Ali Riza Kural

Outcome of Nephron-Sparing Surgery: Elective versus Imperative Indications

Introduction: The increase in the detection of renal tumors incidentally in earlier stages has enhanced the enthusiasm for nephron-sparing surgery (NSS). Patients and Methods: We performed NSS in 76 patients (53 male, 23 female) with a mean age 52.3 between December 1988 and September 2001. Patients were sub-classified into 2 groups as elective or imperative indication group. They were compared regarding surgical technique, time of surgery, pathological analysis, complications, and disease free status. Results: Elective indication group (group I) with a normal contralateral kidney consisted of 50 patients, whereas there were 26 patients in the imperative indication group (group II). Tumors were incidentally detected in 63%; 74% in group I and 42% in group II. Although the mean diameter of the tumor was slightly higher in group II (39.1 vs. 36.3 mm), this difference did not reach statistical significance (p > 0.05). The partial nephrectomy was performed more frequently compared to enucleation in group I (90 vs. 69%, p = 0.050). However, the mean operation time as well as the mean clamping time did not differ significantly between the two groups (p > 0.05). In the histological evaluation tumors were benign in 16 (21%) and malignant in 60 patients. All of the patients but one with renal cell carcinoma had stage T1-T2 disease. Major complications were observed in 14 (18%) and 12 were from group II. Complication rate was significantly higher in group II (p = 0.000). Of 60 patients with renal cell carcinoma, 2 died of unrelated causes. One patient died with multiple visceral metastases. One patient was lost to follow-up. In the remaining 56 patients with a mean follow-up of 37.1 months (1–152), local recurrence or distant metastases were not detected. Serum creatinine levels have remained almost the same compared to preoperative levels (1.2 ± 0.6 vs. 1.5 ± 0.9). Overall and cancer-specific survivals were 100 and 100% in group I, 85 and 95% in group II, and 94 and 98% for the entire patient population, respectively. Conclusion: NSS is an effective and reliable treatment in low stage renal tumors. It prevents unnecessary nephrectomy in benign lesions that could not be diagnosed preoperatively. However, the patients who underwent NSS with elective indication outcome with better results, compared to those with imperative indication.

Doppler ultrasonography-guided pelvic plexus block before systematic needle biopsy of the prostate: A prospective randomized study.

OBJECTIVESnTo report a new method to block pelvic plexus and compare its efficacy with widely used periprostatic nerve block (PPNB) for transrectal ultrasonography-guided prostate biopsy. Pelvic plexuses were localized with the aid of color Doppler ultrasonography to create the pelvic block.nnnMETHODSnThis study was a single-center, prospective randomized trial. A total of 80 patients were recruited in 2 groups, with 40 patients in each. In group 1 (PPNB group), 2 mL of 2% lidocaine was injected between the prostate base and seminal vesicle on each side, using ultrasonic guidance. In group 2 (pelvic plexus block group), 2 mL of 2% lidocaine was injected into the region of the pelvic plexus lateral to the tip of vesicula seminalis on each side, using ultrasonic guidance. Color Doppler ultrasonography was used to identify injection sites. Patients were given an 11-point visual analog scale (VAS) to evaluate the level of pain encountered during probe insertion, injection of local anesthetic, and biopsy procedure.nnnRESULTSnIn both groups, probe insertion was the least painful stage. With regard to local anesthetic injection, VAS pain score was significantly lower in group 2 (2.05 vs 3.12, P = .0007). Sampling the prostate was the most painful stage in both groups and group 2 had significantly lower biopsy VAS pain scores (2.7 vs 4.97, P < .0001). There were no major complications.nnnCONCLUSIONSnAdministration of lidocaine in the area of the pelvic plexus under Doppler ultrasonographic guidance provides superior analgesia to PPNB, with limited morbidity during transrectal ultrasonography-guided biopsy of the prostate.

Multilocular cystic nephroma: an unusual localization

We present a case of multilocular cystic nephroma with an unusual localization treated by a nephron-sparing procedure. A 21-year-old white woman presented with a history of hematuria and right lumbar pain. Imaging techniques revealed a multilocular cystic mass originating from the renal parenchyma but mainly involving the renal pelvis. The lesion was localized almost entirely within the renal pelvis at surgery and was treated by excision. Pathologic analysis was consistent with multilocular cystic nephroma. The patient remains free of recurrence with 10 years of follow-up. We conclude that multilocular cystic nephroma may present as a cystic lesion localized within the renal pelvis, and we advocate simple excision of these lesions.

Transitional cell carcinoma of the bladder in patients under 40 years of age

There are conflicting reports about the natural history and prognosis of bladder tumours in patients under 40 years of age. A review of 156 patients younger than 40 treated at our Department between 1960 and 1991 with transitional cell carcinoma of the bladder revealed that 89.1% had superficial (Ta/T1) disease and the remaining 10.9% presented with invasive disease. Slightly more than half of the patients with superficial disease had multiple tumours. The follow-up of 97 patients over a period of 12–372 months revealed that there was a recurrence rate of 10.3% and 38.4% for Ta and T1 tumours, respectively (p<0.01). Further analysis comparing patients under 30 to those between 30 and 40 years revealed recurrence rates of 7.5% and 22%, respectively (p<0.05). Progression rates for Ta and T1 tumours are 3.5% and 19.3% (p<0.05). In the invasive disease group 8 patients were lost for follow-up, 2 died of the disease and the remaining 7 are alive, with a mean follow-up of 3.6 years.We conclude that while transitional cell carcinoma of the bladder in patients under 30 behave less aggressively, the behaviour of the disease in patients 30 to 40 years old is similar to the older age group and should be monitored closely, especially when risk factors for recurrence and progression are present.

Small cell carcinoma of the bladder: a case report and review of the literature.

Primary pure small cell neuroendocrine carcinoma of the bladder is a rare condition. It is an aggressive tumor with an average five-year survival rate of less than 10% as cited by multiple case reports. We report a 48xa0year-old male patient with primary small cell neuroendocrine carcinoma of the bladder who was treated with TUR-T, adjuvant carboplatin-based chemotherapy and radiotherapy. The patient is free of disease at the end of 30 months with a normally functioning bladder.

Factors affecting the survival of patients treated by standard nephroureterectomy for transitional cell carcinoma of the upper urinary tract.

Purpose:In this study we tried to evaluate the predictive factors for survival in patients with upper urinary tract tumors. Materials and methods: From 1993 to 2003, 46 patients were treated by standard nephroureterectomy for upper urinary tract tumor, but only 24 patients (52%) who had regular follow-up were included in the study. Age, sex, presenting symptoms of the patients, tumor localization, tumor stage and grade were analyzed with respect to survival. Univariate and multivariate analyses were done using Kaplan–Meier method with log-rank test and Cox proportional hazards regression model, respectively. Results: The median of patient age was 61 years (34–74). Of the 24 patients, 9 (37.5%) were disease-free and alive at a mean time of 54 (26–97) months, 8 (33.3%) died of disease at a mean period of 23.4xa0months (2 because of bladder tumor, 2 had liver metastases, 1 had lung metastasis and 3 had lung and liver metastases) and 7 (29.2%) died disease-free at a mean period of 30.3xa0months. Metastases were detected in a mean period of 11.8 (6–24) months. Survival according to tumor stage Ta, T1-2, and invasive tumors were 87.5, 43.9, 15.7xa0months (p = 0.0001), respectively. Survival of the patients with low-grade tumors was significantly longer than those with high-grade tumors (77.3 and 31.4xa0months, respectively, p = 0.01). Patients with pelvis tumors when compared to ureter tumors (28.5 and 61.6xa0months, respectively, p = 0.038) and those presenting with flank pain when compared to those presenting with macroscopic hematuria and bladder cancer (17.7, 45.7, and 57.9xa0months, respectively, p = 0.046) had shorter survival rates. When multivariate analyses were done using Cox regression test, the only factor that affected survival was the stage of the tumor. Age and gender had no impact on survival. Conclusions: In univariate analysis, the stage, grade, localization of the tumor and presenting symptoms were found important predictors that affect the prognosis of the transitional carcinoma of the upper tract. However, tumor stage was the only independent predictor of survival in multivariate analysis. For high grade and high stage tumors, really effective adjuvant treatments along with aggressive surgery may be considered.

Adult clear cell sarcoma of the kidney: A case report

BackgroundClear cell sarcoma of the kidney (CCSK) in adults is extremely rare. Optimal treatment of adult patients with CCSK remains unclear.Case presentationA 22-year-old man presented with a 2-month history of left flank pain. A color duplex sonography revealed a hypervascular, heterogeneous renal mass. Abdominal and pelvic computerized tomography showed a heterogeneous mass originating from the lower pole of the left kidney and infiltrating to the psoas muscle. Further evaluation including bone scan did not demonstrate any evidence of metastases. A left radical nephrectomy with hilar lymphadenectomy through an intraperitoneal approach with an anterior subcostal incision was performed. The histopathological diagnosis of the mass was a clear cell sarcoma of the kidney. No lymph node metastases were found. Concomitant chemo-radiotherapy was performed. Therapy-related serious side effects were not observed. There was no evidence of local recurrence or metastases during the following twenty-four months after therapy.ConclusionWe believe that the combination therapy is efficacious for preventing the local recurrence and distant metastases. Accurate diagnosis is very important and therapy must also include doxorubicin regardless of the disease stage in adult patients with CCSK.

Polypropylene mesh tape for male sphincteric incontinence

Objective: Management of male sphincteric incontinence is still challenging. We present our experience with a new male sling technique using polypropylene mesh tape (PMT). Material and Methods: A total of 12 patients (age range 17-75 years; median age 61 years) underwent the procedure. Sphincteric incontinence was due to radical prostatectomy in three patients, transurethral prostatectomy in four, open prostatectomy in two and neurologic etiologies in three. All patients had urodynamic stress incontinence with a mean Valsalva leak point pressure of 48.8u2005cmH2O (range 40-68u2005cmH2O). Through a midline incision the PMT sling was passed through the perineal membrane on each side and the limbs of the tape were withdrawn to a suprapubic incision with the help of trocars. The tension of the tape was adjusted during a retrograde sphincterometry until a retrograde leak point pressure of 30-50u2005cmH2O was achieved. Results: The average operative time was 65u2005min (45-110u2005min). Follow-up was 12.1-46.4 months (median 31.6 months). Urinary incontinence was cured or improved in nine patients (75%) and there was no improvement in three (25%). Intermittent catheterization was initiated in three patients with impaired detrusor contractions due to neurologic etiology. One patient had intraoperative bladder perforation and one had perineal numbness lasting for 2 months. None of the patients had urethral erosion, wound infection or any other major complications. Conclusions: This procedure seems to be an effective and safe treatment for patients with sphincteric incontinence. Regarding the etiology of urinary incontinence, this technique seems to be more effective in transurethral prostatectomy-related sphincteric incontinence than in sphincteric incontinence of other etiologies. Further experience with more patients and a longer follow-up period is mandatory to determine the long-term effectiveness of the technique.

Three-dimensional noninvasive contrast-enhanced electron beam tomography angiography of the kidneys: adjunctive use in medical and surgical management.

OBJECTIVEnTo indicate the use of 3D electron beam computerized tomography angiography (EBCTA) for renal artery lesions, vascular variants that are crucial to detect before surgery, especially partial nephrectomy and extension of the intravascular tumor.nnnMETHODSnForty patients (30 men, 10 women, age range 13-82, mean age 54.2) underwent EBCT (GE-Imatron, C 150 ultrafast CT scanner) of the renal arteries. It is essential to review the axial images for all necessary information before the 3D technique is performed.nnnRESULTSnMaximum intensity projection (MIP) and volume rendering (VR) images were excellent in demonstrating stenosis of the renal arteries. Accessory and main renal arteries were easily depicted, and stenosis has been shown. In our study, among 40 renal angiography patients, 21 had stenosis of the renal arteries with different percentages. A total of 12 accessory renal arteries (five left, seven right) were detected. EBCT, with its 3D techniques, was found to be accurate and useful for renal vascular anatomy as a noninvasive test to delineate renal tumors and renal anatomy prior to nephron sparing surgery because it is known to conserve normal renal parenchyma adjacent to tumor.nnnCONCLUSIONnEBCT, with its noninvasive VR and MIP techniques, is easy to apply and is functional and accurate for neoplasms, renal vascular anatomy and renal artery stenosis.

Bilateral Percutaneous Nephrolithotomy in a Patient with Hemophilia A Disorder

A 50-year-old man with hemophilia A presented with recurrent hematuria due to renal stone disease. He was receiving approximately 50,000 units of recombinant factor (rF) VIII concentrate every year due to hematuria. Between 1996 and 2002, his serum creatinine level increased from 0.7 to 1.2 ng/ml. In an effort to resolve the problems of excessive blood loss with transfusions, recurrent rF VIII replacements and deteriorating renal function, he was offered treatment with percutaneous nephrolithotomy (PNL) in conjunction with rF VIII administration. He underwent left PNL for left staghorn calculi in November 2002 with administration of 52,000 units rF VIII, and another PNL for the right kidney in April 2004 with the administration of 90,500 units rF VIII. A pneumatic lithotriptor was used in both operations. The serum creatinine level was 0.8 ng/ml upon completion of treatment and the patient was symptom and stone free at 10-month follow-up. He has not suffered from hematuria since that time. We conclude that bleeding disorders may not be a contraindication for PNL if corrected and monitored appropriately.