Thomas Akkad

Photodynamic therapy with intravesical instillation of 5-aminolevulinic acid for patients with recurrent superficial bladder cancer: a single-center study

OBJECTIVES Photodynamic therapy (PDT) is an effective treatment option for patients with superficial bladder cancer uncontrolled by transurethral resection and/or intravesical bacille Calmette-Guérin (BCG) immunotherapy alone. We determined the efficacy and side effects of PDT in patients with recurrent superficial bladder cancer. METHODS Between April 1994 and July 2001, PDT was performed in 31 patients (23 men and 8 women). 5-Aminolevulinic acid (50 mL) in a 3% concentration was instilled intravesically. Patients were instructed to hold the solution as long as possible and were irradiated transurethrally with a mean light dose of 3.9 W using laser light emitting a wavelength of 633 nm for a mean time of 1260 seconds. RESULTS The mean patient age at the procedure was 70.2 years. At an average follow-up of 23.7 months (range 1 to 73), 16 patients were free of tumor recurrence; 15 patients had developed tumor recurrence after a mean of 8.3 months. Of 10 patients with prior BCG treatment, 4 were free of tumor recurrence. Treatment was well tolerated, with the only side effect being dysuria due to urinary tract infection in 4 patients and hematuria in 7 patients. No phototoxic skin reactions were observed. CONCLUSIONS PDT represents a safe, effective, and less-invasive treatment for patients with recurrent superficial bladder cancer. Because of the favorable side-effect profile, PDT can also be applied to patients with comorbidity precluding surgical treatment. Furthermore, PDT represents a second-line treatment for patients with tumor recurrence after BCG failure.

Tumor Recurrence in the Remnant Urothelium of Females Undergoing Radical Cystectomy for Transitional Cell Carcinoma of the Bladder: Long-Term Results From a Single Center

PURPOSE We analyzed the risk factors and incidence of secondary TCC of the remnant urothelium in women following radical cystectomy for TCC of the bladder. MATERIALS AND METHODS A total of 85 women with a mean age of 64.5 years with clinically localized TCC of the bladder underwent radical cystectomy between 1992 and 2004. Orthotopic bladder substitution was performed in 46 females, while 39 underwent nonorthotopic urinary diversion. Of the entire cohort 22 (26%) patients underwent cystectomy for multifocal or recurrent TCC. Followup examinations were performed at 6-month intervals. RESULTS Mean followup in the entire cohort was 49.8 months (median 42). Intraoperative frozen sections obtained from the urethra and distal ureters were negative for TCC and CIS in all patients. Four women (4.7%) had TCC in the remnant urothelium at a mean of 56 months postoperatively. These patients had undergone cystectomy for multifocal or recurrent TCC (4 of 22 or 18%). No secondary TCC was seen in the 63 patients with solitary invasive or nonrecurrent bladder cancer (p <0.05). Urethral recurrence was found in 2 patients (4.3%) 65 and 36 months after orthotopic neobladder surgery, respectively. In the orthotopic group 1 patient (2.1%) had an upper urinary tract tumor 76 months after surgery, while in the nonorthotopic group 1 (2.5%) was found to have an upper urinary tract tumor 48 months postoperatively. CONCLUSIONS Recurrent or multifocal TCC may represent a risk factor for secondary TCC of the remnant urothelium after cystectomy. In our series all recurrent tumors were late recurrences (more than 36 months postoperatively). Because the rate of urethral recurrence in the current series corresponds to that reported in men (2% to 6%), urethra sparing cystectomy with orthotopic bladder replacement does not appear to compromise the oncological outcome in women.

Management of incidental impalpable intratesticular masses of ≤ 5 mm in diameter

To gain more insight into the histology of small incidental intratesticular lesions and evaluate the need for surgical management, as exploratory surgery is the only way to exclude malignancy in testicular tumours.

Three-dimensional ultrasonography of the urinary bladder: preliminary experience of assessment in patients with haematuria

To assess the value of three‐dimensional (3D) vs two‐dimensional (2D) ultrasonography (US) in the diagnostic evaluation of the urinary bladder in patients with haematuria.

Early diagnosis and straight forward surgery of an asymptomatic primary angiosarcoma of the kidney led to long‐term survival

Abstract  We report the first case of a diagnosis of an asymptomatic primary renal angiosarcoma. The patient underwent laparoscopic nephrectomy and is alive after long‐term follow up. We provide the preoperative imaging studies and the histologic features of this exceedingly rare tumor.

Organ‐sparing surgery does not lead to greater antisperm antibody levels than orchidectomy

To assess a possible development of antisperm antibodies (ASA), present in a high percentage of infertile patients, after organ‐sparing surgery for small testicular tumours, to identify any additional immunogenic effect of this procedure compared with standard orchidectomy.

Two cycles of cisplatin-based chemotherapy for low-volume retroperitoneal stage II nonseminomatous germ cell tumours.

To evaluate the oncological efficacy of reducing cisplatin‐based chemotherapy to two cycles in patients with low‐volume retroperitoneal stage II nonseminomatous germ cell tumours (NSGCTs).

Wegener’s granulomatosis presenting with gross hematuria due to prostatitis

Sir, Wegener’s granulomatosis (WG) represents a systemic vasculitis usually affecting the upper respiratory tract (74%), lungs (70%) and kidneys (46%) and affecting men and women equally, with a peak occurrence during the fifth and sixth decades of life [4, 5]. The etiology is unknown, but generation of anti-neutrophil cytoplasmic antibodies (c-ANCA) and activation of cellular response probably triggered by a preceding infection are discussed [1]. The diagnosis of WG should be made considering clinical presentation, histological findings in biopsy specimens and measurement of c-ANCA, which are highly specific [4]. Histologically, “dirty” liquefactive and/or coagulative necroses with a large number of eosinophilic granulocytes, scanty lymphocytes, plasma cells and multinucleated giant cells associated with a destructive leukocytoclastic vasculitis of arteries and veins are usually found in the lesions of the upper airways and lungs [5]. Renal disease includes focal necrotizing glomerulonephritis or interstitial nephritis [2, 5]. Clinically, WG presents with symptoms of the upper and lower respiratory tract, including nasal obstruction, discharge, ulcers, sinusitis or otitis, cough, hemoptysis and dyspnea, often associated with a progressive loss of renal function with microhematuria, nephritic urine sediment, moderate proteinuria up to rapidly progressive renal failure and systemic symptoms such as fever, weight loss and sweats [5]. We report the case of a 51-year-old man who was admitted to our hospital in September 1996 with a 3month history of gross hematuria and mild dysuria. The patient claimed to have increasing weakness, sweats and weight loss as well as subfebrile temperatures. For the previous 3 weeks, the patient had arthralgias in the large joints and suffered from tinnitus accompanied by a hearing loss. The patient’s blood pressure was 115/ 89 mmHg. He had a Horner syndrome on the right eye and chronic seromucinous otitis media. Chest X-ray remained inconspicuous. Magnetic resonance scan revealed increased contrast medium storage in the mastoid bone, the frontal and maxillar sinus on the left side consistent with an inflammatory process. Except for leukocytosis, increased C-reactive protein (10.64 mg/ml) and a serum creatinine of 0.9 mg/dl, laboratory parameters were unremarkable. Urine analysis revealed leukocyturia (75 leukocytes/ml), gross hematuria (250 erythrocytes/ml) but no proteinuria. Urine sediment contained a few hyaline and cellular casts. Urine cultures remained sterile. c-ANCA titer was 1:20. The diagnosis of WG was made and a renal biopsy was performed to determine the extent of renal involvement, revealing just a scarce interstitial chronic inflammatory infiltrate with normal glomeruli. The patient was referred to the urologist for further examination of gross hematuria. On digital rectal examination, the prostate was firm. Cystoscopy showed an inconspicuous bladder, but the prostatic tissue was extensively damaged with ulcers and paracollicular necrosis, suspicious for tuberculosis. Total serum prostate-specific antigen was 0.5 ng/ml. Prostate biopsy was performed, and histological examination revealed multiple granulomas with irregular, stellate and geographic necroses surrounded by histiocytes, lymphocytes, plasma cells and eosinophilic granulocytes (Fig. 1A, C). The center of the granulomas was filled with dirty, amorphous debris. The prostatic acini showed atrophic epithelium with scattered inflammatory infiltrate. A few small blood vessels were cuffed by histiocytes and granulocytes, indicating the presence of vasculitis (Fig. 1B, D). After special stains were performed, there was no evidence of infectious agents; thus, the histological appearance was consistent with the diagnosis of WG. The patient was given cyclophosphamide as well as A. Brunner · A. Tzankov · G. Mikuz ()) Institute of Pathology, University of Innsbruck, Muellerstrasse 44, 6020 Innsbruck, Austria e-mail: gregor.mikuz@uibk.ac.at Tel.: +43-512-5073650 Fax: +43-512-582088

INFLUENCE OF INTRAVESICAL POTASSIUM ON PELVIC FLOOR ACTIVITY IN WOMEN WITH OVERACTIVE BLADDER SYNDROME: COMPARATIVE URODYNAMICS MIGHT PROVIDE BETTER DETECTION OF DYSFUNCTIONAL VOIDING

To assess the influence of intravesical potassium on pelvic floor activity (PFA) during voiding in women with symptoms of overactive bladder (OAB), by using comparative urodynamics (CUD).

Metastasizing Renal Cell Carcinoma Developing in a Congenital Ectopic and Dysplastic Kidney

We present the first case of a metastasizing renal cell carcinoma arising within a partially regressed multicystic dysplastic and ectopic left kidney in a 34-year-old patient. Despite nephrectomy and adjuvant immunotherapy, the patient died 4 months after diagnosis. Even though a recent systematic review found no evidence to support any of the different modalities for following up children with MCKD by ultrasound (Oxford Centre for Evidence-Based Medicine, Level of Evidence: 3a), our case supports the contrary and we emphasize that an annual control could be an important diagnostic choice (Level of Evidence: 4).