Allopurinol use leading to xanthine nephrolithiasis in pediatric tumor lysis syndrome: a case series.

Tumor lysis syndrome (TLS) is a life-threatening metabolic disorder caused by massive tumor lysis. Allopurinol, a xanthine oxidase inhibitor, is initiated during chemotherapy to prevent hyperuricemia and subsequent acute kidney injury (AKI). We report two cases of xanthine nephrolithiasis during TLS in newly diagnosed hematologic malignancy patients receiving prophylactic allopurinol. Allopurinol use likely promoted xanthine crystallization, stone formation, and AKI.

Survey of COVID-19 impact on pediatric urology services.

INTRODUCTION: To better understand how the COVID-19 pandemic has forced rapid operational changes in the global healthcare industry, changes implemented on an individual, institutional basis must be considered. There currently is not adequate literature about the overall impact COVID-19 has had on pediatric urology services worldwide. We believe that they have dramatically decreased during the COVID-19 crisis, but have adapted to accommodate changes. We hypothesize that patient care was widely variant due to inadequate standardized recommendations or crisis planning. MATERIALS AND METHODS: A web-based survey was deployed to 377 pediatric urologists globally via email to analyze COVID-19's impact on various types of pediatric urology practices. Key categories included impacts on elective services, telemedicine use, finances, and recovery operations. A total of 114 responses were collected between April 29th - May 22nd, 2020. RESULTS: The widespread cancellation of elective surgical procedures caused significant disturbances in the field. There was a uniform, significant increase (75%) in telemedicine use across practices. The pandemic has created many changes in care provision for physicians, institutions, and patients themselves. Furthermore, the sudden economic burden on healthcare facilities could lead to cost-cutting measures, creating further strain within institutions. Though telemedicine has its limitations, it is a very viable option when traditional services are unavailable. CONCLUSIONS: Immediate steps should be taken to ensure that the recovery phases of pediatric urology practices are as efficient as possible. Institutions should develop task forces to develop critical workflow processes in the event of health crises, while still maintaining patient-centered care. This will be essential in maximizing appropriate care allocation.

24-Hour Urinary Parameters in Overweight and Obese Children with Urolithiasis.

PURPOSE: The increasing incidence of pediatric nephrolithiasis is a growing concern and its association with obesity continues to be an area of debate. We present data on urine chemistries of overweight/obese children compared to those with a normal body mass index and history of urolithiasis treated at a single institution in the United States, and assess risk factors. MATERIALS AND METHODS: We retrospectively identified 110 stone forming patients who underwent 24-hour urine collection and stratified them according to the Centers for Disease Control and Prevention definitions of overweight/obese (body mass index above 85th/95th percentile). Absolute urine collection quantities were compared between groups. Stone risk factors were analyzed according to Litholink® specified reference ranges. RESULTS: Compared to patients with low or normal body mass index, overweight and obese patients had lower body surface area adjusted citrate (242 mg/1.73 m(2) vs 315 mg/1.73 m(2), p = 0.03), lower urine phosphate (12 mg/kg vs 14 mg/kg, p = 0.04), lower urine magnesium (1.2 mg/kg vs 1.6 mg/kg, p = 0.01) and increased incidence of hypercalciuria (31% vs 11%, p = 0.02). Differences in urine citrate, phosphate and magnesium were not apparent when analyzing stone risk factors. There was no association between body mass index and urine pH. CONCLUSIONS: Overweight and obese stone forming children have decreased levels of urine citrate, phosphate and magnesium compared to patients with normal body mass index. The incidence of hypercalciuria is increased in overweight/obese patients. In contrast to findings in adults, there is no association between urine pH and body mass index.

Robot-assisted laparoscopic ureteric reimplantation: extravesical technique.

OBJECTIVES: To describe our standardised approach to performing robot-assisted extravesical ureteric reimplantation. PATIENTS AND METHODS: A total of 29 children, with high grade (III-V) vesico-ureteric reflux (VUR) underwent robot-assisted extravesical ureteric reimplantation between September 2010 and September 2013. Follow-up renal ultrasonography was performed at 1 month and 3 months and a voiding cysto-urethrogram (VCUG) was obtained at 4 months to assess VUR resolution. RESULTS: The mean (range) patient age at the time of surgery was 5.38 (3.0-10.0) years. Postoperative VCUG showed complete resolution of VUR in 32/40 ureters (80%). Of the remaining refluxing ureters, downgrading of VUR on VCUG was shown in 7/8 ureters (87.5%). The mean (range) length of hospital stay was 1.8 (1-3) days. CONCLUSIONS: In conclusion, robot-assisted extravesical ureteric reimplantation is technically feasible with acceptable resolution of VUR.

The prognostic significance of perineural invasion and race in men considering active surveillance.

OBJECTIVE: To determine the importance of perineural invasion (PNI) on diagnostic biopsy in men enrolled in active surveillance (AS). PATIENTS AND METHODS: Eligibility criteria for AS included clinical stage ≤ T2a and Gleason score ≤6, ≤3 cores positive, maximum single core involvement <50%, and total tumour volume ≤5% on diagnostic biopsy. All men received 12-core confirmation biopsy at ≤6 months. AS 'failure' on confirmatory biopsy was defined as failure to meet one or more eligibility criteria. Risk of AS failure was compared in men with and without PNI. RESULTS: For the 165 men comprising the study population, the mean (sd) age was 66.9 (6.5) years and the median (interquartile, IQR) PSA level of men at study entry was 4.4 (3.2-6.0) ng/mL. The median (IQR) follow-up was 5.5 (1.1-9.9) months. In all, 8.5% (14/165 men) had PNI on diagnostic biopsy. Compared with those without PNI, men with PNI tended to have more cores involved with cancer, at a mean (sd) of 2.0 (0.7) vs 1.6 (0.8) cores (P = 0.08) but did not have significantly a greater mean (sd) total tumour length on diagnostic biopsy, at 3.0 (2.1) vs 2.3 (3.6) mm (P = 0.27). Men with PNI on diagnostic biopsy were significantly more likely to meet criteria for disease progression on confirmatory biopsy (57% [8/14] vs 21% [32/151]; P = 0.006). PNI remained a significant predictor for AS failure after adjustment for number of positive cores, maximum percentage core involvement, and total tumour length (odds ratio 4.4, 95% confidence interval 1.4-14.2). CONCLUSIONS: PNI on diagnostic biopsy is associated with disease progression on confirmatory biopsy. The presence of PNI should factor into appropriate patient selection and counselling in AS.

Outcomes of infants undergoing robot-assisted laparoscopic pyeloplasty compared to open repair.

PURPOSE: Robotic surgery has evolved from simple extirpative surgery to complex reconstructions even in infants. Data are lacking comparing surgical and direct costs to open approaches. We describe the feasibility, salient tips and outcomes of robot-assisted laparoscopic pyeloplasty compared to an open approach. MATERIALS AND METHODS: We evaluated patients undergoing open pyeloplasty or robot-assisted laparoscopic pyeloplasty. Ten patients in each group met inclusion criteria. RESULTS: Mean patient age was 3.31 months in the open group and 7.3 months in the robotic group (p=0.02). Postoperative outcomes including length of stay (2.2 vs 2.1 days), estimated blood loss (6.5 vs 7.6 ml), days to regular diet (1 vs 1.1) and days to Foley catheter removal (1.3 vs 1.3) were similar between the open and robotic groups. Total operating time (199 vs 242 minutes) was significantly longer in the robotic group. Postoperative improvement in hydronephrosis was identical in both groups. Direct costs, excluding amortization, robotic cost, maintenance and depreciation, were $4,410 in the open group and $4,979 in the robotic group (p=0.10). CONCLUSIONS: In our preliminary experience robotic pyeloplasty in infants is feasible and safe. The immediate outcomes are similar to those of an open approach. The robotic technique in infants currently has the benefits of improved esthetic appearance, improved pain control and similar direct costs compared to the traditional open approach.

Obstructive uropathy secondary to rectus sheath hematoma.

Rectus sheath hematoma (RSH) is uncommon and is often reported in the setting of anticoagulation or trauma. Typically RSH presents with localized or diffuse abdominal pain and a fixed abdominal wall mass, however, various presentations and complications have been reported depending on the setting and extent of the hematoma. We report a case of a rapidly expanding RSH causing obstructive anuria and hydronephrosis in addition to a review of literature on this rare presentation of RSH.

Increasing Prevalence of Pediatric Community-acquired UTI by Extended Spectrum ß-Lactamase-producing E. coli: Cause for Concern.

BACKGROUND: Antimicrobial resistance and emerging spectrum-ß-lactamase (ESBL) infections are a rising concern in public health. Despite the increasing prevalence of community-acquired (CA) ESBL-E. coli UTIs, there is little data on the antibiotic resistance profiles of this bacterial strain in the pediatric population. We review antibiotic resistance profile and rising trend in pediatric ESBL-E. coli UTI presentation at our pediatric hospital. METHODS: This retrospective study reviewed data drawn from the infectious disease database at our pediatric hospital for all patients whose urine culture grew ESBL-E. coli from 01/2015 to 01/2021. Demographic information and antimicrobial susceptibility test results for ESBL-E. coli isolates from CA-UTIs were collected. Annual changes in resistance to antimicrobial agents and average annual percent change in ESBL-E. coli UTI presentation over the study period are reported. RESULTS: From 01/2015 to 01/2021, 6403 urine cultures at our hospital grew E. coli. Of these, 169 urine cultures from 135 children grew ESBL-E. coli. The study population was 57% male (77) with a mean age of 6.9 ± 6.2 years and multiethnic. CA-UTI by ESBL-producing E. coli accounted for 2.62% of total E. coli UTIs within the study period and increased from 0.97% in 2015 to 3.54% in 2020 by an average of 0.51% each year. CONCLUSIONS: These findings demonstrate an increase in CA-ESBL E. coli UTIs in children. We observed most isolates demonstrated multidrug resistance. As CA-ESBL E. coli UTIs are associated with prolonged hospitalization and increased morbidity, our findings highlight the rising trend in pediatric CA-ESBL E. coli UTI.

Risk factors for community acquired pediatric urinary tract infection with extended-spectrum-ß-lactamase Escherichia coli - A case-control study.

INTRODUCTION: Community-acquired (CA) infections caused by extended-spectrum ß-lactamase (ESBL) producing Escherichia coli urinary tract infections (UTI) have become increasingly prevalent, posing a serious threat to public health. Risk factors for ESBL UTI have not been extensively studied in the pediatric population. We report findings from a case control study to identify risk factors for CA ESBL-producing E. coli UTI in children. MATERIALS AND METHOD: A cohort of children with CA ESBL Escherichia coli UTI evaluated at a tertiary referral hospital from January 2014 through April 2021, were matched 1:3 with control group of non-ESBL CA E. coli UTI based on age at first episode of non-ESBL UTI. To identify potential risk factors for ESBL E. coli UTI, conditional logistic regression model was utilized accounting for age matching. Univariate models were fitted for each clinical risk factor. Factors found to be significantly associated with ESBL UTI were simultaneously included in a single model to check for associations adjusted for all other factors. RESULTS: On conditional multivariate analyses for univariate testing, male sex (P = 0.021), history of Urology care (P = 0.001), and antibiotic treatment within 30 days prior to positive culture (P = 0.004) were identified as independent risk factors for CA ESBL E. coli UTI. Comorbidity scores were assigned to each patient according to pediatric comorbidity index (PCI); children with ESBL UTI were more likely to have higher morbidity risk than non-ESBL UTI children (P < 0.001). From the logistic model, the higher the morbidity scores, the more likely children will have CA ESBL UTI (P < 0.001). DISCUSSION: Identifying risk factors for ESBL-producing E. coli UTI in children is important because of limited therapeutic options. This knowledge is essential for clinical decision making and to develop intervention strategies to reduce disease burden. Our study found that although females have an increased predisposition to UTIs, we observed that the male sex is an independent risk factor for ESBL E. coli UTI. This finding warrants further investigation to determine underlying cause. Because of the retrospective design of the study, collection of data from a single center, and differences in characteristics between patient populations, treatments, and prescribing patterns in the community, this study may not be generalizable. CONCLUSIONS: Findings from our case-control study suggest that the male sex, history of Urology care, and previous antibiotic exposure are independent risk factors for CA ESBL-GNB UTI. Children with ESBL E. coli UTI are more likely to have longer admission duration and higher comorbidity index.

Quality of lymphadenectomy is equivalent with robotic and open cystectomy using an extended template.

PURPOSE: Extended lymph node dissection for bladder cancer provides better staging, cancerous node removal and potentially survival. Minimally invasive techniques have been criticized about the ability to adequately perform extended lymph node dissection. We compared the extended lymph node dissection quality of robotic and open cystectomy by assessing node yield and positivity. MATERIALS AND METHODS: We compared extended lymph node dissection in 120 open and 35 robotic cystectomy cases. Extended lymph node dissection included skeletonization of structures in each nodal group below the aortic bifurcation (common iliac, external iliac, obturator, hypogastric and presacral nodes). Nodes were processed identically but submitted as 1 or 2 packets for robotic cases and as 10 or more packets for open surgery cases. RESULTS: The mean±SD node count in the open group was 36.9±14.8 (range 11 to 87) and in the robotic group the mean yield was 37.5±13.2 (range 18 to 64). Only 12 of 120 open (10%) and 2 of 35 robotic (6%) cases had fewer than 20 nodes. A total of 36 open (30%) and 12 robotic (34%) cases were node positive. Open extended lymph node dissection identified 80% and 90% confidence of accurate staging as pN0 when obtaining 23 and 27 nodes, respectively. A node count of 23 or 27 was achieved in 87% and 77% of open cases, and in 91% and 83% of robotic cases, respectively. Of patients with open surgery 36% received neoadjuvant chemotherapy compared to 31% of those with robotic surgery. CONCLUSIONS: No difference was identified in the lymph node yield or the positive node rate when comparing open and robotic extended lymph node dissection. Local recurrence and survival data are needed to confirm whether the 2 techniques are oncologically equivalent.

Hemangioma of the scrotal septum: a rare entity in infants with review of the literature.

Hemagiomas are most common tumors in infancy; however, scrotal septum hemangiomas are very rare with only 45 cases reported in the literature. We report a case of a 6-month-old child who presented with a scrotal mass at birth which had increased in size with age. A scrotal ultrasound with color doppler analysis, revealed a soft tissue mass with diffusely increased blood flow. Scrotal mass excision was performed and the pathology confirmed a capillary hemangioma.

Pediatric Non-Testicular Torsion Acute Scrotum-Is the Use of Prophylactic Antibiotics in Patients With Normal Urine Analysis Justified?

OBJECTIVE: To determine if empirical antibiotic treatment for non-testicular torsion (NNT) acute scrotum is necessary in the setting of a normal urine analysis (UA). METHODS: Retrospective chart review revealed 314 pediatric patients with clinically diagnosed NTT acute scrotum with negative UA between 2004-2019. Exclusion criteria included previous urological history and immunocompromised state. Patients were divided into those with antibiotics treatment vs those without. The independent t test was used to compare numerical variables while the chi-squared test was used to compare categorical variables. RESULTS: Of the 314 patients identified, 141 (44.9%) received empiric antibiotics despite negative UA. Clinical findings and demographic characteristics between groups were not found to be significant. Patients clinically diagnosed with epididymo-orchitis were more likely to be prescribed antibiotics (48.2 vs 30.6%, P =.02). Trimethoprim-sulfamethoxazole accounted for 83% of the antibiotics that were prescribed in our study. There was no significant difference in symptom resolution between patients prescribed antibiotics and those not prescribed antibiotics (5.1 days vs 4.6 days, P =.71). Additionally, no patient in either group returned with complications such as worsening symptoms or urinary tract infection between presentation and their scheduled follow up visit. CONCLUSION: Based on our analysis, antibiotics in NTT acute scrotum appear to have no benefit in symptom resolution or complication reduction in patients without any predisposing urological risk factors and negative UA at presentation. Given the risk and rise of antibiotic resistance providers need to be careful to select treatments based on available evidence.

Pediatric female genital trauma managed under conscious sedation in the emergency department versus general anesthesia in the operating room- a single center comparison of outcomes and cost.

INTRODUCTION: Pediatric female genital trauma (PFGT) comprises injuries to the female external and internal genitalia. Examination under general anesthesia (GA) in the operating room (OR) is traditionally recommended, however repair at the bedside under conscious sedation (CS) in the emergency department (ED) may be a safe alternative. The Genitourinary Injury Score (GIS) objectively classifies PFGT severity, but designates all vaginal and urethral injuries as Grade III. OBJECTIVE: To compare outcomes and cost of patients with PFGT managed under CS in the ED vs GA in the OR. STUDY DESIGN: All patients treated by a pediatric urologist from May 2009 to September 2019 with associated ICD codes for PFGT were included. Exclusion criteria included PFGT from sexual abuse or obstetric related complications. Clinical and demographic data was extracted from the EMR. A cost analysis comparing ED vs OR management was performed. RESULTS: 33 patients were identified with a median age of 6.8 years. The primary etiology was straddle trauma. Injuries were predominately GIS I-III (30, 91%) with possible urethral involvement in 6 patients. Sedation and repair in the ED was performed for 12 (36%) patients vs 21 (64%) taken to the OR. For the OR cohort, 15 (71%) were taken to the OR immediately and 6 (29%) initially underwent CS but this was aborted due to injury complexity. Aborting CS and proceeding to the OR did not result in compromised outcome or prolonged hospitalization. No patients in the ED cohort required post-procedural admission whereas all patients taken to the OR were admitted postoperatively. Cost of care for ED repair was less than two-thirds (60%) that of surgical repair in the OR. Using Onen GIS III or less without deep vaginal and/or urethral involvement as a cutoff for attempted bedside repair vs proceeding directly to the OR could have spared 7 (47%) patients GA and subsequent admission. A female-specific modification to the Onen GIS III criteria is proposed in light of these findings. DISCUSSION: The present study suggests CS and bedside repair of low-grade PFGTs is safe with a cost benefit. This is reflected by a proposed modification to the Onen GIS III criteria. These findings should be interpreted with caution given the retrospective nature of this single institution, small cohort study. CONCLUSION: CS and bedside repair of low-grade PFGT appears to be safe and cost effective. Delineating GIS III injuries according to urethra and/or deep vaginal involvement may improve the GIS scale's clinical utility.

A Rare, Unusual Presentation of Newberyite Urolithiasis in Adolescent Female -A Case Report and Review of Literature.

We report a rare case of newberyite (magnesium monohydrate phosphate trihydrate) urolithiasis in a young female with a past medical history significant for longstanding autoimmune hepatitis. She presented to the emergency department with newly diagnosed nephrolithiasis. Over the next 2 years, she had recurrent renal calculi and 3 urologic procedures. Notably, she did not have any history of urinary tract infections or genitourinary abnormalities. Her last stone analysis revealed the unusual combination of newberyite and ammonium acid urate. The pathophysiology of ammonium acid urate and newberyite stone formation as well as risk factors of development are discussed in this report.

Effect of age, BMI, and gender on urinary risk factors in pediatric idiopathic stone formers.

INTRODUCTION: The incidence of pediatric urolithiasis has been increasing over the years; however, the etiology of this increase is not well understood. Age, body mass index, and gender have been examined as possible risk factors for stone disease, but with inconsistent and variable associations. OBJECTIVE: We aim to investigate the urine chemistry factors, as assessed by 24-h urinary parameters, in pediatric stone formers at a large volume tertiary referral center in the highest areas in the United States, the Southeast, based on age, body mass index, and gender. STUDY DESIGN: We retrospectively reviewed all pediatric stone formers who completed a 24-h study between 2005 and 2016. Patients were stratified by age (3-10 versus 11-18 years of age), overweight status (above versus below the 85th percentile for body mass index), and gender (male versus female) (Summary Figure). Statistical analysis included analysis of variance and logistic regression. RESULTS: 243 patients were included in our analysis. Patients in the first decade of life were found to have greater numbers of urinary risk factors than those in the second decade. Non-overweight patients were more likely to have hyperoxaluria and hyperuricosuria, while overweight patients were more likely to have hypocitraturia. Female patients were more likely to have higher hyperoxaluria, while male patients were more likely to have hypercalciuria. DISCUSSION: In contrast to prior publications, obesity is not linked to increased risk of urolithiasis with non-overweight individuals having a greater number of risk factors than the overweight cohort. Despite stone disease being more prevalent in adolescents, the greatest number of risk factors were present in the first decade of life. Lastly, female children had more urinary risk factors than males. Further understanding of the underlying causes of stone disease in various pediatric populations is warranted. CONCLUSION: While more urinary risk factors were identified in younger, non-overweight, and female patients, there remains no consensus on the urinary risk factors for pediatric urolithiasis. Further study is needed to elucidate the risk factors and pathophysiology of pediatric stone disease.

Prospective evaluation of radiation dose with conventional fluoroscopic voiding cystourethrogram in pediatric patients.

INTRODUCTION: Skin entrance doses for voiding cystourethrogram (VCUG) have not been well characterized in the literature. Radiation exposure is measured as either dose area product (DAP) or air kerma, which estimates the effective dose, but does not accurately reflect absorbed dose at skin level. OBJECTIVE: The objective of this study was to measure the skin entrance dose during fluoroscopic VCUG study in pediatric patients using single point dosimeters. STUDY DESIGN: Pediatric patients undergoing fluoroscopic VCUG were prospectively enrolled in our study. Landauer NanoDot™OSLD dosimeters were affixed to the skin overlying the sacrum to measure skin entrance dose. The fluoroscopic unit was set to the following parameters: low dose setting, skin-to-source distance of 54 cm, pulsed fluoroscopy at 3 frames/sec. RESULTS: Forty-four patients with a median age of 13.6 months (IQR 3.7-42.3) were enrolled. Median fluoroscopic time was 54 s (IQR 36-72). The median values absorbed dose by dosimeter and air kerma were 0.32 mGy (IQR 0.13-0.56, range 0.01-2.9) and 0.24 mGy (IQR 0.14-0.37), respectively. There was a positive correlation between the air kerma and absorbed dose (r = 0.69, p < 0.001) and fluoroscopy time and absorbed dose mGy (r = 0.60, p < 0.001). Absorbed dose was independent of age, body mass index and body surface area (p = 0.19, p = 0.57 and p = 0.16, respectively). Median whole body effective dose was 0.04 mSv (IQR 0.02-0.7). DISCUSSION: Overall, the absorbed dose received by the dosimeter remained low at a median of 0.32 mGy (range 0.01-2.91). These values are remarkably low and well within the accepted radiation exposure norms. Our radiologists follow a strict protocol to reduce the overall radiation emitted during a VCUG. These measures include setting the x-ray source at a low dose mode, collimating to the smallest area possible, and using pulsed fluoroscopy at 3 frames/sec. Limitations to this study include a slight variability in technique of VCUG between different technicians and providers, for which we cannot control. CONCLUSION: The radiation dose absorbed at the skin entrance and uniform whole body effective dose is low for a single VCUG when utilizing strict parameters. While newer non-ionizing technologies continue to emerge, our data is encouraging and will serve as a valuable tool when educating parents regarding radiation doses associated with a VCUG.

Pediatric urology amidst SARS-CoV-2 pandemic: Building the future with current knowledge.

INTRODUCTION: The COVID-19 pandemic has ripped around the globe, stolen family members and forced healthcare systems to operate under an unprecedented strain. As of December 2020, 74.7 million people have contracted COVID-19 worldwide and although vaccine distribution has commenced, a recent rise in cases suggest that the pandemic is far from over. METHODS: This piece explores how COVID-19 has explicitly impacted the field of pediatric urology and its patients with a focus on vulnerable subpopulations. RESULTS: Various medical and surgical associations have published guidelines in reaction to the initial onset of the pandemic in early 2020. DISCUSSION AND CONCLUSION: As the number of patients with COVID-19 increases, long-term recovery and future preparedness are imperative and should be cognizant of patient subpopulations that have been subject to disproportionate morbidity and mortality burden. Development of a dedicated response team would aid in achieving preparedness by drafting and implementing plans for resource allocation during scarcity, including logistic and ethical considerations of vaccine distribution. LEVEL OF EVIDENCE: III.

How do commonly performed lymphadenectomy templates influence bladder cancer nodal stage?

PURPOSE: Determining pathological nodal stage in patients with bladder cancer is important for prognosis. We determined how the extent of lymphadenectomy and the lymph node count influence accurate nodal staging. MATERIALS AND METHODS: The study included 120 patients who underwent at least extended lymphadenectomy at radical cystectomy. Different anatomical templates for lymphadenectomy were evaluated for nodal staging accuracy. The cumulative percent was plotted to determine a lymph node count that confidently identified node positive cases. RESULTS: The mean +/- SD total lymph node count in the study population was 36.9 +/- 14.8 at extended lymphadenectomy. Of the patients 36 (30%) had lymph node metastasis, including 14 (39%) with metastasis involving the common iliac and/or presacral lymph nodes. Limited, standard and extended lymphadenectomy accurately identified 75%, 88.9% and 100% of node positive cases, respectively. Removing 23 and 27 lymph nodes provided 80% and 90% confidence, respectively, that a case was accurately staged as pN0. No patient had lymph node metastasis above the aortic bifurcation without nodal metastasis below the aortic bifurcation and none had a change in pN stage by extending lymphadenectomy above the aortic bifurcation. CONCLUSIONS: To accurately identify node positive and negative cases, and correctly assign pN stage in node positive cases it is necessary to perform extended lymphadenectomy. Identifying at least 23 to 27 lymph nodes on final pathological evaluation provides a high level of confidence that a case is correctly staged as node positive or negative.

Contemporary referral pattern for robotic prostatectomy.

BACKGROUND AND OBJECTIVES: In spite of the current widespread application of robotic surgery in the treatment of prostate cancer, it remains unclear whether current patterns of use are based on patient benefit or driven by marketing. We sought to investigate this possibility by analyzing the source of our patient population for robot-assisted laparoscopic prostatectomy (RALP). METHODS: We reviewed 200 consecutive patients who underwent robotic prostatectomy by a single surgeon (RA) at our institution. The source of referral for each patient was analyzed along with individual patient characteristics to identify whether only low-risk or unusually ideal candidates were referred. RESULTS: Of the 200 patients, 90.5% were referred by a urologist with only 5.5% being referred by another urologist at our institution. Only <10 patients cited media or marketing sources as the reason for self-referral, and 10 were referred by primary care physicians or other acquaintances. This referral pattern did not change between the first and second 100 patients. Referred patients included those up to 80 years of age, up to 51 kg/m(2) in body mass index, and up to Gleason 9 on biopsy, with 36% of those referred by urologists having some history of previous abdominal or prostate surgery. CONCLUSION: The referral pattern for RALP at our institution may reflect a growing acceptance of robotic surgery among urologists in our region and is unlikely driven by patient-directed marketing. Additionally, urologists may also be more confident in the role of RALP as evidenced by their referral of even complex and higher-risk patients.

Robotic nephroureterectomy with partial duodenectomy for invasive ureteral tumor.

Robotic surgery is gaining acceptance in the management of diverse urological disorders. Any minimally invasive procedure carries a risk of open conversion either for complications or unexpected intraoperative findings, but the additional dexterity of robotic instrumentation may allow even complex situations to be managed laparoscopically. We report the case of an upper tract transitional cell carcinoma discovered at the time of robotic nephroureterectomy to be invading the duodenum that was successfully excised robotically.