Bilateral renal cell carcinoma with bilateral synchronous adrenal gland metastases - a case report.

The authors reported a case of a 52-year-old patient with bilateral synchronous renal cell carcinoma synchronously disseminated in adrenal glands is presented. The patient underwent surgical treatment: radical nephrectomy on the right side, bilateral adrenectomie on the right and partial nephrectomy on the left side. Five years after surgery, patient is in complete remission.

Preoperative Gleason score, percent of positive prostate biopsies and PSA in predicting biochemical recurrence after radical prostatectomy.

PURPOSE: To determine the factors that can improve the prediction of biochemical recurrence after radical prostatectomy for the patients with prostate adenocarcinoma. METHODS: Our study included 182 patients with prostate adenocarcinoma who were biopsied and underwent radical surgical treatment at the Clinic of Urology, Clinical Center of Serbia, Medical Faculty in Belgrade from 1994 to 2004. Patients were prospectively followed-up and monitored for a minimum of 8 years and data were statistically processed by multivariate regression analysis. We arranged the predictors into 3 regressive models. In the first model the predictors were clinical stage of the disease, preoperative Gleason score, F/T PSA ratio and PSA. In the second model these predictors were accompanied with the number of positive biopsies and percent of positive prostate biopsies. In the third model, patient follow-up was added to the predictors. In all 3 models biochemical recurrence was considered as a dependent variable. RESULTS: On multivariate analysis, patient follow-up (p<0.0001), percent of positive prostate biopsies (p<0.0001), bioptic Gleason score (p<0.0001) and preoperative PSA (p<0.003) were significant independent predictors of biochemical recurrence. The most successful prediction of recurrence that provided accurate prognosis for 80% of the patients was obtained by the third model using the percent of positive prostate biopsies, PSA and patient follow-up. CONCLUSION: As stated in multivariate analysis, the independent predictors according to the significance are the follows: patient follow-up, percent of positive prostate biopsies, bioptic Gleason score and preoperative PSA, whereas preoperative F/T PSA ratio is dependent predictor. The number of positive biopsies and clinical stage of the disease are of no significance.

The case of the diverticular bladder tumor treated with diverticulectomy.

INTRODUCTION: The majority of diverticular bladder tumors (DBT) are urothelial. Due to the lack of the muscular layer in the diverticulum, the progression of these tumors is easier than in the bladder wall. CASE REPORT: The case of invasive DBT with painless hematuria is presented. The patient was treated with diverticulectomy. CONCLUSION: Unifocal Stage-T3 DBTs can be successfully treated with diverticulectomy.

Diagnostic value of the nuclear matrix protein 22 test and urine cytology in upper tract urothelial tumors.

OBJECTIVE: To investigate the diagnostic value of the nuclear matrix protein 22 (NMP22) test in comparison to urine cytology for the detection of upper tract urothelial carcinoma. PATIENTS AND METHODS: Patients with transitional cell carcinoma of the upper urinary tract (n = 34) and patients with renal calculosis (n = 25) were included in this study. Voided urine samples and separated catheter urine specimens were assayed for NMP22 and cytological examination. RESULTS: The sensitivity of the NMP22 test in separated and voided urine was 73.2 and 70.5%, respectively, compared to 64.7 and 58.8% of urine cytology. The specificity of the NMP22 test in separated and voided urine was 88 and 92%, respectively, compared to 96 and 96% of urine cytology. The combination of separated and voided urine is the best method because the sensitivity is 79.41% and specificity 88%. There is a high agreement of the NMP22 test in voided and separated urine (kappa = 0.795, p < 0.01), indicating that the voided urine is adequate for diagnosis. CONCLUSIONS: The NMP22 test has higher sensitivity but lower specificity than cytology. The combination of these two tests could be a very useful diagnostic method for detection of upper urothelial tumors.

Radical perineal prostatectomy: the first experience.

OBJECTIVE: to present relatively uncommon surgical procedure for the treatment of localized prostate cancer. MATERIAL AND METHODS: Six patients with localized prostate cancer (PCa) underwent perineal radical prostatectomy (PRP) from 2006 to 2010. The average age was 65 +/- 5.2 years. The average preoperative PSA was 7.8 +/- 1.3 ng/ml. Two patients had pT2b stage, while four had pT2c stage. Gleason score ranged from 4-7. RESULTS: All patients had negative surgical margins. Average operative time was 109 +/- 20 minutes and average blood loss was 525 +/- 180 ml. The urethral catheter was removed after 12 days in all patients except one, who required prolonged catheterization due to urinary fistula. All patients were continent after three months. Average postoperative PSA was 0.07 +/- 0.03 ng/ml. CONCLUSION: Perineal radical prostatectomy is valuable surgical procedure that provides good oncological results as well as urinary and sexual function.

What are the possible reasons for urethral PSA varieties after radical prostatectomy?

OBJECTIVE: To examine the possible reasons for great varieties in urethral prostate specific antigen (urPSA) levels, in patients after radical prostatectomy (RP). MATERIALS AND METHODS: In 46 patients with pros-tate cancer, PSA, urPSA, total testosterone, body-mass index (BMI) and the stage of androgenic alopecia (AGA) were determined. Forty-five patients underwent retropubic RP, while one underwent cystoprostatectomy with orthotopic bladder construction, due to bladder cancer. RESULTS: Average patients age prior to surgery plus or minus standard deviation was 65.2 +/- 5.8 years. Average urPSA was 20.9 +/- 47.5 ng/ml (0.05 to 212 ng/ml, median 2.24 ng/ml). With urethral PSA cut-off of 2.0 ng/ml, two groups were formed: A (urPSA < 2.0 ng/ml) and B (urPSA = 2.0 ng/ml). Patients in the group A had significantly lower average AGA score, than the patients from the group B (2.4 +/- 1.3 vs. 4.4 +/- 2.2, p = 0.0003). In addition, patients from the group A had significantly lower pos-toperative PSA (0.07+0.08 ng/ml vs. 0.14 +/- 0.06 ng/ml, p = 0.0014). CONCLUSIONS: The patients with higher urPSA have higher AGA scores and higher postoperative PSA. This phenomenon is probably the consequence of higher local dihydrotestosterone activity in the scalp and PSA-secreting urethral glands.

The case of cavernous testicular hemangioma.

OBJECTIVE: To present the rare case of testicular hemangioma. CASE REPORT: A 45-year-old clerk presented with painless swelling in the left testicle, which he noticed one month ago. Inguinal orchidectomy on the left side was performed and pathological report proved cavernous hemangioma. CONCLUSION: Hemangioma of the testis is very rare clinical condition. Clinical appearance and diagnostic exams are usually not sufficient for the diagnosis. Sometimes, hyperechoic lesion with increased vascularity can be seen on Doppler ultrasonography.

Urinary PSA level and relative tumor volume after prostate biopsy.

OBJECTIVES: To estimate the ratio between urinary prostate specific antigen (uPSA) and tumor volume after prostate biopsy. METHODS: From 2000 to July 2008, uPSA concentration was determined in 60 patients with clinically organ-confined prostate cancer (PCa). All patients underwent six-area transrectal ultrasound (TRUS)--guided biopsy, with at least 12 biopsy cores. Single pathologist determined tumor grade (G), Gleason score (GS), the percentage of tumor infiltration (% TI) and the percentage of positive cores (% PC) in all biopsy cores. Additionally, relative tumor-biopsy volume (RTV) was calculated by multiplying % PC, % TI and prostate ultrasound-derived volume (Vol). Forty-one patients underwent retropubic radical prostatectomy (RRP), while 19 patients underwent radiation therapy. RESULTS: Average uPSA was 308.6 +/- 311.9 ng/ml (range 0.06-988 ng/ml), average PSA was 9.7 +/- 5.5 ng/ml (range 1.2-24.3 ng/ml), tumor grade 1.7 +/- 0.8, Gleason score 5.2 +/- 1.3, the percentage of tumor infiltration 27.6 +/- 21.8%, and the percentage of positive cores, 52.2 +/- 30.7%. Average RTV was 6.3 +/- 8.4 ml (0.29-56 ml). All patients were divided in two groups: I, with RTV 4 ml and II, with RTV = 4 ml. The patients with RTV 4 ml had lower G (1.4 +/- 0.6 vs. 2.1 +/- 0.8, p = 0.0002), lower GS (4.5 +/- 1 vs. 5.8 +/- 1.3, p = 0.003) and higher uPSA (389.4 +/- 340.8 vs. 193.1 +/- 229.7, p = 0.014). There were no differences in serum PSA levels between the groups. CONCLUSION: Relative tumor-biopsy volume (RTV) is useful parameter in the preoperative assessment of tumor volume. Patients with higher RTV had significantly higher G and GS. However, these patients had significantly lower uPSA. This phenomenon could be the consequence of compromised PSA drainage from the peripheral zone of the prostate, caused by the tumor.

Penile metastasis from invasive bladder cancer.

OBJECTIVE: To present the rare case of penile metastasis from bladder cancer. PATIENT REPORT: A 68-year-old man with invasive bladder cancer disseminated in penile shaft and the pelvic lymph nodes is presented. The patient underwent cystoprostatectomy, total penectomy and adjuvant chemotherapy. RESULTS: Ten months after surgery, patient is in complete remission. CONCLUSION: Despite the fact that secondary penile tumors usually require palliative therapy, in selected cases surgical treatment of primary tumor and penectomy, followed with chemotherapy, can improve survival.

Renal cell carcinoma in a horseshoe kidney.

A case of an adenocarcinoma within a horseshoe kidney (HK) is presented. Male patient presented with a history of a painless hematuria. A contrast enhanced magnetic resonance (MR) scan showed a horseshoe kidney. A large soft tissue mass was also noted on the right side. Kidney was receiving supply from two arteries on the left side and one at the right side. Angiography of the right renal artery demonstrated hypervascular tumor staining. The kidney was approached through midline abdominal incision, and a right heminephrectomy was performed. The histopathology examination showed pT2, grade 2 renal cell carcinoma. To conclude, angiography is indispensable for guiding surgical interventions.

[Retrocaval ureter based on a series of 16 cases]. / Uretère rétrocave: à propos de 16 cas.

INTRODUCTION AND OBJECTIVES: To analyse the postoperative results of surgical treatment for retrocaval ureter. MATERIAL AND METHODS: The authors report a retrospective clinical study of a series of 16 patients (six women and 10 men) with a mean age of 38 years (range: 15-45 years) with retrocaval ureter treated between 1975 and 2005. The mean follow-up was 18 months (range: 12 to 34 months). All patients were evaluated by the standard diagnostic protocol for the time and were treated by one of the following surgical techniques: resection of the ureter and renal pelvis to renal pelvis anastomosis; resection of the ureter and pyelo-ureteric anastomosis; resection of the ureter and oblique end-to-end uretero-ureteric anastomosis; nephrectomy. RESULTS: The mean operating time was 95 min. Late postoperative follow-up revealed two cases (13%) of ureteric stenosis at the site of the oblique end-to-end uretero-ureteric anastomosis. Surgical revision was performed in one patient with resection of the ureter and reanastomosis, while anterograde dilatation of the stenosis was performed in the other patient. The postoperative course was uneventful in both patients. All patients were reviewed at six months with a satisfactory result, corresponding to reduction of hydronephrosis and improvement of renal function. CONCLUSION: Over the last 30 years, the diagnosis of retrocaval ureter has become more reliable and less invasive. Satisfactory results can be obtained with conventional surgical management.

[A new generation of urethral stents--Allium in the therapy of symptomatic prostatic enlargement of various etiology].

A number of urethral stents made of different materials, with different time of indwelling and different designs, primarily based on the vascular stent concept, have been applied in the clinical practice so far. According to the published studies, urethral stents have justified their clinical application, however with certain limitations. Within an attempt to overcome the limitations, a covered, temporary urethral stent was initially designed by Daniel Yachie and Ijko Markovi in Allium corporation from Israel. With its triangular shape, the stent is a replica of the obstructive prostatic urethral lumen. In has been applied in a series of 14 patients with lower urinary tract symptoms caused by the obstruction at the level of the prostatic urethra. The subjects were averagely aged 77.4 +/- 5.1 years. Allium prostatic stent remained in place in the patients for 4.93 +/- 3.17 months, at the average.

[Percutaneous-retrograde recanalization of ureteral stricture with a curved metal stent].

Our own experience in application of a combined percutaneous-retrograde approach for recanalization of the urethral structures in 4 patients in presented. Metallic guide is placed via the previously created percutaneous nephrostomy while dilatation or insertion of the metallic stent is performed retrogradely. The approach is used in the strictures in which percutaneou's placement of the recanalization balloon catheter into the stricture site was impossible. The method was successfully applied in all 4 cases in absence of any complications.

[Recanalization of urethral strictures using a temporary curved biocompatible new generation metal endoprosthesis]].

The male urethral stricture treatment is actual clinical issue with its resolution being increasingly frequently based on application of minimum invasive therapeutic interventional uroradiology methods. Since the methodology is applied over the last two decades, the most reasonable therapeutic algorithm has not been defined yet with respect to the correlation with the contemporary surgical treatment. The results of application of the temporary covered self-expandable nitinol Allium stents, which have been applied for the first time ever at our Institution in October 2003. Over the last 3 years, the method was applied in 40 males, averagely aged 54 years with urethral strictures previously treated by urological methods. In four cases, stent placement was performed after endourethral incision. The most common etiology of the stricture was the posttraumatic (55%), post-inflammatory (32%) and iatrogenic (10%). In all the cases, stents were removed 12-14 months after their insertions. The results are evaluated using uroflowmetry and urethrocystography, revealing in 85% of the cases permanent recanalization free of dysuric complaints. Development of a stricture on the anterior stent end was evidenced in 15% of the cases.

Treatment of emergency surgical complications of kidney transplantations.

Surgical complications subsequent to the kidney transplantation are not infrequent and they are characterized by the high percentage of graft loss (596-18% in standard surgical procedures and up to 37% in atypically performed transplantations). The study included 311 transplanted patients (206 (66.2%) living donors and 105 (33.8%) cadaver donors). Surgical complications developing during the immediate posttransplantation period as well as during the late period (after a year and a half) were classified as: I urinary complications; II vascular complications; III other complications. In majority of the cases urinary complications (urinary fistulas, ureteral obstructions, vesico-ureteral reflux) as well as other complications (cholecystopancreatitis and lymphocele) did not necessitate urgent treatment, unlike most of the vascular complications. All the vascular complications (29/311) developed during the immediate postoperative period, except for occurrence of arterial stenoses which ensued later on, while the development of symptoms was rapid. Severity of both symptoms and clinical picture necessitated urgent surgical re-intervention in order to preserve the graft and patient's life. Vascular complications were classified as: true vascular complications, hemorrhages and kidney ruptures in order to distinguish technical and other factors contributing to development of the complications. Onset of the true vascular complications related to the graft and recipient blood vessel changes was evidenced in 20 patients (69%/29 patients) while the incidence of hemorrhages and ruptures was considerably lower (14%/29 patients and 17%/29 patients). As for the true vascular complications, vascular stem thrombosis subsequent to cadaveric transplantations was the most frequent, and transplantectomy was performed in all the cases in absence of any lethal outcomes. Two cases with iliac artery rupture resulted in graft loss subsequent to urgen exploration. In all cases with hemorrhages the applied therapy resulted in positive responses, except in one case in which massive gastrointestinal hemorrhage led to lethal outcome. The response to the urgent surgical treatment of spontaneous kidney graft ruptures was positive in 60% of the cases, while in the remaining 40% transplantectomy was necessitated due to the extensiveness of the lesion in order to preserve patient's life.

Evaluation and management of traumatic rupture of the corpus cavrnosum.

Fracture of the penis, or rupture of the corpus c avernosum is an uncommon injury, but probably under-reported entity. Only approximately 180 cases have been reported in the literature. Penile fracture with urethral injury is even more uncommon, accounting for approximately 10 to 20% of the cases reported. Early reports on this injury suggest conservative therapy as the choice of treatment. Recent reports emphasize immediate surgical repair to prevent late sequelae of injury, especially those associated with urethral rupture. We review 5 cases with evaluation, treatment and followup. Delays in treatment lead to long-term complications.

The history of urinary diversion.

The earliest attempt to divert urine flow from the ureters to the intestine, was performed in 1851 by John Simon. In the absence of antibiotics, ureterosigmoidostomy and its modifications during the 19th and early 20th century have been associated with high rate of surgical and metabolic complications. In 1910, Robert Coffey demonstrated a new method for ureterointestinal anastomosis, which renovated primary enthusiasm in ureterosigmoidostomy and it gained broad popularity during the next forty years. In 1950, Ferris and Odel reported 80% incidence of hyperchloremic metabolic acidosis following ureterosigmoidostomy. Based on further investigations by Lapides in 1951, Parsons, Powel and Pyrah in 1952, and Stamey in 1956, which clearly demonstrated that hyperchloremic metabolic acidosis is inevitable complication of ureterosigmoidostomy, this urinary diversion lost its popularity. In 1950's ileal conduit, popularized by Bricker, became the gold standard for the subsequent 35 years. Early attempts for continent urinary diversion occurred form 1888, by Guido Tizzoni and Alfonso Poggi, while the first reservoir-type ileal loop urinary diversion was performed by Cuneo in 1911. By better understanding of principles of detubularization, based on works of Kock and principles of clean intermittent catheterization, established by Lapides, interest in continent urinary diversion has increased. Up to date, various continent cutaneous stomal reservoirs, sigmoidorectal pouches and orthotopic bladder substitutes have been described. Regarding encouraging improvements in biocompatible materials, alloplastic bladder replacement could be the next step for the future in bladder replacement surgery.

Evaluation of the Bard BTA-test in the diagnosis of upper urinary tract tumours.

The BTA-test is an agglutination assay that qualitatively detects the presence of complexes of basement membrane within the urine of patients with bladder cancer. However, the significance of BTA test in other urotelial tumours has not been extensively studied. Therefore, in the present research, we examined the validity of BTA-test in patients suffering from ureteral or renal pelvis cancer, and compare results with urincitology. 35 patients were included in this study (13 with ureteral and 22 with renal pelvis cancer). BTA-test and urincitology in each patient was performed on two urine specimens: morning voiding urine and separate urine. Separate urine was obtained by means of ureteral catheter. The results of BTA test were compared with urine cytology. All patients udervent routine clinical examination (biochemical analysis, ultrasonography, i.v. urography and retrograde urography). The presence of urothelial carcinoma was histopatologically proved in all cases. 35 patients with renal calculosis without malignancy were control group. Separate and voided urine was taken for examination with BTA test and urincitology from all these patients. BTA test in urine specimen obtained by ureteral catheter were positive in 22 (62.9 %) patients and in complete urine in 18 (51,4%) patients. Urine cytology was positive in 20 (57,1%) separate urine specimen and in complete urine in 17 (48.6%) patients. Characteristics of each patient, clinical findings and patohystology findings take places in statistic evaluation of the results. The sensitivity of BTA test depends directly on histopatology characteristics of tumours. Tumours with high grade and high stage more often have positive resuIts of test and urincitology. The test had the highest sensitivity among the group of high risk patients, with T2, T3, T4 stadium, 77,8% in separate urine and 61.11% in voided urine with specificity of 80% for separate urine and 85.71% for voided urine. Sensitivity for cytology in the same group was 72,22% for separate and 55,56% for voided urine, with specificity of 97,14% in both specimens. Based on the obtained results, we can conclude that simple and rapid BTA test can have significant position in the diagnostics of upper urinary tract tumours, but we still have to search for an ideal tumour marker for transitional cell carcinoma of upper urinary tract.

Results of application of orthotopic urine diversion according to Studer.

INTRODUCTION: Prolonged survival of patients undergoing radical cystectomy due to the infiltrative carcinoma of the urinary bladder has increased the need for development of the orthotopic bladder enabling preservation of the upper urinary ways for the extended period of time. Orthotopic bladder with tubular afferent segments in which ureters are implanted without antireflux mechanism has been introduced into the practice in 1984 by Studer and collaborates. MATERIAL AND METHODS: In the period 1998-2007 12 patients averagely aged 62 years were subjected to orthotopic derivation from ileum, when low-pressure reservoir was constructed and the ureters were implanted into the afferent non detubularized segment of ileum without antireflux mechanism. The follow-ups included determination of serum creatinine level, ultrasound monitoring of the upper urinary ways condition in three-month intervals and pyeloureterography with intravenously applied contrast medium one year after the surgery. Immediately before the follow-up examinations, the patients were asked to complete voiding and incontinence onset diary. RESULTS: Complete exclusion of the kidney that was in the stasis before surgery was evidenced only in one case, in a patient with tumor infiltration of the ureteral orifice. Significant obstruction of the uretero-ileal anastomosis was found in 4 renal units and it was resolved by antegrade balloon catheter dilatation. Diurnal continence was established in all patients within the initial 6 months after the surgery. Mild form of nocturnal incontinence persisted in 33% of the patients. Stenosis of the urethrovesical anastomosis was a cause of urine retention in 1.8% of patients and it was endoscopically resolved. CONCLUSION: The advantage of implantation into the afferent non detubularized segment of ileum over the antireflux mechanism has been verified in our study based on the low percent of stenoses.

Orthotopic neobladder: a 22-year experience.

OBJECTIVE: To analyze the outcome of orthotopic ileal neobladder related to complications and quality of life. PATIENTS AND METHODS: From 1985 to 2006, 75 patients with mean age of 57 years, (41-75) underwent radical cystectomy and orthotopic ileal neobladder substitution. The mean follow up was 72 months (6-144). Mean operative time was 240 minutes. RESULTS: Intraoperative blood loss ranged from 250 to 2810 ml. Ureteral stents were removed on 14th postoperative day, and patients were discharged at 2st day, average. Complications appeared in 23 patients. There were two recurrent TCC in the neobladder. Three patients died from pulmonary embolism. Vesicoureteral reflux appeared in three patients, and it was bilateral in two patients. Total of 98% patients have daytime continence. CONCLUSION: Continent urinary reservoirs represent the state of the art in urinary diversion. Surgeons who perform these operations are urgent to institute requirements for careful long-term follow-up of these patients.