Patient's perception of kidney stone prevention within the emergency department and its adherence factors: a single institution study.

BACKGROUND: No known data in the literature assessing practice of kidney stone prevention in the emergency department (ED) is available. OBJECTIVES: Assess patient perception and compliance to kidney stone prevention given within the emergency department. It also indirectly detects the attitude and practice patterns of primary care providers in kidney stone prevention. MATERIALS AND METHODS: This is a qualitative study done in a single institution from January 2018 to January 2019 that includes 99 patients that were diagnosed with kidney or ureteral stone in ED and were discharged home, all of them where stone formers. They were asked to fill a self- administered questionnaire when they are able to read, or interviewed by the resident within the ED when they are unable to read. RESULTS: The majority of patients (68%) did not receive any instructions about kidney stones prevention within the ED. Most of patients who follow instructions if it was given were educated (90%), had an insurance coverage (85%), and had an income higher than $1000 per month (76%), (p < 0.05). Seventy one percents of patients believe in the effectiveness of stone prevention if it was provided and most of them are interested in learning about these preventive strategies (82%). Reasons for not following the instructions about kidney stones prevention measures were the cost (53.1%) following by the lack of explanation by ED physicians (18.8%). The majority of patients (62.6%) prefer to receive kidney stones prevention measures from urologists. CONCLUSION: Most of patients in our institute did not receive kidney stones prevention measures in ED despite that they declared their interest in following these measures. Most of the time they did not adhere to those measures due to socioeconomic factors and lack of clarifications. If these instructions were given within the ED, it could lead to an acceptable compliance rate.

An up-to-date evaluation of darolutamide for the treatment of prostate cancer.

Introduction: Currently, in prostate cancer, an increasing number of novel drugs are being used to delay its advancement to metastatic castration-resistant prostate cancer (mCRPC). Apalutamide, enzalutamide, and most recently, darolutamide (novel androgen receptor antagonists) have been approved for nonmetastatic castration-resistant prostate cancer (nmCRPC).Areas covered: The authors have evaluated darolutamide, covering all aspects of the clinical development, competence, and safety profile of the drug.Expert opinion: The unique structure of darolutamide is characterized by a high affinity for androgen receptors and detainment of antagonist activity in mutant isoforms of androgen receptors. In clinical practice, this is the main reason that makes darolutamide exceptional in terms of safety and efficacy compared to other drugs in this category. Darolutamide is considered to have the lowest probability for adverse events (AEs) compared to apalutamide and enzalutamide. Future studies, along with real-world clinical data are warranted to improve personalized treatment strategies as well as sequencing treatment between approved novel drugs.

Profile of Enfortumab Vedotin in the Treatment of Urothelial Carcinoma: The Evidence to Date.

Nowadays the therapeutic landscape for advanced and metastatic urothelial carcinoma continues to evolve. The recent regulatory approval of enfortumab vedotin (EV) for the treatment of advanced urothelial cancer confirms the evolving role of antibody-drug conjugates. EV demonstrates a favorable profile in heavily pretreated patients with locally advanced or metastatic urothelial carcinoma. Early survival reports demonstrate a significant antitumor effectiveness along with a rather acceptable safety profile in a difficult-to-treat population.

Adrenocortical carcinoma in a young adult male with chronic urticaria: A case report and literature review.

BACKGROUND: Adrenocortical carcinoma (ACC) is a rare endocrine malignancy, often with an unfavorable prognosis. Radical adrenalectomy is the gold standard of treatment of localized disease. CASE DESCRIPTION: We report a case of a 23-year-old male patient who presented with persistent left flank pain and urticaria for 3 months. Imaging studies confirmed the presence of a large left adrenal mass with malignant features. The biochemical workup was unremarkable. Open left radical adrenalectomy was performed, the final pathologic examination showed ACC with negative surgical margins. The patient remained disease-free for eighteen months period of follow up after surgery. DISCUSSION: ACC is a rare neoplasm with poor prognosis and with an incidence of one in one million population. There is a slight female predilection. The ACC may be functional with a clinically pure endocrine syndrome like Cushing syndrome. Most of patients with ACC present with symptoms and signs of hormonal secretion. Adrenal computed tomography (CT) scanning and magnetic resonance imaging (MRI) are the imaging studies of choice in ACC. When feasible, total resection remains the treatment of choice for the definitive treatment of ACC. The benefit of the use of mitotane as an adjuvant treatment has been considered controversial. Adjuvant mitotane significantly decreases the recurrence and mortality rate after resection of ACC in patients without distant metastasis as proved by some studies, but these findings need further validation. CONCLUSION: ACC is a rare neoplasm characterized by a high risk of recurrence after surgical resection.

Novel anticancer therapy in BCG unresponsive non-muscle-invasive bladder cancer.

INTRODUCTION: Many patients with non-muscle-invasive bladder cancer (NMIBC) failed intravesical BCG therapy. Currently, radical cystectomy is the recommended standard of care for those patients. There is unfortunately no effective other second-line therapy recommended. AREAS COVERED: In this review, we present the topics of BCG unresponsive NMIBC; definition, prognosis, and further treatment options: immunotherapy, intravesical chemotherapy, gene therapy, and targeted individualized therapy. EXPERT OPINION: There are major challenges of the management of NMIBC who failed BCG therapy as many patients refuse or are unfit for radical cystectomy. Multiple new modalities currently under investigation in ongoing clinical trials to better treat this category of patients. Immunotherapy, especially PD-1/PD-L1 inhibitors, offers exciting and potentially effective strategies for the treatment of BCG unresponsive NMIBC. As the data expands, it is sure that soon there will be established new guidelines for NMIBC.

Pharmacotherapeutic advances for recurrent urinary tract infections in women.

INTRODUCTION: Treatment of recurrent Urinary tract infections (UTIs) has become challenging because of the dramatic increase in the rates of recurrent infection andof multidrug-resistant (MDR) infections. AREAS COVERED: The authors review recurrent UTIs(rUTI) management in women. EXPERT OPINION: Continuous or post-coital prophylaxis with low-dose antimicrobials or intermittent self-treatment has all been demonstrated to be effective in managing rUTIs in women. Intravaginal estrogen therapy , shows potential toward preventing rUTI. Oral vaccine Uro-Vaxom seems to reduce the number of UTIs. There is evidence that other therapies (e.g. cranberry, Methenamine hippurate, oral D-mannose) may decrease the number of symptomatic UTIs. The treatment of CRE-UTIs is focused on a colistin backbone. Carbapenems are considered first-line agents for UTIs caused by ESBL, but their use is associated with increased MDR. The usage of non-carbapenem for the treatment of ESBL UTIs is necessary. Cefepime, Piperacillin-Tazobactam, Ceftolozane-Tazobactam, and Ceftazidime-Avibactam are justified options. Oral therapy with Pivmecillinam, Fosfomycin, and Nitrofurantoin can be used against uncomplicated UTIs due to ESBL infection.

Pharmacotherapeutic strategies for castrate-resistant prostate cancer.

INTRODUCTION: Metastatic castration-resistant prostate cancer (CRPC) is a potentially symptomatic disease with an eventual lethal outcome. Novel pharmaceutical agents are continuously studied with encouraging results in CRPC. AREAS COVERED: In this perspective, the authors present established and promising pharmacotherapeutic strategies for the management of CRPC; both with and without metastases. Apart from the different treatment strategies, the authors present the relevant sequence of treatment through disease progression. EXPERT OPINION: Usually, docetaxel should be considered the first line treatment in mCRPC. Abiraterone acetate (AA) plus prednisone or enzalutamide (ENZ) could be alternative treatments in chemotherapy naïve patients. Sipuleucel-T has been approved for the treatment of asymptomatic or minimally symptomatic mCRPC. Ra-223 has been approved for patients with mCRPC with symptomatic bone metastases (not visceral metastases). Cabazitaxel has been approved as the second line treatment to docetaxel in mCRPC. No differences in the overall survival has been observed between sequences starting with docetaxel versus AA/ENZ. Between AA-to-ENZ and ENZ-to-AA sequence, the AA-to-ENZ sequence appeared to be more favorable than the ENZ-to-AA regarding progression-free survival but not overall survival. Carbazitaxel seemed to retain its activity regardless of the treatment sequence. Of note, ENZ and apalutamide have been approved in non-metastatic CRPC.

Established and recent developments in the pharmacological management of urolithiasis: an overview of the current treatment armamentarium.

Introduction: Urolithiasis is a common, highly recurrent disease with increasing prevalence worldwide. There are many dietary and pharmacological measures to prevent kidney stones.Areas covered: Herein, the authors explore medical expulsive therapy as well as pharmacological therapies to prevent/treat urolithiasis.Expert opinion: All stone formers should be advised to increase their fluid intake sufficiently to achieve a urine volume of at least 2.5 L/day. In the case of hypercalciuria, a thiazide diuretic should be prescribed while in cases of hypocitraturia, potassium citrate should be given. In the case of hyperoxaluria, the treatment depends on the type of hyperoxaluria. Pyridoxine or calcium supplements with a meal can be offered. For uric acid stone formers, alkali therapy is the standard of care whereas allopurinol can be beneficial in hyperuricosuric stone formers. For cystine stone formers, increased fluid intake, restriction of sodium and animal protein ingestion, and urinary alkalinization are the standard therapies used. Cystine binding thiol drugs such as tiopronin and D-penicillamine are reserved for patients where a conservative approach fails. For struvite stone formers, optimal management is the complete stone removal. Acetohydroxamic acid may be offered only after surgical options have been exhausted, for patients with residual stones but it has many side effects.

Isolated Penile Fournier's gangrene: A case report and literature review.

BACKGROUND: Fournier's gangrene(FG) is a rare, necrotizing fasciitis of the external genitalia, perineal or perianal regions. Penile FG is a very rare clinical entity. It is reported in only a few cases in the literature. CASE DESCRIPTION: We reported an unusual case of isolated penile FG of a 58-year-old man with uncontrolled diabetes. Our patient presented for blackish discoloration and painful swelling of the penis associated with high-grade fever. The patient was treated with immediate surgical debridement after he received broad-spectrum antibiotics. When the wound exhibited healthy bed, we used an unexpanded, meshed, split-thickness skin graft for penile reconstruction. The recovery phase was uneventful with satisfactory cosmetic results. DISCUSSION: FG is a rare necrotizing infection of the perineum and genital region with a high mortality rate that can reach up to 50% of cases. It is frequently due to polymicrobial infection. The diagnosis is often made clinically, although radiologic studies can be helpful to define the extent of the disease. The clinical features of FG include sudden pain and swelling in the scrotum or wound discharge. Isolated penile FG are documented in few cases where the corpora cavernosa are usually spared. Its presence are related to patients sexual habits or traumatic insult. Mainstays of treatment include rapid and aggressive surgical debridement of necrotized tissue, broad-spectrum antibiotic and early resuscitation. CONCLUSION: Only a few cases of penile FG have been reported. Early debridement of all necrotic tissue is the golden rule.

Scrotal Dartos-Fascio-Myo-Cutaneous flaps for penis reconstruction after iatrogenic skin shaft sub-amputation.

Penile amputation is an uncommon genital injury, the causes of penile trauma are varied; it can be iatrogenic or caused by traffic accidents, burns, circumcision, animal bites, gunshots or self-mutilation. The type and extent of penile trauma vary from mild to severe injuries, sometimes even with total amputation. A wide variety of surgical options exist for penile reconstruction. Often, not only the surgical but also psychological aspects of treatment will determine the success or failure of therapy. Regardless of the method of reconstruction, the goals of surgery remain the same; these include creating a functional and esthetic phallus. We present a case of 49-year-old male diabetic presented for penile reconstruction after iatrogenic skin shaft sub-amputation post penile implant surgery complications done 1 year ago in a country where technical experts for this surgery are absent. Dartos Fascio-Myo-Cutaneous Flaps for penile skin loss is used with satisfactory results.

Spontaneous cavernosal abscess: a case report and review of literature.

A cavernosal abscess is a rare condition. It can be idiopathic or with an underlying cause such as intracavernosal injection therapy, foreign bodies, perineal abscesses extension, priapism or trauma. The most common presenting symptoms were penile pain and swelling. Standard treatment consists of drainage via an incision, followed by broad-spectrum antibiotics where some authors describe less invasive techniques such as image-guided aspiration. We present a case of spontaneous left cavernosal abscess diagnosed on MRI in a 60-year-old patient with uncontrolled diabetes mellitus that was treated by percutaneous ultrasound-guided aspiration drainage and systemic antibiotic therapy without any long-term sequela.

Leiomyosarcoma of the spermatic cord: A case report and literature review.

BACKGROUND: Leiomyosarcoma of the spermatic cord is a rare entity. It presents as a firm and painless intrascrotal mass. For diagnosis radiological methods such as ultrasound, CT or MRI are necessary. Radical orchiectomy is the gold standard of treatment. CASE DESCRIPTION: We reported a one case of a 66-year-old man that he has suffered from a painless hard mass in the right hemiscrotum since three years. Ultrasound revealed a paratesticular mass. Further workup revealed no distant metastasis before surgery. Right radical orchiectomy was performed, the final pathologic examination showed a leiomyosarcoma of the spermatic cord. The patient remained disease-free twelve-month during follow up after surgery. DISCUSSION: Leiomyosarcoma of the spermatic cord is a rare condition, it arises from mesenchymal cells of the spermatic cord and occurs mainly in elderly patients. The diagnosis of spermatic cord leiomyosarcoma is difficult if based only on imaging procedures, it is revealed by histological examination post surgery. No treatment protocol has yet been established for paratesticular leiomyosarcoma due to the rarity of the disease. Standard treatment is radical orchidectomy with high ligation of the spermatic cord. The benefit of adjuvant chemotherapy, radiotherapy, and retroperitoneal lymphadenectomy are not well understood and may differ according to the surgeon's preferences. CONCLUSION: The lack of such cases results in the challenging nature of the diagnosis and treatment of leiomyosarcoma of the spermatic cord. Additional studies are needed to better define optimal management strategies.

Penoscrotal Elephantiasis nostras verrucosa: A case report and literature review.

BACKGROUND: Elephantiasis Nostras Verrucosa (ENV) is a rare clinical condition associated with chronic non-filarial lymphedema caused by bacterial or non-infectious lymphatic obstruction. CASE DESCRIPTION: We reported an unusual case of isolated peno-scrotal ENV of a 67-year-old man with a history of Gastrointestinal Stromal Tumors (GIST) of the stomach. Our patient presented for progressive painless lymphedema of the penis and scrotum since 8 years ago before the diagnosis of GIST tumors, associated with skin changes consistent of superimposed hyperkeratotic papulonodules with a verrucose or cobblestone-like appearance. The patient refused surgical excision. He was treated with oral Acitretin 30 mg/day for 4 weeks where a minimal improvement was noted. Acitretin was stopped due to an increase in liver enzymes. Conservative treatment was applied to decrease lymphostasis. DISCUSSION: ENV is characterized by lymphedema and skin changes consisting of hyperkeratotic, verrucous and papillomatous lesions. It is most commonly caused by bacterial infection, trauma, neoplasia and obesity. The diagnosis of ENV is achieved clinically by history and typical skin changes. Imagery and skin biopsy are used to differentiate ENV from other diseases. Management of ENV remains challenging. Strategies to reduce lymph stasis include lymphatic massages, compressive dressings are often inadequate. Surgical debridement may be considered in cases where there is no improvement depsite medical therapy. Oral retinoids can be used if tolerated with variable results. CONCLUSION: ENV is a rare disorder that results from chronic obstructive lymphedema. There is no standard therapy but a variety of medical and surgical treatment options have been reported.