Jon Jones

Incidence, Clinical Symptoms and Management of Rectourethral Fistulas After Radical Prostatectomy

PURPOSEnRectourethral fistula is a rare but severe complication after radical prostatectomy and there is no standardized treatment. We retrospectively evaluated the incidence, symptoms and management of rectourethral fistulas based on our experience.nnnMATERIALS AND METHODSnFrom 1999 to 2008 we performed 2,447 radical prostatectomies. Patients in whom postoperative rectourethral fistulas developed were identified. Based on the therapeutic approach patients were categorized into group 1-conservative treatment, group 2-colostomy with or without surgical closure and group 3-immediate surgical closure without colostomy.nnnRESULTSnRectourethral fistulas developed in 13 of 2,447 patients (0.53%) after radical prostatectomy. The risk of rectourethral fistulas was 3.06-fold higher (p = 0.074) for perineal (7 of 675, 1.04%) than for retropubic prostatectomy (6 of 1,772, 0.34%). In 7 of 13 patients (54%) a rectal lesion was primarily closed at radical prostatectomy. Median followup was 59 months. In all patients in group 1 (3) the fistula closed spontaneously with conservative treatment. None of these patients had fecaluria. In group 2 of the 9 patients 3 (33%) experienced spontaneous fistula closure after temporary colostomy and transurethral catheterization. In this group 6 patients (67%) required additional surgical fistula closure, which was successful in all. Surgical fistula closure (1) without colostomy in presence of fecaluria failed (group 3).nnnCONCLUSIONSnThe therapeutic concept for rectourethral fistulas should be guided by clinical symptoms. Rectal injury during radical prostatectomy is a major risk factor. In cases with fecaluria colostomy is required for control of infection and may allow spontaneous fistula closure in approximately a third of cases. In the remainder of cases surgical fistula closure was successful in all after protective colostomy.

Diagnosis and Surgical Management of Colovesical Fistulas Due to Sigmoid Diverticulitis

PURPOSEnDiverticular disease of the colon is the most frequent cause of colovesical fistulas. In this study we evaluated the accuracy of different diagnostic procedures for the detection of colovesical fistula and the clinical outcome in a series of 49 patients who underwent surgery for colovesical fistula due to sigmoid diverticulitis.nnnMATERIALS AND METHODSnBetween 1982 and 2007, 42 men and 7 women underwent surgery for colovesical fistula due to sigmoid diverticulitis. Preoperative diagnostic procedures included the poppy seed test, abdominopelvic computerized tomography, magnetic resonance tomography of the abdomen, cystogram, retrograde colonic enema, urethrocystoscopy and colonoscopy.nnnRESULTSnAll patients had urinary tract infections and dysuria. Pneumaturia and fecaluria, which are pathognomonic symptoms of colovesical fistula, were present in 71.4% and 51.0% of the patients (35 and 25 of 49), respectively. Colovesical fistula was correctly diagnosed by the poppy seed test in 94.6% (35 of 37 examined patients) compared to abdominopelvic computerized tomography in 61.0% (25 of 41), magnetic resonance tomography in 60.0% (3 of 5), cystogram in 16.7% (5 of 30), retrograde colonic enema in 35.7% (15 of 42), cystoscopy in 10.2% (5 of 49) and colonoscopy in 8.5% (4 of 47). Patients underwent resection of the fistulized bowel, single stage bowel anastomosis without protective colostomy and closure of the bladder defect. Postoperative morbidity was 8.2% (4 of 49) and mortality was 0%. During a median followup of 68 months there were no recurrent fistulas.nnnCONCLUSIONSnIn our series the poppy seed test had the highest sensitivity to detect colovesical fistulas. However, abdominopelvic computerized tomography, colonoscopy and cystoscopy are essential diagnostic procedures because the presence of colon or bladder cancer as an underlying cause of colovesical fistula will determine further therapy.

Single Center Comparison of Anastomotic Strictures After Radical Perineal and Radical Retropubic Prostatectomy

OBJECTIVESnTo analyze the incidence and management of anastomotic strictures (ASs) after radical perineal prostatectomy (RPP) and retropubic prostatectomy (RRP) and to identify possible predisposing factors.nnnMETHODSnBetween 1997 and 2007, we performed 866 RPP and 2052 RRP for localized prostate cancer. Median follow-up was 52 months (12-136). We analyzed preoperative serum prostate-specific antigen, prostate size, clinical and pathologic tumor stage, neoadjuvant hormone deprivation, previous transurethral resection of the prostate, transfusion requirement, anastomotic insufficiency, and acute urinary retention (AUR) and its subsequent management to identify possible predisposing factors for AS formation.nnnRESULTSnThe rate of AS after RPP and RRP was 3.8% (33/863) and 5.5% (113/2048), respectively (P = .067). In multivariate analysis, RRP was a statistically significant risk factor for AS (P = .0002). On survival analysis, the incidence of AS was lower for RPP as compared with RRP at median follow-up (P = .0229). Primary response to endoscopic AS incision or resection was 94% (31/33) and 72.6% (82/113) after RPP and RRP, respectively. On multivariate logistic regression analysis biopsy Gleason score, previous transurethral resection of the prostate, prostate volume, pathologic tumor stage and grade, transfusion requirement, AUR, and surgical technique were independent risk factors for the development of AS. An AS developed in 45.4% (20/44) and 10.9% (5/46) of the postoperative AUR cases treated with a suprapubic cystostomy tube and a transurethral Foley catheter, respectively (P <.05).nnnCONCLUSIONSnASs occur more frequently after RRP in comparison with RPP. Primary endoscopic AS incision or resection are both highly successful. Treating postoperative AUR with a suprapubic cystostomy poses a high risk for AS formation and should be avoided.

Pathway analysis of high-throughput biological data within a Bayesian network framework

MOTIVATIONnMost current approaches to high-throughput biological data (HTBD) analysis either perform individual gene/protein analysis or, gene/protein set enrichment analysis for a list of biologically relevant molecules. Bayesian Networks (BNs) capture linear and non-linear interactions, handle stochastic events accounting for noise, and focus on local interactions, which can be related to causal inference. Here, we describe for the first time an algorithm that models biological pathways as BNs and identifies pathways that best explain given HTBD by scoring fitness of each network.nnnRESULTSnProposed method takes into account the connectivity and relatedness between nodes of the pathway through factoring pathway topology in its model. Our simulations using synthetic data demonstrated robustness of our approach. We tested proposed method, Bayesian Pathway Analysis (BPA), on human microarray data regarding renal cell carcinoma (RCC) and compared our results with gene set enrichment analysis. BPA was able to find broader and more specific pathways related to RCC.nnnAVAILABILITYnAccompanying BPA software (BPAS) package is freely available for academic use at http://bumil.boun.edu.tr/bpa.

Functional Analysis of Elective Nephron-sparing Surgery vs Radical Nephrectomy for Renal Tumors Larger than 4 cm

OBJECTIVEnTo preserve renal function, nephron sparing surgery (NSS) for renal tumors should be performed. Little is known about perioperative morbidity and long-term functional outcome of patients after elective NSS compared with radical nephrectomy (RN) in renal tumors >4 cm.nnnMATERIALS AND METHODSnEight-hundred twenty-nine patients were treated with either RN (n = 641) or NSS (n = 188) for renal tumors >4 cm. After pairing the cohort for age, grading, TNM, size, gender, and preoperative renal function and excluding patients with imperative indication and metastases, 247 patients remained for functional analysis. Serum creatinine (SCr) values were used to estimate glomerular filtration rate (eGFR) via Modification of Diet in Renal Disease. Chronic kidney disease (CKD) was defined as eGFR <60 mL/min/1.73 m(2) and regression analyses were used to identify clinical risk factors for CKD and perioperative complications stratified by the Clavien-Dindo score.nnnRESULTSnThe Charlson comorbidity index was similar between patients undergoing NSS (n = 101) and RN (n = 146) (P = .583). The complication rates did not differ significantly between both groups (P = .091). Age (OR 0.94, P = .009), ASA score 3+4 (OR 3.55, P = .004), RN (OR 10.75, P < .001), and preoperative eGFR (OR 1.06, P < .001) were independent risk factors for developing CKD postoperatively, whereas tumor size had no impact (OR 1.01, P = .245). Overall survival was comparable between the groups (P = .896).nnnCONCLUSIONnAlthough overall survival was similar, patients undergoing RN for renal tumors >4 cm had a significantly higher risk of developing CKD than patients treated with NSS. Complication rate did not differ significantly between both groups, even for tumors >7 cm. Our findings support elective NSS for tumors >4 cm, whenever NSS is technically feasible for maintaining renal function.

URETHRAL RECURRENCE OF TRANSITIONAL CELL CARCINOMA IN A FEMALE PATIENT AFTER CYSTECTOMY AND ORTHOTOPIC ILEAL NEOBLADDER

A 63-year-old woman presented elsewhere with a unifocal pT1, G3 transitional cell carcinoma at the bladder base in 1995. She underwent urethral sparing cystectomy and ileal neobladder. Intraoperative frozen section from the proximal urethra did not demonstrate tumor involvement. Final histological examination revealed pT1, pN2, G3 transitional cell carcinoma. Adjuvant chemotherapy was not given. In 1998 the patient had symptoms of obstructive voiding due to a 3 3 3 cm. solid mass at the neobladder-urethra anastomosis (see figure). After 6 cycles of methotrexate, vinblastine, doxorubicin and cisplatin and a transient tumor size reduction, the patient was referred to us for local tumor progression. Endoscopy identified a tumor at the neobladder-urethra anastomosis. Magnetic resonance imaging demonstrated a 2.5 3 1 cm. tumor infiltrating the anterior vaginal wall. With a combined abdominovaginal approach complete removal of the tumor was accomplished, including removal of the introitus and vagina, lower third of the ileal neobladder and entire urethra. The ileal neobladder was converted to a continent cutaneous urinary diversion with umbilical stoma. Histopathological examination revealed poorly differentiated transitional cell carcinoma and tumor-free margins of resection. Two months later multiple hepatic metastases were diagnosed and the patient died 3 months later.

PROSTATOSYMPHYSEAL FISTULA AFTER TRANSURETHRAL RESECTION OF THE PROSTATE

The formation of a urethrosymphyseal fistula is a rare complication after transurethral resection of the prostate. It may develop secondary to previous radiation therapy of the pelvis. We describe a case of spontaneous fistula formation after transurethral resection of the prostate. CASE REPORT

An Unusual Case of Ureteral Ectopia in the Seminal Vesicle: Diagnosis and Surgical Management

We report the case of a young man who presented with numerous episodes of ipsilateral epididymitis. Selected imaging studies with consideration of urogenital embryology lead to the rare diagnosis of a dysplastic kidney with ureteral ectopia in the seminal vesicle. After nephroureterectomy and vesiculectomy, convalescence was uneventful. No specific symptoms, equivocal diagnostic findings and the small number of patients limit the surgical experience in diseases of the seminal vesicle. Suprainguinal extravesical extirpation, however, appears to be an excellent operative approach in cases of unilateral seminal vesicle cysts.

Clinical Trials Report: Pazopanib for Advanced Renal Cell Carcinoma: Comments on the Results from the Phase 3 Study

Despite improved molecular understanding leading to the advent of numerous target therapy options in renal cell carcinoma (RCC), clinical success still is limited. The authors of this article analyzed the results of a recent phase 3 trial on the effects of the new oral receptor tyrosine kinase inhibitor (TKI) pazopanib in patients with locally advanced or metastatic RCC who were either treatment naïve or cytokine pretreated. The primary end point was progressionfree survival (PFS).