Real-World Eligibility for HIV Pre-exposure Prophylaxis Among People Who Inject Drugs.

Recent studies have highlighted the efficacy of and willingness to use pre-exposure prophylaxis (PrEP) to prevent HIV infection among people who inject drugs (PWID), however knowledge of real-world applicability is limited. We aimed to quantify the real-world eligibility for HIV-PrEP among HIV-negative PWID in Montreal, Canada (n = 718). Eligibility was calculated according to US Centers for Disease Control and Prevention (CDC) guidelines and compared to risk of HIV acquisition according to the assessing the risk of contracting HIV (ARCH-IDU) risk screening tool. Over one-third of participants (37%) were eligible for HIV PrEP, with 1/3 of these eligible due to sexual risk alone. Half of participants were considered high risk of HIV acquisition according to ARCH-IDU, but there was poor agreement between the two measures. Although a large proportion of PWID were eligible for HIV-PrEP, better tools that are context- and location-informed are needed to identify PWID at higher risk of HIV acquisition.

The role of stent placement in laparoscopic ureteroureterostomy: experimental porcine model.

OBJECTIVE: Laparoscopic ureteral surgery is becoming increasingly common; however, advanced laparoscopic skills are required due to the precise suturing involved. Because of the size of the ureter and need for careful mucosal apposition to prevent stricturing, there is less room for error than with larger lumens, as in pyeloplasty. We sought to identify whether the presence of a stent is beneficial or a hindrance in performing ureteroureterostomy both for the novice and more experienced laparoscopist. MATERIALS AND METHODS: Eight ureteroureteral anastomoses were performed on each ureter of a 50 kg female pig for a total of 16 anastomoses. Eight were performed with a stent in place, and 8 were performed without a stent. An equal number with and without a stent were performed by a novice and an experienced laparoscopist. Anastomoses were graded by time to complete and quality of the anastomosis. Quality was graded by the presence and size of defects and patency of the lumen. RESULTS: The overall times required for ureteral division and spatulation, initial stitch placement, completion of the anastomosis, and total time for the stented vs. nonstented procedures were 4.3 vs. 2.2 minutes (P=0.05), 4.2 vs. 4.4 minutes (P=0.16), 10.4 vs. 13.5 (P=0.22) minutes, and 18.3 vs. 20.1 minutes (P=0.49), respectively. For stented and nonstented ureters, 3 vs. 5 anastomoses were found to have no or very small gaps, 5 vs. 1 anastomosis were found to have large gaps, and 0 vs. 2 anastomoses were found to have occluded lumens, respectively. CONCLUSIONS: For both the novice and experienced surgeon, presence of a stent did not affect the overall time to complete a ureteroureteral anastomosis despite the significantly longer time needed to divide and spatulate the ureter. There were no occlusions when the ureteral stent was placed prior to suturing, which may indicate a reduced risk of "back-walling" the ureter.

Renal metastasis of an ovarian granulosa cell tumour inducing growth of a cystic nephroma.

A 44-year-old woman presented with a large pelvic mass. Pathology revealed a granulosa cell tumour of the left ovary. The patient was followed after surgery with inhibin B levels and interval imaging. Six years later, she began to experience severe back pain. A vertebral biopsy was positive for metastatic granulosa cell tumour. She underwent radiation to the spine. Inhibin B levels began to rise and, several months later, a CT scan showed a large heterogeneous mass essentially replacing the left kidney. She underwent an open left radical nephrectomy. Pathology revealed a 12 cm cystic nephroma with a 5 cm nodule of metastatic granulosa cell tumour. Immunohistochemistry demonstrated that the mass was inhibin and oestrogen receptor positive. This is a novel presentation of these coexisting pathologies. This unique case sheds light on the possibility of induction of cystic nephroma by the altered hormonal environment created by a granulosa cell tumour metastasis.

Robot-assisted partial nephrectomy utilizing a hybrid-port technique.

Robot-assisted laparoscopic partial nephrectomy is increasingly being favored for treatment of small renal cortical neoplasms. The technique utilized varies based upon the institution and surgeon experience and several modifications have been proposed. We choose to utilize the fourth robotic arm as well as the Satinsky vascular clamp for these cases. Previously, we would utilize the fourth arm through a robotic port until the hilum was dissected, then replace the trocar with a flexible trocar for the Satinski clamp. We now utilize a hybrid-port technique where we establish placement of the flexible trocar and pass a robotic trocar through this to begin with the fourth arm in use. We then remove the fourth arm and the trocar after the hilum is dissected to place the Satinski clamp. The technique and description will be discussed.

The multi-disciplinary management of high-risk prostate cancer.

Prostate cancer is the most frequently diagnosed cancer and the second most common cause of cancer death in men in the United States. Such men can experience a continuum of disease presentations from indolent to highly aggressive. For physicians who care for these men, a significant challenge has been and continues to be identifying and treating those men with localized cancer who are at a higher risk of dying from their disease. We discuss the risk stratification of patients in order to better identify those patients at higher risk of progression. A comprehensive review of the literature was then performed reviewing the roles of surgery, radiotherapy, hormone therapy, and chemotherapy, as well as combinations of these modalities, in treating these challenging patients. An integrated approach combining local and systemic therapies can be beneficial in the management of high-risk localized prostate cancer. The choice of therapy or combination of therapies is dependant upon many considerations, including patient preference and quality of life aspects. It is becoming clearer that the addition of hormonal therapies or chemotherapies to established therapies, such as radiotherapy or surgery, will have significant benefits. As evidence accumulates regarding the efficacy of these new regimens, our hope is that the challenge of optimizing the management of high-risk prostate cancer will be delivered. However, many important questions remain unresolved regarding the optimal type, combination, timing of therapy, and duration of therapy. Such questions will only be answered with large, well-designed prospective clinical trials.

A novel technique for laparoscopic or robotic partial nephrectomy: feasibility study.

OBJECTIVE: Laparoscopic partial nephrectomy is a technically challenging procedure with concern over limiting warm ischemia time in order to prevent irreversible injury. We investigate the feasibility of a novel approach with the potential to minimize ischemia time as well as maximize precision of tumor excision. MATERIALS AND METHODS: Seven partial nephrectomies were performed in 45-50 kg female pigs with excisions ranging in size from 2 x 2 cm to 5 x 3 cm using the following technique. The renal hilum is dissected in standard fashion and the excision site marked with cautery. Prior to vascular clamping, sutures needles are placed in the renal parenchyma along the length of the simulated tumor under laparoscopic ultrasound guidance. The needles remain in the tissue for optimal visualization during resection, which is performed within the inner surface of the needles. Suture material is left attached to the needles with a single LapraTy clip on the end. Vascular clamping is only performed after placing all needles. The base of the resection site is oversewn, and the pre-placed needles are then passed out of the parenchyma until the distal LapraTy clip is against the renal capsule. A second LapraTy clip is then placed proximally under tension completing the bolsters. RESULTS: All animals survived for 2 weeks without complications. Seven resections were performed: two wedge resections, three polar nephrectomies and two heminephrectomies. The mean and median warm ischemia times (WIT) were 14 min and 41 sec and 15 min and 22 sec, respectively. Estimated blood loss was less than 50 ml. CONCLUSIONS: Preplacement of needles with attached bolster sutures before vascular clamping under laparoscopic ultrasound guidance is a technically feasible approach to performing laparoscopic partial nephrectomy. In addition to using the preplaced needles as a guide for resection, the preplaced bolsters may reduce warm ischemia time.