Ioannis Anastasiou

Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies.

Study Type – Prognosis (case series)

Prevalence of dementia in elderly patients with hip fracture.

Hip fractures occur commonly and are a cause of disability for older adults and lead to increased dependence and requirements for social support. Dementia is one of the possible risk factors for falling and hip fracture, a potential source for complications during surgery and during the postoperative period, difficulties in rehabilitation and a risk factor for hip fracture reccurence. However, in previous studies of hip fracture patients, cognitive status has not been formally assessed during the inpatient stay and diagnosis was based only on previous history. Additionally, no previous studies have compared prevalence of dementia between elderly patients with hip fracture and patients with other surgical pathology. Our aim was to define whether dementia was more prevalent in older subjects with hip fracture than in other elderly patients undergoing surgery. In this study, we prospectively assessed all patients aged 68 and older admitted to our hospital for hip fracture surgery during a one year period and compared them with age and gender matched patients attending other surgical departments. 80 hip fracture patients and 80 controls were assessed for dementia. Dementia was common in both groups, presumably reflecting the advanced mean age of both groups and cognitive deterioration due to hospitalization-status. Dementia was significantly higher in the hip fracture group (85%) compared to the control group (61.5%; p=0.002). Dementia is very common in older patients admitted for surgery to a general hospital and extremely common in those with hip fracture. It seems that dementia is under diagnosed in elderly hospitalised patients. Our data confirm that dementia is a major risk factor for hip fracture in the elderly.

Radical cystectomy over the age of 75 is safe and increases survival.

BackgroundRadical cystectomy (RC) is probably underused in elderly patients due to a potential increased postoperative complication risk, as reflected by their considerable comorbidities. Our objective was to estimate the overall complication rate and investigate a potential benefit to patients over the age of 75 subjected to RC in terms of disease-free survival.MethodsA total of 81 patients, 61 men and 20 women, from two urological departments, with a mean age of 79.2 ± 3.7 years, participated in the study. The mean follow-up period was 2.6 ± 1.6 years. All patients underwent RC with pelvic lymphadenectomy. An ileal conduit, an orthotopic ileal neobladder and cutaneous ureterostomies were formed in 48.1%, 6.2% and 45.7% of the patients, respectively. The perioperative and 90-day postoperative complications were recorded and classified according to the modified Clavien classification system. Survival plots were created based on the oncological outcome and several study parameters.ResultsThe perioperative morbidity rate was 43.2%; the 90-day morbidity rate was 37%, while the 30-day, 90-day and overall mortality rates were 3.7%, 3.7% and 21%, respectively. Overall mortality rates were recorded at the final year of data gathering (2009). Increased age, increased body mass index (BMI), longer hospitalization and age-adjusted Charlson comorbidity index (ACCI) more than six, were associated with greater hazard for 90-day morbidity. The cumulative mortality / metastasis-free rates for one, two, three and five years were 88.7%, 77.5%, 70.4%, and 62.3%, respectively. Tumour stage and positive nodes were prognostic predictors for oncological outcome.ConclusionsRC in patients over 75 is justified and feasible, due to acceptable complication rates and high 5-year cancer-specific survival, which support an aggressive approach. Prospective studies are needed for the verification of the above results.

Synchronous chromophobe and papillary renal cell carcinoma. First report and review of the pathogenesis theories

The coexistence of different subtypes of renal cell carcinoma (RCC) within a single kidney is an extremely unusual entity. Presented herein is the case of a 57‐year‐old man with two RCC of chromophobe and papillary histology. Very few reports in the literature describe double or triple synchronous renal neoplasms. To our knowledge this is the first report of this RCC subtype combination, which might trigger further investigation on the RCC pathogenesis theories.

Primary Enteric-Type Mucinous Adenocarcinoma of the Urethra in a Patient With Ulcerative Colitis

Primary carcinoma of the male urethra accounts for less than 1% of malignancies in men. Mucinous adenocarcinoma of the urethra is extremely rare, and its biologic behavior is poorly understood. We present herein a rare case of mucinous urethral adenocarcinoma in a male patient with longstanding ulcerative colitis and multiple sclerosis. The patient presented with a voluminous pelvic mass; core biopsy of the lesion demonstrated a mucus-producing adenocarcinoma. Given the patients history of subtotal colectomy, preoperative diagnosis was oriented towards a rectal stump adenocarcinoma. The patient underwent a pelvic exenteration: surprisingly, histology marked the prostatic urethra as the primary lesion site.

Clear cell carcinoma of the lower urinary tract in a male patient. Presentation and update on histogenesis and management.

To the Editor: Clear cell carcinoma (CCC) of the lower urinary tract is a rare condition, especially in men. Only 11 cases have been reported worldwide since then. The differential diagnosis of the disease is problematic for the pathologist. We encountered such a case of invasive CCC of the bladder in a middleaged man with lymph node metastasis, in which clinical information and immunohistochemistry provided significant assistance. Differential diagnosis of CCC includes (i) vesical adenocarcinoma of Müllerian origin; (ii) tubular cystic clear cell adenocarcinoma of the prostate or the seminal vesicles, probably of Müllerian origin; (iii) small papillary urothelial carcinoma of the bladder; (iv) clear cell adenocarcinoma of the urethra; (v) hepatic adenocarcinoma of the bladder with clear cell pattern; (vi) metastatic CCC, such as renal cell carcinoma with coexistence of urothelial carcinoma; and (vii) nephrogenic adenoma, a benign process that may cause a significant diagnostic confusion. In the present case the nephrogenic adenoma was excluded due to the large size of the lesion and the absence of some form of mucosal irritation such as infection, urinary calculi, immunosuppressive treatment, genitourinary trauma or genitourinary tract procedures. Cells were cuboid or flat, in contrast to the CCC, occasionally with a mild to moderate nuclear atypia and a rare mitotic figure. The possibility of a metastatic renal CCC was also ruled out because no renal involvement was evident (Fig. 1). The tumor was identified as a high-grade CCC (Fig. 2), which fully infiltrated the bladder wall, extending into the perivesical fat, the prostate, the spermatic vesicles and four of the resected pelvic lymph nodes. Focal areas with typical characters of high-grade urothelial carcinoma were present. The clear cell element of the malignancy was characterized by a solid, pseudopapillae pattern without a clear vascular axis. The tumor cells were medium sized with an almost spherical and open colored nucleus, clearly visible nucleolus and abundant clear cytoplasm. The tumor infiltrated a great number of blood and lymphatic vessels. No signs of endometriosis or Müllerian duct remnants were recognized. Furthermore, no typical glandular configuration was observed in the outer layer of cells, which had a characteristic hobnail nuclear pattern. The immunohistological phenotype of the CCC is focally or diffusely positive for CA125, which is not a specific marker for this tumor. Moreover, the tumor is positive for cytokeratin 7 (CK7), a keratin that is sensitive but not specific for the urothelial origin of the tumor. CK20 is present in adenocarcinomas and urothelial carcinomas, but is negative or weakly positive in CCC. Positive immunostaining for uroplakin III is also demonstrated in approximately 50% of cases. In the present patient’s mass, neoplastic cells were strongly positively stained for CK7, CK20 (Fig. 3), p53, PAS, weakly positive for CA125, and negative for prostate-specific antigen, CD10, AFP, and hepatocyte, while Ki 67 was highly expressed. The histological origin of these tumors is uncertain, but interesting. A theory of a Müllerian origin was initially proposed. In men the prostatic utricle is considered to be a remnant of the Müllerian duct, while there is also the possibility of remnant elements in the bladder or the urethra. Another theory describes a glandular differentiation of the urothelial carcinoma. A third hypothesis is that CCC are probably adenocarcinomas of non-Müllerian origin, which have a clear cell pattern for unknown reasons. Very recently, compelling evidence was reported for a urothelial origin of CCC of the lower urinary tract, in which urothelial and CCC share common chromosomal mutations. CCC seems to be a particularly aggressive tumor and radical surgery with adjuvant chemotherapy is considered to be the treatment of choice. In contrast, the accumulated experience confirms that despite high stage at diagnosis, a favorable prognosis is maintained regardless of length of follow up. Figure 1 CT of the bladder. Pathology International 2009; 59: 595–597 doi:10.1111/j.1440-1827.2009.02413.x

Multiple Metastases of Prostatic Adenocarcinoma to the Urethra after Radical Prostatectomy

We present a rare case of multiple metastases of a prostatic adenocarcinoma to the urethra. Radical prostatectomy had been performed 13 years before, and during this time he had been frequently treated with transurethral resections of the bladder neck for obstructive urinary symptoms.

The impact of body mass on managelent of patients with renal colic

Objective: To study the impact of bodymass on diagnosis and initial response tomedical treatment in patients presenting withrenal colic. Patients and methods: Onehundred and sixty-five consecutive patientspresenting with symptoms of renal colic havebeen examined. Patients were divided in 3groups according to their body mass index:normal-weight (BMI ≤ 24.9 kg/m2),overweight (BMI 25.0–29.9 kg/m2) and obese(BMI ≥ 30 kg/m2). Diagnosis of renal colicwas based on history, clinical examination,presence of hematuria in a urine sample,appearance of a stone on a plain radiograph,and/or presence of hydronephrosis inultrasonography. In addition, previous historyof renal colic, time to seek medical advice andtime to pain relief following administration ofmedications were examined. Results: Meanbody mass index did not differ between patientswith a history of ≤1, 1–5 and ≥5 renalcolics (P = 0.65). Prevalence rates of appearanceof either lithiasis or hydronephrosis vs normalfindings on the Kidney-Ureter-Bladder plainradiograph or ultrasonography were notdifferent between normal-weight, overweight andobese subjects (P = 0.38 and P = 0.90respectively). The time to seek for medicaladvice and the response to treatment were notdifferent between the study groups (P = 0.24 andP = 0.53 respectively). Conclusion: Bodymass does not have any impact on diagnosis,time to seek for medical advice or response totreatment in patients with renal colic.