Ahmed Abdelhalim

Prostatic abscess: Objective assessment of the treatment approach in the absence of guidelines

Abstract Objective: To assess the outcome of the drainage procedure used for treating a prostatic abscess, and to propose a treatment algorithm to reduce the morbidity and the need for re-treatment. Patients and methods: We retrospectively reviewed patients who were admitted and received an interventional treatment for a prostatic abscess. All baseline relevant variables were reviewed. Details of the intervention, laboratory data, duration of hospital stay, follow-up data and re-admissions were recorded. Results: A prostatic abscess was diagnosed in 42 patients; 30 were treated by transurethral deroofing and 12 by transrectal needle aspiration. The median (range) size of the abscess was 4.5 (2–23) mL and 2.7 (1.5–7.1) mL in the deroofing and aspiration groups, respectively (P = 0.2). In half of the cases multiple abscesses were evident on imaging before the intervention. The median (range) hospital stay after deroofing and aspiration was 2 (1–11) and 1 (1–19) days, respectively (P = 0.04). Perioperative complications occurred only in the deroofing group, in which two patients developed septic shock requiring intensive care (Clavien 4) and one developed epididymo-orchitis (Clavien 2). There were two late complications in the deroofing group, in which one patient developed a urethral stricture that required endoscopic urethrotomy (Clavien 3a) and one developed a urethral diverticulum and urinary incontinence that required diverticulectomy and a bulbo-urethral sling procedure (Clavien 3b). A urethro-rectal fistula developed after aspiration in one patient. Re-treatment for the abscess was indicated in two (7%) patients in the deroofing group, which was treated by aspiration. Conclusion: Transrectal needle aspiration for a prostatic abscess, when done for properly selected cases, could minimise the morbidity of the drainage procedure.

Ileal Urinary Reservoir in Pediatric Population: Objective Assessment of Long- term Sequelae With Time-to-event Analysis

OBJECTIVE To evaluate the long-term outcomes of an ileal urinary reservoir in children. METHODS This was a longitudinal study of pediatric patients who had undergone total ileal substitution of the bladder. Continence status was assessed, and all patients were evaluated for kidney function and biochemical profile. Standardized growth charts were used to assess linear growth. To assess bone mineral density, dual-emission x-ray absorptiometry scanning was performed. Claviens scale was used to report and grade the long-term complications and their timing. We used a simple quality of life questionnaire to assess the effect of the procedure on the quality of life of the growing child. RESULTS A total of 17 patients were included; 3 with orthotopic and 14 with continent cutaneous reservoirs. After a mean follow-up of 87.3 months, all patients were voiding with clean intermittent catheterization, with a 94% final continence rate. Two patients (11.7%) had an estimated glomerular filtration rate of ≤ 45 mL/min/1.73 m(2) at the last follow-up examination. However, no clinically manifest metabolic acidosis was detected. No anemia or neurologic deficit was detected, with a low-normal serum level of vitamin B(12) in 2 patients (11.7%) and a low level in 1 patient (5.7%). One patient (5.7%) had chronic diarrhea. Low bone mineral density was found in 4 patients (22.8%), with 3 patients (17.1%) not exceeding the fifth percentile of height for age. High-grade complications (grade 3a-5) represented 64.5% of the complications, and the need for reintervention occurred late in the follow-up period. A high level of quality of life satisfaction was reported (88.5%). CONCLUSION Ileal neobladder construction allows child to pass into adolescence dry with more confidence and self-esteem, with no external urine collection set. However, long-term follow-up is mandatory to maintain the positive outcome.

Colovesical Fistula: Unexpected Complication 7 Years After Augmentation Ileocystoplasty

Augmentation enterocystoplasty has been extensively used to attain high-capacity low-pressure urinary reservoirs in patients with neuropathic bladder, exstrophy-epispadias complex, valve bladder syndrome, and contracted bladder. Enterovesical fistula might occur as an early complication after enterocystoplasty. We report the case of a 16-year-old boy, who presented with chronic watery diarrhea 7 years after augmentation ileocystoplasty. A colovesical fistula was diagnosed. We discuss the clinical presentation, management plan, and operative findings.

Complete Primary Repair of Bladder Exstrophy: Critical Analysis of the Long-term Outcome

OBJECTIVE To demonstrate the long-term outcome of a contemporary series of 64 children who underwent complete primary repair of bladder exstrophy (CPRE) in a single tertiary referral center. MATERIALS AND METHODS Between 1998 and 2012, 64 children, 47 boys and 17 girls, were identified. Only 60 of the 64 cases were available for follow-up. The follow-up was done by renal bladder ultrasound and serum creatinine every 3 months and voiding cystourethrogram from 6 to 12 months postoperatively. Continence was defined as dryness ≥3 hours. RESULTS Median (range) follow-up is 14 years (from 5 to 19 years). Voided continence was achieved in 14 children (23%) after CPRE only. Additionally, 6 children were continent after bladder neck reconstruction (BNR) and 2 after bladder neck injection (BNI), raising the percentage of voided continence to 36%. The remaining 38 (64%) patients were using clean intermittent catheterization. All cases were continent at last assessment. The results of BNR or BNI were better in de novo than in redo cases (P <.05). The percentage of cases that needed augmentation ileocystoplasty in combination with multiple bladder neck procedures was lower in both female and de novo cases (P <.05). CONCLUSION The percentage of children with classic bladder exstrophy who underwent CPRE who will achieve continence with volitional voiding via the urethra is 36%. The continence results after BNR and BNI are better in de novo cases than in redo ones. Continence in female and de novo cases is more likely to be achieved with lower number of continence procedures.

Cloacal Duplication: Single-center Experience in the Management of a Rare Anomaly

Cloacal duplication is an exceedingly rare group of anomalies with a limited number of cases reported so far. The anomaly may be confined to partial bladder duplication or it may involve complete duplication of the urogenital tract, hindgut, spine, lower limbs, and vascular structures. Every case is unique and ought to be approached individually. By means of imaging studies and endoscopy, anatomic details should be carefully defined before endorsing surgical correction. A satisfactory outcome can be achieved in the majority of cases. In this report, we describe 3 girls with cloacal duplication, and review pertinent imaging and surgical management.

MP10-15 PATTERNS OF RECURRENCE IN DIFFERENT HISTOLOGICAL SUBTYPES OF BLADDER CANCER FOLLOWING RADICAL CYSTECTOMY

INTRODUCTION AND OBJECTIVES: While recurrent disease patterns following radical cystectomy (RC) for urothelial carcinoma (UC) of the urinary bladder have been described, little is known regarding other histologic subtypes of bladder cancer. Herein, we describe recurrence patterns of different histological subtypes {adenocarcinoma (AC), squamous cell carcinoma (SCC), and UC with glandular/squamous metaplasia (UCM)} following RC. METHODS: We retrospectively analyzed patients who underwent RC between 1997-2004 at a Mansoura, Egypt. Patient demographics, tumor pathologic features and recurrence sites were retrieved. The association between recurrence sites and different histopathological features was evaluated. RESULTS: Of 1,238 RC patients identified, 374 (30%) {181 (48%) UC, 105 (28%) SCC, 35 (9%) AC, and 53 (14%) UCM} had recurrent disease. 180 (48%) had local recurrence, 106 (28%) had distant, and 88 (24%) had both. SCC had the highest local (62%), UC the highest distant (32%), and UCM the highest combined local and distant recurrence rates (30%) (p1⁄40.05). High tumor stage was significantly associated with recurrence, regardless of the site (p1⁄40.006). There were no significant associations between recurrence sites and tumor grade, lymphovascular invasion, lymph node positivity, a history of schistosomiasis infection, gender, and age (p>0.05 for all). The most common site of local recurrence was the pelvis (87%) across all histologic subtypes; for distant recurrence, the most common site (50%) was bone (Table 1). AC recurred the most in bone (62%) and less in the lung (5%), while lung metastasis accounted for 16% of SCC recurrence. CONCLUSIONS: Patterns of disease recurrence vary significantly among different histopathological types and stages of bladder cancer. Tumor grade, lymphovascular invasion, lymph node positivity, schistosomiasis history, gender, and age are not associated with patterns of recurrence following RC for bladder cancer; further study is required to explain recurrence patterns.

PD33-04 PATHOLOGICAL CHARACTERISTICS AND PROGNOSTIC INDICATORS OF DIFFERENT HISTOPATHOLOGICAL TYPES FOLLOWING RADICAL CYSTECTOMY: A LARGE COHORT WITH LONG-TERM FOLLOW-UP

INTRODUCTION AND OBJECTIVES: Pathological features and prognostics are better characterized for urothelial cancer (UC) compared to other histological types. Herein we determined differences in pathological features and prognostics among 4 different histological types: UC, UC with metaplasia (UCM), squamous cell carcinoma (SCC) and adenocarcinoma (ADC) utilizing a large cohort of radical cystectomy (RC) patients with long term follow up. METHODS: We retrospectively evaluated 1,280 patients who underwent RC between 1997-2004 at Mansoura, Egypt. Pathological features were compared and prognostics were determined using multivariate analyses; after exclusion of very rare types. RESULTS: We included 1,238 patients (975 males) with median age 58 (29-87) and a median follow up 39 months (0-109). There were significant differences between pathological features and demographics among different subtypes (Table 1, all p <0.05). Schistosmiasis was associated with SCC and ADC (76%) followed by UCM (69%). Nearly all patients with UC and UCM had high-grade disease, versus 41% and 68% patients with SCC and ADC, respectively. Grade was an independent predictor of recurrence only in SCC (HR 1.6, p value 1⁄4 0.023). Despite the lower incidence of lymphovascular invasion (LVI) in SCC and ADC, it was an independent prognostic in these subtypes (HR 2.1, p < 0.05). Lymph node (LN) involvement was most common in UCM (1/3 of cases) and was the most predictor of recurrence (HR 2.14, p value 1⁄4 0.012). CONCLUSIONS: Histological subtypes of bladder cancer differ significantly in clinicopathological features and prognostics. SCC and ADC are more associated with younger age, schistosomiasis, and low grade tumor, less LVI and LN involvement. LVI seems to play a greater prognostic role in SCC and ADC. LN metastasis is more common and is associated with worse oncological outcomes in UCM. Future subtype specific prognostic models based on independent predictors can guide selection for multimodal treatments and clinical trials design. Source of Funding: none

Primary Yolk Sac Tumor of the Prostate in a Child: Case Report

Extragonadal germ cell tumors comprise a rare entity of germ cell neoplasms. The central nervous system, mediastinum, and retroperitoneum are the most common locations. The prostate is a rare potential site, with only 7 cases reported in the literature to our knowledge. The diagnosis is on the basis of elevation of serum afetoprotein (AFP) level, characteristic histologic appearance, and positive immune-histochemical staining for AFP. Exclusion of a testicular primary, using physical and ultrasound examination, is critical before the diagnosis is made. The role of testicular biopsy has been debated. Microscopically, the tumor is composed of polygonal cells arranged in solid sheets, microcystic, papillary, or glandular structures. Tumor cells have eosinophilic cytoplasm, prominent nucleoli, and stain positive for AFP. The exceptional rarity of the disease, absence of reproducible treatment protocols in addition to lack of reference ranges for AFP in young children adds to the diagnostic and therapeutic conundrum of prostatic yolk sac tumor in children. Treatment is essentially multimodal entailing platinumbased chemotherapy and radical surgery. A survival advantage was noted with preoperative chemotherapy. Herein we report, to our knowledge, the first case of primary prostatic yolk sac tumor in a child who was treated with combination chemotherapy followed by radical prostatectomy. Unfortunately, the disease relapsed 17 months after the initial diagnosis and the patient eventually succumbed to the disease. Because of the dismal prognosis of the disease, a strict long-term follow-up including testicular surveillance for metachronous tumors is mandatory.

390 ROLE OF KI-67 PROLIFERATION MARKER IN PREDICTING RECURRENCE OF HIGH GRADE TA & T1 BLADDER TRANSITIONAL CELL CARCINOMA

However, the AUC increased significantly to 0.74 when gamma-H2AX ratio was incorporated. CONCLUSIONS: Our findings suggest that a higher susceptibility to induction of DSBs as measured by the gamma-H2AX assay is significantly associated with an increased risk for bladder cancer. This might help to identify individuals at high risk for this cancer, adding new perspectives to established epidemiological and genetic risk factors. Further research of the role of gamma-H2AX in biological processes of bladder cancer is warranted.