Riyadh F. Talic

Granulosa Cell Tumor of the Adult Type A Case Report and Review of the Literature of a Very Rare Testicular Tumor

We report a case of testicular granulosa cell tumor of the adult type in a 48-year-old man. Microscopically, the tumor consisted of round to ovoid cells with grooved nuclei that were arranged in several patterns, including microfollicular, macrofollicular, insular, trabecular, gyriform, solid, and pseudosarcomatous. These cells demonstrated strong immunopositivity with MIC2 (O13) antibody, vimentin, and smooth muscle actin and focal positivity with cytokeratin. Although this type of sex cord-stromal tumor is relatively common in the ovaries, it is still extremely unusual in the testis, and it probably represents the rarest type of testicular sex cord-stromal tumor.

Prospective randomized study of transurethral vaporization resection of the prostate using the thick loop and standard transurethral prostatectomy

OBJECTIVES Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral prostatectomy (TURP). The procedure uses one of the novel, thick resection loops coupled to augmented electrocutting energy. We evaluated the safety and efficacy of TUVRP in comparison with TURP. METHODS Sixty-eight patients with prostatic outflow obstruction were prospectively randomized between equal TUVRP and TURP treatment groups. Safety parameters evaluated included changes in serum hemoglobin, hematocrit, and sodium 1 and 24 hours after resection. Operative time, catheterization time, and incidence of complications were noted. Efficacy parameters included evaluation by the International Prostate Symptom Score and maximum flow rate. RESULTS Patients of both groups were balanced for the different baseline variables. One hour after TURP, patients had significantly lower levels of hemoglobin, hematocrit, and sodium (P = 0.03, 0.03, and 0. 01, respectively). The prostate resection weight was similar in both groups; however, the difference in the mean operative time was significant (TUVRP group 42.4 minutes and TURP group 35.9 minutes, P = 0.02). The postoperative catheterization time was significantly shorter for the TUVRP group (23.1 +/- 10.3 versus 36 +/- 17.3 hours, P <0.0001). All patients were followed up for an average of 9 months. The International Prostate Symptom Score was 4 +/- 3.4 and 5.6 +/- 3.1 and the maximum flow rate was 19 +/- 6.5 and 15.2 +/- 10 mL/s for the TUVRP and TURP groups, respectively; these differences were statistically significant (P = 0.03 and 0.01, respectively). Complications included urethral strictures (6 patients) and delayed hemorrhage with clot retention (2 patients); no differences in the incidence of complications were noted between the two groups. CONCLUSIONS The results of the present study have demonstrated that TUVRP is as safe and efficacious as TURP in the treatment of men with prostatic outflow obstruction. The shorter catheterization time observed after TUVRP may be clinically significant, considering the demand for lower morbidity profiles by patients. The longer operative time in TUVRP was related to the slower motion of the Wing electrode needed to add the advantages of electrovaporization.

Extracorporeal shock wave lithotripsy for lower pole nephrolithiasis: Efficacy and variables that influence treatment outcome

OBJECTIVES Extracorporeal shock wave lithotripsy (ESWL) for the treatment of lower caliceal stones (LCS) tends to have a poor success rate, prompting many urologists to advocate alternative treatment modalities. This study attempts to identify variables that may influence the outcome of ESWL treatment for LCS to help in selecting patients that are likely to benefit from the treatment. METHODS One hundred forty-two patients with isolated LCS treated with the Dornier HM3 lithotriptor were reviewed. The study data include characteristics of patients, stones, urinary tract treated, previous treatment of stones in the same kidney, and details of the ESWL treatment. RESULTS Eighty patients (56%) were stone free 3 months after ESWL. Multivariate analysis with logistic regression identified six independent and significant variables that influenced treatment outcome: these included number of stones (P = 0.001), previous percutaneous nephrostolithotomy (PNL) treatment (P = 0.001), side of the stone (P = 0.002), presenting stone type (P = 0.004), number of ESWL sessions (P = 0.01), and maximum kilovoltage setting of ESWL at treatment (P = 0.02). Stone size did not influence the treatment outcome in this study. CONCLUSIONS ESWL provides an acceptable first line treatment for patients with LCS. Patients who fail ESWL and have poor prognostic features (ie, multiple LCS, hard stones requiring high voltage and multiple ESWL sessions, lower caliceal stone formation secondary to ESWL treatment of stones in other locations of the renal unit, or previous treatment with PNL) should be counseled for alternative treatment modalities.

Extracorporeal shock-wave lithotripsy monotherapy in renal pelvic ectopia

OBJECTIVES To determine the efficacy of extracorporeal shock-wave lithotripsy (ESWL) in the treatment of urinary stones in pelvic kidneys. METHODS Fourteen male patients with renal pelvic ectopia and stones were treated with ESWL monotherapy using the unmodified Dornier HM3 lithotriptor with its original generator and ellipsoid. Twelve patients were treated in the prone position using cystoscopically placed ureteral catheters to aid in fluoroscopic localization, whereas 2 patients were treated in the supine position. A review of their stone disease, ESWL treatment, ancillary procedures, outcome, and complications is presented. RESULTS All pelvic kidneys were free of infection and obstruction in this group. The mean stone burden was 30.2 +/- 37.8. Most patients required a single session (9 of the 14 [64%]), 2 patients required two sessions, and 2 patients required multiple sessions. The average number of shock waves per session was 1689 (range 450 to 3500), with average kilovoltage of 21.5 (range 18 to 24). Eighty-two percent of the patients followed (9 of 11) were stone-free at 3 months. No ancillary endourologic procedures were required to deal with the presenting stones. Obstructive steinstrasse complicated treatment in only 2 patients (14%) and was successfully treated by further ESWL in both patients: in 1 of them, ureteroscopy was needed. CONCLUSIONS ESWL monotherapy of renal pelvic ectopia stones is very effective and should be considered as the first therapeutic option for these patients, provided that accurate localization of the stone treated and proper positioning of patients that ensures adequate delivery of shock-wave energy can be maintained.

Transurethral Vaporization–Resection of the Prostate versus Standard Transurethral Prostatectomy: Comparative Changes in Histopathological Features of the Resected Specimens

Objectives: Transurethral vaporization resection of the prostate (TUVRP) is a recent modification of the standard transurethral resection of the prostate (TURP). TUVRP uses a band electrode coupled to a high electrocuting energy to achieve simultaneous resection, vaporization and coagulation of the prostate. We evaluated the histopathological resection specimens of patients treated with TUVRP to see whether the higher energy used will result in thermal artifacts that will interfere with the pathological evaluation of the prostate, and compared the results to TURP specimens. Material and Methods: The histopathological specimens of 50 patients that underwent TUVRP or TURP were reviewed. Artifactual pathological patterns that were identified in the specimens included: abnormal cellular orientation and spindling, artifactual cellular detachment from the underlying basement membrane, atypical cytological changes or areas of stromal coagulative necrosis. Each identified pattern was awarded 1 point. The severity of cautery artifact was graded into mild, moderate or severe according to the sum of points in each specimen. Results: Mild cautery artifact changes were noted in 1 patient who underwent TURP. Moderate changes were noted in 21 patients in each TURP and TUVRP groups while severe changes were noted in 4 and 3 patients undergoing TUVRP and TURP respectively. There were no statistically significant differences between the groups with regard to the severity of the cauterization– induced changes. Conclusions: The quality of histopathological specimens produced by TUVRP is similar to the standard TURP. It seems that the higher energy use in electrovaporization technique does not result in greater thermal injury to the tissues possibly because of the cooling effect of the irrigation fluids used intraoperatively.

Rare association of unilateral renal oncocytoma and angiomyolipoma.

A 65-year-old woman presented to the hospital with left loin pain and haematuria, radiological diagnostic studies demonstrated left renal mass suggestive of renal cell carcinoma and radical nephrectomy was performed. Pathological examination demonstrated the very rare association of renal angiomyolipoma and oncocytoma.

The 'wing' versus the 'Vapor Cut' electrodes in transurethral electrovaporization-resection of the prostate : Comparative changes in safety parameters

We compared the early safety features of two-band resection devices used in transurethral vaporization-resection of the prostate (TUVRP). Ninety patients with prostatic outflow obstruction were prospectively evaluated in two open studies for the treatment using the ‘Wing’ cutting electrode in group 1 (Richard Wolf, Germany) and the ‘Vapor Cut’ electrode in group 2 (Karl Storz, Germany). Patients in both groups were comparable in age, presentation, prostate size and blood parameters. Safety features evaluated included changes in serum hemoglobin, hematocrit, sodium concentration and incidence of side effects. The mean drop in hemoglobin, hematocrit and serum sodium 1 h postoperatively for the Wing group were 0.54 g/dl, 2.04 ml/dl and 0.084 mEq/l respectively compared to a mean drop of 1.1 g/dl, 3.07 ml/dl and 3.1 mEq/l in the Vapor Cut group. These differences were statistically significant (p = 0.004, 0.03 and <0.0001 respectively). The mean resection weight was 24.78 ± 10.4 and 24.46 ± 14.79 g in groups 1 and 2, respectively; however, the mean operation time was significantly longer in the Wing group (47.7 vs. 37.1 min, p = 0.003). We conclude that both loops were safe and efficacious in the treatment of patients with prostatic outflow obstruction. Safety features that are related to the vaporization effect are influenced by the speed of resection.

Extracorporeal Shockwave Lithotripsy for Ureterolithiasis in Patients with Urinary Bilharziasis: Efficacy and Variables That Influence Treatment Outcome

Objectives: Schistosomiasis affecting the ureter is commonly accompanied by ureteric dilatation with or without ureteric stricture and altered ureteric wall motility that can influence extracorporeal shockwave lithotripsy (ESWL) results. This study attempts to identify variables that may influence the outcome of ESWL in the treatment of ureterolithiasis in patients with urinary bilharziasis.Patients and Methods: Forty–three patients with urinary schistosomiasis and ureterolithiasis treated with ESWL were reviewed. The study data include characteristics of patients, stones, urinary tract treated and details of ESWL treatment.Results: Thirty–five patients (81.3%) were stone–free at 3 months. Multivariate analysis with logistic regression identified two significant variables that influenced treatment outcome, namely the presence of ureteric stricture (p = 0.004) and the ESWL voltage (p = 0.003). Ten ureteric strictures were encountered in 9 patients (21%), the majority of these were diagnosed post–ESWL when patients failed to pass well–fragmented stones in spite of pre–ESWL evaluation.Conclusions: In situ ESWL is a safe and effective first line of treatment for urinary stones in bilharzial ureters. The presence of concomitant bilharzial stricture is a significant variable which affects the treatment outcome. Every effort should be made to rule out and deal with possible complicating factors such as ureteric strictures in the pretreatment period.

Paramedian Extraperitoneal Approach for Combined Nephrectomy and Augmentation Ureterocystoplasty in Children with Neurovesical Dysfunction

Objectives: We describe and evaluate our approach to combined nephrectomy and augmentation ureterocystoplasty using a single paramedian extraperitoneal incision.Patients and Methods: Three patients with neurogenic bladders (2 posterior urethral valves and 1 myelodysplasia) underwent nephrectomy and augmentation ureterocystoplasty. The mean age of the patients was 4.6±1.5 years. The indications for the procedure included control of urinary incontinence or preservation and stabilization of renal function.Results: The integrity of the peritoneal cavity was easily preserved throughout the procedure using a paramedian incision. No complications were encountered in these patients. Early postoperative resumption of normal diet and activity was noted in all patients.Conclusion: The paramedian extraperitoneal approach through a single incision provides the advantages seen with other extraperitoneal techniques combining two incisions. The single paramedian incision has the potential to save on operative time and obviates the need to change the patient’s position on the operating table while under anesthesia. Furthermore, the paramedian extraperitoneal approach provides the reconstructive surgeon with the chance to convert the procedure into a transperitoneal technique to incorporate bowel segments in order to complement ureterocystoplasty.

Unilateral traumatic hematocele--an unusual presentation of bilateral testicular rupture.

The case of a young male patient with penile laceration and right hematocele following blunt trauma to the genitalia is presented. Both testes were found ruptured at exploration and were repaired. The value of early surgical intervention in scrotal trauma is reiterated and indications for bilateral testicular exploration in cases of unilateral traumatic hematocele are suggested.