Diagnostic value of MRI in a pelvic mass of prostatic origin: Part 2.
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Humans↗
Biomedical subjects
Aristotelis G Anastasiadis
Publications and source records attributed to Aristotelis G Anastasiadis.
Closing the tract of mini-percutaneous nephrolithotomy with gelatine matrix hemostatic sealant can replace nephrostomy tube placement.
OBJECTIVES: To investigate the outcomes using gelatine matrix hemostatic sealant to close the tract after mini-percutaneous nephrolithotomy (mini-PCNL), resulting in a tubeless setting. METHODS: After complete stone removal after mini-PCNL, a double-J ureteral stent was placed in an antegrade manner. After withdrawing the 17F Amplatz sheet from the collecting system under direct vision without irrigation, the urothelium collapsed. While retracting the sheet further, the gelatine matrix hemostatic sealant was injected. The skin incision was closed with glue. An ultrasound examination was performed on the first postoperative day to exclude the presence of urine extravasation. RESULTS: Mini-PCNL was performed in 11 patients, either as a primary, small stone, single-access procedure or as a second-look mini-PCNL because of small residual fragments after extracorporeal shock wave lithotripsy. The time to seal the mini-PCNL tract through the kidney parenchyma was 2 to 5 minutes. The mean operative time was 79 minutes. In the first 5 cases, intravenous urography was performed in addition to ultrasonography and demonstrated an intact collecting system. The subsequent procedures demonstrated similar findings, with the exception of 1 case of temporary paravasation. In all other patients, the catheter was removed on the first postoperative day. Ten of 11 patients had an uneventful follow-up until removal of the double-J catheter. No major complications were observed. CONCLUSIONS: Closing the tract of the mini-PCNL with gelatine matrix hemostatic sealant is a safe and fast alternative and provides the option of discharging the patient in good condition without the commonly used nephrostomy tube.
Adult↗
Radical cystectomy and orthotopic bladder replacement in females.
INTRODUCTION: More than 15 years ago, several centers started to offer urethra-sparing cystectomy and orthotopic urinary diversion for female patients with bladder malignancies. Several studies have been published, outlining both the anatomical and oncological aspects of such an approach. METHODS: In this contribution, the main aspects regarding the surgical technique of cystectomy and orthotopic urinary diversion in female patients, including technical variations which have been derived over the years, are presented. RESULTS AND CONCLUSION: The video shows a detailed description of the surgical technique, and the main steps of the procedure are demonstrated in schematic drawings as well as in animations to facilitate understanding. Emphasis is given on important anatomical and physiological aspects, which have influenced the current surgical steps. Possible sequelae on oncological and functional outcome, which play an important role in the evaluation of this procedure, are also discussed.
Cystectomy↗
Diagnostic value of MRI in a pelvic mass of prostatic origin.
We report on the case of a 55-year-old male with acute urinary retention, caused by a large pelvic mass. Contrast enhanced computed tomography showed a vascularized prostatic mass with calcifications. To rule out potential bladder and rectum infiltration and to optimize imaging prior to surgical exploration, an MRI examination including MR angiography and spectroscopy was performed. Clinical findings including intraoperative results are presented in this report in detail and correlated to the results of the state of the art magnetic resonance imaging.
Calcinosis↗
MRI-guided biopsy of the prostate increases diagnostic performance in men with elevated or increasing PSA levels after previous negative TRUS biopsies.
OBJECTIVES: Repeatedly negative prostate biopsies in individuals with elevated prostate specific antigen (PSA) levels can be frustrating for both the patient and the urologist. This study was performed to investigate if magnetic resonance imaging (MRI)-guided transrectal biopsy increases diagnostic performance in individuals with elevated or increasing PSA levels after previous negative conventional transrectal ultrasound (TRUS)-guided biopsies. METHODS: 27 consecutive men with a PSA >4 ng/ml and/or suspicious finding on digital rectal examination, suspicious MRI findings, and at least one prior negative prostate biopsy were included. Median age was 66 years (mean, 64.5+/-6.8); median PSA was 10.2 ng/ml (mean, 11.3+/-5.5). MRI-guided biopsy was performed with a closed unit at 1.5 Tesla, an MRI-compatible biopsy device, a needle guide, and a titanium double-shoot biopsy gun. RESULTS: Median prostate volume was 37.4 cm3 (mean, 48.4+/-31.5); median volume of tumor suspicious areas on T2w MR images was 0.83 cm3 (mean, 0.99+/-0.78). The mean number of obtained cores per patient was 5.22+/-1.45 (median, 5; range, 2-8). Prostate cancer was detected in 55.5% (15 of 27) of the men. MRI-guided biopsy could be performed without complications in all cases. CONCLUSION: According to our knowledge, this is the largest cohort of consecutive men to be examined by MRI-guided transrectal biopsy of the prostate in this setting. The method is safe, can be useful to select suspicious areas in the prostate, and has the potential to improve cancer detection rate in men with previous negative TRUS-biopsies.
Biopsy↗
Size does matter: 1.5 Fr. stone baskets almost double irrigation flow during flexible ureteroscopy compared to 1.9 Fr. stone baskets.
With a new generation of flexible ureterorenoscopes, a new area in stone management is emerging. Limitation of vision with these new instruments is often caused by insufficient irrigation flow, especially when using instruments like stone baskets, resulting from partial obstruction of the working and irrigation channel with these instruments. Empirically, new available smaller stone baskets seem to dramatically improve irrigation and therefore vision in clinical use. The goal of this study was to show objective differences in basket diameters and flow rates in an in vitro setting. Diameters and irrigation flows in flexible ureterorenoscopes depending on different sizes of stone baskets (Fr. 1.5-1.7-1.9-2.2-2.4-3.0) and different deflections were measured. The measured diameter of the baskets varied within the first 20 cm and the true measured size varied from the manufacturer's specified size to a different extent. The new generation of 1.5 and 1.7 Fr. baskets improved irrigation flow, even compared to the smallest commonly used baskets, up to 68%. Interestingly, deflection did not influence irrigation flow. This study confirmed the subjective impression of inadequate description of relevant basket diameters as well as that of a significant improvement of irrigation flow with the newest generation of stone baskets with smaller diameters.
Calibration↗
Comparison of flexible grasping forceps and stone basket for removal of retracted ureteral stents.
BACKGROUND: Ureteral-stent dislocation can occur either during positioning or postoperatively. Grasping the distal end of the stent and removing it depends on the angulation between the extraction device and the stent, the size and length of the instrument, and the force of the branches and resistance of the dislocated stent. PATIENTS AND METHODS: Six cases of challenging stent removal are presented, and details of the surgical technique are described. By in-vitro testing, we investigated the deflection of flexible cystoscopes and ureteroscopes using forceps or a four-wire stone basket, the ability to grasp a stent depending on the angle between the stent axis and the extraction device, and the force that can be applied on the stent with the different devices. RESULTS: In all cases, it was possible to extract the stent with a stone basket. In an in-vitro setting, maximum extraction forces, measured with a macro scale, were 1.3 kg (cystoscopic forceps) and 0.4 kg (ureteroscopic forceps) until the forceps slipped off the stent. In the same setting, a rupture of the wires of the 1.9F stone basket occurred at 0.8 kg, whereas with a 2.4F basket, a force of 1.9 kg led to rupture of the stent, leaving the basket intact. CONCLUSIONS: Using a stone basket instead of grasping forceps in difficult cases of dislocated stents opens new possibilities for their cystoscopic and ureteroscopic removal. Because the superiority of the basket is counterbalanced by its higher costs, we suggest the basket extraction method only in difficult cases.
Adult↗
Introducing a novel technique to remove accidentally stitched or entrapped urethral catheters after radical prostatectomy.
INTRODUCTION: A crucial step during radical prostatectomy is anastomosing the bladder neck to the urethral stump after specimen removal. For this purpose, a Foley catheter is inserted transurethrally to achieve a patent and watertight anastomosis. The catheter should be removed 6-10 days after the procedure to avoid ascending infection and stricture formation. On occasion, catheter removal is not possible due to fixation by one of the anastomotic sutures. In this case, a longer catheterization period may increase the risk of infection and formation of an anastomotic stricture. MATERIALS AND METHODS: In the present report, we suggest a technique to overcome this problem by using an endoscopic laser dissection of the anastomotic suture. In 2 patients, a 4.8-Fr pediatric ureteroscope was passed through the urethra along the fixated catheter. After carefully inspecting the anastomosis, a laser fiber was brought in direct contact with the responsible suture. RESULTS AND CONCLUSIONS: By activating the laser, the suture was cut immediately, and the catheter could be removed. Both patients showed no signs of anastomotic leakage or stricture on cystography. Fixation of the catheter after radical prostatectomy is a rare, but bothersome complication, which can compromise the functional outcome of the procedure. Using a pediatric ureteroscope and a laser fiber is an elegant, minimally invasive method to solve this problem. It can be easily and safely performed under local anesthesia in an outpatient setting.
Adenocarcinoma↗
Clinical outcome after cystectomy in patients with lymph node-positive bladder cancer.
Whereas radical cystectomy is the standard of care in high-grade, invasive bladder tumors, the extent of lymphadenectomy and its diagnostic and/or therapeutic potential is controversial. Independent predictors for lymph node involvement are T-stage, histological grading and lymphovascular invasion. Preoperative assessment, including 3D magnetic resonance imaging and sentinel node detection, are promising concepts for the future. The extension of lymphadenectomy is not yet defined, although prospective data regarding the absence of skipped lesions in the case of pelvic lymphadenectomy and the damage of autonomic nerves in the case of extensive lymphadenectomy are arguments for a limited or stepwise approach. Outcome of N1 patients appears to be nearly equivalent to N0 patients in organ-confined tumors, whereas the outcome of N3 patients is poor in all studies presented to date. Therefore, it has been suggested that a meticulous lymphadenectomy in N1 patients, with positive lymph nodes almost exclusively localized within the endopelvic region, has a long-term therapeutic impact in terms of an improvement in the patient's clinical prognosis. For N2 patients, a long-term survival benefit from extensive lymphadenectomy remains to be demonstrated. Recognizing the inevitably poor clinical prognosis in cases with gross nodal involvement (N3), the clinical value of an extended lymph node dissection in these patients is very questionable.
Cystectomy↗
Laparoscopic sentinel lymph node dissection--a novel technique for the staging of prostate cancer.
OBJECTIVES: Pelvic lymph node metastases indicate a poor prognosis for prostate cancer patients. The aim of this study was to evaluate the suitability of laparoscopic radioisotope guided sentinel lymph node (SLN) dissection in staging of prostate carcinoma. METHODS: 28 patients with prostate cancer and intermediate or high risk for lymph node metastases considered for external beam radiotherapy underwent laparoscopic pelvic lymphadenectomy at our institution. For visualization of individual SLN distribution, an image fusion system consisting of a gamma-camera with integrated X-ray tube was used. During laparoscopic lymphadenectomy, SLN were identified using a laparoscopic gamma probe. RESULTS: Preoperative imaging and laparoscopic gamma probe allowed an excellent delineation of SLN. 57% (preoperative imaging) as well as 48% (intraoperative measurements) of SLN were found outside the obturator fossa. All SLN were removed successfully without intra- or postoperative complications. Despite extended lymphadenectomy, no significant lymphocele appeared. 10 lymph node metastases were found in 7 out of the 31 patients (23%) with 3 of the 10 metastases lying outside the obturator fossa representing the standard lymphadenectomy area. CONCLUSIONS: The present data demonstrate that laparoscopic SLN dissection is an excellent minimally invasive and technically feasible tool for staging of intermediate and high risk prostate cancer.
Aged↗
Application of angiogenic factors for therapy of erectile dysfunction: protein and DNA transfer of VEGF 165 into the rat penis.
OBJECTIVES: To establish a laboratory animal model for vascular endothelial growth factor (VEGF) transfer in the rat penis to invent a curative therapy for erectile dysfunction (ED). Vascular insufficiency is a common pathomechanism of ED. Previous investigations have shown neovascularization of ischemic organs after gene transfer of VEGF. METHODS: For VEGF-protein transfer, osmotic pumps were connected to the renal arteries of rats. The pumps were filled with human VEGF 165 protein (n = 20) or sterile saline (n = 20). After 28 days, a VEGF serum immunoassay was performed to document successful delivery. For VEGF-DNA transfer, liposome complexes containing VEGF 165 expression vectors were injected into rat corpora cavernosa. After immunostaining, computerized image analysis was performed to quantify the percentage of area (within the corpora cavernosa) covered by smooth muscle or endothelial cells. RESULTS: The immunoassay of the VEGF-protein transfer showed a 10-fold greater VEGF concentration in the serum of rats carrying VEGF pumps than in the control group. In the VEGF-DNA transfer, the penes transfected with VEGF 165 vectors showed a 283-bp polymerase chain reaction product according to specific primers for human VEGF. Although statistical trends were measured in the VEGF protein-treated group, no statistically significant difference in smooth muscle or endothelial cell content was found between the control and VEGF-treated rats. CONCLUSIONS: Our findings have established proof of principle for successful delivery of VEGF protein and VEGF-DNA transfer in the rat penis. This study was a prelude to attempt to manipulate genetically expression of angiogenic factors in insufficient erectile tissue as a curative therapy for ED.
Animals↗
Current aspects of the surgical management of organ-confined, metastatic, and recurrent renal cell cancer.
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Bone Neoplasms↗
Antibiotic coating reduces penile prosthesis infection.
AIM: To evaluate the efficacy of a new antibiotic-coated (rifampicin+monocycline) penile prosthesis in prevention of bacterial adhesion and reduction of penile prosthesis infection. METHODS: In a retrospective analysis of medical records of men who had undergone implantation of American Medical Systems (AMS) inflatable penile prostheses between July 1990 and November 2003, we compared patients with AMS antibiotic-coated prostheses and patients with AMS nonantibiotic-coated prostheses. A total of 152 men aged from 27 to 79 years with erectile dysfunction underwent implantation of the AMS inflatable penile prosthesis. Fifty-eight patients received the antibiotic-coated prosthesis between July 2001 and November 2003, and 94 patients received the nonantibiotic-coated prosthesis between July 1990 and June 2001. RESULTS: In most cases infection was present; it was detected 1-2 days or up to 3-6 months after implantation. Complications including infection, which required surgical intervention, were observed in 15 patients of the nonantibiotic-coated prosthesis group (three reoperations for infection), and noninfection-related failure in five patients of the antibiotic-coated prosthesis group. In the nonantibiotic-coated prosthesis group of patients, time to infection ranged from 1 day to 6 months (mean 3.5 months). The antibiotic-coated prosthesis group of patients immediately after surgery and during the short- and intermediate-term follow-up had no infection of the penile prosthesis. CONCLUSIONS: We suggest that the antibiotic locally delivered from the prosthesis coating might be an effective supplement for prevention of prosthesis-related infection in penile prosthesis surgery.
Adult↗
Zyflamend, a unique herbal preparation with nonselective COX inhibitory activity, induces apoptosis of prostate cancer cells that lack COX-2 expression.
Cyclooxygenase (COX) inhibitors have suppressive effects on several types of cancer cells including prostate cancer. In this study, we considered the potential COX-inhibitory activity of a unique anti-inflammatory herbal preparation (Zyflamend; New Chapter, Inc., Brattleboro, VT) and analyzed its effects on the human prostate cancer cell line LNCaP. COX inhibitory activity of Zyflamend was determined by a spectrophotometric-based assay using purified ovine COX-1 and COX-2 enzymes. Effects of Zyflamend on LNCaP cell growth and apoptosis in vitro were assessed by cell counting, Western blot detection of poly ADP-ribose polymerase (PARP) cleavage, and measurement of caspase-3 activity in treated and control cell extracts. Western blotting techniques were conducted to determine the effects of this herbal preparation on the expression of the cell signaling proteins, p21, androgen receptor (AR), phospho-protein kinase C (pPKC)(alpha/beta), and phospho (p)Stat3. The phospohorylation status of several signal transduction phosphoproteins was profiled using a high-throughput phosphoprotein screening assay in treated cells and compared to controls. Zyflamend dramatically decreased COX-1 and COX-2 enzymatic activity. Elevated p21 expression coincided with attenuated cell growth following treatment of LNCaP cells with Zyflamend. PARP cleavage fragments were evident, and caspase-3 activity was upregulated over the control indicating the ability of Zyflamend to induce apoptosis of these cells. Androgen receptor expression levels declined by 40%, and decreases were observed in the active forms of Stat3 and PKC(alpha/beta) in Zyflamend-treated LNCaP cells. Zyflamend inhibited both COX-1 and COX-2 enzymatic activities, suppressed cell growth, and induced apoptosis in LNCaP cells. However, our data suggests that the effects are likely due to COX-independent mechanisms potentially involving enhanced expression of p21 and reduced expression of AR, pStat3, and pPKC(alpha/beta).
Apoptosis↗
A novel surgical approach to subinguinal varicocelectomy: artery and lymphatic isolation technique.
Clinically relevant varicoceles require surgical management through one of several techniques. We introduce an innovative technique for varicocelectomy via a subinguinal approach that allows identification and preservation of the arteries and lymphatics. This method allows the safe excision of the varicocele, while minimizing the risk of complications.
Humans↗
Comparison of health-related quality of life and prostate-associated symptoms after primary and salvage cryotherapy for prostate cancer.
PURPOSE: Recent advances in cryosurgery of the prostate have led to the ability to treat tumors successfully with decreased morbidity. The patients' perspectives of this relatively new technique, however, have not yet been addressed. The purpose of this study was to compare health related quality of life (QoL) as well as prostate-associated symptoms in patients after primary and salvage cryoablation for clinically localized prostate cancer using a self-administered questionnaire. METHODS: A total of 131 consecutive patients who underwent cryoablation of the prostate between 1997 and 2001 were included in this confidential mailing study. The patients were either (a) patients with localized prostate cancer with contraindications for radical surgery, including patients refusing other forms of therapy, or (b) had locally recurrent prostate cancer after failure of radiation therapy. All patients received 3 months of neoadjuvant androgen deprivation therapy prior to cryosurgery and were surgically treated by the same surgeon using an argon-based system. We used the EORTC QLQ-C30, a commonly used, multidimensional instrument together with a supplementing, prostate-cancer-specific module. RESULTS: Eighty-one of the 131 patients (response rate 62%) returned the questionnaires. The two groups were comparable regarding age (mean age 72.8 vs 70.1 for the primary and the salvage group, respectively; p=0.22). The overall QoL scores were high in both groups. Primary cryotherapy patients fared significantly better regarding physical (p=0.005) and social (p=0.024) functioning compared with salvage cryotherapy patients. The most prominent prostate-related symptom in both patient groups was sexual dysfunction, followed by urinary symptoms, which were significantly more severe in the salvage group (p=0.001). Incontinence rates were 5.9 and 10% in the primary and the salvage group, respectively. Severe erectile dysfunction was reported in 86 and 90% of the primary and the salvage group, respectively. CONCLUSIONS: The present study demonstrates that, in selected patients, cryotherapy is a treatment option which has a functional outcome comparable to traditionally used prostate cancer treatments. More information regarding QoL is necessary for appropriate patient counseling and individual decision-making in the presence of various treatment alternatives.
Aged↗
Quality of life aspects in kidney cancer patients: data from a national registry.
GOALS: We investigated quality of life aspects, including health-related quality of life, psychological functioning, relationship issues and sexual functioning in kidney cancer patients. PATIENTS AND METHODS: We conducted an anonymous, cross-sectional survey of a random sample of patients with kidney cancer from a national database. A questionnaire was mailed to 301 members of the Kidney Cancer Association. The questionnaire included demographics, medical history, the Watts Sexual Function Questionnaire (WSFQ), the SF-12 Health Survey, the Center for Epidemiologic Studies Depression Scale (CES-D), and the Revised Dyadic Adjustment Scale (RDAS). RESULTS: Of the 266 eligible participants, 84 (33%) returned the questionnaire. The mean ages of the respondents were 57.5 and 57.9 years for men and women, respectively. Overall, the total WSFQ scores as well as the four domain scores (desire, arousal, orgasm and satisfaction) were similar in men and women, and lower than in female breast cancer and male hypertensive populations reported in the literature, indicating relatively worse sexual function. While subjects reported health-related quality of life and relationship scores similar to the general population, 51% of men and 57% of women reported depressive symptoms (CES-D >/=16). CONCLUSIONS: This is the first study in which sexual function in patients with renal cancer has been addressed. While most patients remain sexually active in non-distressed relationships, many reported depressive symptoms, and sexual functioning may be worse than in comparable chronically ill populations. Quality of life and sexual function issues should be addressed when counseling urological cancer patients.
Adult↗
Acute hypoxia increases the aggressive characteristics and survival properties of prostate cancer cells.
BACKGROUND: Androgen withdrawal, the standard therapeutic strategy for advanced prostate cancer, induces a rapid reduction of blood flow to prostate and prostate cancer tissues and the concomitant onset of a hypoxic environment in these tissues. To establish whether hypoxia-responsiveness (by means of the action of hypoxia inducible factor [HIF] -1alpha protein) might affect the tumorigenic or survival properties of prostate cancer cells, we studied how acute exposure of cultured human prostate cancer cells (LNCaP cell line) to hypoxia might alter their pattern of gene expression and their in vitro behavior. METHODS: LNCaP cultures were placed in a hypoxia chamber for up to 24 hr and were compared with control (normoxic) cells for the expression of gene products by Western blotting and semiquantitative reverse transcription-polymerase chain reaction techniques. RESULTS: Exposure of LNCaP cells to acute hypoxia activated a typical cellular hypoxia response characterized by up-regulation of HIF-1alpha and vascular endothelial growth factor protein expression. In contrast, expression of differentiation-specific proteins (prostate specific antigen and androgen receptor) or proliferative-regulatory proteins (c-myc, cyclin D1, p27) were down-regulated by hypoxia. Some of these latter changes (reduction of c-myc and cyclin D expression) were not accompanied by corresponding reduction of mRNAs and were abrogated by a proteosome inhibitor (MG132), suggesting that their loss was associated with their increased degradation rather than through transcriptional controls. The phosphorylation of Akt/protein kinase B and its downstream target, forkhead protein, was highly up-regulated by hypoxia, and cells exposed to transient periods of hypoxia became significantly less sensitive to an apoptotic stimulus (exposure to phorbol ester) when compared with normoxic cells. CONCLUSION: This study demonstrates that even acute hypoxia has the potential to drastically alter the growth, differentiation characteristics, and apoptotic sensitivity of a prostate cancer cell.
Apoptosis↗