Sertac Yazici

Renal Artery Pseudoaneurysm: Complication of Minimally Invasive Kidney Surgery

PURPOSE We retrospectively reviewed the charts of patients with renal artery pseudoaneurysms (RAPs) to document their clinical presentation, surgical background, and outcome. MATERIALS AND METHODS In all, 7 of the 1965 patients who underwent percutaneous stone surgery and 3 of the 25 patients who underwent laparoscopic nephron-sparing surgery had a diagnosis of RAP and were treated accordingly. The most common symptom was hematuria, which was classified as early or delayed according to the time of presentation, as mild, moderate, or severe according to the hemodynamics of the patient. In addition, angiographic images were reviewed, and the correlation between the clinical presentation of RAP and its location was investigated. RESULTS In the percutaneous stone surgery group, four patients experienced early mild to moderate hematuria and three experienced late moderate hematuria. All of the RAPs were located on the interlobar and arcuate arteries. In the laparoscopic nephron-sparing surgery group, one patient was asymptomatic, with diagnosis of renal-cell cancer recurrence at the 3-month follow-up, and had radical nephrectomy. Two patients presented with delayed moderate hematuria with lesions that were located on the interlobar, arcuate, and segmentary arteries. Two sessions of embolization were sufficient to stop bleeding in one patient with a segmentary artery aneurysm that had unfortunately lost kidney function during follow-up. CONCLUSION There is no predictive factor for patients undergoing percutaneous nephrolithotomy procedure yet, but laparoscopic partial nephrectomy for tumors localized in the central portion of kidney may end up with RAP especially if no adjuvant sealing agents are used. The outcome of RAPs depends primarily on early recognition and a high index of suspicion, which facilitates correct diagnosis and appropriate management. Selective angiography and embolization together is the gold standard, both for diagnosis and treatment.

Proteasome inhibitor bortezomib increases radiation sensitivity in androgen independent human prostate cancer cells.

OBJECTIVES To investigate the effects of a strong proteasome inhibitor, bortezomib alone or in combination with radiotherapy on androgen-independent DU145 human prostate cancer cells. Proteasomes play important roles in cell cycle, proliferation, apoptosis, angiogenesis, and cellular resistance to chemotherapy and radiotherapy. METHODS Increasing concentrations of bortezomib alone or in combination with radiation were applied to DU145 cells and IC(50) values that inhibited cell growth by 50% were determined by 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium-bromide assay. Apoptosis was determined using annexin V staining by flow cytometry. mRNA levels of proapoptotic caspase-3 and antiapoptotic Bcl-2 genes were examined by reverse transcriptase polymerase chain reaction. RESULTS The IC(50) value of bortezomib was found to be 28 microm although 400- and 800-cGy radiation decreased the cell proliferation by 14% and 28%, respectively. In 400- and 800-cGy radiation applied DU145 cells, IC(50) value of bortezomib decreased to 23- and 12 microm, respectively. Exposure to 5 microm bortezomib for 48 hours caused apoptosis in 35% of the population whereas 800-cGy radiation resulted apoptosis in 14% of cells. However, 42% of DU145 cells that were exposed to 800 cGy and 5 microm bortezomib underwent apoptosis. Reverse transcriptase polymerase chain reaction results showed a significant decrease in mRNA levels of antiapoptotic Bcl-2 gene and an increase in proapoptotic caspase-3 gene expression in the combination group compared to control group. CONCLUSIONS Bortezomib increases radiation sensitivity in androgen-independent human DU145 prostate cancer cells through inhibition of Bcl-2 and induction of caspase-3 genes.

Primary osteosarcoma of the urinary bladder following cyclophosphamide therapy for systemic lupus erythematosus: a case report

IntroductionThe association of systemic lupus erythematosus with malignancies is an uncommon occurrence. We present the case of an osteosarcoma of the urinary bladder developing in a patient with a prolonged history of active systemic lupus erythematosus. This is a previously unreported association. Primary osteosarcoma is an extremely rare disease in the urinary bladder.Case presentationA 24-year-old Caucasian woman with a 13-year history of systemic lupus erythematosus, who had been treated with high dose immunosuppressive agents, presented with pain and hematuria. A deeply invasive high-grade tumor was detected in the urinary bladder and the patient underwent radical surgery. A diagnosis of osteosarcoma was made based on the characteristic histology.ConclusionPredisposing factors for primary sarcomas in the urinary bladder are mostly unknown; however, in our case, long-term administration of immunosuppressive agents, as well as long standing systemic lupus erythematosus, may both be of significance.

Renal cell carcinoma with inferior vena cava thrombus: The Hacettepe experience

OBJECTIVES We evaluated the clinical outcome and factors affecting survival in patients with renal cell carcinoma (RCC) and tumor thrombus involving inferior vena cava (IVC). METHODS Between 1990 and 2007, 28 patients with RCC and tumor thrombus extending into IVC underwent radical nephrectomy and thrombectomy. Patient data were reviewed retrospectively to evaluate the demographics, clinical presentation, surgical approach, pathological features, clinical outcomes, and survival. RESULTS Twenty-eight patients with a mean age of 52.7 years were operated. Thrombus level was infrahepatic in 15 patients (54%), intrahepatic in 3 patients (10%), suprahepatic in 3 patients (10%), supradiaphragmatic in 2 patients (8%), and intracardiac in 5 patients (18%). All patients with intracardiac thrombi underwent cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA). The mean tumor size was 98.21 mm. Four patients had distant metastases and 3 patients had lymph node involvement. Pathological examination revealed RCC of clear cell type in 26 patients, papillary in 1 and chromophobe in 1 patient. At a mean follow-up of 36.4 months, 16 patients were still alive while 8 patients died due to disease progression and 2 patients died of other causes. Two patients died of pulmonary emboli in the early postoperative period. Lymph node involvement, distant metastases, hypercalcemia, and sarcomatoid component were found to be factors affecting overall survival significantly. Level of tumor thrombus and Fuhrman grade did not affect survival. CONCLUSIONS Radical nephrectomy and tumor thrombectomy is currently known to be the most effective method in patients with RCC and tumor thrombus extending into IVC. Factors affecting survival are the ones related to tumor biology. Tumor thrombus level does not affect the prognosis.

Radical Prostatectomy After Previous Prostate Surgery: Effects on Surgical Difficulty and Pathologic Outcomes

OBJECTIVES To evaluate the surgical difficulty and pathologic outcomes of patients who had undergone radical prostatectomy after previous prostate surgery. METHODS A total of 45 patients with previous prostate surgery underwent radical retropubic prostatectomy for prostate cancer. The surgical difficulty and pathologic outcomes for this group of patients (group 1) were compared with those for 50 consecutive patients who had undergone radical retropubic prostatectomy as their only prostatic surgery (group 2). The estimated blood loss and operative time were accepted as surrogates for surgical difficulty. Surgical margin status, seminal vesicle invasion, and extracapsular extension were evaluated to determine the pathologic outcomes. Late complications, including urinary incontinence and anastomotic stricture, were also assessed. RESULTS Radical prostatectomy was technically more challenging in the patients after previous prostate surgery compared with surgery-naive patients, with significantly more estimated blood loss (P <.05) and a longer operative time (P <.001). A unilateral or bilateral nerve-sparing procedure was performed in only 9 patients in group 1 but in 35 patients in group 2, resulting in low potency rates in group 1. The mean hospital stay was significantly longer in group 1. The continence rate was significantly greater in surgery-naive patients. No difference was found between the groups with regard to the rate of seminal vesical invasion, extracapsular extension, and surgical margin status. CONCLUSIONS Although radical retropubic prostatectomy is technically more difficult after previous prostate surgery, it can be performed safely with no difference in pathologic outcomes from those seen in patients with no history of prostate surgery.

A Preoperative Prognostic Model Predicting Recurrence-free Survival for Patients With Kidney Cancer

OBJECTIVE To develop a preoperative prognostic model in order to predict recurrence-free survival in patients with nonmetastatic kidney cancer. METHODS A multi-institutional data base of 1889 patients who underwent surgical resection between 1987 and 2007 for kidney cancer was retrospectively analyzed. Preoperative variables were defined as age, gender, presentation, size, presence of radiological lymph nodes and clinical stage. Univariate and multivariate analyses of the variables were performed using the Cox proportional hazards regression model. A model was developed with preoperative variables as predictors of recurrence after nephrectomy. Internal validation was performed by Harrells concordance index. RESULTS The median follow-up was 23.6 months (1-222 months). During the follow-up, 258 patients (13.7%) developed cancer recurrence. The median follow-up for patients who did not develop recurrence was 25 months. The median time from surgery to recurrence was 13 months. The 5-year freedom from recurrence probability was 78.6%. All variables except age were associated with freedom from recurrence in multivariate analyses (P < 0.05). Age was marginally significant in the univariate analysis. All variables were included in the predictive model. The calculated c-index was 0.747. CONCLUSIONS This preoperative model utilizes easy to obtain clinical variables and predicts the likelihood of development of recurrent disease in patients with kidney tumors.

Port site and local recurrence of incidental solitary renal plasmacytoma after retroperitoneoscopic radical nephrectomy.

Port site and local recurrences are rather rare, especially after laparoscopic excision of renal malignancies. In addition to the known risk factors, including inappropriate surgical technique and specimen removal, the tumor biology is important. Renal plasmacytomas are rare manifestations of plasma cell tumors. We report a case of port site and local tumor recurrence of a solitary renal plasmacytoma after retroperitoneoscopic radical nephrectomy without any known risk factors, other than the aggressive tumor biology itself.

Urinary and Fecal Diversion Following Pelvic Exenteration: Comparison of Double-Barrelled and Plain Wet Colostomy

PURPOSE To assess early and late-term outcomes of patients who had undergone pelvic exenteration and simultaneous fecal and urinary diversion with plain wet colostomy (PWC) or double-barrelled wet colostomy (DBWC). MATERIALS AND METHODS The medical records of all patients who had undergone pelvic exenteration and urinary diversion between 2006 and 2017 at our hospital were reviewed retrospectively. RESULTS In total, 15 patients with a mean age of 56 ± 13 years were included in the study. Simultaneous urinary and fecal diversions were carried out as PWC (n = 8), or DBWC (n = 7). No significant differences were found between PWC and DBWC groups in terms of operation time (373.7 ± 66.5 versus 394.2 ± 133.2 min, P = .955), estimated blood loss (862.8 ± 462.4 versus 726.2 ± 489.4 mL, P = .613), length of hospital stay (13.2 ± 9.1 versus 14.1 ±6.9 days), early complications (25% versus 28.6%, P = 1.0) and late term complications (37.5% versus 42.9%, P = 1.0). The rate of recurrent pyelonephritis in PWC group was higher than DBWC group but not statistically significant (37.5% versus 14.3%, P = .569). Overall survival (OS) of the patients was 385 ± 91 days. There was no difference between OS of patients with PWC and DBWC (414 ± 165 versus 352 ± 70 days, P = .618). CONCLUSION PWC and DBWC are valid options for creating simultaneous urinary and fecal diversion after extensive pelvic surgery in patients with short life expectancy. DBWC might be superior to PWC in terms of decreased risk of recurrent pyelonephritis.

Predictors of prostate cancer in ultrasound-guided transperineal saturation biopsy in Turkish men with multiple prior negative biopsies.

Background Transperineal prostate biopsy (STPB) is associated with an improved cancer detection rate and an increase in anterior and apical prostate cancers compared to standard transrectal biopsy. Patients and Methods A total of 48 men with at least two sets of prior prostate biopsies underwent transrectal ultrasound-guided STPB. Prostate rebiopsy indications were serum prostate-specific antigen (PSA) levels greater than 2.5 ng/mL and/or abnormal digital rectal examination and/or presence of high-grade prostatic intraepithelial neoplasia (HGPIN; ≥2 cores) or atypical small acinar proliferation (ASAP) at previous biopsies. The procedure was performed at dorsal lithotomy position under general anesthesia using a perineal 0.5 cm brachytherapy template attached to the transrectal ultrasound probe. Specimens from each zone were sent separately for pathological examination. Results Mean PSA level at STPB was 15.9 ng/mL (range 4.03 to 59.57). An average of 54.5 cores was obtained. Prostate adenocarcinoma was detected in 15 of 48 (31%) patients. Mean percentage of malignant cores was 11.9%. Multivariate logistic regression analysis revealed that age and presence of ASAP or HGPIN at previous biopsies were independent predictors of prostate cancer (p<0.05). No major complications, including sepsis and severe urinary or rectal bleeding, were observed in any of the patients. Five patients (10%) developed acute urinary retention after the procedure requiring urethral catheterization. Conclusions Considerable number of patients with negative multiple biopsies were diagnosed with prostate cancer. STPB is a well-tolerated procedure with minimal morbidity, which can be considered for the diagnosis of prostate cancer in patients with previous negative biopsies.

The Ewing’s Sarcoma Family of Tumors of Urinary Bladder: A Case Report and Review of the Literature

BACKGROUND Only 15 cases of Ewings Sarcoma (EWS) family of tumors of urinary bladder have been documented in the literature to date. CASE REPORT We presented here a 38 year-old female with primary urinary bladder EWS with no distant metastases. She had presented with macroscopic hematuria and had undergone transurethral resection of the tumor within the following week. Microscopic examination revealed a tumor diffusely infiltrating the lamina propria and muscularis propria under an intact urothelium, which was composed of small round blue cells with scant cytoplasm, monotonous round or oval nuclei, stippled chromatin and small nucleoli. Immunohistochemistry showed strong vimentin, synaptophysin and membranous CD99 expression by the tumor. Fluorescent in situ hybridization analysis displayed the EWSR1 rearrangement. Radical cystectomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy, extended lymph node dissection, and ileal conduit were performed. As adjuvant chemotherapy, she received vincristine, doxorubicin, cyclophosphamide and mesna, alternating with courses of etoposide, iphosphamide and mesna. She is alive and well with no evidence of disease 14 months after the surgery. CONCLUSION Surgery supported with chemotherapy should be considered as an option, especially in advanced Ewings sarcoma family of tumors of urinary bladder.