Author Reply: Comparing Medicolegal Risk Surrounding Vasectomy in Spanish and American Society We thank the authors for sharing the Catalonian experience and how it both complements and differs from the US experience. We recognize the limitations of WestLaw which, nonetheless, is the most comprehensive dataset available in US. International data clearly confirms that urologists are at considerably high medicolegal risk, and must take certain steps to minimize this. One aspect in particular that must be addressed is communication. Dealing with recovery and complications from procedures can be a lonely experience for patients.
Nocturia: A Highly Prevalent Disorder with Multifaceted Consequences Nocturia is a bothersome, multifactorial condition with many underlying causes and contributing factors. Nocturnal polyuria (NP; overproduction of urine at night) is a frequent component. The prevalence of nocturia increases with age; specific estimates of prevalence are influenced by frequency thresholds used to define it. There is a tendency toward higher prevalence in young women than young men, which is reversed in later life.The association between frequency of nocturnal voiding and sleep disruption is well-documented.
Lynch syndrome in urologic malignancies – what does the urologist need to know? Lynch Syndrome (LS) entails a defective DNA mismatch repair system, which is the post-replicative proofreading and editing system, ensuring our genome's integrity. LS predisposes to several cancers, most commonly colorectal and endometrial cancers. LS occurs in approximately 1 in 250–1,000 people.LS is associated with urological malignancies with upper tract urothelial carcinoma the most common, although still clinically underestimated. Other urologic malignancies possibly associated with LS include bladder, prostate, testis, and renal cell carcinoma.
Images in Clinical Urology: Laparoscopic repair of Bochdalek Hernia, presenting as a renal colic Bochdalek hernia (BH) is a postero-lateral diaphragmatic congenital defect. Although most commonly diagnosed at birth, 0.17-6% of cases can also be seen in adults.A third of the cases may contain abdominal organs like small bowel, kidney or spleen.In our literature search we only found 3 reported cases of urinary obstruction secondary to herniation of the renal pelvis through a BH. Here we describe a rare case of upper urinary tract obstruction caused by a BH successfully treated by laparoscopic surgery in our center.
Hidradenocarcinoma of the scrotum Lesions of the skin and soft tissues of the penis and scrotum may be confusing in urological practice, since rare differential diagnoses can be challenging to providers with limited dermatological experience. Hidradenocarcinoma is one of such diagnoses, a rare and aggressive malignant tumor originating from sweat glands.A 61 year-old man presented with a nodule in the penoscrotal region which had appeared 1 year before consultation. He had no history of penile lesions, sexually transmitted diseases or other complaints.
Intravesical Electromotive Botulinum Toxin Type A (Dysport®) Administration in Children with Myelomeningocele Electromotive drug administration (EMDA) presents a minimally-invasive method of intravesical instillation of therapeutic agents without the need for general anesthesia 1. It employs a combination of iontophoresis, electrophoresis, and electroporation to deliver drugs into deep tissue layers using an electrical current created between two electrodes 2. This video shows feasibility of botulinum toxin type A (BoNTA) EMDA in myelomeningocele (MMC) children with urinary incontinence secondary to neuropathic detrusor overactivity.
Robotic One Access Surgery (R-1): Initial Pre-Clinical Experience for Urological Surgeries Laparoendoscopic single-site surgery (LESS) was developed to minimize the morbidity associated with laparoscopic surgery. Application of robotics in urologic surgery has been widely adopted given the advantages it provides over standard laparoscopy including three-dimensional vision, improved ergonomics and enhanced precision and dexterity. The real benefit of robotic LESS is still unbalanced by the limitations of this approach and the sole applicability by highly skilled surgeons. The ideal robotic platform for single port surgery should have the possibility of being deployed through a single access site restoring intra-corporeal triangulation for precise instrument maneuvers.
Acute Renal Transplant Failure Secondary to an Obstructing Ileal Conduit Adenocarcinoma: Case Report and Literature Review A 38-year-old Caucasian male with a complex urologic history of renal transplantation and ileal conduit urinary diversion was admitted with acute renal failure and found to have an obstructing ileal conduit mass. The patient's history was notable for posterior urethral valves status post ablation as an infant, construction of a catheterizable channel at age 2, ileal conduit urinary diversion at age 4, left nephrectomy for recurrent pyelonephritis in a nonfunctioning kidney at age 7, and living-related kidney transplant for progressive chronic kidney disease at age 27.
Fibroepithelial Vaginal Polyps in a Newborn Female Vaginal fibroepithelial polyps in newborn females are rare. There are only four previously documented reports.1-4 There have been no reported cases of a single infant with multiple broad-based polyps that were not amendable to full resection. All other reported cases of this particular disorder in the newborn period have been of a singular fibroepithelial vaginal polyp. In this case report, the diagnosis and management of a neonatal female with a rare type of interlabial mass is reviewed.
Prostatic stromal tumors of uncertain malignant potential We present a 53-year-old man with a multilocular solid and cystic mass measuring 19 cm on cross-sectional imaging. After undergoing pelvic mass excision, final histopathology confirmed the diagnosis of primary prostatic stromal tumor of uncertain malignant potential (STUMP). Prostatic STUMPs are rare mesenchymal tumors with diverse histological patterns. They are distinct from prostatic stromal sarcomas as they do not behave aggressively, although some may occasionally demonstrate local recurrence after resection.
A Case Study Evaluating the Diagnosis and Treatment of a Rare Mesenchymal Tumor The objective of this study is to report a benign mesenchymal neoplasm, cellular angiofibroma. We describe a 34-year-old male with a 4-month history of a painless right inguinal mass. CT scan of the abdomen and pelvis showed a 6.6 cm, oval-shaped mass without any distinguishing radiographical features. Surgical excision of the mass was performed. Tissue was extracted for immunohistochemical analysis, which stained positive for CD34 and Desmin, confirming cellular angiofibroma of the spermatic cord.
Transvaginal Cystolithotomy: A Novel Approach To describe a novel surgical option for cystolithiasis management in female patients with no urethral access and prior abdominal surgeries. We present a 51-year-old female with a history of traumatic spinal cord injury with pelvic fractures and resultant neurogenic bladder. She underwent transabdominal bladder neck closure and bladder augmentation with continent diversion two years prior. CT abdomen/pelvis demonstrated a 3cm stone and significant amount of bowel anterior to the bladder.
Future Considerations in Nocturia and Nocturnal Polyuria Nocturnal polyuria (NP), the most common etiology of nocturia, can be caused by various medical conditions, including cardiovascular disease, obstructive sleep apnea, renal tubular dysfunction, as well as medications (eg, diuretics) and/or behavioral patterns. NP in the absence of underlying medical conditions has been described as NP syndrome and is thought be the result of impaired circadian release of endogenous arginine vasopressin. Desmopressin, a synthetic arginine vasopressin analog, has been shown to be an effective replacement therapy in adults with nocturia due to NP.
Scrotal Hydrocele in Acute Pancreatitis Acute pancreatitis a common diagnosis. Although extremely rare, extravasated pancreatic fluid has the potential to third-space into the peritoneal cavity or retroperitoneal space. We report the case of a 33-year old male with idiopathic subacute pancreatitis who developed acute scrotal pain and swelling. Computer tomography (CT) of the abdomen/pelvis revealed tracking of peritoneal fluid into the scrotum consistent with a pancreatic hydrocele, confirmed by ultrasound. He was taken to the operating room for exploration and evacuation of the scrotal hydrocele.
Juxtaglomerular Cell Tumor: A Rare, Curable Cause of Hypertension in a Young Patient An otherwise healthy 25-year-old woman diagnosed with a renal neoplasm on work-up of new onset hypertension was referred to Urology clinic for further evaluation and management. The patient initially presented to her primary care provider 3 weeks prior for a well visit and was diagnosed with stage 2 hypertension with a blood pressure of 172/117 mm Hg and heart rate of 87 beats per minute. She endorsed history of intermittent headaches, but denied palpitations, diaphoresis, anxiety, or visual changes.
Advances in the Diagnosis and Management of Nocturnal Polyuria Nocturnal polyuria (NP), the most common etiology of nocturia, is a bothersome condition characterized by overproduction of urine at night.1,2 NP may result from abnormalities in the normal circadian variation in endogenous arginine vasopressin (AVP) secretion,3 and it can also be associated with various medical conditions, including congestive heart failure, diabetes mellitus, obstructive sleep apnea, peripheral edema, excessive night-time fluid intake, as well as “normal” aging.4 There is a strong need to manage this burdensome condition by identifying the causative factors and associated comorbidities.
Healthcare Costs of Post-Prostate Biopsy Sepsis Sepsis following transrectal prostate biopsy occurs in 2-5% of cases and the risk is increasing. We performed a comprehensive literature search for the cost of post-prostate biopsy sepsis to define the potential cost savings of reducing infectious complications. Reporting of cost is varied and presents a challenge to interpretation. Length of hospitalization ranged from 1.1-14 days and the percent admitted to an ICU ranged from 1.1-25%. The estimated cost of sepsis post-prostate biopsy, adjusted for inflation, ranged from $8,672-$19,100.
Functional Recovery From Prolonged Warm Ischemia: Compelling Case Scenarios A 69-year-old man with a history of rheumatoid arthritis and pulmonary fibrosis presented with an incidentally discovered 11.5 cm left renal mass with a level 3 inferior vena cava (IVC) tumor thrombus, including involvement of the left adrenal and lumbar veins. The thrombus was highly vascularized as shown in Figure 1A-C. Preoperative evaluation was negative for metastatic disease and the serum creatinine (SCr) level was 1.55 mg/dL, correlating with an estimated glomerular filtration rate (eGFR) of 46 mL/min/1.73m2.
Evolution of the Liquid Biopsy in Metastatic Prostate Cancer We reviewed the literature for the biologic, prognostic, and predictive significance of circulating prostate cancer tumor cells (CTCs), and circulating tumor DNA (ctDNA) in the blood of metastatic castration resistant prostate cancer patients (mCRPC). CTCs demonstrate robust prognostic value independent of PSA in predicting overall survival. The CTC androgen receptor variant receptor 7 (AR-V7) phenotype predicts resistance to androgen receptor synthesis inhibitors and sensitivity to taxane based chemotherapy in mCRPC patients who are candidates for second line therapy.
Magnetic Resonance Imaging Findings of Penile Abscess A 72-year-old man presented with pain and swelling in the penis, indicating penile infection or abscess. An ultrasound was performed but unable to lead to a diagnosis of abscess. Magnetic resonance imaging with diffusion-weighted imaging was strongly suggestive of penile abscess. The puncture of the abscess was unsuccessful. However, pus was drained spontaneously via the urethra, and the symptoms disappeared eventually. Although ultrasound can be useful, sometimes it might be difficult to distinguish between inflammatory tissue and abscess containing necrotic tissue.
Anteroposterior Duplicated Exstrophy: A Case Report Duplicated bladder exstrophy is an extremely rare variant of the exstrophy/epispadias complex. Duplicated exstrophy defines an exstrophic mucosal plate in hypogastric area with a normal closed bladder. We present a unique case of an anteroposterior duplicated exstrophy in a female newborn.
Glanular Venous Malformation in Pediatric Age: An Uncommon Vascular Disorder Glanular venous malformations are uncommon in pediatric patients. The diagnosis can be easily achieved by observation, even if color Doppler ultrasound is useful for a better characterization. Abdomino-pelvic MRI is necessary to assess the extension of complex lesions and check for associated anomalies. Several therapeutic options are reported in literature. We report 3 paediatric cases successfully treated by surgery with no complications and functional sequelae. Cosmetic results were satisfactory, with minimal surgical scarring.
Locally Invasive Primary Squamous Cell Carcinoma of the Left Ureter in a Patient with a Duplicated Inferior Vena Cava A 56-year-old female presented to an outside institution for several days of abnormal uterine bleeding. At that time, she underwent a dilation and curettage and was discharged. Five days postoperatively, she presented to the emergency room with abdominal cramping, vaginal bleeding, hematuria, and left flank pain. Cross-sectional imaging was obtained which revealed left moderate hydronephrosis and a soft tissue midureteral mass (Figs. 1 and 2). The endometrial biopsy performed by gynecology resulted in only endometrial hyperplasia.
[18F]Fluciclovine-PET Guided Salvage Lymph Node Dissection Following Radical Prostatectomy Despite advances in standard-of-care treatment for prostate cancer, including pelvic radiotherapy and radical prostatectomy with lymph node dissection, biochemical recurrence remains a problem with some studies reporting up to 30% of patients with biochemical recurrence at 10-years following treatment. Upon detection of a rise in serum prostate-specific antigen following treatment, clinicians are left with the dilemma of how best to treat these patients. Frequently, these patients are restaged with CT of the abdomen and pelvis or MRI of the pelvis in addition to a nuclear medicine bone scan.
Teaching Urologists “How to Read Multi-Parametric Prostate MRIs Using PIRADSv2”: Results of an iBook Pilot Study To create an online resource that teaches urologists how to interpret prostate multiparametric magnetic resonance imaging (mpMRI). As prostate mpMRI becomes widely adopted for cancer diagnosis and targeted biopsy, it is increasingly important that urologists are comfortable and experienced in assessing the images. The purpose of this study was to create an online mpMRI ibook and measure its effect on instilling proficiency among urology residents.
Adoption of Abiraterone and Enzalutamide by Urologists To investigate the adoption of abiraterone and enzalutamide by urologists. Abiraterone and enzalutamide are oral therapies approved for the treatment of metastatic castration-resistant prostate cancer, a disease most commonly treated by medical oncologists.
Atypical Presentation of Seminoma in the Prostate – Case Report Seminoma is a very common germ cell tumor (GCT) of the testicle. It is a malignant neoplasm and is one of the most treatable and curable cancers, with a survival rate of over 95% if discovered in early stages. Primary extragonadal GCTSs (EGCTs) are rare, and nearly two thirds are seminomatous tumors.1 As majority of the EGCTs originate from the midline structures, commonly reported locations include the mediastinum, thymus, retroperitoneal organs, and pineal gland.2,3 EGCTs have a good prognosis and a low rate of metastatic potential.
King of the Queen City: The Urologist Who Saved Buffalo When thinking of the great men and women of urology, one might consider the early pioneers in treatment of stones, voiding dysfunction, infertility, or cancer. Throughout history, urologists have also been technological leaders and have been at the cutting edge of medicine and public health. One such leader, Walter D. Greene, emerged in the “Queen City” of Buffalo, New York at the turn of the 20th century, when one of the most serious issues facing American cities was the outbreak of venereal and infectious diseases.
Indocyanine Green (ICG) in Urologic Surgery Indocyanine green (ICG) is a dye used for fluorescent-guided surgery. This review article addresses the recent surge in reported uses of ICG in various surgical fields and provides a comprehensive and up to date review of the uses of ICG in urologic surgery.
Management of the Clinically Negative (cN0) Groin Penile Cancer Patient: A Review To determine the role of noninvasive, minimally invasive diagnostic modalities and current management recommendations for cN0 PNC, a literature review using PubMed and Web of Science search engines were conducted. We found that for predicting ILN+: physical exam has limitations, nomograms are not validated, conventional computerized tomography/magnetic resonance imaging/positron imaging tomography scans have minimal role, and dynamic sentinel lymph node biopsy is the most reliable minimally invasive modality.
Pan-Urethral Condylomata Acuminata in an Immunocompromised Patient A 59-year-old African American male was referred for urologic evaluation of symptomatic anogenital warts. The patient was initially diagnosed with anogenital warts 1 year prior, however he did not seek further evaluation at that time. Subsequently, the lesions grew in size and number resulting in pain and occasional bleeding ultimately prompting him to seek medical attention. Additionally, he noted worsening postvoid dribbling but denied other lower urinary tract symptoms (LUTS) or hematuria. The patient has a past medical history of benign prostatic hyperplasia (BPH) treated with Tamsulosin and Acquired Immune Deficiency Syndrome (AIDS) treated with Highly Active Antiretroviral Therapy.
Preventable Cancer Deaths Associated with Bladder Preservation for Muscle Invasive Bladder Cancer This commentary introduces the concept of preventable cancer death associated with bladder preservation for muscle-invasive bladder cancer (MIBC). Neoadjuvant chemotherapy (NAC) and radical cystectomy (RC) is the standard of care for most MIBC. Another approach is bladder preservation. Trimodal therapy (complete transurethral resection [TUR] and chemo-radiation1 or NAC and bladder-sparing surgery (BSS),2 offer survival rates similar with cystectomy in properly selected cases. Tumor recurrence in the bladder is common after bladder sparing, however the impact of local recurrence on mortality is neither well defined nor emphasized in bladder preservation studies.
Advanced Bladder Cancer Rechallenged With an Immune Checkpoint Inhibitor: A Case Report Immune checkpoint inhibitors (ICIs), nivolumab, pembrolizumab, atezolizumab, durvalumab, and avelumab, are currently approved for locally advanced and metastatic urothelial cancer. Unfortunately, adverse events associated with these medications are not entirely uncommon. Of those patients suffering from adverse events associated with ICI therapy, approximately 20% experience an immune-related adverse event (irAE).1 High-grade irAE, as defined by CTCAE, have led to countless discontinuations of ICI therapies.
Sentinel Lymph Node Biopsy in Renal Tumors: Surgical Technique and Safety To understand uncertainties and knowledge gaps regarding lymphatic drainage in renal tumors, we performed 2 prospective studies to demonstrate regional lymph node (LN) drainage with sentinel lymph node (SN) imaging and biopsy. Here, we report the technique and perioperative safety of retroperitoneal SN dissection with different surgical approaches.
Large Renal Arteriovenous Malformation in a Patient With von Willebrand Disease We describe a rare case of a large renal arteriovenous malformation in a patient with von Willebrand disease. Initial attempts at technically challenging embolization failed requiring a nephrectomy. Extra-intestinal vascular malformations are rare in von Willebrand disease. However, there is more recent evidence of von Willebrand factor's regulatory role in angiogenesis and vascular malformations.
Predicting the Impacted Ureteral Stone with Computed Tomography To evaluate whether preoperative computed tomography (CT) findings could predict the presence of an impacted stone. Preoperative identification of an impacted ureteral stone may influence patient preparation and operative decisions. Factors predicting ureteral stone impaction have not been clearly identified.
Urologist Practice Structure and Spending for Prostate Cancer Care To investigate the impact of urologist practice structure on health care spending for men with prostate cancer. We hypothesize that 3 elements of urologist practice structure may influence spending for prostate cancer care: urologist participation within a multispecialty group (MSG), practice size among single specialty urology groups, and intensity-modulated radiation therapy (IMRT) ownership.
Three-year Active Surveillance Outcomes in a Contemporary Community Urology Cohort in the United States To determine the 3-year outcomes of men with prostate cancer managed with active surveillance (AS) in a cohort of geographically diverse community-based urology practices. AS is the management of choice for a majority of men with lower risk prostate cancer.1,2,3 Little is known about the contemporary “real-world” follow-up and adherence rates in the most common setting of urologic care, community (private) practice.4
Prostate Leiomyosarcoma: A Rare Misleading Tumor 73 year-old patient present with lower urinary tract symptoms (LUTS) and a low serum prostate specific antigen (PSA) diagnosed with a prostate leiomyosarcoma following a TURP. Afterwards, he was submitted to radical prostatectomy. A multimodal approach with radiotherapy was considered although death occurred less than three months after surgery.
An Uncommon Case of a Traumatic Corporal Cutaneous Fistula Penetrating perineal trauma is an unusual urologic injury. Even less common is a delayed presentation. Herein we present the case of a patient with delayed development of a corporal cutaneous fistula 3 months following perineal trauma.
Small Bowel Adenocarcinoma of Ileal Ureter 40 Years After Ureteral Reconstructive Surgery Malignant neoplasm arising from ileal ureter used for ureteral reconstructive surgery is an exceedingly rare event. Ureteroileoplasty was being performed since the beginning of the last century, but it was described more extensively in literature during the 1950s.1,2 Recurrent urinary infections, chronic renal failure, urolithiasis, anastomotic stricture, metabolic acidosis, and chronic dilation of the graft had been described as late complications of ureteroileoplasty.3,4 Herein, we describe history, imaging and pathologic findings of a small bowel adenocarcinoma arising from ileal ureter in a woman of 78-year-old, subjected to ureteroileoplasty about 40 years earlier.
Possible Drop Metastasis After Treatment of Renal Cell Carcinoma With Percutaneous Cryoablation A 69-year-old male with no documented past medical history presented to an outside institution with a 2.9 cm left lower pole renal mass that was incidentally discovered on imaging performed for abdominal and back pain. He denied any history of hematuria or flank pain. He was referred to the interventional radiology service for CT-guided percutaneous biopsy and cryoablation of the left renal mass. Three core needle biopsies were performed using a 20 gauge cutting needle with coaxial technique. Hydrodissection was used to displace the colon in preparation for cryoablation due to the lesion's anterior location.
A Thoughtful Pause for Sparing Oophorectomy We read with interest the recent article by Abboud et al1 regarding ovarian malignancy in women after radical cystectomy (RC). The authors demonstrate a low rate of subsequent ovarian malignancy, and conclude that oophorectomy at the time of RC may be omitted. While we applaud the goal to spare the undesirable morbidity of oophorectomy, we suggest a pause to blanket implementation of this recommendation.
Ovotesticular Disorder of Sex Development: A Rare Case of Lateral Subtype 45X/46XY kariotype Diagnosed in Adulthood A 53-year-old male referred to our centre because of hypergonadotropic hypogonadism detected during urological follow-up for urethral lithiasis. Physical examination showed short stature, micropenis, ambiguous external genitalia, and normal secondary sexual characteristics. Karyotype: 45 × 0/46XY. Abdominal MRI revealed the presence of uterus-like structure, right annex, and left testes without prostate. He underwent laparoscopic removal of dysgenetic tissues; histologic examination confirmed the presence of little uterus, fallopian tubes, little atrophic ovary, and vaginal tract; left testes was atrophic with sclero-jalinosis of seminal tubes and Leydig's cells hyperplasia.
Genetic and Environmental Influences on Urinary Conditions in Men: A Classical Twin Study To evaluate the genetic and environmental relationship among prostatitis and other urological conditions, including benign prostatic hyperplasia (BPH) and prostate cancer (CaP), a classical twin design and biometric modeling was used. While prostatitis—characterized by pain and voiding symptoms, no clear etiology, and functional and quality of life impairments—co-occurs with other urinary conditions, the degree of shared overlapping etiologic processes among them remains unclear. We examined the contribution of genetic and environmental factors to these conditions and the etiology of their associations at the level of genetic and environmental influences.
The Impact of 68Ga-PSMA PET/CT and PET/MRI on the Management of Prostate Cancer Prostate-specific membrane antigen (PSMA) is a transmembrane protein with significantly increased expression in the cells and metastases of prostate carcinoma (CaP). PSMA-expression correlates with higher serum levels of prostate-specific antigen (PSA) and a higher Gleason score (GS). This finding has led to the development of novel imaging modalities such as 68Ga-/18F-labeled PSMA positron emission tomography/computed tomography (PET/CT) and positron emission tomography/magnetic resonance imaging (PET/MRI).
Second Reported Case of Pediatric Bladder Alveolar Soft Part Sarcoma as Secondary Malignancy After Prior Cytotoxic Chemotherapy Alveolar soft part sarcoma (ASPS) is a rare malignancy with high rates of metastasis at presentation, defined by an unclear cellular origin and a unique unbalanced ASPSCR1-TFE3 translocation (der(17)t(X:17)(p11:q25)).1 ASPS is insensitive to chemotherapy and has been reported to involve the bladder only twice in the pediatric literature; once as a primary malignancy,2 and once as a secondary malignancy after cytotoxic chemotherapy.3 Herein, we report the third case of pediatric bladder ASPS in a female patient who received cytotoxic chemotherapy for low-risk neuroblastoma.
Robot-assisted Partial Nephrectomy and Bilateral Pyelolithotomy in Ectopic Pelvic Kidneys To show how to perform a robot-assisted partial nephrectomy and bilateral pyelolithotomy in ectopic pelvic kidneys. This is a congenital abnormality of position and rotation1 frequently associated with urolithiasis.2 Renal cell carcinoma is a very rare event in pelvic kidneys.3,4 These 2 findings in the same patient could be a surgical challenge and whenever possible a “one stage” treatment is preferred.
Contemporary Management of Incident Prostate Cancer in Large Community Urology Practices in the United States To characterize the contemporary management of prostate cancer patients in large community practices. The optimal management of incident prostate cancer has changed in the last decades to include active surveillance for a large number of men. At the same time, many community practices have merged into larger groups. The adoption of evidence-based guidelines is of increasing importance, but poorly understood in this newer practice setting.
A Case of Metastatic Prostate Cancer to the Urethra That Resolved After Androgen Deprivation Therapy An 83 year-old male with Gleason score 4+3 prostatic adenocarcinoma status post brachytherapy developed obstructive voiding symptoms 9 years after brachytherapy. Prostate-specific antigen was 0.67. Cystoscopy noted multiple papillary urethral tumors concerning for primary urethral carcinoma. Immunophenotype of biopsies supported diagnosis of Gleason score 4+4 prostatic adenocarcinoma. Androgen deprivation therapy was started. Cystoscopy performed 4 years later, for microhematuria workup, noted complete resolution of the urethral tumors.
Acute Urinary Retention Due to Late Migration of a Retained Bullet to the Urethral Meatus Urethral obstruction due to retained bullets migrating into the genitourinary system has rarely been reported. The literature describes 2 main methods of retained bullet removal from the genitourinary system: (1) spontaneous expulsion during voiding and (2) manual extraction due to urethral obstruction causing acute urinary retention. We present a case in which a 21-year-old man presented with acute urinary retention 3 years after suffering a gunshot wound to the abdomen. A retained bullet eroded through the bladder wall, migrated through the bladder and urethra, and eventually became lodged in the external urethral meatus, causing obstruction and urinary retention.
A Rare Cause of Urinary Peritonitis: Intra-abdominal Adhesion Rupture Intra-abdominal adhesions are a common complication following any surgical procedure involving the abdominopelvic cavity. The mechanism behind adhesion formation is still not well understood, however, is thought to be caused from inflammatory signaling and mesothelial surface disruption.1 Adhesion occurrence following a laparotomy is estimated to be as high as 95%1 with the other 2 main causes of adhesion formation being chronic inflammation of the bowel and postradiation therapy.2-4 Bladder perforation due to intra-abdominal adhesions has never been reported but may be something to consider when other causes of peritonitis have been excluded.
Three Cases of Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia—A Diagnostic and Therapeutic Challenge A 23-year-old man presented with massive enlargement of his testes. He had a known history of salt-wasting congenital adrenal hyperplasia due to 21-hydroxylase deficiency (CAH) and was on glucocorticoid and mineralocorticoid replacement since initial diagnosis at birth with a current treatment regimen of prednisolone 7.5 mg and fludrocortisone 75 µg daily. However, compliance was poor as reflected by hormonal control parameters out of target range (Table 1). Ultrasound of the testes revealed the presence of massive bilateral tumors with mixed hypo- and hyperechogenic appearance.
Transobturator Tape: Over 10 Years Follow-up To assess subjective and objective outcomes in incontinent patients following “out-in” TOT, at >10-year follow-up; to evaluate effect on quality of life and other urinary symptoms, late adverse events and predictive factors for failure.
The Natural History of Wilms Tumor–A Case Comparison of Two Different Tumors Due to the rarity of Wilms tumor (WT) and the relative urgency with which pediatric renal tumors are treated, there is little reported data on the natural history and growth of WTs. Historical reports of estimated doubling times of WTs were based on time to disease recurrence after initial diagnosis and treatment, and were published before the current advancements in molecular biomarker testing. We compare 2 cases of WT with sequential imaging, and postulate how the growth parameters of these tumors may be associated with differing chromosomal traits.
Ex-vivo Imaging of Upper Tract Urothelial Carcinoma Using Novel ICG-Var3 pHLIP Imaging Agent To improve visualization of upper tract urothelial carcinomas (UTUC). Previous studies using the novel pH low insertion peptide (pHLIP) variant 3 (Var3) conjugated to indocyanine green (ICG) have demonstrated high sensitivity and specificity for imaging of bladder urothelial carcinoma. Here, we describe a novel approach for the imaging of UTUC using ICG-Var3 pHLIP.
A Case of Primary Paratesticular Wilms Tumor in an Undescended Testis Extrarenal Wilms tumor is rare. We describe the first reported case of primary paratesticular extrarenal Wilms tumor with regional metastasis in 8-month old male with left undescended testis. Patient underwent left radical orchiectomy with regional lymph node excision. The inguinal node and paratesticular mass demonstrated the classic Wilms triphasic pattern, stained positively for WT-1 and demonstrated no loss of heterozygosity of chromosomes 1p and 16q. Work-up was negative for primary renal Wilms tumor or distant metastasis.
Adult Wilms Tumor During Pregnancy: Case Report and Literature Review Adult Wilms tumor (WT) is a well-known, albeit rare entity and has historically been associated with worse overall clinical outcomes when compared to younger patients. Because WT is uncommon in adult patients, it is often misdiagnosed and treated off standardized pediatric protocols. WT associated with pregnancy is even more rare, and there is not a standardized approach to this small subset of patients. We present a case of an adult WT discovered and managed during the perinatal period and review prior published cases.
Dermatofibrosarcoma Protuberans in a Male Infant Dermtofibrosarcoma protuberans is a rare cutaneous malignancy known to be locally aggressive. It is uncommonly seen in the pediatric population and can be difficult to distinguish from other benign skin lesions. We present a case of dermatofibrosarcoma protuberans of the penis in a 6-month-old child managed with surgical resection. This case highlights the challenges of diagnosis of genital lesions in children and the complexities of genitourinary reconstruction following surgical resection.
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.
AUTHOR REPLY Vasectomy is the safest and most cost-effective means of long-term permanent contraception, and is easily and safely performed in the office setting, under local anesthesia. Although some patient factors, such as body habitus, prior failed vasectomy, or extreme anxiety, may warrant consideration of vasectomy under sedation, these instances are infrequent and cannot account for the finding that approximately 18% of all vasectomies were performed in the ambulatory surgery center (ASC setting) during the study period.
EDITORIAL COMMENT This article is an excellent and timely comparison of the cost burden of vasectomy with regards to surgical setting and associated ancillary services. The authors point out that vasectomy is “the most common non-diagnostic operation performed by urologists in the United States.” They also discuss the growth of ambulatory surgical centers (ASCs) in the United States, and the possibility that physician ownership of ASCs may drive procedures and pathology services to increase as a result of case shift to such centers.
EDITORIAL COMMENT The overuse of resources and excessive spending of healthcare dollars in the US are among the reasons that the US is the most expensive healthcare system in the world, while still failing to achieve similar outcome metrics as many other developed nations. There is no better procedure to evaluate such excess than vasectomy. As the most effective, safest, and lowest cost option of permanent sterilization, vasectomy is a commonly utilized and incredibly important procedure for couples. However, as one of many alternatives in contraception, it remains a comparatively expensive, elective procedure utilized almost exclusively by an insured population.
AUTHOR REPLY The critical role of practiced based research has been articulated for at least a decade.1 Now with intense societal and political interest in how best to control costs and improve quality in healthcare, there is more need than ever to evaluate care in each of the myriad delivery models in the United States (US). Private practice, while decreasing each year as a percentage of all US health care delivery settings, remains a predominant modality and, yet, detailed evaluations of private practice care are often lacking.
EDITORIAL COMMENT In the treatment paradigm for prostate cancer, the pendulum has swung towards increasing use of active surveillance (AS) for lower risk disease, reflected by the most recent guidelines from the American Urological Association.1 These recommendations are supported largely by level-1 evidence from the PIVOT and ProtecT trials, which revealed similar mortality outcomes between observation and primary treatment for patients with clinically localized disease.2,3 In the present study, the authors characterize the management patterns of a unique, sizable cohort of patients with very low, low, or intermediate risk prostate cancer diagnosed in one of several large community practices distributed geographically across multiple states.
EDITORIAL COMMENT This is a nonrandomized report on comparing 2 penile plication surgeries for penile curvature disorders. The majority of the patients are for congenital curvature but there were 127 patients with Peyronie's disease, almost equally divided to have undergone modified Nesbit corporoplasty or 16 dot plication technique. The results are from 3 institutions and thus more than 1 surgeon's results are presented. Selection criteria for how assignment to either surgical procedure was done is lacking so selection bias is possible.
AUTHOR REPLY We agree wholeheartedly with the editorial comments regarding the significant unmet need in the management of upper tract urothelial carcinoma (UTUC). Despite therapeutic advances such as checkpoint inhibitors for urothelial carcinoma and advances in disease characterization on a genomic level, UTUC continues to pose a diagnostic and therapeutic challenge. Given the rarity of this disease, as mentioned by the reviewer, we need to rely on multi-institutional collaborations and retrospective studies to help us establish standards of care and protocols for the administration of systemic therapy and extirpative surgery.
EDITORIAL COMMENT Despite improvements in cross-sectional imaging and endoscopy, survival rates for patients with high-grade upper tract urothelial carcinoma (UTUC) have not improved in 2 decades. Nearly half of all patients with high-risk features die within 5 years, and patients with locally-advanced disease have less than a 2-year median survival.1,2 Given the persistently poor prognosis for patients with high-risk UTUC, a shift in treatment paradigm is needed.3
AUTHOR REPLY Several nonmalignant histological prostate findings have been shown to be of clinical relevance. For example, we and others have shown chronic histological prostate inflammation in needle biopsies is associated with worsening prostatitis- and benign prostate hyperplasia (BPH)-related symptoms over time.1,2 While basal cell hyperplasia (BCH) in the transitional zone has been associated with BPH in prior studies, the clinical significance of BCH in needle biopsies of the peripheral zone has not been previously studied in earnest.
EDITORIAL COMMENT Repeat biopsies in prostate disease are notoriously difficult to acquire, but provide a wealth of data linking phenotype with disease progression.
Author Reply The authors performed a retrospective study on 125 patients who experienced a biochemical relapse following radical prostatectomy (RP) and who were subjected to a PSMA-PET/CT in order to assess if the recurrent cancer foci were located within standard radiation target volumes.1 According to their data, 53% of the patients demonstrated PSMA-positive foci of which 25 lesions were located outside of the small pelvis. The authors concluded that the use of PSMA-PET/CT would have a dramatic effect on the design and the use of salvage radiation therapy.
Editorial Comment We appreciate the thoughtful editorial comment in regards to our manuscript.1 Although it is true that just over 50% of patients included in our study demonstrated prostate-specific membrane antigen (PSMA) Positron Emission Tomography (PET) avidity, this is actually a fairly high percentage given the population study. Inclusion of patients was limited to those with a prostate-specific antigen (PSA) <2.0 ng/dL, resulting in median PSA of 0.4 (0.28-0.63). PSMA PET sensitivity has been shown to be dependent on PSA levels and kinetics, and is associated with higher risk disease.
AUTHOR REPLY We very much appreciate the comments and are in complete agreement with the majority of points raised. The take-home message of this manuscript should be that based on very preliminary data, Xiaflex injections in PD men with ventral curvatures are reasonably safe and offer equivalent, if not better, outcomes compared to other directions. However, more data and external validation are mandated prior to routine implementation of this practice. This is further supported by our impression that ventral curvatures are more challenging to accurately inject and are probably best avoided until sufficient experience is gained with other curvatures.
EDITORIAL COMMENT Collagenase clostridium histolyticum (CCH) is the first medical treatment approved by the Food and Drug Administration for intralesional management of Peyronie's disease (PD). Based on the product monograph developed from Phase I-III trials, CCH is not currently approved for use in complex, hourglass, or ventral curvatures.1 The incidence of these atypical deformities is significant and the use of CCH in these patients is an evolving area of therapeutics. With this series, the authors provide an important addition to the literature addressing the question of efficacy and safety of treating ventral curvatures.
AUTHOR REPLY We identified a novel nonsynonymous mutation in RAF1 in a Caucasian family whose father experienced cryptorchidism while both sons had bilateral testicular torsion shortly after birth. Testing our hypothesis that RAF1 is part of the MEK/ERK pathway, we demonstrated in testicular tissue sample that decreased expression of RAF/MEK/ERK proteins. A limitation to all familial genetic studies is that causal relationships cannot be established rather only associations can be reported; however, the screening of nonaffected individuals and tissue analysis further strengthens these associations.
EDITORIAL COMMENT The basic science of this article is likely beyond the scope of the average practicing urologist, but nevertheless raises interesting genetic and clinical issues.
AUTHOR REPLY We sincerely thank the colleagues for the nice editorial comment. We are glad they appreciated the present manuscript. Given the increasing number of robot-assisted radical cystectomies performed worldwide, comparing the outcomes of extracorporeal urinary diversion (ECUD) vs intracorporeal urinary diversion (ICUD) represents a key research priority.
EDITORIAL COMMENT The authors report on a single-institution comparison between 2 surgeons, one performing exclusively intracorporeal ileal conduit urinary diversion (ICUD), while the other performed exclusively extracorporeal ileal conduit urinary diversions (ECUD). In this series, which compared perioperative complication and oncologic outcomes, no significant differences between the techniques were established. The utilization of robotic-assisted radical cystectomy (RARC) continues to rise, nearly 25-fold over the last decade,1 which makes studies like this imperative.
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