Patient selection, follow-up strategy, and indication for delayed intervention for active surveillance remain centered around PSA, digital rectal exam, and biopsy findings. Novel tools which include imaging, biomarkers, and genetic assays have been investigated as potential prognostic adjuncts; however, their role in active surveillance remains institutionally dependent. Although 30-50% of patients on active surveillance ultimately undergo delayed treatment, the vast majority will remain free of metastasis with a low risk of dying from prostate cancer. The optimal method for patient selection into active surveillance is unknown; however, cancer-specific mortality rates remain excellent. New prognostication tools are promising, and long-term prospective, randomized data regarding their use in active surveillance will be beneficial.
Polyembolokoilamania is the insertion of foreign objects into body orifices for sexual gratification. While the retrieval of these objects from the urethra and bladder is a well-known task among urologists, we present a rare case of an usual and serious injury from this practice: complete avulsion of the urethra at the penoscrotal junction. A single-stage urethroplasty was used to reconstruct the urethra with good result. The patient motivation, as well as concomitant medical or psychological conditions, should be explored in order to prevent further occurences.
A 68-year-old woman presented with a 3month history of persistent, gradually worsening dry cough, which, on occasion, woke her from sleep. She had no history of hemoptysis, recent respiratory tract infection, postnasal drip, asthma, seasonal allergies, travel or constitutional symptoms. She had quit smoking 10 years earlier. Her medical history included gastroesophageal reflux disease and benign adenomas of the colon. Her current medications included rabeprazole, atorvastatin and trazodone. The results of extensive investigations, including chest radiography, spirometry, flexible nasoendoscopy and a battery of blood tests, were negative, except for microcytic anemia, which we attributed to iron deficiency (hemoglobin 107 [normal 123-157] g/L).Six months following the initial presentation, our patient returned with worsening cough and complaints of drenching night sweats and unexplained weight loss of 5 lbs. A contrastenhanced computed tomography (CT) scan of the thorax showed prominent varicosities on the right side of the retroperitoneum. A subsequent CT of her abdomen and pelvis showed a hypervascular mass in the upper pole of the right kidney ( Figure 1), with no evidence of retroperitoneal lymphadenopathy.Our patient underwent open right radical nephrectomy for renal cell carcinoma (Führman grade 3, clear cell, with negative margins); there was no evidence of hepatic invasion. Following the surgery, the patient's cough completely resolved and did not recur during the next 2 years of follow-up.This patient's case represents a rare cause of chronic cough and an unusual presentation of renal cell carcinoma. Renal cell carcinomas secrete prostaglandins (mainly prosta glan din E 2 ), which have been implicated in enhancing the cough reflex via the EP 3 receptor pathway. 1,2 In our patient's case, a mass effect by the tumour on the posterior diaphragm may have also contributed to irritation and reflex cough. 3 References 1. Ishiura Y, Fujimura M, Nobata K, et al. Prostaglandin I 2 enhances cough reflex sensitivity to capsaicin in the asthmatic airway.Figure 1: Computed tomograph showing a large hypervascular right renal mass associated with the upper pole (arrow) in a 68-year-old woman with cough. There are multiple tumour lobulations that indent the hepatic capsule.Clinical images are chosen because they are particularly intriguing, classic or dramatic. Submissions of clear, appropriately labelled high-resolution images must be accompanied by a figure caption and the patient's written consent for publication. A brief explanation (250 words maximum) of the educational significance of the images with minimal references is required.
Introduction: Partial nephrectomy remains the gold standard in the management of small renal masses. However, minimally invasive partial nephrectomy (MIPN) is associated with a steep learning curve, and optimal, standardized techniques for time-efficient hemostasis are poorly described. Given the relative lack of evidence, the goal was to describe a set of actionable guiding principles, through an expert working panel, for urologists to approach hemostasis without compromising warm ischemia or oncological outcomes. Methods: A three-step modified Delphi method was used to achieve expert agreement on the best practices for hemostasis in MIPN. Panelists were recruited from the Canadian Update on Surgical Procedures (CUSP) Urology Group, which represent all provinces, academic and community practices, and fellowship- and non-fellowship-trained surgeons. Thirty-two (round 1) and 46 (round 2) panellists participated in survey questionnaires, and 22 attended the in-person consensus meeting. Results: An initial literature search of 945 articles (230 abstracts) underwent screening and yielded 24 preliminary techniques. Through sequential survey assessment and in-person discussion, a total of 11 strategies were approved. These are temporally distributed prior to tumor resection (five principles), during tumor resection (two principles), and during renorrhaphy (four principles). Conclusions: Given the variability in tumor size, depth, location, and vascularity, coupled with limitations of laparoscopic equipment, achieving consistent hemostasis in MIPN may be challenging. Despite over two decades of MIPN experience, limited evidence exists to guide clinicians. Through a three-step Delphi method and rigorous iterative review with a panel of experts, we ascertained a guiding checklist of principles for newly beginning and practicing urologists to reference.
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