Israel Medical Association Journal

Objectives: To define preoperative predictors for MPC in prostatectomy specimens and to examine the accuracy of such prediction.

Methods: Data collected on 1526 consecutive radical prostatectomy patients operated in a single center between 2003 and 2008 included: age, body mass index, preoperative prostate-specific antigen level, biopsy Gleason score, clinical stage, percentage of positive biopsy cores, and maximal core length (MCL) involvement. MPC was defined as < 5% of prostate volume involvement with organ-confined Gleason score ≤ 6. Univariate and multivariate logistic regression analyses were used to define independent predictors of minimal disease. Classification and Regression Tree (CART) analysis was used to define cutoff values for the predictors and measure the accuracy of prediction.

Results: MPC was found in 241 patients (15.8%). Clinical stage, biopsy Gleason`s score, percent of positive biopsy cores, and maximal involved core length were associated with minimal disease (OR 0.42, 0.1, 0.92, and 0.9, respectively). Independent predictors of MPC included: biopsy Gleason score, percent of positive cores and MCL (OR 0.21, 095 and 0.95, respectively). CART showed that when the MCL exceeded 11.5%, the likelihood of MPC was 3.8%. ;Conversely, when applying the most favorable preoperative conditions (Gleason ≤ 6, < 20% positive cores, MCL ≤ 11.5%) the chance of minimal disease was 41%.

Conclusions: Biopsy Gleason score, the percent of positive cores and MCL are independently associated with MPC. While preoperative prediction of significant prostate cancer was accurate, clinical prediction of MPC was incorrect 59% of the time. Caution is necessary when implementing clinical data as selection criteria for active surveillance. 

Background: One of the major concerns in performing nephron-sparing surgery (NSS) for renal cell carcinoma (RCC) is the risk of tumor recurrence.

Objectives: To assess the rate, predictors and mechanisms of oncological failure in patients after NSS[1] for renal cancer.

Methods: Between 1993 and 2008 NSS was performed in 229 patients via flank incision. Only patients without metastases at diagnosis and minimal 12 months follow-up were included in the outcome analysis.

Results: During a mean follow-up of 45 ± 34 months (range 6–168 months) tumor recurrence was observed in 13 patients (5.6%). Mean follow-up time for detection of oncological failure was 51 months (range 6–132 months).  All patients with oncological failure were males, with a mean age of 61 years (median 58, range 51–74 years). The average size of the enucleated lesion was 5 cm (range 4–7 cm). Intraoperative frozen sections as well as postoperative final pathological examination of the surgical margins were negative in all recurrent cases. Mechanisms of recurrence were distant metastases (n=4), surgical scar implantation (n=2), perirenal fat recurrence (n=2), local renal recurrence at the surgical site (n=1), and new renal lesions (n=4). Predictors of oncological failure included warm ischemia time (P = 0.058), tumor size (P = 0.001), tumor location (central versus peripheral) (P = 0.015), and multifocality (P = 0.001).

Conclusions: Distant dissemination, seeding during surgery, residual disease and new growth are the mechanisms responsible for cancer relapse. Large central lesions, long warm ischemia time and multifocality were significant predictors of oncological failure.

Background: Renal artery stenosis is one of the most frequent causes of secondary hypertension. Appropriate methods for screening, diagnosis and therapy are currently under debate.

Objectives: To evaluate and recommend methods for screening and diagnosing renal artery stenosis, and to assess the clinical outcomes of renal artery stenting.

Methods: A total of 450 patients undergoing non-emergent coronary angiography fulfilled the selection criteria for selective renal arteriography; those with severe (luminal narrowing ≥ 70%) renal artery stenosis underwent percutaneous transluminal renal angioplasty with renal artery stenting.

Results: Of 166 patients (36.9%) with renal artery stenosis, 41 (9.1%) had severe stenosis that required renal artery stenting, and 83% had ostial renal stenosis. The primary success rate was 100% and there were no complications. During the follow-up period, two patients required a second PTRA[1]. After stent deployment, significant reductions were observed in systolic and diastolic pressures (P < 0.001 and P = 0.01, respectively) and in the number of antihypertensive drugs used by the patients (P < 0.001). These reductions were sustained during follow-up. Hypertension was cured (systolic blood pressure < 130 mmHg) in 9 (21.4%) and improved in 27 (64.3%) patients. Plasma creatinine did not change significantly.

Conclusions: Selective renal angiography is an effective diagnostic tool for identifying symptomatic cases of renal artery stenosis in patients undergoing coronary angiography. Our finding of a high success rate and low complication rate supports the use of primary renal artery stenting in symptomatic patients with renal artery stenosis.

Background: Tubeless percutaneous nephrolithotomy is defined as PCNL[1] without postoperative nephrostomy tubes. It is reported to reduce postoperative pain, hospital stay and recovery time. To date the procedure has been reserved for selected patients.

Objectives: To assess our initial experience in extending the implementation of tubeless PCNL without preoperative patient selection.

Methods: All consecutive PCNLs performed during 2004–2008 were evaluated. Tubeless PCNL was performed when residual stones, bleeding and extravasation were excluded intraoperatively. Staghorn stones, stone burden, supracostal and multiple accesses, anatomic anomalies, solitary kidneys and operative time were not considered contraindications. We analyzed the clinical data and the choice of tubeless PCNL over time.

Results: Of 281 PCNLs performed during the study period, 200 (71%) were tubeless. The patients' average age was 53 years (range 28–82 years), the stone burden was 924 mm² (400–3150 mm²), operative time was 99 minutes (45–210 min), complication rate was 14% and immediate stone-free rate 91%. There were 81 conversions to standard PCNL (29%) due to expected second-look (n=47, 58%), impression of bleeding (n=21, 26%), suspected hydrothorax (n=7, 9%) and extravasation (n=6, 7%). The transfusion rate was 1%. The median hospital stay was 1 day (1–15 days) and recovery time 7 days (5–20 days). The rate of implementing the tubeless procedure increased steadily along time from 46% to 83% (P = 0.0001). 

Conclusions: Tubeless PCNL can be safely and effectively performed based on intraoperative decisions, without preoperative contraindications. They are easily accommodated by experienced endourologists and provide real advantages.

Background: Stem cell-based therapy is a promising approach for the treatment of neurodegenerative disease. In our laboratory, a novel protocol has been developed to induce bone marrow-derived mesenchymal stem cells into neurotrophic factor-secreting cells. These cells produce and secrete factors such as BDNF (brain-derived neurotrophic factor) and GDNF (glial-derived neurotrophic factor).

Objectives: To evaluate the migratory capacity and efficacy of NTF-SC[1] in animal models of Parkinson's disease and Huntington's disease.

Methods: MSCs[2] underwent two-phase medium-based induction. An efficacy study was conducted on the 6-hydroxydopamine-induced lesion, a rat model for Parkinson's disease. Cells were transplanted on the day of 6-OHDA[3] administration, and amphetamine-induced rotations were measured as a primary behavioral index. In a second experiment, migratory behavior was examined by transplanting cells a distance from a quinolinic acid-induced striatal lesion, a rat model for Huntington's disease. Migration, in vivo, was monitored using longitudinal magnetic resonance imaging scans followed by histology.

Results: NTF-SCs attenuated amphetamine-induced rotations by 45%. HPLC analysis demonstrated a marked decrease in dopamine depletion, post-cellular treatment. Moreover, histological assessments revealed that the engrafted cells migrated and acted to regenerate the damaged striatal dopaminergic nerve terminal network. In a preliminary work on an animal model for Huntington's disease, we demonstrated by high resolution MR images and correlating histology that induced cells migrated along the internal capsule towards the QA[4]-induced lesion.

Conclusions: The induced MSCs are a potential therapy for neurodegenerative diseases, due both to their NTF secretion and their ability to migrate towards the diseased tissue.