H συννοσηρότητα ως προγνωστικό εργαλείο για την εκδήλωση μετεγχειρητικών επιπλοκών μετά από νεφρεκτομή

Σκοπός Η συννοσηρότητα μαζί με τα χαρακτηριστικά του όγκου και του ασθενούς, λαμβάνονται υπόψη όταν αποφασίζεται η χειρουργική θεραπεία του νεφροκυτταρικού καρκίνου. Η συννοσηρότητα έχει χρησιμοποιηθεί σαν ανεξάρτητος προβλεπτικός παράγοντας για την εκδήλωση μετεγχειρητικής επιπλοκής σε πολλές μείζονες ουρολογικές επεμβάσεις συμπεριλαμβανομένης και της ριζικής νεφρεκτομής για νεφροκυτταρικό καρκίνο. Σκοπός της παρούσης μελέτης είναι η αντικειμενική διερεύνηση της συσχέτισης μεταξύ συννοσηρότητας και μετεγχειρητικών επιπλοκών μετά από ριζική νεφρεκτομή για νεφροκυτταρικό καρκίνο, χρησιμοποιώντας τυποποιημένα συστήματα για να βαθμονομήσουμε τόσο τη συννοσηρότητα όσο και τη βαρύτητα των μετεγχειρητικών επιπλοκών. Υλικό & Μέθοδος Προοπτική μελέτη που συμπεριέλαβε όλους τους ασθενείς (182) που υποβλήθηκαν σε προγραμματισμένη ριζική νεφρεκτομή, για όγκους νεφρού στο διάστημα 1/1/2010 – 3/9/2013. Η εκτίμηση της συνοδού νοσηρότητας έγινε υπολογίζοντας τον δείκτη Charlson Comorbibidity Index (CCI) και τον Age Adjusted Charlson Comorbidity Index (AA-CCS). Οι μετεγχειρητικές επιπλοκές καταγράφηκαν για διάστημα 40 ημερών και βαθμονομήθηκαν με το σύστημα Clavien Dindo. Aποτελέσματα Στη μελέτη συμπεριλήφθηκαν 171 ασθενείς (11 ασθενείς είχαν ελλιπή στοιχεία και δεν μελετήθηκαν) 35-88 ετών (μ.ο. 63,6±11.7 έτη) Ο CCI ήταν 0 για 87 ασθενείς, 1 για 38 ασθενείς, 2 για 21 ασθενείς , 3 για 8 ασθενείς, 4 για 4 ασθενείς, 5 για 1 ασθενή, 6 για 8 ασθενείς, 7 για 2 ασθενείς και 8 για 2 ασθενείς. Ο AA-CCI ήταν 0 για 19 ασθενείς, 1 για 26 ασθενείς, 2 για 31 ασθενείς , 3 για 40 ασθενείς, 4 για 18 ασθενείς, 5 για 15 ασθενείς, 6 για 3 ασθενείς, 7 για 8 ασθενείς, 8 για 8 ασθενείς, 9 για έναν ασθενή και 10 για 2 ασθενείς. 98 ασθενείς (57,3%) δεν είχαν καμία επιπλοκή, Από τους 73 ασθενείς που εμφάνισαν επιπλοκές, τo grade κατά Clavien Dindo ήταν: 1 για 35 ασθενείς, 2 για 24 ασθενείς, 3 για 4 ασθενείς, 4 για 6 ασθενείς και 5 για 4 ασθενείς Η ανάλυση έδειξε στατιστική σημαντικότητα στο συσχετισμό του CCI και του AA-CCI με το Clavien (p=0,038 και p=0,014 αντίστοιχα) και θετική προγνωστική ικανότητα για τους ασθενείς που πρόκειται να υποστούν σοβαρή επιπλοκή (Clavien >2) (ROC curve area 0,794 και 0,753 αντίστοιχα) p<0,05. Συμπεράσματα H παρούσα προοπτική μελέτη έδειξε ότι σημαντικά περισσότερες σοβαρές επιπλοκές συμβαίνουν σε ασθενείς με βαριά συννοσηρότητα.Οι δείκτες CCI και ΑΑ-CCI υπολογίζονται εύκολα και πρέπει να ενσωματωθούν στην προεγχειρητική συμβουλή, ειδικά σε ηλικιωμένους ασθενείς με σημαντική συννοσηρότητα και ευνοϊκά ογκολογικά χαρακτηριστικά, στους οποίους μπορούν να εφαρμοστούν λιγότερο επεμβατικές παρεμβάσεις ή ακόμα και ενεργητική παρακολούθηση.Introduction and Objectives Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, by using standardized systems to grade both comorbidity and severity of postoperative complications. Material and Methods All patients that underwent scheduled radical Nephrectomy during the period 1/1/2010 – 30/9/2013 were included in our prospective study. Comorbidity was evaluated by the Charlson Comorbibidity Index (CCI) and Age Adjusted Charlson Comorbidity Index (AA-CCS). Postoperative complications were monitored for 40 postoperative days and graded according to the Clavien-Dindo system. Results 171 patients were included in our study (11 patients excluded due to insufficient data) aged 35-88 years (mean. 6.,6±11.7 years). CCI was 0 for 87 patients, 1 for 38 patients, 2 for 21 patients, 3 for 8 patients, 4 for 4 patients, 5 for one patient, 6 for 8 patients, 7 for 2 patients and 8 for 2 patients. Ο AA-CCI was 0 for 19 patients, 1 for 26 patients, 2 for 31 patients, 3 for 40 patients, 4 for 18 patients, 5 for 15 patients, 6 for 3 patients, 7 for 8 patients, 8 for 8 patients, 9 for one patient και 10 for 2 patients. 98 patients (57.3%) suffered no complications. Of the 73 patients that suffered a complication, the grade according to Clavien Dindo was: 1 for 35 patients, 2 for 24 patients, 3 for 4 patients, 4 for 6 patients και 5 for 4 patients Data analysis reveal statistical significant correlation of CCI and AA-CCI with Clavien (p=0.038 and p=0.014 respectively) and positive prognostic ability for patients in danger of suffering a serious (Clavien >2) (ROC curve area 0.794 και 0.753 respectively) p<0.05. Conclusions The present prospective study showed that significantly more major complications occur in patients with major comorbidities. CCI and AA-CCI are easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied

Metastasis to Sartorius Muscle from a Muscle Invasive Bladder Cancer

Bladder cancer constitutes the ninth most common cancer worldwide and approximately only 30% of cases are muscle invasive at initial diagnosis. Regional lymph nodes, bones, lung, and liver are the most common metastases from bladder cancer and generally from genitourinary malignancies. Muscles constitute a rare site of metastases from distant primary lesions even though they represent 50% of total body mass and receive a large blood flow. Skeletal muscles from urothelial carcinoma are very rare and up to date only few cases have been reported in the literature. We present a rare case of 51-year-old patient with metastases to sartorius muscle 8 months after the radical cystectomy performed for a muscle invasive bladder cancer

Comorbiditiy as a prognostic tool for the manifestation of postoperative complications after radical nephrectomy

Introduction and Objectives: Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, by using standardized systems to grade both comorbidity and severity of postoperative complications. Material and Methods: All patients that underwent scheduled radical Nephrectomy during the period 1/1/2010 – 30/9/2013 were included in our prospective study. Comorbidity was evaluated by the Charlson Comorbibidity Index (CCI) and Age Adjusted Charlson Comorbidity Index (AA-CCS). Postoperative complications were monitored for 40 postoperative days and graded according to the Clavien-Dindo system. Results: 171 patients were included in our study (11 patients excluded due to insufficient data) aged 35-88 years (mean. 6.,6±11.7 years). CCI was 0 for 87 patients, 1 for 38 patients, 2 for 21 patients, 3 for 8 patients, 4 for 4 patients, 5 for one patient, 6 for 8 patients, 7 for 2 patients and 8 for 2 patients.Ο AA-CCI was 0 for 19 patients, 1 for 26 patients, 2 for 31 patients, 3 for 40 patients, 4 for 18 patients, 5 for 15 patients, 6 for 3 patients, 7 for 8 patients, 8 for 8 patients, 9 for one patient και 10 for 2 patients.98 patients (57.3%) suffered no complications. Of the 73 patients that suffered a complication, the grade according to Clavien Dindo was: 1 for 35 patients, 2 for 24 patients, 3 for 4 patients, 4 for 6 patients και 5 for 4 patientsData analysis reveal statistical significant correlation of CCI and AA-CCI with Clavien (p=0.038 and p=0.014 respectively) and positive prognostic ability for patients in danger of suffering a serious (Clavien >2) (ROC curve area 0.794 και 0.753 respectively) p2) (ROC curve area 0,794 και 0,753 αντίστοιχα) p<0,05. Συμπεράσματα: H παρούσα προοπτική μελέτη έδειξε ότι σημαντικά περισσότερες σοβαρές επιπλοκές συμβαίνουν σε ασθενείς με βαριά συννοσηρότητα.Οι δείκτες CCI και ΑΑ-CCI υπολογίζονται εύκολα και πρέπει να ενσωματωθούν στην προεγχειρητική συμβουλή, ειδικά σε ηλικιωμένους ασθενείς με σημαντική συννοσηρότητα και ευνοϊκά ογκολογικά χαρακτηριστικά, στους οποίους μπορούν να εφαρμοστούν λιγότερο επεμβατικές παρεμβάσεις ή ακόμα και ενεργητική παρακολούθηση

Prediction of post radical nephrectomy complications based on patient comorbidity preoperatively

Objectives: Comorbidity along with tumor and patient characteristics is taken into account when deciding for the surgical treatment of renal cell carcinoma (RCC). Comorbidity has also been used as an independent predictive factor for postoperative complications of several major urological procedures including radical nephrectomy for RCC. The aim of the present study was to objectively evaluate the association between comorbidity and postoperative complications after radical nephrectomy for RCC, using standardized systems to grade both comorbidity and severity of postoperative complications. Materials and methods: Clinicopathological data of 171 patients undergoing open radical nephrectomy for lesions suspected of RCC were prospectively recorded for a period of 3 years. Comorbidity was scored using the Charlson Comorbidity Index (CCI) while postoperative complications were graded according to the Clavien-Dindo system. Results: Patients were predominantly males (59.1%); their age ranged from 35 to 88 years (mean +/- SD: 63.6 +/- 11.9 yrs) with 50.8% of them being &lt;= 65 yrs. CAI ranged from 0 to 8 with the majority (85.3%) scoring &lt;= 2. The procedure was uncomplicated in 57.3% cases; 10 patients suffered major (grade III/IV) complications and 4 patients died within the 40 days postoperative period. CCI correlated with the manifestation of any postoperative complication, Clavien( )&gt;= 1, OR (95% CI): 1.47 (1.09-1.96), p = 0.011 and the occurrence of severe complications, Clavien &gt; 2. OR (9.5% CI): 1.29 (1.01-1.63), p = 0.038. Conclusions: The present prospective study showed that considerable complications occur in patients with major comorbidities. CCI is easily calculated and should be incorporated in preoperative consultation especially in cases of elder patients with severe comorbidity and favorable tumor characteristics where less invasive interventions or even active surveillance could be applied

Correcting and sharing our complications. Misplacement of pigtail catheter, during a Robot Assisted Pyeloplasty. Clinical findings, diagnosis, possible causes and endoscopic treatment

Objective: Robotic assisted pyeloplasty (RAP) is rapidly adopted by surgeons around the world. We present a unique complication of the technique, consisting of pigtail misplacement, which was endoscopically resolved. We discuss the clinical findings, differential diagnosis and principles of endoscopic treatment. Materials and Methods: A 41 years old female patients underwent transperitoneal right side RAP with the Hynes-Anderson technique for ureteropelvic junction obstruction. Pigtail was placed intraoperatively in an antegrade fashion. Post operative course appeared normal but Kidney-Ureterer-Bladder(KUB) X-ray, revealed a misplaced pigtail. Patient underwent a semirigid ureterorenoscopy demonstrating that the pigtail was exiting the collecting system in the rear line of suturing between continuous sutures. Pigtail was retrieved with a stone retrieval forceps with short upward motions in the renal pelvis under fluoroscopy and then removed from patient, in order to avoid stressing the anastomosis. No leakage was noted in fluoroscopy, a pigtail was correctly placed and patient recovery was uneventful. Results: Retrograde pyelography was the key to accurate diagnosis and endoscopic treatment, because the exact point of exit and anastomosis integrity were established. Retrieval of the pigtail was the most challenging part. Lack of proper visualization and mobilization of the rear part of the anastomosis during surgery, combined with lack of tactile feedback, because of robotic instrumentation, were of critical importance in the manifestation of such a mishap. Endoscopy facilitated case resolve, but proper handling is required to protect the anastomosis. Conclusions: The introduction of novel techniques can carry the burden of novel complications. A surgeon must always keep in mind the complications inherent to the technique and at the same time the limitations of the equipment used, especially the lack of tactile feedback in robotic instrumentation

A two staged treatment procedure for the difficult to treat bladder neck contractures with concomitant incontinence. In the search of a solution to a complex problem

Objective: To examine the efficacy of a two staged treating strategy with the use of a non-permanent urethral ALLIUM® stent for the management of recurrent bladder neck stenosis and subsequently the use of an artificial sphincter AUS800® by AMS for the management of the incontinence. Materials and Methods: We progressively identified patients eligible for the study creating a population of cases with recurrent bladder neck stenosis and concomitant incontinence occurring after the last intervention for the stenosis. Efficacy for the treatment of the stenosis was defined as no recurrence both prior and post to the sphincter placement and efficacy for the treatment of the incontinence was defined as continence (0-1pads) after the sphincter placement. Results and Limitations: 14 white males with a mean age of 66.21, ranging from 59 to 73 years consisted the population of the study. All patients had severe stress incontinence following the last transurethral resection. The efficacy of the treatment of the bladder neck stenosis was 93% (13/14) while the efficacy for the treatment of the incontinence was 100%. A single patient had a recurrent bladder neck stenosis after the artificial sphincter placement and was treated with transurethral resection using a long pediatric 13 F resectoscope at 12 months. Our limitations is the absence of a control group and the small number of patients enrolled, with a relatively short time of follow up. Conclusions: In our series we propose the use of a non-permanent urethral ALLIUM® stent for 6 months in order to control the growth of fibrotic scar tissue, a further 6 months follow up for recurrence, and then placement of an artificial sphincter. The results are very promising both on stabilizing the vesicourethral stenosis, and on patient safety and tolerability

A Cough Deteriorating Gross Hematuria: A Clinical Sign of a Forthcoming Life-Threatening Rupture of an Intraparenchymal Aneurysm of Renal Artery (Wunderlich's Syndrome)

Macroscopic hematuria regards the 4% to 20% of all urological visits. Renal artery aneurysms (RAAs) are detected in approximately 0.01%–1% of the general population, while intraparenchymal renal artery aneurysms (IPRAAs) are even more rarely detected in less than 10% of patients with RAAs. We present a case of a 58-year-old woman that came into the emergency room (ER) complaining of a gross hematuria during the last four days. Although in the ER room the first urine sample was clear after a cough episode, a severe gross hematuria began which led to a hemodynamically unstable patient. Finally, a radical nephrectomy was performed, and an IPRAA was the final diagnosis. A cough deteriorating hematuria could be attributed to a ruptured intraparenchymal renal artery aneurysm, which even though constitutes a rare entity, it is a life-threatening medical emergency

Diagnosis of Low-Grade Urothelial Neoplasm in the Era of the Second Edition of the Paris System for Reporting Urinary Cytology

Background: The Paris System for Reporting Urinary Cytology (TPS) is considered the gold standard when it comes to diagnostic classifications of urine specimens. Its second edition brought some important changes, including the abolition of the diagnostic category of “low-grade urothelial neoplasm (LGUN)”, acknowledging the inability of cytology to reliably discern low-grade urothelial lesions. Methods: In this retrospective study, we assessed the validity of this change, studying the cytological diagnoses of histologically diagnosed low-grade urothelial carcinomas during a three-year period. Moreover, we correlated the sum of the urinary cytology diagnoses of this period with the histological diagnoses, whenever available. Results: Although all the cytological diagnoses of LGUN were concordant with the histological diagnoses, most low-grade urothelial carcinomas were misdiagnosed cytologically. Subsequently, the positive predictive value (PPV) of urinary cytology for the diagnosis of LGUN was 100%, while the sensitivity was only 21.7%. Following the cyto-histopathological correlation of the sum of the urinary cytology cases, the sensitivity of urinary cytology for the diagnosis of high-grade urothelial carcinoma (HGUC) was demonstrated to be 90.1%, the specificity 70.8%, the positive predictive value (PPV) 60.3%, the negative predictive value (NPV) 93.6% and the overall accuracy 77.2%, while for LGUN, the values were 21.7%, 97.2%, 87.5%, 58.6% and 61.9%, respectively. Risk of high-grade malignancy was 0% for the non-diagnostic (ND), 4.8% for the non-high-grade urothelial carcinoma (NHGUC), 33.3% for the atypical urothelial cells (AUCs), 65% for the suspicious for high-grade urothelial carcinoma (SHGUC), 100% for the HGUC and 12.5% for the LGUN diagnostic categories. Conclusions: This study validates the incorporation of the LGUN in the NHGUC diagnostic category in the second edition of TPS. Moreover, it proves the ability of urinary cytology to safely diagnose HGUC and stresses the pivotal role of its diagnosis