Renal tumor biopsy does not increase the risk of surgical complications of minimally invasive partial nephrectomy.

BACKGROUND: For patients with cT1 renal lesions, Partial Nephrectomy (PN) is the gold standard treatment. However, 20% of small renal masses are benign, situation in which the PN is an overtreatment. The percutaneous Renal Tumor Biopsy (RTB) may lower the risk of overtreatment as there is a 90% concordance rate on histotype between the RTB and the final pathology. It has been suggested that the RTB could increase the difficulty of the PN and increase the risk of surgical complications. OBJECTIVE: To compare surgical outcomes and complications of PN with or without previous RTB. DESIGN, SETTING, AND PARTICIPANTS: monocentric retrospective review of patients who underwent laparoscopic or robotic-assisted PN between January 2012 and December 2019. MEASUREMENTS: perioperative complications were recorded using Clavien-Dindo classification, peroperative data included operative time, clamping time and blood loss, and histological outcomes of RTB and PN. RESULTS AND LIMITATIONS: In total, 163 patients were included in our study. There were significantly less benign lesions in PN with prior RTB: 7% (4/56) vs. 20% (22/107) without prior RTB (P=0.03). There were no significant differences regarding Clavien-Dindo>2 perioperative complications with respectively 7% (4/56) vs. 10% (11/107) (P=0.57). Same goes for peroperative data such as duration of surgery (P=0.81), warm ischemia (P=0.07) and blood loss (P=0.13). CONCLUSIONS: RTB does not increase the risk of surgical complications of PN and may reduce the risk of small renal masses overtreatment.

Ultrasensitive Label-Free Detection of Protein-Membrane Interaction Exemplified by Toxin-Liposome Insertion.

Measuring the high-affinity binding of proteins to liposome membranes remains a challenge. Here, we show an ultrasensitive and direct detection of protein binding to liposome membranes using high throughput second harmonic scattering (SHS). Perfringolysin O (PFO), a pore-forming toxin, with a highly membrane selective insertion into cholesterol-rich membranes is used. PFO inserts only into liposomes with a cholesterol concentration >30%. Twenty mole-percent cholesterol results in neither SHS-signal deviation nor pore formation as seen by cryo-electron microscopy of PFO and liposomes. PFO inserts into cholesterol-rich membranes of large unilamellar vesicles in an aqueous solution with Kd = (1.5 ± 0.2) × 10-12 M. Our results demonstrate a promising approach to probe protein-membrane interactions below sub-picomolar concentrations in a label-free and noninvasive manner on 3D systems. More importantly, the volume of protein sample is ultrasmall (<10 µL). These findings enable the detection of low-abundance proteins and their interaction with membranes.

[Rectourethral fistula treatment using the modified York Mason technique: Failure factors assessment]. / Cure de fistule recto-urétrale par la technique modifiée de York Mason : évaluation des facteurs d'échec.

OBJECTIVES: To assess surgical outcomes and failure factors in the management of rectourethral fistulas treated surgically with the modified York Mason technique based on our center's 25 years of experience. METHODS: From 1997 to 2021, in a single center study, a total of 35 consecutive patients, underwent rectourethral fistula cure, using the modified York Mason technique. Preoperative patient data, surgical outcomes and failure factors were assessed. RESULTS: Of the 35 patients, 28 were successfully managed without the need of further intervention (80%). Median age was 67 years (IQR 62-72) and median follow-up time was 71 months (IQR 30-123). There was no significant difference between the patients that had recurrence or not after the first York Mason. CONCLUSIONS: The modified York Mason technique offers a high success rate for the cure of iatrogenic rectourethral fistulas. No predictive factor of failure, after a first cure of recto-uretral fistula by modified York-Mason technique was reported. LEVEL OF EVIDENCE: 3.

Robotic-Assisted Partial Nephrectomy: Techniques to Improve Clinical Outcomes.

PURPOSE OF REVIEW: To summarize current options available for robot-assisted partial nephrectomy RECENT FINDINGS: Partial nephrectomy (PN) is a standard treatment option for management of cT1 renal masses. It may be carried out by multiple approaches. Robot-assisted (RA) PN is one such option. The goal of treatment is both correct oncological (negative surgical margins) and functional (preservation of sufficient amount of renal parenchyma of the operated kidney) outcome. Appropriate outcomes depend on multiple factors. There are many, but among others tumor characteristics (size, location, i.e., tumor complexity), patient baseline renal function, patient comorbidities, and performance status etc. Based on all these, the surgeon adapts the intervention for each mass/patient by preoperative planning, absence/use/duration of warm or cold ischemia, perioperative imaging, resection technique adapted to tumor location and depth of invasion, use of hemostatics, type and degree of renal parenchymal closure and others details. Nephroprotective agents have not shown efficacy so far. It should not be forgotten that surgeon's experience plays a key role in the achievement of good results. Although multiple factors have a role in the RA partial nephrectomy, surgeon experience and adaptation of technique of intervention have the crucial role in the achievement of both functional and oncological results.

Renal Tumor Biopsy: Rationale to Avoid Surgery in Small Renal Masses.

PURPOSE OF REVIEW: The use of renal tumor biopsy (RTB) for small renal masses (SRMs) in daily practice, although safe and accurate, is unusual. Considering the large number of benign tumors in patients with renal masses < 4 cm, some patients with benign tumors are directly referred for surgery instead. This study aimed to report the diagnostic rates of RTB, determine the concordance with surgical pathology, and assess the number of procedures that could have been avoided. We retrospectively studied 255 patients who underwent RTB at our institution in 2010-2019. Of them, 73 were excluded from the analysis (exclusion criteria: > 4 cm, cystic lesion, missing data). The remaining 182 with undetermined SRMs ≤ 4 cm underwent RTB under computed tomography guidance. RECENT FINDINGS: Biopsies were diagnostic in 154/182 (84.6%) cases. Of the non-diagnostic biopsies, 11 were diagnostic when repeated. When RTB was performed of all undetermined SRMs, active treatment (surgery or cryotherapy) was avoided in 50/182 patients (27.5%) because of a benign diagnosis, while 9/182 patients (4.9%) underwent surveillance after a shared multidisciplinary decision. The overall diagnostic rate was 90.6%. All adverse events (approximately 4%) were Clavien-Dindo grade I and did not require active treatment. RTB histology results and nuclear grade were highly concordant with the final pathology (96% and 86.6%, respectively). On univariate logistic regression analysis, male sex was the only contributing factor of diagnostic biopsy. RTB of SRMs should be performed more frequently as part of a multidisciplinary decision-making process since it avoided unnecessary surgical treatment in 1 of 3 patients in our institution.

Partitioning of mesophyll conductance for CO2 into intercellular and cellular components using carbon isotope composition of cuticles from opposite leaf sides.

We suggest a new technique for estimating the relative drawdown of CO2 concentration (c) in the intercellular air space (IAS) across hypostomatous leaves (expressed as the ratio cd/cb, where the indexes d and b denote the adaxial and abaxial edges, respectively, of IAS), based on the carbon isotope composition (δ13C) of leaf cuticular membranes (CMs), cuticular waxes (WXs) or epicuticular waxes (EWXs) isolated from opposite leaf sides. The relative drawdown in the intracellular liquid phase (i.e., the ratio cc/cbd, where cc and cbd stand for mean CO2 concentrations in chloroplasts and in the IAS), the fraction of intercellular resistance in the total mesophyll resistance (rIAS/rm), leaf thickness, and leaf mass per area (LMA) were also assessed. We show in a conceptual model that the upper (adaxial) side of a hypostomatous leaf should be enriched in 13C compared to the lower (abaxial) side. CM, WX, and/or EWX isolated from 40 hypostomatous C3 species were 13C depleted relative to bulk leaf tissue by 2.01-2.85‰. The difference in δ13C between the abaxial and adaxial leaf sides (δ13CAB - 13CAD, Δb-d), ranged from - 2.22 to + 0.71‰ (- 0.09 ± 0.54‰, mean ± SD) in CM and from - 7.95 to 0.89‰ (- 1.17 ± 1.40‰) in WX. In contrast, two tested amphistomatous species showed no significant Δb-d difference in WX. Δb-d correlated negatively with LMA and leaf thickness of hypostomatous leaves, which indicates that the mesophyll air space imposes a non-negligible resistance to CO2 diffusion. δ13C of EWX and 30-C aldehyde in WX reveal a stronger CO2 drawdown than bulk WX or CM. Mean values of cd/cb and cc/cbd were 0.90 ± 0.12 and 0.66 ± 0.11, respectively, across 14 investigated species in which wax was isolated and analyzed. The diffusion resistance of IAS contributed 20 ± 14% to total mesophyll resistance and reflects species-specific and environmentally-induced differences in leaf functional anatomy.

Prostate-sparing radical cystectomy for selected patients with bladder cancer.

OBJECTIVES: To review the current literature about prostate-sparing radical cystectomy (PSRC) and its potential for management of a selected population of patients with bladder cancer. MATERIALS AND METHODS: The PubMed, EMBASE and Scopus databases were searched for the key words 'prostate', 'sparing' and 'cystectomy' between 1984 and 2012. Articles in English, French and German were considered relevant for review. Institutional experience with this procedure was also included. RESULTS: PSRC remains a controversial procedure for the treatment of patients harboring bladder carcinoma, mainly due to insufficient knowledge of clear indications and/or contraindications. Experience with PSRC is still limited to very few referral centers and there is a lack of large series with long-term outcomes. The potential for excellent functional outcomes must be carefully balanced against inconsistent oncological results. CONCLUSIONS: PSRC may become an option for carefully selected and extensively informed patients. Suggestions for possible indications and contraindications are presented.

The sensing of membrane microdomains based on pore-forming toxins.

Membrane rafts are transient and unstable membrane microdomains that are enriched in sphingolipids, cholesterol, and specific proteins. They are involved in intracellular trafficking, signal transduction, pathogen entry, and attachment of various ligands. Increasing experimental evidence on the crucial biological roles of membrane rafts under normal and pathological conditions require new techniques for their structural and functional characterization. In particular, fluorescence-labeled cytolytic proteins that interact specifically with molecules enriched in rafts are of increasing interest. Cholera toxin subunit B interacts specifically with raft-residing ganglioside G(M1), and it has long been the lipid probe of choice for membrane rafts. Recently, four new pore-forming toxins have been proposed as selective raft markers: (i) equinatoxin II, a cytolysin from the sea anemone Actinia equina, which specifically recognizes free and membrane-embedded sphingomyelin; (ii) a truncated non-toxic mutant of a cytolytic protein, lysenin, from the earthworm Eisenia foetida, which specifically recognizes sphingomyelin-enriched membrane domains; (iii) a non-toxic derivative of the cholesterol-dependent cytolysin perfringolysin O, from the bacterium Clostridium perfringens, which selectively binds to membrane domains enriched in cholesterol; and (iv) ostreolysin, from the mushroom Pleurotus ostreatus, which does not bind to a single raft-enriched lipid component, but requires a specific combination of two of the most important raft-residing lipids: sphingomyelin and cholesterol. Nontoxic, raft-binding derivatives of cytolytic proteins have already been successfully used to explore both the structure and function of membrane rafts, and of raft-associated molecules. Here, we review these four new derivatives of pore-forming toxins as new putative markers of these membrane microdomains.

Mycobacterium marinum epididymoorchitis: case report and literature review.

Mycobacterium marinum is the most frequent non-tuberculous Mycobacterium in humans. We report the first ever described case of epididymoorchitis resulting from hematogenous spread of M. marinum from hand oligoarthritis. This was initially mistaken for rheumatoid disease and methylprednisolone-induced immunosuppression led to hematogenous spread of infection to the testis and epididymis.

[Laparoscopic pyeloplasty in adults--mid-term results in 32 laparoscopic pyeloplasties during 2003-2008]. / Laparoskopická pyeloplastika u dospelých--strednedobé výsledky 32 laparoskopických pyeloplastik 2003-2008.

Pyeloureteric iunction obstruction is the most common inborn error of the upper urinary pathways. In the time of routine prenatal ultrasound examination, this disease is discovered in the child's age, when it is treated most frequently. Publication summarizes the results of modern laparoscopic management in the adults, who had not been diagnosed previously and symptoms occurred many years after their birthdate. The surgical treatment has been changed in the approach, but not the goal of desobtruction. The results in the adults are influenced not only by the operation technique, but also by the length of time the obstruction lasted and by the number and severity of the inflammatory changes.

[Outcomes of transperitoneal laparoscopic nephrectomy for renal adenocarcinoma]. / Výsledky transperitoneání laparoskopické nefrektomie pro renální adenokarcinom.

Laparoscopic radical nephrectomy (LRN) is method of choice in malignant renal tumors (RCC) stage T1-3. Procedure has proved to be technically safe with low post-operative morbidity and standard oncological results, provided the patients are secondaries free in the time of surgery, and there was no positive margin in resected tissue. There was no recurrence even after 6 years of follow-up. The most influential variables regarding the survival of patients postoperatively were: presence of metastases in the time of surgery p <0.0001, pathological grade p < 0.001, stage p < 0.018 and p < 0.046, respectively, if the tumors were 4 cm and bigger. It could be concluded, that laparoscopic way of removing the tumor with the kidney has proved the same oncological results even in the mid-term follow-up, if compared with classical open surgery done lege artis.

[Progress of laparoscopic surgery in adults at the Department of Urology of the First Faculty of Medicine and General Teaching Hospital]. / Rozvoj laparoskopické operativy dospelých na Urologické klinice 1. LF UK a VFN v Praze.

Laparoscopy is the most modern operative technique, the main advantage of which is the least invasivity. In urology, the laparoscopy has won its yield only in nineties of 20th century, but it was in urology, where the robots were launched as first, and nowadays using them it is possible to perform ablative/reconstructive surgery in a tiny intracorporeal space. The price of laparoscopic operations is high and has been the only limit up to now, but technical approaches and indications have already been fixed.

[Analysis of results of percutaneous nephrolithotomies]. / Analýza výsledku perkutánních extrakcí konkrementu.

BACKGROUND: Percutaneous nephrolithotomy is an effective less invasive method for the treatment of nephrolithiasis. Authors retrospectively analysed results of this procedure performed in a single centre (Department of Urology, General University Hospital, Prague) from January 2005 till June 2007. METHODS AND RESULTS: Patients were acquired by an analysis of operating reports performed over a period January 2005 till June 2007 and subsequently a retrospective analysis of electronic and paper patient's records was carried out. Percutaneous nephrolithotomy was performed in 150 patients. Of those, 117 (78%) patients underwent primary and 33 (21.3%) secondary procedure. Analysed group consisted of 85 (56.7%) men and 65 (43.3%) women. Right-sided procedure was performed in 46% (69 times) and left-sided in 54% (81 times) of cases. Mean patient's age was 52.9 years (SD +/- 16.3). Mean stone size was 18.3 (SD +/- 9.5) mm. Staghorn calculi were present in 19 (12.7%) patients and 77 (51.3%) patients had more than 1 stone. Intracorporeal lithotripsy was necessary in 82 (54.7%) cases. Seventy eight (52.9%) patients were stone free after the procedure. There were 24 (16%) patients with an anatomic abnormality of upper urinary tract. The most common (in 64.3%) component in analysed stones was a calcium oxalate. CONCLUSIONS: The amount of stone free patients is rather lower compared to the literature results. However, definitive results are always affected by auxiliary procedures (mainly extracorporeal shock wave lithotripsy), which are not included in the analysis.

[Chlamydia infections in urogenital tract--application of direct immunofluorescence in the diagnostics of Chlamydia trachomatis in the East Bohemian Region of Czech Republic during 1997-2003]. / Chlamydiové infekce urogenitáln'iho systému-- vyuzití prímé imunofluorescence v diagnostice Chlamydia trachomatis ve východoceském regionu Ceské republiky v letech 1997-2003.

OBJECTIVE: The aim of the study was an evaluation of results of Chlamydia trachomatis antigen detection by means of direct immunofluorescence in samples from patients suspected from this infection. DESIGN: Retrospective study. SETTING: Institute of clinical microbiology, University Hospital and Medical Faculty of Charles University, Hradec Králové. METHODS: Samples from females were swabs from uterine cervix, vagina and urethra, from male urethral swabs; moreover conjunctival swabs, bronchoalveolar irrigation, lower respiratory tract aspirates and sputum. Samples were fixed and "dyed" with monoclonal specific antibody labeled by fluorescent dye in the lab with a commercial diagnostic kit and they were evaluated microscopically after adding a drop of glycerol and covering with a top slide. RESULTS: Within a group of 6126 samples from patients suspected from Chlamydia infection we have found positivity in 14.4%. Of this subgroup 14.1% in samples from genitourinary tract of females and 15.2% in males, 14.1% from conjunctival swabs and 3.7% from lower respiratory tract. According to an age differentiation, positive samples in individual life-decades from genitourinary tract were 0-13-14.4-13.9-13.9 and in females over 60 13.9%. In males the corresponding walues were 0-21.4-15.1-16-13.4 and those over 60 years 16%. So, the highest positivity in our region has been detected in samples from young men aged 20-30, where it is nearly two-fold higher comparison to age-matched females. CONCLUSION: Direct detection of Chlamydia trachomatis antigen with immunofluorescence method still remains a reliable diagnostic tool. But for a control or confirmation of disputable results it is inconditionally necessary to have at least one more method available, e.g. PCR.

Cytotoxic activity of a tumor protease-activated pore-forming toxin.

Equinatoxin II is a pore forming toxin produced by the sea anemone Actinia equina. It is able to kill very unspecifically most cell types by the membrane-perturbing action of an amphiphilic alpha-helix located at its N-terminal. A normally active N-terminal mutant, containing one single cys in the amphiphilic alpha-helix, becomes totally inactive when it is bound to avidin via a biotinylated linker. By choosing, as a linker, a peptide containing a tumor protease cleavage site, we were able to construct an enzymatically activable conjugate which should be selective for tumor cells. The introduced cleavage site was designed in order to be digested by both cathepsin B and matrix metalloproteases (MMPs). We confirmed that this conjugate could be activated in vitro by cathepsin B and MMPs. After having measured the enzymatic activity of fibrosarcoma and breast carcinoma cells, we analyzed the cytotoxic effect of the conjugate on the same lines and on human red blood cells (HRBC) as controls. We found that the conjugate was activated, at least in part, by the tumor cell lines used, whereas it was inactive on HRBC. That the activation process was dependent on the enzymatic action of cathepsin B and MMPs, was indicated by three lines of evidence: (1) binding occurred normally on all type of cells including HRBC which however were insensitive being devoid of enzymes; (2) the cytotoxic effect correlated with the amount of cathepsin B activity expressed by the cells; (3) conjugate activation was reduced by specific inhibitors of cathepsin B and MMPs. These results demonstrate the possibility of tumor cell killing by a pore-forming toxin conjugate specifically activated by tumor proteases.

[Asynchronous occurrence of three neoplastic diseases: chronic B-cell lymphatic leukemia, renal carcinoma and prostatic adenocarcinoma]. / Asynchronní triplicitní výskyt nádorového onemocnení: chronické B lymfatické leukemie, karcinomu ledviny a adenokarcinomu prostaty.

Authors present a case of three asynchronous malignancies in man working life-long in chemical industry. Course of diseases and their treatment are described: B chronic lymphatic leukaemia (B-CLL) (age of 55), conventional clear cell renal carcinoma (CRCC) (age of 61) and adenocarcinoma of prostate (CaP) (age of 72). B-CLL treatment was chlorambucil for 2 years and follow-up subsequently. CRCC treatment was radical transperitoneal nephrectomy. Due to locally advanced CaP bilateral orchiectomy and radical external beam radiotherapy were performed. Patients is alive 30 months without any signs of any malignity. Incidence of multiple malignancies and particularly triplicities are discussed in this article. Authors point out pertinence of radical therapeutic approach also in multiple malignancies and oncological screening not only in patients with heamatological malignancy, but considering it in all tumours.

[Fournier's gangrene]. / Fournierova gangréna.

The authors present their own experiences with diagnostics and treatment of men with necrotising fasciitis of the scrotum (Fournier's gangrene). During 1995-2001 8 men were treated for the above diagnosis at the Clinic of Urology, Faculty Hospital in Hradec Králové. Six cases were patients with diabetes type II, in one patient we found during basic examinations a large tumour of the sigmoid and one patient was 7 days after total scrotal orchiectomy (because of prostatic adenocarcinoma). Repeated open revision under general anaesthesia was performed in all men with necessary necrectomy, testicles were intact (except a patient after orchiectomy). The infection was spread into the hypogastric area in two patients and in one patient spontaneous rupture of bulbar urethra occurred. By a combination of antibiotic therapy and repeated necrectomies, open wound healing and wet compresses we achieved cure of infection and granulations, which made final scrotal plastic surgery possible. From microbiological point of view it was mixed aerobic and anaerobic flora.

[Aspergillosis--a rare complicating disease in patients after renal transplantation]. / Aspergilóza--vzácné komplikující onemocnení u nemocných po renální transplantaci.

The authors submit a detailed analysis of the death of a 42-year-old man after a second renal transplantation. The patient died with symptoms of cardiac failure in a septic condition of obscure etiology where even detailed examination did not provide a timely answer as regards the lethal pathogen. Aspergillus fumigatus is a rare lethal pathogen. Despite this it is, as all opportune infections, for patients with immunosuppressive therapy a serious life threatening infection [1, 2]. In a group of 650 transplantations performed since 1961 in Hradec Králové it is the first death caused by generalized Aspergillus infection.

[Comparison of 2 methods of diagnosis of changes in transplanted kidneys in the early postoperative period: biopsy vs dynamic scintigraphy of the graft]. / Srovnání dvou metod v diagnostice zmen transplantované ledviny v casném pooperacním období: biopsie versus dynamická scintigrafie stepu.

Renal transplantation is at present a standard therapeutic method in chronic renal insufficiency. For a favourable development of the graft some investigated criteria are of basic importance: basic diagnosis which led to renal failure, period of dialyzation treatment, high standard collection and perfusion and early diagnosis of the rejection episode. Non-invasive diagnostic methods of the rejection episode are always indirect and correlate with histologically confirmed rejection, depending on the period of transplantation in 10-90% patients. Indirect diagnosis is based in particular on a rise of the creatinemia, decline of glomerular filtration, fluid retention variations of blood pressure and increase of the Doppler assessed index of resistance (IR) in the peripheral veins of the graft [1]. For many years the role of nuclear diagnostics are tested. The disadvantage of direct diagnosis--biopsy--is increased haemorrhage and loss of the graft [1, 2, 3, 4]. The greatest problem is the differentiation of acute (cellular) rejection as compared with acute tubular necrosis during the initial days after transplantation. The authors describe their experience with 81 biopsies in the course of 3 years in patients during the first 10 days after transplantation, comparison with dynamic scintigraphy of the graft. Their attention is focused on the technique and risks of renal biopsy.