Retroperitoneal Soft Tissue Sarcoma: Emerging Therapeutic Strategies.

Retroperitoneal soft tissue sarcoma (RPS) is a rare and heterogenous disease for which surgery is the cornerstone of treatment. However, the local recurrence rate is much higher than in soft tissue sarcoma of the extremities since wide resection is usually unfeasible in RPS due to its large size, indistinct tumour borders, anatomical constraints and the thinness of the overlying peritoneum. Local recurrence is the leading cause of death for low-grade RPS, whereas high-grade tumours are prone to distant metastases. In recent decades, the role of emerging therapeutic strategies, such as more extended surgery and (neo)adjuvant treatments to improve oncological outcome in primary localised RPS, has been extensively investigated. In this review, the recent data on the evolving multidisciplinary management of primary localised RPS are comprehensively discussed. The heterogeneity of RPS, with their different histological subtypes and biological behaviour, renders a standard therapeutic 'one-size-fits-all' approach inappropriate, and treatment should be modified according to histological type and malignancy grade. There is sufficient evidence that frontline extended surgery with compartmental resection including all ipsilateral retroperitoneal fat and liberal en bloc resection of adjacent organs and structures, even if they are not macroscopically involved, increases local tumour control in low-grade sarcoma and liposarcoma, but not in leiomyosarcoma for which complete macroscopic resection seems sufficient. Additionally, preoperative radiotherapy is not indicated for all RPSs, but seems to be beneficial in well-differentiated liposarcoma and grade I/II dedifferentiated liposarcoma, and probably in solitary fibrous tumour. Whether neoadjuvant chemotherapy is of benefit in high-grade RPS remains unclear from retrospective data and is subject of the ongoing randomised STRASS 2 trial, from which the results are eagerly awaited. Personalised, histology-tailored multimodality treatment is promising and will likely further evolve as our understanding of the molecular and genetic characteristics within RPS improves.

Bladder Leiomyoma with Synchronous Solitary Fibrous Tumor of the Pleura.

Bladder leiomyomas (BLs) are extremely rare benign tumors of mesenchymal origin. The exact pathophysiological mechanisms that lead to their appearance remain unclear including hormonal disorders, chromosomal abnormalities, and fetal remnants in the bladder. They usually remain asymptomatic for a long period of time. Solitary fibrous tumors (SFTs) are also rare neoplasms of mesenchymal origin with malignant potential usually affecting the pleura. The pathogenesis of SFTs remains unclear. We report the case of a 28-year-old male presenting with SFT of the pleura and synchronous BL. The patient presented with persistent cough as a sole symptom. Computed tomography (CT) of the thorax revealed a pleural mass, which was surgically removed and proved to be a SFT. At an early follow-up, abdominal CT scan revealed a bladder wall mass that proved to be a BL. This is the first report of BL with synchronous SFT of the pleura. Synchronous BLs and SFTs may be incidental, but the coexistence of two mesenchymal tumors at different sites, in a young patient, may raise the suspicion of a new clinical syndrome that warrants further investigation.

Takotsubo Cardiomyopathy after Spinal Anesthesia for a Minimally Invasive Urologic Procedure.

We present the case of a patient who suffered from Takotsubo cardiomyopathy (TCM) immediately after the initiation of subarachnoid anesthesia for a minimally invasive urologic procedure (tension-free vaginal tape (TVT) surgery for stress urine incontinence). TCM mimics acute coronary syndrome and is caused by an exaggerated sympathetic reaction to significant emotional or physical stress. Our patient suffered from chest pain, palpitations, dyspnea, and hemodynamic instability immediately following subarachnoid anesthesia and later in the postanesthesia care unit. Blood troponin was elevated and new electrocardiographic changes appeared indicative of cardiac ischemia. Cardiac ultrasound indicated left ventricular apical akinesia and ballooning with severely affected contractility. The patient was admitted to coronary intensive care for the proper care and finally was discharged. TCM was attributed to high emotional preoperative stress for which no premedication had been administered to the patient. In conclusion, adequate premedication and anxiety management are not only a measure to alleviate psychological stress of surgical patients, but, more importantly, an imperative mean to suppress sympathetic nerve system response and its cardiovascular consequences.

Contrast-induced nephropathy: Basic concepts, pathophysiological implications and prevention strategies.

Contrast-induced nephropathy (CIN) is reversible acute renal failure observed following administration of iodinated contrast media (CM) during angiographic or other medical procedures such as urography. There are various mechanisms through which CM develop their nephrotoxic effects, including oxidative stress and apoptosis. CIN is a real-life, albeit not very rare, entity. Exact pathophysiology remains obscure and no standard diagnostic criteria apply. The Acute Kidney Injury Network criteria was recently employed but its incidence/clinical significance warrants further clarification based on recent methodological advancements, because most published studies to date were contaminated by bias. The current study is a comprehensive review conducted to provide an overview of the basic concepts of CIN and summarize recent knowledge on its pathophysiology and the evidence supporting potential prevention strategies. CIN is expected to increase morbidity, hospital stay and mortality, while all patients scheduled to receive CM should undergo risk assessment for CIN and high-risk patients may be considered candidates for prevention strategies. The value of using compounds with antioxidant properties other than sodium bicarbonate, remains controversial, warranting further clinical investigation.

Nephrotoxicity in rabbits after long-term nandrolone decanoate administration.

Among the various side effects of supra-physiological dose of anabolic androgenic steroids that are described, renal toxicity remains the least evaluated. The present study provides evidence that long-term administration of nandrolone decanoate could lead to alterations of renal function and structure in the experimental rabbit model. A pronounced increase in serum urea, creatinine, SGOT and SGPT is observed in the treated animals, with intramuscular administration being more detrimental. Histopathological evaluation of kidneys indicated hyperaemia, fibrosis and focal inflammation. Furthermore, the significantly increased telomerase activity found in the kidneys of the intramuscularly treated animals could possibly represent a counteracting survival mechanism. Oxidative stress markers that were influenced the most were TBARS, indicating lipid peroxidation, and GSH. An interesting finding in our study though, was that while intramuscular administration showed the highest biochemical derangement, oxidative stress markers provided mixed results between intramuscularly and subcutaneously treated rabbits. In conclusion, nephrotoxicity of nandrolone decanoate remains a multi-factorial, partly irreversible effect that involves augmented tissue oxidative status.

Dedifferentiated paratesticular liposarcoma with osseous metaplasia.

Paratesticular liposarcoma is a rare tumour of the genitourinary track but the most common of all sarcomas in adults. The dedifferentiated variation occurs only in 10% of liposarcoma cases. The typical clinical presentation is similar to an inguinal hernia or a benign lipoma. We present the case of a dedifferentiated paratesticular liposarcoma with osseous metaplasia of the spermatic cord, in a male presented with acute scrotum.

Hypospadias in offspring is associated with chronic exposure of parents to organophosphate and organochlorine pesticides.

We have currently evaluated the possible association between hypospadias and exposure to organophosphorus (OP) and organochlorine (OC) pesticides. For this purpose, we measured the dialkyl phosphate metabolites of organophosphate pesticides (DAPs) in the hair and blood, as well as OC pesticides (DDTs, HCHs) in the hair collected from children with hypospadias and their parents. The concentration of HCHs in the hair samples obtained from mothers was higher than that previously reported for people working in open cultivations, while the concentration of DDTs in the hair samples obtained from mothers, fathers and their children with hypospadias was much higher than that previously reported for occupationally exposed individuals. The DMP concentration in hair samples obtained from mothers was much higher not only from that reported for the general population, but even higher than that reported for occupationally exposed individuals. Furthermore, SUMDEPs and SUMDAPs in the hair samples obtained both from the hypospadiac boys, as well as from their parents were higher than the corresponding values previously reported for the general population. Our study supports the hypothesis that organophosphate and organochlorine pesticide exposure may be a potential risk factor for hypospadias.

Primary renal angiosarcoma: radiologic-pathologic correlation and literature review.

We present a case of primary renal angiosarcoma. We focus on the characteristic striated pattern of the tumor on T2-w MR sequence as well as on other radiological features and correlate them with the pathologic findings. A review of the imaging characteristics of cases published in the literature was subsequently performed.

First case of complete bladder duplication in the coronal plane with concomitant duplication of the urethra in an adult male.

Duplication of the lower urinary tract is a very rare congenital anomaly which is diagnosed either at birth or during early childhood. These rare malformations are most of the times accompanied by other concomitant anomalies and are therefore diagnosed immediately after birth. In some even rarer cases there are no concomitant anomalies and symptoms thus leading to a diagnosis later in childhood. This is the first case in the literature of complete bladder duplication in the coronal plane with concomitant duplication of the urethra and no other associated anomalies in a 52-year-old male who remained asymptomatic and therefore undiagnosed for more than 5 decades.

Strategic lithotripsy using the Doli S EMSE 220 F-XP for the management of staghorn renal calculi.

AIM: The presentation of our results using the Dornier lithotripter (Doli) S electromagnetic shockwave emitter (EMSE) 220 F-XP for the strategic management of staghorn renal calculi. METHODS: Sixteen patients with renal staghorn stones of more than 35 mm in maximum length on plain X-rays were treated by shock wave lithotripsy (SWL) monotherapy with the Doli S EMSE 220 F-XP. Double-J ureteral stent was inserted to all prior to the first SWL treatment. Shock wave counts varied from 2,500 to 3,600 with a shock release frequency of 70-80 pulses per minute. The number of sessions varied from 2 to 6. The interval between the SWL sessions was around 1 month. Fragmentation rate of 20-25% of the stone load per session was considered a valid criterion for progressing to further SWL sessions. RESULTS: Nine patients became stone free at the end of SWL sessions and two patients had renal stone fragments smaller than 4 mm, which were eliminated 6 months later. Two patients developed streinstrasse that was managed with ureteroscopy. Auxiliary SWL was also performed on three patients with residual ureteral calculi. The mean follow up period was 12 months. The remaining five patients underwent open surgery for incomplete stone fragmentation. No major complications developed during the follow up period. The predominant composition of stones available for analysis was struvite. CONCLUSION: Doli S EMSE 220 F-XP can be a safe and effective treatment option for renal staghorn stones on an outpatient basis.

Extracorporeal shock wave lithotripsy in the treatment of pediatric urolithiasis: a single institution experience.

PURPOSE: To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model. MATERIALS AND METHODS: Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F--XP Dornier lithotripter was used from April 2003 to May 2006. RESULTS: In the first group, 21/26 children (80.7%) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23%), brief hematuria (<24 h) resolved with increased fluid intake in 5 (19.2%), while slightly elevated body temperature (<38°C) occurred in 4 (15.3%). Four children (15.3%) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7%). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26%), brief hematuria (<24 h), resolved with increased fluid intake in 4 (21%) and slightly elevated body temperature (<38° C) monitored for 48 hours occurred in 6 (31.5%). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model. CONCLUSIONS: Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

Extracorporeal shock wave lithotripsy in the treatment of pediatric urolithiasis: a single institution experience

PURPOSE: To compare the efficacy and safety of the electromagnetic lithotripter in the treatment of pediatric lithiasis to that of the earlier electrohydraulic model. MATERIALS AND METHODS: Two groups of children with lithiasis aged between 10 and 180 months who underwent extracorporeal shock wave lithotripsy (ESWL). In the first group (26 children), ESWL was performed by using the electrohydraulic MPL 9000X Dornier lithotripter between 1994 and 2003 while in the second group (19 children) the electromagnetic EMSE 220 F-XP Dornier lithotripter was used from April 2003 to May 2006. RESULTS: In the first group, 21/26 children (80.7 percent) were stone free at first ESWL session. Colic pain resolved by administration of an oral analgesic in 6 (23 percent), brief hematuria (< 24 h) resolved with increased fluid intake in 5 (19.2 percent), while slightly elevated body temperature (< 38°C) occurred in 4 (15.3 percent). Four children (15.3 percent) failed to respond to treatment and were treated with ureteroscopy. In the second group 18/19 children were completely stone free at first ESWL session (94.7 percent). Complications were infrequent and of minor importance: colic pain treated with oral analgesic occurred in 1 (5.26 percent), brief hematuria (< 24 h), resolved with increased fluid intake in 4 (21 percent) and slightly elevated body temperature (< 38°C) monitored for 48 hours occurred in 6 (31.5 percent). Statistical analysis showed that electromagnetic lithotripter is more efficacious and safer than the earlier electrohydraulic model. CONCLUSIONS: Technological development not only has increased efficacy and safety of lithotripter devices in treating pediatric lithiasis, but it also provided less painful lithotripsy by eliminating the need for general anesthesia.

Does educational printed material manage to change compliance with prostate cancer screening?

BACKGROUND/AIM: The effects of printed educational material on cancer screening in women (Pap test and mammography) are well documented and confirmed by several studies. The aim of our study was to evaluate the impact of similar printed educational material on prostate cancer screening by PSA and DRE. MATERIAL AND METHODS: Thousand five hundred men aged between 50 and 86 years of age, who attended our institutions for various medical conditions except prostate-related conditions, were randomly assigned to two study groups. Men in the informed group, received an educational leaflet with simple, general information on prostate cancer screening methods given by their physician along with treatment and other regular recommendations, while men in the non-informed group, were only informed by their physician in the examination room during an interview. RESULTS: After 24 months, there was no statistically significant difference between the two groups in terms of DRE screening. The percentages of men who were actually screened by DRE were 4 and 5% in the informed and non-informed groups, respectively, while the difference in the percentages of PSA screening was of statistical significance, with 31% of men screened in the non-informed group as compared to 93% of men screened in the informational leaflet group. CONCLUSIONS: A single, one-shift distribution of printed educational material on prostate cancer screening, changed their attitude regarding prostate cancer screening only in favour of PSA testing, while did not manage to change the DRE acceptance behavior. However, since the combination of the two tests is more sensitive for diagnosis than either one alone, there is a need of introducing intervention strategies, in the efforts of ameliorating the prostate cancer screening behavior.

Electrothermal bipolar coagulation for radical prostatectomies and cystectomies: a preliminary case-controlled study.

INTRODUCTION: Hemostasis is of utmost importance in urologic cancer surgery. The aim of this initial case-controlled study was to evaluate the use of an electrothermal biporal coagulator (Ligasure device) in major urologic procedures, including open radical prostatectomies and radical cystectomies. MATERIALS AND METHODS: Over the years 2001 to 2002, 58 patients aged 56-74 years (mean: 65 years) underwent open radical prostatectomies and open radical cystectomies performed by the same surgeon, employing either conventional ligation in the control group (radical prostatectomy, n = 15; radical cystectomy n = 9) or the Ligasure device in the study group (radical prostatectomy, n = 24; radical cystectomy n = 10) to ensure blood vessel patency. Effectiveness and postoperative outcomes were evaluated. RESULTS: The 2 groups were similar regarding demographic and clinical variables. The mean operation time was significantly shorter in the Ligasure group compared with the control group for both the prostatectomy (125 minutes vs. 144 minutes, p < 0.001) and the cystectomy procedures (253 minutes vs. 281 minutes, p < 0.001). The mean intra-operation blood loss was significantly lower in the Ligasure group compared with the control group for both prostatectomy (569 ml vs. 685 ml, p = 0.04) and cystectomy procedures (637 ml vs. 744 ml, p = 0.02). Intraoperative blood transfusion was only required in 2 patients (1 radical prostatectomy, 1 radical cystectomy) in the Ligasure group and in 7 patients in the control group respectively (p = 0.01). There was no effect of surgical specimen size on operation time for both prostatectomy (r = -0.03, p = 0.8, n = 39) and cystectomy procedures (r = 0.02, p = 0.9, n = 19). There were no serious intra-operation or postoperative complications related to the use of the Ligasure device. CONCLUSIONS: Ligasure radical prostatectomy and radical cystectomy are safe, and significantly decrease both the operation time and the blood loss, when compared to the conventional ligation method.

Spontaneous perirenal hemorrhage: a 10-year experience at our institution.

OBJECTIVE: To report our experience in patients with spontaneous perirenal hemorrhage (SPH) seen at our institution over a 10-year period. MATERIAL AND PATIENTS: Over the years from 1992 to 2002, 13 patients with SPH without a history of trauma, were treated at our hospital. There were 5 male and 8 female patients with a mean age of 55.7 years (range 36-79 years). The patients' records were reviewed retrospectively with respect to etiology, clinical presentation, radiologic findings and therapeutic management of SPH. RESULTS: All patients were presented with flank or abdominal pain. Radiological evaluation included ultrasonography (U/S) in 7 cases and computed tomography (CT) in 13 cases. An underlying renal mass was indentified employing U/S in 2 cases and using CT in 10 cases respectively. The etiology of SPH was determined in 12 cases. The most common causes were angiomyolipoma (5 patients) and renal cell carcinoma (4 patients). Out of the remaining 4 cases with SPH, one was associated with anticoagulant therapy; polyarteritis nodosa and Wegener angeitis were the underlying diseases in 2 cases respectively; finally, the etiology could not be determined in 1 case. All but two patients were managed surgically. Complete nephrectomy was performed in 6 cases, partial nephrectomy in 4 and simple evacuation of the haematoma was performed in 1 case. CONCLUSIONS: SPH presence should arouse suspicions concerning its etiology, since the most common cause is a renal tumor and approximately 50% of such tumors are malignant. CT scanning is a useful imaging modality for the initial evaluation of SPH, permitting identification of the underlying cause in most instances.