Said Kattan

Changing Trends in Presentation, Diagnosis and Management of Renal Angiomyolipoma: Comparison of Sporadic and Tuberous Sclerosis Complex-associated Forms

OBJECTIVES To evaluate the changing management of sporadic renal angiomyolipoma and renal angiomyolipoma associated with the tuberous sclerosis complex (TSC) during the past 16 years. METHODS We retrospectively reviewed the charts of 60 patients with angiomyolipoma seen at our institutions. RESULTS The median age at presentation was 45 years (range 7-78). The presentation was pain in 30 patients and hematuria in 13; it was incidentally discovered in 17 patients. Of the 60 patients, 43 were females. TSC was present in 14 patients. The median tumor size was 4 cm (range 0.3-40, mean 6.5 +/- 1.1). Of the 60 patients, 31 were followed up expectantly. Surgery or intervention was needed for 29 patients to control hemorrhage or relieve pain or because of the suspicion of malignancy. Of these 29 patients, 12 underwent nephrectomy, 11 partial nephrectomy, and 6 embolization. The patients treated for hemorrhage had a median tumor diameter of 11 cm (range 2-21). Patients were followed up for a mean of 39.3 +/- 5.4 months. The lesions grew an average of 4.7 +/- 3.4 cm for TSC tumors and 0.6 +/- 0.2 cm for sporadic angiomyolipoma tumors. None of the patients developed renal impairment. Patients with TSC presented at a younger age, had larger and bilateral lesions, and were more symptomatic during follow-up. In the past 6 years, a significant trend was seen toward finding tumors in asymptomatic patients and toward the use of conservative or interventional (embolization) treatment. CONCLUSIONS Renal angiomyolipoma has a slow growth rate. The preservation of renal function was noted in all our patients. A recent shift was noted toward finding smaller tumors in asymptomatic patients and the use of conservative and interventional treatment.

Incidence and Pattern of Varicocele Recurrence after Laparoscopic Ligation of the Internal Spermatic Vein with Preservation of the Testicular Artery

OBJECTIVES To determine the incidence and pattern of recurrence of varicocele after laparoscopic internal spermatic vein ligation with testicular artery preservation. METHODS In a prospective study, 16 patients who underwent 20 laparoscopic varix ligation were evaluated postoperatively for recurrence by clinical physical examination and percutaneous spermatic venography. RESULTS No significant complications were encountered with the surgical or radiological procedure. Clinical recurrence was detected by physical examination in 20% of cases, while percutaneous spermatic venography detected recurrence in 45% of cases. The sensitivity and specificity of clinical physical examination for detecting varicocele recurrence was 33% and 90.9%, respectively with an accuracy rate of 65%. Recurrences were through parallel collaterals or medial transverse collaterals in 88.8% and 11.2%, respectively. Parallel collaterals joined the spermatic vein in mid or high retroperitoneum in seven patients while it joined the renal vein in one patient. There were no low retroperitoneal parallel collaterals. CONCLUSIONS Laparoscopic ligation of internal spermatic vein with preservation of testicular artery is a procedure that is associated with low morbidity and quick recovery. It is able to achieve its surgical objective in only 55% of cases, however. Such information should be taken into consideration during patient counselling when selecting the operative technique of choice for varicocele ligation.

Double-blind randomized crossover study comparing intracorporeal prostaglandin e1 with combination of prostaglandin e1 and lidocaine in the treatment of organic impotence

OBJECTIVES To study the efficacy of lidocaine 1% in relieving pain associated with intracorporeal prostaglandin E1 and to assess its effect on the pharmacological erection. METHODS Twenty-two patients who had previously experienced pain with intracorporeal prostaglandin E1 injections were submitted to a double-blind randomized crossover study to evaluate comparatively the effects of intracorporeal prostaglandin E1 alone and in combination with lidocaine. The signed rank test was used for statistical analysis of the results. RESULTS With prostaglandin E1 monotherapy (20 micrograms) 86.3% of patients experienced pain and 27.2% had an adequate erection. With combination therapy (prostaglandin E1 20 micrograms plus lidocaine 1% 1 cc) 45.4% of patients experienced pain and 57.8% of patients had improvement of pain compared with prostaglandin E1 monotherapy. The adequate erectile response rate with combination therapy was 63.6%; in addition, 31.8% of patients noted enhancement in the duration of erection. The signed rank test was significant for the pain response (P < 0.01) and for the degree of erection (P < 0.01). The signed rank test was not, however, significant for the increase in duration of erection after combination therapy. No significant side effects were noted after either injection. CONCLUSIONS Lidocaine 1% can be safely and usefully combined with intracorporeal prostaglandin E1 in the treatment of erectile dysfunction with alleviation of pain and enhancement of erectile effect.

Co-administration of intravesical bacillus Calmette-Guérin and interferon α-2B as first line in treating superficial transitional cell carcinoma of the urinary bladder.

Study Type – Therapy (individual cohort)

Spermatic cord torsion in adults

A five year retrospective review of 15 cases of spermatic cord torsion in male patients 18-years or older was performed. Eighty percent of patients were correctly diagnosed at time of initial presentation while 20% of patients were misdiagnosed as epididymitis. Fifty three percent of cases has history of similar previous attacks. The average delay prior to presentation was 7 hours. Absence of fever was the rule occurring in all patients. Leucocytosis and significant pyuria were commonly encountered occurring in 33% and 27% of patients respectively. Our orchidectomy rate was 20%. Our data suggest that while, in adult patients presenting with scrotal pain, the absence of pyuria make the diagnosis of epididymitis unlikely as a cause of the condition, the presence of significant pyuria even if associated with leucocytosis does not exclude spermatic cord torsion and further studies with Doppler examination and Radionuclide Scans are necessary to establish the diagnosis.

Immediate Recurrence of Simple Renal Cyst After Laparoscopic Unroofing

A large simple cyst arising from the lower pole of the left kidney was unroofed with a laparoscopic transperitoneal approach, but was seen to recur in the immediate postoperative period. The possible causes of this recurrence and the limitations of the laparoscopic procedure are discussed. Technical modifications are recommended in order to reduce the risk of recurrence.

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 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.

Is Survival after Radical Cystectomy for Bladder Cancer in Saudi Patients Different from that of Western Patients

BACKGROUND Although radical cystectomy (RC) is considered the gold standard treatment of muscle invasive bladder cancer, nearly half of patients develop metastases and ultimately die within 2 years. OBJECTIVE To assess survival, evaluate different prognostic factors that may affect disease-free survival (DFS) in Saudi patients after RC for carcinoma of the bladder and to compare our results with those of Western countries. DESIGN Retrospective chart review. SETTING A tertiary care center in Saudi Arabia. PATIENTS AND METHODS We collected data on patients who underwent RC for bladder cancer in the period between 1979 and 2014. Demographic, clinical and pathological variables and the application of perioperative chemotherapy were reviewed. Univariate and multivariate analyses were done with DFS as the end point. MAIN OUTCOME MEASURE Disease-specific survival. RESULTS On 328 patients for whom data was available, the median follow up was 23 months (range, 2 month–28 years) and median age was 58 years (range, 21–90). Of these patients, 268 were males (81.7%), 235 (71.7%) had urothelial carcinoma (UC), 79 (24.1%) had squamous cell carcinoma (SCC), and 208 (63.4%) had pathological tumor stage 3 or more. The 5-year overall survival (OS) and DFS were 52% and 48%, respectively. There was no statistically significant difference in DFS of patients with UC and pure SCC. On univariate analysis, lymph node status and pathological tumor stage were significant predictors of DFS. Both variables sustained statistical significance in a multivariate analysis. CONCLUSION Survival following RC is almost the same as others. Moreover, pathological tumor stage and lymph node metastasis were the only independent predictors for survival following RC. Future cooperative prospective studies are required to gain data on our region. LIMITATIONS Relatively small sample size and retrospective.