Testosterone replacement attenuates intimal hyperplasia development in an androgen deficient model of vascular injury.

BACKGROUND: Androgen deficiency (AD) is associated with increased risk of vascular disease. Dysfunctional remodeling of the vessel wall and atypical proliferative potential of vascular smooth muscle cells (VSMCs) are fundamental processes in the development of intimal hyperplasia (IH). We have demonstrated an inverse relationship between dihydrotestosterone (DHT) levels, matrix metalloproteinase activity, and VSMC migration and proliferation in vitro. Here, we investigated the role of AD and testosterone (TST) replacement in IH development in an animal model of vascular injury to elucidate mechanisms modulated by AD that could be playing a role in the development of vascular pathogenesis. METHODS: Aged orchiectomized male rats underwent TST supplementation via controlled release pellet (0.5-35 mg). Young adult and middle-age adult intact (MI) and orchiectomized placebo (Plac) groups served as controls. All groups underwent balloon angioplasty of the left common carotid at a 14-d post-TST. Carotid tissue was collected at a 14-d post-balloon angioplasty and subjected to morphologic and immunohistochemical analyses. Human male VSMCs were treated with DHT (0-3000 nM) for 24 h then subjected to quantitative PCR for gene expression analyses and costained for F-actin and G-actin for visualization of cytoskeletal organization. RESULTS: I:M ratio was increased in Plac, subphysiological, low-physiological, and high pharmacologic level TST animals compared with MI controls but was decreased with high-physiological TST supplementation. Injury-induced expression of previously defined matrix metalloproteinase remodeling enzymes was not significantly affected by TST status. Urotensin (UTS) receptor (UTSR) staining was low in injured vessels of all young adult intact, MI, and Plac controls but was significantly upregulated in all groups receiving exogenous TST supplementation, irrespective of dose. In vitro DHT exposure increased the expression of UTSR in VSMCs in a dose-dependent manner. However, this did not correlate with any change in proliferative markers. F:G actin staining revealed that DHT-induced cytoskeletal organization in a dose-dependent manner. CONCLUSIONS: AD increased IH development in response to vascular injury, whereas physiological TST replacement attenuated this effect. AD-induced IH occurs independent of matrix remodeling mechanisms known to be heavily involved in vascular dysfunction, and AD alone does not affect the UTS and/or UTSR mechanism. Exogenous TST and/or DHT increases UTSR pathway signaling in vitro and in vivo. This modulation correlates to a shift in cytoskeletal organization and may exacerbate vasoconstrictive pathogenesis. While physiological TST replacement attenuates AD-modulated IH development, its UTS-mediated effect on vasotone may prove deleterious to overall vascular function.

Low testosterone elevates interleukin family cytokines in a rodent model: a possible mechanism for the potentiation of vascular disease in androgen-deficient males.

BACKGROUND: Androgen deficiency (AD) is associated with increased risk of atherosclerosis, cardiovascular, and peripheral arterial disease. Although the biochemical and molecular mechanisms underlying this risk remain unclear, higher testosterone (TST) levels correlate to significant immunoprotective molecular and cellular responses. Our group has previously demonstrated that female sex hormones influence vascular pathogenesis via inflammatory-modulated matrix metalloproteinase (MMP) regulation. Here we investigated the role of AD and androgen replacement therapy in the modulation of these hormonally responsive pathways that could be playing a role in the development of vascular pathogenesis. METHODS: Aged orchiectomized male rats underwent TST supplementation per controlled release pellet implantation (0-150 mg). Young and aged intact groups served as controls. Serum was collected at 0-4 wk and analyzed by enzyme-linked immunosorbent assays, qualitative cytokine screening, and quantitative multiplex analyses. Human aortic smooth muscle cells were treated with 4,5α-dihydrotestosterone (DHT; 0-3000 nM) before or after interleukin 1ß (IL-1ß; 5 ng/mL) stimulation. Quantitative polymerase chain reaction and in-gel zymography was used to assay the effect on MMP expression and activity. RESULTS: Subphysiological, physiological, and supraphysiological levels of TST were achieved with 0.5, 2.5, and 35 mg TST pellet implants in vivo, respectively. Inflammatory arrays indicated that interleukin cytokines, specifically IL-2, IL-6, IL-10, IL-12, and IL-13, were elevated at subphysiological level of TST, whereas TST supplementation decreased interleukins. Supraphysiological TST resulted in a significant increase in MMP-9 and tissue inhibitor of metalloproteinase-1 (TIMP-1) in vivo. Pretreatment with IL-1ß slightly increased membrane type 1-MMP (MT1-MMP) and MMP-2 expression at low to mid-level DHT exposure in vitro, although these trends were not statistically significant. CONCLUSIONS: Here we demonstrate AD is a proinflammatory modulator and indicate that MMP-independent mechanisms may play a role downstream of AD-induced inflammatory signaling in dysfunctional vascular remodeling. Future in vivo studies will examine AD and TST supplementation in acute inflammatory response to vascular injury and in MMP-modulated vascular disease.

Androgens regulate MMPs and the cellular processes of intimal hyperplasia.

BACKGROUND: Testosterone deficiency has been associated with an increased risk of vascular disease. Matrix metalloproteinases (MMPs) have been implicated in vascular remodeling. Our group has demonstrated an association between female hormones and MMP-modulated intimal hyperplasia. In the present study, we investigated testosterone in the modulation of MMPs and the cellular processes of intimal hyperplasia. MATERIALS AND METHODS: Male vascular smooth muscle cells (VSMCs) were treated with a range of testosterone or dihydrotestosterone (DHT) concentrations (0.3-3000 nM). MMPs were assayed using quantitative polymerase chain reaction, Western blot analysis, and zymography. VSMC migration and proliferation were assayed using Boyden chamber and MTT assays. RESULTS: MT1-MMP gene expression was not affected by low DHT exposure but was downregulated at high levels (3000 nM = 85% ± 3%). TIMP-2 gene expression was downregulated at low DHT exposure (0.3 nM = 82% ± 4%, 3.0 nM = 82% ± 1%) but was not affected at high levels. MMP-2 enzymatic activity was increased at low DHT exposure (3.0 nM = 110% ± 4%) and decreased below basal levels at high doses (300 nM = 91% ± 7%, 3000 nM = 77% ± 8%). High concentrations of DHT decreased VSMC migration (3.0 nM = 72% ± 9%, 30 nM = 50% ± 6%, 300 nM = 47% ± 5%, 3000 nM = 53% ± 6%). Testosterone also decreased migration but had less effect. The highest tested concentration of DHT and testosterone decreased the basal VSMC proliferation (3000 nM = 87% ± 3% and 87% ± 4% respectively). CONCLUSIONS: The DHT levels differentially affected the expression of regulatory isoforms responsible for the activation and inhibition of MMP-2, leading to an inverse relationship among the DHT levels, MMP-2 activity, and VSMC migration. In vivo studies will be used to examine testosterone deficiency and supplementation in MMP-modulated intimal hyperplasia in animal models of vascular disease. These studies are needed as a prerequisite to determining whether testosterone replacement in testosterone-deficient men should be evaluated for attenuation of atherosclerosis.

Single incision mid-urethral sling for treatment of female stress urinary incontinence.

OBJECTIVES: To present the longitudinal outcomes in an observational cohort of patients who had undergone treatment of stress urinary incontinence with a single incision mid-urethral sling (MUS). METHODS: A prospective, observational study of all female patients who had undergone surgical intervention with the MiniArc MUS was performed. The surgical candidates underwent history and physical examination and urodynamic testing, as indicated. Quality of life questionnaires (Urogenital Distress Inventory [UDI-6] and Incontinence Impact Questionnaire [IIQ-7]) were administered preoperatively. The salient operative data were recorded. The patients were followed up postoperatively for evidence of treatment success and adverse events. The patients completed the UDI-6, IIQ-7, and Female Sexual Function Index questionnaires at 1 and 12 months after treatment. RESULTS: From September 2007 to October 2008, 120 patients underwent placement of the MiniArc MUS for the treatment of stress urinary incontinence. The mean patient age was 58.4 years. The mean body mass index was 27.2 kg/m(2). The mean preoperative daily pad use was 2.4. The mean preoperative IIQ-7 and UDI-6 score was 86.58 and 62.5, respectively. Of the 120 patients, 108 (90%) completed a minimum follow-up period of 12 months. Of these 108 patients, 101 (94%) were cured/dry. The mean postoperative pad use was 0.2 (P < .001). The mean IIQ-7 and UDI-6 score was 13.32 (P < .001) and 12.5 (P < .001), respectively. The Female Sexual Function Index results demonstrated no discomfort with intercourse in 49%, occasional discomfort in 9%, and frequent discomfort in 2%. The remaining 40% of our patients were not sexually active. CONCLUSIONS: Our results have shown that the MiniArc MUS offers excellent outcomes that are durable at 1 year after treatment.

Intermediate-term follow-up of patients treated with percutaneous embolization for grade 5 blunt renal trauma.

BACKGROUND: The short-term efficacy and safety of percutaneous embolization for the treatment of hemodynamically unstable patients with grade 5 renal injuries secondary to blunt trauma has been previously established; however, there has been no published intermediate-term follow-up. The purpose of this study is to report intermediate-term follow-up and complications for this treatment modality. METHODS: A retrospective study was performed to determine intermediate-term outcomes in an observational cohort of patients who underwent percutaneous embolization for the management of grade 5 blunt renal trauma. Demographic and perioperative data were obtained. Follow-up was performed via mail and/or phone questionnaires. RESULTS: Between October 2004 and July 2008, 10 hemodynamically unstable patients with grade 5 blunt renal trauma were treated with percutaneous embolization. Mean age of the cohort was 29 years (range, 5-50). Mean follow-up via phone and/or mail questionnaires was 2.7 years (1.5-5.1 years). One patient reported a new diagnosis of hypertension, which is well controlled by a single antihypertensive medication. There were no reported complications of refractory hypertension, altered renal function, new urolithiasis, chronic pain, urine leak, arteriovenous fistula, or pseudoaneurysm. No other procedures were required after the initial embolization for their renal trauma. CONCLUSIONS: Management of grade 5 renal injuries with percutaneous embolization is safe and is not associated with intermediate-term adverse events.

Sacral nerve stimulation for refractory overactive bladder in the elderly population.

PURPOSE: We determined the long-term outcome of sacral nerve stimulation for refractory overactive bladder in the elderly population. MATERIALS AND METHODS: We performed a prospective longitudinal study to better characterize the outcome of sacral nerve stimulation in female patients 70 years old or older with refractory overactive bladder. Demographic and perioperative data were recorded. Patients were followed postoperatively for evidence of successful stage conversion, device durability and efficacy, and postoperative complications. Patients were retrospectively compared to a cohort of female patients younger than 70 years with refractory overactive bladder. Statistical analysis was performed. RESULTS: Between July 2001 and February 2008, 19 elderly female patients with refractory overactive bladder underwent stage 1 lead placement. Of the patients 17 (90%) who reported greater than 50% improvement in symptoms based on a 1-week followup voiding log underwent implantable pulse generator placement. No intraoperative or immediate postoperative complications were noted. At a mean followup of 48.5 months 11 patients (65%) had a functional implantable pulse generator with greater than 50% objective improvement over baseline. Compared to matched patients younger than 70 years elderly patients had a similar conversion rate and adverse events but were significantly more likely to undergo device removal (p = 0.018). CONCLUSIONS: Based on our experience elderly patients have a high conversion rate, few adverse events, and a high level of device efficacy and durability with sacral nerve stimulation. Although more mature multicenter data are needed, it appears that sacral nerve stimulation in geriatric patients is safe and efficacious, and should be judiciously offered to those with refractory voiding symptoms.

Incidence and predictors of complications with sacral neuromodulation.

OBJECTIVES: To determine the incidence and predictors of complications with sacral nerve stimulation (SNS). METHODS: A prospective, longitudinal analysis of all patients treated with SNS was performed to define the incidence of complications and identify the predictors of these adverse events (AEs). All patients underwent staged SNS placement with the InterStim device for treatment of refractory voiding dysfunction. The patients were followed up for evidence of AEs and device efficacy. The patient and device variables were examined statistically for evidence of predictive value. RESULTS: From September 2001 to March 2008, 221 patients with a mean age of 48.8 years underwent SNS lead placement for the treatment of intractable urinary urgency/frequency (n = 121), urge incontinence (n = 63), or urinary retention (n = 37). Of this group, 202 patients (91.4%) experienced a >50% improvement in symptoms and underwent implantable pulse generator placement. At a mean follow-up of 36.9 months, 67 patients (30.3%) had experienced AEs (pain in 6, elective removal in 10, lack of efficacy in 11, trauma in 18, infection in 7, hematoma in 3, and lead migration in 12) requiring 44 lead revisions and 47 implantable pulse generator revisions. The significant predictors of AEs included a history of trauma (P < .001), a change in body mass index class (P < .001), enrollment in a pain clinic (P = .008), the duration of follow-up (P = .002), and a history of AEs (P < .001). CONCLUSIONS: The results of our study have shown that SNS is an effective treatment for patients with intractable voiding dysfunction. Complications are not uncommon but can be minimized with better patient selection.

Percutaneous embolization for the management of grade 5 renal trauma in hemodynamically unstable patients: initial experience.

PURPOSE: We evaluated the efficacy and safety of percutaneous embolization for the treatment of grade 5 renal injuries secondary to blunt trauma in patients who are hemodynamically unstable. MATERIALS AND METHODS: This study was a retrospective analysis of grade 5 blunt renal trauma managed with percutaneous embolization between October 2004 and December 2007. Technical success was defined as complete occlusion of all renovascular bleeding at the end of the procedure. Clinical success was defined as the stabilization of vital signs and absence of need for further surgical or radiological intervention. RESULTS: Nine patients (6 male and 3 female) with grade 5 renal injury secondary to blunt trauma were treated with percutaneous embolization. These patients did not require surgery for other intra-abdominal injuries. Mean patient age was 30 years (median 34, range 5 to 56, SD 15). Mean hospital length of stay was 18 days (median 13, range 5 to 46, SD 14). Mean units of packed red blood cells transfused for each patient was 6 (median 5, range 0 to 17, SD 5) with 2 receiving none. Technical success was achieved in all patients (100%) and all showed complete resolution of active extravasation on angiography. Clinical success was achieved in all patients (100%) with none requiring further intervention. CONCLUSIONS: Percutaneous embolization for the management of grade 5 renal injuries is safe and effective with an excellent success rate in our series. The overall complication rate is minimal. Larger studies with long-term followup are needed to assure durability and efficacy.

Nephron sparing surgery using a bipolar radio frequency resection device.

PURPOSE: We evaluated operative outcomes during nephron sparing surgery using a handheld radio frequency ablation resection device. MATERIALS AND METHODS: Patients with a newly diagnosed renal mass who elected treatment were prospectively enrolled in a comparative trial designed to evaluate the usefulness of the handheld HABIB 4X radio frequency ablation device during open nephron sparing surgery. Preoperative variables were determined and patients subsequently underwent open nephron sparing surgery with (group 1) or without (control group 2) the assistance of the radio frequency ablation device. Data were collected on preoperative and postoperative creatinine and hematocrit, estimated operative blood loss, intraoperative and postoperative complications, and pathological outcomes. RESULTS: A total of 90 patients underwent open nephron sparing surgery with (45) and without (45) the radio frequency ablation device. Mean pathological tumor size was 3.31 and 3.13 cm in groups 1 and 2, respectively (p = 0.49). Mean estimated blood loss was 133.2 and 417.2 cc in groups 1 and 2, respectively (p <0.001). Mean operative time was 83.5 and 97.2 minutes in groups 1 and 2, respectively (p = 0.012). Ten of 45 group 2 patients underwent hilar clamping with hypothermia, while no patients in group 1 underwent hilar clamping. Margins were positive in 1 patient in group 1 (2.2%) and in 2 in group 2 (4.4%). Group 1 complications included postoperative urine leakage in 1 case, which required stent placement. Group 2 complications included 2 cases of urine leakage requiring stent placement, 4 of blood transfusion, 2 of ureteral lacerations, 2 episodes of clot retention and 1 death. CONCLUSIONS: The handheld radio frequency ablation device can yield a significant benefit during open nephron sparing surgery, namely decreased blood loss and operative time.

Short-term efficacy of botulinum toxin a for refractory overactive bladder in the elderly population.

PURPOSE: We determined the efficacy of intravesical botulinum toxin A injection for refractory overactive bladder in elderly patients. MATERIALS AND METHODS: Patients 75 years or older with refractory urinary urgency were prospectively evaluated and offered treatment of symptoms with botulinum toxin A. A voiding log was obtained and urodynamics were performed before treatment. Patients underwent injection of 200 U botulinum toxin A (Botox(R)) into the detrusor muscle at 20 sites under cystoscopic guidance. Patients were followed postoperatively for evidence and duration of success, and treatment related complications. RESULTS: From January 2006 to June 2007, 18 females and 3 males with a mean age of 81.2 years (range 75 to 92) in whom detrusor overactivity was confirmed on urodynamics and who were refractory to or intolerant of antimuscarinics were treated with intravesical botulinum toxin A. Preoperatively the mean +/- SD number of daily voids was 11.4 +/- 1.67 and the mean number of pads per day was 4.0 +/- 0.89. One month after treatment 16 of the 21 patients (76%) reported greater than 50% improvement in symptoms after 1 injection. Specifically there was a significant improvement in the mean number of voids per day (5.19 +/- 0.83, p <0.001) and in the number of pads used daily (1.3 +/- 0.60, p <0.001). Two of the remaining 5 patients demonstrated greater than 50% improvement following repeat injection, while 3 did not show improvement after 2 injections. Mean time to deterioration was 7.12 months. There were no treatment related complications. CONCLUSIONS: Intravesical botulinum toxin A for detrusor overactivity in the elderly population appears to be efficacious and durable. Given its low incidence of adverse events, it should be considered a viable treatment option in this population.

Splenic rupture following shock wave lithotripsy.

We present the case of a 61-year-old female who underwent extracorporeal shock wave lithotripsy (ESWL) treatment of a 12 mm left ureteropelvic junction stone. Following an uneventful and successful treatment, the patient was discharged. The patient re-presented to the emergency room 24 hours later with abdominal pain and hypotension. CT of the abdomen revealed a shattered spleen necessitating emergent removal. The patient recovered without difficulty. Although splenic rupture following shock wave lithotripsy (SWL) has been reported previously, this case represents the only published report of splenic rupture with use of a third generation electromagnetic lithotripter. Our report will highlight the details of the case and comment on the salient literature concerning visceral injury following lithotripsy.

Sacral nerve stimulation for treatment of refractory urinary retention: long-term efficacy and durability.

OBJECTIVES: To examine the long-term efficacy and durability of sacral nerve stimulation (SNS) for the treatment of refractory, nonobstructive urinary retention. METHODS: A retrospective study of all patients who underwent SNS with the InterStim device for refractory, nonobstructive urinary retention was performed. All patients had their history taken, underwent physical examination and urodynamic study, and completed a voiding diary before treatment with staged SNS. Patients with greater than 50% improvement in symptoms underwent implantable program device placement. Patients were followed up for evidence of postoperative complications, device failure, and treatment efficacy. Statistical analyses were performed. RESULTS: From June 1, 2000 to February 1, 2007, 40 patients were treated with SNS for refractory, nonobstructive urinary retention. Of the 40 patients, 29 had complete urinary retention (using clean intermittent catheterization), and 11 demonstrated incomplete retention (elevated postvoid residual urine volume). Of the 40 patients, 28 (70%) demonstrated greater than 50% improvement in symptoms and underwent implantable program device placement. At a mean follow-up of 40.03 +/- 19.61 months, 24 (85.7%) of 28 patients demonstrated sustained improvement of greater than 50%. Of the 28 patients, 4 (14.3%) had their InterStim device removed and 6 (21.4%) required revision. Among those with complete retention, significant improvement occurred in the number of catheterizations/day and the volume/catheterization (P <0.001). Among those with incomplete retention, significant improvement occurred in the postvoid residual urine volume (P <0.001). CONCLUSIONS: At a mean follow-up of 40 months, 85.7% of patients with refractory, nonobstructive urinary retention demonstrated greater than 50% improvement in symptoms with SNS. For 911 patients, a statistically significant improvement in voiding parameters resulted.

Low-dose computed tomography for the evaluation of flank pain in the pregnant population.

BACKGROUND: Evaluation of the pregnant patient with suspected renal colic is complex. Fetal irradiation concerns have traditionally prohibited the use of CT in this population. We report our institution's experience using low-dose CT in the evaluation of pregnant patients with refractory flank pain. PATIENTS AND METHODS: A retrospective review of all patients who underwent low-dose CT evaluation of the urinary tract for suspected urinary tract stones was performed. Data obtained included gestational age, urinalysis and ultrasonography results, CT findings, and calculated fetal radiation exposure. RESULTS: Between April 2004 and December 2006, 20 patients with an average gestational age of 26.5 weeks presented to our institution with acute, refractory flank pain consistent with a diagnosis of urolithiasis. All patients underwent renal ultrasonographic evaluation before unenhanced CT of the abdomen and pelvis using a low-dose protocol. The average radiation exposure was 705.75 mrads (range 210-1372; SD +/- 338.66 mrads). Of the 20 patients, CT demonstrated urinary stones (1-12 mm) in 13. Of those patients with documented stones, 4 were treated conservatively, 2 underwent intrapartum stent placement, 5 had ureteroscopy with stone extraction, and 2 were treated postpartum. CONCLUSION: Low-dose CT is highly sensitive and specific for the detection of urinary calculi in the pregnant population. CT confers a low risk of fetal harm and can improve patient care when used judiciously.

Prospective radiographic followup after en bloc ligation of the renal hilum.

PURPOSE: We determined the risk of arteriovenous fistula after en bloc ligation of the renal hilum. MATERIALS AND METHODS: A prospective evaluation of all patients who underwent en bloc ligation of the renal hilum during nephrectomy for malignant disease was performed. Pertinent operative data were recorded and patients were followed for clinical evidence of arteriovenous fistula formation, including hypertension, abdominal bruit and new onset congestive heart failure. Patients with at least 12 months of followup underwent computerized tomographic arteriography to assess arteriovenous fistula formation. RESULTS: A total of 94 patients underwent en bloc renal hilar ligation during open (43) and laparoscopic (51) nephrectomy using a 45 mm titanium endovascular stapler. Of this cohort 11 patients were lost to followup and 3 died of disease. The remaining 80 patients were followed an average of 35.2 months with no clinical evidence of arteriovenous fistula formation. Specifically there was no statistically significant difference in preoperative and postoperative blood pressure (p = 0.18 and 0.62, respectively), no evidence of abdominal bruit on examination and no new onset congestive heart failure. A total of 32 had increased serum creatinine and, therefore, they were excluded from followup computerized tomographic arteriography. Eight patients had a followup of less than 1 year and they were not yet eligible for evaluation. In the 40 patients who underwent computerized tomographic arteriography no fistulas were noted. CONCLUSIONS: Based on clinical followup and prospective radiographic evaluation there appears to be a low risk of arteriovenous fistula formation after en bloc ligation of the renal hilum using a titanium endovascular stapler.

Validity of Pelvic Pain, Urgency, and Frequency questionnaire in patients with interstitial cystitis/painful bladder syndrome.

OBJECTIVES: To determine the validity of the Pelvic Pain, Urgency, and Frequency (PUF) questionnaire according to its correlation with cystoscopy with hydrodistension (C-HD) findings. METHODS: A prospective study of new patients with a clinical history consistent with interstitial cystitis/painful bladder syndrome (IC/PBS) was undertaken. All patients underwent history and physical examination, urinalysis, and urine culture and completed a PUF questionnaire before undergoing C-HD. The pertinent data collected included the preoperative PUF scores, bladder capacity, and cystoscopic findings consistent with IC/PBS (petechial hemorrhage and/or terminal hematuria). Statistical analysis was performed. RESULTS: From June 1, 2005 to December 31, 2005, 97 patients with a new clinical diagnosis of IC/PBS were prospectively evaluated. All patients completed a PUF questionnaire before C-HD. The average PUF score was 21 (range 8 to 35). The mean bladder capacity was 756 mL (range 250 to 1400). The C-HD was positive in 54 (56%) of 97 patients. Of these 54 patients, 27 had a PUF score of less than 20, 22 had a PUF score of 20 to 29, and 5 patients had a PUF score of greater than 30. When evaluated statistically, no correlation was apparent between the PUF questionnaire scores and the cystoscopic findings of IC/PBS (P <0.05). CONCLUSIONS: As determined by the correlation with the C-HD, the PUF questionnaire appears to be neither a reliable predictor of IC/PBS nor a valuable predictor of disease severity. However, the inherent limitations of C-HD and the lack of a definitive diagnostic instrument for IC/PBS limit any authoritative conclusions. Therefore, the diagnosis of IC/PBS should remain one of exclusion and should depend on a constellation of widely recognized symptoms.

Metastasis of squamous cell carcinoma of the bladder to the heart: case report and review of the literature.

A 79-year-old woman with no previous history of genitourinary disease presented to an outside urologist with gross hematuria and irritative voiding symptoms. Cystoscopy revealed a papillary bladder mass thought initially to represent urothelial carcinoma of the bladder with squamous features. The patient presented to our hospital 6 months later with dyspnea and edema. Computed tomography of the chest revealed a cardiac mass, and endomyocardial biopsy revealed metastatic squamous cell carcinoma. A review of the patient's pathology report confirmed the very rare diagnosis of metastatic squamous cell carcinoma of the bladder to the heart.

Seminal vesicle cyst presenting as rectal obstruction.

We report an unusual case of a pelvic mass arising from the seminal vesicle. A 45-year-old man presented with difficulty voiding and difficult bowel movements. Computed tomography demonstrated a large 14 x 10 x 15-cm cystic pelvic mass displacing the bladder anteriorly and the rectum posteriorly. Magnetic resonance imaging confirmed that this lesion appeared to be originating from the right seminal vesicle. On surgical exploration of the abdomen, a large cystic lesion in the posterior retroperitoneum was identified and removed. The patient improved, with restoration of normal bowel function.

Hand-assisted laparoscopic radical nephrectomy: comparison with transabdominal radical nephrectomy.

The purpose of this study was to investigate whether hand-assisted laparoscopic radical nephrectomy (HALN) has benefits over the traditional transabdominal radical nephrectomy. More specifically we focused on the use of the hand-assisted technique as a definitive oncologic procedure for renal cancers. This study is a retrospective nonrandomized study comparing 12 hand-assisted laparoscopic radical nephrectomies with 12 transabdominal radical nephrectomies. All patients included in the study had the preoperative diagnosis of renal mass. HALN population averaged 1.83 +/- 1.64 (mean +/- standard deviation) major comorbidities versus 1.08 +/- 0.8 open (P = 0.032). The HALN OR time averaged 103 +/- 32.8 versus 57 +/- 18.3 minutes open (P = 0.001). The estimated blood loss mean for HALN was 83 versus 318 cm3 open (P = 0.001). Length of stay for HALN was 4.9 +/- 2.2 versus 5.9 +/- 2.9 days (P = 0.35). Days to regular diet was 2.9 +/- 2.3 in HALN versus 3.5 +/- 2.11 open (P = 0.52). Days of intravenous pain medications were 1.8 +/- 0.72 HALN versus 3.0 +/- 1.28 open (P = 0.016). Postoperative complication rates for the two groups were identical: two of 12 (ileus and post-operative bleeding). Tumor size mean was 6.8 +/- 2.99 cm for HALN versus 4.2 +/- 1.29 cm open (P = 0.012). Tumor margins were negative for 12 of 12 in HALN versus 11 of 12 open. Selection bias (selecting ailing patients to the HALN cohort) diminished the statistical significance of our postoperative recovery data. It is likely that a prospectively randomized study with a larger population may prove the hand-assisted approach equal if not superior to the open technique. The use of HALN in patients with renal tumors is an effective alternative to traditional transabdominal radical nephrectomy.