Intravesical recurrence of chromophobe renal cell carcinoma.

Metachronous metastasis from renal cell cancer (RCC) after radical surgery can occur in up to one third of patients, most commonly from clear cell RCC. Metastatectomy is a suitable management strategy in oligometastatic disease. We present the case of a 78-year-old woman who developed haematuria 2 years after left radical nephroureterectomy for a pT3aNx chromophobe RCC (ChRCC). No adjuvant therapy was given and surveillance to date was negative for metastasis. A large solitary bladder tumour which was resected, and histopathology confirmed intravesical recurrence of the ChRCC. We present this case and discuss intravesical recurrences of renal cancer.

The effect of bipolar bihemispheric tDCS on executive function and working memory abilities.

Introduction: Cognitive functioning is central to the ability to learn, problem solve, remember, and use information in a rapid and accurate manner and cognitive abilities are fundamental for communication, autonomy, and quality of life. Transcranial electric stimulation (tES) is a very promising tool shown to improve various motor and cognitive functions. When applied as a direct current stimulus (transcranial direct current stimulation; tDCS) over the dorsolateral pre-frontal cortex (DLPFC), this form of neurostimulation has mixed results regarding its ability to slow cognitive deterioration and potentially enhance cognitive functioning, requiring further investigation. This study set out to comprehensively investigate the effect that anodal and cathodal bipolar bihemispheric tDCS have on executive function and working memory abilities. Methods: 72 healthy young adults were recruited, and each participant was randomly allocated to either a control group (CON), a placebo group (SHAM) or one of two neurostimulation groups (Anodal; A-STIM and Cathodal; C-STIM). All participants undertook cognitive tests (Stroop & N Back) before and after a 30-minute stimulation/ sham/ control protocol. Results: Overall, our results add further evidence that tDCS may not be as efficacious for enhancing cognitive functioning as it has been shown to be for enhancing motor learning when applied over M1. We also provide evidence that the effect of neurostimulation on cognitive functioning may be moderated by sex, with males demonstrating a benefit from both anodal and cathodal stimulation when considering performance on simple attention trial types within the Stroop task. Discussion: Considering this finding, we propose a new avenue for tDCS research, that the potential that sex may moderate the efficacy of neurostimulation on cognitive functioning.

Long-Term Surveillance and Laparoscopic Management of Zinner Syndrome.

Zinner syndrome was first described in 1914 and represents the triad of unilateral renal agenesis and ipsilateral seminal vesicle cyst and ipsilateral ejaculatory duct obstruction. Seminal vesicle cysts are often asymptomatic but can also present with pain, haematospermia, or other lower urinary tract symptoms. Treatment strategies include observation and surgical excision. We present the laparoscopic management of an enlarged seminal vesicle cyst, consistent with Zinner syndrome, 14 years after the initial diagnosis. A 58-year-old male patient was diagnosed with a left-sided seminal vesicle cyst while undergoing assessment for renal transplant due to progressively worsening renal function in his solitary right kidney. The otherwise asymptomatic cyst enlarged from the time of initial diagnosis in 2004 (11.3 cm × 9.7 cm × 13.1 cm) to nearly double the size in 2018 (12.8 cm × 11.9 cm × 14.2 cm). This cyst size ultimately precluded renal transplant, and the patient was referred for excision. Laparoscopic excision of the cyst was performed, histopathology confirmed seminal vesicle cyst tissue, and there has been no recurrence of the cyst to date. The patient remains active on the renal transplant waitlist. Zinner syndrome is a rare syndrome, with the seminal vesicle cysts being managed by observation or surgical excision. We report the longest documented observation of a seminal vesicle cyst, culminating in a safe and successful laparoscopic excision.

Urethral cancer managed with phallus preserving surgery: a case report.

BACKGROUND: Primary urethral carcinoma (PUC) is rare and accounts for < 1% of all genito-urinary cancers. There is a male predominance of 3:1 and a peak incidence in the 7th and 8th decades. The aetiology of this cancer is similar to penile cancer, and the human papilloma virus (HPV) is thought to be an essential factor in tumorigenesis. Urethral cancer should be diagnosed and staged with a combination of tumour biopsy, MRI, and CT with treatment involving a multimodal approach. Contemporary management emphasises phallus-preserving surgery where feasible. CASE PRESENTATION: Here, we describe a case of distal urethral carcinoma, which presented as a metastatic groin mass and identifying the primary lesion proved challenging. Diagnostic flexible cystoscopy identified a tiny lesion in the navicular fossa, which was biopsied and confirmed to be a squamous cell carcinoma. The patient then underwent phallus preserving surgery, including distal urethrectomy with bilateral inguinal lymph node dissections. The final stage was pT1N1M0, and adjuvant chemotherapy was started. The distal urethrectomy involved the surgical creation of a hypospadic meatus in the midshaft of the penis. Normal voiding and sexual function were preserved. CONCLUSIONS: Urethral cancer is a rare malignancy and clinicians should bear in mind that early diagnosis of this disease can be very difficult depending on the anatomical location of the tumour. Treatment currently favours penis-preserving surgery.

Direct mechanical characterization of prostate tissue-a systematic review.

BACKGROUND: Direct mechanical characterization of tissue is the application of engineering techniques to biological tissue to ascertain stiffness or elasticity, which can change in response to disease states. A number of papers have been published on the application of these techniques to prostate tissue with a range of results reported. There is a marked variability in the results depending on testing techniques and disease state of the prostate tissue. We aimed to clarify the utility of direct mechanical characterization of prostate tissue in identifying disease states. METHODS: A systematic review of the published literature regarding direct mechanical characterization of prostate tissue was undertaking according to PRISMA guidelines. RESULTS: A variety of testing methods have been used, including compression, indentation, and tensile testing, as well as some indirect testing techniques, such as shear-wave elastography. There is strong evidence of significant stiffness differences between cancerous and non-cancerous prostate tissue, as well as correlations with prostate cancer stage. There is a correlation with increasing prostate stiffness and increasing lower urinary tract symptoms in patients with benign prostate hyperplasia. There is a wide variation in the testing methods and protocols used in the literature making direct comparison between papers difficult. Most studies utilise ex-vivo or cadaveric tissue, while none incorporate in vivo testing. CONCLUSION: Direct mechanical assessment of prostate tissue permits a better understanding of the pathological and physiological changes that are occurring within the tissue. Further work is needed to include prospective and in vivo data to aid medical device design and investigate non-surgical methods of managing prostate disease.

Regrowth-free integration of injection locked slotted laser with an electroabsorption modulator.

Optical injection locking was used to red shift an integrated semiconductor laser up to 30 nm away from the main free running lasing mode. This injection locking of the laser beyond its band edge enabled its integration with an electroabsorption modulator to produce a 2.5 Gb/s eye diagram. The electroabsorption modulator was shown to have a 3 dB bandwidth of 5.5 GHz, which was limited by the contact capacitance. This paper demonstrates that such devices could be applied in a regrowth free, monolithic coherent wavelength division multiplexing transmitter.

Health policy and the policymaking system: A case study of primary care in Ireland.

In 2001 the Irish government published a reforming policy intended to modernise and expand the delivery of primary care in Ireland. Fifteen years later, the Irish health system remains beset by problems indicative of a fragmented and underdeveloped primary care system. This case study examines the formation and implementation of the 2001 primary care policy and identifies key risk categories within the policymaking process itself that inhibited the timely achievement of policy objectives. Our methodology includes a directed content analysis of the policy formation and implementation documents and the influencing academic literature, as well as semi-structured interviews with key personnel involved in the process. We identify three broad risk categories - power, resources and capability - within the policymaking process that strongly influenced policy formation and implementation. We additionally show that the disjoint between policy formation and policy implementation was a contested issue among those involved in the policy process and provided space for these risks to critically undermine Ireland's primary care policy.

Comparative effectiveness of adrenal sparing radical nephrectomy and non-adrenal sparing radical nephrectomy in clear cell renal cell carcinoma: Observational study of survival outcomes.

INTRODUCTION: We compare the survival outcomes of patients with clear cell renal cell carcinoma (RCC) treated with adrenal sparing radical nephrectomy (ASRN) and non-adrenal sparing radical nephrectomy (NASRN). METHODS: We conducted an observational study based on a composite patient population from two university teaching hospitals who underwent RN for RCC between January 2000 and December 2012. Only patients with pathologically confirmed RCC were included. We excluded patients undergoing cytoreductive nephrectomy, with loco-regional lymph node involvement. In total, 579 patients (ASRN = 380 and NASRN = 199) met our study criteria. Patients were categorized by risk groups (all stage, early stage and locally advanced RCC). Overall survival (OS) and cancer-specific survival (CSS) were analyzed for risk groups. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards regression. RESULTS: The median follow-up was 41 months (range: 12-157). There were significant benefits in OS (ASRN 79.5% vs. NASRN 63.3%; p = 0.001) and CSS (84.3% vs. 74.9%; p = 0.001), with any differences favouring ASRN in all stage. On multivariate analysis, there was a trend towards worse OS (hazard ratio [HR] 1.759, 95% confidence interval [CI] 0.943-2.309, p = 0.089) and CSS (HR 1.797, 95% CI 0.967-3.337, p = 0.064) in patients with NASRN (although not statistically significant). Of these patients, only 11 (1.9%) had adrenal involvement. CONCLUSIONS: The inherent limitations in our study include the impracticality of conducting a prospective randomized trial in this scenario. Our observational study with a 13-year follow-up suggests ASRN leads to better survival than NASRN. ASRN should be considered the gold standard in treating patients with RCC, unless it is contraindicated.

Lymphovascular invasion: a comprehensive appraisal in colon and rectal adenocarcinoma.

BACKGROUND: Colon and rectal adenocarcinomas differ at a multitude of levels. The association between outcome and predictor in 1 group may obscure the relationship between outcome and predictor in the other. OBJECTIVE: The current study aims to evaluate the prognostic properties of lymphovascular invasion in colon and rectal adenocarcinoma separately. MATERIALS AND METHODS (DESIGN, SETTING AND PATIENTS): A comparative retrospective analysis was undertaken to determine the prognostic properties of lymphovascular invasion in colon and rectal adenocarcinomas. Patients were classified as lymphovascular invasion positive and lymphovascular invasion negative in separate colon and rectal cancer cohorts. Within cohorts, a univariate analysis was undertaken to determine the association between lymphovascular invasion positivity and local/systemic recurrence and overall/disease-free survival. Findings were evaluated by using Kaplan-Meier estimates, log-rank analysis, and a Cox proportional hazards multivariate model. MAIN OUTCOME MEASURE: The primary outcomes measured were overall and disease-free survival. RESULTS: Five hundred twenty-seven patients were included in the analysis (379 with colon cancer and 148 with rectal cancer). On univariate analysis, lymphovascular invasion positivity was associated with adverse locoregional recurrence in colon (p = 0.002) but not rectal adenocarcinoma (p = 0.13). Conversely, lymphovascular invasion positivity was associated with adverse systemic recurrence in rectal (p = 0.002) but not colon adenocarcinoma (p = 0.35). On multivariate analysis, lymphovascular invasion positivity was an independent predictor of adverse disease-free survival in colon (p = 0.02) and rectal adenocarcinoma (p < 0.001). Regarding overall survival, lymphovascular invasion positivity was a poor prognostic indicator in rectal adenocarcinoma only (p = 0.04). LIMITATIONS AND CONCLUSIONS: In this retrospective analysis, lymphovascular invasion positivity was associated with different patterns of disease recurrence in colon and rectal cancer. Lymphovascular invasion positivity was associated with adverse overall survival in rectal cancer only.

Preoperative staging CT thorax in patients with colorectal cancer: its clinical importance.

BACKGROUND: Recent studies suggest that there is little benefit to routine preoperative staging CT of the thorax in colorectal cancer. OBJECTIVE: The current study hypothesized that staging CT of the thorax is not mandated in all patients with colorectal cancer. DESIGN: This study was a tertiary-care center retrospective observational study. PATIENTS: Patients with a diagnosis of colon and rectal adenocarcinoma during 2006 to 2011 were included in a hospital database. Demographic, pathological, radiological, survival, and clinical factors were recorded. Three hundred eighty-two patients were included in the analysis (234 male, 148 female). INTERVENTIONS: All patients underwent preoperative staging CT of the thorax to determine the presence of pulmonary metastasis and/or indeterminate lesions. MAIN OUTCOME MEASURES: Patients demographics were reviewed, and the factors associated with pulmonary metastasis and indeterminate lesions were evaluated. RESULTS: Distant metastases were evident in 61 patients (16%). CT scans revealed pulmonary metastasis in 23 patients (6%), and indeterminate lesions in 33 (8.6%). Only one-third of pulmonary lesions were evident on chest x-ray. On logistic regression analysis, nodal positivity was associated with an increased risk for pulmonary metastasis (p = 0.03). There was no difference in overall survival between patients with pulmonary metastasis and indeterminate lesions (p = 0.35, Kaplan-Meier estimate, log rank analysis). Pulmonary metastasis developed during postoperative surveillance in 7 patients with indeterminate lesions (21.2%). LIMITATIONS: This is a retrospective, single-center study with a relatively small sample size. CONCLUSIONS: Pulmonary metastasis is relatively rare in colorectal cancer, and staging CT of the thorax may not be mandated in low-risk patients.

An appraisal of lymph node ratio in colon and rectal cancer: not one size fits all.

BACKGROUND: Lymph node ratio (LNR) is increasingly accepted as a useful prognostic indicator in colorectal cancer. However, variations in methodology, statistical stringency and cohort composition has led to inconsistency in respect of the optimally prognostic LNR. OBJECTIVE: The aim was to apply a robust regression-based analysis to generate and appraise LNRs optimally prognostic for colon and rectal cancer, both separately and in combination. METHODS: LNR was established for all patients undergoing either a colonic (n = 379) or rectal (n = 160) cancer resection with curative intent. The optimal LNR associated with disease-free and overall survival were established using a classification and regression tree technique. This process was repeated separately for patients who underwent either colonic or rectal resection and for the combined cohort. Survival associated with differing LNR was estimated using the Kaplan-Meier method and compared using a log-rank test. Relationships between LNR, disease-free survival (DFS) and overall survival (OS) were further characterised using Cox regression analysis. All statistical analyses were conducted in the R programming environment, with statistical significance was taken at a level of p < 0.05. RESULTS: Optimal LNRs differed between each cohort, when either overall or disease-free survival was considered. LNRs generated from combined cohorts also differed from those generated by individual cohorts. In relation to DFS, LNR values were obtained and included 0.18 for the colon cancer cohort and 0.19 for the rectal and combined colorectal cancer cohorts. In relation to OS, multiple LNR values were obtained for colon and combined cohorts; however, an optimal LNR was not evident in the rectal cancer cohort. Survival patterns according to LNR closely resembled those associated with standard nodal staging. CONCLUSION: Application of a data-driven approach based on recursive partitioning generates differing lymph node ratios for colon, rectal and combined colorectal cohorts. In each cohort, LNR was similarly prognostic to standard nodal staging in respect to overall and disease-free survival. Overall survival was associated with a multiplicity of LNR values, whilst disease-free survival was associated with a single LNR only. The paper demonstrates the merits of utilising a data-driven approach to determining lymph node ratios from specific patient cohorts. Utilising such an approach enabled the generation of those LNRs that were most associated with particular survival trends in relation to overall and disease-free survival. These differed markedly for colon cancer, rectal cancer and combined cohorts. In general, the survival patterns associated with LNRs generated were similar to those observed with standard nodal staging.