Molecular Characterization of Extended-Spectrum ß-Lactamase Enterobacteriaceae Isolated from Egyptian Patients with Community- and Hospital-Acquired Urinary Tract Infection.

Extended-spectrum ß-lactamases (ESßLs) pose a serious problem in the treatment of urinary tract infections (UTIs). The ESßL-producing organism is an expanding global health problem. Therefore, screening for ESßL, detection of their drug-resistance pattern, and molecular characterization should be a continuous process. The present study was performed to determine the antibiotic resistance profile and the genetic characterization of ESßL isolates from hospital- and community-acquired UTIs. Two hundred fifty Enterobacteriaceae isolates were obtained from urine samples of outpatient clinic attendants and hospitalized patients at Kasr Al-Aini Hospital. By phenotypic screening tests, 100 ESßL isolates were detected among the studied groups. Furthermore, detection of beta-lactamase (bla) cefotaxime (CTX)-M, sulfhydryl variable, and temoneira ESßL genes was investigated by polymerase chain reaction. A subset of 25 CTX-M-positive isolates was further identified by gene sequencing technology. Among the 100 ESßL isolates, 66% were Escherichia coli and 34% were Klebsiella spp. There was no statistical difference in the prevalence of ESßL Enterobacteriaceae in community-acquired versus hospital-acquired UTIs. The susceptibility of all ESßL isolates to carbapenems was the most prevalent finding. In addition, all ESßL E. coli isolates were susceptible to fosfomycin, whereas all community-acquired ESßL isolates were susceptible to nitrofurantoin. A total of 98% of the ESßL isolates harbored bla-CTX-M genes, with CTX-M-15 being the most prevalent. It could be concluded that ESßL production is present at a high rate among Egyptian patients with hospital- and community-acquired UTI. The high prevalence of bla-CTX-M may suggest it as a candidate for molecular screening of ESßL.

A Prospective Evaluation of High-Resolution CT Parameters in Predicting Extracorporeal Shockwave Lithotripsy Success for Upper Urinary Tract Calculi.

OBJECTIVE: To evaluate the ability of noncontrast CT parameters (stone size, stone attenuation, and skin-to-stone distance [SSD]) to predict the outcome of extracorporeal shockwave lithotripsy (SWL) in a prospective cohort of patients with renal and upper ureteric stones. PATIENTS AND METHODS: Patients with stones 5 to 20 mm were prospectively enrolled from 2011 to 2014. Patients had NCCT with recording of stone size, stone mean attenuation, and SSD, as well as various stone and patient parameters. The numbers of needed sessions as well as the final outcome were determined, with SWL failure defined as residual fragments >3 mm. Predictors of SWL failure were assessed by multiple regression analysis. RESULTS: Two hundred twenty patients (mean ± standard deviation [SD] age 41.5 ± 12.4 years) underwent SWL. Mean ± SD stone size was 11.3 ± 4.1 mm, while mean ± SD stone attenuation was 795.1 ± 340.4 HU. Mean ± SD SSD was 9.4 ± 2.1 cm. The average number of sessions was 1.64. SWL was effective in 186 (84.5%) patients (group A), while 34 (15.5%) patients had significant residual fragments (>3 mm). On univariate analysis, predictors of SWL failure included stone attenuation >1000 HU, older age, higher body mass index, higher attenuation value, larger stone size, and longer SSD. Increased SSD and higher stone attenuation retained their significance as independent predictors of SWL failure (p < 0.05) on multiple regression analysis both after first session and as final SWL outcome. A positive correlation was found between number of SWL sessions and mean stone attenuation (r = 0.6, p < 0.001) and SSD (r = 4, p < 0.001). CONCLUSIONS: Stone mean attenuation and SSD on noncontrast CT are significant independent predictors of SWL outcome in patients with renal and ureteric stones. These parameters should be included in clinical decision algorithms for patients with urolithiasis. For patients with stones having mean attenuation of >1000 HU and/or large SSDs, alternatives to SWL should be considered.

Rising incidence of acute prostatitis following prostate biopsy: fluoroquinolone resistance and exposure is a significant risk factor.

OBJECTIVE: To evaluate the frequency and potential risk factors for infection-related complications after transrectal prostate biopsy and to propose adjustments in current antimicrobial prophylaxis recommendations. METHODS: During 2008-2010, 107 patients underwent transrectal ultrasound-guided biopsies of the prostate at our institution. Charts were reviewed for infection-related complications within 30 days of the procedure. Potential risk factors were evaluated, including age, diabetes mellitus, chronic constipation/diverticular disease, prior use of quinolones, enema and prostatitis, on the pathology report. For patients with acute prostatitis, urine and blood samples were assessed for bacteriology and antibiotic susceptibility. RESULTS: Of our 107 patients, acute prostatitis developed in 10 (9.3%). The most significant risk factor was prior use of a fluoroquinolone antimicrobial, with acute prostatitis developing in 7 (17.1%) of 41 patients who had used a fluoroquinolone compared with 3 (4.5%) of 66 patients who had not (P=.042). Patients who received an enema before the procedure were slightly less likely to develop prostatitis (P=.061). Of 8 positive specimens, the organisms isolated were Escherichia coli in 6, Klebsiella pneumoniae in 1, and Staphylococcus epidermidis in one. Isolated Gram-negative organisms were fluoroquinolone-resistant in 85.7% of samples. CONCLUSION: Prior fluoroquinolone intake is a significant risk factor behind a rising incidence of acute prostatitis after transrectal prostate biopsy. Identified pathogens are mostly Gram-negative organisms with a high rate of fluoroquinolone resistance. Alternative prophylaxis regimens for the biopsy procedure should be considered in patients with recent quinolone intake.

Prostate cystadenoma presenting with obstructive azoospermia.

We report on a case of prostate multilocular cystadenoma presenting with primary infertility and obstructive azoospermia. Our patient is a 36-year-old presenting with primary infertility in addition to mild deep pelvic pain. Semen analysis revealed azoospermia with positive fructose. His prostate-specific antigen was 0.7 ng/dL and his imaging revealed a large multilocular cystic mass with multiple internal enhancing septa. Transrectal ultrasonography-guided aspiration and biopsies revealed a lining of regular low cuboidal cells. Surgical removal was undertaken through a transperitoneal/retroperitoneal approach and pathology was consistent with a prostatic multilocular cystadenoma. Further studies are needed to characterize and classify cystic lesions of the prostate.

Prevalence of renal cysts in a Middle-Eastern population: an evaluation of characteristics and risk factors.

OBJECTIVE: To assess the prevalence of renal cysts in a large Middle-Eastern population presenting for a health-screening programme, evaluating cyst characteristics and risk factors for their development. PATIENTS AND METHODS: The reported prevalence of renal cysts detected by ultrasonography (US) in the general population is 5.0-20.8%, and their development has been linked to several factors. The electronic charts of 8551 patients (from eight nations, predominantly Egypt and Yemen) presenting for the 'check-up' programme at the author's institution during 2005 were retrospectively reviewed. The presence and characteristics of renal cysts on abdominal US were noted, as were any associated renal pathologies. Various risk factors were evaluated for renal cyst development, i.e. age, gender, hypertension, diabetes mellitus and serum creatinine levels, and hyperlipidaemia and a history of bilharziasis were also assessed. RESULTS: The prevalence of renal cysts was 4.2%, ranging from 0.6% for patients in their third decade, to a third of those aged >80 years. Cysts were detected in 4.8% of men and 2.8% of women (P < 0.001). The mean serum creatinine level was 1.02 mg/dL in those with cysts and 0.88 mg/dL in those without (P < 0.001). On univariate analysis, hypertension, diabetes and hyperlipidaemia had a significant influence on the occurrence of renal cysts, but not in the multivariate model. Of the 361 patients with renal cysts, 58 (16.1%) had bilateral and 26 (7.2%) had multiple unilateral cysts, with a mean (range) size of 26 (4-104) mm. The vast majority of cysts were classified as Bosniak I simple cysts; seven were Bosniak II and there was one Bosniak IV cyst. Associated renal pathologies included renal stones in 39 patients, hydronephrosis in nine, increased parenchymal echogenicity in 18, small atrophic kidneys in three, haematuria (not associated with other imaging abnormalities) in six, and a renal mass in one patient. CONCLUSIONS: The prevalence of renal cysts detected by US in a health-screened population from the Middle East was 4.2%. Increasing age, male gender and a higher serum creatinine level were significant independent risk factors for cyst development. There was also a relatively high prevalence of associated renal pathologies (increased parenchymal echogenicity and stones).

Complications of post-chemotherapy retroperitoneal lymph node dissection for testis cancer.

PURPOSE: Post-chemotherapy retroperitoneal lymph node dissection (PC RPLND) is a tool in the management of testis cancer. Our impression has been that the short-term morbidity of standard PC RPLND has diminished with time. Therefore, we attempted to verify this hypothesis by evaluating the morbidity of the procedure in 2 comparable groups of patients from 2 different periods. MATERIALS AND METHODS: We compared 150 patients who underwent post-chemotherapy RPLND between July 2000 and July 2002 to 79 patients who underwent the same procedure between 1990 to 1992. All patients had clinical stage II-III testis cancer and had received 3 to 4 courses of standard platinum based chemotherapy before surgery. We compared surgical morbidity and postoperative complications in both groups. We also assessed a number of factors (patient characteristics, mass size, pathological features and surgical aspects) that could impact the rate of complications. RESULTS: The 2 groups were comparable regarding preoperative clinical stage, patient characteristics and postoperative pathological findings. PC RPLND procedures were performed using the same technique. Compared to patients in the 1990 to 1992 group, the patients from the 2000 to 2002 group had fewer intraoperative complications and additional procedures (44 [29.3%] of 150 versus 41 [51.9%] of 79, p = 0.0008), a trend toward a lower postoperative complication rate (10 [6.7%] compared to 11 [13.9%], p = 0.07) and shorter hospital stay (average 5.6 versus 8.4 days [p <0.0001]). CONCLUSIONS: With time morbidity and hospital stay after standard PC RPLND have decreased. This finding probably reflects differences in patterns of care rather than changes in surgical technique. Therefore, comparing newer surgical techniques to historical controls is inappropriate since differences may not actually represent the technical advances of the newer procedure.

Histology in mixed germ cell tumors. Is there a favorite pairing?

PURPOSE: Mixed germ cell tumors account for approximately 30% to 50% of testicular tumors. To our knowledge a systematic review with statistical analysis of the associations of histological subtypes in mixed germ cell tumors has not been done previously. It was our impression that such associations exist. Delineating concordant histological types may provide insight into the ontogeny of testicular tumors and also have important clinical implications. MATERIALS AND METHODS: We retrospectively reviewed the testis cancer data base at our institution. The primary tumor of orchiectomy specimens was examined in 2589 patients. Of these patients mixed histology was noted in 1765 (68.2%). ORs were calculated for all possible combinations of teratoma, embryonal carcinoma, yolk sac tumor, choriocarcinoma and seminoma. In addition, we evaluated the association of various histological types with teratoma at post-chemotherapy retroperitoneal lymph node dissection. RESULTS: Of 10 possible combinations of histological types in the primary tumor, positive correlations were noted in 4. The strongest correlation was found between teratoma and yolk sac tumor (OR 2.58, p <0.001). Teratoma or yolk sac tumor in the testis was associated with teratoma in the pathology specimen at post-chemotherapy retroperitoneal lymph node dissection. CONCLUSIONS: The strongest associations of histological subtypes in mixed germ cell tumors were seen between yolk sac tumor and teratoma. Similar associations are seen in late relapse and in some cases of prepubertal tumors. Further study of these associations may prove valuable in understanding the biology and clinical behavior of germ cell tumors.

Does retroperitoneal lymph node dissection have a curative role for patients with sex cord-stromal testicular tumors?

BACKGROUND: Sex cord-stromal tumors account for < 5% of all adult testicular tumors, and 10% are malignant. Due to the limited reported experience, there is no agreement on the best management, especially in patients who have tumors with malignant pathologic features or who present with metastatic disease. The authors attempt to evaluate the role of retroperitoneal lymph node dissection (RPLND) in the management of patients with these malignant sex cord-stromal tumors. METHODS: Reviewing the Indiana University testis cancer registry revealed 17 patients who underwent RPLND for sex cord-stromal tumors. Pathology was reviewed for features suggestive of malignancy. The data examined included clinical and pathologic stage, surgical procedure, additional therapy received, and outcome. RESULTS: Pathology included Leydig tumors in six patients, Sertoli tumors in four patients, sex cord-stromal tumors in five patients, a granulosa cell tumor in one patient, and a poorly differentiated non-germ cell tumor in one patient. Nine patients had histologic features suggestive of malignancy. Clinical stage at surgery was Stage I in nine patients and Stage IIA-IIIA in eight patients. Patients underwent modified or bilateral RPLND. Nine patients had pathologic Stage I tumors, and the remaining eight patients and had pathologic Stage IIB-IIIA tumors. Follow-up ranged from 8 months to 11 years. Of the eight patients with Stage II-III disease, six patients eventually died of metastatic disease despite additional radiotherapy and/or chemotherapy. CONCLUSIONS: Sex cord-stromal tumors have a potentially aggressive malignant behavior that is difficult to predict based on clinical and pathologic features. Although the therapeutic role of RPLND in patients with small-volume metastatic retroperitoneal tumors is unclear, RPLND remains an option to be performed immediately after orchiectomy, especially in patients who have tumors with malignant features and/or small-volume metastatic disease.

Is post-chemotherapy resection of seminomatous elements associated with higher acute morbidity?

PURPOSE: A seminomatous element in patients undergoing retroperitoneal lymph node dissection for testicular cancer is associated with a desmoplastic reaction that renders retroperitoneal surgery more challenging. We examined the impact of seminomatous elements on the rate of complications and the need for additional intraoperative procedures in patients undergoing post-chemotherapy retroperitoneal lymph node dissection. MATERIALS AND METHODS: The testis cancer data base at our institution was retrospectively reviewed and 1,366 patients were identified who underwent post-chemotherapy retroperitoneal lymph node dissection between 1973 and 2001. In 97 patients there was an element of seminoma in the dissection specimen and/or pure seminoma in the testicular primary specimen (seminoma group). The remaining 1,269 patients underwent post-chemotherapy retroperitoneal lymph node dissection for nonseminomatous testicular tumors. The rates of intraoperative complications and additional procedures as well as postoperative complications were analyzed. RESULTS: Of the 97 patients in the seminoma group 37 (38.1%) required a total of 47 additional intraoperative procedures, including 25 nephrectomies, 9 inferior vena caval resections, 5 arterial grafts, 5 bowel resections and 3 hepatic resections/biopsies, compared with 340 of the 1,269 patients (26.8%) in the group without seminomatous elements (p = 0.02). Postoperatively complications occurred in 24 of 97 patients (24.7%) in the seminoma group versus 257 of 1,269 (20.3%) in the group without seminomatous elements (p = 0.29). One of the 97 patients in the seminoma group died secondary to postoperative complications. CONCLUSIONS: A seminomatous element in patients undergoing post-chemotherapy retroperitoneal lymph node dissection is associated with a higher rate of additional intraoperative procedures and postoperative complications than in patients without seminomatous elements. However, resection is still possible with acceptable morbidity when indicated in appropriately selected patients.