- Email: [email protected]
SINGLE CENTER COMPARISON OF MULTIDETECTOR CT AND ADRENAL VEIN SAMPLING FOR DETECTING THE LATERALIZATION OF PATIENTS WITH PRIMARY HYPERALDOSTERONISM
18
THE JOURNAL OF UROLOGY®
METHODS: Since September 1993, 124 patients underwent laparoscopic adrenal surgery via a lateral transperitoneal approach. Surgical indications included: primary hyperaldosteronism (n=52), Cushing’s syndrome (n=29), pheochromocytoma (n=26), non-functioning adenoma (n=16), myelolipoma (n=1). We retrospectively reviewed our experience with adrenal-sparing surgery and post-operative outcomes. RESULTS: Laparoscopic total adrenalectomy was performed unilaterally in 111 cases and bilaterally in 9 cases. Laparoscopic partial adrenalectomy was employed in 4 cases (3.3%) for primary hyperaldosteronism. Patients underwent partial adrenalectomy for aldosterone-producing adenomas 1.5 cm and 3.1 cm (right) and 2.5 cm and 5.0 cm (left) using ultrasonic shears, a bipolar vessel-sealing device, or a vascular linear stapling device. The mean age was 64 years (range 61 - 83), operative time was 152 min, estimated blood loss was 76 mL, and length of hospital stay was 1.2 days. All four SDWLHQWV H[SHULHQFHG LPPHGLDWH QRUPDOL]DWLRQ LQ VHUXP DOGRVWHURQH and potassium levels following the procedure. At a mean follow-up of PRQWKVHDFKSDWLHQWKDVUHPDLQHGDV\PSWRPDWLFZLWKVWDELOL]DWLRQ of blood pressure and greater than 75% reduction in anti-hypertensive medication requirement. CONCLUSIONS: Laparoscopic adrenal-sparing surgery offers the potential advantages of treating benign functioning adrenal tumors while sparing certain patients from the potential need for lifelong hormonal supplementation. Laparoscopic partial adrenalectomy is a safe and feasible technique for treating exophytic adrenal lesions. The potential sequelae of this procedure are incomplete lesion excision, and recurrence of disease within the adrenal remnant. While total adrenalectomy remains as the standard, partial adrenalectomy via a minimally invasive approach appears to be a suitable option for select patients with solitary functioning adrenal glands and those at risk for recurrent tumors. Source of Funding: None
Vol. 179, No. 4, Supplement, Saturday, May 17, 2008
50 CYSTIC PHEOCHROMOCYTOMA IS A DISTINCTIVE SUBGROUP WITH SPECIAL CLINICAL, IMAGING AND HISTOLOGICAL FEATURES THAT MAY MISLEAD DIAGNOSIS Cassio Andreoni*, Rodrigo Krebs, Claudio E Kater, Valdmar Ortiz. Sao Paulo, Brazil. INTRODUCTION AND OBJECTIVE: Adrenal cystic masses are usually associated with non-functional lesions, however, it may be a pheochromocytoma, which has been reported on anecdotal series or DVLVRODWHGFDVHUHSRUWV VXFKFDVHVRSHUDWHGDWRXULQVWLWXWLRQDQGWKH SUHYLRXVO\SXEOLVKHGGDWDDUHKHUHLQUHSRUWHGDQGDQDO\]HG METHODS: The prospective adrenalectomy database at our LQVWLWXWLRQ ZDV UHYLHZHG IRU ¿QGLQJ SDWLHQWV ZLWK SKHRFKURPRF\WRPD and cystic lesions. The clinical, radiological and histological features of the cystic pheochromocytoma were particularly evaluated. A search for other previously published data was conducted and compared with the current series. RESULTS: A total of 107 adrenalectomies were performed at our institution from November 2000 to March 2007. Thirty-one out of 107 DGUHQDOHFWRPLHVKDGDFRQ¿UPHGGLDJQRVLVRISKHRFKURPRF\WRPDDQG 6 of them (19 %) were cystic pheochromocytomas. Three out of the 6 FDVHVZHUHDV\PSWRPDWLFDQGKDGQHJDWLYHELRFKHPLFDOZRUNXS WKHUH ZHUHPDOHDQGIHPDOHV DYHUDJHWXPRUVL]HZDVFP WKHLPDJLQJ diagnosis was mainly done based upon CT and MRI and the foremost feature was the enhancement of the tumor rim associated with a central cystic mass. Nine other previously published cases were reviewed CONCLUSIONS: It can be drawn from the current largest series and from adding previous anecdotal reported cases, that patients with cystic pheochromocytomas are more likely to be asymptomatic, to complain of chronic abdominal pain, and to have negative biochemical work up, which may refrain physicians from performing a full work up IRUSKHRFKURPRF\WRPDDQGPLVOHDGWKH¿QDOGLDJQRVLVDVVXFKWKLV subgroup of patients could have even higher prevalence that is yet to be determined Source of Funding: None
49 ROBOTIC ADRENALECTOMY FOR ADRENAL TUMORS: PROSPECTIVE ASSESSMENT OF PERIOPERATIVE OUTCOMES Sanjeev Kaul*, Ronald S Boris, Louis S Krane, Vinod Narra, Mani Menon. Detroit, MI. INTRODUCTION AND OBJECTIVE: Laparoscopic adrenalectomy is accepted as the gold standard for surgical treatment of adrenal masses. Recently reports of robotic adrenalectomy have appeared in literature, however there is no data regarding peri operative outcomes. We prospectively evaluated the peri operative outcomes following robotic adrenalectomy performed at our institution. METHODS: Eleven patients underwent robotic adrenalectomy for 12 adrenal masses (one bilateral). A prospective database was maintained including demographic data, operative time, blood loss, post operative pain (visual analogue scale), analgesic use and perioperative complications. We compared our outcomes to contemporary series of laparoscopic adrenalectomy. RESULTS: Seven males and 4 females of mean age 53 years underwent robotic adrenalectomy between January and August 2007. $IRXUSRUWWUDQVSHULWRQHDOWHFKQLTXHZDVXVHG0HDQWXPRUVL]HZDV 3.5 cm and mean console time 79 min. Average blood loss and hospital stay was 59 ml and 1.4 days respectively. Mean pain on POD1 was 4 on VAS and only 2 patients required opioids for pain control. There were no conversions to open surgery or intra operative complications. CONCLUSIONS: Robotic adrenalectomy provides perioperative outcomes (operative time, hospital stay, blood loss) superior to contemporary series of laparoscopic adrenaectomy. Post operative pain on POD 0 is not bothersome to patients and can be controlled with NSAID’s without need for opioid drugs. Source of Funding: None
51 SINGLE CENTER COMPARISON OF MULTIDETECTOR CT AND ADRENAL VEIN SAMPLING FOR DETECTING THE LATERALIZATION OF PATIENTS WITH PRIMARY HYPERALDOSTERONISM Shigeto Ishidoya*, Akihiro Ito, Seiichi Saito, Fumitoshi Satoh, Tadashi Ishibashi, Yoichi Arai. Sendai, Japan. INTRODUCTION AND OBJECTIVE: With the accumulation of the managements for patients with primary hyperaldosteronism, it appeared that some patients revealed aldosterone-hypersecreting after unilateral adrenalectomy based on a computed tomography (CT) determination. The aim of the study is to assess the discrepancy of multidetector row CT (MDCT) and adrenal vein sampling (AVS) in GHWHUPLQLQJ WKH UHVSRQVLEOH ODWHUDOL]DWLRQ EDVHG RQ D VLQJOH FHQWHU experience. METHODS: A total of 87 patients with primary K\SHUDOGRVWHURQLVPZHUHUHWURVSHFWLYHO\DQDO\]HG$OOSDWLHQWVUHFHLYHG a 16 channel MDCT and AVS. By MDCT, we examined adrenal regions in contiguous 1.0-mm-thick slice with contrast agent. Simultaneous bilateral AVS was performed with adrenocorticotropic hormone (ACTH) stimulation. Successful adrenal vein cannulation and sampling was achieved in all patients. RESULTS: According to the results of MDCT and AVS, 61 patients were diagnosed as having aldosterone-producing adenoma (APA) and underwent laparoscopic adrenalectomy, and 21 patients were diagnosed as idiopathic hyperaldosteronism (IHA). Five patients refused the operation and continued conservative therapy. Among 52 patients with unilateral adenoma, 48 revealed the results with concordant ORFDOL]DWLRQ KRZHYHU SDWLHQWV VKRZHG DOGRVWHURQHK\SHUVHFUHWLQJ from the contaralateral side. We could not determine a correct side by MDCT in 14 patients because of bilateral adenoma or invisible microadenoma (Table 1).
Vol. 179, No. 4, Supplement, Saturday, May 17, 2008
CONCLUSIONS: We could accurately detect only 55% of aldosterone-hypersecreting adenoma by MDCT alone. Examining with CT and AVS is recommended for patients with primary hyperaldosteronism before considering surgery. Table 1 Comparison of MDCT and AVS for detecting aldosterone-hypersecreting site (n=87) 8QLODWHUDO$3$FRQFRUGDQWODWHUDOL]DWLRQ 48 (55.2%) 8QLODWHUDO$3$GLVFRUGDQWODWHUDOL]DWLRQ 4 (4.6%) Bilateral adenoma 5 (5.7%) APA not detected by MDCT (microadenoma) 9 (10.4%) Idiopathic hyperaldosteronism 21 (24.1%)
Source of Funding: None
52 ADRENAL TUMORS WITH VENOUS THROMBOSIS: INCIDENCE, MANAGEMENT AND PROGNOSIS Yasser M Osman*, Abdul-Monem Gomha, Mohsen El-Mekresh, Ibrahim Eraky, Mohamed Abo-alghar, Hamdy A El-Kappany. Mansoura, Egypt. INTRODUCTION AND OBJECTIVE: To assess incidence, imaging techniques, therapeutic options and prognosis of adrenal tumors associated with venous thrombosis. METHODS: Between 1976 through 2005, 238 patients with 246 adrenal masses were diagnosed in a single institute. The clinical charts of 206 patients who underwent adrenal surgery were reviewed. 'DWD RI 3DWLHQWV ZLWK SDWKRORJLFDOO\ FRQ¿UPHG YHQRXV WKURPERVLV XWLOL]HGGLDJQRVWLFPRGDOLWLHVRSHUDWLYHWUHDWPHQWDQGSURJQRVLVZHUH analysed. 5(68/76 9HQRXVWKURPERVLVZDVFRQ¿UPHGSDWKRORJLFDOO\ in association with 6 masses of the excised 206 masses (2.9%). All patients were men with mean age of 25.7 ± 23.9 years (range 2 years - 54 years). The presentation was loin pain in 3, abdominal mass in 2 while it was incidentally discovered in the remaining patient. Masses ZHUHULJKWVLGHGLQSDWLHQWVDQGOHIWVLGHGLQSDWLHQWV6L]HRIWKH masses was 11.5 ± 5.2 cm (range from 4- 20 cm). All tumors showed extensive areas of hemorrhage and necrosis. Venous thrombosis was GLDJQRVHGSUHRSHUDWLYHO\LQRQO\PDVVHV DGUHQDOYHLQWKURPERVLVLQ one patient and renal vein thrombosis in the other (one by CT and the other by MRI). Venous involvement was diagnosed intra-operatively in an extra-patient. All of the masses were successfully excised via open approach (thoracoabdominal in 3, dorsolumbar in 2 and abdominal in 1) and it was associated with nephrectomy in 3. There was no operative mortality or gross morbidity with post-operative hospital stay of 5.3 ± 1.3 days (range 4 - 7 days). Pathologically, there was venous thrombosis limited to the adrenal vein in 5 patients and extended to the renal vein in 2. Pathology of the masses was: neuroblastoma in 2, pheochromocytoma in 2 and adrenocortical carcinoma in 1 and pleomorphic sarcoma in the remaining patient. Metastasis developed within 6 months in 3 of these patients. CONCLUSIONS: Venous thrombosis in association with adrenal tumours is a rare pathological condition. Although preoperative imaging provides a poor diagnostic yield, it could be expected in large masses with extensive hemorrhage and necrosis. Open surgery is the standard of care. Primary malignant adrenal masses with venous thrombosis have poor prognostic outcome. Source of Funding: None
THE JOURNAL OF UROLOGY®
19
Trauma & Reconstructive Surgery (II) Moderated Poster Session 3 Saturday, May 17, 2008
3:30 - 5:30 pm
53 ANASTOMOTIC URETHROPLASTY AND DORSAL ONLAY GRAFT URETHROPLASTY FOR URETHRAL STRICTURES: IMPACT OF PREVIOUS URETHRAL MANIPULATION ON THE FINAL OUTCOME Murat Tunc, Oner Sanli, Omer Acar*, Murat Atar, Cavit Ozsoy, Tarik Esen, Necdet Aras. Istanbul, Turkey. INTRODUCTION AND OBJECTIVE: Patients with urethral stricture disease are challenging cases for urologists in routine clinical practice. For many years endoscopic procedures has been considered WKH FXUH IRU D VLJQL¿FDQW QXPEHU RI SDWLHQWV +RZHYHU UHFXUUHQFH still remains the major complication of these endoscopic procedures. Open surgery remains the gold standard in the treatment of recurrent strictures. In the present study, we compared the results of open urethral reconstructions with regard to whether patients underwent previous endoscopic manipulations. METHODS: A total of 175 patients underwent perineal urethral reconstruction due to urethral stricture disease between June 1985 and September 2007. Excision of the strictured segment and primary end to end anastomosis was performed in 145 (82.8%) patients. Thirty patients (17.14%) underwent dorsal onlay graft urethroplasty. Trauma (n: 70, 40%) and transurethral manipulation (n: 48, 33%) were the leading etiologic factors. Seventy-four patients (42.2%) did not undergo any urethral, open or endoscopic, surgery (group 1). The remaining 101 (57.7%) patients underwent previous endoscopic procedures (group 2) including internal urethrotomy in 28, urethral dilation in 64 and endoscopic realignment in 19. Majority of the initial endoscopic interventions (67/101, 66.3%) were carried out in a primary care center and patients were referred to our FOLQLFIRUGH¿QLWLYHWUHDWPHQW&OLQLFDORXWFRPHZDVGH¿QHGDVVXFFHVV if no auxillary procedures were necessary in the absence of obstructive YRLGLQJV\PSWRPVDQGWKHPD[LPDOXULQDU\ÀRZUDWHEHLQJPOVHF Success rates were compared. RESULTS: Mean age of the study population and mean duration of follow-up was 36 years (range: 16 - 65) and 26 months (range: 12 - 34) respectively. Mean stricture length was 2.8±1.4 (range: 1.6 - 3.8). Majority of the strictures were located at the level of bulbar (n:65, 37.1%) and membranous (n:58, 33.14%) urethra. Patients without urethral manipulation before open urethroplasty had a success rate of 96%. However 84% of those patients for whom endoscopic interventions were the primary therapeutic measure had satisfactory results. The GLIIHUHQFHZDVVWDWLVWLFDOO\VLJQL¿FDQWEHWZHHQWZRJURXSV S CONCLUSIONS: Previous endoscopic interventions for urethral strictures have a negative impact on the results of open urethral reconstructions. The quality of the initial management for urethral strictures is the key to a successful outcome. Source of Funding: None
54 RETROSPECTIVE OUTCOME ANALYSIS OF ONE-STAGE PENILE URETHROPLASTY USING FLAP OR GRAFT IN A HOMOGENEOUS SERIES OF 62 PATIENTS Guido Barbagli, Giuseppe Morgia, Massimo Lazzeri*. Arezzo, Italy, Messina, Italy, and Florence, Italy. INTRODUCTION AND OBJECTIVE: To evaluate and compare WKHRXWFRPHVRIRQHVWDJHSHQLOHXUHWKUDOUHFRQVWUXFWLRQXVLQJÀDSRU graft urethroplasty. METHODS: 62 patients, with an average age of 51 years, underwent penile urethral reconstruction using one-stage techniques. Patients with failed hypospadias repair or lichen sclerosus were excluded. Eighteen patients (29%) underwent one-stage dartos fascial ÀDSZLWKVNLQLVODQGXUHWKURSODVW\DFFRUGLQJWRWKH2UDQGLWHFKQLTXHZLWK VRPHPRGL¿FDWLRQVDQGSDWLHQWV XQGHUZHQWRQHVWDJHJUDIW urethroplasty using penile skin (23 cases) or buccal mucosa (21 cases) as substitute graft material. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilation.
THE JOURNAL OF UROLOGY®
METHODS: Since September 1993, 124 patients underwent laparoscopic adrenal surgery via a lateral transperitoneal approach. Surgical indications included: primary hyperaldosteronism (n=52), Cushing’s syndrome (n=29), pheochromocytoma (n=26), non-functioning adenoma (n=16), myelolipoma (n=1). We retrospectively reviewed our experience with adrenal-sparing surgery and post-operative outcomes. RESULTS: Laparoscopic total adrenalectomy was performed unilaterally in 111 cases and bilaterally in 9 cases. Laparoscopic partial adrenalectomy was employed in 4 cases (3.3%) for primary hyperaldosteronism. Patients underwent partial adrenalectomy for aldosterone-producing adenomas 1.5 cm and 3.1 cm (right) and 2.5 cm and 5.0 cm (left) using ultrasonic shears, a bipolar vessel-sealing device, or a vascular linear stapling device. The mean age was 64 years (range 61 - 83), operative time was 152 min, estimated blood loss was 76 mL, and length of hospital stay was 1.2 days. All four SDWLHQWV H[SHULHQFHG LPPHGLDWH QRUPDOL]DWLRQ LQ VHUXP DOGRVWHURQH and potassium levels following the procedure. At a mean follow-up of PRQWKVHDFKSDWLHQWKDVUHPDLQHGDV\PSWRPDWLFZLWKVWDELOL]DWLRQ of blood pressure and greater than 75% reduction in anti-hypertensive medication requirement. CONCLUSIONS: Laparoscopic adrenal-sparing surgery offers the potential advantages of treating benign functioning adrenal tumors while sparing certain patients from the potential need for lifelong hormonal supplementation. Laparoscopic partial adrenalectomy is a safe and feasible technique for treating exophytic adrenal lesions. The potential sequelae of this procedure are incomplete lesion excision, and recurrence of disease within the adrenal remnant. While total adrenalectomy remains as the standard, partial adrenalectomy via a minimally invasive approach appears to be a suitable option for select patients with solitary functioning adrenal glands and those at risk for recurrent tumors. Source of Funding: None
Vol. 179, No. 4, Supplement, Saturday, May 17, 2008
50 CYSTIC PHEOCHROMOCYTOMA IS A DISTINCTIVE SUBGROUP WITH SPECIAL CLINICAL, IMAGING AND HISTOLOGICAL FEATURES THAT MAY MISLEAD DIAGNOSIS Cassio Andreoni*, Rodrigo Krebs, Claudio E Kater, Valdmar Ortiz. Sao Paulo, Brazil. INTRODUCTION AND OBJECTIVE: Adrenal cystic masses are usually associated with non-functional lesions, however, it may be a pheochromocytoma, which has been reported on anecdotal series or DVLVRODWHGFDVHUHSRUWV VXFKFDVHVRSHUDWHGDWRXULQVWLWXWLRQDQGWKH SUHYLRXVO\SXEOLVKHGGDWDDUHKHUHLQUHSRUWHGDQGDQDO\]HG METHODS: The prospective adrenalectomy database at our LQVWLWXWLRQ ZDV UHYLHZHG IRU ¿QGLQJ SDWLHQWV ZLWK SKHRFKURPRF\WRPD and cystic lesions. The clinical, radiological and histological features of the cystic pheochromocytoma were particularly evaluated. A search for other previously published data was conducted and compared with the current series. RESULTS: A total of 107 adrenalectomies were performed at our institution from November 2000 to March 2007. Thirty-one out of 107 DGUHQDOHFWRPLHVKDGDFRQ¿UPHGGLDJQRVLVRISKHRFKURPRF\WRPDDQG 6 of them (19 %) were cystic pheochromocytomas. Three out of the 6 FDVHVZHUHDV\PSWRPDWLFDQGKDGQHJDWLYHELRFKHPLFDOZRUNXS WKHUH ZHUHPDOHDQGIHPDOHV DYHUDJHWXPRUVL]HZDVFP WKHLPDJLQJ diagnosis was mainly done based upon CT and MRI and the foremost feature was the enhancement of the tumor rim associated with a central cystic mass. Nine other previously published cases were reviewed CONCLUSIONS: It can be drawn from the current largest series and from adding previous anecdotal reported cases, that patients with cystic pheochromocytomas are more likely to be asymptomatic, to complain of chronic abdominal pain, and to have negative biochemical work up, which may refrain physicians from performing a full work up IRUSKHRFKURPRF\WRPDDQGPLVOHDGWKH¿QDOGLDJQRVLVDVVXFKWKLV subgroup of patients could have even higher prevalence that is yet to be determined Source of Funding: None
49 ROBOTIC ADRENALECTOMY FOR ADRENAL TUMORS: PROSPECTIVE ASSESSMENT OF PERIOPERATIVE OUTCOMES Sanjeev Kaul*, Ronald S Boris, Louis S Krane, Vinod Narra, Mani Menon. Detroit, MI. INTRODUCTION AND OBJECTIVE: Laparoscopic adrenalectomy is accepted as the gold standard for surgical treatment of adrenal masses. Recently reports of robotic adrenalectomy have appeared in literature, however there is no data regarding peri operative outcomes. We prospectively evaluated the peri operative outcomes following robotic adrenalectomy performed at our institution. METHODS: Eleven patients underwent robotic adrenalectomy for 12 adrenal masses (one bilateral). A prospective database was maintained including demographic data, operative time, blood loss, post operative pain (visual analogue scale), analgesic use and perioperative complications. We compared our outcomes to contemporary series of laparoscopic adrenalectomy. RESULTS: Seven males and 4 females of mean age 53 years underwent robotic adrenalectomy between January and August 2007. $IRXUSRUWWUDQVSHULWRQHDOWHFKQLTXHZDVXVHG0HDQWXPRUVL]HZDV 3.5 cm and mean console time 79 min. Average blood loss and hospital stay was 59 ml and 1.4 days respectively. Mean pain on POD1 was 4 on VAS and only 2 patients required opioids for pain control. There were no conversions to open surgery or intra operative complications. CONCLUSIONS: Robotic adrenalectomy provides perioperative outcomes (operative time, hospital stay, blood loss) superior to contemporary series of laparoscopic adrenaectomy. Post operative pain on POD 0 is not bothersome to patients and can be controlled with NSAID’s without need for opioid drugs. Source of Funding: None
51 SINGLE CENTER COMPARISON OF MULTIDETECTOR CT AND ADRENAL VEIN SAMPLING FOR DETECTING THE LATERALIZATION OF PATIENTS WITH PRIMARY HYPERALDOSTERONISM Shigeto Ishidoya*, Akihiro Ito, Seiichi Saito, Fumitoshi Satoh, Tadashi Ishibashi, Yoichi Arai. Sendai, Japan. INTRODUCTION AND OBJECTIVE: With the accumulation of the managements for patients with primary hyperaldosteronism, it appeared that some patients revealed aldosterone-hypersecreting after unilateral adrenalectomy based on a computed tomography (CT) determination. The aim of the study is to assess the discrepancy of multidetector row CT (MDCT) and adrenal vein sampling (AVS) in GHWHUPLQLQJ WKH UHVSRQVLEOH ODWHUDOL]DWLRQ EDVHG RQ D VLQJOH FHQWHU experience. METHODS: A total of 87 patients with primary K\SHUDOGRVWHURQLVPZHUHUHWURVSHFWLYHO\DQDO\]HG$OOSDWLHQWVUHFHLYHG a 16 channel MDCT and AVS. By MDCT, we examined adrenal regions in contiguous 1.0-mm-thick slice with contrast agent. Simultaneous bilateral AVS was performed with adrenocorticotropic hormone (ACTH) stimulation. Successful adrenal vein cannulation and sampling was achieved in all patients. RESULTS: According to the results of MDCT and AVS, 61 patients were diagnosed as having aldosterone-producing adenoma (APA) and underwent laparoscopic adrenalectomy, and 21 patients were diagnosed as idiopathic hyperaldosteronism (IHA). Five patients refused the operation and continued conservative therapy. Among 52 patients with unilateral adenoma, 48 revealed the results with concordant ORFDOL]DWLRQ KRZHYHU SDWLHQWV VKRZHG DOGRVWHURQHK\SHUVHFUHWLQJ from the contaralateral side. We could not determine a correct side by MDCT in 14 patients because of bilateral adenoma or invisible microadenoma (Table 1).
Vol. 179, No. 4, Supplement, Saturday, May 17, 2008
CONCLUSIONS: We could accurately detect only 55% of aldosterone-hypersecreting adenoma by MDCT alone. Examining with CT and AVS is recommended for patients with primary hyperaldosteronism before considering surgery. Table 1 Comparison of MDCT and AVS for detecting aldosterone-hypersecreting site (n=87) 8QLODWHUDO$3$FRQFRUGDQWODWHUDOL]DWLRQ 48 (55.2%) 8QLODWHUDO$3$GLVFRUGDQWODWHUDOL]DWLRQ 4 (4.6%) Bilateral adenoma 5 (5.7%) APA not detected by MDCT (microadenoma) 9 (10.4%) Idiopathic hyperaldosteronism 21 (24.1%)
Source of Funding: None
52 ADRENAL TUMORS WITH VENOUS THROMBOSIS: INCIDENCE, MANAGEMENT AND PROGNOSIS Yasser M Osman*, Abdul-Monem Gomha, Mohsen El-Mekresh, Ibrahim Eraky, Mohamed Abo-alghar, Hamdy A El-Kappany. Mansoura, Egypt. INTRODUCTION AND OBJECTIVE: To assess incidence, imaging techniques, therapeutic options and prognosis of adrenal tumors associated with venous thrombosis. METHODS: Between 1976 through 2005, 238 patients with 246 adrenal masses were diagnosed in a single institute. The clinical charts of 206 patients who underwent adrenal surgery were reviewed. 'DWD RI 3DWLHQWV ZLWK SDWKRORJLFDOO\ FRQ¿UPHG YHQRXV WKURPERVLV XWLOL]HGGLDJQRVWLFPRGDOLWLHVRSHUDWLYHWUHDWPHQWDQGSURJQRVLVZHUH analysed. 5(68/76 9HQRXVWKURPERVLVZDVFRQ¿UPHGSDWKRORJLFDOO\ in association with 6 masses of the excised 206 masses (2.9%). All patients were men with mean age of 25.7 ± 23.9 years (range 2 years - 54 years). The presentation was loin pain in 3, abdominal mass in 2 while it was incidentally discovered in the remaining patient. Masses ZHUHULJKWVLGHGLQSDWLHQWVDQGOHIWVLGHGLQSDWLHQWV6L]HRIWKH masses was 11.5 ± 5.2 cm (range from 4- 20 cm). All tumors showed extensive areas of hemorrhage and necrosis. Venous thrombosis was GLDJQRVHGSUHRSHUDWLYHO\LQRQO\PDVVHV DGUHQDOYHLQWKURPERVLVLQ one patient and renal vein thrombosis in the other (one by CT and the other by MRI). Venous involvement was diagnosed intra-operatively in an extra-patient. All of the masses were successfully excised via open approach (thoracoabdominal in 3, dorsolumbar in 2 and abdominal in 1) and it was associated with nephrectomy in 3. There was no operative mortality or gross morbidity with post-operative hospital stay of 5.3 ± 1.3 days (range 4 - 7 days). Pathologically, there was venous thrombosis limited to the adrenal vein in 5 patients and extended to the renal vein in 2. Pathology of the masses was: neuroblastoma in 2, pheochromocytoma in 2 and adrenocortical carcinoma in 1 and pleomorphic sarcoma in the remaining patient. Metastasis developed within 6 months in 3 of these patients. CONCLUSIONS: Venous thrombosis in association with adrenal tumours is a rare pathological condition. Although preoperative imaging provides a poor diagnostic yield, it could be expected in large masses with extensive hemorrhage and necrosis. Open surgery is the standard of care. Primary malignant adrenal masses with venous thrombosis have poor prognostic outcome. Source of Funding: None
THE JOURNAL OF UROLOGY®
19
Trauma & Reconstructive Surgery (II) Moderated Poster Session 3 Saturday, May 17, 2008
3:30 - 5:30 pm
53 ANASTOMOTIC URETHROPLASTY AND DORSAL ONLAY GRAFT URETHROPLASTY FOR URETHRAL STRICTURES: IMPACT OF PREVIOUS URETHRAL MANIPULATION ON THE FINAL OUTCOME Murat Tunc, Oner Sanli, Omer Acar*, Murat Atar, Cavit Ozsoy, Tarik Esen, Necdet Aras. Istanbul, Turkey. INTRODUCTION AND OBJECTIVE: Patients with urethral stricture disease are challenging cases for urologists in routine clinical practice. For many years endoscopic procedures has been considered WKH FXUH IRU D VLJQL¿FDQW QXPEHU RI SDWLHQWV +RZHYHU UHFXUUHQFH still remains the major complication of these endoscopic procedures. Open surgery remains the gold standard in the treatment of recurrent strictures. In the present study, we compared the results of open urethral reconstructions with regard to whether patients underwent previous endoscopic manipulations. METHODS: A total of 175 patients underwent perineal urethral reconstruction due to urethral stricture disease between June 1985 and September 2007. Excision of the strictured segment and primary end to end anastomosis was performed in 145 (82.8%) patients. Thirty patients (17.14%) underwent dorsal onlay graft urethroplasty. Trauma (n: 70, 40%) and transurethral manipulation (n: 48, 33%) were the leading etiologic factors. Seventy-four patients (42.2%) did not undergo any urethral, open or endoscopic, surgery (group 1). The remaining 101 (57.7%) patients underwent previous endoscopic procedures (group 2) including internal urethrotomy in 28, urethral dilation in 64 and endoscopic realignment in 19. Majority of the initial endoscopic interventions (67/101, 66.3%) were carried out in a primary care center and patients were referred to our FOLQLFIRUGH¿QLWLYHWUHDWPHQW&OLQLFDORXWFRPHZDVGH¿QHGDVVXFFHVV if no auxillary procedures were necessary in the absence of obstructive YRLGLQJV\PSWRPVDQGWKHPD[LPDOXULQDU\ÀRZUDWHEHLQJPOVHF Success rates were compared. RESULTS: Mean age of the study population and mean duration of follow-up was 36 years (range: 16 - 65) and 26 months (range: 12 - 34) respectively. Mean stricture length was 2.8±1.4 (range: 1.6 - 3.8). Majority of the strictures were located at the level of bulbar (n:65, 37.1%) and membranous (n:58, 33.14%) urethra. Patients without urethral manipulation before open urethroplasty had a success rate of 96%. However 84% of those patients for whom endoscopic interventions were the primary therapeutic measure had satisfactory results. The GLIIHUHQFHZDVVWDWLVWLFDOO\VLJQL¿FDQWEHWZHHQWZRJURXSV S CONCLUSIONS: Previous endoscopic interventions for urethral strictures have a negative impact on the results of open urethral reconstructions. The quality of the initial management for urethral strictures is the key to a successful outcome. Source of Funding: None
54 RETROSPECTIVE OUTCOME ANALYSIS OF ONE-STAGE PENILE URETHROPLASTY USING FLAP OR GRAFT IN A HOMOGENEOUS SERIES OF 62 PATIENTS Guido Barbagli, Giuseppe Morgia, Massimo Lazzeri*. Arezzo, Italy, Messina, Italy, and Florence, Italy. INTRODUCTION AND OBJECTIVE: To evaluate and compare WKHRXWFRPHVRIRQHVWDJHSHQLOHXUHWKUDOUHFRQVWUXFWLRQXVLQJÀDSRU graft urethroplasty. METHODS: 62 patients, with an average age of 51 years, underwent penile urethral reconstruction using one-stage techniques. Patients with failed hypospadias repair or lichen sclerosus were excluded. Eighteen patients (29%) underwent one-stage dartos fascial ÀDSZLWKVNLQLVODQGXUHWKURSODVW\DFFRUGLQJWRWKH2UDQGLWHFKQLTXHZLWK VRPHPRGL¿FDWLRQVDQGSDWLHQWV XQGHUZHQWRQHVWDJHJUDIW urethroplasty using penile skin (23 cases) or buccal mucosa (21 cases) as substitute graft material. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilation.