Eirikur Jonsson

Incidental Detection of Renal Cell Carcinoma is an Independent Prognostic Marker: Results of a Long-Term, Whole Population Study

PURPOSE The true effect of incidental detection on the survival of patients with renal cell carcinoma has been debated. We used centralized databases in Iceland to study prognostic factors of survival, focusing on the effect of incidental detection. MATERIALS AND METHODS This retrospective study included all living patients diagnosed with renal cell carcinoma in Iceland from 1971 to 2005. Hospital charts and histology were reviewed. Incidentally diagnosed renal cell carcinomas were compared to symptomatic tumors and prognostic factors were evaluated using Cox multivariate analysis. RESULTS Of the 910 patients 254 (27.9%) were diagnosed incidentally, most often by abdominal ultrasound (29.5%) or computerized tomography (28.3%). The incidental detection rate increased from 11.1% in 1971 through 1975 to 39.2% in 2001 through 2005 (p <0.001). During the same period the incidence increased significantly in males but in females only during the last 5 study years. Mortality remained unchanged for each gender. Incidentally detected tumors were an average of 2.6 cm smaller and diagnosed at lower stage and lower grade than symptomatic tumors. Age and histology were similar in each group. TNM stage was by far the strongest independent prognostic factor of survival but age, calendar year of diagnosis and ESR were also significant. After correcting for confounders patients with symptomatic renal cell carcinoma had worse survival than those diagnosed incidentally. CONCLUSIONS With increased incidence and unchanged mortality the survival of patients with renal cell carcinoma has improved. This is mainly related to a steep increase in incidental detection. Incidental detection affects survival favorably and to a greater extent than can be explained by lower stage compared to the survival of patients diagnosed with symptoms.

Angiographic Management of Retroperitoneal Hemorrhage from Renal Angiomyolipoma in Polycystic Kidney Disease

Angiographic management of bilateral angiomyolipomas complicated by hemorrhage in autosomal dominant polycystic kidney disease is presented. The patient had mild stigmata of tuberous sclerosis, and a family history of tuberous sclerosis and autosomal dominant polycystic kidney disease. The radiographic features at diagnosis, and those present during and after embolization are described. Radiological criteria for diagnosis and successful control of bleeding with intra-arterial selective embolization are discussed. Radiographic features before, during and after embolization are exhibited.

Continuous Infusion of Intrathecal Morphine to Control Acquired Immunodeficiency Syndrome-Associated Bladder Pain

A 36-year-old man with acquired immunodeficiency syndrome had incapacitating dysuria and vesical pain secondary to interstitial cystitis. When medical management and suprapubic urinary diversion failed to control the symptoms the patient was started on subarachnoid morphine sulfate. Bupivacaine was added 1 year later via an implanted Therex M-3000 implantable continuous infusion pump, which has continued successfully for more than 18 months. We believe that subarachnoid narcotics and other analgesic agents, such as clonidine, bupivacaine hydrochloride and baclofen, may prove equally valuable in the treatment of bladder spasm and pain. Furthermore, implanted intrathecal ports and pumps may have less associated risk of infection than the percutaneous vascular access catheters presently used for the continuous delivery of medications in immunosuppressed patients.

Explosion of the urinary bladder during transurethral resection of the prostate

Abstract Transurethral resection of the prostate (TURP) remains the gold standard for the surgical treatment of benign prostatic hyperplasia. Complications during the procedure are rare. An extremely rare complication is a rupture of the urinary bladder. This article reports a case where an explosion occurred during TURP, resulting in a large intraperitoneal rupture of the urinary bladder. The patient underwent emergency laparotomy to repair the bladder.

Chromophobe renal cell carcinoma in Iceland: An epidemiological and clinicopathological study

Abstract Objective. Numerous studies have suggested that the rare chromophobe renal cell carcinoma (CRCC) has a more favourable prognosis than the other more common subtypes of RCC, clear cell RCC (CCRCC) and papillary RCC (PRCC). These studies have, however, usually involved selected patient cohorts and not whole populations. This study compared CRCC patients with patients with the other two major histological subtypes and established a population-based age-standardized incidence rate (ASR). Material and methods. Of 828 histopathologically confirmed RCCs diagnosed between 1971 and 2005 in Iceland, 15 CRCC cases were identified. Histological material was reviewed, the TNM system was used for staging and cancer-specific survival was estimated. Univariate and multivariate analysis was used to compare CRCC to both CCRCC (n = 740) and PRCC (n = 66). Mean follow-up was 6.7 years. Results. CRCC accounted for 1.8% of RCCs, the ASR being 0.17/100 000 per year. Compared to other subtypes, CRCC was detected incidentally less often (7% vs 29%, p = 0.02), but was more often diagnosed at lower stages (73% vs 45% at stage I + II, p < 0.001). One patient had synchronous metastasis and another developed recurrent CRCC; both died of CRCC. Five-year survival for CRCC, CCRCC and PRCC was 86%, 59% and 50%, respectively (p = 0.004). After correcting for TNM stage (odds ratio 1.98), multivariate analysis did not indicate that CRCC subtype was an independent predictive factor for survival. Conclusion. CRCC is a rare neoplasm with an ASR of 0.17/100 000 per year. These tumours often present with symptoms despite being at lower stages than the other RCC subtypes. The more favourable survival of the CRCC subtype appears to be explained by these tumours being diagnosed at low stages. These findings may suggest that CRCC has a different biological behaviour.

Evaluation and comparison of five experimental BPH/prostate cancer treatment modalities

Five non-pharmacological, experimental, prostate (benign hyperplasia/cancer) treatment modalities including transurethral radiofrequency thermotherapy (TURT); transurethral microwave thermotherapy (TUMT); transurethral and transrectal microwave thermotherapy (TUMT/TRMT); interstitial laser coagulation (ILC); and interstitial cryotherapy (IC), are evaluated. These and other similar techniques are currently in various stages of development and clinical use. Most of these modalities produce relatively similar effects in tissue; however, each has pathophysiologic features and potential complications which may preference its use in a specific anatomical and/or disease situation. All treatments were performed using the canine prostate model, by the same investigators. Our studies have shown that although the canine prostate does not respond to injury exactly as the human prostate does, the effects are similar enough to be conceptually, and often specifically, valuable from efficacy and safety standpoints. Two of the five treatments evaluated (TURT, TUMT/TRMT) resulted in marked dilation of the prostatic urethra without significant parenchymal effect. Three of the treatments (IC, ILC, TUMT) resulted in parenchymal ablation with only minor dilation of the urethra. Although each technique has encouraging experimental findings, ultimate success will be determined by further definition of the instrumentation technique and appropriate clinical implementation.

Radical cystectomy in the treatment of bladder cancer in Iceland: A population-based study

Abstract Objective: Radical cystectomy (RC) is the standard treatment for muscle-invasive bladder cancer. Postoperative complications are reported to be as high as 65%. The objective of this study was to investigate complications and survival in Icelandic patients with bladder cancer who underwent RC. Materials and methods: All patients who had bladder cancer and underwent RC in Iceland from 2003 to 2012 were included. Information was obtained retrospectively from patients’ medical records and from the Icelandic Cause of Death Registry. Complications were classified according to the Clavien–Dindo classification system. The Kaplan–Meier method was used in the survival analysis. Only patients with transitional cell carcinoma (TCC) were included in the survival analysis. Results: Overall, 108 patients (male 81%, median age 68 years) underwent the procedure during the study period and 100 of them had TCC. Ileal conduit was performed in 86% of procedures and orthotopic neobladder in 14%. The median operation time was 266 min and the median blood loss during the procedure was 1000 ml. No patient died within 30 days of surgery, but one patient (0.9%) died within 90 days of surgery from complications of the surgery. Complications were reported for 62 patients (57%) overall. Major complications (Clavien 3–5) were reported in 32 patients (29%), and 30 patients (28%) had only minor complications (Clavien 1–2). Twenty-four patients (22%) had to undergo reoperation. Overall 5 year survival was 54%. Conclusion: Morbidity after RC is high but similar to that seen in other studies. Long-term survival of Icelandic patients is comparable to that in neighboring countries.

Genome-wide associations for benign prostatic hyperplasia reveal a genetic correlation with serum levels of PSA

Benign prostatic hyperplasia and associated lower urinary tract symptoms (BPH/LUTS) are common conditions affecting the majority of elderly males. Here we report the results of a genome-wide association study of symptomatic BPH/LUTS in 20,621 patients and 280,541 controls of European ancestry, from Iceland and the UK. We discovered 23 genome-wide significant variants, located at 14 loci. There is little or no overlap between the BPH/LUTS variants and published prostate cancer risk variants. However, 15 of the variants reported here also associate with serum levels of prostate specific antigen (PSA) (at a Bonferroni corrected P < 0.0022). Furthermore, there is a strong genetic correlation, rg = 0.77 (P = 2.6 × 10−11), between PSA and BPH/LUTS, and one standard deviation increase in a polygenic risk score (PRS) for BPH/LUTS increases PSA levels by 12.9% (P = 1.6×10−55). These results shed a light on the genetic background of BPH/LUTS and its substantial influence on PSA levels.Elderly males are often affected by benign prostatic hyperplasia and associated lower urinary tract symptoms (BPH/LUTS), but their link to prostate cancer risk is not well defined. Here, a genome-wide association study of BPH/LUTS patients from Iceland and the UK found 23 significant variants at 14 loci, and 15 of these variants associate with prostate specific antigen, which is linked to prostate cancer risk.