Biomedical subjects
Publications and source records attributed to Shimon Meretyk.
Asymptomatic hematuria is very common in pediatric and adolescent patients. In contrast to painless hematuria in adults, the differential diagnosis and investigative modalities in the pediatric population is vastly different. This article presents the major diseases that may cause hematuria in children and suggests an evaluation algorithm for the pediatric urologist.
PURPOSE: We assessed the efficacy of extracorporeal shock wave lithotripsy for large (more than 10 mm) ureteral calculi with the unmodified Dornier HM3 lithotriptor. MATERIALS AND METHODS: A total of 96 consecutive patients with large ureteral stones were treated with shock wave lithotripsy using an unmodified HM3 lithotriptor. Patients, stone characteristics, preliminary treatment before shock wave lithotripsy, additional procedures after shock wave lithotripsy, complications and clinical outcomes were assessed. RESULTS: Between 2000 and 2003 a total of 96 patients (75 males, 21 females, mean age 51 years [range 16 to 81]) with large ureteral stones underwent shock wave lithotripsy. Average stone size was 14 mm (range 10 to 22), 90 stones were calcified, and 66 stones were located in the upper ureter, 20 in the mid ureter and 10 in the distal ureter. A total of 77 (80.2%) patients underwent a single shock wave lithotripsy session, 18 (18.7%) underwent 2 sessions and 1 (1.1%) patient underwent 3 sessions. The overall stone-free rate was 86.5% (83 patients). Complications occurred in 10 (10.4%) patients. Shock wave lithotripsy failed in 13 (13.5%) patients who were successfully treated with ureteroscopy. CONCLUSIONS: Our data show that shock wave lithotripsy for large ureteral stones along the entire ureter with the unmodified HM3 lithotriptor has a high success rate with minimal morbidity. We recommend it as first line treatment.
INTRODUCTION: Age has never been considered as a factor in the treatment of ureteral stones, but elderly male patients may suffer from concomitant illnesses that may affect SWL results, such as voiding difficulties and musculo-skeletal and cardio-vascular disorders. The aim of this study was to assess the success rate and complications of shock wave lithotripsy (SWL) for all size and location ureteral stones in patients older than 70 years of age. PATIENTS AND METHODS: We retrospectively reviewed the charts and radiology films of all patients who had undergone SWL for ureteral stones with the HM3 lithotriptor and compared the results of patients younger than 70 years to those older than 70 years. RESULTS: During 2000-2003, 238 consecutive male patients (23 older than 70 years) underwent SWL under regional anesthesia for all size and locations ureteral stones. Stone sizes, locations, opacity, and pre-operative drainage procedures matched in both groups. The overall stone-free rate was 91% for both groups. Complications were recorded in 1% of the older patients and 3.7% of the younger ones. No treatment-related mortality was recorded. CONCLUSIONS: Age itself has no effect on the success rate of SWL with the HM3 lithotripter for ureteral stones. In general, SWL treatment showed a high success rate with minimal morbidity and no treatment-related mortality.
A symptomatic hematuria is very common in pediatrics and adolescence. In contrast to painless adult hematuria, the differential diagnosis and investigative modalities in the pediatric population is vastly different. This article presents the major diseases that may cause hematuria in children and suggests an evaluation algorithm for the pediatric urologist.
INTRODUCTION: The association between staghorn calculus of the kidney long-standing and urothelial tumors of the renal pelvis is well documented. We describe 3 patients with urothelial cancer in a kidney who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Retrospective analysis of our series of more than 500 PCNLs revealed 3 patients in whom urothelial cancer of the renal pelvis was diagnosed during or following percutaneous stone removal. Preoperative assessment included IVP, renal sonography and renal scan using DTPA in all 3 patients, and CT in 2 patients. Imaging did not raise the suspicion of a neoplastic lesion. RESULTS: All patients had a long history of urolithiasis and urinary infections. No patient was diagnosed preoperatively. One patient was diagnosed postoperatively, when a CT demonstrated a renal lesion. The second patient underwent simple nephrectomy due to a non-functioning kidney, and the tumor was found on pathological analysis. In the third patient, biopsies were taken from a suspicious-looking tissue in the renal pelvis during the PCNL session. All patients had transitional cell carcinoma: 1 associated with sarcomatoid features and 1 with squamous carcinoma. They all died from metastatic disease 2-19 months after the diagnosis of urothelial cancer. CONCLUSIONS: The preoperative diagnosis of urothelial cancer in patients with staghorn stones is difficult due to the existing stone and inflammation. Since the prognosis of urothelial cancer is extremely poor, biopsies of the renal pelvis, obtained directly through the nephroscope during the PCNL session, may be the only key for early diagnosis and treatment. A high index of suspicion should be raised when patients suffering from infected staghorn calculi are encountered, and such intraoperative biopsies should be considered.
INTRODUCTION: Optimal treatment for ureteral stones is still controversial. The main retreatment options include ureteroscopy and shock wave lithotripsy (ESWL). The study aimed to assess the efficacy of ESWL using the unmodified HM3 lithotripter (Dornier Medical Systems) to achieve stone-free status in patients with ureteral calculi, regardless of stone size and location along the ureter. MATERIAL AND METHODS: We retrospectively reviewed the charts and radiology studies of all patients who had ESWL for ureteral stones. Following ESWL with the HM3 lithotripter, patients had imaging examinations performed after 1 and 3 months, and thereafter, according to the residue status of the stones. RESULTS: During the years 1998-2003, 661 patients underwent ESWL for ureteral stones. The mean age was 51 years (range: 4-85 years) and the average stone size was 8 x 10 mm (range: 3-30 mm). Forty percent of the patients had upper ureteral calculi, 17% mid and 43% lower ureteral stone. Overall stone-free status was 93.6%. According to stone location, the success rate for upper ureteral calculi was 93.6%, and 93.6% and 95.5% for mid and lower ureteral stones. Complications were recorded in 28 (4.2%) patients, 20 had acute urinary tract infection treated with i.v. antibiotics, and 8 had renal colic treated conservatively. CONCLUSIONS: Our data shows that ESWL using HM3 lithotripter for ureteral stones at any level and size has a high success rate with minimal morbidity. ESWL using the HM3 lithotripter is our preferred treatment of choice for ureteral calculi.
PURPOSE: Prostate carcinomas show a low level of the cell cycle inhibitor p27, which correlates with tumor aggressiveness. In tumors p27 is of the WT species and its deregulation is due to aberrant ubiquitin mediated degradation. The p27 is degraded following phosphorylation and subsequent recognition by SCFSkp2 ubiquitin ligase. We examined the relationship between p27 and its specific ligase Skp2 in normal and malignant prostate tissues. A possible correlation among the levels of these proteins, tumor grading and clinical state was also investigated. MATERIALS AND METHODS: Using immunohistochemistry immunofluorescence microscopy and Western blot analysis 51 samples from needle biopsies, transurethral resection and radical prostatectomy were analyzed for p27 and Skp2 expression. Correlation with tumor grading (Gleason) was performed. In 22 proven metastatic or organ confined cases correlation was also done with the Ki67 proliferative marker. RESULTS: Skp2 expression demonstrated a significant and direct correlation with malignancy (p <0.0001). Furthermore, a significant correlation was found between Skp2 level and tumor aggressiveness graded by Gleason score (p <0.0002) and prostate specific antigen. Patients with metastases had significantly higher Skp2 and Ki67 expression than those with organ confined disease (p <0.0001). In addition, Skp2 levels significantly correlated with Ki67 (r = 0.73, p <0.0001). An inverse correlation was found between p27 and Skp2 ligase. CONCLUSIONS: Skp2 expression in prostate biopsies may be used as an additional marker for tumor aggressiveness. The results also suggest a role for Skp2 in the pathogenesis of prostate malignancy.
PURPOSE: Urethrocutaneous fistula is the most common (2% to 10%) complication of hypospadias surgery. The correction of such fistula is associated with a 10% to 40% failure rate. The key measure to ensure a successful repair is separation of the suture lines in the urethra and skin, using well vascularized elastic tissue. If the dartos fascia is unavailable and local penile skin is fibrotic as a result of previous operations, a tunica vaginalis flap may be considered. We report our experience with tunica vaginalis flap as an adjunct to fistula repair. MATERIALS AND METHODS: We used tunica vaginalis flap for the repair of recurrent urethrocutaneous fistulas in 14 children with a mean age of 7.6 years (range 3 to 15). All patients had undergone previous hypospadias repairs and previous attempts to close the fistula had failed. The mean number of fistulas per patient was 1.6 (range 1 to 4), and the locations were perineal (1), penoscrotal (3), midshaft (10), and subcoronal (8). The mean number of failed previous closures with local penile skin flaps was 2.4 (range 1 to 5). Surgery was initiated by injecting povidone solution via the urethral meatus to identify all fistulas. Calibration or cystoscopy excluded distal urethral strictures. Surgery was performed using a microscope and fistulas were closed primarily in 12 patients and with an onlay island flap in 2. The urethral suture line was covered with a flap of tunica vaginalis, which was harvested through a small scrotal incision and mobilized via a subcutaneous tunnel into the penis. The testis was then fixed to the scrotum. A urethral stent with or without suprapubic catheter drainage provided urinary diversion for 2 to 7 days. RESULTS: The repair was successful in all patients. During a mean followup of 44 months (range 8 to 60) there was no evidence of recurrent fistulas or urethral strictures. Penile cosmesis was excellent, and all parents reported a straight penis when erected. No postoperative complications were encountered in the testicles. CONCLUSIONS: Repair of recurrent urethrocutaneous fistulas with a tunica vaginalis flap is highly effective regardless of fistula location. This flap is easy to mobilize and provides excellent coverage of the urethral suture line. It is a simple procedure with no complications to the testicles.
PURPOSE: Extracorporeal shock wave lithotripsy (ESWL) in older children appears to have comparable results when compared to adults, no study has focused on its use in younger children. We reviewed our ESWL experience in children under age 3.5 years to evaluate its safety, and define optimal treatment parameters. METHODS: We retrospectively reviewed consecutive medical and diagnostic imaging records from three ESWL centers, pertaining to 34 children under 3.5 years of age (36 renal units-RU). The children were from two distinct populations served exclusively by the three centers. We analyzed patient presentation, etiology, age, weight, stone size, preoperative interventions, energy settings, number of shock waves, number of treatments, success (stone fragments < 2 mm), and complications. We performed all forty-nine procedures under general anesthesia and modified the Dornier MFL 5000 table and the Dornier HM3 gantry to improve coupling and localizing of the calculi. RESULTS: In each population, we noted similar presentations, etiologies, and treatment parameters. Patient age ranged from 6 to 40 months (mean 23.4 months). Stone size ranged from 4 mm to 22 mm diameter (average 13 mm). ESWL parameters included an average of 2210 shocks (range 900-3400) at average of 20.9 kV (range 19 kV-25 kV). Preoperative ureteral stent placement was not shown to be beneficial. Our one and multiple treatment ESWL success rates were 66% and 86%, respectively. No major acute or long-term complications occurred. CONCLUSIONS: We successfully performed ESWL using treatment parameters similar to adults in 86% of children under 3.5 years without major complications. Modifications of the positioning device improved coupling and localization in smaller patients. Routine preoperative ureteral stenting for large stones is not recommended.
BACKGROUND: The current study evaluated the efficacy and toxicity of interleukin-2 (IL-2), interferon-alpha (IFN-alpha), 5-fluorouracil (5-FU), and vinblastine (VBL) in the treatment of metastatic renal cell carcinoma (MRCC). METHODS: Sixty-two MRCC patients, median age 63 years, received immunochemotherapy. Eastern Cooperative Oncology Group performance status was 1 for 45 patients and 2 for 17 patients. Fifty-four patients underwent nephrectomy prior to treatment. Sites of disease were lungs, lymph nodes, bone, kidney, and liver. Treatment consisted of IL-2 10 MIU/m(2) subcutaneous (SC), three times per week, Weeks 1-4; IFN-alpha 6 MIU/m(2) SC, once per week, Weeks 1-4 and 9 MIU/m(2), three times per week, Weeks 5-7; 5-FU 600 mg/m(2) and VBL 6 mg/m(2), intravenous bolus, Day 1 of Weeks 5 and 7. RESULTS: In a median followup of 34 months, 62 patients were evaluated for tumor response. Four patients achieved complete response for 26+, 34+, 51+, and 56+ months, respectively; 14 patients achieved partial response for a median of 14 months; and 20 patients achieved stable disease for a median of 9 months. Seven patients (5 partial response, 2 stable disease) underwent complete resection of residual tumor. Five patients remained alive with no evidence of disease for 27, 32, 36, 42, and 48 months, respectively. Nine patients achieved long-term complete response for a median of 36 months. Three-year survival rate for the entire group and for 11 complete responders was 88%. Common side effects were flu-like symptoms, nausea, headache, and depression. Four patients were excluded because of treatment intolerance, and one patient died after nephrectomy. CONCLUSIONS: Immunochemotherapy is effective and well-tolerated by patients with MRCC. Surgical intervention for resection of residual disease is justified.
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