Development of a computer assisted gantry system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy

PURPOSE: To design a simple, cost-effective system for gaining rapid and accurate calyceal access during percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: The design consists of a low-cost, light-weight, portable mechanical gantry with a needle guiding device. Using C-arm fluoroscopy, two images of the contrast-filled renal collecting system are obtained: at 0-degrees (perpendicular to the kidney) and 20-degrees. These images are relayed to a laptop computer containing the software and graphic user interface for selecting the targeted calyx. The software provides numerical settings for the 3 axes of the gantry, which are used to position the needle guiding device. The needle is advanced through the guide to the depth calculated by the software, thus puncturing the targeted calyx. Testing of the system was performed on 2 target types: 1) radiolucent plastic tubes the approximate size of a renal calyx (5 or 10 mm in diameter, 30 mm in length); and 2) foam-occluded, contrast-filled porcine kidneys. RESULTS: Tests using target type 1 with 10 mm diameter (n = 14) and 5 mm diameter (n = 7) tubes resulted in a 100 percent targeting success rate, with a mean procedure duration of 10 minutes. Tests using target type 2 (n = 2) were both successful, with accurate puncturing of the selected renal calyx, and a mean procedure duration of 15 minutes. CONCLUSIONS: The mechanical gantry system described in this paper is low-cost, portable, light-weight, and simple to set up and operate. C-arm fluoroscopy is limited to two images, thus reducing radiation exposure significantly. Testing of the system showed an extremely high degree of accuracy in gaining precise access to a targeted renal calyx.

Retroperitoneal less donor nephrectomy

Donor nephrectomy with laparo-endoscopic single site (LESS) surgery has been reported via the transperitoneal approach. We describe a novel technique of retroperitoneal donor nephrectomy using a single surgical incision in the groin, below the abdominal skin crease or "bikini line". The LESS groin incision offers superior cosmesis, while the retroperitoneal approach has distinct advantages, such as the ability to identify the renal vessels early. The new procedure has been performed in two obese patients (body mass index 32 and 33 kg/m2, respectively). The operative times were 4 and 5 hours, warm ischemic times 135 and 315 seconds, blood loss 100 and 250 mL, and hospitalization 3 and 2 days, respectively. Retroperitoneal LESS donor nephrectomy through a single, inconspicuous groin incision is feasible and safe. Further evaluation of the technique in a larger patient cohort is indicated.

Urinary Retention in Women: Causes and Management

Urinary retention in women is uncommon and there are numerous etiological factors. Most reported studies are from Europe and North America; with few studies from developing countries. The aim of this study was to review the etiology of urinary retention in women referred to our institution; a public sector hospital serving a largely indigent population. Patients and Methods We reviewed the clinical records of all patients admitted with urinary retention to the Urology wards in our hospital during the period September 1998 to June 2007. In total there were 589 patients with urinary retention; 558 (94.7) men and 31 (5.3) women. Results The average age of the 31 women was 51.9 years (range 20 to 88 years). The underlying pathology was cervical carcinoma (4 patients); urethral carcinoma (4); transitional cell carcinoma of the bladder (3); eosinophilic cystitis (3); hematuria due to miscellaneous causes (3); antiincontinence surgery (2); cerebral palsy (2); multiple sclerosis (1 patient); diabetes mellitus (1); hypotonic detrusor (1); bladder stone (1); vaginal leiomyoma (1); cyclophosphamide cystitis (1); constipation (1); postpartum (1); blocked indwelling catheter and idiopathic (1). Renal dysfunction was present in 17 (55) of the patients. Conclusion The most common causes of urinary retention in women in this study were malignancy in 11 patients (36) and neuropathic bladder dysfunction in 5 (16). Eosinophilic cystitis; normally a rare condition; was diagnosed in 3 women (10). The high incidence of malignancy in this study differs from other reported series; in which neuropathic bladder dysfunction was the most common cause of urinary retention in women

Male circumcision and HIV/AIDS Risk - Analysis of the scientific evidence

"Objective: The aim of this review was to evaluate the scientific evidence supporting the hypothesis that male circumcision reduces the risk of HIV infection and consequently the incidence of acquired immunodeficiency syndrome (AIDS). Patients and Methods: We performed a literature search of the major databases (Medline; Embase; Cochrane Library; Biosis and Science Citation Index) for papers published in the period 1999 to 2008; using the terms ""male circumcision""; ""HIV infection"" and ""sexually transmitted infection;"" plus the combination of the search terms ""foreskin"" and ""HIV receptor"" to identify 1;048 articles. We reviewed the abstracts to identify 278 articles meriting detailed review. This detailed review considered how well individual studies were designed and carried out; using a standard checklist to provide a systematic quality rating for individual studies. This process identified a total of 80 papers; which were rated following the level of evidence and grade of recommendation scales modified from the Oxford Center for Evidence-Based Medicine. Results: Detailed analysis of the selected articles on male circumcision and HIV infection risk revealed the following. Systematic reviews; meta-analyses and modeling studies: there were 11 papers; 10 positive (favoring circumcision) and 1 negative; of the 10 positive studies; 4 were level 3 evidence; 5 were level 2 and 1 was level 1 evidence. Randomized controlled trials: there were 3 studies; all positive with level 1 evidence. Non-randomized cohort studies: there were 6 papers; 5 were positive (2 level 3 and 3 level 2 evidence) and 1 was negative (level 3 evidence). Casecontrol studies: there were 12 studies; 11 positive (all level 3) and 1 negative (level 3 evidence). Case series: there were 2 studies; both positive (level 3 evidence). Expert opinion: there were 34 studies; 30 positive (15 level 4; 15 level 3 evidence); 2 negative (both level 4) and 2 neutral (both level 4 evidence). Cost-effectiveness studies: there were 3 studies; all positive; all level 2 evidence. Pertinent biological studies: there were 3 studies; all positive; all level 4 evidence. The three large; exceptionally well-done randomized; controlled trials of adult male circumcision among consenting; healthy men in three African countries enrolled a total of 10;908 uncircumcised; HIV-negative adult men. The cumulative HIV infection risk estimated using intention-to-treat Kaplan-Meier analysis showed an overall rate ratio (RR) of 0.42 (95confidence interval (CI) 0.31-0.57); corresponding to a protective effect of 58(95CI 43-69). Meta-analysis of the ""as-treated"" results of the three trials showed even stronger protection against HIV infection in the circumcision group (summary RR 0.35; 95CI 0.24-0.54). Conclusions: Rigorous analysis of the available scientific evidence clearly supports a positive recommendation that male circumcision should be actively promoted in populations at high risk of HIV infection. There is a need to provide safe male circumcision services for high-risk populations; because this is one of very few proven HIV prevention strategies. Male circumcision provides a much-needed addition to the limited HIV prevention armamentarium. The challenges to implementation must now be faced"

Is Prostate Cancer more Common and more Aggressive in African Men?

The highest prostate cancer incidence and mortality rates in the world have been reported among Black African-American men (AAM) living in the United States of America. These rates are significantly higher for AAM compared to White (Caucasian) American men (CAM). However; prostate cancer is not the only malignancy which is more common in AAM compared to White American men or women. Although prostate cancer has the highest Black/White mortality ratio; it is not the only malignancy which has a higher mortality in AAM compared to CAM. Numerous reports have shown that AAM present with higher grade and stage tumors; higher serum PSA levels; and that they are less likely to receive definitive or curative treatment and have a worse prognosis compared with CAM. It has been suggested that prostate cancer is not only more common; but also more biologically aggressive in AAM compared with CAM. Hypotheses attempting to explain this include genetic differences; dietary factors; higher testosterone levels or increased androgen receptor activity. However; the majority of reports from the USA indicate that; when controlled for major prognostic factors; the outcome for clinically localized as well as advanced prostate cancer does not depend on race. Several studies have indicated that socio- economic factors; decreased awareness of prostate cancer and limited access or decreased utilization of health care contribute to the poorer outcomes in AAM. Earlier studies have suggested that prostate cancer is relatively rare among indigenous Black men living in Africa. However; cancer incidence data in Africa are likely to underestimate the true rates because of underdiagnosis and underreporting. The frequency distribution of cancers in African countries; as well as more recent data indicate that prostate cancer is not rare among Black men living in Africa and that the incidence is probably similar to that of White men; although not as high as that reported for Black men living outside Africa. It is well documented that African men with prostate cancer present with more advanced disease and that palliative rather than curative treatment is used in the majority of patients. There are no reliable age-adjusted prostate cancer mortality rates available for African countries. However; there is as yet no evidence that prostate cancer in Black men living inside Africa is biologically more aggressive than in other populations

Penectomy with Simultaneous Compared to deferred Bilateral Inguinal Lymph Node Dissection for Squamous Cell Carcinoma of the Penis - Evaluation of Surgical Complications

Objective: In men with advanced squamous cell carcinoma of the penis; inguinal lymph node dissection is usually deferred for 6 weeks after primary penectomy. The rationale is that the penile lesion is usually infected and immediate lymphadenectomy may lead to a higher surgical complication rate. However; some patients do not return for deferred node dissection and then present much later with incurable metastatic disease. The aim of this study was to compare the complication rates of simultaneous versus deferred bilateral inguinal lymph node dissection. Patients and Methodsn: From October 1999 to September 2006; 29 men with histologically confirmed squamous cell carcinoma of the penis were treated. Penectomy with simultaneous bilateral inguinal lymph node dissection was performed in 18 patients with locally advanced primary lesions (cT2 in 8; cT3 in 10) and palpable inguinal nodes. The complications were compared with a previous study of 34 men who underwent bilateral inguinal lymph node dissection at a mean of 72 days after penectomy at Tygerberg Hospital during the period November 1983 to April 1995. Results: Post-operative complications occurred in 11 of 18 patients (61.1): lymphocele formation in 8; lymph leak in 1; wound dehiscence and skin edge necrosis in 5; wound sepsis in 1; lymphedema of the legs in 2; scrotal edema in 1 and cellulitis in 2 patients (more than one complication occurred in some patients). In the previously reported comparison group who had undergone deferred inguinal lymph node dissection at a mean of 72 days after penectomy; complications occurred in 26 of 34 (76.5) patients: wound sepsis in 12; wound dehiscence in 7; lymphocele in 7; lymph leak in 4; wound abscess in 3; necrosis of wound edges in 2 and hematoma formation in 1. Conclusion: Penectomy with simultaneous bilateral inguinal lymph node dissection in men with squamous cell carcinoma of the penis does not lead to a higher complication rate compared with primary penectomy and deferred inguinal lymph node dissection performed at a mean of 10 weeks after the primary procedure

Antegrade scrotal sclerotherapy versus inguinal microsurgical varicocelectomy in the treatment of varicocele ­ a prospective, randomized, parallel group study

Objective To evaluate the efficacy; safety and cost-effectiveness of antegrade scrotal sclerotherapy (ASS) compared to inguinal microsurgical varicocelectomy (IMV) for the treatment of varicocele of the testis. Patients and Methods Male patients above 13 years of age with grade 2 to 3 varicocele; who were either symptomatic or presented with an abnormal semen analysis; were included in the study. The patients were randomized in a ratio of 1:1 between ASS or IMV. ASS was performed using sodium tetradecyl sulphate (Fibro-veinr) as sclerosing agent in a 1and 3mixture. IMV was performed using an inguinal approach and microsurgery loupes during spermatic cord dissection to identify and preserve the testicular artery and lymphatics. Color doppler ultrasound was used to measure testicular volume and pampiniform vein diameter before treatment and at 6 and 12 month follow-up visits. Semen analysis was obtained at the same time intervals. The efficacy parameters included serum follicle stimulating hormone (FSH); luteinizing hormone (LH); semen analysis; pregnancy rate of partners and estimation of costs involved. Results Between April 2000 and December 2003; 25 patients were included in the study. ASS was performed on 12 patients (6 bilateral procedures) and IMV on 13 patients (2 bilateral). Obliteration of the clinically detectable varicocele was achieved in 10/12 patients in the ASS and in 11/13 in the IMV group (89and 87success rate; respectively). ASS was superior to IMV with regard to costs; average theatre time; hospitalization and postoperative recovery. Both procedures had a one year pregnancy rate of 50. The mean sperm count and mean sperm morphology improved significantly from baseline to 12 months in both groups. However; there were no statistically significant differences between the two methods with regard to semen analysis improvement; testicular volume or biochemical data (LH; FSH; testosterone). Serum FSH decreased in those who had successful treatment of their varicocele; but not in those with recurrence; although the difference was not statistically significant (p=0.09); probably due to the small patient numbers. Conclusion ASS is a minimally invasive treatment for varicocele; which is feasible as an out-patient procedure in adolescents and adults. It can save costs; theatre time; hospitalization and time lost from work. ASS and IMV appear to be equally successful in terms of varicocele recurrence; pregnancy rate and semen analysis improvement