Intravesical gemcitabine in combination with mitomycin C as salvage treatment in recurrent non-muscle-invasive bladder cancer.

OBJECTIVES: To evaluate oncological outcomes after combination intravesical therapy with gemcitabine (GC) and mitomycin C (MMC) in the setting of recurrent non-muscle-invasive bladder cancer (NMIBC) after failure of previous intravesical therapy. PATIENTS AND METHODS: We retrospectively identified patients with recurrent NMIBC after previous intravesical therapy, who refused or were not candidates for cystectomy, between 2005 and 2011. GC and MMC were sequentially instilled weekly for 6-8 weeks. Data were collected regarding patient demographics, bladder cancer history, and number and type of intravesical therapies before GC/MMC. Outcomes evaluated included time to recurrence and/or progression after GC/MMC. Recurrence-free outcomes were estimated using the Kaplan-Meier method, and Cox proportional hazards regression models were used to test the association of clinicopathological features with outcomes. RESULTS: In all, 27 patients were identified, 23 with high-risk disease (high-grade or carcinoma in situ) and four with intermediate-risk disease (multifocal or recurrent low-grade). All patients received prior intravesical therapy, and 17 patients (63%) received multiple courses. Twenty-four patients were treated with BCG. The median (range) disease-free survival of all patients was 15.2 (1.7-39.3) months. Seventeen patients (63%) developed recurrent bladder cancer, a median of 15.2 months after therapy. One patient progressed to muscle-invasive disease 5 months after treatment, and one developed metastatic disease 22 months after treatment. Three patients went on to cystectomy. Ten patients (37%) had no evidence of disease at last follow-up, with a median follow-up of 22.1 months. CONCLUSION: The combination of intravesical GC and MMC could offer durable recurrence-free survival to some patients with recurrent NMIBC who are not candidates for, or refuse, cystectomy.

Extended antimicrobial use in patients undergoing percutaneous nephrolithotomy and associated antibiotic related complications.

PURPOSE: Despite global concern about antibiotic related complications the duration of antibiotic therapy at percutaneous nephrolithotomy varies based on individual physician practice. We evaluated perioperative antibiotic related complications in patients who received extended antimicrobial therapy at percutaneous nephrolithotomy. MATERIALS AND METHODS: We reviewed the records of 227 consecutive patients treated with percutaneous nephrolithotomy from 2009 to 2013. Patients with positive urine or stone cultures received extended antimicrobial treatment. All others received 7 days of empirical therapy preoperatively and postoperatively. Adverse antibiotic related events were recorded for up to 3 months. RESULTS: The median duration of antibiotic therapy was 14 days (IQR 14-34). Perioperatively 143 (63%), 67 (30%), 75 (33%) and 41 patients (18%) received nitrofurantoin, trimethoprim/sulfamethoxazole, fluoroquinolones and other antibiotics, respectively. Antibiotic related complications developed in 23 patients (10%) at a median of 12 days (IQR 8-19). Common complications included rash in 7 cases (3%), gastrointestinal upset in 6 (3%) and Clostridium difficile colitis in 1 (0.4%). Trimethoprim/sulfamethoxazole was associated with an increased likelihood of an adverse event (p = 0.04) but patient age, gender, and therapy type (therapeutic vs prophylactic) and duration were not. Finally, antibiotic and multidrug resistance developed in 4 (36%) and 3 patients (27%), respectively, who experienced a urinary tract infection. CONCLUSIONS: We report a low rate of adverse antibiotic related events in patients treated with percutaneous nephrolithotomy who received extended perioperative antibiotic therapy. Exposure to trimethoprim/sulfamethoxazole was the only identifiable risk factor for a complication. These findings should be considered when counseling patients on the risks of perioperative antimicrobial therapy at percutaneous nephrolithotomy.

Acute bilateral ureteral obstruction secondary to guaifenesin toxicity.

Several medications or their metabolites have been associated with urolithiasis, although overall they remain an infrequent cause of urolithiasis. Guaifenesin stones were originally reported as complexed with ephedrine, and subsequent reports have demonstrated pure guaifenesin stones, occurring after long term abuse. We report a case of a 23-year-old male who ingested a large, one time dose of guaifenesin, resulting in acute bilateral ureteral obstruction, which, to our knowledge, is the first such reported case in the literature.

Outcomes Following Radical Cystectomy for Plasmacytoid Urothelial Carcinoma: Defining the Need for Improved Local Cancer Control.

OBJECTIVE: To evaluate oncological outcomes after radical cystectomy (RC) in patients with plasmacytoid urothelial carcinoma (UC) and to compare survival to that in patients with pure UC of the bladder. MATERIALS AND METHODS: We identified 46 patients with plasmacytoid UC and 972 with pure UC who were treated with RC between 1980 and 2009. All pathologic specimens were re-reviewed by a single GU pathologist. Patients were matched 1:2 by age, gender, Eastern Cooperative Oncology Group performance status, pathologic tumor stage, and nodal status to patients with pure UC. Survival was estimated using the Kaplan-Meier method and compared with the log rank test. RESULTS: Patients with plasmacytoid UC were more likely to have extravesical disease (≥pT3) (83% vs 43%, P < .0001) and positive margins (31% vs 2.1%, P < .0001) than patients with pure UC. Plasmacytoid UC was associated with decreased overall survival (27% vs 45% at 5 years, relative risk [RR] 1.4, P = .04), cancer-specific survival (36% vs 57% at 5 years, RR 1.7, P = .01), and local recurrence-free survival (63% vs 81% at 5 years, RR 2, P = .01). When patients with plasmacytoid UC were matched to those with pure UC, there were no significant differences in 5-year overall, cancer-specific, and local or distant recurrence-free survival. CONCLUSION: Plasmacytoid UC is associated with a high rate of locally advanced disease and positive margins at RC, as well as increased local recurrence rates. Further research is necessary to delineate adjuvant or neoadjuvant treatment strategies to improve local cancer control of this rare subtype of UC.

The Utility of Magnetic Resonance Imaging in the Evaluation of Accessory Scrotum in the Newborn.

Accessory scrotum, a rare form of congenital scrotal anomaly that is often associated with other genitourinary and anorectal anomalies, is characterized by ectopic scrotal tissue in the presence of a normal, orthotopic scrotum. Here, we present a case of accessory scrotum in a newborn male. We describe our experience with the utilization of preoperative pelvic magnetic resonance imaging to characterize the complex relationship between the accessory scrotum and ano-sphincteric complex, as well as identify associated genitourinary abnormalities. We also provide a brief literature review.

Characterization of Inner Medullary Collecting Duct Plug Formation Among Idiopathic Calcium Oxalate Stone Formers.

OBJECTIVE: To study the prevalence of, risk factors for, and renal functional consequences of ductal plug formation in idiopathic calcium oxalate (iCaOx) stone formers (SF). PATIENTS AND METHODS: Accessible renal papillae were videotaped to determine the percent surface area (SA) occupied by plaque and ductal plug in a consecutive cohort of iCaOx SF undergoing percutaneous nephrolithotomy for stone removal. RESULTS: Between 2009 and 2014, iCaOx SF comprised 96 of 240 enrolled patients. Of these, 41 (43%) had ductal plugs. Mean plaque SA did not differ between the low and high % plug groups (2.1% vs 3.4%, respectively). The amounts of mean % SA plaque and ductal plug were not strongly correlated (Spearman's ρ = 0.12, P = .3). Patients with >1% mean SA plug had a higher urinary pH (median 6.5 vs 6.0, P = .02) and elevated urinary hydroxyapatite supersaturation (median 5.4 vs 3.7 delta G; P = .04). Those with >1% plugging had more extensive ductal dilation (P = .002) compared to those with ≤1%. However, estimated glomerular filtration rate was the same (median 75.4 mL/min/1.73 m(2) vs 74.7 mL/min/1.73 m(2)). Number of prior stone events was associated with mean and maximum papillary SA occupied by plug (P < .05 for both), but not plaque (P = .3 and p = .5, respectively). CONCLUSION: Within a cohort of iCaOx SF, macroscopic plaque and ductal plugs often coexist. Intraluminal features known to favor calcium phosphate crystallization appear to play a role in plug formation. The pathogenic significance of these plugs remains to be established, although their extent appears to correlate with stone burden.

Presentation, Endoscopic Management, and Significance of Hemostatic Clip Migration into the Lower Urinary Tract Following Radical Prostatectomy.

OBJECTIVES: Hemostatic clip migration into the lower urinary tract is a potential complication of radical prostatectomy that may cause symptoms, anxiety, and functional concern. Our objective was to evaluate initial presentation, endoscopic management, and outcomes of patients with hemostatic clip migration following radical prostatectomy. PATIENTS AND METHODS: We retrospectively identified all patients with hemostatic clip migration at our institution from 1977 to 2012. Patient records were then reviewed to identify causative factors, presentation, and long-term functional outcomes. RESULTS: Seventeen patients were identified with clip migration following radical prostatectomy. Eight (47%) patients had undergone open retropubic radical prostatectomy, and 9 (53%) had received robot-assisted radical prostatectomy. Hemostatic clip migration was diagnosed at a median of 8 (range, 1-252) months after prostatectomy. The majority of patients (n = 16, 94%) were symptomatic upon the diagnosis of clip migration. Symptoms included irritative urinary symptoms (n = 14, 82%), perineal pain (n = 3, 18%), hematuria (n = 2, 12%), and infection (n = 2, 12%). Five (29%) had concomitant bladder neck contracture. Fifteen (88%) underwent successful endoscopic clip removal, whereas 2 (13%) patients required a repeat operation for recurrent clip erosion. With a median follow-up of 1.6 years, the majority (n = 13, 87%) had complete symptom resolution after clip removal, although 2 patients had recurrent bladder neck contracture. CONCLUSIONS: Hemostatic clip migration after prostatectomy is often symptomatic with irritative voiding complaints, perineal pain, hematuria, infection, or bladder neck contracture. Fortunately, clips can be removed endoscopically with expected symptom resolution in the vast majority of patients.

Analysis of the utility of stone gram stain in urolithiasis treated with percutaneous nephrolithotomy.

OBJECTIVE: To define the sensitivity and specificity of stone gram stain for infected urolithiasis treated with percutaneous nephrolithotomy (PCNL). METHODS: PCNL procedures performed at our institution were analyzed between January 2009 and May 2013. Stone fragments were sent in a sterile fashion for aerobic and fungal cultures. A gram stain and fungal smear were performed on the stones and reported within 24 hours of collection. RESULTS: A total of 228 patients underwent 248 PCNLs. Of the 248 stones, 81 (33%) had a positive stone culture. Stone gram stain was positive in 31 cases and negative in 50. There were 167 negative stone cultures, and in these cases, gram stain was positive in 5 and negative in 162. The calculated sensitivity and specificity of stone gram stain were 38% and 97%. The positive and negative predictive values were 86% and 76%, respectively. In the subset of 16 patients with positive stone fungal cultures, fungal smear was performed in 12 and was positive in 4, giving fungal smear a sensitivity of 33%. CONCLUSION: The results of this study suggest that stone gram stain cannot be relied on to detect a positive stone culture and may fail to detect up to 62% of infected stones. However, when positive, gram stain accurately predicts a positive stone culture in 86% of cases.