Raouf M. Seyam

Neurogenic bladder in spinal cord injury patients.

Neurogenic bladder dysfunction due to spinal cord injury poses a significant threat to the well-being of patients. Incontinence, renal impairment, urinary tract infection, stones, and poor quality of life are some complications of this condition. The majority of patients will require management to ensure low pressure reservoir function of the bladder, complete emptying, and dryness. Management typically begins with anticholinergic medications and clean intermittent catheterization. Patients who fail this treatment because of inefficacy or intolerability are candidates for a spectrum of more invasive procedures. Endoscopic managements to relieve the bladder outlet resistance include sphincterotomy, botulinum toxin injection, and stent insertion. In contrast, patients with incompetent sphincters are candidates for transobturator tape insertion, sling surgery, or artificial sphincter implantation. Coordinated bladder emptying is possible with neuromodulation in selected patients. Bladder augmentation, usually with an intestinal segment, and urinary diversion are the last resort. Tissue engineering is promising in experimental settings; however, its role in clinical bladder management is still evolving. In this review, we summarize the current literature pertaining to the pathology and management of neurogenic bladder dysfunction in patients with spinal cord injury.

Pheochromocytoma in children and adolescents: a clinical spectrum

PURPOSEnThe purpose of the study was to identify the spectrum of disease characteristics of pheochromocytoma in children.nnnMETHODSnRecords of 21 consecutive children diagnosed with pheochromocytoma were reviewed. Patients age, sex, presentation, associated conditions, diagnostic and imaging modalities used, preoperative preparation, operative details, outcome, and follow-up were recorded.nnnRESULTSnThe study included 21 children. Patients were diagnosed clinically and confirmed by biochemical tests. Tumors were localized by imaging studies and all were confirmed pathologically. Patients included 17 with adrenal and 4 with extra-adrenal tumors including 1 in the urinary bladder. Seventeen had sporadic and 4 had familial pheochromocytoma. Associated manifestations were the predominant features in 1 of the 4 patients with familial pheochromocytoma. The patient with bladder pheochromocytoma presented with gross hematuria. Hypertension and visual disturbances were prominent findings in the other patients with sporadic form. Two patients (1 sporadic and 1 familial) had malignant pheochromocytoma. One patient with benign pheochromocytoma had multiple recurrences in chromaffin-containing sites. All patients were treated surgically. Seventeen patients were treated preoperatively with alpha-adrenergic blockade. Two patients continued to have significant visual disturbances. One patient with malignant pheochromocytoma died of the disease, and 1 with recurrent pheochromocytoma had neurologic consequences.nnnCONCLUSIONSnPheochromocytoma in children has unique characteristics. To our knowledge, this series is one of the largest reports of adrenal pheochromocytoma in children. It also reflects the spectrum of pheochromocytoma in this age group.

Outcome of Penile Cancer in Circumcised Men

PURPOSEnWe previously reported on a group of patients with post-circumcision carcinoma of the penis. We now study the long-term outcome of these patients.nnnMATERIALS AND METHODSnWe retrospectively reviewed the available charts of 22 patients presenting between October 1979 and May 2000.nnnRESULTSnOf 22 patients 18 underwent ritual circumcision with extensive scar development. Median age at diagnosis was 62.4 years. The penile lesion was dorsal and proximally located in 15 patients. Median delay before diagnosis was 12 months. Clinically 14 patients had stage T1-T2 disease, with 13 having no lymph node involvement and none with distant metastasis, 8 patients had stage T3-T4 disease. A total of 15 patients were treated surgically with total penectomy (10) or conservative local excision (5), inguinal lymph node dissection (9) and subsequent penile reconstruction (3). Pathological staging in 15 patients revealed 10 patients with stage T1 and in 8 patients with lymph node dissection none had nodal metastasis. Histopathological classification was 20 squamous cell carcinoma, 1 sarcoma and 1 verrucous carcinoma. Six patients refused surgery and 1 was referred for palliation. Median followup was 14.5 months and median survival was 14.5 months. The 3-year survival was 42% for stage T1-T2 and 13% for T3-T4 (p = 0.0052). Median survival for the surgical group was 34 months whereas for nonsurgical group was 3 months (p = 0.0016). Recurrence-free survival in the surgical group was 50%.nnnCONCLUSIONSnPenile carcinoma in circumcised men is a distinct disease commonly following nonclassic vigorous circumcision. Delayed diagnosis and deferring surgical treatment are associated with increased mortality.

Evaluation of a no-needle penile injector: a preliminary study evaluating tissue penetration and its hemodynamic consequences in the rat*

OBJECTIVESnIntracavernous needle injection is an effective delivery method for pharmacotherapy of erectile dysfunction. Needle phobia, pain, and concern about local tissue injury have stimulated the search for new, less invasive means of inducing penile erection. In this preliminary communication, we evaluate a jet injector as an alternative to needle injection for intracavernous delivery of vasoactive drugs.nnnMETHODSnJet injection was evaluated in three groups of rats receiving either India ink, saline, or papaverine into the penis. The ability of the jet injection to penetrate through the tunica albuginea and deliver liquid to the corpora cavernosa smooth muscle was assessed by the degree of staining within the corpus cavernosum (ink group), histologic change (saline group), and rise in intracavernous pressure (papaverine group). Erectile capacity following cavernous nerve electric stimulation was compared before and 1 hour after injection of saline or papaverine.nnnRESULTSnInk traversed the skin and tunica albuginea with extensive deposition noted within the cavernous spaces. Varying degree of subcutaneous hemorrhage were seen with saline jet injection; however, the corpus cavernous smooth muscles showed no evidence of injury. Jet injection of papaverine 3250 micrograms significantly increased cavernous pressure (39.4 +/- 4.6 cm H2O) compared with saline injection (2.8 +/- 1.3 cm H2O).nnnCONCLUSIONSnWe conclude that acute jet injection is an effective method for intracavernous delivery of drugs. Long-term effects should be evaluated prior to clinical use.

Penile autotransplantation in rats: An animal model

Context: Penile allotransplantation might be a viable option for patients who need penile reconstruction. Aims: A successful autotransplantation rat model is the first step toward proceeding for allotransplantation. We herein evaluate autotransplantation following transaction of the rat penis just distal to the urethral bulb. Settings and Design: Experimental animal study. Materials and Methods: Five Sprague–Dawely rats weighing 520 g (SD 19) were used. Utilizing a magnification of 6-40, transection and immediate anastomosis of the tunica albuginea, urethra, dorsal vein and nerves were carried out. Vesicostomy was made to divert urine. The glandular skin was sutured to the perineum and the abdominal wall was closed in layers. Statistical Analysis Used: Descriptive statistics. Results: Average surgery time was 8 h. The first two rats had no vesicostomy and died in the first postoperative day from retention. Three rats tolerated well the procedure and survived to the end point. One rat was sacrificed at day 10 and histopathology showed 30-50% necrosis of the implanted penis. Another rat was sacrificed at day 20 and showed normal cavernous tissue. The fifth rat was sacrificed 3 months postoperatively and showed evidence of moderate corporal fibrosis. Urethral fistula and necrosis of corpus spongiosum, dorsal nerve necrosis and dorsal vein occurred in all animals. Conclusions: Penile autotransplantation in rats is feasible and provides the basis for evaluation of the corpora cavernosa in an allotransplantation model. Long-term urethral continuity and dorsal neurovascular bundle survival in this model is difficult to establish.

The clinical spectrum of phaeochromocytoma: analysis of 115 patients

To analyse the presentation, manifestations and outcome in consecutive patients with phaeochromocytoma, as this disease has a wide range of pathological and clinical expressions.

The Risks of Renal Angiomyolipoma: Reviewing the Evidence

Renal angiomyolipoma (RAML), though a rare benign tumor, may impose a significant morbidity or even mortality due to its unique characteristics and the complications subsequent to its treatment. The classic tumor variant is composed of smooth muscular, vascular, and fatty components. The most straightforward diagnosis is when the fat component is abundant and gives a characteristic appearance on different imaging studies. In fat-poor lesions, however, the diagnosis is difficult and presumed a renal cell carcinoma. Yet, some variants of RAML, though rare, express an aggressive behavior leading to metastasis and mortality. The challenge lies in the early detection of benign variants and identifying aggressive lesions for proper management. Another challenge is when the vascular tissue component predominates and poses a risk of hemorrhage that may extend to the retroperitoneum in a massive life-threatening condition. The predicament here is to identify the characteristics of tumors at risk of bleeding and provide a prophylactic treatment. According to the clinical presentation, different treatment modalities, prophylactic or therapeutic, are available that span the spectrum of observation, embolization, or surgery. Renal impairment may result from extensive tumor burden or as a complication of the management itself. Improvement of diagnostic techniques, super-selective embolization, nephron-sparing surgery, and late treatment with the mammalian target of rapamycin inhibitors have provided more effective and safe management strategies. In this review, we examine the evidence pertaining to the risks imposed by RAML to the patients and identify merits and hazards associated with different treatment modalities.

Serum testosterone levels and other determinants of sperm retrieval in microdissection testicular sperm extraction

Background Microdissection testicular sperm extraction (microTESE) has become the standard of care for sperm retrieval in non-obstructive azoospermia (NOA) patients. Understanding the significant determinants of microTESE outcomes may result in improvements in sperm retrieval rates and provide better-informed clinical decisions. Methods This is a clinical retrospective study conducted through chart review of 421 NOA patients who underwent microTESE between August 2009 and July 2015 in a tertiary-care referral hospital. Clinical, biochemical and histopathological characteristics were collected. Normal serum testosterone level was defined as testosterone >9.9 nmol/L. Multiple logistic regression was used to identify determinants of microTESE in the studied population. A P<0.05 was considered significant. Results Sperms were successfully retrieved in 39.4% of cases. The average testosterone level was 11.51±7.40 and 11.67±6.42 in patients with successful and unsuccessful microTESE, respectively (P=0.820). No significant association was found between serum testosterone level and sperm motility and amount. Of all variables, histological subtype remained to be the most significant determinant of microTESE outcomes in the examined population, with hypospermatogenesis having over a 3-fold higher odd of successful microTESE than sertoli-cell only. Conclusions Serum testosterone level appears to have no significant association with microTESE outcomes in NOA. The underlying histological pattern is a significant determinant of the procedure’s success.

Visual Internal Urethrotomy for Adult Male Urethral Stricture Has Poor Long-Term Results

Objective. To determine the long-term stricture-free rate after visual internal urethrotomy following initial and follow-up urethrotomies. Methods. The records of all male patients who underwent direct visual internal urethrotomy for urethral stricture disease in our hospital between July 2004 and May 2012 were reviewed. The Kaplan-Meier method was used to analyze stricture-free probability after the first, second, third, fourth, and fifth urethrotomies. Results. A total of 301 patients were included. The overall stricture-free rate at the 36-month follow-up was 8.3% with a median time to recurrence of 10 months (95% CI of 9.5 to 10.5, range: 2–36). The stricture-free rate after one urethrotomy was 12.1% with a median time to recurrence of eight months (95% CI of 7.1–8.9). After the second urethrotomy, the stricture-free rate was 7.9% with a median time to recurrence of 10 months (95% CI of 9.3 to 10.6). After the third to fifth procedures, the stricture-free rate was 0%. There was no significant difference in the stricture-free rate between single and multiple procedures. Conclusion. The long-term stricture-free rate of visual internal urethrotomy is modest even after a single procedure.

Isolated ureteric endometriosis presenting as a ureteric tumor.

A 32 year old lady presented with recurrent left flank pain for 4 weeks and chronic lower back pain. CT without contrast showed no stones and mild left hydronephrosis. CT of the spine suggested an inflammatory process at L5-S1 vertebra. The diagnosis was supported by a bone scan. Incidentally, the scan showed nonfunctioning left kidney. Diuretic renography confirmed poor perfusion and no excretion. A retrograde study showed narrowing of the ureter at the pelvic brim. Ureteroscopy showed a papillary mass in the lumen of the ureter from which multiple cold cup biopsies were taken. The pathology however was not conclusive. A robotic nephroureterectomy was carried out. Definitive pathology showed intrinsic endometriosis of the ureter. We conclude that endometriosis should be considered in the differential diagnosis of unexplained ureteric obstruction and ureteric lumen filling defects in young women.