Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies.

UNLABELLED: Study Type - Prognosis (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Partial nephrectomy (PN) is the gold standard operation for small renal tumours. The decision for or against a PN has been based mostly on preoperative radiological evaluation of the tumour. Three nephrometry scoring systems have been recently proposed for prediction of postoperative complications of PN (RENAL, C-index and PADUA). We validate externally the accuracy of the PADUA system and suggest for the first time a novel scoring system, based on the original PADUA system, which implements three other significant factors for the postoperative course of a partial. OBJECTIVE: • To externally validate the Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) classification of renal tumours managed by partial nephrectomy (PN). PATIENTS AND METHODS: • Seventy-four consecutive patients in a single academic tertiary institution underwent open PN. • Incidence of 90-day complications was stratified by several clinicopathological variables, such as gender, age of the patient, hospital stay, pathology report, tumour characteristics and positive surgical margins. PADUA scores were given to each case. • The severity of complications was also categorized with the Clavien system. RESULTS: • The optimal threshold of PADUA for the prediction of complications was 8 with a sensitivity equal to 90.9% and a specificity equal to 77.8% (area under the curve [AUC], 0.89; 95% confidence interval [CI], 0.73-1.00). • Multivariate analysis revealed that that PADUA is an independent predictor for the risk of complications. • Also, PADUA score ≥ 8 identified a group of patients with almost 20-fold higher risk of complications (hazard ratio [HR]= 19.82; 95% CI, 1.79-28.35; P= 0.015). • Patients with papillary histology had greater risk for complications than those with clear-cell tumours (HR = 4.88; 95% CI, 1.34-17.76; P= 0.016). CONCLUSIONS: • The PADUA score is a simple anatomical system that predicts the risk of postoperative complications. This is the first external validation of this system for open PN from a single centre. • The authors believe that PADUA is an efficient tool, since the only variable of the present study that predicted a higher incidence of complications was the histology type, which is determined after surgery. • However, it should be applied to laparoscopic and robot-assisted series and it could also include the ischaemia time and surgeon experience in the overall scoring to be complete.

Zinc α2-glycoprotein as a potential novel urine biomarker for the early diagnosis of prostate cancer.

UNLABELLED: What's known on the subject? and What does the study add? The use of biomarkers to detect a cancer early, especially prostate cancer, is not a new idea and PSA has been proved to be the best biomarker for the early diagnosis of prostate cancer. Since the introduction and wide use of PSA various efforts have been made to find novel biomarkers in both serum and urine of individuals at high risk for prostate cancer. The best example of a biomarker detected in the urine after a vigorous digital rectal examination is PCA3, which is used mainly in the subgroup of patients with PSA 4-10 ng/mL whose prostate biopsy was repeatedly negative for prostate cancer in order to decide the performance or not of a new biopsy. Proteomics is a state of the art new biotechnology used to identify the proteome of a certain tissue meaning the whole group of proteins related to the anatomy and biochemistry of the tissue. Using proteomics can effectively and more specifically identify proteins that can be used as potential biomarkers for the early diagnosis of prostate cancer. Zinc α2-glycoprotein has been studied in the past as a protein related to cancer cachexia and it has been measured in both prostate tissue and serum in patients with prostate cancer. Zinc α2-glycoprotein has also been recently identified by proteomics in prostate tissue showing different values in patients with prostate cancer and benign prostate hyperplasia. It is the first time that zinc α2-glycoprotein has been systematically measured and studied in an easily obtained biological fluid such as urine showing a very optimistic potential both as a novel solo biomarker and as an adjunct to PSA for the early diagnosis of prostate cancer. PSA has revolutionized the way we approximate prostate cancer diagnosis. Even though PSA is still the best biomarker for the diagnosis of prostate cancer it constitutes an organ-specific and not a disease-specific biomarker and diagnostic dilemmas are often raised concerning the performance or not of a prostate biopsy. Thus novel biomarkers are required in order to improve the diagnostic ability of PSA. Increasingly in the literature it is stated that the future of prostate cancer diagnosis could be not a single biomarker but a band of different biomarkers that as a total could give the possibility of an individual having prostate cancer. By detecting and measuring zinc α2-glycoprotein in the urine we believe that interesting conclusions can be made: first that proteomics is the way to detect with accuracy proteins that could be proved to be valuable novel biomarkers; second that zinc α2-glycoprotein detected in the urine could be used both as a solo biomarker and as an adjunct to PSA for the early diagnosis of prostate cancer. OBJECTIVE: • To examine the potential utility as a novel biomarker in the urine of zinc α2-glygoprotein (ZAG) for the early diagnosis of prostate cancer. PATIENTS AND METHODS: • The urine of 127 consecutive candidates for a transrectal ultrasound prostatic biopsy with a mean age of 65.7 ± 8.7 years and mean PSA 9.1 ± 5.3 ng/mL was collected. • Western blot analysis and immunohistochemistry for ZAG were performed. • Receiver operating characteristic curves and logistic regression models were used to estimate the predictive ability of ZAG and to determine the optimal sensitivity and specificity by using various cut-off values for the prediction of prostate cancer. RESULTS: • In all, 42 patients had prostate cancer, 29 showed high grade prostatic intraepithelial neoplasia and 56 were negative. • Receiver operating characteristic curve analysis showed a significant predictive ability of ZAG for prostate cancer. The area under the curve (AUC) for the prediction of prostate cancer was 0.68 (95% CI 0.59-0.78). • The combination of ZAG with PSA showed a significant improvement in the predictive ability (P= 0.010), with AUC equal to 0.75 (95% CI 0.66-0.85). Separate analysis in patients with PSA levels of 4-10 ng/mL (70.1%) showed that ZAG had a discriminative power with AUC equal to 0.68. • The optimal cut-off was 1.13 for ZAG, which corresponded to 6.88 times greater odds for prostate cancer. CONCLUSIONS: • Urine detected ZAG showed promising results in the prediction of prostate cancer. • Further validation is required to establish ZAG as a novel biomarker.

Radical cystectomy over the age of 75 is safe and increases survival.

BACKGROUND: Radical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival. METHODS: A total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2 ± 3.7 years, participated in the study. The mean follow-up period was 2.6 ± 1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively. The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters. RESULTS: The perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome. CONCLUSIONS: RC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results.

Proteomic Analysis of Prostate Cancer FFPE Samples Reveals Markers of Disease Progression and Aggressiveness.

Prostate cancer (PCa) is the second most common cancer in men. Diagnosis and risk assessment are widely based on serum Prostate Specific Antigen (PSA) and biopsy, which might not represent the exact degree of PCa risk. Towards the discovery of biomarkers for better patient stratification, we performed proteomic analysis of Formalin Fixed Paraffin Embedded (FFPE) prostate tissue specimens using liquid chromatography coupled with tandem mass spectrometry (LC-MS/MS). Comparative analysis of 86 PCa samples among grade groups 1-5 identified 301 significantly altered proteins. Additional analysis based on biochemical recurrence (BCR; BCR+ n = 14, BCR- n = 51) revealed 197 significantly altered proteins that indicate disease persistence. Filtering the overlapping proteins of these analyses, seven proteins (NPM1, UQCRH, HSPA9, MRPL3, VCAN, SERBP1, HSPE1) had increased expression in advanced grades and in BCR+/BCR- and may play a critical role in PCa aggressiveness. Notably, all seven proteins were significantly associated with progression in Prostate Cancer Transcriptome Atles (PCTA) and NPM1NPM1, UQCRH, and VCAN were further validated in The Cancer Genome Atlas (TCGA), where they were upregulated in BCR+/BCR-. UQCRH levels were also associated with poorer 5-year survival. Our study provides valuable insights into the key regulators of PCa progression and aggressiveness. The seven selected proteins could be used for the development of risk assessment tools.

A novel approach for the surgical management of Peyronie's disease using an acellular, human dermis tissue graft: preliminary results.

PURPOSE: To present for the first time, the use of an acellular, dermis tissue graft from serologically screened human donors (Εpiflex(®), Deutshes Institut für Zell- und Gewebeersatz) for covering cavernosal defects after plaque incision. METHODS: Five patients with a mean age of 57.4 ± 2.1 years and an International Index of Erectile Function (IIEF-5) score >20, diagnosed with Peyronie's disease (PD) with disease duration and a stable penile deformity of at least 12 and 6 months, respectively, underwent reconstructive surgery. The curvature was dorsal in two, dorsal and left in two and dorsal and right in one patient. The patients were scheduled for follow-up at 1, 3 and 6 months. RESULTS: Placement of the Epiflex(®) graft (size 20 × 40 mm) was performed after appropriate spatulation and fixation with 4-0 Monocryl sutures in all patients. Two of the patients also underwent a small plication of the convex side in order to achieve 100% straightening during artificial erection. All patients had an uneventful course and resumed successful sexual activity 1 month later. No penile deformity, infection, antigenicity or de novo erectile dysfunction was observed during the follow-up period. CONCLUSIONS: This is the first study on the use of an acellular, human dermis tissue graft for the surgical management of PD. Despite our small number of patients, we now routinely use this type of graft, due to its superior biomechanical properties, excellent results and maximum safety. Larger patient series with longer follow-up periods are needed to verify our results.

Metabolic acidosis may be as protective as hypercapnic acidosis in an ex-vivo model of severe ventilator-induced lung injury: a pilot study.

BACKGROUND: There is mounting experimental evidence that hypercapnic acidosis protects against lung injury. However, it is unclear if acidosis per se rather than hypercapnia is responsible for this beneficial effect. Therefore, we sought to evaluate the effects of hypercapnic (respiratory) versus normocapnic (metabolic) acidosis in an ex vivo model of ventilator-induced lung injury (VILI). METHODS: Sixty New Zealand white rabbit ventilated and perfused heart-lung preparations were used. Six study groups were evaluated. Respiratory acidosis (RA), metabolic acidosis (MA) and normocapnic-normoxic (Control - C) groups were randomized into high and low peak inspiratory pressures, respectively. Each preparation was ventilated for 1 hour according to a standardized ventilation protocol. Lung injury was evaluated by means of pulmonary edema formation (weight gain), changes in ultrafiltration coefficient, mean pulmonary artery pressure changes as well as histological alterations. RESULTS: HPC group gained significantly greater weight than HPMA, HPRA and all three LP groups (P = 0.024), while no difference was observed between HPMA and HPRA groups regarding weight gain. Neither group differ on ultrafiltration coefficient. HPMA group experienced greater increase in the mean pulmonary artery pressure at 20 min (P = 0.0276) and 40 min (P = 0.0012) compared with all other groups. Histology scores were significantly greater in HP vs. LP groups (p < 0.001). CONCLUSIONS: In our experimental VILI model both metabolic acidosis and hypercapnic acidosis attenuated VILI-induced pulmonary edema implying a mechanism other than possible synergistic effects of acidosis with CO2 for VILI attenuation.

Early removal of nasogastric tube is beneficial for patients undergoing radical cystectomy with urinary diversion.

PURPOSE: Examine the beneficial effect of early nasogastric tube (NGT) removal in patients undergoing radical cystectomy with urinary diversion. PATIENTS AND METHODS: 43 consecutive patients underwent radical cystectomy with urinary diversion and were randomized into 2 groups. In the intervention group (n = 22), the NGT was removed 12 hours after the operation. Comparatively, in the control group (n = 21), the NGT remained in place until the appearance of the first flatus. The appearance of ileus, patient ambulation, time to regular diet, and hospital discharge of the two patient groups were assessed. Patient discomfort due to the NGT was also recorded. RESULTS: The 2 groups showed statistical homogeneity of their baseline characteristics. Two patients (9.09%) from the intervention and 3 patients (14.3%) from the control group developed postoperative ileus and were treated conservatively. No significant differences in intraoperative, postoperative, bowel outcomes or other complications were found between the two groups. All patients preferred the NGT to be removed first in comparison to their other co-existing drains. CONCLUSIONS: This is the first randomized, prospective study, to our knowledge, to assess early NGT removal after radical cystectomy. We advocate early removal, independently of the selected type of urinary diversion, since it is not correlated with ileus and is advantageous in terms of patient comfort and earlier ambulation.

Polycystin-1 induces activation of the PI3K/AKT/mTOR pathway and promotes angiogenesis in renal cell carcinoma.

In the present study we investigated the expression and the functional role of mechanosensitive polycystins in renal cell carcinoma (RCC). In 115 RCC patients we evaluated the protein expression of polycystin-1 (PC1), polycystin-2 (PC2), VEGF and protein components of the PI3K/Akt/mTOR pathway, which have been implicated both in RCC and polycystic kidney disease. PC1 and PC2 demonstrated reduced expression throughout the RCC tissue compared to the adjacent normal tissue. PC1 and PC2 revealed high expression when they were associated with higher grade and decreased 5-year survival respectively. PC1 and PC2 were positively correlated with p110γ subunit of PI3K and high PC1 expressing cells tended to display activation/phosphorylation of Akt. There was also a positive association between PC1 and VEGF expression, whereas PC1 augmented the tumor's microvascular network in stage IV carcinomas. In human RCC cells, functional inhibition of PC1 resulted in upregulation of the PI3K/Akt/mTOR pathway, enhanced cell proliferation and led to inhibition of cell migration. Conclusively, aberrant PC1 regulation is associated with increased angiogenesis and features of advanced disease in RCC tissues.

Hydronephrosis promotes expression of hypoxia-inducible factor 1 alpha.

BACKGROUND: Obstructive uropathy is argued to involve an ischemia-type tissue injury. Further, hypoxia-inducible factor 1 alpha (HIF-1 alpha) constitutes a nuclear transcription factor normally upregulated under hypoxic conditions. We hypothesized that HIF-1 alpha is expressed in the hydronephrotic renal pelvis, as a result of tissue hypoxia. PATIENTS AND METHODS: Renal pelvis tissue specimens were obtained from 2 patient groups. Group 1 (controls, n = 10) consisted of patients who underwent nephrectomy due to nonobstructive renal malignancy. Group 2 (n = 18) consisted of patients who underwent open procedures due to intractable hydronephrosis, not amenable to conservative measures. HIF-1 alpha detection was conducted via immunohistochemical techniques, while histological alterations in both groups were also recorded. RESULTS: Smooth muscle hypertrophy and urothelial hyperplasia were major findings in group 2. HIF-1 alpha-positive cells (fibroblasts and occasionally macrophages), mainly localized in the stroma, were also found to a greater extent in group 2 (p = 0.0066). CONCLUSION: We conclude that HIF-1 alpha is mainly expressed in stroma fibroblasts of the hydronephrotic renal pelvis, implying the presence of significant tissue hypoxia at the dilated upper urinary tract.

Ureterointestinal strictures following Bricker ileal conduit: management via a percutaneous approach.

OBJECTIVE: Urinary diversion after radical cystectomy is commonly performed via an ileal conduit using the Bricker method. However, 4-8% of these cases are complicated with stricture formation at the ureterointestinal junction. Thus, this could eventually lead to hydronephrosis and kidney loss in neglected patients. Few data exist concerning the outcomes of patients with ureterointestinal junction strictures managed via a percutaneous approach and balloon dilatation of the stricture. The potential of managing these strictures, using a stent replacement strategy, was evaluated. PATIENTS AND METHODS: A total of 14 patients (10 male, 4 female; age range 24-72 years) were enrolled in the study. Mean follow-up time was 30.9 months. Invasive bladder cancer was diagnosed in 11, neurogenic bladder in 2 and shrunk bladder after external beam radiation for prostate cancer in 1 patient. They were all managed by radical cystectomy followed by Bricker ileal conduit. In 6 cases, ureterointestinal strictures bilaterally were discovered, whereas unilateral (left-sided) strictures were noted to the remaining 8 patients. All strictures were managed via a percutaneous approach and balloon dilatation. A double J stent was placed at the end of the procedure and was regularly replaced after an interval of 3-6 months. RESULTS: A percutaneous nephrostomy was successfully placed in all patients. Double J stent insertion was possible in 18 of a total of 20 (90%) obstructed ureters. No major complications were observed in any of the cases while adequate renal function was preserved in all patients. Quality of life is not reported to be significantly compromised in any patient. Double J ureteral stent replacement is performed every 3-6 months in a retrograde fashion. One patient died in the follow-up period due to disease progression. CONCLUSION: Placement of a double J stent via a percutaneous approach seems to have offered a viable option in the management of ureterointestinal strictures in this patient population. In addition, periodical retrograde replacement of the stent probably does not constitute a factor compromising quality of life. However, further studies are required to justify these primary clinical data.

Local anesthesia during transrectal ultrasonography-guided prostate biopsy: does it have any effect on sexual function?

INTRODUCTION: TRUS (Trans Rectal Ultra Sonographic)-guided biopsy of the prostate is the procedure of choice for prostate cancer diagnosis in urological clinical practice. TRUS-guided biopsies are associated with pain and anxiety and may interfere with sexual function and potency. The aim of this study was to evaluate whether local anesthesia during TRUS-guided prostate biopsies has any effect on the sexual behavior of patients and to compare the periprostatic infiltration with lidocaine to simple sonographic gel application in a randomized prospective trial. PATIENTS AND METHODS: A total of 62 consecutive patients were included in the study randomized in two groups; Group A (n = 30, control group) and Group B (n = 32, lidocaine infiltration group). Interviews regarding their sexual status were conducted at the time they were informed of the need for biopsy, at the time of biopsy and at two scheduled interviews following the biopsy. RESULTS: Similar results of sexual dysfunction were observed between the two groups. About 6% of patients experienced some degree of dysfunction in anticipation of biopsy (P > 0.02 between the two groups) that was resolved by the end of the follow-up period. In total, only one Group B patient continued to show sexual dysfunction at the time of the last interview compared to two patients in Group A. CONCLUSIONS: Local infiltration with lidocaine does not seem to play a role in sexual dysfunction following prostate biopsies. Psychological factors influence patients and the urologist should be ready to inform and reassure both the patient and his family.

Downregulated KLK13 expression in bladder cancer highlights tumor aggressiveness and unfavorable patients' prognosis.

PURPOSE: Despite recent research advantages on the molecular and subcellular background, bladder cancer (BlCa) remains a clinically neglected malignancy. This is strongly reflected by the generic approach of disease diagnosis and management. Additionally, patients' prognosis became a rather demanding task due to the great disease heterogeneity. Here, we aimed to evaluate, for the first time, the clinical value of KLK13 in BlCa. METHODS: A total of 279 bladder specimens (137 tumors, 107 adjacent normal tissues and 35 healthy samples) were included. Total RNA was extracted, reverse transcribed, and KLK13 expression was assessed by quantitative real-time PCR. RESULTS: KLK13 expression is significantly increased in bladder tumors compared to normal adjacent epithelium. However, reduced KLK13 expression is correlated with disease aggressiveness, including higher tumor stage and grade, and high-risk TaT1 tumors according to the EORTC stratification. Moreover, Kaplan-Meier and Cox regression analysis highlighted the prognostic value of the reduced KLK13 expression for the prediction of TaT1 patients' recurrence and shorter disease-free survival following TURBT. Finally, the combination of KLK13 expression with EORTC-risk stratification results to an improved prediction of TaT1 patients' outcome. CONCLUSION: This first clinical study of KLK13 in BlCa reveals its deregulated expression in bladder tumors and highlights KLK13 as a promising marker for improving TaT1 patients' prognosis following treatment.

Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review.

Controversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.

Simultaneous laparoscopic management of ureteropelvic junction obstruction and renal lithiasis: the combined experience of two academic centers and review of the literature.

INTRODUCTION: Approximately one out of five patients with ureteropelvic junction obstruction (UPJO) present lithiasis in the same setting. We present our outcomes of simultaneous laparoscopic management of UPJO and pelvic or calyceal lithiasis and review the current literature. METHODS: Thirteen patients, with a mean age of 42.8±13.3 years were diagnosed with UPJO and pelvic or calyceal lithiasis. All patients were subjected to laparoscopic dismembered Hynes-Anderson pyeloplasty along with removal of single or multiple stones, using a combination of laparoscopic graspers, irrigation, and flexible nephroscopy with nitinol baskets. RESULTS: The mean operative time was 218.8±66 minutes. In two cases, transposition of the ureter due to crossing vessels was performed. The mean diameter of the largest stone was 0.87±0.25 cm and the mean number of stones retrieved was 8.2 (1-32). Eleven out of 13 patients (84.6%) were rendered stone-free. Complications included prolonged urine output from the drain in one case (Clavien grade I) and urinoma formation requiring drainage in another case (Clavien grade IIIa). The mean postoperative follow-up was 30.2 (7-51) months. No patient has experienced stone or UPJO recurrence. CONCLUSION: Laparoscopy for the management of UPJO along with renal stone removal seems a very appealing treatment, with all the advantages of minimally invasive surgery. Concomitant renal stones do not affect the outcome of laparoscopic pyeloplasty, at least in the midterm. According to our results and the latest literature data, we advocate laparoscopic management as the treatment of choice for these cases.

Differences in ureteroscopic stone treatment and outcomes for distal, mid-, proximal, or multiple ureteral locations: the Clinical Research Office of the Endourological Society ureteroscopy global study.

BACKGROUND: Ureteroscopy has traditionally been the preferred approach for treatment of distal and midureteral stones, with shock wave lithotripsy used for proximal ureteral stones. OBJECTIVE: To describe the differences in the treatment and outcomes of ureteroscopic stones in different locations. DESIGN, SETTING, AND PARTICIPANTS: Prospective data were collected by the Clinical Research Office of the Endourological Society on consecutive patients treated with ureteroscopy at centres around the world over a 1-yr period. INTERVENTION: Ureteroscopy was performed according to study protocol and local clinical practice guidelines. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Stone location, treatment details, postoperative outcomes, and complications were recorded. Pearson's chi-square analysis and analysis of variance were used to compare outcomes among the different stone locations. RESULTS AND LIMITATIONS: Between January 2010 and October 2012, 9681 patients received ureteroscopy treatment for stones located in the proximal ureter (n=2656), midureter (n=1980), distal ureter (n=4479), or multiple locations (n=440); location in 126 patients was not specified. Semirigid ureteroscopy was predominantly used for all stone locations. Laser and pneumatic lithotripsy were used in the majority of cases. Stone-free rates were 94.2% for distal ureter locations, 89.4% for midureter locations, 84.5% for proximal ureter locations, and 76.6% for multiple locations. For the proximal ureter, failure and retreatment rates were significantly higher for semirigid ureteroscopy than for flexible ureteroscopy. A low incidence of intraoperative complications was reported (3.8-7.7%). Postoperative complications occurred in 2.5-4.6% of patients and varied according to location, with the highest incidence reported for multiple stone locations. Limitations include short-term follow-up and a nonuniform treatment approach. CONCLUSIONS: Ureteroscopy for ureteral stones resulted in good stone-free rates with low morbidity. PATIENT SUMMARY: This study shows that patients who have ureteral stones can be treated successfully with ureteroscopy with a low rate of complications for the patient.

Detection of circulating tumor cells in bladder cancer using multiplex PCR assays.

AIM: The aim of this study was to develop multiplex-PCR assays for the detection of circulating tumor cells in peripheral blood and urine samples of patients with bladder cancer. MATERIALS AND METHODS: Peripheral blood and urine samples were collected from 208 patients (169 patients and 39 healthy volunteers). After RNA extraction and cDNA synthesis, the samples were analyzed for the expression of cytokeratin 19 (CK19), CK20 and epidermal growth factor receptor (EGFR) mRNA in blood and for SURVIVIN, human telomerase reverse transcriptase (hTERT), cytokeratin 20 (CK20) mRNA in urine, using multiplex-PCR assays. RESULTS: EGFR and CK20 alone or in combination as well as all urine markers correlated well with histological grade. hTERT correlated well with primary tumor size T≥3. Patients with positive urine markers had significantly worse progression-free survival. CONCLUSION: Multiplex-PCR assays can be a useful tool for staging and monitoring purposes in patients with bladder cancer.

A rare case of a 39 year old male with a parasite called Dioctophyma renale mimicking renal cancer at the computed tomography of the right kidney. A case report.

We present a very rare case of a 39 year old patient with Dioctophyma renale depicted as a Bosniak cyst IV of the right kidney who was finally subjected to a robotic assisted radical nephrectomy.

Renal transplant lithiasis: analysis of our series and review of the literature.

BACKGROUND AND PURPOSE: Renal transplant lithiasis represents a rather uncommon complication. Even rare, it can result in significant morbidity and a devastating loss of renal function if obstruction occurs. We present our experience with graft lithiasis in our series of renal transplantations and review the literature regarding the epidemiology, pathophysiology, and current therapeutic strategies in the management of renal transplant lithiasis. PATIENTS AND METHODS: In a retrospective analysis of a consecutive series of 1525 renal transplantations that were performed between January 1983 and March 2007, 7 patients were found to have allograft lithiasis. In five cases, the calculi were localized in the renal unit, and in two cases, in the ureter. A review in the English language was also performed of the Medline and PubMed databases using the keywords renal transplant lithiasis, donor-gifted lithiasis, and urological complications after kidney transplantation. Several retrospective studies regarding the incidence, etiology, as well as predisposing factors for graft lithiasis were reviewed. Data regarding the current therapeutic strategies for graft lithiasis were also evaluated, and outcomes were compared with the results of our series. RESULTS: Most studies report a renal transplant lithiasis incidence of 0.4% to 1%. In our series, incidence of graft lithiasis was 0.46% (n=7). Of the seven patients, three were treated via percutaneous nephrolithotripsy (PCNL); in three patients, shockwave lithotripsy (SWL) was performed; and in a single case, spontaneous passage of a urinary calculus was observed. All patients are currently stone free but still remain under close urologic surveillance. CONCLUSION: Renal transplant lithiasis requires vigilance, a high index of suspicion, prompt recognition, and management. Treatment protocols should mimic those for solitary kidneys. Minimally invasive techniques are available to remove graft calculi. Long-term follow-up is essential to determine the outcome, as well as to prevent recurrence.

Recurrent urethrovesical anastomotic strictures following artificial urinary sphincter implantation: a case report.

INTRODUCTION: The management of an anastomotic stricture after a radical prostatectomy can become a complex and difficult situation when an artificial urinary sphincter precedes the formation of the stricture. The urethral narrowing does not allow the passage of the routinely used urological instruments and no previous reports have suggested alternate approaches. CASE PRESENTATION: We present the case of a 68-year-old Greek man diagnosed as having a recurrent anastomotic stricture approximately two years after a radical prostatectomy and three years after the implantation of an artificial urinary sphincter, and propose novel alternate methods of treatment. Our patient was first subjected to stricture incision with the use of a rigid ureteroscope with a holmium:yttrium-aluminium-garnet laser fiber, which was followed by a second successful attempt with the use of a pediatric resectoscope. After a one-year follow-up, our patient is doing well, with no evidence of recurrence. CONCLUSIONS: To the best of our knowledge, this is the first report of the management of recurrent urethral strictures following an artificial urinary sphincter implantation. Minimal invasive techniques with the use of small caliber instruments may offer efficient treatment options, diminishing the danger of urethral corrosion.

Spinal versus General Anaesthesia in Postoperative Pain Management during Transurethral Procedures.

We compared the analgesic efficacy of spinal and general anaesthesia following transurethral procedures. 97 and 47 patients underwent transurethral bladder tumour resection (TUR-B) and transurethral prostatectomy (TUR-P), respectively. Postoperative pain was recorded using an 11-point visual analogue scale (VAS). VAS score was greatest at discharge from recovery room for general anaesthesia (P = 0.027). The pattern changed significantly at 8 h and 12 h for general anaesthesia's efficacy (P = 0.017 and P = 0.007, resp.). A higher VAS score was observed in pT2 patients. Patients with resected tumour volume >10 cm(3) exhibited a VAS score >3 at 8 h and 24 h (P = 0.050, P = 0.036, resp.). Multifocality of bladder tumours induced more pain overall. It seems that spinal anaesthesia is more effective during the first 2 postoperative hours, while general prevails at later stages and at larger traumatic surfaces. Finally, we incidentally found that tumour stage plays a significant role in postoperative pain, a point that requires further verification.