Outcomes of Bilateral Adrenalectomy in Cushing's Syndrome.

CONTEXT: The literature on outcomes of bilateral adrenalectomy (BADx) in Cushing's syndrome (CS) is scant. AIMS: The aim of this study is to analyze the short- and long-term outcomes of patients who underwent BADx and to compare the outcomes among different etiologies of CS. SETTINGS AND DESIGN: This is a retrospective analysis of patients who underwent BADx for CS at our center between 2005 and 2018. MATERIALS AND METHODS: In all, 33 patients were studied for clinical outcomes, survival rates, and long-term complications. STATISTICAL ANALYSIS: All analyses were performed with SPSS software (version 21.0). RESULTS: The mean age at surgery was 39.33 ± 15.67 years. The primary etiology for CS was Cushing's disease (CD) in 42.42%, ectopic source in 36.36%, primary pigmented nodular adrenocortical disease (PPNAD) in 12.12%, and adrenocorticotrophin hormone-independent macronodular adrenal hyperplasia (AIMAH) in 9.09% of patients. The median follow-up time was 72.77 months. Improvement in hypertension and diabetes status after surgery was seen in 78% and 76.19% of patients, respectively. Proximal myopathy improved in 68% of patients. Nelson's syndrome and adrenal crisis were seen in 21.4% of patients each on long-term follow-up. Total mortality after BADx was 33.3%. Mortality in the first 30 days after surgery was seen in five patients (15.15%). Higher cortisol levels at presentation and age more than 40 years were predictors of mortality. Among the Cushing's subtypes, PPNAD had the best prognosis followed by CD. Perioperative Infections were a major cause of mortality. CONCLUSION: BADx is an effective treatment for CS especially in patients with PPNAD and CD but carries a significant mortality rate too.

Extensive prostatic calculi in alkaptonuria: An unusual manifestation of rare disease.

Extensive prostatic calculi in a young man should always elicit the suspicion of alkaptonuria. Although prostatic calculi are seen in chronic prostatitis, chronic pelvic pain syndrome and benign prostate hyperplasia, none of these have prostatic calculi or calcification as extensive as in alkaptonuria. A 36 years young man who had severed obstructive lower urinary tract symptoms with extensive prostatic calculi was found to be alkaptonuric on further evaluation.

Renal Cell Carcinoma Associated with Xp11.2 Translocation/TFE3 Gene Fusion: A Rare Case Report with Review of the Literature.

Introduction. The recently recognized renal cell carcinomas associated with Xp11.2 translocations are rare tumors predominantly reported in children. Chromosome Xp11.2 translocation results in gene fusion related to transcription factor E3 (TFE3) that plays an important role in proliferation and survival. Case Report. Herein, we present two cases of a TFE3 translocation-associated RCC in young female adults, one detected incidentally and the other one presenting with gross hematuria. Tumor is characterized by immunohistochemistry and a literature review with optimal treatment regimen is presented. Discussion. Xp11.2 translocation RCCs in adult patients are associated with advanced stages, large tumors, and extracapsular disease and usually have an aggressive clinical course. Conclusion. In TFE3 RCC, the genetic background may not only contribute to tumorigenesis, but also determine the response to chemotherapy and targeted therapy. Therefore it is necessary to diagnose this tumor entity accurately. Because of the small number of TFE3 gene fusion-related renal tumors described in the literature, the exact biologic behavior and impact of current treatment modalities remain to be uncertain.

Page kidney following renal allograft biopsy - early recognition and treatment.

Ultrasound- guided percutaneous allograft renal biopsy is commonly done to evaluate graft dysfunction. Complications of renal biopsy are usually minor, and major complications occur only in less than 1% cases. We report a case of allograft renal biopsy which caused a subcapsular hematoma, Page kidney and deterioration of graft function. This was diagnosed by computed tomography (CT) scan, and early surgical intervention led to complete recovery.

Laparoscopic adrenal surgery in children: Lessons from a single centre experience.

PURPOSE: Although commonly performed in adults, laparoscopic adrenalectomy in children is performed only in centres with advanced laparoscopic expertise. MATERIALS AND METHODS: This is a retrospective analysis of laparoscopic adrenalectomies performed at a single centre between January 2003 and May 2010. After preoperative evaluation with biochemical assays and radiologic imaging, surgery was performed by using the lateral transabdominal approach in all patients. RESULTS: Ten laparoscopic adrenalectomies (including three bilateral) were performed in seven children, with a mean age of 9.6 years. The tumours ranged from 2 - 7 cms in size. The operative durations were 75 - 130 minutes (unilateral) and 250 - 270 minutes (bilateral). Operative blood loss was minimal. There were no open conversions, but terminal hand assistance was required in one large right pheochromocytoma. The postoperative hospital stay ranged from 3 - 10 days. The final pathological diagnoses included pheochromocytoma, hyperplasia and neuroblastoma. Follow-up at 24 - 87 months was uneventful. CONCLUSION: With adequate experience in laparoscopy, it is possible to perform adrenalectomy in selected children.

Prospective analysis of psychological distress in men being investigated for prostate cancer.

OBJECTIVES: To determine the level and prevalence of anxiety and depression in men being investigated for prostate cancer (CaP) and also to identify those aspects of the diagnostic pathway that induces the most stress. MATERIALS AND METHODS: All patients undergoing transrectal ultrasound-guided biopsy (TRUS-B) of the prostate for suspected CaP at our institute between June 2008 and April 2009 were enrolled in this prospective study. All patients completed two questionnaires, prior to their biopsy (HADS1) and before receiving results (HADS2), containing the Hospital Anxiety and Depression Scale (HADS). The data were analyzed and the differences in HADS were compared. RESULTS: A total of 112 men were included in the trial. Two patients could not complete the second part of HADS (HADS2) and were excluded from the study. Prevalence of anxiety among the 110 patients was 43/110 (39.1%). Mean score for anxiety in these 43 patients before biopsy (HADS A1) was 10.74 and score just before receiving the biopsy report (HADS A2) was 11.55. Prevalence of depression before TRUSB (HADS D1) was 21/110 (19.1%) with a mean score of 10.59. Prevalence of depression while awaiting the biopsy report (HADS D2) was 22/110 (20%) with mean score of 10.62. CONCLUSION: There was a high prevalence of anxiety and depression in our study population and waiting for biopsy results was the most stressful event. Questionnaires such as HADS can identify patients with psychological distress. Minimizing the stress while waiting for a diagnosis should help optimize patient care.

Concomitant laparoscopic urological procedures: Does it contribute to morbidity?

AIM: With advancement in minimal access surgery two laparoscopic procedures can be combined together shortening the total hospital stay, decreasing morbidity and overall reduced cost. Combining two laparoscopic procedures in a single session has been reported in general surgery. Very few articles are available in literature with regard to combined urological laparoscopic surgeries. This article retrospectively analyses the outcomes of multiple laparoscopic procedures performed in a single stage at our centre. MATERIALS AND METHODS: Patients undergoing simultaneous procedures from May 2003 to Jan 2009 were included in the study. Patients were categorised into three groups according to the primary urological organ involved, for better comparison with the control group. Diseases involving the adrenals gland were grouped in (group 1), kidney (group 2) and renal collecting system/ureter (group 3). All patients had one urological procedure for either of the above-mentioned organs combined with another surgical procedure. Similarly three control groups were chosen according to the primary urological organ involved (group 1c- unilateral laparoscopic adrenalectomy, group 2c- unilateral laparoscopic radical nephrectomy and group 3c- unilateral laparoscopic ureterolithotomy) for comparative study. The operative details, hospital stay and complications were analysed. RESULTS: Thirty-two patients underwent 64 laparoscopic procedures under single anaesthesia. The most common procedure in this series was laparoscopic adrenalectomy (n=34) followed by laparoscopic nephrectomy (n=13). Group 1 patients had a prolonged operative time ( P=0.012) and hospital stay ( P=0.025) when compared with group 1c. However, blood loss was comparable in both the groups. Patients in groups 2 and 3 had comparable operative times, blood loss and recovery period with respect to their controls. Intraoperatively, the end tidal carbon dioxide levels were within permissible limits. All procedures were completed using the laparoscopic approach, without any conversion. CONCLUSIONS: Simultaneous laparoscopic procedures can be done for urological diseases in selected patients with the advantages of single anaesthesia and hospital admission without increasing the morbidity.

Schwannoma of the penis: a common tumour at a rare site.

Schwannoma is a benign tumour arising from neurilemmal cells and is commonly seen along cranial nerves. We describe the case history and histologic findings of a young adult with a schwannoma at a very rare site: the penis. Surgical excision was done and the patient remains disease-free after 2 years.