Sonographic evaluation of hydronephrosis in the pediatric population: is well-tempered sonography necessary?

OBJECTIVES: Standardized protocols exist for diuretic renography. There are no specific guidelines regarding hydration before renal sonography. This study assessed the importance of the hydration status by sonographic measurements of the anteroposterior diameter and its effect on Society for Fetal Urology (SFU) hydronephrosis grading. METHODS: Children aged 6 weeks to 16 years (mean age, 22 months) with unilateral SFU grade 3 or 4 hydronephrosis requiring diuretic renal scintigraphy were recruited to undergo prehydration and posthydration renal sonography. Hydrated diuretic renal scintigraphy, or "well-tempered" renography, was then performed. Renal sonograms were reviewed by a blinded pediatric radiologist and pediatric urologist. Two-sided statistical tests assessed whether SFU grades and the anteroposterior diameter changed significantly after hydration. RESULTS: Among 67 kidneys, the pediatric urologist (L.P.M.) and pediatric radiologist (V.J.R.) reported no SFU grade change in 45 (67%) and 52 (78%) kidneys after hydration. In kidneys that changed, the posthydration grade was more likely to be higher. This difference was statistically significant (14 of 22 and 13 of 15 differences were higher grades after hydration for L.P.M. and V.J.R., respectively; P= .06; P= .007). Most kidneys that changed with hydration differed by only 1 SFU grade. Differences greater than 1 grade were seen in 5 control kidneys, which increased from SFU grade 0 to 2. The mean anteroposterior diameter increased significantly between prehydration and posthydration sonography for both hydronephrotic kidneys (1.46 versus 1.72 cm; P< .001) and control kidneys (0.22 versus 0.39 cm; P= .019), but did not correlate with increased SFU grades. CONCLUSIONS: Hydration does have a substantial effect on the anteroposterior diameter, but it does not correlate with a substantial effect on the SFU grade; therefore, well-tempered sonography seems unnecessary.

Hydrocele: an atypical presentation of metastatic sarcomatoid renal cell carcinoma.

Herein is a case of a 55-year-old man who presented with epididymitis. He subsequently failed medical management for the suspected infection and progressed to develop an acute scrotum and sonographic findings consistent with a pyocele. Concurrent computed tomography (CT), obtained for persistent abdominal pain, revealed a large enhancing upper pole renal mass suspicious for malignancy. He was taken for emergent scrotal exploration to drain the presumptive pyocele. However, during scrotal exploration, no purulence or evidence of infection was seen. Although, seemingly unrelated to the renal mass, the thickened hydrocele sac was excised and sent as a specimen. Pathology of the sac revealed a diagnosis of metastatic sarcomatoid renal cell carcinoma. Appropriate chemotherapy was initiated based on the scrotal pathology, circumventing the need for a CT directed retroperitoneal lymph node biopsy or nephrectomy.

Impact of race in using PSA velocity to predict for prostate cancer.

OBJECTIVE: To assess whether race is a significant factor in the ability of prostate-specific antigen velocity (PSAV) for predicting high-grade prostate cancer (HGPC). METHODS: Records of men who underwent prostate biopsy between January 2003 and December 2007 were retrospectively reviewed to collect demographic data, self-reported race, prostate-specific antigen (PSA) data, and pathology results. PSAV was calculated using linear regression. Subjects were stratified by the presence or absence of HGPC. Median PSA and PSAV values were compared within each racial group using receiver operating characteristic analysis and Student t test. RESULTS: Static PSA was significantly higher in Caucasian men with HGPC (4.81 vs. 8.3 ng/mL, p = 0.0000001) while PSAV was also higher in men with HGPC (0.639 vs. 1.15 ng/mL/yr, p = 0.081). Static PSA in Asians did not perform well in predicting HGPC (5.3 vs. 9.42 ng/mL, p = 0.11), but fared much better than PSAV (0.51 vs. 0.93 ng/mL/yr, p = 0.27). PSA in African Americans did not significantly predict HGPC (6.27 vs. 7.7 ng/mL, p = 0.474), but PSAV showed a stronger trend toward significance (0.615 vs. 1.54 ng/mL/yr, p = 0.068). CONCLUSIONS: PSAV may complement static PSA in African Americans and help identify early stage aggressive cancers.

Treatment efficacy of virtual reality distraction in the reduction of pain and anxiety during cystoscopy.

OBJECTIVE: Assessment of virtual reality (VR) distraction for alleviating pain and anxiety during flexible cystoscopy. Cystoscopy is a common ambulatory procedure performed in Urology and can be associated with moderate pain and anxiety. Sophisticated distraction techniques are not used with cystoscopy and VR has not been studied for this procedure. We designed a prospective, randomized, controlled trial assessing the efficacy of VR for alleviating pain and anxiety during flexible cystoscopy. METHODS: Adult men referred for cystoscopy were randomized into a control or VR group. Subjects were given preprocedure and postprocedure questionnaires addressing anxiety, pain, and time spent thinking about pain. Vitals signs and galvanic skin monitors were used as objective measures. The control group underwent routine cystoscopy and the VR group underwent cystoscopy with VR. Physicians answered a postprocedure questionnaire assessing the difficulty of the exam. All questionnaires used a visual analog score for assessment. RESULTS: 23 patients enrolled in the control group and 22 in the VR group. Mean scores and Student's t-test were employed to analyze the data. No data endpoints showed a statistically significant difference between the 2 groups. CONCLUSIONS: We concluded no benefit to VR distraction mitigating pain in male patients during cystoscopy.

The impact of metformin use on recurrence and cancer-specific survival in clinically localized high-risk renal cell carcinoma.

BACKGROUND: Recent data suggest that metformin may have anti-neoplastic properties. We sought to determine what effect metformin had on recurrence and cancer-specific survival (CSS) rates of patients with clinically localized pT2 and pT3 renal cell carcinoma (RCC) following radical or partial nephrectomy. METHODS: We obtained data on 784 patients who underwent partial or radical nephrectomy for pT2 or pT3 tumours at our centre between 1996 and 2011. Patients with benign masses, nodal positivity, or metastasis at the time of surgery were excluded. Using a competing-risks regression model, we compared differences in probability of recurrence between patients who used metformin versus those who did not. RESULTS: The patients on metformin at the time of surgery had worse disease recurrence than patients not on metformin. However, this was not statistically significant on multivariate analysis when controlling for age, race, body mass index, glomerular filtration rate, and tumour stage and grade (hazard ratio [HR], 1.22; 95% confidence interval [CI], 0.66-2.27 [p = 0.5]). Metformin use was associated with a lower risk of cancer-specific mortality, but this was not statistically significant when adjusted for clinical and tumour characteristics (HR, 0.76; 95% CI 0.21-2.7 [p = 0.7]). Limitations include the retrospective nature of the study and the lack on information on duration of metformin use. CONCLUSIONS: Metformin use at the time of surgery for high-risk clinically localized RCC is not protective in terms of recurrence or CSS. Further studies should be done to confirm these findings and determine what effect concurrent metformin use might have on improved response to targeted therapies in the metastatic setting.

Fatal hyponatremia in a 7-year-old girl with cloacal exstrophy after cystoscopy for a bladder stone.

A case of fatal hyponatremia in a 7-year-old girl following a percutaneous cystolithotomy is presented. Stone removal by percutaneous cystolithotomy is considered a safe and effective procedure, but this may depend on the type of solution used for irrigation. In this case less than 2L of sterile water was used as irrigation in an augmented bladder causing a drop in sodium to 120 mmol/L in 30 min. The result was a massive shift of water into the cerebral tissue, cerebral edema and death.