/dL to 5.50 ± 2.57 μg/dL, P =. 004). Patients with DGF experienced a significantly greater decrease in the serum level of T3 at the end of the 1st week after transplantation compared with patients with normal kidney function (P =. 02). This significant decrease in T3 continued until the end of the 2nd week. Serum levels of T4 reduced comparably in the two groups, until the end of the 1st week, when it showed a significantly more reduction in the patients with DGF (P =. 04). Both T3 and T4 reduced early after kidney transplantation,and this reduction was significantly more prominent in those with DGF. This is compatible with a consequence rather than a cause of DGF, explained in the setting of sick euthyroid syndrome.

Urogenital fistula is one of the most devastating complications that can result from labor or urogenital surgeries. It is still a frequent problem in the developing world. Urogenital fistulas can lead to devastating medical, social, and psychological problems; thus cause major impact on the lives of girls and women. However, these cases are still largely neglected in the developing world. We aimed to evaluate causative factors and discuss management of urogenital fistulas. Forty-two cases of urogenital fistula developing within 5 to 38 days after delivery, pelvic surgery, and obstetric procedures were treated over a period of 5 years from 2003 to 2008. These included 37 vesicovaginal fistulas (88.1%), 4 uterovesical fistulas (9.5%), and 1 pure ureterovaginal fistula (2.4%). All of the patients were catheterized immediately on presentation and the catheter was left in situ for a minimum of 3 weeks before surgical intervention. The most common cause of vesicovaginal fistulas was obstructed labor, while other varieties of fistulas were mostly associated with pelvic surgery. Spontaneous closure occurred in 3 cases of vesicovaginal fistula. Surgical intervention needed in 39 patients. Peritoneal flap and Martius flap were interposed between suture lines in transabdominal and transvaginal approaches, respectively. Thirty-four fistulas (80.1%) were closed at the first attempt. There was no mortality from the surgical procedure. Vasicovaginal fistula is the most common urogenital fistula. Obstructed labor and its complications are still the leading cause of its development. Peritoneal flap interposition technique is a successful and effective treatment method for urogenital fistula.

A wide variety of therapeutic modalities have been tried for treatment of premature ejaculation. Selective serotonin reuptake inhibitors are from the latest and most effective medical agents. Among these drugs, fluoxetine hydrochloride has been used for some years in our institutions with considerable drug untoward effects and significant failure rates. We tried to salvage treatment process by using citalopram in fluoxetine-resistant patients. In a prospective clinical trial, we used citalopram hydrobromide as a salvage agent in 16 newly married men with premature ejaculation who experienced a history of unsuccessful treatment with fluoxetine hydrochloride. Intravaginal ejaculation latency time (IVELT) was recorded by a stopwatch before and after the treatment, and a 5-stage visual scale was designed and used to compare patients’ sexual satisfaction levels during the 1-month treatment period. The IVELT and sexual satisfaction levels both significantly improved after citalopram prescription. The mean measured IVELT was 0.388 ± 0.212 minutes before the treatment, which increased to 4.313 ± 2.886 minutes after the treatment. The reported drug untoward effects were mild. Citalopram was ineffective only in 1 patient, which was discontinued after 4 weeks. Our study showed that citalopram is effective and safe in the treatment of premature ejaculation in newly married men after failed treatment with fluoxetine.

In a prospective study, outcome of oral mucosa graft urethroplasty (OMGU) was assessed in patients suffering from stricture of the urethra. Patients who underwent OMGU between July 2005 and December 2007 were included in this prospective study. Forty-eight patients with stricture of the urethra were divided into 2 groups of those who consumed tobacco and had poor oral hygiene and those who did not consume tobacco and had satisfactory oral hygiene. The oral cavity was inspected. The type of tobacco consumption and the duration of exposure to tobacco were noted. The mean follow-up was 18.2 months (range, 6 to 36 months). The patients were evaluated to assess the outcome of OMGU. The final outcome was analyzed in 42 patients. Thirty-one patients were asymptomatic and/or satisfied with their urinary flow rate, who were considered to have a successful outcome (73.8 %). Successful outcome in patients who consumed tobacco was significantly less (58.3%) compared to that in the tobacco nonusers (94.4%; P =. 008). Failure rate of OMGU was higher in patients who consumed tobacco and had a poor oral hygiene, which might be due to adverse effects of these substances on the oral mucosa, leading to a poor graft quality.

Open prostatectomy is the conventional surgical treatment of benign prostatic hyperplasia. The major early complication of this procedure is bleeding. We introduce a technique of prostatectomy in order to prevent significant bleeding, reduce morbidity, and shorten convalescence and hospital stay periods. We enrolled 202 consecutive patients diagnosed with benign prostatic hyperplasia who were candidates for open prostatectomy. The operation was performed by one surgeon within 6 years using a modified technique of simple suprapubic prostatectomy (no bladder drainage and no bladder neck suture). Clot retention episodes, hemoglobin decrease, urethral catheterization time, and hospital stay were evaluated postoperatively. The patients were followed up for 1 to 2 years. The mean operative time was 18 minutes (range, 14 to28 minutes) with an estimated mean intra-operative blood loss of 120 mL. The mean hospital stay was 3 days (range, 2 to 4 days). The median urethral catheterization time was 5 days. No intra-operative complication or mortality was noted. Return to baseline urinary function and subjective continence at 3 months were 100% and 99%, respectively. Only in 1 patient (0.4%), bladder neck contracture was detected 3 months after the operation. Transurethral prostate resection has been introduced as the surgical treatment of choice in patients with benign prostatic hyperplasia. However, open prostatectomy still has a place. Suprapubic prostatectomy with no bladder drainage and no bladder neck suture appeared to be successful in decreasing convalescence and hospitalization times, with no significant complication, major blood loss, or bladder neck contracture.

Learning laparoscopic skills is difficult in the current era of fast developing laparoscopic urology. There are many commercially available good-quality laparoscopy trainers, but their prohibitive costs have limited their use in developing countries. To answer this problem,we conceptualized a home-made economical digital camera coupled with a laparoscopy trainer. Digital camera has also been used in endourology for documenting interesting findings.(

Perirenal fluid accumulation (floating kidney) is an unusual presentation of nephroticsyndrome. In this condition, the renal parenchyma is compressed and kidney function is impaired. We present a 27-year-old woman with membranoproliferative glomerulonephritis (MPGN) and massive bilateral perirenal fluid accumulation.

Foodborne botulism is a rare toxi-infection in France (20 to 30 cases per year).(1) Incubation time is comprised between few hours to 8 days. Clostridium botulinum is ananaerobic gram-positive organism which is ubiquitously found in soil and aquatic sediments in the spore form. Several forms of botulism exist. The foodborne form is the most frequent in the human botulism. Clostridium botulinum produces 7 different toxins of typeA, B, C, D, E, F, and G. Toxin type A is the most frequent and is found in the home-canned. Toxin type B is found in the cooked pork meats. All forms of botulism producethe same clinical symptoms: symmetrical cranial nerve palsies followed by descending, flaccid paralysis of voluntary muscles, which may progress to respiratory arrest. Prominent autonomic symptoms include accommodative paralysis with mydriasis, anhydrosis with severe dry mouth and throat, and orthostatic hypotension. Constipation and bladder paralysis are rarely reported.(2) All toxins exert their action on the cholinergic system at the presynaptic motorneuron terminal by blocking acetylcholine transmission across the neuromuscular junction. It causes neuromuscular blockade, resulting in a flaccid paralysis.(3) This article describes a caseof a 43-year-old man who presented with severe botulismmanifestations. In addition to the severe cranial motor nerves paralysis, a complete bladderparalysis was observed.

Adrenal myelolipomas are nonfunctioning benign tumors composed of adipose tissue and hemopoietic elements resembling bone marrow. Before the availability of modern imaging,they were detected only at autopsy with an incidence of 0.08% to 0.2%.(1) These tumors are now being picked up more frequently with the availability of computedtomography and ultrasonography, but they are usually small and isolated.(2) The first excision of a myelolipoma was carried out in 1922. Since then, more than 100 cases of surgically resected adrenal myelolipomas have been documented. The managementof incidentally found tumors and their pre-operative diagnosis is discussed. We describe the largest asymptomatic adrenal myelolipoma weighing 5.5 kg.