Robot-assisted laparoscopic prostatectomy in patients with preexisting three-piece inflatable penile prosthesis.

INTRODUCTION: Robotic-assisted laparoscopic radical prostatectomy (RARP) is becoming the preferred surgical treatment option for management of organ-confined prostate cancer. Although not a contraindication, previous pelvic surgery can make RARP challenging. Presence of a three-piece inflatable penile prosthesis, with a perivesical pelvic reservoir, has the potential to induce steric hindrance making RARP difficult. AIM: The main purpose of this publication is to report our experience with RARP in patients with previously inserted three-piece inflatable penile prostheses. METHODS: Two patients with previously inserted AMS 700 penile prosthesis and with organ-confined, biopsy proven adenocarcinoma of the prostate underwent RARP. We describe intraoperative findings, surgical technique, oncologic and functional outcomes. RESULTS: Both patients underwent safe and successful RARP with out any complications. Surgical margins were not affected with pelvic reservoir-sparing technique. In both patients, the penile prosthesis remained functional postoperatively. CONCLUSIONS: RARP can be safely performed in patients with previously inserted three-piece inflatable penile prosthesis. Nontraumatic handling of the pelvic reservoir is mandatory to preserve prosthesis' integrity.

Thermal ablation of small renal masses: intermediate outcomes from a Canadian center.

INTRODUCTION: Cryoablation (CA) and radio frequency ablation (RFA) are nephron sparing procedures that destroy renal tissue in situ rather than by surgical removal. Both thermal ablative techniques are advocated in select patient population with a small renal mass and multiple comorbidities which may preclude major surgery. Unfortunately long term oncologic outcomes of these procedures are unknown. MATERIALS AND METHODS: We report oncologic outcomes following CA and RFA in patients with small renal masses, from a single center, during a 48 month follow up period. Thirty patients underwent thermal ablation of a small renal mass, 7 with RFA and 23 with CA. RESULTS: Median tumor size on preoperative CT was 2.6 cm ± 0.87 cm. Four patients experienced a loco-regional treatment failure and underwent subsequent radical nephrectomy. Two patients were diagnosed with metastatic renal cell cancer in the follow up period. Six patients died during the follow up period, five from unrelated cause and one from metastatic RCC (overall survival 80%, RCC-specific survival 96%). CONCLUSIONS: This study demonstrates low RCC recurrence rates and in combination with previously published reports supports the effectiveness of thermal ablation therapy as primary therapeutic option in a very specific patient population.

Porosity of porcine bladder acellular matrix: impact of ACM thickness.

The objectives of this study are to examine the porosity of bladder acellular matrix (ACM) using deionized (DI) water as the model fluid and dextran as the indicator macromolecule, and to correlate the porosity to the ACM thickness. Porcine urinary bladders from pigs weighing 20-50 kg were sequentially extracted in detergent containing solutions, and to modify the ACM thickness, stretched bladders were acellularized in the same manner. Luminal and abluminal ACM specimens were subjected to fixed static DI water pressure (10 cm); and water passing through the specimens was collected at specific time interval. While for the macromolecule porosity testing, the diffusion rate and direction of 10,000 MW fluoroescein-labeled dextrans across the ACM specimens mounted in Ussing's chambers were measured. Both experiments were repeated on the thin stretched ACM. In both ACM types, the fluid porosity in both directions did not decrease with increased test duration (3 h); in addition, the abluminal surface was more porous to fluid than the luminal surface. On the other hand, when comparing thin to thick ACM, the porosity in either direction was higher in the thick ACM. Macromolecule porosity, as measured by absorbance, was higher for the abluminal thick ACM than the luminal side, but this characteristic was reversed in the thin ACM. Comparing thin to thick ACM, the luminal side in the thin ACM was more porous to dextran than in the thick ACM, but this characteristic was reversed for the abluminal side. The porcine bladder ACM possesses directional porosity and acellularizing stretched urinary bladders may increase structural density and alter fluid and macromolecule porosity.

Effects of subinhibitory concentrations of ciprofloxacin on Staphylococcus saprophyticus adherence and virulence in urinary tract infections.

BACKGROUND AND PURPOSE: Staphylococcus saprophyticus is a frequent cause of both uncomplicated and complicated urinary tract infections (UTI) in young females and has recently been established as the most prominent gram-positive uropathogen. Although the effects of subinhibitory concentrations of antimicrobials on numerous other pathogenic bacteria have been studied, little is known regarding how S saprophyticus responds under such conditions. MATERIALS AND METHODS: In this study, we investigated the effects of subminimum inhibitory concentrations (MIC) of ciprofloxacin (CIP) on S saprophyticus attachment to glass microscope slides, ureteral stent material, and T24 bladder cells, as well as its effects on S saprophyticus-induced proinflammatory cytokine expression in bladder cells. RESULTS: Adherence to glass microscope slides, ureteral stent material, and bladder cell monolayers were all significantly increased in the presence of sub-MIC levels of CIP. While the S saprophyticus challenge of T24 bladder cell monolayers significantly upregulated both interleukin (IL)-6 and IL-8 expression, sub-MIC CIP abrogated these effects, returning their secretion to control levels. CONCLUSIONS: Our results demonstrate that exposure to sub-MIC CIP increases S saprophyticus adherence to both abiotic and biotic surfaces including urinary device material and cultured bladder cells. In addition, low levels of this antimicrobial downregulate S saprophyticus-stimulated proinflammatory cytokine secretion in the bladder. These changes may make S saprophyticus more effective at colonizing the urinary tract and highlights the need for clinicians to consider the impact of subinhibitory concentrations of antimicrobials on bacteria when designing treatment strategies to manage UTI.

A phantom model as a teaching modality for laparoscopic partial nephrectomy.

PURPOSE: To evaluate a materials model for laparoscopic ultrasound identification and partial nephrectomy of kidney tumors. METHODS: Five urology fellows performed laparoscopic ultrasonography (LUS) examination of the tumor model, and the time for identification was recorded. After identifying the tumor, they performed a laparoscopic partial nephrectomy using the target tumor with measurement of operative parameters. They completed a questionnaire and rated the quality of the renal tumor model on a 5-point Likert scale. RESULTS: The participants were able to identify 49 tumors by LUS (98%). The mean time to identify the renal tumors by LUS was 1.12 minutes ± 0.93 standard deviation (SD). A partial nephrectomy was successfully completed on 49 tumor models (98%). The mean resection time was 7.69 minutes ± 3.8 SD. All of the participants considered that this model was helpful in the practice of LPN. The fellows would recommend this model as a teaching tool for residents/fellows to perform tumor imaging by LUS and for practicing LPN in a simulated environment. CONCLUSION: We have developed a unique model that simulates small kidney tumors that can be used for training surgeons in the clinical skills of laparoscopic partial nephrectomy.

Preliminary assessment of a renal tumor materials model.

PURPOSE: To evaluate a materials model for laparoscopic guided cryotherapy or radiofrequency tissue ablation (RFA) of kidney tumors through expert surgeon assessment. MATERIALS AND METHODS: During the inaugural American Urological Association 2010 Tissue Ablative course content, validity testing of a renal tumor model was undertaken. Five expert faculty in cryotherapy and RFA techniques for renal tumors performed laparoscopic ultrasonography (US) examination of the tumor model. They performed US guided placement and activation of the treatment probe into the tumor of the model. They completed a questionnaire and rated the quality of the renal tumor model on a 5 point Likert scale. RESULTS: All of the subjects assigned a score of 5 of 5 on the Likert scale regarding the ability to identify the tumor with US, were able to deploy the ablative probe into the model under US guidance, and would recommend the use of this teaching model to residents or fellows. They thought that this tumor model was appropriate for teaching laparoscopic US imaging of a renal tumor during ablative treatment procedures, teaching and practicing laparoscopic US-guided cryotherapy, and teaching and practicing laparoscopic US-guided RFA. CONCLUSION: We have developed a unique model that simulates small kidney tumors that can be used for training surgeons in ablative techniques.

Third prize: the impact of fluid environment manipulation on shockwave lithotripsy artificial calculi fragmentation rates.

BACKGROUND AND PURPOSE: Studies have suggested that shockwave lithotripsy (SWL) stone fragmentation rates can be affected by characteristics of the fluid media surrounding the stone, although evidence to implicate the impact of urine specific gravity (SG) is limited and inconclusive. Our aim is to further explore the impact fluid media and SGs have on stone fragmentation using a variable focus lithotripter. MATERIALS AND METHODS: Artificial stones were presoaked for 24 hours in urine and then shocked in various fluid media including artificial urine (SG 1.010 control, 1.020, and 1.07), human pooled urine (HPU), degassed HPU, Pentastarch, 100% and 30% contrast, degassed 30% contrast, 100% ethanol, deionized water (dH(2)O), degassed dH(2)O, 5% glucose, Ringer lactate, 0.9% saline, glycerol, whole blood, and lubricating gel. After soaking, SWL using the Modulith SLX-F2 electromagnetic lithotripter was performed. Fragments were dried and sieved using a 4-mm diameter opening grid. Fragments >4 mm were weighed and fragmentation coefficients (FCs) calculated (pre-SWL weight - post-SWL weight)/(pre-SWL weight) × 100. Fifteen stones were shocked for each fluid group. RESULTS: Fluid type, viscosity, and degassing all significantly impacted stone fragmentation. While the solutions' SG, per se, did not appear to affect stone fragmentation, the use of degassed 30% contrast significantly improved stone destruction over the SG 1.010 artificial urine control (95.3% vs 71.4, P < 0.01). Furthermore, degassing improved comminution rates by increasing the number of completely fragmented stones (FC = 100%). Using degassed 30% contrast, 12/15 stones were completely fragmented, compared with only 2/15 in the control group (P = 0.007). Among the whole blood, glycerol, and lubricating gel groups, only 1/15, 0/15, and 1/15 stones reached 100% FC respectively in the narrow focus, possibly because of the detrimental impact of increased viscosity. CONCLUSIONS: Different fluid media can significantly affect FC in vitro. Among the various fluids tested, degassed 30% contrast significantly increased the FC and total number of completely fragmented stones.

Robot-assisted pyeloplasty: follow-up of first Canadian experience with comparison of outcomes between experienced and trainee surgeons.

BACKGROUND AND PURPOSE: Robot-assisted pyeloplasty (RAP) has been established recently as an option in the management of ureteropelvic junction obstruction (UPJO). We present the first Canadian experience with RAP with respect to operative results and outcomes. We compare the surgical outcomes between experienced and trainee surgeons, with respect to operating room times and success rates. PATIENTS AND METHODS: Eighty-eight patients underwent transperitoneal RAP for UPJO using the da Vinci robotic platform. Two surgeons performed Anderson-Hynes dismembered pyeloplasty in 85 cases and YV-plasty in 5 cases. Five patients had RAP for secondary UPJO after failure of other treatments. Diuretic renography was performed at 6 weeks, and 6, 12, 18, 24, and 36 months postpyeloplasty. The mean follow-up was 14.1 ± 8.5 months. RESULTS: The mean operative time was 167.7 ± 43.2 minutes, and the mean anastomotic time was 41.9 ± 14.1 minutes. The mean operative duration significantly decreased with time (P < 0.05). Ten patients needed simultaneous nephroscopic stone management via the pyelotomy incision. The mean blood loss was 56.6 ± 55.4 mL, and the mean hospital stay was 2.5 ± 0.5 days. There were five major postoperative (stent migration, urinoma) and three minor complications that were associated with the RAP procedures. Postoperative renal scintigraphy demonstrated only four cases with persistent obstruction. Eighty-three (94.3%) patients experienced improvement of symptoms whereas 5 continued to be symptomatic. Two patients needed secondary procedures to relieve persisting obstruction. There were no statistical differences in outcomes between the experienced surgeons and trainees (P = 0.28). CONCLUSIONS: In the first large case series of RAP from Canada, we demonstrate that RAP can be performed with relatively short operative times and is safe and effective, achieving similar long-term results with standard open repair. We show that robot-assisted surgery can be safely transitioned to surgical trainees. With its cost and availability, its role in the Canadian system needs further study.

Myxoid chondrosarcoma of the scrotum: a case report and review of the literature.

Extraskeletal myxoid chondrosarcomas are relatively rare soft tissue malignant tumours, most commonly located in the extremities. Their occurrence in the genitourinary tract is extremely rare. We present a clinical case report of an extraskeletal myxoid chondrosarcoma originating in the scrotum.

A rare case of carcinoma cuniculatum of the penis in a 55-year-old.

Carcinoma cuniculatum of the penis is an extremely rare variant of squamous cell carcinoma characterized by an endophytic deeply branching and burrowing growth pattern. One documented case series demonstrated afflicted patients ranging in age from 73-83 years with the tumour located on the glans penis, coronal sulcus or foreskin. We report a case of a 55-year-old with disease located on the ventral aspect of the shaft of the penis. The tumour was invasive into the deep dermal connective tissue, comparatively superficial to all previous documented cases. He subsequently underwent a partial penectomy. The case is discussed with a brief review of the literature.