Sami Arap

Guidelines for the diagnosis and treatment of benign prostatic hyperplasia: a comparative, international overview

G within the healthcare system aim to rationalize the diagnosis, treatment, and monitoring of a particular disease and can be applicable on an international scale or may be country-specific. This information is directed at either the specialist or the general practitioner (GP). Guidelines have been produced by governmental agencies or professional organizations on various diseases in the urologic field, such as urolithiasis, erectile dysfunction, penile cancer, bladder cancer, prostate cancer, and benign prostatic hyperplasia (BPH). BPH is an increasingly common condition in the aging male. By the age of 60 years, more than 50% of men will have microscopic evidence of the disease,1 and more than 40% of men beyond this age will have lower urinary tract symptoms.2 This factor, together with the geographic variations in patterns of practice, high cost of treatment, and increasing number of treatment options, make BPH a suitable candidate for practice guidelines. In general, guideline development involves the participation of specialists who determine the clinical evidence for individual practices. Subsequently, a series of recommendations are proposed, the strength of which depends on the available evidence. This can be a lengthy procedure, as evidenced by the 3 years it took for the development of the U.S. guidelines on BPH by the Agency for Health Care Policy and Research (AHCPR) published in 1994.3 The process involved the review of the world literature on BPH diagnosis and treatment, and the draft guidelines were extensively reviewed by experts and practitioners in the fields of urology, internal medicine, and family practice before a final report was published. Another body, the International Consultation (IC), patronized by the World Health Organization, is an international group of experts in prostatic diseases who meet as individual committees to develop recommendations on the diagnosis and treatment of BPH using a “consensus approach,” again based on a detailed review of the published data. This review aims to compare and contrast the current guidelines available both internationally and within individual countries. The goals are to determine whether patients might receive similar care in different countries and whether guidelines are sufficiently up-to-date to keep up with the new developments in the targeted disease area.

A Prospective Study Evaluating the Efficacy of the Artificial Sphincter AMS 800 for the Treatment of Postradical Prostatectomy Urinary Incontinence and the Correlation Between Preoperative Urodynamic and Surgical Outcomes

OBJECTIVES We have evaluated prospectively the long-term efficacy of the artificial urinary sphincter (AUS) AMS 800 for the treatment postradical prostatectomy urinary incontinence (PRPUI) patients. We also evaluated the correlation between preoperative urodynamic findings and surgical outcomes. METHODS From May 1997 to April 2003, 40 consecutive patients with PRPUI caused by intrinsic sphincter deficiency (ISD) were treated with the AMS 800. Mean age was 68.3 +/- 6.3 years. Continence status was evaluated on the basis of pad count, impact of urinary incontinence on the quality of life, complications, and surgical revisions. Preoperative urodynamic findings were correlated with surgical outcomes. RESULTS Follow-up ranged from 27 to 132 months (mean = 53.4 +/- 21.4 months). There was a significant reduction in pad count from 4.0 +/- 0.9 to 0.62 +/- 1.07 diapers per day (P <0.001) leading to continence in 90%. There was a significant reduction on the impact of incontinence decreasing from 5.0 +/- 0.7 to 1.4 +/- 0.93 (P <0.001) in a visual analogue scale (VAS). Surgical revision rate was 20%. Preoperative urodynamics was useful to identify sphincter deficiency. Except by a tendency of worse results in patients with reduced bladder compliance (RBC), other urodynamic parameters did not correlate with a worse surgical outcome. CONCLUSIONS The AMS 800 offers good long-term continence to most PRPUI patients. Preoperative findings like detrusor hyperactivity (DH), impaired detrusor contraction (IDC), low Valsalva leak point pressure, bladder outlet obstruction (BOO), and mild RBC were not associated with worse surgical outcomes.

Port site tumor recurrences of renal cell carcinoma after videolaparoscopic radical nephrectomy.

Videolaparoscopic radical nephrectomy is considered safe and oncologically appropriate for patients with renal cell carcinoma. We report a case of port site tumor recurrence 5 months after videolaparoscopic radical nephrectomy. CASE REPORT

Pheochromocytoma : Study of 50 cases

PURPOSE We studied the clinical picture, sensitivity of the biochemical tests and imaging studies, pathological findings, surgical results and followup of patients with pheochromocytoma. MATERIALS AND METHODS The records of 50 patients with pheochromocytoma were identified. Hyperadrenergic symptoms and signs; urinary dopamine, epinephrine, norepinephrine and vanillylmandelic acid levels; serum dopamine, epinephrine and norepinephrine levels; ultrasonography; computerized tomography; magnetic resonance imaging and 131iodine-metaiodobenzylguanidine images were analyzed. The size, weight and malignancy of the tumors, as well as the operative mortality, survival rate and clinical condition of the patients were also studied. RESULTS The hyperadrenergic syndrome alone was found in 90% of the patients, Cushings syndrome alone in 2%, both syndromes in 4%, a palpable abdominal tumor only in 2% and incidental tumors in 2%. The sensitivities of the urinary evaluation in the diagnosis were metanephrines 97%, vanillylmandelic acid 90%, epinephrine 64%, norepinephrine 93% and dopamine 66%. For serum assessment the sensitivities were epinephrine 67%, norepinephrine 93% and dopamine 63%. The sensitivities of the localization examinations were 89, 94, 100 and 88% for ultrasonography, computerized tomography, magnetic resonance imaging and 131I-metaiodobenzylquanidine, respectively. There was only 1 operative death. Of the patients with benign tumors 88% were cured and 12% remained hypertensive with no clinical or biochemical evidence of a hyperadrenergic profile. Of the 8 patients with malignant pheochromocytoma 1 was lost to followup and 3 died of widespread disease (1 without surgery and at 2, 24 and 78 months postoperatively). Of the 4 living patients 3 had no evidence of disease and 1 was well, although with pulmonary metastases.

Clinical, Hormonal and Pathological Findings in a Comparative Study of Adrenocortical Neoplasms in Childhood and Adulthood

PURPOSE We reviewed clinical and laboratory findings in 6 male and 32 female patients with functional adrenocortical neoplasms, and compared pediatric and adult data. MATERIALS AND METHODS Hormonal measurements were performed by radioimmunoassay, histological analysis was based on Weiss criteria and staging was done according to previously established guidelines. RESULTS Children had a higher incidence of virilization (72%), whereas in adults the predominant feature was Cushings syndrome (60%). A high testosterone level was the most common finding in adults and children with virilization followed by high dehydroepiandrosterone sulfate, androstenedione and dehydroepiandrosterone levels. High 11-deoxycortisol levels were frequently associated with tumor recurrence. Cortisol suppression after dexamethasone was altered in 93% of patients with virilization and no clinical features, suggesting autonomous cortisol secretion. CONCLUSIONS No statistically significant relation was noted between tumor weight and prognosis but there was a negative correlation between patient age and prognosis since children had a more favorable followup than adults. Mixed features in both groups resulted in the worst prognosis. A Weiss criteria grade IV or greater correlated well with a poor prognosis in adults but not children, while staging was more reliable in children.

GENITAL TRAUMA DUE TO ANIMAL BITES

PURPOSE Animal bites to the external genitalia are rare. We retrospectively evaluated our experience with treating genital trauma caused by animal attacks. MATERIALS AND METHODS We studied the medical records of 10 patients treated in the surgical emergency department at our hospital who presented with genital injury caused by an animal bite from 1983 to 1999. Special attention was given to the severity of injury, surgical treatment, antibiotic prophylaxis and outcome. RESULTS Of the 2 men and 8 boys 8 were attacked by dogs, 1 by a horse and 1 by a donkey, respectively. In all cases initial local treatment involved débridement and copious wound irrigation with saline and povidone-iodine solution. Five patients who presented with minimal or no skin loss underwent primary skin closure, including 2 in whom urethral lacerations were surgically repaired. There was moderate to extensive tissue loss in 5 patients, including degloving penile injury in 2, traumatic spermatic cord amputation in 1, complete penile and scrotal avulsion in a 5-month-old infant, and partial penectomy in 1. Reconstructive procedures provided satisfactory cosmetic and functional results in 8 cases. Antibiotic prophylaxis was administered in all patients and no infectious complications developed. CONCLUSIONS Animal bite is a rare but potentially severe cause of genital trauma and children are the most common victims. Morbidity is directly associated with the severity of the initial wound. Because patients tend to seek medical care promptly, infectious complications are unusual. Management involves irrigation, débridement, antibiotic prophylaxis, and tetanus and rabies immunization as appropriate as well as primary wound closure or surgical reconstruction. Good functional and cosmetic results are possible in the majority of cases.

CpG hypermethylation of promoter region and inactivation of E-cadherin gene in human bladder cancer

Several studies have shown that E‐cadherin expression is lost during malignant transformation. We hypothesized that CpG methylation in the promoter region may inactivate the expression of the E‐cadherin gene in human bladder cancer. Normal and bladder cancer samples from 51 patients were compared in terms of E‐cadherin gene expression and methylation status by immunohistochemistry, methylation‐specific polymerase chain reaction (MSP), and bisulfite genome‐sequencing techniques. Ten different CpG sites (nt 863, 865, 873, 879, 887, 892, 901, 918, 920, and 940) in the promoter region were studied. Thirty‐five of 51 (69%) bladder cancer samples lacked E‐cadherin expression, whereas only six of 51 (12%) normal bladder samples lacked E‐cadherin immunoreactivity. MSP analysis of bladder cancer samples suggested that 43 of 51 (84%) showed methylation of the promoter region, whereas only 12 of 51 (24%) normal bladder samples showed hypermethylation. Sodium bisulfite genome‐sequencing analysis revealed that of 10 CpG sites, two sites (nt 892 and nt 940) showed 100% methylation in all the cancer samples analyzed. Other CpG sites were partially methylated (47–91%). Normal tissue showed only 12% methylation (range, 1–33%) on various CpG sites. Also supporting these data, E‐cadherin–negative bladder cancer cell lines restored expression of the E‐cadherin gene after treatment with the demethylating agent 5‐aza‐2′‐deoxycytidine. The present study showed that CpG hypermethylation was an important mechanism of E‐cadherin gene inactivation in bladder cancer and also that specific CpG sites consistently presented higher methylation levels than others. These findings may provide a better strategy for the diagnosis and management of bladder cancer.

Treatment of Peyronie’s Disease by Incomplete Circumferential Incision of the Tunica Albuginea and Plaque With Bovine Pericardium Graft

OBJECTIVES To study the surgical treatment of Peyronies disease using a single incision in the tunica albuginea and fibrotic plaque and repair of the defect by bovine pericardium graft. METHODS Between April 1999 and May 2001, 33 patients who had had symptoms of Peyronies disease for more than 12 months and whose disease had been stable for more than 6 months underwent surgery. The reason for surgery was deformity of the penis that made sexual intercourse, even with erection, difficult or impossible. Two paraurethral incisions were made in Bucks fascia to separate the neurovascular bundle from the tunica albuginea. An incomplete circumferential incision, forked at the extremities, was made in the tunica albuginea and in the plaque at the point of maximal curvature, followed by a septal incision for the lengthening of the short side of the penis. A bovine pericardium graft was used to repair the defect in the tunica. All procedures were performed by a single surgeon (P.H.E.). The average follow-up time was 19.4 months (range 5 to 30). RESULTS No rejection or retraction of the graft was observed. All patients maintained their state of preoperative erection, with the penis corrected in 87.9% of cases and with discrete curvature (less than 15 degrees ) in 12.1%. All recovered their ability to penetrate with no difficulty. In addition, an intraoperative average increase of 2.21 cm (range 1 to 4) occurred in the size of the penis. CONCLUSIONS This procedure is effective for all types of penile deformity, regardless of the plaque characteristics.

A single relaxing incision to correct different types of penile curvature: surgical technique based on geometrical principles

Penile curvature, whether caused by Peyronie’s disease or congenitally, leads to reduced functional penile length and may be associated with penile shaft constriction and/ or erectile dysfunction. The current available surgical treatment consists of shortening the healthy tunica albuginea on the long side, invariably associated with loss of penile length [1–5], or lengthening the short side by incision and/or excision of the tunica with graft placement [6–10].

Laparoscopic Adrenal Surgery in Children

PURPOSE The laparoscopic approach to the adrenal gland was first reported in 1992. Since then, more than 400 studies have been published, comprising hundreds of adults. There are few reports of laparoscopic adrenalectomy in the pediatric population. We reviewed our experience with laparoscopic adrenal surgery in children. MATERIALS AND METHODS Laparoscopic adrenalectomy was performed in 8 girls and 5 boys 15 years or younger (mean age 6.3) between December 1994 and August 2001. The clinical diagnosis before surgery was virilizing tumor in 5 cases, nonfunctioning solid adrenal tumor in 3, Cushings syndrome in 2, pheochromocytoma in 2 and Cushings pituitary disease in 1. Unilateral adrenal lesions were 15 to 80 mm. at the longest axis (mean 41.4) on computerized tomography. RESULTS Two of the 13 procedures (15.4%) were converted to open surgery. No deaths occurred. No patients presented with postoperative complications. Average operative time in unilateral nonconverted procedures was 107 minutes (range 25 to 195). Blood transfusion was required in 1 case (7.7%). Average hospital stay was 5.5 days (range 1 to 17). Average postoperative followup was 16 months (range 1 to 60). The final clinicopathological diagnosis was virilization in 4 cases, Cushings syndrome in 2, pheochromocytoma in 2, neuroblastoma in 2, Cushings pituitary disease in 1, teratoma in 1 and primary carcinoma in 1. CONCLUSIONS Laparoscopic adrenalectomy is feasible and shows positive results in select pediatric patients.