Prognostic factors of treatment among patients with multidrug-resistant tuberculosis in Egypt.

BACKGROUND/PURPOSE: Multidrug-resistant tuberculosis (MDR-TB) represents 5% of TB cases globally. In Egypt, it represents 11.4% of TB cases (2.2% of new and 38.2% of previously treated). Our objectives were to evaluate the treatment outcomes and determine the associated prognostic factors among the first national treatment cohort of MDR-TB from 2006 to 2010. METHODS: All patients diagnosed with MDR-TB from July 2006 to December 2010 who were admitted to Abbassia Chest Hospital, the first Egyptian national center established for MDR-TB treatment, were included. They were followed up clinically, radiologically, and bacteriologically by sputum smear, culture, and drug-susceptibility testing at regular intervals. Individualized treatment regimens were prescribed according to each patient's drug-susceptibility testing and the drug treatment history. Patients received at least five effective drugs. Outcome rates, and crude and adjusted odds ratios of unsuccessful outcomes were calculated. RESULTS: The number of bacteriologically proven MDR-TB patients was 228, of which 225 were pulmonary cases. Half of the cases showed moderate or extensive lung lesions, and 15.8% were diabetics. A total of 158 (119 cured and 39 completed treatment) patients achieved successful outcome (69.3%), 16 (7.1%) failed treatment, 27 (11.8%) were lost to follow up, and 27 (11.8%) died. Predictors of unsuccessful outcome were delay in sputum culture conversion to 2 months or more, moderate or extensive lung lesions, and a history of diabetes. CONCLUSION: A treatment success rate of approximately 69% was achieved with the first national treatment cohort of MDR-TB under the Egyptian program. Predictors of unsuccessful treatment were delayed culture conversion, moderate or extensive lung affection, and diabetes.

Trimodal therapy versus radical cystectomy for cT2N0M0 urothelial muscle-invasive bladder cancer: Single-center experience.

Background: Bladder cancer is ranked the ninth most common cancer in the world. Locally, the incidence of bladder cancer has increased tenfold over the past 26 years. Radical cystectomy (RC) is considered a gold standard management option for muscle-invasive bladder cancer (MIBC), but trimodal therapy (TMT) has shown comparable oncological outcomes in selected patients. Materials and Methods: This is a retrospective study in which we reviewed medical records of patients diagnosed with MIBC without nodal disease or distant metastasis (cT2N0M0) who underwent either RC or TMT. Demographic data, comorbidities, histopathological and clinical staging, neoadjuvant/adjuvant therapy, and follow-up were analyzed. Results: We included a total of 31 patients in the study, with 10 patients in the TMT group and 21 patients in the RC group. There was no significant difference in recurrence between the TMT and RC groups (P = 0.58). The TMT group had a higher percentage of local recurrence (40% vs. RC 5.2%, P = 0.018) but no significant difference in metastasis (0% vs. 10%, P = 0.420). The difference in overall survival between the TMT and RC groups was not significant (P = 0.25). Conclusion: TMT may be considered an alternative option for patients unwilling to undergo RC due to related complications and prioritize a better quality of life. However, the decision should be made after considering the cost of extensive follow-ups and patient compliance with surveillance.

Prostate-specific Antigen Density as a Proxy for Predicting Prostate Cancer Severity: Is There Any Difference between Systematic and Targeted Biopsy?

Background: Prostate cancer screening with prostate-specific antigen (PSA) can result in unnecessary biopsies and overdiagnosis. Alternately, PSA density (PSAD) calculation may help support biopsy decisions; however, evidence of its usefulness is not concrete. Objective: To evaluate the predictive value of PSAD for clinically significant prostate cancer detection by systematic and MRI-targeted biopsies. Methods: This prospective study was conducted at two tertiary hospitals in Riyadh, Saudi Arabia, between December 2018 and November 2021. Patients suspected of prostate cancer were subjected to multi-parametric MRI, and for those with positive findings, systematic and targeted biopsies were performed. Clinically non-significant and significant prostate cancer cases were classified based on histopathology-defined ISUP grade or Gleason score. The PSAD was measured using the prostate volume determined by the MRI and categorized into ≤0.15, 0.16-0.20, and >0.20 ng/ml2 subgroups. Results: Systematic and targeted biopsies were carried out for 284 patients. The discriminant ability of PSAD is higher in MRI-targeted biopsy compared with systematic biopsy (AUC: 0.77 vs. 0.73). The highest sensitivity (97%) and specificity (87%) were detected at 0.07 ng/ml2 in targeted biopsy. More than half of the clinically significant cases were detected in the >0.2 ng/ml2 PSAD category (systematic: 52.4%; targeted: 51.1%). The CHAID methodology found that the probability of having clinically significant cancer (CSC) in patients with PSAD >0.15 ng/ml2 was more than threefold than that in patients with PSAD ≤0.15 ng/ml2 (64% vs. 20.2%). When considered by age, in PSAD ≤0.15 ng/ml2 subgroup, the percentage of CSC detection rate increased from 20.2% to 24.6% in patients aged ≥60 years. Conclusion: PSAD has good discriminant power for predicting clinically significant prostate cancer. A cutoff of 0.07 ng/ml2 should be adopted, but should be interpreted with caution and by considering other parameters such as age.

Transperineal versus transrectal multi-parametric magnetic resonance imaging fusion targeted prostate biopsy.

OBJECTIVES: To compare transperineal biopsies (TPBx) with transrectal ultrasound-guided biopsy (TRUSBx) in order to provide evidence, making clinicians able to select the appropriate biopsy approach under different conditions. METHODS: A comparative prospective study, conducted in King Khalid University Hospital (KKUH) and King Faisal Specialist Hospital and Research Centre (KFSH&RC), Riyadh, Kingdom of Saudi Arabia, between March 2019 and February 2020. All patients with raised prostate-specific antigen or atypical digital rectal examination findings were subjected to multi-parametric magnetic resonance imaging (MRI). Those with positive findings were referred to targeted fusion- guided biopsy either TPBx or TRUSBx, randomly. Complication rate, cancer detection rate, and procedure time were recorded. RESULTS: Transperineal biopsies and TRUSBx had an equivalent complication rate. However, both case detection rate and clinically significant cancer detection rate were significantly higher in TPBx versus TRUSBx (45.1% versus 29.1%, p=0.003; and 71.8% versus 43.7%, p=0.002; respectively). Transperineal biopsies was a longer procedure than TRUSBx (41.2±0.7 min versus 13±2.3 min, p=0.0001). CONCLUSION: No difference in complication rate was detected between the 2 procedures; however, TPBx was more effective for cancer detection in general and clinically significant cancer detection in particular.

The grasper-integrated disposable flexible cystoscope is comparable to the reusable, flexible cystoscope for the detection of bladder cancer.

Flexible cystoscopy under local anaesthesia is standard for the surveillance of bladder cancer. Frequently, several reusable cystoscopes fail to reprocess. With the new grasper incorporated single-use cystoscope for retrieval of ureteric stents, we explored the feasibility of using it off-label for diagnosis and the detection of bladder cancer. Consecutive diagnostic flexible cystoscopies between Mar 2016 and Nov 2018 were reviewed comparing the reusable versus the disposable cystoscopes. A total of 390 patients underwent 1211 cystoscopies. Median age was 61.5 years (SD 14.2, 18.8-91.4), males 331 (84.9%) and females 59 (15.1%). Indication for cystoscopy was prior malignancy in 1183 procedures (97.7%), haematuria 19 (1.6%) or bladder mass 7 (0.6%). There were 608 reusable and 603 disposable cystoscopies. There was no significant difference between groups at baseline in age, sex, BMI, smoking status, or prior tumor risk category. There was no significant difference in positive findings (123/608, 20.2% vs 111/603, 18.4%, p = 0.425) or cancer detection rates (95/608, 15.6% vs 88/603, 14.4%, p 0.574) among the two groups, respectively. We conclude that the disposable grasper integrated cystoscope is comparable to reusable cystoscope in the detection of bladder cancer.

Arabic validation of the short form of Urogenital Distress Inventory (UDI-6) questionnaire.

AIMS: To translate and validate the Arabic version of the short form of Urogenital Distress Inventory (UDI-6) questionnaire in a sample of women with lower urinary tract symptoms (LUTS). METHODS: Two native Saudis independently translated the original UDI-6 into Arabic. These two translations were harmonized, and then checked by independent back translation by two English teachers. They collaborated with the clinical investigators to reach a consensus version of the questionnaire. The harmonized version was pre-tested in a pilot study on 20 patients. The final version of the UDI-6 was applied to 68 consecutive patients aged 22 years or over complaining of LUTS for at least 3 months at our tertiary care hospital. The patients were rerated after 1 week to assess test-retest reliability. To assess the capacity of the questionnaire to discriminate between women with and without LUTS, cases, and controls of healthy women sample were involved and assessed. The psychometric properties of the questionnaire, such as reliability and validity were assessed. RESULTS: The correlation co-efficient between ratings was >0.75 and the discriminate power between cases and control were confirmed. The UDI showed good internal consistency total score cronbach alpha = 0.71. CONCLUSIONS: The Arabic version of UDI-6 is a valid and robust instrument and a reliable method to use in daily practice and clinical research.

Screening for diabetes among tuberculosis patients: a nationwide population-based study in Egypt.

BACKGROUND: The prevalence of type 2 diabetes mellitus (DM) is increasing rapidly in Egypt and considered one of the major health problems in the Eastern Mediterranean region. OBJECTIVES: To measure the prevalence of diabetes and detect the undiagnosed cases of diabetes mellitus among patient with tuberculosis. METHODS: Study Design: Nationwide population-based study. To diagnose DM among TB patients, we used a fasting blood sugar level of ≥ 126 mg/dl and a post-prandial blood glucose test result of ≥ 200 mg/dl. RESULTS: Screening for DM among 1435 TB patients' with no history of DM detected 30 new cases of DM, with a case detection rate of 2.09%. The highest screening yields were among TB patients aged ≥ 40 years, females and those with pulmonary TB. The number needed to screen (NNS) TB patients for detecting one new case of DM was 48 while the lowest values were for older age (NNS=27) and females (NNS=29). CONCLUSION: Older age and being females and those with pulmonary type of TB were more prone to the double burden of TB and DM. Identifying cases with double burden of diseases will improve the proper management of both diseases and prevent complications.

Is survival after radical cystectomy for bladder cancer in Saudi patients different from that of Western patients?

BACKGROUND: Although radical cystectomy (RC) is considered the gold standard treatment of muscle invasive bladder cancer, nearly half of patients develop metastases and ultimately die within 2 years. OBJECTIVE: To assess survival, evaluate different prognostic factors that may affect disease-free survival (DFS) in Saudi patients after RC for carcinoma of the bladder and to compare our results with those of Western countries. DESIGN: Retrospective chart review. SETTING: A tertiary care center in Saudi Arabia. PATIENTS AND METHODS: We collected data on patients who underwent RC for bladder cancer in the period between 1979 and 2014. Demographic, clinical and pathological variables and the application of perioperative chemotherapy were reviewed. Univariate and multivariate analyses were done with DFS as the end point. MAIN OUTCOME MEASURE: Disease-specific survival. RESULTS: On 328 patients for whom data was available, the median follow up was 23 months (range, 2 month-28 years) and median age was 58 years (range, 21-90). Of these patients, 268 were males (81.7%), 235 (71.7%) had urothelial carcinoma (UC), 79 (24.1%) had squamous cell carcinoma (SCC), and 208 (63.4%) had pathological tumor stage 3 or more. The 5-year overall survival (OS) and DFS were 52% and 48%, respectively. There was no statistically significant difference in DFS of patients with UC and pure SCC. On univariate analysis, lymph node status and pathological tumor stage were significant predictors of DFS. Both variables sustained statistical significance in a multivariate analysis. CONCLUSION: Survival following RC is almost the same as others. Moreover, pathological tumor stage and lymph node metastasis were the only independent predictors for survival following RC. Future cooperative prospective studies are required to gain data on our region. LIMITATIONS: Relatively small sample size and retrospective.

Proliferating cell nuclear antigen (PCNA) overexpression and microvessel density predict survival in the urinary bladder carcinoma.

OBJECTIVE: To study proliferating cell nuclear antigen (PCNA) over expression and angiogenesis with their relationship to tumor parameters in squamous cell carcinoma of the urinary bladder in patients who underwent radical cystectomy. PATIENTS AND METHODS: The mean age of the patients was 53.53 years (range; 29-70 years) and the males were 98 of 154. Sections from paraffin embedded tissues were retrieved and stained with antibodies against PCNA for proliferation and CD34 for angiogenesis using immunohistochemical technique. Fisher's exact test was used to evaluate the relationship between categorical variables and the Kaplan-Meier procedure was used to assess survival outcomes. The Cox regression model was used for multivariate analysis. RESULTS: The median follow up period was 65 months. microvessel density (MVD), PCNA, tumor grade, P-stage, DNA ploidy, lymph node status had a significant impact on the 5-year survival of patients in univariate analysis. In Cox proportional hazard model, MVD, PCNA, DNA ploidy and stage sustained their significant impact on survival of the patients. CONCLUSIONS: MVD, PCNA, DNA ploidy and stage are independent prognostic factors in patients with squamous cell carcinoma of the urinary bladder.

Qualitative interviews with non-national tuberculosis patients in Cairo, Egypt: understanding the financial and social cost of treatment adherence.

Limited data are available about the challenges of non-national TB patients undergoing long-term treatment courses in an urban setting. This study aimed to understand the financial and social cost of adherence of non-national TB patients in Cairo, Egypt as a means to inform the development of context-specific interventions to support treatment adherence. In 2011, 22 in-depth interviews were conducted with TB patients from Sudan, Ethiopia, Eritrea, Somalia and Djibouti to obtain qualitative data. Analysis was based on thematic analysis that aimed to identify recurrent themes and codes from the narratives. The study identified a number of factors that influence TB treatment adherence. Uncertain financial status due to limited or no employment was frequently discussed in interviews, which resulted in fear of not being able to support family, loss of pride, dependence on family and friends, fear of losing housing, food insecurity and limited food options. Respondents also feared infecting other household members and longed for opportunities to discuss their illness and treatment experiences with other individuals but their social networks were often limited. TB-related stigma was driven by shame and blame of infection. Respondents also believed stigma was based on their foreign origin. Stigma manifested in distancing and exclusion in various ways, resulting in isolation, psychological distress and reluctance to disclose TB status to others. Poverty-related factors and social context with a special focus on stigma should be considered when developing strategies for supporting long-term treatment courses for non-national patients in Cairo and other similar urban settings.

First insight into the genetic population structure of Mycobacterium tuberculosis isolated from pulmonary tuberculosis patients in Egypt.

The present study aimed to assess the population structure of Mycobacterium tuberculosis (MTB) isolates from Egypt. A total of 230 MTB isolates were analysed using spoligotyping, large sequence polymorphism (LSPs), mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing and multi-locus sequence typing (MLST). The majority of isolates (93.0%) belonged to lineage 4, including 44.3, 13.4 and 10.8% of the ill-defined T clade, LAM and Haarlem families, respectively, and lineage 3 was identified in 7.0% of the isolates. MIRU-VNTRs typing allowed efficient discrimination of the spoligotype-defined clusters, including spoligo-international types (SIT) 53, 34, and 4, into 56 patterns, including 13 clusters and 43 unique patterns. A new SNP at position 311614 was identified in all six isolates to form the biggest MIRU-VNTR cluster, which suggested a recent clonal expansion. This SNP could possibly be used as a genetic marker for robust discriminations of Egyptian MTB isolates belonging to SIT53. The combination of spoligotyping, 12 MIRU-VNTRs loci and MLST provided insight into the genetic diversity and transmission dynamics of the Egyptian MTB genotypes and could be a key to implementation of effective control measures by public health authorities.

Retrograde vaginal methylene blue injection for localization of complex urinary fistulas.

BACKGROUND: Ureterovesical and vesicovaginal fistulae usually are easily diagnosed with standard techniques, including radiology, double-dye test, cystoscopy, and vaginal examination. In a few complex cases, however, the localization of the fistulous orifice may be extremely difficult. METHOD: We describe a novel technique of retrograde vaginal methylene blue testing that may assist in the proper localization of the fistulous opening. RESULTS: Our experience with one case each of ureterovesical and vesicovaginal fistula easily diagnosed with this method proves its efficacy, simplicity, and safety. CONCLUSION: This technique should be reserved for cases of urinary fistulae when all standard diagnostic methods have failed.

Laparoscopic ablation of giant renal cyst.

We report a case of a symptomatic giant (18 x 10 x 8-cm) renal cyst in a 40-year-old woman that was marsupialized laparoscopically and excised. The surgical technique, based on progressive decompression of the cyst, is fully described. Excellent results were achieved. The recent application of laparoscopic ablation of different types of renal cysts is reviewed. This minimally invasive technique, when properly mastered, is highly effective and offers results similar to those of open surgery. It is associated with definitive postoperative advantages and is the treatment of choice for very large renal cysts, especially those located anteriorly, when sclerotherapy is ineffective or is contraindicated.

Predictors of viable germ cell tumor in postchemotherapeutic residual retroperitoneal masses.

OBJECTIVE: The aim of this study was to identify predictors of viable germ cell tumor (GCT) in postchemotherapeutic residual retroperitoneal masses. MATERIALS AND METHODS: The pertinent clinical and pathologic data of 16 male patients who underwent postchemotherapeutic retroperitoneal lymph node dissection (PC-RPLND) at King Faisal Specialist Hospital and Research Centre between 1994 and 2005 were reviewed retrospectively. It was found that all patients received cisplatin-based chemotherapy for advanced testicular GCT. RESULTS: Out of the 16 male patients, 2 (13%), 8 (50%), and 6 (37%) had viable GCT, fibrosis, and teratoma, respectively. Ten (10) of the patients with prechemotherapeutic S1 tumor markers did not have viable GCT, and two of the six patients who had prechemotherapeutic S2 tumor markers have viable GCT. All tumor marker levels normalized after chemotherapy even in patients with viable GCT. Four patients had vascular invasion without viable GCT. Furthermore, four patients had more than 60% embryonal elements in the original pathology, but only 1 had viable GCT at PC-RPLND. Four of the five patients with immature teratoma had teratoma at PC-RPLND but no viable GCT; however, out of the four patients with mature teratoma, one had viable GCT and two had teratoma at PC-RPLND. Of the two patients with viable GCT, one had 100% embryonal cancer in the original pathology, prechemotherapeutic S2 tumor markers, history of orchiopexy, and no vascular invasion; the other patient had yolk sac tumor with 25% embryonal elements and 40% teratoma in the original pathology, and prechemotherapeutic S2 tumor markers. CONCLUSION: None of the clinical or pathological parameters showed a strong correlation with the presence of viable GCT in PC-RPLND. However, patients with ≥S2 may be at higher risk to have viable GCT. Further studies are needed to clarify this.

Isolated ureteric endometriosis presenting as a ureteric tumor.

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.

Isolated renal hydatid disease in a non-endemic country: a single centre experience.

OBJECTIVE: Isolated renal hydatid disease (HD) is rare in non-endemic countries. Clinical and radiological suspicion warrants appropriate serological tests, preoperative treatment and intra-operative precautions. We present a tertiary care centre experience of isolated renal HD in a non-endemic country. METHODS: We reviewed the medical records of patients with HD treated in the past 20 years. We identified patients with the definitive diagnosis of isolated renal HD and described their management. RESULTS: Of the 119 cases with HD, 6 were found to have isolated renal involvement (5%). Their median age was 46.5 (28-70) years. Five patients presented with flank pain and 1 had an incidentally discovered renal mass. Radiologic investigations raised the suspicion of possible HD in 4 cases, while 2 cases were diagnosed as renal tumours. Computerized tomography showed complex renal cyst in 4, solid renal mass with heterogonous enhancement in 2 and calcification in 5. Eosinophilia and indirect hemagglutination test (IHA) were positive in 3 of the 4 suspected cases. Three cases were treated as renal tumours, while 3 were managed as HD. Four cases had total nephrectomy and 2 had partial nephrectomy. Histopathology revealed that all cases had renal HD. Patients were followed for a median of 7.3 (0.4-11.3) years with no evidence of recurrence. CONCLUSIONS: Isolated renal HD is a challenging preoperative diagnosis in non-endemic countries. The definitive diagnosis is only possible by histopathology. Retrospectively, HD mimicked renal tumours in half the cases and should be considered in the differential diagnosis of renal space occupying lesions.

Prospective randomized trial of 100u vs 200u botox in the treatment of idiopathic overactive bladder.

AIM: To evaluate the clinical outcomes of two different doses of BTX-A in patients with refractory idiopathic overactive bladder. PATIENTS AND METHODS: Thirty nine patients with refractory idiopathic overactive bladder from 1/1/2008 till 30/3/2009 were evaluated in a tertiary care hospital. Patients were evaluated using urodynamic studies, voiding diary, UDI-6 and IIQ-7 questionnaires prior to being prospectively randomized (alternate randomization) to the BTX-A applications and three months after treatment. Voiding diary and residual volume were followed two weeks later. All patients received intradetrusorial injections of BTX-A (Botox, Allergan, Irvine, CA) of 100u or 200u under cystoscopic control on an outpatient basis. The primary endpoint was assessed for the improvement of urodynamic parameters and adverse events at three months after the initial treatment. Secondary end points included urinary frequency, urgency and UUI episodes as assessed by voiding diary and QoL. RESULTS: Eleven patients were enrolled to each arm of the study. There were no significant differences in demographic characteristics between the two groups. Urodynamic assessment at the end of the third month showed significant improvement in urodynamic variables in both groups. There was no statistically significant difference in urodynamic parameters and in the voiding diary between the two groups. QOL was significantly improved in both groups with no statistically significant difference between the different doses. Only three patients developed acute urinary retention. CONCLUSION: BTX-A at 100u and 200u appears to improve symptoms, urodynamic parameters and QoL with no statistical significance between the two groups.

Changing trends in presentation, diagnosis and management of renal angiomyolipoma: comparison of sporadic and tuberous sclerosis complex-associated forms.

OBJECTIVES: To evaluate the changing management of sporadic renal angiomyolipoma and renal angiomyolipoma associated with the tuberous sclerosis complex (TSC) during the past 16 years. METHODS: We retrospectively reviewed the charts of 60 patients with angiomyolipoma seen at our institutions. RESULTS: The median age at presentation was 45 years (range 7-78). The presentation was pain in 30 patients and hematuria in 13; it was incidentally discovered in 17 patients. Of the 60 patients, 43 were females. TSC was present in 14 patients. The median tumor size was 4 cm (range 0.3-40, mean 6.5 +/- 1.1). Of the 60 patients, 31 were followed up expectantly. Surgery or intervention was needed for 29 patients to control hemorrhage or relieve pain or because of the suspicion of malignancy. Of these 29 patients, 12 underwent nephrectomy, 11 partial nephrectomy, and 6 embolization. The patients treated for hemorrhage had a median tumor diameter of 11 cm (range 2-21). Patients were followed up for a mean of 39.3 +/- 5.4 months. The lesions grew an average of 4.7 +/- 3.4 cm for TSC tumors and 0.6 +/- 0.2 cm for sporadic angiomyolipoma tumors. None of the patients developed renal impairment. Patients with TSC presented at a younger age, had larger and bilateral lesions, and were more symptomatic during follow-up. In the past 6 years, a significant trend was seen toward finding tumors in asymptomatic patients and toward the use of conservative or interventional (embolization) treatment. CONCLUSIONS: Renal angiomyolipoma has a slow growth rate. The preservation of renal function was noted in all our patients. A recent shift was noted toward finding smaller tumors in asymptomatic patients and the use of conservative and interventional treatment.

Crural tunica albuginea autograft for corporoplasty: an experimental animal study of hemodynamic, histopathological, and molecular effects in the long term.

INTRODUCTION: Correction of penile deformity caused by Peyronie's disease by a variety of grafts varies in success. A long-term follow-up shows a significant number of graft scarring and erectile dysfunction. The clinical success of autologous crural tunica albuginea graft (TAG) has not resulted in wide application. AIM: To identify in healthy baboons the limitations and merits of autologous crural TAG over 1 year in a way difficult to pursue in humans. METHODS: Under general anesthesia, eight sexually active adult baboons underwent pharmacological cavernosometry (CM) and cavernosography. TAG from crus was implanted in the distal penile shaft. After 6 months, six animals were reevaluated and two were sacrificed, and the penises were excised. After 1 year, the remaining six animals were evaluated and sacrificed. The TAG and underlying corpus cavernosum (CC) were examined histologically and by Western blot analysis for nitric oxide synthase (NOS), neuronal (nNOS), endothelial (eNOS) and inducible (iNOS) isoforms, and transforming growth factor-beta1 (TGF-beta1). MAIN OUTCOME MEASURES: Sexual activity, CM, cavernosography, histopathology, and Western blot analysis. RESULTS: All animals resumed normal sexual activity 1 month postsurgery. Cavernous pressure was comparable before, at 6 months, and 1 year after surgery. A cavernovenous insufficiency developed in four animals at 6 months, and ceased in two at 1 year. Penile angulation (<20 degrees) was seen in three animals at 6 months, and an additional two at 1 year. Histologically, TAG was indistinguishable from the adjacent tunica with no fibrosis. In CC, iNOS and nNOS decreased at 1 year, whereas there was no change in TGF-beta1 levels. In TAG, there was no significant change in TGF-beta1 and eNOS levels, but there was a significant decrease in iNOS at 1 year. CONCLUSION: Autologous free TAG is associated with normal sexual activity, minimal hemodynamic changes, excellent histological outcome, and no rise in iNOS or TGF-beta1. However, cavernovenous insufficiency, mild penile angulation, and decreased nNOS persisted at 1 year.

Outcome of penile cancer in circumcised men.

PURPOSE: We previously reported on a group of patients with post-circumcision carcinoma of the penis. We now study the long-term outcome of these patients. MATERIALS AND METHODS: We retrospectively reviewed the available charts of 22 patients presenting between October 1979 and May 2000. RESULTS: Of 22 patients 18 underwent ritual circumcision with extensive scar development. Median age at diagnosis was 62.4 years. The penile lesion was dorsal and proximally located in 15 patients. Median delay before diagnosis was 12 months. Clinically 14 patients had stage T1-T2 disease, with 13 having no lymph node involvement and none with distant metastasis, 8 patients had stage T3-T4 disease. A total of 15 patients were treated surgically with total penectomy (10) or conservative local excision (5), inguinal lymph node dissection (9) and subsequent penile reconstruction (3). Pathological staging in 15 patients revealed 10 patients with stage T1 and in 8 patients with lymph node dissection none had nodal metastasis. Histopathological classification was 20 squamous cell carcinoma, 1 sarcoma and 1 verrucous carcinoma. Six patients refused surgery and 1 was referred for palliation. Median followup was 14.5 months and median survival was 14.5 months. The 3-year survival was 42% for stage T1-T2 and 13% for T3-T4 (p = 0.0052). Median survival for the surgical group was 34 months whereas for nonsurgical group was 3 months (p = 0.0016). Recurrence-free survival in the surgical group was 50%. CONCLUSIONS: Penile carcinoma in circumcised men is a distinct disease commonly following nonclassic vigorous circumcision. Delayed diagnosis and deferring surgical treatment are associated with increased mortality.