Pinhas M. Livne

PREDICTING THE SUCCESS OF RETROGRADE STENTING FOR MANAGING URETERAL OBSTRUCTION

PURPOSEnRetrograde ureteral stenting is often considered the first line option for relieving ureteral obstruction when temporary drainage is indicated. Several retrospective studies have implied that in cases of extrinsic obstruction retrograde ureteral stenting may fail and, therefore, percutaneous nephrostomy drainage is required. We examined the efficacy of retrograde ureteral stenting for resolving ureteral obstruction and identified clinical and radiological parameters predicting failure.nnnMATERIALS AND METHODSnEnrolled in our prospective study were 92 consecutive patients with ureteral obstruction, which was bilateral in 8. Retrograde ureteral stenting was attempted in all cases by the urologist on call. When stent insertion failed, drainage was achieved by percutaneous nephrostomy. Patients were followed at 3-week intervals for 3 months. Each followup visit included a medical interview, blood evaluation, urine culture and ultrasound. Stent malfunction was defined as continuous flank pain manifesting as recurrent episodes of acute renal colic, 1 or more episodes of pyelonephritis, persistent hydronephrosis or elevated creatinine. Preoperative data and outcomes were compared in cases of intrinsic and extrinsic obstruction. Univariate and multivariate analysis was done to identify predictors of the failure of ureteral stent insertion and long-term function.nnnRESULTSnThe etiology of obstruction was intrinsic in 61% of patients and extrinsic in 39%. Extrinsic obstruction, which was associated with a greater degree of hydronephrosis, was located more distal. Retrograde ureteral stenting was successful in 94% and 73% of patients with intrinsic and extrinsic obstruction, respectively. At the 3-month followup stent function was maintained in all patients with intrinsic obstruction but in only 56.4% with extrinsic obstruction. On multivariate logistic regression the type of obstruction, level of obstruction and degree of hydronephrosis were the only predictors of stent function at 3 months. Stent diameter and preoperative creatinine had no predictive value.nnnCONCLUSIONSnRetrograde ureteral stenting is a good solution for most acutely obstructed ureters. In patients with extrinsic ureteral obstruction a more distal level of obstruction and higher degree of hydronephrosis are associated with a greater likelihood of stent failure. These patients may be better served by percutaneous drainage.

Comparative evaluation of treatments for erectile dysfunction in patients with prostate cancer after radical retropubic prostatectomy.

Objective To assess the effectiveness of a progressive local treatment protocol for erectile dysfunction (ED) in patients after undergoing radical retropubic prostatectomy (RRP) for prostate cancer.

Significance of angiogenesis and microvascular invasion in renal cell carcinoma

The aim of this study is to evaluate the relationship between tumor angiogenesis and microvascular invasion, and the subsequent development of metastatic disease in patients undergoing surgery for renal cell carcinoma (RCC). The study group consisted of 102 patients who underwent surgery for RCC between the years 1990 and 1997 in our institute with a mean follow up period of 81.3 months. Paraffin blocks were stained for Factor VIII-related antigen and CD34 which decorate endothelial cells in order to assess angiogenesis and microvascular invasion and their relevance for developing metastatic disease. When Factor VIII-related antigen staining was used we found that the microvessel count correlated with the development of metastatic disease with a mean count of 49.7 for patients with no evidence of disease and a mean count of 95.5 for patients who developed metastatic disease (p<0.05). We also found that microvascular invasion correlated with the development of metastatic disease. It was demonstrated in 55.5% of patients who developed metastatic disease versus 23.8% of patients with no evidence of disease with Factor VIII staining (p<0.05), and in 33.3% and 7.1%, respectively (p<0.05) with CD34 staining. This study suggest that demonstration of intense angiogenesis and microvascular invasion may be a predictor of a more aggressive tumor mandating closer follow up and consideration of adjuvant therapy.

THE EFFECT OF CHOLINERGIC ENHANCEMENT DURING FILLING CYSTOMETRY: CAN EDROPHONIUM CHLORIDE BE USED AS A PROVOCATIVE TEST FOR OVERACTIVE BLADDER?

PURPOSEnOveractive bladder, a highly prevalent disorder, is suspected of having a low detection rate due to the lack of sensitive diagnostic tools. Recent studies imply the involvement of the cholinergic system in the pathophysiological mechanism underlying overactive bladder. We determined whether in vivo enhancement of cholinergic activity with edrophonium chloride, a potent cholinesterase inhibitor, would serve as a provocative maneuver to increase the sensitivity of filling cystometry.nnnMATERIALS AND METHODSnA total of 27 patients underwent a multichannel video urodynamic evaluation, followed by filling cystometry with the intravenous administration of 10 mg. edrophonium chloride. The response to edrophonium was defined as a significant change in sensation and decreased bladder capacity, the induction or amplification of involuntary detrusor contractions, or significantly decreased detrusor compliance. Findings were compared in responders and nonresponders.nnnRESULTSnWe identified 11 responders and 16 nonresponders. A response was noted in 78% of the patients with the symptomatology of overactive bladder but in none with no specific complaints suggesting bladder overactivity. In 7 of the 12 responders (64%) baseline cystometry was interpreted as normal. In 6 of the 11 responders (54%) uninhibited urinary leakage was observed in response to edrophonium. There were no serious adverse reactions to the drug.nnnCONCLUSIONSnThis preliminary study implies that edrophonium may serve as a novel, practical and safe drug for provocative cystometry. By significantly increasing cystometry sensitivity the drug would facilitate the identification of the subset of patients with overactive bladder who are currently classified with sensory urgency.

Three-year outcome of a progressive treatment program for erectile dysfunction with intracavernous injections of vasoactive drugs.

OBJECTIVESnTo perform a comparative evaluation and follow-up of patients with erectile dysfunction (ED) who were treated with intracavernous injection of vasoactive drugs, starting with simple drugs and advancing to complex combinations.nnnMETHODSnThe study included 625 patients, 26 to 85 years old, with ED. Four intracavernous injection protocols were used: protocol 1, papaverine plus phentolamine; protocol 2, prostaglandin E(1); protocol 3, papaverine, phentolamine, and prostaglandin E(1); and protocol 4, atropine sulfate, papaverine, phentolamine, and prostaglandin E(1). A positive response was defined as an erection sufficient for penetration. Patients for whom the basic protocol failed were successively switched to the more advanced protocols until a positive response was achieved.nnnRESULTSnA positive response was achieved by 415 (66.4%) of the 625 patients given protocol 1; 75 (36%) of the remaining 210 patients given protocol 2; 98 (72.6%) of the 135 patients given protocol 3; and 22 (59.5%) of 37 patients given protocol 4. All four protocols failed in only 15 patients (2. 4%). At the 3-year follow-up visit (n = 610), 349 had achieved coitus, 65 (10.6%) without an injection and 202 (33.1%) with an injection. Eighty-two patients sometimes performed coitus without an injection. Sixty-three patients (10.3%) abandoned the program because of marital or health problems; 198 asked to be switched to Viagra during the follow-up period, and 120 returned to the program.nnnCONCLUSIONSnOverall, our progressive treatment yielded a high positive response rate (97.6%), with 57.2% achieving successful coitus on follow-up. The main advantage of the program is that it spares patients who are responsive earlier from using more complex, painful, and costly drugs.

Human DNA topoisomerase‐IIα expression as a prognostic factor for transitional cell carcinoma of the urinary bladder

To investigate the immunohistochemical expression of topoisomerase II‐α (TII‐α, a nuclear enzyme, the expression of which increases rapidly at the end of the S to G2/M phase and declines when mitosis ends) in bladder urothelial neoplasms (transitional cell carcinoma), and its correlation with grade, stage and survival.

Retrograde Endoureterotomy for Persistent Ureterovesical Anastomotic Strictures in Renal Transplant Kidneys After Failed Antegrade Balloon Dilation

OBJECTIVEnTo evaluate the long-term outcomes and complications of retrograde endoureterotomy for persistent ureterovesical anastomotic strictures in renal transplant patients after percutaneous balloon dilation failure.nnnMETHODSnFrom January 2000 to May 2010, 26 (2.6%) of 1004 renal transplant patients developed ureterovesical anastomotic stricture after surgery. Seven of these patients and five additional referred patients with similar characteristics were treated with retrograde endoureterotomy after ≥1 previous unsuccessful attempt at percutaneous balloon dilation. All strictures treated were <1 cm in length. The clinical characteristics and outcomes were analyzed. Success was defined as the absence of symptoms and the resolution of obstruction on imaging after the procedure.nnnRESULTSnThe median interval from initial treatment to endoureterotomy was 2.9 months (range 1.3-62.1). Before endoscopic treatment, 8 patients (67%) were treated with a single trial of balloon dilation and 4 (33%) with multiple trials. Endoureterotomy was performed using cold knife, holmium:yttrium-aluminum-garnet laser, and Bugbee electrode in 9, 2, and 1 patients, respectively. The median follow-up period was 44.4 months (range 2.4-68.6). Recurrent stricture developed in 2 patients during a mean follow-up of 4.7 months. Thus, the overall success rate was 83%. Postoperative complications appeared in 3 patients (25%) with culture-positive urinary tract infection. One graft failure occurred but was not related to a recurrent stricture.nnnCONCLUSIONnAfter failure of antegrade percutaneous balloon dilation, retrograde endoureterotomy is an effective salvage procedure for well-selected cases of renal transplant patients with a short ureterovesical anastomotic stricture.

Type ii ureteral triplication associated with ectopic ureter

We report a case of type II ureteral triplication associated with ectopic ureter. The ureter, draining the upper renal segment, entered the vagina, and the other two ureters, draining the middle and lower renal segments, had joined and entered the bladder. The anatomic findings are compatible with those predicted by the Weigert-Meyer law. A thorough evaluation of such an anomaly is essential for effective management.

Abdominal compartment syndrome: urological aspects.

ACS is prevalent in various surgical conditions and in a large percentage of critically ill patients. Measuring the IAP is important in the early diagnosis of ACS and can be easily done by measuring the intravesical pressure. ACS adversely affects many organ systems; the pathogenesis of renal dysfunction is probably multifactorial, from a combination of reduced cardiac output, reduced GFR mediated by secretion of renin and angiotensin, aldosterone-mediated water reabsorption, increased renal parenchymal pressure and direct compression of the renal vein. Successful treatment requires a high index of suspicion, prompt recognition and early surgical abdominal decompression.

DCC protein expression in clear cell renal cell carcinoma.

To investigate whether the expression of protein from the ‘deleted in colorectal cancer’ (DCC) gene, which predicts a poor outcome for patients with colorectal carcinoma, can also serve as a prognostic factor in renal cell carcinoma (RCC).