B. Lobel

Consensus statement on bladder injuries

The consensus on genitourinary trauma continues this month with the statement on bladder trauma from several internationally recognised experts on the subject. They describe blunt, penetrating and iatrogenic injuries and their management, considering paediatric injuries separately. They underline the importance of prompt diagnosis and treatment, stressing that problems raised when the diagnosis is delayed.

Prognostic significance of the mode of detection in renal tumours

Objective u2002To evaluate the mode of detection of 400 renal tumours as a prognostic factor compared with the usual clinical and pathological prognostic variables.

Value of immunohistochemical Ki-67 and p53 determinations as predictive factors of outcome in renal cell carcinoma☆

OBJECTIVESnNuclear grade and tumor stage are important prognostic factors in renal cell carcinoma, but tumors of similar stage and grade can exhibit a wide variation in biologic behavior and clinical outcome. In this retrospective study, we evaluated the immunologic markers, Ki-67 (MIB1) and p53, in 73 cases of conventional (clear cell) renal cell carcinoma and compared these markers with the accepted prognostic features of grade, stage, and tumor size in predicting outcome.nnnMETHODSnSpecimens of 73 renal cell carcinomas of different nuclear grade (20 Furhman I/II, 32 Fuhrman III, and 21 Fuhrman IV) and different stage (10 pT1, 23 pT2, 36 pT3, and 4 pT4) were immunostained with monoclonal antibodies against Ki-67 and p53.nnnRESULTSnUnivariate statistical analysis showed that tumor size (P <0. 001), nuclear grade (P <0.01), tumor stage (P <0.01), Ki-67 index (P <0.001), and p53 immunostaining (P <0.03) correlated significantly with a poor prognosis. A Ki-67 index of 20% was a powerful predictor of survival in all patients (P <0.00001), with strong predictive values. On multivariate analysis, the Ki-67 index and metastases were significant independent prognostic factors (P <0.02 and <0.01, respectively).nnnCONCLUSIONSnKi-67 immunostaining appeared to be an additional prognostic indicator of biologic aggressiveness in renal cell carcinoma. Immunohistochemical assessment of tumor antigens could be used to identify patients at high risk of tumor progression in addition to conventional prognostic factors.

A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments.

Objectives To determine the feasibility of a conservative (expectant) approach to major blunt renal laceration with urinary extravasation and devitalized renal segments.

Early endoscopic realignment of post-traumatic posterior urethral disruption

OBJECTIVESnThe management of complete or partial urethral disruption is controversial, and much debate continues regarding immediate versus delayed definitive therapy. We further analyze our experience and long-term results using early endoscopic realignment.nnnMETHODSnBetween April 1987 and January 1999, 29 men with posterior urethral disruption (23 complete and 6 partial) underwent primary urethral realignment 0 to 8 days after injury. Pelvic fractures were present in 23 patients. In all patients, the actual operating time for realignment was 75 minutes or less. All patients were evaluated postoperatively for incontinence, impotence, and strictures.nnnRESULTSnAfter a mean follow-up of 68 months (range 18 to 155), all patients were continent. Four patients (13.7%) required conversion to an open perineal urethroplasty. At the last follow-up visit, 25 (86%) of the 29 patients were potent and 4 achieved adequate erections for intercourse using intracorporeal injections (prostaglandin E(1)). Twelve patients (41%) developed short secondary strictures and were successfully treated with internal urethrotomy. The mean follow-up of these 12 patients was 83 months (range 34 to 120). Urinary flow rate measurement at the last follow-up visit revealed satisfactory voiding parameters in all patients.nnnCONCLUSIONSnPrimary endoscopic realignment offers an effective method for treating traumatic urethral injuries. Our long-term follow-up provides additional support for the use of this technique by demonstrating that urethral continuity can be established without an increased incidence of impotence, stricture formation, or incontinence. In case of failure, endoscopic realignment does not compromise the result of secondary urethroplasty.

Is ipsilateral adrenalectomy a necessary component of radical nephrectomy

Due to the increased use of modern imaging systems during the last few years, kidney tumors are often diagnosed at an earlier and less advanced stage. This fact implies a reevaluation of the operative technique of radical nephrectomy that was recommended 30 years ago. The ipsilateral adrenal involvement during radical nephrectomy for renal cell carcinoma is assessed and the necessity of its extirpation is discussed. Between September 1987 and September 1993, we performed 299 radical nephrectomies for renal cell carcinoma and removed 285 ipsilateral adrenal glands. Eleven adrenal glands (3.8%) were involved with the kidney tumor and 274 (96.2%) were free of disease. In 7 of the adrenal gland involved cases (63.6%) the tumor invaded the gland by direct extension from the superior pole of the kidney. In the other 4 cases the ipsilateral adrenal gland was affected by a metastatic lesion. In all 11 adrenal gland involved cases the tumors were at an advanced stage (the lowest was stage pT3N1). Our results led us to recommend adrenalectomy during radical nephrectomy only when direct extension of the kidney tumor into the gland is suspected (upper pole or large tumors) or when the adrenal is the site of a single metastasis. Macroscopically normal adrenal glands at radical nephrectomy should not be routinely extirpated. Metastatic renal cell carcinoma (not by contiguity) in the ipsilateral adrenal gland should be regarded as a stage M+ (distant metastasis) tumor.

Accuracy of ultrasound diagnosis after blunt testicular trauma

The aim of this study is to determine the value of ultrasound evaluation for the diagnosis of testis rupture due to blunt scrotal trauma. We reviewed 16 operated cases of blunt scrotal trauma with hematocele, which were evaluated by ultrasound preoperatively. In 2 cases a tunica albuginea rupture was correctly diagnosed by ultrasonography but there were 2 false-positive and 5 false-negative diagnoses of rupture. Systematic exploration of the 16 cases revealed testicular rupture in 7, simple hematocele in 7 and hematocele associated with spermatic cord injury in 2. In 2 cases orchiectomy was necessary. From our experience the accuracy rate of ultrasound evaluation of blunt scrotal trauma was 56%, with a 58% negative predictive value. Considering these results, ultrasound examination of blunt scrotal trauma with hematocele is not sufficiently accurate to eliminate surgical exploration and, therefore, we recommended early surgical exploration as primary therapy in these cases.

45 Chromophobe renal cell carcinoma: A comprehensive analysis of 104 cases from a multicentric European database

bjectives. To analyze the clinical behavior of chromophobe renal cell carcinoma (CRCC), we retrospecively evaluated the data from six European centers. In 1985, CRCC was identified as a new RCC histologic ubtype. Because of its low frequency, only few large CRCC series are available. ethods. We created a renal cancer database including 3228 patients who underwent surgery between 986 and 2002 in six European centers. The relevant clinical and pathologic data were extracted from the linical charts at each institution and collected into a unique database. esults. Of the 3228 patients, 104 (3.2%) affected by CRCC were identified. The mean age at diagnosis was 7.6 years (range 22 to 83). Of the 104 patients, 51 (49%) were men and 53 (51%) were women. The mean umor size was 6.4 3.6 cm. An incidental diagnosis accounted for 61.5% of the cases. Radical nephrecomy was performed in 88 patients (85%). After a median follow-up of 38 months (mean 44, range 1 to 153), o local recurrence was observed. The 5-year overall survival rate for CRCC was 81%. Of the 104 patients, (4.8%) and 9 (8.6%) died of unrelated causes and renal cancer, respectively. onclusions. Our series confirmed a favorable outcome for the CRCC subtype with little local aggressiveess and a low propensity for progression and death from cancer. UROLOGY 65: 681–686, 2005.

Artificial sphincter insertion after radiotherapy: is it worthwhile?

Objective To determine the influence of radiotherapy on the outcome of artificial urinary sphincter implantation.

Spinal cord compression in metastatic prostate cancer.

INTRODUCTIONnSpinal cord compression (SCC) in metastatic prostate cancer is not rare occurring in 1 to 12% of patients. We have analysed patients treated for this condition in our institution assessing outcome and prognostic factors.nnnMATERIAL AND METHODSnRetrospective analysis of the notes of 24 patients hospitalised with SCC due to metastatic prostate cancer from 1987 to 2001.nnnRESULTSnAt presentation 3 patients were ambulant with mild neurological deficit, 12 patients were paraparetic and 9 patients were paraplegic. Diagnosis was established by emergency myelogram, CT-scan or MRI of the spine. 8 patients had received no hormone treatment prior to diagnosis of SCC. 19 patients presented dorsal or lumbar pain requiring opioid treatment on average 60 days before onset of neurological symptoms (range 10-840). All patients underwent steroid treatment; the 8 patients without prior hormone therapy were treated with bilateral orchidectomy, 1 out of these 8 patients had castration without other treatments; 12 patients underwent radiotherapy alone and 9 radiotherapy and laminectomy; 2 patients were in terminal conditions and receive only steroid treatment. Overall 15/24 patients were ambulant after treatment. 8 out of 9 patients treated by laminectomy and radiotherapy were ambulant after treatment versus 7 out of 12 patients treated by radiotherapy alone.17 patients died during follow-up with a median survival of 4 months (2 weeks to 49 months). 7 patients were alive at the last control with a mean follow-up of 10 months (range 4-40).nnnCONCLUSIONnOutlook in patients with spinal cord compression from metastatic prostate cancer is poor. Efforts must be concentrated on prevention of spinal cord compression. Patients with hormone resistant prostate cancer who develop persistent back pain should undergo imaging studies (bone scan, spine CT-scan or MNR) and prophylactic local radiotherapy to the spine if bony metastases are identified.