Urology Journal

PURPOSE: To discuss the role of membrane androgen receptors and to investigate the potential role of testosterone-albumin conjugate in the prostate cancer (PCa) treatment. MATERIALS AND METHODS: We identified studies published from 1990 onwards by searching the MEDLINE database of the National Library of Medicine. Initial search terms were “androgen receptors, cytoplasmic androgen receptor, and membrane androgen receptor” combined with “testosterone, testosterone-albumin conjugate, and prostate cancer treatment”. RESULTS: The androgen receptor plays a critical role in both development and progression of PCa. The latter is associated with changes in the androgen receptor axis and more precisely, with its conversion from a paracrine dependent signaling pathway for proliferation and survival of prostatic cells to an independent autocrine process. This malignant conversion is due to functional changes in which the androgen receptor activates not only normal genomic, but also novel non-genomic signaling pathways, which are not present in normal prostatic epithelial cells. Thus, treatments for neoadjuvant, adjuvant, and recurrent disease, all center on the regulation and manipulation of the androgen pathway. Recent discoveries however offer strong evidence of a direct apoptotic action induced by activation of the membrane androgen receptor by testosterone-albumin conjugates. CONCLUSION: Investigation of the molecular pathways of apoptosis through activation of the membrane androgen receptors in the androgen-independent PCa cell is important on the one hand because future manipulation of this mechanism can help with understanding and interpreting unknown to date characteristics of PCa and on the other hand, can contribute to the establishment of activators of membrane androgen receptors. In addition, study of the testosterone-albumin complex can constitute the basis for future treatments for PCa.

PURPOSE: To compare efficacy and complications of spinal anesthesia versus general anesthesia in percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: In a prospective randomized study, 110 patients were randomly assigned into two groups for PCNL; group 1 (n = 52) underwent general anesthesia and group 2 (n = 58) received spinal anesthesia. In group 1, PCNL was performed using standard technique under general anesthesia. In group 2, spinal anesthesia was done by injecting bupivacaine and fentanyl in spinal space L4 in sitting position. Thereafter, a urethral catheter was placed in lithotomy position, head of the bed was tilted down for 5 to 10 minutes, and the level of anesthesia was checked. Then, PCNL was done by standard technique. Complications were recorded and analyzed by SPSS software using Chi-Square and Student’s t tests. RESULTS: Mean stone size in groups 1 and 2 was 34.2 ± 9.8 mm and 31.3 ± 7.9 mm, respectively. Intra-operative hypotension and postoperative headache and low back pain were more in spinal group than the general group with a significant difference (P < .05). No neurologic complication was observed in both groups. Need to narcotic medications on the day of operation in groups 1 and 2 was 12.4 ± 3.1 mg and 7.8 ± 2.3 mg of morphine sulphate, respectively (P = .03). The cost of anesthetic drugs was 23 ± 3.7 US $ and 4.5 ± 1.3 US $ in groups 1 and 2, respectively (P = .001). CONCLUSION: Spinal anesthesia with combined bupivacaine and fentanyl is a safe, effective, and cost-effective method for performing PCNL in adult patients.

PURPOSE: To compare efficacy and safety of holmium:YAG laser and pneumatic lithotripter in the management of ureteral stones. MATERIALS AND METHODS: One hundred and twelve patients with 1 to 2 cm ureteral calculi were selected for pneumatic or holmium:YAG laser transurethral ureterolithotripsy (56 patients in each group). Ultrasonography and plain abdominal x-ray were performed for all the patients before the operation. The pneumatic lithoclast was Swiss LithoClast, while in laser lithotripsy, holmium:YAG laser frequency was used, which was usually set between 5 and 10 Hz at a power of 10 to 15 Watt. Intravenous urography was performed for all the patients at 3 months to assess functional status and to delineate the ureteral anatomy. RESULTS: The mean patients’ age and stones’ size were the same in both groups, and there were no statistical differences. Mean duration of lithotripsy was 13.7 ± 12.6 minutes in laser group and 7.9 ± 4.2 minutes in pneumatic lithotripsy group. Immediate stone-free rate was 100% and 82.1% in the laser and pneumatic groups, respectively (P = .001). Stone pushing back occurred only in 10 (17.9%) patients in pneumatic group. In terms of complications, such as perforation, mucosal injury, and bleeding, there were no differences between the two groups. No intravenous pyelography related complication was seen at 3-month follow-up. CONCLUSION: Laser lithotripsy is a superior approach for the management of upper ureteral stones of 1 to 2 cm in size due to its higher rate of stone clearance.

PURPOSE: To describe our initial experience with unclamped laparoscopic hand-assisted partial nephrectomy for predominantly endophytic renal masses in the setting of relative contraindication to warm ischemia. MATERIALS AND METHODS: Unclamped laparoscopic hand-assisted partial nephrectomy was performed on eight consecutive patients from June 2009 to March 2010. All patients had predominantly endophytic renal masses with a preferential enhancing rim noted on the pre-operative computed tomography. The unclamped hand-assisted approach was utilized for no warm ischemia, minimal blood loss, and enhanced visualization of the tumor bed with improved operative exposure. RESULTS: Mean age of the participants was 55.8 years. All patients underwent unclamped hand-assisted partial nephrectomy (ie, zero ischemia). Mean estimated blood loss was 368.8 cc (range, 100 to 800 cc) and mean operation time was 236.9 minutes (range, 175 to 272 minutes). There were no intra-operative complications and no open conversions. There was one grade II (ileus with small pneumothorax) and one grade IV (pulmonary embolism) in the 90-day peri-operative period. There was one positive surgical margin, which was recognized intra-operatively. CONCLUSION: While our results are preliminary, we feel this technique provides superior visualization and adequate hemostasis while preserving oncologic efficacy and renal function in this patient population.

PURPOSE: To evaluate the influence of perinephric fat infiltration and tumor size on survival of patients with renal cell carcinoma (RCC). MATERIALS AND METHODS: We have retrospectively reviewed the records of 338 consecutive patients with pT1-3aN0M0 RCC, including 275 pT1-2 and 63 pT3a tumors, who underwent open partial or radical nephrectomy between 1995 and 2008. Univariate and multivariate analyses were performed in order to evaluate the prognostic factors. RESULTS: Median follow-up period was 36.07 months. Receiver Operating Characteristic curve analysis determined the optimal tumor size cutoff value as 7 cm (Area Under the Curve: 0.65 ± 0.047; 95% Confidence Interval: 0.558 to 0.741). Perinephric fat invasion and Fuhrman grade were independent prognostic factors for disease-specific survival (DSS). In patients with tumor size >7 cm, perinephric fat invasion affected DSS significantly. Tumor size (according to the cutoff value of 7 cm) significantly affected DSS in patients with pT3a disease. According to the TNM 2002 staging system, perinephric fat invasion did not have any significant effect on DSS in patients with tumor size smaller than 4 cm, unlike tumor size of 4 to 7 cm and >7 cm. pT3a tumors larger than 7 cm demonstrated the worst prognosis compared to other groups. CONCLUSION: Perinephric fat invasion was demonstrated as a significant prognostic factor for RCC patients with tumor size >4 cm. Consequently, evaluation of pT3a patients should take tumor size into consideration for better prognostic analysis.

PURPOSE: To evaluate the efficacy of needle biopsy for diagnosing Wilms tumor (WT) before chemotherapy. MATERIALS AND METHODS: We reviewed our institutional experience with Tru-Cut biopsy of pediatric renal masses in patients who subsequently underwent nephrectomy. We compared biopsy pathology with nephrectomy specimens to determine if biopsy accurately predicted final pathology. RESULTS: Seven children underwent Tru-Cut renal mass biopsy followed by surgical resection. In 4 patients, the final biopsy pathology was definitively read as WT and in 3 subjects, the pathology was read as WT versus hyperplastic nephrogenic rest. In all 7 patients, the nephrectomy pathology confirmed a diagnosis of WT. There were no complications after biopsy, and no patients have had local or regional recurrence. CONCLUSION: In our experience, pre-therapy Tru-Cut biopsy safely provides an adequate specimen for pathologic review in diagnosing WT.

PURPOSE: To evaluate postoperative renal function and risk factors for the loss of renal function in patients who had undergone radical cystectomy. MATERIALS AND METHODS: A retrospective single institutional study evaluated 70 patients, including 54 men and 16 women who underwent radical cystectomy. The median follow-up period was 34.5 months (range, 12 to 228 months). In this cohort, four types of urinary diversions were studied, including ileal neobladder (n = 24), ileocecal neobladder (n = 12), ileal conduit (n = 25), and cutaneous ureterostomy (n = 9). Postoperative changes in renal function were reviewed, and the estimated serum creatinine-based glomerular filtration rate (eGFR) was calculated. The variables analyzed were age, a prior history of hypertension or diabetes mellitus, pre-operative renal function, type of urinary diversion, the postoperative occurrence of acute pyelonephritis, and the presence of chemotherapy. RESULTS: The mean eGFR was 74.6 (range, 15.2 to 155.1) mL/min/1.73 m2 before surgery and 63.6 (range, 8.7 to 111.5) mL/min/1.73 m2 at the last follow-up. The 10-year renal deterioration-free interval was 63.8%. Multivariate analysis showed that a postoperative episode of acute pyelonephritis [Odds Ratio (OR), 3.21; 95% Confidence Interval (CI), 1.14 to 9.02; P = .03] and the presence of chemotherapy (OR, 3.27; 95% CI, 1.33 to 8.01; P = .01) were significant adverse factors. CONCLUSION: Twenty-four (34.2%) patients demonstrated reduced renal function during the follow-up period. Postoperative episodes of acute pyelonephritis and the presence of chemotherapy were found to be significant adverse factors.

PURPOSE: To determine the optimal number of biopsies in patients with non-obstructive azoospermia (NOA) who undergo testicular sperm extraction (TESE), and assess the impact of testicular histology on outcome. MATERIALS AND METHODS: Seven hundred and forty-one patients with NOA who underwent TESE in our institution were enrolled in the study. Testicular sperm extraction was performed applying an open surgical technique on the larger testis. The number of biopsies varied according to the presence or absence of spermatozoa. No further biopsies were obtained once spermatozoa were detected. If no spermatozoa were seen, the procedure was continued to a maximum number of 5 biopsies, including a single biopsy of the contralateral testis. RESULTS: Spermatozoa were obtained in 330 (44.5%) patients after a single biopsy. The success rate increased to 381 (51.4%), 416 (56.1%), 433 (58.4%), and 441 (59.5%) after the second, third, fourth, and contralateral sampling, respectively. Multiple sampling increased the success rate; however, success rate did not increase considerably after the third sampling. Performing contralateral testicular biopsy was advantageous in patients with uniform or mixed pattern hypospermatogenesis. CONCLUSION: We recommend performing at least 3 biopsies in patients with NOA who undergo TESE. Further biopsies may also be advantageous when the NOA is a consequence of either uniform or mixed pattern hypospermatogenesis.

PURPOSE: To present our experience of using an adjustable male sling, Argus® (Promedone SA; Cordoba, Argentina), in patients with stress urinary incontinence (SUI), and report its success, extension of indications, and management of complications. MATERIALS AND METHODS: We retrospectively evaluated Argus implantation results in 17 patients, including 15 post prostatectomy incontinence, one exstrophy-epispadias, and one neurogenic bladder patient. Of 17 patients, 12 had severe (more than 5 pads daily) and 5 had moderate SUI (2 to 5 pads daily). Seven patients had history of previous surgeries. Patients were evaluated pre-operatively with urodynamic study and cystoscopy. RESULTS: After median follow-up of 11.8 months (range, 3 to 22 months), 9 patients were continent, 7 had mild SUI (1 pad daily), and one had the device removed due to perineal and bladder symptoms. Argus adjustment was done in 10 out of 17 patients; 8 tightening and 2 loosening. In a totally incontinent exstrophy-epispadias patient with a history of multiple bladder surgeries, continence was achieved after device readjustment. In a patient with neurogenic bladder with a history of cystoplasty, severe SUI changed into a moderate sporadic SUI. In 2 patients, prosthesis infection occurred, which was managed with antibiotics without the need for Argus explantation. CONCLUSION: Argus is a simple and good device to control incontinence in men. It may also be used in exstrophy-epispadias patient who is not a candidate for urinary sphincter implantation. Infection complication may be managed conservatively. To the best of our knowledge, this is the first report of successful Argus implantation in exstrophy-epispadias patient.

While the incidence of renal cell carcinoma is rising constantly, it remains a relatively uncommon malignancy in the pediatric population. Renal cell carcinomas can present in solid or cystic mass patterns. Multilocular cystic renal cell carcinoma is an uncommon clinical entity in adults and to our knowledge, it has been reported only once in a pediatric patient in the literature. In this case report, a 14 years old young boy with multilocular cystic renal cell carcinoma is presented and discussed with the relevant literature.

 

Key Words: Kidney, cancer, multilocular cysts, child, nephrectomy.