Correlation of angiogenesis with grade and recurrence in superficial and invasive urinary bladder transitional cell carcinoma

The aim of this study was to correlate the level of MVD with the grade, recurrence and prognosis of the tumor in an attempt to understand the events controlling angiogenesis so as to evaluate the use of anti-angiogenic therapy in the treatment of urinary bladder tumours. The material of this study consisted of 52 selected PT1 and PT2 cases of transitional cell carcinoma [TCC] obtained by transurethral resection biopsy. Cases were collected from El-Sahel teaching hospital during the period from Januray 2006 to January 2009. Age, sex and other clinical data of the patients were taken from the clinical sheets. Each paraffin block was re-cut by microtome at five Um thickness,stained with haemtoxylin and eosin for routine histopathological examination and grading of the tumour and assessment of muscle invasion. Immunohistochemical staining of the endothelial cells was done by monoclonal antibody against CD31 antigen. 32 cases were superficial TCC while 20 were invasiveTCC. Superficial TCC cases were treated starting 2 weeks after TURBT by intravesical Bacillus Calmete and Guerin [BCG] in 28 out of the 32 cases of superficial TCC. All cases went under follow up for a period of 24 months,however,only 30 cases showed regular follow up. Six cases showed recurrence of the tumour after a follow-up period ranging from 20 - 24 months.Invasive TCC cases were treated by radical cystectomy and urinary diversion with follow up every 6 months, however, pelvic nodules were seen in 4 cases after 2 years. Histopathological evaluation was done for grade of tumour and the extent of invasion,counting the neovascular density after immunostaining by monoclonal antibody against CD31 antigen to determine the MVD. The age of Jhe patients in all studied cases ranged from 30 to 79 years with 41 males and 11 females.Of the 52 studied cases,32 [61.5%] were stage pTl, while 20 cases [38.5%] were stage pT2. Grades 1,2,3 were respectively found in 18,30 and 4cases. All grade 1 cases were stage pTl [100%], while grade 2 cases showed 14 cases [46.6%] stage pTl and 16 cases [53.4%] stage pT2. All grade 3 cases were stage pT2 [100%]. Six cases showed recurrence after treatment; 2 were grade 1 and 4 were grade 2. All recurrent cases were stage pTl,2of them showed bilharzial infestation and were grade 2.MVD was counted per high power field [HPF] at magnification x400The median MVD in grade 1 cases was 37 vessels/HPF In grade 2 cases it was 53.5 vessels/HPF ,some of which were superficial tumours ,while others were invasive .In grade 3 cases it was 116.5 vessels/HPF .According to the stages of the studied cases of TCC, MVD ranges in stage pTl,pT2 and pT3 cases were 19-88,39-148 and 116.5vessels/HPF.The median MVD of stage pTl grade 1 cases was 37 vessels/HPF, median MVD in stage pTl grade 2 cases was 53.5 vessels/ HPF, while stage pT2 grade 2 cases was 68.5 vessels/HPF. As for grade 3, all cases were stage pT2, the median MVD was 116.5 vessels/HPF. The median MVD is increasing as the grade increases [P <0 .001]. The median MVD for grade 1 cases showing recurrence was 46, and grade 2 cases showing recurrence was 53.5, while grade 1 cases without recurrence was 36 and grade 2 was 57. Out of the 52 cases,there were 6 cases of recurrence;3 cases were within a MVD range 0-50,another 3 cases were in the MVD range 51-100 while there were no cases of recurrence found in the MVD range over l00.The remaining 46 cases without recurrence were 22 cases in a MVD range 0-50, 21 cases in the MVD range 51-100 and 3 cases in the MVD range above 100. Tumor grade and MVD are valuable to predict prognosis in superficial TCC while quantification of angiogenesis does not help in the prediction of the recurrence in superficial TCC. Moreover,a significant correlation was found between MVD and tumour grade for stages PTl and PT2.Thus,MVD correlation with tumour grade can help in planning for anti-angiogenesis strategies. We recommend to further study the effect of anti-angiogenic treatment as a curative modality together with the routine therapeutic regimen for grades 2 and 3

Tamsulosin in the expulsion of distal ureteral calculi

The purpose of the work is to evaluate the effectiveness of Tamsulosin for patients with distal ureteral calculi with respect to its effect on stone expulsion and time to stone expulsion. This prospective randomized controlled study included a total of 70 patients with distal ureteral calculi, who presented to the outpatient clinic of El-Sahel Teaching Hospital between March 2009 and May 2011. Their age range was between 19-65 years in the Tamsulosin group and 20 - 68 years in the control group. Selection criteria included a ureteral calculus located in the distal ureter [Juxtavesical or Intramural], single, size less than 1 cm with no or minimal ipsilateral hydronephrosis and normal contralateral kidney. Patients with solitary kidney, renal insufficiency and high grade obstruction, were excluded. All patients were initially assessed by appropriate physical examination followed by plain UT and I.V.U to locate site and size of the calculus. Urinary tract ultrasound was done to exclude solitary kidney or high grade obstruction and for follow up of patients during the study. Renal functions in the form of blood urea and serum creatinine, were done. Patients with ipsilateral ureteral surgical manipulation, serious medical conditions,pregnancy and those receiving calcium channel blockers or corticosteroids, were excluded. A written informed consent was signed by all patients included in the study. The patients were randomlly categorized into 2 groups, each group consists of 35 patients: Group I [Control Group] included 35 patients who were given oral sodium diclofenac 50 mg twice/day for 10 days. Group II [Tamsulosin group] included 35 patients, who were given Tamsulosin 0.4 mg once/day for 28 days or until stone expulsion [whoever is nearer] in addition to oral sodium diclofenac 50 mg twice/day for 10 days. All patients in both groups were instructed to drink a minimum of 2 liters of water every day and for follow up including number of pain episodes, serum creatinine, KUB and urinary ultrasound. The primary endpoint of the study was the determination of the stone passage time, episodes of renal colic, need for analgesia, drug adverse effects, stone size and distal ureteral stone site whether Juxtavesical or Intramural. Sex distribution was 24 males and 11 females in group 1 [control group] compared to 22 males and 13 females in group 2 [Tamsulosin group]. Age ranges were 20 - 68 years [mean 41.2 +/- 10.55 years] and 19 - 65 years [mean 39.3 +/- 10.67years] for groups 1 and 2 respectively. Stone sizes ranged bet ween 4-10 mm in both groups [mean of 5.3 +/- 1.24 and 5.8 +/- 1.58 mm in groups 1 and 2 respectively].In both groups, no significant statistical differences,were noted as regards patients age,sex distribution or laterality [P= 0.453, P= 0.615 and P= 0.461 respectively]. The overall stone expulsion rate was 60% and 94.3% in groups 1 and 2 respectively. For stones < 6 mm, expulsion rates were 76.2% and 95.7% in groups 1 and 2 respectively. For stones 7-10 mm, the expulsion rates were 35.7% and 91.7% in groups 1 and 2 respectively.The improvements percentages in stone expulsion attained were 37.5% and 120% for stones < 6mm and 7-10 mm respectively. Episodes of renal colic were reported in 26 patients [74.3%] in the control group versus 8 patients [22.9%] in the Tamsulosin group [P< 0.001]. Tamsulosin is an effective and safe therapy for uncomplicated distal ureteral calculi as it improves stone passage rates,shortens passage time,decreases analgesia requirements and decreases the need for intervention. Moreover, these results allowed home management without hospitalization and allowed the patient to almost regularly perform everyday activities. Tamsulosin augments stone passage rates for all stone sizes especially for larger stones than smaller ones.Moreover,Tamsulosin shortens the time of stone passage especially for smaller stones than larger ones

Experience of El-Sahal teaching hospital for repair of urethrocutaneous fistula after hypospadias repair

Urethrocutaneous fistula [UCF] after hypospadias repair remains a frustrating problem for pediatric urulogist, furthermore, with the improvement of suture materials and surgical techniques, such complications are increasingly unacceptable. During the last decade many principles of an ideal repairing technique have been clarified. To evaluate the outcome of urethrocutaneous fistula repair after hypospadias and determine the role of the fistula characteristics on the outcome of repair. Sixty patients with a mean age of 7.6 years, range [2.5 to 20 years], underwent repair of urethrocutaneous fistula after hypospadias surgery at Al-Sahel teaching hospital, Cairo, Egypt from May 2007 till May 2010. The fistulae were small [less than 2mm] in 27 cases and large [more than 2mm] in 33 cases. Fistulas were coronal in 10, distal penile in 20, mid penile in 15 and proximal penile in 15 cases. The interval between primary hypospadias repair and first attempt of fistula repair was 6 to 9 months. Small fistula repair by multiple layer simple closure, large coronal fistula changed into complete hypospadias and re do TIP with or without incised plate and covered by Dartos flap. Small coronal fistula repaired by trapped door flap and large fistula repaired by using rotational skin flap, Dartos fascia flap or tunica vaginalis flap used for recurrent cases. The overall success rate of repair was 75% [45 of 60 cases]. The relationship between the success of repair and the site, size and number of fistulas I. No statistically significant relation was fond between the success rate of the operation and these parameters [p>0.05]. The recurrent fistula occur in 25% [15 from 60 cases], The success rate [100%] was 6 from 6 with the use of tunica vaginalis flap and 5 from 9 [55.5%] with the use of the Dartos fascia flap, which is statistically significant [p<0.05]. The recurrent cases after Dartos fascia flap treated by tunica vaginalis flap with success rate of 100%

Comparative study of drugs used for treating primary nocturnal enuresis

To study the effect of different drugs used in the treatment of primary nocturnal enuresis. This prospective study was conducted on 120 patients between 7 and 16 years. All patients had nocturnal enuresis without any previous treatment taken before. After proper history taking and careful clinical examination, investigations as urine analysis, abdominopelvic US, plain UT and voiding diary were asked for. These patients were randomly divided into 3 groups, each group included 40 patients. The first group was given desmopressin, second group was given oxybutynin and the third group was given imiprami ne. Behavioral therapy was advised for all groups.Follow up was done for 6 months and 83 patients maintained this follow up. Failed treated patients [37] were subjected to urodynamic evaluation to detect bladder instability and evaluation of functional bladder capacity for age, however, 22 only maintained follow up. Desmopressin had the best cure rate [44%] compared to oxybutynin and imipramine, that had a cure rate of 27% and 33.3% respectively. The cure rate of desmopressin was dose related with no reported side effects. Decreased functional bladder capacity and bladder instability were detected in 20 [90%] and 9[40%] patients respectively Out of the 22 patients who were nonresponding to single drug therapy. Combined treatment of desmopressin and oxybutynin gives a cure rate of 40.8% in resistant cases. Thirteen patients refused urodynamics because of invasive nature of procedure. Relapse rate was the highest with imipramine [64.7%] and lowest with desmopressin [37%]. It is recommended that behavioral therapy is advised in all cases in addition to pharmacotherapy: Using desmopressin, it gave the highest cure rate [44%] in short time with minimal relapse while combined desmopressin and oxybutynin were effective in patients resistant to single drug use with a cure rate of 41% approximately. Urodynamics are of value only in resistant cases. Although imipramine is of low cost, yet its highest relapse rate limits its use

Correlation between sonographic and clinically palpable varicoceles with their effects on semen quality and testicular size

To evaluate the effects of different grades of palpable varicoceles, on the testicular volume and semen quality in men with infertility. This prospective study included 90 infertile patients presenting to Urology Department El-Sahel Teaching Hospital from May 2006 to May 2009. Their ages ranged between 22-35 years with a mean of 25.7 +/- 3.15 years. After excluding female factor and taking informed consent, evaluation started and included complete history, clinical and sonographic examination, and semen analysis. Scrotal colour Doppler ultrasound using 6 - 12 MHz transducer, was done to detect veins calibers, testicular dimensions on the ipsilateral and contralateral sides of varicocele, presence or absence of venous reflux and its degree. Postoperatively, scrotal ultrasound and semen analysis were done, 6 - 9 months after varicocelectomy. There were 42 [46.6%], 30 [33.3%] and 18 [20%] patients with veins calibers 6 - 9 mm, 5 - 6 mm and 4mm in grades III, II, I varicocele respectively. Patients with grades III and II varicoceles, had a significant reduction of testicular volume on the affected side in addition to impaired semen quality as regards sperm motility and concentration. Patients with grade I varicocele showed no significant change of testicular volume in addition to normal semen analysis. Varicocelectomy improved sperm motility and concentration in grades Ill, II varicocele patients. Venous reflux was present in all patients with grades III and II varicocele but in none of grade I varicocele patients. Scrotal colour Doppler Ultrasound is highly valuable in detecting varicoceles, testicular volumes, venous reflux and determining its degree. Varicocele exerts a deleterious effect on the ipsilateral testicular volume, sperm motility and concentration so careful evaluation and early surgical intervention is recommended in grades III and II varicocele patients to improve sperm motility and concentration. Varicocelectomy improved sperm motility and concentration in grades III, II varicocele patients but the reduction of the ipsilateral testicular volume [caused by varicocele], did not significantly change 6 - 9 months postoperatively

Elevated serum PSA and abnormal prostatic echo pattern. Is prostate cancer a must?

To evaluate the distribution of malignant and non-malignant conditions in patients undergoing prostate needle biopsies and correlate the presence of malignancy to their sonographic pattern and PSA level. Over 3 years period from June 2006 till June 2009. 152 patients were included prospectively in the study. Their ages ranged between 57 years to 81 years with a mean age of 68.94 years +/- 8.41 years. Inclusion criteria for suspecting prostate cancer include abnormal digital rectal examination, increased total serum PSA level or abnormal suspicious sonographic echopattern. The prostate was evaluated with a high resolution 5-9 MHZ endorectal probe and TRUS guided core biopsies were taken. A total of 12 cores were sampled for every patient plus any suspicious lesion seen on TRUS examination. The presence of prostate cancer was correlated with the echo pattern of the biopsied areas and the PSA level. Statistical analysis was done. In our 152 cases, the serum PSA range was between 1.5 and 100 ng/ml with a median of 27.2 ng/ml. Prostate cancer was detected in 12 cases [28.57%] out of 42 cases with hypoechoic lesions while it was detected in 2 cases out of 16 cases with isoechoic lesions [37.53]. The difference between both groups was statistically significant [X2 = 16.48. P value < 0.001]. The pathological results of TRUS guided biopsies [n=152] showed adenocarcinoma in 18 cases [11.8%], benign prostatic hyperplasia [BPH] in 103 cases [67.8%]. BPH and prostatitis in 27 cases [17.8%]. BPH and high grade PIN in 4 cases [2.6%]. Any suspicious echo pattern lesion should undergo 12 core biopsy. The majority of pathology on biopsy in patients with suspected prostate cancer is nonmalignant with BPH being the most common [67%] followed by BPH and prostatitis [17.8%]. The higher the PSA above 10 ng/ml the higher the probability of prostate cancer

Renal Cell Carcinoma: a clinico-pathological characteristics and evaluation of twenty four patients

To evaluate survival of patients with renal cell carcinoma postoperatively and the age of discovery. 24 patients were retrospectively included in our study during the last 3 years [2005-2007]. The full history including age, sex, geographic distribution, special habits, exposure to carcinogens and renal disease was assessed for all cases. Clinical examination was performed followed by laboratory and radiological evaluations and CT scan. Midline transperitoneal incision was done in 16 cases, thoraco-abdominal approach in 2 cases because of large upper pole renal mass and a classic fl ank lumber incision with rib resection in 4 cases. Radical nephrectomy was done in all cases except enuclation of a small renal mass less than 4cm in diameter was done for one case. All cases were localized at the time of presentation. All cases showed unilateral renal mass except one patient who had an asynchronous bilateral renal mass. The mean age was 48 years with 10 patients below 45 years. The male to female ratio was 2:1. laterality was equal between right and left sides while the lower pole was affected in 20 cases [83.4%] the upper pole in 4 other cases [16.6%]. The presenting symptoms were dull ache in 8 cases [33.3%] with presentation of gross haematuria in 6 cases [25%] and having a palpable fl ank mass in 6 of them [25%]. However two cases were presenting with paraneoplastic syndrome. Laboratory investigations done were normal apart from the 2 cases of paraneoplastic syndrome.The follow up, done every 3 month in the 1st year and every 6 months in the 2nd year where, 16 cases [66.7%] showed good prognosis for 2 years disease free survival. The other 8 cases showed local recurrence and one of them developed neooccurrence in the contra lateral side 6 months after surgery and died one year later.The Histopathological diagnosis was renal cell carcinoma: 18 conventional RCC, 4 cases were papillary renal cell carcinoma and 2 cases were chromophobe RCC. Renal cell carcinoma occurred in young age group in 41.9% of our patients [below 45 years] but with a good prognosis. Follow up is needed for the new occurrence of renal cell carcinoma in the contra lateral side

use of transverse rotational pedicle flap for the treatment of midpenile and proximal hypospadias in circumcised patients

To evaluate the use of transverse rotational pedicle flap for the treatment of midpenile and proximal hypospadias in circumcised patients. The transverse penile rotational pedicled flap, was performed on 20 circumcised patients with midpenile and proximal hypospadias with chordae. Of the 20 circumcised boys, 10 had midpenile and 10 had penoscrotal hypospadias, after excision of the chordae. Mean age of patients is 4.7 years, mean follow up period is 1 year. Cosmetic results were good. Complications were urethrocutaneous fistula in 3 patients [15%] and meatal stenosis in 2 patients [10%]. The modified technique as shown in our procedure reduces the fistula rate. Thus, we recommend the use of transverse island rotational penile pedicled flaps for the treatment of midpenile and proximal hypospadias with chordae in circumcise patients

Horton divine technique in the surgical management of Peyronie's disease

Peyronie's disease [plastic induration of the penis] is a well-recognized clinical problem affecting middle age and older men. Patients usually present with complaints of painful erection, curvature of the penis and poor erection distal to the involved area. Examination of the penile shaft reveals a palpable dense, fibrous plaque involving the tunica albuginea

Objective: Horton Devine procedure for the surgical management of Peyronie's disease had gained popularity. This study was done to evaluate this procedure in correcting penile curvature

Patients and Methods: ten patients having Peyronie's disease were surgically corrected using Horton Devine technique where the fibroses or calcified plaque is removed with tunica albuginea and the tunica is replaced with a free graft of dermis, brought from the lower abdomen, being rich in elastic tissue

Results: complete success with correction of penile curvature, was obtained in 8 cases [80%] as proved by duplex US to the penile blood vessels while in the remaining 2 cases, secondary infection and complete failure of the procedure

Conclusion: Horton De- vine technique is recommended in the surgical management of severe cases of Peronei's disease when the lesion is more than 1 cm as it provides good cosmetic and functional results