Ureterolysis with ureterotomy and omental sleeve wrap in patients with radiation induced pelvic retroperitoneal fibrosis.

INTRODUCTION: Secondary retroperitoneal fibrosis (RPF) due to pelvic radiation alone or together with pelvic surgery is one of the causes of obstructive renal failure. Ureteral obstruction is caused by ischemic stricture and encasement by fibrotic tissue. Endo-ureterotomy alone, without vascular supply, is not successful in these cases. MATERIAL AND METHODS: We present eleven cases of ureteral obstruction due to radiation and surgery induced RPF. Seven patients had radiation therapy with or without radical hysterectomy and three patients had anterior resection of the rectum with pre-emptive radiation and one patient had anal cancer treated with local excision and radiation therapy. Nine of the eleven patients had bilateral ureteral obstruction. Open ('intubated') stented ureterotomy and omental sleeve wrap was performed. In one patient, Boari flap ureteroneocystostomy was necessary. RESULTS: Of the eleven patients (twenty renal units) we succeeded in nine patients (eighteen renal units). In two patients with bilateral ureteral obstruction, we were able to reestablish ureteral patency in only one renal unit each. CONCLUSIONS: Ureterolysis with ureterotomy and omental sleeve wrap is a valid surgical approach for alleviation of ureteral ischemic obstruction due to secondary retroperitoneal fibrosis caused by radiation alone or together with pelvic surgery.

Recurrent urinary retention due to imperforate hymen after hymenotomy failure: a rare case report and review of the literature.

Acute urinary retention (AUR) is unusual in children. We report for the first time a case of recurrent urinary retention due to massive hematocolpos resulting from an imperforate hymen in a 14-year-old girl. In case of AUR in adolescent girls, clinicians should keep in mind that imperforate hymen may be a causative factor and this condition may easily be treated surgically, but follow-up is still necessary to ensure that there is no recurrence.

Upper pole multicystic dysplasia and ureteropelvic junction obstruction associated with obstructive-refluxing megaureter in a neonate with a single kidney.

A 20-day-old male neonate presented with fever and hydronephrosis. Evaluation revealed that the patient had a single left kidney and a rare combination of multiple congenital malformations: upper pole segmental multicystic dysplasia, ureteropelvic junction obstruction, and an obstructive and refluxing megaureter (ureterovesical junction obstruction). We performed percutaneous drainage of the infected and obstructed upper collecting system and then used a sequential approach to manage the patient's anomalies. First, we performed an upper pole partial nephrectomy and pyeloplasty with a modified Y ureterostomy. Second, when the child was older, we performed ureterovesical reimplantation with ureteral tailoring. Currently, after 5 years of follow up, the patient has stable renal function.

Ureteral injury concomitant with kidney injury due to blunt trauma: case report.

A 27- year old man fell from seven meters high. A CT of abdomen and pelvis with contrast injection showed injury of right kidney, perirenal hematoma, and periureteral extravasation of contrast. Retrograde pyelography confirmed the diagnosis of partial transection of the right upper ureter. Conservative management of the case is discussed. A JJ internal ureteral stent was inserted successfully.

Urinary tract infection as a single presenting sign of multiple vaginal foreign bodies: case report and review of the literature.

BACKGROUND: Vaginal foreign bodies in children usually present with foul-smelling discharge and/or vaginal bleeding. Rarely, these basic clinical diagnostic signs are not present. CASE: We report on a 5(1/2)-year-old girl with recurrent lower urinary tract infection as the sole presentation of multiple vaginal foreign bodies. Ultrasound of the lower urinary tract was inconclusive, and cystography indicated for recurrent urinary tract infections was declined by the patient in an outpatient setting. Cystography under general anesthesia raised the suspicion of foreign vaginal objects, and the definitive diagnosis was made by vaginoscopy. The relevant literature covering this subject is reviewed. CONCLUSION: High level of suspicion and strict basic diagnostic protocol are the most important steps for a timely diagnosis of this condition.

[External ureteral injuries].

INTRODUCTION: Traumatic ureteral injuries are quite uncommon. Penetrating and non-blunt trauma are the most common cause of ureteral injuries. Most of the blunt ureteral injuries described in the literature are case reports. Simultaneous bilateral ureteral injury is extremely rare. DIAGNOSIS: In homodynamic stable patients imaging studies should be conducted when there is suspicion of urinary tract injury. Abdominal computerized tomography with contrast injection and delayed scans are the gold standard for staging such injuries. Excretory urography may be used when computerized tomography is not feasible. When both of these imaging studies are not diagnostic and there is still a high suspicion of injury, a retrograde pyelography would be the next imaging study option. MANAGEMENT: Partial ureteral transection can be managed with ureteral stent placement. Complete ureteral transection and some grade III injuries should be explored and repaired with debridement, placement of ureteral stent and tension-free anastomosis of healthy ureteral ends with absorbable stitches and omental or peritoneal wrap. The type of anastomosis depends on the height of the ureteral injury and whether the contralateral ureter is existent and with no diseases. CONCLUSIONS: A high index of suspicion is needed in diagnosing ureteral injury in patients with blunt or penetrating trauma. Delay in diagnosis or inappropriate treatment would lead to serious immediate and delayed complications, from mild hematoma to abscess, sepsis, strictures, obstructive nephropathy, and renal unit loss.

Three cases of penile paraffinoma: a conservative approach.

Injection of foreign materials into different body parts has long been performed to change the body contour. The treatment of choice should be radical excision, otherwise recurrence of the symptoms can occur. However, in selected patients, conservative treatment should be considered. We report the cases of 3 Thai foreign workers, with a history of penile oil injections.

Obstructive uropathy secondary to inguinal bladder hernia: case report and review of the literature.

We report a case of a large inguino-scrotal bladder hernia presenting with obstructive lower urinary symptoms and causing massive unilateral uretero-hydronephrosis with ipsilateral renal function deterioration. Careful anamnesis and computer tomography (CT) scan of the abdomen and pelvis were important for the diagnosis. Open surgery with mesh hernia repair was successful. The obstructive lower tract symptoms subsided following surgery while the deteriorated renal unit regained only part of its function.

[Numerical aberrations of chromosomes 11 and 17 detected by fish--fluorescence in situ hybridization combined with cytology in exfoliated cells from voided urine in patients with urothelial carcinoma of the bladder].

OBJECTIVES: To study the use of FISH analysis for detecting the presence of numerical alterations of chromosomes 11 and 17 combined with cytology in exfoliated cells from voided urine as a method for diagnosis and follow-up in patients with urothelial carcinoma (UC) of the bladder. MATERIALS AND METHODS: During the period April 2005 till June 2006, three groups were studied. The first group included 15 patients without UC. The second group included 25 patients undergoing evaluation for suspected UC. The third group included 25 patients enrolled in cystoscopy follow-up for previous UC. All the patients underwent cystoscopy, cytologic examination and FISH analysis for centromeric probes 11 and 17 performed on voided urine. After diagnosing the bladder UC, the tumor was staged and graded according to the pathologic findings. The sensitivity and specificity of FISH and Cytology were assessed. Data were analyzed with t-test when comparing two groups, and using ANOVA test when comparing more than two groups. These statistical analyses were executed with statistical software PRISM version 4.03. RESULTS: The sensitivity of FISH when using the centromeric probes of chromosomes 11 and 17 was 95.2%. The specificity was approximately 94.4%. The monosomy, trisomy, and polysomy in the patients with UC were 95.2%, 78.6% and 35.7% (p < 0.05) respectively. FISH was positive in 92.3% (24/26) in low grade tumors and in 100% (16/16) in high grade tumors (p > 0.05). The sensitivity of cytology was 31%. The cytology was positive in 23% (6/26) in low grade tumors and in 43.8% (7/16) in high grade tumors (p < 0.05). CONCLUSIONS: FISH analysis using centromeric probes of chromosomes 11 and 17 is an effective noninvasive method for the detection of altered chromosome numbers in bladder cancer cells in urine exfoliated cells. The sensitivity of FISH is higher than that of cytology in detecting UC. The combined analysis of FISH and cytology, does improve the accuracy of cytology but does not improve the specificity. Monosomy is the most prevalent numerical aberration found in patients with UC of the bladder. FISH analysis might give better results especially when cytology is negative. This method may help to decrease the frequency of cystoscopies in the follow-up of patients with confirmed bladder UC. Using multi-probe FISH test may improve the sensitivity. However, further studies are needed to confirm our results and conclusions.

Renal pelvis flap--guide for ureteral spatulation and handling during dismembered pyeloplasty.

INTRODUCTION: To present a technical modification of the classic dismembered pyeloplasty technique. We have implemented it in 112 pyeloplasties performed during the past 15 years. TECHNICAL CONSIDERATIONS: The technical modification is based on a renal pelvis flap kept undetached from the ureteropelvic junction, and consequently from the ureter, until near completion of the new ureteropelvic anastomosis. This flap is used for ureteral handling (a "no touch" technique) during pyeloplasty and also serves as a very reliable guide for lateral ureteral spatulation, preventing ureteral twisting and subsequent misalignment of the de novo ureteropelvic junction. We experienced early complications in 4 patients (3.6%). Two patients had excessive urinary leakage from the ureteropelvic anastomosis because of misplacement of a Nelaton retroperitoneal tube drain. We have used soft Penrose drains for retroperitoneal drainage since. Two other patients needed reoperation because of a redundant renal pelvis and ureter consequent to a remnant high anastomosis and insertion of the ureter to the renal pelvis with subsequent kinking and obstruction. No other early or late complications attributable to obstruction of the anastomosis resulting from devascularization or misalignment between the ureter and renal pelvis were encountered. CONCLUSIONS: Modification of the classic pyeloplasty technique has proved relatively easy and reliable in our experience. With the increasing popularity of the laparoscopic approach for pyeloplasty, the described technical modification may become useful for laparoscopic handling of the ureter.

[Epidemiology of transitional cell carcinoma among Israeli Arabs].

INTRODUCTION AND OBJECTIVE: Environmental, nutritional and hereditary factors are known to influence the epidemiology and the course of transitional cell carcinoma of the bladder (TCCB) and hence attribute to major ethnic and national differences. The focus of this study was on the characteristics of TCCB among Israeli Arabs who form a particular ethnic group in the Israeli population and were treated in our medical centers. METHODS: All the Arab patients who presented with TCCB between 1993-2003 to 3 medical centers (Meir, Kfar Saba; Soroka, Beer Sheba and Hillel Yaffe, Hadera) were included in this study. Data was collected retrospectively, with special attention given to epidemiological parameters, risk factors, and treated history of TCCB among these patients. RESULTS: Of 1638 patients who presented with TCCB between 1993 and 2004 at those 3 medical centers, 100 (6.1%) were Israeli Arabs. Male to female ratio among Arabs was 13.4:1 (93 males, 7 females). The prevalence of smoking was 91% and 14% among Arab men and women respectively. The mean age at presentation was 64 (22-93). Arab women were older than men at the time of presentation (mean age 75.7 and 63.1 respectively). Eighty-three percent of patients presented with superficial TCCB and 17% were diagnosed with invasive disease: 80% of patients who presented with superficial TCCB did not progress during the follow-up. In 15% of the patients with stage Ta TCCB progressed to stage T1, while 20% of the patients with superficial TCCB progressed to an invasive stage. The distribution of tumor grades at presentation was 21%, 47% and 32% for grades 1, 2 and 3 respectively. CONCLUSIONS: This study demonstrates some major differences in the epidemiology of TCCB among Israeli Arabs in comparison to the general Jewish population. The male to female ratio is significantly skewed towards male predominance. The mean age of the Arab men at presentation with TCCB is younger in comparison to Jewish men as well as to Arab women. The prevalence of smoking among Arab men who present with TCCB is especially high. On the other hand, the treated history and course of TCCB among Arabs seems to follow the known figures of TCCB. Environmental, life style, nutritional and hereditary factors characteristic to the Israeli Arab population may be associated with these ethnic epidemiological differences.

Fluorescence in situ hybridization performed on exfoliated urothelial cells in patients with transitional cell carcinoma of the bladder.

OBJECTIVES: To evaluate comparatively fluorescence in situ hybridization (FISH) and cytology performed on exfoliated urothelial cells obtained from voided urine and bladder washings as a method of diagnosis and follow-up in patients with transitional cell carcinoma (TCC) of the bladder. METHODS: Thirty patients with confirmed bladder TCC, 10 patients enrolled in cystoscopy follow-up for previous bladder tumors, and 10 patients with bladders free of tumor without a previous history of bladder TCC underwent cytologic examination and FISH performed on voided urine and bladder washing specimens. The FISH probes were targeted to chromosomes 7 and 9. RESULTS: FISH had a sensitivity of 92% for high-grade tumors in both voided urine and bladder washing specimens, significantly greater than that of cytology at a sensitivity of 64% in voided urine and 67% in the bladder washing specimens (P = 0.02). The sensitivity of FISH and cytology were both low and not significantly different statistically from each other for the low-grade tumors. Monosomy of chromosome 9 correlated with early tumor recurrence. Polysomy of chromosomes 7 and 9 correlated with high-grade tumors (80% and 92%, respectively). CONCLUSIONS: According to our results, with the local cytopathology expertise, FISH performed on urothelial cells from voided urine has a sensitivity that supersedes that of cytology, making the former a valuable complementary method in the diagnosis and follow-up of patients with bladder TCC.

[Biochemical failure after radical prostatectomy].

An elevated or detectable serum PSA after radical prostatectomy for prostate cancer is significant in the great majority of the cases with recurrent or persistent disease. Elevation of serum PSA causes concern for the patient and his physician since the best way to treat these patients is yet unknown. Analysis of large series of patients who underwent radical prostatectomy demonstrates that as many as 30% of patients will experience biochemical relapse represented by elevation of serum PSA. Most of the relapses occur in the first 5 years. However, 10 to 15 years are necessary to ascertain the true clinical progression rate of prostate cancer after radical prostatectomy. The time lag between the biochemical and clinical manifestation of metastatic disease may extend for up to 8 years, followed by an additional 5-year median time until cancer specific death. Radiation therapy may be beneficial as an adjuvant or early salvage if PSA < 1.5 ng/ml and for patients with high probability of local recurrence. Early salvage radiation therapy is a more acceptable option than adjuvant radiation therapy, saving 70% of patients with adverse pathology unnecessary treatment. Hormonal treatment at the time of biochemical relapse is justified in selected patients.

Non contrast computerized tomography and dynamic renal scintigraphy in the evaluation of patients with renal colic: are both necessary?

OBJECTIVES: To determine the value of the combined use of non contrast computerized tomography (NCCT) and dynamic renal scintigraphy (DRS) in the evaluation of patients with renal colic. METHODS: Forty-nine consecutive patients with renal colic were evaluated with abdominal plain films (KUB), NCCT and DRS with Tc-99m DTPA or MAG-3. NCCT results showed size and location of the urolithiasis, as well as secondary signs of obstruction. DRS was used to determine the degree of obstruction in the affected renal unit. Patients were submitted to urologic intervention or followed, decision made on the basis of clinical symptoms, degree of obstruction, size, and location of the stone. RESULTS: Three patients had other etiologies than stone for their symptoms and were excluded from the study. Of the remaining 46 patients, KUB detected stones in 24 (52.2%), while NCCT in all. NCCT showed secondary signs of obstruction in 35 patients (76%). Seven patients in this group (15%) had severe hydronephrosis on NCCT and complete obstruction on DRS. Twenty-eight patients (61%) showed moderate hydronephrosis and/or peri-renal and peri-ureteral stranding on the NCCT. In this latter group, DRS diagnosed complete obstruction in 5 (18%) patients, partial obstruction in 16 (57%) and no signs of obstruction in 7 (25%) patients. Overall 34% (12/35) of the patients with secondary signs of obstruction on NCCT had complete obstruction on DRS. NCCT revealed no secondary signs of obstruction in 11 patients (24%) with partial obstruction diagnosed by DRS in one of them (9%). All 12 patients with complete obstruction on the DRS underwent early intervention. Of the 16 patients with partial obstruction of the DRS, two patients (12.5%) necessitated ureteric stent insertion. Three patients with no obstruction on the RNS underwent elective extracorporal shock wave lithotripsy (ESWL) while the rest of the patients were followed and passed their stones spontaneously. CONCLUSIONS: The combination of non-enhanced helical CT and DRS assesses both anatomy and function. When NCCT shows no secondary signs of obstruction, NCCT as the sole imaging study performed may be adequate. If there are secondary signs of obstruction on NCCT, DRS can distinguish patients with different degrees of obstruction and together with the clinical course, size, and location of the lithiasis may help in selecting patients who need earlier intervention from those who may be safely observed.