2018-1 — Summary
Surgical treatment of a huge scrotal elephantiasis
DOI: 10.22591/magyurol.2018.1.magyara.17
Authors:
Magyar András dr., Póth Sándor dr., Köves Béla dr., Tenke Péter dr.
Jahn Ferenc Dél-pesti Kórház és Rendelőintézet, Urológiai Osztály, Budapest (osztályvezető: Tenke Péter dr.)
Summary
Objective: While in subtropical areas elephantiasis of the scrotum, or scrotal lymphedema is a common disease, caused by endemic filariasis, in Hungary, this condition is rarely seen. In Europe the most common cause of scrotal elephantiasis is the occlusion of lymphatic vessels secondary to other medical disorders. We wish to demonstrate the proper diagnostic workup and the surgical management of a giant scrotal lymphedema.
Case report: Our patient is 66 years old, has not been abroad recently and has already undergone an abdominal reconstruction due to lymphedema before. Following laboratory testing and ultrasound examination, a biopsy of the scrotum was performed, which did not prove the presence of any malignancy or inflammation. After counselling with a plastic surgeon, the enormous scrotal mass was surgically removed, followed by plastic reconstructive surgery of the scrotum. The wound healed without any complication and the patient has reported a significant improvement in his quality of life.
Conclusion: The physician should find out if the patient has travelled to an area where filariasis is endemic. To exclude malignancy, biopsy of the scrotum might be necessary. The reconstruction of the scrotum requires plastic surgical expertise.
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Bladder augmentation: a treatment for neurogenic bladder dysfunction
DOI: 10.22591/magyurol.2018.1.kubika.12
Authors:
Kubik András dr., Keszthelyi Attila dr., Nyirády Péter dr., Majoros Attila dr.
Semmelweis Egyetem, Urológiai Klinika és Uroonkológiai Centrum, Budapest (igazgató: Nyirády Péter dr.)
Summary
Objective: Treatment of neurogenic bladder dysfunction is staggered, based on intermittent self-catheterization (CIC) in many cases. Unfortunately, over time either primarily or during progression in such cases urinary bladder becomes high pressured, reduced capacitated and expanded. If other minimal invasive treatments (such as clean intermittent catheterisation, anticholinergics, botulinum toxin, sphincterotomy) fail to reduce urinary bladder pressure and increase its capacity, compliance, then augmentation of bladder with excluded ileum section may result a good solution in high pressure reflux, renal impairment and recurrent urinary tract infections causing permanent disease.
Patients and methods: At our clinic, a 23-year-old and a 28-year-old female patient had open bladder augmentation due to neurogenic bladder dysfunction. In both cases, congenital spinal cord disorders (congenital sacrum agenesia or meningomyelocele) formed the basis for neurogenic bladder dysfunction. Conservative (anticholinergicum + CIC) and minimal invasive (botox intradetrusor injection) therapy was ineffective; bladder augmentations with excluded ileum sections were performed in both patients.
Results: Following the operation, the patients’ continence was improved, the numbers of urinary tract infections were decreased and their urinary bladder was still emptied by intermittent catheterization. The control urodynamic study demonstrated a significant increase in bladder capacity and compliance.
Conclusion: The first-line therapy, in many cases the base therapy for neurogenic bladder dysfunction is intermittent self-catheterization. If the conservative treatment does not manage to maintain low pressure, good compliance and capacity of the bladder, then augmentation of the urinary bladder is recommended with bowel application.
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Development of a laparoscopic partial nephrectomy training model
DOI: 10.22591/magyurol.2018.1.sarlosd.8
Authors:
Sarlós Donát Péter dr., Czétány Péter med.
PTE KK, Urológiai Klinika, Pécs (igazgató: Szántó Árpád dr.
Summary
Objective: Urologists seek opportunities for the development of surgical skills. Our objective was the development of a laparoscopic partial nephrectomy (PN) training model.
Methods: The base of the PN model is polyurethane foam, in which a silicone artificial tumour is implanted. Latex Foley catheter and examination glove fingers are used to simulate vessels and collecting system. Sixteen medical students, who were novice in laparoscopy tested the model, performing a total of 160 PNs. CAE LapVR laparoscopic virtual-reality surgical simulator was used to test laparoscopic dexterity before and after the training.
Results: The model’s mechanic properties show good similarity with the normal human kidney. The steps of the PN operation can be trained, bleeding and urine leakage can be simulated. The price of the materials for one model is under 1 Euro and can be self-produced in less than 10 minutes. During the testing candidates showed a significant progression in resection time (746±338 s vs. 244±123 s, p<0.01), number of stitches placed (1 [0–2] vs. 4.5 [2–5.5], p<0.05) and post-operative bleeding (19.1±2.6 ml vs. 15.7±4.9 ml, p<0.05). Laparoscopic peg transfer, cutting and stitching dexterity has improved, along with significant reduction of unnecessary movements.
Conclusions: We created a widely available and low cost model for PN training that has been proven to better laparoscopic surgical skills. We hope it will help advance skill training in urology and flatten PN learning curves.
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The role of neoadjuvant and adjuvant chemotherapy in urothelial cancer pati-ents suitable for cystectomy
DOI: 10.22591/magyurol.2018.1.maraza.2
Authors:
Maráz Anikó dr., Varga Linda dr.
Szegedi Tudományegyetem, Onkoterápiás Klinika, Szeged (igazgató: Kahán Zsuzsanna dr.)
Summary
Introduction: Based on randomized studies and meta-analyses, survival data of metastatic bladder cancer patients are more favorable if they receive neoadjuvant or adjuvant cisplatin-based chemotherapy before or after cystectomy. Data of neoadjuvant therapy are more favorable, although in Hungary, it has only been administered in the recent years. In comparison with the Western European countries, in Hungary, cystectomy requires significant experience and caution of the surgeon due to the advanced stages and the co-morbidities of the patients. In case of these patients, neoadjuvant therapies could only be performed if multidisciplinary tumor boards would make the decision before cystectomy, and if the procedures for the patients would be adequately defined. Our article summarizes the evidence of different studies, international guidelines, and the results of pre- and postoperative chemotherapy in case of muscle-invasive urothelial cancer patients who underwent radical cystectomy.
Patients, methods: Based on the ESMO and EAU guidelines, we interpret the different advantages of neoadjuvant chemotherapy, such as early decrease of tumor spreading, opportu-nity of tumor down-staging, improving the ratio of R0 resection, knowledge of chemosensitivity, and the well-known benefits of the adjuvant chemotherapy, such as appropriate pathological staging and earlier definitive operation. We analyzed the result of the most important phase III studies and meta-analyses of neo-adjuvant and adjuvant chemotherapy regarding the type of chemotherapy protocols, stage of the participants, and the effectivity.
Results: Based on the meta-analyses, in case of neoadjuvant cisplatin-based chemotherapy, the 5-year survival benefit is 5%. In a Norwegian phase III study, the benefit was 8%, in case of T3 patients, it was 11%, and according to the 8-year follow-up data, it was 16%. The outcome is even more favorable in case of patients who respond well to neoadjuvant chemotherapy (pCR 12–50% MVAC, 12–22% in case of GC protocol). More than 3 months delay of cystectomy does not significantly reduce the survival if chemotherapy is performed before the operation. Results of adjuvant phase III studies and meta-analyses are not so unambiguous as neoadjuvant data, but chemotherapy seems to influence favorably the survival, especially in case of pT3/4 and/or N+ (and high grade or margin positivity) cases. The outcome of adjuvant chemotherapy is more favorable than in case of deferred chemotherapy started after progression.
Conclusions: Based on the current knowledge, neoadjuvant cisplatin-based chemotherapy is recommended for patients with T2b-T4a tumors before radical cystectomy. If the patients cannot receive cisplatin, neoadjuvant chemotherapy does not have any advantage. In case of T2aN0 stage, the potential presence of micrometastases is lower due to the smaller tumor mass; thus, neoadjuvant chemotherapy can be administered individually in this stage. Adjuvant chemotherapy is recommended in case of all patients with pT3/4 and/or N+ tumor or positive resection margin who did not receive neoadjuvant chemotherapy.