Tumor of the testis of extragonadal origin accidentally found in clinical examination

REVIEWS Factors of Testicular Cancer Ocular side - effects

ORIGINAL ARTICLES Laparoscopic Partial Nephrectomy Management of non Retrac-tile Foreskin Evaluation of the Pps in Opn

CASE REPORTS Tumor of testis Treatment of urinoma

HELLENIC UROLOGY Official Journal of the Hellenic Urological Association

VOLUME 26 | ISSUE 3

JULY AUGUST

SEPTEMBER

2014

Quarterly Publication by the Hellenic Urological Association

Hellenic

ISSN

2241

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Σχετικά με το σκίτσο του εξωφύλλου: Το σχήμα ενσωματώνει εικαστικά την εικόνα του υπερήχου μέσα σε μια κύστη ώστε το ένα να είναι μέρος του άλλου. Το νόημα εμπεριέχεται στην Δαντική φράση: trattando le ombre come cosa salda (απο το 21ου άσμα του Καθαρτήριου).

About the cover drawing: The drawing depicts the image of a cyst ultrasound as if one is part of the other. The meaning is generated by the Dantes phrase: trattando le ombre come cosa salda (21st verse of Purgatorio).

Quarterly Publication by the Hellenic Urological Association

Hellenic

EDITORGeorge MoutzourisPresident of H.U.A.

EDITORIAL BOARD

EDITOR - IN - CHIEF Ioannis Varkarakis

ASSISTANT EDITOR - IN - CHIEF Andreas SkolarikosASSOCIATE EDITORS

Nikolaos FerakisStilianos Giannakopoulos

Athanasios PapatsorisASSISTANT EDITORS Ioannis AdamakisIraklis Mitsogiannis

Konstantinos StamatiouMEMBERS

Charilaos KatsifotisIraklis Poulias

Grigorios Raptidis

Distributed at no charge to all members of the Hellenic Urological AssociationIndexed in Iatrotek and the National Documentation Centre ISSN 2241-9136

HELLENIC UROLOGY OFFICIAL JOURNAL OF THE H.U.A.Address: 23, Ravine St., 115 21 Athens, Greece

tel.: +30 210 7223 126 tel. - fax: +30 210 7245 959 e-mail: [email protected] www.huanet.gr

Published by ZITA CONGRESS & TRAVEL S.A., 1st klm Peanias-Markopoulou Avenue, Peania, Attica, Greece

tel.: +30 211 1001 777, fax: +30 211 1001 779, e-mail: [email protected]

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Instructions to authors 10-13

ReviewsAetiological Factors of the Testicular Cancer. Myths and Reality 15-20Georgios Kallinikas, Konstantinos Stravodimos

Ocular Side-Effects of Urological Pharmacy 21-23Nikolaos A. Kostakopoulos, Vasileios G. Argyropoulos

Original Articles

Laparoscopic Partial Nephrectomy : Initial Experience 24-28Anastasios G. Michalakis, Vasileios Migdalis, Leonidas Karamoutzos, Dimitrios Liapis, Ioannis Siafakas, Grigorios Raptidis

Management of non Retractile Foreskin. A 10-Year Experience 29-35Georgios Pergamalis, Zoi Metaxa, Alexandra Oeconomopoulou, Stavros Diamantopoulos

Evaluation of the Padua Predicting Score (Pps) in Open Partial Nephrectomy (Opn).Can the Prediction of Postoperative Complications Improve? Results of the First Urological Clinic, School of Medicine, University of Athens 36-41Stavros I. Tyritzis, Ioannis Adamakis, Ioannis Anastasiou, Christos Alamanis, Konstantinos Stravodimos, Dionisios Mitropoulos, Konstantinos A. Konstantinidis

Case Reports

Tumor of the Testis of Extragonadal Origin Accidentally Found in Clinical Examination 42-44Konstantinos Stamatiou, Avakian Raffi, Thivi Vasilakaki, Hippocrates Moschouris

Treatment of Urinoma due to Ureteral Perforation by Percutaneous Nephrostomy (Pcn) and Antegrade Placement of Ureteral Stent 45-47Stamatiou Konstantinos, Avakian Raffi, Papadatou Aggeliki, Moschouris Hippocrates

Contents

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Hellenic Urology” is the official scientific jour-nal of the Hellenic Urological Association. Its main objective is to publish original articles, reviews and case reports on diseases of the

genitourinary system. The journal “Hellenic Urolo-gy” is also concerned in the continuous education of the Urologists and aims at promoting the science of Urology. The journal publishes papers, which concern clinical research and scientific achievements. It also welcomes clinical investigations as well as basic and applied laboratory research; new data and recent de-velopments of urological interest are also welcomed. Papers published in another journal are not accepted.

Submission of Papers1. General Information:The official language of “Hellenic Urology” is English. Authors whose native language is not English will have their manuscripts proofread by a professional copye-ditor offered by the editorial team. The authors are al-lowed to submit their manuscript into Greek and trans-lation will be provided.

All the authors are jointly responsible for the contents of the paper and sign together the Authorship Respon-sibility, Financial Disclosure and Acknowledgment form. The list of authors should not exceed six (6) otherwise the participation of those exceeding the above numbers should be justified accordingly. In case of reports, the authors should not exceed four (4). In review articles the authors should not exceed the number of two. The fol-lowing should be observed in the case of clinical studies:a) The authors should state that the research was con-ducted according to the principles as have set forth by the Helsinki Declaration of 1975.b) In the Studies that involve human subjects, a state-ment-approval from the appropriate human ethics com-mittees should be obtained.c) A statement-approval of the competent scientific committee of the centre in which the research work was carried out, pertaining to the protocol of the perspective studies, should be included.

In the case of the experimental studies on animals a statement should be made that the paper has ad-hered to the international guidelines for research in-volving animals, which has been recommended by the WHO, stating that “all research on animals was conducted in accordance with guidelines tendered by international law”.

2. Copyright Transfer:Papers published in Hellenic Urology constitute cop-yright ownership of the manuscript to the Hellenic Urological Association (HUA). Thus any reproduction and/or copying of said manuscript is allowed only af-ter consent of the Editorial Board of the Journal.

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of the manuscript and number of registration. The manuscripts are first checked whether they have been written and submitted according to the instruc-tions of the journal (instructions to authors). Manu-scripts which do not meet the requirements of cor-rect submission are returned to the corresponding author with instructions for due corrections. The man-uscript is double –blind checked by special consult-antsreviewers of the journal.

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The final decision for acceptance of the manuscript lies on the Editorial Board that decides for approval, or return of manuscript for supplementary informa-tion, decision for re-approval or to reject the manu-script. As soon as the paper is accepted and has been allotted final publication, a proof is dispatched to the authors for final checking.

Article types Reviews - maximum 4,000 words, 50 references, 6 tables and 10 figures, Abstract 300 words

Instructions to Authors

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Original Articles - maximum 3,000 words, 30 refer-ences, 6 tables and 10 figures, Abstract 200 words

Case Reports - maximum 1,500 words, 10 referenc-es and 6 figures, Abstract 100 words

Letter to the editor - maximum 600 words, 6 refer-ences, 1 table and 1 figureAll article types should be accompanied by an ab-

stract in Greek. For authors whose native language is not Greek, a Greek translation will be provided by the Editorial Board.

Article structureSubdivisionDivide your article into clearly defined sections. Any subsection may be given a brief heading. Each head-ing should appear on its own separate line.IntroductionState the objectives of the work and provide an ade-quate background, avoiding a detailed literature sur-vey or a summary of the results.Material and methodsProvide sufficient detail to allow the work to be repro-duced. Methods already published should be indicat-ed by a reference: only relevant modifications should be described. Statistical methods should be included in Material and Methods section.ResultsResults should be clear and concise.DiscussionThis should explore the significance of the results of the work, not repeat them. Avoid extensive citations and discussion of published literature.ConclusionsThe main conclusions of the study may be presented in a short conclusions section, which may stand alone or form a subsection of a Discussion section.

Title page information Title Concise and informative. Titles are often used

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SummaryA concise and factual abstract is required. The ab-stract should state briefly the purpose of the research, the principal results and major conclusions. An ab-stract is often presented separately from the arti-cle, so it must be able to stand alone. For this reason, references should be avoided, but if essential, then cite the author(s) and year(s). Also, non-standard or uncommonabbreviations should be avoided, but if essential they must be defined at their first mention in the abstract itself. Abstracts should be structured to include items of Objectives, Methods, Results and Conclusions.

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AbbreviationsIn the main text, abbreviation should be detailed at

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their first mention. Ensure consistency of abbrevia-tions throughout the article.

AcknowledgementsCollate acknowledgements in a separate section at the end of the article before the references. List here those individuals who provided assistance during the research.

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Submit graphics that are disproportionately large for the content.

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References

Citation in textPlease ensure that every reference cited in the text is also present in the reference list. Any references cit-ed in the abstract must be given in full. Unpublished results and personal communications are not recom-mended in the reference list, but may be mentioned in the text. If these references are included in the ref-erence list they should follow the standard reference style of the journal and should include a substitution of the publication date with either 'Unpublished re-sults' or 'Personal communication'. Citation of a ref-erence as 'inpress' implies that the item has been ac-cepted for publication.

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List: Number the references (numbers in square brackets) in the list in the order in which they appear in the text.

Examples:Reference to a journal publication:1. Van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a scientific article. J Sci Commun 2000;163:51–9.

Reference to a book:2. Strunk Jr W, White EB. The elements of style. 3rd ed. New York: Macmillan; 1979.

Reference to a chapter in an edited book:3. Mettam GR, Adams LB. How to prepare anelectronic version of your article. In: Jones BS,Smith RZ, editors. Introduction to the electronicage, New York: E-Publishing Inc; 1999, p. 281–304.

Note shortened form for last page number. e.g., 51–9, and that for more than 6 authors the first 6 should be listed followed by „et al.“ For further details you are referred to „Uniform Requirements for Manu-scripts submitted to Biomedical Journals“ (J Am Med Assoc 1997;277:927–934) (see also http://www.nlm.nih.gov/bsd/uniform_requirements.html). U

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Aetiological Factors of the Testicular Cancer. Myths and Reality, p. 15-20

IntroductionTesticular cancer accounts for 1-1.5% of the total num-ber of neoplasias developing in men and for 5% of the total urological tumors with 3-10 new cases per 100.000 of male population per annum in the Western world. During the 70s and the 80s, an in-cidence increase was recorded, especial-ly in Northern Europe countries, where-as the majority of industrially developed countries in Europe, North America and Oceania present a clear tendency in in-cidence increase. The incidence of tes-ticular cancer has doubled over the last 40 years, yet, it remains a rather uncommon disease and its incidence ranges from 1/100.000 in Asians, Af-ricans and Afro-Americans to 9.2/100.000 in Denmark. The age distribution in patients with testicular cancer is clearly differentiated from that of other malignant neoplasias, with the majority of patients being within the age range of 25-35. A second but clearly smaller ex-treme value in the distribution of such neoplasias ap-pears after the age of 80. Regarding the correlation be-tween race and testicular cancer incidence, the white race evidently presents an increased incidence com-pared to the rest races. The countries mainly exhibit-ing an increase in frequency in the disease develop-

ment are the so-called “Western world countries” like Canada, USA, UK and Scandinavia1. The mortality rates are generally low, with a 5-year survivorship increas-ing from 63% to more than 90% over the last 30 years. Health scientists usually etiologically associate a num-

ber of factors with testicular cancer such as the white race, ectopic testis, gonad-al dysgenesis, family history etc. Howev-er, a thorough review of the literature re-veals fewer than anticipated factors with established aetiological correlation. The present review aims not only to indicate the aetiological factors but also to make

the readership think of the reasons the malignant tes-ticular neoplasias incidence rate to double over the last decades.

The reasons why the malignant testicular neoplasia has doubled over the last decadesCryptorchism: The first reports on the correlation be-tween cryptorchism and testicular cancer trace back to the 19th century. Even though the aetiological corre-lation has not been documented, based on repeated studies, the factor statistically associated with testicu-lar cancer is cryptorchism 2,3,4. Cryptorchism increases the risk of developing testicular cancer by 2 to 4 times;

Aetiological Factors of the Testicular CancerMyths And Reality

Georgios Kallinikas1

Konstantinos Stravodimos2

1Department of Urology, Gartnavel General Hospital , Glasgow, Scotland2First Urological Clinic, University of Athens, School of Medicine– “Laiko” General Hospital, Athens, Attica, Greece

Corresponding author:Kallinikas Georgios, Email: [email protected], Mobile: +306938394765

REVIEW

Testicular cancer constitutes a rather rare malignant neoplasia which primarily affects younger males. The introduction of platinum in the armory of chemotherapeutic agents over the last 40 years, has led to exceptionally high rates in total cancer survivorship. At approximately the same period, the incidence of

the disease has doubled. The aetiological correlations of factors are few so far, and thus, no accepted theory explaining the phenomenon has been established. The present study was realized by searching for published epidemiological studies on the Internet.

Abstract

Key wordscancer, testicles,

epidemiology

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certain studies report the risk of developing testicu-lar cancer in patients with cryptorchism as 5-fold or 10-fold5. Over the last 40 years, Danish epidemiolog-ical data report an increase in the impact of cryptor-chism6. Nonetheless, it is impressive that between the neighboring countries Denmark and Finland, sig-nificant differences have been found in relation to the sperm quality as well as the incidence of cryptorchism7. Between the countries in question, there are differenc-es regarding the incidence of testicular cancer as well8.

Carcinoma in situ (Cis): This specific correlation was first described in the 1970s. In essence, Cis constitutes the precursor histological lesion from which seminomatous and/or non-seminomatous testicular tumors will emerge. Exceptions are the infantile seminoma and sperm cell seminoma. 50% of the patients diagnosed with Cis, will develop invasive cancer within the next 5 years9.

Factors related to pregnancy and perinatal factors: regarding the correlation of birth weight and testicu-lar cancer development, some studies conclude in a positive correlation meanwhile in other studies the correlation is unclear11,12. An increase potential of de-veloping cancer by 50% was observed on premature newborns (born at least 2 weeks earlier than expect-ed), whereas the chances of newborns developing can-cer in the future where limited 10. Based on the above, it was presumed that the positive correlation between premature birth and testicular cancer development is precipitated by the increase exposure to intrauterine oestrogens11.

With respect to children of females smoking during pregnancy, most studies conclude that there is an evi-dent correlation between the risk of developing cancer and smoking during pregnancy11. Interestingly, there is a positive correlation between metachronous lung cancer in females smoking during pregnancy and tes-ticular cancer in their male children. The carcinogenic effect of smoking hereto, is supported by its anti-oes-trogenic effect13.

Hormones: Based on the fact that a) intrauterine ex-posure of the male fetus to increased concentration of oestrogens predisposes for tescticular cancer develop-ment and b) assuming that the intrauterine concentra-tion of oestrogens is increased on first deliveries com-pared to the subsequent ones for the same mother, it is advocated that first-born males exhibit increased probability to develop testicular cancer compared to the next male children. This assumption seems to be supported by a study on males born in Sweden prior to 196014.

Diethylstilbestrol, a hormone prescribed from 1940 until the 1970s to pregnant females for the avoidance

of complications during gestation - later withdrawn due to its documented correlation with the manifes-tation of clear cell vaginal cancer in the female children of pregnant women on the hormone during gestation- is supposed to proportionally relate to the develop-ment of testicular carcinogenesis. However, there is no evidence to prove this assumption so far. In any case, the administration of hormones (any type), seems to condition for developing testicular cancer.11

Factors related to the individual himselfAge: In general terms, cancer is a disease of the el-der adults and testicular cancer is the exception that proves the rule. The age distribution of neoplasia is ev-ident, primarily peaking in ages 25-35 and with a dis-tinct smaller peaking after the age of 80. The manifes-tation of certain cases soon after puberty, led to the presumption that the flood of genital hormones in puberty forces the survivorship and dominance of the cancerous cells15.Race: Testicular cancer cases have a certain increased incidence rate on the white race compared to the oth-er races 16. The aetiology is not yet detected albeit the indications of hormonal involvement. Androgens: A study associating the development of baldness to testicular cancer found that males with ex-tended baldness exhibited a 20% reduced probability of being affected17. Biologically, males with increased androgen values in serum, develop baldness at an ear-lier age. Consequently, the androgens seem to have a protective role.Age of puberty onset: Even though this factor is pure-ly subjective and extremely difficult to define, it is pos-sible that late puberty onset in men acts protectively against developing testicular cancer18.Body Mass Index (BMI): Data on BMI and testicular can-cer association are quite confusing. The risk of malig-nant neoplasia development is reported as increased in both patients with high and low17 BMI. At times, the evidence of any correlation is not obtained12,19,20. The situation is clearer regarding testicular cancer and height; the majority of investigators conclude in a pos-itive correlation between height and cancer20. The con-ceivable aetiology has been attributed to nutritional as well as to hormonal factors (the latter mainly associat-ed with Insulin-like growth factor-IGF21). Working environment: Despite the positive associa-tion between certain professions and testicular can-cer development 22,23,24,25, the study field on the spe-cific factor is endless. DiMethylFormamide (DMF) has been identified as a carcinogenic factor in tanners and aircraft maintenance workers.

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Other potential carcinogenic factors include: fertiliz-ers (especially nitrogen-rich fertilizers), exposure to emissions and smoke and chemical agents used in pesticides. An increased incidence rate of the disease has also been observed in individuals that used to reside in areas with increased water pollution from nitrogens26. Reproductive ability: As “subfertility” we define the “failure to conceive after a year of regular unprotect-ed sexual intercourse with the same partner”27. Subfer-tile males bear the increased risk of growing testicular cancer3. Nevertheless, whether subfertility constitutes a risk factor for the development of testicular cancer or whether cancer and subfertility share aetiology, is a matter that requires authentication.

It is of great interest that after World War II, accord-ing to the epidemiological data, male fertility rates de-cline, whilst at the same period, testicular cancer inci-dence progressively increases28. A data meta-analysis of 61 investigations revealed that during the period 1938 to 199029, a substantive decrease in sperm vol-ume as well as in sperm count is observed. A number of logical assumptions explain this fact: intrauterine exposure to diethylstilbestrol, exposure to environ-mental chemicals which invade and disturb the endo-crine glands function30, change in eating habits subse-quent to the increase of high standard of living31 and the dominance of sedentary life32. These factors sug-gest that the hormonal balance in males is determin-ing in the avoidance of testicular carcinogenesis.Sperm duct ligation or transaction: Around the end of the 1980s, sperm duct ligation or transaction was considered as a predisposing factor for developing tes-ticular cancer. In many countries, the said technique constitutes the most commonly known contracep-tion method. While investigating the credibility of the aforementioned hypothesis, no significant statistical correlation was found3.

Conditions possibly correlated to testicular neoplasmsUnilateral testicular neoplasms: Men with unilateral tes-ticular neoplasm bear increased probabilities of develop-ing testicular cancer to the contralateral testis as well33.Inguinal hernia: Inguinal hernias diagnosed prior to the age of 15, seem to be associated with unilateral tes-ticular neoplasms34.

A great number of infectious and non-infectious fac-tors have been evaluated with regard to their possible correlation to malignant testicular neoplasms. These include: sexually transmitted diseases (STD), hydrocele, infectious mononucleosis (IM), neonatal jaundice (NJ) and parotitis-induced orchitis17,23. In relation to the lat-

ter factor, albeit the evident view to the contrary, no positive correlation has been established 17,3.Other factors:Smoking: Testicular cancer is a disease mainly affect-ing younger ages when the patients either have not started smoking yet or they have not been exposed to the harmful tobacco products for a long term. Electromagnetic Radiation (EMR): The electromagnetic waves have literally invaded our everyday lives over the last 30 years the least. Conducted studies on the association between the electromagnetic fields in non-working environments and the likelihood of de-veloping malignant testicular neoplasias are practi-cally unsubstantial. The single study (which discusses the effect of the electromagnetic waves produced by electric blankets on the possibility of developing ma-lignant testicular neoplasms) does not deliver a posi-tive correlation35.Mechanical trauma: Scrotal trauma used to be con-sidered as a predisposing factor for developing testic-ular tumors26. Nowadays, the trauma in question is no longer considered to cause de novo cancer but rather either to increase the mitotic activity in the af-fected testis or to urge the individual to pay more at-tention in an area where a malignant disorder was pre-viously concomitant.Testicular temperature: Despite the established view to the contrary, no well-documented correlation be-tween the increased testicular temperature and tes-ticular cancer is found yet.

Factors associated with lifestyleSocio-financial status: Increased socio-financial sta-tus is reported as a predisposing factor for testicular carcinogenesis. Education, a widely common index of socio-financial status, has been inculpated as a predis-posing factor for developing testicular cancer.Physical fitness: There are no reliable studies correlat-ing a person’s physical fitness to testicular neoplasms.Eating habits: The association of eating habits with tumorigenesis increasingly gains the way37. Testicular cancer38, as well as a number of hormone-dependent cancers like mammary cancer, prostatic cancer, ovari-an cancer, colorectal cancer, have been correlated with the increased intake of fatty acids. The introduction of increased intake of dairy products since the 1940s and the 1950s coincides with the synchronous increase in malignant testicular carcinogenesis39. Given that the aforementioned products present increased content in female hormones such as oestrogens and proges-terone, it was presumed that the female hormones in the dairy products trigger the development of testicu-

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lar tumors. The intake of vegetable oestrogens through diet does not seem to take part in tumorigenesis 40. The low intake of fruits and vegetables and the increased consumption of meat41 are associated with the possi-bility of growing testicular tumors.Urban residency: It has not been scientifically docu-mented that living in a city constitutes a predisposing factor to developing testicular cancer42.

Familial correlation – genetic predisposition:The increased familial incidence rate of testicular can-cer43,44 guides us to hypothesize the existence of a ge-nome predisposing the development of the disease. Isochromosome 12i(12p) appears in 80% of malignant testicular neoplasias. This is the change most commonly met in cancers of this type45. Chromosomes 7, 8, 12, 21, X additions and chromosomes 11, 13, 18 deletions are frequently observed46. A recently guilty gene is Xq2747 which is found in 33% of testicular cancer cases48.

Testicular germ cell tumors (TGCT) in adolescents and adults are responsible for 1.5-2% of all germ cell tumors in adults. The relative risk (RR) for developing TGCT is 3.8x for fathers, 8.3x for brothers and 3.9x for sons-carriers; this shows that the genetic predispo-sition constitutes an important predisposing factor for developing testicular cancer49. The onset of the disease at an early age, the bilateral existence of tu-mor sites and the increased aggression of the disease suggest familial predisposition50. Investigations into the correlation between genetic predisposition and probability of developing adult testicular cancer51, found a positive correlation at 25%. In general terms,

the changes concerning chromosomal alterations be-tween familial/bilateral and sporadic TGCT are insig-nificant52. Nevertheless, the Testicular Cancer Linkage Consortium (TCLC) has determined an area which is responsible for both the development of testicular cancer and cryptorchism in Xq27. Generally, the view of the genetic predisposition in the development of testicular tumors is underlying, however, the exist-ence of solitary alteration responsible for the totality of malignancies should rather be excluded.

TransgendersIndividuals with 46XY, 45X/46XY gonadal dysgenesis, manifest extremely increased probabilities in devel-oping testicular cancer; some investigators claim it ac-counts for 10-50%.

ConclusionTesticular cancer is a rare type of cancer which primar-ily affects white men and constitutes the most com-mon malignant neoplasma in males aged 15-34. Over the last 40 years, the total survivorship rate has impres-sively increased reaching almost 90% nowadays. Few of the factors reported as aetiological are scientifical-ly documented. Most of them remain to be elucidat-ed. The change in eating habits as well as the environ-mental changes with the addition of chemicals and the increase of exposure to EMR after the World War II coincides with the increase in male subfertility as well as the increase of testicular cancer incidence rate. Per-haps, it is this particular point that investigators should pay more attention to in the future. U

Ο καρκίνος του όρχεως αποτελεί ένα μάλλον σπάνιο κακόηθες νεόπλασμα το οποίο προσβάλλει κυ-ρίως τις νεότερες ηλικίες. Η είσοδος της πλατίνας στη χημειοθεραπευτική φαρέτρα κατά τα τελευ-ταία 40 έτη έχει οδηγήσει σε εξαιρετικά υψηλά ποσοστά συνολικής επιβίωσης. Κατά το ίδιο περίπου χρονικό διάστημα η επίπτωση της νόσου έχει διπλασιαστεί. Οι παράγοντες με αιτιολογική συσχέτι-ση είναι έως τώρα ελάχιστοι με αποτέλεσμα να μην έχει διατυπωθεί κάποια αποδεκτή θεωρεία για την εξήγηση του φαινομένου. Η κάτωθι εργασία πραγματοποιήθηκε κατόπιν αναζητήσεως δημοσιευμένων επιδημιολογικών με-λετών μέσω του διαδικτύου.

Περίληψη

Λέξεις ευρετηριασμού

καρκίνος, όρχεις,

επιδημιολογία

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1. Dos Santos Silva I, Swerdlow AJ, Stiller CA, Reid A. Incidence of testicular germ-cell malignancies in England and Wales: trends in children compared with adults. Int J Cancer J Int Can-cer 1999;83(5):630–4.

2. Swerdlow AJ, De Stavola BL, Swanwick MA, Maconochie NE. Risks of breast and testicular cancers in young adult twins in England and Wales: evidence on prenatal and genetic aetiolo-gy. Lancet 1997;350(9093):1723–8.

3. Møller H, Knudsen LB, Lynge E. Risk of testicular can-cer after vasectomy: cohort study of over 73,000 men. BMJ 1994;309(6950):295-9.

4. Herrinton LJ, Zhao W, Husson G. Management of cryp-torchism and risk of testicular cancer. Am J Epidemiol 2003;157(7):602–5.

5. Swerdlow AJ, De Stavola B, Maconochie N, Siskind V. A pop-ulation-based study of cancer risk in twins: relationships to birth order and sexes of the twin pair. Int J Cancer J Int Cancer 1996;67(4):472–8.

6. Boisen KA, Kaleva M, Main KM, et al. Difference in prevalence of congenital cryptorchidism in infants between two Nordic countries. Lancet 2004;363(9417):1264–9.

7. Jørgensen N, Carlsen E, Nermoen I, et al. East-West gradient in semen quality in the Nordic-Baltic area: a study of men from the general population in Denmark, Norway, Estonia and Fin-land. Hum Reprod Oxf Engl 2002;17(8):2199-208.

8. Adami HO, Bergström R, Möhner M, et al. Testicular cancer in nine northern European countries. Int J Cancer J Int Cancer 1994;59(1):33-8.

9. Rørth M, Rajpert-De Meyts E, Andersson L, et al. Car-cinoma in situ in the testis. Scand J Urol Nephrol Suppl 2000;(205):166-86.

10. Coupland CAC, Forman D, Chilvers CED, Davey G, Pike MC, Oli-ver RTD. Maternal risk factors for testicular cancer: a popula-tion-based case-control study (UK). Cancer Causes Control Ccc 2004;15(3):277–83.

11. Weir HK, Marrett LD, Kreiger N, Darlington GA, Sugar L. Pre-na-tal and peri-natal exposures and risk of testicular germ-cell cancer. Int J Cancer J Int Cancer 2000;87(3):438–43.

12. Rasmussen F, Gunnell D, Ekbom A, Hallqvist J, Tynelius P. Birth weight, adult height, and testicular cancer: cohort study of 337,249 Swedish young men. Cancer Causes Control Ccc 2003;14(6):595–8.

13. Kaijser M, Akre O, Cnattingius S, Ekbom A. Maternal lung can-cer and testicular cancer risk in the offspring. Cancer Epidemi-ol Biomarkers Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 2003;12(7):643–6.

14. Richiardi L, Akre O, Lambe M, Granath F, Montgomery SM, Ek-bom A. Birth order, sibship size, and risk for germ-cell testicu-lar cancer. Epidemiol Camb Mass 2004;15(3):323–9.

15. Møller H, Evans H. Epidemiology of gonadal germ cell cancer in males and females. Apmis Acta Pathol Microbiol Immunol Scand 2003;111(1):43-46; discussion 46-48.

16. Parkin DM; M, C. s , Whelan, S. L. , Gao, Y.-t , Ferlay, J. , Pow-ell, J. (eds. Cancer Incidence in Five Continents, Volume 6. un-known; 1993.

17. Petridou E, Roukas KI, Dessypris N, et al. Baldness and other correlates of sex hormones in relation to testicular cancer. Int J Cancer J Int Cancer 1997;71(6):982–5.

18. Weir HK, Kreiger N, Marrett LD. Age at puberty and risk of tes-ticular germ cell cancer (Ontario, Canada). Cancer Causes Con-trol Ccc 1998;9(3):253–8.

19. Davies TW, Prener A, Engholm G. Body size and cancer of the testis. Acta Oncol Stockh Swed 1990;29(3):287–90.

20. Richiardi L, Askling J, Granath F, Akre O. Body size at birth and adulthood and the risk for germ-cell testicular cancer. Cancer Epidemiol Biomarkers Prev Publ Am Assoc Cancer Res Cospon-sored Am Soc Prev Oncol 2003;12(7):669–73.

21. Khandwala HM, McCutcheon IE, Flyvbjerg A, Friend KE. The ef-fects of insulin-like growth factors on tumorigenesis and neo-plastic growth. Endocr Rev 2000;21(3):215–44.

22. Hayes RB, Brown LM, Pottern LM, et al. Occupation and risk for testicular cancer: a case-control study. Int J Epidemiol 1990;19(4):825–31.

23. Mills PK, Newell GR, Johnson DE. Testicular cancer associated with employment in agriculture and oil and natural gas extrac-tion. Lancet 1984;1(8370):207–10.

24. Rhomberg W, Schmoll HJ, Schneider B. High frequency of met-alworkers among patients with seminomatous tumors of the testis: a case-control study. Am J Ind Med 1995;28(1):79–87.

25. Van den Eeden SK, Weiss NS, Strader CH, Daling JR. Occupa-tion and the occurrence of testicular cancer. Am J Ind Med 1991;19(3):327–37.

26. Møller H. Work in agriculture, childhood residence, nitrate ex-posure, and testicular cancer risk: a case-control study in Den-mark. Cancer Epidemiol Biomarkers Prev Publ Am Assoc Cancer Res Cosponsored Am Soc Prev Oncol 1997;6(2):141-4.

27. Wong WY, Thomas CM, Merkus JM, Zielhuis GA, Steegers-The-unissen RP. Male factor subfertility: possible causes and the in-cidence of nutritional factors. Fertil Steril 2000;73(3):435–42.

28. Jensen TK, Toppari J, Keiding N, Skakkebaek NE. Do environ-mental estrogens contribute to the decline in male reproduc-tive health? Clin Chem 1995;41(12 Pt 2):1896–901.

29. Carlsen E, Giwercman A, Keiding N, Skakkebaek NE. Evidence for decreasing quality of semen during past 50 years. BMJ 1992;305(6854):609–13.

30. Oliver RT, Oliver JC. Endocrine hypothesis for declin-ing sperm count and rising incidence of cancer. Lancet 1996;347(8997):339–40.

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31. Joffe M. Are problems with male reproductive health caused by endocrine disruption? Occup Environ Med 2001;58(4):281–287; quiz 287–288, 260.

32. Sharpe RM. Lifestyle and environmental contribution to male infertility. Br Med Bull 2000;56(3):630–42.

33. Colls BM, Harvey VJ, Skelton L, Thompson PI, Frampton CM. Bi-lateral germ cell testicular tumors in New Zealand: experience in Auckland and Christchurch 1978-1994. J Clin Oncol Off J Am Soc Clin Oncol 1996;14(7):2061–5.

34. Coupland CA, Chilvers CE, Davey G, Pike MC, Oliver RT, Forman D. Risk factors for testicular germ cell tumours by histological tumour type. United Kingdom Testicular Cancer Study Group. Br J Cancer 1999;80(11):1859–63.

35. Verreault R, Weiss NS, Hollenbach KA, Strader CH, Daling JR. Use of electric blankets and risk of testicular cancer. Am J Epi-demiol 1990;131(5):759–62.

36. Haughey BP, Graham S, Brasure J, Zielezny M, Sufrin G, Burnett WS. The epidemiology of testicular cancer in upstate New York. Am J Epidemiol 1989;130(1):25–36.

37. Swerdlow AJ, De Stavola BL, Swanwick MA, Mangtani P, Ma-conochie NE. Risk factors for testicular cancer: a case-control study in twins. Br J Cancer 1999;80(7):1098–102.

38. Sigurdson AJ, Chang S, Annegers JF, et al. A case-control study of diet and testicular carcinoma. Nutr Cancer 1999;34(1):20–6.

39. Sharpe RM, Skakkebaek NE. Are oestrogens involved in falling sperm counts and disorders of the male reproductive tract? Lancet 1993;341(8857):1392–5.

40. Walcott FL, Hauptmann M, Duphorne CM, Pillow PC, Strom SS, Sigurdson AJ. A case-control study of dietary phytoestrogens and testicular cancer risk. Nutr Cancer 2002;44(1):44–51.

41. Gallagher RP, Huchcroft S, Phillips N, et al. Physical activ-ity, medical history, and risk of testicular cancer (Alber-ta and British Columbia, Canada). Cancer Causes Control Ccc 1995;6(5):398–406.

42. Schouten LJ, Meijer H, Huveneers JA, Kiemeney LA. Urban-rural differences in cancer incidence in The Netherlands 1989-1991. Int J Epidemiol 1996;25(4):729–36.

43. Westergaard T, Olsen JH, Frisch M, Kroman N, Nielsen JW, Mel-bye M. Cancer risk in fathers and brothers of testicular cancer patients in Denmark. A population-based study. Int J Cancer J Int Cancer 1996;66(5):627–31.

44. Hemminki K, Li X. Cancer risks in twins: results from the Swedish family-cancer database. Int J Cancer J Int Cancer 2002;99(6):873–8.

45. Murty VV, Chaganti RS. A genetic perspective of male germ cell tumors. Semin Oncol 1998;25(2):133–44.

46. Van Echten J, Timmer A, van der Veen AY, Molenaar WM, de Jong B. Infantile and adult testicular germ cell tumors. a different pathogenesis? Cancer Genet Cytogenet 2002;135(1):57–62.

47. Rapley EA, Crockford GP, Teare D, et al. Localization to Xq27 of a susceptibility gene for testicular germ-cell tumours. Nat Gen-et 2000;24(2):197–200.

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Ocular Side-Effects of Urological Pharmacy, p. 21-23

IntroductionContinuous advances in the treatment of several uro-logical diseases and conditions are associated with the development of novel drugs and the evolution of old-er agents as well. The above may have led to a rising number of prescriptions of urological medications by non-specialized physicians, an evolving incidence of prescriptions with irrational drug combi-nation and an increasing rate of side ef-fects occurrence. Actually, most of the medication currently used in the treat-ment of benign prostatic hyperplasia, uri-nary bladder instability and erectile dys-function is safe for most of the patients, however several of them may develop oc-ular side effects. The last may result in a disproportion-ate concern both for the patients and the clinicians. In this article, we outline several ocular side effects of the most commonly prescribing urological medications and we provide information on their frequency, natu-ral history and clinical importance.

1. 5-Phosphodiesterase inhibitors (5-PDE Inhibitors: Sildenafil, Tadalafil)

The main ocular side effect associated with phosphodi-esterase inhibitors use is the non-Arteritic Anterior Is-chemic Optic Neuropathy (NAION). Actually, few clini-cians are aware of an unusual and yet unpleasant side

effect of these agents. NAION is the most common cause of acute optic neuropathy in adults and it de-velops in 1.500-1.600 individuals annually in the USA

1,2,3. Fifty NAION cases associated with phosphodiester-ase inhibitors intake have been reported up-to-date 4,5. NAION develops upon reduced arterial infiltration at the anterior lamina of the optic disc, causing sparse

retinal infarcts 6. Predisposing factors are: hypertension hyperlipidemia diabetes mellitus (DB) and ischemic heart disease (IHD).

Almost all patients developing NAION, usually manifest optic disc congestion which results in ischemia of optic nerve

axes as they are compressed among them. It has been documented that the 5-PDE inhibitors may deteriorate the optic nerve ischemia and result in vision loss, by af-fecting the nitrogen monoxide levels in the optic nerve vascularisation 5.

It should be mentioned that 5-PDE inhibitors re-main the most effective medical treatment option for the management of erectile dysfunction 7. Re-cent data do not provide clear evidence indicating that the 5-PDE inhibitors use constitute an independ-ent predisposition factor for developing NAION. How-ever, patients should be informed of the possibility to suffer from vision loss. This should be particular-ly stressed to IHD or atherosclerosis predisposed pa-

Ocular Side-Effects of Urological PharmacyNikolaos A. Kostakopoulos, Vasileios G. Argyropoulos

Department of Urology, IASO General Hospital, Athens, Greece

Corresponding author:Nikolaos A. Kostakopoulos, e-mail: [email protected]

REVIEW

The increasing rate of aging population worldwide has resulted in a more frequent diagnosis of aging related urological diseases and conditions such as benign prostatic hyperplasia, urinary bladder instability and erectile dysfunction. This has subsequently led to the wider prescription of medications such as phosphodiesterase

inhibitors, antimuscarinic agents and alpha-inhibitors which may induce severe ocular side effects. This review outlines potential ocular side effects of the above-mentioned drugs, provides information on their frequency and natural history and highlights their importance to the clinician.

Abstract

Key wordsurological

medications, ocular side effects

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tients. Patients with pre-existing monocular NAION should not be prescribed phosphodiesterase inhib-itors given that the risk of developing NAION in the other eye exceeds 20%.

2. Antimuscarinic agents (oxybutynin, tolterodine)The bladder’s detrusor muscle is rich in innervations with muscarinic receptors. Muscarinic acetylcho-line (mACh) receptor antagonists reduce the con-tractions of detrusor muscle and usually improve symptoms of overactive bladder syndrome (OAB) such as frequency and urgency. Intraocularly, there is a stable condition between the formation and the absorption of the aqueous humor (AqH) which is re-sponsible for the humidification of the basic ocu-lar structures and the maintenance of the organ’s spherical shape. Normal intraocular pressure pres-ervation depends on the AqH outflow. Any intraocu-lar pressure increase may be caused by the increased resistance in the AqH outflow (open-angle glaucoma – OAG) or stricture/obstruction in the anterior cham-ber (closed-angle glaucoma – CAG) due to trabecu-lar meshwork (TM) dysfunction. The iris constantly changes its shape being affected by the parasympa-thetic (muscarinic) (PNS) and the sympathetic nerv-ous system (SNS). The antimuscarinic agents cause mydriasis. In those patients with an anatomical “nar-row” angle, this may result in acute occlusion of the drainage angle. This particular case constitutes an ocular emergency which, if not treated, may cause permanent vision loss. Vision loss cases have been reported after angle occlusion episodes induced by oxybutynin 8 and other anticholinergic agents e.g. propiverine 9. Prognosis is favoured by accurate di-agnosis and early treatment.

CAG should be managed with laser iristomy dur-ing or after an acute episode. This prevents any fur-ther acute episodes by creating an alternative path for the AqH outflow and thusly preventing obstruc-tion. When treated, the risk of an episode anew is zero. Therefore, anticholinergic treatment in pa-tients with surgically treated CAG is safe.

Regarding clinicians, their poor update on glau-coma creates confusion over the management of OAB and glaucoma 9. Both may co-exist in the el-derly. By definition, OAG bears no evidence of AqH outflow mechanical obstruction and accordingly the anticholinergic treatment is safe 10.

Prior to anticholinergic agents administration, tak-ing a detailed history of the glaucoma patient is of vital importance. Anticholinergic agents must be avoided in patients reporting a narrow angle not

surgically treated. In patients on anticholinergic medication, it must be recommended emergency medical consultation in case of painful eye redness or acute vision loss.

3. a- Blockers (e.g. tamsulosin, alfuzosin ) The main ocular side effect associated with a Block-ers use is the Intra-operative floppy iris syndrome- IFIS.

Selective a1-antagonists are widely used in the im-provement of lower urinary tract obstruction symp-toms and micturition flow. Pharmacologically, a1-sub-type presents the greatest interest in BPH treatment. On the other hand, both the iris and the protective tis-sue present a variety of several a-receptors subtypes 11. Those of a1-subtype have an important role in the cataract surgical treatment. In fact, safe and successful cataract surgical treatment requires full and maintain-able dilation of the pupil. The insufficient dilation in-creases the risk of intra-operative complications given that the surgical site is disturbed 12. The eye is pharma-cologically dilated prior to cataract surgery. In normal conditions, this dilation lasts throughout the surgery. Intra-operative cataract surgery difficulties have been reported in patients receiving tamsulosin. It has been found that, in stable intraocular conditions, the iris is pathologically mobile and tends to prolapse towards the surgical instruments. During surgery, an iris spasm has also been observed which usually does not re-spond to the pharmacological treatment. The spasm in question limits the surgical site and technically im-pedes the procedure. These intra-operative findings are known as Intra-operative floppy iris syndrome (IFIS).

Chang and Campbell (12) studied over 500 patients who had been subjected to more than 700 cataract procedures over a 12-month period. They found that the total IFIS impact accounted for 2%. However, 63% of the patients on a-inhibitors developed IFIS during the cataract procedure. 94% of IFIS patients had been receiving tamsulosin on a regular basis. Traditional in-tra-operative techniques for the iris dilation during oc-ular surgery, e.g. mechanical dilation or dissection of the iris sphincter are ineffective in such cases.

Several IFIS-induced complications have been re-ported including iris atrophy and capsular rupture. Fur-ther studies have also shown increased impact of the complications in IFIS eyes. The complications in ques-tion were more common when on tamsulosin com-pared to terazosin 13. Once the surgeon is informed of the tamsulosin intake, s/he may use several alternative strategies for the improvement of the surgical site 14. To avoid the aforementioned complications, pre-op-

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erative interruption of the a-inhibitors for 1-2 weeks is advised 15,16,17.

ResultsIt is a fact that a pool of urological conditions (BPH, un-detected prostatic cancer, OAB, atonic bladder, geni-tal glands infection, erectile dysfunction etc) can now-adays be safely and effectively treated with applicable

pharmacy. Some of these medicines are now widely prescribed by unqualified clinicians causing great con-cern about ocular side-effects. It should be fully under-stood that the ocular complications induced by urolog-ical pharmacy administration are rare, yet manageable. Nevertheless, the appropriate cooperation and com-munication between the urologist and the ophthal-mologist is an undoubted prerequisite. U

Η αυξανόμενη γήρανση του πληθυσμού έχει σαν αποτέλεσμα συχνότερη εμφάνιση συμπτωμάτων καλοήθους υπερπλασίας του προστάτη, ασταθούς κύστεως και στυτικής δυσλειτουργίας. Αυτό έχει σαν επακόλουθο ευρεία συνταγογράφηση. φαρμάκων, όπως αναστολέων της φωσφοδιεστεράσης, αντιμουσκαρινικών παραγόντων και α-αναστολέων που προκαλούν μερικές φορές σοβαρές παρε-νέργειες από τους οφθαλμούς. Σ΄αυτή την ανασκόπηση θα αναφερθούν περιληπτικά οι διάφορες δυνητικές οφθαλμικές παρενέργειες, η συχνότητά τους, η φυσική τους ιστορία και η σημασία τους για τον κλινικό γιατρό.

Περίληψη


ουρολογικά φάρμακα, οφθαλμικές

παρενέργειες

1. Hayreh S. Anterior ischemic optic neuropathy. Arch Neurol 1981;38: 675-8

2. Mcgwin Gl, Vaphiades M, Hall T, Owsley C. Non-arteritic ante-rior ischaemic optic neuropathy and the treatment of erectile dysfunction.Br J Ophthalmol 2006;90:154-7

3. Hattenhauer M, Leavitt J, Hodge D, Grill R, Gray D. Incidence of nonarteritic anterior ischemic optic neuropathy. Am J Ophthal-mol 1997;123:103-7

4. Tomsak R. PDE5 inhibitors and permanent visual loss. Int J Im-pot Res 2005;17: 547-9

5. Pomeranz H, Smith K, Hart Wj, Egan R. Sildenafil-associated nonarteritic anterior ischemic optic neuropathy. Ophthalmol-ogy 2002; 109: 584-7

6. Pomeranz H. Can erectile dysfunction drug use lead to ischae-mic optic neuropathy. Br J Ophthalmol 2006; 90:127-8

7. Palumbo F, Bettocchi C, Selvaggi F, Pryor J, Ralph D. Sildenafil : efficacy and safety in daily clinical experience.Eur Urol 2001; 40:176-80

8. Sung V, Corridan P. Acute-angle closure glaucoma as a side-ef-fect of oxybutynin. Br J Urol 1998;81: 634-5

9. Kato K, Yoshida K, Suzuki K, Murase T, Gotoh M. Managing pa-tients with an overactive bladder and glaucoma: a question-naire survey of Japanese urologists on the use of anticholiner-gi BJU Int 2005;95:98-101

10. Ouslander J, Blaustein J, Connor A, Orzeck S, Yong C. Pharma-

cokinetics and clinical effects of oxybutynin in geriatric pa-tients. J Urol 1988;140:47-50

11. Schwinn D, Afshari N. alpha (1)-Andrenergic receptor antag-onists and thiris: new mechanistic insights into floppiris syn-drome. Surv Ophthalmol 2006;5:501-12

12. Chang D, Campbell J. Intraoperative floppy iris syndrome asso-ciated with tamsulosin. J Cataract Refract Surg 200;31:664-73

13. Blouin M, Blouin J, Perreault S, Lapointe A, Dragomir A. Intra-operative floppy-iris syndrome associated with alpha1-adreno-receptors: comparison of tamsulosin and alfuzosin J Cataract Refract Surg 2007;33:1227-34

14. Chang D, Osher R, Wang L, Koch D. Prospective multicenter evaluation of cataract surgery in patients taking tamsulosin (flomax).Ophthalmology 2007;114:957-64

15. Srinivasan S, Radomski S, Chung J, Plazker T, Singer S, Slomov-ic A. Intraoperative floppy-iris syndrome during cataract sur-gery in men using alpha-blockers for benign prostatic hyper-trophy. J Cataract Refract Surg 2007;33:1826-7

16. Lawrentschuk N, Bylsma G. Intraoperative “floppy iris “ syn-drome and its relationship to tamsulosin: a urologist´s guide.BJU Int 2006;97:2-4

17. Pärssinen O, Leppänen E, Keski-Rahkonen P, Mauriala T, Dugué B, Lehtonen M. Influence of tamsulosin on the iris and its im-plications for cataract surgery. Invest Ophthalmol Vis Sci 2006; 47:3766-71

References

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Laparoscopic Partial Nephrectomy: Initial Experience, p. 24-28

IntroductionThe widespread use of abdominal imaging modali-ties and especially ultrasound has resulted in an increase in the detection of incidental small renal masses 1. Open partial nephrec-tomy (OPN) is the gold standard procedure for the treatment of masses less than 4 cm and even in less than 7cm, if it is technically feasible 2, offering the same oncological re-sults as radical nephrectomy 3. Additionally, patients who undergo partial nephrectomy have better renal function and are less like-ly to require renal replacement therapy than patients who undergo radical nephrectomy 4,5.

Laparoscopic partial nephrectomy (LPN) is an alter-native option to OPN demostrating comparable onco-

logical and functional results, adding reduced morbid-ity and offering all the advantages of minimal invasive

surgery (less hospital stay, quicker recov-ery, less blood loss and need for transfu-sion, better cosmetic result , less postoper-ative complications etc.) 6 . Unfortunately, LPN is technically challenging and laparo-scopic experience is a prerequisite in order to reproduce the same results as the open procedure 7. In our study we present our in-itial experience in laparoscopic partial ne-phrectomy for small renal masses.

Patients and methodsBetween October 2012 and March 2014, 9 consecu-tive patients (6 males and 3 females) were diagnosed

Laparoscopic Partial Nephrectomy: Initial Experience

Anastasios G. Michalakis, Vasileios Migdalis, Leonidas Karamoutzos, Dimitrios Liapis, Ioannis Siafakas, Grigorios Raptidis

251 Airforce General Hospital, Urology Department

Corresponding author:Anastasios G. Michalakis, Urology Department, 251 Airforce General Hospital and Veterans, Kanellopoulou 3 – Goudi, Athens , GreeceTel: +302107463849, Fax:+302107715690, email : [email protected]

ORIGINAL PAPER

INTRODUCTION: Partial nephrectomy is considered the gold standard procedure in managing small renal masses less than 4cm. Minimal invasive surgery is a alternative option in those cases. Laparoscopic partial nephrectomy has equivalent oncological results with open partial, offering in the same time all the advantages of minimal invasive surgery. The purpose of our study is to present our initial experience in laparoscopic partial nephrectomy.MATERIAL AND METHODS: Between October 2012 and March 2014, 9 selected patients with enhancing renal masses observed by CT scan, were submitted to laparoscopic partial nephrectomy. Patient demographics, preoperative tumor characteristics and detailed operative , postoperative and pathologic data were collected.RESULTS: 6 patients had a right partial nephrectomy and 3 a

left one, with no intraoperative complications. In one patient a laparoscopic radical nephrectomy was done because of bleeding. The operation time ranged from 120 to 225 min, estimated blood loss (EBL) ranged from 30 to 300 ml and warm ischemia time (WIT) ranged from 15 to 42 min. One patient didn’t require any hilar clamping. Overall, no transfusions were necessary and there were no intraoperative or major postoperative adverse events. One patient occurred with a small subcutaneous haematoma in a port side and another one with a slight transient haematuria which was resolved spontaneously. There was one patient with a microscopic positive surgical margin and all patients are disease free at the 6 month follow up .CONCLUSION: Laparoscopic partial nephrectomy is a safe and feasible approach in small renal masses, offering all the advantages of minimal invasive surgery.

Abstract

Keywords partial

nephrectomy, laparoscopy,

initial experience, renal tumor

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with small enchancing renal masses discovered in computed tomography (CT). For the prediction of potential morbidity of the nephron sparing surgery, the R.E.N.A.L. Nephrometry score was used (8). Lapa-roscopic partial nephrectomy was performed by one surgeon with previous laparoscopic experience in up-per urinary tract. Patient demographics and preoper-ative tumor characteristics are presented in Table 1. There were no cases with multiple renal tumors or pre-vious renal surgery. Perioperative data included oper-ative time ( time from the completion of trocar place-ment till the extraction of the specimen), estimated

blood loss (EBL), warm ischemia time (WIT) and intra-operative complications. Intraoperative complications included significant injury to an adjacent organ, major vessel, ureter or pleura and conversion for visceral inju-ry or hemorrhage. The pathology results are presented in Table 3. Patients with renal tumors were scheduled to perform an ultrasound or a CT scan in a 6 month in-terval follow up according to European Urology Guide-lines follow up protocol.

Surgical techniqueThe patients were placed in the flank position with the operative side facing up, and the operating table par-tially flexed. The abdomen was insufflated with CO2

via transperitoneal optical trocar access to a maxi-mum pressure of 12 mmHg. Five trocars were placed at the end (two five mm ports, one 12mm port , one 11mm port and the optical trocar for the camera). Af-ter insufflation was observed, the colon was refleced medially and the kidney was exposed from the lower pole to the upper pole. The renal pedicle was identi-fied and the Gerota’s fascia was dissected over the kid-ney. The lesion was identified and the edges of it was marked using the Hook. A laparoscopic Satinski clamp was placed and both the renal artery and vein was oc-cluded. In one case the hole procedure was done with-out clamping. Using laparoscopic scissors the lesion was excised. The collecting system was repaired using a 3-0 V loc suture. For renal reconstruction 3-0 polyg-lactin sutures was placed through the renal capsule in a continuous manner using sliding Hemolok clips at the

TAbLE 1 Patient demographicsVariable Mean (range) or number

Age, years 53,37 (45-67) Gender (male/female) 06/03/14Tumor sideLeft 3Right 6 Tumor size pathology data

2,7 ( 1,2 – 4,5 ) cm

Tumor locationUpper pole 2Mid pole 3Lower pole 4Nephrometry score4a 45a 36a 18p 1

TAbLE 2 Perioperative VariablesVariable Mean (range) or number

ORT (min) 174(120-225) EBL (ml) 187 (30-300)

WIT (min)

Hilar clamping en block 8 cases 28,8min (15-42)

No clamping 1 case

Conversion to lap radical nephrectomy

1

Transfusion 0

Hospital stay (days) 3 (2-5)

Intraoperative complications

0

Postoperative complications

2

Urinary leak 0

TAbLE 3 Pathologic dataVariable Mean (range) or number

Positive surgical margins 1Malignant tumor histologyClear cell 6Papillary 0Chromophobe 1Microvascular invasion 0Fuhrman grade1 02 63 1Benign tumorsOncocytoma 1Angiomyolipoma 1

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edges of it. The Satinski clamp was released and the in-tra abdominal pressure was lowered to 6mmHg. Then an hemostetic agent (Floseal) was placed over the tu-mor bed. The tumor was placed in a laparoscopic or-gan bag and a 15F Jackson – Pratt drain was placed around the kidney.

ResultsPerioperative data and final pathology reports are pre-sented in table 2 and 3. Six patients had a laparoscopic partial nephrectomy on the right side and three on the left side. One patient had a conversion to laparoscopic radical nephrectomy because of uncontrollable hem-orrhage. None of the other patients had an intraop-erative complication. Tumor sizes ranged between 1,2 cm and 4,5 cm as it were measured in the final pa-thology report. For the categorization of the tumors the R.E.N.A.L. nephrometry score was used. Most of the tumors were mainly exophytic and the nephrometry score was from 4a to 8p. Three patients had a lower pole tumor, two had an upper pole tumor and three had a mid pole tumor. Mean operative time was 174 min (120-225 min), counting from the insertion of the trocars till the extraction of the specimen. Mean esti-mated blood loos was 187 ml ( 30 -300 ml), mean warm ischemia time was 28,8 min (15 - 42min) and mean hos-pital stay was three days 2 -5. No patient needed a trans-fusion. All patients had a satisfactory renal function after surgery ; none suffered from postoperative hem-orrhage or developed a clinical significant urine leak. One patient developed a small subcutaneous hemat-oma in one port side and another one presented with a mild hematuria. All of the complications were consid-ered minor acccording to the Clavien- Dindo classifi-cation 9,10 and were treated by observation or medical measures. No patient required operative reintervention. The pathology report demonstrated the following re-

sults; six patients had a clear cell adenocarcinoma, one patient had a chomophobe carcinoma , one had an on-cocytoma and one had an angiomyolipoma. One pa-tient had a microscopic positive surgical margin. Pa-tients with low risk tumors defined as stage pT1a – b Fuhrman grade 1 or 2 had an ultrasound and a chest ra-diograph in 6 month period and a CT scan in one year . Patients with intermediate risk tumors defined as high grade Fuhrman 3-4 had a 6 month CT scan and a chest X-ray.

DiscussionOver the past two decades the role of partial nephrec-tomy has been expanding. By providing oncologic out-comes equivalent to radical nephrectomy, along with improved preservation of renal function, partial ne-phrectomy has become established as a standard of care for renal masses, even in patients with a normal kidney.5,7

Laparoscopic partial nephrectomy has become the less invasive alternative approach , offering equivalent oncological results to open partial, while offering pa-tients a shorter hospital stay and recovery time 6,11-13.

In our study we present our initial experience in lap-aroscopic partial nephrectomy, performed by one surgeon with previous laparoscopic experience in up-per urinary tract. All the patients had rather exophytic masses with low nephrometry score. Upper pole tum-ors were more difficult because a greater mobilization of the kidney was needed in order to have a better ex-posure of the tumor. Unfortunately no intraoperative ultrasound was used and the excision of the masses was based on meticulous study of the preoperative CT scan . Both renal artery and vein was occluded and that was necessary in order to have a bloodless field and clear visibility, which lowers the positive surgical mar-gin. The important of hilar control prior to mass exci-sion, in order to obtain adequate hemostasis, has been

Image 1: Preoperative CT scan Image 2: Specimen

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suggested by other authors 14–16. The median ischemia time was 28 minutes which is lower than the 30 min-utes limit which is set as safety for renal preservation. In one case we avoided hilar clamping because the tu-mor was small and mostly exophytic. No major peri-operative complication was occurred and no patient had a blood transfusion. Only in one patient, after an initial trial to control the bleeding with sutures, we performed a radical nephrectomy laparoscopically. That was happened because the Satinski clamp was malfunctioned in a way that the renal hilum was not clamped at all. Estimated blood loss, peri and post op-erative complications and mean hospital stay are fol-lowing the published literature for laparoscopic par-tial nephrectomy series14-16.

Laparoscopic partial nephrectomy may be the most challenging and complex laparoscopic technique performed by any surgeon, given the requirement for perfect extirpation and satisfactory reconstruc-tion within a limited time 17. In experienced hands laparoscopic procedure can duplicate both function-al and oncological results of open partial nephrecto-my. Warm ischemia time is the most important factor that has to be lowered as much as possible. Clampless partial nephrectomy is an option but it is quite diffi-cult in big , central located tumors, needs great ex-perience and it raises the percentage of positive sur-gical margins 18.

The present study has several inherent limitations because it is a prospective study with a small cohort of highly selected patients (with no control arms) who

were only followed for a short period of time. Never-theless, the present study was able to show that laparo-scopic partial nephrectomy is a safe and feasible option for the management of selected small renal tumors. Furthermore, our operative time, estimated blood loss and WIT results were comparable to those of previous LPN studies, whish is rather encouraging because the present series reflects our initial experience.

Open partial nephrectomy is still considered to be the gold standard for the treatment of renal tumors less than 7cm according to the EAU Guidelines . How-ever, laparoscopic partial nephrectomy is alternative procedure which in experienced hands has equiva-lent oncologic and functional outcomes with a slight-ly bigger proportion of WIT and Clavien III/IV compli-cation rate 19,20. Our future perspectives are to expand our indications in bigger and more endophytic tum-ors in order to offer to our patients all the advantag-es of laparoscopic partial nephrectomy, with accepted oncological and functional results.

ConclusionsLaparoscopic partial nephrectomy is a feasible and safe approach to remove small renal masses amena-ble to partial nephrectomy, offering all the advantag-es of laparoscopic surgery (less blood loss, less pain , shorter hospital stay, quicker recovery time, etc). Our future aim is to extent our indications in bigger and more complex masses and at the same time to lower the WIT as mush as possible, and even perform clamp-less laparoscopic partial nephrectomies. U

Η

Περίληψη

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1. Belldegrun A, Tsui KH, deKernion JB, Smith RB: Efficacy of nephron-sparing surgery for renal cell carcinoma: analysis based on the new 1997 tumor-node-metastasis staging system. J Clin Oncol. 1999; 17: 2868-75.

2. European Urology Guidelines 2014,3. Fergany AF, Hafez KS, Novick AC: Long-term results of nephron

sparing surgery for localized renal cell carcinoma: 10-year follow up. J Urol. 2000; 163: 442-5

4. McKiernan J, Simmons R, Katz J, Russo P: Natural history of chronic renal insufficiency after partial and radical nephrecto-my. Urology. 2002; 59: 816-20.

5. Lau WK, Blute ML, Weaver AL, Torres VE, Zincke H: Matched com-parison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal con-tralateral kidney. Mayo Clin Proc. 2000; 75: 1236-42.

6. Gill IS, Kavoussi LR, Lane BR, Blute ML, Babineau D, Colombo JR Jr, et al.: Comparison of 1,800 laparoscopic and open partial ne-phrectomies for single renal tumors. J Urol. 2007; 178: 41-6.

7. Porpiglia F, Volpe A, Billia M, Scarpa RM : Laparoscopic versus open partial nephrectomy: analysis of the current literature Eur Urol 2008;53:732-42;discussion 742-3

8. Kutikov A., Uzzo RG., The R.E.N.A.L. Nephrometry score :a com-prehensive standarized system for quantitating renal tumor size location and depth J Urol 2009 Sep;182(3) 844-53

9. Clavien PA, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholocyst-ectomy. Surgery 1992 May;111(5):518-26

10. Dindo D, Demartines N, Clavien PA. Classification of surgical com-

plications: a new proposal with evaluation in a cohort of 6336 pa-tients and results of a survey. Ann Surg 2004 Aug;240(2):205-13

11. Uzzo RG, Novick AC.,.Nephron sparing surgery for renal tumors: indications, techniques and outcomes. J Urol 1993;149:1633-6

12. Gong EM., Orvieto MA., Zorn KC, et al. Comparison of laparo-scopic and partial nephrectomy in clinical T1a renal tumors J Endourol 2008;22:953-7

13. Lane BR, Gill IS. 5-year outcomes of laparoscopic partial ne-phrectomy. J Urol 2007;177:70-4

14. Abukora F, Nambirajan T, Albqami N, et al . Laparoscop-ic nephron sparing surgery : evolution in a decade. Eur Urol 2005;47:488-93

15. Kim FJ, Rha KH, Hernandez F, et al. Laparoscopic radical ver-sus partial nephrectomy : assessment of complications. J Urol 2003;170:408

16. Finelli A, Gill IS, Laparoscopic partial nephrectomy: Contempo-rary technique and results. Urol Oncol 2004;22:139

17. Guillonneu B., Bermudez H, Gholami S, et al Lparoscopic partial nephrectomy for renal tumor : single center experience com-paring clamping and no clamping techniques of the renal vas-culature. J Urol 2004;171:1443

18. Gordon A., Brown. MD, Surena F, Matin MD Laparoscopic par-tial nephrectomy : Experience in 60 cases

19. White WM, Goel RK, Haber GP, Kaouk JH: Robotic partial ne-phrectomy without renal hilar occlusion

20. Aliaf ME, Bhayani SB, Rogers C, Varkarakis I, Link RE, Inagaki T, et al. Laparoscopic partial nephrectomy : evaluation of long term oncological outcomes J Urol 2004;172:871-3

References

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Management of non Retractile Foreskin. A 10-Year Experience, p.29-35

IntroductionThe term “phimosis” (from the Greek word “φίμωση”- pronounced “fimosi” which means “closure”) is used to describe the difficulty in retracting the prepuce (non retractile foreskin). The three different clini-cal conditions causing non retractile foreskin are: a) preputial adhesions (Figure 1), b) partial or physi-ological phimosis or narrow preputial ring (Figure 2) and c) complete or pathological phimosis or bal-anitis xerotica obliterans-BXO and cicatricial steno-sis (Figure 3) 1-3.

The inadequate understanding of the structure, function and development of the prepuce in the past and the non-classification of phimosis into par-tial and complete, has led a great number of the pop-ulation to the surgical removal of the prepuce (cir-

cumcision)4-7. Apart from the religious canons and cultural traditions mandating circumcision, in many countries, it has been observed that a great num-ber of newborns, infants and children were subject-

Management of non Retractile Foreskin A 10-Year Experience

Georgios Pergamalis, Zoi Metaxa, Alexandra Oeconomopoulou, Stavros DiamantopoulosIaso Children’s Hospital

Corresponding author:Alexandra Oeconomopoulou, 5, Myrtidiotissis street, Alimos, PC 17456, Attica, Greece, Tel: 2109922820 , Mob: ++306972747503, Email: [email protected]

ORIGINAL PAPER

AIM: The aim of this study is to present the management of non retractile foreskin, with the minimum intervention, when this is judged essential. It was worked out under a protocol which determined the aetiology of closed prepuce, the indications for its opening, the choice of therapeutic methods (conservative or surgical) and recorded the treatment results for 10 years. MATERIALS & METHODS: During 1998-2008, 812 children, aged 1-15 years, were presented with phimosis. 608 children (74.9%) had at least one medical indication for preputial opening, while in 204 children (25.1%) there was no intervention established and re-examination was recommended. The 608 children were divided into three groups depending on the cause of non retractile foreskin. 99 children (Group A) exhibited preputial adhesions, 489 children (Group B) had partial or physiological phimosis and 20 children (Group C) had complete or pathological phimosis. Groups B and C were treated with betamethasone cream, and then, where

possible, preputial opening was performed, while group A was managed with direct adhesiolysis.RESULTS: Of the 204 children in which no intervention was realized, 122 (60%) were followed up 3-7 years later and the foreskin automatically opened at 75%. 404 children (82.8%) in Group B responded to treatment with betamethasone cream while, in Group C the preputial opening resulted from a combination of betamethasone and preputioplasty for 11% (two children) of the study group. Out of all 608 children, 90 children (14.8%) underwent preputioplasty and 17 children (2.9%) circumcision. CONCLUSIONS: The opening of the prepuce before puberty should be performed if specific medical indications are present. In children with partial phimosis, topical betamethasone cream results to the opening up of prepuce in high percentage whereas a low percentage is scheduled for preputioplasty. In complete phimosis, the majority will not escape circumcision.

Abstract

Figure 1. Preputial adhesions

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Management of non Retractile Foreskin. A 10-Year Experience, p. 29-35

ed to circumcision without manifesting clear medi-cal indications8-11.

The establishment of the important role of the pre-puce in the penile function and sexual intercourse and the failure of false impressions as per the great-er morbidity rate of the genitourinary sys-tem in uncircumcised males resulted in the review of non retractile foreskin man-agement 12,13. Conservative treatments by topical corticosteroids application (SAIDs) and alternative surgical techniques (preputioplasty) aiming to the preserva-tion of the prepuce, were proposed.

In the present study, we point out the re-sults of the least invasive opening non re-tractile foreskin, when deemed necessary, based on a protocol for a period of 10 years.

Materials & methodsThe protocol followed, determined the non retractile foreskin aetiology, the med-ical indications for opening, when judged essential, the treatment method and the recording of the results.

During 1998-2008, 812 children aged 1-15 years pre-sented to the office. The children in question were re-ferred to by pediatricians throughout Greece for non retractile foreskin, commonly reported by them as “phimosis”.

Out of the 812 children, 204 (25.1%) exhibited prepu-tial adhesions, showing no medical indication for fore-skin opening and thusly no procedure was performed. The parents were informed that the foreskin would open spontaneously and that they should only re-vis-it in case one of the medical indications for opening arose. Follow-up was recommended before puberty by explaining the reasons to the parents (painful erec-tions, masturbation, sexual intercourse).

608 children (74.9%) presenting at least one medi-

cal indication for preputial opening, were divided into 3 groups depending on the non retractile foreskin ae-tiology, as follows:

Group A: 99 children (16.2%) with preputial adhesions Group B: 489 children (80.5%) with partial phimosis

– narrow prepuce and Group C: 20 children (3.2%) with true

phimosis. Of them, 8 children were diag-nosed with BXO and 12 with post-trau-matic phimosis, based on their history and clinical evaluation.

75% of Group A children referred to with preputial adhesions, had episodes of bal-anoposthitis. Of Group B children with narrow foreskin, 12 (2.45%) were asymp-tomatic, whereas 477 (78.4%) manifest-ed episodes of balanoposthitis, 25 (4.2%) children showed prepuce dilation during micturition (ballooning), 13 (2.1%) suf-fered from an episode of paraphimosis, 20 children (3.3%) had previous urinary tract infection (UTI) and 421 (69.3%) exhibited

concentration of apoptosed epithelial cells between the prepuce and the foreskin and complained of local-ized discomfort.

All 20 BXO children of Group C (100%) had recurring episodes of balanoposhtitis - 12 of them were trauma-tized in their effort to violently manipulate the fore-skin (Chart 1).

ResultsManagement was based on the non retractile fore-skin protocol followed in our clinic. 14 (Chart 2)In 204 children (25.1%) with asymptomatic prepu-tial adhesions and narrow preputial ring, no treat-ment was applied. A follow-up in 10 years time was advised except for the cases where balanoposthi-tis, paraphimosis, UTIs or concentration of epitheli-al cells would develop in the meantime - in such cas-

Keywords non retractile

foreskin, preputioplasty,

circumcision, preputial

adhensions, physiologic or

partial phimosis, pathologic

or complete phimosis

Figure 2. Narrow foreskin Figure 3. Balanitis Xerotica Obliterans (BXO)

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es, the earlier re-examination was recommended. It was stressed that no effort should be put in retract-ing the foreskin which, to a great extent, would open spontaneously until the age of 10; if at the age of 10 the foreskin had not opened, then, an opening pro-cedure would be performed.

The rest 608 children (74.9%), presenting one

of the foreskin opening medical indications, were treated with betamethasone cream 0.05% for 4 or 5 weeks and they were advised to re-visit the office on the 5th or 6th week for foreskin opening procedure.

Children with symptomatic preputial adhesions (Group A) underwent foreskin opening and direct preputial adhesiolysis by topical anaesthetic ap-

Chart 1. Narrow foreskin

0

100

200

300

400

500

600 SyptomaticAsyptomatic

Chart 2. Symptoms

TAbLE 1 (DATA OF CHART 2 ) Symptoms (608 children)

A B CBalanoposthitis 95(15.6%) 477(78.4%) 20(3.2%)Ballooning - 25(4.2%) 3(0.3%)Paraphimosis - 13(2.1%) -UTI - ACM 1x1.7 cm

Concentration of apoptosed epithelial cells – local discomfort

87(14.2%) 421(69.3%) 5(0.7%)

TOTAL 99(16.2%) 489(80.5%) 20(3.2%)

0

100

200

300

400

500 BalanoposthitisBallooningParaphimosisUTILocal discomfortTotal

CBA

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plication (EMLA) and orally administered analge-sics (paracetamol). Children with narrow foreskin (Group B) underwent foreskin opening and prepu-tial adhesiolysis on the 5th or 6th week subsequent-ly to the betamethasone treatment. We also treated all children with BXO or cicatricial stenosis (Group C) with betamethasone, having previously informed their parents of the few chances of treatment suc-cess. Children in Group B, whose foreskin remained non retractile even after the conservative treatment, underwent preputioplasty whereas, those in Group C whose treatment did not prove favorable, under-went circumcision.

All children who underwent foreskin opening were followed-up 1 month and 1 year later.

60% of the children, who were not subjected to any kind of procedure, were followed-up 3-7 years later and their foreskin opened spontaneously by 75%. To the betamethasone treatment, 404 children (82.8%) of Group B responded well, whereas in 11% (2 children) of Group C, foreskin opening was accom-plished via a combination of betamethasone admin-istration and preputioplasty. Out of 608 children pre-senting medical indication for foreskin opening, 90 children (14.8%) underwent preputioplasty and 17 underwent (2.9%) circumcision.

24 children of Group A (25%) with preputial adhe-sions exhibited recurring adhesions and adhesiol-ysis was performed anew. 85 children from Group B (17.2%) with preputial stenosis, re-visited the of-fice with preputial restenosis in less than a year’s time and a second session took place with topical treatment with betamethasone. 70 of said children (14.4%), eventually underwent preputioplasty. In 6 (8.5%) children with narrow foreskin who had been subjected to preputioplasty, foreskin stenosis re-curred and we finally proceeded with hemi-circum-cision (removal of the inner preputial lamina). Out of the 20 children with BXO and cicatricial stenosis (Group C), 19 (95%) were eventually operated; 2 chil-dren (11%) had a preputioplasty and 17 (85%) were circumcised.

Discussion Non retractile foreskin in childhood may be caused by three different clinical conditions. 3,6,7,10,15

a) Preputial adhesions which are physiologic ep-ithelial tissue intervening between the foreskin and the prepuce. Usually, they lyse spontaneously and the prepuce separates from the inner preputial lam-ina within the first 6 months up to 3 years. However, it is not uncommon that they persist until puberty.

Chart 3: Algorithm of non retractile foreskin management

NON RETRACTILE FORESKIN

PREPUTIAL ADHESIONS

PARTIAL OR PHYSIOLOGIC PHIMOSIS – NARROW FO

SKIN

COMPLETE OR PATHOLOGIC PHIMOSIS

PRIOR TO PUBERTY ONSET

PUBERTY ONSET SAIDs TRETAMENT

ASYMPTOMATIC

BALANOPOSTHITIS

UNACCOMPANIED UTI ?

BALLOONING?

IMROVEMENT SAME CONDITION

SAIDs MANAGEMENT

CURE

SAME CONDITION

LATERAL PREPUTIOPLASTY

NO MANAGEMENT

CIRCUMCISION

PREPUTIAL ADHESIOLYSIS

PARAPHIMOSIS ?

CONCENTRATION OF APOPTOSED EPITHELIAL CELLS – LOCAL DISCOMFORT

PUBERTY

ON

SET

PRIOR TO PUBERTY

ON

SET

BALANOPOSTHITIS

CONCENTRATION OF APOPTOSED

EPITHELIAL CELLS – LOCAL DISCOMFORT

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b) Partial or pathologic phimosis or narrow preputial ring, a tissue ring around the preputial or-ifice which usually expands until the age of 5-7 years or rarely until puberty, and

c) Complete or pathologic phimosis - in children, it is usually induced by cicatricial stenosis or BXO. Cicatricial stenosis develops after an injury result-ing from forcible retraction. BXO usually develops af-ter the age of five and bears definite clinical aspects differentiating it from narrow foreskin, although this differentiation is not always clear, since no objective criteria have been set 4,6,13,16,17 .

Taking into consideration the foreskin develop-ment until puberty and its important role in sexual intercourse, it should be understood that non retrac-tile foreskin does not need opening prior to sexual intercourse onset except in cases presenting specif-ic medical indications.

Patients with persistent non retractile foreskin of all causes, should undergo foreskin opening at pu-berty onset (after the age of 10) to facilitate prepuce retraction. The reason is the difficulty (pain) they will encounter during masturbation and sexual inter-course as well as the risk of developing secondary phimosis induced by friction.

The medical indications for opening non retractile foreskin prior to sexual intercourse onset and its man-agement are proportionate to the cause. Namely,

a) Preputial adhesions (Figure 1). Medical indi-cations for opening the non retractile foreskin due to the existence of preputial adhesions is balanop-osthitis and local discomfort (itching and stinging) which increase friction and the possibility to devel-op balanoposthitis.

Nevertheless, asymptomatic patients do not re-quire any treatment, let alone prior to sexual inter-course onset on condition that the non retractile foreskin persists. When adhesiolysis is considered necessary, it should be performed by a surgical instru-ment following the application of a topical anaesthet-ic. The attempt to forcibly retract the foreskin by the hands results in traumas at the prepuce orifice which may cause scars (fibrosis) and complete phimosis.

b) Complete or partial phimosis (BXO, post-trau-matic cicatricial stenosis (Figure 2). BXO usually de-velops after the age of 5 and is histologically man-ifested as skin oedema, lymphatic infiltration and degeneration of the Malpighian layer (stratum mal-pighi)4,18. Most authors consider circumcision (sur-gical removal of the foreskin) as the most advisable treatment yet, others support that the combination of topical steroidal anti-inflammatory drugs (SAIDs) ap-

plication and preputioplasty at an early stage is effec-tive in about 20% of the patients 11,15-17,20. The question is, of course, if it is worth trying to preserve prepuce via this approach by subjecting a child to a second procedure (circumcision) given the small rate of res-toration in BXO cases. Post-traumatic cicatricial steno-sis is induced by a trauma caused during violent ma-nipulation of the foreskin to retract.

c) Partial or pathologic phimosis (narrow prepu-tial ring). Medical indications for the opening of the narrow foreskin and the retraction of the prepuce pri-or to sexual activity onset are recurrent balanoposthi-tis, scars at the prepuce orifices which mainly result from the attempt to open the foreskin and localized discomfort. The foreskin dilation during micturition (ballooning), unaccompanied UTI and paraphimosis have been the subject of controversy regarding their management 21.

Until the beginning of the 1970s, the narrow fore-skin was restored by circumcision. Later, alternative treatments were proposed aiming to the preservation of the foreskin in cases where its amputation was not deemed necessary.

Management with topical SAIDs has many sup-porters claiming that the restoration rate reaches 70-90%. The treatment plan includes topical SAIDs (betamethasone 0.05%) for 4-5 weeks twice on a dai-ly basis with subsequent attempt to open the fore-skin10,11,15,22-24. Some authors suggest the application of topical nonsteroidal anti-inflammatory drugs-NSAIDs (Diclofenac)25.

Management of partial phimosis with preputio-plasty is effective in the expansion of the narrow ring without removing the foreskin. Several preputio-plasty techniques have been applied10,22,26,27. Lateral preputioplasty is preferred, in our opinion, given that compared to the rest of the approaches, bears the smallest rate of re-stenosis and has a better aesthetic result. When non retractile foreskin opening is judged essential, a topical SAIDs treatment should be applied at first and in case the results are not the anticipated ones, to proceed with preputioplasty.

ConlusionsΝon retractile foreskin is due to preputial adhe-sions, partial or physiologic phimosis and complete or pathologic phimosis. The accuracy of diagnosis is crucial – all these different clinical conditions require different management.

Partial phimosis and preputial adhesions are nor-mal conditions and until puberty onset, we expect the spontaneous foreskin opening; complete phimo-

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ΣκοΠοΣ της μελέτης αυτής είναι να παρουσιάσει τον τρόπο αντιμετώπισης της κλειστής ακροποσθίας, με την μικρότερη δυνατή παρέμβαση, όταν αυτή κρίνεται απαραίτητη. Εκπονή-θηκε βάσει πρωτοκόλλου το οποίο καθορίζει τα αίτια της κλει-στής ακροποσθίας, τις ενδείξεις διάνοιξης αυτής, την επιλογή των θεραπευτικών μεθόδων (συντηρητικών ή χειρουργικών) και καταγράφει τα αποτελέ-σματα της αντιμετώπισης για χρονικό διάστη-μα 10 ετών. ΥΛικο-μέθοδοΣ. Κατά το διάστημα 1998-2008, 812 παιδιά, ηλικίας 1-15 χρονών, προ-σήλθαν σε τακτικό ιατρείο με την αιτιολογία της φίμωσης. Τα 608 παιδιά (74,9%) είχαν μία του-λάχιστον ένδειξη διάνοιξης της ακροποσθίας, ενώ στα 204 παιδιά (25,1%) δεν έγινε καμία πα-ρέμβαση και συστήθηκε επανέλεγχος. Τα 608 παιδιά χωρίστηκαν σε τρεις ομάδες ανάλογα με την αιτιολογία της κλειστής ακροποσθίας. Βα-λανοποσθικές συμφύσεις είχαν 99 παιδιά (ομά-δα Α), μερική ή φυσιολογική φίμωση είχαν 489 παιδιά (ομάδα Β) και ολική ή παθολογική φίμωση είχαν 20 παιδιά (ομάδα Γ). Στις ομάδες Β και Γ χορηγήθηκε θεραπεία με τοπική εφαρμογή κρέ-

μας βηταμεθαζόνης, και στη συνέχεια έγινε διάνοιξη της ακρο-ποσθίας, όπου ήταν εφικτό, ενώ στην ομάδα Α έγινε συμφυσιό-λυση άμεσα. ΑΠοτέΛέΣμΑτΑ. Από τα 204 παιδιά στα οποία δεν έγινε καμία παρέμβαση τα 122 (60%) επανελέγχθηκαν 3-7 χρόνια μετά και

η ακροποσθία άνοιξε αυτόματα στο 75%. Στη θεραπεία με βηταμεθαζόνη ανταποκρίθηκαν 404 παιδιά (82,8%) της ομάδας Β, ενώ στην ομάδα Γ η διάνοιξη της ακροποσθίας έγινε με συνδυασμό χορήγησης βηταμεθαζόνης και πλαστικής σε ποσοστό 11% (2 παιδιά). Από τα 608 παιδιά, 90 παιδιά (14,8%) υπεβλήθησαν σε πλαστική της ακροποσθίας, ενώ 17 παιδιά (2,9%) σε περιτομή.ΣΥμΠέρΑΣμΑτΑ. Η διάνοιξη της ακροπο-σθίας πριν την εφηβεία πρέπει να διενεργεί-ται εφόσον υπάρχουν συγκεκριμένες ενδείξεις. Στα παιδιά με μερική φίμωση η χορήγηση βη-ταμεθαζόνης έχει ως αποτέλεσμα τη διάνοιξη

της ακροποσθίας σε υψηλό ποσοστό ενώ μικρό ποσοστό οδηγεί-ται σε πλαστική αποκατάσταση της ακροποσθίας. Στην ολική φί-μωση το μεγαλύτερο ποσοστό δεν θα αποφύγει την περιτομή.

Περίληψη


κλειστή ακροποσθία,

βαλανοποσθικές συμφύσεις,

φυσιολογική φίμωση, παθολογική

φίμωση

sis is primarily manifested after the age of five.Opening prior to puberty onset should only be per-

formed based on specific medical indications. None-theless, if the foreskin is still non retractile at the be-ginning of puberty, the opening is mandatory in order to avoid any problems during sexual intercourse.

When deemed necessary, the non retractile foreskin opening procedure must be the most conservative one aiming to the preservation of the prepuce. Cir-cumcision should only be performed when all other approaches have proved ineffective, thusly consider-ing circumcision of total necessity.

The treatment option for preputial adhesions is ad-hesiolysis. The opening of narrow foreskin is initially attempted with topical SAIDs and, in case of failure, it is managed with preputioplasty. BXO is the sole cause of non retractile foreskin where circumcision seems to advance over other treatment methods, although the combination of SAIDs and preputioplasty should be studied in further. Concluding, it should be stressed out that topical SAIDs treatment, preputioplasty or the combination of both may prevent foreskin ampu-tation which protects the prepuce and is of great im-portance in sexual intercourse. U

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1. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CDJ. Circum-cision for phimosis and other medical indications in Western Australian boys. Med J Aust 2003, 178: 155-158

2. Rickwood AMK, Kenny SE, Donnell SC. Towards evidence based circumcision of English boys: survey of trends in practice. BMJ 2000, 321: 792-793.

3. Paddy A. Dewan. Treating phimosis. MJA 2003, 178(4):148-1504. Rickwood AM, Walker J. Is phimosis over diagnosed in boys and

are too many circumcisions performed in consequence? Ann R Coll Surg Engl 1989, 71: 275-277.

5. Spilsbury K, Semmens JB, Wisniewski ZS, Holman CD. Routine cir-cumcision practice in Western Australia 1981-1999. ANZ J Surg. 2003 Aug, 73(8):610-4

6. Chao Yang, Xing Liu, Guang-Hui Wei, Foreskin develop-ment in 10 421 Chinese boys aged 0-18 years, World J Pediatr 2009;5(4):312-315

7. P.Kumar, M. Deb, K. Das, Preputial Adhesions – A Misunderstood Entity, Indian Journal of Pediatrics (2009), Volume 76, 829-832

8. Griffiths D, Frank JD. Inappropriate circumcision referrals by GPs. J R Soc Med 1992,85:324–5

9. Williams N, Chell J, Kapila L. Why are children referred for circum-cision? Br Med J 1993, 306: 28

10. O. Quaba, G.A. MacKinlay, Changing Trends in a Decade of Cir-cumcision in Scotland Journal of Pediatric Surgery, (2004) 39, 1037-1039

11. C.S. Kikiros, S.W. Beasley, A.A. woodward, The response of phi-mosis to local steroid application, Pediatr Surg Int (1993) 8: 329-332

12. JR Taylor, AP Lockwood, AJ Taylor. The prepuce: specialized mu-cosa of the penis and its loss to circumcision. Br J Urol 1996, 77:291-5

13. CJ Cold, JR Taylor The prepuce. Br J Urol 1999, 83.(Suppl. 1): 34-4414. G. Pergamalis, Phimosis: myth and reality, Ann Clin Paediatr

2008, 55 (1):49-5815. C.Esposito,A.Centonze, F.Alicchio,A.Savanelli, A.Settimi , Top-

ical steroid application versus circumcision in pediatric pa-tients with phimosis: a prospective randomized placebo con-

trolled clinical trial, World J Urol (2008) 26:187–19016. M.V.Vincent, E.MacKinnon, The response of clinical balanitis

xerotica obliterans to the application of topical steroid-based creams, Journal of Pediatric Surgery (2005) 40, 709–712

17. Das S, Tunuguntla HS. Balanitis xerotica obliterans-a review. World J Urol. 2000 Dec, 18(6):382-7.

18. Gordon Α. and Collin J. Save the normal foreskin. ΒΜJ 1993, Vol 306, Pages 1-2.

19. N.Zampieri,M. Corroppolo, V.Zuin, S. Bianchi,F.S. Camoglio, Phi-mosis and topical steroids: new clinical findings, Pediatr Surg Int (2007) 23:331–335

20. Kiss A, Csontai A, Pirot L, Nyirady P, Merksz M, Kiraly L. The re-sponse of balanitis xerotica obliterans to local steroid application compared with placebo in children. J Urol 2001, 165: 219-220.

21. Babu R, Harrison SK, Hutton KA. Ballooning of the foreskin and physiological phimosis: is there any objective evidence of ob-structed voiding? BJU Int 2004, 94(3):384-7.

22. A.Dessantia, G.Ginesua, M.Iannuccellia, A.Balata, Phimosis. Preputial plasty using transversal widening on the dorsal side with EMLA local anesthetic cream, Journal of Pediatric Surgery (2005) 40, 713–715

23. Ashfield JE, Nickel KR, Siemens DR, MacNeily AE, Nickel JC. Treatment of phimosis with topical steroids in 194 children. J Urol. 2003 Mar, 169(3):1106-8.

24. Elmore JM, Baker LA, Snodgrass WT. Topical steroid therapy as an alternative to circumcision for phimosis in boys young-er than 3 years. J Urol. 2002 Oct, 168(4 Pt 2):1746-7; discus-sion 1747.

25. M. Kemal Atilla, Rusen Dündaröz, Oner Odabas, Haluk Oztürk, Ridvan Akin and Erdal Gökçay.A non surgical approach to the treatment of phimosis: local nonsteroidal anti-inflammatory ointment application. Journal of Urology July 1997, Volume 158: pages 196-197.

26. Lane TM, South LM. Lateral preputioplasty for phimosis J.R.Coll.Surg.Edinb. October 1999, 44:310-12.

27. J.C.Langer, A.L.Winthrop, Ventral slit for phimosis and paraphi-mosis in children, Pediatr Surg Int (1995) 10: 209-210

References

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Evaluation Of The Padua Predicting Score (Pps) In Open Partial Nephrectomy (Opn), p. 36-41

Introduction:Radical nephrectomy (RN) used to constitute the gold standard management for RCC, however, the change in the characteristics of newly diagnosed ne-oplasms, led the surgical technique to also adjust by the gradual application and prevalence of partial ne-phrectomy (PN). PN oncologic outcomes are equiva-lent to RN outcomes, yet, they greatly advance over the first given the preservation of the renal unit and the improved quality of life (QOL) in patients5. These positive outcomes have resulted to the rapid and wide acceptance of the technique which now con-stitutes a therapeutic approach in treating T1a and T1b tumors, where feasible, according to the guide-lines of the European Association of Urology (EUA)6.

PN is a technically challenging procedure in which the anatomy of the kidney and the tumor site affect the perioperative outcomes. The treatment choice for patients who are candidates for PN is mainly

based on the radiographic and morphological fea-tures of the tumor. For the best preoperative assess-ment of the patients and the prediction of postop-erative outcomes and complications, several scoring systems have been suggested. Namely, in 2009, Fi-carra et al presented the preoperative aspects and dimensions used for an anatomical (PADUA) score as a prediction tool for the postoperative complica-tions after PN, utilizing the tumor’s morphological parameters as these are available from the preop-erative assessment on computed tomography7. Fol-lowing a study conducted in our clinic, where we, as external observers, had validated the score with out-comes justifying the initial application of the PADUA score8, we applied PADUA in a new series of our pa-tients and we tried to investigate on the possibility of its improvement by adding extra parameters ei-ther preoperatively available or associated with the surgical procedure.

Evaluation Of The Padua Predicting Score (Pps) In Open Partial Nephrectomy (Opn)

Can The Prediction Of Postoperative Complications Improve?Results Of The First Urological Clinic, School Of Medicine, University Of Athens

Stavros I. Tyritzis 1,2,3, Ioannis Adamakis1, Ioannis Anastasiou1, Christos Alamanis1, Konstantinos Stravodimos1, Dionisios Mitropoulos1, Konstantinos A. Konstantinidis11.

First Urological Clinic, School of Medicine, University of Athens – “Laiko”, University General Hospital of Athens, Greece2. Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden

3. Center for Minimally Invasive Urologic Surgery, Athens Medical Center, Greece

Corresponding author:Stavros I. Tyritzis, L. Kifisias 39, 11523, Athens, e-mail:[email protected]

ORIGINAL PAPER

Over the last years, important changes have taken place on the incidence rate and natural course of renal cell carcinoma (RCC). We observe a significant incidence increase rate in new diagnoses, over-doubled from 7.1 cases per 100.000 of population in the USA to 15.3 and from 2.3% to 4.3% over the last 30 years. Deaths remain practically stable from 3.6 to 3.9; 5-year survivorship

related to the disease has increased from 52.1 to 73.5% 1. Most patients are now diagnosed at T1 stage2. These changes are primarily due to the introduction in everyday medical practice of modern imaging methods (ultrasounds, X-ray, MRI) facilitating more and earlier diagnoses3. The most common treatment choice is the tumor’s surgical removal4.

Abstract

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Materials & MethodsDuring 2009-2012, retrospective analysis was per-formed on 63 consecutive OPNs. All patients were sub-jected to the same surgical technique. The access was extraperitoneal with lumbar section – complete re-nal immobilization and vascular pedicle preparation preceded. Hot ischemia was accomplished via vessel loop in 60 cases; ischemia was not performed in the rest 3 cases. Tumor localization and resection margins were optically identified without use of fluorescence assay. The surgical resection was performed with cold biopsy forceps unaccompanied by diathermy applica-tion and included supra-tumoral en block dissection of the adipose capsule of the kidney (perirenal fat). No re-section margins cold biopsies were processed. In cases where a pelvicalyceal system rupture was recognized, this was sutured with a 3-0 Vicryl® suture (Johnson & Johnson New Brunswick, NJ, USA) and a figure-of-eight haemostatic suture. On the kidney bed we performed interrupted suturing with a 0 Vicryl stitch via a liver needle (atraumatic). In 49 out of the 63 patients and ac-cording to the surgeon’s preference, haemostatic ma-

terials were used on the kidney bed which included: a Surgicel® haemostatic gauze (Ethicon Somerville, NJ, USA) in 37 cases, a Tachosil® haemostatic patch (Bax-ter Healthcare Corporation Westlake Village, CA, USA) in 15 cases and Bioglue® haemostatic glue in 4 cases (Cryolife Kennesaw, GA, USA); in 5 cases a combina-tion of the materials was applied. The ischemia time was recorded in 38 cases, mean time 16.15 minutes (time range 0-25) and the variable was analysed only for these cases. No pigtail ureteric stent was placed ei-ther preoperatively or intraoperatively. There were no cases where a switch was made to RN. Out of the 63 cases, one was excluded from total analysis on the ba-sis of insufficient data.

The demographic characteristics of the patients, the co-morbidity assessment on the Charlson-age adjust-ed score (AAC)9, Body Mass Index (BMI) and estimat-ed glomerular filtration rate (eGFR) factors are present-ed in Table 1.

The oncologic characteristics regarding the diagno-sis and results of the patients are presented in Table 2.

The postoperative complications were recorded for

TAbLE 1 Demographic characteristics

N %

GenderMales 35 56

Females 28 44

Age 56-69 26-81

Charlson score

0 28 45

1 1 2

2 8 13

3 8 13

4 4 6

5 6 10

6 5 8

7 2 3

TAbLE 1

N %

Preoperative EGFR 100,36 35,21-166,52

BMI 27,84 18,4-53,2

TAbLE 2 Oncologic characteristics

N %

LocalizationRt 34 55

Lt 28 45

Histology

Benign 15 24

Clear-cell 33 53

Papillary 12 19

Chromophobic 2 3

Clinical Diagnosis

pT1a 43 69

pT1b 16 26

pT2a 2 3

pT2b 1 2

Surgical marginsPositive 2 3

Negative 60 97

Pathologo-anatomic diagnosis

pT1a 51 81

pT1b 8 13

pT2a 1 2

pT2b 1 2

pT3a 1 2

Indication of Partial Nephrectomy

Εκλεκτική 49 79

Σχετική 10 16Απόλυτη 3 5

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90 days postoperatively (POD) and were graded ac-cording to the Clavien Dindo10 recording system. In total, 28 complications were observed in 23 patients; only 3 patients manifested Clavien ≥ 3 complications. The complications are presented in detail in Table 3 along with their management, according to the EAU guidelines.

The primary aim of the study is the evaluation of the PADUA score in predicting the manifestation of post-operative complications for 90 days subsequent to the procedure. The statistics concern the calculation of sensitivity and specificity of the PADUA score on ROC curves for the prediction of Clavien-graded complica-tions. Synchronous to the primary study aim, a quali-tative and quantitative analysis was performed on the improvement potential of the predictive power of the PADUA score in combination with a series of preop-erative, intraoperative and oncologic parameters via the Wald test. Namely, the parameters assessed were: gender, age, BMI, Age-Adjusted Charlson Comorbidity (AAC) index score and preoperative eGFR, hot ischemia time and tumor’s histologic subtype and Grade.

The secondary study aim was the analysis of the sen-sitivity and specificity of the PADUA score on mixed ef-fect analysis for the prediction of renal function impact and specifically that of postoperative eGFR in 3 and 6 months follow-up. The postoperative eGFR values were

available only for 33 patients and the statistical analy-sis is based only on this sample.

ResultsThe distribution of 62 patients based on PADUA score is depicted in Table 4.

The relation between the PADUA score and the po-tential of manifesting postoperative complications was investigated on ROC curves. Graph 1

The ROC curve shows high sensitivity but low speci-ficity with total moderate predictive power.1,0

In a further analysis on the increase potential of the PADUA score prognostic value in combination with the preoperative parameters such as gender, age, BMI, Age- AAC index score and preoperative eGFR, no sig-nificant statistical difference is observed. Similarly, the addition of intraoperative data such as ischemia time and/or postoperative data such as the tumor’s mor-phology delivered no significant statistical difference.

Only the tumor’s Grade shows a tendency of ap-proaching a statistically significant difference, which however, cannot be well-documented based on the present sample. The Wald test results and p-values are presented in Table 4.

As a secondary aim of our study, the PADUA score was investigated as a factor for the prediction of post-operative eGFR and its differentiation (decrease) from

TAbLE 3

N Complication Management Clavien

3 Urine leak Conservative (Drainage maintenance) 1

2 Haematocrit decrease Conservative 1

1 Haematoma 30th POD Conservative 1

1 Febrile Conservative 1

1 Febrile urinary tract infection Antibiotics switch 2

1 Thrombophlebitis - Febrile Antibiotics switch 2

1 Respiratory infection Antibiotics switch 2

7 Febrile Antibiotics switch 2

1 Febrile, Hypokaliaemia Antibiotics switch, Electrolytes added 2,1

1 Urine leak, Febrile Conservative (Drainage maintenance), Antibiotics switch 2,1

1 Allergy, incisional hernia Anti-histaminics, , Conservative 2,1

1 Hemorrhage 4th POD Revision, Nephrectomy 3

1 Urinoma 20th POD Allergy, incisional hernia 3

1Febrile, Haemodynamic instability, Sepsis, Respiratory distress

Antibiotics switch, ICU hospitalization 4

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the preoperative eGFR in 3- and 6-month periods. The statistical analysis regards a sample of 33 patients giv-en these were the only ones with complete data of postoperative renal function. The documentation of the value difference of eGFR 3 months postoperative-ly compared to the baseline according to PADUA score is presented in Graph 2.

This difference shows a strong correlation, based on the Pearson correlation coefficient, with the PADUA score r=0.524 (p=0.002). The performed mixed effects analysis which considered the eGFR values as repeat-ed measurements associated with the baseline (preop-erative baseline measurement), revealed that the pe-riod between 3 and 6 months did not determine any statistically significant difference between the 3- and 6-months interval. Nevertheless, there is a statistical-

ly significant negative correlation between the PAD-UA score and postoperative eGFR, i.e. the bigger the value of the PADUA score, the smaller the eGFR post-operatively with regression coefficient -3.53 (SE 1.13), p=0.004, 95% CI [-5.82, -1.24].

Conclusions - DiscussionThe prognostic value of the PADUA score in our results, presents a statistical significance, with high sensitivity but moderate specificity. This fact does not diminish the value of the PADUA score in total, as we had revealed in our initial study on the external validation of the PAD-UA score8, but it possibly reflects the increasing surgi-cal experience and the reduced complications in total and especially those of greater importance graded by Clavien ≥ 3. In any case, it remains an objective assess-ment method for the complexity of the tumor preoper-atively. It includes all the anatomic aspects, which the surgeon should take into consideration when deciding on the treatment plan for partial nephrectomy (PN), i.e. site, size, depth, relation to the renal hili etc.

The clinical importance of its application in every day practice and the need for greater prognostic signifi-cance, led to the investigation of the increase potential in combination with other parameters. The choice of the preoperative factors investigated- gender, age, BMI, AAC and preoperative eGFR-, constitute factors that may af-fect the perioperative results. Of the intraoperative fac-tors, we chose the hot ischemia time as a factor related to the complexity of the procedure and the possibility of preserving the renal function. Concluding, we inves-tigated the oncologic parameters, i.e. the histologic sub-type and the tumor’s Grade as an expression of the neo-

TAbLE 4

PADUA Score Patients Rate

6 17 27

7 22 35

8 6 10

9 9 15

10 6 10

11 1 2

12 1 2

TOTAL 62

0,0

0,2

0,4

0,6

0,8

1,0

0,2 0,4 0,6 0,8 1,0

Sens

itivi

ty

ROC CURVE

Diagonal segments are produced by tiesSpecificity

TAbLE 5

Variable Wald test P-value

Gender 0,145 0,703

Age 0,289 0,591

ΒΜΙ 0,867 0,352

AAC index score 0,183 0,669

Preoperative eGFR 0,803 0,370

Ischemia time 0,897 0,344

Morphology 1,638 0,441

Grade 3,442 0,064

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plasm’s aggressiveness. The reason behind our decision to combine a preoperative scoring system with intraop-erative and postoperative data, may not contribute to the patient’s preoperative assessment, yet, it may result in the increased postoperative awareness for “high risk” patients. No factor improves the predictive power of the PADUA score. The outcome strengthens the use of the PADUA score as a tool in every day clinical practice since it can provide considerable information on the patient’s postoperative course.

As a secondary study aim, we addressed the corre-lation of PADUA score with the affected eGFR in 3 and 6 months postoperatively. The statistical analysis re-vealed a strong correlation between the complexity of the tumor and the decrease in renal function propor-tionately, i.e. the bigger the PADUA score, the greater the value difference between preoperative and post-operative eGFR. The outcome is considered of great im-portance since it constitutes the basic reason behind a surgeon’s decision to opt for PN instead of RN. The protection of the renal function and the possibility of preoperatively assessing the extent to which the re-nal function may be affected, hold the primary role in choosing the management.

At a clinical level, many authors have also widely ap-plied the PADUA score to describe and classify the renal neoplasias according to their complexity and to affect the decision on the applicable treatment, the choice of PN, the prediction of the need for hot ischemia and its

time11,12. Moreover, it is applied in predicting the clinical outcome in terms of positive surgical margins, intraop-erative hemorrhage, complications and postoperative renal function13. To conclude, it has been studied and es-tablished as a critical factor in predicting the postoper-ative course of all types of PNs14, including laparoscop-ic15, single-site laparoscopic16 and robotically-assisted17.

Given the above, the clinical use of the PADUA score in the preoperative assessment of patients who are can-didates for PN is extremely determining and overrides its academic and investigating purpose. Potentially, the PADUA score could be utilized as a preoperative index of the complexity of the surgery, of the risk to manifest postoperative complications and of the eventual renal function in case the patient should undergo PN.

The study limitations include its retrospective char-acter and the lack of data for some patients regard-ing the hot ischemia time and postoperative eGFR. Additionally, the relatively small number of postoper-ative complications, as a result of the increased surgi-cal experience, did not allow for the predictive capaci-ty of the PADUA score and mostly its specificity to fully emerge in this series of patients.

It is necessary, in combination with the results of sim-ilar clinical studies, to draw up a multicentric prospec-tive study that will designate the clinical importance of the PADUA score in every day practice for the appro-priate preoperative assessment of the patients sched-uled for PN. U

PADUA score

GRAPH 2

Diff

eren

ce in

eGF

R be

twee

n

-10,00

0,00

10,00

20,00

30,00

40,00

6 9 10 117 8

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1. SEER Database 1975-2011 Update 2. Fergany AF , Hafez KS , Novick AC. Long-term results of nephron

sparing surgery for localized renal cell carcinoma: 10-year fol-low-up. J Urol 2000 ; 163: 442-5

3. Jayson M, Sanders H. Increased incidence of serendipitously dis-covered renal cell carcinoma. Urology 1998 ; 51(2) : 203-5.

4. Jansen NK, Kim HL, Figlin RA, et al. Surveillance after radical or partial nephrectomy for localized renal cell carcinoma and management of recurrent disease. Urol Clin Nrth Am 2003 ; 30: 843-52

5. Van Poppel H, Da Pozzo L, Albrecht W, et al. A prospective, ran-domised EORTC intergroup phase 3 study comparing the onco-logic outcome of elective nephron- sparing surgery and radical nephrectomy for low-stage renal cell carcinoma. Eur Urol 2011; 59(4) : 543-52

6. EAU Guidelines, edition presented at the 29th EAU Annual Con-gress, Stockholm 2014. ISBN 978-90-79754-65-6

7. Ficarra V , Novara G , Secco S et al . Preoperative aspects and di-mensions used for an anatomical (PADUA) classification of renal tumours in patients who are candidates for nephron-sparing sur-gery . Eur Urol 2009 ; 56 : 786-93

8. Tyritzis S, Papadoukakis S, Katafigiotis I et al Implementation and external validation of Preoperative Aspects and Dimensions Used for an Anatomical (PADUA) score for predicting complications in 74 consecutive partial nephrectomies. BJU Int. 2012;109(12): 1813-8

9. Charlson M, Szatrowski T, Peterson J, et al. Validation of a com-bined comorbidity index J ClinEpidimiol 1994; 47(11):1245-1251

10. Dindo D , Demartines N , Clavien PA .Classification of surgical

complications. A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004 ; 240: 205-13

11. Mottrie A, Schatteman P, De Wil P, et al. Validation of the preop-erative aspects and dimensions used for an anatomical (PADUA) score in a robot-assistedpartial nephrectomy series. World J Urol. 2013 ; 31(4) : 799-804

12. Ficarra V, Bhayani S, Porter J, et al. Predictors of warm ischemia time and perioperative complications in a multicenter, interna-tional series of robot-assisted partial nephrectomy. Eur Urol. 2012 ; 61(2) : 395-402

13. Vittori G. Open versus robotic-assisted partial nephrectomy: a multicenter comparison study of perioperative results and complications. World J Urol. 2014 ; 32(1) : 287-9

14. Hew MN, Baseskioglu B, Barwari K, et al. Critical appraisal of the PADUA classification and assessment of the R.E.N.A.L. Nephrom-etry score in patients undergoing partial nephrectomy. J Urol. 2011 ;186(1) : 42-6

15. Porpiglia F, Bertolo R, Amparore D, et al. Margins, ischaemia and complications rate after laparoscopic partial nephrectomy: im-pact of learning curve and tumour anatomical characteristics. BJU Int. 2013 ; 112(8) : 1125-32

16. Greco F, Autorino R, Rha KH, et al. Laparoendoscopic single-site partial nephrectomy: a multi-institutional outcome analysis. Eur Urol. 2013 ; 64(2) : 314-22

17. Volpe A, Garrou D, Amparore D, et al. Perioperative and re-nal functional outcomes of elective robot-assisted partial ne-phrectomy for renal tumors with high surgical complexity. BJU Int. 2014 Mar 27. doi: 10.1111/bju.12751. [Epub ahead of print]

References

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Tumor of the testis of extragonadal origin accidentally found in clinical examination, p. 42-44

IntroductionMetastatic testicular cancers are rare accounting for 2,4%-3,6%1,2 . Tumors of various origin have been re-ported to metastasize to the testes such as sarcomas, melanomas and adenocarcinomas of the prostate, lung, colon and kidney1-4. The prevalence of testicu-lar metastasis from colon cancer is ap-proximately 8 per cent of all testicular metastatic lesions. Less than 50 cases of colon metastasis to the testicle have been reported either at autopsies or as isolated case reports of advanced met-astatic disease2,5-10.

Case ReportA 58 year old man presented with suprapubic pain in the ED. In clinical examination a painless right tes-ticular mass was noted. Serum chorionic gonado-trophin fetoprotein and human placental lactogen values were within the reference ranges Ultrasonog-raphy of the scrotum revealed a solitary testicular

mass measuring 1,97x1cm. CT scan of the chest, abdomen and pelvis were negative for lymphatic and distant metastases. The patient reported an il-eo-hemicolectomy for a stage IIIB (T3N1M0), moder-ately differentiated adenocarcinoma of the sigmoid colon 3 years priory to his current visit. He received

adjuvant chemotherapy and postop-erative radiotherapy and he was on regular follow-up with no evidence of disease.

A right radical orchidectomy was performed. On microscopic exami-nation the tumor exhibited an inter-stitial growth pattern with preserva-tion of tubules. Vascular invasion was

also noted (figures 1-3). The immunohistochemical study showed that the tumor cells were positive for CKAE1,CKAE3,CK20 and CDX2 and negative for Vi-mentin,PLAP,CD30,AFP and HGC (figure 4).

The morphology of the tumor and the immunohis-tochemistry were consistent with metastatic colon

Tumor of the testis of extragonadal origin accidentally found in clinical examination

Konstantinos Stamatiou1, Efstratios Kouroumbas1, Efstathios Zygogiannis1, Aikaterini Tsavari2, Kalliroi Koulia2, Thivi Vasilakaki2 Hippocrates Moschouris3.

1Departement of Urology “Tzaneion” General Hospital of Piraeus, Greece2Departement of Pathology “Tzaneion “ General Hospital of Piraeus, Greece

3Departement of Radiology“Tzaneion” General Hospital of Piraeus, Greece

Corresponding author:Konstantinos N. Stamatiou, Tzaneio Hospital, Afendouli 1 Ave, 18536 Pireas, Attica - Greece E-mail - [email protected]

CASE REPORT

INTRODUCTION: Metastatic cancers of the testis are rare accounting for less than 4% of all testicular tumors. Among most rare are those of colon cancer.CASE REPORT: A 58 year old man presented with suprapubic pain in the ED. In clinical examination a painless right testicular mass was noted. He reported an ileo-hemicolectomy for a stage IIIB sigmoid colon adenocarcinoma 3 years priory to his current visit.

Pathology examination of the orchidectomy specimen diagnosed metastatic colon adenocarcinoma. Although patient refused further treatment he is disease free 12 months after surgery.CONCLUSION: Although rare, metastasis to testes should be considered as a differential diagnosis especially in older men with history suggesting the presence of a non-testicular malignancy.

Abstract

KeywordsColon cancer,

testicular metastasis, immunohistochemistry

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adenocarcinoma. Although patient refused further treatment he is disease free 12 months after surgery.

DiscussionThe exact mechanism of metastasis from the colon to the testes remain unknown however in the present case a retrograde lymphatic spread is not to be excluded. Other routes of metastatic spread include arterial em-bolisation and retrograde spread through spermatic veins from the renal veins or the retroperitoneum due to the absence of valves 2,8,10. Several authors suggested that isolated testicular relapses may have a better prog-nosis than systemic relapse in other organs such as liver, lung and distant lymph nodes2. In confirmation to the above, the patient presented in this report is disease free 12 months after surgery despite post-operative dis-continuation of the treatment. Whether isolated testic-ular relapses have a better prognosis than systemic re-

lapses in other organs needs to be confirmed by pooled analysis of the outcomes of patients described in simi-lar case reports. From the pathologic point of view met-astatic carcinomas to the testis are usually solitary and may simulate primary neoplasms, including rete adeno-carcinoma and sertoli cell tumor10. However, the pres-ence of extensive vascular and lymphatic invasion and the interstitial pattern in which the seminiferous tu-bules are spared are suggestive of a metastasis2,4. The patient’s medical history and the immunohistochemi-cal findings facilitate the origin of the tumor.

ConclusionTesticular metastatic disease is uncommon particu-larly from colon cancer. Although rare,metastasis to testes should be considered as a differential diagno-sis especially in older men with history suggesting the presence of a non-testicular malignancy. U

Figure 1: Metastatic colon adenocarcinoma with vascular invasion (H-Ex40). Figure 2: Metastatic colon adenocarcinoma of the testis (H-Ex100).

Figure 3: The tumor exhibits an interstitial growth pattern with preserva-tion of tubules (H-Ex100).

Figure 4: CDX2 positive stain (x200).

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1. Ostapiuk M, Swiatoniowski G, Bruzewicz S, Suder E, Ceglarski B, Prudlak E et al. Testicular metastasis as the first symptom of colon cancer. A case report. Nowotwory Journal of Oncology 2006;56 (4):407-409

2. Venkitaraman R, George M, Weerasooriya S, Nayagam S. Late soli-tary testicular metastasis from rectal cancer.JCRT 2010;6(1):89-91.

3. Peter SR, Richardsan RL, Kvols L. Metastatic cancer to the testes: a report of 20 cases and review of the literature. J Urol 1989;142:1003-5.

4. Haupt HM, Mann RB, Trump DL, Abeloff MB. Metastatic carcino-ma involving the testis. Clinical and pathologic distinction from primary testicular neoplasms Cancer 1984;54(4):709-14

5. Ouellette JR, Harboe-Schmidt JE, Luthringer D, Brackert S, Sil-berman AW. Colorectal cancer metastasis presenting as a tes-ticular mass:case report and review of the literature. Am.Surg 2007;73:79-81.

6. Meacham RB, Mata JA, Espada R, Wheeler TM, Schum CW, Scardino P.T. Testicular metastasis as the first manifestation of colon carcinoma J Urol 1988;140(3):621-2.

7. Deshpande MS, Kulkarni JN. Metastatic adenocarcinoma intes-tis presenting as a testicular mass. A case report and review of literature can J.Urol 2003;10(1):1770-1.

8. Hatoum HA, Abisaad GS, Otrock ZK, Barada KA, Shamsed-dine AL. Metastasis of colorectal carcinoma to the testes: clinical presentation and possible pathways. Int J Clin Oncol 2011;16(3):203-9.

9. Levy B, Lavell M, Davies J, Rockall T. Testicular metastasis found in a patient with previous large bowel tumor. BMJ Case Rep. 2009,doi:10.1136/bcr 06.2008.0339.

10. Rampa M, Battaglia L, Caprotti A, Gazzano G, Prestianni P, Mus-cara C, Vanneli A. Metastasis of sigmoid colon cancer in cryp-torchid testis: report of a case. Tumori 2012;98(2):63-66.

References

έιΣΑγωγή: Οι μεταστατικοί καρκίνοι των όρχεων είναι σπάνιοι και υπολογίζονται στο 4% όλων των όγκων των όρχεων. Μεταξύ των πιο σπάνιων είναι εκείνοι του καρκίνου του παχέος εντέρου. ΑνΑφορΑ ΠέριΣτΑτικοΥ: Ένας 58χρονος άνδρας προσήλθε με υπερηβικό άλγος στο ΤΕΠ. Στην κλινική εξέταση παρατηρήθηκε μια ανώδυνη μάζα στον όρχι. Ο ασθενής ανέφερε σιγμοει-δές αδενοκαρκίνωμα του παχέος εντέρου στάδιο ΙΙΙΒ για το οποίο υποβλήθηκε σε ημικολεκτομή προ 3ετίας. Η ιστολογική εξέταση του δείγματος της ορχεκτομής διέγνωσε μεταστατικό αδενο-καρκίνωμα του παχέος εντέρου. Αν και ο ασθενής αρνήθηκε περαιτέρω θεραπεία είναι ελεύθε-ρος νόσου 12 μήνες μετά την επέμβαση. ΣΥμΠέρΑΣμΑ: Αν και σπάνια, η μετάσταση σε όρχεις θα πρέπει να θεωρείται ως μια διαφορική διάγνωση ειδικά σε ηλικιωμένους άνδρες με ιστορικό που υποδηλώνει την παρουσία μίας έξω ορχικής κακοήθειας.

Περίληψη


καρκίνος παχέος εντέρου, μεταστατικοί

καρκίνοι όρχεων, ανοσοιστοχημεία

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Treatment of urinoma due to ureteral perforation by percutaneous nephrostomy (PCN) and antegrade placement of ureteral stent, p. 45-47

IntroductionDouble-J ureteral stents (also known as “pigtails”) are widely used in everyday urological practice mainly for the ureteric patency preservation. Surgically inserted under fluoroscopic guidance, via a C-arm mobile radiography or fluoroscopy system, the stents are reversely placed in the ureter via the ureteral orifices following cystoscopy. In private practice, or where no radiography equipment is availa-ble, the placement is empirically performed solely assisted by the stent’s graduation markings. The result is then approximate-ly studied on a kidney-ureter-bladder (KUB) radiography. Alternatively, and especially when retrograde access is not feasible, the stents are inserted in antegrade fashion af-ter percutaneous puncture in the renal pelvicalyceal sys-tem. Stent placement via or next to a pre-existing stent is relatively rarely encountered in everyday practice and cit-ed in literature [1,2]. The aim of the present report is the de-scription of a case of complicated urinary infection with ectopic ureteral stent retrograde placement, ureteral per-foration-induced urinoma and its management.

Case reportA 41-year-old female patient was hospitalized with persistent febrile infection. She reported an attempt of cystoscopic retrograde ureteral stent placement else-where. Pain during ureteral stent placement, resistance

to stent advancement and pus excretion from the ureteral orifice and the stent’s free-end -reported by the patient- sug-gested complicated urinary tract infec-tion. Despite the antibiotic treatment’s adjustment to the blood culture antibi-ogram data, the clinical and laboratory signs did not improve (temperature: 40o C, WBC 23840/ml, CRP: 22). The transab-dominal ultrasound study revealed left-kidney hydronephrosis and dilation

of the imaged part of the ureter, of unspecified aetiol-ogy. The plain KUB radiography showed that the cys-toscopically placed stent was within the conceivable course of the ureter though at a level lower than antic-ipated for the renal pelvis.

Given the non-improvement of the patient’s condi-tion and the questionable effectiveness of the previ-

Treatment of urinoma due to ureteral perforation by percutaneous nephrostomy (PCN)

and antegrade placement of ureteral stentKonstantinos Stamatiou1, Raffi Avakian1, Aggeliki Papadatou 2, Hippocrates Moschouris Ι2.

1 Urology Department, Tzaneio General Hospital, Piraeus, Greece2 Urology Department, Tzaneio General Hospital, Piraeus, Greece

Corresponding author:Dr. Konstantinos N. Stamatiou, Tzaneio General Hospital , 1 Afendouli Ave., PC 18536, Piraeus, Attica - Greece E-mail : [email protected]

CASE REPORT

Percutaneous antegrade placement of ureteral stent is performed under fluoroscopic guidance and represents a treatment option when retrograde, cystoscopically assisted ureteral stent placement is not feasible. This is a report of a complicated urinary infection in a 41-year-old woman, in whom the initial attempt of retrograde

ureteral stent placement was unsuccessful and caused perforation of the ureter. Percutaneous antegrade, fluoroscopically guided approach to the pelvicalyceal system and ureter and the subsequent placement of a new ureteral stent were successful and associated with quick clinical and laboratory improvement.

Abstract

Key wordsureteral stent,

double “J”, percutaneous

antegrade placement

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ous procedure, the drainage procedure was decided for the pelvicalyceal system via percutaneous access; a percutaneous drainage kit was initially used (Intro-ducer Drainage Catheter Kit, Bioteque Corporation, Taiwan). Under ultrasound guidance, a dilated left up-per pole calyx was punctured via a 21g Chiba nee-dle and the pelvicalyceal system was opacified with iodinated contrast agent (diluted with normal saline 50/50). The imaging study of the ureter exhibited the part of the initial double-J ureteral stent emerging the ureter at the height of the 5th lumbar vertebra (where the obstructing calculus was detected as opacifica-tion deficit) (Figure 1) Via the Chiba needle, a 0.018” Mandril guidewire was introduced into the pelvical-yceal system and, properly maneuvered, it was then advanced up to the initial part of the ureter. Wire guidance assisted in the catheterization of the pelvi-calyceal system with coaxial implantation system and the Mandril wire was replaced by a 0.035” Heavy Duty one. This wire was relatively easily advanced into the ureter and up the bladder (Figure 2). Also assisted by

the guidewire, a 9-F peel-away sheath (Cook Medical Europe Ltd. Limerick, Ireland) was introduced into the pelvicalyceal system. Via the sheath and guided by the Heavy Duty wire, we placed a new 4.8-F double-J ureteral stent and its pusher to the ureter (Standard Loop Stent, Bioteque Corporation, Taiwan). When the double-J stent was well-advanced in the bladder and its final place in the pelvis was confirmed, the wire was then retrieved followed by its pusher. Through this sheath, an extra 8-F nephrostomy catheter -com-ponent of the initial drainage kit- was placed, to en-sure the kidney drainage in case of stent malfunction (Figure 3).

The patient manifested clinical and laboratory im-provement soon after the successful drainage (tem-perature: 38.5o C, WBC 12840/ml, CRP:12, approxi-mately on the 18th post-procedural hour). The initial ectopic ureteral catheter was removed the next day via cystoscopy. The day thereafter, the nephrostomy catheter was also removed having previously verified, via contrast medium, the patency of the percutane-ously placed ureteral stent. The patient was sched-uled for lithotripsy.

CommentDouble-J ureteral stents are widely used in the man-agement of ureteral stricture or obstruction induced by internal or external causes (calculus, neoplasia, post-operatively, radiation etc) [3, 4]. Usually, the placement of such stents is retrograde, cystoscopically assisted through the cystoureteral orifice, although it is not always feasible. The hardest part in placing the ure-teral stents is the acquired stricture site as well as the natural strictures at the pelvi-ureteric junction (PUJ), the bladder and the iliac vessels confluence. The per-foration of the ureter is a common complication in all kinds of catheterization and placement techniques

Figure 3. Nephrostomy catheter placement for safety reasons in case of stent malfunction.

Figure 1. Initial percutaneous access to the pelvicalyceal system Figure 2. Antegrade ureteral stent placement- fluoroscopy.

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1. Amendola MA, Banner MP, Pollack HM, Gordon RL. Fluoroscopically guided pyeloureteral interventions by using a perurethral transvesical approach. AJR 1989;152:97-102

2. Yedlicka JW Jr, Aizpuru R, Hunter DW, Castaneda-Zοniga WR, Amplatz K. Retrograde replacement of internal double-Jureteral stents. AJR 1991;156:1007-1009

3. von der Recke P, Nielsen MB, Pedersen JF. Complications of

ultrasound-guided nephrostomy. A 5-year experience. Acta Radiol 1994;35:452–454.

4. Ahallal Y, Khallouk A, El Fassi MJ, Farih MH. Risk factor analysis and management of ureteral double-j stent complications. Rev Urol. 2010;12(2-3):e147-51.

5. Papanicoalou N. Uroradiological Intervention. In: Watkinson A, Adam A (eds) Interventional Radiology. A practical guide. Radcliff Medical Press Inc. New York 1996:108-112

References

Η διαδερμική, κατιούσα τοποθέτηση ουρητηρικών καθετήρων (stents) γίνεται με ακτινοσκοπική καθοδήγηση και αποτελεί μια θεραπευτική επιλογή, όταν η ανιούσα, μέσω κυστεοσκόπησης τοπο-θέτηση ουρητηρικού καθετήρα είναι αδύνατη. Στην παρούσα αναφορά περιγράφεται περιστατικό επιπλεγμένης ουρολοίμωξης σε γυναίκα 41 ετών, στην οποία η αρχική προσπάθεια για τοποθέτηση ουρητηρικού καθετήρα μέσω της ανιούσας οδού απέτυχε και προκάλεσε διάτρηση του ουρητήρα. Η διαδερμική κατιούσα, υπό ακτινοσκοπικό έλεγχο προσπέλαση του πυελοκαλυκικού συστήματος και του ουρητήρα και η επακόλουθη τοποθέτηση νέου ουρητηρικού καθετήρα υπήρξε επιτυχής και συνοδεύτηκε από άμεση κλινική και εργαστηριακή βελτίωση.

Περίληψη


ουρητηρικός καθετήρας, διπλό J,

διαδερμική κατιούσα τοποθέτηση

and is more likely to occur in blind introduction [4].Percutaneous antegrade ureteral stent insertion,

as described above, constitutes an alternative fluoro-scopically assisted technique that allows for the suc-cessful double-J placement and the treatment of the perforated ureter. By using the refined intervention-al radiology material (coaxial insertion systems, peel-away sheaths), the maneuvers are safer and better tolerated ensuring the precision in advancing the ma-

terials into the drainage system of the kidney. Of par-ticular importance and for the technical success of the procedure, is the initial access site to the pelvicalyceal system which should be performed through one of the middle or upper calyces. Lower calyx access is not preferred since it is accompanied by increased angu-lation of the introducers, the wires, the catheters etc, which consequently cannot be easily advanced inside the ureter [5]. U

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Tumor of the testis of extragonadal origin accidentally found in clinical examination

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