Case report: HIV negative isolated scrotal Kaposi's sarcoma.

INTRODUCTION: Kaposi's sarcoma (KS) is a rare angioproliferative disorder of the vascular endothelium. The development of KS requires Human Herpes Virus 8 (HHV-8) infection. An associated HIV infection is usually seen. Isolated scrotal KS has rarely been reported. In this article, we present a case of KS that primarily involved the scrotum in a HIV negative patient. PRESENTATION OF CASE: A 71-year old male patient admitted to the outpatient department due to nodular lesions on the scrotum. The patient declared that these lesions were present for nearly 5 years. Past medical history revealed that he underwent left thoracotomy and upper lobectomy in 2006 for adenosquamous lung carcinoma. Then, he received a single cycle of adjuvant chemotherapy consisted of docetaxel and cisplatin. Physical examination revealed 3 black small nodules on the scrotum. The anti-HIV test was negative. All scrotal lesions were surgically excised. The pathological investigation revealed KS of the lymphangioma-like type. DISCUSSION: The pathogenesis of KS has still not been clearly elucidated. However, it is known that all forms of KS are associated with HHV-8 infections. A defect in immune system was almost always necessary. Therefore, KS is usually associated with HIV infection. KS of the penis has been reported in HIV negative patients. Very few cases of scrotal KS have been presented. In a recent review, only 1 patient had scrotal KS out of 32 cases with HIV negative KS. In our case, the patient received a cycle of chemotherapy that might affect his immune system. The lymphangioma-like type is a common morphological sub-type. While lymph edemas are commonly observed in this sub-type, no edema in the lymphs was present in our case. CONCLUSION: Classical KS is generally observed in the lower extremities, it can rarely affect scrotal skin as isolated lesions. Therefore, a careful physical examination should also include scrotum for these patients.

A rare consequence of blunt abdominal trauma: bilateral renal infarction.

A 28-year-old man was admitted to the emergency department with lumbar pain owing to a motorbike accident. On clinical examination, abdominal tenderness, pelvic and left cruris pains were present. Erythrocytes, leucocytes and protein was found to be positive in urine analysis. Abdominal computed tomography with intravenous contrast solution showed contrast enhancement in 80% of right kidney, and 30% of left kidney; some intra-abdominal free fluid was also seen. Conservative management was planned for bilateral renal infarction. Urine output was 1.1 L per day. He was discharged on the seventh day of the hospital stay. The patient had not got any problems on the sixth month follow-up. Urine output is a very important parameter for multiple trauma patients. Any decrease in urine output may not be seen inspite of the presence of bilateral renal damage as in the case of the patient, and this situation does not allow ruling out renal injury completely. Hence, emergency physician should still be careful about the risk of renal injury.

Case report: Large adrenal ganglioneuroma.

INTRODUCTION: Ganglioneuromas are localized tumors derived from neural crest tissues. Characteristically, they originate in the posterior mediastinum. Pure adrenal gangliomas are extremely rare. PRESENTATION OF CASE: A left adrenal mass with the size of 68mm×50mm×86mm on magnetic resonance imaging was documented in a 53-year-old female patient. Endocrine tests revealed a non-functioning adrenal mass. The actual size of the mass was macroscopically measured to be 16cm×8.5cm×6cm after the surgery. Histopathological examination indicated ganglioneuroma. DISCUSSION: Most adrenal ganglioneuromas can incorrectly be diagnosed as other adrenal tumors, since they are rare neurogenic benign tumors with no specific imaging properties. They have a slow growth pattern and usually asymptomatic. Our case represents a huge adrenal ganglioneuroma in a female patient with nondiagnostic flank pain. Radiological imaging showed a large adrenal mass with no differentiation from other adrenal tumors. Endocrine evaluation should be performed for such adrenal masses. Since our case had a relatively large size, open surgery was preferred. Pathology revealed the definitive diagnosis. CONCLUSION: This case suggests that ganglioneuromas can wrongly be diagnosed as other adrenal tumors. It is significant that a proper differential diagnosis should be performed by using hormonal and imaging techniques. Nevertheless, pathological examination is usually required for definitive diagnosis.

Role of ultrasonography with color-Doppler in the emergency diagnosis of acute penile fracture: a case report.

Penile fracture is the rupture of tunica albuginea, typically resulting from blunt trauma, intercourse, or penile manipulation. Diagnosis is made clinically. Ultrasound is not used frequently in diagnosis of penile fracture but it provides a fast, non-invasive alternative to more often used MRI and cavernography. We aimed to present diagnostic ultrasound and color Doppler images of a patient with acute penile fracture in conjunction with literature.

Leiomyoma of the urinary bladder in asymptomatic women.

Most bladder tumors are derived from the urothelium. Benign mesenchymal tumors are rare. Leiomyomas account for less than 0.43% of all bladder tumors. Genitourinary leiomyomata may arise in any anatomic structure containing smooth muscle. They have been reported to involve single or multiple organs. Since they may also mimic malignant lesions, they should always be considered in the differential diagnosis of any pelvic mass, with a possibility of being asymptomatic and discovered incidentally by radiographic imaging. We, herein, report a case illustrating clinical and pathological features in particular immunohistochemistry, and discuss its etiology and differential diagnosis.

Free prostate-specific antigen is a better tool than total prostate-specific antigen at predicting prostate volume in patients with lower urinary tract symptoms.

OBJECTIVE: To evaluate the relationships among age, total prostate-specific antigen level (PSA), free PSA level, and prostate volume. METHODS: A total of 656 patients complaining of lower urinary tract symptoms who attended our urology outpatient department were enrolled. The standard assessment for lower urinary tract symptoms was applied, including serum total and free PSA determinations and transabdominal prostate volume measurement. Patients with a history of transurethral surgery, prostate cancer, and conditions other than benign prostatic hyperplasia that could affect the PSA levels were excluded. A linear regression model was used to estimate the prostate volume. Receiver operating characteristic curves were constructed to evaluate the ability of serum PSA and free PSA to estimate threshold prostate volumes and to select the optimal serum PSA and free PSA cutoff values. RESULTS: The linear regression model included age (P < .000), total PSA (P < .006), and free PSA (P < .000) as independent predictors of prostate volume. Consequently, an easy to use equation was developed to estimate the prostate volume. Free PSA performed better than total PSA at predicting the prostate volume. An area under the curve of 0.668 ± 0.022 at predicting prostate volume >40 cm(3) with total PSA increased to 0.721 ± 0.021 with free PSA. Moreover, free PSA with a cutpoint of 0.495 ng/mL correctly estimated a prostate volume of >40 and <40 cm(3) in 71% and 66% of the cases, respectively. CONCLUSION: The prostate volume can be estimated using easily obtained serum PSA levels, and free PSA had a better performance.

Myxoma of the renal sinus: case report and literature review.

Myxoma is a rare mesenchymal tumor and it is mainly seen in heart and skin. Renal myxoma is extremely rare. To date, eleven cases of kidney myxomas have been reported in the literature. One of them is myxoma of the renal sinus. Our case was an 82-year-old man admitted to our hospital symptoms related to the urinary tract obstruction. Abdominal computerized tomography revealed a solid, hypodense mass 9 cm in diameter infiltrating the renal parenchyma in the renal pelvis. The patient underwent nephrectomy. The resected kidney contained gelatinous tumor with indistinct borders. The tumor was composed of slender, bland, spindle-shaped cells with large amounts of mucoid material. Tumor cells were positively stained with vimentin, focally stained positive for smooth muscle actin and had negative reactivity for S-100 protein, epithelial membrane antigen and pancytokeratin. Herein we report the second case of renal myxoma arising from the renal sinus.

Randomized comparison of efficacy of paracetamol, lornoxicam, and tramadol representing three different groups of analgesics for pain control in extracorporeal shockwave lithotripsy.

PURPOSE: Extracorporeal shockwave lithotripsy (SWL) is the mainstay treatment modality for upper urinary tract stones. However, it is a relatively painful procedure and so an efficient analgesia is required for better clinical success. The ideal method of anesthesia has not been standardized. The objective of this randomized study, for the first time in the literature, was to compare the efficacy of three common analgesics, each belonging to a different group, in pain control during SWL. PATIENTS AND METHODS: In this randomized controlled study, 90 patients with upper urinary tract stones undergoing SWL were randomly divided into three groups. Group I (n = 30) received 1 g of paracetamol, group II (n = 30) received 8 mg of lornoxicam, and group III (n = 30) had 1 mg/kg of tramadol. No premedication was applied in all groups. Pain scores by visual analog scale (VAS), blood pressure, heart rate, respiratory rate, and peripheral oxygen saturation were noted before procedure and at 1 minute and every 5 minutes during the SWL. Supplementary analgesic consumption was recorded. Moreover, all adverse effects and both patient and urologist satisfaction were documented. RESULTS: Demographic parameters of the three groups were similar. All monitored parameters were also not different among the groups. The mean VAS scores at all measured times during SWL were below 4 except for two occasions, indicating a relatively efficient overall pain control provided by these three medications. Moreover, the mean VAS scores were similar among these three groups at all measured times during SWL except for those at 5 and 20 minutes at which groups III and II showed lesser pain control, respectively. No difference was observed in the amount of supplementary analgesia, which was required at higher voltages in a majority of patients. There was no significant difference in side effects. CONCLUSION: This study suggests that paracetamol, lornoxicam, and tramadol can be safely and efficiently preferred in pain control during SWL.

The effect of non-dipper pattern of hypertension on erectile dysfunction.

BACKGROUND: The purpose of this study was to evaluate the relationship between erectile dysfunction (ED) and non-dipper pattern in hypertensive patients. METHODS: A total of 750 consecutive patients with essential hypertension, who had been evaluated with ambulatory BP monitoring, were screened for this study. One hundred and thirty-two male patients (age range 28-54 years) who had fulfilled the inclusion and exclusion criteria were included in the final analysis. Dipper and non-dipper patterns were detected and sexual function was assessed by the self-administered questionnaire of the International Index of Erectile Function (IIEF). RESULTS: There was no significant difference between the two groups regarding the number of medications taken and the proportion of each class of antihypertensive medications. Mean age, body mass index, lipid profiles, rate of smoking were similar between the two groups. IIEF score was significantly higher in non-dippers than dippers (p= 0.009). Non-dipping was also found to be an independent determinant for ED. CONCLUSION: The result of the present study further suggests that non-dipping is a risk indicator for early deterioration of erectile function in hypertensive patients.

Single vs. double dartos interposition flaps in preventing urethrocutaneous fistula after tubularized incised plate urethroplasty in primary distal hypospadias: a prospective randomized study.

INTRODUCTION: This prospective study was designed to compare symmetrical overlapping double flaps with a single dartos flap in regard to fistula formation as an adjunct to tubularized incised plate urethroplasty (TIPU). PATIENTS AND METHODS: 77 consecutive children with primary coronal or subcoronal hypospadias were randomized into 2 groups. A single layer dartos flap was used to cover the anastomotic site in the first group (37 patients). A wider dorsal dartos flap bisectioned in the midline was utilized in the second group of 40 patients. The complication rates were compared. RESULTS: There was no difference between the 2 groups in terms of age, and meatal location. Postoperative median follow-up was 34 months. Urethrocutaneous fistula occurred in 3 patients (8.1%) of the monolayer group. No fistula developed in the second group with double flaps. CONCLUSIONS: The current study proposes that the use of double dorsal flaps, although statistically not significant, better prevents fistula formation compared to monolayer dartos flaps following TIPU operation.

Prospective evaluation of the efficacy of antibiotic prophylaxis before cystoscopy.

BACKGROUND: The aim of this study was to prospectively compare single-dose intravenous antibiotic prophylaxis vs. no prophylaxis before minor cystoscopic procedures, including punch biopsy and transurethral resection (TUR) of small bladder tumors. MATERIALS AND METHODS: A total of 200 patients with a mean age of 47.3 years old (range: 19-84 years old) with initial negative urine cultures were recruited. All patients underwent a diagnostic cystoscopy. Patients were then randomized into 2 groups: One group that did not receive antibiotics (100 patients) and the other group that received antibiotic treatment (100 patients with a single intravenous dose of cefoperazone). All patients had urine analysis and urine cultures on the second day after the operation. Additionally, clinical parameters including fever and dysuria were recorded. In 15% of the patients, incidental additional interventions such as punch biopsy or TUR of a small bladder tumor that were similarly distributed in both groups were performed. RESULTS: In 1 patient from the antibiotic group and 2 patients from the no prophylaxis group, the urine cultures after cystoscopy were positive. No statistically significant difference was observed between these groups based on the microbiological and clinical parameters. CONCLUSION: The current study provides evidence that no antibiotic prophylaxis is required before diagnostic cystoscopy in patients without bacteriuria. But, the absolute risk of infection was small, suggesting that a much larger study is required.

Prospective assessment of the efficacy of single dose versus traditional 3-day antimicrobial prophylaxis in 12-core transrectal prostate biopsy.

OBJECTIVES: To prospectively evaluate the efficacy of single dose antibiotic prophylaxis in 12-core transrectal ultrasonography (TRUS) guided prostate biopsy. METHODS: A total of 400 patients who underwent prostate biopsy with TRUS guidance were included. The patients were prospectively randomized in three groups regarding antibiotic prophylaxis. The first group (139 patients) received a single gram of intramuscular ceftriaxone, while the second group (131 patients) had a 3-day course of oral ciprofloxacin. The third group (130 patients) had single oral 500 mg of ciprofloxacin. All patients had urine cultures prior to biopsy and on the second day after biopsy. RESULTS: The study groups were compared in terms of the results of urine cultures and clinical parameters. Overall, only seven patients (1.8% of the cases) had positive urine cultures with no difference between these three groups. Additionally, no significant difference was observed regarding morbidity rates in all groups. Only eight patients (2%) developed major complications requiring hospitalization. There was no increase in the rate of infectious complications when the biopsy core numbers were increased up to 12. CONCLUSIONS: The current study suggests that a single oral dose of antimicrobial prophylaxis is reasonable in TRUS prostate biopsy even in the case of 12-core sampling.

Combined periprostatic and intraprostatic local anesthesia for prostate biopsy: a double-blind, placebo controlled, randomized trial.

PURPOSE: Transrectal ultrasonography guided prostate biopsy is the principle procedure in the histological diagnosis of prostate cancer. Recently a trend toward increasing the number of cores has been popularized. This practice further increases the need for a proper anesthetic application. However, there is no consensus on a standard local anesthetic strategy, while groups at most institutions currently prefer periprostatic anesthesia. We prospectively evaluated the contribution of intraprostatic anesthesia for transrectal prostate biopsies even when the sampling number was doubled to 12 cores. MATERIALS AND METHODS: A total of 200 patients who underwent prostate biopsy with transrectal ultrasound guidance were included. The 2 groups received the usual periprostatic anesthesia. Consequently patients were prospectively randomized into 2 groups. Group 1 received additional intraprostatic lidocaine injection, while group 2 received the same amount of injection of 0.9% NaCl. The efficiency of applied local anesthesia was assessed by a visual analog pain scale. RESULTS: The study groups were comparable regarding patient age, prostate size and cancer rate. Pain scores revealed that the combination of intraprostatic and periprostatic local anesthesia provided significantly better pain control than periprostatic infiltration alone. No difference was observed regarding the morbidity rate in the 2 groups. CONCLUSIONS: The current study suggested that adding intraprostatic local anesthesia provides a significantly efficient strategy during transrectal ultrasound prostate biopsy, even in cases of 12-core sampling. Subsequent trials are needed to establish a standard analgesia policy for prostate biopsy.

Short-term subjective efficacy of doxazosin in predicting probability of prostatectomy in the management of benign prostatic hyperplasia in patients with severe symptoms.

BACKGROUND: The severity of symptoms still constitutes the major indication for transurethral prostatectomy, despite the extensive utilization of medical treatments. The aim of the study presented here was to investigate the impact of doxazosin on symptoms in relation to the probability of consequent surgery in severely symptomatic patients. METHODS: Patients with an International Prostate Symptom Score (IPSS) between 18 and 35 were included in the study. The patients received 4 mg/day doxazosin, and subjective efficacy was assessed by IPSS at the first and third months. In addition, the patients were classified at the third month according to a single question regarding satisfaction with medical treatment in terms of symptom relief as 'ineffective, no change, and effective'. RESULTS: A total of 178 patients constituted the study group. Mean total symptom scores were 24, 19 and 17 at baseline, first and third months, respectively (P < 0.05). According to results of the questionnaire, 23% of the patients claimed the treatment was ineffective, and subsequently, the majority of this group (93%) underwent prostatectomy in a year. In addition, 33% of the patients reported no change in their symptoms, while 44% reported that the medication was effective. However, after 1 year, 59% and 15% of these cases underwent surgical treatment, respectively. The probability of surgery in the 'ineffective' group was significantly higher compared to the remaining groups (P < 0.05). CONCLUSION: The majority of patients with severe symptoms who were not satisfied with the medication at the 3rd month underwent surgery. This observation may provide a predictor for subsequent probability of prostatectomy. Therefore, reassessment of patients would be a cost-effective approach for the treatment of BPH in severely symptomatic patients.