Extracorporeal shock wave lithotripsy for treatment of large pediatric renal pelvic stone burden more than 2 cm.

BACKGROUND: The high recurrence rates in pediatric urolithiasis indicate the need for none invasive or a minimally invasive treatment such as SWL. Therefore, EAU, ESPU and AUA recommend SWL as a first line treatment for renal calculi ≤ 2, and RIRS or PCNL for renal calculi > 2 cm. SWL is superior to RIRS and PCNL as it is inexpensive, outpatient procedure, and it has a high SFR in well selected cases specially pediatrics. On the other hand, SWL therapy has a limited efficacy with a lower SFR, and high retreatment rate and/or additional interventions for treatment of larger and harder renal calculi. OBJECTIVE: We carried out this study to evaluate the efficacy and safety of SWL for treatment of renal stones > 2 cm to extend its indications for pediatric renal calculi. METHODS: Between January 2016 and April 2022, we reviewed the records of patients with renal calculi treated by SWL, mini-PCNL, RIRS and open surgery in our institution. Forty-nine eligible children aged 1-5 years old, presented with renal pelvic and/or calyceal calculi measuring 2-3.9 cm and underwent SWL therapy were picked up and participated in the study. The data of an additional eligible 79 children with the same age and had renal pelvic and/or calyceal calculi > 2 cm up to stag horn calculi and underwent mini-PCNL, RIRS and open renal surgery were also picked up and participated in the study. We retrieved the following preoperative data from the records of the eligible patients; age, gender, weight, length, radiological findings (stone size, side, site, number and radio-density), renal function tests, routine laboratory findings, and urine analysis. The outcomes data in the form of; operative time, fluoroscopy time, hospital stay, SFRs, retreatment rates and complication rates were also retrieved from the records of patients treated with SWL and other techniques. Also, we collected the SWL characteristics in terms of; position, number and frequency of shocks, voltage, time of the session and U/S monitoring to assess stone fragmentation. All SWL procedures were performed according to the institution's standards. RESULTS: The mean age of patients treated with SWL was 3.23 ± 1.19 years old, the mean size of the treated calculi was 2.31 ± 0.49 and the mean length of the SSD was 8.2 ± 1.4 cm. All patients had NCCT scan and the mean radio-density of the treated calculi was 572 ± 169.08 HUs based on NCCT scans Table (1). Single- and two-session SFRs of SWL therapy were 75.5% (37/49 patients) and 93.9% (46/49 patients), respectively. The overall success rate was 95.9% (47/49 patients) after three-session of SWL. Complications experienced by 7 patients (14.3%) in the form of fever (4.1%), vomiting (4.1%), abdominal pain (4/1%), and hematuria (2%). All complications were managed in outpatient settings. Our results were obtained on the basis of preoperative NCCT scans for all patients and postoperative plain KUB films and real-time abdominal U/S. Furthermore, single-session SFRs for SWL, mini-PCNL, RIRS and open surgery were 75.5%, 82.1%, 73.7% and 90.6%, respectively. Two-session SFRs by the same technique were 93.9%, 92.8%, and 89.5% for SWL, mini-PCNL and RIRS, respectively. A lower overall complication rate and higher overall SFR were found with SWL therapy compared to other techniques, Fig. (1). DISCUSSION: Being a non-invasive outpatient procedure with a low complication rate and good spontaneous passage of stone fragments is the main advantage of SWL. In this study, the overall SFR is 93.9% where 46 out of 49 patients were completely rendered stone free after three session of SWL with overall success rate 95.9%. Badawy et al. reported overall success rates of 83.4% for renal stones with a mean stone size of 12.5 ± 7.2 mm. In children with renal stones measuring 18.2 mm, Ramakrishnan et al. reported a 97% SFR in accordance with our results. The high overall success rate (95.9%) and SFR (93.9%) in our research were attributed to the regular use of ramping procedure, low shock wave rate, percussion diuretics inversion (PDI) approach and alpha blocker therapy in all participants and short SSD. The limitations of our study are small sample of patients and its retrospective nature. CONCLUSION: The non-invasive nature and replicability of the SWL procedure, along with the high success and low complication rates, give us a new insight to consider its application for treating pediatric renal calculi > 2 cm over the other more invasive techniques. Short SSD, the use of ramping procedure, low shock wave rate, 2 min break, PDI approach and alpha blockers therapy help better success of SWL. LEVEL OF EVIDENCE: IV.

Can pyeloplasty restore normal renal function in patients with severe unilateral ureteropelvic junction obstruction and DRF < 35.

PURPOSE: To assess the outcome of successful pyeloplasty in infants with Ureteropelvic Junction Obstruction (UPJO) and a differential renal function of (DRF) < 35% whether they can attain normal postoperative renal function or not. METHODS: All children who were diagnosed with antenatal hydronephrosis due to UPJO were presented to our institutions and were prospectively followed up. Pyeloplasty was performed based on predefined indications such as: initial DRF ≤40%, progression of hydronephrosis, and febrile urinary tract infection (UTI). A total of 173 children, who had successful surgical intervention due to impaired DFR, were divided according to their pre-intervention DRF value as follows: DRF <35% (group I) and DRF 35-40% (group II). The renal morphology and function changes were recorded and used for comparison between both groups. RESULTS: Group I was comprised of 79 patients, and group II included 94 patients. Pyeloplasty achieved significant improvement in the anatomical and functional indices in both groups (p-value <0.001). The degree of improvement in Anteroposterior diameter (APD) and cortical thickness was comparable in both groups (P-value, 0.64 and 0.44 respectively). While the improvement in the DRF was significantly higher in group I (16.06 ± 6.6) than in group II (6.25 ± 2.66) (P-value <0.001). Despite that, a significantly higher percentage of infants in group II (61.7%) achieved normal final DRF compared with only (10.1%) in group I (Figure). CONCLUSION: Even in severely impaired renal function (<35%), successful pyeloplasty can recover a significant part of lost renal function. However, most of these patients do not achieve normal postoperative renal function.

Surgical outcomes and complications of Tube® (Promedon) malleable penile prostheses in diabetic versus non-diabetic patients with erectile dysfunction.

OBJECTIVE: To evaluate surgical outcome, complications, and patients satisfaction with the Tube® (Promedon, Cordoba, Argentina) malleable penile prosthesis in diabetic and non-diabetic patients with refractory erectile dysfunction (ED). PATIENTS AND METHODS: The records of 128 eligible patients who received Tube malleable penile prostheses at our institute between September 2008 and October 2015 were reviewed. RESULTS: Of the 128 patients, who received Tube penile prostheses at our institute, 53 were diabetics and 75 were non-diabetics. Both groups of patients were comparable for mean age, education level, marital status, hospital stay, time to commencing sexual intercourse, and median follow-up. Complications included: inter-corporeal septal perforation (2.3%), glanular urethral injury (1.5%), acute urinary retention (3.9%), superficial wound infection (7%), penile discomfort (9.4%), and penile prostheses infection (5.5%). Moreover, 3.9% developed atrophy of the cavernosal tissue, 5.5% experienced bad cosmesis, 6.3% experienced ejaculatory disorders, and 2.3% developed bladder calculi. In all, 13 prostheses (9.4%) were removed, seven of them due to infection, three on the patients' demand and three due to mechanical failure. The satisfaction rates with the prostheses were 77.3% and 79.4% in the diabetic and non-diabetic patients, respectively; with an overall satisfaction rate of 78.5%. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients. CONCLUSION: Tube malleable penile prostheses are associated with low complication and high satisfaction rates. There was no significant difference in the complication rate or prostheses infection between diabetic and non-diabetic patients. A prospective comparative study with a large number of patients is recommended.

Reduced expression of erythropoietin-producing hepatocyte B6 receptor tyrosine kinase in prostate cancer.

Loss of erythropoietin-producing hepatocyte (Eph) B6 gene expression is associated with poor prognosis in neuroblastoma, melanoma and other tumors. The present study evaluated the expression of EphB6 receptor tyrosine kinase in normal and prostate cancer tissue using immunohistochemistry. The association between EphB6 expression, clinicopathological findings, proliferating-cell nuclear antigen (PCNA; another prognostic marker) and progression of prostate cancer was analyzed. Tissue microarray samples of normal prostatic tissue and prostate cancer tissue from 46 patients treated with radical prostatectomy for prostate cancer were included in this study. Polyclonal anti-EphB6 and monoclonal anti-PCNA antibodies were used to assess EphB6 and PCNA expression by immunohistochemistry. EphB6 was expressed in normal and prostate cancer tissue; however, its expression was significantly reduced in prostate cancer tissue compared with normal prostatic tissue (P<0.0001), in high volume (≥4 cm3) cancer compared with low volume (<4 cm3; P=0.015), and in pT3 stage compared with pT2 stage of the disease (P=0.0007). No correlation was observed between the expression of EphB6 and PCNA. Short biochemical progression-free survival was associated with low EphB6 protein expression (P=0.157). This study revealed that EphB6 may have a tumor suppressor effect in prostate cancer, at least during early stages of this disease. This provides new insight into the potential utility of EphB6 receptor as a diagnostic/prognostic marker for prostate cancer.

Capability of SART3(109-118) peptide to induce cytotoxic T lymphocytes from prostate cancer patients with HLA class I-A11, -A31 and -A33 alleles.

We previously reported the SART3 gene to be a tumor-rejection antigen gene encoding a peptide at positions 109-118 (SART3(109-118)) with the ability to induce HLA-A24-restricted cytotoxic T lymphocytes. In this study, we investigated both humoral and cellular responses to this peptide in cancer patients with alleles other than HLA-A24 to explore the possibility of using this peptide as a cancer vaccine for these patients. IgG reactive to SART3(109-118) peptide was identified in sera of the vast majority of non-cancer subjects (n=50) and all cancer patients (n=50) tested without apparent HLA-A association. Levels of anti-SART3(109-118) peptide antibody in cancer patients were significantly higher than those of non-cancer subjects, but no difference was found between HLA-A24+A2- and HLA-A24-A2+ cancer patients. This peptide induced cancer cell-reactive cytotoxic T lymphocytes from peripheral blood mononuclear cells of both healthy donors and prostate cancer patients with HLA-A11, HLA-A31 and HLA-A33 alleles, but not with HLA-A2. These results suggest that this peptide can be applicable as a cancer vaccine not only for HLA-A24+, but also for HLA-A11+, HLA-A31+ and HLA-A33+ prostate cancer patients.

Dexamethasone did not suppress immune boosting by personalized peptide vaccination for advanced prostate cancer patients.

BACKGROUND: To evaluate the immunological responses of personalized peptide vaccination combined with low-dose glucocorticoids for advanced hormone refractory prostate cancer (HRPC) patients (pts). METHODS: Eleven pts with advanced HRPC were treated with the vaccination and low-dose glucocorticoids; 6 pts with 10 mg/day of prednisolone (PDL) followed by 1 mg/day of dexamethasone at the time of progression, 1 pt with PDL, and 4 pts with dexamethasone. Peptide-specific cellular and humoral responses were employed to monitor pre- and post- (6th) vaccination samples. RESULTS: The vaccination combined with glucocorticoids was well tolerated with no severe adverse effects. Increments of IgG responses were observed in 1 of 4 or 8 of 10 pts tested who received PDL or dexamethasone, respectively, increment of cytotoxic T lymphocyte activity was observed in 2 of 4 or 5 of 7 pts tested, respectively. Vaccination with PDL or dexamethasone resulted in a decline of PSA (at least 50%) in 1 of 7 or 6 of 10 pts with significantly longer median TTP in the dexamethasone group, respectively. CONCLUSION: Vaccination combined with dexamethasone could be recommended for further clinical trials from both immunological and clinical points of view.

A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy.

OBJECTIVE: To evaluate, in a prospective, single-blind, randomized trial, the safety and efficacy of a suspension technique for improving early recovery of continence after radical retropubic prostatectomy (RRP). PATIENTS AND METHODS: We randomly assigned 60 men with clinically localized prostate cancer to RRP; 30 were treated with the suspension technique and the remaining 30 were not. All patients had RRP by the same surgeon followed by early catheter removal on the third day after RRP. The primary outcome measures were the interval to recovery of continence, and the positive margin rates. The continence status was evaluated by a third party using validated questionnaires at baseline before RRP and at 4 and 7 days, and 2 weeks, 1, 3, 6 and 12 months after RRP. RESULTS: The suspension technique resulted in significantly greater continence rates at 1, 3 and 6 months after RRP of 53% vs 20%, 73% vs 47% and 100% vs 83%. Kaplan-Meier curves also showed that patients in the suspension group had a significantly earlier recovery of continence than in the no-suspension group; the median (95% confidence interval) interval for recovery was 31 (12-74) days in the suspension group and 90 (65-150) days in the no-suspension group (log rank test, P = 0.002). The groups had no significant differences in their histological status. CONCLUSIONS: The suspension technique had a significant effect on the earlier recovery of urinary continence within 6 months after RRP, without compromising the oncological outcome of RRP.