Ioannis Karyotis

Independent predictors of failure of shockwave lithotripsy for ureteral stones employing a second-generation lithotripter.

PURPOSE: To define factors associated with the failure of shockwave lithotripsy (SWL) in the treatment of ureteral stones. PATIENTS AND METHODS: We retrospectively studied 405 men and 283 women (mean age 52.6 years) who underwent SWL with a second-generation lithotripter in the period 1994 to 2001. We evaluated available clinical and radiologic features that might have been related to failure of SWL therapy. RESULTS: Treatment was successful in 502 patients (73%). The 186 patients (27%) in whom treatment failed underwent endourologic alternatives or open surgery. Multivariate logistic regression analysis revealed that unsuccessful outcome was significantly related to: (1) pelvic ureteral stones (odds ratio [OR] 4.02; 95% CI 1.97, 8.19); (2) stone size >10 mm (OR 3.46; 95% CI 2.16, 5.53); (3) obstruction (OR 1.93; 95% CI 0.99, 3.77); and (4) obesity (OR 1.87; 95% CI 0.95, 3.77). Although the predictive value of each individual parameter was relatively low (15.3%-27.9%) the cumulative risk was 82.95% when patients had all four features. The strongest independent predictors of failure were pelvic stones and stones >10 mm (cumulative predictive value 57.3%). CONCLUSIONS: These variables may enable identification of a subgroup of patients who will fail initial SWL. These patients may be candidates for endourologic alternatives as first-line treatment.

Nephron-sparing surgery for localized renal cell carcinoma with a normal contralateral kidney: A European three-center experience

OBJECTIVES To assess the long-term effectiveness and safety of nephron-sparing surgery for the treatment of localized renal cell carcinoma with a normal contralateral kidney. METHODS Since 1973, 118 patients have undergone nephron-sparing surgery for renal cell carcinoma on an elective basis at our institutions. The vast majority of these tumors were incidental findings, with a mean tumor diameter of 3.35 cm (range 0.7 to 5.6). The median follow-up was 8.5 years (range 0.5 to 18), and of those patients alive, 27 (28%) were followed up for more than 10 years. RESULTS The pathologic stage was pT1N0M0 in 110 cases (93.2%) and pT3aN0M0 in 8 (6.7%); 59 were grade 1, 52 were grade 2, and 7 were grade 3. Complications occurred in 4 patients, including retroperitoneal bleeding in 1 treated by reoperation, urinomas in 2, and ureteral stricture in 1 treated conservatively. Renal function remained normal during the whole follow-up period, and slight proteinuria was observed in 13 patients. The 10-year distant and local recurrence rate was 4% and 3.9%, respectively. The cancer-specific 5, 10, and 15-year survival rate was 97.3%, 96.4%, and 96.4%, respectively. CONCLUSIONS Our experience, based on a long median follow-up, suggests that nephron-sparing surgery on an elective basis can achieve long-term survival for the treatment of incidental and low-stage renal cell carcinomas without compromising the efficacy of cancer treatment.

Long-term results after percutaneous minimally invasive procedure treatment of symptomatic simple renal cysts

Objective: To assess the effectiveness and long-term results of two repeated ethanol injections in the treatment of symptomatic renal cysts. Methods: Sixty-eight patients 47to 75 years old with 77 large (6.3–14.8 cm; mean 8.62 cm)symptomatic cysts were included in this study. Of the 68patients, in 4 cases there were renal cysts associated with renal calculi. An 8FR Pigtail catheter was inserted into the cyst under ultrasound guidance followed by aspiration of cystic fluid. Two repeated ethanol 95% injections were performed every 24 hours. Patients were followed-up by ultrasonography for a period of 12–48 months (mean 30). Results: In two patients the cyst puncture was not feasible because of poor visualization of puncture site while in one patient there was communication of cystic cavity with the pelvocaliceal system. In these patients surgical resection of cysts was performed. Complete and partial regression rates were 57/68 (83.82%) and 8/68 (11.76%)respectively. In four patients with renal stones and renal cysts, extracorporeal shock wave lithotripsy (ESWL) was successfully executed 1 month after sclerotherapy. Conclusion: Our results suggest that percutaneous aspiration followed by two repeated ethanol injections is highly effective on reducing recurrence of simple renal cysts.

Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: A preliminary case-controlled study

Introduction: Hemostasis is of utmost importance in urologic cancer surgery. The aim of this initial case-controlled study was to evaluate the use of an electrothermal biporal coagulator (Ligasure device) in major urologic procedures, including open radical prostatectomies and radical cystectomies. Materials and methods: Over the years 2001 to 2002, 58 patients patients aged 56–74 years (mean: 65 years) underwent open radical prostatectomies and open radical cystectomies performed by the same surgeon, employing either conventional ligation in the control group (radical prostatectomy, n = 15; radical cystectomy n = 9) or the Ligasure device in the study group (radical prostatectomy, n = 24; radical cystectomy n = 10) to ensure blood vessel patency. Effectiveness and postoperative outcomes were evaluated. Results: The 2 groups were similar regarding demographic and clinical variables. The mean operation time was significantly shorter in the Ligasure group compared with the control group for both the prostatectomy (125 minutes vs. 144 minutes, p < 0.001) and the cystectomy procedures (253 minutes vs. 281 minutes, p < 0.001). The mean intra-operation blood loss was significantly lower in the Ligasure group compared with the control group for both prostatectomy (569 ml vs. 685 ml, p = 0.04) and cystectomy procedures (637 ml vs. 744 ml, p = 0.02). Intraoperative blood transfusion was only required in 2 patients (1 radical prostatectomy, 1 radical cystectomy) in the Ligasure group and in 7 patients in the control group respectively (p = 0.01). There was no effect of surgical specimen size on operation time for both prostatectomy (r = -0.03, p = 0.8, n = 39) and cystectomy procedures (r = 0.02, p = 0.9, n = 19). There were no serious intra-operation or postoperative complications related to the use of the Ligasure device. Conclusions: Ligasure radical prostatectomy and radical cystectomy are safe, and significantly decrease both the operation time and the blood loss, when compared to the conventional ligation method.

Finasteride: A Long-Term Follow-Up in the Treatment of Recurrent Hematuria Associated with Benign Prostatic Hyperplasia

Objectives: To assess the effectiveness and long-term results after finasteride treatment of recurrent hematuria associated with benign prostatic hyperplasia (BPH). Materials and Methods: The study comprised 80 patients, aged 62–86 (mean 74) years, of whom 50 received finasteride 5 mg once daily for 4 years and 30 were used as controls. Patients with malignancy, severe hepatic or renal failure and hematologic disorders were excluded. Patients were divided into 3 groups according to the severity of hematuria (minor, moderate, severe). All patients were followed up at 3, 12, 24 and 48 months. Results: The follow-up ranged from 8 to 48 (mean 22) months in the finasteride group and 3–42 (mean 23) months in the control group. Hematuria recurrence rates were 6/50 (12%) and 23/30 (77%) in the finasteride and control groups, respectively. Surgical treatment was needed in 6 patients of the finasteride group and 19 of the control group. Patients with minor hematuria experienced no recurrence of symptoms in the finasteride group in contrast to 13 of 17 patients in the control group. For the patients with moderate hematuria, recurrence of symptoms was observed in 3 of 13 in the finasteride group and 3 of 5 in the control group. Three of six patients with severe hematuria had a recurrence of symptoms after finasteride treatment in contrast to 7 of 8 in the control group. Conclusion: Finasteride has proved to be a safe, well tolerable and effective medication in reducing or preventing recurrent hematuria related to BPH.

The implication of initial 24-core transrectal prostate biopsy protocol on the detection of significant prostate cancer and high grade prostatic intraepithelial neoplasia

PURPOSE To assess the diagnostic value of an initial 24-sample transrectal ultrasound guided (TRUS) prostate biopsy protocol compared to the 10-core technique. MATERIALS AND METHODS We retrospectively reviewed the prostate biopsy database of consecutive men undergoing prostate biopsies under local anesthesia by using the 10 (Group A) and 24 (Group B) protocols. Men were stratified according to biopsy protocol and PSA levels. Exclusion criteria were age ≥ 75 years and PSA > 20 ng/mL. The Mann-Whitney U and Fishers exact test were used for statistical analysis. RESULTS Between April 2007 and August 2009, 869 men underwent TRUS prostate biopsies of which 379 were eligible for the study. Group A (10-cores) consisted of 243 (64.11%) men and group B (24-cores) included 139 (35.89%) men. The overall prostate cancer detection rate was 39.09% and 34.55% in Group A and B, respectively (p = 0.43). An overall 9.8% increase in Gleason 7 detection rate was found in Group B (p = 0.24). The high-grade prostatic intraepithelial neoplasia (HGPIN) detection rate in men with negative initial biopsies was 15.54% and 35.55% in Group A and B, respectively (p < 0.001). In patients with PSA < 10 ng/mL, the 24-core technique increased Gleason 7 detection rate by 13.4% (p = 0.16) and HGPIN by 23.4% (p = 0.0008), compared to the 10 core technique. The 24-core technique increased the concordance between needle biopsy and prostatectomy specimen compared to 10-core technique (p < 0.002). CONCLUSIONS The initial 24-core prostate biopsy protocol did not show any benefit in the detection of prostate cancer compared to the 10-core technique. However, it improved the HGPIN detection and the correlation between biopsy results and radical prostatectomy Gleason score in men with lower PSA levels.

Giant ureteral stone in association with primary megaureter presenting as an acute abdomen

A 20-year-old woman presented with abdominal pain of 4-h duration and of sudden onset. A plain abdominal radiograph showed a giant ureteral stone measuring 12 cm causing ureteral obstruction. Abdominal ultrasound revealed severe dilatation of the two upper thirds of the left ureter and a hydronephrotic ipsilateral kidney. Subsequent renal scan demonstrated that it was a non-functional kidney while the contralateral kidney was normal. A left nephroureterectomy was performed.

INDEPENDENT PREDICTORS OF FAILURE OF SHOCKWAVE LITHOTRIPSY FOR URETERAL STONES EMPLOYING A SECOND-GENERATION LITHOTRIPTER

PURPOSE To define factors associated with the failure of shockwave lithotripsy (SWL) in the treatment of ureteral stones. PATIENTS AND METHODS We retrospectively studied 405 men and 283 women (mean age 52.6 years) who underwent SWL with a second-generation lithotripter in the period 1994 to 2001. We evaluated available clinical and radiologic features that might have been related to failure of SWL therapy. RESULTS Treatment was successful in 502 patients (73%). The 186 patients (27%) in whom treatment failed underwent endourologic alternatives or open surgery. Multivariate logistic regression analysis revealed that unsuccessful outcome was significantly related to: (1) pelvic ureteral stones (odds ratio [OR] 4.02; 95% CI 1.97, 8.19); (2) stone size >10 mm (OR 3.46; 95% CI 2.16, 5.53); (3) obstruction (OR 1.93; 95% CI 0.99, 3.77); and (4) obesity (OR 1.87; 95% CI 0.95, 3.77). Although the predictive value of each individual parameter was relatively low (15.3%-27.9%) the cumulative risk was 82.95% when patients had all four features. The strongest independent predictors of failure were pelvic stones and stones >10 mm (cumulative predictive value 57.3%). CONCLUSIONS These variables may enable identification of a subgroup of patients who will fail initial SWL. These patients may be candidates for endourologic alternatives as first-line treatment.