Bacillus Calmette-Guérin in the management of superficial bladder cancer.

Intravesical Bacillus Calmette-Guérin (BCG) is the mainstay of superficial bladder cancer treatment. We performed a literature search through Medline/Pubmed using key words 'Bacillus Calmette-Guérin', 'intravesical', 'bladder neoplasm' and 'immunotherapy' for published data in the English language from 1970 to 2007 to review the current status of intravesical therapy and practice recommendations. The exact mechanism of action of intravesical BCG is yet to be elucidated. However, it appears that it is mediated by the local immune response, mainly through T-helper cell response. It reduces the recurrence rate by an average of 40% and progression by more than 20% in papillary tumors over the patients without BCG therapy. However, progression prevention is seen only in series which have used maintenance therapy at least for one year. It is effective in CIS of bladder with a response rate of more than 40% and prevention of progression in one-fourth patients. Most acceptable dose, induction treatment and maintenance therapy protocols are discussed. However, these are yet to be confirmed in large randomized trials. Intravesical BCG is well tolerated in most of the patients with mild to moderate side-effects in induction therapy; however, most patients do not complete maintenance therapy due to side-effects which is the most common concern at the present time.

Dorsal onlay buccal mucosa versus penile skin flap urethroplasty for anterior urethral strictures: results from a randomized prospective trial.

PURPOSE: Reconstructive techniques for anterior urethral strictures have not been subjected to a randomized comparison. In a randomized controlled study we compared outcomes of buccal mucosa dorsal onlay vs skin flap dorsal onlay urethroplasty in patients with complex anterior urethral strictures. MATERIALS AND METHODS: In this prospective study 55 patients with anterior urethral strictures were randomized to undergo buccal mucosa dorsal onlay (27) or penile skin flap (28) urethroplasty. Operative time, hospital stay, short and long-term complications, recurrence rates, and patient satisfaction were compared between the 2 groups. RESULTS: The number of patients with pendulous, bulbar and bulbopendulous strictures as well as mean stricture length and median followup were comparable between the 2 groups. Mean operative time was significantly higher in the penile flap (224 minutes) vs the buccal mucosa group (162 minutes, p = 0.001). In the penile flap group 6 patients had superficial penile skin necrosis, 1 had extensive skin loss and required skin grafting, and 2 had penile torsion. In the buccal mucosa group 25.6% of patients had minor morbidity which settled by 4 weeks after surgery. There were 9 (34.1%) patients in the penile flap group and 4 (14.8%) in the buccal mucosa group (p = 0.001) who had troublesome post-void dribbling. In the buccal mucosa group 89% and in the penile flap group 65% said they would recommend this procedure to another patient (p = 0.001). The success rate in the buccal mucosa (89.9%) and penile flap (85.6%) groups was similar (p >0.05). CONCLUSIONS: On intermediate followup dorsal onlay penile skin flap and buccal mucosa urethroplasty provide similar success rates. Compared to buccal mucosa, penile flap procedures are technically complex, associated with higher morbidity and less preferred by patients.

New therapeutic targets in the treatment of prostate cancer.

Androgen deprivation therapy has become the mainstay of the treatment of advanced prostate cancer, being used in every clinical setting of the disease, from neoadjuvant to metastatic disease. Despite success in controlling the disease in the majority of men, hormonal manipulations will eventually fail. New agents are being developed for patients with hormone refractory disease. Important advances in molecular oncology have improved our understanding regarding the cellular mechanisms that regulate cell death in the prostate. It is hoped that these new insights will lead to development of more efficacious and easy to tolerate therapies for cancer prostate. This review focuses on the current literature on tumor vaccines, angiogenesis inhibitors, antisense oligonucleotides, differentiation agents, cancer-specific genes, endothelial receptor antagonists, anti-apoptotic agents, agents acting on signaling pathways and androgen and estrogen receptors.

Inferior vena cava in urology: importance of developmental abnormalities in clinical practice.

Anomalies of the inferior vena cava (IVC) have been known since 1793, when Abernethy first described a congenital, mesocaval shunt and azygous continuation of the IVC in a 10-month-old infant with polysplenia and dextrocardia. The IVC is formed by a complex process of embryogenesis during the sixth to tenth week of gestation. It forms from continuous appearance and regression of the three paired veins: posterior cardinal, subcardinal, and supracardinal. Improper completion of the developmental process may result in at least 14 anatomic anomalies, out of which the following four are usually encountered in clinical practice: duplication of the IVC, transposition or left-sided IVC, retroaortic left renal vein, and circumaortic left renal vein. It is suggested that the preoperative diagnosis of the vascular anomalies reduces the complication rate of abdominal vascular procedures. Our vast experience with approximately 400 kidney donors who were evaluated preoperatively with spiral CT scan with three-dimensional reconstruction (3D) reconfirmed this view. Thereafter, it became easier to choose the side and decide between laparoscopic vs. open approach. This prompted us to write the present article focusing on those developmental anomalies of the IVC that may be encountered by the urologist and their implication on the clinical practice.

Serum ferritin in renal cell carcinoma: effect of tumor size, volume grade, and stage.

AIM: To study the levels of serum ferritin in patients of renal cell carcinoma (RCC). PATIENTS AND METHODS: Serum ferritin levels were measured preoperatively in 32 patients with radiological evidence of RCC using an enzyme immunoassay. The largest diameter of the primary tumor was measured in the pathological specimens in patients undergoing radical nephrectomy while in patients with non-operable tumor maximum tumor dimension was taken from CT scan. Pathological staging was done according TNM-1997. RESULTS: Mean serum ferritin value in patients of RCC was 283.23+/-77.38 ng/ml while in controls the mean value was 79.98+/-32.96 ng/ml (P CONCLUSIONS: Serum ferritin levels are elevated in patients with RCC although its actual source is unclear. Further studies are needed to establish the role of ferritin in RCC.

The role of laparoscopy in the localization and management of adult impalpable testes.

BACKGROUND: Very few studies are available that describe the role of laparoscopy in adults with impalpable testes. This study compares laparoscopy with ultrasonography in this subset of patients. METHODS: Fourteen adults, having a mean age of 21 years, with 19 undescended testes were evaluated. None of the testes was palpable, preoperative ultrasound localized 7 testes (36.8%), but a change in findings was observed in 3 of these cases (42.8%) on subsequent laparoscopy. On laparoscopy, 18 (94.7%) of the testes were localized as intraabdominal. The remaining patient had a case of true anorchia. Seven patients with unilateral undescended testes underwent laparoscopic orchiectomy, and 2 patients with unilateral undescended testes and all the patients with bilateral undescended testes underwent laparoscopic-assisted orchiopexy. No complication was noted in any of the cases. Hernia, present in 4 patients, was simultaneously repaired laparoscopically. CONCLUSION: Laparoscopy is a safe and effective modality in the localization and management of adult undescended testes. In adults, orchiectomy with the subsequent reduction in the risk of malignancy is the major issue of concern. Also, the repair of concomitant hernias is desirable. Both of these procedures can be done laparoscopically in the same sitting without the need for inguinal exploration.

Tubeless percutaneous nephrolithotomy--should a stent be an integral part?

PURPOSE: We compared the outcome of tubeless percutaneous nephrolithotomy with or without Double-J(R) stent. MATERIALS AND METHODS: From January 2004 to March 2006 patients with renal stones matched for age and stone size who underwent tubeless percutaneous nephrolithotomy were prospectively evaluated in 2 groups treated by 2 surgeons. Group 1 had a Double-J stent and group 2 did not. Inclusion criteria for tubeless percutaneous nephrolithotomy included contralateral normal kidney, intact pelvicaliceal system, complete stone clearance under fluoroscopy and single infracostal puncture. These groups were compared for analgesic requirement, hospital stay, and intraoperative and postoperative complications. RESULTS: During a period of 27 months 52 patients (57 renal units) underwent tubeless percutaneous nephrolithotomy. Group 1 had 25 (28 renal units) and group 2 had 27 patients (29 renal units). Mean stone volume was 4.34 +/- 2.12 cm(3) in group 1 and 4.14 +/- 1.14 cm(3) in group 2. Mean pain score was 2.96 +/- 1.24 and 2.82 +/- 0.81 in groups 1 and 2, respectively. Analgesic (intramuscular or oral diclofenac sodium) requirement and mean hospital stay was comparable in groups 1 and 2, eg 170 +/- 110 vs 163.24 +/- 98.07 mg and 2.52 +/- 0.12 vs 2.35 +/- 0.12 days. Two patients in group 1 and 1 in group 2 had urinary leak from the percutaneous nephrolithotomy tract. Similarly 3 patients in group 1 had severe stent related problems and 1 required early removal of the Double-J stent. CONCLUSIONS: Avoiding use of the Double-J stent may not compromise the safety of tubeless percutaneous nephrolithotomy.

Percutaneous nephrolithotomy of a staghorn stone in thoracic ectopic kidney.

Congenital thoracic ectopic kidney is a very rare developmental anomaly and the rarest form of all ectopic kidneys. It is usually asymptomatic and discovered incidentally on routine chest radiography. Herein we reported the first case of staghorn stone in a thoracic kidney managed successfully by percutaneous nephrolithotomy.

Is laparoscopic nephrectomy the preferred approach in xanthogranulomatous pyelonephritis?

OBJECTIVES: To report our experience with laparoscopic nephrectomy in patients with xanthogranulomatous pyelonephritis (XGP) and compare it with the open approach. XGP is an atypical and severe form of chronic renal infection. Open nephrectomy has been the procedure of choice for XGP. The laparoscopic approach has been used in cases of XGP but with increased complications and operative time. METHODS: A retrospective analysis of all the patients who underwent laparoscopic nephrectomy with a pathologic diagnosis of XGP from January 2001 to August 2005 was done. The demographic profile and data on the operative time, operative technique, blood loss, and complications were obtained. RESULTS: In all, 25 patients underwent nephrectomy with a pathologic diagnosis of XGP, 10 laparoscopically and 15 by the open approach. Laparoscopic nephrectomy for XGP was successful in 80% of the cases. The dissection of the kidney was comparatively difficult in all cases because of dense adhesions in the perirenal region and required modification of the technique. The incidence of major complications was 20% and 10% in the open and laparoscopic groups, respectively. The mean hospital stay in the laparoscopic group was 3.8 days, significantly less than that for the open nephrectomy group (8.2 days). The mean operative time in the laparoscopic group was 3.8 hours compared with 2.5 hours in the open group. CONCLUSIONS: Laparoscopy can be successfully performed in patients with a pathologic diagnosis of XGP. Although a longer operative time is required because of perinephric adhesions, the postoperative recovery is faster and cosmesis superior compared with the open approach. Modifications in the standard laparoscopic technique can be made to complete the procedure successfully and safely.

Retroperitoneal ganglioneuroma presenting as right renal mass.

A primary retroperitoneal ganglioneuroma was found in a 37-year-old woman on computed tomography, which revealed a homogeneous mass just above the right kidney. The tumor was resected through a transabdominal approach. The resected specimen measured 11 x 9 x 4.5 cm and weighed 270 g. The histologic examination showed that the lesion was a ganglioneuroma composed of both mature ganglion cells and nerve fibers.