Nessn H. Azawi

Hand-assisted partial nephrectomy with early arterial clamp removal: Impact of the learning curve.

Abstract Objective. The aims of this study were to present the results of hand-assisted laparoscopic partial nephrectomy according to the margin, ischaemia and complications system; to assess the role of the learning curve; and to compare this approach with other approaches. Material and methods. Data from 60 consecutive patients were obtained from a prospectively maintained database. The patients were divided into three cohorts (1, 2 and 3), with 20 patients each, according to their surgery dates. Results. The overall margin, ischaemia and complications rate was 90%. The warm ischaemia time was 9.5 min in cohort 1, decreasing to 5 min in cohort 3 (p < 0.0001). The Padua score (p = 0.0287) and tumour size (p = 0.0003) were significantly increased in cohort 3, but loss of kidney function decreased significantly to 3.5% in this cohort. Loss of kidney function of less than 5% was reported for eight (40%), nine (45%) and 14 (70%) patients in cohorts 1, 2 and 3, respectively (p = 0.0185). Conclusions. Hand-assisted laparoscopic partial nephrectomy with early removal of arterial clamps is safe and easy to learn. An expert laparoscopic surgeon can perform hand-assisted laparoscopic partial nephrectomy for complex tumours with a relatively high success rate according to the margin, ischaemia and complications system. Warm ischaemia time could be obtained within 5 min after 40 procedures.

Hand-assisted laparoscopic versus laparoscopic nephrectomy as outpatient procedures: a prospective randomized study

Abstract Objectives: The aims of this study were to discuss the hand-assisted laparoscopic nephrectomy (HALNo) outpatient procedure and compare it to the transperitoneal laparoscopic nephrectomy (LNo) outpatient procedure. Materials and methods: A prospective, randomized study of 30 patients with renal tumor who were recruited between November 2014 and February 2016 was performed. The primary endpoint of the study was length of hospital stay (LOS). Results: Fifteen patients received HALNo and 15 received LNo, with a male to female ratio of 2:1. The mean age was 60 years for HALNo and 64 years for LNo (p = 0.62). All patients were discharged within 6 h after the operation. The mean ± SD operation time was 65 ± 24 min [95% confidence limits (CL) 51–79] and 69 ± 24 min (95% CL 56–83) for HALNo and LNo, respectively (p = 0.95). The mean time for which patients stayed at the postoperative care unit was 85 ± 53 min (95% CL 44–126) and 91 ± 66 min (95% CL 54–127) for HALNo and LNo, respectively (p = 0.14). The mean LOS was 220 ± 96 min (95% CL 155–284) and 272 ± 80 min (95% CL 224–320) for HALNo and LNo, respectively (p = 0.53). Conclusion: HALNo, when performed as an outpatient procedure, is safe and feasible for a well-informed, well-educated and well-selected patient group, and is comparable to LNo regarding postoperative LOS.

A Retrospective Study of Erectile Function and Use of Erectile Aids in Prostate Cancer Patients After Radical Prostatectomy in Denmark

Introduction Radical prostatectomy (RP) offers a good long-term cancer control for clinically localized prostate cancer. However, complications such as erectile dysfunction and substantial decreases quality of life of the afflicted men and their sexual partners. Identification of pre-, per-, and postoperative factors that correlate with poor postoperative erectile status must be considered an important step to improving penile rehabilitation. Aim To describe postoperative erectile function after RP in a Danish cohort. Methods The medical records of 1,127 patients undergoing RP from March 2003 through September 2014 were reviewed retrospectively with a 12-month follow-up after surgery. In all, 704 patients fulfilling the inclusion criteria were included in the final analysis. Recovery was defined as self-reported erection sufficient for intercourse (ESI) with or without usage of erectile aids. Main Outcome Measures Subjective reporting of erectile function and usage erectile aids 12 months after RP. Results ESI with or without erectile aids was reported by 226 men (32.1%), among whom 109 (48.2%) required erectile aids. Erectile dysfunction (ED) was reported by 478 men (67.9%) and by 121 (25.3%) despite use of erectile aids. Of men with ED, 155 (22%) stated not being interested in penile rehabilitation, 26 (3.7%) stated not having resumed their sex life 12 months after RP, and 241 (34.2%) had ED and were unsatisfied with the condition. We found that 134 of 445 men (30.1%) who underwent non–nerve-sparing RP had ESI 12 months after RP. Age older than 60.5 years, a high body mass index, comorbidity, and a high American Society of Anesthesiologists score were negative predictors of erectile function 12 months after RP. Conclusion Twelve months after RP, 32.1% of men had ESI; half these men required the use of erectile aids. Age older than 60.5 years, a high body mass index, comorbidity, and a high American Society of Anesthesiologists score were negative predictors for ED 12 months after RP. Haahr MK, Azawi NH, Andersen LG, et al. A Retrospective Study of Erectile Function and Use of Erectile Aids in Prostate Cancer Patients After Radical Prostatectomy in Denmark. Sex Med 2017;5:e156–e162.

Eosinophilic cystitis: three cases, and a review over 10 years.

Eosinophilic cystitis (EC) is a rare disease. We describe three cases, where presentations of the disease are similar. To highlight probable causes of the disease, symptoms, clinical findings and treatment modalities, we reviewed 56 cases over a 10-year period. The most common symptoms were frequency, dysuria, urgency, pain and haematuria. Common clinical findings were presence of bladder mass, peripheral eosinophilia and thickened bladder wall. A variety of medical treatments were used, most frequently steroids, antibiotics and antihistamines. Recurrence occurred in patients on tapering or discontinuing prednisone, among other reasons. There is no consensus about the treatment of EC, but In light of our findings in this review, the treatment of choice in our department will be tapered prednisone over 6–8 weeks in combination with antihistamine.

Disorders of sex development presenting as unilateral cryptorchidism.

Abstract Disorders of sex development (DSD) present in different forms but, in most cases, with visible anomalies of the external genitalia. The diagnosis of DSD can have a vast impact on an individual; in addition to concerns about fertility and a higher risk of neoplasia, it may have severe psychosocial impact on the patient. This report presents two apparently healthy cases referred for operation because of unilateral undescended testis. In these two patients, uterine remnants were found during the operation, and underlying DSD conditions were unexpectedly diagnosed. One patient had a 45,X/46,XY mosaic karyotype, while the second patient had persistent müllerian duct syndrome, probably due to an anti-müllerian hormone receptor defect. Both conditions are extremely rare, but the findings reinforce that DSD should be considered in patients with cryptorchidism, especially if other clinical signs are present.

Case Report: Partial priapism

With only 34 prior cases in world literature, partial priapism (PP), also called partial segmental thrombosis of the corpus cavernosum, is a rare urological condition. The aetiology and treatment of PP is still unclear, but bicycle riding, trauma, drug usage, sexual intercourse, haematological diseases and α-blockers have been associated with PP. In this case report and world literature review, we describe the case of a 50-year-old man suffering from PP after ingesting 100 mg of sildenafil. The patient was treated with a surgical incision for corpus cavernosum and clot evacuation, as a conservative treatment of PP was not feasible due to severe pain and unresponsiveness to analgesics.

Non-invasive, low-grade papillary urothelial carcinoma in the urachus

The urachus is a duct connecting the allantois with the fetal bladder, forming the median umbilical ligament; it usually obliterates during fetal life. Carcinomas arising from urachal remnants are rare but associated with a poor prognosis. We present one case of non-invasive urachal papillary urothelial carcinoma, and through a systematic literature search, we identified 12 additional cases of urachal urothelial carcinoma reported in English literature in the past 20 years. The cases were compared according to the Sheldon Staging System and the Mayo Staging System presented by Ashley et al in 2006, and both Staging Systems tend to predict clinical outcome. The urachal carcinoma is an important differential diagnosis in patients presenting with haematuria or an infraumbilical mass, because the symptoms may be sparse and diagnosis at an early stage is essential for successful treatment.

Renal cell carcinomas mass of <4 cm are not always indolent

Context: The rate of progression to metastatic disease in patients undergoing active surveillance for small renal tumors varies in the literature between 1% and 8%. Aims: This study aims to examine the incidence of metastasis in small renal tumors of <4 cm in a Danish cohort. Settings and Design: Retrospective. Methods and Material: Data on 106 patients who were diagnosed with renal cancer (RCC) of <4 cm by CT scan from January 2005 to December 2013 were collected retrospectively in January 2016 from patient charts and analyzed. Statistical Analysis Used: The cancer-specific survival (CSS) and overall survival (OS) were estimated using Kaplan-Meier methods. Results: The mean age was 62 years (range 40–84 years). Two patients (1.9%) had metastases at the time of diagnosis. Radical nephrectomy was performed in 74 patients (70%); of them, one patients (1.4%) experienced late metastasis (LM). Partial nephrectomy was performed in 30 patients (28%); of them, two patients (6.7%) experienced LM. The mean time to LM was 27 ± 12 months (95% confidence interval: 4–56). CSS rates were 98%, 97%, and 97% for 1, 3, and 5 years, respectively, while OS rates were 96%, 92%, and 86% for 1, 3, and 5 years, respectively. On multivariate analysis, tumor size (P = 0.04), pT3a (P = 0.0017), and patients age (P = 0.02) at the time of diagnosis were significant predictors of LM. Conclusions: Even small renal carcinomas may be aggressive, and caution should be taken when offering active surveillance.

Symptomatic urachal remnants: Case series with results of a robot-assisted laparoscopic approach with primary umbilicoplasty.

Abstract Objective: Between 2012 and 2014, nine consecutive patients with symptomatic urachal remnants were treated at Roskilde Hospital, Denmark, with a robot-assisted laparoscopic en bloc resection of their urachal remnants with partial cystectomy and umbilectomy with primary umbilicoplasty. The objective of this study is to report surgical results and give recommendations for the management of urachal remnants. Materials and methods: The patient group consisted of four women and five men with a median age of 59 years. Indications for surgery included bothersome umbilical secretion in two patients, and suspicion of malignancy in seven patients with unexplained haematuria. Three patients also suffered from recurrent urinary tract infections. Urachal remnants were confirmed on computed tomography scans in all patients. The median surgical time was 120 min with no significant intraoperative problems. Results: The surgical approach led to cosmetically satisfactory results in all patients. However, three patients suffered subsequent rupture of the fascia and one required an exploratory laparotomy to secure haemostasis of a bleeding spleen. Histology revealed a well-differentiated adenocarcinoma with negative surgical margins in one patient while no signs of malignancy were observed in the remaining eight patients. Umbilical secretion, haematuria and urinary infections subsided in all patients after the surgery. Conclusions: Based on these findings, it would be reasonable to offer surgery to patients with symptomatic urachal remnants. However, one should be aware that there is a significant risk of complications and that the risk of cancer seems to be limited.

Unilateral Ultrasound-Guided Transversus Abdominis Plane Block After Nephrectomy; Postoperative Pain and Use of Opioids

Background Pain has a wide spectrum of effects on the body and inadequately controlled postoperative pain may have harmful physiologic and psychological consequences and increase morbidity. In addition, opioid anesthetic agents in high doses can blunt endocrine and metabolic responses following surgery and are associated with side effects including dizziness, nausea, vomiting, constipation, and respiratory depression. Objectives The current study aimed to investigate if unilateral ultrasound-guided transverse abdominal plane block (TAP-block) could reduce pain and postoperative use of patient requested analgesics following nephrectomy compared to local injection of the same ropivacaine dose in the surgical wound. Patients and Methods Retrospective chart reviews were performed in 42 consecutive patients who received TAP-block in conjunction with nephrectomy from November 2013 to August 2014 (group A). For comparison, data were used from 40 other nephrectomy patients registered as part of a previous study (group B). In this group the patients had received local ropivacaine injection in the surgical wound. On univariate analyses, the groups were compared by t-test and the Fisher exact test. Multivariate analyses were conducted by multiple linear regression. Results Mean surgical time was 162 minutes in group A and 92 minutes in group B (P < 0.0001). The means of visual analogue scale (VAS) were 3.05 and 1.55 in A and B groups, respectively (P = 0.001). The means of morphine consumption were 5.2 mg and 5.9 mg in groups A and B, respectively (P = 0.58); while the means of sufentanil use were 9.8 μg and 6.0 μg in groups A and B, respectively (P = 0.06). When controlling for age, tumor size and American society of anesthesiologists classification (ASA) score on multivariate analysis, TAP-block was associated with a significant increase in VAS (+1.4 [95% CI, 0.6 - 2.3], P = 0.001) and sufentanil use (+6.2 μg [95% CI, 2.3 - 10.2], P = 0.003). There was no difference in morphine use on multivariate analysis (P = 0.99). Conclusions TAP-block in conjunction with laparoscopic nephrectomy did not reduce pain or opioid consumption. On the contrary, it seemed to prolong surgical time.