A Modified Neobladder Technique: The „I-Pouch“ – Illustration of Surgical Approach and Tricks Various techniques for orthotopic neobladder (ONB) are currently used and have shown satisfactory oncological and functional outcomes. Among the relevant oncological and functional aspects for long-term follow up is the easy accessibility of the upper urinary tract in urinary diversion for endoscopic monitoring. In addition, variety exists in the amount of ileum needed to create a urinary reservoir. Depending on the ONB technique, up to 60cm of ileum are required, and bowel dysfunction may be a consequence especially when the ileocecal valve is used for the urinary diversion.
Recurrent genital ulcers Papulonecrotic tuberculid represents a hypersensitivity reaction to Mycobacterium tuberculosis or its products that disseminate through hematogenous route to the skin from an internal tuberculous focus. It is characterized by recurrent eruptions of asymptomatic, dusky red papules, which undergo ulceration and crusting, and eventually heal after a few weeks with varioliform scarring. Although it most commonly involves extragenital sites, isolated glans penis involvement has been reported very rarely.
UNUSUAL PRESENTATION, RELAPSE AND METASTASIS OF A PEDIATRIC TESTICULAR YOLK SAC TUMOR: CASE REPORT. Testicular tumors are not uncommon in children and represent 1-2% of all pediatric malignancies. Prepubertal testicular yolk sac tumor is the most common childhood testicular cancer, accounting for 70-80% of all cases. The clinical presentation varies from one patient to another; most common presentation is painless scrotal mass. Herein, we present a case of pediatric patient with a testicular yolk sac tumor who had unusual presentation followed by a local relapse and metastasis and continued to have high markers while he was on chemotherapy, then underwent retroperitoneal lymph node dissection (RPLND) and local recurrence excision.
Authors’ Reply We would like to thank Dr. Zivkovic et al for their interest in our article and the thoughtful comments. The true incidence of bladder bowel dysfunction (BBD) in children is not well understood; however, it is estimated that BBD symptoms represent approximately 40% of pediatric urology consultations.1 The link between lower urinary tract and bowel symptoms is properly described in the literature. Common innervation of bladder and bowel and involvement of the pelvic floor muscles in the function of both systems result in close interaction between bladder and bowel, therefore patients often present with bowel complaints as well.
Women Leaders in Academic Urology: The Views of Department Chairs Women now comprise the majority of matriculants to medical school (51.6% in 2018),1 yet continue to be underrepresented in academic leadership. Across specialties, women comprise 14% of department chairs, 22% of vice chairs, 22% of division directors, and 17% of decanal positions.2 The lack of women who hold these leadership positions in the field of urology is more pronounced. In a 2017 study, women comprised 3.3% (4 of 122) of department chairs, 4.5% (2 of 44) vice chairs, and 7.9% (20 of 253) division directors.
Chief Year: Finding a New Normal During Uncertain Times On Saturday March 14, 2020, my off-site rotation director informed me that the rotation would be suspended, but should resume at the end of April. These early days of the pandemic were filled with equal parts confidence and denial. I, like so many others, was being reassigned. In the months that followed, I saw the drastic changes in normalcy through a very personal lens. Redeployed to the VA Hospital to help manage the overwhelming burden of rescheduling veteran's clinic appointments and taking call for emergencies, I spent much of the remainder of my fourth year of residency at home.
New Insights on the Basic Science of Bladder Exstrophy-epispadias Complex The exstrophy-epispadias complex is a rare congenital anomaly presenting as a wide spectrum of disorders. The complex nature of this malformation leads to continuous investigations of the basic science concepts behind it. Elucidating these concepts allows one to fully understand the mechanisms behind the disease in order to improve diagnosis, management, and treatment ultimately leading to improvement in patient quality of life. Multiple technological advancements within the last 10 years have been made allowing for new studies to be conducted.
Urethral Mucinous Adenocarcinoma of the Prostate: An Uncommon and Diagnostically Complex Disease A 66-year-old male presented with hematuria and mucosuria. A transurethral resection of the prostate revealed adenocarcinoma in situ with mucinous features. He underwent a robotic-assisted radical prostatectomy with lymph node dissection. Pathology confirmed T2 primary mucin-producing urothelial type adenocarcinoma in the prostatic urethra. Urothelial adenocarcinoma arising in the prostatic urethra is an uncommon disease that warrants clear differentiation from other malignancies due to its aggressive nature.
Pentosan Polysulfate Maculopathy: What Urologists Should Know in 2020 To conduct a review of current literature to assess whether an association exists between Pentosan Polysulfate Sodium and the development of macular disease, as it is the only oral medication approved by the Food and Drug Administration for the management of interstitial cystitis.
Complications Associated with Ureteroscopic Management of Upper Tract Urothelial Carcinoma Limited information is available regarding complications associated with kidney-sparing ureteroscopic management of low-grade upper tract urothelial carcinoma (UTUC). To identify the associated complications rates and contributing factors, we examined data from relevant clinical studies. Thirty-eight publications (7 prospective, 31 retrospective; >1100 total patients) were identified. Ureteral stricture was the most frequent complication (studies; rates) (26/38; 0-27%), with incidence associated with number of procedures and treatment method.
Burnout Through the Lens of a Photographer With a stained shirt, sunken eyes, and a shadow well beyond 5 o'clock, the man looked haggard and disheveled to say the least. He anxiously paced the small alcove outside our urology offices with a rapidity matched only by his darting eye motions. He was nervous. Or scared – hard to tell. With a twisted sense of curiosity, I lingered in the area to uncover this interloper's intentions. As I pondered, it dawned on me that in my blood-and-sweat-tinged scrubs approaching 28 hours old, my appearance (and odor) was not terribly dissimilar.
Infiltrative Renal Masses: Clinical Challenges A healthy 56-year-old male presented with gross hematuria and computed tomography scan showed a 9 cm right renal mass concerning for renal cell carcinoma (RCC) with venous involvement. The tumor also exhibited an irregular shape, diffusely replacing renal parenchyma with no clear interface between the tumor and normal parenchyma indicative of an infiltrative renal mass (IRM) (Fig. 1 A,B; Table 1, Case 1). Metastatic evaluation was negative and radical nephrectomy (RN) was performed with final pathology confirming pT3a,N0,M0 clear cell RCC, grade 4, with extensive sarcomatoid differentiation.
Inflammatory Myofibroblastic Tumor of the Bladder With FN1-ALK Gene Fusion: Different Response to ALK Inhibition Inflammatory myofibroblastic tumors are rare tumors with an ALK (anaplastic lymphoma kinase) gene rearrangement in up to 65% of all cases. In our patient, the tumor was not primary resectable due to its extension. Under neoadjuvant treatment with the first generation ALK inhibitor crizotinib no tumor response was seen, but the following therapy with the next generation ALK inhibitor lorlatinib led to a rapid and deep response, enabling a complete tumor resection by partial cystectomy. Our case indicates that ALK positive inflammatory myofibroblastic tumors which do not respond to ALK inhibition with crizotinib can be successfully treated with newer agents.
Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery? The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.
Current Status and Role of Patient-reported Outcome Measures (PROMs) in Endourology Kidney stone disease can have a number of adverse effects on patients including quality of life. Studies assessing outcome measures in this area have largely been focused on objective assessments such as stone free rate. However, as part of the evolution to shift healthcare to a more patient centered position, patient-reported outcome measures have emerged as an improved tool to address this deficit. Key patient-reported outcome measures in Urology now include Ureteral Stent Symptom Questionnaire, Wisconsin Stone QoL Questionnaire, Cambridge Ureteric Stone PROM, Cambridge Renal Stone PROM, and Urinary Stones and Intervention Quality of Life.
Seminal Vesicle Cysts With Upper Urinary Tract Abnormalities: A Single-center Case Series of Pediatric Zinner Syndrome Seminal vesicle cysts are usually congenital and frequently accompanied by upper urinary tract abnormalities due to mesonephric duct maldevelopment. Zinner syndrome, first described in 1914, refers to a triad of features consisting of seminal vesicle cysts, ejaculatory duct obstruction, and unilateral (mostly ipsilateral) renal agenesis. We herein present four pediatric patients with Zinner syndrome diagnosed at a children's medical center. A remnant ureteral structure was observed in three (75%) patients.
Dr. Alexander Randall III and the Discovery of Randall's Plaques Urolithiasis has plagued humankind since before written history. Bladder stones have been recovered from 4500- to 5000-year-old mummies in Egypt.1 Similarly, kidney stones or nephrolithiasis has been described for thousands of years. Hippocrates described the painful passing of sand through the penis originating from the kidneys.2 The first operation on a kidney was not performed until many years later when in 1550 Cardan of Milan opened a lumbar abscess and removed 18 renal stones in the process.
Metoidioplasty with Urethral Lengthening: A Stepwise Approach Metoidioplasty is a gender-affirming surgical option for individuals who desire masculine genitalia while preserving erogenous sensation and avoiding the morbidity of phalloplasty. Concurrent urethral lengthening offers patients the potential to stand to urinate.
Statewide Price Variation for Generic Benign Prostatic Hyperplasia Medications To examine the geographic and pharmacy-type variation in costs for generic benign prostatic hyperplasia (BPH) medications in order to improve drug price transparency and reduce health disparities. Medical therapy for BPH can be expensive, having significant implications for uninsured and underinsured patients.
Women in Leadership in Urology: The Case for Increasing Diversity and Equity There is a persistent male gender predominance in urology, especially with respect to female representation in leadership. We review the current status of women in urology leadership, discuss challenges women face in leadership positions, present the case for adopting inclusive practices that increase diversity and gender equity in urology leadership, and review the potential benefits of such an expansion. We discuss practical strategies to grow the role of women in urologic leadership, including increasing mentorship, modifying academic promotion criteria, and addressing implicit bias, while presenting a roadmap toward achieving equity and diversity at the highest ranks of urologic leadership.
Hyperbaric Oxygen as Salvage Therapy for Neonates Suffering From Critical Ischemia of the Glans Penis After Circumcision Ischemic complications of glans penis following circumcision are rare, and if occurs can culminate in irreversible necrosis with severe long-term consequences. Here we present 2 challenging cases of neonates suffering from acute severe glans penis ischemia after circumcision that were treated by hyperbaric oxygen treatment (HBOT). In addition to case presentations, the literature related to complications of circumcision and the physiological effects of HBOT are being reviewed. Based on the review and the case presented, we conclude that HBOT can be used as salvage treatment for circumcision induced glans ischemia as early as possible before full necrosis develops.
Cystoscopic Management of Prostatic Utricles In this case series (n = 7) on prostatic utricles (PU), retention of urine was seen in 5 of 7, urinary tract infection (4 of 7), recurrent epidydymo-orchitis (3 of 7), and scrotal sinus (1 of 7). Voiding cystourethrogram established diagnosis in 3 of 7 patients while CT/MRI in 4 of 7 patients. Four patients were primarily managed by cystoscopic widening of mouth of PU. Three with large PU underwent initial open (2) or laparoscopic (1) excision but later warranted cystoscopic widening for residual PU.
Mature Ovarian Cystic Teratoma Mimicking a Bladder Diverticulum in a 16-year-old Female A 16-year-old female was incidentally found to have an abnormal pelvic ultrasound while undergoing evaluation for mild scoliosis. A large, thick-walled, lobular, fluid-filled structure was found at midline in the pelvis that initially resembled bladder diverticula due to its anatomical position and sonographic appearance. Voiding cystourethrogram (VCUG) and computed tomography (CT) later revealed a large cystic mass originating from the right ovary. This report outlines a case of a mature cystic teratoma convincingly mimicking bladder anomaly on sonography.
Management of Testicular Torsion and a Contralateral Testicular Mass Presenting Synchronously Testicular masses found in prepubertal males are often benign in nature. This has led to an increase in the use of testis-sparing surgery. Testicular torsion is considered a urologic emergency that requires immediate surgical intervention. Based off literature review, it is rare for these unique entities to present synchronously in a single patient. This report demonstrates that in the pediatric population it is possible to safely treat a suspected benign testicular mass with testis sparing mass enucleation if it presents synchronously with testicular torsion in the contralateral testis.
Clinical Challenges in Urology: An Enhancing Mass Abutting the Collecting System We present a clinical imaging question focusing on a patient with a history of gross hematuria and an enhancing mass abutting the left renal collecting system. In patients with nondiagnostic cytology and imaging, upper tract urothelial carcinoma should be explored as a potential etiology prior to definitive surgical management.
A Rare Case of Urethral Schwannoma The patient is a 28-year-old male referred to our GU Reconstruction Center due to a slowly growing ventral penile mass. The patient described the mass as slowly growing over 2 years with recent development of urinary symptoms including weak stream, post void dribbling, and urine splaying. Work up with a pelvic magnetic resonance imaging showed an oval enhancing nodule in the distal aspect of penile urethra measuring 2.4 × 1.3 × 1.4 cm with apparent involvement of the spongiosum. It did not appear to be involving the corpora and no pelvic lymphadenopathy was noted (Fig.
Laparoscopic Partial Nephrectomy in Allograft Kidney The incidence of renal tumor on the allograft kidney is relatively rare. There is no standard treatment available for the management of such cases. However, if technically feasible nephron-sparing surgical approaches, whether open or minimally invasive, should be preferred for the management of these challenging cases. To our knowledge, there is no pure laparoscopic technique reported in the literature but only 3 cases of robot-assisted partial nephrectomy. In this article, we aimed to present the application of pure transperitoneal laparoscopic partial nephrectomy for the management of a renal mass on the allograft kidney.
Germline HSD3B1 Genetics and Prostate Cancer Outcomes Dihydrotestosterone synthesis in prostate cancer from adrenal DHEA/DHEA-sulfate requires enzymatic conversion in tumor tissues. 3β-hydroxysteroid dehydrogenase-1 is an absolutely necessary enzyme for such dihydrotestosterone synthesis and is encoded by the gene HSD3B1 which comes in 2 functional inherited forms described in 2013. The adrenal-permissive HSD3B1(1245C) allele allows for rapid dihydrotestosterone synthesis. The adrenal-restrictive HSD3B1(1245A) allele limits androgen synthesis. Studies from multiple cohorts show that adrenal-permissive allele inheritance confers worse outcomes and shorter survival after castration in low-volume prostate cancer and poor outcomes after abiraterone or enzalutamide treatment for castration-resistant prostate cancer.
Nephrolithiasis in Pregnancy: Treating for Two Symptomatic nephrolithiasis affects less than 1% of all pregnancies but poses unique risks to both mother and fetus. Diagnostic imaging in this population is challenging due to physiologic changes of pregnancy and concerns regarding fetal ionizing radiation exposure. Ultrasound remains the imaging modality of choice. Most patients can be managed with expectant management, but percutaneous nephrostomy or ureteral stent placement are options if intervention is warranted. Growing evidence also supports the safety and efficacy of definitive stone treatment.
Surgical Treatment of Primary Penile Scrotal Lymphedema: A Case Report Lymphedema is the result of altered lymphatic drainage. Primary lymphedema is a rare condition with a reported incidence of only 0.6%. Most cases in children are caused by congenital factors. We report a 4-year-old child with primary penile scrotal lymphedema combined with bilateral hydrocele, and satisfactory therapeutic and aesthetic results were obtained through surgical resection and genital reconstruction.
Optimizing Women's Sexual Function and Sexual Experience After Radical Cystectomy Survivorship in bladder cancer has improved in terms of lower morbidity, mortality, and improved oncological outcomes. However, there is a dearth of research on women's quality of life, specifically, on the effect of radical cystectomy on women's sexual function and sexual experience. This narrative literature review focuses on the current state of knowledge about women's sexual function after cystectomy, identifies patient and provider-related factors that have contributed to the lack of research and sexual health support in clinical practice, and proposes a model for sexual rehabilitation as well as future areas for research.
Morphologic Factors Associated With Open Conversion During Holmium Laser Enucleation of the Prostate To determine if there is an association between patient body habitus as measured by body mass index (BMI), body surface area (BSA), preoperative prostate volume, postoperative specimen weight, and open conversion with cystotomy or perineal urethrotomy (PU) during holmium laser enucleation of the prostate (HoLEP). We attempt to provide meaningful criteria to assist in preoperative patient counseling.
Endovascular Management of Renal Arteriovenous Fistula With Large Aneurysm Masquerading as a Renal Cyst Large renal aneurysms can masquerade as simple renal cysts on ultrasound, especially if Doppler examination is not routinely done to assess flow characteristics. We present a case report of a 26-year-old male, as a clinical challenge in urology, who had minimal symptoms, yet had an arteriovenous fistula with a large aneurysm which was diagnosed as a parapelvic cyst on ultrasound. Endovascular treatment of the arteriovenous fistula was done using a vascular plug with satisfactory outcomes.
Rare Case of Disseminated Coccidioidomycosis Presenting as a Renal Mass Mimicking Carcinoma A 75-year-old Caucasian West Texas man presented with a history of night sweats, fatigue, and a 40-pound unintentional weight loss for 2 months accompanied by urinary frequency and urgency. Urinalysis was positive for microscopic hematuria. He was referred to the urology clinic and underwent cystoscopy that revealed 2 small right lateral wall bladder tumors – together 2.5 cm in size – and moderate enlargement of the prostate. Transurethral resection of bladder tumors was performed without complications.
Baseline renal volumes in children born with cloacal anomalies To better understand why children born with cloacal anomalies are at a high risk of renal insufficiency, this study aims to determine baseline renal volume in children with cloacal anomalies compared to controls. We hypothesized children with cloacal anomalies would be born with less renal volume.
Multiple Arteries Kidney Offer Kidneys with more than 3 arteries are very rare and decision to use or not these organs can be difficult, because there is an increased risk of post-transplant vascular complications, with a higher risk of worse outcome.Here we report a case of a successful transplant a deceased donor left kidney with 5 arteries, using 2 separate wide patches containing 3 and 2 arteries, respectively.These kidneys should be considered as a source for maximize the number of organs available, but a careful selection of the recipient is also crucial for minimize the risk of complications.
Warfarin-induced Spontaneous Retroperitoneal Hemorrhage in a Patient With Metallic Mitral Valve–Dilemmas in Management We report a 70-year-old gentleman who attended the emergency department with a 1 day history of sudden onset right-sided flank pain. He was on warfarin due to metallic mitral valve. On presentation, he was hemodynamically stable, but his international normalized ratio was deranged at 4.7. An initial noncontrast computed tomography (CT) scan of abdomen showed a large right retroperitoneal hematoma and subsequent CT renal angiogram revealed evidence of active bleeding. There were dilemmas whether or not to reverse the effect of warfarin, proceed with angioembolization or explore the patient surgically.
Translation in Urology: Caring for a Primarily Non-native English Speaking Population “My life is in your hands doctora, whatever you think is best.” What a phrase to hear as an urologist in training. It is, on one hand, exciting to accept the responsibility which we have trained so hard to prepare for. On the other hand, that phrase conveys the immense gravity of such responsibility. In this particular case, my patient was a middle-aged man, Spanish-speaking, with a new diagnosis of low-intermediate risk prostate cancer. I was trying to explain to him his diagnosis and his options, including androgen deprivation therapy/radiation and surgery.
Renal Hilar Clamping With a Standard Robotic Bulldog Clamp Using the Single Port da Vinci Robot Renal hilar clamping during a robotic partial nephrectomy is essential for a successful, nephron-sparing tumor resection. Standard robotic bulldog clamps are modified to accommodate multiport robotic surgical systems with alterations including knobs to fit robotic forceps and reduced spring tension. Despite the lower spring tension, a standard robotic bulldog clamp cannot be loaded and opened using one Single Port robotic arm. The angled path instrument cables take through multiple robotic arm articulations lowers the maximum force generated by Single Port instruments to below what is necessary to load and open a robotic bulldog clamp.
Urologists for Equity: Letter to the Urologic Community The recent murders of Breonna Taylor, George Floyd, Tony McDade, and countless others, and the disproportionate toll of COVID-19 on communities of color, have exposed deep wounds in our country. As our nation confronts systemic racism, we must all reflect upon our own contributions to the current crisis and on actions we must take to create sustainable change.
Isolated Metastasis to the Brain From Upper Tract Urothelial Carcinoma Isolated brain metastasis from cancers of urothelial origin are rare, especially after a long recurrence-free interval with few reports in the literature. We herein present the case of a 62 year old male with history of recurrent bladder cancers treated in 2004 and 2005 and a left distal ureteral high grade pT3aN1M0 urothelial cancer treated with distal ureterectomy and reimplant followed by adjuvant chemotherapy in 2014 who presented after a 5 year recurrence-free interval with tonic-clonic seizure.
Segmental Testicular Infarction Associated to Torsion: First Case Report in Childhood Testicular torsion in children is not uncommon emergency problem which occur due to twist in the spermatic cord leading to ischemia or infarction to testicle. Hemorrhagic infarction can occur following testicular torsion is globally; however, in extremely rare situation, such infarction can be segmental.Segmental testicular infarction (STI) was reported in an infant due to epididymitis and a newborn with STI in 1 testicle with complete infarction in the contralateral testicle due to birth trauma.
Supernumerary Kidney Associated With Horseshoe Malformation and Ureteric Stricture With Hydroureteronephrosis – A Rare Case Supernumerary kidney is an accessory kidney with its own vasculature, collecting-system and encapsulated parenchyma with about 100 cases reported in the literature. However, there is no report of supernumerary kidney associated with horseshoe malformation with ureteric stricture. We report a rare case of 20 months old female admitted with left-sided abdomen lump and mild abdominal pain. During surgery, supernumerary kidney with horseshoe component with grossly-dilated left-sided pelvicalyceal system and proximal 1-cm of left-ureter, distal to which whole of left-ureter was noncanalized, was seen.
High Submuscular IPP Reservoir Placement: The “Five-Step” Technique High submuscular (HSM) placement of inflatable penile prosthesis (IPP) reservoirs is a promising new FDA approved alternative to traditional space of Retzius reservoir placement. In 2011, we began placing all reservoirs in a HSM position at our tertiary center. In 2014, we proposed a refined, “Five-Step” HSM reservoir placement technique (FST) to prevent deep pelvic complications.
Urinary pubic symphysis fistula leads to histopathologic osteomyelitis in prostate cancer survivors To assess the histologic findings in the pubic bone resected during extirpative surgery for urinary pubic symphysis fistula (UPF). The concurrent presence of osteomyelitis and the need for bone resection at time of extirpative surgery for UPF has been debated. We hypothesized that UPF results in histopathologically confirmed osteomyelitis, underscoring the importance of bone resection at the time of surgery.
Spontaneous Intraperitoneal Urinary Bladder Rupture Due to Alcohol-Intoxication A 21-year-old Hispanic female arrived to the emergency department with sudden onset of generalized abdominal pain. She reported drinking alcohol the night before and stated that the symptoms developed after she was done drinking, about 19 hours prior to presentation. She denied any falls, trauma or injury when she was out drinking. Movement and inspiration exacerbated the pain. The patient also reported that she has had no desire to void since the pain started. She took ibuprofen, but it did not provide relief.
Risk of Genitourinary Malignancy in the Renal Transplant Patient To better understand the risk of genitourinary malignancies in the renal transplant patient. Currently, no consensus exists regarding screening and intervention, with much of the clinical decision-making based on historical practices established before recent progress in immunosuppression protocols and in genitourinary cancer diagnosis and management.
AUTHOR REPLY We are happy to answer some of the questions you asked. PRP is a blood component used in regenerative medicine with limited use in urology and there are few studies about this topic. We hope the present study fills a gap in the literature and acts as a guide for different studies at advanced level.1
The Curious Case of Primary Prostatic Seminoma Primary extragonadal germ cell tumor (GCT) is a rare but well described entity, the common sites being retroperitoneum or mediastinum. GCTs are further classified as seminomatous and nonseminomatous GCTs, with extragonadal ones predominantly being seminomas. Primary seminoma arising in the prostate is extremely rare, and only 7 similar cases have been reported in the medical literature. We present this unusual case of a middle aged male with complaints of severe lower urinary tract symptoms. On being further evaluated for a clinical suspicion of locally advanced prostate cancer; he was unexpectedly diagnosed as a case of “Primary prostatic seminoma.”
Native Ureter Ventriculo-Ureteral Shunt Placement for Management of Refractory Hydrocephalus in a Child With a History of Renal Transplant: Case Report and Technical Note This report describes the case of a 5-year-old male with intractable hydrocephalus secondary to neonatal intraventricular hemorrhage who was ultimately managed with the placement of a ventriculo-ureteral (VU) shunt. He had previously failed numerous attempts at cerebrospinal fluid shunting, choroid plexus cauterization, and endoscopic third ventriculostomy. The patient had a history of end stage renal disease, and had previously undergone renal transplant. In an operation that involved Neurosurgeons, Pediatric Urologists, and Transplant surgeons, a Gibson incision was used to avoid the patient's multiple intra-abdominal adhesions, and his nonfunctioning renal unit was used to implant a VU shunt without early or late complications.
Gynecologic Considerations for the Urologic Surgeon While gynecologic malignancy is uncommon in women with conditions such as pelvic organ prolapse and bladder cancer, urologists should be acquainted with the relevant gynecologic literature as it pertains to their surgical care of female patients. While taking the patient history, urologists should be aware of prior cervical cancer screening and ask about vaginal bleeding, which can be a sign of uterine cancer. Urologic surgeons should also discuss the role of concomitant prophylactic oophorectomy and/or salpingectomy for ovarian cancer risk reduction at the time of pelvic surgery.
Laparoscopic Abdominoscrortal Hydrocele: A Case Series To evaluate the effect of laparoscopic percutaneous extraperitoneal closure (LPEC) of the internal inguinal ring for the treatment in pediatric abdominoscrotal hydrocele (ASH) and to assess the feasibility and safety of the procedures.
A Rare Case of Prolapsed Ureterocele with Large Redundant Flap After Unroofing in Adult Female We present a case of 26-year female who presented with acute urinary retention and vulvar mass. She denies any urinary complaints in the past except for occasional straining for voiding. Imaging revealed a prolapsed ureterocele, it was successfully managed with incision and excising a flap of ureterocele due to the risk of postoperative protrusion of the redundant ureterocele. On follow-up at 6 months she was voiding well without any complaints.
Refractory Lymphatic Ascites After Radical Prostatectomy Lymphatic ascites after pelvic lymphadenectomy is a rare complication and is rarely reported after urologic surgery. We report a case of delayed and refractory lymphatic ascites following robotic-assisted laparoscopic radical prostatectomy.
Strangulated Internal Hernia Beneath the Obturator Nerve After Laparoscopic Radical Cystectomy With Extended Pelvic Lymph Node Dissection Internal hernia beneath the vascular structures after pelvic lymphadenectomy is a rare condition. Herein, we report a case of a strangulated internal hernia beneath the obturator nerve 38 months after laparoscopic radical cystectomy with extended pelvic lymphadenectomy. Computed tomography revealed dilated small bowels and a closed loop in the pelvis. The emergency laparotomy was performed, and a strangulated internal hernia beneath the obturator nerve was observed. It is necessary to consider the possibility of internal hernia beneath the vascular structure, including the obturator nerve, after the pelvic lymph lymphadenectomy, particularly via a minimally invasive approach.
Heterotopic Bone Formation in Clear Cell Renal Cell Carcinoma Clear cell renal cell carcinoma is associated with calcium deposition in a significant percentage of patients. However, frank ossification within a tumor is extremely rare. We report a case of a 41-year-old male with a slow-growing left renal mass who underwent minimally invasive nephron-sparing surgery. Final pathology revealed clear cell renal cell carcinoma with focal areas of heterotopic bone formation. While prognostic implications of this variant are unclear, patients with renal cell carcinoma with osseous metaplasia can present with slow growth kinetics and early-stage disease.
Diagnostic Accuracy of Multiparametric MRI for Local Staging of Bladder Cancer: A Systematic Review and Meta-Analysis To evaluate diagnostic accuracy of multiparametric magnetic resonance imaging (mpMRI) for local staging of urothelial bladder carcinoma (UBC), a systematic review was performed. Of 2369 records, 20 studies met the inclusion criteria (n=1724). We found a pooled sensitivity and specificity for differentiating between stages ≤T1 and ≥T2 of 0.92 (95% CI 0.88-0.95) and 0.88 (95% CI 0.78-0.94). mpMRI shows high sensitivity and specificity for the differentiation between non-muscle invasive and muscle invasive bladder cancer, but does not appear to be useful for staging per T-stage.
Emphysematous Pyelonephritis in a Horseshoe kidney Emphysematous pyelonephritis is a necrotizing renal infection that results in the presence of gas in renal parenchyma, collecting system, and surrounding tissues. Ninety-five percent of the patients have underlying uncontrolled diabetes mellitus, but non-diabetic patients may be affected due to ureteral obstruction and infection with gas forming pathogens. Several poor prognostic factors have been described, such as thrombocytopenia, acute kidney failure, impaired consciousness, and shock. We present a case of a 41-year-old female who attends to the emergency department with signs of septic shock and diffuse abdominal pain.
Urethral Multiplicity: When Two Are Better Than One Urethral multiplicity is a rare congenital anomaly that may be associated with lower urinary symptoms, whereas congenital urethral diverticulum is even more rare and may predispose to obstructive uropathy and urinary sepsis. We report 2 cases of boys with urethral multiplicity, to include urethral duplication associated with duplicated urethral diverticula and a case of urethral triplication.
Rising Tides: Challenges and Opportunities for Women in the Urologic Workforce The number of practicing female urologists has increased from < 2% in 1980 to 9.2% in 2018. Despite this increase, urology trails far behind medical fields overall and surgical subspecialties, in achieving gender parity. Barriers, such as pervasive biases and institutional policies, exist at the medical student, resident, and practicing urologist levels. Once recognized as detrimental, action can be taken to combat these forces to allow for advancement of women in the field of urology. This will result in a richer workforce better able to serve its patient population and advance the field.
Let's Talk About Sex: Special Considerations in Reproductive Care and Sexual Education in Young Women With Spina Bifida Medical advances in the last several decades have allowed an increasing number of children with spina bifida to reach adolescence and adulthood. As they reach puberty, girls with spina bifida face unique social and health challenges to their sexuality, such as orthopedic restrictions, continence, and pelvic floor disorders. Recent research efforts have focused on better understanding female sexual desires, dysfunctions, and activity and the role of the physician in educating this vulnerable population.
Congenital Lymphedema of the Foreskin in a 3-Year-Old Boy: A Case Report and Literature Review Congenital lymphedema of the external genitalia is a rare, disfiguring disorder. We describe here a case of a 3-year-old male with primary foreskin lymphedema persisting since birth. A compact, heterogenous swelling of the foreskin's distal third was observed, inhibiting preputial retraction (phimosis). Right lower extremity lymphedema was also observed in this case, while no further abnormalities were found. Surgery was performed, maintaining the foreskin, producing an excellent result with no recurrence at 10-month follow up.
Management of a Ureteral Stent Displaced Into the Abdominal Aorta: A Case Report A 46-year-old female patient presented to her gynecologist who complained of 1-month history of irregular vaginal bleeding and abdominal pain 2 months ago. She first visited the local hospital, abdominal B-mode ultrasound showed multiple myomas of the uterus. The patient had severe vaginal bleeding symptoms and no fertility requirements, so laparoscopic hysterectomy was a suitable treatment option. It was found that the lower segment ureter and the uterine tumor were obviously adhered during the operation.
Gastric Adenocarcinoma Arising in Gastrocystoplasty Gastric cancer is a rare long-term complication in gastrocystoplasty. We report 2 cases of gastric adenocarcinoma and review the literature for similar cases. A total of 14 cases are identified. The majority of patients are males, presented with hematuria, and developed cancer at a younger age, more than 10 years after gastrocystoplasty. Long-term follow up information was limited, but 5 patients (36%) died within 5 years of diagnosis. Annual surveillance for malignancy may not be effective due to its rarity.
Acute Scrotum Secondary to Torsion of a Tunica Vaginalis Cyst This is a case of an 8-year-old boy with a chief complaint of left-lower-quadrate abdominal pain for 3 days. Examination revealed swollen left hemi-scrotum and scrotal ultrasound showed a para-testicular cystic mass, which was later proven to be a torsion of a benign scrotal tunica cyst during emergent scrotal exploration. Torsion of the tunica vaginalis cyst is a rare cause of acute scrotum, and we present this case to share our experience of diagnosis and management of this peculiar disease.
Squamous Cell Carcinoma of the Bladder Is Not Associated With High-risk HPV To evaluate the clinical features, pathologic features, and prevalence of human papilloma virus (HPV) in squamous cell carcinoma (SCC) of the bladder. SCC of the bladder is known to be associated with conditions that cause chronic inflammation/irritation. The literature is inconsistent regarding the association of HPV with pure SCC of the bladder.
Predictive Risk Factors for Continued Smoking after the Diagnosis of a Genitourinary Malignancy To determine risk factors for continued smoking following a diagnosis of a genitourinary (GU) malignancy. Smoking is a well established risk factor in the development of cancers involving the GU tract. Unfortunately, a large percentage of patients continue to smoke or relapse after cancer diagnosis; by doing so, there is an increased risk of recurrence, poor survival rates, treatment complications, secondary primary cancers, and other chronic smoking related illnesses.
Understanding the Complex Relationship Between Androgens and SARS-CoV2 In the United States, 54% of hospitalizations for COVID-19 are among men.1 In Italy, men represent 70% of COVID-19-related deaths.2 Additionally, there is a relative lack of prepubertal infection.3 The reason for these higher rates of infection and mortality in men, and the correspondingly low rates in prepubertal children remains unknown. It is possible that an androgen-dependent process may help account for these epidemiological findings, which is a topic of intense focus currently.4-6
Incidence of Significant Findings of Microhematuria Workup in Women—What Guidelines Work Best? To apply the American Urogynecological Society (AUGS)/American College of Obstetricians and Gynecologists (ACOG) recommendations of foregoing workup in patients under 50 years of age with less than 25 red cells per high-powered field, to a cohort of asymptomatic microscopic hematuria (AMH) patients, and assess diagnostic accuracy, sensitivity, specificity, positive, and negative predictive value compared to the American Urologic Association (AUA) guidelines.
Testicular Torsion From Bell-clapper Deformity A 12-year-old otherwise healthy boy presents to a local emergency room with sudden onset, sharp, continuous left testicular pain for 9 hours, associated with nausea and vomiting. Exam and ultrasound is consistent with testicular torsion. During scrotal exploration, a bell-clapper deformity of the left testicle is appreciated, with a normal gubernacular attachment of the right testicle. Bell-clapper deformity is a congenital failure of the posterior attachment of the gubernaculum to the testis, which increases testicular mobility within the tunica vaginalis and predisposes individuals to testicular torsion.
Diagnosis and Management of Urolume Urethral Stent Complications Using Ultrasonography and Magnetic Resonance Imaging The UroLume urethral stent (American Medical Systems) was introduced to the market in 1988 for management of male urethral stricture and benign prostatic hyperplasia.1 However, recent reports in the literature showed long-term complications, including: urethral restenosis, urethral pain, recurrent urinary tract infections, and stent migration. Therefore, UroLume's efficacy in managing bladder outlet obstruction had to be weighed against an alarmingly high rate of long-term complications.2,3 In this report, the role of ultrasonography scan and magnetic resonance in the diagnosis and management of UroLume complications is evaluated.
Presentation and Diagnosis of Ureteral Quadruplication: Case Report and Analysis of the Literature Ureteral quadruplication is exceedingly rare. All except for 2 cases were symptomatic and nearly all underwent intervention. We present the first case of asymptomatic ureteral quadruplication in the presence of ureteral cyst. The report is first to prove ureteral quadruplication, even with ureteral cyst, can have normal renal function and parenchyma without obstruction or reflux. The report analyzes differences between the 14 cases of ureteral quadruplication in the English literature. It is first to describe bilateral ureteral cysts with ureteral quadruplication and triplication, and is first to accurately characterize the appearance of quadruplicated ureters inside the kidney.
A Tale of Two Eras: The Effect of the COVID-19 Pandemic on Stone Disease Presentations The novel coronavirus disease-19 (COVID-19) pandemic triggered a national emergency declaration in the United States on March 13, 2020. The resultant diversion of healthcare and public attention toward disease exposure avoidance, propagated a concerning reduction in emergency department (ED) presentations for many serious medical conditions.1 Urinary stone disease (USD) is a frequent cause of ED visits and can be life or organ threatening if not treated in a timely manner.2 One small Italian study showed that the pandemic had no effect on USD emergency presentation rates3 but its effect in a larger US cohort remains unknown.
Gender-affirming Vaginectomy–Transperineal Approach Gender-affirming vaginectomy treats gender dysphoria associated with the presence of a vagina in transgender males.1,2 Prior reported approaches include transperineal vaginectomy, mucosal fulguration, and robotic-assisted. We present key steps in transperineal gender-affirming vaginectomy in a 39-year-old transgender male.
Regional Anesthesia. An Alternative to General Anesthesia in the Management of Neonatal Testicular Torsion We report a case of a 1-day-old male newborn with neonatal testicular torsion, in whom an immediate orchiectomy with prophylactic orchidopexy under caudal regional anesthesia was practiced. The aim of this report is to propose early surgical intervention with caudal regional anesthesia as an alternative in order to avoid possible side effects related to general anesthesia and the complications related to a missed asynchronous torsion of the contralateral testis.
Noninvasive Ewing's Sarcoma of the Penis: A Rare Entity A 53-year-old male with history of colon cancer status postneoadjuvant chemotherapy, radiation and colectomy, hyperlipidemia, non–insulin-dependent diabetes mellitus, obesity, hernia repair, and asthma presented to the urology clinic complaining of left inguinal swelling. Upon presentation, vital signs were unremarkable, but physical exam revealed a firm, palpable, nontender abnormality of the left inguinal region. Subsequent computed tomography (CT) scan with IV contrast revealed a large presacral fluid collection (7.0 × 2.4 cm) and complex cystic structure arising from the left tunica albuginea (3.8 × 3.0 cm) adjacent to the left corpora cavernosa.
The Clinical Application and Potential Roles of Circulating Tumor Cells in Bladder Cancer and Prostate Cancer Circulating tumor cells (CTCs) are considered to be promising biomarkers in malignant diseases. Recently, molecular profiles of CTCs in prostate cancer (PCa) and the role of CTCs in neoadjuvant chemotherapy and transurethral resections of bladder cancer (BCa) are intensely studied. However, localized PCa and nonmuscle-invasive BCa are less investigated and discussed. Moreover, the benefit and feasibility of clinical applications of CTCs should be critically questioned and reevaluated. This review focuses mainly on clinical issues and lesser on methodologies, and summarizes the quintessence of available works dealing with clinical applications of CTCs in PCa and BCa management.
AUTHOR REPLY We thank the authors for their interest in our study. Our main finding was that cutting the fiber tip results in a reduction in power output and lithotripsy. The amount of fragmentation is far greater with a brand-new tip, vs one that is cut with Mayo scissors. The parameters used in our study, lithotripsy of 3.6 minutes and 2.2 kJ, could be considered on the lower end of clinically reported parameters.1 Ritchie et al performed laser lithotripsy for 10 minutes duration and found the stripped fiber provided greater fragmentation compared to an unstripped fiber.
Laser Fibers and Transparent Tips? No Thanks! The degradation of the laser fiber due to prolonged activation is a common and well-described experience. Cutting the fiber has been suggested as a strategy for restoring its effectiveness. Aldoukhi et al1 tested in vitro the degradation of 2 different fibers during both fragmentation and dusting of Begostones. The lithotripsy efficacy of factory-new disposable and reconditioned reusable fibers was compared both in their native setup (ie, transparent tip) and after being cut with Mayo scissor (no stripping).
A Call to Action for Resident Parental Leave The AUA Residents and Fellows Committee sought to investigate parental leave trends among US residents and to define any relation to burnout. With the help of the AUA Data Committee and AUA Science and Quality Council, the Residents and Fellows Committee developed a trainee module for the AUA 2019 Census.1 Of the 512 responses received, 415 were validated US residents, making this survey the largest representative sample of trainees to date.2 Residents were provided a range of resources and asked to prioritize the ones most important to them in preventing burnout.
A Urology Department's Experience at the Epicenter of the COVID-19 Pandemic Since the first reported case of the novel coronavirus disease 2019 (COVID-19) in Washington State,1 the United States has become the global epicenter of the pandemic. With many predicting critical shortages of hospital beds, ventilators, and health care providers in New York City (NYC), the NewYork-Presbyterian Hospital and Columbia University Irving Medical Center (CUIMC) quickly implemented system-wide changes to prepare our response. As of May 26, 2020, NYC itself had 204,111 cases and 20,795 deaths, the latter only surpassed by 5 countries outside the United States.
Optimizing Nonsurgical Treatments of Overactive Bladder in the United States Overactive bladder syndrome is a prevalent condition impacting quality of life, activities of daily living, work productivity, physical and psychological health, sleep, and sexuality. Published guideline recommendations and effective behavioral, pharmacologic, and neuromodulatory therapies exist; however, adherence can be poor. Clinicians have important roles educating patients, setting treatment expectations, and providing follow-up. Determining patient goals, routinely assessing and adjusting therapy, and combining treatment strategies may improve outcomes.
AUTHOR REPLY Botulinum toxin A (BoNT-A) is used sparingly in detrusor external sphincter dyssynergia (DESD) and that was the primary reason we conducted this systematic review. DESD is a difficult condition to treat with few treatment options, especially for patients who wish to avoid a lifetime of intermittent catheterization or cannot perform it regularly themselves. Further intermittent catherization itself can be associated with many complications such as an increased risk of urinary tract infections or potential stricture, erosion, or calculus formation with long-term use.
Multimodal Surgical Management of Severe Scrotal Lymphedema and Buried Penis A 42-year-old man with a history of Type II diabetes mellitus, hypertensive disorder and hyperlipidemia presented with a 7-year history of progressive lymphedema and inflammation of the scrotum and penile shaft. He had no prior surgical history, was obese with an initial BMI of 44.77, and had also been a heavy smoker for 30 years. He had undergone an extensive workup at an outside facility which did not reveal any infectious etiologies. At time of initial consultation, severe scrotal and penile shaft lymphedema was observed, with the scrotum measuring approximately 20 cm by 20 cm with some mild erythema and the penis completely buried (Fig.
A Rare Case of T-Cell Lymphoma Presenting With Bilateral Nephrolithiasis and Acute Renal Failure We present the rare case of a young boy who was found to have T-cell lymphoma after presenting with flank pain and bilateral nephrolithiasis. He initially underwent bilateral ureteral stent placement but returned with oliguria and acute renal failure. His subsequent workup revealed lymphoma involving both kidneys. He was started on chemotherapy for his lymphoma and dialysis for his renal failure. His stones ultimately dissolved with aggressive hydration and correction of serum uric acid levels. In this report, we discuss the identification and management of this rare condition.
Characteristics of Genitourinary Fistula in Kigali, Rwanda; 5-Year Trends To assess the characteristics of women presenting with genitourinary fistula over a 5-year period in Kigali, Rwanda. Genitourinary (GU) fistula is a devastating condition that can result from difficult vaginal deliveries or as a surgical complication. Rwanda has seen notable increases in cesarean section rates as a result of a successful universal health care system. It is unclear how the increase in cesarean section rates may influence the types of fistula diagnosed.
Grade IV Renal Laceration in a 13-Year-Old Boy With Cross-fused Renal Ectopia A 13-year-old boy presented with gross hematuria following a skateboarding accident and was found to have cross-fused renal ectopia of the left kidney with a grade IV right renal laceration and urinary extravasation. Despite a double-J ureteral stent, urinoma drain, and indwelling bladder catheter, his urinoma drain maintained high output. He underwent a ureteral stent exchange and upsizing. A percutaneous nephrostomy tube was subsequently placed for maximal urinary diversion, which ultimately led to the resolution in his urinary leak.
Nested Variant Urothelial Carcinoma of the Bladder Papillary subtype urothelial carcinoma constitutes the majority of bladder cancers and upper tract urothelial cancers.1 Variant histologies including nested variant urothelial carcinoma (NVUC) present diagnostic challenges, are often under-reported, and portend a more aggressive clinical course.2 We present a case of newly diagnosed nested variant urothelial carcinoma of the bladder and highlight its clinical presentation, pathologic appearance, and treatment considerations. We further place this diagnosis in the context of a patient who is a poor surgical candidate and comment on the management of bladder cancers in this challenging population.
A Systematic Review and Meta-Analysis of Methods Used to Reduce Infectious Complications Following Transrectal Prostate Biopsy We reviewed and analyzed the most effective methods to reduce infectious complications (IC) after transrectal prostate biopsy (TRPB). We included only prospective randomized-controlled trials in the analysis. The analysis neither demonstrated any superiority of fluoroquinolones over other antibiotic classes nor of targeted antibiotics over empiric regimens in men undergoing TRPB. However, longer course antibiotics (3 days or more) compared to single dose or day regimens, combination of fluoroquinolones with aminoglycosides compared to fluoroquinolones alone and povidone-iodine rectal cleansing compared to control significantly reduced IC following TRPB.
Jean Oliver: Master of the Nephron The purview of the urologist is the collecting system, while that of the nephrologist is the nephron. Jean Redman Oliver (Fig. 1, b. 8/19/1889, d. 11/19/1976), a pathologist, was able to bridge this gap through meticulous dissections, hand drawn illustrations, and experiments which underpin our current understanding of renal anatomy and physiology. The work of Jean Oliver has popularized the contemporary understanding of the nephron as a three-dimensional structure spanning superficial cortex to the tip of the papilla.
Nephrolithiasis and Elevated Urinary Ammonium: A Matched Comparative Study To describe the associations between elevated urinary ammonium and clinical characteristics of kidney stone formers. A 24-hour urine test is recommended in high-risk patients to identify urinary abnormalities and select interventions to reduce the recurrence risk. While elevations in urine ammonium may be seen in acidosis, diarrhea, high protein diets or due to pathogenic bacteria, the clinical characteristics of these patients have not been previously described.
Chemoablation in Urothelial Carcinoma: A Systematic Review and Future Perspectives Chemoablation is an emerging treatment for urothelial carcinomas. This review provides an overview of the evidence for intracavitary chemoablation in the treatment of urothelial carcinomas. The benefits of such agents include a reduction in morbidity and diseased organ preservation. While numerous agents have shown promise, research is limited due to small patient cohorts, varying follow-up, and no standardized methodology to assess response. Therefore, to date, chemoablation has not been widely adopted.
Posterior Reversible Encephalopathy Syndrome Following Failure of Conservative Management in Renal Trauma: Case Report Blunt renal trauma is relatively common in children. Conservative management has become the mainstay of treatment. A 4-year-old boy presented following a fall onto his right abdomen resulting in renal trauma. Initial conservative management was followed by complete embolization of the kidney. The resulting continued hypertension, as well as endothelial disruption, resulted in PRES as manifested by a single instance of generalized seizure. The patient regained normal neurological function following nephrectomy.
Female Sexual Dysfunction – Awareness and Education Among Resident Physicians To develop a better understanding of the strengths and deficiencies of female sexual health education and the attitudes toward female sexual health amongst urology, obstetrics and gynecology, psychiatry, and family medicine trainees. Female sexual dysfunction (FSD) is characterized as distress related to sexual pain, interest/arousal, or orgasm. Despite the high prevalence of FSD there are few clinical resources available for patients and providers in Canada.
Necrotizing Fasciitis Following Routine Genitourinary Surgery in Healthy Infants Morbidity and mortality associated with pediatric necrotizing fasciitis are strongly dependent on early diagnosis and timely intervention. Yet, the lack of early cutaneous findings and nonspecific symptoms may result in initial delayed diagnosis or misdiagnosis. Infants may be particularly at risk of missed or delayed diagnosis due to inherent barriers in communication and rarity of the condition, especially among healthy patients. We describe 2 cases of necrotizing fasciitis following routine genitourinary surgery in healthy infants.
Urethral Triplication With Diverticulum Malformation: A Case Report and Literature Review A 3-year-old boy presented to our pediatric urology with a history of urine flow under the scrotum when voiding in a squatting position but not when standing. And the ventral side of the front penis became enlarged during urination and dribbled afterward. Physical examination revealed the boy had 2 urethras opening at the tip of glans, and another accessory urethra opening at perineum. Rigid cystoscopy and voiding cystourethrography confirmed it to be a urethral triplication malformation. This condition, the combination of urethral diverticulum and urethral triplication, consisting of urethro-perineum fistula, has not been previously reported.
Post-cystectomy Enterocele: A Case Series and Review of the Literature To present a case series and literature review on post radical cystectomy (RC) pelvic organ prolapse (POP) to heighten awareness of the symptoms, imaging findings, and risk factors associated with this complication and discuss opportunities for prevention. Women with muscle invasive bladder cancer undergo RC with anterior exenteration, significantly disrupting the pelvic floor. These women are at risk for POP.
Myoepithelial Carcinoma of Urinary Bladder in a Pediatric Patient. A Case Report Myoepithelial carcinoma is a rare pathological variant, usually expressed in salivary gland. This case report describes a case of pediatric myoepithelial carcinoma in the urinary bladder. A 4-year-old male patient was admitted to a specialized hospital in Lima, Peru for hematuria. A CT scan showed a tumor lesion in the bladder wall, and biopsy revealed myoepithelial carcinoma of urinary bladder. Six courses of chemotherapy + partial cystectomy + radiotherapy was completed. The treatment was defined based on the pathological variant and the tumor location.
Vaginal Estrogen–What a Urologist Should Know The implications of estrogen depletion on the lower urinary tract and vagina are relevant to the urologist treating women with genitourinary symptoms. The main symptoms of vaginal estrogen depletion that affect women are dyspareunia and vaginal dryness, recurrent UTIs and lower urinary tract symptoms. Vaginal estrogen can be used to effectively treat these conditions. Vaginal estrogen is available in a variety of formulations. Each formulation has different considerations regarding its use and patients should be actively involved in choosing the right product for them.
High-Risk Non-Muscle Invasive Bladder Cancer: Selecting the Appropriate Patient for Timely Cystectomy The heterogenous nature of high-risk non-muscle invasive bladder cancer encompasses a wide range of tumor biologies with varying recurrence and progression risks. Radical cystectomy provides excellent oncologic outcomes but is often underutilized. Timing for these patients is critical, however, to its effectiveness. Certain unfavorable tumor characteristics predict worse outcomes and may help select the most appropriate patients for more aggressive initial therapy. This manuscript aims to outline factors that predict worse outcomes in high-risk non-muscle invasive bladder cancer and proposes which patients may benefit most from a timely radical cystectomy.
Nonobstetrical Robotic-Assisted Laparoscopic Surgery in Pregnancy: A Systematic Literature Review Urologic and gynecologic surgeons are the top utilizers of robotic surgery; however, nonobstetrical robotic-assisted laparoscopic surgery (RALS) in pregnant patients is infrequent. A systematic literature review was performed to ascertain the frequency, indication and complications of RALS in pregnancy. Results showed 38 pregnancies from eleven publications between 2008 and 2020. Five cases were for urologic indication and 33 for gynecologic indication. Minimal surgical alterations were required.
Identifying Opportunities to Improve Patient Experience With Sacral Neuromodulation: A Human Factors Approach To use a human factors approach to conduct a needs assessment of patient preparedness, education, device usability, and satisfaction regarding all stages of sacral neuromodulation therapy and identify opportunities for improvement. Sacral neuromodulation, though minimally invasive, involves an initial testing phase that requires active patient participation. This process is relatively complex and, if a patient does not receive adequate preprocedure education, can be difficult to conceptualize.
Recurrent UTIs in Girls: What Is the Role of the Microbiome? Urinary tract infections (UTIs) are one of the most common childhood bacterial infections. Recurrent UTIs can lead to renal scarring. Compared to boys, girls are more likely to develop scars as a result of recurrent UTIs. Therefore, there is a need to identify girls at high risk for recurrent UTIs and develop interventions to decrease the risk of recurrent UTIs. In this commentary, we will review the hypothesized pathophysiology of recurrent UTIs, explore the literature on the role of the microbiome in recurrent UTIs, focusing on female pediatric patients when able, and highlight the need for future research in this area.
A Review of Mullerian Anomalies and Their Urologic Associations Structural anomalies of the female reproductive tract, known as Mullerian anomalies, can occur in isolation or in association with anomalies of other organ systems. Due to shared embryology, the most common association in up to 40% of patients is with renal, ureteral, and bladder anomalies. Affected girls can have a wide range of genitourinary symptoms with urologists playing an integral role in their diagnosis and treatment. To facilitate the recognition and management of these conditions, we provide a review of Mullerian anomalies including the embryology, classifications, syndromes, evaluation, and treatments with attention to their urologic applicability.
The Impact of Sex and Gender on Clinical Care and Research Design in Nephrolithiasis Although classically a disease of male preponderance, scrutiny of the available data on nephrolithiasis reveals substantial epidemiological discrepancies between males and females, suggesting sex-based pathophysiology underlying this disease.1 Furthermore, sex-based differences may exist in underlying urinary risk factors, presentation, and treatment response. Recognizing these differences will be essential to further understand the multitude of etiologies of kidney stone disease and aid in developing appropriately designed comparative effectiveness trials.
Robotic Adrenalectomy for Functional Adenoma in Second Trimester Treats Worsening Hypertension A 33-year-old G6P3023 was found to have a 4.2 cm right adrenal incidentaloma during an admission for right pyelonephritis. Computed tomography (CT) was performed to rule out perinephric abscess in the setting of worsening leukocytosis while on antibiotics (Fig. 1). Initial differential diagnosis from endocrinology included pheochromocytoma and primary aldosteronism. Due to the lack of typical physical exam stigmata, Cushing syndrome was initially of low concern. Of note, her past medical history included hypertension treated with amlodipine 10 mg and hydrochlorothiazide 12.5 mg.
Commentary RE: The International Index of Erectile Function (IIEF): A Multidimensional Scale for Assessment of Erectile Dysfunction The advent of effective oral pharmacotherapy for erectile dysfunction (ED) signified the modern era of clinical management of this condition. Albeit a critical piece of this new paradigm, the relevance of sexual function questionnaires is often overlooked despite their indispensable use by which new therapies have come to be evaluated and accepted. So goes the storyline hailing the launch of sildenafil, which occurred in conjunction with the construction of the International Index of Erectile Function (IIEF) questionnaire in the mid 1990s.
Lower Urinary Tract Symptoms: Advances in Women's Urologic Health From MAPP and LURN Urinary tract conditions causing urinary symptoms, including pain and discomfort, are common in women of all ages. Lower urinary tract symptoms (LUTS) are highly prevalent with 59.2% of women exhibiting storage symptoms; 19.5% exhibiting voiding symptoms; and 14.2% exhibiting postmicturition symptoms and the prevalence of symptoms increases with age.1 Lower urinary tract pain, in particular, appears to be a problem more common in women than men.1 Unfortunately, many patients who seek care for LUTS experience neither total nor permanent resolution of their symptoms with current management approaches.
Single-Port Laparoscopic Surgery in Urology ‘What is Now Proved was Only Once Imagined’ Much has changed in the nearly 10 years since we published our initial experience with single-port urologic surgery.1 In 2008, laparoscopy was an established but still evolving platform within our field, and robotics was only beginning to gain momentum beyond prostatectomy.2,3 Indeed, few surgeons/centers had yet tackled robotic partial nephrectomy wholesale and even fewer were entertaining robotic cystectomy and RPLND (the debate continues in that regard).4-6 But as surgeon experience was translated into (arguably) superior outcomes, robotics became engrained into our residents’ and fellows’ educations, it became an expectation among patients, and remains a ‘measuring stick’ among programs.
Historical Perspective on Partial Nephrectomy and Renal Functional Preservation In this 2002 study from Memorial Sloan Kettering Cancer Center we evaluated the renal functional impact of partial nephrectomy (PN) or radical nephrectomy (RN) for renal tumors of 4 cm or less. We reported that RN patients were more likely to develop renal insufficiency as defined by a serum creatinine of > 2.0 mg/dL.1 This result confirmed similar findings reported from Mayo Clinic2 and both studies brought new concerns for the preservation of renal function into sharp focus for urologists performing kidney tumor operations.
The Changing Landscape of Upper Tract Urothelial Carcinoma Management Upper tract urothelial carcinoma (UTUC) is a rare malignancy of the urinary system and comprise roughly 5%-10% of all urothelial cancers.1 Despite the rarity of this disease which makes large scale trials difficult to conduct, there have been significant advances recently in both treatment options and molecular characterization of UTUC. These advances today would likely not have been possible without historical studies that drew early interest in this rare malignancy and stimulated interest. One of these studies by Hall et al on the 30-year experience of a single academic center, published in Urology in 1998, has been cited over 500 times since it has been published.
Commentary RE: Hard Measures of Subjective Outcomes: Validating Symptom Indexes in Urology Urology was⁎⁎ among the first surgical specialties to embrace the field of psychometrics, the process of describing and quantifying objective outcomes. Understanding and reliably measuring the patient experience of disease (namely symptoms) was novel in the late 1980s and early 1990s. Reliable measures are designed to yield consistent results when repeated. Validity is also a big component of such measures. They need to quantify what they are supposed to.
Commentary RE: Tolterodine Once Daily: Superior Efficacy and Tolerability in the Treatment of the Overactive Bladder Prior to 1990, treatment options for patients with overactive bladder were relatively limited. Oxybutynin and hyoscyamine were the primary pharmacologic agents used at the time. Both of these agents were developed primarily for gastrointestinal conditions and were used secondarily for the treatment of overactive bladder. Both were immediate-release formulations and required multiple dosages per day and had significant side effect profiles which often led to the discontinuation of therapy. If pharmacologic treatment failed, patients were left with few options except surgery, with augmentation cystoplasty being the most common procedure performed for treatment.
Commentary RE: The Sextant Protocol for Ultrasound-Guided Core Biopsies of the Prostate Underestimates the Presence of Cancer Following the citation trail from this Urology paper from 1997,1 it is mainly cited as providing evidence around 2 issues in prostate cancer diagnosis: Targeted biopsies added to systematic biopsies increases the sensitivity; however, a systematic sextant protocol even if combined with targeted biopsies is not sensitive enough to be a satisfactory protocol. Thus, it supports the use of combined protocols and the use of more extensive systematic biopsies than the original sextant mapping, protocols that still are considered to be standard in many guidelines.
Patient-Reported Urinary Continence and Sexual Function After Anatomic Radical Prostatectomy For patients faced with a prostate cancer diagnosis, treatment decision making unsurprisingly considers quality of life aspects. This matter is particularly relevant for this disease state in which possibly adverse effects of treatment may rival the impact, in terms of life fulfillment, presented by the disease threat itself. This realization is not new for prostate cancer, and specialists in this field have long debated the best strategies for management of this disease with the least likelihood of complications.
Commentary RE: Effect of Radical Prostatectomy for Prostate Cancer on Patient Quality of Life: Results From a Medicare Survey In the early 1990s, the increasingly widespread use of prostate-specific antigen as a screening test resulted in an impressive “spike” in the incidence of prostate cancer, unprecedented in the history of oncology. Men with clinically localized cancers facing treatment generally had to decide among radical prostatectomy, external beam radiation therapy, and some form of expectant management. Our group had documented that rates of radical prostatectomy among Medicare beneficiaries increased 5-fold between 1984 and 1990.
Bladder Tissue Engineering: The Past and the Future The paper “Bladder Augmentation using Allogenic Bladder Submucosa Seeded with Cells,” published in 1998, is the first journal article in the biomedical field describing the replacement of bladder tissue with a scaffold with and without seeded cells.1 At the time of this publication, the term “regenerative medicine” had not been coined, and the first description of human embryonic stem cells had not yet occurred; however, the promising concept of regenerating tissue had been front and center for a number of investigators worldwide.
Commentary RE: Upregulation of PSMA Following Androgen Deprivation Therapy The seminal and highly cited article by George L. Wright and collaborators that described the upregulation of prostate specific membrane antigen (PSMA) in Urology in 1996 was one of a number of articles in which he and colleagues provided important clinical correlations for the role of PSMA as a target for imaging and therapy.1 Using human specimens obtained before and after therapy and a quantitative immunostaining procedure that included the number of cells expressing the marker and the intensity of that staining, they observed an increase in PSMA expression in 55% (11 of 21) of primary prostate carcinoma specimens and 100% (4 of 4) of post-treatment metastatic specimens.
Commentary RE: Increased Incidence of Serendipitously Discovered Renal Cell Carcinoma This article from 1998 is remarkable due to its simplicity but also its clinical impact.1 In just over 2 pages the authors highlight a major change in the field of kidney cancer, as they reported on 131 patients managed with nephrectomy at Yale between 1989 and 1992. The main finding pertains to a shift to incidental or serendipitous discovery, which was found in the majority of cases (61%) in their series, rather than symptomatic presentation, which was the norm in the decades prior. Only 1 patient presented with the “too late triad” of hematuria, flank pain, and abdominal mass, and only 1 presented with a possible paraneoplastic syndrome.
Laying the Foundation for Bladder Health Promotion in Women and Girls Prevention strategies have been effective in many areas of human health, yet have not been utilized for lower urinary tract symptoms (LUTS) or bladder health (BH). This commentary outlines LUTS prevention research initiatives underway within the NIH-sponsored Prevention of Lower Urinary Tract Symptoms Research Consortium (PLUS). Prevention science involves the systematic study of factors associated with health and health problems, termed protective and risk factors, respectively. PLUS is enhancing traditional prevention science approaches through use of: (1) a transdisciplinary team science approach, (2) both qualitative and quantitative research methodology (mixed methodology), and (3) community engagement.
The Prognostic Value of PIK3CA Copy Number Gain in Penile Cancer To determine whether phosphatidylinositol-4,5-bisphosphate 3- kinase, catalytic subunit alpha (PIK3CA) copy number gain in penile cancer has prognostic value and association with histopathological parameters, human papillomavirus (HPV), and clinical outcome.
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.
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.
EDITORIAL COMMENT The use of artificial intelligence (AI) in medicine is steadily increasing. In the field of urology, AI projects are being used to augment screening, diagnosis, and treatment decisions.1-3
EDITORIAL COMMENT In humans, at ∼8-9 weeks’ gestation, sexual differentiation of the external genitalia is initiated into either male or female forms.1 Masculine development of the external genitalia involves both androgen-dependent and androgen-independent morphological events,2 while development of female external genitalia is androgen-independent. Androgen-dependent events that distinguish the developing human penis from the clitoris include fusion of the urethral groove into a tubular urethra within the penile shaft and formation of the glanular urethra by a complex process of direct canalization followed by mesenchymal confluence and cellular remodeling ventral to the urethra3,4 (Fig.
AUTHOR REPLY Thank you to the authors for their thoughtful comments. We certainly agree that there are many valuable research experiences in addition to PubMed-Indexed work for urology applicants. Program directors (PDs) may value research experience because it may show an applicant's intellectual curiosity and work ethic. It is likely that they examine this part of the application closely and then decide for themselves whether it brings merit to their program. For example, in the common scenario that a student decides to pursue urology late in their third year of medical school, publishing a peer reviewed manuscript would be difficult.
EDITORIAL COMMENT The Urology Residency Match Program remains a competitive resident selection process. Although match rates have increased in recent years, the average number of applications submitted per applicant has also steadily and disproportionately risen over the past 7 cycles.1,2 Among the factors motivating excess applications is a dearth of published data on successful applicants, which may provoke anxiety among applicants about having too few publications, too few interviews, and too few programs to rank.
AUTHOR REPLY Thank you to the reviewers for your comments. While we continuously improve our technique, we are happy with the techniques and outcomes which we share in this video.
EDITORIAL COMMENT This is a demonstration of how to perform complete vaginal mucosa resection via perineal approach. Avoiding visceral injuries despite peritoneal entry 43.6% of the time is a testament to their surgical skill and should be applauded. Other authors have previously reported potential for major intraoperative complications.1
AUTHOR REPLY All patients in our study were previously established with and examined by a urologist. Over 80% had commercial insurance, resulting in reimbursement comparable to clinic encounters due to Michigan's favorable telehealth parity laws.1,2 The regulatory landscape limited which patients could be seen from their homes and how clinics were reimbursed for video visits. It is possible that new patients who have never seen a urologist, the elderly, and those whose socioeconomic status qualify them for Medicaid stand to benefit the most from reduced travel time and the convenience of performing these visits from their home or work.
EDITORIAL COMMENT In the United States, specialty care has traditionally been delivered through a familiar structure: a patient sees his primary care provider and, if the provider believes input from a specialist would be helpful, she refers the patient to a specialist, who then sees the patient in a face-to-face visit. This flow has endured mostly through inertia, with room for improvement of specialists’ ability to manage populations of patients.1 Innovative alternative models have shown a more nuanced way to deliver specialty care that meets the needs of patients and populations.
AUTHOR REPLY The burgeoning field of transitional urology is faced with many challenging conditions that require a balance of surgical and health-related outcomes with the inherent biases of physicians, societal norms, and patient satisfaction. We too found the long-term data from our center surprising, given that even patients who were ambulatory or with non-neurologic conditions were seemingly content with a long-term vesicostomy. As we care for adolescents and young adults with spina bifida and other congenital conditions, the focus on both health and quality of life outcomes must come to the forefront together.
EDITORIAL COMMENT In young patients with “hostile” bladders, vesicostomy, usually as a temporizing option, has proved its utility in protecting the upper tracts. The kidneys are always our initial concern and remains a primary focus in these patients throughout their lives. Terry Hensle used to say “Life with a bad is a drag” (Personal Communication). Many of us who were trained and entered practice during the early era of undiversion and continent reconstruction probably held an inherent bias, whereby societal norms promoted our making all children clean and dry.
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