Urotoday International Journal Volume 4 - October 2011 Table of Contents: October, 2011

® UIJ UroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 Table of Contents: October, 2011

Bladder Cancer • The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer Eric S. Reid, Hooman Djaladat, Siamak Daneshmand

• Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and Oncologic Outcomes Adel Denewer, Fayez Shahato, Osama Hussein, Sameh Roshdy, Omar Farouk, Ashraf Khater, Mohammed Hegazy, Waleed ElNahhas, Mahmoud Mosbah, Mahmoud Adel

Renal Transplantation • Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence Taqi F Toufeeq Khan, Mirza Anzar Baig

Stress Urinary Incontinence • The Link Between Female Obesity and Urinary Stress Incontinence HH Eltatawy, TM Elhawary, MG Soliman, MR Taha

Urologic Residency • Challenges for a Resident in Urology in Tunisia in 2011 Sallami Satâa

Case Reports • Giant Bladder Calculus Sanjay Kolte, Chandrashekhar Mahakalkar, Rucha Jajoo

• Intravesical Explosion During TURP: A Rare Complication of a Common Procedure – What We Should Know Rahul Kapoor, Hemant R Pathak

• Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature Eng Hong Goh, Akhavan Adel, Praveen Singam, Christopher Chee Kong Ho, Guan Hee Tan, Badrulhisham Bahadzor, Zulkifli Md Zainuddin, Fauzah Abdul Ghani, Noraidah Masir

• Page Kidney – Rare but Correctable Cause of Hypertension Kapil Singla, Ashish K Sharma, Sistla B Viswaroop, Myilswamy Arul, Ganesh Gopalakrishnan, Sangam V Kandasamy

©2011 Digital Science Press, Inc. / UIJ / Vol 4 / Iss 5 / October http://www.urotodayinternationaljournal.com ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJ UroToday International Journal • Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis Fumitaka Shimizu, Kazuhiko Fujita, Takeshi Ieda, Kentaro Imaizumi, Taiki Mizuno, Kazuo Suzuki

• Spontaneous Rupture of Adrenal Myelolipoma Minori Matsumoto, Katsumi Shigemura, Masato Fujisawa

• Squamous Cell Carcinoma of Renal Pelvis with Fungal Infectionin a Non-Functioning Kidney – A Rare Entity Anubha Singh Yadav, Santosh Kr Singh, Devendra Singh Pawar, SK Mathur, Asha Kumari

• Squamous Cell Carcinoma of the Urinary Bladder Associated with a Big Bladder Stone in a 55-Year-Old Female: A Case Report Hamdy AbdelMawla Aboutaleb, Atef Badawy, Ahmed Gamal-eldin, Mohammed Badr-eldin

• Von Hippel-Lindau Disease – A Case Report and Review of Literature Vedamurthy Pogula Reddy, Dandu Venkata Satya Rambabu, Surya Prakash Vaddi, Subramanian S

The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer

Eric S. Reid,1 Hooman Djaladat,2 Siamak Daneshmand 2 1Division of Urology, Oregon Health & Science University, Portland, OR USA 2Norris Comprehensive Cancer Center, USC Institute of Urology, Los Angeles, CA USA Submitted April 1, 2011 - Accepted for Publication June 16, 2011

ABSTRACT

PURPOSE: To determine if the combination of photodocumentation and electronic medical record keeping led to changes in the management of suspicious lesions in patients with bladder cancer undergoing surveillance cystoscopy. METHODS: We reviewed the charts of all patients undergoing surveillance cystoscopy for bladder cancer during a 15-month period. We evaluated patients who had photodocumentation of bladder lesions in our electronic medical record (EPIC). Baseline demographics, surveillance data, and biopsy results were collected, and the outcome of photodocumentation was analyzed. A cost base analysis was performed using figures obtained from the billing department. RESULTS: During the study period, 50 patients underwent flexible cystoscopy for bladder cancer surveillance at our institution. Fifteen were identified who met the study criteria. Using photodocumentation in EPIC, nine patients had well-documented lesions that had no change during the surveillance period with negative urine cytology and therefore did not undergo biopsy. Six patients, however, did undergo biopsy based on a change in the appearance of the lesion. Biopsies demonstrated 3 benign lesions, 2 low-grade transitional cell carcinomas, and 1 muscle-invasive lesion. An economic base analysis demonstrated a cost reduction of 27% and 55% compared with office-based biopsy and transurethral resection of bladder tumor, respectively, by using photodocumentation. CONCLUSIONS: Photodocumentation of lesions during flexible cystoscopy is a useful tool in bladder cancer surveillance. It provides support for clinical decisions and is a cost-effective way to monitor patients undergoing frequent interventions.

KEYWORDS: Bladder neoplasm; Cystoscopy; Biopsy; Economic CORRESPONDENCE: Siamak Daneshmand, M.D., Associate Professor of Clinical Urology, Norris Comprehensive Cancer Center, USC Institute of Urology, Los Angeles, CA 90033, USA ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 58. doi:10.3834/uij.1944-5784.2011.08.14

INTRODUCTION non-invasive disease treated with transurethral resection of the bladder tumor (TURBT) and intravesical therapy. Despite these Bladder cancer is the 4th most common cancer among treatments, recurrence rates have been reported as 37%, 45%, American men and the 11th most common cancer among and 54% in low, intermediate, and high-risk groups [2]. Flexible American women [1]. The majority of these patients will have cystoscopy is routinely used in the surveillance of patients with

UroToday International Journal original study UIJ The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer Table 1. Patient demographics in the study population. doi: 10.3834/uij.1944-5784.2011.08.14t1 Patient Sex Age Grade Stage BCG CIS 1 M 70 2 Ta Yes No 2 M 68 3 T1 Yes No 3 M 87 2 Ta No No 4 M 73 3 T1 Yes No 5 M 55 3 T1 Yes No 6 M 70 3 Ta Yes No 7 M 80 2 Ta No No 8 M 62 2 T1 Yes Yes 9 M 28 1 Ta No No 10 M 80 CIS Tis Yes Yes 11 M 63 Myeloproliferative pattern — No No 12 M 71 Inverted papilloma — No No 13 F 75 1 Ta No No 14 M 70 3 Ta Yes No 15 M 87 3 T1 No No

bladder cancer. Several protocols have been recommended with intravesical Mitomycin C. Intravesical BCG was indicated in any increasing intervals between cystoscopies when no new lesions high-grade disease, multifocality, presence of carcinoma in are found [3]. These regimens rely on descriptive notations situ (CIS) or large tumor (> 5 cm) and rapidly recurrent disease. regarding areas which may represent early recurrence. Differ These patients were then started on a surveillance protocol that ences in description may lead to excessive biopsies when there included urine cytology and flexible cystoscopy every 3 months is no objective measure to document suspicious lesions. for the first year, every 4 months for the second year, every 6 months for the third year, and annually thereafter. Flexible Photodocumentation has commonly been used by ophthal cystoscopy was done using a digital Olympus cystoscope fitted mologists and dermatologists to monitor suspicious nevi in with a camera. During the procedure, any suspicious area was order to increase accuracy for detecting melanoma [4]. This photographed digitally and documented electronically. These has been further improved with adoption of electronic medical photos were uploaded into the patient’s medical record (EPIC). records that allow documenting and sharing this information Patients without photographic comparisons were excluded with other members of the treatment team. The goal of this study was to evaluate how the use of photodocumentation from the study. Baseline demographics, surveillance data, and coupled with electronic medical records affects the decision biopsy results were collected for each patient. The outcome making and the cost of bladder cancer surveillance in a rather of photodocumentation was analyzed and an economic base high-volume academic center. analysis was performed using related figures from the billing department at our institution. METHODS RESULTS We performed a retrospective review of all patients undergoing office-based flexible cystoscopy for bladder cancer surveillance During the 15-month study period, 50 patients underwent during a 15-month study period using an Institutional Review office-based surveillance cystoscopy for bladder cancer. Board-approved database. Patients with non-muscle invasive Out of these, 15 patients (30%) met the study criteria. The transitional cell carcinoma (TCC) of the bladder were treated with remaining patients had normal cystoscopic findings or did not TURBT followed by a single dose of immediate postoperative have sequential photographs documented in the electronic

UroToday International Journal original study UIJ Eric S. Reid, Hooman Djaladat, Siamak Daneshmand www.urotodayinternationaljournal.com Table 2. Results of photodocumentation on management of patients with surveillance cystoscopy for superficial bladder cancer. doi: 10.3834/uij.1944-5784.2011.08.14t2 Patient Change in management Result of biopsy 1 Biopsy Chronic inflammation 2 No biopsy — 3 Biopsy — 4 No biopsy Granulomatous inflammation 5 Biopsy — 6 No biopsy — 7 Biopsy Grade 1 Ta 8 No biopsy — 9 Biopsy Benign polyp 10 No biopsy — 11 Biopsy — 12 No biopsy — 13 Biopsy Grade 1 Ta 14 No biopsy — 15 Biopsy Grade 2 T2

medical record. The characteristics of our cohort (15 patients) cost would have been $9,315, $17,100, or $117,360, respectively. are described in Table 1. The majority of patients (46%) had Since we were able to eliminate 9 biopsies through the use of pathologic stage Ta disease. photodocumentation, only 6 patients required an additional intervention. Had all 6 remaining patients undergone During surveillance cystoscopy, the current lesions were cystoscopy with office-based biopsy, the cost would have been compared with prior images stored in the electronic medical reduced to $12,429. Alternatively, if TURBT had been required record. Based on the comparison, the decision was made to for all suspicious lesions in these 6 patients, the cost would have continue with the surveillance protocol or to undergo either been $52,533 (Figure 3). Therefore, the overall reduction in cost office-based biopsy or TURBT. Nine of 15 (60%) patients was 27% and 55% in each group when photodocumentation did not undergo biopsy due to a stable appearance of the was used to eliminate unnecessary biopsies or TURBTs. lesion (Figure 1). All patients who underwent surveillance without biopsy had a negative urine cytology. During a 2-year follow-up, none of these patients have had a progression of DISCUSSION their lesion or change to positive cytology. Six patients (40%) The primary reason for monitoring patients with a history of underwent biopsy due to changes in the appearance of bladder cancer is to survey the urothelium for development suspicious lesions (Figure 2). Of patients for whom biopsies were of new tumor or any change in previous lesions. Although taken, three cases were benign, two had grade I/Ta disease, and new methods in detection of bladder cancer recurrence using one patient had grade II/T2 disease (Table 2). biomarkers and fluorescence endoscopy are evolving, flexible/ rigid cystoscopy still remains the gold standard technique in A cost analysis was performed using the existing cost information bladder cancer surveillance [5] accompanied by urine cytology. from the billing department. In order to compare the cost of biopsy versus observation, we assumed that all patients with an Cystoscopy has a tumor detection rate of greater than 90% erythematous lesion would undergo either office-based biopsy and cystoscopic evaluation correctly discriminates between or TURBT. If all 15 patients had undergone cystoscopy only, dysplastic/malignant and benign/reactive lesions with cystoscopy with biopsy, or cystoscopy followed by TURBT, the a sensitivity and specificity of nearly 100% [6].

UroToday International Journal original study UIJ The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer Figure 1. Comparison of suspicious, but without change, Figure 2. Comparison of suspicious areas with new 4 areas on surveillance cystoscopy (patient 2). changes on surveillance cystoscopy (patient 15). doi: 10.3834/uij.1944-5784.2011.08.14f1 doi: 10.3834/uij.1944-5784.2011.08.14f2

(a) (b) (a) (b)

Herr showed the correlation of outpatient cystoscopy and patients over the age of 60 years with a previous history of histological findings [7]. Similarly, Satoh et al. found that TCC [5]. cystoscopy was reliable in predicting a muscle-invasive bladder tumor [8], supporting the reliability of cystoscopy in the Guy et al. showed that following BCG therapy shows that the evaluation of bladder lesions. diagnostic accuracy of biopsy in patients with suspicious lesions on cystoscopy with negative urine cytology was only 50% [14]; The concept of simplifying surveillance programs in patients with therefore a high percentage of patients undergo unnecessary non-invasive bladder cancer is not a novel idea. Eliminating the biopsy. In our study, 40% of patients underwent biopsy and 3-month biopsy in patients with a normal office cystoscopy or recurrent disease was found in half of them, which is consistent an erythematous bladder but a normal cytology was introduced with prior reports. by Dalbagni et al. [9]. This modification decreased the number of endoscopic procedures significantly without compromising One of the most important results of our study is its dramatic the accuracy of the post-BCG evaluation. cost reduction. Bladder cancer is the most expensive cancer to treat both per patient per year and lifetime costs [15], There is a discussion in the literature regarding the significance in comparison to other cancers like invasive cervical of taking random bladder biopsies, as opposed to sampling cancer [16]. It is noteworthy that the largest component of visible lesions, in order to detect concomitant dysplasia or this cost is due to non-invasive disease [15]. In the Hedelin CIS. Some evidence indicates that random biopsies may play study [17], approximately 40% of costs were due to TURBTs. an important role in the detection of multifocal disease [10, The cost of the follow-up cystoscopies was only 13% of the 11], while others argue that it does not contribute to disease total bladder tumor cost and every third cystoscopy resulted in stages or the choice of adjuvant therapy [12, 13]. In our study, a therapeutic procedure. At our institution, the cost of TURBT no patient underwent random biopsies. is 6 times that of biopsy/fulguration in the office and 12 times that of surveillance cystoscopy. With the exclusion of TURBT in Although in the European guidelines on the management of 60% of this population, the cost reduction for this study was superficial bladder cancer it is mandatory to perform a biopsy $64,827. Also we have to consider the elimination of TURBT/ of any suspect/new lesion of the bladder, there was no data biopsy complications that would definitely lead to further on the histological findings and the frequency of malignant cost reduction. Given the low diagnostic accuracy of biopsy in lesions detected by doing so. To the best of our knowledge, no patients who have undergone BCG therapy, further reduction randomized prospective study has showed the proper approach in cost may be possible with more detailed documentation of to abnormal but stable lesions of bladder on surveillance for lesions. bladder cancer. In a study by Swinn et al. positive predictive value for malignancy of red patch biopsy was 12%; the majority Several studies have used conservative management with of these were CIS. They recommended red patch biopsy in observation in patients with low grade Ta disease [18, 19, 20].

UroToday International Journal original study UIJ Eric S. Reid, Hooman Djaladat, Siamak Daneshmand www.urotodayinternationaljournal.com Figure 3. Cost comparison for patients undergoing surveillance cystoscopy and photodocumentation versus biopsy or TURBT of all erythematous lesions. doi: 10.3834/uij.1944-5784.2011.08.14f3

Soloway et al. demonstrated that in a low risk population only none developed a positive urine cytology during the study 6.7% of patients progressed from a low-grade non-invasive period, nor did they progress clinically. tumor (G I to II/Ta) to a high-grade Ta or T1 disease [21]. No patient in these studies developed muscle invasive The limitations of this study include the small sample size, disease. The decision to perform biopsy in these patients was the retrospective nature of the study, and the use of close based on changes in the appearance of the lesion over time. observation in patients with previous intermediate and Photodocumentation is ideal for this type of clinical situation, high-risk disease. This study represents the initial examination which may miss subtle differences in the lesions based on of the use of this technology as an adjunct to currently accepted interobserver variability or differences in the description of practices. It does not suggest replacing cystoscopy/biopsy when the lesion. It is also an appropriate option for patients with a clinically relevant. The study does however, even with its small history of low grade/Ta tumors, especially older ones who have sample size, show the significant cost reduction provided by significant medical co-morbidities and are not fit to undergo this technology. A 27% reduction in cost for surveillance would repeat TURBT/biopsies. However, with such a conservative be important when applied to the high volume of procedures management strategy, patients must remain under careful performed on an annual basis. cystoscopic and cytological surveillance as there remains some Video endoscopy and photodocumentation as well as digital risk for grade and stage progression in this population [18]. imaging are considered integral parts in the surveillance of During our study, only one patient had muscle invasive disease patients with superficial bladder cancer. The use of photodocu but he already had T2 disease and failed bladder preserving mentation may help clinicians decide when biopsy is likely to therapies. His cystoscopy was difficult to interpret due to prior yield a positive result by direct comparison of lesions through BCG and radiation effects, but photodocumentation clearly time, particularly after the use of intravesical BCG. The potential showed a difference in the appearance of the lesion and he was advantages and safety of this protocol need further prospective taken for TURBT that demonstrated recurrence of his muscle- studies in a larger cohort of patients. invasive disease. In patients who underwent observation alone,

UroToday International Journal original study UIJ The Role of Photodocumentation in Surveillance Cystoscopy for Bladder Cancer CONCLUSION 11. Taguchi I, Gohji K, Hara I, et al. Clinical evaluation of random biopsy of urinary bladder in patients with superficial Photodocumentation when coupled with the electronic bladder cancer. Int J Urol. 1998;5(1):30–34. medical record is a powerful tool in bladder cancer surveillance. It is useful not only to improve communication between health 12. Kiemeney LALM, Witjes JA, Heijbroek RP, Koper NP, providers but also as a way to clearly describe the appearance of Verbeek ALM, Debruyne FMJ, and Members of the Dutch suspicious bladder lesions. In addition, it is financially beneficial South-East Co-Operative Urological Group. Should random and may prevent the additional cost and patient discomfort urothelial biopsies be taken from patients with primary from unnecessary biopsies. superficial bladder cancer? A decision analysis. Br J Urol. 1994;73(2):164–171. REFERENCES 13. van der Meijden A, Oosterlinck W, Brausi M, Kurth KH, Sylvester R, de Balincourt C, and EORTC-GU Group Superficial Bladder Committee. Significance of bladder 1. Jemal A, Siegel R, Ward E, et al. Cancer Statistics, 2008. CA biopsies in Ta,T1 bladder tumors: a report from the EORTC Cancer J Clin. 2008;58(2):71–96. Genito-Urinary Tract Cancer Cooperative Group. Eur Urol. 2. Millán-Rodríguez F, Chéchile-Toniolo G, Salvador-Bayarri J, 1999;35(4):267–271. Palou J, Algaba F, Vicente-Rodríguez J. Primary superficial 14. Guy L, Savareux L, Molinié V, Botto H, Boiteux JP, Lebret bladder cancer risk groups according to progression, T. Should bladder biopsies be performed routinely mortality and recurrence. J Urol. 2000;164(3):680–684. after bacillus Calmette-Guérin treatment for high-risk 3. Jones JS, Campbell SC. Non-muscle-invasive bladder cancer superficial transitional cell cancer of the bladder?Eur Urol. (Ta, T1, and CIS). In: Wein AJ, Kavoussi LR, Novick AC, Partin 2006;50(3):516–520, discussion 520. AW, and Peters CA (Eds.). Campbell’s Urology. Philadelphia: 15. Stenzl A, Hennenlotter J, Schilling D. Can we still afford Saunders; 2007, pp. 2447–2467. bladder cancer? Curr Opin Urol. 2008;18(5):488–492. 4. Kittler H, Binder M. Risks and benefits of sequential imaging 16. Ricciardi A, Largeron N, Giorgi Rossi P, et al. Incidence of of melanocytic skin lesions in patients with multiple atypical invasive cervical cancer and direct costs associated with its nevi. Arch Dermatol. 2001;137(12):1590–1595. management in Italy. Tumori. 2009;95(2):146–152. 5. Swinn MJ, Walker MM, Harbin LJ, et al. Biopsy of the 17. Hedelin H, Holmäng S, Wiman L. The cost of bladder red patch at cystoscopy: is it worthwhile? Eur Urol. tumour treatment and follow-up. Scand J Urol Nephrol. 2004;45(4):471–474; discussion 474. 2002;36(5):344–347. 6. Cina SJ, Epstein JI, Endrizzi JM, Harmon WJ, Seay TM, 18. Pruthi RS, Baldwin N, Bhalani V, Wallen EM. Conservative Schoenberg MP. Correlation of cystoscopic impression with management of low risk superficial bladder tumors.J Urol. histologic diagnosis of biopsy specimens of the bladder. 2008;179(1):87–90, discussion 90. Hum Pathol. 2001;32(6):630–637. 19. Gofrit ON, Pode D, Lazar A, Katz R, Shapiro A. Watchful 7. Herr HW. Does cystoscopy correlate with the histology waiting policy in recurrent Ta G1 bladder tumors. Eur Urol. of recurrent papillary tumours of the bladder? BJU Int. 2006;49(2):303–307, discussion 306–307. 2001;88(7):683–685. 20. Hernández V, Alvarez M, Peña E, et al. Safety of active 8. Satoh E, Miyao N, Tachiki H, Fujisawa Y. Prediction of surveillance program for recurrent nonmuscle-invasive muscle invasion of bladder cancer by cystoscopy. Eur Urol. bladder carcinoma. Urology. 2009;73(6):1306–1310. 2002;41(2):178–181. 21. Soloway MS, Bruck DS, Kim SS. Expectant management 9. Dalbagni G, Rechtschaffen T, Herr HW. Is transurethral of small, recurrent, noninvasive papillary bladder tumors. biopsy of the bladder necessary after 3 months to evaluate J Urol. 2003;170(2):438–441. response to bacillus Calmette-Guerin therapy? J Urol. 1999;162(3):708–709. 10. Zieger K, Wolf H, Olsen PR, Højgaard K. Long-term survival of patients with bladder tumours: the significance of risk factors. Br J Urol. 1998;82(5):667–672.

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.08.14 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and Oncologic Outcomes

Adel Denewer, Fayez Shahato, Osama Hussein, Sameh Roshdy, Omar Farouk, Ashraf Khater, Mohammed Hegazy, Waleed ElNahhas, Mahmoud Mosbah, Mahmoud Adel Surgical Oncology Center, Mansoura University, Egypt Submitted May 19, 2011 - Accepted for Publication July 25, 2011

ABSTRACT Background & Objective: Open radical cystectomy is the standard procedure for the treatment of muscle-invasive bladder cancer. There has been a recent trend towards minimally invasive techniques aiming to decrease blood loss, hospital stay, and complications. Therefore, hand-assisted cystectomy (HAC) emerged as a rational choice, combining the merits of laparoscopic surgery with the feasibility of performing a continent urinary reservoir in a reasonable operative time and with reasonable treatment costs. Patients & Methods: Forty patients with invasive bladder carcinoma were offered radical cystectomy with the HAC approach. Thirty-two men and 8 women underwent HAC. The mean age was 57.5 years. The mean operation time was 200 minutes for the extirpative part and 90 minutes for the reconstructive part of the procedure. Estimated blood loss was 450 ml. The mean hospitalization time was 17 days (range of 10 to 30). At a median follow-up of 2 years, no cases of port-site, incisional, or isolated pelvic recurrence was detected. The median DFS is 14.6 month (95%CI = 13.2–15.8). Conclusions: HAC is a rational procedure that can be used to perform radical surgery of invasive bladder carcinoma and orthotopic urinary diversion.

Introduction times. Moreover, previous abdominal surgery, neoadjuvant pelvic irradiation, or morbid obesity may make LRC even more Open radical cystectomy is the standard procedure for the difficult [6-12]. treatment of muscle-invasive bladder cancer [1, 2]. There has been a recent trend towards minimally invasive techniques Although several anecdotal reports described the performance aiming to decrease blood loss, hospital stay, and complications of totally intracorporeal procedures [6-12], a mini-laparotomy [3-5]. Several authors reported the technique of purely is typically needed for safe specimen retrieval and for laparoscopic radical cystectomy (LRC) [6-12]. However, such construction of the continent urinary reservoir when indicated. a procedure entails increasing treatment costs and operative Therefore, hand-assisted cystectomy (HAC) emerged as a

KEYWORDS: Radical cystectomy; Ileal neobladder; Bladder carcinoma CORRESPONDENCE: Adel Denewer, Surgical Oncology Center, Mansoura University, Egypt ([email protected]). CITATION: UroToday Int J. 2011 Aug;4(5):art 59. doi:10.3834/uij.1944-5784.2011.10.6

UroToday International Journal original study UI Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and J Oncologic Outcomes Figure 1. Illustration of the sites of laparoscopic ports. Figure 2. LapDisc hand piece. doi: 10.3834/uij.1944-5784.2011.10.6f1 doi: 10.3834/uij.1944-5784.2011.10.6f2

rational choice, combining the merits of laparoscopic surgery not stress on oncologic outcomes of SCC rather than TCC, but with the feasibility of performing a continent urinary reservoir the main concern was oncologic safety of HAC regardless of in a reasonable operative time and with reasonable treatment tumor types, in addition to the feasibility of incorporating an costs. HAC gained wide acceptance and is comparable to open orthotopic ileal neobladder to such a technique. cystectomy regarding operation time [13, 14], lymph node harvest [13], and short-term oncologic results [14]. HAC is also Procedure equivalent to pure LRC in terms of mean operative time, blood Patients under general anesthesia were placed in a modified transfusions, and time-to-oral intake [15]. However, most of lithotmy position with pronounced head-down tilt. Yellow the time the technique is adapted to perform ileal conduit fin stirrups and appropriate padding were used to avoid diversion after radical resection [14-20]. The utility of the hand- peripheral neuropathies. Closed pneumoperitoneum with a assisted procedure to perform radical resection and orthotopic Veress needle was established. Five ports were placed in the urinary reservoir is not yet characterized. Here we describe our umbilibal region, both lumbar regions at the mid-clavicular results using HAC to perform radical cystectomy followed by lines, and both iliac fossae. Initial inspection was performed a continent urinary substitute using our previously published with the camera through the umbilical port, which was then orthotopic ileal neobladder [21]. converted into an infra-umbilical minilaparotmy of 7 cm long (Figure 1). A LapDisc hand piece (Hakko Medical, Tokyo) was Patients and Methods inserted (Figure 2). The first assistant standing on the left side of the patient introduced his right hand through the LapDisc Patients (Figure 3). In case the LapDisc was not available, the LapDisc Forty patients with invasive bladder carcinoma were offered was substituted with a surgical glove that was sutured to the radical cystectomies with a hand-assisted laparoscopic approach. edges of the minilaparotomy (Figure 4). The operating surgeon Patients with cardiovascular diseases, morbid obesity, or an and the second assistant stood on the right side of the patient. ASA score above II were excluded. All patients were informed The peritoneum of the vesico-rectal pouch was opened and of the expected advantages and risks of the procedures. The the incision was extended on both sides of the bladder into internal committee of the Department of Surgery at Mansoura a U-shaped incision exposing the iliac lymph nodes. Bilateral University approved the study protocol. In our work, we do lymphadenectomy was performed in the standard pattern

UroToday International Journal original study UI Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and J Oncologic Outcomes Figure 3. Introduction the right hand through the LapDisc. Figure 4. In case the LapDisc was not available, it was doi: 10.3834/uij.1944-5784.2011.10.6f3 substituted with a surgical glove that was sutured to the edges of the minilaparotomy. doi: 10.3834/uij.1944-5784.2011.10.6f4

(Figure 5a,b). In men, the vasa deferentia were transacted at the internal ring and both ureters identified, mobilized, and transacted 2 cm above their insertion (Figure 6a,b). Lateral Follow-up vesical pedicles were skeletonised with the surgeon’s hand and secured with LigaSure (Valleylab, Colorado). Posterior dissection Patient follow-up protocol involved physical examination, continued into the vesic-rectal space, freeing the seminal renal ultrasonography, intravenous pyelography, ascending vesicles. The surgeon’s hand was used to retract the bladder pouchography, and pelviabdominal CT. Urethropouchoscopy inferiorly and open the retropubic space. The dorsal vein was performed in select patients complaining of voiding complex was secured with LigaSure. Combined finger dissection symptoms, hematuria, or incontinence. Postoperative and electrocautry were used to skeletonise the prostate and continence was evaluated according to Stein et al [22]. prepare the urethral stump, which was transacted distal to the prostatic apex. In women, anterior pelvic exentration was Results performed. Round ligaments, infundibulopelvic ligaments, and lateral pedicles were transacted with LigaSure. Ureters Patient and tumor characteristics were mobilized and transacted 2 cm above their insertion. Thirty-two men and 8 women underwent HAC. The mean age The vagino-rectal space and the lateral pelvic ligaments were was 57.5 years. Follow-up of at least 1 year was available for all dissected with the surgeon’s hand. The urethra was divided patients. Tumor characteristics are described in Table 1. at a lower level than the vagina. In both sexes, urethral and ureteric stumps were subjected to frozen section pathological Operative results examination. The specimen was retrieved through the hand port. The LapDisc was then removed and replaced with a Kelly The mean operative time was 200 minutes for the extirpative retractor. The left ureter was then tunnelled beneath the part and 90 minutes for the reconstructive part of the procedure. sigmoid colon. Orthotopic urinary diversion was performed Estimated blood loss was 450 ml. Most patients received 1 unit (Figure 7) as we described before [21]. of whole blood intraoperatively. Conversion to open surgery was not required in any case. Postoperative analgesic use consisted of 1 dose of meperdine at the first postoperative night only. In this series, none of the patients necessitated continued

UroToday International Journal original study UI Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and J Oncologic Outcomes Figure 5. (A) The peritoneum of the vesico-rectal pouch Figure 6. (6A) In men, the vasa deferentia were transacted was opened and the incision was extended on both sides at the internal ring. of the bladder into a U-shaped incision exposing the iliac (6B) Both ureters identified, mobilized and transacted 2 lymph nodes. cm above their insertion. (B) Bilateral lymphadenectomy was performed in the doi: 10.3834/uij.1944-5784.2011.10.6f6 standard pattern. doi: 10.3834/uij.1944-5784.2011.10.6f5

Three patients developed distant metastases; 2 of them also narcotic use. Oral intake was resumed by the fourth day. Mean have pelvic recurrence. The median DFS is 14.6 months (95%CI hospitalization time was 17 days (range of 10–30). = 13.2–15.8) (Figure 8).

Post-operative complications Discussion There was no perioperative mortality. Early complications (within In the present study, we performed radical cystectomy for 3 months of surgery) included pneumonia and prolonged ileus bladder cancer in 32 men and 8 women. We used a hand- in one patient each. Three cases developed urine leaks. Late assisted laparoscopic approach to accomplish radical resection postoperative complications included 1 patient developing and orthotopic urinary diversion. In this series, disease-free an adhesive intestinal obstruction and 1 patient developed a survival was 14.6 months and the median lymph node harvest poucho-urethral stricture that was managed with dilatation. was 11 nodes. Table 2 describes postoperative results. The technique of LRC was first reported in 1995 when Puppo Continence and voiding et al. described 5 cases of transvaginal laparoscopically assisted Daytime continence was good in 33 patients and satisfactory in cystectomy [23] and Sanchez de Badajoz described a case 5 patients. Two patients had unsatisfactory daytime continence. of laparoscopic cystectomy with 2 minilaparotomies in both Nighttime continence was good in 30 patients, satisfactory in flanks [24]. In 2001, Turk et al. reported a totally intracorporeal 5 patients, and unsatisfactory in 5 patients. Thirty patients cystectomy and rectosigmoid diversion [7]. The following year, voided to completion without the need for catheterization. Ten Abdel-Hakim et al. reported orthotopic ileal neobladder using patients necessitated intermittent catheterization. intracorporeal suturing in 6 patients [25].

Oncological results The oncologic outcome of the standard open cystectomy for invasive cancer is well-described. The procedure is associated At a median follow-up of 2 years, no cases of port-site, incisional, with a perioperative mortality of 2 to 3% (26 to 27). Most of or isolated pelvic recurrence were detected. Median lymph the treatment failure occurs in the first 3 years after surgery node harvest was 11 nodes (range 10 to 16). However, none with a median recurrence time of around 12 to 16 months (26 of the patients had infiltrated lymph nodes at postoperative to 28). Stein et al. reported 68% 5-year disease-free survival in pathology as with most of our patients from rural areas, who a large cohort of 1054 patients with invasive bladder cancer usually have bilharsial cystitis with bladder cancer. Hence, there [27]. In this series, extra-vesical tumor extension and lymph is fibrosis that hinders lymphatic spread. node metastases significantly decreased the 5-year disease-free

UroToday International Journal original study UI Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and J Oncologic Outcomes Figure 7. Orthotopic urinary diversion was performed. Figure 8. Kaplan-Meyer illustration of the survival. doi: 10.3834/uij.1944-5784.2011.10.6f7 doi: 10.3834/uij.1944-5784.2011.10.6f8

survival down to 46% and 35%, respectively [27]. Similar results cystectomies and extracorporeal reconstructions, and followed were reported by other groups [26, 28, 29]. their patients for a mean period of 18 months. They observed 5 cases of pelvic recurrence and no port-site recurrence [32]. For laparoscopic cystectomy, reports of oncological oucomes are sparse. Haber et al. described the results of laparoscopic The addition of a minilaparotomy with a laparoscopic cystectomy radical cystectomy in 37 consecutive patients. [30]. Twenty- retained the main advantages of laparoscopic surgery in the three male patients had radical cystoprostatectomy and 14 form of earlier returns to oral diets while avoiding the longer women had anterior pelvic exentration. Of those patients, 73% operative time and the technical difficulties associated with had organ-confined tumors (pT1: pT3a). The median lymph the pure intracorporeal laparoscopic approach. Cathelineau node yield was 6 with limited lymphadenectomy (11 patients) et al. retrospectively compared 70 open cystectomies to 84 and 21 with extended lymphadenectomy (26 patients). The laparoscopic cystectomies and extracorporeal reconstructions 5-year-overall and cancer-specific survivals were 58% and (ileal conduit in 33 patients and neobladder in 51 patients). 68%, respectively. None of the patients developed port-site An open cystectomy resulted in double the volume of blood recurrence. These authors performed orthotopic neobladder or loss while operative times were comparable in both groups ileal conduit for diversion (30). Deger et al. reported the follow- [32]. Taylor et al. prospectively compared the hand-assisted up data for 20 patients who received rectosigmoid diversion (12 laparoscopic technique to open cystectomy [14]. In their report, patients), orthotopic neobladder (5 patients), or ileal conduit 16 consecutive patients underwent open [8] or hand-assisted diversion (3 patients) after laparoscopic radical cystectomy [8]. laparoscopic [8] cystectomy and ileal conduit. HAC achieved an The lymph node harvest averaged 10. Two patients had extra operative time similar to the open approach while maintaining vesical tumor extensions and 3 patients had nodal metastases. the benefits of laparoscopic surgery in the form of less analgesic At a median follow-up of 33 months, no patient developed use, an earlier return of bowel functions, and a shorter hospital a local recurrence and 3 patients developed systemic relapse. stay. Similar results were reported by Wang et al. These authors Huang et al. performed 85 laparoscopic cystectomies, pelvic retrospectively compared 31 HAC patients with 39 open lymphadenectomies, and extracorporeal constructions of the cystectomy patients. Operative times were comparable while orthotopic ileal neobladder. At an average follow-up period blood loss was less and a return to a normal diet was earlier in of 21.3 months, 3 local recurrences and 1 port-site recurrence HAC group [13]. Haber et al. performed a laparoscopic radical were observed [31]. Cathelineau et al. performed 84 radical cystectomy and orthotopic neobladder in 28 patients. The

UroToday International Journal original study UI Hand-Assisted Laparoscopic Radical Cystectomy and Orthotopic S-Shaped Ileal Neobladder: Functional and J Oncologic Outcomes Table 1. Patients’ demographics and tumor’s characteristics Table 2. Early and late postoperative complications in .in forty patients .forty patients doi: 10.3834/uij.1944-5784.2011.10.6t1 doi: 10.3834/uij.1944-5784.2011.10.6t2 Treatment Patients› demographics Number of patients Complications No. pts No. conservative Age Diversion unrelated 50–60 years 30 complications: Wound infection 0 0 60–70 years 10 Fascial dehiscence 0 0 Sex Prolonged ileus 1 1 DVT 0 0 Male 32 Pneumonia 1 1 Female 8 Incisional hernia 0 0 Adhesive intestinal 1 1 Tumors characteristics Number of patients obstruction

Pathologic diagnosis Diversion related complications: PT2N0 8 Urinary leakage 3 3 PT3N0 24 Urethral stricture 1 1 Ureteroileal obstruction 0 0 PT4N0 8 Pyelonephritis 0 0 Mean number of lymph 11 (range 10–16) nodes removed

Mean follow-up (months) 24

Median DFS (months) 14.6 this procedure, compared with open and pure laparosocopic cystectomies, will be of great value in our future randomized study.

Conclusion extirpative part of the procedure was done laparoscopically Hand-assisted cystectomy is a rational procedure that can be while the diversional part was performed intracorporeally used to perform radical surgery of invasive bladder carcinomas in 9 patients and through a mini-incision in 19 [33]. In their and orthotopic urinary diversion. In this series, HAC retained experience, adoption of the open-assisted approach for many of the advantages of minimally invasive approaches and orthotopic diversion significantly decreased the incidence of achieved acceptable oncologic control. major postoperative complications requiring secondary surgery (11% vs. 44%). Acknowledgement Our early postoperative results are similar to other reports of HAC. Wang et al. performed 31 HAC procedures, including We are grateful to our colleagues at the surgery department of 7 cases of orthotopic diversion. They reported an average Mansoura University Cancer Center. This work was supported operation time of 365.7 minutes, an average blood loss of by internal funds from Mansoura University Oncology Center. 250.9 cc, and an average hospital stay of 19.7 days [16]. The oncologic outcome in this series is comparable to reported DFS after radical cystectomy although we cannot correct for the bias introduced at the case selection. Moreover, the cost for

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©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.6 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence

Taqi F Toufeeq Khan,1 Mirza Anzar Baig1 1Division of Kidney Transplant Surgery, Riyadh Military Hospital, Riyadh, Kingdom of Saudi Arabia Submitted June 11, 2011 - Accepted for Publication Aug 12, 2011

ABSTRACT Objective: To determine the impact of our surgical techinique on the incidence of lymphoceles in all patients who underwent renal transplantation, and identify other risk factors responsible for the development of lymphoceles. Materials and Methods: The records of all patients who underwent kidney transplantation at the Riyadh Military Hospital from March 2007 to March 2011 were retrospectively reviewed to determine the incidence of lymphocele. Demographic characteristics, risk factors, and surgical technique were outlined. All transplants were performed by a single surgeon and his team. Results: A total of 273 patients underwent kidney transplantation; only 1 recipient was diagnosed with a lymphocele on ultrasound 6 weeks after transplantation. This patient underwent ultrasound-guided aspiration with complete resolution without recurrence at a 1-year follow-up. Our surgical technique is based on (1) ligation of all paravascular hilar tissue in the allograft, (2) ligation and division of all lymphatic vessels when dissecting the recipient iliac artery and vein, (3) ligation and division of all lymphatics if iliac lymph nodes require removal, and (4) routine use of suction drains. The known risk factors are comparable with other studies and include acute rejection (AR) rates of 6.6%, a body mass index (BMI) >30(24%), diabetes at 22%, retransplants at 15%, zero de novo sirolimus therapy, and 14.6% of recipients on a steroid-free regimen. Discussion: Post-renal transplant lymphoceles are not uncommon and can result in unnecessary morbidity. These patients can present with a palpable mass, renal impairment from obstruction of the ureter, lower limb edema from iliac vein thrombosis, and sepsis in case of infection. Diagnosis and follow-up with an ultrasound (US) is simple and efficient. The prevention of lymphoceles may be possible with meticulous surgical techniques where all lymphatics are carefully ligated. The reduction of known risk factors can also help reduce its incidence and morbidity. Treatment options include aspiration, sclerosant instillation, and surgery, but lymphoceles can recur and every effort must be made to reduce its incidence. Conclusion: We feel that a meticulous surgical technique with ligation of all lymphatics, both during dissection of the recipient vessels and the donor allograft, along with appropriate suction drainage, was significant in reducing the incidence of lymphoceles following kidney transplantation in our recipients.

KEYWORDS: Post-renal transplant lymphocele; Meticulous surgical technique; Ligation of lymphatics; Risk factors; Incidence CORRESPONDENCE: Taqi F Toufeeq Khan, Division of Kidney Transplant Surgery, PO Box 7897/624N, Riyadh Military Hospital, Riyadh, 11159, Kingdom of Saudi Arabia ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 64. doi:10.3834/uij.1944-5784.2011.10.7

UroToday International Journal original report UIJ Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence Figure 1. Tissue overlying the artery is lifted and stretched Figure 3. Large lymph nodes obscure the distal half of the (a), 2 silk ties are passed , tied (b), and tissue divided. This external iliac vessels (see arrows in 3a) and visible vessels is repeated several times till adequate length of artery is following lymphadenectomy (b). A large lymphatic is mobilized. The arrow shows a large lymphatic. visible (see arrowhead) and several silk ligatures are doi: 10.3834/uij.1944-5784.2011.10.7f1 visible and represent tied lymphatics. doi: 10.3834/uij.1944-5784.2011.10.7f3 (a) (b) )a) (b(

Figure 2. Thick tissue is lifted off the vein (a); this tissue is then tied (b) and divided to expose the vein. This step is risk factors associated with the formation of lymphoceles are repeated till adequate length of vein is mobilized. diverse and include acute rejection (AR) [6-8], delayed graft doi: 10.3834/uij.1944-5784.2011.10.7f2 function (DGF) [6], obesity with a body mass index (BMI) over 30 (a) (b) kg/m2 [2, 7, 9], sirolimus [3, 7, 10], and steroids [6, 11]. A potent yet preventable risk factor is inadequate ligation of lymphatics during back table preparation of the donor allograft vessels [12] and hilum, and during dissection of recipient iliac vessels [1, 6, 13]. Ultrasound (US) is very useful for diagnosis, therapeutic percutaneous aspiration, placement of catheters for sclerosis, and follow-up [14]. However, recurrent lymphoceles require operative drainage into the peritoneal cavity [2]. The objective of this study is to (1) determine the incidence of lymphocele in all patients who underwent kidney transplantation, (2) present our results and identify contributory risk factors, and (3) describe our surgical technique and discuss its impact on the Introduction incidence of lymphoceles in our kidney transplant recipients.

Lymphoceles are the commonest fluid collections observed Materials and Methods after kidney transplantation with an incidence that ranges All patients who underwent live or deceased donor kidney from 0.6 to 61% [1-3]. The majority of lymphoceles, which occur transplantation at the Riyadh Military Hospital from March 2007 within 1 year of transplantation, are small and asymptomatic, to December 2010 were included in this analysis. Excluded were and require no treatment [4]. Larger and symptomatic the recipients operated on by locum staff. Data was collected lymphoceles can cause (1) allograft dysfunction by obstructing from consecutive patients operated on by the senior author. the ureter, (2) deep vein thrombosis and lower-limb edema The data was collected retrospectively and the minimum by compressing the iliac veins, (3) paraincisional mass, and (4) follow-up was 3 months. Exclusion criteria consisted of death, abdominal pain. These large lymphoceles are associated with nephrectomy, graft loss within 30 days, or lack of follow-up. increased morbidity and frequently require urgent intervention. The incidence of lymphocele in this group of patients was Infective complications can result in mortality [3]. The reported calculated along with the type of treatment performed.

UroToday International Journal original report UIJ Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence Figure 4. A bunch of silk ligatures are visible (see arrows) develop the retroperitoneal space and retractors are placed where the lymph vessels were divided during lymph node appropriately. All vascular anastomoses are end-to-side to the removal. external iliac vessels or, if these vessels are not usable, to the doi: 10.3834/uij.1944-5784.2011.10.7f4 common iliacs and the extravesical ureteroneocystostomy is stented. The important features of our technique are as follows:

Dissection of iliac vessels. The external iliac vessels are identified and the artery is dissected first. The artery is strapped to the posterior abdominal wall by a layer of fibro fatty tissue that also contains lymphatics and lymph nodes. Mobilization of the artery requires that this tissue layer be divided. This tissue is lifted off the artery (Figure 1a) and two 4/0 silk ligatures are passed and tied on both sides of the artery and divided (Figure 1b). We proceed in this manner by securing sections of tissue until the desired length of artery required for anastomosis has been mobilized. The artery is lifted up using a vessel loop. This exposes the tissue that lies posterior and needs to be divided to fully mobilize the artery. If this tissue appears to be thick, we divide it between ligatures. If flimsy, we use electrocautery.

The tissue layer overlying the veins can also be thick and contain lymphatics (Figure 2a), and it is generally divided with Figure 5. (a) Lymph node medial to external iliac vein (see electrocautery. We, however, proceed to expose and mobilize arrow). (b) This node is being removed after ligating its the external iliac vein in exactly the same manner as the artery lymphatics to expose the vein. by ligating and dividing this tissue (Figure 2b) until the required doi: 10.3834/uij.1944-5784.2011.10.7f5 length of vein for anastomosis is exposed. These 4/0 silk ligatures )a) (b( are placed to prevent leaks from divided lymphatic vessels. In cases where the common iliac artery is used for anastomosis, mobilization is achieved similarly by ligating and dividing all overlying tissue.

Lymph nodes obscuring the external iliac artery (Figure 3a) are also removed by ligating all tissue before dividing (Figure 3b). A bunch of silk ties are proof of having secured the lymphatics entering the lymph nodes (Figure 4) from the lower limb. At times, lymph nodes are also found along the medial wall of the vein with lymphatics coursing over the vein within this thick tissue layer. These nodes are also removed after ligating its lymphatics (Figures 5a and 5b).

Patient Characteristics Allograft. In the same manner, all divided lymphatics present in the allograft hilum and along its vessels are carefully ligated Patient demographics along with known risk factors associated to prevent leakage (Figure 6a). Some donor kidney lymphatics with lymphoceles are given in Table 1. become obvious after perfusion and are similarly ligated (Figure 6b). Surgical Technique Suction drain. At the end of the procedure, a closed suction Recipient surgery is performed through an extraperitoneal Jackson-Pratt drain is placed in all patients and only removed hockey stick incision. The peritoneum is swept medially to when drainage is less than 40 mL for 2 consecutive days.

UroToday International Journal original report UIJ Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence Figure 6. (a) Live donor allograft dissection. Lymphatics around the artery being secured with 4/0 silk ligatures. (b) Lymphatics that become obvious after perfusion; also secured with silk ligatures (see arrow). doi: 10.3834/uij.1944-5784.2011.10.7f6 )a) (b(

Ultrasound (US) is performed on the first postoperative day, the no known risk factors. The allograft preparation and recipient day before discharge, and as needed. Following discharge, a vascular dissection was performed in the usual meticulous baseline ultrasound is carried out in the clinic and is repeated manner by the same team that performed all the transplants. at 4 weeks, 3 months, and then annually. It is also performed She received our standard depleting antibody (Thymoglobulin) when indicated. induction with a triple drug maintenance regimen and was discharged home on day 6 after removal of the drain when the Immunosuppression. Recipients were given anti T-cell antibody drainage was less than 40ml/day for 2 consecutive days. The (Thymoglobulin, Genzyme) induction when receiving deceased presence of other risk factors in our cohort of patients is shown donor kidneys, live donor kidneys with more than 2 mismatches, in Table 1. The incidence of lymphoceles in some recent studies retransplantation, and if highly sensitized. Basiliximab (Simulect, is shown in Table 2. Novartis) was given to recipients with 2 or less mismatches. All recipients received methylprednisolone induction and zero Discussion mismatch recipients were induced with methylprednisolone only. Maintenance immunosuppression comprised tacrolimus, Lymphoceles cause increased morbidity and can result in mycophenolate mofetil, and steroids. Sirolimus was only given mortality [3], and every effort should be made to reduce its to recipients of extended criteria kidneys 4 to 6 weeks after incidence. Based on lymphangiography, 2 pathophysiologic transplantation. mechanisms have been demonstrated that may result in lymphocele formation: drainage from open lymphatics divided Results at the time of recipient iliac vessel dissection [13] and divided lymphatics in the donor kidney hilum [12]. We are meticulous Out of 273 transplants carried out, only 1 (0.3%) recipient was in ligating all possible lymphatics, not only ones along the diagnosed with a lymphocele. This patient presented with artery but also those along the iliac veins and when removing paraincisional fullness and pain 6 weeks after transplantation. lymph nodes. The same meticulous technique is carried US confirmed a lymphocele that was aspirated under with out during back table allograft dissection. The role of risk complete resolution and did not recur at the 1-year follow-up. factors [2, 3, 6-11] in lymphocele pathophysiology may be that This was her first kidney transplant and the live donor kidney was of delaying the healing of such divided lymphatics, but if these placed in the right iliac fossa, and except for steroids, she had

UroToday International Journal original report UIJ Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence Table 1. Recipient demographics and lymphocele risk Table 2. Lymphocele incidence in some recent studies. factors. doi: 10.3834/uij.1944-5784.2011.10.7ft2 doi: 10.3834/uij.1944-5784.2011.10.7ft1 Age (range) 4–74 Reference Incidence of lymphocele (%)

Total 273 Rogers et al. (11) 5.5%

Male (%) 170 (62%) Goel et al. (7) 33%

Live/deceased donor 183/90 Langer et al. (10) 17%

Diabetes 59 (22%) Dubeaux et al. (1) 0.6%

Acute rejection 18 (6.6%) Atray et al. (2) 26%

BMI>30kg/m2/range 68 (24%)/18–39 Khuali et al. (6) 22%

Retransplants 24 (9%)

DGF total/live donor 9 (3.2%)/1 (0.5%)

negatively influenced lymphocele development or wound Steroid-free regimen 40 (14.6%) healing. Our only case of lymphocele was a recipient of a first transplant from a live donor with none of the risk factors De novo Sirolimus zero except steroids (no sirolimus, non-diabetic, BMI: 22, no AR/DGF) and it is likely that perhaps not all the lymphatics were secured. Steroids were the only known risk factor in our case; however, the vast majority of our other recipients were also on steroids but didn’t develop lymphoceles. Our incidence of lymphocele lymphatics are adequately ligated, we feel that the role of risk is very low compared to several recent series. Another series factors can be reduced, if not eliminated. De novo sirolimus with a similarly low incidence also stresses surgical technique therapy has been associated with the highest incidence of with the need for careful ligation of lymphatics [1]. Another lymphoceles [3, 7, 9, 10], and the proposed mechanism being series, also with a low incidence, suggests reducing lymphatic a failure of adhesion formation and lymphangiogenesis [15]. disruption by using vessels that are more proximal can reduce We have used it selectively in DD kidney transplants to replace lymph leakage and lymphoceles, the emphasis being on tacrolimus 6 to 8 weeks after transplantation, and feel that preventing lymph leaks [13]. Whatever role the risk factors play perhaps this delayed introduction of sirolimus may reduce its can be negated by preventing lymph leaks with properly placed impact on wound healing and lymphoceles. In analyzing the ligatures. The presence of suction drains creates negative individual risk factors, our incidence of DGF and AR is lower pressure and brings opposing surfaces together to collapse than most studies and may have played a part in preventing and seal any open lymphatics. One advantage and a possible lymphoceles; however, the use of steroids, BMI, retransplants, reason for the low incidence of lymphoceles was that all the and diabetes in our recipients is similar to most series. A transplants were carried out by the same surgeon with the steroid-free regimen was introduced in mid-2009 to reduce same meticulous technique every time. Different surgeons use cardiac and bony complications in diabetic recipients, and different techniques and may lack uniformity. Some may prefer may have been responsible for improved wound healing and electrocautry to ligatures during dissection. A limitation of this lymphoceles reduction, at least in this group of 40 recipients. study was the retrospective data collection and analysis, and it Since the overall incidence of lymphoceles was only 0.3% did not involve a comparison of various groups. Additionally, with no wound breakdowns, it is unlikely that this regimen drains were used in all recipients and could not be blinded.

UroToday International Journal original report UIJ Post Kidney Transplant Lymphoceles: Meticulous Ligation of Lymphatics Reduces Incidence In our study, the non-detection of lymphoceles was not the 7. Goel M, Flechner SM, Zhou L, et al. The influence of various reason for the reported low incidence; primarily because in maintenance immunosuppressive drugs on lymphocele the first 3 months, US is carried out at least 3 times and every formation and treatment after kidney transplantation. 3 months thereafter for the first year. US is also carried out J Urol. 2004;171(5):1788–1792. PubMed ; CrossRef whenever there is a suspicion of lymphocele with recipients presenting with pain, renal impairment, lower limb edema, or 8. Bischof G, Rockenschaub S, Berlakovich G, et al. a palpable mass. Lymphoceles result in morbidity in terms of Management of lymphoceles after kidney transplantation. increased hospital stays, costs, invasive procedures, and surgery. Transpl Int. 1998;11(4):277–280. PubMed ; CrossRef Additionally, a significant recurrence rate has been reported 9. Tiong HY, Flechner SM, Zhou L, et al. A systematic approach following aspiration (33%), sclerotherapy (25%), and surgery to minimizing wound problems for de novo sirolimus- (12%) [2], and justifies the extra time spent in placing ligatures treated kidney transplant recipients. Transplantation. if lymphoceles can be prevented. Based on our experience, 2009;87(2):296–302. PubMed ; CrossRef we feel that it may be possible to reduce lymph leakage and prevent the formation of lymphoceles by carefully ligating all 10. Langer RM, Kahan BD. Incidence, therapy, and lymphatics. consequences of lymphocele after sirolimus-cyclosporine- prednisone immunosuppression in renal transplant recipients1. Transplantation. 2002;74(6):804–808. PubMed REFERENCES ; CrossRef

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©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.7 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 The Link Between Female Obesity and Urinary Stress Incontinence

H. H. Eltatawy,1 T. M. Elhawary,2 M. G. Soliman,1 M. R. Taha1 1Urology department Faculty of Medicine, Tanta University, Tanta, Egypt 2Obstetrics & Gynecology Department, Tanta University, Tanta, Egypt Submitted May 27, 2011 - Accepted for Publication July 25, 2011

ABSTRACT

Background: Stress urinary incontinence (SUI) has an observed prevalence of between 4 and 35%. Aging, obesity, and smoking have consistent causal relationships with the condition. Objective: To elucidate the relationship between obesity and urinary incontinence in women and a possible explanation of this relationship by ultrasound of the urethrovesical angle and bladder neck descent. Material and Methods: This prospective, comparative study was conducted in Tanta University Hospital from January 2006 to July 2010, and it included 100 obese women compared to 100 normal-weight control women regarding symptoms of SUI, ultrasonographic examination of the bladder neck, and bladder neck descent during straining for the detection of SUI. Results: In the obese group, 70% of patients had symptoms of SUI, whereas in the normal-weight group, 17% of patients had symptoms of SUI, denoting a significant increase among the obese. Ultrasonographic examination revealed that in obese women, the urethrovesical angle is nearly at a right angle with an empty urinary bladder at rest and becomes obtuse at straining; but when the bladder was full, this angle became obtuse at rest and during straining. In normal-weight women, the urethrovesical angle was acute at rest and nearly at a right angle at straining while the bladder was empty, and it became a right angle with a full bladder at rest and slightly obtuse at straining with a full urinary bladder. In obese women, the average bladder neck descent during straining was 10 ± 3.5 mm compared with a mean of 3±1.2 mm in the normal weight group, with a significant difference between the 2 groups. Conclusion: Female obesity is an important risk factor for the occurrence of SUI.

Introduction studies have consistently shown that both increased weight and

obesity are important risk factors for the development of various The prevalence of obesity is increasing worldwide and has lately reached epidemic proportions in many countries. Epidemiological female pelvic floor disorders, including urinary incontinence [1].

KEYWORDS: Obesity; Female stress incontinence CORRESPONDENCE: M. G. Soliman, Lecturer of Urology, Urology Department, Faculty of Medicine, Tanta University, Tanta, Egypt ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 63. doi:10.3834/uij.1944-5784.2011.10.5

UroToday International Journal original study UIJ The Link Between Female Obesity and Urinary Stress Incontinence Stress urinary incontinence (SUI) is defined as a loss of urine with Figure 1. Transvaginal ultrasonographic picture of the exertion or an increase in abdominal pressure that occurs with bladder neck with an empty bladder. activities such as coughing, sneezing, walking, and bending [2]. doi: 10.3834/uij.1944-5784.2011.10.5f1 SUI is estimated to affect between 4 and 35% of adult women. This is due to the difference in epidemiological research and population studies, as well as the difference in the definition of SUI used by the investigators [3]. There are many risk factors, such as aging, pregnancy, route of delivery, previous pelvic operations, smoking, obesity, diabetes, and others.

Strong associations between obesity and SUI in women have been frequently reported in urogynecologic literature [1]. The aim of this work was to elucidate the true relationship between obesity and stress incontinence in women and a possible explanation of this relationship by ultrasound of the urethrovesical angle and bladder neck descent.

Patients

• Participants of this investigation were recruited and studied during their visits to the outpatient clinics in Tanta University Hospital. The study was carried out during the • A standardized 1-hour pad-weighing test and cough stress period of January 2006 to July 2010. The study included 100 test with a full bladder (300 mL) were done. obese women (with a body-mass index of ≥ 30) (group I) and 100 normal-weight control women (with a body-mass index • The posterior urethrovesical angle (PUVA) of each case of 19.8 to 26) (group II). was measured at rest and during straining by transvaginal 7.5 Mhz and transperineal ultrasonographic 3.5 Mhz • Patients enrolled in this study after learning the aim of the examinations with an empty and full urinary bladder. We investigation, and written consent was signed from every measured the descent of the bladder neck during straining woman. (Figures 1-3) [4]. • The inclusion criteria were married women aged • All data was collected, and a statistical analysis of the data 20 to 45 years with fair general condition. The exclusion using the mean, standard deviation, and unpaired t-test was criteria were virginal and menopausal women, the developed. presence of urinary fistula and/or a history of previous anti- incontinence surgery (not recurrent), DM, and neurologic Results problems. • Regarding age, it ranged from 23 to 45 years old with Methods a mean of 29 + 4.8 years for members of group I, whereas the corresponding values ranged from 22 to 46 years with For each patient, the following was done: a mean of 31 + 5.2 years in members of the normal-weight • History taking with stress on urinary complaints was group. performed. (The patient was asked whether she leaked • Concerning parity, in members of the obese group, it ranged urine when she coughed, sneezed, laughed, or exercised.) between nullipara to 7 para with a mean of 3 ± 1, while in A complete general examination, a genital examination for members of the normal-weight group, it ranged between the detection of pelvic organ prolapse, and for the detection para I to para 8 with a mean of 4 ± 1. of SUI, if any, was performed. • With reference to body-mass index, it ranged between • A complete urine analysis was performed. 32 to 40 kg/m2 with a mean of 34 + 2.5 kg/m2 in members

UroToday International Journal original study UIJ The Link Between Female Obesity and Urinary Stress Incontinence Figure 2. Transvaginal ultrasonographic picture of the Figure 3. Transvaginal ultrasonographic picture of the bladder neck with a full bladder at rest. bladder neck with a full bladder with straining. doi: 10.3834/uij.1944-5784.2011.10.5f2 doi: 10.3834/uij.1944-5784.2011.10.5f3

• The bladder neck descent in members of the obese group of the obese group; meanwhile, it ranged between 19 to ranged from 7 to 13 mm with a mean of 10 + 3.5 mm during 24 kg/m2 with a mean of 23 + 2.7 kg/m2 in members of the straining. Meanwhile, the bladder neck descent ranged from normal-weight group. There was a significant difference 2 to 6 mm with a mean of 3 + 1.2 mm in the normal-weight between both groups. group. The variation between both groups was significant • In the obese group, 70% of cases had symptoms of SUI, (Tables 1 and 2). whereas only 17% of women had symptoms of SUI in the normal-weight group. The difference between the 2 groups Discussion was statistically significant. According to the recently standardized terminology of the • In the obese group, 85% of women had an objective loss International Continence Society (ICS), urinary incontinence of urine that was established during examination while in (UI) is defined as the complaint of any involuntary leakage of the normal-weight group, only 24% of the women had an urine [5]. Several types of UI have been described in literature. objective loss of urine during examination with a significant The most common subtypes of UI are [5] stress urinary difference between both groups. incontinence (SUI) [6], urge urinary incontinence (UUI), and • Urge incontinence was present in 23% of members of the mixed urinary incontinence (MUI) [7]. obese group and in 18% in the normal-weight group (Figure 4). SUI is characterized by the complaint of involuntary leakage • Regarding the ultrasonographic evaluation of the urethro upon effort or exertion, or when sneezing or coughing [5]. vesical angle: In the obese group, this angle was nearly right In SUI, the intra-abdominal and, therefore, the intravesical with an empty urinary bladder at rest and became obtuse pressure exceeded the maximal closure pressure of the urethra during straining, but when the bladder was full, this angle in the absence of involuntary detrusor contractions (IDCs). was obtuse at rest and during straining. In the normal- This implies a failure in the urethral closure capacity. This may weight group, the urethrovesical angle was acute at rest be due to an alteration of “sphincterial mechanisms” of the and nearly right during straining while the bladder was urethra wall (collagen, smooth muscle, arterial anastomosis, empty, and it became a right angle with a full bladder at endothelium, etc.) that produces a low urethral closure pressure rest and slightly obtuse during straining with a full urinary due to intrinsic sphincter deficiency. A hypermobile bladder bladder. neck or urethra, which is displaced during a sudden increase in

UroToday International Journal original study UIJ The Link Between Female Obesity and Urinary Stress Incontinence Table 1. Transvaginal US of the urethrovesical angle on Table 2. Transvaginal US of the urethrovesical angle on empty urinary bladder at rest and during straining. full urinary bladder at rest and during straining. doi: 10.3834/uij.1944-5784.2011.10.5t1 doi: 10.3834/uij.1944-5784.2011.10.5t2

US parameters Obese Control Significant US parameters Obese Control Significant empty bladder group Group difference full bladder group group difference Urethrovesical angle at rest: Urethrovesical angle at rest: Acute Acute 20% P<0.05 P<0.05 Right 10% 20% Right 10% 80% Obtuse 90% 80% Obtuse 90% Urethrovesical angle at straining: Urethrovesical angle at straining: Acute Acute 30% P<0.05 P<0.05 Right 40% 70% Right 60% Obtuse 60% 30% Obtuse 100% 10% Range of bladder neck 7–13 2–6 descent during straining in mm P<0.05 Mean of bladder neck 10 + 3 + 1.2 descent during straining difficulty in understanding the contribution of obesity to SUI in mm is that many obese women with the condition also have other risk factors, such as multiparty estrogen deficiency and pelvic operations. Nevertheless, epidemiologically, obesity has been associated with urinary incontinence of all types [17]. intra-abdominal pressure, may also lead to SUI due to pelvic- One of the explanations is that obesity leads to increased floor weakness or injury [8, 9]. Both of these conditions may intra-abdominal pressure and increased pressure on the coexist in the same female. The urodynamic observation of bladder. In women with UI, body-mass index correlates with IDCs during the filling phase, either spontaneous or provoked, both intravesical and intra-abdominal pressure [18]. Chronic distinguishes this condition from SUI [9]. pressure leads to chronic straining and tension on the muscles, connective tissues, and the pudendal nerve supplying the pelvic Obesity is common among women in developed countries, with support structures resulting in nerve injuries and pelvic floor an incidence of 33% [10], and may contribute to SUI [11]. The dysfunction [19]. This typically leads to stress UI due to the present study demonstrates that urinary stress incontinence loss of support of urethrovesical junction [20] and, to a lesser is an important concomitant of obesity in women. We found extent, to urge UI from detrusor muscle overactivity [21]. that 70% of obese women have subjective symptoms of SUI compared with only 17% among normal-weight women. The other explanation is that the chronically increased Obviously, the difference is a significant one. This conforms abdominal pressure stressed the pelvic floor and thus to the conclusion of numerous studies stating that obesity is contributed to SUI. That theory melds well with epidemiological a strong risk factor for incontinence [12-14]. Richter et al. studies from the UK [22] and Egypt [23], which suggested an reported that the prevalence of urinary and anal incontinence association between obesity and urogenital prolapse, although is high in morbidly obese women compared to the general Peacock [24] suggested that this correlation might not apply to population, depending on subjective symptoms only [15]. In other ethnic groups. addition, several studies have suggested that weight loss may reduce the frequency of urinary incontinence [16]. There is evidence that a subset of women with elevated body-mass indexes and urge incontinence may have a ß3- Obese women are at risk for the development of SUI. However, adrenergic receptor mutation that simultaneously affects both the reasons for this have not been completely elucidated. One insulin sensitivity and ß3-mediated detrusor muscle relaxation

UroToday International Journal original study UIJ The Link Between Female Obesity and Urinary Stress Incontinence Figure 4. Incontinence symptoms, subjective urine descent in continent women than in incontinent women during loss, and objective urine loss (the clinical detection of straining [36, 37]. incontinence). In our study, ultrasonographic assessment of the urethrovesical doi: 10.3834/uij.1944-5784.2011.10.5f4 junction revealed that the urethrovesical angle was more obtuse with a full bladder and right-angled with an empty bladder in obese women than in normal-weight counterparts.

Furthermore, the bladder neck descent measured by ultrasound was more marked in the obese compared with the normal- weight group, and all these findings suggest the presence of anatomical defects in these obese patients.

We conclude that female obesity is an important risk factor for the occurrence of SUI that can be explained by our ultrasonographic finding of anatomical defects in obese patients; therefore, we suggest future studies on a large number of obese women undergoing weight control to clarify the effects of weight loss on SUI.

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©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.5 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Challenges for a Resident in Urology in Tunisia in 2011

Sallami Satâa Department of Urology, La Rabta University Hospital, Tunis, Tunisia Submitted January 24, 2011 - Accepted for Publication July 3, 2011

ABSTRACT

This article presents the actual state of urology and highlights some of the most significant challenges facing resident urological training in Tunisia. These include a specifically limited number of trained urologists, limited training capacity, limited availability of some modern equipment, and non-recognition of subspecialties related to urology. Brief suggestions to overcome these problems are made, and the need for a wholesome review of the economic and health care policies is emphasized.

Introduction Urology is changing!

Surgical specialities, especially urology, have been largely Across the world, the specialty of urology is in constant affected by rapid innovation in medical therapies, surgical evolution [2]. Much of these changes have been the result of techniques, local resources, and patient demographics these improved technology. Many of the traditional surgical and last years. This impacted the quality of care directly. even endoscopic approaches are now largely obsolete.

The new generations of extracorporeal lithotriptors have The objectives of the residency training should match this already revolutionized the therapy of urinary tract stones. evolution. We have to think about our future practice and be Lasers are in their infancy, but it will influence the practice of prepared for all of these expected changes. There is a constant urology in the management of neoplasms and the management challenge to the urological education programs to provide the of calculi. Many urologic operations that have been done by most appropriate, advanced, and comprehensive training in open surgery are performed by laparoscopy. The development the constantly expanding technologies and techniques [1]. of new chemotherapeutic agents and advances in radiological imaging of the urinary tract are improving our practice. Herein, we examine the quality and the effectiveness of the current urological training in Tunisia and if it is appropriate to Skills and experiences using all these techniques will our current and long-term urological realities. undoubtedly be an important part of urologic practice in the future. Emerging and developing techniques are becoming

KEYWORDS: Urology; Training; Residency; Education; Clinical competence; Motivation; Evaluation; Curriculum; Medical; Surgery; Endourology; Endoscopy; Laparoscopy CORRESPONDENCE: Sallami Satâa, Department of Urology, La Rabta University-Hospital, Tunis, Tunisia ([email protected]). CITATION: UroToday Int J. 2011 Aug;4(5):art 59. doi:10.3834/uij.1944-5784.2011.10.1

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 more difficult to attend but mandatory [3]. This requires young years, additional independent centers were established in Sfax, urologists to be actively involved in continuing education. Sousse, Monastir, and Kairouan. Currently there are 7 urology training centers in Tunisia. Why have we chosen urology? On 6 June 1986, the first kidney transplantation was performed, Urologists are, first and foremost, surgeons and clinicians. and over 3 years, 60 kidney transplantations were performed It is still an extremely selective specialty [4]. Urologists are [9]. The Tunisian Urological Society (TUS) was founded in 1991. increasingly valued and in growing demand in society today. In As of September 2010, there are 207 trained and registered Tunisia and the rest of the Arab countries, people are becoming urologists in Tunisia [8, 10], serving a population of 10 million increasingly aware of the importance of preventing urological (i.e., a ratio of 1: 48.300). Ten of them had already become neo- pathology, and new treatments for previously incurable specialists. urological diseases are becoming available. (A) Medical study in Tunisia Many authors had investigated why some medical students select urology as a career. The top 4 reasons for students in In order to be granted a residency in urology in Tunisia, the the UK to select urology as a career included (1) inspirational candidate must fulfil several criteria. First of all, he or she must role models, (2) exposure to urology as a house officer, (3) a have a medical diploma that is recognized in Tunisia. In Tunisia, variety of open and endoscopic urological procedures, and (4) medical studies take 5 years. In addition, the candidate must the quiet on-calls and sociable lifestyle [5]. In a similar survey have an internship certificate or an equivalent of the same in the USA, investigators point to the importance of the mix training abroad. of medicine and surgery in this speciality, the diversity of urological procedures, and clinical exposure to the field as the The internship consists of a training rotation in general surgery, most common citations [6]. internal medicine, paediatrics, obstetrics-gynaecology, and 2 other chosen favorite disciplines. It takes 24 months. At the Demography of Tunisia end of these 2 years, students finish medical school by passing a final exam, the “Examen clinique.” Tunisia is a North-African country with an estimated population of 10 million people of various sociocultural ethnic groups (Arab, After that, the majority of medical doctors take a competitive Berber, European, and black) [7]. The health program of the state exam to be admitted to postgraduate specialist training. country is based on a national health policy and strategy, which This exam is scheduled each year in September and concurrently aims at achieving health for all Tunisians. This policy identifies at the Faculty of Medicine in Tunis. This examination covers all 3 levels (primary, secondary, and tertiary) for the provision of subjects and consists of hundreds of multiple-choice questions health care. Tertiary health institutions are responsible for the and cases. After success, candidates are offered residency posts training of medical students and residents and for carrying out according to their examination marks and personal preferences. research [8]. Tunisia has 4 medical universities with, all together, The number of residency posts in each specialty is defined by 14 university hospitals [8]. The doctor-to-population ratio in the government. Each year, around 5 to 7 new residents enter Tunisia is about 1:1000, but the majority of these doctors are urological training in Tunisia. Residency is considered as part of located in the urban regions [8]. educational studies in Tunisia and is funded by the government.

When a resident is accepted for further urological training, the Urology in Tunisia Ministry of Health lists him or her in a special registry that tracks all achievements until the eventual certification as urologist. In Tunisia, the specialty of urology was founded in the sixties by Pr. Zmerli who is one of the pioneers of urology in the (B) The training program for Tunisian urological residents Maghreb, Arab, and African countries. The specialty of urology in Tunisia, an entity now distinct from general surgery, is less Historically, surgical training in Tunisia has followed the than 50 years old. The first independent department of urology Halstedian tradition of an apprenticeship. The trainee starts in Tunisia was founded at Charles Nicolle’s Hospital, Tunis, in with an internship and continues through residency training 1961 to 1962 with Pr. Zmerli as chair [9]. Over the next few with increasing responsibility until the trainee should have

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 almost the same abilities as the teacher. However, this system twice weekly, during which residents present their patients is characterized by long hours with poorly defined goals and and discuss pathologies. In each training center there are haphazard, random experiences that depend on patient flow educational conferences in the form of clinical presentations, and disease presentation [11]. lectures, reviews of recent literature, discussions of research projects, and pathology reviews. (a) General characteristics In Tunisia, training in urology begins immediately after an Regular 1-day courses taken within the “collège d’Urologie” is internship as in Belarus, Norway, Germany, Italy, Romania, assumed to provide continuous and adequate training. To this and the Ukraine. It starts after a preresidency in Denmark and can be added the training provided by the educational courses the Netherlands, and after “common trunk” general surgery of European School of Urology (ESU) in Tunisia, the annual residency in Finland, France, Greece, and the UK [12]. In Tunisia, meeting of the TUS, and the annual meting of the Tunisian as with the majority of European countries, general surgery Society for Research on Sexuality and Impotence (STRSI), the training is incorporated within the framework of a urology Tunisian Association of Surgery (ATC), the Tunisian Association residency program [12]. Italy, Estonia, and the Ukraine remain of Paediatric Surgery (ATCP), and the Tunisian Laparoscopic the only 3 European countries where residents spend no time Surgery Society (STCL). in general surgery [12]. All residents should attend these courses and national meetings, The average time spent in general surgery training in conferences, seminars, and so forth. They give residents European countries is longer than the Tunisian model and lasts the opportunity to listen and learn from the experiences 16.2 months [12]. Furthermore, it is longer in India and takes of colleagues and experts and to develop their own work. 3 years [13]. Moreover, residents (especially chief residents) are strongly encouraged to attend international meetings and conferences. All training in Tunisia lasts for 4 years and comprises a 2-stage approach: the first stage consists of general surgical (visceral In Tunisia, all urologists and all residents-in-training are members surgery, paediatric surgery, or any other surgical speciality) of TUS and are encouraged to be members of international education (12 months as in the USA), preferably during the urological associations, including the French Association of first year of residency, and the second phase (2 to 3 years) Urology (AFU), the European Association of Urology (EAU), the concerns, specifically, urological education. Moreover, residents Société Internationale d’Urologie (SIU), and even the American are strongly advised to spend 6 months in gynaecology and Urological Association (AUA). 6 months in nephrology. Our web page—www.urotunisia.com—was launched several (b) Curriculum and clinical experiences: goals years ago and has already proven to be a very useful source of and objectives information for Tunisian residents and urologists. Our residency program is designed to provide the maximum educational experience in operative, procedural, and office (c) Curriculum and clinical experiences: timing urology. It is based on gradually acquiring knowledge and Establishing the foundation of urological practice is really a further responsibilities under the supervision of a tutor and complex process, during which we are learning a lot of data. senior staff at the training site. The goal of the urological In general, urological training aims to provide the acquisition training program is to produce a reasonably well-trained of improved uro-diagnostic capability; a better understanding general urologist who has a broad understanding of most of urogenital pathophysiology and uro-pharmacology; common urological conditions relative to Tunisia and an endourological skill; the improvement of pelvic, perineal, and ability to perform correctly the majority of common urological retroperitoneal surgical skill; exposure to newer technological procedures. advances; renal replacement therapy options; and the surgical treatment of localized urological malignancies [1]. All of these The training involves patient care, assisting in the operation competences should be attended gradually during residency. theater, performing all possible diagnostic procedures, work in the outpatient ward, night shifts, and scientific writing. Patient rounds are made daily, and grand rounds are held

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 General surgery training (especially bladder, prostate, and renal cancers), infertility, and impotence. Surgical competence in open and endoscopic surgery As said by Pr. Zmerli: “Give me a brave surgeon, I will give you must be demonstrated. He or she should also demonstrate an excellent urologist.” competence in the management of some local urologic entities Urology residents are required to spend 1 year in a department specific to the Maghreb, including fistula between the bladder of general surgery (almost the first year). During this year, and the vagina arising after obstetrical manoeuvres, urinary residents must demonstrate competence in history taking, tuberculosis, renal hydatid cysts, and penal fracture [9]. physical examination, and the appropriate utilization of To attend all these goals in time, which is a real challenge, adjunctive laboratory tests in different pathologies necessitating residents have exposure to the operating room and act as surgical treatment. With this prior general surgical training, the primary surgeons on a large number of cases. Each of these urological trainee will be comfortable with abdominal anatomy activities prepares the resident to enter the profession of and handling of the bowel, performing simple inguinal urology. surgeries, and may have basic laparoscopic surgical skills [1]. The urology residency experience is reinforced with rotations First year of urology training at many hospitals. The number of institutions the resident must The main objective of this year is the development of a solid rotate through does not affect the duration of training. infrastructure necessary to become an excellent urologist. In Denmark, the Netherlands, and in Tunisia, at least 2 institutions The resident has to improve his or her knowledge concerning are required. In France and the UK, training in more than 2 basic urology anatomy, physiology, and the pathophysiology hospitals is mandatory. In other countries (Bulgaria, Finland, of urologic diseases. Residents must learn the indications for Germany, Greece, Italy, Norway, Romania, and the Ukraine), surgical interventions, the various endoscopic techniques, residents may do all of their training at just 1 hospital [12]. and the studies needed to determine the aetiology of the Larre and colleagues had found that residents carrying out disease. The urology resident will gain expertise in urology their residency in different urology departments performed history taking and physical examination. Moreover, residents better than those trained in a single department [14]. will gain confidence and skill, and they will demonstrate competence in all office-based urologic procedures, including (d) La Rabta department of urology as a model cystoscopy, transrectal ultrasound (with and without biopsy), A golden rule is always respected in our center: “Junior and extracorporeal shock wave lithotripsy (ESWL). residents work closely with the chief residents.” They have the opportunity to participate in almost all activities. Second year of urology training

At the beginning of this year, residents will start their first steps General urology/endourology: Residents perform a large in the evaluation and management of patients. They participate number of open surgeries, including prostatectomy, in the care of these patients when surgery or hospitalization is nephrectomy, all types of open lithotomy, and pyeloplasty. necessary. Moreover, they will handle the consultative services They diagnose and treat common urologic conditions such as and improve their capacity in following the management urolithiasis, BPH, carcinoma of the bladder, prostate carcinoma, and treatment of their patients. By the end of the second and scrotal conditions, such as hydroceles. They currently year, residents are expected to demonstrate competence in perform cystoscopy, transurethral incision of the prostate understanding the physiologic basis for urologic disease, basic (TUIP), transurethral resection of the prostate (TURP), and small endoscopic skills, and basic operative skills. bladder tumors. They actively participate with many cases of ESWL, percutaneous nephrolithotomy, and rigid ureteroscopy. Third year of urology training

During the chief year, the resident gains greater surgical skills Laser TURP, and transurethral destruction of prostate tissue by and clinical acumen. He will demonstrate competence in the radiofrequency thermotherapy are not available, nor is flexible management of all urologic entities, particularly with voiding ureteroscopy. I should like to mention the large number of endourological procedures carried out by the department. dysfunction, calculus disease, urethra stricture, oncology

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 Table 1. Surgical procedures included in each group [14, 15]. doi: 10.3834/uij.1944-5784.2011.10.1t1

Minor open surgery Major open surgery Endourology Laparoscopy Simple nephrectomy Radical nephrectomy Transurethral resection of Radical nephrectomy Bladder augmentation Partial nephrectomy prostate Radical prostatectomy Prostatic adenomectomy Nephroureterectomy Transurethral resection of Sacrocolpopexy TVT, TOTa Radical prostatectomy bladder tumour Varicocelectomy Sacrocolpopexy Cystoprostatectomy/bricker Rigid ureteroscopy Colpoperineorrhaphy Cystoprostatectomy/ Flexible ureteroscopy Vasectomy orthotopic neobladder Percutaneous nephrostomy Nesbit procedure Adrenalectomy Extracorporeal lithotripsy Circumcision Kidney transplant Varicocelectomy Donor nephrectomy Pyeloplasty (cadaver/living donor)

Oncology/minimally invasive uro-oncology: The service performed by the resident (under the constant supervision of manages a large volume of routine and complex urologic experienced medical staff). oncology cases, including endoscopic resection, radical prostatectomy, radical cystectomy with various types of urinary This is a simplified list of activities residents in Tunisia have to diversion, and surgery for renal tumors, including nephron- be able to perform: ✓ sparing surgery and radical nephrectomy. Physical Examination ✓ Cystoscopy Neurourology and reconstructive surgery: A wide variety of ✓ Ureteroscopy surgical procedures for the treatment of urinary incontinence ✓ Prostate biopsies and voiding dysfunction are performed in this service, including ✓ Kidney surgery sling procedures, fistula management, and reconstructive ✓ Ureter and pelvis surgery surgery. ✓ Bladder surgery ✓ Prostate surgery Male infertility and infectious disease: Residents learn the ✓ Testis surgery diagnosis and treatment techniques for these patients and ✓ Penis / scrotum surgery gain operative experience in general open and endoscopic ✓ procedures. Prevention and management of complications of urology surgery Paediatrics: We did not have paediatric urology department ✓ ESWL indications and follow-ups until now, so we have a little experience with paedriatic With regard to urologic emergency procedures required, urological problems. the treatment of urosepsis, hematuria, obstructive anuria, genitourinary trauma, urinary retention, testicular torsion, Radio-diagnostic: Residents in urology independently perform and priapism are the usual conditions that should fall into the abdominal and endorectal ultrasounds, which are evaluated by program of a trained urologist. It does not create any problems senior doctors. for our residents.

In the Tunisian urological training program, the requirements Table 1 resumes the surgical procedures (underlined) that for the theoretical training are well defined although there are a Tunisian resident should be able to do at the end of his or no exact numbers on how many surgical procedures have to be her training.

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 Most residents believe that laparoscopic renal and adrenal In Tunisia, after 4 years of training, the resident must pass a surgery are the gold standard, but they are less certain regarding final theoretical exam to receive a certificate of completion of the future value of laparoscopic/robotic prostatectomy [16]. urological training. Minimum requirements are as follows:

The strength of our urology program lies in the diversity of our ✓ Obligatory training in urology: at least 24 months of interests and the large variety of clinical opportunities. The training at accredited urological centers. ease of access to the operative room in Tunisian departments ✓ Obligatory training in other specialities: 6 to 12 months remains a very important attraction for young urologists, as in in a surgical department, 6 months in a nephrology center, and 6 months in a department of the resident´s other countries [17, 18]. choice (gynaecology, oncology, etc.). ✓ Although our residency program is designed to provide a varied Prerequisites to be admitted to the final exams: The applicant will document the application for experience in patient care, teaching, and research addressing the examination with data about his medical and the full range of male and female genitourinary conditions, educational research, schooling activities, completion many “routine” items are not available for resident, including of obligatory training and all educational activities, renal transplantation, microsurgery, reconstructive surgery, and confirmation of active participation in scientific paediatric urology, urodynamics, laparoscopic surgery, and conferences and scientific publications. andrology. In Tunisia, one must apply for the license of urologist in order (e) Teaching and self-education to have the right to practise. The license will be issued by the competent authority upon presentation of the certificate Grand rounds, attending rounds, and chief rounds are among of urological training. A urology license issued in Tunisia is the weekly departmental conferences. Residents also routinely recognized in other EU countries. attend special programs of the liege center in Belgium and the Mansoura center in Egypt. They are encouraged to attend It is definitive and we are not obliged to attend any training national and international meetings, they are encouraged to activities, as in other countries. present research papers at national meetings, and they are supported and funded for their activities. In Tunisia, residents One more thing we do not have in Tunisia is postgraduate are strongly advised to attend theoretical courses but they are education in urology, so there is no further subspecialization not mandatory. In other countries (Belgium, Georgia, Germany, in the urological field, as in France or the USA. Greece, Portugal, Romania, and Turkey), residents do not need to attend any theoretical or practical courses [12]. (h) Resident’s book The establishment of the internal book is already a reality in (f) Research opportunities the vast majority (67% to 74%) of European countries [12]. Up The department of urology encourages both clinical and until now, in Tunisia, we do not have an official “resident’s basic science research (urologic oncology, medical therapy for book” or journal that is used to evaluate residents in all medical BPH, etc.). Unfortunately, Tunisian residents do not have the fields. In some countries (Germany, Greece, Poland, Portugal, opportunity to participate in any of the department’s research and Sweden), logbooks are not used [12]. efforts. Larre and colleagues found that a supporting senior surgeon (g) Examination and the use of a logbook were associated with better technical performance [14]. In most European countries (Belgium, Croatia, the Czech Republic, France, Italy, Latvia, the Netherlands, Poland, Turkey, (i) Financial data the Ukraine, and the UK), residents have to pass examinations to be able to continue their residency [12]. We do not have the Urological residents work about 45 hours per week and receive same system in Tunisia and residents pass automatically after a base salary of approximately 400 to 500 euros (540 to 675 judgment of the head department. In case of an unfavorable dollars) per month, depending on the number of years they view, he or she has to repeat the half-period of training in the have been in training. Any additional medical activities, besides same center. the hospital job, in order to compliment one’s salary are not

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 permitted. In general, the average urologist from Tunisia will (B) Lack of structured and standardized training finish his studies and can start work as a doctor at age 30. curriculum

However, despite all of these problems, the Tunisian urological In Tunisia, most training centers lack a structured training residents are full of optimism and hope for early improvement. curriculum. Most trainees (and trainers) do not have a clear idea of what skills they are expected to acquire on a semester- Our point of weakness to-semester basis. Additionally, each center may have a different focus in urology. As a result, trainees from different Overall, urology training in Tunisia has been reasonable centers complete the training with varying levels of skills and over the years. Most trainees in our system have a vast fund knowledge. A good training program will provide exposure of theoretical knowledge, although the practical surgical to complex and rare procedures despite the fact that many training has not been of the same standard. Trainees from the of them would not be performing such procedures in their Tunisian system have done well, both in Tunisia and in Europe. clinical practice [1]. In the USA, Canada, Europe, and Israel, the The formal training system needs to be revamped to provide curriculum is structured with specific training objectives for better technical training in rapidly changing urological practice each year. scenarios across the world. I believe it may be worth considering the development of a Multiple factors have contributed to the changing dynamics new approach in surgical education for our residents in the of urology resident education, including the development form of a core surgical curriculum for all training programs. This of contemporary educational mandates as well as changes in curriculum would be based on didactic and hands-on surgical the human and technological resources necessary to sustain a laboratory teaching with adjunctive use of virtual surgical tools urology training program [19]. and Internet technologies. Through such a curriculum, residents would obtain an early understanding of the principles and Although urology is classified as a surgical specialty, knowledge techniques of surgery (open, laparoscopic, and endoscopic). of internal medicine, paediatrics, gynaecology, and other They could then proceed to surgical training in specific types of specialties is required by the urologist because of the wide procedures [3]. Additionally, teaching rounds, case discussions, variety of clinical problems encountered. and symposia presentations usually complete the academic input requirements [1]. The question is: “What are the gaps in urology training in Tunisia?” (C) Cultural barrier

First of all, no training system is perfect and each has its own As an independent speciality, urology is still avoided by female pros and cons. Some potential areas of weakness in the Tunisian students. It is considered a male speciality. In all of Tunisia, system of urological training are listed below. there is only 1 female senior urologist and, unfortunately, no residents at all. (A) Duration of training (D) Lack of experimentation The current 3-year urology residency may not provide the right foundation in these changing times [13]. According to the actual Many teachers, themselves, are still learning. As a result, they system, the trainee should learn all urology within a period of may not be in the best position to teach others. The experienced 3 years only. While this may be enough for academic learning, senior urologists may not have enough experience to guide a the vast majority of trainees do not get sufficient operating junior trainee through a procedure such as PCNL or laparoscopic experience in this short time. This is true even for “simple” procedures. procedures, such as the transurethral resection of prostate/ bladder tumors. The resident training period in Tunisia has (E) Laparoscopy not as yet been increased from 4 to 5 or 6 years. This raises a In Tunisia, the detachment of urology from “mother” general number of doubts and problems in regard to medical residents surgery is relatively recent. In many hospitals, the urologist acquiring suitable training in all areas of urology. practices under a surgeon chief. In such conditions, where

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 general surgeons monopolize new procedures, especially training program. Residents are not allowed to participate in laparoscopy, urologists will never obtain sufficient training and these programs, clinical research, or in basic science projects. experience to perform with excellence. On the other hand, since Moreover, there is no protected research time for residents. hospitals belonging to the public health system do not provide The present efforts in research and development are hampered laparoscopic treatment, trainees have little to no opportunity principally because few bright residents are involved in research. to learn and practice laparoscopic urology. According to a Medline search performed on September (F) Subspecialties 30 2010, there were a total of only 14 Tunisian manuscripts published in the Journal of Urology, BJU International, Urology, Constant improvements in andrology, female urology, and European Urology during the past 10 years. This is indeed paediatric urology, neurourology, and even current urological more than paltry as compared to 235 publications from Egypt, conditions (BPH, incontinence, and impotence) have made 237 publications from Israel, 397 publications from France, and them distinct subspecialties [20]. It is almost impossible for an more than 6899 publications from institutions in the USA in individual to have a depth of understanding of each of these these journals during the same time period. The reasons for subspecialties. This rapid explosion of urological knowledge this vast gap includes a general lack of time and facilities for and skills in the field of uro-diagnosis, therapeutic options, urological research in Tunisia and other developing countries. and surgical advancements cannot be effectively taught to the urological trainee’s tract [1], resulting in the advent and The new 5-year program with more research facilities would growth of new subspecialties [2] and a greater amount of time provide a greater opportunity to perform high-quality research required to train urologists in these skills [13]. during the training period by ensuring a more rational time allocation to this aspect of residency training, resulting in an In almost all countries, at the completion of the residency increase in the number of urological publications coming out program, residents have an option of a variety of subspecialty of Tunisian academic institutions [13]. training fellowships; it’s not the same in Tunisia. (I) Lack of epidemiologic data While subspecialties may be beneficial in selected institutions, most urologists in peripheral centers who cater to the It’s a logical result of a lack of clinical research in our country. majority of the Tunisian population need to be well versed in general urological skills covering a wide array of these new (J) Resident society subspecialties. One of the main problems facing the Tunisian urological residents is the absence of their own society and their own (G) Financial support meetings, as in European countries. The application of new urological technology certainly requires time and patience, but it also demands financing. Economic (K) Lack of practical skills issues are very important and often the main limiting factor. A second problem is the lack of opportunities to acquire practical skills. First, in large university centers, it is common that Availability of a method is also decisive for the selection of a the majority of operations are performed by older, experienced treatment [21]. Many new therapeutic technologies (laser, surgeons. Second is the heavy workload residents face at brachytherapy, robotic surgery, etc.) are still unavailable their workplace and the lack of time to enter into continuous because of their prices. education programs.

(H) Research: the neglected component It is not only in Tunisia that a large number of residents, Clinical/basic science research is a vital component of a residency even in leading institutions, report a deficiency of practical training program. Not only does it enrich the individual operating experience in our urology residency programs. This during training, but it also ensures growth and development lack of proper practical training is distressing. Duchene et al. of our specialty in the future. Progress in the field of urology discovered that only 38% of US urology residents felt that their depends on persistent efforts in research and progress [22]. laparoscopic experience was at least average or acceptable [23]. Research appears to be a low priority/absent in our resident This is so different from our actual reality but reflects a general problem.

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 Proposition ✓ Clearly, surgical volume is needed to provide good surgical experience in educating residents in surgical Training urologic students represents the most important techniques. However, something more structured challenges for the academic urologist today. There has been and fundamental may be needed to create a basis recent interest in revising urology residency training as shown of training with greater consistency and provide an educational experience that is more cohesive and by the increase of publications dealing with this subject. Medical standardized for each trainee to become surgically educationists believe that apart from a technical/professional qualified [3]. competency, all physicians should possess 6 core competencies: I would like to suggest the following to stimulate debate so patient care, medical knowledge, practice-based learning that the most appropriate program could be put in place for and improvement, interpersonal and communication skills, urologic training in Tunisia. Some of these views have been professionalism, and systems-based practice [1]. Any revisions previously reported [13]. Such programs could be an example should consider these fields. for other Maghreb, Arab, and African countries that have Training in the Urology Residency Program is expected to similar economic, educational, and health conditions. provide residents with an excellent background in all aspects of There are more than valid reasons for urology training to be adult and paediatric urology, as well as a foundation in research extended. It is true that this option will be poorly viewed by and academic urology, which will later give them the ability many, given the precarious financial and employment conditions to pursue private practice, a fellowship, or academic urology. of medical residents. We point to the importance of fifth-year What should we do to attend these objectives? residents to improve their technicality, conduct research, and The foundation of a comity to update and educate Tunisian publish articles so as to fill gaps in their curriculum vitae. Five- urologists would be a solution. year training seems to be adequate. The first 2 years should be devoted to general surgery (obligation of one year) and other This comity will introduce and improve uro-technology, relevant specialties (nephrology, vascular surgery, gynaecology, including minimally invasive treatments for BPH, the oncology, etc.). There is no doubt that a solid foundation in latest technologies for the endo-urological treatment of general surgery is essential for specialization in any surgical urolithiasis, innovative approaches for the treatment of cancers branch, but how long should be the period of surgical training? (brachytherapy, cryotherapy, HIFU, photodynamic therapy), An intensive 1-year general surgery rotation would be good advances in imaging to improve diagnosis, and the staging of enough to develop the basics and then build on it to make a tumors and urological laparoscopy [21]. An important step in comprehensively trained general urological surgeon [13]. The the accomplishment of this objective is the assessment of the next 3 years should be devoted to core urology. present practice and future needs. Repartition of different activities along the urology training Urology trainees in Tunisia are faced with serious challenges. At period of 4 years will be deeply discussed between the STU, the least 4 considerations should be kept in mind when developing comity of urology training, head departments of all urologic our educational model: departments, and medical universities.

✓ First, they need to be trained primarily to become We should define strict goals for every 6 months of training, good general urologists. assess if they were achieved, and define remedial measures that ✓ Second, a certain percentage of trainees exiting the must be taken if they were not attended. residency program need to acquire subspecialist training so that the highest quality specialist care could A 6-month or yearly trainee evaluation of trainers (practical be provided to those patients who need such care. The and theoretical knowledge) should be an integral part of the role of the general urologist would be channeling residency program, and definitions of measures to take in case patients to the appropriate specialist. of repeated negative reports. ✓ The economic considerations of urology practice in Tunisia are different from those of western medical More attention must be given to poorly known pathology, systems, which are driven by free market principles. Cost benefit analyses are very important in our country such as overactive bladder, erectile dysfunction, pelvic pain with very limited resources. syndrome, and so forth.

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 Surgical training must now incorporate both open and At the end of the training, after successful completion of the minimally invasive approaches for the same disease. This exit examination, residents would have the option and are demands more patience and time on both the educator and the encouraged to pursue a 1- to 2-year fellowship program in student. Both must maximize every opportunity for teaching various subspecialties at designated centers of excellence and and training [24]. An intensive, short, “hands-on” laboratory appropriate to our service demand. Therefore, through review curriculum for residents for improving skills in laparoscopy, of practice guidelines, statistical data, and other evidence- endourology, minimally invasive therapies, and robotic based references, they can identify and focus on areas that techniques should be carefully considered [25, 26]. present themselves as knowledge or skill gaps, and concentrate their efforts to master specific learning challenges. Resident participation in the operating room may be improved by viewing the surgical-generic and procedure-specific videos Continuing medical education programs and the introduction through a centralized Internet library as part of the core of “mini-fellowships” [28] for practicing urologists can further curriculum. Use of this Internet library would compliment improve their technicality, as well as update the practice of additional educational experiences with virtual surgery urology [1]. technologies and hands-on use of animal models in learning fundamental surgical techniques specific to urology [27]. High- Similar to other countries and societies (AUA and EAU), we have level training as the robot-assisted laparoscopic prostatectomy to create our one educational teaching platform to allow and robot-assisted laparoscopic partial nephrectomy are not residents and other membership the opportunity to choose actually in our immediate aims. the learning method that best suits the individual, including traditional didactic sessions, enduring materials available in Greater monitored operative supervision is mandatory. various formats, and hands-on educational courses. Of the surveyed urologists, 92.8%, 89.6%, and 94.9% were interested The standardization of a broad-based national training in hands-on courses, simulators, and live surgery, respectively curriculum for all urology programs should be implemented. [21]. Each program must satisfy the minimum criteria and should provide training in all relevant disciplines. If certain programs do In our model, opportunities to enhance skills should be available not fullfill the requisite criteria, they should not be accredited in a variety of topic areas, including female pelvic surgery, by the comity of urology training [3]. laparoscopic training and office urodynamics, and even robotic surgery and percutaneous tissue ablative therapies. Propose an adequate Tunisian logbook for our conditions and epidemiologic data. The acquisition of practical skills needs Finally, we would like to conclude by saying that our attention to cover more than the simple listing in a logbook of the will definitely focus on building a bridge between Tunisian procedures that have to be performed. The assessment of how residents and all international colleagues, especially European competently the trainee carries out these procedures has to be and American through the EAU and the AUA. Such collaboration mandatory, and whether this is always done under supervision should greatly benefit all. or alone, and whether the trainee can manage or not manage the common complications of these procedures will also need I should probably apologize for being so optimistic, but the recording [28]. future would appear to be even more promising. Future developments in urology will undoubtedly lead to exciting All urology training programs should be under the aegis of the progress in urology and we should participate in this progress. “TSU.” By creating this curriculum, which will become available to all TSU members on the TSU website, these programs can Conclusion provide guidelines to residents for materials that are required learning during their training, as well as providing new Overall, urology training in Tunisia has been reasonable over information and guidelines for practicing urologists. the years. Actually, a lot of change and improvement must be done to keep, improve, and excel in our quality of care and Define a minimum research/publication output per resident per management. year beginning in the second core urology year.

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 References: 13. Gautam G. The current three-year postgraduate program in urology is insufficient to train a urologist.Indian Journal of Urology. 2008;24(3):336–338. PubMed ; CrossRef 1. Wadhwa P. The current three-year postgraduate program in urology is insufficient to train urologists: against the 14. Larre S, Dubosq F, Keskin S, et al. La formation chirurgicale motion. Indian Journal of Urology. 2008;24(3):339–342. des urologues français est-elle plus efficace que celle PubMed ; CrossRef des autres pays européens? Prog Urol. 2007;17(1):92–97. PubMed ; CrossRef 2. Kekre NS. Urology in the next century. Indian Journal of Urology. 2007;23(4):339. PubMed ; CrossRef 15. Rodríguez-Covarrubias F, Erikson S, Petrolekas A, et al. Comparison of the self-reported training level between 3. Droller MJ. Changing aspects in residency education. Mexican and Western Europe residents in urology: J Urol. 2005;174(5):1727–1728. PubMed ; CrossRef Results of an international survey. Med Teach. 2009;31(3): e69–e73. PubMed ; CrossRef 4. Andriole DA, Schechtman KB, Ryan K, Whelan A, Diemer K. How competitive is my surgical specialty? Am J Surg. 16. Macneily AE. The training of Canadian urology residents: 2002;184(1):1–5. PubMed ; CrossRef Whither open surgery? Can Urol Assoc J. 2010;4(1):47–48. PubMed 5. Shah J, Manson J, Boyd J. Recruitment in urology: a national survey in the UK. Ann R Coll Surg Engl. 2004;86(3):186–189. 17. Bruyère F, d’Arcier BF, Lanson Y. Reasons for the choice PubMed ; CrossRef of urology by residents. Prog Urol. 2005;15(4):681–683. PubMed 6. Kerfoot BP, Nabha KS, Masser BA, McCullough DL. What makes a medical student avoid or enter a career 18. Dubosq F, Beley S, Neuzillet Y, et al. How to anticipate in urology? Results of an international survey. J Urol. specialization at the Examen National Classant (National 2005;174(5):1953–1957. PubMed ; CrossRef Entrance Examination) to encourage interns to choose urology. Prog Urol. 2006;16(3):356–360. PubMed 7. Available from: http://www.studentsoftheworld.info/ informations_pays.php?Pays=TUN 19. Dickler R, Shaw G. The Balanced Budget Act of 1997: its impact on U.S. teaching hospitals. Ann Intern Med. 8. Available from: http://www.santetunisie.rns.tn/msp/msp. 2000;132(10):820–824. PubMed html 20. Aron M. Urology training in India: Balancing national 9. Zmerli S. My life in urology. Tunis Med. 2008;86(11): needs with global perspectives. Indian Journal of Urology. 949–953. PubMed 2009;25(2):254–256. PubMed ; CrossRef

10. Available from: http://www.urotunisia.com 21. Delarosette JJ, Gravas S, Muschter R, Rassweiler J, Joyce A, On behalf of the members of the Board of the 11. McDougall EM, Watters TJ, Clayman RV. 4-year curriculum European Society of Uro-Technology. Present practice and for urology residency training. J Urol. 2007;178(6): development of minimally invasive techniques, imaging 2540–2544. PubMed ; CrossRef and training in European urology: results of a survey of the European Society of Uro-Technology (ESUT). Eur Urol. 12. Parkar SP, Fuglsig S, Nunes P, Keskin S, Kniestedt WJ, 2003;44(3):346–351. PubMed ; CrossRef Sedelaar JPM; European Society of Residents in Urology. Urological training in Europe: similarities and differences. 22. Hinman F Jr. The future for surgery and the surgical BJU Int. 2005;96(2):207–211. PubMed ; CrossRef specialties through research and development. Surg Gynecol Obstet. 1981;152(6):833–836. PubMed

UroToday International Journal original study UIJ Challenges for a Resident in Urology in Tunisia in 2011 23. Duchene DA, Moinzadeh A, Gill IS, Clayman RV, Winfield HN. Survey of residency training in laparoscopic and robotic surgery. J Urol. 2006;176(5):2158–2167, discussion 2167. PubMed ; CrossRef

24. Buscarini M, Stein JP. Training the urologic oncologist of the future: where are the challenges? Urologic Oncology: Seminars and Original Investigations. 2009;27(2):193–198. PubMed ; CrossRef

25. Chatterjee S, Radomski SB, Matsumoto ED. Durability of endourologic skills: two-year follow-up study. J Endourol. 2007;21(8):843–846. PubMed ; CrossRef

26. Traxer O, Gettman MT, Napper CA, et al. The impact of intense laparoscopic skills training on the operative performance of urology residents. J Urol. 2001;166(5): 1658–1661. PubMed ; CrossRef

27. Jones DB. Video trainers, simulation and virtual reality: a new paradigm for surgical training. Asian J Surg. 2007;30(1):6–12. PubMed ; CrossRef

28. Vela Navarrete R, Andersen JT, Borowka A, et al. The future of urology in Europe: an overview from the European association of urology. Eur Urol. 2001;39(4):361–368. PubMed ; CrossRef

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.1 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Giant Bladder Calculus

Sanjay Kolte, Chandrashekhar Mahakalkar, Rucha Jajoo Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, Maharashtra, India Submitted April 7, 2011 - Accepted for Publication July 3, 2011

ABSTRACT

We present a case of a 28-year-old male who presented with complaints of continous urinary incontinence and a lower abdominal lump over a few months. The X-ray KUB showed a large radio-opaque shadow occupying the entire urinary bladder, suggestive of a calculus. A suprapubic cystolithotomy was done. The calculus weighed 1064 grams and had a size of 13.2 cms x 10 cms x 9 cms. Giant bladder stones are an extreme rarity these days. This, we believe, is the largest bladder stone in terms of volume and weight reported in recent times.

CASE REPORT cystolithotomy. The bladder was opened by a cruciate incision. The calculus adhered to the bladder wall at places. However, A 28-year-old emaciated young adult male presented to us it could be removed in toto. Recovery was uneventful. One with complaints of continuous incontinence and a lump in the month after surgery, an ultrasound showed a normal bladder lower part of the abdomen over a 3-month duration. He had wall but 170 mL of residual urine. The patient was advised stopped passing urine in a stream for the last 6 months. There self-catheterization twice daily. At a 1-year follow-up, he was was an episode of hematuria 2 years ago. On examination, he doing well and the residue had come down to 100 mL. The was found to have a hard, large oval lump in the suprapubic creatinine was normal. region. The prostate was not enlarged but the lump was palpable, per rectally, as a hard mass. His urine examination DISCUSSION revealed microscopic hematuria and few pus cells. His renal profile was marginally deranged; creatinine was 2.4 and blood Bladder stones were very common in the last century; urea was 65. The ultrasound showed a large calculus occupying however, giant stones weighing more than 100 gm and the entire bladder and bladder wall thickening. The kidneys larger than 10 cm in dimension were not common even and ureters were normal. Metabolic workup did not reveal then. In recent times, such stones have virtually disappeared any abnormality. Cystoscopy was attempted but we could not from modern literature [1]. The largest stone reported to enter the bladder as the calculus was occupying the bladder date measured 10.4 cm in its maximum dimension. This was completely. However, there was no stricture in the urethra or almost 35 years ago [2]. The common causes of bladder stones any bladder outlet obstruction. We performed a suprapubic are bladder outlet obstruction, recurrent cystitis, bladder

KEYWORDS: Bladder calculus; Giant stone CORRESPONDENCE: Sanjay Kolte, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha 442004, Maharashtra, India ([email protected]) CITATION: UroToday Int J. 2011 Oct;4(5):art 61. doi:10.3834/uij.1944-5784.2011.10.3

UroToday International Journal case report UIJ Giant Bladder Calculus Figure 1. X-ray KUB showing the calculus appearing like Figure 2. Calculus anterior view. a full cystogram. doi: 10.3834/uij.1944-5784.2011.10.3f2 doi: 10.3834/uij.1944-5784.2011.10.3f1

could possibly distend and accommodate with no space remaining for urine storage. Consequently, he had continuous incontinence. It was huge and it appeared like a contrast filled diverticuli, intravesical foreign bodies, neurogenic bladder, and urinary bladder on X-ray KUB. The size of the calculus did not hyperparathyroidism [3]. With the passage of time, increased awareness and easy accessibility to medical devices has led permit us to even contemplate using any modern modalities of to early diagnosis of all these predisposing conditions and, treatment for removal of this calculus. We successfully removed consequently, there is a steep decline in the incidence of primary it by simple cystolithotomy. Chemical analysis of the drilled- bladder stones. Stones attaining a giant size is practically an out specimen showed the composition to be magnesium, unseen phenomenon now [4]. Bladder stones forming in the ammonium phosphate, and carbonate apatite. absence of underlying uropathy are termed primary or endemic The pathogenesis of the stone formation in our patient remains bladder stones [5]. uncertain. Having ruled out any obstructive, metabolic, or Our patient presented with a large suprapubic, hard neurogenic causes, we conclude that it was a primary or abdominopelvic lump resembling a distended and obstructed endemic bladder stone that went unnoticed during childhood urinary bladder. The stone had grown as big as the bladder and progressively increased to the present size.

UroToday International Journal case report UIJ Giant Bladder Calculus Figure 3. Calculus lateral view. doi: 10.3834/uij.1944-5784.2011.10.3f3

REFERENCES

1. Shokeir AA, Dawaba M, Hafiz AT, Taqui AH, Shokeir MA. Giant bladder stone in a child. Br J Urol. 1995;76(5): 661–662. PubMed ; CrossRef

2. Williams JP, Mayo ME, Harrison NW. Massive bladder stone. Br J Urol. 1977;49(1):51–56. PubMed ; CrossRef

3. Di Tonno F, Forte M, Guidoni E, Cavazzana A, Barbui P. A giant bladder stone, Br J Urol. 1988;62(1):90–91.

4. Hammad FT, Kaya M, Kazim E. Bladder calculi: did the clinical picture change? Urology. 2006;67(6):1154–1158. PubMed ; CrossRef

5. Ataş B, Çaksen H, Arslan Ş, et al. A girl with a giant bladder stone. J Emerg Med. 2004;26(1):123–125. PubMed ; CrossRef

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.08.09 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Intravesical Explosion During TURP: A Rare Complication of a Common Procedure – What We Should Know

Rahul Kapoor,1 Hemant R. Pathak 2 1 Department of Urology, Apollo BSR Hospital, Junwani Road, Bhilai, Chhattisgarh, India 2 Department of Urology, B.Y.L. Nair Charitable Hospital and T.N. Medical College, Mumbai, India Submitted April 8, 2011 - Accepted for Publication June 1, 2011

ABSTRACT

A case of bladder rupture due to intravesical explosion during transurethral resection of prostate (TURP) is presented. Exploratory laparotomy done on clinical suspicion revealed a large inverted “V” shaped bladder tear that was sutured in 2 layers. An incidence of intravesical explosion during TURP is extremely rare. It occurs due to a mixture of explosive gases produced during TURP, with the air introduced into the bladder while activating the electrosurgical instrument. The presentation aims to bring attention to this rare complication once again with a literature review and emphasis on the necessary precautions needed to prevent it.

INTRODUCTION III gland with firm consistency was felt. On ultrasound, the prostate volume was 96 cc with a high residual volume of 150 cc. TURP is considered the gold standard surgical procedure His serum PSA was 10.8 ng/ml. A prostate biopsy revealed for benign hyperplasia of the prostate [1]. Being regularly benign enlargement with prostatitis. TURP was advised and performed, we are aware of its common complications like performed with a Storz 26 Fr continuous-flow resectoscope hematuria, perforation, and so forth. Intravesical explosion is with 1.5% glycine as our irrigant. A thin cutting loop and a a very rare complication with only 20 such cases reported so Valleylab cautery was used with cutting settings of 100 W far. This preventable complication occurs due to a mixture of and coagulation at 60 W. A cautery pad was placed on the explosive gases with the air once they come in contact with posterior aspect of the right thigh. At the end of the procedure, sparks from electrocautery. Along with the case, we will discuss when haemostasis was achieved at the 12-o’clock position, a the mechanism and preventable strategies. loud sound was heard with vibrations on the abdomen and a sudden decrease in endoscopic vision. There was no return Case history of the irrigation fluid and abdominal distension started, confirming the probable diagnosis of bladder rupture due to A 70-year-old male presented with a 5-year history of lower intravesical explosion. We decided to perform an exploratory urinary tract symptoms (AUA score = 13 / 35). He was on a laparotomy. There was a sudden gush of air upon opening the combination of dutasteride and tamsolusin for 6 months peritoneum and 400 cc of hemorrhagic fluid was drained. A without resolution. On the digital rectal exam (DRE), a grade large inverted “V” shaped tear extending from the dome of

KEYWORDS: Transurethral resections of the prostate; Intravesical explosion; Bladder rupture CORRESPONDENCE: Rahul Kapoor, Department of Urology, Apollo BSR Hospital, Junwani Road, Bhilai 242002, Chhattisgarh, India ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 60. doi:10.3834/uij.1944-5784.2011.10.2

UroToday International Journal case report UI Intravesical Explosion During TURP: A Rare Complication of a Common Procedure – What We J Should Know the bladder close to both the ureteric orifices was seen, margins to cause explosion. Therefore, the introduction of air during of which were ragged and bleeding. Though hemostasis was TURP is crucial in the production of a bladder explosion. achieved, margins were not freshened. The bladder rupture These gases accumulate at the bladder dome, represented by was repaired in 2 layers using 2-0 vicryl with an omental patch. the air bubble. An inflammable mixture of these gases and air A suprapubic catheter and abdominal drain were placed. On explodes when the resectoscope loop comes in contact with post-operative day 12, the patient developed a right perivesical the gases present at the bladder dome [8]. abscess that required repeat exploration and drainage. Finally, the patient was discharged after 3 weeks. A histopathological Hableton et al. [9] analyzed the gases produced during report showed benign prostatic hyperplasia with prostatitis. On electrocoagulation of dog prostates as early as 1935. They follow-up at 18 months, the patient was healthy, passing urine concluded that hydrogen is the explosive component when with a good stream and minimal residual volume. mixed with air. Similarly, Ning et al. [10] analyzed the gases produced during transurethral surgery and hypothesized that hydrogen is derived from electrolysis of intracellular water. DISCUSSION Air can be introduced into the bladder through a leak in the Intravesical explosion during TURP is a rare complication [2]; manual irrigation tubing whenever the resectoscope is opened around 20 cases reported [3] to date. It has also been reported during surgery and the fluid bottle replaced. As a personal with a transurethral resection of a bladder tumor (TURBT) [2]. A thought, the more common error is an incomplete evacuation of case of renal pelvic explosion during ureteroscopic fulguration air introduced into the bladder during washes through an Ellik of renal papillary transitional cell carcinoma was reported in evacuator. This occurs when either it’s almost finishing time but 1991 [4]. Three cases have been reported from the same institute more resection is needed, or due to inadequate haemostasis, over 15 years [5]. Despite the large number of TURP performed which compels the surgeon to reintroduce the resectoscope, all over, complications are kept at a low 18% [1]. The most resulting in incomplete evacuation of the bladder. Among frequent complications are closed and open perforation of the the risk factors mentioned in the literature, the use of a high- prostatic capsule (2%) [1], mechanical trauma of the prostate power current during coagulation by increasing carbonization and urethra (0.3 and 0.15%) [6], TUR syndrome (2%) [1], and and the duration of resection increases the hazard. It has been intraoperative bleeding compensated by hemotransfusion suggested that the irrigation liquid (1.5% glycine or distilled (3.9%) [1]. Rare complications include injury of the ureteral water) does not seem to play any role, while the type of tissue ostia (0.09%) [6] and rupture of the urinary bladder (0.02%) [6]. resected (necrotic, for example) could be significant. Moreover, Adherence to precision and technique minimizes serious it is suggested in literature that a continuous-flow resectoscope, complications. This complication, though rare but serious, in comparison to intermittent ones, could be more dangerous always entails immediate surgical correction. All in all, the because it allows the slow, continuous accumulation of gas explosion occurred toward the end of the procedure during under the bladder vault. Some surgeons have suggested resection or achieving haemostasis of the apical lobe at the cystography as a prerequisite for evaluation of this mishap, but I 12-o’clock position. In all cases, external air had already been feel that it is unnecessary in the presence of endoscopic finding. introduced in the bladder prior to explosion while removing In case of clinical suspicion, the patient should be explored. TURP chips. From the point of preventive measures, ureteral catheter It has been postulated that carbonization of the prostatic tissue evacuation of the gas and positioning of the patient to displace during contact with the electric loop while resecting produces the bubble have been suggested. Suprapubic cystostomy, inflammable gases like hydrogen (30%), carbon monoxide, if done, would also allow these gases to escape and, should and oxygen (3%) [7]. The most important constituent is an explosion occur, the pressure is vented and the bladder is hydrogen. Intracellular fluid, electrolysis, and pyrolysis spared. Careful attention should be given to the size of the air of prostatic tissue result in the release of these explosive bubble present at the bladder dome. It is here all the explosive gases during resection due to the high temperature of the gases formed during resection accumulate. Frequent bladder resectoscope [7]; therefore, the greater the temperature, the evacuation with the beak of the resectoscope angled toward larger the gas accumulation. It is well known that not pure the bladder dome to decrease the size of air bubble should be hydrogen but the addition of oxygen makes it potentially done. Among the many practical rules that should always be explosive. The amount of the oxygen produced is not sufficient taken into consideration while performing TURP, the following

UroToday International Journal case report UI Intravesical Explosion During TURP: A Rare Complication of a Common Procedure – What We J Should Know appear particularly suited in order to further minimize these 8. Seitz M, Soljanik I, Stanislaus P, Sroka R, Stief C. Explosive rare complications [3]: gas formation during transurethral resection of the prostate (TURP). Eur J Med Res. 2008;13(8):399–400. 1. The use of current of moderate power during coagulation PubMed and decreasing the tissue resection time. 9. Hambleton BF, Lackey RW, Van Duzen RE. Explosive gases 2. Minimize the entry of air into the bladder by keeping all formed during electrotransurethral resection. JAMA. connections and joints leak proof, and timely and careful 1935;105(9):645–646. replacement of irrigation fluid. 10. Ning TC Jr., Atkins DM, Murphy RC. Bladder explosions 3. Carefully evacuate the bladder either frequently or during transurethral surgery. J Urol. 1975;114(4):536–539. continuously to keep the size of the air bubble as small as PubMed possible.

4. The bladder should be allowed to evacuate completely by angling the beak of the resectoscope toward the bladder dome.

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1. Fitzpatrick JM. Minimally invasive and endoscopic management of benign prostatic hyperplasia. In, Wein AJ, ed. Campbell-Walsh Urology, 9th ed. Philadelphia, Saunders Publishers, 2007;2803–2844.

2. Horger DC, Babanoury A. Intravesical explosion during transurethral resection of bladder tumors. J Urol. 2004;172(5):1813. PubMed ; CrossRef

3. Di Tonno F, Fusaro V, Bertoldin R, Lavelli D. Bladder explosion during transurethral resection of the prostate. Urol Int. 2003;71(1):108–109. PubMed ; CrossRef

4. Andrews PE, Segura JW. Renal pelvic explosion during conservative management of upper tract urothelial cancer. J Urol. 1991;146(2):407–408. PubMed

5. Mohammadzadeh Rezaee M. Intravesical explosion during endoscopic transurethral resection of prostate. Urol J. 2006;3(2):109–110.

6. Martov AG, Kornienko SI, Gushchin BL, Ergakov DV, Sazonov OA. [Intraoperative urological complications in transurethral surgical interventions on the prostate for benign hyperplasia]. Urologiia. 2005;4(4):3–8. PubMed

7. Davis TRC. The composition and origin of the gas produced during urological endoscopic resections. Br J Urol. 1983;55(3):294–297. PubMed ; CrossRef

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.2 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature

Eng Hong Goh,1 Akhavan Adel,1 Praveen Singam,1 Christopher Chee Kong Ho,1 Guan Hee Tan,1 Badrulhisham Bahadzor,1 Zulkifli Md Zainuddin,1 Fauzah Abdul Ghani,2 Noraidah Masir 2 1 Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia 2 Department of Pathology, Universiti Kebangsaan Malaysia Medical Center, Kuala Lumpur, Malaysia Submitted April 12, 2011 - Accepted for Publication May 11, 2011

ABSTRACT

Myeloid sarcoma, an uncommon proliferative hematological entity associated with leukemia, can present in various extramedullary soft tissues in the body and its outcome is generally undesirable. Due to its rarity, the diagnosis can be challenging and commonly missed. A search through PubMed revealed only 8 cases in English literature. We would like to present a case of myeloid sarcoma in the bladder and briefly discuss this disease.

KEYWORDS: Myeloid sarcoma; Chloroma; Bladder CORRESPONDENCE: Eng Hong Goh, Urology Unit, Department of Surgery, Universiti Kebangsaan Malaysia Medical Center, Jalan Yaacob Latif, Bandar Tun Razak, Kuala Lumpur 56000, Malaysia ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 48. doi:10.3834/uij.1944-5784.2011.08.13

INTRODUCTION had a history of myelodysplastic syndrome in remission and received no treatment at current presentation. Cystoscopic Myeloid sarcoma (MS) is a type of hematological disease in examination showed a polypoidal growth at the base of the which there is a localized deposition of immature myeloid bladder and the bladder mucosa appeared carpeted with cells in extramedullary sites such as intestine, skin, or orbit. extensive erythematous lesions. The tumor was subsequently It could present as a primary manifestation or secondary in resected transurethrally. The surgery was complicated by cases whereby there is established proliferative hematological difficult bleeding control but despite so, the tumor appeared disorders such as acute myelogenous leukemia (AML), or completely resected at the end of surgery. Post-operatively, myeloproliferative or myelodysplastic syndromes [1, 2, 3]. For the patient redeveloped bouts of hematuria and cystoscopic the reason of rarity, making a diagnosis of MS is a challenge, hemostasis was performed thrice. The bleeding was finally especially in the absence of proliferative hematological disease. controlled by aluminium solution irrigation. The histopathology A search through PubMed in English literature revealed only 8 result was reported as MS. A section from the bladder biopsy cases so far, and we would like to present our case and discuss showed multiple fragments of tumor tissue composed of briefly this rare but serious disease with grave outcomes. medium-sized, polygonal, malignant cells arranged in solid sheets. Some of the cells were seen surrounding the blood CASE REPORT vessels. The malignant cells were large and pleomorphic with hyperchromatic nuclei and prominent nucleoli. A A 72-year-old Chinese lady presented in July, 2009 with a one- distinct cell border was noted and some of the malignant week history of hematuria accompanied by suprapubic pain. cells had moderate cytoplasm. No Reed-Sternberg cells were Otherwise, she had no other urinary symptoms. This patient seen. Mitotic figures were abundant (more than 40 per 10

UroToday International Journal case report UIJ Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature Figure 1. Large pleomorphic and hyperchromatic Figure 3. The CT scan shows the residual tumor at the nuclei with prominent nucleoli and distinct cell border right lateral wall of the bladder. (hematoxylin and eosin, x 60). doi: 10.3834/uij.1944-5784.2011.08.13f3 doi: 10.3834/uij.1944-5784.2011.08.13f1

Figure 2. The malignant cells are diffusely positive for immunostaining by myeloperoxidase (MPO) (X60). The cytogenetic assessments with karyotype demonstrated doi: 10.3834/uij.1944-5784.2011.08.13f2 47, XX + 8, 46, XX, 7q– [9]. A workup CT scan of the thorax/ abdomen/pelvis showed a residual tumor in the bladder and a bone scan revealed an absence of bony metastasis (Figure 3). A bone trephine biopsy confirmed the presence of acute myeloid leukemia (AML) and the patient was planned for palliative Ara-c regime. However, she later developed bouts of sepsis and lower-gastrointestinal-tract bleeding and these delayed the chemotherapy. The patient was subsequently lost to follow-up.

DISCUSSION

MS is the deposition of immature myeloid cells in the extramedullary sites [1]. Its occurrence in the bladder was described as extremely rare [4]. A few case series revealed that the common sites include the skin, lymph nodes, and central nervous system, and none of these papers reported bladder cases [3, 5, 6, 7]. It has been thought that the tumor originates in the bone marrow and subsequently migrates to other organs high-power field) and areas of necrosis were present (Figure through Haversian canals [8]. The lesion could occur primarily 1). Immunohistochemical stainings showed immunopositivity in the absence of or occur later in an established proliferative for leucocyte common antigen (LCA), myeloperoxidase (MPO), hematological disorder such as AML or myelodysplastic CD 99, and CD 117 (weak and scattered positivity) (Figure 2). syndrome. Disregard of this differentiation, MS basically The rest of the immunostainings were negative; Cytokeratin, predates the onset or presents as the manifestation of AML [2]. CD 3, CD 79alpha, CD 20, PAX5, CD 5, Cyclin D1, CD 23, CD 10, A case series by Breccia et al. [3] reported that 11 out of 12 MS CD 138, and CD 4. Ki67 showed a proliferation index of 80%. patients developed AML after an average of 10.5 months of first evidence of disease and its incidence was 2% to 4.7% in

UroToday International Journal case report UIJ Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature Table 1. An expanded data originally produced by Al-Quran et al. on the reported cases of myeloid sarcoma of the bladder [11]. doi: 10.3834/uij.1944-5784.2011.08.13t1

Tumor Case Initial Cytogenetic Source Year Age Sex Symptoms location Treatment Outcome no. diagnosis studies and size 1 Liu et al. 1973 NR NR ML NR Bladder NR NR NR

Combination chemotherapy Chaitin Dysuria, Trigone 80 x 2 1984 29 F None NR (Doxorobicin, NED,13 month et al. Haematuria 70 x 60 mm Vincristine, Ara-C, Prednisone)

Left ureteral Death due to Cartwright 3 1991 16 M AML-M2 Haematuria orifice, 20 x NR External radiotherapy sepsis 2months et al. 30 mm after treatment Surgery, Bekassy Chemotherapy, Repeat Alive, 4 1996 17 M AML-M2 NR NR NR et al. allogeneic bone 75 months marrow transplant

Fatigue, Left antero- Combination Death due to pollakiuria, lateral wall, 5 Aki et al. 2002 36 M None NR chemotherapy sepsis day 16 of 76 x 67 x pain, (Ara-C, Idarubicin) treatment hematuria 36 mm Left antero- Dysuria, 6 Kerr et al. 2002 80 F RAEB lateral wall NR Local radiotherapy Recurrence haematuria 20 x 20 mm Combination Urinary Trigone, chemotherapy 7 Uner et al. 2004 57 F None incontinence NR NED, 1 month 74x21 mm (Ara-C, Idarubicin); and fatigue external radiotherapy Bone marrow Haematuria, Trigone 47, XY, flank 40x20x30mm, Combination Al-Quran inv(16), +22; 8 2006 47 M None pain, right right chemotherapy NED, 32 month et al. testicular epidydmis Bladder (Ara-C, Idarubicin) swelling 40 mm inv(16) by FISH Bone marrow, Haematuria, Base of 47,X X 9 Our case 2009 72 F RAEB suprapubic bladder, Chemotherapy: Ara-C ? + 8 [13] pain 25 mm 46,XX, 7q- [9] NR indicates not reported, ML, myelogenous leukemia; NA, not applicable; Ara-C, cytosine arabinoside hydrochloride; NED, no evidence of disease; AML-M2, acute myeloid leukemia-M2; RAEB, refractory anemia with excess blasts; FISH, fluorescence in situ hybridization.

UroToday International Journal case report UIJ Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature the course of AML. Its rarity therefore reasonably explains the In summary, although MS is rare, recognizing this disease high frequency of misdiagnosis of up to 75% in the absence of early might prolong survival and perhaps result in avoiding prior proliferative hematological disease and 47% of MS were unnecessary and irrelevant investigation and treatment. initially diagnosed as malignant lymphoma [3, 9]. In fact, all of the Breccia et al. cases were first labeled as non-Hodgkins REFERENCES lymphoma and the reasons being the similar appearance of the blasts to large-cell lymphoma and the presence of lymphoglandular bodies, eosinophilic myelocytes, and the 1. Gittin RG, Scharfman WB, Burkart PT. Granulocytic sarcoma: scarcity of Auer rods [3, 10]. Aki et al. [2] described a primary three unusual patients. Am J Med. 1989;87(3):345–347. case of bladder MS that was initially diagnosed as transitional PubMed ; CrossRef cell carcinoma and treated with combination therapy. The correct diagnosis was only made after disease progression and 2. Aki H, Baslar Z, Uygun N, Ozguroglu M, Tuzuner N. Primary repeat biopsy. Compounding the issue of rarity is the various granulocytic sarcoma of the urinary bladder: case report terminologies used to describe basically the same disease. In and review of the literature. Urology. 2002;60(2):345. this regard, there are at least 5 other names for MS and these PubMed ; CrossRef include chloroma, granulocytic sarcoma, monocytic sarcoma, myeloblastoma, and extramedullary myeloid cell tumor [11]. Uniformity in terminology used would have been desirable for 3. Breccia M, Mandelli F, Petti MC, et al. Clinico-pathological the ease of understanding the disease and for the benefit of characteristics of myeloid sarcoma at diagnosis and during patients. Although it is typically found in patients under the age follow-up: report of 12 cases from a single institution. of 15 and between the ages of 20 and 44, MS could occur at any Leuk Res. 2004;28(11):1165–1169. PubMed ; CrossRef age, such as in our case [3]. The presentation in a case of bladder MS is nonspecific. A typical symptom is hematuria followed by 4. Kerr P, Evely R, Pawade J. Bladder chloroma complicating dysuria, although pollakiuria, urinary incontinence, and fatigue refractory anaemia with excess of blasts. Br J Haematol. have been described [11]. The various literatures also did not 2002;118(3):688. PubMed ; CrossRef describe any specific cystoscopic finding relevant to MS; thus the diagnosis depends on histopathological finding, and the provision of a positive history of proliferative hematological 5. Neiman RS, Barcos M, Berard C, et al. Granulocytic sarcoma: disease should prove helpful. Its presence of undifferentiated a clinicopathologic study of 61 biopsied cases. Cancer. blasts and immature cells therefore warrants the use of myeloid 1981;48(6):1426–1437. PubMed ; CrossRef markers for diagnosis [2, 9]. Known to be an aggressive form of AML, patients with MS have a median survival of 7 months 6. Tsimberidou AM, Kantarjian HM, Estey E, et al. Outcome once a diagnosis of MS is made, and 3 months when there is in patients with nonleukemic granulocytic sarcoma a manifestation of AML [3]. The survival could be improved treated with chemotherapy with or without radiotherapy. if the diagnosis is picked up early and appropriate treatment Leukemia. 2003;17(6):1100 –1103. PubMed ; CrossRef initiated promptly. Complete remission or even cures have been observed in some patients [11]. In this regard, systemic therapy 7. Ansari-Lari MA, Yang CF, Tinawi-Aljundi R, et al. prolonged the survival to 40.5 months as compared to local FLT3 mutations in myeloid sarcoma. Br J Haematol. therapy in which the survival was 26 months [12]. However, 2004;126(6):785–791. PubMed ; CrossRef whether local or systemic therapy is instituted, it is considered palliative since the survival is short in almost all cases once there are extramedullary lesions [1]. 8. Novick SL, Nicol TL, Fishman EK. Granulocytic sarcoma (chloroma) of the sacrum: initial manifestation of Given the small number of cases of bladder MS, a compilation of leukemia. Skeletal Radiol. 1998;27(2):112–114. PubMed ; various case reports should be useful for the purpose of study. CrossRef Al-Quran et al. [11] made such a table in their case report in 2006 highlighting the previous 7 as well as their cases, 4 of which are 9. Hasegeli Uner A, Altundag K, Saglam A, Tekuzman G. primary and the other 4 have a prior history of various types of Granulocytic sarcoma of the urinary bladder. Am J proliferative hematological disease. Ours should be numbered Hematol. 2004;75(4):262–263. PubMed ; CrossRef ninth as a whole and a fifth case of “secondary” (Table 1).

UroToday International Journal case report UIJ Myeloid Sarcoma of the Bladder: Case Presentation and Review of the Literature 10. Suh YK, Shin HJ. Fine-needle aspiration biopsy of granulocytic sarcoma: A clinicopathologic study of 27 cases. Cancer. 2000;90(6):364–372. PubMed ; CrossRef

11. Al-Quran SZ, Olivares A, Lin P, Stephens TW, Medeiros L J, Abruzzo LV. Myeloid sarcoma of the urinary bladder and epididymis as a primary manifestation of acute myeloid leukemia with inv(16). Arch Pathol Lab Med. 2006;130(6):862–866. PubMed

12. Byrd JC, Edenfield WJ, Shields DJ, Dawson NA. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. J Clin Oncol. 1995;13(7):1800 –1816. PubMed

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.08.13 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 Page Kidney – Rare but Correctable Cause of Hypertension

Kapil Singla, Ashish K. Sharma, Sistla B. Viswaroop, Myilswamy Arul, Ganesh Gopalakrishnan, Sangam V. Kandasamy Department of Urology, Vedanayagam Hospital and Postgraduate Institute, Coimbatore 641002, Tamil Nadu, India Submitted April 25, 2011 - Accepted for Publication May 19, 2011

ABSTRACT

A case of Page kidney as a result of injury followed by hypertension is presented. An abdominal ultrasound revealed soft tissue mass suggestive of a hematoma, resulting in a nephrectomy during which there were dense adhesions on the posterior surface of the kidney due to a large sucapsular hematoma. This presentation aims to bring attention to Page kidney’s causes associated with hypertension and its correctable treatment.

KEYWORDS: Page kidney; Subcapsular hematoma; Hypertension CORRESPONDENCE: Sistla B. Viswaroop, Department of Urology, Vedanayagam Hospital, 52 East Bashykaralu Road, Coimbatore 641002, Tamil Nadu, India ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 54. doi:10.3834/uij.1944-5784.2011.10.10

INTRODUCTION were normal. A clinical diagnosis of left Page kidney was made on the basis of a presence of a triad of hypertension, perinephric Page kidney is a rare phenomenon of hyperreninemic hematoma, and left loin pain. A DTPA renogram was done, hypertension caused by compression of the renal parenchyma which showed no cortical tracer uptake in the left kidney. leading to a subcapsular hematoma. It has been reported in A medical consult was obtained for uncontrolled hypertension healthy individuals after abdominal trauma and after invasive and he was started on ACE inhibitors, and his BP was controlled. nephrological interventions. We present a rare case of Page He underwent nephrectomy. Intraoperatively, there were kidney following a trivial trauma. He underwent nephrectomy dense adhesions on the posterior surface of the kidney due and he had a complete recovery. to the presence of a large subcapsular hematoma (Figure 2). Following nephrectomy, his blood pressure was normal and CASE REPORT he did not require further antihypertensives. A CT scan of the specimen kidney was done for academic interest (Figure 3). A 53-year-old gentleman had dull, aching, left loin pain for 10 days. He was not a known hypertensive or diabetic. On examination, his BP was 180/110 mm of Hg and systemic DISCUSSION examination was unremarkable. He was clinically diagnosed Page kidney is the external compression of a kidney usually with left ureteric colic. An abdominal ultrasound revealed caused by a subcapsular hematoma [1]. It was named after a soft tissue mass of 23 mm thickness in the perinephric Dr. Irvin Page (1901–1989) who first produced a renin- space suggestive of a hematoma (Figure 1), and the color dependent model of hypertension by wrapping a dog kidney in Doppler showed no flow within the mass. Upon probing, he cellophane. The clinical equivalent of this hypertensive model remembered a trivial road traffic accident 6 months back but is the kidney compressed by a subcapsular or perirenal process he remained asymptomatic after trauma. His renal parameters causing renal ischemia leading to unilateral hypersecretion

UroToday International Journal case report UIJ Page Kidney – Rare but Correctable Cause of Hypertension Figure 1. USG picture showing perinephric hematoma doi: 10.3834/uij.1944-5784.2011.10.10f1

Figure 2. Gross specimen of Page kidney Figure 3. CT confirming thinned out renal parenchyma doi: 10.3834/uij.1944-5784.2011.10.10f2 with thickened perinephric fat doi: 10.3834/uij.1944-5784.2011.10.10f3

of renin and contralateral suppression. Subcapsular bleeding complicates renal biopsy and ESWL but usually does not cause compression from perinephric hematoma or chronic perirenal hemodynamic instability. Although hypertension is the most scarring results from an intrarenal artery or segmental branch common feature, renal insufficiency can occur in the setting of stenosis [3]. One explanation is that rapid deceleration a diseased contralateral kidney, single functioning kidney, or a stretches the renal artery, causing an intimal injury that renal allograft [1]. Following injury, the onset of hypertension leads to arterial obstruction and ischemia. The infarcted ranges from days to decades, with a mean of 36 months [2]. kidney develops collateral blood flow from the ureteric The pathophysiology of hypertension associated with renal

UroToday International Journal case report UIJ Page Kidney – Rare but Correctable Cause of Hypertension and perinephric capsular systems and the direct exchange ACKNOWLEDGEMENT between perforating capsular vessels. Collateralization results in a small but critical amount of renal perfusion. This leads The authors would like to thank S. Boopathy Vijaya Raghavan, to a preservation of the endocrine function of the kidney, MD and Anabarasu Cherian, MD for input and diagnostic activating an increase in the secretion of renin (normal, guidance. 1.9–3.7 ng⁄mL⁄h) and eventually causing hypertension [4, 5]. The diagnosis of Page kidney depends on the presence REFERENCES of either a surrounding hematoma or an encasing fibrous pseudocapsule. CT abdomen is the preferred modality as it is noninvasive and can detect even very small hematomas [6]. 1. Haydar A, Bakri RS, Prime M, Goldsmith DJ. Page kidney– An MRI may be helpful in assessing the age of the hematomas a review of the literature. J Nephrol. 2003;16(3):329–333. and patency of renal blood vessels. The treatment of Page PubMed kidney aims to preserve renal function and cure hypertension [7]. The gold standard is selective renal arteriography with 2. Santucci RA, Wessells H, Bartsch G, Descotes J, Heyns CF, renal-vein renin assays. Lesions in the renal vasculature are McAninch JW, Nash P, Schmidlin F. Evaluation and readily identified and renal-vein renin values will confirm the management of renal injuries: consensus statement of the functional significance of an identified lesion. Elevated renin renal trauma subcommittee. BJU Int. 2004;93(7):937–954. production from the responsible kidney and suppressed renin PubMed ; CrossRef production from the contralateral kidney in a ratio >1.5:1 or 2:1 will predict which lesions will respond to surgical treatment in more than 90% of cases [5]. 3. Carroll PR, McAninch JW, Klosterman P, Greenblatt M. Renovascular trauma: risk assessment, surgical Antihypertensive therapy and observation, percutaneous management, and outcome. J Trauma. 1990;30(5):547– evacuation of the perirenal hematoma, open drainage of 552; discussion 553–554. the hematoma, capsulectomy, partial nephrectomy, and nephrectomy have been used. The appropriate duration of 4. McCune TR, Stone WJ, Breyer JA. Page kidney: case medical therapy before resorting to more aggressive treatment report and review of the literature. Am J Kidney Dis. is unclear, but irreversible parenchymal changes are likely 1991;18(5):593–599. PubMed to occur if the hypertension does not resolve within 1 to 2 years [8]. Direct renin inhibitor (i.e., aliskiren) can be used to adequately control BP until surgery can be performed. 5. Sterns RH, Rabinowitz R, Segal AJ, Spitzer RM. ‘Page There are no published reports of the use of aliskiren in these kidney’. Hypertension caused by chronic subcapsular types of cases, however direct renin inhibitors are known to hematoma. Arch Intern Med. 1985;145(1):169–171. control the hypertension. A hematoma may reabsorb, relieving PubMed ; CrossRef the parenchymal compression without forming an adhesive fibrotic pseudocapsule. In acute cases, therapy starts with ACE 6. Patel TV, Goes N. Page kidney. Kidney Int. 2007;72(12):1562. inhibitors to control blood pressure while waiting for the local PubMed ; CrossRef hematoma to be absorbed. Surgery is the treatment of choice when a documented renovascular obstruction or damage is 7. Chung J, Caumartin Y, Warren J, Luke PP. Acute Page present. Large liquid hematomas may respond to percutaneous kidney following renal allograft biopsy: a complication drainage. Patients who present with old hematoma or severely requiring early recognition and treatment. Am J impaired kidney function may need active intervention, Transplant. 2008;8(6):1323–1328. PubMed ; CrossRef including capsulectomy, partial nephrectomy (if compression is to a polar area), or a total nephrectomy [9]. Watts and Hoffbrand [10] reported in a review paper that nephrectomy 8. Montgomery RC, Richardson JD, Harty JI. Posttraumatic cured hypertension in 89% of 18 patients. Although technically renovascular hypertension after occult renal injury. challenging, Page kidney has been treated laparoscopically J Trauma Inj Infect Crit Care. 1998;45(1):106–110. with a dissection of the perinephric fibrosis [9]. PubMed ; CrossRef

UroToday International Journal case report UIJ Page Kidney – Rare but Correctable Cause of Hypertension 9. Castle EP, Herrell SD. Laparoscopic management of Page kidney. J Urol. 2002;168(2):673–674. PubMed ; CrossRef

10. Watts RA, Hoffbrand BI. Hypertension following renal trauma. J Hum Hypertens. 1987;1(2):65–71. PubMed

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.10 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011 Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis

Fumitaka Shimizu,1 Kazuhiko Fujita,1 Takeshi Ieda,1 Kentaro Imaizumi,1 Taiki Mizuno,1 Kazuo Suzuki 2 1 Department of Urology, Juntendo Shizuoka Hospital, Shizuoka, Japan 2 Department of Urology, Shintoshi Hospital, Hakodate, Hokkaido, Japan Submitted March 21, 2011 - Accepted for Publication May 25, 2011

ABSTRACT A 68-year-old female, diagnosed with essential hypertension, demonstrated a muscular depression caused by hypokalemia. Endocrinological data revealed elevated plasma rennin activity (PRA), plasma aldosterone concentration (PAC), and cathecholamine, and the computed tomography (CT) presented a 6 cm mass above the left kidney. I-metaiodobenzylguanidine (MIBG) scintigraphy showed an uptake in accord with the tumor and I-adosterol scintigraphy showed no abnormal accumulation. Magnetic resonance angiography (MRA) demonstrated left renal artery stenosis (RAS). Peak systolic velocity in the left renal artery measured by a duplex ultrasound was elevated. We considered that the left RAS accompanied by compression caused hyperreninemia. The tumor strongly adhered to the left renal artery and vein, so we performed a laparoscopic left nephroadrenalectomy. Two weeks after the operation, PRA, PAC, and cathecholamine were almost normalized. We present a rare case of pheochromocytoma with the renovascular hyperreninemia attendant on RAS diagnosed by MRA and a duplex ultrasound.

KEYWORDS: Pheochromocytoma; Renovascular hyperreninemia; Renal artery stenosis CORRESPONDENCE: Fumitaka Shimizu, M.D., Department of Urology, Juntendo Shizuoka Hospital, 1129 Nagaoka, Izunokuni- shi, Shizuoka 410-2295, Japan ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 56. doi:10.3834/uij.1944-5784.2011.08.12

INTRODUCTION CASE REPORT

The coexistence of renal artery stenosis (RAS) and A 68-year-old female, diagnosed with essential hypertension, pheochromocytoma was reported in 1958 [1]. The reports demonstrated muscular depression caused by hypokalemia concerning pheochromocytoma with RAS have been seen at the outpatient clinic. Endocrinological data revealed afterwards, and the diagnosis of RAS was performed by catheter elevated PRA, PAC, and cathecholamine, and the CT presented angiography [2]. However, catheter angiography is an invasive a 6 cm mass above the left kidney (Figure 1). Both PRA and test and has the possibility of postangiographic dissection PAC values, measured 2 or more times on a similar condition, or occlusion [3]. Recently, the utility of other noninvasive were also elevated. The patient was referred to the Juntendo methods to diagnose RAS have been reported [4-6]. We report Shizuoka Hospital. She had had a history of headaches the pheochromocytoma with the renovascular hyperreninemia associated with palpitations and diaphoresis. attendant on RAS diagnosed by using magenetic resonance angiography (MRA) and a duplex ultrasound preoperatively. In the pooled urine, a total catecholamine and the noradrenaline were elevated. A 123I-metaiodobenzylguanidine (MIBG)

UroToday International Journal case report UIJ Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis Figure 1. CT scan showing a 6 cm mass above the left Figure 3. MRA on axial section demonstrated left RAS kidney caused by tumor compression doi: 10.3834/uij.1944-5784.2011.08.12f1 doi: 10.3834/uij.1944-5784.2011.08.12f3

(Figure 3) were performed and demonstrated left RAS caused by tumor compression.

Figure 2. MRI on colonal section demonstrated left RAS The renal-aortic ratio (RAR) was calculated by dividing the peak caused by tumor compression systolic velocity in the renal artery by that in the aorta using a doi: 10.3834/uij.1944-5784.2011.08.12f2 Doppler ultrasound [4]. The right and left peak systolic velocity in the renal artery was 30.3 cm/s and 101.1 cm/s. Peak systolic velocity in the aorta was 45.6 cm/s. The right and left RAR were 0.66 and 2.22, respectively.

We considered that the left RAS accompanied by tumor compression caused hyperreninemia. A tumor strongly adhered to the left renal artery and vein, so we performed a laparoscopic left nephroadrenalectomy. The systolic blood pressure that rose up to 180 mm Hg during the procedure returned to a normal value when temporarily interrupting the operation. The pathological finding was a paraganglioma arising from the left renal hilus. In addition, a slight arteriosclerotic change was identified in a left renal artery.

Two weeks after the operation, PRA, PAC, and cathecholamine were almost normalized. scintigraphy showed an uptake in accord with the tumor, DISCUSSION though a 131I-adosterol scintigraphy showed no abnormal accumulation. She was preoperatively diagnosed with a Nephroadrenalectomy might not be common in the case pheochromocytoma arising from the adrenal glands or that pathological finding is a benign condition. However, we retroperitoneum. selected the nephroadrenalectomy because the malignant pheochromocytoma had been strongly doubted by the adhesion The abdominal magnetic resonance imaging system (MRI) and vascularization of the tumor during the procedure. (Figure 2) and magentic resonance angiography (MRA)

UroToday International Journal case report UIJ Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis After laparoscopic surgery for the pheochromocytoma, tests to establish the diagnosis of RAS [19]. However, the the case that the local recurrence occurred by sowing in precision in CTA and MRA decreases in the case that the kidney 3 to 4 years was reported [7]. The sowing caused by the tumor function is deceased, though the sensitivity and specificity capsule injury must be avoided [8]. are high. Captopril renal scintigraphy is not recommended. Catheter angiography is the gold standard when the clinical Not pushing the tumor strongly and keeping the lower index of suspicion is high and the results of noninvasive tests pneumoperitoneum pressure within the possible range are inconclusive. However, we cannot distinguish whether prevents a hypertensive crisis. Matsuda et al. reported that the patient with RAS has a functional problem with catheter blood pressure variation in the laparoscopic surgery was angiography. The Doppler ultrasound enables us to evaluate, lower compared to the conventional open adrenalectomy functionally, the difference in pressure, in addition to the [9]. We consider laparoscopic surgery appropriate for the degree of RAS. The difficulty in this examination is that pheochromocytoma. precision depends on the capability of the investigator.

Causes of the hyperreninemia in pheochromocytoma In consideration for her kidney function, we performed the non-enhanced MRA and a Doppler ultrasound. Several investigators reported the pheochromocytoma with hyperreninemia [2]. RAS, which was on the same side as the In conclusion, several factors may affect the hyperreninemia tumor, had accompanied by tumor compression [10]. However, in this case. Noninvasive methods without the catheter the case that RAS did not present during the operation or the angiography were useful for the diagnosis of RAS. The Doppler catheter angiography, and the case for whom RAS improved ultrasound helps us to evaluate functionality. Performing the by administering the hypotensive drug, were reported [11-14]. Doppler ultrasound, in addition to CTA or MRA, might be The vasoconstrictive effect on an excessive catecholamine was effective for the objective diagnosis of RAS. considered the cause of RAS in such a case [11, 15]. PRA does not rise in the noradrenaline secretion type but rises in the adrenaline secretion type or the dopamine secretion type [16]. REFERENCES This corresponds with the use of the secretion of the renin through receptor. On the other hand, Brewster et al. reported β 1. Harrison JH, Gardner FH, Dammin GJ. A note on that the vasoconstrictive effect was strong in the tumor outside pheochromocytoma and renal hypertension. J Urol. the adrenal gland of the noradrenaline domination type [11]. 1958;79(2):173–178. PubMed PRA increased by renal ischemia resulting from vasoconstrictive action of noradrenaline secreted from the tumors [17]. 2. Hill FS, Jander HP, Murad T, Diethelm AG. The coexistence Other considerable mechanisms for hyperreninemia include of renal artery stenosis and pheochromocytoma. Ann redistribution of intrarenal blood flow, concomitant renal Surg. 1983;197(4):484–490. PubMed ; CrossRef artery lesions, including atherosclerosis, fibromusclar hyperplasia, and transient vasospasm during cathecholamine 3. Gill IS, Meraney AM, Bravo EL, Novick AC. crisis [18]. Pheochromocytoma coexisting with renal artery lesions. J Urol. 2000;164(2):296–301. PubMed ; CrossRef In our case, administering the hypotensive drug decreased PRA slightly. Two main causes were considered for the 4. Olin JW, Piedmonte MR, Young JR, DeAnna S, Grubb M, hyperreninemia. One is the vasoconstrictive effect of the Childs MB. The utility of duplex ultrasound scanning of noradrenaline, and the other is RAS attendant on tumor the renal arteries for diagnosing significant renal artery compression. stenosis. Ann Intern Med. 1995;122:833–838. Diagnosis of the RAS 5. Soulez G, Oliva VL, Turpin S, Lambert R, Nicolet V, Therasse For the diagnosis of RAS, CT angiography (CTA), MRA, a E. Imaging of renovascular hypertension: respective Doppler ultrasound, and catheter angiography, including values of renal scintigraphy, renal Doppler US, and MR digital subtraction angiography (DSA), have been used. In angiography. Radiographics. 2000;20(5):1355–1368; the American College of Cardiology Foundation/American discussion 1368–1372. PubMed Heart Association Task Force on Practice Guidelines, duplex ultrasonography, CTA, and MRA are recommended screening

UroToday International Journal case report UIJ Pheochromocytoma with the Renovascular Hyperreninemia Attendant on Renal Artery Stenosis 6. Diamond JA. Interesting clinical case studies involving 16. Vetter H, Vetter W, Warnholz C, et al. Renin and secondary causes of hypertension. Mt Sinai J Med. 2002; aldosterone secretion in pheochromocytoma: effect of 69(5):305–311. PubMed chronic alpha-adrenergic receptor blockade. Am J Med. 1976;60(6):866–871. PubMed ; CrossRef 7. Li ML, Fitzgerald PA, Price DC, Norton JA. Iatrogenic pheochromocytomatosis: a previously unreported result of 17. Maebashi M, Miura Y, Yoshinaga K, Sato K. Plasma laparoscopic adrenalectomy. Surgery. 2001;130(6):1072– renin activity in pheochromocytoma. Jpn Circ J. 1077. PubMed ; CrossRef 1968;32(10):1427–1432. PubMed

8. Kercher KW, Novitsky YW, Park A, Matthews BD, Litwin 18. Cheng CI, Wang HJ, Huang CC, et al. Adrenal DEM, Heniford BT. Laparoscopic curative resection of pheochromocytoma associated with transient pheochromocytomas. Ann Surg. 2005;241(6):919–928; hyperreninemia. Int J Cardiol. 2006;111(1):180–181. discussion 926–928. PubMed ; CrossRef PubMed ; CrossRef

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Minori Matsumoto,1 Katsumi Shigemura,1, 2 Masato Fujisawa1 1 Division of Urology, Department of Surgery, Kobe University Graduate School of Medicine, Kobe, Hyogo, Japan 2 Department of Urology, Shinko Hospital, Kobe, Hyogo, Japan Submitted March 22, 2011 - Accepted for Publication June 1, 2011

ABSTRACT Adrenal myelolipoma is a benign tumor composed of adipose tissue and hematopoietic lesions. It is usually diagnosed incidentally in imaging tests such as computed tomogram (CT) or by patient symptoms such as retroperitoneal hemorrhage due to tumor rupture. We present a patient with retroperitoneal hemorrhage due to spontaneous rupture of a myelolipoma with enlargement of the mass and hemorrhage during the follow-up regimen of watchful waiting.

KEYWORDS: Rupture of Adrenal Myelolipoma; Enlargement of the mass and hemorrhage; Watchful waiting CORRESPONDENCE: Katsumi Shigemura MD, PhD, Division of Urology, Department of Organs Therapeutics, Faculty of Medicine, Kobe University Graduate School of Medicine, 7-5-1 Kusunoki-Cho, Chuo-Ku, Kobe, Hyogo 650-0017, Japan ([email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 55. doi:10.3834/uij.1944-5784.2011.08.11

INTRODUCTION function, and serum electrolytes were within normal range. He had slight anemia (serum hemoglobin: 11.4 g/dl). White Adrenal myelolipoma is a benign and endocrinologically blood cell count and C-reactive protein were elevated to non-functioning tumor generally composed of fat and 13600 /μL (normal, 4000–8000 /μL) and 4.0 mg/dl (normal, hematopoietic elements. It is now found more frequently than < 1.0 mg/dl), respectively. His abdominal ultrasound and plain in the past because of routine ultrasound and computerized CT demonstrated a large mass (70 mm × 65 mm) between the tomography (CT) procedures. Rupture and bleeding of the right hepatic lobe and right kidney (Figure 1). The mass was myelolipoma is an infrequent complication resulting in diagnosed as a ruptured angiomyolipoma at first. a massive retroperitoneal hemorrhage. The spontaneous rupture of the myelolipoma that we report here is an unusual Renal arteriography showed that the inferior adrenal branch occurrence. of the right renal artery was compressed by tumor; however, pooled contrast fluid and tumor feeding vessels were not CASE REPORT identified, and therefore embolization of the artery feeding the tumor was not performed (Figure 2). Contrast-enhanced A 65-year-old man with a history of diabetes mellitus was CT after renal arteriography revealed that the mass had admitted to the emergency department with persistent flank fatty component areas, and that the hematoma existed pain on the right side. He had no recent trauma, hematuria, in peritumoral and perirenal spaces (Figure 3). Abdominal voiding complaints, nausea/vomiting, or fever, and had magnetic resonance imaging (MRI) showed a heterogenous tenderness and a palpable mass in the right upper abdomen. mass with fat intensity areas in fat-suppressed T1-weighted The patient had no history of cardiac diseases. Vital signs, images. The peri-tumoral and peri-renal hematoma had higher urinalysis, hemostasis, prothrombin time, hepatic and renal intensity than the tumor mass and right kidney, suggesting

UroToday International Journal case report UIJ Spontaneous Rupture of Adrenal Myelolipoma Figure 1. Plain abdominal CT shows a large mass (70 mm × Figure 2. Angiography of the right renal artery. No pooled 65 mm) in the space between the right hepatic lobe and contrast fluid or tumor feeding vessels were identified. right kidney at the time of the patient’s admission (as The upper pole of the right kidney was considered to be shown by the arrow). compressed by tumor (as shown by the arrow). doi: 10.3834/uij.1944-5784.2011.08.11f1 doi: 10.3834/uij.1944-5784.2011.08.11f2

the mass was compatible with right hemorrhagic myelolipoma (Figure 4).

The patient was observed with conservative therapy under 0.08–0.2% and it consists of mature adipose cells and hospitalization for 22 days after admission on the watchful hematopoietic elements in varying proportions [1, 2]. They waiting plan. Over this period, his symptoms, including flank are usually asymptomatic, and associated with obesity pain, were diminished. His serum hemoglobin did not drop and hypertension [3]. It is considered a very rare case of remarkably. A follow-up CT showed a larger and non-enhanced retroperitoneal bleeding due to spontaneous rupture of mass (120 mm × 100 mm × 90 mm) than at the time of admission a large adrenal myelolipoma [4] even though adrenal in the right suprarenal region. The mass had become larger as myelolipoma is the most common among benign adrenal soft a result of perinephric hemorrhage (Figure 4). Then radical tissue tumors [5]. resection of the right adrenal gland was performed through a midline incision of abdomen. The tumor, hematoma, and Occasionally, they may cause symptoms like flank pain, adrenal gland were so tightly adherent to the right kidney that secondary to compression from tumor bulk, necrosis, and their separation was hard to do. The pathological diagnosis was hemorrhage. Small asymptomatic myelolipomas are generally non-malignant adrenal myelolipoma (Figure 5). considered candidates for watchful waiting, but symptomatic ones require treatment [6]. They are diagnosed incidentally DISCUSSION during imaging by CT or MRI [7]. In general, CT demonstrates fat density with areas of soft tissue. The fatty areas have increased Adrenal myelolipomas are benign tumors with fat and bone signal intensity, and the areas of bone marrow elements show marrow elements. The incidence of this tumor at autopsy is moderate hyperintensity on T1-weighted MRI [8]. When the mass is detected in the upper pole of the kidney, as we reported,

UroToday International Journal case report UIJ Minori Matsumoto, Katsumi Shigemura, Masato Fujisawa www.urotodayinternationaljournal.com Figure 3. Abdominal gadrinium-enhanced MRI revealed Figure 4. Follow-up abdominal CT showed an enlarged a heterogenous mass with fat intensity areas on fat- and non-enhanced mass (120 mm × 100 mm × 90 mm) suppressed T1-weighted images. The peri-tumoral and in the right suprarenal region compared with the CT at peri-renal hematoma had lower intensity than the tumor the time of patient’s admission (Figure 1) (as shown by mass and right kidney (as shown by the arrow). the arrow). doi: 10.3834/uij.1944-5784.2011.08.11f3 doi: 10.3834/uij.1944-5784.2011.08.11f4

the original organ associated with the tumor can be difficult to define and the differential diagnosis of the retroperitoneal and MRI can possibly distinguish hemorrhagic myelolipoma fatty mass such as renal angiomyolipoma, liposarcoma, lipoma, from other conditions such as renal angiomyolipoma, adrenal or adrenal myelolipoma [9] is necessary. In our case, CT and metastases, pheochromocytoma, and renal adenocarcinoma, MRI demonstrated the fatty areas and the hematoma in the which also can cause spontaneous hemorrhage [3, 11, 12, peritumoral and suprarenal space. The margin of the tumor 13]. Arteriography is one of the best methods for accurate between the liver and the right kidney was sharp and clear on diagnosis [14] but can cause severe stress to patients from the coronal MRI. Angiography showed a hypovascular tumor. adverse events. Imaging tests can be simpler and more helpful Taken together, we were able to diagnose myelolipoma with for the accurate diagnosis of hemorrhagic myelolipoma. In retroperitoneal hemorrhage. one reported case [15], urgent surgery was needed when the CT showed a myelolipoma hematoma compressing the This case is the 22nd to our knowledge in which spontaneous vena cava. Otherwise, preoperative embolization of ruptured rupture of the mass led to retroperitoneal hemorrhage. myelolipoma can be useful in stabilizing patients prior to Characteristics include male dominance (20 of 22) and definitive operation [3, 10, 14]. Our case was initially managed right-sided predilection (20 of 22), with a mean age of by watchful waiting as it was recognized that retroperitoneal 44 years (range: 20–69) and mean tumor size of 11.7 cm hemorrhage was not ongoing. When ruptured myelolipoma (range: 4–20.5). All known cases were symptomatic tumors. is diagnosed, the conservative or watchful waiting approach Sudden onset of acute pain is usually due to intratumoral is recommended because it is safe and less invasive for the hemorrhage. Extratumoral hemorrhage has been rarely patient. When the initial conservative therapy can control the described [10]. In most cases, surgical treatments were retroperitoneal hemorrhage and maintain a good general performed immediately although spontaneous rupture of condition, an immediate surgical removal with the risk of the tumor is a rare condition; therefore, the preoperative re-bleeding can be avoided. If an operation is needed due to the diagnosis of myelolipoma is important. Imaging including CT failure of conservative treatment of a large adrenal myelolipoma

UroToday International Journal case report UIJ Spontaneous Rupture of Adrenal Myelolipoma Figure 5. Histological findings demonstrated that 5. Loyd RV, Kawashima A, Tischier A. Adrenal soft tissue and hematopoietic tissue was surrounded with mature fat germ cell tumours. In: DeLellis RA, Lloyd RV, Heitz PU, cells. (hematoxylin & eosin stain. ×200). Eng C. eds. World Health Organization Classification of doi: 10.3834/uij.1944-5784.2011.08.11f5 Tumours. Pathology & Genetics. Tumors of Endocrine Organs. Lyon, France: IARC Press, 2004:169–171.

6. Medeiros LJ, Wolf BC. Traumatic rupture of an adrenal myelolipoma. Arch Pathol Lab Med. 1983;107(9):500.

7. Kalidindi RS, Hattingh L. Bilateral giant adrenal myelolipomas. Abdom Imaging. 2006;31(1):125–127.

8. Nakajo M, Onohara S, Shinmura K, Fujiyoshi F, Nakajo M. Embolization for spontaneous retroperitoneal hemorrhage from adrenal myelolipoma. Radiat Med. 2003;21(5):214–219.

9. Meaglia JP, Schmidt JD. Natural history of an adrenal myelolipoma. J Urol. 1992;147(4):1089–1090.

10. Catalano O. Retroperitoneal hemorrhage due to a ruptured adrenal myelolipoma. A case report. Acta Radiol. 1996;37(5):688–690. by the watchful waiting approach, an improvement in the 11. Tong YC, Chieng PU, Tsai TC, Lin SM. Renal angiomyolipoma: patient’s general condition is still important before the report of 24 cases. Br J Urol. 1990;66(6):585–589. operation is conducted. 12. Friedman AC, Hartman DS, Sherman J, Lautin EM, REFERENCES Goldman M. Computed tomography of abdominal fatty masses. Radiology. 1981;139(2):415–429.

1. Manassero F, Pomara G, Rappa F, Cuttano MG, Crisci A, 13. Pode D, Caine M. Spontaneous retroperitoneal Selli C. Adrenal myelolipoma associated with adenoma. hemorrhage. J Urol. 1992;147(2):318–331. Int J Urol. 2004;11(5):326–328. 14. Chng SM, Lin MB, Ng FC, Chng HC, Khoo TK. Adrenal 2. Agarwal A, Tamidari H, Mishra AK, Gupta S. Catecholamine myelolipoma presenting with spontaneous retroperitoneal secreting adrenal myelolipoma. Indian J Med Sci. haemorrhage demonstrated on computed tomography 2006;60(8):331–333. and angiogram—a case report. Ann Acad Med Singapore. 2002;31(2):228–230. 3. Hofmockel G, Dämmrich J, Garcia HM, Frohmüller H. Myelolipoma of the adrenal gland associated with 15. Suárez G, Valera Z, Ángel Gómez M, Docobo F, María contralateral renal cell carcinoma: case report and review Álamo J. Etiología y diagnóstico del hematoma of the literature. J Urol. 1995;153(1):129–132. retroperitoneal complicado, actitud e indicación quirúrgica. Cir Esp. 2005;78(5):328–330. 4. Amano T, Takemae K, Niikura S, Kouno M, Amano M. Retroperitoneal hemorrhage due to spontaneous rupture of adrenal myelolipoma. Int J Urol. 1999;6(11):585–588.

Squamous Cell Carcinoma of Renal Pelvis with Fungal Infection in a Non-Functioning Kidney–A Rare Entity

Anubha Singh Yadav ,1 Santosh Kr. Singh, 2 Devendra Singh Pawar, 3 S. K. Mathur, 4 Asha Kumari 1 1Resident, Department of Urology, Pt. BDS PGIMS, University of Health Sciences, Rohtak 2Senior Professor and Head, Deptartment of Urology, Pt. BDS PGIMS, University of Health Sciences, Rohtak 3Associate Professor, Department of Urology, Pt. BDS PGIMS, University of Health Sciences, Rohtak Department of Urology 4Senior Professor, Department of Pathology, Pt. BDS PGIMS, University of Health Sciences, Rohtak Submitted April 30, 2011 - Accepted for Publication July 3, 2011

ABSTRACT

Squamous cell carcinoma of the urinary tract is a very rare tumor associated with chronic renal calculi and infection. This tumor is highly aggressive and often detected at an advanced stage with a poor outcome. We hereby describe a case report of a 56-year-old male who presented with hydronephrosis and hydroureter in a non-functioning left kidney with ureteric calculi. Histopathology of the nephrectomy specimen revealed unexpected squamous cell carcinoma with chronic pyelonephritis. The pus culture came out positive for fungus—Geotrichum.

Introduction established before the histopathological examination of the resected surgical specimen [2]. Early metastatic spread is common Squamous cell carcinoma of the renal pelvis and ureter is rare and the prognosis is poor with a few patients surviving longer with an incidence of 6 to 15% of all urothelial tumors [1]. Very than 5 years [1]. few cases of primary squamous cell carcinoma of the kidney have been reported in world literature. The insidious onset of We are reporting the rarest case of squamous cell carcinoma symptoms and the lack of any pathognomic sign lead to a delay along with infection in the non-functioning kidney. in diagnosis and treatment.

Case report Squamous cell carcinoma is frequently associated with urolithiasis and hydronephrosis [2-4]. Solid masses, hydronephrosis, and A 56-year-old male patient, non-alcoholic and non-smoker, calcifications are common but are nonspecific radiological presented with pain in his left flank for 1.5 months. Examination findings, which may explain why diagnosis is not frequently of the abdomen was unremarkable. He was non-diabetic and

KEYWORDS: Non-functioning kidney; Fungal infection-Geotrichum; Squamous cell carcinoma CORRESPONDENCE: Anubha Singh Yadav, Department of Urology, Pt. BDS PGIMS, University of Health Sciences, Rohtak (uropgi. [email protected]). CITATION: UroToday Int J. 2011 Oct;4(5):art 62. doi:10.3834/uij.1944-5784.2011.10.4

UroToday International Journal case report UI Squamous Cell Carcinoma of Renal Pelvis with Fungal Infection in a Non-Functioning J Kidney–A Rare Entity Figure 1. Intravenous pyelography film. Figure 2. Nephrectomy specimen. doi: 10.3834/uij.1944-5784.2011.10.4f1 doi: 10.3834/uij.1944-5784.2011.10.4f2

Figure 3. Showing cyst along with malignant squamas cells. Histopathological Examination at 100x and 400x (H and E staining). doi: 10.3834/uij.1944-5784.2011.10.4f3

HIV negative. On ultrasonography, the left kidney showed grade III hydronephrosis and hydroureter. The right kidney was normal. On IVP, there was non-visualization of the left kidney (Figure 1). A DTPA scan was done and showed 0.0% relative function of the left kidney and a non-obstructed right kidney with 100% relative function.

The patient was diagnosed with hydronephrosis and hydroureter along with a non-functioning left kidney with The representative microsections examined showed changes of ureteric calculi. Laparoscopic left nephrectomy with ureteric chronic pyelonephritis with extensive squamous metaplasia of stone removal was planned and undertaken. On laparoscopy, the pelvis progressing to moderately differentiated squamous a densely adherent pyonephrotic kidney with white-colored cell carcinoma (Figure 3), stage pT3. A segment of the ureter pus was seen. The pelvis was densely adherent to surrounding was unremarkable and free from tumor infiltration. The structures. Lower ureteric stones were removed and chemical analysis of the calculus was done and its composition nephroureterectomy was done. On the pus culture, Geotrichum was calcium oxalate and phosphate. Postoperative contrast- fungus was present. A nephrectomy specimen with a segment enhanced computed tomography was done in which the left of ureter on a cut section revealed a dilated pelvicalyceal kidney was not visualized, and enlarged lymph nodes were seen system and a greyish-white solid area in the pelvis (Figure 2).

UroToday International Journal case report UI Squamous Cell Carcinoma of Renal Pelvis with Fungal Infection in a Non-Functioning J Kidney–A Rare Entity Figure 4. Fungal morphology. Some authors reported that the treatment of choice was doi: 10.3834/uij.1944-5784.2011.10.4f4 nephrectomy with total ureterectomy, including a bladder cuff around the ureteric orifice [10]. However, others suggested nephrectomy and only partial ureterectomy [11]. Chemotherapy conveys little benefit and the value of radiotherapy is debatable.

REFERENCES

1. Blacher EJ, Johnson DE, Abdul-Karim FW, Ayala AG. Squamous cell carcinoma of renal pelvis. Urology. 1985;25(2):124–126. PubMed ; CrossRef

2. Li MK, Cheung WL. Squamous cell carcinoma of the renal pelvis. J Urol. 1987;138(2):269–271. PubMed

3. Kimura T, Kiyota H, Asano K, et al. Squamous cell carcinoma of the renal pelvis with inferior vena caval extension. Int J Urol. 2000;7(8):316–320. PubMed ; CrossRef

4. Busby JE, Brown GA, Tamboli P, et al. Upper urinary in para-aortic area at the celiac axis and superior mesenteric tract tumors with nontransitional histology: a single- artery on the left side. The follow-up period is 2.5 months center experience. Urology. 2006;67(3):518–523. without any local recurrence. PubMed ; CrossRef

5. Mazeman E. Tumours of the upper urinary tract (calices, Discussion pelvis, ureter). J Urol Nephrol Paris suppl. 1972;9:1–219. The relevant medical history of squamous cell carcinoma often 6. Holmäng S, Lele SM, Johansson SL. Squamous cell includes episodes of chronic pyelonephritis or nephrolithiasis. carcinoma of the renal pelvis and ureter: incidence, Mazeman reported that squamous cell carcinoma was symptoms, treatment and outcome. J Urol. 2007;178(1):51– associated with calculi in 30 to 60% of these cases [5]. It is 56. PubMed ; CrossRef believed that chronic irritation of the urothelium leads to squamous metaplasia, which may subsequently develop into 7. Bhandari A, Alassi O, Rogers C, MacLennan GT. Squamous squamous cell carcinoma [6, 7]. Geotrichosis candidum urinary cell carcinoma of the renal pelvis. J Urol. 2010;183(5):2023– tract infection was reported in patients with renal stones [8]. 2024. PubMed ; CrossRef Staghorn stones are more likely to be associated with renal pelvic neoplasm. In our case, chronic irritation and superadded 8. Drach GW, Carlton CE, Chenault OW, Dykhuizen RF. Fungal superinfection: geotrichosis of the urinary fungal infection is most likely the etiology of this rare carcinoma tract in association with parathyroid adenoma. J Urol. of the renal pelvis. 1968;100(1):82–84. PubMed

Ureteral obstruction is the main cause of presenting symptoms. 9. Keane PF, McKenna M, Johnston SR. Fungal bezoar Fungal accretions termed fungal balls are known to cause causing ureteric obstruction. Br J Urol. 1993;72(2):247–248. ureteral obstruction [9]. Diagnosis is difficult since imaging PubMed techniques usually only reveal calculi with hydronephrosis and diffuse ureteral obstruction. Therefore, the initial diagnosis of squamous cell carcinoma is mostly based on histopathological examination, as it was in our case.

UroToday International Journal case report UI Squamous Cell Carcinoma of Renal Pelvis with Fungal Infection in a Non-Functioning J Kidney–A Rare Entity 10. Dutkiewicz S, Kałczak M. Planoepithelial squamous cell carcinoma of the renal pelvis. Int Urol Nephrol. 1994;26(6):631–635. PubMed ; CrossRef

11. Mhiri MN, Rebai T, Turki L, Smida ML. Association between squamous cell carcinoma of the renal pelvis and calculi. Br J Urol. 1989;64(2):201–202. PubMed ; CrossRef

©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.4 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Squamous Cell Carcinoma of the Urinary Bladder Associated with a Big Bladder Stone in a 55-Year-Old Female: A Case Report

Hamdy AbdelMawla Aboutaleb,1 Atef Badawy,1 Ahmed Gamal-eldin,1 Mohammed Badr-eldin1 1Department of Urology, Minoufiya University Hospital, Shebin Elkom, Minoufiya, Egypt Submitted April 14, 2011 - Accepted for Publication June 13, 2011

ABSTRACT

A 55-year-old-female Egyptian presented to us with severe dysuria. Laboratory investigations showed high serum creatinine of 3.4 mg/dl. A urinalysis revealed pyuria and hematuria. Liver enzymes were very high due to viral hepatitis and the daily usage of NSAIDs. A KUB showed a large, lamellated, radio-opaque shadow in the pelvis. A non-contrast CT revealed a contracted bladder with diffuse thickening of the bladder wall, and a single, large urinary bladder stone 5 x 6 cm, bilateral marked hydronephrosis, and hepatomegaly. A VCUG showed left reflux grade IV. A cystoscopy confirmed the presence of the stone with multiple biopsies from the erythematous bladder wall. A histopathology showed invasive squamous cell carcinoma. A right percutaneous nephrostomy was inserted with a urethral catheter. There was conservative management for liver disease till the liver functions returned to normal. A radical cystectomy and ileal conduit urinary diversion was performed successfully. The association between a large, neglected bladder stone and SCC should be considered.

KEYWORDS: Bladder stone; Squamous cell carcinoma Abbreviations and Acronyms CORRESPONDENCE: Hamdy AbdelMawla Aboutaleb, Department of SCC, squamous cell carcinoma Urology, Minoufiya University Hospital, Shebin Elkom, Minoufiya, Egypt CT, computerized tomography ([email protected]) KUB, kidney ureter bladder X-ray VCUG, voiding cystourography CITATION: UroToday Int J. 2011 Oct;4(5):art 67. doi:10.3834/uij.1944-5784.2011.10.8 NSAIDs, Nonsteroidal anti-inflammatory drugs

INTRODUCTION are made of calcium oxalate. These are more often single than multiple stones. They are associated with outlet obstruction Squamous cell carcinoma (SCC) of the urinary bladder is the of the bladder due to BPH or lazy bladder in women. We most common cancer in Egypt [1]. It is the most common in present a female patient with a huge, neglected bladder stone the seventh decade of life, and more in males than females. associated with SCC of the urinary bladder. [2]. In general, risk factors for SCC of the bladder include those situations that commonly induce squamous metaplasia, a CASE REPORT process that results from chronic irritation of the urothelium, A 55-year-old female patient from Egypt was presented to us such as bladder stones. with severe dysuria. Her past medical history was unremarkable The incidence of bladder stones is 2 to 6% of urinary stones. for hypertension, diabetes mellitus, and coronary artery disease. Males are more affected than females. Most bladder stones She had no family history of malignancy. She is known to use NSAIDs as a daily analgesic for headaches. There is a history of

UroToday International Journal case report UI Squamous Cell Carcinoma of the Urinary Bladder Associated with a Big Bladder Stone in a 55-Year-Old J Female: A Case Report Figure 1. KUB X-ray shows a big radio-opaque shadow in Figure 2A. This figure shows the stone after removal and the pelvis of a 55-year-old female patient. its size of 5 x 6 cm. doi: 10.3834/uij.1944-5784.2011.10.8f1 doi: 10.3834/uij.1944-5784.2011.10.8f2a

Figure 2B. Surgical specimen of urinary bladder shows the thickness of the wall (see arrows). doi: 10.3834/uij.1944-5784.2011.10.8f2b

schistosomiasis and she received medical treatment a long time ago. Her initial laboratory investigations revealed a high serum creatinine of 3.4 mg/dl. Urinalysis revealed pyuria, microscopic hematuria, mild proteinuria, and a culture grew Escherichia coli. Her liver enzymes were AST: 655 U/L and ALT: 372 U/L. Her total bilirubin was 2.4 mg/dl and her direct bilirubin was 1.9 mg/dl. Her ALP was 973 U/L and her GGT was 84 U/L. She was found to have hepatitis B and C. An abdominopelvic ultrasound and a non-contrast CT revealed a contracted bladder associated with diffuse thickening of the bladder wall, a large urinary lesions. Multiple biopsies and histopathological examination bladder stone of 5 x 6 cm, a bilateral marked hydronephrosis, revealed invasive SCC grade II (Figure 3). A right percutaneous and hepatomegaly. A KUB revealed a large, lamellated radio- nephrostomy was inserted with a urethral catheter. Creatinine opaque shadow at the pelvis (Figure 1). VCUG revealed left improved to 1.7 mg/dl and liver functions returned to normal reflux grade IV. Cystoscopy confirmed the presence of the levels after supportive treatment. A radical cystectomy (Figure 2A stone with underlying multiple erythematous bladder wall and 2B) and ileal conduit urinary diversion were done successfully.

UroToday International Journal case report UI Squamous Cell Carcinoma of the Urinary Bladder Associated with a Big Bladder Stone in a 55-Year-Old J Female: A Case Report Figure 3. Section of bladder mass showing squamous cell in English reports throughout our search in PubMed. The carcinoma of the urinary bladder (HE staining, original association with stones and chronic UTIs suggest that it may magnification × 40). be a response to continued inflammation and irritation of the doi: 10.3834/uij.1944-5784.2011.10.8f3 bladder that is probably a predisposing factor for metaplasia and SCC transformation in the urinary bladder.

The causes of bladder stones are not completely understood. Stones are more common in men and rare in children and women. Diet and fluid intake appear to be important factors. Stones seem to be more common in hot climates and during summer months. There is also a strong association with poverty. There is an association between infection and triple phosphate stones, which may be single, large stones in the presenting case because of the presence of magnesium, ammonia, and phosphate. This type of stone is usually associated with chronic infection in the bladder and may grow very large. People with bladder stones sometimes have no symptoms and that may explain why patients wait until stones reach large sizes. More often, however, they will have obstructive symptoms. Large, single stones may lead to an infection, bleeding, or even painful filling of the bladder and continuous irritation. The relationship between bladder stones and SCC should be discussed.

The treatment of clinically localized bladder SCC is usually surgical because of resistance to chemotherapy and radiation, DISCUSSION similar to SCC of other sites. The prognosis for patients with An incidence of SCC in the United States is only 3 to 7% of bladder SCC is poor, and most die from their disease within bladder cancers and 1% in England, but up to 75% in Egypt 3 years after diagnosis. The reported 5-year survival rate is where schistosomiasis is endemic [3]. SCC is usually related 30 to 50%. Death is usually due to local progression to the to chronic infection, bladder stones, and chronic indwelling bladder neck or ureters, causing obstruction and subsequent catheters. Almost all SCCs are advanced and muscle-invasive at renal failure. Distant metastases are rare. The presenting case the time of diagnosis. SCCs of the bladder have an unfavorable had viral hepatitis associated with SCC of the urinary bladder. prognosis due to a local, advanced stage at the time of Moreover, there was vesicoureteral reflux on the left side due presentation [4]. to the small capacity of the bladder with increased intravesical pressure and right marked hydronephrosis due to ureteral In Egypt, bladder cancer has been the most common cancer obstruction. A urethral foley catheter and right percutanuous during the past 50 years. Interestingly, SCC is the most nephrostomy tube improved the renal functions. A supportive common histopathological type in Egypt, constituting 59 to treatment for the liver improved its condition and surgery was 81% of reported bladder cancers between 1960 and 1980. performed successfully. Finally, we concluded that SCC of the Chronic bladder infection with schistosomiasis has been the urinary bladder is common in Egypt. Schistosomiasis and bladder most important risk factor in Egypt, in contrast to smoking stones are well known predisposing factors. The association and occupational exposures in Europe [1]. Interestingly, our between a large neglected bladder stone and SCC should be patient has been exposed to schistosomiasis, recurrent urinary considered and excluded before proceeding to bladder stone tract infections, and a bladder stone that developed SCC. It is surgery. not clear to us whether bladder stones and recurrent UTIs or schistosomiasis caused or accelerated the development of SCC in this patient, but it may have masked symptoms of a serious bladder disease. Carcinoma of the bladder has been reported in association with recurrent UTIs and long-term catheterization [5]. A few Japanese reports mention the direct association with bladder stones [6]. To our knowledge, there is a shortage

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©2011 Digital Science Press, Inc. http://www.urotodayinternationaljournal.com UIJ / Vol 4 / Iss 5 / October / doi:10.3834/uij.1944-5784.2011.10.8 ISSN 1944-5792 (print), ISSN 1944-5784 (online) ® UIJUroToday International Journal www.urotodayinternationaljournal.com Volume 4 - October 2011

Von Hippel-Lindau Disease–A Case Report and Review of Literature

Vedamurthy Pogula Reddy,1 Dandu Venkata Satya Rambabu,2 Surya Prakash Vaddi,1 Subramanian S2 1Department of Urology and Renal Transplantation, Narayana Medical College and Hospital, Andhra Pradesh, India 2Department of Urology, SVIMS, Andhra Pradesh, India Submitted May 1, 2011 - Accepted for Publication July 3, 2011

ABSTRACT Von Hippel-Lindau disease is a dominantly inherited familial cancer syndrome with variable expression. Here we are reporting a case of von Hippel-Lindau disease in a family.

Introduction Case report

The familial form of the common clear-cell variant of RCC is A 32-year-old male presented with a sudden onset of blurry von Hippel-Lindau disease. Major manifestations include the vision in his left eye in 2002. On investigation, he was found to development of RCC, pheochromocytoma, retinal angiomas, and have bilateral retinal angiomas and bilateral renal tumors. He hemangioblastomas of the brain stem, cerebellum, or spinal cord was treated with laser therapy for retinal angiomas. A CECT [1]. All these tumor types are vascular and can lead to substantial scan of the abdomen revealed bilateral renal tumors (4 cm on morbidity, much of which can be avoided with prompt recognition the right side and 1 cm on the left side) and multiple pancreatic cysts (Figure 1). He underwent a right partial nephrectomy and and careful, skilled management. With improved management later, the patient was on regular follow-up. A twin brother of the central nervous system manifestations of the disease, RCC was also affected and underwent surgery for bleeding from has now become the most common cause of mortality in patients cerebellar hemangioblastoma. The patient’s wife conceived, with von Hippel-Lindau disease [1]. and chorionic villous sampling revealed the VHL gene was positive, and aborted. A CECT scan of the abdomen in 2007 revealed a left, lower pole renal tumor of about 4.3 cm with

KEYWORDS: Von Hippel-Lindau disease; Familial renal cancer Abbreviations and Acronyms CORRESPONDENCE: Vedamurthy Pogula Reddy, Department of Urology and Renal RCC, renal cell carcinoma Transplantation, Narayana Medical College and Hospital, Nellore, Andhra Pradesh, India 524002 ([email protected]). VHL, von Hippel-Lindau VEGF, vascular endothelial growth CITATION: UroToday Int J. 2011 Oct;4(5):art 64. doi:10.3834/uij.1944-5784.2011.10.6 factor HIF, hypoxia induced factor PDGF, platelet derived growth factor

UroToday International Journal case report UIJ Von Hippel-Lindau Disease–A Case Report and Review of Literature Figure 1. CECT scan of the abdomen revealed bilateral Figure 2. CECT scan of the abdomen revealed a left renal tumors (4 cm on right side and 1 cm on left side) lower pole renal tumor of about 4.3 cm with multiple and multiple pancreatic cysts. pancreatic cysts. doi: 10.3834/uij.1944-5784.2011.10.6f1 doi: 10.3834/uij.1944-5784.2011.10.6f2

multiple pancreatic cysts (Figure 2). A DTPA renogram showed and its role as a tumor suppressor gene for both the sporadic a normally functioning right kidney and a space-occupying and the familial forms of clear cell RCC has been confirmed [3]. lesion (SOL) in the left lower pole renal parenchyma. A brain CT showed a normal study. After a preoperative workup, a left The VHL gene consists of 3 exons, and it encodes a protein of 213 partial nephrectomy was done. A frozen section revealed the amino acids. Both alleles of the VHL gene must be mutated or margins were tumor free. A histopathology revealed a clear cell inactivated for development of the disease. Almost all patients variant of low-grade renal cell carcinoma. The patient is now in with von Hippel-Lindau disease were found to have germ line follow-up. mutations of 1 allele of the VHL tumor suppressor gene, and autosomal dominant inheritance from the affected parent was confirmed [3, 4]. The second allele is commonly lost by Discussion gene or chromosome deletion. A critically important function The familial form of the common clear cell variant of RCC is of the VHL protein complex is to target the hypoxia-inducible von Hippel-Lindau disease. This relatively rare autosomal factor 1 (HIF-1) for ubiquitin-mediated degradation, keeping dominant disorder occurs with a frequency of 1 per 36000 of the levels of HIF‑1 low under normal conditions. HIF‑1 is an the population. Major manifestations include the development intracellular protein that plays an important role in regulating of RCC, pheochromocytoma, retinal angiomas, and cellular responses to hypoxia, starvation, and other stresses. hemangioblastomas of the brain stem, cerebellum, or spinal Inactivation or mutation of the VHL gene leads to dysregulated cord (Table 1) [1]. RCC develops in about 50% of patients with expression of HIF-1, and this protein begins to accumulate in von Hippel-Lindau disease and is distinctive for its early age at the cell [5, 6]. This, in turn, leads to a several-fold upregulation onset, often in the third, fourth, or fifth decade of life, and of the expression of vascular endothelial growth factor (VEGF), for its bilateral and multifocal involvement [1]. Sophisticated the primary pro-angiogenic growth factor in RCC, contributing molecular genetic linkage studies in patients with von Hippel- to the pronounced neovascularity associated with clear cell Lindau disease eventually led to the identification of the VHL RCC [4]. HIF-1 also upregulates the expression of tumor growth factor- , platelet-derived growth factor (PDGF), glucose tumor suppressor gene [2]. This gene, which is located at α transporter (Glut 1), erythropoietin, and carbonic anhydrase 9 chromosome 3p25-26, has now been completely sequenced,

UroToday International Journal case report UIJ Von Hippel-Lindau Disease–A Case Report and Review of Literature Figure 3. Biologic functions of the VHL protein. The wild-type VHL protein targets HIF-α for degradation. Mutation of the VHL gene allows HIF-α to accumulate, leading to increased expression of VEGF, Glut 1, and PDGF. This, in turn, has important implications with respect to tumor angiogenesis, metabolic activity, and autocrine stimulation. doi: 10.3834/uij.1944-5784.2011.10.6f3

Table 1. Manifestations of von Hippel-Lindau syndrome. doi: 10.3834/uij.1944-5784.2011.10.6t1

Organ System Lesion Incidence (%) Eye Benign retinal angiomas 49–59 Central nervous system Benign hemangioblastomas 42–72 Clear cell RCC 24–70 Kidney Renal cysts 22–59 Adrenal gland Pheochromocytoma 18 Islet cell tumors 12

Pancreas Malignant islet cell tumor 2

Pancreatic cysts 21–72 Epididymis Cystadenoma 10–26 Ear Endolymphatic sac tumor 10

UroToday International Journal case report UIJ Von Hippel-Lindau Disease–A Case Report and Review of Literature (CA-9), a tumor-associated antigen with specificity for clear cell 5. Ratcliffe PJ, Maxwell PH, Wiesener MS, et al. The tumour RCC (Figure 3) [4, 7, 8]. suppressor protein VHL targets hypoxia-inducible factors for oxygen-dependent proteolysis. Nature. This syndrome should be considered in any patient with early- 1999;399(6733):271–275. PubMed ; CrossRef onset or multifocal RCC or RCC in combination with any of the following: a history of visual or neurologic symptoms; 6. Yu F, White SB, Zhao Q, Lee FS. Dynamic, site-specific a family history of blindness, central nervous system tumors, interaction of hypoxia-inducible factor-1α with the von or renal cancer; or coexistent pancreatic cysts, epididymal Hippel-Lindau tumor suppressor protein. Cancer Res. lesions, or inner-ear tumors [1, 4, 9]. Patients suspected of 2001;61(10):4136–4142. PubMed having von Hippel-Lindau disease, or the appropriate relatives of those with documented disease, should strongly consider 7. Zbar B, Kaelin W, Maher E, Richard S. Third International genetic evaluation. Patients with germ line mutations can Meeting on von Hippel-Lindau disease. Cancer Res. be identified and offered clinical and radiographic screening 1999;59(9):2251–2253. PubMed that can identify the major manifestations of von Hippel- Lindau disease at a presymptomatic phase, allowing potential 8. Grabmaier K, de Weijert MCA, Verhaegh GW, amelioration of the considerable morbidity associated with this Schalken JA, Oosterwijk E. Strict regulation of CAIX (G250/ syndrome [10]. Investigators at the National Institutes of Health MN) by HIF-1α in clear cell renal cell carcinoma. Oncogene. have recommended that such patients be evaluated with (1) an 2004;23(33):5624–5631. PubMed ; CrossRef annual physical examination and ophthalmologic evaluation beginning in infancy; (2) estimation of urinary catecholamines 9. Choyke PL, Glenn GM, Walther MM, Zbar B, Linehan WM. at the age of 2 years and every 1 to 2 years thereafter; (3) an Hereditary renal cancers. Radiology. 2003;226(1):33–46. PubMed ; CrossRef MRI of the central nervous system biannually beginning at the age of 11 years; (4) an ultrasound examination of the abdomen 10. Maranchie JK, Linehan WM. Genetic disorders and renal and pelvis annually beginning at the age of 11 years, followed cell carcinoma. Urol Clin North Am. 2003;30(1):133–141. by CT scanning every 6 months if cysts or tumors develop; and PubMed ; CrossRef (5) periodic auditory examinations [10].

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