RESUMEN

BACKGROUND One-third of renal cell carcinoma cases present with an initial metastasis to various organs, emphasizing the tumor's unpredictable behavior. Prognosis is poor once metastasis is discovered. Multiple-organ involvement with metastatic lesions has a particularly dismal survival rate. Surgical resection alone of metastatic masses can extend patient survival with reasonable quality of life. CASE REPORT Here, we present the case of a healthy 46-year-old woman who initially presented with an incidental localized clear cell renal cell carcinoma. During the follow-up period, she presented with sequential asynchronous metastasis to the pancreas, thyroid, skin, contralateral kidney, and lung. She has no family history of malignancy. Her physical examination and laboratory investigations were normal even upon presentation of most of her metastatic organs. The first metastasis was in her sixth year of follow-up. She underwent consecutive metastasectomy of all the organs described above, excluding the lung. She eventually was started on sunitinib after non-resectable lung nodules were discovered. Her survival is now over 10 years since her first metastasectomy, with good performance status. CONCLUSIONS Metastasis to a single organ has a poor prognosis and dramatically affects survival. Nevertheless, our patient had multiple consecutive examples of metachronous metastasis, yet she has survived for over a decade since the occurrence of metastasis. Our case offers more information to fill the gaps in understanding the favorable role of surgical resection in advanced renal cell carcinoma metastasis.

Asunto(s)

RESUMEN

INTRODUCTION: Zinner syndrome is a rare congenital malformation characterized by the association of an ipsilateral renal agenesis, ipsilateral seminal vesicle cyst, and ipsilateral ejaculatory duct obstruction. This case is one of the first to be reported in the Kingdom of Saudi Arabia. CASE PRESENTATION: A 20-year-old Saudi male patient presented complaining of chronic left groin pain radiating to the left testis and the medial aspect of the left thigh for the last 6 years. Patient is also complaining of painful ejaculation with no history of lower urinary tract symptoms, hematuria, or trauma. Physical examination was unremarkable. Ultrasound (US) report from the referring hospital mentioned that there is a left pelvic mass. Computed tomography (CT) and magnetic resonance imaging (MRI) showed diffuse distension of left seminal vesicle (9 X 7 cm) cyst with ipsilateral left renal agenesis which corresponds to Zinner syndrome. Left seminal vesicle cyst excision through a low midline incision was done. The patient was asymptomatic during his follow-up in our clinic with disappearance of the pain. CONCLUSION: The combination of a good clinical history and radiological assays aided in making the diagnosis. Surgical intervention is the mainstay in the management plan in symptomatic patients.

RESUMEN

OBJECTIVE: To review the mode of presentation and clinical course of patients with prostate cancer during a specified period, as the detection rate is tending to increase, with most patients presenting at an advanced stage, and yet the overall incidence and prevalence rates are low. PATIENTS AND METHODS: We retrospectively reviewed all aspects of care for patients who were diagnosed between May 2006 and July 2010. RESULTS: In all, 76 men had a histologically confirmed prostatic adenocarcinoma diagnosed between May 2006 and July 2010 (mean age 71.1 years, SD 8). The median (range) prostate-specific antigen level at diagnosis was 52 (1.2-16,230) ng/mL. Of the patients, 74% had a Gleason grade of â©¾ 7 on diagnosis, and 64% had extraprostatic disease on presentation. Active surveillance was adopted in four patients, and four others were maintained on watchful waiting. Six patients had a radical prostatectomy, in one of whom it was a salvage procedure. Six patients received external-beam radical radiotherapy, five of whom had neoadjuvant, concurrent and adjuvant hormonal therapy. All remaining patients were treated primarily with androgen-deprivation therapy (ADT). Of the patients on hormonal manipulation, in 56% the cancer became castrate-resistant within the mean (SD) follow-up of 17.2 (15) months. Of patients treated primarily with ADT, 34% died. The death rate among the whole group was 23%. Both percentages include both prostate cancer-specific and non-specific mortality. CONCLUSION: An advanced stage of disease at presentation mandates an early-detection, hospital-based screening programme. Further research should include many more patients and be based in several centres.

Asunto(s)

RESUMEN

Introduction. Liposarcoma is a rare pathological entity. By far it is the most common histological subtype of genitourinary sarcomas in adults. Approximately two hundred cases were reported in the literature. We are hereby presenting a case with a typical clinical scenario of paratesticular liposarcoma. Case report. A 75-year-old gentleman presented with a painless right hemiscrotal swelling that was progressively increasing in size over the last 6 years. Testicular tumour markers were negative. Imaging showed a heterogenous mass with fat component. Subsequently he underwent wide local excision that included the paratesticular mass along with the right testicle and all right inguinal canal contents up to the deep inguinal ring with the sparing of right illioinguinal nerve. Histopathological examination showed a well differentiated liposarcoma of the spermatic cord. He remained recurrence-free so far after 18 months of followup. Conclusion. Radical orchidectomy with wide local excision comprises the cornerstone of treatment of paratesticular liposarcoma. Due to the rarity of the disease there is no definite universal consensus of opinion as regards the role of radiotherapy and chemotherapy.

RESUMEN

OBJECTIVE: To evaluate the efficacy of two drugs: the anticholinergic agent oxybutynin (Ditropan) and the calcium channel blocker verapamil (Isoptin) in the management of nocturnal enuresis in patients with orthotopic ileal reservoirs. MATERIAL AND METHODS: The study population comprised 20 male enuretic patients who had undergone radical cystoprostatectomy and formation of an orthotopic ileal reservoir (hemi-Kock or W-neobladder). All patients were clinically evaluated regarding their continence state. Basal medium-fill enterocystometry was performed for every patient. The patients were randomized on entry into one of the two arms of the study: oxybutynin followed by verapamil (n =10); or verapamil followed by oxybutynin (n = 10). Each group received both drugs for a period of 2 weeks each. After administration of each drug, patients were re-evaluated both clinically and urodynamically. RESULTS: Oxybutynin and verapamil improved continence status in 70% and 55% of the patients, respectively. Both drugs significantly increased the bladder volume at first desire, at normal desire and at the maximum enterocystometric capacity. The maximum enterocystometric capacity increased from 585+/-148.6 ml at baseline to 667.5+/-180.8 and 621.05+/-170.5 ml after administration of oxybutynin and verapamil, respectively. Despite this, there was no significant change in any of the pressure parameters with the exception of the basal pressure at maximum enterocystometric capacity, which decreased significantly from 20.1+/-8.3 cmH2O at baseline to 16.07+/-5.1 cmH2O after administration of verapamil. The number of uninhibited contractions in the last 5 min of filling decreased significantly from 3.6+/-0.7 at baseline to 1.9+/-1.2 after administration of oxybutynin and to 2.1+/-1.26 after administration of verapamil. The amplitude of maximum uninhibited contraction decreased from 41.15+/-9.1 cmH2O at baseline to 34.95+/-12.77 and 33.25+/-11.52 cmH2O after treatment with oxybutynin and verapamil, respectively. Neither drug significantly changed the initial, late or total compliance of the pouch. No significant side-effects occurred with either drug. CONCLUSIONS: Both drugs used in this study had beneficial effects on the continence status of our patients, with minimal side-effects. Both drugs clinically improved nocturnal incontinence after radical cystoprostatectomy and formation of orthotopic ileal reservoirs, which was verified by the associated improvements in urodynamic characteristics.

Asunto(s)

RESUMEN

PURPOSE: Some authors reported that adopting a nerve sparing technique during radical cystoprostatectomy improves the continence outcome of orthotopic diversion in patients with invasive bladder carcinoma. We urodynamically evaluated the effect of nerve sparing cystoprostatectomy on external urethral sphincteric function. MATERIALS AND METHODS: A total of 30 consecutive male patients who underwent nerve sparing cystoprostatectomy and ileal neobladder (NS group) were compared to a control group of 30 patients who underwent a similar procedure but without nerve sparing (non-NS group). Continence status was thoroughly clinically evaluated in parallel to erectile function in both groups. The urethral sphincteric mechanism was evaluated with urethral pressure profilometry in different positions. RESULTS: Better urethral pressure profile parameters were found in patients in the NS group. Significantly longer functional urethral length (34.8 mm) was detected in NS group than in the non-NS group (30.1 mm). Moreover, the maximum urethral pressure was higher in the NS group but not to a statistically significant level. In the NS group there were no statistically significant differences between potent and impotent subgroups regarding the continence rate or urethral pressure parameters. CONCLUSIONS: There is urodynamic evidence that the nerve sparing technique improved urethral sphincteric function and, consequently, the continence rate. The denervated, most proximal part of the urethra in non-NS cases with lack of contraction and, therefore, any pressure, is a possible explanation for the difference in UPP.

Asunto(s)

RESUMEN

OBJECTIVE: To report our experience with the use of 95% ethanol as sclerotherapy for symptomatic simple renal cysts. PATIENTS AND METHODS: Sixty patients with 64 symptomatic simple renal cysts were treated by ultrasonography (US)-guided percutaneous aspiration and injection of 95% ethanol (31 men and 29 women, mean age 46 years, SD 22). The main presentation was renal pain in 34 patients, renal mass in nine, hypertension in 11 and haematuria in six; 24 cysts were on the right, 32 on the left and four bilateral. Patients were evaluated after 1 month and then every 6 months by clinical assessment, US and intravenous urography. Success was defined as complete when there was total ablation of the cyst and partial when there was a recurrence of less than half the original cyst volume with the resolution of symptoms. Failure was defined as the recurrence of more than half of cyst volume and/or persistent symptoms. RESULTS: After aspiration and ethanol sclerotherapy, there was microscopic haematuria in two patients and low-grade fever (<38.3 degrees C) in two, but no major complications. During a mean (range) follow-up of 19 (14-40) months there was complete cyst ablation in 54 cysts and partial resolution in 10. Pain disappeared or was much improved in all patients. After cyst ablation hypertension was well controlled with no medication in all 11 hypertensive patients and haematuria disappeared in all six affected patients. CONCLUSIONS: Ethanol sclerotherapy for symptomatic simple renal cysts is simple, minimally invasive and highly effective. We recommend it as the first therapeutic option in these patients.

Asunto(s)

RESUMEN

OBJECTIVE: To establish urodynamic criteria differentiating between men with a radical cystoprostatectomy and ileal neobladder who are persistently enuretic and those who are occasionally enuretic. PATIENTS AND METHODS: Fifty enuretic men at least 1 year after a radical cystoprostatectomy and ileal neobladder (hemi-Kock or 'W' neobladders) were divided into two groups according to the persistence of their complaint; 17 men were persistently enuretic (nightly) and 33 were occasionally enuretic (<3 episodes/week). Both groups were compared with 50 fully continent men with similar reservoirs. Uroflowmetry, enterocystometry and urethral pressure profilometry were carried out according to International Continence Society standards and terminology. RESULTS: Both enuretic groups had significantly higher residual urine volumes, pressure at mid-capacity and at maximum enterocystometric capacity, amplitude of uninhibited contractions, and lower compliance than continent men. Men with occasional enuresis also had a significantly higher frequency and duration of uninhibited contractions than continent men. Men with persistent enuresis had significantly lower average and maximum urinary flow rates than continent men, and significantly lower functional urethral length and maximum urethral pressure. Uroflowmetric and urethral pressure differences were dissimilar between men with occasional enuresis and controls. CONCLUSION: Enuretic men had significantly higher residual urine volumes and enterocystometric pressure variables than continent men. Men with persistent enuresis had significantly lower flow rates and less urethral resistance. Pharmacological inhibition of reservoir contraction and/or management of residual urine by clean intermittent catheterization before sleep might cure occasional enuresis.

Asunto(s)

RESUMEN

PURPOSE: We evaluated whether an artificial neural network (ANN) can improve the prediction of stone-free status after extracorporeal shock wave lithotripsy (ESWL) (Dornier Medical Systems, Inc., Marietta, Georgia) for ureteral stones compared to a logistic regression (LR) model. MATERIALS AND METHODS: Between February 1989 and December 1998, 984 patients with ureteral stones, including 780 males and 204 females with a mean age +/- SD of 40.85 +/- 10.33 years, were treated with ESWL. Stone-free status at 3 months was determined by urinary tract plain x-ray and excretory urography. Of all patients 919 (93.3%) were free of stones. The impact of 10 factors on stone-free status was studied using an LR model and ANN. These factors were patient age and sex, renal anatomy, stone location, side, number, length and width, whether stones were de novo or recurrent, and stent use. An LR model was constructed and ANN was trained on 688 randomly selected patients (70%) to predict stone-free status at 3 months. The 10 factors were used as covariates in the LR model and as input parameters to ANN. Performance of the trained net and developed logistic model was evaluated in the remaining 296 patients (30%), who served as the test set. The sensitivity (percent of correctly predicted stone-free cases), specificity (percent of correctly predicted nonstonefree cases), positive predictive value, overall accuracy and average classification rate of the 2 techniques were compared. Relevant variables influencing the construction of the 2 models were compared. RESULTS: Evaluating the performance of the LR and ANN models on the test set revealed a sensitivity of 100% and 77.9%, a specificity of 0.0% and 75%, a positive predictive value of 93.2% and 97.2%, an overall accuracy of 93.2% and 77.7%, and an average classification rate of 50% and 76.5%, respectively. LR failed to predict any nonstone free cases. LR and ANN identified stone location and stent use as important factors in determining the outcome, while ANN also identified stone length and width as influential factors. CONCLUSIONS: ANN and LR could predict adequately those who would be stone-free after ESWL for ureteral stones. The neural network has a higher ability to predict those who fail to respond to ESWL.

Asunto(s)

RESUMEN

PURPOSE: A significant percentage of patients with post-prostatectomy incontinence have been reported to void by Valsalva's maneuver, which is our observation as well. We determine the mechanism of voiding in patients with post-prostatectomy incontinence and correlate this to demographic data, urodynamic parameters and outcome after artificial urinary sphincter implantation, and identify possible risk factors. MATERIALS AND METHODS: Videourodynamic data from 61 consecutive patients with post-prostatectomy incontinence were reviewed to determine voiding patterns. The causes of incontinence were radical prostatectomy in 58 patients and transurethral resection of the prostate followed by radiation therapy in 3. The relationship between voiding patterns and demographic data (age, diabetes mellitus, degree and duration of incontinence, history of radiation therapy or treated bladder neck contracture) as well as urodynamic parameters (bladder capacity, compliance, instability, sensation, leak point pressure and residual urine) were studied. After artificial urinary sphincter implantation outcome was assessed in relation to the voiding patterns. RESULTS: Stress incontinence was present in all patients while concomitant urgency/urge incontinence was present in 48%. Of the patients 43 (70.5%) voided by detrusor contraction (group 1) while the remaining 18 (29.5%) voided by straining (group 2). Mean patient age +/- SD was 70.8 +/- 6.9 and 69.2 +/- 7.2 years, and duration of incontinence was 48 +/- 33 and 46 +/- 30 months in groups 1 and 2, respectively (p >0.05). Also, no significant differences were found between the groups with regard to other demographic data. Delayed first sensation (at volume greater than 140 ml.) was seen in 42.5% and 29.4%, capacity less than 300 ml. in 41.9% and 39%, impaired/poor compliance in 25.6% and 22.2%, bladder instability in 16.3% and 5.6%, abdominal leak point pressure 60 cm. H(2)O or less in 59.4% and 60% and residual urine greater than 50 ml. in 11.6% and 17.6% in groups 1 and 2, respectively (p >0.05). After artificial urinary sphincter implantation 35% and 22.2% of patients used greater than 1 pad a day in groups 1 and 2, respectively. One patient in each group reported difficulty during urination and both patients had no residual urine. CONCLUSIONS: No identifiable demographic or urodynamic risk factors could be detected in association with the strain pattern of voiding in patients with post-prostatectomy incontinence. The absence of a difference in bladder compliance, residual urine volume and outcome after artificial urinary sphincter implantation between detrusor and strain voiders would suggest no increased risk for complications in the strain voiding group.

Asunto(s)

RESUMEN

PURPOSE: We studied the possible causes of chronic retention after radical cystectomy and orthotopic bladder substitution in women. MATERIALS AND METHODS: Between January 1995 and January 2001, 136 women with a mean age plus or minus standard deviation of 52 +/- 8 years underwent standard radical cystectomy and orthotopic substitution for organ confined bladder cancer. Videourodynamics, pelvic floor electromyography, pelvic floor magnetic resonance imaging and pan-endoscopy were done. In the last 37 cases some technical modifications were adopted to circumvent the development of chronic urinary retention. RESULTS: One woman died postoperatively of massive pulmonary embolism. Of the 100 patients evaluable at a mean followup of 36 months 95 were continent in the daytime, 86 were continent at night, 2 were completely incontinent and 16 were in chronic retention. Videourodynamics showed that retention was mechanical in nature due to the pouch falling back in the wide pelvic cavity, resulting in acute angulation of the posterior pouch-urethral junction. In addition, herniation of the pouch wall through the prolapsed vaginal stump was observed in most cases. Pelvic floor electromyography demonstrated complete pelvic floor silence during voiding. No abnormality of the pelvic floor or rhabdosphincter was noted on magnetic resonance imaging. Pan-endoscopy showed a normal urethra with no urethroileal stricture. A 4 mg. dose of the alpha1-adrenergic blocker doxazosin daily was ineffective, excluding the possibility that sprouting from adjacent adrenergic neurons into the denervated proximal urethral muscles may have been the cause of this problem. After omental packing behind the pouch, suturing of the peritoneum on the rectal wall to the vaginal stump, suspension of the latter by the preserved round ligaments and suspension of the pouch near its dome to the back of the rectus muscle at cystectomy the incidence of chronic retention decreased from 18.7% (14 of 75 cases) before to 8% (2 of 25) after modifications. Furthermore, after vaginal wall descent was mechanically corrected by a pessary there was significant improvement in evacuation. CONCLUSIONS: Strong evidence was provided that chronic urinary retention after orthotopic substitution is due to anatomical rather than to functional or neurogenic reasons. Modifications to increase back support of the pouch with ventral suspension near its dome and support the vaginal stump are recommended to avoid this complication.

Asunto(s)

RESUMEN

OBJECTIVES: To evaluate angiogenesis as a prognostic marker in squamous cell carcinoma of the urinary bladder in 154 patients who underwent radical cystectomy. METHODS: The tumors from 98 men and 56 women (mean age 46.3 +/- 8.4 years) were examined. Vessels were stained using an antibody to the platelet endothelial cell adhesion molecule CD31. Microvessels were counted in active areas of angiogenesis within the tumors. Microvessel density (MVD) was quantified using the mean of three counts. Age, sex, tumor grade and stage, DNA ploidy, and MVD were evaluated in relation to outcome. Univariate and multivariate analyses of survival were performed. RESULTS: The median follow-up period was 63 months. The overall 5-year survival rate was 56 +/- 4.1. Tumor grade, tumor stage, DNA ploidy, and MVD had a significant impact on the survival of patients in univariate analysis. The 5-year survival rate in patients with a low MVD (11 or less) was 68.1% compared with 50.4% for those with a high MVD (greater than 11; P <0.01). Men had more vascular tumors than did women. Also, high-grade tumors had significantly higher vascular counts. In a Cox proportional hazard model, tumor angiogenesis sustained its significant impact on survival of the patients in addition to tumor stage and DNA ploidy. CONCLUSIONS: These findings suggest that angiogenesis and DNA ploidy are independent additional prognostic factors in patients with squamous cell carcinoma of the urinary bladder.

Asunto(s)

RESUMEN

PURPOSE: Detrusor instability is a common urodynamic finding in patients with prostatic obstruction. In prospective fashion we evaluated detrusor instability in patients with lower urinary tract symptoms attributable to benign prostatic hyperplasia and determined its possible association with the degree of obstruction. MATERIALS AND METHODS: A total of 459 men with a mean age plus or minus standard deviation of 60.4 +/- 9.4 years who were investigated for lower urinary tract symptoms at our facility answered an Arabic standardized version of International Prostate Symptom Score and underwent simple uroflowmetry, outpatient cystoscopy and transrectal ultrasound. Invasive urodynamics, including filling and voiding cystometry, was done with pressure flow analysis according to the Schäfer nomogram. Statistical significance was tested by the Mann-Whitney U and Wilcoxon rank sum tests. RESULTS: Of the 459 patients 108 (23.5%) had detrusor instability. Instability significantly affected patient symptom score and conception of quality of life. Moreover, instability significantly affected the degree of obstruction, as measured by the maximum flow rate, post-void residual urine, prostate volume and Schäfer grade of obstruction. CONCLUSIONS: Detrusor instability affects patient symptoms and quality of life. It also signifies a more severe degree of obstruction in male patients with lower urinary tract symptoms and bladder outlet obstruction due to benign prostatic hyperplasia.

Asunto(s)

RESUMEN

PURPOSE: We retrospectively reviewed our experience with the artificial urinary sphincter for post-prostatectomy incontinence, comparing the outcome of those patients who did and did not receive previous radiation therapy. MATERIALS AND METHODS: A total of 86 patients with post-prostatectomy incontinence treated with implantation of artificial urinary sphincter includes 58 who did not (group 1) and 28 who did (group 2) receive prior radiation therapy during treatment of prostate carcinoma. In group 2 radiation was the primary treatment followed by salvage prostatectomy in 5 patients, adjuvant after radical retropubic prostatectomy 20 and after transurethral prostatic resection 3. Mean patient age plus or minus standard deviation was 68.3 +/- 6.6, and 69.7 +/- 6.6 years in groups 1 and 2, respectively. Activation of the sphincter was 4 weeks from the date of surgery, and deactivation at night was not adopted in either group. Patients were followed for a mean period of 31 +/- 23, and 36 +/- 21 months in groups 1 and 2, respectively. Comparison of continence, urodynamic testing, complication rate, overall satisfaction and quality of life was done between both groups. RESULTS: Reoperation was required in 13 (22.4%) patients in group 1 and 7 (25%) group 2 (p >0.05). Urethral atrophy and/or inadequate compression was seen in 8 (14%) and 4 (14%) patients, and urethral erosion was observed in 1 (2%) and 2 (7%) in groups 1 and 2, respectively (p >0.5). Infection of the device was observed in 4 (7%) patients in group 1 but none group 2 (p >0.05). Continence status was similar in both groups, with 60% and 64% of patients who wore 0 to 1 pad daily in groups 1 and 2, respectively (p >0.05). Urgency with or without urge incontinence was reported after implantation of artificial urinary sphincter in 47%, and 44% of patients in groups 1 and 2, respectively (p >0.05). On a visual analog scale (range 0 to 5, 0-not satisfied at all, 5-extremely satisfied) for satisfaction with the results of the artificial urinary sphincter 86% and 91% of patients reported 4 or greater in groups 1 and 2, respectively (p >0.05). CONCLUSIONS: The artificial urinary sphincter has a similar outcome in patients with post-prostatectomy incontinence whether or not they have received previous radiation therapy. No special precaution needs to be adopted for the men in group 2 with post-prostatectomy incontinence considering implantation of artificial urinary sphincter.

Asunto(s)