Mátyás Benyó

Follow-up of thrombin generation after prostate cancer surgery: global test for increased hypercoagulability.

Recent studies provided evidence that evaluation of thrombin generation identifies patients at thrombotic risk. Thrombin generation has a central role in hemorrhage control and vascular occlusion and its measurement provides new metrics of these processes providing sufficient evaluation of an individual’s hemostatic competence and response to anticoagulant therapy. The objective of the study is to assess a new measure of hypercoagulability that predisposes to venous thromboembolism in the postoperative period after radical prostatectomy. Pre- (day-1) and postoperative (hour 1, day 6, month 1 and 10) blood samples of 24 patients were tested for plasma thrombin generation (peak thrombin), routine hematology and hemostasis. Patients received low molecular weight heparin for thromboprophylaxis. Peak thrombin levels were higher in patients compared to controls at baseline (p<0.001), and elevated further in the early postoperative period (p<0.001). Longer general anesthesia and high body mass index were associated with increased thrombin generation after surgery (p = 0.024 and p = 0.040). D dimer and fibrinogen levels were higher after radical prostatectomy (p = 0.001 and p<0.001). Conventional clotting tests remained within the reference range. Our study contributed to the cognition of the hypercoagulable state in cancer patients undergoing pelvic surgery and revealed the course of thrombin generation after radical prostatectomy. Whilst it is unsurprising that thrombin generation increases after tissue trauma, further evaluation of this condition during the postoperative period would lead urologists to an international and well-supported consensus regarding thromboprophylaxis in order to provide better clinical outcome. Considering the routine evaluation of procoagulant activity and extending prophylactic anticoagulant therapy accordingly may potentially prevent late thrombotic events.

Effect of hydrocele on appendix testis in children.

The purpose of this study was to investigate the effects of an elevated hydrostatic pressure of hydrocele on the structural integrity and steroid receptor expression pattern of the appendix testis in children. Twenty-six testicular appendages were obtained from boys (aged between 13 and 79 months, mean 40 months) who underwent surgical exploration because of hydrocele or congenital inguinal hernia. The tissue sections of testicular appendages were stained with hematoxylin-eosin. Immunohistochemistry and immunofluorescence laser microscopy were performed using monoclonal mouse anti-human receptors against androgen and estrogen receptors. Patients were divided into three groups: group A (n = 8) represented patients with groin hernia without hydrocele, who served as control group; group B (n = 7) represented patients with communicating hydrocele; and group C (n = 11) represented patients with noncommunicating hydrocele. The tissue sections of appendix testis expressed both androgen and estrogen receptors in all patients in groups A and B, and epithelial destruction was not present. The presence of androgen receptor (two of 11, P < 0.001) and estrogen receptor (four of 11, P = 0.006) was lower and the number of appendix testes with epithelial destruction was higher (eight of 11, P = 0.001) in group C. We demonstrated that groin hernia and communicating hydrocele did not influence the receptor expression pattern and the anatomic structure of testicular appendages, whereas noncommunicating hydrocele caused damage as indicated by the absence of steroid receptors and destruction of the epithelial surface. A better understanding of the physiological role of testicular appendages may change the indications of surgical treatment in patients with noncommunicating hydrocele.

Laparoscopic removal of a paracaval air gun bullet in a child.

Air guns are known as low-velocity arms and are considered harmless. However, injuries from air weapons can be serious and even fatal, particularly in children. We present a potentially life-threatening penetrating retroperitoneal injury of a 3-year-old boy caused by an air gun, and the successful removal of the bullet via a laparoscopic approach. The patient was brought to our center with a penetrating air gunshot wound on his right side in the waist area. He was accidentally shot by his brother at their home. The patient’s clinical condition was stable. Computed tomography scan showed the bullet in the retroperitoneum near the inferior vena cava. A three-port laparoscopic transperitoneal approach was performed. The bullet was found just 0.5 cm caudal to the right renal hilum and 0.5 cm near the inferior vena cava; it was then removed. Operation time was 42 min and the postoperative course was uneventful. Thanks to improvements in laparoscopic surgical techniques, laparoscopy has become a feasible and effective treatment modality even for the removal of foreign bodies in children.

Fertility preservation in cases of laparoscopic treatment of seminal vesicle cysts.

Seminal vesicle cysts can cause sub- or infertility. Minimally invasive techniques have the advantage of preserving the vas deferens by the treatment of symptomatic cases. After reviewing the published articles, only a few of them presented data on fertility before and after surgery. The authors now report the successful treatment of two patients with seminal vesicle cysts, in which laparoscopic cyst removal resolved the symptoms, preserving fertility and erectile function. Due to the rarity of seminal vesicle cysts, preoperative examinations and treatment modalities should focus not only on the relief of symptoms but also on the preservation of fertility and erectile function.

[Influence of malignant tumors occurring in the reproductive age on spermiogenesis: studies on patients with testicular tumor and lymphoma].

INTRODUCTION The application of chemo- and radiotherapy results in good survival prognosis for young men with malignant tumors, but long-term gonadoxic effect has to be considered. In addition, malignant disease itself has a negative impact on spermiogenesis. AIM The aim of the authors was to examine the spermiogenetic effect of the most common tumors occurring in the reproductive age in men: testicular cancer, Hodgkin disease and non-Hodgkin disease. METHOD Spermiogram of men with testicular cancer (N = 68), Hodgkin disease (N = 37) and non-Hodgkin disease (N = 14) who were referred for sperm cryopreservation were analysed in the Reproductive Andrology Laboratory of the authors. RESULTS Azoospermia was found in 11.8% of all patients (N = 119), while 58.8% of the patients had oligozoospermia even before the treatment. Sperm concentration of men with testicular cancer was significantly lower than those with lymphomas (32.8 M/mL vs. 24.9 M/mL, p = 0.03). There was no difference in sperm concentration between the Hodgkin and non-Hodgkin lymphoma groups. CONCLUSIONS Spermiogenetic defect is more pronounced in men with testicular cancer than those with lymphomas. Cryopreservation before treatment for fertility preservation should be offered for all reproductive aged men with malignant disease, especially for those with testicular cancer.

The significance of premature ejaculation

Central European Journal of Urology79Cent European J Urol 2014; 67: 79-80 10.5173/ceju.2014.01.art17It is an honor to have the opportunity to comment on the article by Koyuncu and colleagues evaluating the possible correlation between intravaginal ejaculato -ry latency time (IELT) and enuresis [1].Premature ejaculation (PE) is a very common male sexual dysfunction; the prevalence is over 20% in each age group, so there is a need for identification of such patients, as PE leads to personal distress, diminished self-esteem and sexual problems [2]. It is difficult to study PE in the everyday practice, since patients are often unwilling to discuss their symp-toms. On the other hand many physicians do not know about effective treatments [3]. This could lead to a false diagnosis or treatment. PE is classified as lifelong (primary) or acquired (sec-ondary). The latter form is described as a gradual or sudden appearance of PE following normal ejacula-tion experiences before onset, and the time to ejacu-lation is short, but usually longer than in the lifelong form. The secondary type of PE is mostly due to per-sonal distress caused by a new relationship or other stressful event. In the lifelong form, PE is present from the first sexual intercourse, remains during the individual’s lifetime, and in which ejaculation occurs too fast (before vaginal penetration or 1-2 min there-after) [4].Even though the definition of PE is not unified, an evidence-based one has been determined; it has been applied by Koyuncu et al as well. This definition is limited to men with lifelong PE who engage in vagi-nal intercourse [5]. Although PE is poorly understood and its etiology is yet to be determined, promising studies are un-der way to evaluate the pathogenesis of the disease. One such research paper, presented by Koyuncu et al., involves the study of PE in relation to enuresis. This is one of the largest studies, which has been published recently; exceeding previously published articles in terms of patient and control numbers. The authors’ aim to search for a correlation between PE and enuresis may lead to a better understanding of the disease, since serotonergic pathways appear to be essential in both entities. One other possible aim of the upcoming studies can be the evaluation of irri -table bowel syndrome as studied by Barghi [6].The authors have evaluated the detailed sexual histo-ry of the patients, along with their laboratory tests, in an effort to identify any underlying medical conditions associated with PE. It is really praiseworthy, since IELT alone is not sufficient to define PE, as significant overlap is known to exist between men with or without PE [7]. Although the specificity of PE assessment ques-tionnaires (Premature Ejaculation Diagnostic Tool, Ar -abic Index of Premature ejaculation) seems to be lower, their use should be considered during research activity [8, 9].The major limitation of the present research – and, in fact, all studies of this kind – was the retrospec-tive evaluation of nighttime bed wetting during childhood in the study population, but it would be really challenging to perform an absolutely prospec-tive study following-up children with enuresis to see if PE will develop in their cases.I hope that the authors will persist with their re-search to evaluate this disease and they will contin -ue to present such high quality papers.Editorial referring to the paper published in this issue on pp. 74–78

Present Practice of Thrombosis Prophylaxis of Radical Prostatectomy in a European Country: A Hungarian Multicenter Study

Venous thromboembolism is a possible fatal complication after pelvic surgery. There is a lack of trials assessing the effect of prophylactic measures in urology. The aim of the study was to evaluate the practice of thrombosis prophylaxis in a Central European country. A questionnaire of performed radical prostatectomies, way of thrombosis prophylaxis and number of experienced thrombotic events was posted to all departments of urology in Hungary. With a response rate of 59%, 506 radical prostatectomies were reported. Low molecular weight heparin was administered by 100% of the departments. Graduated support stockings were applied by 37% of the patients. Early mobilization was the most common form of mechanic prophylaxis (57%). Thrombotic events were experienced in 1.4%, 0.2% were fatal. The thrombosis prophylaxis of patients undergoing radical prostatectomy is not unified. Due to the potential mortality of thrombotic complications it should be evaluated and prophylaxis should be recommended in urological guidelines.

Designer drugs and sexual dysfunction.

New or novel psychoactive substances (NPS) are the most recent forms of designer drugs. These materials are sold as “bath salt” mixtures or fertilizers through the internet and in head shops worldwide [1]. Of course there are no proven medical purpose of these compounds which mostly contain synthetic cathiones or piperazines. The form is usually powder or bath salt like crystalline which are insufflated, ingested or injected. Psychostimulant effects can be similar to cocaine or amphetamines. The form and method of distribution has made the possession, use and synthesis of designer drugs legal for a long time, and there are compounds, which are still circumventing existing legislative classifications and penalties. The spread of these NPS is known worldwide from the US to Japan, since these designer drugs are used in 94 countries worldwide and 348 NPS have already been reported by 2013 [2]. Addicts commonly use NPS along with other substances like alcohol, antidepressants or herbal aphrodisiacs as presented by Jones et al. [3]. Herbal aphrodisiacs may contain regular pharmaceuticals (phosphodiesterase 5 inhibitors) in pharmacologically relevant quantities having no known safety profile [4]. Designer drugs and administration of antidepressants are also increasing risky sexual behavior leading to increased incidence of sexually transmitted diseases in this population [5]. The combinations of different substances may lead to unknown synergistic effects resulting in different forms of sexual dysfunction as highlighted by Jones et al. describing a case of an illegal substitute for Sildenafil citrate with a NPS leading to ischemic priapism [3]. Obtaining the proper diagnosis is essential in cases of prolonged erection, since therapy is different between low and high flow priapism. Taking detailed history is helpful, but color doppler ultrasound and blood gas analysis must verify the ischemic form [6]. When conservative treatment options (aspiration, intracavernosal drug administration) fail, surgical treatment provides detumescence by forming drainage for the hypoxic blood. A high rate of erectile dysfunction is reported especially after proximal shunts. Immediate insertion of penile prosthesis is proposed beyond 72 hours of priapism, although the application can be limited by the high cost of the device [7]. Implantation will be considered by the patient Nicholas Rukin et al. as well, however the patients low compliance and high risk behavior requires a detailed psychological assessment, and prosthesis is recommended only after full psychiatric recovery in order to avoid complications. The most important take-home message is the close follow-up of patients with antipsychotic medication, not only by screening for sexual dysfunctions such as erectile dysfunction but also by assessing risky sexual behavior and abuse of psychoactive substances.

Nondetectable prostate cancer in radical prostatectomy specimens

UNLABELLED Since the widespread use of prostate-specific antigen, early diagnosis of prostate cancer at an early stage has been increased. Consequently, a greater frequency of low-volume disease or no tumor has been found in radical prostatectomy specimen. AIMS In the present study authors analyzed patients classified as pT0 after radical prostatectomy at their center. METHODS 1134 radical prostatectomies were evaluated retrospectively at the authors center between 1996 and 2010. If there was no evidence of prostate cancer in the specimen, patient was staged as pT0. Patients were divided into two groups: received neoadjuvant hormonal therapy or not. RESULTS Overall 32 (2.8%) patients were staged as pT0. The rate of pT0 staging was 9.3% and 1.2% in the hormonally treated group and non-hormonally treated group. False-positive prostate biopsy was found in 2 cases. The rate of pT0 staging was higher in patients with incidental prostate cancer, low Gleason score and enlarged prostate. Biochemical relapse was observed in 3 pT0 patients in the hormonally treated group, among them there was one clinical relapse. In non-hormonally treated group no recurrence was detected. CONCLUSION The rate of pT0 staging was higher in the hormonally treated group. Because of biochemical and clinical relapse despite vanishing prostate cancer phenomenon, these cases are considered not to be true pT0. On the basis of present study and other reports the rate of pT0 staging is about one percentage in non-hormonally treated patients. Prognosis of these patients is excellent.

Very Late Relapse of Testicular Tumour in Combination with Renal Cancer and Their Retroperitoneoscopic Removal

Late relapse of a testicular cancer is an uncommon occurrence. We report a case of late relapse of a testicular tumour combined with a renal cancer and their successful removal with retroperitoneoscopy. The 36-year-old patient underwent left orchiectomy, retroperitoneal lymph node dissection, and chemotherapy, because of mixed tumor including teratoma and embryonal carcinoma. 18 years after the successful primary therapy elevated serum alpha-fetoprotein level had been confirmed, then MRI and PET-CT scans demonstrated a 30 mm left renal mass and 22 mm retroperitoneal lymph node above the bifurcation of the left common iliac artery. We performed retroperitoneoscopic lymph node dissection and left renal tumour resection in the same session. The histology revealed embryonal carcinoma for the retroperitoneal lymph node and renal cell carcinoma for the left renal mass. We can conclude that late followup of patients with testicular tumour is important. Retroperitoneoscopy is feasible approach for the removal of retroperitoneal lymph node metastasis and resection of renal tumor.