Syed M. Nazim

Alpha-Blockers Impact Stent-Related Symptoms: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND AND PURPOSE Ureteral stents are indispensable tools in endourology, although they often are associated with bothersome lower urinary tract symptoms. This study was conducted to evaluate the effect of alfuzosin on urinary symptoms, quality of life, and pain in patients after Double-J ureteral stent placement in a randomized, placebo-controlled trial. PATIENTS AND METHODS This study was conducted from July 2008 to May 2009. A total of 130 patients underwent placement of a Double-J stent after retrograde semirigid ureteroscopy for ureteral stones. They were randomized in two groups. Group 1 (n=65) received alfuzosin 10 mg once daily and group 2 (n=65) received placebo for 1 week. Both groups also received standardized analgesia. The stent symptoms were measured and recorded 1 week after the procedure. Statistical analyses were performed using the chi-square test and Student t test with P<0.05 considered significant. RESULTS The demographic profile including patient and stone-related parameters were comparable. Group 1 had significantly less urinary symptoms (P<0.05). The quality-of-life assessment was better in the alfuzosin arm than in the placebo arm (P<0.001). The mean pain score was 1.15 in group 1 and 3.89 in the placebo group (P<0.001). None of the patients in either of the arms withdrew from treatment; there were minimal adverse effects in the treatment arm. The limitation of the current work includes relatively smaller sample size and use of single type of stent. CONCLUSIONS Alfuzosin 10 mg once daily in patients with a Double-J stent significantly decreases the bothersome urinary symptoms, besides decreasing significantly the pain associated with the stent.

Efficacy of Semirigid Ureteroscopy with Pneumatic Lithotripsy for Ureteral Stone Surface Area of Greater Than 30 mm2

OBJECTIVES To study the outcome and safety of semirigid ureteroscopy (URS) using pneumatic lithotripsy for treatment of ureteral stones of surface area >30 mm2 and to assess the impact of size and location on stone-free (SF) rate. PATIENTS AND METHODS In this study, 265 patients with >30 mm2 isolated ureteral stones treated by semirigid URS were included. URS was performed using an 8F, 7F, or 6.4F semirigid ureteroscopes with pneumatic lithotripsy (Swiss Lithoclast). Stones were fragmented to approximately 2-3 mm particles, and removed. The outcome parameters assessed at 3-month follow-up were SF rate and efficiency quotient (EQ); impact of stone size and site on SF/EQ was also analyzed. The patient demographics, stone, procedure, and patient-related parameters and complications were noted. RESULTS At 3-month follow-up overall SF was 74% and EQ 59.2%. SF for 30-100 mm2 and >100 mm2 was 79.2% and 68.5%, respectively (p < 0.003). The SF/EQ for upper, middle, and lower ureteral stones were 59/40.7, 53/37.5, and 92/84.5, respectively (p < 0.001). There was no major complication; the minor complication rate was 12.5%. CONCLUSIONS Semirigid URS using pneumatic lithotripsy for treatment of stones >30 mm2 is a safe and highly efficacious procedure particularly in the distal ureter. There is a significant difference in the SF and EQ between upper/middle ureteral stone and lower ureteral stone. Stone size has a direct relation with the SF and EQ. Upper ureteral stones have a longer time to SF compared to middle and lower ureteral stones (p < 0.001).

New and contemporary markers of prognosis in nonmuscle invasive urothelial cancer

Nonmuscle invasive (NMI) urothelial cancer (UC) is associated with varied biological potential. It is characterized by frequent recurrence and progression, which thus worsens the oncological outcome. Nearly three-quarters of NMI UCs recur within 5 years, whereas half can progress during follow-up. Progression is particularly seen in T1 and carcinoma in situ (CIS). Undoubtedly, NMI UC is one of the most expensive cancers to manage. The European Organisation for Research and Treatment of Cancer (EORTC) risk calculator is a commonly used tool for assessing the recurrence and progression potential of a newly diagnosed cancer. The parameters used in the assessment are tumor size and number, pathological stage and grade of the cancer, presence of CIS, and prior recurrence rate. The main advantages of the EORTC tool are its ease of use and the lack of need to run expensive molecular tests. However, reproducibility of pathologic stage and grade is modest, which is a concern to clinicians. Molecular markers have potential for predicting the clinical outcome of NMI UC, given that clinico-pathologic variables are not sufficient for prediction of prognosis in an individual. Significant work has been done in the past 2 decades in understanding the molecular biology of bladder cancer; however, the translational value of this knowledge remains poor. The role for molecular markers in predicting recurrence seems limited because multifocal disease and incomplete treatment are probably more important for recurrence than the molecular features of a resected tumor. Urinary markers have very limited value in prognostication of bladder cancer and are used (mainly as an adjunct to cytology) for detection and surveillance of urothelial cell cancer recurrence. Prediction of progression with molecular markers holds considerable promise. Nevertheless, the contemporary value of molecular markers over clinico-pathologic indexes is limited.

Measurement of Ureteric Stone Diameter in Different Planes on Multidetector Computed Tomography – Impact on the Clinical Decision Making

OBJECTIVE To determine if the measurement of ureteric stone in coronal reconstruction plane is different from the measurement in axial plane and whether the difference can impact the management decision in patients with ureteric colic. METHODS All patients who underwent unenhanced multidetector computed tomographic (MDCT) scan for the evaluation of reno-ureteral colic in outpatient clinics and emergency room were evaluated. The scans were evaluated on Picture Archiving Computer System with a 3-mm axial and reformatted 3-mm coronal sections. Maximal stone diameter was measured in 2 dimensions in the axial and reformatted coronal sections by 2 reviewers. Only scans with isolated, unilateral, solitary ureteric calculi were included in the final analysis. All patients were monitored up to 4 weeks after MDCT to determine the clinical outcome. RESULTS A total of 331 patients (272 male and 59 female; mean age ± standard deviation, 39.8 ± 13.8 years) were included. One hundred seventy-one (51.7%) stones passed spontaneously during the follow-up period. There was a 20% underestimation of maximal stone diameter in axial plane for all stones and a 17% for the stones that passed spontaneously or with medical expulsive therapy, as compared with measurement on coronal reconstruction. CONCLUSION Measuring the transverse stone diameter on axial images of MDCT scan underestimates size of ureteric stone. This can have an impact on counseling of patients and their clinical outcome, coronal reformatted images be used for size estimation.

Prospective evaluation of outcome of percutaneous nephrolithotomy using the 'STONE' nephrolithometry score: A single-centre experience.

Abstract Objective: To assess the prediction of stone clearance and complications of percutaneous nephrolithotomy (PCNL) using the ‘STONE’ nephrolithometry score, assessing stone size, tract length (skin-to-stone distance), degree of obstruction, number of calyces involved and stone essence (density). Patients and methods: This was a prospective study of patients undergoing single-tract PCNL while prone, conducted at a university hospital. All patients had non-contrast-enhanced computed tomography within 3 weeks of the procedure. Only patients with a unilateral procedure and radio-opaque stones were included. The five variables of the STONE nephrolithometry score were calculated before the procedure. The stone-free rates were assessed with a plain abdominal film at 4 weeks and complications were graded using the modified Clavien system. Results: In all, 107 patients were included in the final analysis. Overall, 80% of patients were rendered stone-free. Among the individual variables, a larger stone (P = 0.002) and the involvement of multiple calyces (P = 0.04) were associated with residual stones, while tract length (skin-to-stone distance), stone density and presence of hydronephrosis were not. Patients who were rendered stone-free had a statistically significant lower overall STONE score than those with residual stones, at 7.24 vs. 8.14 (P = 0.02). The score also correlated with operative duration, which was significantly longer with a higher STONE score (P = 0.03). The complication rate was 18% and most complications were Clavien grade 2, with bleeding requiring a blood transfusion (11 patients) being the commonest. There were no deaths within 30 days of surgery, but there was no correlation between the STONE score and complications. Conclusion: The STONE nephrolithometry score is a simple and easy to apply system for predicting complexity in stone clearance with PCNL.

Persistent fetal lobulation of kidney mimicking renal tumour

Renal pseudotumour is a term coined to describe conditions of renal anatomic variants that simulate focal renal pathology like a tumour on ultrasonography. These include persistent fetal lobulation, hypertrophy of Bertin columns and dromedary humps. We report a case of a 30-year-old nulliparous woman who was managed in gynaecology clinic for menorrhagia and was subsequently referred to us for management of recurrent urinary tract infections. The clinical examination was normal and on ultrasound scan, she was found to have multiple enlarged heterogeneous solid masses in both kidneys with significantly increased vascularity, suspicious for neoplastic lesions. She subsequently underwent a CT urogram and her case was discussed in uro-radiology meeting where a diagnosis of persistent fetal lobulation was made excluding other diagnoses. She was managed conservatively. We also present grey scale and Doppler ultrasound and CT urogram findings of this condition along with the literature review.

Fibrous Pseudotumor of Tunica Albuginea Testis Mimicking Testicular Neoplasm in a Young Man

Intrascrotal lesions are common findings with a majority occurring in paratesticular tissue. Fibrous pseudotumors are rare, benign lesions of the testicular tunics and present with mass lesion(s) in the scrotum. Preoperative clinical and radiological diagnosis is challenging. We report a case of a 34-year-old man who presented with a 3-year history of left testicular swelling and was advised left radical orchidectomy by another surgeon. Physical examination revealed a firm, nontender mass attached to the lower pole of the testis. Testicular tumor markers were all negative, and ultrasound scan showed a relatively hypoechoic lesion closely associated with the left testis and suspicious for neoplastic process. The patient underwent a testicular sparing surgery. An intraoperative frozen section biopsy confirmed the lesion to be benign and this was reported on permanent section to be fibrous pseudotumor of the tunica albuginea. We also present the clinical, sonographic, and histopathological findings of this condition along with the literature review.

Multi-disciplinary and shared decision-making approach in the management of organ-confined prostate cancer

Abstract Decision-making in the management of organ-confined prostate cancer is complex as it is based on multi-factorial considerations. It is complicated by a multitude of issues, which are related to the patient, treatment, disease, availability of equipment(s), expertise, and physicians. Combination of all these factors play a major role in the decision-making process and provide for an interactive decision-making preferably in the multi-disciplinary team (MDT) meeting. MDT decisions are comprehensive and are often based on all factors including patients’ biological status, disease and its aggressiveness, and physician and centres’ expertise. However, one important and often under rated factor is patient-related factors. There is considerable evidence that patients and physicians have different goals for treatment and physicians’ understanding of their own patients’ preferences is not accurate. Several patient-related key factors have been identified such as age, religious beliefs, sexual health, educational background, and cognitive impairment. We have focused on these areas and highlight some key factors that need to be taken considered whilst counselling a patient and understanding his choice of treatment, which might not always be match with the clinicians’ recommendation.

Adrenalectomy for solitary metastasis of hepatocellular carcinoma post liver transplantation: case report and literature review

Liver transplantation (LT) is the treatment of choice for localized hepatocellular carcinoma (HCC) associated with cirrhosis. Extra hepatic metastasis is the most common cause of death in these patients. There is very little evidence regarding the natural history and treatment options for patients developing HCC recurrence after LT. Surgical resection offers a unique opportunity for solitary metastasis. We report a 61 year old male with solitary right adrenal metastasis 15 months post LT which was managed with open adrenalectomy. The patient is alive and disease free 24 months after the surgery. The case, histo-pathological findings and literature review is discussed.

Pheochromocytoma associated with von Hippel-lindau disease in a Pakistani family

Objectives: The aim was to study the presentation, disease characteristics, operative outcome, and prognosis in patients with familial Pheochromocytoma associated with von Hippel-Lindau (VHL) disease. Materials and Methods: There were six patients belonging to two generations of a single family who developed features of VHL over a period of 13 years and were treated at our institute. Patients′ characteristics, that is, age, gender, presenting complaints and clinical signs, laboratory and biochemical evaluation, and the presence of associated conditions was gathered from medical records. The preoperative and postoperative radiological imaging and histopathological results were also collected. Results: Out of six cases, five were male, and one was female. The mean age at first presentation was 25 years (16-40). All patients presented with uncontrolled hypertension and were found to have Pheochromocytoma on workup. Three patients had unilateral adrenal tumor, and three had bilateral disease. None of the patients had extra-adrenal Pheochromocytoma. All patients were managed with adrenalectomy and had benign pathology. Two patients subsequently had craniotomy for excision of cerebellar hemangioma, and one patient had bilateral partial nephrectomy at the time of adrenalectomy. There was no peri- post-operative mortality and all patients are being followed by the surgeon(s) and endocrinologist. Conclusion: Pheochromocytoma can be a part of familial conditions including VHL. Other associated features should be suspected, investigated, and treated in these patients that can influence patients′ clinical course and prognosis. Family members should also be screened to achieve early diagnosis.