Adel Nabeeh

Does the Extent of Lymphadenectomy in Radical Cystectomy for Bladder Cancer Influence Disease-Free Survival? A Prospective Single-Center Study

BACKGROUND Controversy exists regarding the optimal extent of lymphadenectomy and the number of lymph nodes to be retrieved at radical cystectomy (RC). OBJECTIVE To compare the disease-free survival of patients with standard lymphadenectomy (endopelvic region composed of the internal, external iliac, and obturator groups of lymph nodes) versus extended lymphadenectomy (up to the level of origin of the inferior mesenteric artery) at RC in a prospective cohort of patients at a single, high-volume center. DESIGN, SETTING, AND PARTICIPANTS Prospective data were collected from 400 consecutive patients treated with RC for bladder cancer by two high-volume surgeons at Mansoura Urology and Nephrology Center. Of the 400 patients, 200 (50%) received extended lymphadenectomy and the other 200 (50%) underwent standard lymphadenectomy at RC. The patients did not receive any neoadjuvant or adjuvant therapy. MEASUREMENTS Patient characteristics and outcomes are evaluated. RESULTS AND LIMITATIONS Median patient age for the entire group was 53.0 yr. Ninety-six patients (24.0%) had lymph node metastases. Median follow-up was 50.2 mo. Estimates of 5-yr disease-free survival in the extended lymphadenectomy group were 66.6% compared with 54.7% for patients with standard lymphadenectomy (p = 0.043). Extended lymphadenectomy was associated with better disease-free survival after adjusting for the effects of standard pathologic features (p = 0.02). When restricting the analyses to lymph node-positive patients, patients with extended lymphadenectomy had much better 5-yr disease-free survival compared with patients with standard lymphadenectomy (48.0% vs 28.2%; p = 0.029). The study was nonrandomized. CONCLUSIONS Extended lymphadenectomy is associated with better disease-free survival for bladder cancer patients with endopelvic lymph node involvement and should be considered in these patients.

GreenLight™ Laser (XPS) Photoselective Vapo-Enucleation versus Holmium Laser Enucleation of the Prostate for the Treatment of Symptomatic Benign Prostatic Hyperplasia: A Randomized Controlled Study

PURPOSE After the advent of the GreenLight XPS™ (180 W) 532 nm laser, photoselective vapo-enucleation of the prostate could compete with holmium laser enucleation of the prostate as a size independent procedure. We assessed whether photoselective vapo-enucleation of the prostate-XPS is not less effective than holmium laser enucleation of prostate for improvement of lower urinary tract symptoms secondary to benign prostatic hyperplasia. MATERIALS AND METHODS A randomized controlled noninferiority trial comparing holmium laser enucleation of the prostate to photoselective vapo-enucleation of the prostate-XPS 180 W was conducted. I-PSS, flow rate, residual urine, prostate specific antigen and prostate volume changes as well as perioperative and late adverse events were compared. Noninferiority of I-PSS at 1 year was evaluated using a 1-sided test at 5% level of significance. The statistical significance of other comparators was assessed at the (2-sided) 5% level. RESULTS Overall 50 and 53 patients were included in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively. Operative time, hospital stay and time to catheter removal were comparable between the groups. There was significant, comparable improvement in I-PSS and post-void residual urine volume at 1, 4 and 12 months. After 4 months prostate size reduction was significantly higher in the holmium laser enucleation of prostate group (74.3% vs 43.1%, p=0.001). At 12 months maximum urine flow rate was significantly higher in the holmium laser enucleation of prostate group (26.4 ±11.5 vs 18.4 ±7.5 ml per second, p=0.03). Re-intervention was needed in 2 and 3 cases in the holmium laser enucleation and photoselective vapo-enucleation of the prostate groups, respectively (p=1.0). Mean estimated cost per holmium laser enucleation of prostate procedure was significantly lower than per photoselective vapo-enucleation of the prostate procedure. CONCLUSIONS Compared to holmium laser enucleation of prostate, GreenLight XPS laser photoselective vapo-enucleation of the prostate is safe, noninferior and effective in treatment of benign prostatic hyperplasia.

SEQUENTIAL BACILLUS CALMETTE-GUERIN AND EPIRUBICIN VERSUS BACILLUS CALMETTE-GUERIN ALONE FOR SUPERFICIAL BLADDER TUMORS: A RANDOMIZED PROSPECTIVE STUDY

PURPOSE This study was designed to find a new therapeutic modality that may have the same efficacy and lower toxicity than bacillus Calmette-Guerin (BCG) for the treatment of superficial transitional cell carcinoma of the bladder. MATERIALS AND METHODS Between January 1993 and July 1997 a prospective randomized trial was conducted on 139 patients with stages pTa and pT1 bladder transitional cell carcinoma to compare the prophylactic efficacy and toxicity of sequential BCG and epirubicin (group 1) versus BCG alone (group 2). Group 1 comprised 69 patients who received alternating doses of 150 mg. BCG and 50 mg. epirubicin (1 drug at a time), while 70 patients in group 2 received 150 mg. BCG at each instillation. Treatment was continued for 6 weeks followed by 10 monthly instillations. RESULTS Therapy was discontinued permanently in 3 group 1 and 12 group 2 patients due to severe side effects, and they were excluded from the study. Among the 124 evaluable patients (96 men and 28 women, mean age 58.2 years) mean followup was 30.4 months (range 12 to 50). Recurrence and progression rates were statistically comparable in both groups. Interval to first recurrence with or without progression was longer in group 1 than in group 2 (log rank p = 0.05). Toxicity and complications were significantly lower with sequential treatment than with BCG alone at rates of 27.3% (18 patients) and 70.7% (41), respectively (p = 0.001). CONCLUSIONS Sequential BCG and epirubicin are comparable to BCG alone in efficacy and superior in terms of toxicity.

Digital subtraction angiography in potential live-kidney donors: a study of 1000 cases.

Intravenous digital subtraction angiography (IV-DSA) combined with excretory urography (IVU) were utilized to study the renal anatomy of 1000 potential live-kidney donors. In the entire series, 712 donors (71.2%) had bilateral single renal arteries, whereas 255 (25.5%) had unilateral multiple, 26 (2.6%) had bilateral multiple, and 7 (0.7%) had unilateral hypoplastic or absent renal arteries determined by IV-DSA. Major renal abnormalities that might be potentially significant for safe renal donation were detected in 76 donors (7.6%) by combined IV-DSA and IVU studies. In 10% of the potential donors, intraarterial digital subtraction angiography (IA-DSA) was required because of the equivocal results of IV-DSA. Of the 1000 potential donors, 700 underwent nephrectomy and the number of renal arteries at nephrectomy was compared with both IV-DSA and IA-DSA reports. Analysis of data revealed a sensitivity of 96% vs 95%, a specificity of 57% vs 75% and an overall accuracy 93% vs 90% for IV-DSA and IA-DSA, respectively. both IV-DSA and IA-DSA were accurate enough in identification of single renal arteries. However, the accuracy of IA-DSA was better than that of IV-DSA in visualization of double (84% vs 64%) and triple (66% vs 33%) renal arteries. It is concluded that IV-DSA combined with IVU is an effective technique for the evaluation of potential kidney donors. In cases where IV-DSA is equivocal, we recommend confirming IA-DSA.

Long-term follow-up of the remaining kidney in living related kidney donors

In this work 45 living related kidney donors (LRD) and 20 healthy sex and age matched controls were examined. Donors were evaluated up to 122 months after donation. Hyperfiltration was observed in the remaining kidney with a mean one-kidney GFR value of 82.9±36.8 ml/min while the control value was 71.04±31.5 ml/min. The kidney was significantly larger in the donor group than in the controls. In the LRD group, 3 were hypertensive, 7 showed microscopic haematuria and 5 had mild proteinuria. In the control group 3 were mildly hypertensive, and 2 showed microscopic haematuria. Serum creatinine of the donor group was found to be significantly higher than in the controls, yet it was stable and within the normal range (0.89±0.28 mg/dl).Examination for microalbuminuria showed that 11% of the donor group excreted higher amounts of albumin, being above the upper limit of the control group.We have concluded that kidney donation will result in minor abnormalities in kidney functions which will not affect the donor morbidity or mortality.

Ureteric Injury After lumbosacral Discectomy : A Case Report and Review of the Literature

Herein, a case of ureteric injury was inflected during lumbo-sacral laminectomy is reported to be added to the previously published 15 cases. Ureteric injury is a rare complication that may be encountered during lumbar disc surgery. We traced 15 cases that were published in literatures allover the past years with different management techniques. To the best of our knowledge, we report the first case that was treated by ileal ureteric replacement. Special attention should be paid regarding ureteric injury during surgery. Despite rare incidence of such injury with laminectomy, there were some reportable complications. So, surgeons should be aware of prediction, early diagnosis, and possible management alternatives for such injuries to safe patients from unsuspected handicapping.

Clinical and urodynamic efficacy of oxybutynin and verapamil in the treatment of nocturnal enuresis after formation of orthotopic ileal neobladders : A prospective, randomized, crossover study

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.

Xanthogranulomatous Pyelonephritis in Bilharzial Patients: A Report of 25 Cases

The preoperative diagnosis of xanthogranulomatous pyelonephritis is difficult due to its similarities to other renal diseases. Also, its relationship to bilharziasis to the best of our knowledge has never been studied. We attempted to explore these 2 problems by reviewing the files and pathological slides of 25 patients whose diagnosis was proved histopathologically to be xanthogranulomatous pyelonephritis. We concluded that the diagnosis of xanthogranulomatous pyelonephritis preoperatively still is difficult. We believe that bilharziasis is an etiologic factor for the disease by increasing the incidence of urinary tract obstruction, infection and stone formation. We plan to study this relationship further by examining the freshly removed kidneys immunohistologically.

Construction of predictive models for recurrence and progression in >1000 patients with non-muscle-invasive bladder cancer (NMIBC) from a single centre.

To construct predictive models based on the objectively calculated risks of progression and recurrence of non‐muscle‐invasive bladder cancer (NMIBC) in a large cohort of patients from a single centre.

DWI-MRI: Single, Informative, and Noninvasive Technique for Prostate Cancer Diagnosis

Aim. To evaluate diffusion weighted image-MRI (DWI) as a single diagnostic noninvasive MRI technique for prostate cancer (PCa) diagnosis. Material and Methods. A prospective study was conducted between July 2008 and July 2009. Candidates patients were equal or more than 40 years old, with suspicious digital rectal examination (more than clinical T2) or PSA >4 ng/mL. Informed consent was signed. DWI-MRI was performed at 1.5 T with a body coil combined with a spine coil in consecutive 100 cases. The histopathology of biopsies has been used as reference standard. Two examiners were evaluating MRI and TRUS, both of them were blinded regarding pathological findings. Accuracy, specificity, and sensitivity were statistically analyzed. Results. Based on pathological diagnosis: group A (cancerous); 75 cases and group B (non-cancerous); 25 cases. Mean age was 65.3 and 62.8 years in groups A and B, respectively. Mean PSA was 30.7 and 9.2 ng/mL in groups A and B, respectively. Sensitivity of DWI was 58.3% while specificity was 83.8%. Accuracy of lesion detection was 52.4–77.8% (P < 0.05). Moreover, DWI at ADC value 1.2 × 10−3 mL/sec could determine 82.4% of true positive cases (P < 0.05). ADC values were lower with Gleason score ≥7 (P < 0.05). Conclusion. DWI could represent a non invasive single diagnostic tool not only in detection and localization but also in prediction of Gleason score whenever DWI is used prior to invasive TRUS biopsy. Furthermore, targeted single biopsy could be planned after DWI to minimize patient morbidity by invasive techniques.