Atypical Small Acinar Proliferation and High Grade Prostatic Intraepithelial Neoplasia in the Era of Multi-Parametric MRI: a Contemporary Review Multiparametric Magnetic Resonance Imaging (mpMRI) has added to the armamentarium for the diagnosis and surveillance for organ confined prostate cancer. Atypical small acinar proliferation (ASAP) and high-grade prostatic intraepithelial neoplasia (HGPIN) are premalignant prostatic lesions. The management of such lesions remains contentious, and the addition of mpMRI introduces further uncertainty given its ability to pick up indolent lesions and its use in targeted biopsy. We aimed to perform a comprehensive review of current evidence regarding ASAP, HGPIN and mpMRI to ascertain a consensus for a current management algorithm.
Laser Endopyelotomy in the Management of Pelvi-Ureteric Junction Obstruction in Adults: a Systematic Review of the Literature Laser endopyelotomy (LEP) is considered as an option to treatment of pelvi-ureteric junction obstruction (PUJO) in adults. A comprehensive systematic search of the published literature was performed to assess the success rate and peri-operative complications of LEP in the treatment of primary and secondary PUJO and identify the factors that may impact of the success of LEP. The evidence available has significant limitations with heterogeneous study design and definitions of outcomes. The average overall success rate of the pooled data was 75% with a mean follow-up of 29 months.
Bladder Recurrence of Clear Cell Sarcoma of the Kidney 7 Years after Initial Presentation Clear cell sarcoma of the kidney (CCSK) is the second most common pediatric renal malignancy after Wilms tumor. CCSK has the potential to metastasize to distant sites and was historically known as the bone metastasizing renal tumor. We report an exceedingly rare case of a bladder recurrence of CCSK. Our patient presented with gross hematuria 7 years after initial complete response. He was found to have a large sessile bladder tumor and underwent a partial cystectomy with right pelvic lymph node dissection.
Editorial Comment In this article, Dr. Morey and his group report their outcomes with urethral ligation with suprapubic tube drainage, as an alternative to formal urinary diversion or persistent severe urinary incontinence, in older debilitated men with “end-stage” urethra following artificial urinary sphincter (AUS) placement. The authors subjectively describe end-stage urethra as a compromised, nonviable bulbar urethra that is not amenable to AUS replacement following AUS cuff erosion in a patient with a history of either open urethroplasty or AUS cuff erosion.
The Expanding Role of Advanced Practice Providers in Urologic Procedural Care To understand the role of Advanced Practice Providers (APPs) in urologic procedural care, and its change over time. As the population ages and the urologic workforce struggles to meet patient access demands, the role of APPs in the provision of all aspects of urologic care is increasing. However, little is currently known about their role in procedural care.
Author Reply We appreciate your kind words regarding our manuscript.
Editorial Comment Pezzoni et al's article is a very good study looking at differences in values for peak systolic velocity, end-diastolic velocity (EDV), and derived resistive index in more than 100 patients each in 2 groups of patients with erectile dysfunction (ED) confirmed by International Index Erectile Function at 2 anatomic sites. The first group was positive for clinical patterns of arterial insufficiency and the second group did not display clinical pattern of arterial disease. The first group obtained a suitable erection with intracavernosal injection of 20 µg of prostaglandin E-1 (PGE-1) and the second group failed to obtain erection with PGE-1, but did obtain a suitable erection with a bimix (20 µg of PGE-1 and 20 mg of papaverine) intracavernosal injection.
Raynaud's Phenomenon: Revisiting a Rare Sign of Pheochromocytoma/Paraganglioma Paraganglioma (PGL) are rare tumors arising from extraadrenal chromaffin cells and occasionally secret catecholamines. The patient commonly presents with headache, palpitation, anxiety, diaphoresis and episodic or sustained hypertension. Rarely patient can present with Raynaud's phenomenon. We present a case of adolescent girl who presented with isolated Raynaud's phenomenon as only manifestation of metastasis of PGL three years after undergoing surgical excision of normetanephrine secreting abdominal PGL.
New “Show Me How” Video Section We are excited to provide a new opportunity for surgical teams contributing to surgical education by submitting videos dealing with new surgical techniques, tips and tricks, and trouble shooting. The aim is to explore a stepwise approach to surgical innovation (a “Show Me How format”), describe surgical nuances, and present brief outcomes of the technique.
Malignant Mesothelioma of the Tunica Vaginalis Testis: Outcomes Following Surgical Management Beyond Radical Orchiectomy Objective:To describe clinical management and outcomes of a cohort of patients with malignant mesothelioma of the tunica vaginalis testis (MMTVT) who received treatments beyond radical orchiectomy.Methods:Patients with confirmed MMTVT at a single tertiary-care institution were identified. Treatments, pathologic outcomes, and survival were recorded. Prognostic variables associated with survival were analyzed with a Cox proportional hazards model and Kaplan-Meier curves.Results:Overall, 15 patients were included.
Ovotestis in Adolescence: Two Case Reports We present two patients found to have ovotesticular disorder of sexual differentiation (otDSD) in late adolescence. Two 15-year-old phenotypically male patients presented to a large pediatric hospital with different complaints: one with concern for testicular rupture after a straddle injury; the other with gynecomastia. Further work-up, including imaging and lab tests, was performed before surgical exploration. The first patient had unilateral ovotestis, contralateral testis, and SRY-negative 46,XX karyotype.
Congenital Aphallia: Novel Use of Acellular Dermal Matrix during Scrotal Flap Phalloplasty Phallic reconstruction is an important part of management for congenital aphallia. Scrotal flap phalloplasty has been described in pediatric patients to create the appearance of a non-functioning phallus. We describe a modified scrotal flap technique with the addition of an acellular dermal matrix patch (AlloDerm®) to provide additional girth and support to the phallus. The post-operative cosmetic outcome has been satisfactory and there is no documented complication over a 12 month follow-up. Alloderm® dermal matrix can be a safe addition to phallic reconstruction and its overall application needs to be further studied.
Do Overweight and Obese Pediatric Stone Formers Have Differences In Metabolic Abnormalities Compared With Normal Weight Stone Formers? Our study may serve as a geographically widespread analysis of stone disease in at risk children but we acknowledge that it is only a reference point and not the definitive study in this subject area. We agree that dietary information is necessary to put these findings in complete context and offer a potential road map to dietary modification as the ideal method to prevent de novo and recurrent stone disease. This is one of the primary aims of our prospective multi-institutional collaboration CUP (Collaborative in Urolothiasis in Pediatrics) which involves pediatric Urology and Nephrology specialists from 7 institutions around the country and will continue to leverage data from standardized 24 hour urine collections from a diverse pediatric population.
“Surgical Management of Primary Spindle Cell Sarcoma of Prostate” Primary spindle cell sarcoma of prostate is an extremely rare malignancy and very few cases of it have been reported [1, 2]. We searched literature through Med-Line database using Pub-Med and Scopus for the articles published between January 1988 and September 2016. Our search was limited to the following keywords: “spindle cell sarcoma”, “prostate” and “surgical management”. Most of the papers focused on histopathology of the tumour; very few were found discussing the surgical management. We here present a case of localized primary spindle cell sarcoma of prostate operated at our institute with the difficulties we faced and their management.
Author Reply We appreciate the commentary provided and are in agreement on nearly all points mentioned, including that the take-home point should not be that penile traction (PTT) is not a viable therapy for men with Peyronie disease (PD). We are also supportive of PTT in general and strongly recommended it during collagenase Clostridium histolyticum (CCH) injections because of a belief that it would enhance outcomes. Both the paper and commentary highlight 3 important points:
Editorial Comment Traction therapy has emerged over the past decade as 1 of the 3 primary nonsurgical treatment options for men with Peyronie disease (PD), including oral medications and intralesional injection therapy.1 Traction therapy has been shown to induce changes in tissue by a process known as mechanotransduction.2 Chung et al demonstrated the effects of tension applied to fibroblasts derived from Peyronie plaques in a cyclic cell strain model.3 They found that there was decreased smooth muscle actin, representing decreased myofibroblast activity and an increase in metalloproteinase activity.
A Retroperitoneal Serous Cystadenoma of Müllerian Origin Masquerading as a Massive Renal Cyst A 78 year old female presented to the Urology clinic with a large, symptomatic left-sided abdominal cyst for many years believed to be renal in etiology and had been percutaneously drained three times prior with persistent regrowth. The patient underwent laparoscopic resection of this mass which proved to be a completely distinct retroperitoneal cystic structure and not renal in nature. Pathological analysis ultimately revealed a rare occurrence: a benign retroperitoneal Müllerian serous cystadenoma.
Author Reply As presented in this Author Reply, one of the largest challenges facing urologic practice is the generation of appropriate educational tools to ensure that patients are receiving accurate, complete, and understandable information about prostate-specific antigen (PSA) testing. The ease with which patients have access to information about any subject through the Internet and the social media is great, but, depending on the source of that information, it may be compromised by bias or lack of completeness.
Editorial Comment The controversies surrounding routine use of prostate-specific antigen (PSA) and digital rectal examination for prostate cancer screening are now well known. To a large degree, this clinical debate is attributable to the marked disagreement ranging from the United States Preventive Services Task Force issuing a grade D recommendation against prostate cancer screening for all men at average risk for prostate cancer contrasted to the American Urological Association, American Cancer Society, and National Comprehensive Cancer Network endorsing shared decision making (SDM) about reviewing the merits of screening and eliciting patient preferences into the decision for early detection of prostate cancer.
Editorial Comment The authors provided an interesting look at the academic profile of the current urologic chairs in the United States.1 I am impressed by the academic productivity as measured by the number of published manuscripts as well as the impact these articles have had in promoting overall urologic scientific discovery. Scientific impact as measured by H-factor was higher for urology chairs compared to other departments such as orthopedic surgery and radiation oncology. It would be interesting if the authors had been able to compare and contrast the temporal changes in the academic and demographic characteristics of chairs over the last several decades.
Editorial Comment Accurate risk calculators for predicting the presence of significant prostate cancer at the time of prostate biopsy. Avoiding overdiagnosis and overtreatment is especially important given the increased awareness of prostate biopsy complications and the preventative task force's recommendations on prostate-specific antigen (PSA) screening.1
From the Associate Editor of Video Articles “Show Me How” On behalf of the Editor-in-Chief, Dr Eric Klein, I am excited to announce this unique opportunity to publish your work in a video format. The Gold Journal is adding a new section called “Show Me How” that gives authors the ability to present surgical movies accompanied with a short abstract. Movies should be created in a high-quality format with illustrations and animations encouraged for clarity when suitable. Topics can cover any urologic subspecialties including research and clinical procedures.
Malignant Infiltration of the Penis From Urothelial Carcinoma of the Bladder A 62-year old-African American male with a history of hepatitis C and pseudotumor cerebri presented to an outside hospital for evaluation of recurrent headaches and pelvic pain. He was a former cocaine and active tobacco user. He reported episodes of gross hematuria, but denied dysuria, fevers, chills, genitourinary trauma, priapism or sexually transmitted illnesses. He denied being sexually active. On physical examination, the patient was cachectic with palpable firm non-tender nodules throughout the entirety of his penile shaft within bilateral corpora, which the patient noted to have been present for several months.
Editorial Comment Robotic radical cystectomy (RRC) is increasingly gaining popularity in many academic medical centers in the United States. This is a review comparing RRC and open radical cystectomy (ORC) using the Statewide Planning and Research Cooperative System (SPARCS) database in New York State. An interesting finding is that RRC was performed by surgeons and in hospitals with lower approach-specific radical cystectomy volume. Another interesting data point is the fact that in both 2009 and 2012 the highest approach-specific surgeon volumes for ORC were 34 and 30, respectively, and that for RRC were 12 and 19.
EAU and AUA/SUO Guidelines on Risk Categories for Non-Muscle Invasive Bladder Cancer May Lead to Overtreatment for Low Grade Ta Bladder Tumors In 1998, the International Society of Urological Pathology (ISUP)/World Health Organization (WHO) eliminated the intermediate G2 bladder tumor (BT) grade, classifying BTs as low grade (LG) or high grade (HG).1 These changes were made to avoid placing a large percentage of bladder tumors into the G2 category, which does not help the clinician whose task is to make a decision regarding treatment. The 2004 WHO/ISUP classification system retained these two broad categories.2 The European Association of Urology (EAU) and the American Urological Association (AUA)/Society of Urologic Oncology (SUO) have released guidelines for the diagnosis and treatment of non-muscle invasive bladder cancer (NMIBC) and have incorporated this classification system.
Reply by the Authors To the Editor — We read with interest the above comments to our recent article on the importance of asymptomatic bacteriuria in patients undergoing urological surgical procedures1. In this paper we demonstrated that in patients undergoing urological surgical procedures who are receiving antimicrobial prophylaxis in accordance with EAU guidelines, the preoperative presence of asymptomatic bacteriuria was not associated with a higher incidence of postoperative symptomatic UTI1. We concluded that the preoperative urine culture evaluation in these patients might be unnecessary1.
Robotic-Assisted Thoracoscopic Transdiaphragmatic Adrenalectomy (RATTA) for Metastatic Renal Cell Carcinoma Robotic-assisted thoracoscopic transdiaphragmatic adrenalectomy (RATTA) represents a novel surgical approach for the management of adrenal pathology in patients with a history of extensive trans-peritoneal or retroperitoneal procedures. Here we report the first described case of RATTA in a 56 year old female with metastatic renal cell carcinoma to the left adrenal gland and right lung. With the assistance of cardiothoracic surgery this patient underwent robotic-assisted thoracoscopic pulmonary wedge resection and RATTA.
Altering the Approach: Open Minimally Invasive Renal Transplant in Obese Patients Through the Anterior Rectus Sheath As the obese population has expanded, minimally invasive renal transplant techniques have attempted to improve the issues of complications related to wounds and hernias. The Anterior Rectus Sheath approach, which facilitates a minimal incision, has been adopted at our center for all renal transplants, including obese patients. Retrospectively, we analyzed the wound issues for obese patients as well as outcomes/graft survival, hypothesizing improvement over the standard approach.
Editorial Comment Chalfin et al use the National Cancer Database records from 2004 to 2013 to assess how often men with D'Amico low-risk prostate cancer undergo a pelvic lymph node dissection (PLND). They found that ~40% of men had a PLND yet lymph node involvement (LNI) was found in only .37% of cases. Compared with robotic surgery, PLND was more likely to be performed in open surgery, at academic institutions, and related to income and insurance status.
Chronic Kidney Disease is More Common in Locally-Advanced Renal Cell Carcinoma To retrospectively evaluate clinical predictors of CKD in RCC patients to identify associations between patient- and tumor-specific factors with poorer renal function. Chronic kidney disease (CKD) and renal cell carcinoma (RCC) are inter-related, with 26-44% of RCC patients having concomitant CKD at diagnosis.
Intraductal Carcinoma of the Prostate: A Risk for Rapid Recurrence Intraductal carcinoma of the prostate (IDC-P), recently defined by the World Health Organization in 2016, is a distinct histologic entity associated with an aggressive clinical course, including increased risk of biochemical recurrence, metastasis, and mortality. Differential diagnosis includes intraductal spread of urothelial carcinoma, prostatic ductal carcinoma, and high-grade prostatic intraepithelial neoplasia. BRCA mutations are associated with an increased risk of IDC-P. The presence of IDC-P on initial biopsy or radical prostatectomy should trigger aggressive treatment and should be considered a contraindication to active surveillance, regardless of tumor volume.
Author Reply In this study, a few fertility-focused prompts by a nurse, which were added to an already scheduled nursing education session (covering topics including treatment logistics, chemotherapy side effects, nutrition, and support services), led to a significant increase in sperm banking rates. We believe that the strength in this finding is that it can be broadly applied. Whether from a nurse or physician, even a brief standardized reminder with available pamphlets of information was able to make a significant difference in sperm banking rates.
Editorial Comment Patients with new malignancies have a myriad of urgent therapeutic considerations. The authors demonstrated the value of a separately scheduled nursing counseling session regarding sperm banking and fertility preservation before oncologic therapy is initiated.1 There are many reasons that oncologists may not offer counseling about fertility preservation. Among these reasons are lack of knowledge of options for fertility preservation, discomfort about discussing sperm banking, intense focus on the patient's malignancy while ignoring fertility considerations, and simple disinterest in fertility considerations.
Editorial Comment A decade after the initial clinical reports on robotic radical cystectomy, we now have a preponderance of data to assess potential benefits and harms of this minimally invasive procedure. Multiple studies—ranging from case series to randomized trials to meta-analyses—have demonstrated the potential for the robotic approach to (1) reduce blood loss and transfusion requirements, (2) decrease postoperative pain, (3) reduce 30- and 90-day complications (especially wound complications), and (4) decrease length of stay (LOS) (demonstrated in multiple series including the present study by Borza et al).
Author Reply The authors bring up a relevant point, in that structured follow-up of patients after a midurethral sling procedure is lacking. It is challenging to do, as most patients do well postoperatively, and wonder why they must attend repeated physician's appointment. However, if a “higher-risk” group could be identified, that would make systematic follow-up more significant for physicians, cost-effective for the medical system, and pertinent to the patient. In our previous work, we found that a large number of women have their midurethral sling complication treated by a different physician, highlighting a potential problem with accessing their prior surgeon.
Re: Punjani et al.: Postoperative Urinary Retention and Urinary Tract Infections Predict Midurethral Sling Mesh Complications (Urology 2017;99:42-48) We read this manuscript with great interest. Although the midurethral sling (MUS) is considered by many to be the gold standard treatment for stress urinary incontinence, it is also associated with notable mesh-related complications. Research has sought to evaluate predictive factors for MUS complications. The majority of available investigation focuses on risk factors for postoperative voiding dysfunction, de novo irritative symptoms, or surgical failure.1-3 Although these data are important, similar investigation is lacking to help understand risk factors for the most severe adverse events following MUS, including urethral or bladder perforation and fistula.
Clear Cell Renal Cell Carcinoma With Extensive Osseous Metaplasia: Report of a Rare Case A 48-year-old Chinese woman presenting with continuing dull pain in the right lower back and abdomen was found to have a tumor with extensive osseous metaplasia in the upper-middle pole of the right kidney. The excised neoplasm specimen revealed a 29 × 26 mm hard tumor with dense ossification. Histopathological examination of the tumor showed that it contained lamellar bone forming trabeculae intermingled and spherical or polygonal epithelial cells that contained slightly irregular nuclei with small nucleoli and abundant pink to clear cytoplasm.
Radiation With or Without Antiandrogen Therapy in Recurrent Prostate Cancer This double-blind, placebo-controlled trial aimed to determine the benefit of salvage radiation (SR) on overall survival (OS) with the addition of androgen-deprivation therapy compared to SR alone in a cohort of patients with biochemical recurrence following radical prostatectomy for localized prostate cancer.
Beware the Looping Vas Deferens in Orchidopexy A looping vas deferens may be present in up to 20% of undescended testes located within or proximal to the inguinal canal. This associated abnormality is vulnerable to transection during orchidopexy. We present an example of a very long looping vas to emphasize the importance of inspection for this anomaly, and demonstrate the extreme extent that a looping vas may extend. Identification of the vas among cord structures may provide false reassurance of normal ductal anatomy. Examination for a looping vas by inspecting structures caudal to the testis should occur at an early opportunity during orchidopexy to avoid inadvertent transection.
A Unique Case of Pentaorchidism Polyorchidism is a rare congenital anomaly with less than 200 case reports in literature. Triorchidism, the condition of having 3 testicles, is the most common presentation. We present an unusual case of a patient who was diagnosed with 5 testicles by magnetic resonance imaging. To the best of our knowledge, this rare presentation has not previously been reported in the medical literature.
Robotic Surgery in Uro-oncology: A Systematic Review and Meta-analysis of Randomized Controlled Trials Robotic surgery represents a new horizon in minimally invasive urologic surgery. This systematic review of the literature and meta-analysis examines the effectiveness of robotic surgery compared with laparoscopic or open surgery for major uro-oncological procedures. Twenty-five articles reported findings from 8 trials of prostatectomy (4 trials) and cystectomy (4 trials) including 1033 participants. Robotic surgery is comparable with laparoscopic or open surgery for oncological outcomes and overall complications, and provides somewhat better functional outcome when compared with laparoscopic and open surgery.
Biliary Stent Migration: A Rare Cause of a Bladder Stone Our patient presented with dysuria and pneumaturia without any prior urologic instrumentation. History included choledocolithiasis requiring endoscopic retrograde cholangiopancreatography and biliary stenting. Imaging showed a large bladder stone. The patient was taken to surgery and found to have diverticulitis. The sigmoid was resected and the bladder was found to have a small fistula tract. The bladder was opened and a large calculus was identified and extracted. The stone was opened and found to contain a biliary stent.
Adding Mirabegron to Solifenacin to Treat Overactive Bladder Has Little Impact on Postvoid Residual Volume or Urinary Retention Risk Urinary retention is a complex and important urologic health issue that describes the inability to completely empty the bladder.1 The sudden inability to void is termed acute urinary retention, which is usually accompanied by pain and severe urgency, and can have serious consequences if untreated.2 Occasionally, acute urinary retention may be precipitated by an event such as infection or medication; thus, the definition is further subdivided into precipitated or spontaneous.1 Chronic urinary retention describes the persistent inability to completely empty the bladder and is usually painless and imperceptible to the patient.
Author Reply Patients remain misinformed or underinformed about the indications and risks associated with testosterone replacement therapy (TRT), despite the Food and Drug Administration's Drug Safety Communications regarding testosterone products.1 Most patients are unaware of the association between low serum testosterone, medical comorbidities, such as obesity, diabetes mellitus, and obstructive sleep apnea, and generally unhealthy lifestyles, characterized by stress, lack of physical exercise, poor sleep hygiene, and poor dietary intake.
Editorial Comment The issue of patient knowledge and or perceptions about a medical condition and treatment is always intriguing. The disconnect between what the medical community knows and where patients get their information; what education level they actually understand their body, and how much they hear and retain this information is the essence of awareness, communication, and compliance with care in medicine. The gap between patient knowledge and best medical information is often vast and requires providers many times to backtrack on what patients know or think they know as the truth based on the best evidence.
Author Reply We agree that there is still a certain controversy about the risks and the efficacy of pregnancy in patients with a history of urinary diversion. However, our study proved that it is safe and showed a good mothers' and children's outcome with a minimum of risks under strict multidisciplinary monitoring. In our study, the main underlying conditions and types of urinary diversion were represented. Nevertheless, we totally agree with the stated objection that the question remains whether these observations and recommendations can be transferred to women in childbearing age with a neobladder.
Editorial Comment Controversy remains about the wisdom and efficacy of pregnancy in women of childbearing age who have a history of urinary diversion. This retrospective study evaluated 37 pregnancies in women with continent diversion, generally for exstrophy or neurogenic bladder.
Author Reply We appreciate the authors' interest on our paper and state our opinions about the editorial comment. Statistics is a highly interdisciplinary field concerned with developing and studying methods for collecting, analyzing, interpreting, and presenting empirical data. Many statistical methods can be used when designing any work. In general, commonly accepted methods preferred more often to evaluate the results. Our prospective, comparative study was performed to evaluate the cognitive effects of hormone therapy.
Cognitive Effects of Androgen Deprivation Therapy in Men With Advanced Prostate Cancer: Methodological Issues We read the article authored by Gunlusoy et al, which was published in the journal of Urology in 2017, with great interest.1 A case-control study was conducted to examine prostate cancer effects of androgen deprivation therapy (ADT) through a systematic set of methods to determine specific cognitive functions in patients with prostate cancer. The case group included 78 patients with prostate cancer who received ADT treatment for 12 months. Also, 78 patients who underwent radical prostatectomy without any additional treatment were included as controls.
Editorial Comment An excellent work by Mayer et al demonstrates the continuing urology gender gap within academic medical centers; men have higher mean h-indices and academic ranks than their female colleagues. Notably, there was no difference in total number publications over career length (m-quotient). Unfortunately, this slower ramp up to equivalent productivity means that women will continue to leave academic positions at higher rates than men,1 that our specialty will continue to lag in women in academic leadership positions.
Author Reply We appreciate the authors' informative comments on our manuscript. We agree with the comment about reliability of results and the requirement of more objective evaluation. Androgen deprivation therapy (ADT) has survival benefits. Mounting evidence has demonstrated extensive adverse effects including metabolic, cardiovascular, bone, and cognitive.1 Among these side effects, interpretation of cognitive dysfunctions is the most difficult because of the most complex findings. Cognitive functions are seriously affected by decreasing testosterone levels naturally with age.
Editorial Comment In the accompanying article the authors present their prospective findings of the cognitive effects of androgen deprivation therapy (ADT) on a cohort of patients receiving therapy for locally advanced or metastatic (non–central nervous system) disease. Their primary finding is that after 12 months of therapy, there is a statistically significant reduction in language ability, short-term memory (as measured by Montreal Cognitive Assessment test), as well as in mental flexibility and inhibition (as measured by frontal assessment battery test) compared with a cohort of age- and comorbidity-matched men with localized prostate cancer treated by radical prostatectomy.
Spontaneous Shrinkage of Testicular Teratoma in a Prepubertal Child Limited numbers of pediatric intratesticular cystic lesions have been reported. Although the majority of pediatric intratesticular cystic masses are benign, natural history of testicular cystic lesion in children has been rarely reported so far. We report a case of intratesticular cystic lesion in a prepubertal child who underwent testis sparing surgery after shrinkage during conservative follow-up. As an initial strategy for intratesticular cystic lesions in prepubertal children, observational approach with serial ultrasonographic evaluations may be a management of choice.
Author Reply Patients with suspected ureteropelvic junction obstruction (UPJO) and equivocal 99mTc-mercaptoacetyltriglycine (MAG3) diuretic renographic study constitute a diagnostic challenge. The tracer uptake and excretion curve during a nuclear renal scan are functions of complex interactions between renal function, collecting system volume, and outflow obstruction. This creates challenges in translating curve morphology into an easily reported yes or no answer concerning the presence or absence of obstruction.
Editorial Comment Without prompt diagnosis and treatment, ureteropelvic junction obstruction (UPJO) can lead to impaired renal function.1,2 Diagnosis of UPJO is chiefly made on the basis of 99mTc-mercaptoacetyltriglycine (MAG3) diuretic renography revealing a functional obstruction. A clinical dilemma exists in patients with signs and symptoms suggestive of UPJO, but who otherwise lack evidence of obstruction on nuclear imaging. In this study, von Rundstedt and colleagues3 aimed to increase the sensitivity of diuretic renography for diagnosing UPJO by evaluating P40, the percentage of maximal tracer counts present at 40 minutes, with an abnormal P40 identifying anatomical obstruction.
Surgical Technique for Robot-assisted Sacrocolpopexy Performed via a Single Port Sacrocolpopexy is considered the gold standard for the treatment of pelvic organ prolapse (POP). This procedure was the first technique used to treat POP with robotic assistance and has gone a long way since the open procedure was introduced. Originally, 5 trocars were inserted and there remained issues in terms of scarring, morcellation, and possibly an increased risk of infection. The objective of this video was to demonstrate a surgical technique and a few tips and tricks for a robot-assisted sacrocolpopexy performed via a single port in the umbilicus.
Pathological Findings in Multiparametric Magnetic Resonance Imaging/Ultrasound Fusion-guided Biopsy: Relation to Prostate Cancer Focal Therapy The introduction of widespread prostate-specific antigen screening brought about an increase in the detection of clinically low-risk prostate cancer. Many of these patients are overtreated by radical prostatectomy and radiation. Comparatively, focal therapy for prostate cancer offers the advantage of decreased rates of incontinence and impotence. The 12-core extended sextant transrectal ultrasound-guided needle biopsy is unable to safely identify candidates for focal therapy. Multiparametric magnetic resonance imaging (MRI) and MRI/ultrasound fusion-guided biopsy can detect more clinically significant prostate cancers and aid in accurate detection of higher-grade disease.
Reply by the Authors We are pleased that our recent publication was the source of discussion at your journal club.1 For the question of tumor sizes listed in table 1, the values listed are medians and interquartile ranges. In other words, “the upper range” listed is actually the 75th percentile value. In fact, the absolute upper limit was 14.5 cm for the partial nephrectomy group and 16 cm for the radical nephrectomy group. For the issue of the survival curves in figure 2, the stages indicated are clinical stage. Some clinical T2 tumors were upstaged to pT3 disease at final pathology, accounting for the higher number at risk in figure 2.
Ureteric Obstruction From Malignant Melanoma in Both Right Double Moiety and Left Single Moiety Ureters We report the first documented case of malignant melanoma obstructing ureters of both moieties of a duplex kidney and contralateral single moiety ureter in a 51-year-old male. The patient presented with fever, coryzal symptoms, and liver function test derangement several years after 2 superficial spreading melanomas were excised with clear margins. Ultrasonography demonstrated hydronephroureter in both moieties of a complete right-sided duplex kidney. Retrograde pyelograms showed bilateral hydronephroureter and filling defects in all 3 ureters.
“Renal Calculi as Big as Eggs”: Urolithiasis and Chronic Kidney Disease of Ludovico I, Marquis of Saluzzo (1406-1475) The Marquisate of Saluzzo in Piedmont (northwest of Italy, close to the French border) was an important and independent territory from 1125 until 1548 when, after the deposition of the last Marquis Gabriel, it was annexed to the crown of Paris and then to the Duchy of Savoy. Saluzzo reached its period of greatest splendor in the 15th century under Marquis Ludovico I Del Vasto (1406-1475) (Fig. 1), who, with a neutral policy toward Italian belligerence, was able to act as mediator in the discord between the emperor and the king of France.
Encountering “Dropped” Gallstones During Robotic-assisted Laparoscopic Radical Prostatectomy We describe a case of an unusual finding during robotic-assisted laparoscopic radical prostatectomy and bilateral pelvic lymphadenectomy in a 66-year-old man with stage IIb (T2c, N0, M0) prostate adenocarcinoma. During the operation, intraperitoneal examination of the rectovesical pouch revealed calcifications and stones, which were subsequently identified as gallstones. Although these stones were not noted initially on this patient's preoperative multiparametric magnetic resonance imaging, a retrospective review demonstrated hypointense foci in the rectovesical pouch.
Delayed Radiographic Manifestation of Renal Pseudoaneurysms After Blunt Trauma Pseudoaneurysms may cause recurrent hematuria after blunt renal trauma. We report on an 18-year-old patient with radiographic manifestation of pseudoaneurysm 41 days after blunt renal trauma. Initial and follow-up imaging for recurrent hematuria, including angiography, was without signs of pseudoaneurysm or active bleeding. This case illustrates that recurrent gross hematuria as a typical symptom of pseudoaneurysm may be present initially in the absence of radiographic signs. Repeat angiography should be taken into consideration if recurrent bleeding persists.
Long-term Survival After Resection of Sentinel Node Metastatic Renal Cell Carcinoma We present a case of a patient who took part in a prospective sentinel lymph node (SN) study to investigate the drainage pattern from renal tumors. The patient was treated with laparoscopic radical nephrectomy, for a clinically node negative left renal tumor of 6 cm combined with SN and non-SN lymph node dissection. Histopathologic examination revealed a papillary type 2 pT1b renal cell carcinoma with 2 para-aortic metastatic SNs. No adjuvant treatment was applied. The patient is free of disease at 63 months after surgery.
Pyogenic Granuloma: Possible Cause for Macroscopic Hematuria in Children Pyogenic granuloma (PG) is a benign, vascular tumor that is rarely reported in the urinary tract of pediatric population. Herein we present a case of a child followed up for recurrent painless macroscopic hematuria.We performed ureteroscopy, and a whitish lesion was discovered in the upper calyx of the right kidney. The lesion resected endoscopically, and microscopic examination of the lesion was consistent with PG.It is important for pediatricians and urologists to properly recognize PG as a possible source of hematuria in the pediatric population.
Robot-assisted Laparoscopic Resection of Renal Vein Leiomyosarcoma Leiomyosarcoma, a rare and aggressive retroperitoneal tumor, arises from the smooth muscle of the tunica media. Accurate preoperative diagnosis is rare as the origin is often unclear, and its involvement of the vessels makes biopsy prohibitively dangerous (Maturen et al, 20136). Herein, we describe the laparoscopic dissection of a retroperitoneal renal vein tumor using a robotic approach.
Editorial Comment A biofilm is a structured community of bacterial cells enclosed in a self-produced polymeric matrix, which can adhere to an inert (or living) surface.1 Implantable prostheses such as the artificial urinary sphincter (AUS) are at increased risk for bacterial biofilm colonization as they do not have the protective mechanisms that characterize healthy tissue. Once established, a biofilm is often impossible to eradicate with oral or intravenous antibiotics, due to the protective matrix. Thus, the attraction of antibiotic-coated implantable prostheses—to prevent biofilm formation, and thereby resist device infection.
Cystoscopic Evaluation of Bladder Leiomyoma We report the case of a 40-year-old woman with a history of uterine polyps and 3 months worth of gross hematuria who was found to have a bladder mass on cystoscopy. While this mass appeared benign visually, it demonstrated enhancement on axial imaging with increased internal vascularity on Doppler ultrasound. A transurethral resection demonstrated bladder leiomyoma. This case increases the urologist's recognition of a well-described but previously under-represented condition by showcasing its visual appearance on cystoscopy.
Right-sided InterStim Placement in a Patient With Left Sacral Hypoplasia Sacral hypoplasia is a rare anomaly and the least severe pattern of caudal regression syndrome as described by the Renshaw classification system. These patients may suffer from bladder or bowel dysfunction. Here, we present a successful case of right InterStim placement for the treatment of refractory urinary urgency, frequency, and urinary incontinence in a patient with left sacral hypoplasia.
Aggressive Angiomyxoma of the Penis: The First Case Report in a 9-Month-Old Infant Aggressive angiomyxoma (AA) is a rare, benign, mesenchymal tumor of the pelvis and perineum. It usually occurs in females at reproductive age. However, rare cases have been reported in male children. We present the first case of AA in the penis of a 9-month-old Somalian boy. The infant presented with large, nodular penile mass. The diagnosis was confirmed following complete surgical removal and histopathologic examination. Over a 6-month follow-up period, no recurrence was noticed. Therefore, we recommend complete surgical removal of the mass with wide safety margin and long-term follow-up for cases of AA.
Repair of Urethrovaginal Fistula Secondary to Pelvic Fracture With a Labia Minora Skin Flap in Young Girls The study aims to evaluate the efficacy of transpubic access using a pedicle flap from the labia minora for urethral reconstruction in young girls with urethrovaginal fistula secondary to pelvic fracture. Between January 2011 and January 2016, 4 cases of traumatic urethrovaginal fistula in young girls were treated using a pedicle flap from the labia minora. The mean follow-up was 27 months. All patients voided well and achieved normal urinary control. One patient had recurrent urethrovaginal fistula.
Urothelial Carcinoma of the Ureter and Urinary Bladder With Rectal Linitis Plastica A 62-year-old woman presented with abdominal pain, anorexia, persistent diarrhea, and a 3-month history of dyspepsia. She had no significant medical or surgical history. Laboratory examination revealed high serum levels of carbohydrate antigen 125 (CA 125; 48.5 U/mL) and CA 19-9 (113.4 U/mL). Colonoscopy revealed edematous and irregular mucosal thickening of the rectum, suggestive of rectal cancer. However, the pathology report from the colonoscopic biopsy revealed only chronic inflammation. Abdominal computed tomography (CT) showed circumferential rectal wall thickening with relatively preserved mural stratification, resulting in significant bowel obstruction (Fig. 1A).
Recurrent Urinary Tract Infections in a Female Child With Polydactyly and a Pelvic Mass: Consider the McKusick-Kaufman Syndrome A 3-year-old female child presented with a history of recurrent urinary tract infections. On general examination, polydactyly and a pelvic mass were present. An imperforate hymen was also documented on vaginal inspection. Further inquiry revealed a positive history of parental consanguinity. A magnetic resonance imaging study defined a hydrometrocolpos responsible for an obstructive cause of the recurrent urinary tract infections. In view of the above, a diagnosis of McKusick-Kaufman syndrome was made.
The Present and Future Challenges Facing Urology Departments at Academic Health Centers Academic health centers (ACHs) represent the pinnacle of health care by providing innovative clinical care, cutting-edge research, and premier education. However, recent changes in health care put their tripartite mission at risk. The coming years will bring immense change to AHCs as they adjust to new market conditions impacting the 3 distinct elements of their mission. Fundamental adaptations are required for AHCs to survive, let alone thrive and continue to represent the best of medical research, education, and health.
Treatment of Post-transplant Lymphocele in Children To review our single-center experience in managing posttransplant lymphoceles in pediatric kidney recipients. Lymphoceles are well-known complications after pediatric kidney transplantation (KT). However, there is no standard treatment for lymphoceles, and the literature lacks consensus on which is the most appropriate approach.
Xanthogranulomatous Pyelonephritis Manifesting as a Nephrocutaneous Fistula in a 5-Year-Old Female A 5-year-old girl presented to an outside emergency department (ED) with a lump on her left flank. By report, the lump was noted 3 weeks prior and had been increasing in size. The lump was 3 cm in diameter, flesh colored, hard, and mildly tender to palpation (Fig. 1). The diagnosis was a hematoma, and conservative management with ice and observation was recommended. Two weeks later, the patient presented to the same ED complaining of increasing erythema and pain in the area. Abdominal ultrasound (US) findings were consistent with superficial abscess.
Clear Cell Papillary Renal Cell Carcinoma: New Clinical and Imaging Characteristics To investigate clear cell papillary (CCP) renal cell carcinoma (RCC), an uncommon tumor of low malignant potential characterized by low-grade, clear cells, showing papillary and tubular architecture. This relatively newly described entity is still being characterized. We present our series of CCP RCC with new clinical and imaging findings.
Adenocarcinoma in Continent Anal Urinary Diversion: Is a Sigma Rectum Pouch a Surgical Option After Failed Ureterosigmoidostomy? To report our experience of radical resection of secondary cancers after ureterosigmoidostomy. Ureterosigmoidostomy was the most common continent urinary diversion before the era of continent cutaneous diversion and neobladders, specifically in children. When performed for bladder exstrophy, patients will live with this kind of diversion for quite a long time. As a result, urologists will be confronted with patients presenting with an adenocarcinoma in their ureterosigmoidostomy. In most cases reported in the literature, an ileal conduit was used for urinary conversion.
Author Reply The immunomodulatory effect of blood transfusion (BT) has recently garnered significant attention in regard to oncological and perioperative outcomes for bladder cancer patients. Our results were unique in failing to show BT as a significant, prognosticator of worse recurrence, cancer, and overall survival.
Editorial Comment The impact of perioperative blood transfusion (BT) and specifically intraoperative BT on survival outcomes in radical cystectomy (RC) patients has been established in retrospective series.1,2 Whether several theories have been proposed to explain this association, one of the most intriguing is represented by the direct immunosuppressive effect exerted by BT. Specifically, it has been postulated that BT might modulate the immune system due to the presentation of large amounts of antigen.3 Therefore, it is certainly of interest to evaluate if leukocyte-depleted BT impact on survival outcomes in RC patients.
Adjuvant Sunitinib in High-Risk Renal-Cell Carcinoma after Nephrectomy The main aim of this multi-centre, double-blind phase III trial was to determine the efficacy and safety of 12 months of adjuvant sunitinib treatment versus placebo in patients with loco-regional clear cell renal cell carcinoma (ccRCC) with high risk of disease recurrence after curative nephrectomy.
Efficacy of Cranberry in Preventing Recurrent Urinary Tract Infections: Have We Learned Anything New? In a recent study by Juthani-Mehta et al, 185 elderly women in nursing homes were randomized into a double-blind clinical trial to evaluate the effect of cranberry capsules on bacteriuria plus pyuria.1 During the 1-year study period, 92 women received cranberry capsules (72 mg total, equivalent to 20 ounces of cranberry juice) compared with the 93 women who received placebo. The primary outcome was the presence of bacteriuria with pyuria. Secondary outcomes were symptomatic urinary tract infection (UTI), mortality, hospitalizations, or any other clinically meaningful outcomes as per the study team.
The Role of the Urologist in the Era of In Vitro Fertilization-Intracytoplasmic Sperm Injection The use of in vitro fertilization and intracytoplasmic sperm injection has dramatically increased. In spite of this, the male partner in the couple is often not evaluated for fertility status or other general health conditions associated with male infertility. Such an approach goes against established guidelines recommending dual partner evaluations and does not address longer term male health risks. In this review, we discuss the urologist's role in the era of in vitro fertilization-intracytoplasmic sperm injection, which includes diagnosing serious conditions associated with infertility, treating reversible causes of infertility, defining untreatable causes of testis failure, and, when appropriate, facilitating sperm retrieval.
A 72-Year-Old Man With Obstructive Voiding Symptoms, Elevated Prostate-specific Antigen Level, and Nodular Digital Rectal Examination A 72-year-old Caucasian man presented to a multidisciplinary genitourinary cancer clinic for evaluation of lower urinary tract obstructive voiding symptoms. He had elected to stop taking tamsulosin due to associated side effects. The patient reported a prior transrectal ultrasound (TRUS)-guided prostate needle biopsy 10 years ago due to an elevated prostate-specific antigen (PSA) level. The previous biopsy was reported to be benign. Additional pertinent medical history is significant for hypertension and congenital hip dysplasia.
Prostate Biopsy-related Infection: A Systematic Review of Risk Factors, Prevention Strategies, and Management Approaches A systematic review to identify risk factors for prostate biopsy-related infection, preventative strategies, and optimal management of infectious complications was conducted. Significant risk factors for postbiopsy infection include urogenital infection, antibiotic use, international travel, hospital exposure, bacteriuria, previous transrectal biopsy, and resistance of fecal flora to antibiotic prophylaxis (especially fluoroquinolones). Patients at risk may benefit from an adjusted biopsy protocol comprising transrectal biopsy under targeted prophylaxis, and/or the use of rectal disinfection techniques or using a transperineal approach.
Reply by the Authors We appreciate your comments and understand your question. The variables were statistically evaluated based on the assumption of normality (Fig. 1). There were no interactions between most variables in the multivariable regression model. However, weight, body mass index, and waist circumference were found to have multicollinearity. Thus, we selected the weighted variables and removed body mass index and waist circumference because we focused on the correlation between weight status and prostate volume.
Percutaneous Nephrolithotomy for Stones in Solitary Kidney: Evidence From a Systematic Review Stones in solitary kidney represent a management dilemma for the endourologist. The advantage of bilateral fully functioning kidneys is not present. Therefore, any insult to either the solitary kidney itself or drainage system can lead to significant morbidity. Key clinical objectives include maximum preservation of existing renal function, high stone clearance, and minimizing post-procedure complications. To date, there exists no Level 1 evidence on this subject. This systematic review serves to evaluate the safety and efficacy of percutaneous nephrolithomy for patients (adults only) with stones in a solitary kidney.
T-Shaped Shunt with Intracavernosal Tunneling, for a Pediatric Case of Refractory Ischemic Priapism We present the first reported case of refractory pediatric priapism treated by intracavernosal tunneling T shunt. A 12 year-old male, with sickle cell disease, presented with 72 hrs of painful erection. The patient failed conservative measures including aspiration, injection of phenylephrine, as well as distal shunt procedure. A T-T shunt was performed, as previously described in the adult literature. There was immediate resolution of the erection with no complications. At 1 year follow-up, he reports no subsequent episodes of priapism and normal erections.
C. Everett Koop: Pioneer in Pediatric Surgery, U.S. Surgeon General and Early Contributor to Pediatric Urology Charles Everett Koop (1916-2013) was born in Brooklyn, New York in 1916. He received his A.B. degree from Dartmouth in 1937, where he was given the nickname “Chick” (an allusion to “chicken coop”). (1) While attending Dartmouth College he met his wife, Elizabeth Flanagan, a student at Vassar College. (1) They were married in 1938 and would go on to have 4 children together (Allen, Norman, David and Elizabeth). He earned his medical degree from Cornell University Medical College in 1941. He completed his residency at the University of Pennsylvania Hospital in 1946 working under Dr Isadore S.
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.
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