Raja B. Khauli

Periprostatic infiltration with local anesthesia during transrectal ultrasound-guided prostate biopsy is safe, simple, and effective:A pilot study

OBJECTIVE Transrectal ultrasound (TRUS)-guided prostate needle biopsy is the standard procedure to diagnose prostate cancer. It can be associated with significant discomfort and pain. We evaluated if periprostatic infiltration with local anesthetic reduces this discomfort. MATERIAL AND METHODS 72 patients underwent TRUS-guided prostate needle biopsy. All patients had 12 cores, with four prostatic zones of biopsies. In 25 consecutive patients (G1) with a median prostate size of 47 cc, no anesthesia was given; while in 47 sequential patients (G2) with a median prostate size of 50 cc, 2 ml of 2% lidocaine was infiltrated in the periprostatic area around the neurovascular bundle using 20-cm-long, 22-gauge needle on both sides as guided by color Doppler. Biopsies were performed in standard fashion. Discomfort was graded on a scale from 0 to 10 with 0 meaning no discomfort, 1-3 mild, 4-6 moderate, and 7-10 severe. RESULTS 12/25 (48%) of G1 patients reported no discomfort compared to 70% in G2 (P=.025). Mild discomfort was reported in 5/25 (20%) patients of G1 and 9/47 (19%) patients of G2. Moderate or severe discomfort was reported in 8/25 (32%) patients and 5/47 (11%) patients in G2 (P=.039). Prostate size did not affect degree of discomfort within each group and between both subgroups. No adverse reactions were observed secondary to lidocaine infiltration. CONCLUSION Periprostatic infiltration with local anesthesia at the time of TRUS-guided prostate needle biopsy significantly reduces discomfort. It is easy to perform, safe, and should be considered in all patients irrespective of the prostate size.

Solitary Fibrous Tumors of the Kidneys: Presentation, Evaluation, and Treatment

Introduction: Renal solitary fibrous tumors (SFTs) are spindle cell neoplasms of mesenchymal origin, and very rare with only 46 cases reported worldwide to date. It is crucial to differentiate this tumor from other tumors of the kidney, so as to avoid unnecessary treatment. Therefore, our objective was to review reports of renal SFTs, their clinical presentations, imaging methods, and surgical management, updated to 2013. Material and Methods: We retrospectively reviewed articles published in the USA, Europe, and Asia from 1996 to date using PubMed, Medscape, Medline, and several major journals. We report on areas of controversy and well-established guidelines. Results: We reviewed 58 articles which confirmed, with a high level of evidence-based medicine, that the male-to-female ratio is equal and their most common presentation is an incidental finding on a radiological study, in which it is difficult to differentiate them from renal cell carcinoma. Nephrectomy is the gold standard treatment, with almost no recurrence. Conclusions: In symptomatic patients, complete surgical resection of renal SFTs may provide a very good outcome, with almost no recurrence.

Successful transplantation of a kidney with early membranous nephropathy

This report describes a patient with end-stage renal disease secondary to long-standing type II diabetes mellitus who received a cadaveric renal transplant from a 37-year-old woman who died of massive cerebral infarction. An autopsy performed on the donor following organ procurement revealed no obvious contraindications to transplantation. A renal biopsy of the donor kidney performed at the time of transplantation, however, subsequently showed early membranous nephropathy by electron microscopy. There was immediate graft function and the recipient continues to have good renal function 3 years post-transplantation.

Missile injury of upper ureter treated by delayed renal autotransplantation and ureteropyelostomy

We report a case of extensive upper ureteral loss due to a missile injury managed by delayed renal autotransplantation and ureteropyelostomy using the residual lower ureteral segment. The successful outcome attests to the value of this therapeutic strategy in severe traumatic injuries to the ureter secondary to bullet or shrapnel fragments.

USE OF SMALL AND LARGE BOWEL IN RENAL TRANSPLANTATION

The continued success of renal transplantation has provided a higher quality of life for properly selected patients with ESRD. It is also a much more cost-effective and efficient treatment of ESRD compared with chronic dialysis. Innovative urologic reconstructive surgery using enteric segments for both continent and incontinent urinary diversions has permitted this therapeutic modality to be offered to the recipient with lower urinary tract disease not previously amenable to renal transplantation. These same reconstructive techniques using ileal segments have also permitted preservation of renal allografts with previously nonreconstructable renal pelvic or ureteral disease.

Posttransplant Lymphocele Presenting as ‘Acute Abdomen’

Lymphoceles occurring after renal transplantation are frequently asymptomatic and are usually identified on routine ultrasonography of the allograft. A small percentage of them may increase in size and manifest due to their compression effects on adjacent structures or as lymphocutaneous fistula. An infected lymphocele would, in addition, give rise to local and systemic features. A case of infected lymphocele occurring 4.5 months after cadaveric renal transplant is reported. The patient presented in septicemia and features of generalized peritonitis. Emergency diagnostic laparoscopy revealed fluid collection in the peritoneal cavity. However, on exploratory laparotomy no intra-abdominal pathology was detected. Further evaluation revealed a large perigraft lymph collection which was drained percutaneously. Fluid and blood cultures grew Staphylococcus aureus. The patient recovered completely following external drainage and antibiotic administration.

Modified extravesical ureteral reimplantation and routine stenting in kidney transplantation

Abstract In the past, extravesical ureteroneocystostomy has been technically modified several times, with varying results. In this study, we evaluate our experience with modified extravesical re‐implantation and routine stenting. From January 1988 to September 2001, 411 consecutive renal transplantations (220 LRD/LUD, 191 CAD) were performed at our institutions. Of 220 kidneys utilized for living related transplantation, 39 were retrieved laparoscopically and 181 were retrieved by open nephrectomy. The ureteroneocystostomy performed was a modified Lich–Gregoir re‐implantation with routine stenting, using the upper transplant ureter. A double ureter was encountered in 11 patients and was managed with a conjoint ureteral ostium‐to‐mucosa anastomosis, using two stents. In two patients with graft ureteropelvic junction (UPJ) stenosis, a doule ipsilateral drainage was performed, applying modified extravesical reimplantation with concomitant ureteroneocystostomy. There were no ureteral leaks. Five (1.22%) patients developed temporary ureterovesical junction (UVJ) obstruction/edema following stent removal, which necessitated restenting for 4–6 weeks. Two patients (0.49%) developed delayed stenosis and were successfully treated with retrograde balloon dilatation. (One at the UPJ of a pediatric kidney, and one at UVJ). All patients with functioning grafts in this series are currently stent‐free. We conclude that the modified extravesical reimplantation with routine stenting is an effective and safe technique in renal transplantation, associated with almost no complications.

The case for routine circumcision

Few issues in medicine create as much debate and controversy as the need for routine circumcision. With one-third of the world male population and at least 60% (and up to 80%) of males in the USA being circumcised circumcision remains the most commonly performed surgical procedure. In 1971 the American Academy of Pediatrics (AAP) Task Force on circumcision considered the procedure unnecessary. With the accumulation of data in support of circumcision the AAP revisited this issue twice in 1989 and 1999 stating that circumcision definitely has potential benefits. Nevertheless no recommendation for routine circumcision was made. Today there is no consensus and circumcision remains a personal decision that should be preceded by an informed consent. For this review we found ample evidence pointing towards the advantages of circumcision. (excerpt)

Effect of atorvastatin on antibody, interleukin-4 and gamma-interferon production in mice immunized with egg albumin.

Three-hydroxy-3-methylglutaryl CoA reductase inhibitors, also known as statins, are widely used as the drug of choice for the treatment of hyperlipidemia. However, actions beyond that of simply lowering cholesterol levels have been reported. This study aims at evaluating the effect of atorvastatin on antibody interleukin-4 and γ-interferon production in mice immunized with egg albumin. Antibody levels were determined by an enzyme linked immunosorbent assay and cytokine transcripts by reverse transcriptase–polymerase chain reaction. Results indicated that repeated daily doses of 40 mg/Kg body weight of atorvastatin following immunization suppressed the antibody response in mice to egg albumin. Moreover, a decline in interleukin-4 and γ-interferon transcripts was observed.

High-Dose Calcitriol, Docetaxel and Zoledronic Acid in Patients with Castration-Resistant Prostate Cancer: A Phase II Study

Introduction: Docetaxel has become the standard chemotherapy for patients with castration-resistant prostate cancer (CRPC). We wanted to assess the efficacy and safety of a weekly high-dose calcitriol, docetaxel and zoledronic acid combination in CRPC. Patients and Methods: Thirty patients were enrolled to receive calcitriol 0.5 µg/kg orally in 4 divided doses over 4 h on day 1 of each treatment week, docetaxel 36 mg/m2 i.v. infusion on day 2 of each treatment week and zoledronic acid 4 mg i.v. on day 2 of the first and fifth week of each cycle. Treatment was administered weekly for 6 consecutive weeks on an 8-week cycle. Results: Out of 23 evaluable patients, there was a response of prostate-specific antigen (PSA) in 11 patients (47.8%); 6 (26.1%) had a stable PSA level for a median of 4.2 months. The median survival time was 15 months (95% confidence interval 13.9–16.1 months). The regimen was generally tolerated; anemia was the only grade 3/4 hematological toxicity in 2 patients. Conclusions: This regimen was tolerated, and half of the patients had a PSA response. Although our response rates are inferior to some studies using docetaxel, we believe our response rates are acceptable knowing that we are treating CRPC, which still has variable outcomes.