Jack Baniel

Neutrophil-to-lymphocyte ratio predicts progression and recurrence of non–muscle-invasive bladder cancer

OBJECTIVEnNeutrophil-to-lymphocyte ratio (NLR) predicts advanced stage disease and decreased survival in patients undergoing radical cystectomy for urothelial carcinoma of the bladder. The predictive value of NLR in non-muscle-invasive bladder cancer (NMIBC) has not been well studied. We aimed to evaluate whether NLR predicted disease recurrence and progression in NMIBC.nnnMATERIALS AND METHODSnThe medical records of 122 consecutive, newly diagnosed, patients with NMIBC treated with transurethral tumor resection, between the years 2003 and 2010, were reviewed. Patients with hematological malignancies (n = 4) and without preoperative NLR (n = 11) were excluded. Cutoff points for NLR were tested separately for recurrence and progression using the standardized cutoff-finder algorithm. Univariate and multivariate Cox regression analyses were used to evaluate the association between NLR and disease recurrence and progression.nnnRESULTSnThe study cohort comprised 91 men and 16 women at a median age of 68 years. The median NLR was 2.85 (interquartile range: 2-3.9). In total, 68 patients (64%) had an NLR>2.41. Patients with NLR>2.41 were more often men (P = 0.02) and had T1 category tumors (P = 0.034). Analyzed as a continuous variable, higher NLR showed a weak positive association with high tumor grade (R = 0.21, P = 0.028). The median follow-up for patients without disease recurrence was 40 months (interquartile range: 23-51). The estimated 3-year progression-free survival rate in patients with an NLR>2.41 was 61%, compared with 84% in patients with an NLR≤2.41 (P = 0.004). On multivariate analysis, an NLR>2.41 (hazard ratio [HR] = 3.52; 95% CI: 1.33-9.33; P = 0.012) and high-risk tumors compared with low-intermediate-risk tumors (HR = 4.83; 95% CI: 1.31-17.77; P = 0.018), as defined by the European Organization for Research and Treatment of Cancer risk tables, were associated with disease progression. An NLR>2.43 (HR = 1.75; 95% CI: 1.05-2.92; P = 0.032) and treatment with intravesical instillations (HR = 0.49; 95% CI: 0.28-0.85; P = 0.011) were associated with disease recurrence on multivariate analysis.nnnCONCLUSIONSnNLR is an independent predictor of disease progression and recurrence in patients with NMIBC without hematological malignancies. Prospective studies are required to validate the role of NLR as a prognostic marker in NMIBC.

Transurethral resection of bladder tumour complicated by perforation requiring open surgical repair – clinical characteristics and oncological outcomes

Study Type – Therapy (case series)u2028Level of Evidenceu20034

Evaluation of the relationship between semen parameters, pregnancy rate of wives of infertile men with varicocele, and gonadotropin-releasing hormone test before and after varicocelectomy

OBJECTIVESnTo determine whether the gonadotropin-releasing hormone (GnRH) test can serve as an indicator for the need and timing of surgery in infertile men with varicocele.nnnMETHODSnThe GnRH test was performed in 121 infertile men with varicocele before surgical correction and 4 to 6, 9 to 12, and 16 to 18 months after. Levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) were evaluated immediately before the test and 45 minutes after intravenous injection of 100 jig Relisorm L (a synthetic GnRH analogue). Eighteen fertile men with normal semen parameters served as control patients for defining the preoperative hormone levels. A more than twofold increase in FSH and a more than fivefold increase in LH was considered a positive result. Findings were correlated with semen parameters and rate of pregnancy in the patients wives at 18 months postoperatively.nnnRESULTSnOf the 121 patients, 89 (73.5%) had a positive GnRH test result, and 32 had a negative result. Semen parameters were improved postoperatively in 72 of the GnRH-positive patients (80.9%) and in only 6 of the GnRH-negative patients (1 8.7%). Corresponding pregnancy rates at 18 months in the two subgroups were 60 (67.4%) and 3 (9.3%), respectively.nnnCONCLUSIONSnA positive preoperative GnRH test is a good predictor of improvement in semen parameters and pregnancy after varicocele surgery. We suggest that the GnRH test can serve as an additional indicator for varicocelectomy.

A novel algorithm to improve pathologic stage prediction of clinically organ-confined muscle-invasive bladder cancer

An algorithm was created to predict pathologic stage in patients with clinically organ‐confined muscle‐invasive bladder cancer.

Antiandrogen withdrawal syndrome with cyproterone acetate

OBJECTIVESnTo determine whether the antiandrogen withdrawal syndrome occurs with the steroidal antiandrogen cyproterone acetate.nnnMETHODSnCyproterone acetate was withheld in 12 patients with progressing androgen-independent metastatic prostate cancer. Eight patients had been receiving cyproterone acetate concomitant with androgen ablation, and in 4 patients it was prescribed after failure of androgen suppression. Time to response and to disease progression were defined by serum prostate-specific antigen (PSA) levels and imaging studies.nnnRESULTSnPSA levels decreased in 5 of the 1 2 patients; in 4 of them (33%), the decrease exceeded 50%. The decline lasted a median of 24 weeks (range 9 to 37.8). All 5 patients had received initial concomitant exposure to androgen ablation and cyproterone acetate.nnnCONCLUSIONSnWe recommend that the steroidal antiandrogen cyproterone acetate be added to the list of agents capable of inducing antiandrogen withdrawal syndrome.

Transitional cell carcinoma in a fused crossed ectopic kidney

Nephroureterectomy is considered the reference standard treatment for invasive transitional cell carcinoma of the ureter. When this malignancy occurs in a patient with renal fusion anomaly, separating the involved kidney from its conjoint mate becomes a challenging task for the surgeon. We report a unique case in which a patient with an L-shaped left-to-right crossed ectopic kidney was diagnosed with invasive ureteral transitional cell carcinoma. The preoperative assessment in these uncommon cases should include renal angiography or computed tomography angiography to provide key information about the renal vasculature, which is essential for planning the surgical dissection and line of separation between the kidneys.

Penile edema and meatal ulceration after intravesical instillation with bacillus Calmette-Guerin.

Bacillus Calmette-Guérin (BCG) bladder instillation is an accepted treatment modality in the management of superficial transitional cell carcinoma but is associated with frequent side effects. A report of intravesical BCG-induced penile edema and meatal ulceration that occurred in 2 patients is presented. During induction therapy, both patients complained of progressive penile edema. In 1 patient the edema appeared after the second instillation and in the other after the fourth instillation. Edema was associated with ensuing meatal ulceration and enlarged inguinal lymph nodes. BCG instillation was aborted, and oral antituberculous treatment was initiated. There was no report of external spillage during the administration of BCG or of genital or urethral trauma during catheterization. Patients were treated at different clinics but with BCG of the same strain and batch. Symptoms continued for 6 weeks until they abated. Both patients were managed with oral antituberculous drugs for a period of 3 months. Adverse effects of BCG intravesical administration affect several organs in the genitourinary system. The penis and urethra may also be involved, presenting as penile edema and meatal ulceration. Physicians who administer BCG must be familiar with the possible complications and their appropriate management.

Dismembered pyeloplasty in children with and without stents

OBJECTIVESnTo assess the benefit of performing nonstented pyeloplasty in infants.nnnMETHODSnForty-eight consecutive pyeloplasties were performed by two surgeons using different techniques, from 1987 to 1992. One used stents in all cases (23) and the other performed a nonstented anastomosis with external drainage (25 cases). Patients with specific indications for internal drainage, i.e. poor renal function, extreme pyelocaliectasis, were excluded from the study. Parameters of cost and complications were assessed.nnnRESULTSnThe group with stents had more febrile episodes, needed more antibiotics and were hospitalized twice as long as the nonstented group. Pre- and postoperative renal function was similar in both groups.nnnCONCLUSIONSnPerforming pyeloplasties in children without stenting the anastomosis is safe and cost-effective.

Urinary tract infections in patients with orthotopic neobladder

OBJECTIVEnOrthotopic neobladder urinary diversion is associated with a high rate of infectious complications, especially in the early postoperative period. The aim of the study was to assess the incidence, associated pathogens, and predictors of symptomatic urinary tract infection (UTI) in patients with an orthotopic neobladder.nnnMETHODS AND MATERIALSnThe medical records of 79 patients treated with radical cystectomy and orthotopic neobladder urinary diversion at a tertiary medical center in 2004 to 2012 were reviewed for data pertaining to bacteriuria and symptomatic UTI after hospital discharge. Cumulative incidences of clinical events were assessed with the Kaplan-Meier method. Univariate and multivariate Cox regression models were used to identify clinical predictors of infection.nnnRESULTSnA total of 69 men and 10 women were included in the study cohort. The estimated cumulative rates of symptomatic UTI were 34% at 3 months, 40% at 6 months, and 43% at 12 months. New events of symptomatic UTI occurred in 36% of the patients during the first 3 postoperative months, but only in 10% at 3 to 6 months and 8% at 6 to 12 months. Common pathogens were Pseudomonas aeruginosa (24%) and Escherichia coli (24%); 78% of bacterial pathogens were susceptible to amikacin. On multivariate analysis, there was no effect of age, gender, intermittent catheterization, bowel segment used for reconstruction, or perioperative chemotherapy on rates of UTI.nnnCONCLUSIONSnSymptomatic UTI is a common complication after neobladder reconstruction, usually occurring within the first 3 months of surgery. P. aeruginosa infection is common. Inpatient empirical treatment with amikacin is recommended in this setting.

The 471delAAAG mutation and C353T polymorphism in the RNASEL gene in sporadic and inherited cancer in Israel.

The rate of RNASEL 471delAAAG mutation was previously reported to be less than 7% in Ashkenazi prostate cancer patients. It seems plausible that the same mutation may also be involved in breast/ovarian cancer predisposition in Jewish individuals. To evaluate the role of this mutation in cancer predisposition, a total of 1011 individuals including 294 Jewish men with prostate cancer, 61 Ashkenazi women with ovarian cancer and 50 unaffected women, matched for age and ethnicity, were genotyped for sequence anomalies in a single RNASEL gene amplicon using DGGE and sequencing. Additionally, 209 Ashkenazi BRCA1/2 mutation carriers, 205 high-risk non-carriers matched for cancer type and age at diagnosis, and 192 healthy Ashkenazi women were screened, using DHPLC and restriction methods. The 471delAAAG mutation was detected in a single male with prostate cancer (1/294, 0.3%), in two ovarian cancer patients (2/141, 1.4%) and in one of 242 healthy controls (0.41%). An abnormal DHPLC profile identical to the one produced by the 471delAAAG mutation was noted in 23 additional women. The rate of this polymorphism was significantly elevated in high-risk non-carrier women (16/205; 7.8%) than in BRCA1/2 carriers (2/209; 1.0%) and controls (5/192; 2.6%) (χxa0=xa011.670; Pxa0<xa00.001). Sequence analysis disclosed a silent polymorphism in Valine at codon 118: c.353 C-xa0>xa0T.The 471delAAAG mutation occurs rarely in Israeli prostate and breast/ovarian cancer patients. A silent polymorphism in the RNASEL gene occurs more␣prevalently in high-risk Ashkenazi breast/ovarian cancer patients without a BRCA1/2 mutation.