A unique case of large cell calcifying type sertoli tumor.

Sertoli cells tumors are a rare testicular malignancy, with prevalence estimated to be less than 1% of testicular cancers. Furthermore, testicular cancer only accounts for approximately 0.5% of all diagnosed cancers. This is a unique case of a 19-year-old male where physical exam and ultrasonography findings revealed an intratesticular mass that, after pathologic analysis, demonstrated T1 large cell calcifying type Sertoli cell tumor which is infrequently documented in the literature.

A rare case of follicular lymphoma of the bladder.

This case details a 69-year-old female with a 3cm bladder mass on imaging who underwent transurethral resection of the bladder with pathology revealing non-Hodgkin follicular lymphoma to the bladder. The rarity and complexity of this presentation generated a challenging treatment dilemma regarding surveillance and active treatment.

Metastatic melanoma to the proximal ureter.

We present an exceptionally rare scenario of obstructive uropathy secondary to a ureteral mass. This case details a 68-year-old female with metastatic stage IIID melanoma of the right heel found to have a two cm right proximal ureteral mass with associated hydronephrosis. Pathology from ureteroscopic biopsy revealed metastatic melanoma to the ureter, creating a unique treatment quandary.

Medial versus lateral camera port placement for robotic nephron-sparing surgery: evaluating surgical complications and outcomes.

As the growing popularity of robotic-assisted laparoscopic procedures for the treatment of renal cancer increases, there exists a variation in surgical technique among institutions and surgeons alike. One variation that exists in robotics is the anatomical placement of the camera port (medial versus lateral camera port placement). The purpose of this study is to evaluate surgical complications and outcomes in comparison to site of camera port placement during nephron-sparing surgery in an academic setting. Over a three-year period, outcomes for all robotic surgeries for renal cancer were examined. A total of 229 cases were discovered. Patient demographics and comorbidities were analyzed along with perioperative surgical data including location of camera port, surgery length, warm ischemia time, blood loss, pathological tumor margins, tumor size, length of stay and laboratory data. 134 patients had surgery performed with lateral camera port placement versus 95 patients with medial camera port placement. Operative time was significantly lower with an average operative time of 165.8 min for the lateral group versus 209.1 min in the medial group (p < 0. 0001). Warm ischemia time was also less in the lateral group with an average of 11 min versus 15.5 min for the medial group (p < 0. 0001). Blood loss was less in the lateral camera port group with an average of 158.2 mL (± 196.5 mL) versus 248.6 mL in the medial group (± 252.6) (p = 0.0040). Drain use, positive surgical margin rate, transfusion rate, conversion to radical nephrectomy, change in pre-operative versus postoperative creatinine and glomerular filtration rate and length of hospital stay did not statistically differ. Lateral camera port placement is associated with decreased operative time and warm ischemia time in this series. There may be certain laparoscopic advantages through a better visualization of surgical anatomy, thus allowing for faster extirpation of renal lesions and decrease in surgical time. These advantages may result in better long-term renal function and decreased clinical sequela from chronic kidney disease.

Evaluating the Efficacy of Employing Local Anesthetic Prostatic Blocks During Rezum Procedure.

Introduction Rezum is a minimally invasive, outpatient procedure using convective water vapor to relieve outlet obstruction from benign prostatic hyperplasia (BPH). Evidence on the technical approach of Rezum therapy, particularly pain control, is lacking. The purpose of this study was to evaluate the efficacy of utilizing a local anesthetic prostate block for postoperative pain control during Rezum therapy for BPH. A multimodal approach is typically utilized for pain control during and after Rezum. However, little is known about which elements are most critical. Methods This is a single-center retrospective study of 109 patients who underwent Rezum for BPH. Patients were then divided into two groups: Local anesthetic prostatic block verse no local anesthetic prostatic block for the procedure. A phone survey was performed to assess the patients' subjective pain scores and postoperative analgesics usage. A comparison of reported pain scores on a 0-10 Likert scale as well as usage of prescription and non-prescription analgesics medications was performed. Results There were 109 patients who underwent Rezum therapy, and 86 (79%) of patients responded to phone surveys. There was no significant difference in postoperative pain scores between patients who received local anesthetic prostatic block vs those who did not (2.10 vs 3.03). Similarly, there were no significant differences in postoperative narcotics or non-prescription analgesic medications usage. Conclusion Our data suggest that when performing Rezum using conscious sedation in the operating room or cystoscopy suite, it is unnecessary to perform a local anesthetic prostate block as it has no significant effect on patient-reported pain or the use of analgesics in the postoperative period.

Diagnostic dilemmas: a multi-institutional retrospective analysis of adrenal incidentaloma pathology based on radiographic size.

INTRODUCTION/BACKGROUND: Adrenal incidentalomas (AIs) are masses > 1 cm found incidentally during radiographic imaging. They are present in up to 4.4% of patients undergoing CT scan, and incidence is increasing with usage and sensitivity of cross-sectional imaging. Most result in diagnosis of adrenal cortical adenoma, questioning guidelines recommending removal of all AIs with negative functional workup. This retrospective study analyzes histological outcome based on size of non-functional adrenal masses. MATERIAL AND METHODS: 10 years of data was analyzed from two academic institutions. Exclusion criteria included patients with positive functional workups, those who underwent adrenalectomy during nephrectomy, < 18 years, and incomplete records. AI radiologic and histologic size, histologic outcome, laterality, imaging modality, gender, and age were collected. T-test was used for comparison of continuous variables, and the two-sided Fisher's exact or chi-square test were used to determine differences for categorical variables. Univariate analysis of each independent variable was performed using simple logistic regression. RESULTS: 73 adrenalectomies met the above inclusion criteria. 60 were detected on CT scan, 12 on MRI, and one on ultrasound. Eight of 73 cases resulted in malignant pathology, 3 of which were adrenocortical carcinoma (ACC). Each ACC measured > 6 cm, with mean radiologic and pathologic sizes of 11.2 cm and 11.3 cm. Both radiologic and pathologic size were significant predictors of malignancy (p = 0.008 and 0.011). CONCLUSIONS: Our results question the generally-accepted 4 cm cutoff for excision of metabolically-silent AIs. They suggest a 6 cm threshold would suffice to avoid removal of benign lesions while maintaining sensitivity for ACC.

Reducing Radiation Exposure to Patients and Staff During Routine Ureteroscopic Stone Surgery: Adopting a Fluoroless Technique.

Purpose Urologists have an obligation to limit radiation exposure during routine stone surgery. We therefore sought to evaluate the impact of our technique for fluoroless ureteroscopy on perioperative outcomes. Methods Medical records of 44 patients who underwent ureteroscopy with laser lithotripsy without the use of fluoroscopy between October 2017 and December 2018 were examined. Multiple variables were collected, including age, body mass index (BMI), mean stone volume and density, operative times, complications, and stone-free rates. These patients were then compared to a cohort of 44 patients who underwent stone surgery with a conventional technique prior to the adoption of a fluoroless technique by the same surgeons. The primary study outcome was reduction of intraoperative fluoroscopy. Secondary outcomes included complications, operative time, and stone-free rates. Results Of the 44 patients undergoing a fluoroless technique, 38 (86.4%) were able to receive ureteroscopy without the use of fluoroscopy. A significant difference was observed in mean fluoroscopy times for the fluoroless group (2.8 seconds) and the conventional group (33.7 seconds). No complications were observed in either group. Operative length was 38.9 minutes in the fluoroless group versus 42.2 minutes in the conventional group. Age, BMI, stone characteristics, and stone-free rates were similar in both. Conclusions The use of a fluoroless technique for the treatment of uncomplicated stones is not only safe but also effective and efficient. This technique eliminates extraneous radiation doses to the patient and operative staff in most cases.

Post-Operative Opioid Prescribing Practices and Trends Among Urology Residents in the United States.

INTRODUCTION: With the opioid epidemic escalating across the country, we sought to evaluate and characterize post-operative opioid prescribing habits and trends among urology residents in the United States. METHODS: Urology residents were sent a 16-question survey regarding opioid prescribing patterns, influencing factors, opioid training experience, and amounts of opioids prescribed for common urologic procedures. RESULTS: One hundred and four urology residents participated in the survey (75% male and 25% female). Common factors influencing opioid prescribing were standard prescribing practice for certain operations (80%), attending/senior resident preference (62.1%), and immediate post-operative pain (54.7%). Residents reported prescribing more opioids at discharge for open abdominal and robotic procedures (167.9 and 134.2 morphine milligram equivalents, MME, respectively) and lower amounts for outpatient surgeries (39.7 and 55.8 MME for vasectomy and transurethral resections). Only 15.5% of residents utilize any formal algorithm for post-operative opioid prescribing at their institution. Further, 51.6% of residents received no formal education on safe opioid prescribing during residency, and only 42.1% routinely assess patient risk for opioid abuse. Urology residents who received formal opioid training prescribed less opioids on average for common urologic procedures compared to those who had not trained. CONCLUSIONS: This study highlights the importance of increasing resident education on opioid prescribing during residency training, as well as an opportunity for the implementation of standardized post-operative opioid prescribing regimens to help improve trends in urology resident opioid prescribing.

Prognostic implications of renal vein involvement in T3a renal cancer.

INTRODUCTION: The TNM staging system is used globally as the standard for interpreting the extent of cancer. Currently, T3a renal cell carcinoma is classified as tumor extending into the perinephric fat or renal vein. Prognostic outcomes may vary among renal cell carcinomas with renal vein involvement (RVI) versus those with perinephric fat involvement (PFI). MATERIALS AND METHODS: We reviewed the medical records of all patients who underwent radical or partial nephrectomy at our institution by a single group of urologists between 2000 and 2014. After identifying those patients with T3a renal cell carcinoma, we further analyzed their prognostic features. Overall and disease-free survival using Kaplan-Meier analysis with log rank comparison was performed among patients with renal vein involvement and PFI. Gender, smoking status, age at diagnosis, body mass index, tumor grade, tumor size, and tumor histology were also analyzed. RESULTS: Of 139 patients with T3a renal cell carcinoma, 42 patients were found to have RVI, leaving 97 patients with PFI. Mean follow up was 52.1 months (0.3-183.4) versus 28.8 months (0.3-98.0) for patients with PFI and RVI, respectively. Overall survival (p < 0.048) and disease-free survival (p < 0.049) were significantly lower for patients with RVI. CONCLUSION: In our study, patients with T3a renal cell carcinoma that have RVI as opposed to PFI have lower overall and disease-free survival. These findings suggest that patient with T3a renal cell carcinoma with RVI should be monitored more closely than their counterparts with only PFI.

Intraoperative mannitol during robotic-assisted-laparoscopic partial nephrectomy.

Mannitol is routinely used during partial nephrectomies due to its renoprotective properties. With minimally invasive techniques, the need for mannitol has been questioned. Robotic-assisted laparoscopic partial nephrectomy (RALPN) has been shown to decrease warm ischemia time, which may potentially minimize the benefit of mannitol. To date, no prospective, randomized, controlled trials have investigated the use of mannitol in only robotic procedures. We hypothesize that the intraoperative mannitol use during RALPN provides no statistically significant benefit for post-operative renal function outcomes. We conducted a randomized, controlled, double-blinded, single surgeon, prospective study to assess renal function after RALPN. Patients were randomized into a control group with intravenous normal saline infusion prior to clamping of the vessels or to an experimental group with an infusion of mannitol. Estimated glomerular filtration rate (eGFR) were obtained prior to the surgery as well as post operatively at 24 h, 1 week, and 30 days. Preoperative eGFR showed no statistical differences between the groups and evaluation of median percent change in eGFR after surgery did not indicate a statistical difference between the groups after RALPN. After prospective analysis of the change in post-operative renal function of randomized groups who received 12 g of mannitol following RALPN, we determined that infusion of mannitol does not provide significant improvement of maintenance of renal functions after RALPN. Based on our results, we recommend discontinuing routine use of mannitol during RALPN.

Are we fearful of tubeless percutaneous nephrolithotomy? Assessing the need for tube drainage following percutaneous nephrolithotomy.

OBJECTIVE: The objective was to demonstrate that percutaneous nephrolithotomy (PCNL) can be safely performed with a tubeless or totally tubeless drainage technique. INTRODUCTION: Standard PCNL includes nephrostomy tube placement designed to drain the kidney and operative tract at the conclusion of the procedure. Modern technique trend is tubeless PCNL and totally tubeless PCNL, which are performed without standard nephrostomy drainage. We aim to reinforce current literature in demonstrating that PCNL can be safely performed using a tubeless technique. With compounded supportive data, we can help generate a trend toward a more cost-effective procedure with improved pain profiles and patient satisfaction, as previously shown with the tubeless technique. METHODS: Retrospective analysis of 165 patients who underwent PCNL treatment was performed. Of this group, 127 patients underwent traditional nephrostomy drainage following PCNL. A tubeless procedure was performed in the remaining 38 patients. Patient's postoperative stone size and burden as well as complication profiles were analyzed. Largest stone size and total stone burden was similar between the groups. RESULTS: Patient characteristics and demographic information were compared and no significant statistical difference was identified between the groups. Complication rates between the groups were compared and no statistical difference was noted. A total of 23 patients had at least one postoperative complication. CONCLUSION: Tubeless and totally tubeless PCNL demonstrates equivalent outcomes in the properly selected patient group when compared to PCNL performed with a nephrostomy tube. Although this is not the first study to demonstrate this, a large majority of urologists continue standard nephrostomy placement after PCNL. More studies are needed that demonstrate safety of this practice to shift the pendulum of care. Thus, tubeless and totally tubeless PCNL can be performed safely and effectively, which has previously been shown to improve cost, patient pain profiles, and length of hospitalization.

Not all penile cancers are created equal.

Warty carcinoma variant of squamous cell carcinoma of the penis is a rare condition, making up 7% to 10% of all penile carcinomas. We present a case of warty carcinoma variant of squamous cell carcinoma of the penis in a 43-year-old Caucasian. The tumor presented in a locally invasive manner, requiring a total penectomy. The primary lesion measured over 15 cm x 16 cm, covering the entire perineum. The clinical features, diagnosis, surgical treatment and pathology are reviewed. In light of the locally invasive nature of warty carcinoma of the penis and high recurrence rate, early diagnosis and aggressive treatment is necessary for this type of unique penile cancer.

Atypical presentation of priapism in a patient with acute iliocaval deep venous thrombosis secondary to May-Thurner syndrome.

We report on a 42-year-old male who presented with priapism, severe scrotal swelling, and left lower extremity pain and swelling. Initial management of priapism failed, and he was noted to have both cavernosal and glandular venous obstruction. Computed tomography (CT) was performed and identified extensive acute thrombosis involving the distal inferior vena cava and the left iliac veins. Pharmacomechanical thrombolysis (PMT) was started over the course of two days. At completion of thrombolysis, the culprit lesion in the left common iliac vein was treated with angioplasty and stenting. His postoperative course was uneventful, and his priapism as well as the scrotal and leg swelling improved. He was discharged home on full anticoagulation. To our knowledge, this is the first available description of this rare presentation along with a literature review of the underlying vascular etiology for priapism.

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.

Percutaneous nephrolithotomy versus extracorporeal shock wave lithotripsy for moderate sized kidney stones.

OBJECTIVE: To compare the outcomes of percutaneous nephrolithotomy (PNL) and extracorporeal shock wave lithotripsy (ESWL) for moderate sized (1-2 cm) upper and middle pole renal calculi in regards to stone clearance rate, morbidity, and quality of life. METHODS: All patients diagnosed with moderate sized upper and middle pole kidney stones by computed tomography (CT) were offered enrollment. They were randomized to receive either ESWL or PNL. The SF-8 quality of life survey was administered preoperatively and at 1 week and 3 months postoperatively. Abdominal radiograph at 1 week and CT scan at 3 months were used to determine stone-free status. All complications and outcomes were recorded. RESULTS: PNL established a stone-free status of 95% and 85% at 1 week and 3 months, respectively, whereas ESWL established a stone-free status of 17% and 33% at 1 week and 3 months, respectively. Retreatment in ESWL was required in 67% of cases, with 0% retreatment in PNL. Stone location, stone density, and skin-to-stone distance had no impact on stone-free rates at both visits, irrespective of procedure. Patient-reported outcomes, including overall physical and mental health status, favored a better quality of life for patients who had PNL performed. CONCLUSION: PNL more often establishes stone-free status, has a more similar complication profile, and has similar reported quality of life at 3 months when compared with ESWL for moderate-sized kidney stones. PNL should be offered as a treatment option to all patients with moderate-sized kidney stones in centers with experienced endourologists.

Proposed duplex velocity criteria for carotid restenosis following carotid endarterectomy with patch closure.

BACKGROUND: Duplex ultrasound velocity criteria have been used to evaluate the severity of carotid stenosis, however, these standard velocities may not be applicable to carotid restenosis after carotid endarterectomy (CEA) with patch angioplasty. The purpose of this study is to determine if patch angioplasty closure alters velocities just distal to CEA and to define the optimal velocities for detecting >or=30%, >or=50%, and >or=70% restenosis. METHODS: This study includes 200 CEAs randomized into 100 with polytetrafluoroethylene (PTFE) ACUSEAL patch and 100 with Hemashield Finesse patch. All patients underwent immediate postoperative duplex ultrasounds, which were repeated at 1 month and every 6 months thereafter. Patients with a peak systolic velocity (PSV) of the internal carotid artery ([ICA], just distal to the patch) of >or=130 c/s underwent computed tomography angiogram (CTA). PSVs, end diastolic velocities (EDV), and internal carotid artery/common carotid artery (ICA/CCA) ratios were correlated to completion arteriograms/CTAs. Receiver operator characteristic curves analyses were used to determine optimal velocity criteria in detecting >or=30%, >or=50%, and >or=70% restenosis. RESULTS: One hundred ninety-five pairs of imagings (duplex ultrasound vs CTA/angiogram) were available for analysis. When standard velocity criteria for nonoperated arteries were applied, 37% and 10% of patients were believed to have >or=50% to <70% and >or=70% to 99% restenosis vs 11.3% and 11.3% on CTA/angiography, respectively (P < .001). The mean PSV for >or=30%, >or=50%, and >or=70% restenosis were 172, 249, and 389 c/s, respectively (P < .001). An ICA PSV of >or=155c/s was optimal for >or=30% restenosis with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and overall accuracy (OA) of 98%, 98%, 98%, 98%, and 98%, respectively. A PSV of >or=213 c/s was optimal for >or=50% restenosis with sensitivity, specificity, PPV, NPV, and OA of 99%, 100%, 100%, 98%, and 99%, respectively. An ICA PSV of 274 c/s was optimal for >or=70% restenosis with sensitivity, specificity, PPV, NPV, and OA of 99%, 91%, 99%, 91%, and 98%, respectively. ROC analysis showed that the PSVs were significantly better than EDVs and ICA/CCA ratios in detecting >or=30% and >or=50% restenosis. CONCLUSIONS: The mean PSVs of a normal ICA distal to CEA patching were higher than normal nonoperated ICAs, therefore, standard duplex velocities criteria should be revised after CEA with patch closure.

Calcifying nanoparticles associated encrusted urinary bladder cystitis.

Encrusted cystitis is a subtype of chronic cystitis characterized by multiple calcifications in the form of plaques located in the interstitium of the urinary bladder mucosa and frequently associated with mucosal ulcers. It is a very rare disease of controversial etiology. Our transmission electron microscopy of the calcified plaques of encrusted cystitis has revealed that the smallest formed particles (elementary units) of these calcifications are electron-dense shells surrounding an electron lucent core, diagnostic of calcifying nanoparticles (previously called nanobacteria). We pioneer the notion that calcifying nanoparticles are the causative agents of encrusted urinary bladder cystitis.