Ureteric stent versus percutaneous nephrostomy for acute ureteral obstruction - clinical outcome and quality of life: a bi-center prospective study.

BACKGROUND: To compare quality of life (QoL) indices between ureteral stent (DJS) and nephrostomy tube (PCN) inserted in the setting of acute ureteral obstruction. METHODS: Prospective bi-centered study. Over the span of 2 years, 45 DJS and 30 PCN patients were recruited. Quality of life was assessed by 2 questionnaires, EuroQol EQ-5D and 'Tube symptoms' questionnaire, at 2 time points (at discharge after drainage and before definitive treatment). RESULTS: Patients' demographics and pre-drainage data were similar. There were no clinically significant differences in patient's recovery between the groups, including post procedural pain, defeverence, returning to baseline renal function, and septic shock complications. More DJS patients presented to the emergency room with complaints related to their procedure compared to PCN patients. At first, DJS patients complained more of urinary discomfort while PCN patients had worse symptoms relating to mobility and personal hygiene, with both groups achieving similar overall QoL score. At second time point, PCN patients' symptoms ameliorated while symptoms in the DJS group remained similar, translating to higher overall QoL score in the PCN group. CONCLUSIONS: The two techniques had a distinct and significantly different impact on quality of life. Over time, PCN patients' symptoms relieve and their QoL improve, while DJS patients' symptoms persist. Specific tube related symptoms, and their dynamics over time, should be a major determinant in choosing the appropriate drainage method, especially when definitive treatment is not imminent.

Postoperative Urinary Leakage Following Partial Nephrectomy for Renal Mass: Risk Factors and a Proposed Algorithm for the Diagnosis and Management.

OBJECTIVES: To evaluate the current incidence, risk factors, management, and long-term follow-up of urinary leakage following partial nephrectomy, in order to propose an algorithm for diagnosis and evaluation of postoperative urinary leakage. MATERIALS AND METHODS: The study included 752 patients who underwent elective partial nephrectomies for renal masses between the years 1988 and 2013. Patients' demographics, clinico-pathologic variables, and operative details were collected retrospectively. The associations between urinary leakage and patients' variables were assessed by univariate and multivariate analyses. RESULTS: Of the 752 patients, 21 (2.8%) experienced urinary leakage; 4 of the 21 patients with urinary leakage had spontaneous resolution, 1 patient underwent nephrectomy, and 16 patients were treated by retrograde ureteral stents insertion. One of them necessitated insertion of an additional percutaneous nephrostomy and another one deserved concomitant percutaneous drainage of a perirenal urinoma. The average period of time that elapsed from the operation until the insertion of stent was 8.5 ± 4.5 days. Stents were removed 68 ± 20.5 days postoperatively. None of the patients had either persistent or repeated leakage. On univariate analysis, hilar renal masses (p < 0.04) and higher preoperative creatinine levels (p < 0.01) were found to be associated with higher rates of urinary leakage. None of these variables was significant on a multivariate analysis. Review of the urinary leakage rate over time revealed it has been constantly decreasing over time, from 4% in early cases to 1.3% among the most recent ones. CONCLUSION: None of the preoperative variables that were examined in this study was significantly associated with increased risk of urinary leakage. However, cumulative surgical experience was associated with lower rates of urinary leakage, suggesting that the decrease in its incidence is related to the improved surgical skills, rather than to differences in tumors' or patients' characteristics.

Reconsidering the necessity of ipsilateral adrenalectomy during radical nephrectomy for renal cell carcinoma.

OBJECTIVES: Ipsilateral adrenalectomy is traditionally advocated as part of radical nephrectomy performed for renal cell carcinoma. The current study addresses the controversy of whether ipsilateral adrenalectomy should be performed routinely during radical nephrectomy. METHODS: A total of 225 patients were treated surgically for renal cell carcinoma over an 18-year period. Of these patients, 158 underwent nephrectomy and simultaneous ipsilateral adrenalectomy and the other 67 had sparing of the ipsilateral adrenal gland. A retrospective analysis of the medical records and assessment of the clinical and the pathologic data were performed. Rates of survival and progression were evaluated in a subgroup of 109 patients, further subdivided into 54 patients who underwent concomitant adrenalectomy and 55 patients with the ipsilateral adrenal preserved during surgery. RESULTS: Histopathologic abnormalities were detected in seven adrenal specimens (4.4%); however, only 3 patients (1.9%) had involvement of the adrenal by renal cell carcinoma. All cases of adrenal involvement were detected by the preoperative imaging modalities. Ipsilateral adrenalectomy did not improve the outcome in comparison to adrenal preservation. CONCLUSIONS: In view of the rarity of ipsilateral adrenal metastasis, the questionable prognostic merits of concomitant adrenalectomy, and the availability of accurate imaging modalities, we conclude that ipsilateral adrenalectomy is not necessary in the majority of the patients undergoing radical nephrectomy for renal cell carcinoma.

Extensive necrosis in renal cell carcinoma specimens: potential clinical and prognostic implications.

BACKGROUND: Extensive necrosis is rare in primary renal cell carcinoma. This finding may reflect the biological characteristics of the carcinoma and therefore could be of prognostic and clinical value. OBJECTIVES: To assess the incidence of necrosis in renal cell carcinoma and its potential prognostic value. METHODS: We conducted a consecutive retrospective study of 173 patients after radical nephrectomy for renal cell carcinoma. Clinical and pathological data were collected from hospital medical records and compiled into a computerized database. RESULTS: Extensive necrosis was found in 31 tumor specimens (17.9%). Univariate analysis showed that the specimens with extensive necrosis were significantly larger and manifested more perirenal and venous extension than the tumors without necrosis. The size of the renal tumor was the only parameter that remained significant in multivariate analysis (P = 0.0001). Overall disease-free survival did not differ significantly between patients with necrotic tumors and those without (68% and 66% respectively). CONCLUSIONS: The finding of extensive necrosis in renal cell carcinoma specimens does not seem to be related to tumor biology but rather may reflect the relation between size and vascularity of the tumor.

[Primary retroperitoneal extra-gonadal germ cell tumor].

Malignant retroperitoneal tumors are relatively rare. The most likely diagnosis by a surgeon encountering a retroperitoneal mass is metastatic disease, but primary retroperitoneal malignant disease or benign tumor should also be considered. The most common primary retroperitoneal tumors are lymphoma and sarcoma. Primary extragonadal germ cell tumors constitute 1-2% of all germ cell tumors, most of which are found in the mediastinum and retroperitoneum. We report the successful treatment of a 20-year-old man whose primary retroperitoneal extragonadal germ cell tumor was treated by chemotherapy and surgery.

[Radical prostatectomy--experience with 50 patients].

Between 1986-1991 we treated 50 men with adenocarcinoma of the prostate by radical prostatectomy. Ages ranged from 44-74 and clinical stages were A-C. Follow-up lasted 1-63 months (mean 15.1) and was designed to rule out recurrence and/or spread of the disease and to evaluate quality of life. The rate of complications was low, the postoperative course short and uneventful, and there was preservation of urinary continence in 96% and of potency in 10.2%. As compared with radiotherapy, surgery gave superior results and is recommended.

[The Mitrofanoff pouch in lower urinary tract reconstruction].

The Mitrofanoff principle, first described in 1980, consists of implanting a tubular organ such as the appendix, ureter, or fallopian tube into the wall of the bladder (or urinary reservoir) to create a non-refluxing, catherizable urinary conduit. Between 1993-1996, 7 men and 1 woman (aged 48-64, average 59) underwent radical cystectomy and urethrectomy combined with the creation of a MAINZ I urinary reservoir (based on the Mitrofanoff principle). In men the indication for the procedure was the diagnosis of invasive transitional cell carcinoma of the bladder with involvement of the prostatic urethra. All patients had refused urinary diversion to an ileal conduit because of its deleterious effect on the quality of life. In all patients the postoperative course was uneventful, apart from intraperitoneal urinary leakage from the reservoir in 1, successfully managed conservatively. The patients have gained full control of urinary drainage, performing intermittent self-catheterizations every 4-5 hours. In 3 patients there were difficulties with catheterization due to stenosis of the conduit, usually at the skin level. None have suffered leakage from the reservoir, during the day, even when it was full. Our experience shows that creation of a continent urinary reservoir according to the MAINZ I technique is an excellent surgical solution for patients in whom the creation of an orthotopic reservoir is impractical. The use of the umbilicus as a stomal site preserves normal body image and thus does not interfere with quality of life as in those undergoing radical cystectomy.

[Nephrogenic adenoma--benign lesion of urinary tract system].

Nephrogenic adenoma is a rare metaplastic benign lesion of the urinary tract caused by chronic irritation to the urinary epithelium. The appearance of this lesion is usually characterized by hematuria and irritative symptoms. Nephrogenic adenoma may be found most commonly in the bladder and the urethra and less frequently in the renal pelvis and ureters. We present 5 patients who underwent surgery due to bladder or urethral nephrogenic adenoma. Despite the fact that nephrogenic adenoma is a benign lesion, long term follow-up is needed due to the high recurrence rate and the potential, though rare, malignant transformation.

[Management of neonatal testicular torsion].

Neonatal testicular torsion is rare, and is distinguished both clinically and anatomically from torsion in the older age group. We describe 2 cases of neonatal torsion treated in different ways, which reflect the current controversy regarding the timing of surgical exploration, the need for orchiectomy, as well as the indications for contralateral orchiopexy. The distinction between prenatal and the postnatal subgroups is emphasized and a policy of treatment is proposed.

[Endometriosis of the bladder].

We report a case of endometriosis of the bladder in a 32-year-old healthy woman suffering from longstanding suprapubic pain, and urinary urgency and frequency. The disease, which is uncommon, usually has a high morbidity rate and is difficult to diagnose. A high level of suspicion is necessary for diagnosis, since neither the clinical presentation, nor imaging procedures are pathognomonic for endometriosis.

[Malignant lymphoma of the bladder].

Urinary tract lymphoma is usually reported when the secondarily stem is affected by widespread non-Hodgkin lymphoma. We describe an 83-year-old woman who presented with secondary lymphoma of the bladder 3 years after diagnosis when it initially infiltrated her breast. Treatment included local transurethral excision followed by chemotherapy, during which she died of disseminated disease.

[Can preoperative urodynamic examination allow us to predict the risk of incontinence after radical prostatectomy?]. / L'examen urodynamique préopératoire permet-il de prédire le risque d'incontinence après prostatectomie radicale?

OBJECTIVES: To verify whether bladder dysfunction detected by urodynamic studies prior to radical prostatectomy can predict postoperative continence status. MATERIAL AND METHODS: Twenty patients diagnosed with prostate cancer had multichannel subtracted filling and voiding videocystometry before undergoing radical retropubic prostatectomy. Postoperatively, all patients had periodic clinical assessment of continence status. RESULTS: On preoperative filling cystometry, detrusor instability with a maximal detrusor pressure greater than 15 cm H2O was demonstrated in 12/20 patients (60%). Postoperatively, 11/20 patients (55%) were continent, 4 (20%) had mild stress incontinence and 5 (25%) complained of episodic urge incontinence. However, only 5 of the 12 patients with preoperatively diagnosed detrusor instability manifested clinical urge incontinence after surgery (positive predictive value = 41.6%). CONCLUSION: The incidence of preoperative detrusor instability in our series was high, but little correlation was found between this finding and postoperative incontinence.

Has the data efflux regarding the promising outcome following injection of deflux changed the management of adult vesicoureteral reflux?

Primary vesicoureteral reflux (VUR), traditionally considered a problem of childhood, can also be detected during adulthood. However, while the concept regarding the therapeutic management of VUR in children has undergone revolutionary changes, moving from surgical to conservative approach, the optimal therapeutic approach in adult reflux is poorly addressed and is still unknown. Herein, we review clinical and therapeutic approaches of VUR in pediatric population as published throughout the years. With the introduction of Deflux injection as a minimally invasive procedure, we identify a beginning of a new trend that further extends the indications for endoscopic injections, including its introduction to adult patients as well.

Analysis of rhythmic patterns produced by spinal neural networks.

A network of spinal neurons known as central pattern generator (CPG) produces the rhythmic motor patterns required for coordinated swimming, walking, and running in mammals. Because the output of this network varies with time, its analysis cannot be performed by statistical methods that assume data stationarity. The present work uses short-time Fourier (STFT) and wavelet-transform (WT) algorithms to analyze the nonstationary rhythmic signals produced in isolated spinal cords of neonatal rats during activation of the CPGs. The STFT algorithm divides the time series into consecutive overlapping or nonoverlapping windows and repeatedly applies the Fourier transform across the signal. The WT algorithm decomposes the signal using a family of wavelets varying in scale, resulting in a set of wavelet coefficients presented onto a continuous frequency range over time. Our studies revealed that a Morlet WT algorithm was the tool of choice for analyzing the CPG output. Cross-WT and wavelet coherence were used to determine interrelations between pairs of time series in time and frequency domain, while determining the critical values for statistical significance of the coherence spectra using Monte Carlo simulations of white-noise series. The ability of the cross-Morlet WT and cross-WT coherence algorithms to efficiently extract the rhythmic parameters of complex nonstationary output of spinal pattern generators over a wide range of frequencies with time is demonstrated in this work under different experimental conditions. This ability can be exploited to create a quantitative dynamic portrait of experimental and clinical data under various physiological and pathological conditions.

Testicular prosthesis insertion following testicular loss or atrophy during early childhood--technical aspects and evaluation of patient satisfaction.

INTRODUCTION: The absence of a testis may be a major traumatic experience with possible consequent negative behavioral impact. The current study is aimed to assess young adults who had lost their testicles early in childhood and subsequently underwent testicular prosthesis (TP) implantation at the end of their adolescence. MATERIALS AND METHODS: Nineteen patients aged 19.4 years on average underwent TP implantation following testicular loss at early childhood. A postal anonymous questionnaire was sent to the patients and 13 (68%) replied. RESULTS: Average follow-up was 50 months. Sixty-two percent of patients believed TP size were equal or close to the size of their native testicle, while 23% claimed it was too small. Similarly, 54% had the impression its weight was appropriate, while 38% claimed it was too heavy and 38% supposed its location was too high in the scrotum. However, 85% considered it "very comfortable" or "comfortable" and 77% got used to its presence within 1-4 weeks following surgery. All patients precluded any obstacle in intimate relationships. In accordance, all of them would recommend the operation to a friend with a similar problem. CONCLUSIONS: TP implantation in adolescents with an undeveloped scrotum is a highly successful surgical procedure. The operation positively influences self-confidence, inter-personal interactions and intimate relationships.

Testicular fixation following torsion of the spermatic cord--does it guarantee prevention of recurrent torsion events?

PURPOSE: Patients with history of testicular torsion who have undergone orchiopexy may rarely present with acute scrotum due to recurrent episodes of torsion. Most of the reports in the literature regarding this scenario refer to the era when absorbable sutures were used for testicular fixation. Herein, we review our experience in recent years, focusing upon the surgical technique and sutures' material. MATERIALS AND METHODS: Between 1991 and 2003, 179 patients were operated on at our institute with the clinical diagnosis of unilateral testicular torsion. They ranged in age between neonates to 45 years old (average age 18). In a comprehensive retrospective study we managed to locate 8 patients who experienced recurrent intravaginal testicular torsion following previous fixation performed in our institute. RESULTS: The patients who experienced repeat torsion have initially presented at the mean age of 18.5 years old (range 12 to 30) with unilateral twisted testicle (left 3, right 5). Urgent explorations were generally performed, apart from in 2 cases that underwent spontaneous detorsion which was followed by an elective surgery. Testicular fixation was conducted by suturing of the tunica albuginea to the dartos layer by 2 sutures at each side, using chromic 3-zero in the 3 more early cases, followed by the usage of polyglactin 3-zero stitches in 4 subsequent cases and 3 sutures of polypropylene 4-zero for each testicle, thereafter, in the most recent case. The patients presented with repeat torsion, 0.5 to 23 years subsequently (average 7 years), involving either the ipsilateral testicle in 4 cases or the contralateral gonad in 4. CONCLUSIONS: Recurrent torsion following previous testicular fixation may appear many years following the primary procedure, even in cases in which either polyglactin or, notwithstanding, polypropylene sutures have been applied, in accordance with the common practice used in the last 2 decades. Increased awareness regarding this possibility is imperative for early diagnosis and prevention of testicular loss.