Tailored metabolic workup for urolithiasis: the debate continues

Urolithiasis is one of the commonest afflictions of the urinary tract. Stones are of various chemical compositions, some share some common etiology; but most are specific to the structure and composition of stone. In view of highly recurrent nature of this condition, it is logical to have strategies for prevention. However, due to multiple factors most patients receive no or fragmented information on prevention. The current controversy is to the extent of metabolic workup in adult first time stone former. This requires longitudinal studies to show benefit in prevention strategies. Patients at high risk can have recurrence in weeks to years, depending upon the composition and attending risk factor. They should be targeted with concentric and tailored prevention protocols. The major urological guidelines [EAU and AUA] recommend basic stone workup for all patients. However, indication for detailed workup are less well documented, so one potential solution is to tailor metaphylaxis strategies for individual patient

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.

Functional and clinical outcome of ileal [studer] neo-bladder reconstruction: single centre experience from Pakistan

To determine the medium and long-term outcome of orthotopic continent urinary diversion with ileal [Studer] neo-bladder following radical cystectomy. Case series. Department of Surgery, The Aga Khan University Hospital, Karachi, from January 1998 to September 2010. Thirty eight patients underwent radical cystectomy for invasive bladder tumor with ileal neo-bladder [Studer type] reconstruction. Peri-operative and late complications, functional outcome of neo-bladder, urinary continence, metabolic and upper urinary tract status and overall survival were evaluated in all patients. A total of 29 patients [23 males and 6 females] with mean age of 59 +/- 12 years were included for the final analysis. The mean duration of surgery [both radical cystectomy and urinary diversion] was 520 +/- 70 minutes. Perioperative complication rate was 24% [n=7] with surgical site infection in 4 patients, sepsis in 1 patient and 2 had ureteroileal leak. At 6 months follow-up, 22 patients were fully continent while 7 patients had minimal stress / nocturnal incontinence. The continence rate was 93% [n=27] at one year follow-up. The mean capacity of neo-bladder at 6 months was 384 +/- 66 mLs. The late complication rate was 17% [n=5]. Three patients developed anastomotic stricture requiring transurethral incision of neo bladder neck, one formed stone in neo-bladder and one developed incision hernia. All patients had preserved renal functions on follow-up. The survival rate was 80% [n=23] at a median follow-up of 66.4 +/- 36 months. Two patients developed local recurrence and four developed distant metastasis. Studer ileal neo-bladder is a safe and effective option for urinary diversion in select patients with good oncological and functional outcomes comparable to contemporary literature, even in a low volume center

Impact of Histopathological Variant on the Outcome of Patients Treated by Radical Cystectomy

PURPOSE: It is well established that muscle-invasive urothelial carcinoma (UC) has a marked propensity for divergent differentiation, a fact that has significant diagnostic, prognostic, and therapeutic implications. This work is designed to assess the impact of different histopathologic variants of bladder cancer on morbidity and mortality in patients undergoing radical cystectomy (RC) as compared to the impact in patients with conventional UC. MATERIALS AND METHODS: We reviewed records of 201 patients treated with RC and pelvic lymph node dissections. Demographics as well as clinico-pathologic parameters, including histopathological variant, tumor stage, and nodal status, were reviewed. Multivariate analyses were used to evaluate these parameters for overall survival (OS). Kaplan-Meier curves for overall and cancer-specific survival were plotted. RESULTS: The majority of patients were male (84%), and the mean age was 61+/-13.1 years (range, 27-87 years). The mean follow-up was 67 months (range, 6-132 months). A histological variant of UC tumor was found in 19 patients (11%). The OS was 55%, and the cancer-specific survival was 35%. The histopathologic variance showed significant impact on morbidity and mortality (p=0.02 and p=0.05, respectively). Patients with divergent histopathology of bladder tumor have poorer survival than do those with UC in a multivariate analysis. CONCLUSIONS: The pathologic stages at RC and lymph node involvement are predictors for OS. Because of its aggressive nature, histopathologic variance is an independent risk factor determining the outcome in terms of both morbidity and mortality.

Optimal Management of Lower Polar Calyceal Stone 15 to 20 mm

PURPOSE: To compare the stone clearance rate, efficiency quotient (EQ), and early complications of shock wave lithotripsy (SWL) and percutaneous nephrolithotomy (PCNL) for solitary lower-pole renal stones measuring 15 to 20 mm. MATERIALS AND METHODS: This was a retrospective matched-pair analysis of 142 patients (78 in the SWL and 64 in the PCNL group). Preoperative imaging was done by use of noncontrast computed tomography (CT kidney, ureter, and bladder [KUB]), intravenous urogram, or plain X-ray and ultrasound KUB to assess the largest dimension of the stones. Only patients with radiopaque stones were included. The stone-free rates were assessed with plain X-ray and ultrasound at 4 weeks. Data were analyzed by use of SPSS ver. 19. RESULTS: The patients' demographic profiles (age, body mass index) and the stone sizes were comparable in the two groups. The mean stone size was 17.4+/-2.12 in the PCNL group compared with 17.67+/-2.04 in the SWL group (p=0.45). At 4 weeks, 83% of patients undergoing PCNL were stone-free compared with 51% in the SWL group (p<0.001). The EQ for the PCNL group was 76% compared with 44% for the SWL group (p<0.001). Ancillary procedures were required by 9% of patients in the PCNL group compared with 15% in the SWL group. The complication rate was 19% in both groups. The SWL complications were minor. CONCLUSIONS: Stone clearance from the lower pole of solitary stones sized 15 to 20 mm at the greatest diameter following SWL is poorer. These calculi can be better managed with percutaneous surgery owing to its higher efficacy and acceptably low morbidity.

Grading complication following radical cystectomy and ileal conduit for bladder cancer using clavien grading system

To determine the 30-day complication rate of radical cystectomy and urinary diversion using a validated system. An analytical descriptive study. The Aga Khan University Hospital, Karachi, from 1990 to 2010. Patients who had undergone ileal conduit [IC] formation, following radical cystectomy [RC] for muscle invasive transitional cell carcinoma, were studied, using a prospectively maintained data base. Basic details were determined, complications were noted and graded according to the modified Clavien grading system [CG]. Results were presented using descriptive statistics. Of all the RC performed at this hospital 89 patients received IC. Of them 75 were male and 14 female. Mean age was 60 years. Mean duration of hospital stay was 14 days. Ten patients each received pre-operative chemotherapy and radiotherapy, respectively. Mean duration of surgery was 8.2 hours, with mean estimated blood loss of 1334 ml. Preoperative radiotherapy was associated with more complications. No other factor like ASA, co-morbidities, blood loss or duration of stay influenced the complications. Fifty patients [56.2%] did not have any complications. Most common complication of wound infection was seen in 7 patients [CG-2], followed by uretero-ileal leakage in 5, requiring percutaneous intervention under local anaesthesia [GC-3a]. Mortality rate was 4.5%, classified as CG-V. Radical cystectomy with Ileal conduit is a major procedure with a good safety profile at this institute. Longterm follow up is still needed to evaluate delayed complications and quality of life

Alternate and incidental diagnoses on noncontrast-enhanced spiral computed tomography for acute flank pain

Our aim was to determine the incidence and spectrum of significant alternate or incidental diagnoses established or suggested on spiral computed tomography [CT] in a large series of patients with suspected renal colic. Records of all patients that had undergone spiral CT [5-mm to 7-mm slice thickness] for acute flank pain during a 5-year period were reviewed. The radiological diagnoses of urinary calculi and obstruction as well as clinical entities not suspected otherwise were analyzed. A total of 4000 CT's had been performed in the evaluation of acute flank pain. Urinary calculi had been identified in 3120 patients [78%]. There were 398 patients [9.9%] who had an alternate cause of flank pain or an incidentally detected condition on CT. Of these patients, 102 [25.6%] had more than one additional finding. A total of 153 clinical conditions had been identified mimicking flank pain secondary to calculus and obstruction. In 47 patients [1.2%], incidental solid masses had been detected. Spiral CT is a valuable technique in the evaluation of acute flank pain with uncertain clinical diagnosis. A wide spectrum of alternate and additional diagnoses including abdominal solid organ tumors and other significant abdominal conditions such as pancreatitis can be established or suggested on spiral CT performed for suspected acute urinary colic

Predicting recurrence and progression in non-muscle-invasive bladder cancer using european organization of research and treatment of cancer risk tables

We determined the recurrence and progression at 1 year in patients with non-muscle-invasive urothelial carcinoma who underwent transurethral resection of bladder tumor [TURBT] and compared those with the calculated risk according to the European Organization of Research and Treatment of Cancer [EORTC]. Follow-up data of 92 patients with non-muscle-invasive bladder cancer who underwent TURBT were reviewed, and their 1st year recurrence and progression were recorded. The risk of recurrence and progression were calculated for 1 year according to the EORTC scoring system, using tumors' stage, grade, size, and multiplicity, and the presence of carcinoma in situ and previous recurrence episodes. The outcomes were compared with the EORTC's predictive scores. The patients were 75 men and 17 women with an age range of 31 to 91 years. Sixteen patients [17.4%] had a recurrent disease, 41 [44.6%] had a tumor larger than 3 cm in diameter, 35 [38.0%] had multiple lesions, 2 [2.2%] had carcinoma in situ, 73 [79.3%] had stage T1 lesions, and 8 [8.7%] had a high-grade disease. Recurrence was found in 34 patients [37.0%]. The recurrence rates were 20.0%, 28.2%, 40.5%, and 83.3% in groups with the predicted EORTC risks of 15%, 24%, 38%, and 61%, respectively. There were 2 patients [2.2%] with progression of the diseases. A significant concordance was noted between the EORTC's predicted risk and the actuarial recurrence rate of stage Ta T1 bladder cancer at 1 year. Progression was less than that predicted, probably due to our small sample size

Separate submission of standard lymphadenectomy in 6 packets versus en bloc lymphadenectomy in bladder cancer

Our aim was to evaluate detection of nodal metastasis during radical cystectomy with standard pelvic lymph node dissection versus en bloc lymphadenectomy for the treatment of bladder cancer. Hospital records of a total of 77 patients with radical cystectomy and either standard pelvic lymph node dissection or en bloc lymphadenectomy were reviewed. Nodal dissection specimens during standard lymphadenectomy were sent for pathology examination in 6 separate containers marked as external iliac, internal iliac, and obturator groups from both sides. En bloc dissection specimens were sent in 2 containers marked as the right and the left pelvic nodes. Clinical and pathological findings of these two groups were compared in terms of the number of dissected lymph nodes, number of nodes with metastasis, lymph node density, and clinical outcomes. There were 34 patients with standard lymph node dissection and 43 with en bloc lymphadenectomy [anterior pelvic exenteration]. Age, sex, duration of the disease, number of transurethral resections prior to cystectomy, pathological grade at cystectomy, and stage of the primary tumor were comparable in the two groups of patients. The median numbers of nodes removed per patient were 15.5 [range, 4 to 48] and 7.0 [range, 1 to 24] in those with standard and en bloc lymphadenectomy, respectively [P<.001]. Nodal involvement was detected in 10 [29.4%] and 9 [20.9%] patients, respectively [P=.43]. Although nodal involvement was not significantly different between the two groups, standard lymphadenectomy submitted in 6 different containers significantly improved the nodal yield over en bloc resection. Obturator nodes were the most commonly involved nodes in our study

Intracytoplasmic sperm injection outcome using ejaculated sperm and retrieved sperm in azoospermic men

We aimed to determine pregnancy and miscarriage rates following intracytoplasmic sperm injection [ICSI] cycles using retrieved epididymal and testicular sperm in azoospermic men and ejaculated sperm in oliogospermic and normospermic men. This retrospective study was carried out on 517 couples who underwent ICSI. They included 96 couples with azoospermia and 421 with oligospermia or normal sperm count in the male partner. Of the men with azoospermia, 69 underwent percutaneous epididymal aspiration [PESA] and 47 underwent testicular sperm extraction [TESE]. In the 421 men with oligospermia or normal sperm count, ejaculated sperm was used for ICSI. The differences in the outcomes of ICSI using PESA or TESE and ejaculated sperm were evaluated. The main outcome measures were pregnancy and miscarriage rates. No significant differences were seen in pregnancy and miscarriage rates with surgically retrieved and ejaculated sperm. The pregnancy rates [including frozen embryo transfer] were 43.5%, 36.2%, and 41.4% in couples with PESA, TESE, and ejaculated sperm, respectively [P=.93]. The miscarriage rates were 16.7%, 23.5%, and 12.1, respectively [P=.37]. Intracytoplasmic sperm injection in combination with PESA and TESE is an effective method and can successfully be performed to treat men with azoospermia. The outcomes with these procedures are comparable to ICSI using ejaculated sperm

Single instillation of mitomycin C reduces 1st year recurrence following transurethral resection of non-muscle invasive bladder cancer

To study the impact of single instillation of 40 mg Mitomycin C [MMC-40] within first hour of transurethral resection [TUR], on first year recurrence of non-muscle invasive bladder cancer. In this study of two groups of patients with similar demographics and tumour profile were compared to assess first year tumour recurrence pattern. Group A received MMC-40 within 30 minutes of TUR. Group B patients only had TUR of bladder tumour. Patients' charts were reviewed for demographic profile, preoperative diagnosis and imaging used, cytological work up, tumour profile both during cystoscopy and imaging used, patients records were also reviewed for all subsequent check cystoscopies for recurrence. Any adjuvant treatments like intravesical chemo/immunotherapy etc. were also noted. The results were analysed using a commercially available statistical package, SPSS[TM]. The level of significance was