Recommendations for safe and efficient morcellation after endoscopic enucleation of the prostate (EEP) After EEP (HoLEP, ThuLEP, GreenLEP or bipolar) the enucleated tissue is removed through a process of mechanical morcellation.Morcellation is the last, and very important, step in EEP procedures. It introduces additional time, and the possibility for complications exists. Although this is not a difficult procedure, it requires a learning curve that can pose a challenge for inexperienced surgeons. There are two types of morcellation systems: oscillating and reciprocating (depending on blade movement).
Comparison of RENAL, PADUA, CSA, and PAVP Nephrometry Scores in Predicting Functional Outcomes after Partial Nephrectomy To evaluate the accuracy of Radius, Exophytic/endophytic, Nearness to collecting system/sinus, Anterior/posterior, and Location relative to polar lines (RENAL), Preoperative Aspects and Dimensions Used for Anatomical classification (PADUA), Contact Surface Area (CSA), and Pre-operative Assessment of Volume Preservation (PAVP) nephrometry scores in predicting post-operative renal functional outcomes after partial nephrectomy (PN). Few studies have compared the accuracy of tumor complexity systems directly in the same set of PN patients.
Congenital Duplication of the Urogenital Sinus in an Adult Female A 28 year-old female presented to the emergency room with symptoms of left pyelonephritis. She was admitted and was found on imaging study to have left hydronephrosis and duplicated bladder. A left nephrostomy tube was placed, and urology was consulted for management of her infections in context of her anatomy. During her evaluation, the patient reported three to four urinary tract infections or episodes of left pyelonephritis per year, as well as recurrent left flank pain and mixed urinary incontinence for several years.
Has the Age of Cytoreductive Nephrectomy come to an end? The CARMENA (Cancer du Rein Metastatique Nephrectomie et Antiangiogéniques) trial was a prospective, multicentre, open-label, phase 3 trial that randomly assigned patients with Memorial Sloan Kettering Cancer Center (MSKCC) intermediate or poor risk metastatic renal cell carcinoma (mRCC) to undergo cytoreductive nephrectomy (CNx) followed by sunitinib or to sunitinib alone without nephrectomy. The study was designed to test the non-inferiority of sunitinib alone with respect to the primary endpoint overall survival.
Giant ureteric calculus in a patient with bladder exstrophy
We report a case of giant ureteric calculus in an adult male with bladder exstrophy who presented with urinary incontinence and recurrent urinary tract infection. Investigations revealed a 16cm ureteric calculus, vesical and left staghorn renal calculi. Ureteric stone was removed by open Ureterolithotomy.
Robotic Partial Nephrectomy For Complex Hilar Tumors: Tips & Tricks To report our step-by-step technique and provide tips & tricks for robotic partial nephrectomy (RPN) in a highly complex renal mass. Robotic surgery has widened the indications of the conservative treatment for renal masses1. With increasing experience, larger deeply infiltrative tumors, or tumors involving the renal hilum can be treated with robotic partial nephrectomy2,3.
Diagnosis and treatment of urethrocavernous fistula presenting as urethral bleeding Urethrocavernous fistula is rarely reported, though should be considered within the differential diagnosis for men who present with urethral bleeding, particularly at time of erection. Ultrasonography with concomitant intracavernosal injection can be considered to confirm the diagnosis. Here we report a case of urethrocavernous fistula in a 48 year old man without preceding traumatic event.
High catastrophizing in subjects with painful mesh complications have worse outcomes To identify the rate of catastrophizing in a cohort of subjects with chronic pain after self-reported mesh complications and identify interactions of catastrophization with other patient factors, such as age, number of pelvic surgeries, and intent to sue. Catastrophizing has been shown to be a risk factor for chronicity of pain, disability, and depression.
ASSOCIATION BETWEEN EXSTROPHY-EPISPADIAS COMPLEX AND CONGENITAL ANOMALIES: A GERMAN MULTICENTER STUDY To further investigate associated anomalies in EEC patients CURE-Net database was systematically screened. In literature the exstrophy-epispadias complex (EEC) comprises a spectrum of anomalies, mainly occurring “isolated” without additional congenital defects. Nevertheless, previous epidemiological studies indicated a higher association with renal, anorectal and lower neurotubular anomalies, which may originate from the same developmental morphogenetic fields.
Chronic Prostatitis/Chronic Pelvic Pain as a Psycho-Neuromuscular Disorder–A Meta-analysis To evaluate effectiveness of physical therapy, biofeedback, and/or cognitive behavioral therapy for Chronic Prostatitis/Chronic Pelvic Pain Syndrome (CP/CPPS). This symptom complex has resisted resolution from conventional urologic treatment of the prostate, which includes antibiotics, alpha-blockers, and analgesics. Beginning in 1995, a new paradigm was introduced viewing CP/CPPS as a psycho-neuromuscular disorder driven by protective pelvic floor guarding and psychosocial stress.
Urological Complications Following Pelvic Radiotherapy Radiotherapy is widely used as a curative treatment for pelvic malignancies. The location of these organs leads to unavoidable exposure of the bladder, urethra and distal ureters to radiation and may cause subsequent development of radiation cystitis, fistulas, strictures and secondary malignancy. As cancer survival improves, an ever-increasing number of patients are living with the long-term complications of radiotherapy. Symptoms are not only debilitating for the patient but also pose a treatment challenge to the urologist.
Urine xanthine crystals in tumor lysis syndrome
Urine xanthine crystals are remarkably rare but can be observed by routine urine microscopy. We report the results of a 67-year-old man with T-cell-prolymphocytic leukemia whose urine contained xanthine crystals after chemotherapy and prophylactic administration of febuxostat. Accumulation of xanthine was due to tumor lysis syndrome causing a massive release of DNA. The metabolized DNA caused an increase of xanthine, which was not readily converted to uric acid by xanthine oxidase because of febuxostat inhibition of this enzyme.
A BILATERAL METACHRONOUS MESOTHELIOMA OF THE TUNICA VAGINALIS This is a unique case of bilateral metachronous testicular mesothelioma of the tunica vaginalis. Testicular mesothelioma is a rare entity found in patients with or without asbestos occupational exposure. The tumor most commonly presents as a unilateral testicular mass. More rare presentations include bilateral synchronous or metachronous tumors. Treatment is with surgical resection and prognosis is not generally favorable. The benefits of adjuvant therapy with radiation or chemotherapy remain unknown and further studies are needed.
Localized Inflammatory Myofibroblastic Tumor Involving the Genitourinary System: Adolescent Case Series and Review We describe four adolescent cases of inflammatory myofibroblastic tumor involving the genitourinary system. Two patients with masses of the urinary bladder presented with gross hematuria. The third patient presented with left flank pain and a mass encasing the left ureter causing hydronephrosis. The fourth patient presented with a painless, growing palpable mass of the left hemiscrotum. Currently, no standards exist for the management of inflammatory myofibroblastic tumors. Herein, we discuss the work-up and treatment approaches taken in each case.
A Case of Fatal Clostridial Necrotizing Fasciitis after Radical Prostatectomy A 70-year-old Caucasian male with pT3aN1Mx G3+4 prostate cancer underwent an open radical retropubic prostatectomy with lymphadenectomy without surgical complications. He experienced a slightly prolonged post-operative hospitalization (3 days) secondary to a reaction to an anesthesia study drug (tachycardia and drowsiness) that resolved after discontinuation of said drug and was subsequently discharged. Two weeks later, he was brought to the emergency department after the sudden onset of an acutely severe right groin pain and swelling that began that afternoon.
Assessing the learning curve of Holmium Laser Enucleation of Prostate (HoLEP). A systematic review. We systematically assessed the learning curve of Holmium laser enucleation of the prostate using the available literature to identify, as our primary outcome, the average number of cases required to reach competency. A computerised search of PubMed and Scopus for articles published from inception through to January 2018 was performed including twenty-four studies with a total of 5173 patients. Even though different outcome measures require varying case-loads to reach a plateau, Holmium laser enucleation of prostate has an acceptable learning curve with a proposed figure approximating 25-50 cases, with a structured mentorship programme aiding for faster progress.
Whole Exome Sequencing of a Consanguineous Turkish Family Identifies a Mutation in GTF2H3 in Brothers with Spermatogenic Failure In this case report we describe our investigation into the genetic cause of infertility due to idiopathic non-obstructive azoospermia in a consanguineous Turkish family. We extracted DNA from blood and applied whole exome sequencing (WES) on four infertile brothers in this family diagnosed with oligo- and azoospermia. Standard bioinformatics analysis pipelines were run including alignment to the reference genome, variant calling, and quality control filtering. Potentially pathogenic variants were identified and prioritized using genetic variant annotation software and public variant frequency databases, followed by validation with Sanger sequencing.
Author Reply Noncancer indications for simultaneous genitourinary and fecal diversion mainly include (1) complex enteral, fecal, and urinary fistulas; (2) refractory urinary and fecal incontinence from neurogenic bladder or bowel, or associated with complications from previous pelvic radiation, or from iatrogenic complication at the time of urologic, colorectal, or gynecologic surgery; (3) (promotion of healing of) complex decubitus ulcers affecting the coccygeal, perianal, perineal, and scrotal area. The natural disease progression of these catastrophic conditions is not well understood, and both urinary and fecal diversions are usually offered as the last therapeutic resort with curative or many times with palliative intent.
Editorial Comment Patients requiring urinary and bowel diversion for non-oncologic indications constitute a poorly studied cohort in reconstructive urology. Scant literature exists to guide the colorectal surgeon or urologist on the impact of staged diversions as compared to simultaneous diversions. Oftentimes when faced with these patients, the historical wisdom is to perform staged diversions, as there is significant concern for increased morbidity, prolonged operative time, and delayed convalescence with after simultaneous “double” diversion.
A Review of the FAERS Data on 5-Alpha Reductase Inhibitors: Implications for Post-Finasteride Syndrome To quantify reports made to the Food and Drug Administration Adverse Event Reporting System (FAERS), create a demographic of patient reports, and examine the cluster of symptoms to correlate consistency of post-finasteride syndrome (PFS) complaints. PFS is a provisional diagnosis encompassing a cluster of sexual, physical, and psychological/neurologic symptoms associated with 5-alpha reductase inhibitor (5ARI) use that emerge or continue after discontinuation of medication.
Lynch Syndrome-associated Upper Tract Urothelial Carcinoma A 63-year-old female with known history of Lynch Syndrome with MSH2 gene deletion presented to the emergency department with left flank and epigastric pain worsening over one week. She had a three-year history of intermittent gross hematuria, with no masses or hydronephrosis on non-contrast abdominal and pelvic CT scan 2.5 years prior. Review of systems was otherwise negative. Patient reported previously negative evaluation with cystoscopy and repeat urinalysis for gross hematuria by outside urologist.
Adrenal cyst in pregnancy: a surgical emergency A 41-year-old pregnant woman at 22 weeks of gestation was evaluated for sudden and progressive abdominal distension and increasing pain. Pregnancy showed a normal evolution, routine obstetric ultrasound performed three days before has resulted normal, and laboratory tests were within normal ranges. Obstetric evaluation was normal but abdominal ultrasound (US) showed a huge cyst surrounding the uterus (Fig. 1). A magnetic resonance (MR) was performed and showed a retroperitoneal cyst of 23.12 × 18.64 cm, filled with blood and clots (Fig.
Hemorrhagic Cystitis Associated With Gefitinib Treatment: A Case Report Gefitinib is an oral anticancer agent that inhibits the intracellular phosphorylation of numerous tyrosine kinases associated with transmembrane cell surface receptors and then blocks cancer progression.1 Its efficacy for advanced non-small-cell lung cancer (NSCLC) has been proved in randomized, double-blind, phase III trials.2,3 Common side effects of gefitinib include diarrhea, rash, acne, dry skin, nausea, hepatic dysfunction, and vomiting.1 We describe the rare case of a patient treated with gefitinib, who later presented with hemorrhagic cystitis as a drug-related side effect.
Cognitive Versus Software Fusion for MRI-Targeted Biopsy: Experience Before and After Implementation of Fusion To compare the diagnostic performance of the 2 most common approaches of magnetic resonance imaging targeted biopsy (TB)—cognitive registration targeted biopsy (COG-TB) and software fusion targeted biopsy (FUS-TB)—we assessed our institutional experience with both methods. TB has emerged to complement systematic template biopsy (SB) in prostate cancer (PCa) diagnosis; however, which magnetic resonance imaging targeting methodology is diagnostically better remains unclear.
Polypoid endometriosis presenting as a renal cortical tumor A 41-year-old female presented with left-sided flank pain and gross hematuria temporally unrelated to her menstrual cycle. Abdominal computed tomography scan showed a large left-sided solid, enhancing kidney mass radiographically consistent with renal cell carcinoma. Following surgical resection, histopathological examination revealed polypoid endometriosis. Polypoid endometriosis is rare and mimics a neoplasm clinically, radiographically, and on gross examination. Patients with polypoid endometriosis often present with symptoms related to mass effect rather than classic endometriosis hallmark symptoms such as dyspareunia, dysmenorrhea, and cyclic abdominal pain.
Osteomyelitis of the Pubic Symphysis After Transrectal Biopsies of the Prostate We report a rare complication of magnetic reasonance imaging targeted transrectal biopsy of the prostate. Patient developed severe pain in the right hip and groin area after which he was admitted to the hospital. There was an interval of 2 months between the onset of the symptoms and the diagnosis. Our report is the first to describe osteomyelitis of the pubic symphysis in combination with abscess formation in the surrounding soft tissues due to MRI-guided transrectal biopsy of the prostate.
The Urology Match and Post-Interview Communication To understand the frequency and nature of post-interview communication as it relates to the rules and regulations of the American Urological Association (AUA) Urology Residency Matching, as well as the impact of such communication on the outcomes of the match.
Oral Propranolol in a Child with Infantile Hemangioma of the Urethra
Infantile hemangiomas (IH) are the most common in the head and neck region.1 They can occur anywhere in the skin, however, urethral hemangiomas are very rare.We describe a case report of a three years old boy with extensive lesions of IH in the anterior urethra. Urethral IH were disappeared during one year of oral administration of propranolol though it brought on urinary retention.This is the first report about oral propranolol treatment in a child with urethral IH. Oral administration of propranolol may be effective for urethral IH and beneficial especially for lesions requiring extensive surgical resection and reconstruction.
Complications of Delivery Among Mothers with Spina Bifida : To determine rates and types of peripartum morbidity among delivering women with spina bifida (SB) compared to those without SB. The rates of pregnancy and delivery among women with SB have been significantly increasing. Current knowledge of peripartum outcomes for these women is limited.
Cowper's Gland Syringocele Cowper's gland syringoceles are rare cystic dilations of the Cowper's gland duct. They are typically diagnosed in childhood but occasionally occur in adults. We report the case of a 28-year-old man who presented with a painful perineal and inferior scrotal mass and was found to have a large Cowper's gland syringocele extending into the scrotum associated with a scrotal abscess. Treatment consisted of surgical excision. The magnetic resonance imaging findings of this case are described.
Robot-assisted Vesico-Vaginal Fistula Repair: A Compilation Vesico-vaginal fistulae (VVF) are the most common type of urinary tract fistulae.1 These fistulae represent a complication that generally occurs after an iatrogenic injury during hysterectomy and lower segment cesarean section, obstructed labor, radiation necrosis, pelvic malignancies as well as other radical pelvic surgery.1 The incidence varies between 0.3% and 2%.2 Due to its iatrogenic nature, and symptomatology VVF is associated with considerable emotional and psychologic distress.1, 3 This may be expressed as anger, resentment, and disappointment on the part of the patient toward the treating physician.
Paradoxical Examination and Imaging Findings in a Case of Paratesticular Cutaneous Angioyxoma Angiomyxomas are rare soft tissue neoplasms rich in myxoid matrix and blood vessels that typically present as nodules on the trunk, head, and limbs in adults. They are classified as either cutaneous or aggressive based on histological findings and extent of local growth. There are less than 150 reported cases in the literature. In this case report we describe the first paratesticular case of a cutaneous angiomyxoma in a pediatric patient, who presented with a transilluminating paratesticular mass consistent with a hydrocele, but showed solid and vascular features on ultrasound.
Nephrolithiasis in a 17-Year-Old Male With Seckel Syndrome and Horseshoe Kidneys: Case Report and Review of the Literature We report the case of a 17-year-old male with Seckel syndrome and horseshoe kidneys which had a 7 mm kidney stone in the lower pole calyx of the right moiety. The patient had a history of rotoscoliosis with 60° dextroconvex curvature and hepatic steatosis. Attempted ureteroscopy was unsuccessful due to stone location and anatomy. Percutaneous nephrolithotomy was ultimately required. This case highlights the difficulties of endoscopic treatments of renal calculi in patients with abnormal renal anatomy and dysmorphia.
Aggressive Renal Angiomyolipoma in a Patient With Tuberous Sclerosis Resulting in Pulmonary Tumor Embolus and Pulmonary Infarction, Renal angiomyolipoma (AML) is the most commonly encountered mesenchymal tumor of the kidney which can present spontaneously or in association with tuberous sclerosis complex. Rarely, renal AMLs may demonstrate aggressive features such as renal vein invasion. This common entity and its uncommon complications are diagnosed based on physical examination and computed tomography results. Here we report imaging findings of a renal AML with renal vein and inferior vena cava invasion resulting in pulmonary tumor embolus and pulmonary infarction.
Editorial Comment The authors have studied MRI scans of men prior to laser enucleation of the prostate gland. They have measured the distance from the verumontanum to the distal end of the prostatic adenoma, as well as the distance from the prostate adenoma to the apex of the prostate. They note a correlation between the length of the urethra from the verumontanum to the prostate adenoma to the overall prostate volume in patients over the age of sixty nine.1
Author Reply We thank Dr. Lotan for his editorial comment1 and for raising the critical issue of adherence to intravesical therapy. Our study intended to evaluate compliance with intravesical therapy outside of a clinical trial and in fact, rates of completion of maintenance therapy were lower than reported in a well controlled environment. Unfortunately, despite the substantial evidence in favor of BCG therapy for NMIBC,2,3 data show that its use is not nearly as optimal.4,5
Editorial Comment Intravesical therapy is the standard of care for high risk non-muscle invasive bladder cancer (NMIBC).1 There is considerable evidence that maintenance therapy improves outcomes in patients with high risk disease.2,3 Unfortunately, many patients do not receive the standard of care despite guideline recommendations.3,4 This study in Urology evaluated compliance with intravesical therapies and found that the rate of completion of 6 weeks induction therapy with BCG and mitomycin C was similar (86% and 87%, respectively).
Editorial Comment The Michigan Urological Surgery Improvement Collaborative (MUSIC) program has transformed both population management and quality improvement in urology. In the current study,1 the authors address an important and timely question: do men on active surveillance pursue confirmatory testing after diagnosis of favorable-risk prostate cancer and, when they do, do they persist on active surveillance? In addition to delineating current practices in Michigan of confirmatory testing—the most common being the use of molecular classifiers (55%), followed by magnetic resonance imaging (MRI, 34%) and repeat biopsy (11%), the study also captures a snapshot of how these confirmatory tests are affecting the landscape of active surveillance.
Wilms Tumor After Orthotopic Liver Transplant in a Patient With Alagille Syndrome We present a case of Wilms Tumor in a patient with Alagille syndrome 10 months after liver transplant. We explore a suggested genetic connection between these 2 diseases. In children with Wilms Tumor, we propose a pathoembryologic explanation for not just the tumor, but also for the cause of associated benign ureteral and renal parenchymal aberrancies that are commonly seen in the Alagille population. We also discuss the diagnostic and therapeutic challenges that can arise in a liver transplant patient with Alagille syndrome who subsequently develops a renal mass.
Author Reply The primary objective of our analysis was to demonstrate that patients with simultaneous bilateral ureteral calculi (SBUC) do not all have exactly the same initial clinical presentation. Therefore, a tailored approach should be applied to their management just as in any other clinical condition. Traditionally, patients with SBUC undergo immediate upper tract drainage and deferred definitive stone treatment. As emphasized in our study and the Editorial Comment,1 this staged approach remains the standard of care in patients with SBUC who present with true emergencies including infection, significant renal injury, or electrolyte abnormalities.
Editorial Comment Simultaneous bilateral ureteral calculi (SBUC) represent roughly 1% of all stone patients, as documented in the current study and prior work from multiple authors. SBUC, although rare, presents a distinct risk of acute kidney injury (AKI), oliguria, anuria, and hyperkalemia. In the current study, 30% of patients had AKI with a creatinine rise over 0.5 mg/dL and of the patients with AKI, 9/13 had either oliguria or anuria. Such patients clearly need decompression and time for renal function and electrolytes to stabilize; these are not patients whom primary bilateral URS is appropriate.
Re: Cohen et al.:Impact of Statin Intake on Kidney Stone Formation (Urology 2018) We have read the article “Impact of statin intake on kidney stone formation” by Cohen et al, with utmost interest. The authors presented the effects of statins on nephrolithiasis risk and higher lipids correlation with risk of stone formation.1 We would like to request the authors to elucidate the following points for our better understanding.
Author Reply The commentator underscores several important points. First, since the United States Preventive Services Task Force recommendation to eliminate PSA screening, there has been an increased incidence of more clinically aggressive prostate cancers. Second, although the current data shows that with PSA screening at 12-18 months intervals, prostate cancer morbidity can be substantially reduced, it is critically important to mitigate the impact of unnecessary treatment by utilizing active surveillance, and various newer methods for risk stratification of patients with low-grade, low-stage disease.
Editorial Comment Prostate cancer (PCa) is the most common non-skin cancer and the second leading cause of cancer death for men in the United States.1 Strategies for managing PCa are mainly aimed at early detection because 68% of PCa mortality takes place under the age of 75 (the average life expectancy for men in the US). This is substantiated by scientific literature that demonstrates that early detection can play a vital role in the survival of individuals affected by cancer.2 Despite the evidence surrounding early detection, differences of opinion abound on the screening recommendations for PCa because of the high false positive rate and the over-detection of indolent disease.
Growing Teratoma Syndrome of Testicular Origin A 20-year-old Hispanic male semi-professional soccer player with no prior medial history presented to the emergency department with one month of abdominal distension, and four days of left lower extremity swelling. During initial interview, the patient offered that his testicle had been enlarged for approximately 4-6 years, without any workup or intervention. A firm non-tender abdomen, enlarged left hemi-scrotum, and left lower extremity swelling was noted on physical examination. A left supraclavicular lymph node was also palpable.
A Rare Case of Ureteral IgG4 Disease Masquerading as Urothelial Carcinoma The present paper described a rare case of ureteral IgG4-related disease (IgG4-RD) that mimicked urothelial carcinoma. An otherwise healthy patient presented with computed tomography, ureteroscopic, and biopsy findings that were suspicious of urothelial carcinoma. The patient received a right nephroureterectomy. Histopathology showed ureteral IgG4-RD, without evidence of urothelial carcinoma. Accurate diagnosis of this rare entity should be based on clinical, biochemical, and histopathological findings.
Extra-adrenal Pheochromocytoma Associated With Segmental Renal Artery Compression and Pseudostenosis Classically, pheochromocytomas and paragangliomas result in hypertension secondary to an excess release of catecholamines. However, when the tumor arises near the renal hilum, hypertension may also be secondary to renal artery stenosis, which can occur via several purported mechanisms. We describe an unusual case of a hereditary, extra-adrenal pheochromocytoma causing right lower pole renal artery pseudostenosis, pertinent radiologic signs, relevant surgical findings, and subsequent resolution after extirpative surgery.
Robotic Management of Rectourethral Fistulas After Focal Treatment for Prostate Cancer To describe our management strategy for rectourethral fistula (RUF) after focal treatment for prostate cancer (PCa) using 2 cases as an example. Almost 50% of RUFs are associated with energy treatment modalities for PCa. The adjacent damage to healthy tissue along with limited pliability of it makes the success of the repair troublesome. There is no standardized approach for these scenarios.
Bladder Agenesis and Associated Pelvic Arterial Anomaly in Two Female Pediatric Patients Bladder agenesis is an extremely rare congenital anomaly of the genitourinary tract. Two female patients with known diagnoses of bladder agenesis presented for pre-renal transplant evaluation and neobladder creation. Similar unique pelvic arterial malformations were identified through pre-operative imaging and intraoperative examination. With these similar findings, it could be proposed that such anatomical variants are products of the same insult or involve a causal relationship, with vascular aberrancies potentially provoking pelvic organ maldevelopment.
Simultaneous Bilateral Ureteral Calculi: A New Paradigm for Management To define the need for emergent intervention between patients with simultaneous bilateral ureteral calculi (SBUC) compared to unilateral ureteral calculi (UUC). Patients with SBUC represent a potential urological emergency due to possible anuria or electrolyte imbalance. While conventional practice mandates immediate intervention in these patients, little data exist to define the rate of these events.
Retrograde Ureteral Catheterization: A Possible New Treatment for Renal Fungal Balls in Very Low Birth Weight Infants Invasive candidiasis is a serious pathogen of late-onset sepsis in very low birth weight infants. Kidney is the most common organ involved, and it causes morbidity and mortality, especially when fungal balls are formed. We report a 34-day-old female infant (born at 28 weeks' gestation, 1152 g) with systemic fungal infection complicated obstructive uropathy. On sonography, the fungal balls filled the entire pelvis without hydronephrosis. Percutaneous nephrostomy was not feasible. In addition to systemic antifungals, we successfully performed cystoscopy-assisted retrograde ureteral catheterization to decompress the pelvis, which also provided a route for local amphotericin B irrigation to achieve therapeutic concentration without nephrotoxicity.
Photoselective Vaporisation of the Bladder for the Management of Radiation Cystitis – Technique and Initial Outcomes. ObjectiveTo describe our technique utilising photoselective vaporisation of the bladder (PVB) for the management of haemorrhagic cystitis and initial results of 12 patients.Materials and MethodAn audit of theatre records of a single surgeon was performed to identify patients who had undergone PVB for management of radiation-cystitis. Technique: Rigid cystoscopy was performed. Ureteric catheters were placed and active bleeding sites targeted to optimise vision. Ablation was commenced using the vaporize function.
Reply by the Authors In adults, renal function recovery following partial nephrectomy plateaus, with no significant long-term recovery. Our study emphasizes the timing of this plateau, indicating that it occurs at 6-12 weeks, even earlier than previously suspected. Factors such as age and renal disease, although not investigated in our study, may impact the recovery trajectory. As highlighted, our results cannot be generalized to the pediatric population, where the evidence suggests a greater capacity for long-term recovery of renal function.
Laparoscopic Yang-Monti Ureteral Reconstruction in Children To investigate the clinical outcome of surgical treatment for long ureteral defect in children, we evaluated our experience of managing 6 children with the long defect utilizing laparoscopic ureteral reconstruction technique using Yang-Monti technique.
Nationwide Increase in Cryptorchidism After the Fukushima Nuclear Accident To estimate the change of discharge rate after cryptorchidism surgery between pre- and postdisaster in Japan. Cryptorchidism cannot be diagnosed before birth and is not a factor that would influence a woman's decision to seek an abortion. Therefore, this disease is considered suitable for assessing how the Great East Japan Earthquake and the subsequent Fukushima Daiichi nuclear accident (2011) influenced congenital diseases.
The Role of Imaging in Prostate Cancer Care Pathway: Novel Approaches to Urologic Management Challenges Along 10 Imaging Touch Points We map out a typical prostate cancer care pathway through discussion of updates on modern imaging. Multiparametric magnetic resonance imaging is the most sensitive and specific imaging tool for diagnosis and local staging, but transrectal ultrasound remains the most widely used technique for prostate biopsy guidance. Computed tomography and bone scan are useful in initial staging and recurrence detection. Novel imaging techniques in ultrasound elastography and multiparametric magnetic resonance imaging allow for increased lesion detection sensitivity and have the potential to enhance biopsy, while the development of new positron emission tomography radiotracers has great promise for improved detection of local and metastatic disease in patients with biochemical recurrence.
Priapism Throughout the Ages Long-lasting penile erections are closely associated with the god Priapus. He was regarded as the son of Dionysus, god of the vine, and Aphrodite, goddess of beauty. When Aphrodite was pregnant, the story was that her mother Hera was jealous, had put her hands on the belly of her daughter and pronounced a curse. As a result, Aphrodite gave birth to Priapus, a misshapen dwarf with a large erect penis,1 who, as a result, was subjected to ridicule and assumed to lack intelligence.2 Since antiquity, long-lasting erections have been the object of scientific interest.
Unilateral Papillary Cystadenoma of the Epididymis as a First Presentation of Von Hippel-Lindau Disease Association between papillary cystadenoma of the epididymis (PCE) and Von Hippel-Lindau Disease (VHLD) is well known and stronger for bilateral tumors. Unilateral PCE occurs either as a sporadic tumor without evidence of VHLD or in the context of a known diagnosis of VHLD, indeed it has never been reported as the first manifestation of VHLD. In contrast, we report the case of a boy with an apparently isolated, unilateral PCE that resulted to be the first manifestation of an unknown VHLD. Thus, we recommend screening for VHLD in patients with a new diagnosis of unilateral PCE, especially if the patients are young.
Bilateral Ureteroenteric Strictures: A Case of the “Reverse 7” Anastomotic stricture is a well-known complication of the urinary diversion that accompanies radical cystectomy. Management options range from endoscopic procedures to open surgeries, with a subset of the latter employing bowel as the interposing segment. In this report, we describe a rare patient, who successfully underwent a “Reverse 7” procedure, bypassing strictures at both anastomotic junctions between ureters and neobladder.
Frequent Penile Erection in a Boy With Autism-spectrum Disorder: Case Report Risperidone is commonly prescribed by pediatricians for a variety of behavioral and psychological disorders. We report a boy with autism-spectrum disorder, who developed frequent penile erections after an increase in risperidone dosage for a month. The patient fully recovered 2 days after risperidone discontinuation. This report concerns the youngest case of psychotropic medication-induced sexual disorders, which illustrates the differences in presentation between children and adults. Moreover, this case can serve as evidence that discontinuation should be recommended for the management of drug-induced sexual disorders.
Concurrent Robotic Pyelolithotomy and Partial Nephrectomy: Tips and Tricks With the evolution of robot-assisted surgery in the urology field, this technology is being applied to treat many genitourinary conditions.1 Although incidence of urolithiasis and renal neoplasm has increased, encountering both entities in a single kidney is noteworthy. Our video exhibits the concurrent management of a renal calculus and an ipsilateral renal neoplasm using a robotic platform.
Case Report: Nephron-sparing Surgery in a Patient With Bilateral Multifocal Wilms Tumor We present a case of bilateral multifocal Wilms tumor in a nonsyndromic 12-month-old male. Our management approach included 12 weeks of preoperative chemotherapy for maximal tumor shrinkage and, despite the central location of the tumors, successful staged bilateral nephron-sparing surgery. We advocate for a broader application of nephron-sparing surgery in Wilms tumor cases with the goal of preserving renal function without compromising oncologic outcomes.
Efficacy and Safety of Ureteroscopy for Stone Disease in a Solitary Kidney: Findings From a Systematic Review Management of stone disease in solitary kidney remains a difficult treatment entity for the urologist. The challenge exists to deliver high clearance while maintaining strong safety profile. Twelve eligible studies were included, comprising a total of 693 patients with a male:female ratio of 2:1. Overall, 114 (16.4%) complications were reported. No fatalities were reported in any of the studies. Clavien III complications were recorded in less than 0.5% of the patients. This review confirms the effectiveness, safety, and reliability of this technique for this unique cohort of patients.
Reply by the Authors We thank Van Howe for his letter.1 He posits, without evidence, that meatal stenosis (MS) typically develops 3-5 years after circumcision.1 A recent study that monitored MS onset by repeated examination following neonatal circumcision found that most MS developed in the first 2 months after circumcision: on average 2.3 and 3.8 weeks in the 2 groups studied.2 Symptoms were not reported in 36 of the 38 cases (95%). The authors suggested that this may be due to parents paying less attention to the urination of young babies than of older boys.
Pediatric Robotic Prostatectomy and Pelvic Lymphadenectomy for Embryonal Rhabdomyosarcoma We present the first published case of a pediatric robot-assisted prostatectomy and pelvic lymphadenectomy for refractory prostatic embryonal rhabdomyosarcoma. The patient is a 7-year-old male who had been treated with 3 cycles of chemotherapy and radiation, who underwent prostatectomy and lymphadenectomy for a recurrent mass. Surgery was uncomplicated and yielded negative surgical margins. We highlight the surgical technique and feasibility of utilizing robotic surgery for pediatric prostatectomy.
Giant Renal Hemangioma in an Adolescent Girl: A Very Rare Entity Hemangiomas are benign vascular tumors of childhood and they usually tend to be located in the upper parts of the body (head and neck). However, renal hemangiomas are very rare and usually occur to be small (1-2 cm) in size. Here, we report an adolescent girl with a giant renal hemangioma of 15 cm diameter.
Urinary Ascites Secondary to Bilateral Mid-ureteral Stenosis in a Neonate Urinary ascites is most commonly seen in fetuses and newborns with obstructive uropathy. The majority of cases are associated with lower urinary tract obstruction, such as posterior urethral valves. In this report, we present a unique case of neonatal urinary ascites caused by congenital supravesical obstruction. To date, neonatal urinary ascites secondary to bilateral mid-ureteral stenosis without a history of antenatal diagnosis has not been reported.
Successful Conservative Management of Bilateral Renal Mucormycosis Our patient is a 56-year-old man with medical history of poorly controlled insulin-dependent diabetes, bipolar disorder, and polysubstance abuse. Before presentation at our institution, he had been evaluated at several regional hospitals over the course of the preceding month. His symptoms were recurrent flank pain, fevers, and passage of long filamentous grey strings of material in his urine, which he described as “sea snakes.” Despite several negative urine cultures, he had been diagnosed with presumed pyelonephritis and treated with multiple courses of antibiotics including ceftriaxone, cephalexin, metronidazole, piperacillin-tazobactam, and ciprofloxacin, without any clinical improvement.
Evaluation of Vasectomy Trends in the United States To use the Truven Health MarketScan database to better approximate the annual rate of vasectomies performed in the US population, to determine changes over time, regional differences, providers performing this, and to know if there is any monthly variation in vasectomy rates.
Mucinous Lung Adenocarcinoma Metastasis to Testis in a 29 Year Old—A Case Report Testicular tumors represent 1% of all malignancies in men and are the most common solid tumors occurring in males between the age of 20 and 40 with the majority being primary germ cell tumors.1,2 Metastases to the testes are rare,3 and excluding lymphoma and leukemia, the commonest primary site is the prostate, followed by the lung.2,4,5 Patients with secondaries to the testes are most often over 50 years of age.3,6 We detail a rare case of a young man presenting with a testicular mass, proven to be metastasis from mucinous adenocarcinoma of the lung.
Longitudinal Rupture of Distal Corpus Cavernosum With Concomitant Urethral Injury: An Uncommon Result of a Common Mechanism Fracture of the penis is a well-recognized yet relatively uncommon urologic event. Forceful, blunt trauma with lateral bending of the penis in an erect state typically results in a transverse rupture of the tunica albuginea of the corpus cavernosum. Longitudinal tears of the corpus cavernosum are by themselves considered infrequent. We present a rare case of a patient with longitudinal rupture of the distal corpus cavernosum with concomitant extension to the corpus spongiosum causing partial urethral disruption as a result of trauma during sexual intercourse.
A Rare Case of Pediatric Vaginal Yolk Sac Tumor A 14-month-old girl was evaluated for intermittent vaginal bleeding. Vaginoscopy revealed a friable tumor, and biopsy results confirmed a yolk sac tumor. Alpha-fetoprotein was elevated (1386 ng/mL) at diagnosis but quickly normalized with chemotherapy. The patient remained tumor-free 12 months after diagnosis without the need for radical surgery. Although rare, malignant tumors of the vagina must be included in the differential diagnosis of prepubertal girls who present with vaginal bleeding. Primary yolk sac tumor of the vagina is seen in girls less than 3 years of age and is treated with chemotherapy with or without surgical excision.
Metastatic Pheochromocytoma in an Asymptomatic 12-Year-Old With von Hippel-Lindau Disease Pheochromocytoma is a rare chromaffin cell tumor that may be associated with a genetic predisposition, such as von Hippel-Lindau (VHL) disease. VHL is an autosomal dominant disorder that is characterized by a predisposition to multiple tumors, including retinal and central nervous system hemangioblastomas, renal cell carcinoma, and pheochromocytomas. The classic presentation of pheochromocytoma is episodic hypertension, headaches, palpitations, and diaphoresis. In the pediatric population, 40% of pheochromocytomas have a hereditary basis.
A Homeopathic Alternative to Potassium Citrate in Patients with Recurrent Nephrolithiasis The patient is a 55-year-old man with a history of Crohn's disease requiring multiple small bowel resections and a history of uric acid stones. He developed bilateral staghorn calculi and underwent numerous interventions including 3 left percutaneous nephrolithotomies (PCNLs), 2 right PCNLs, and multiple ureteroscopies with holmium laser lithotripsy (URS-HLL). His most recent procedure performed at our institution was a right PCNL in 2013.
Spermatic Vein Thrombosis A 36-year-old man was transferred from a freestanding emergency department to a nearby tertiary referral center for evaluation of an acute scrotum. He initially experienced midline back and right-sided flank pain in the preceding 24 hours while performing housework, but presented to the outside facility with acute-onset right-sided inguinal and scrotal pain that woke him from sleep. This pain was associated with right hemiscrotum swelling, self-limited gross hematuria, and passage of a small blood clot per urethra.
Impact of Statin Intake on Kidney Stone Formation To determine whether statin intake affects nephrolithiasis risk, and whether higher lipid levels correlate with stone risk. Dyslipidemia is a known independent risk factor for urolithiasis, and emerging evidence suggests common biological pathways. Previous work has suggested that statins protect against new stone formation, but these findings have not been verified by other investigators.
Metallic Ureteric Stents in Malignant Ureteric Obstruction: A Systematic Review The effectiveness of metallic stents in the management of malignant ureteric obstruction is unclear. This systematic review evaluates the use of 4 commercially available metallic stents (Resonance, Memokath 051, Uventa, and Allium URS). Twenty-one studies met eligibility criteria. Overall success rates ranged from 88% for the Allium stent to 65% for Memokath 051. Resonance demonstrated the lowest migration rate (1%). Uventa had the lowest obstruction rate (6%). Metallic ureteric stents offer a viable alternative in the management of malignant ureteric obstruction.
Dual Pathology Causing Congenital Bladder Outlet Obstruction Anterior urethral syringocele is an uncommon congenital deformity characterised by cystic dilatation of bulbo-urethral gland ducts and is usually asymptomatic. We present a case on 4-day-old male neonate who presented with bilateral antenatal hydroureteronephrosis and renal impairment and found to have urethral syringocele and posterior urethral valves (PUV).
Author Reply The comments of the editor truly reflect the findings of our study on the surgical treatment of giant penoscrotal lymphedema. All the 19 patients described in the study were to be treated by surgery. Eight patients, however, defaulted, possibly because of their belief in alternative traditional herbal medicine and or financial constraint, because health insurance schemes are yet to be fully established in our environment.
Is Cryotherapy a Genuine Rival to Robotic-assisted Partial Nephrectomy in the Management of Suspected Renal Malignancy? A Systematic Review and Meta-analysis We systematically reviewed the world literature and compare oncological outcomes, morbidity, renal function, and perioperative outcome between cryotherapy and robotic-assisted partial nephrectomy (RAPN) for suspected renal malignancy. There was a statistically significant difference in “recurrence rates” between the 2 techniques, favoring the RAPN cohort. There was no statistically significant difference in overall and ≥Clavien 3a complication rates between the 2 techniques. The quality of evidence for recurrence rates, overall complication, and ≥Clavien 3a were “moderate”, “low,” and “very low,” respectively, on GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach.
WITHDRAWN: Stented or Unstented Distal Hypospadias Repair The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2017.04.057. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
WITHDRAWN: Reply The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2015.08.053. The duplicate article has therefore been withdrawn.The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.
WITHDRAWN: Editorial Comment The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.urology.2013.02.086.The duplicate article has therefore been withdrawn.
Author Reply We agree that it would be interesting to compare the efficacy of a preincision dorsal penile nerve block with a preincision caudal block. A prospective, randomized trial including a protocol for intraoperative narcotic administration would be ideal. The performance of a dorsal penile nerve block by anesthesiologists using ultrasound guidance, however, may not reflect current clinical practice in the majority of pediatric centers. This is a classic example of efficacy (the performance of an intervention under ideal and controlled circumstances) vs effectiveness (its performance under “real-world” conditions).
Editorial Comment The benefits of regional anesthesia are legion and far exceed the well-documented improvement in analgesia over systemic analgesic strategies.1 In striving to achieve these benefits for our patients, we are careful to minimize the risks that may be associated with the regional anesthetic technique selected. Omitting regional anesthesia is not a no-risk solution, knowing that there are higher rates of adverse events associated with the systemic administration of opioids that likely would be necessary for adequate postoperative analgesia, compared with using modern regional anesthetic techniques to achieve pain control and minimize or eliminate opioids.
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