Neurologic Complications in Percutaneous Nephrolithotomy

PURPOSE: Percutaneous nephrolithotomy (PCNL) has been the preferred procedure for the removal of large renal stones in Iran since 1990. Recently, we encountered a series of devastating neurologic complications during PCNL, including paraplegia and hemiplegia. There are several reports of neurologic complications following PCNL owing to paradoxical air emboli, but there are no reports of paraplegia following PCNL. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had undergone PCNL in 13 different endourologic centers and retrieved data related to neurologic complications after PCNL, including coma, paraplegia, hemiplegia, and quadriplegia. RESULTS: The total number of PCNL procedures in these 13 centers was 30,666. Among these procedures, 11 cases were complicated by neurologic events, and four of these cases experienced paraplegia. All events happened with the patient in the prone position with the use of general anesthesia and in the presence of air injection. There were no reports of neurologic complications in PCNL procedures performed with the patient under general anesthesia and in the prone position and with contrast injection. CONCLUSIONS: It can be assumed that using room air to opacify the collecting system played a major role in the occurrence of these complications. Likewise, the prone position and general anesthesia may predispose to these events in the presence of air injection.

Trends in medical education, an example from a developing country

Iran is presently designing a long-term plan for promoting science, technology and innovation in medicine. An important part of this plan will be a strategy for future planning for medical education considering the important trends affecting the future of health status and medical education in Iran. Here, we sought to clarify such trends in Iran and compare them to trends reported for similar developing countries. For this qualitative study, the opinions of stakeholders and experts were obtained during three focus group discussions, each lasting four hours and including 10- 12 participants [132 total man-hours]. Data were collected using audiotapes, which were then transcribed. Interim analysis was used for member checking and triangulated data from other recent studies were used to increase the trustworthiness of findings. Participants identified the following trends as affecting the health system and medical education in Iran: aging of the population; epidemiologic transition; changes in patients' expectations of health services; increases in the popularity of alternative and traditional Iranian medicine; growth in information and communication technologies; changes in the roles of tutors; new emphasis on basic sciences and new and interdisciplinary fields; increases in the emphasis on research and scientific production; loss of educated persons to other countries [e.g., brain drain]; and new advances in diagnostic and therapeutic technologies. The circumstances and future of a given community's health should be kept in mind when policymakers plan for changes in medical education. The present study found that trends affecting healthcare and medical education in Iran are similar to those in other countries [even developed countries], suggesting that Iranian policymakers could potentially adopt the policies and strategies that have proven useful in other countries when planning for medical education

Expression of survivin and its spliced variants in bladder tumors as a potential prognostic marker

Survivin, a novel inhibitor of apoptosis, is re-expressed in a vast majority of human cancers and is widely considered as a diagnostic marker of cancer. Survivin protein regulates both cell division and apoptosis. There are at least 5 sliced variants of the gene with different subcellular localization and anti-apoptotic property. We examined the expression pattern of survivin and its 2 sliced variants, survivin-delta EX 3 and survivin-2B, and their prognostic values in archival collections of formalin-fixed paraffin-embedded samples of bladder tumors. Total RNA from formalin-fixed paraffin embedded samples [51 samples from 30 patients with bladder cancer and 5-year follow-up] were extracted and analyzed by semiquantitative reverse transcriptase polymerase chain reaction technique. Tissue distribution and subcellular localization of survivin protein in tumor tissues was also examined by immunohistochemistry. The expression of survivin, survivin-delta Ex3, and surviving-2B were detected in 66.6%, 47.8%, and 54.7% of the specimens, respectively. The expression of survivin and survivin-delta Ex3 were preferentially elevated in tumours with higher grades, whereas survivin-2B expression was lower in high-grade tumors [P=.04]. A reverse correlation was observed between survivin-2B expression and high-grade tumors. Immunohistochemistry results also confirmed the nuclear localization of survivin protein within tumoral cells. We were successful in detecting the expression of survivin and its variants in formalin-fixed paraffin-embedded bladder samples. Furthermore, our results showed that overexpression of survivin and survivin-delta Ex3 in bladder tumors correlates with poor prognosis of bladder cancer. We suggest that survivin and its variants are suitable prognostic markers of bladder tumors

Laparoscopic adrenalectomy ten-year experience, 67 procedures

The purpose of this study was to evaluate the short-term and long-term results of laparoscopic adrenalectomies carried out in our center. A total of 67 laparoscopic adrenalectomies were performed during the 10 years between 1995 and 2005 at Shahid Labbafinejad Medical Center. A transperitoneal lateral approach was used in 65 [97.0%] of the patients, and retroperitoneal approach was used in 2 [3.0%]. The clinical characteristics and the outcomes were reviewed in a retrospective study. Indications for laparoscopic adrenalectomy in our patients were as follows: pheochromocytoma in 28 patients [41.8%], aldosterone-producing adenoma in 15 [22.4%], pseudocyst in 6 [9.0%], Cushing syndrome [macronodular adrenocortical hyperplasia] in 5 [7.5%], nonfunctioning adenoma [incidentaloma] in 5 [7.5%], myelolipoma in 2 [3.0%], almost normal adrenal tissue in 2 [3.0%], adrenal cyst in 2 [3.0%], adenocarcinoma in 1 [1.4%], and schwannoma in 1 [1.4%]. The mean operative time for unilateral cases was 149.0 A +/- 36.1 minutes. The mean intraoperative blood loss was 126 A +/- 36 mL. Conversion rate to open surgery was 7.5%. Reoperation due to hemorrhage was performed in 1 patient. Laparoscopic adrenalectomy is a safe procedure in some adrenal tumors and a reasonable option for selected large adrenal tumors when complete resection is technically feasible and there is no evidence of local invasion

Overexpression of BMI1, a polycomb group repressor protein, in bladder tumors: a preliminary report

A polycomb group repressor protein named BMI1 represses the genes that induce cellular senescence and cell death, and it can contribute to cancer when improperly expressed. We aimed to evaluate expression of BMI1 gene in bladder tumors. Tissue specimens containing bladder tumor were evaluated and compared with intact tissues from tumor margins and normal bladder. These were 40 tumor specimens of patients with transitional cell carcinoma of the bladder, 20 tumor-free tissues taken from the margin of the tumors, and 8 specimens from patients without tumor. Specific primers for BMI1 and B2M [as an internal control] were used for reverse transcript polymerase chain reaction technique. The production and distribution of BMI1 protein was also examined by western blotting and immunohistochemistry techniques. Polymerase chain reaction generated a 683-bp product, corresponding to the expect size of BMI1 amplified region. The identity of the amplified fragment was then confirmed by direct DNA sequencing. The mean of expression of BMI1 detected in tumor tissues was significantly higher than that in intact tissues, and there was also a significant association between the mean of gene expression and the stage of malignancy [P<0.001]. The expression of BMI1 at protein level was further confirmed by western blotting and immunohistochemistry. BMI1 is a potent repressor of retinoblastoma and p53 pathways, and hence, elucidating its role in tumorigenesis is very important. We reported for the first time the expression of BMI1 and its correlation with incidence and progress of bladder tumors

Evaluating the expression of survivin gene as a specific tumor marker for prognosis of bladder cancer

Inhibition of apoptosis may favor the onset and progression of cancer. Survivin is an inhibitor of apoptosis that has been considered as a potential marker for diagnostic and/or prognostic of bladder cancer. The survivin protein regulates both cell division and cell death and its overexpressed in the vast majority of human cancers. In this study, the expression pattern and potential prognostic value of survivin was assessed in Fomalin-Fixed Paraffin-Embedded [FFPE] samples of bladder tumor. FFPE samples, from patients with a well-known five-year survival record, were assessed by semi-quantitative RT-PCR technique. 51 samples from 30 patients were analyzed on the basis of Survivin expression. Tissue distribution and subcellular localization of survivin protein in tumor tissues was also examined by immunohistochemistry [IHC]. The expression of survivin in 66.6% of the samples, with an increase of expression in higher grades of tumor. Furthermore, survivin was overexpressed in 2[nd] and 3[rd] recurrences of the same patients. Also, with the increased malignancy and accordingly increase expression of surviving, the overall 5-year survival rate of patients was significantly declined [P=0.036]. IHC results also localized a nuclear localization for Survivin protein in tumor tissues. In coclusion, we were able to detect the expression of survivin in FFPE samples of bladder tissues, at the level of mRNA and protein and find a correlation between the level of Survivin expression and the degree of malignancy of the tumors. Our findings introduce Survivin as a suitable prognostic marker for predicting the bladder tumors

Extracorporeal shock wave lithotripsy and transureteral lithotripsy in the treatment of impacted lower ureteral calculi

We compared the efficacy of extracorporeal shock wave lithotripsy [SWL] with ureteroscopy followed by transureteral lithotripsy [TUL] for the treatment of impacted distal ureteral calculi. A total of 96 patients with solitary impacted distal ureteral calculi were assigned into 2 groups of treatment with SWL [42 patients] and TUL [54 patients] with a 6.9-F semirigid ureteroscope. Characteristics of the patients and the calculi, treatment parameters, clinical outcomes, and patients' satisfaction were assessed for each group as well as efficiency quotient. Demographic characteristics of the patients in the 2 groups were similar as well as the sizes of the calculi. The stone-free rate, 2 months postoperatively, was 71.4% in the patients of the SWL group and 88.9% in those of the TUL group. The efficiency quotient was 56% and 81% for the SWL and TUL groups, respectively [P =.004]. Retreatment rate was 26.2% [11 patients] and 9.3% [5 patients] for the SWL and TUL groups, respectively [P =.027]. Thirty patients in the SWL group [71.4%] and 52 in the TUL group [96.3%] were satisfied with their treatment [P =.001]. There were no major complications in neither of the groups. Minor complications [pain and hematuria] were more common in the TUL group. Based on the results of this study, TUL seems to be more effective than SWL in the treatment of impacted lower ureteral calculi sized smaller than 12 mm, and patients are more satisfied with this treatment method

Prediction of successful sperm retrieval in patients with nonobstructive azoospermia

Our aim was to evaluate the predictive values of factors that indicate successful sperm retrieval in men with nonobstructive azoospermia. We evaluated 85 infertile men with nonobstructive azoospermia who underwent multiple bilateral testicular biopsies. Factors including age, infertility period, surgical history, testicular volume, testicular consistency, serum follicle-stimulating hormone [FSH], serum inhibin B, serum luteinizing hormone, and serum total testosterone were assessed in relation to sperm retrieval results. Spermatozoa were retrieved in 18 biopsies [21.2%]. Follicle-stimulating hormone, serum inhibin B, and testicular volume were associated with the results of sperm retrieval. Men with a higher testicular volume, a higher serum inhibin B, and a lower FSH had successful sperm retrieval. The cutoff points were determined as 9.5 mL for testicular volume, 9.9 IU/L for serum FSH, and 39.8 pg/mL for serum inhibin B. These 3 factors had strong correlations with each other. The sensitivities and specificities were 88.9% and 94% for testicular volume, 97% and 83.3% for FSH, and 72.2% and 95.5% for serum inhibin B, respectively. The positive predictive value for a combination of serum FSH and inhibin B was 100%. Serum FSH and serum inhibin B are useful markers for evaluation of the presence of sperm in patients with nonobstructive azoospermia. Inhibin B has a high specificity when combined with serum FSH and their measurements can be helpful in all patients with nonobstructive azoospermia before decision making for sperm retrieval

Evaluation of sensitivity and specificity of urine surviving as a new molecular marker in diagnosis of bladder tumors

Bladder cancer is one of the most common forms of cancers in the world. The current gold standards for its diagnosis are cystoscopy and urine cytology. Cystoscopy, a naked eye assessment of the bladder, is invasive, uncomfortable and costly with a great deal of personal variability in its results; while urine cytology has high specificity but low sensitivity, particularly for low-grade lesions. Therefore, there is a need for a molecular tumor marker assay capable of detecting bladder cancer with high sensitivity and specificity. A growing list of tumor markers in urine has been introduced so far, but neither of them has been able to replace the current diagnostic methods. Survivin, an inhibitor of apoptosis [IAP] capable of regulating both cell proliferation and apoptosis, has been recently defined as a universal tumor antigen and as the fourth most significant transcript expressed in human tumors. It has been reported to have 100% sensitivity and 95% specificity for detection of bladder cancer. In the present study, the sensitivity and specificity of survivin as a tumor marker in detecting new and recurrent cases of bladder cancer has been evaluated by nested RT-PCR technique. Our results revealed that survivin could be detected in most patients [11/13, sensitivity=0.84] as well as some healthy volunteers with no obvious sign of bladder cancer [6/13, specificity=0.53]. Also, in this work, for the first time, the presence of two alternatively spliced variants of survivin [survivin-2B and survivin-DEx3] urine is being reported. Interestingly, the presence of survivin-DEx3 was better correlated with malignant lesions of bladder compared to the survivin expression [sensitivity=0.84, specificity=0.92]