Introduction of Rezum system technology to Ireland for treatment of lower urinary tract symptoms secondary to benign prostatic hyperplasia: a pilot study on early outcomes and procedure cost analysis.

OBJECTIVE: Rezum technology uses heat from radiofrequency-generated water vapour to ablate prostate tissue. We evaluate the introduction of this thermal therapy to an Irish teaching hospital for the treatment of lower urinary tract symptoms related to benign prostatic hyperplasia. METHODS: A pilot study of men with moderate to severe lower urinary tract symptoms who underwent Rezum treatment to the prostate was performed. Perioperative efficacy was evaluated using international prostate symptom score (IPSS), quality of life score (IPSS-QOL), uroflowmetry and post-void residual (PVR) volumes. Costs were evaluated and compared against matched patients undergoing the standard of care, transurethral resection of the prostate (TURP). RESULT: Ten patients with a mean age of 70 ± 9 years who met the inclusion criteria underwent Rezum treatment. Mean PSA was 4.73 ± 4 ng/mL and mean prostate volume 72 ± 30 cc. Rezum therapy significantly improved both IPSS by 74% from mean baseline score of 20.8 ± 4 to 5.3 ± 1.49 (p < 0.001) and IPSS-QOL score by 84% from mean baseline score of 4.4 ± 0.7 to 0.6 ± 0.7 (p < 0.001) at 3 months. Maximum flow rate increase by 44% from 9.26 ± 2.5 to 13.34 ± 2.3 mL/s (p < 0.001). When compared to ten matched patients undergoing TURP in the same period, there was a significant cost saving of €1986.52 per patient for Rezum, overall up-front cost saving of €22,819 with an additional 19 bed days and 5 theatre hours spared. CONCLUSION: Rezum, a minimally invasive thermal therapy, provides significantly improved symptom relief and quality of life with a significant cost saving to the institution.

Intraductal carcinoma of the prostate in an Irish prostate cancer patient cohort-an aggressive pathology and a strong familial link.

BACKGROUND: The prevalence of intraductal carcinoma of the prostate (IDC-P) is poorly studied in the Irish population. This study investigated the incidence and clinicopathologic characteristics of IDC-P in an Irish prostate cancer (PCa) patient cohort. The study also discusses the rationale for genetic counseling and screening in Irish patients with familial risk factors for IDC-P. MATERIALS AND METHODS: This study investigated patients diagnosed with IDC-P on prostate biopsy from 2012 to 2016. Primary outcome measurements were incidence, management, and clinical outcomes after follow-up in patients with IDC-P. The secondary outcome measurement was to identify a familial link for IDC-P. RESULTS: A total of 1,143 patients were diagnosed with PCa on needle biopsy, of which 30 (2.3%) had concomitant IDC-P. Mean age and prostate-specific antigen at diagnosis were 68.6 ± 10.5 years (range 53-85 years) and 9.15 ± 8.65 ng/mL (range 2.1-166 ng/mL), respectively. In total, 17 of 30 patients (57%) were diagnosed with concomitant high-grade (i.e., ≥Gleason score 8) PCa. Eight patients (27%) were treated with radical prostatectomy; of which five had biochemical recurrence (BCR) after 10.55 ± 25.9 months. Eleven patients (37%) received radical radiotherapy; of which one had BCR after 36 months. Eleven patients (37%) presented with advanced PCa and were managed with androgen deprivation therapy ± chemotherapy. A family history for PCa in first-degree relatives was found in eight patients (27%). CONCLUSIONS: IDC-P is associated with more aggressive clinicopathologic features and an increased risk of BCR after treatment. In Ireland, clinical guidelines and a genetic screening pathway are required to provide early detection and appropriate multimodal management of patients with IDC-P.

Incidence, Management, and Clinical Outcomes of Prostate Cancer in Kidney Transplant Recipients.

OBJECTIVES: We reviewed the incidence, management, and survival outcomes of prostate cancer among kidney transplant recipients and compared these characteristics with a national population (nonrecipients). MATERIALS AND METHODS: A retrospective study was performed on all kidney transplant recipients from a National Kidney Transplant Centre who were subsequently diagnosed with prostate cancer. Primary outcome variables included comparisons of incidence and 5-year overall survival in kidney transplant recipients versus nonrecipients after treatment of prostate cancer. Secondary outcome variables were prostate-specific antigen levels at diagnosis, Gleason grade, treatment strategy, and morbidity from treatment among kidney transplant recipients. RESULTS: Of 4048 kidney transplants performed, 3020 were male recipients (63.9%). In total, 34 kidney transplant recipients (1.1%) were diagnosed with prostate cancer 109 ± 83 months (range, 7-372 mo) after transplant. The mean age at prostate cancer diagnosis was 64 ± 7 years, median prostate-specific antigen level was 10 ng/dL (range, 2.6-771 ng/dL), and 76% (n = 26/34) were diagnosed with localized disease. The incidence of prostate cancer was 1126/100 000 in kidney transplant recipients compared with 160/100 000 nonrecipients in Ireland (P = .01). Treatment strategies included curative radiotherapy (n = 18), curative surgery (n = 2), androgen deprivation therapy (n = 8), and watchful waiting (n = 6). Overall survival rates at 1, 3, and 5 years were not significantly different between kidney transplant recipients with prostate cancer versus nonrecipients with prostate cancer (98% vs 98%, 80% vs 79%, and 77% vs 72%, respectively, P = .8). CONCLUSIONS: The incidence of prostate cancer is significantly higher among kidney transplant recipients compared with nonrecipients in the general population, with most diagnosed with localized disease. Definitive management guidelines should be developed to increase awareness and optimize treatment options in this unique patient cohort.

Laparoscopic and hand-assisted laparoscopic donor nephrectomy: A systematic review and meta-analysis.

OBJECTIVE: To compare the perioperative outcomes of hand-assisted laparoscopic donor nephrectomy (HALDN) and pure LDN, as HALDN and LDN are the two most widely used techniques of DN to treat end-stage renal disease. METHODS: In this systematic review and meta-analysis, we performed a literature search of PubMed, Embase, Web of Science, and Cochrane from 01/01/1995 to 31/12/2014. The primary outcome was conversion to an open procedure. Secondary outcomes were warm ischaemia time (WIT), operation time (OT), estimated blood loss (EBL), complications, and length of stay (LOS). Data analysed were presented as odds ratios (ORs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs), I2, and P values. Subgroup analysis was performed. RESULTS: There were 24 studies included in the meta-analysis; three randomised controlled trials (RCTs), one randomised pilot study, two prospective, and 18 retrospective cohort studies. There were no differences in conversion to an open procedure between the two techniques for both RCTs (OR 0.42, 95% CI 0.06, 2.90; I2 = 0%, P < 0.001) and cohort studies (OR 1.06, 95% CI 0.63, 1.78; I2 = 0%, P = 0.84). WIT was shorter for the HALDN (-41.79 s, 95% CI -71.85, -11.74; I2 = 96%, P = 0.006), as was the OT (-26.32 min, 95% CI -40.67, -11.97; I2 = 95%, P < 0.001). There was no statistically significant difference in EBL, complications or LOS. CONCLUSION: There is little statistical evidence to recommend one technique. HALDN is associated with a shorter WIT and OT. LDN has equal safety to HALDN. Further studies are required.

Ex vivo reconstruction of the donor renal artery in renal transplantation: a case-control study.

Transplantation of renal allografts with anatomic variability or injured vasculature poses a challenge to the transplanting surgeon but can be salvaged for transplantation with ex vivo bench reconstruction of the vasculature. We investigated whether renal allograft function is impaired in these reconstructed allografts; compared to the donor-matched, un-reconstructed allograft. Reconstructed allografts were transplanted into 60 patients at our institution between 1986 and 2012. A control group was selected from the matched pair of the recipient in deceased donor transplantation. We found no significant difference in the overall graft and patient survival rates (P = 1.0, P = 0.178). Serum creatinine levels were not significantly higher in the study group at 1, 3 and 12 months postoperatively. There were two cases of vascular thrombosis in the study group that were not related to the ex vivo reconstruction. A significantly greater proportion of reconstructed patients were investigated with a colour duplex ultrasound postoperatively (0.007). Although we have demonstrated a higher index of suspicion of transplant failure in patients with a reconstructed allograft, this practice has proven to be a safe and useful technique with equivocal outcome when compared to normal grafts; increasing the organ pool available for transplantation.

Outcome of deceased donor renal transplantation in patients with an ileal conduit.

Renal transplantation in recipients with an ileal conduit is uncommon and occasionally controversial as it has been associated with high morbidity and mortality rates. We report on 17 patients with an ileal conduit who received a deceased donor renal transplant at our institution between January 1986 and December 2012. We retrospectively reviewed their allograft and surgical outcome. There were four mortalities at five, five, 39, and 66 months post-transplant. Sixteen of 17 grafts functioned immediately; one patient had primary non-function secondary to vascular thrombosis. Thirteen of 17 (76.5%) grafts were functioning at a mean follow-up period of 105 months. The mean serum creatinine at follow-up was 111 µM (±38.62). Five patients had seven episodes of urosepsis requiring hospital admission, and five patients received treatment for renal stone disease. We conclude that given improvements in immunosuppression, surgical technique, infection treatment, and selection criteria, we believe that renal transplantation in the patient with an ileal conduit yields excellent graft survival, although there is a high morbidity rate in this cohort of patients in the long term.

Ureteral diverticulum: a review of the current literature.

INTRODUCTION: Ureteral diverticulum is a rare urological condition with only 45 cases described in the literature. These previously reported cases vary in their presentation, diagnosis and management and there is no consensus in the literature on the best diagnostic tool available. We describe our experience on diagnosing and managing this condition in two patients and provide a descriptive review of the current literature on ureteral diverticulum. MATERIALS AND METHODS: A Medline search was performed to identify all reported cases of ureteral diverticulum. Key words used were: ureteral diverticulum; abortive bifid ureter; congenital diverticulum; acquired diverticulum. We also reviewed the records of two patients who presented consecutively to our institution with a ureteral diverticulum. The clinical and radiological characteristics of this entity were then evaluated. RESULTS: Forty-one manuscripts were identified, encompassing single case reports and case series, the largest of which contained seven patients. Two additional cases were diagnosed in our institution; a true congenital diverticulum and an abortive bifid ureter which is synonymous with a true ureteral diverticulum. Both were uncomplicated cases and were managed conservatively. Retrograde pyelography was used for definitive diagnosis of this lesion. CONCLUSION: Ureteral diverticulum may present as an incidental finding or with a secondary complication. Conservative management is advocated in the literature for non-complicated cases. Retrograde pyelography is our diagnostic tool of choice.

Ureterocolic fistula in the presence of a solitary kidney.

Among the entero-urinary fistulae, those between the ureter and colon are rare. Most spontaneous ureterocolic fistulae are caused by urinary calculi. We report a case of a spontaneous ureterocolic fistula which occurred as a consequence of diverticular disease. This rare presentation was further complicated as it occurred in the presence of a solitary kidney. The patient underwent a laparoscopic defunctioning loop ileostomy and after 6 weeks underwent definitive surgical treatment of the ureterocolic fistula. We describe the presentation and management of this fistula and review the current literature.

Genital self-mutilation.

A 53-year-old man was brought to the emergency department having removed both testicles and amputated his penis using a bread knife. Examination of the amputated penis showed it to be unsuitable for an attempted replant procedure. The patient was taken to theatre where the perineal wound was debrided and the remaining urethra brought down as a perineal urethrostomy, with a local cutaneous flap rotated to provide coverage for the urethra. Discussed herein are the incidence, predisposing factors, management and complications of genital self-mutilation in the adult male, and the existing literature is reviewed on the subject.

Laparoscopic vs open living donor nephrectomy: a contemporary series from one centre.

OBJECTIVE: To report our experience of laparoscopic living donor nephrectomy (LDN) vs open donor nephrectomy (ODN), as LDN offers potential advantages to the donor and has become a routine procedure for live kidney procurement worldwide. PATIENTS AND METHODS: Between February 2000 and August 2005 we performed 183 donor-recipient operations at our institution (ODN, 83; LDN, 100). We prospectively collected information on all donors and recipients for the same period to audit our experience with the first 100 LDNs. Patients made their operative choice after discussions that included unit experience and published information. We present our findings with the emphasis on donor operative details and early recipient graft outcome. RESULTS: Donor and recipient age, gender, body mass index, human leukocyte antigen mismatches, and vascular anastomotic times did not differ significantly between the groups. There were two conversions to an open operation in the LND group; neither affected recipient-graft outcome. The mean (sd) operative duration was 178 (38) min for the LDN and 159 (34) min for the ODN (P < 0.05). The mean (sd) hospital stay was 4.7 (1.2) days in the LND group and 6.8 (1.5) days in the ODN group (P < 0.05). There was one case of delayed graft function in both groups. Serum creatinine levels at 1, 6 and 12 months after transplantation did not differ significantly between the groups. CONCLUSIONS: Our contemporaneous series shows the safe introduction of a laparoscopic living-donor programme without compromising donor patient safety or allograft outcome.

Pelvic recurrence in stage I seminoma: a new phenomenon that questions modern protocols for radiotherapy and follow-up.

OBJECTIVE: To highlight the increased risk for pelvic relapse in patients with stage 1 seminoma treated with adjuvant radiotherapy limited to para-aortic template alone. PATIENTS AND METHODS: Over a four-year period, three patients presented with early pelvic recurrence after radical orchidectomy and adjuvant irradiation for stage 1 seminoma. In each case, radiotherapy had been limited to the para-aortic region with omission of the ipsilateral hemi pelvis. RESULTS: Pelvic recurrences occurred on the ipsilateral tumor side. Durable complete remission was achieved in each case; however, treatment was complex and there was associated morbidity. CONCLUSION: This significant incidence of pelvic recurrence questions the validity of modern radiotherapy protocol which excludes the ipsilateral pelvis from the radiation field.

Mechanical deformation induced apoptosis in human proximal renal tubular epithelial cells is caspase dependent.

PURPOSE: Ureteral obstruction (UO) results in apoptosis of renal tubular epithelial cells. We postulated that mechanical deformation and inflammation contribute to the cellular loss that occurs as a result of UO and it is mediated through altered heat shock protein 70 (HSP-70) expression and the caspase cascade. MATERIALS AND METHODS: Human HK-2 renal tubular cells were subjected to mechanical stretch. Cell viability and apoptosis were assessed by flow cytometry; HSP-70 and caspase 3 protein expression by Western blotting, and caspase 3 activity by fluorescence substrates. RESULTS: Mechanical stretch caused direct apoptosis induction and it also primed for tumor necrosis factor-alpha induced apoptosis, which was caspase 3 dependent. Although HSP-70 protein expression was increased during mechanical stretch, the protective effects of HSP-70 were only seen after further induction by heat shocking. CONCLUSIONS: Altering HSP-70 expression and manipulating the caspase cell death proteases represent a novel pathway to protect against renal tubular cell apoptosis and the potential for progression to renal failure in UO.

Long-term protective effects of hypothermia on reperfusion injury post-testicular torsion.

OBJECTIVE: As many as two-thirds of salvaged testes post-torsion will atrophy within 2 years. Subsequent testicular damage is due at least in part to an ischaemia/reperfusion injury. Thus we analysed the long-term protective effects of subjecting the ischaemic testis to hypothermia in an attempt to prevent or attenuate subsequent testicular damage. MATERIAL AND METHODS: Forty male Sprague-Dawley rats (mean age 97 days; mean weight 408 g) were randomized to one of two groups. The left testis was removed as a control and the right testis was subjected to torsion through 720 degrees in a clockwise direction and maintained in this position for 3 h. Half of the models were subjected to hypothermia by submerging the testis in a cooling bath, which was kept at a constant temperature of 2-4 degrees C for the final hour prior to detorsion. Testes were retrieved at 1 and 12 weeks and examined by a single blinded pathologist using the following histological criteria: mean seminiferous tubular diameter, mean tubular wall thickness (MTWT) and Johnsen's score. RESULTS: Histological examination revealed significant injury after 1 week of reperfusion in both groups. However, after 12 weeks of reperfusion there was a marked benefit seen in the testes subjected to hypothermia. MTWT (p=0.007) and Johnsen's score (p=0.05) were significantly better in the cooled testes after 12 weeks of reperfusion. CONCLUSION: Hypothermia reduces the degree of long-term testicular damage post-torsion and, if applied in clinical practice, may improve long-term salvage rates.

Exogenous and endogenous angiogenic stimuli do not augment splenic autotransplantation.

OBJECTIVE: To find out if angiogenic stimulation improves the ability of the spleen to regenerate. DESIGN: Experimental study. SETTING: Teaching hospital, Republic of Ireland. ANIMALS: 27 male Sprague-Dawley rats. INTERVENTIONS: Each spleen was removed and half was reimplanted in the greater omentum. The rats were randomised into three groups of 9 each: the first (control) group was given no stimulation; the second had the implanted spleen sutured into the omentum with 6/0 polypropylene; and in the third group the implanted spleen was injected with human recombinant vascular endothelial growth factor (VEGF) 500 microg. MAIN OUTCOME MEASURES: Clearance of Howell-Jolly bodies, and the weight and histological appearance of the splenic remnant at 3 months. RESULTS: The splenic remnant was significantly larger at 3 months in the control group (p = 0.0006). Histological examination of the tissue from the control group showed that it was architecturally similar to that of normal functioning spleen, whereas the tissue from the two treated groups contained less lymphoid tissue and showed widespread acute and chronic inflammatory changes. There was a significantly greater clearance of Howell-Jolly bodies (an index of splenic function) from the peripheral blood of the control group (p = 0.0009). CONCLUSION: The excellent recovery of the splenic remnant in the control group suggests that the procedure of splenic autotransplantation might warrant further consideration and study.

Long-term followup of cadaveric renal transplantation in patients with spina bifida.

PURPOSE: Access related problems in hemodialysis and peritoneal dialysis are increased in cases of spina bifida due to vascular and body habitus limitations. Reports of renal transplantation in this patient group are exceedingly rare. We report long-term followup data on cadaveric renal transplantation for end stage renal failure in cases of spina bifida. MATERIALS AND METHODS: Between February 1986 and April 2000, 17 cadaveric renal transplants were performed in 11 females and 5 males with spina bifida. Mean age at transplantation was 20.2 years (range 10 to 35). Of the patients 11 were wheelchair bound and 5 were independently mobile. Before transplantation surgical management of the urological tract included clean intermittent self-catheterization in 3 cases, enterocystoplasty and clean intermittent self-catheterization in 8, and ileal conduit urinary diversion in 5. A total of 14 patients were on renal replacement therapy before receiving the graft. Cyclosporine based triple therapy was administered to maintain immunosuppression in all cases and antithymocytic globulin was given for induction in 7. RESULTS: Six grafts have failed, including 1 in a patient who underwent successful re-transplantation. Median graft survival was 7.23 years. Two patients died after graft nephrectomy. At a mean followup of 52.8 months (range 1 month to 14 years) 11 of 17 grafts are functioning with a mean serum creatinine of 112.7 +/- 29.4 mmol./l. CONCLUSIONS: These data demonstrate the feasibility of cadaveric renal transplantation in patients with spina bifida and end stage renal failure. We currently recommend that these patients should not be deprived of the benefits of renal transplantation.