Assessing the accuracy of endoscopic estimates of lesion size in urology using in vitro models of the urinary tract.

BACKGROUND AND PURPOSE: Despite the frequency at which urologists endoscopically estimate lesion size, their accuracy has not been established. Our objectives were to determine the accuracy of cystoscopic and ureteroscopic estimates of lesion size using in vitro models of the urinary tract and to assess potential impacting factors. METHODS: Eleven staff urologists and 9 urology learners performed cystoscopy on a series of pig bladders containing mock papillary and flat lesions. Each provided three sets of size estimates: two using only the cystoscope to assess intraobserver agreement and the third with the aid of a ureteral catheter as a visual reference. Similar estimates were made with a flexible ureteroscope on papillary lesions within an inorganic upper urinary tract model. Differences in mean estimates and the agreement between repeated estimates were assessed. RESULTS: The level of endoscopic training did not influence the mean error of estimation (MEE) for either cystoscopy or ureteroscopy regardless of lesion size and appearance. Staff and learners consistently underestimated lesion size with median errors of 34% and 43%, with excellent (median intraclass correlation coefficient [ICC] of 0.97) and fair (median ICC of 0.56) reproducibility for cystoscopy and ureteroscopy, respectively. Use of the visual reference during cystoscopy did not improve the MEE. CONCLUSIONS: Urologists, regardless of their level of training, substantially underestimate lesion size by 34% to 43%. These findings are independent of lesion size and appearance, and the use of a visual reference during cystoscopy. Recognizing this tendency and adjusting estimates accordingly or improving instrumentation should improve clinical and operative decision-making.

Adult granulosa cell tumor of the testicle.

We report a rare case of adult granulosa cell tumor of the testis in a 68-year-old man. A case and literature review of the associated clinical features, histopathological characteristics and immunochemistry are presented. The tumor is typically slow growing but has a higher risk of malignancy when > 5 cm. Our patient was disease-free 18 months following a right radical orchiectomy.

Is an overnight stay after percutaneous nephrolithotomy safe?

OBJECTIVES: To establish a clinical care pathway that plans for hospital discharge the day after percutaneous nephrolithotomy (PCNL), to evaluate the safety, effectiveness and feasibility of this pathway, and to identify factors associated with a postoperative length of hospital stay (LOS) of >1 day. PCNL is the treatment of choice for patients with large kidney stones and those in whom extracorporeal shockwave lithotripsy has failed, and the mean LOS is typically 2-5 days. PATIENTS AND METHODS: We retrospectively reviewed the charts of 109 patients (mean age 57.4 years; 58 men, 53%) who had PCNL between 2006 and 2009. All had nephrostomy tubes placed after surgery. The patients' demographics, LOS, incidence of complications, clinical outcomes, stone-free rates, number of early postoperative emergency-room visits, need for subsequent admission and/or other procedures, were noted and analysed. The modified Clavien classification was used to describe the postoperative complications. Bivariate analyses were used to test for associations between LOS and other variables. RESULTS: The mean (range) stone size was 2.2 (0.9-5.9) cm, and the mean (SEM) LOS was 1.7 (0.13) days. Of the 109 patients, 20% had a LOS of >1 day for surgical, 3% for medical and 5% for social reasons. The stone-free rate was 89%. There was no difference in the number of subsequent hospital visits or ancillary procedures for patients discharged after one or more postoperative nights. No variables were associated with a longer LOS. CONCLUSIONS: An overnight hospital stay after PCNL is safe and represents an effective strategy for improved bed use in selected patients. A longer LOS was not affected by patient age or body mass index, stone size or operative time. We continue to use our clinical care pathway, as supported by these data.

Acute reversible kidney injury secondary to bilateral ureteric obstruction.

BACKGROUND: Acute reversible kidney injury (ARKI) secondary to bilateral ureteric obstruction (BUO) is a common urological problem. Our goals were to describe the etiology, management and outcomes of such patients identified between 2006 and 2009 and to compare them with a similar historical study published in 1982. METHODS: Chart review was performed on 49 patients with AKRI secondary to BUO. ARKI was defined as ≥33% decrease in serum creatinine after intervention. Those with malignant and benign causes of obstruction were identified and management and outcome data were collected. RESULTS: Of these 49 patients, 83% had BUO secondary to malignancy, 28% of these presenting for the first time. Prevalence of bladder cancer was increased (p = 0.04) and cervix trended lower (p = 0.07) compared with the earlier study; prostate cancer was unchanged (p = 0.51). The average survival was 239 days; 90% of patients died within a year after presenting with BUO from a malignant etiology. Compared with the 1982 group, there were trends towards a decrease in the frequency of retroperitoneal fibrosis (p = 0.08) and an increase in bilateral ureteric calculi (p = 0.16) in the benign group. CONCLUSIONS: Patients with ARKI secondary to BUO most likely have an underlying malignancy, with almost a third of them being diagnosed for the first time. Prevalence of bladder cancer increased while cervical cancer trended lower. The cause for the former is unclear; the latter may be due to aggressive screening. Prostate cancer remained unchanged despite the widespread implementation of prostate-specific antigen testing. Patients with an underlying malignancy do poorly and those with a newly diagnosed malignancy do worst. Those with ARKI secondary to benign causes did well.

Bilateral renal sinus myelolipomas.

Adrenal myelolipomas are benign neoplasms consisting of hematopoietic cellular elements and adipose tissue. They are uncommon, found in 0.4% to 1% of the population at autopsy. Extra-adrenal myelolipomas (EM) are extremely rare with fewer than 50 cases reported. We describe the first case of bilateral EM of the renal sinus. They are difficult to diagnose on imaging alone when arising in this location and biopsies may not yield a definitive answer. Management options include both conservative and surgical approaches depending upon the certainty of the diagnosis, progression of the patient's symptoms and evidence of growth.

Suture urolithiasis in the renal pelvis secondary to prior subtotal colectomy.

We report upon a patient who underwent a subtotal colectomy 2 years prior to presenting for a percutaneous nephrolithotomy of a large stone in the left renal pelvis. At the time of surgery, a non-absorbable suture was found embedded in the stone. Both stone and suture were removed percutaneously.

Levels of 5alpha-reductase type 1 and type 2 are increased in localized high grade compared to low grade prostate cancer.

PURPOSE: In the prostate testosterone is converted to dihydrotestosterone by 5alpha-reductase type 1 and/or 2. Although 5alpha-reductase type 2 is predominant in normal prostates, type 1 is increased in cancer vs benign tissue. It is unclear whether 5alpha-reductase type 1/2 levels correlate with cancer grade. We compared the relative expression of 5alpha-reductase type 1 and 2 in localized high and low grade prostate cancer. MATERIALS AND METHODS: Immunostaining for 5alpha-reductase type 1/2 was evaluated in 64 prostate tissues from untreated men with localized prostate cancer. The percent of tumor area with moderate-high intensity staining was estimated for each Gleason pattern in the tissues. Adjacent benign tissue was evaluated in 26 prostate cancer specimens. RESULTS: Moderate-high staining for 5alpha-reductase type 1 increased from 18.8% +/- 2.9% (mean +/- SEM) in 34 Gleason pattern 3 cancers to 31.0% +/- 4.1% in 30 Gleason pattern 4/5 cancers (p = 0.016). Staining for 5alpha-reductase type 2 increased from 22.9% +/- 3.0% in 34 Gleason pattern 3 cancers to 39.2% +/- 4.1% in 30 Gleason pattern 4/5 cancers (p = 0.002). Compared to benign prostatic hyperplasia tissues staining for 5alpha-reductase type 1 was greater than 3-fold higher and staining for 5alpha-reductase type 2 was significantly lower in benign tissue adjacent to cancer (p = 0.006 and 0.0236, respectively). CONCLUSIONS: Levels of 5alpha-reductase type 1 and 2 are increased in localized high vs low grade prostate cancer. Levels of 5alpha-reductase type 1 are higher in benign tissue adjacent to cancer than in benign prostatic hyperplasia. These results raise the possibility that increased 5alpha-reductase type 1 in localized high grade cancers may contribute to the decreased effectiveness of the 5alpha-reductase type 2 selective inhibitor finasteride against high grade prostate cancer in the Prostate Cancer Prevention Trial.

Dystrophic calcified nodule of the testicle: a case report.

Dystrophic calcified nodule of the testis was first reported by Minkowitz and colleagues in 1965, with few subsequent reports. The etiology of this lesion is controversial and unknown partly owing to its rarity. We report the case of a 29-year-old man who presented with generalized right testicular pain. His ultrasound demonstrated a discrete calcified lesion. A right radical orchiectomy was performed identifying a 1.8 x 0.8 x 0.9-cm intratesticular calcific lesion with no evidence of intratubular germ cell tumour and negative tumour markers.

Solid pseudopapillary tumor of the pancreas mimicking malignant adrenal pheochromocytoma.

We report a 75-year old woman with clinical, laboratory and imaging characteristics suggestive of a malignant left adrenal pheochromocytoma with invasion of the tail of the pancreas. The mass involving the tail of the pancreas and the left adrenal was excised Detailed histological diagnosis revealed that the lesion was a rare exocrine tumor of the pancreas.

Microsatellite instability in multifocal urothelial carcinoma and effect on BAX and AXIN2.

OBJECTIVES: Urothelial carcinomas have a synchronous or metachronous multifocal pattern of occurrence, questioning their clonal origin. Genetic alterations such as microsatellite instability (MSI) affect various tumors including urothelial cancers. These alterations can affect repeat sequences and cause mutations in coding regions of genes involved in transformation, tumor suppression and apoptosis. Recently, the eight-guanine (G8) and the seven-guanine (G7) repeat sequences of the BAX and AXIN2 genes respectively, were shown altered in different cancers. Since BAX is involved in apoptosis while the AXIN2 is involved in beta-catenin metabolism, a protein involved in cell adhesion and DNA transcription, and due to the multifocal nature of urothelial cancer, we investigated these two genes for alterations in repeat sequences in patients with this cancer. PATIENTS AND METHODS: The eight microsatellites BAT25, BAT26, D2S123, D3S1029, D5S346, D17S588, D17S261, MYCL1 were used to screen 25 tumors from seven patients with eight upper and 17 lower urinary tract carcinomas and compare them to DNA from normal tissue. Regions spanning the G8 and G7 repeat sequences of BAX and AXIN2 were sequenced for mutations including expansion and deletion abnormalities. RESULTS: Six microsatellites were seen altered in one patient with kidney and bladder cancer affecting both tissues when compared to normal DNA albeit not similarly except for MYCL1. There was no change in the BAX G8 or AXIN2 G7 microsatellites. There was no MSI seen in any of the remaining six patients. CONCLUSION: MSI occurs in urothelial cancer, but was not seen to affect the BAX G8 or AXIN2 G7 repeats in this study. However, to determine if MSI affects these genes in these tumors will require a larger study. Moreover, our results suggest that these tumors may have a monoclonal origin with further genetic changes resulting in oligoclonality, or could suggest a similar initiating event leading to a similar initial genetic alteration at different sites with subsequent varying events due to a genetically unstable malignant phenotype.

Pigmented pseudotumor of the testis: a unique testicular and para-testicular mass.

We report on the case of a 24 year old male with a testicular and paratesticular melanin-like, pigmented lesion. This is the first report of this type of lesion which we have designated a pigmented pseudotumor.

Sclerosing lipogranuloma: an unusual scrotal mass.

Sclerosing lipogranuloma of the male genitalia without a history of injection of exogenous material is extremely rare. This is the first case reported from a Canadian center. This 33 year old man developed sclerosing lipogranuloma of his scrotum 3 months after being diagnosed with infectious mononucleosis. There was no history of injection of exogenous substances or trauma. His lesion was painless, sudden in onset, "Y-shaped", associated with eosinophila and spontaneously regressed after partial resection. A review of the available English literature on sclerosing lipogranuloma from 1966 to 2001 was completed to compare our case report to previously available reports. The results show definite differences in the presentation of primary versus secondary sclerosing lipogranuloma. Sixty-eight per cent of the cases of primary sclerosing lipogranuloma involved the scrotum only while 63% of secondary sclerosing lipogranuloma involved the penis only. Seven per cent of lesions attributed to primary sclerosing lipogranuloma were painful compared to 69% of secondary sclerosing lipogranulomas. Cases of primary sclerosing lipogranuloma were often described as "Y-shaped" and were unlikely to recur. Understanding the typical presentation of this condition will allow future cases to be recognized more easily and managed appropriately. Primary sclerosing lipogranuloma may be diagnosed by fine needle aspiration or excisional biopsy and then managed conservatively avoiding more complex and invasive surgery.

Stability of the Bax (G)8 microsatellite in localized prostatic adenocarcinoma.

OBJECTIVES: Microsatellite instability has been found in a variety of tumors including prostate cancer. Bax, a pro-apoptotic protein from the Bcl-2 family of proteins, has a microsatellite composed of an eight deoxyguanine [(G)8] tract located in exon 3. Prostate carcinoma cells have increased proliferation indices and lower levels of apoptosis when compared to benign tissue. We investigated whether instability in the Bax (G)8 microsatellite contributes to loss of apoptotic control in localized prostate cancer. PATIENTS AND METHODS: Thirty-eight patients undergoing radical prostatectomy for localized prostate carcinoma participated in this study. Prostate carcinoma was microdissected, and polymerase chain reaction amplification of a region containing the (G)8 microsatellite was performed on DNA from peripheral blood leukocytes and tumors, followed by single strand conformational polymorphism (SSCP) analysis and direct DNA sequencing. RESULTS: SSCP analysis showed no alteration in the number of bands detected upon comparison of tumor tissue to leukocytes, suggesting no alterations in the microsatellite. This was confirmed by direct sequencing, which demonstrated a normal (G)8 sequence in each case. CONCLUSION: We conclude that the Bax (G)8 microsatellite is stable in localized stage T2 and T3 prostate cancer. Our findings argue against a mutator phenotype pathway leading to loss of apoptotic control in localized prostate cancer.

Paratesticular tumor of Müllerian duct origin.

A 65 year old Caucasian male presented with a 4 year history of persistent right epididymal discomfort. There was no history of urinary tract infection, dysuria urethral discharge or trauma. Despite several courses of antibiotics and prolonged use of anti-inflammatory medications, his symptoms were unrelenting and had become unbearable. Past history revealed that he had undergone an uncomplicated transurethral prostatectomy for obstructive benign prostatic hyperplasia 6 years previously and a left inguinal herniorrhaphy 15 years ago. There was no history of estrogen use. Physical examination revealed a normal penis, penile urethra, urethral meatus, testes and left epididymis. There was induration of the right epididymis and the caput was exquisitely tender. Complete blood count and urinalysis were normal and urine culture was negative. A scrotal ultrasound failed to show any abnormality. The patient underwent scrotal exploration and a right epididymectomy. An incidental, soft, 2 cm mass was discovered within the spermatic cord adjacent to the superior aspect of the testicle and this was excised. Histologic examination of the epididymis was unremarkable and the other lesion was shown to be a cystic paratesticular müllerian tumor (Figure 1). The epididymalgia resolved post operatively and he has been asymptomatic with no evidence of recurrence for 4 years.