An unusual, delayed, solitary manifestation of a penile lesion in chronic lymphocytic leukemia.

Chronic lymphocytic leukemia (CLL) is the most common type of leukemia in the adult western population. It is characterized by the proliferation of mature but dysfunctional lymphocytes, primarily CD5+ B cells. It primarily affects the reticuloendothelial system in the majority of the cases, but can rarely manifest as extranodal and extramedullary lesions. One of the rare presentations is genitourinary cutaneous infiltration, and only a handful of cases of secondary metastases to the genitourinary skin, have been reported in the literature. The current report describes a patient with solitary lesion of CLL in the penis, manifesting almost two decades after the complete treatment of CLL.

Impact of parenchymal loss on renal function after laparoscopic partial nephrectomy under warm ischemia.

PURPOSE: To elucidate the impact of renal parenchymal loss and the ischemic reperfusion injury (RI) on the renal function after laparoscopic partial nephrectomy (LPN) under warm ischemia (WI). METHODS: Thirty-five patients with a single polar renal mass ≤4 cm and normal contralateral kidney underwent LPN. Transperitoneal LPN with WI using en bloc hilar occlusion was performed. The total differential renal function (T-DRF) using 99mTc-dimercaptosuccinic acid was evaluated preoperatively and postoperatively over a period of 1 year. A special region of interest (ROI) was selected on the non-tumorous pole of the involved kidney, and was compared with the same ROI in the contralateral kidney. The latter comparison was defined as partial differential renal function (P-DRF). Any postoperative decline in the P-DRF of the operated kidney was attributed to the RI. Subtraction of the P-DRF decline from the T-DRF decline was attributed to the parenchymal loss caused by the resection of the tumor and suturing of the normal parenchyma. RESULTS: The mean WI time was 22 min, and the mean weight of resected specimen was 18 g. The mean postoperative eGFR declined to 87 ml/min/1.73 m2 from its baseline mean value of 97 ml/min/1.73 m2 (p value = 0.075). Mean postoperative T-DRF and P-DRF of the operated kidney declined by 7 and 3 %, respectively. CONCLUSIONS: After LPN of small renal mass, decline in renal function is primarily attributed to parenchymal loss caused by tumor resection and suturing of the normal parenchyma rather than the RI.

Surgical removal of a giant non-functional adrenal mass: A case report.

This case report describes the surgical management of a giant left adrenal mass (27 x 26 × 27 cm, 9.370 kg) in a 69-year-old female. We review the multidisciplinary decision-making process for pre-operative preparation, embolization, resection feasibility, and strategies to mitigate intra-operative complications. This is the largest adrenal adenoma removal reported to date. The case highlights the importance of meticulous surgical planning and execution in managing rare and challenging cases, with significant implications for patient outcomes.

Comparison of behavioral activation/inhibition systems, emotional regulation difficulties, and selective attention in adolescents with and without parents.

Existing literature has established a relationship between adverse childhood experiences and negative outcomes in cognitive and affective functioning. However, further research is needed to thoroughly understand and validate these findings. In this regard, the current study aimed to compare behavioral activation/inhibition systems, emotional regulation difficulties, and selective attention in adolescents with and without parents. A sample of 70 adolescents (M age = 16.36, SD = 1.09, 48.57% female) with caretakers from schools and 55 parentless adolescents (M age = 16.58, SD = 1.28, 52.00% female) from orphanage centers in Tehran were recruited and completed the measures tapping behavioral activation/inhibition systems, emotion dysregulation difficulties, and selective attention. The results revealed that parentless adolescents exhibited significantly higher levels of behavioral activation/inhibition scores, emotion regulation difficulties, and impaired selective attention. These findings suggest that the absence of parents during the early years of life may have detrimental effects on behavioral inhibition and activation systems, emotional regulation abilities, and selective attention capabilities. The implications of these findings are further discussed.

Feasibility and Outcomes of Temporary Bulbar Urethral Stent Placement After Internal Urethrotomy in the Largest Multicenter Series.

BACKGROUND: Recent years have seen the development of a new generation of temporary urethral stents as an adjuvant option after direct vision internal urethrotomy (DVIU). Despite some early promising results, large series addressing their safety and outcomes are still lacking. OBJECTIVE: To report complications and outcomes from the largest series of patients receiving a temporary bulbar urethral stent to date. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective analysis of bulbar urethral stenting procedures after DVIU in seven centers. Patients either refused urethroplasty or were not fit for surgery. The stents were removed after at least 6 mo in place unless complications requiring earlier removal occurred. SURGICAL PROCEDURE: DVIU with a cold knife or laser is performed, followed by stent placement. At the end of the treatment period, the stent is removed under cystoscopy with gripping forceps. MEASUREMENTS: All patients underwent postoperative follow-up (FU) for assessment of complications while the stent was in place. After removal, the FU schedule consisted of office evaluation at 6 mo and 12 mo, and then annually. Failure was defined as any treatment for urethral stricture after stent removal. RESULTS AND LIMITATIONS: A total of 49% of the patients experienced complications. The most frequent were discomfort (23.8%), stress incontinence (17.5%), and stent dislocation (9.8%). Some 85% of the adverse events observed were Clavien-Dindo grade <3. The overall success rate at median FU of 38.2 mo was 76.9%. The success rate was significantly lower if the stent was removed before 6 mo (53.3% vs 79.7%; p = 0.026). CONCLUSIONS: Temporary urethral stents may be a safe choice with satisfactory results in patients not undergoing urethroplasty. A stent indwelling time shorter than 6 mo provides worse outcomes that are comparable to those with DVIU alone. PATIENT SUMMARY: We assessed complications and outcomes after placement of a temporary narrow tube in the urethra after surgery to widen a narrowing of the urethra. The treatment is safe and easily reproducible with satisfactory results. Further studies are needed to confirm our findings.

Percutaneous Nephrolithotripsy in Morbidly Obese Patient: A Case Report.

A 50-year old male patient with morbid obesity was admitted for removal of large staghorn calculi and multiple small stones in the left kidney. The patient was managed by Percutaneous Nephrolithotomy (PCNL). Surgery was carried out in prone position and Alken's metal dilators were used for tract dilation. Alken dilators were inserted without any challenges, and the procedure was completed in a shorter span of time than anticipated with total operative time of 2 hours, including the change of positioning from lithotomy to prone. No intra-operative or post-operative complications were encountered. The patient has been followed up for 6 months post-operatively, without any complications or any evidence of stone recurrence.

Direct comparison of 99mTc-PSMA SPECT/CT and 68Ga-PSMA PET/CT in patients with prostate cancer.

OBJECTIVES: 99mTc-PSMA SPECT/CT is a cost effective alternative for 68Ga-PSMA PET/CT. The aim of this study was to directly compare these two techniques in patients with prostate cancer. METHODS: 28 man with prostate cancer were studied using 99mTc-PSMA SPECT/CT and 68Ga-PSMA PET/CT in a short time period (<60 days). No intervention was done between the studies. Whole body PET/CT was done 60 minutes after IV injection of 2 MBq/Kg of 68Ga-PSMA. 99mTc-PSMA kit (PSMA I+S) was used for SPECT/CT and whole body imaging was performed 4 hours after IV injection of 740 MBq of 99mTc-PSMA. Images were interpreted independently and the results of each imaging were recorded. RESULTS: The mean age of the patients was 64.7±9.6 years old and the mean time difference between two sets of images was 16.6±13.5 days. Abnormal uptake was seen in 25 (89.2%) patients by 68Ga-PSMA PET/CT and 20 (71.4%) patients with 99mTc-PSMA SPECT/CT. No patients with positive 99mTc-PSMA SPECT/CT had negative 68Ga-PSMA PET/CT. The mean number of detected lesions was 26.07±27.5 by 68Ga-PSMA PET/CT and 10.52±10.99 by 99mTc-PSMA SPECT/CT (P<0.001). Detection of lymph nodes and bone metastases were not significantly different between two sets of imaging (P>0.05), however 68Ga-PSMA PET/CT were more successful in detection of prostate bed lesions compared to 99mTc-PSMA scan. Interestingly, no patient with PSA level of >2.1 ng/ml had discordant result between two sets of images. CONCLUSION: 99mTc-PSMA SPECT/CT is as accurate as 68Ga-PSMA PET/CT in M staging, however 68Ga-PSMA PET/CT detected more lesions compared to 99mTc-PSMA SPECT/CT. Detection rate was not significantly different between two techniques in patients with PSA levels>2.1 ng/ml.

A Serrated Hyperplastic Colonic Polyp of the Urinary Bladder.

Intestinal metaplasia of the urinary bladder can occur within the surface urothelium due to chronic irritation in repaired exstrophic urinary bladder. Colonic villous adenomas and tubulovillous adenomas with high-grade dysplasia and associated adenocarcinoma have been reported in adult patients with a history of augmented exstrophic bladder. To our knowledge, we report the first example of a nonadenomatous serrated hyperplastic colonic polyp in an elderly patient with a history of exstrophic bladder.

Association between carcinosarcoma and the transplanted kidney.

BACKGROUND: Renal carcinosarcoma is a rare tumor with 12 reported cases in the world literature. To our knowledge, carcinosarcoma of a renal allograft has not been reported to date. CASE REPORT: A multifocal urothelial carcinosarcoma of a transplanted kidney in a 49-year-old woman is described. Genomic analysis of the extracted nuclei of all the neoplastic cells showed uniformly XY genotype proving the transplant origin of the tumor. RESULTS: The carcinogenic role of immunosuppressive medications in kidney-transplanted patients is reported in the literature. In this case, immunosuppression may have promoted the carcinosarcoma. CONCLUSION: Renal transplant patients should be monitored for the development of malignancy in the allograft and elsewhere.

Laparoscopic repair of circumcaval ureter: one-year follow-up of three patients and literature review.

OBJECTIVES: To describe our experience and 1-year follow-up of 3 patients with circumcaval ureter (CU) treated laparoscopically, with the introduction of a new stenting method and review of the published data. Because of its rarity, more reports are needed to advocate more comprehensive knowledge about the preferred surgical technique for the treatment of CU. METHODS: Since November 2005, 3 patients with symptomatic CU have undergone laparoscopic repair of their anomaly at our institutes. In all 3 cases, the ureter was transected and positioned anteriorly with an end-to-end anastomosis. In 2 cases, the retrocavally located ureteral segment was resected. RESULTS: The mean operative time in our series was 210 minutes, without any intraoperative or early postoperative complications. In 1 patient, a slight ureteral stricture was detected that resolved with reinsertion of a double-J stent. Histopathologic examination of the resected ureteral segments revealed sclerosis and muscular hypertrophy. All patients remained symptom free during the 1 year of follow-up. CONCLUSIONS: With all the advantages of a minimally invasive procedure and preserving therapeutic efficacy, the laparoscopic approach should be considered a standard choice for surgical treatment of CU in symptomatic patients. Care should be taken to diagnose and excise the pathologically narrowed ureteral segment.

Laparoscopic approaches in urology.

The use of laparoscopy was one of the most important steps in the progress of medicine, and has developed through the 20th century. Gynaecologists took the initial lead in introducing this technology, followed by general surgeons. Since the first laparoscopic nephrectomy in 1990, most ablative and reconstructive urological surgery has been attempted laparoscopically. Laparoscopic urological surgical approaches include conventional transperitoneal and extraperitoneal; in this review the different approaches, with the relevant anatomical considerations, are discussed.

Progression delay in men with mild symptoms of bladder outlet obstruction: a comparative study of phytotherapy and watchful waiting.

To determine the effect of phytotherapy (Serona repens) on the clinical progression in men with mild symptoms of bladder outlet obstruction (BOO). A total of 189 patients with mild symptoms of BOO, recruited from four different European clinics, were included in the analysis. Age, prostate specific antigen (PSA), international prostate symptom score (IPSS), quality of life (QOL), maximum urinary flow rate (Qmax) and total prostate and transitional zone volume were recorded. Clinical progression was defined as change from the mild-IPSS group into the moderate or severe group or the occurrence of urinary retention and need of surgery. Cumulative progression rate was 1, 7, 9 and 16% at 6, 12, 18 and 24 month, respectively, for the active group (Serona repens) as compared to 6, 13, 15 and 24% for the watchful waiting group. (P=0.03) significant improvements in the Qmax, IPSS and QOL were seen in the group receiving Serona repens. Serona repens significantly reduced the clinical progression rates in men with mild symptoms of BOO. It also led to improvements in urinary symptoms, QOL scores and urinary flow rates.

Laparoscopic partial nephrectomy in cold ischemia: renal artery perfusion.

PURPOSE: Laparoscopic partial nephrectomy represents a feasible option for patients with small renal masses. We describe our initial experience with laparoscopic partial nephrectomy in cold ischemia achieved by renal artery perfusion. MATERIALS AND METHODS: From November 2001 to March 2003 laparoscopic partial nephrectomy in cold ischemia was performed in 15 patients with renal cell carcinoma. Cold ischemia was achieved by continuous perfusion of Ringers lactate at 4C through the renal artery, which was clamped. Tumor excision was performed in a bloodless field with biopsy taken from the tumor bed. The collecting system was repaired if needed. Renal reconstruction was performed by suturing over hemostatic bolsters. RESULTS: All procedures were successfully completed laparoscopically by our new technique. Mean operative time was 185 minutes (range 135 to 220). Mean ischemia time was 40 minutes (range 27 to 101). Estimated mean intraoperative blood loss was 160 ml (range 30 to 650). Entry to the collecting system in 6 patients was repaired intraoperatively. Additional vascular repair was done in 2 patients. There were no significant postoperative complications. Postoperative followup in 8 patients showed that the renal parenchyma was not damaged by the ischemic period. CONCLUSIONS: Our initial experience of incorporating cold ischemia via arterial perfusion into laparoscopic partial nephrectomy shows the feasibility and safety of the technique. We believe that this approach has the potential to make laparoscopic partial nephrectomy for renal cell carcinoma safe and reliable.

Ligation of the renal vein during laparoscopic nephrectomy: an effective and reliable method to replace vascular staplers.

PURPOSE: Application of the endovascular gastrointestinal anastomosis stapler has become a standard procedure to control renal vein during laparoscopic nephrectomy. However, device malfunction resulting in significant complications has been reported. We present a safe and cost-effective technique for renal vein ligation during laparoscopic nephrectomy. MATERIALS AND METHODS: From October 2002 to April 2003 we applied our new technique of renal vein ligation in 20 cases. After renal pedicle dissection the renal artery was secured with Hem-o-lok (Weck Closure Systems, Research Triangle Park, North Carolina) clips. The renal vein was encircled with a suture, which was knotted extracorporeally and pushed down by a knot pusher to shrivel a vein of any size. Subsequently 10 mm Hem-o-lok clips were applied to the vein to occlude it completely. RESULTS: All procedures were successfully completed. The operative costs of vein ligation were decreased. There was no significant increase in mean operative time. CONCLUSIONS: Our approach is a safe, reliable, rapid and inexpensive method to ligate the renal vein during laparoscopic nephrectomy. Therefore, this technique has replaced endovascular gastrointestinal anastomosis stapler use at our center.

Longitudinal study of men with mild symptoms of bladder outlet obstruction treated with watchful waiting for four years.

OBJECTIVES: To determine the risk of clinical progressions in men with mild lower urinary tract symptoms of bladder outlet obstruction and identify the predictors for progression in this group of men. METHODS: A total of 397 men who presented to the urology clinics with mild symptoms of bladder outlet obstruction (International Prostate Symptom Score less than 8) were analyzed in this longitudinal study conducted during a 4-year period. They began with the watchful waiting protocol and were followed up every 3 months for 48 months. Age, International Prostate Symptom Score (IPSS), divided into obstructive symptom score and irritative symptom score, serum prostate-specific antigen level, total prostate volume, transitional zone volume, urinary flow rates, and postvoid residual urine volume were documented. RESULTS: The cumulative incidence of clinical progression, defined as worsening of the IPSS with migration to the moderate symptom group (IPSS 8 to 18) or severe symptom group (IPSS 19 to 35) and an increase in IPSS of more than 2 points, was 6%, 13%, 15%, 24%, 28%, and 31% at 6, 12, 18, 24, 36, and 48 months, respectively. Nineteen patients (4.9%) developed acute urinary retention within the 48-month follow-up period. Of these 19 patients, only 2 (0.6%) required transurethral resection of the prostate. The variables of importance for disease progression in the artificial neural network analysis were, in order of statistical significance, prostate-specific antigen level, obstructive symptom score, and transitional zone volume. CONCLUSIONS: The risk for men with mild symptoms of bladder outlet obstruction to progress clinically and develop complications such as acute retention of urine is moderate. Prostate-specific antigen, obstructive symptom score, and transitional zone volume were identified as important risk factors.