Refractory lymphatic ascites following laparoscopic management of renal lymphangiectasia: An unusual presentation

Renal lymphangiectasia characterised by either unilocular or multilocular cystic lesion in and around the kidney is an uncommon condition. Presentation of these lesions is quite varied, which along with its uncommon occurrence adds to the challenges in the management of this condition. Most of these cases are managed conservatively and very rarely need any intervention. We present an unusual complication of refractory lymphatic ascites following laparoscopic deroofing of a unilocular renal lymphangiectasia in a 21-year-old gentleman who presented with left flank pain. The ascitic fluid analysis suggested non-chylous lymphatic ascites. The surgical outcome was rather exasperating for the patient than the disease itself. Hence, in the interest of the patient with minimal symptoms, if the imaging is highly suggestive of renal lymphangiectasia, either no intervention or the least invasive procedures should be attempted, whenever possible.

Role of miRNA-182 and miRNA-187 as potential biomarkers in prostate cancer and its correlation with the staging of prostate cancer

Purpose

The microRNAs expression has emerged as a potential biomarker for the diagnosis and prognosis of prostate cancer. This study investigated the expression of miRNA-182 and miRNA-187 in prostate cancer patients and established a correlation between miRNA expression and staging of prostate cancer.

Materials and Methods

This prospective observational study involved patients undergoing transrectal ultrasound-guided biopsy for suspicion of prostate cancer. Pre-biopsy urine samples and prostatic core tissue samples of the patients were preserved and the miRNA-182 and miRNA-187 were studied.

Results

Sixty-three patients were included in this study, thirty-three patients were diagnosed with prostate cancer and thirty patients having benign histopathology were considered as controls. The expression of miRNA-182 was significantly increased (p=0.002) and miRNA-187 significantly decreased (p <0.001) in prostate cancer tissue specimens. However, the expression of these miRNAs did not significantly differ in the urine of prostate cancer patients as compared to controls. Serum Prostatic Specific Antigen (PSA) inversely correlated with the median expression of miR-187 in prostatic tissue (p=0.002). Further, the expression of miRNA-187 in prostate cancer tissue was significantly decreased in metastatic prostate cancer (p=0.037). Using ROC analysis, miRNA-187 expression was able to distinguish the presence or absence of bone metastasis [area under ROC (AUROC) (±SD) was 0.873±0.061, p <0.001].

Conclusion

The miRNA-182 and miRNA-187 appear to be promising biomarkers in prostate cancer and miRNA-187 can serve as an important diagnostic marker of metastatic prostate cancer.

Role of circulating tumor cells in patients with metastatic clear-cell renal cell carcinoma

PURPOSE

Circulating tumor cells (CTC) have been demonstrated to have prognostic and predictive role in certain human cancers. However, studies exploring their role in metastatic renal cell carcinoma (mRCC) are scarce. We aimed to evaluate the prognostic and predictive role of CTC in mRCC.

MATERIALS AND METHODS

In this prospective study, 35 patients with mRCC were analyzed for the presence of CTC before starting tyrosine kinase inhibitors (TKI). Progression-free and overall survival rates were estimated using the Kaplan-Meier curves and log-rank test. The prediction to TKI therapy was calculated with the response to treatment determined by standard imaging techniques.

RESULTS

Outcomes were assessed according to the CTC positivity at baseline, before the patients started TKI for mRCC. At a mean follow-up of 12.4 ± 4.1 months, disease progression was noted in 17 patients (48.6%) including 8 deaths (22.9%). CTC positive patients had a significantly lower progression-free survival rate (12.5% vs. 64.1%, respectively; P = 0.009) but not in the overall survival rate (75% vs. 76.3%, respectively; P = 0.88) in the Kaplan-Meier estimation curves. CTC positivity at baseline significantly predicted a poorer response to TKI (87.5% vs. 37.1%, P = 0.01). The multivariate Cox proportional hazards analysis showed that CTC at baseline was the most significant predictor of progression-free survival (hazard ratio 4.17, 95% confidence interval 1.41-11.99, P = 0.01).

CONCLUSIONS

Baseline CTC detection can be an important prognostic factor of progression-free survival and significant predictor of poor response to TKI in patients with metastatic RCC.

Association of Monoamine Oxidase A with Tumor Burden and Castration Resistance in Prostate Cancer

BACKGROUND

Metastatic burden and aggressive behavior determine severity stratification and guide treatment decisions in prostate cancer (PCa). Monoamine oxidase A (MAOA) may promote tumor burden and drug/castration resistance in PCa. A positive association will pave the way for MAOA inhibitors such as moclobemide for PCa therapy.

OBJECTIVE

To analyze MAOA in peripheral blood mononuclear cells qualitatively and p38, c-Jun N-terminal kinases, nuclear factor kappa B, and their phosphorylated forms, vascular endothelial growth factor (angiogenesis), transforming growth factor beta, interleukin 6, and tumor necrosis factor-α (cytokines), Bcl-2 associated X, B-cell lymphoma 2, and P53 (apoptosis), prostate-specific membrane antigen, and epithelial cell adhesion molecules (surface markers) in plasma of patients with PCa.

METHODS

This was a 1-year pilot study in which patients with PCa were recruited and stratified into 2 groups and subgroups: treatment-naive with (M1) (n = 23) or without (M0) (n = 23) bone metastasis; hormone-sensitive prostate cancer (n = 26) or hormone/castration-resistant prostate cancer (n = 26). MAOA was detected using ELISA and other proteins were detected using immunoblotting technique.

RESULTS

MAOA was detected in 8.6% of M0 compared with 30.4% of M1 patients, and in 7.7% of hormone-sensitive compared with 27% of hormone/castration resistant PCa patients, associating it with bone metastasis and castration resistance. Multivariable regression analysis showed a correlation of MAOA with serum prostate-specific antigen, a marker for progression in PCa (Pearson correlation coefficient r = 0.30; P < 0.01). In patients with positive MAOA, there was overexpression of p38, phosphorylated-p38, c-Jun N-terminal kinases, phosphorylated c-Jun N-terminal kinases, nuclear factor kappa B, phosphorylated nuclear factor kappa B, transforming growth factor beta, vascular endothelial growth factor, interleukin 6, tumor necrosis factor α, Bcl-2 associated X, B-cell lymphoma 2, prostate-specific membrane antigen, and epithelial cell adhesion molecule in M1 compared with M0 group patients, associating these proteins with tumor burden. Overexpression of Bcl-2 associated X, tumor protein 53, c-Jun N-terminal kinases, nuclear factor kappa B, transforming growth factor beta, vascular endothelial growth factor, and prostate-specific membrane antigen and underexpression of B-cell lymphoma 2 and phosphorylated nuclear factor kappa B were observed in hormone-sensitive prostate cancer compared with hormone/castration-resistant prostate cancer, associating these proteins with castration resistance.

CONCLUSIONS

Association of key molecules of oncogenesis and metastasis with MAOA suggests that MAOA inhibitors such as moclobemide might be effective in the management of PCa.

Management of Untreated Classical Bladder Exstrophy in Adults: A Single-Institutional Experience

OBJECTIVES

To report our single center experience in the management of untreated adult classical bladder exstrophy.

MATERIALS AND METHODS

A retrospective review of 25 adults aged ≥18 years who underwent repair of the classical bladder exstrophy from April 2000 to February 2020 was performed. Patients with prior repair and neoplastic changes in the exposed bladder mucosa were excluded. The patients and primary caretakers were actively involved in the decision-making of the surgical procedures best suited them. Work-up included upper tract evaluation and random bladder mucosal biopsy.

RESULTS

The mean age of presentation was 25 years. Primary schooling was completed by only 32% patients. The majority (72%) of the patients opted continent catheterizable pouch. Penn pouch was the most common pouch performed. In 3 patients, a complete primary repair was done in a single setting. In 4 patients with lack of education and difficult access to nearby health care settings, ileal conduit was performed. In all except 3 (13.1%), abdominal wall closed primarily. None of the patients required osteotomy. At a mean follow-up of 6.5 years, all patients with continent pouches were continent. One patient required revision of left ureteroneocystostomy at 20 months follow-up. All except one patient, who had complete primary repair were continent at a mean follow-up of 6 years.

CONCLUSION

Management of adult classical bladder exstrophy is challenging. The various pouches extend the surgical options. Ileal conduit may be a simple alternative to complex reconstructions in unmotivated patients with poor access to the hospital.

MR texture analysis in differentiating renal cell carcinoma from lipid-poor angiomyolipoma and oncocytoma

OBJECTIVES

To assess the utility of magnetic resonance texture analysis (MRTA) in differentiating renal cell carcinoma (RCC) from lipid-poor angiomyolipoma (lpAML) and oncocytoma.

METHODS

After ethical approval, 42 patients with 54 masses (34 RCC, 14 lpAML and six oncocytomas) who underwent MRI on a 1.5 T scanner (Avanto, Siemens, Erlangen, Germany) between January 2011 and December 2012 were retrospectively included in the study. MRTA was performed on the TexRAD research software (Feedback Plc., Cambridge, UK) using free-hand polygonal region of interest (ROI) drawn on the maximum cross-sectional area of the tumor to generate six first-order statistical parameters. The Mann-Whitney U test was used to look for any statically significant difference. The receiver operating characteristic (ROC) curve analysis was done to select the parameter with the highest class separation capacity [area under the curve (AUC)] for each MRI sequence.

RESULTS

Several texture parameters on MRI showed high-class separation capacity (AUC > 0.8) in differentiating RCC from lpAML and oncocytoma. The best performing parameter in differentiating RCC from lpAML was mean of positive pixels (MPP) at SSF 2 (AUC: 0.891) on DWI b500. In differentiating RCC from oncocytoma, the best parameter was mean at SSF 0 (AUC: 0.935) on DWI b1000.

CONCLUSIONS

MRTA could potentially serve as a useful non-invasive tool for differentiating RCC from lpAML and oncocytoma.

ADVANCES IN KNOWLEDGE

There is limited literature addressing the role of MRTA in differentiating RCC from lpAML and oncocytoma. Our study demonstrated several texture parameters which were useful in this regard.

Urinary glycoproteomic profiling of non-muscle invasive and muscle invasive bladder carcinoma patients reveals distinct N-glycosylation pattern of CD44, MGAM, and GINM1

Clinical management of bladder carcinomas (BC) remains a major challenge and demands comprehensive multi-omics analysis for better stratification of the disease. Identification of patients on risk requires identification of signatures predicting prognosis risk of the patients. Understanding the molecular alterations associated with the disease onset and progression could improve the routinely used diagnostic and therapy procedures. In this study, we investigated the aberrant changes in N-glycosylation pattern of proteins associated with tumorigenesis as well as disease progression in bladder cancer. We integrated and compared global N-glycoproteomic and proteomic profile of urine samples from bladder cancer patients at different clinicopathological stages (non-muscle invasive and muscle-invasive patients [n = 5 and 4 in each cohort]) with healthy subjects (n = 5) using SPEG method. We identified 635 N-glycopeptides corresponding to 381 proteins and 543 N-glycopeptides corresponding to 326 proteins in NMIBC and MIBC patients respectively. Moreover, we identified altered glycosylation in 41 NMIBC and 21 MIBC proteins without any significant change in protein abundance levels. In concordance with the previously published bladder cancer cell line N-glycoproteomic data, we also observed dysregulated glycosylation in ECM related proteins. Further, we identified distinct N-glycosylation pattern of CD44, MGAM, and GINM1 between NMIBC and MIBC patients, which may be associated with disease progression in bladder cancer. These aberrant protein glycosylation events would provide a novel approach for bladder carcinoma diagnosis and further define novel mechanisms of tumor initiation and progression.

Efficacy and safety of 225Ac-PSMA-617 targeted alpha therapy in metastatic castration-resistant Prostate Cancer patients

Rationale: Despite the success of several standards of care treatment options in metastatic castration-resistant prostate cancer (mCRPC), a significant number of patients attain therapeutic resistance and eventually develop disease progression. Managing these patients are currently challenging. Hence, there is an unmet need for further efficient therapeutic options that induce anti-tumor activity and improve survival. The objective of this study was to assess the safety and therapeutic efficacy of ²²⁵Ac-PSMA-617 targeted alpha therapy (TAT) in mCRPC patients in real-world conditions.

Methods: In this prospective study, we recruited patients with mCRPC who either were refractory to ¹⁷⁷Lu-PSMA-617 radioligand therapy (RLT) or did not receive previous ¹⁷⁷Lu-PSMA-617 RLT. Patients were treated with ²²⁵Ac-PSMA-617 TAT (100 KBq/Kg body weight) at 8-weekly intervals. The primary endpoint included the assessment of biochemical response by measuring the serum prostate-specific antigen (PSA) response rate as per the prostate cancer working group criteria (PCWG3). Secondary endpoints comprised the estimation of overall survival (OS), progression-free survival (PFS), molecular tumor response assessment (PERCIST 1 criteria), disease control rate (DCR), toxicity according to CTCAE v5.0, and clinical response evaluation.

Results: A total of 28 patients were recruited for this cohort study among whom 15 (54%) received prior ¹⁷⁷Lu-PSMA-617 RLT and the remaining 13 (46%) patients were ¹⁷⁷Lu-PSMA-617 RLT naïve. The mean age was 69.7 years (range: 46-87 years). All patients, except one, had extensive skeletal metastases on baseline ⁶⁸Ga-PSMA-11 PET/CT scan; one patient had lymph node dominant disease and advanced primary prostatic tumor. The mean activity administered was 26.5 ± 12 MBq (range: 9.25 - 62.9 MBq) [715.5 ± 327 µCi, range: 250 - 1700 µCi] with a median of 3 cycles (range: 1 - 7 cycles). At 8^th week of post first cycle of ²²⁵Ac-PSMA-617 therapy (initial follow-up) and the end of the follow-up, >50% decline in PSA was observed in 25% and 39%, respectively. The median PFS and OS were 12 months (95% CI: 9 - 13 months) and 17 months (95% CI: 16 months - upper limit not reached), respectively. Molecular tumor response by PERCIST 1 criteria could be conducted in 22/28 (78.6%) patients, which revealed complete response in 2/22 (9%), partial response in 10/22 (45.4%) patients, 2/22 (9%) with stable disease, and 8/22 (36%) with progressive diseases. The disease control rate, according to the biochemical and molecular tumor response criteria, was 82% and 63.6%, respectively. Multivariate analysis revealed PSA progression as adverse prognostic indicator of OS, and any PSA decline as a good prognostic indicator of PFS. There was no Grade III/IV toxicity noted in this series. The most common side-effect was transient fatigue (50%) followed by grade I/II xerostomia (29%).

Conclusion:²²⁵Ac-PSMA-617 TAT showed promising disease control rate, even when all other therapeutic options were exhausted, with low treatment-related toxicities.

A comparative study of autologous rectus fascia pubovaginal sling surgery and synthetic transobturator vaginal tape procedure in treatment of women with urodynamic stress urinary incontinence

OBJECTIVE

To compare short term results of autologous rectus fascia pubovaginal sling surgery with synthetic transobturator vaginal tape procedure in treatment of female stress urinary incontinence (SUI) STUDY DESIGN: It was a comparative study on 30 women between 25-65 years of age with urodynamic proven SUI who were randomly allocated to autologous rectus fascia pubovaginal sling surgery (Group I)(15 women) and synthetic transobturator vaginal tape procedure (Group II) (15 women). Preoperative and postoperative ICIQ (International Consultation on Incontinence Questionnaire) score, urodynamic study and serum CRP and IL-6 were done in all cases.

RESULTS

The baseline characteristics in terms of age, body mass index (BMI), parity, mean ICIQ score and mean preoperative CRP and IL-6 levels were similar in two groups. Mean operative time was significantly longer (55.60 ± 5.77 vs 25.27 ± 4.32 minutes, p = 0.001) in group I than group II. Mean hospital stay of 7.1 ± 1.2 vs 1.2 ± 0.4 days, mean duration of catheterization 5.8 vs 1.2 day (<0.01) and postoperative urinary retention requiring recathterization were all significantly higher in group I than II. Wound infection was more in group I than in group II (p = 0.01) while groin pain was significantly more in group II (p = 0.01). One patient developed vesicovaginal fistula, while one patient required cutting of tape in group I. Pdet at Q max (Detrusor pressure at peak urine flow) increased significantly in both the groups after surgery. ICIQ score was zero in both the groups indicating 100 % success. Surgical trauma was more in group I as shown by significantly higher CRP levels.

CONCLUSION

The success rate of the two groups was similar but, autologous rectus fascia sling surgery took longer, had more complications and urinary retention as compared to transobturator vaginal tape procedure.

Individualised management of obliterative urethral stricture in female patients – four patients and four management strategies

Level of evidence: 4

Uro-oncology in times of COVID-19: The available evidence and recommendations in the Indian scenario

The Corona Virus Disease-2019 (COVID-19), one of the most devastating pandemics ever, has left thousands of cancer patients to their fate. The future course of this pandemic is still an enigma, but health care services are expected to resume soon in a phased manner. This might be a long drawn process and we need to have policies in place, to be able to fight both, the SARS-CoV-2 virus and cancer, simultaneously, and emerge triumphant. An extensive literature search for impact of delay in management of various urological malignancies was carried out. Expert opinions were sought wherever there was paucity of evidence, in order to reach a consensus and come up with recommendations for directing uro-oncology services in the times of COVID-19. The panel recommends deferring treatment of patients with renal cell carcinoma by 3 to 6 months, except for those with ongoing hematuria and/or inferior vena cava thrombus, which warrant immediate surgery. Metastatic renal cell cancers should be started on targeted therapy. Low grade non-muscle invasive bladder cancers can be kept on active surveillance while high risk non-muscle invasive bladder cancers and muscle invasive bladder cancers should be treated within 3 months. Neoadjuvant chemotherapy should be avoided. Management of low and intermediate risk prostate cancer can be deferred for 3 to 6months while high risk prostate cancer patients can be initiated on neoadjuvant androgen deprivation therapy. Patients with testicular tumors should undergo high inguinal orchiectomy and be treated according to stage without delay, with stage I patients being offered surveillance. Penile cancers should undergo penectomy, while clinically negative groins can be kept on surveillance. Neoadjuvant chemotherapy should be avoided and adjuvant therapy should be deferred. We need to tailor our treatment strategies to the prevailing present conditions, so as to fight and defeat both, the SARS-CoV-2 virus and cancer. Protection of health care workers, judicious use of available resources, and a rational and balanced outlook towards different malignancies is the need of the hour.

The relationship between ABO blood group type and tumor grade, stage, recurrence and progression in transitional cell carcinoma of the bladder: A preliminary report

Objectives:

ABO blood grouping is a well-proven prognostic factor in many malignancies. This study aims to study the association and impact of ABO blood group on disease recurrence and progression in bladder carcinoma.

Material and methods:

Patients with bladder carcinoma undergoing transurethral resection of bladder tumor (TURBT) were studied prospectively for at least 1-year follow-up for recurrence and progression of the disease. Demographic profile along with blood group was noted.

Results:

Two hundred patients were included in the study and 194 patients were included in the final analysis. Muscle-invasive bladder cancer was present in 39 (20.1%) patients and the high-grade tumor was present in 88 (45.3%) patients. There was no statistical significance between the association of blood grouping and grade ( p=0.29) and stage of the disease ( p=0.20). During the follow-up period, there were 100 (64.5%) recurrences and 15 (9.7%) patients with non-muscle-invasive bladder carcinoma had progression. The association of blood group with recurrence ( p=0.66) and progression ( p=0.11) of disease was not statistically significant.

Conclusion:

There is no association between bladder cancer and ABO blood group in terms of grade and stage of the disease. The recurrence and progression of the disease did not differ significantly in different blood groups.

Level of Evidence:

2b

Randomized controlled trial to compare outcomes with and without the enhanced recovery after surgery protocol in patients undergoing radical cystectomy

Introduction:

Very few randomized controlled trials are available globally to support routine use of enhanced recovery after surgery (ERAS) protocol after radical cystectomy (RC), and none so far has been conducted in the Indian subcontinent. The aim of the present study was to evaluate hospital stay and 30-day perioperative outcomes following RC with the implementation of the ERAS protocol.

Materials and Methods:

Fifty-four patients undergoing open RC were randomized to ERAS versus conventional surgical care (CSC) at our center from April 2017 to May 2018. Key interventions included avoidance of mechanical bowel preparation, early nasogastric tube removal, early enteral feeding, and early obligatory ambulation. Follow-up was done till 30-day postoperatively or till discharge, whichever longer.

Results:

Twenty-seven patients in each group were analyzed. The demographic profile of the groups was similar. Length of stay in each group (8 days [5–57] ERAS vs. 9 days [5–31] CSC group, P = 0.390) was similar, with time to recovery of bowel function being significantly less in ERAS group (12 h [12–108] vs. 36 h [12–60] for bowel sounds [P = 0.001], 48 h [12–108] vs. 72 h [36–156] for passage of flatus [P = 0.001], and 84 h [36–180] vs. 96 [60–156] for passage of stools [P = 0.013]). Perioperative complication rate (12 patients (44.4%) vs. 14 (51.9%), P = 0.786) was similar.

Conclusions:

ERAS protocol leads to faster bowel recovery compared to conventional care in patients undergoing open RC but fails to demonstrate a shorter length of stay and lower complication rate.

A Case of Type 1 Papillary Renal Cell Cancer with Pelvic Tumor Thrombus Masquerading as Urothelial Cancer with Review of Literature

Background: Adult renal tumors vary from renal cell carcinoma (RCC) to upper tract urothelial cancer (UTUC). Tumor characteristics such as renal vein and inferior vena cava tumor thrombus are usually seen with RCC, but tumor thrombus into pelvicaliceal system (PCS) is a rare entity in RCC. At present only 11 cases have been reported in the literature. Case Presentation: We report an unusual case of papillary type 1 RCC in a young Muslim man mimicking as UTUC radiologically and found to have free tumor thrombus in PCS. At follow-up of 6 months after right nephroureterectomy with bladder cuff excision, he is doing well clinically and radiologically without any recurrence. Conclusion: RCC with tumor thrombus into PCS is an uncommon entity. It can give similar appearance as an urothelial cancer of the pelvis on radiologic imaging. Pelvic tumor thrombus is now considered as a factor of poor prognostic importance and rarely encountered with pure papillary type of RCC.

RASSF1A-Hippo pathway link in patients with urothelial carcinoma of bladder: plausible therapeutic target

RASSF1A is a tumor suppressor gene, and its hypermethylation has been observed in cancers. RASSF1A acts as an upstream regulator of Hippo pathway and modulates its function. The aim of this study was to analyze expression of RASSF1A, Hippo pathway molecules (YAP, MST) and downstream targets (CTGF, Cyr61 and AREG) in bladder cancer patients. Later, the link between RASSF1A and Hippo pathway and a potential therapeutic scope of this link in UBC were also studied. MSPCR was performed to study methylation of RASSF1A promoter. Expression of molecules was studied using qPCR, Western blot and IHC. The link between RASSF1A and Hippo pathway was studied using Spearman's correlation in patients and validated by overexpressing RASSF1A in HT1376 cells and its effect on Hippo pathway was observed using qPCR and Western blot. Further therapeutic potential of this link was studied using MTT and PI assays. The expression of RASSF1A was lower, whereas the expression of YAP, CTGF and CYR61 was higher. The expression of RASSF1A protein gradually decreased, while the expression of YAP, CTGF and CYR61 increased with severity of disease. Based on Spearman's correlation, RASSF1A showed a negative correlation with YAP, CTGF and CYR61. YAP showed a positive correlation with CTGF and CYR61. To validate this link, RASSF1A was overexpressed in HT1376 cells. Overexpressed RASSF1A activated Hippo pathway, followed by a decrease in CTGF and CYR61 at mRNA, and enhanced cytotoxicity to chemotherapeutic drugs. This study finds a previously unrecognized role of RASSF1A in the regulation of CTGF and CYR61 through mediation of Hippo pathway in UBC and supports the significance of this link as a potential therapeutic target for UBC.

Neuroendocrine tumour of urinary bladder: a rare case of aggressively behaving primary well-differentiated neuroendocrine tumour with review of literature

Neuroendocrine tumour (NET) of the urinary bladder (UB) is a rare entity and comprises of well-differentiated, small cell and large cell types. Small and large cell NET like that in lung and gastrointestinal tract have an aggressive nature and are considered high-grade disease. Well-differentiated NET has been thought to be localised and having a good prognosis. We report the first case of metastatic well-differentiated NET of the UB. Our case is a 44-year-old man with well-differentiated NET of UB presented with hepatic and peritoneal metastases on initial diagnosis. He was treated with metaiodobenzylguanidine (MIBG) therapy and had a modest survival of 16 months. The primary well-differentiated NETs can present as a metastatic disease with an aggressive nature. MIBG therapy can be considered as a useful option but overall prognosis is poor. Further research is needed for better understanding and better treatment protocol.

The efficacy of unilateral laparoscopic nephrectomy in the pediatric hypertensive patient

BACKGROUND

Secondary hypertension due to a poorly functioning or non-functional kidney may be refractory to medical management. In such cases, nephrectomy can improve or cure hypertension. With the routine use of laparoscopy, nephrectomy can be performed in a minimally invasive manner, but surgery still carries inherent risks and complications.

OBJECTIVE

The objective of this study is to evaluate the outcomes of laparoscopic nephrectomy performed for secondary hypertension and identify potential predictors of postoperative hypertension resolution.

METHODS

After obtaining approval from institutional review board, patients from January 2002 to March 2018 who underwent laparoscopic nephrectomy were identified using Current Procedural Technology codes. All charts were then manually reviewed to isolate those patients with secondary hypertension present preoperatively. Patient demographics, urologic history, and laboratory and imaging findings were recorded for all patients. Serial blood pressures were recorded at all renal visits along with any antihypertensive medication changes. Postoperative outcomes and complications were also noted for all patients.

RESULTS

A total of 20 patients (7 girls, 13 boys) underwent laparoscopic nephrectomy to treat hypertension at an average age of 10.6 years (range 1.7-17.0 years). Etiology of a solitary non-functional kidney was vesicoureteral reflux in 10 of 20 patients, multicystic dysplastic kidney in 5 of 20, ureteropelvic junction obstruction in 2 of 20, ureteral obstruction in 1 of 20, and renal artery stenosis in 2 of 20 patients. At time of surgery, 3 of 20 patients were on two antihypertensives, 10 of 20 were on one antihypertensive, and 7 of 20 proceeded to surgery with no medical management. In the 30-day postoperative period, no complications were noted. Hypertension improved in 10 of 20 (50%) patients, all of whom were not on any antihypertensive medications after surgery. Hypertension persisted in 4 of 20 (20%) patients, requiring the same antihypertensive regimen and worsened in 6 of 20 (30%) patients, requiring increased doses and/or additional antihypertensives. Average follow-up time was 2.7 years. No significant predictors of postoperative hypertension result were identified when comparing the groups of responders and non-responders.

DISCUSSION

While laparoscopic nephrectomy for a non-functioning kidney in the setting of hypertension is a safe procedure, the cure rate for hypertension in the cohort appears to be on the low side of what was previously reported. While the small sample size is a main limitation, it is among the largest sample sizes for pediatric hypertensive patients. Previously shown predictors were not predictive in the similar-sized cohort.

CONCLUSIONS

Patients should be carefully counseled on the risks and benefits of nephrectomy to treat hypertension, the importance of continued follow-up after nephrectomy, and the possible need for chronic medical management with antihypertensives.

CD44 splice variant (CD44v3) promotes progression of urothelial carcinoma of bladder through Akt/ERK/STAT3 pathways: novel therapeutic approach

PURPOSE

The incidence of Urothelial carcinoma of bladder (UBC) is gradually increasing by changing lifestyle and environment. The development of a tumor has been noted to be accompanied by modifications in the extracellular matrix (ECM) consisting of CD44, hyaluronic acid (HA) and its family members. The importance of CD44 splice variants and HA family members has been studied in UBC.

METHODS

The cohort of study included 50 UBC patients undergoing radical cystectomy and 50 healthy subjects. The molecular expression of CD44 and HA family members was determined. Effect of CD44 variant-specific silencing on downstream signaling in HT1376 cells was investigated. Combinatorial treatment of 4-MU (4-methylumbelliferone) with cisplatin or doxorubicin on chemosensitivity was also explored.

RESULTS

Higher expression of HA, HAS2, and CD44 was observed in Indian UBC patients which also showed the trend with severity of disease. Splice variant assessment of CD44 demonstrated the distinct role of CD44v3 and CD44v6 in bladder cancer progression. shRNA-mediated downregulation of CD44v3 showed an increase effect on cell cycle, apoptosis and multiple downstream signaling cascade including pAkt, pERK and pSTAT3. Furthermore, 4-MU, an HA synthesis inhibitor, observed to complement the effect of Cisplatin or Doxorubicin by enhancing the chemosensitivity of bladder cancer cells.

CONCLUSIONS

Our findings exhibit involvement of CD44 splice variants and HA family members in UBC and significance of 4-MU in enhancing chemosensitivity suggesting their novel therapeutic importance in disease therapeutics.

Do pediatricians routinely perform genitourinary examinations during well-child visits? A review from a large tertiary pediatric hospital

BACKGROUND

The male genital examination is a common source of discomfort for the patient and medical provider. Performance of male genital examination is imperative; however, as many treatable diagnoses can be made. Undescended testicles (UDTs), hernias, testicular tumors, and urethral abnormalities are all potentially concerning findings which can be discovered on routine examination.

OBJECTIVE

The objectives of this study are to determine the rate at which general pediatricians perform routine genitourinary (GU) examinations in the pediatric population and to determine the rate at which UDT are diagnosed or documented in the patient's history. The authors hypothesize the rate of pediatric GU examination during routine well-child visits to be in line with the previously reported rates in the adult literature.

STUDY DESIGN

Nine hundred ninety-six consecutive male well-child visits conducted by general pediatricians at the study institution were reviewed. These visits were evaluated for documentation of a detailed GU examination as well as the presence of UDT from these examinations. In addition, past medical and surgical histories were reviewed to determine if a diagnosis of UDT was noted.

RESULTS

Pediatricians at the study institution documented GU examinations 99.1% of the time during male well-child visits. Only 1.1% of the cohort had a documentation of UDT at any time point. Of the 11 patients with UDT, 6 boys (54.5%) had spontaneous descent with no referral to urology, whereas 5 (45.5%) required orchidopexy.

DISCUSSION

Prior reports suggest 70-75% of routine office visits include a genital examination. None of these reports reviewed the pediatric population, thus making this review novel in this respect. In addition, the results are vastly different from these prior studies as the authors demonstrated over 99% of male well-child examinations included documentation of a thorough genital examination. A limitation of the study is its retrospective nature, which creates a lack of standardization across the data set. In addition, without being physically present in the examination room, one cannot discern whether an examination is simply being documented without actual performance because of the template format of the electronic medical record (EMR). Furthermore, the study was not designed to best evaluate the true rate of UDTs; therefore, the reported rate of 1.1% cannot be accurately associated with a particular age at diagnosis.

CONCLUSIONS

Pediatricians do, in fact, document GU examinations on a routine basis. This finding cannot be taken with complete certainty as verification of actual examination performance is impractical. While the data demonstrated a lower than expected rate of UDT, depending upon age at diagnosis, this could indicate that although examinations are being documented, their accuracy may be diminished because of various factors at play in the healthcare system as a whole, including improper exam performance and EMR templates. Follow-up studies are required to verify these potentially changing rates of UDT and to determine if there is discordance between documentation and performance of GU examinations.

Health related quality of life analysis among testicular germ cell tumor survivors treated in a tertiary cancer hospital in India

e16057

Background: Testicular Germ Cell Tumor (TGCT) is a highly curable malignancy treated with surgery, radiotherapy and chemotherapy. The available literature has conflicting results on quality of life (QoL) of survivors determined using various tools. There is no Indian data on QoL among TGCT patients. Methods: The study was a prospective case-control study. EORTC QLQ-C30 questionnaire were administered to survivors (last treatment completed at least 2 years back) and healthy age matched controls attending the uro-malignancy clinic of AIIMS between 1st January 2017 to 31st December 2018. The functional, symptom and global QoL scales were scored as per EORTC manual and were compared with each other using student t-test and Mann-Whitney test. The data was analysed with stata v.13.0. Results: The mean scores of all domains of functional scales and global QoL of 114 TGCT survivors were significantly worse than 100 controls except role functioning and cognitive functioning (Table). The symptom scores of cases were significantly worse for each domain except insomnia and constipation (Table). There was no difference in QoL parameters between Seminoma or Non-Seminoma or different stages of GCT. Conclusions: The QoL among TGCT survivors was significantly inferior indicating the long term physical, emotional, social, sexual and financial effects of disease and its treatment on survivors. More robust tools and studies are needed to better define QoL among survivors. ± SD of Functional, symptom and Global QoL Scales) [Table: see text]

BK polyomavirus and urothelial carcinoma: Experience at a tertiary care centre in India with review of literature

INTRODUCTION

BK polyomavirus is ubiquitous and remains dormant in the urothelial tract, reactivating and replicating in the immunocompromised state especially in the setting of post-renal transplantation where it is believed to be directly oncogenic based on recent reports. Its oncogenic role in the immunocompetent host is controversial. This study aimed to investigate the association of BK polyomavirus in Urothelial Carcinoma.

MATERIAL AND METHODS

Patients with suspected urothelial carcinoma (UC) admitted under Department of Urology over a period of one year were recruited and transuretheral bladder tumor (TURBT) resection was performed, along with sampling of cystoscopically normal-appearing urothelium away from the tumor. In addition, cystectomy specimens with UC were included, with sampling of grossly normal-appearing urothelium away from the tumor. Immunohistochemistry (IHC) for SV40 T-Antigen and chromogenic in situ hybridization (CISH) using BK polyomavirus specific probe was performed on the paired samples (tumor and normal).

RESULTS

Twenty-three TURBT and 14 cystectomy specimens were assessed. None of the cases showed evidence of BK polyomavirus infection in tumor or in surrounding mucosa by IHC. CISH performed in ten cases were also found to be negative. In comparison, one post-renal transplant urothelial carcinoma in our experience showed diffuse SV40 staining.

CONCLUSIONS

This study suggests that BK polyomavirus infection is not associated with urothelial malignancy in the immunocompetent setting unlike in the immunocompromised setting where it should always be investigated for.

A comparative study of the effects of medical versus surgical androgen deprivation therapy on health-related quality of life in patients with metastatic carcinoma prostate

INTRODUCTION

Androgen deprivation therapy (ADT) is known to adversely affect the quality of life (QoL). One may choose between surgical and medical forms depending on his economic status, education status, and taboos. The aim of this study was to assess the impact of medical versus surgical ADT on health-related quality of life (HRQoL) in patients with metastatic cancer prostate in Indian population.

MATERIALS AND METHODS

From July 2012 to December 2014, 50 patients (10 medical castration and 40 surgical castration) of hormone-naïve metastatic prostate cancer who were started on combined ADT were included in this study. Before starting therapy, baseline data and QoL score (short form [SF-36] scale) were noted and all patients were followed up at 3 months, 6 months, and 1 year. Baseline data and HRQoL at all time intervals between surgical and medical castration groups were compared.

RESULTS

All patients, except two, completed the 1-year follow-up period. Patients who opted for medical castration were more educated and belonged to higher socioeconomic status. For all the domains of SF-36 QoL questionnaire, a similar improvement in the score was noted at first 3-month follow-up which deteriorated in the next follow-up at 6 months and then further at 1 year. There was no difference in HRQoL after medical or surgical castration.

CONCLUSIONS

In patients with metastatic cancer, prostate initiation of ADT, irrespective of method, causes an initial improvement in HRQoL followed later by a more gradual decline below the baseline.