Outcomes and complications related to the management of Bosniak cystic renal lesions.

OBJECTIVE: The objective of our study was to evaluate outcomes and complications related to the management of Bosniak category IIF, III, and IV renal cysts. MATERIALS AND METHODS: For this multiinstitutional retrospective study, a Web-based Research Electronic Data Capture (REDCap) data registry was used to record data of 286 adult patients with 312 prospectively classified Bosniak IIF, III, and IV renal cysts diagnosed between January 2000 and October 2011. Included patients were managed by surgery (n = 86), percutaneous ablation (n = 19), or imaging surveillance of 1 year or more (n = 181). The median number of years of clinical surveillance was 2.4 years (range, 0-11.7 years), 2.6 years (range, 0.4-11.4 years), and 3.2 years (range, 1.1-11.6 years) for patients managed by surgery, ablation, and imaging surveillance, respectively. Pathologic and survival outcomes and complications related to management were evaluated. RESULTS: The malignancy rate at surgical pathology was 38% (3/8) for Bosniak IIF, 40% (29/72) for Bosniak III, and 90% (18/20) for Bosniak IV renal cysts. There were no metastases or deaths (0/144) directly related to Bosniak IIF renal cysts. There were no deaths (0/113) directly related to Bosniak III renal cysts, although one patient (1/113) developed local progression and lung metastases after thermal ablation. One patient with a Bosniak IV renal cyst (1/29) presented with and died of metastatic disease. Moderate to severe complications occurred in 19% (16/86), 5% (1/19), and 0% (0/181) of patients managed by surgery, ablation, and imaging surveillance, respectively (p < 0.0001). Severe complications occurred in 7% (6/86) of surgical patients and included multiorgan failure (n = 2), acute myocardial infarction (n = 1), acute ischemic stroke (n = 1), conversion to hemodialysis-dependent chronic kidney disease (n = 1), and postoperative severe hemorrhage (n = 1). CONCLUSION: There were no deaths from Bosniak IIF or III renal cysts regardless of management approach. Moderate to severe complications are frequent in patients managed by surgery.

Aggressive bladder carcinoma in an HIV-positive man with tetraplegia and neurogenic bladder.

BACKGROUND/OBJECTIVE: Patients with neurogenic bladder secondary to spinal cord injury who are managed long term with an indwelling catheter are known to be at increased risk for transitional cell carcinoma of the bladder. Immunosuppression is a known risk factor for malignancies that often are more aggresSive than those seen in normal populations. METHOD: Case report and discussion of management recommendations. RESULTS: We summarize the case of a 44-year-old HIV-positive C5-C6 incomplete tetraplegic male (date of injury 1980), who was diagnosed with transitional cell carcinoma of the bladder and succumbed to disease within 6 months of diagnosis. The patient was a non-smoker who was never managed with an indwelling catheter. There has been no such case reported in the literature. CONCLUSIONS: HIV infection in the presence of a neurogenic bladder may carry an increased risk of aggressive bladder malignancy. More studies are warranted to determine whether routine annual screening with cystoscopy in all patients with HIV and neurogenic bladder is indicated.

Potential for control of detrusor smooth muscle spontaneous rhythmic contraction by cyclooxygenase products released by interstitial cells of Cajal.

Interstitial cells of Cajal (ICCs) have been identified as pacemaker cells in the upper urinary tract and urethra, but the role of ICCs in the bladder remains to be determined. We tested the hypotheses that ICCs express cyclooxygenase (COX), and that COX products (prostaglandins), are the cause of spontaneous rhythmic contraction (SRC) of isolated strips of rabbit bladder free of urothelium. SRC was abolished by 10 microM indomethacin and ibuprofen (non-selective COX inhibitors). SRC was concentration-dependently inhibited by selective COX-1 (SC-560 and FR-122047) and COX-2 inhibitors (NS-398 and LM-1685), and by SC-51089, a selective antagonist for the PGE-2 receptor (EP) and ICI-192,605 and SQ-29,548, selective antagonists for thromboxane receptors (TP). The partial agonist/antagonist of the PGF-2alpha receptor (FP), AL-8810, inhibited SRC by approximately 50%. Maximum inhibition was approximately 90% by SC-51089, approximately 80-85% by the COX inhibitors and approximately 70% by TP receptor antagonists. In the presence of ibuprofen to abolish SRC, PGE-2, sulprostone, misoprostol, PGF-2alpha and U-46619 (thromboxane mimetic) caused rhythmic contractions that mimicked SRC. Fluorescence immunohistochemistry coupled with confocal laser scanning microscopy revealed that c-Kit and vimentin co-localized to interstitial cells surrounding detrusor smooth muscle bundles, indicating the presence of extensive ICCs in rabbit bladder. Co-localization of COX-1 and vimentin, and COX-2 and vimentin by ICCs supports the hypothesis that ICCs were the predominant cell type in rabbit bladder expressing both COX isoforms. These data together suggest that ICCs appear to be an important source of prostaglandins that likely play a role in regulation of SRC. Additional studies on prostaglandin-dependent SRC may generate opportunities for the application of novel treatments for disorders leading to overactive bladder.

AUA/SUFU adult urodynamics guideline: a clinical review.

The American Urological Association/Society of Urodynamics Female Pelvic Medicine and Urogenital Reconstruction Adult Urodynamics Guideline was published with the intent of guiding the clinician in the role of urodynamics in the evaluation and management of complex lower urinary tract conditions. This article examines each guideline statement and attempts to provide clinical context for each statement. Key points are emphasized in the form of clinical case scenarios, which demonstrate application of the principles stressed in this guideline. It is hoped the reader will have a better clinical frame of reference relative to each statement in these guidelines.