Detailed analysis of patients with metastasis to the prostatic anterior fat pad lymph nodes: a multi-institutional study.

PURPOSE: Lymph nodes in the prostatic anterior fat pad rarely harbor metastatic disease. Therefore, the characteristics of patients with prostatic anterior fat pad lymph node metastasis are not well described in the literature. We identified the perioperative characteristics and assessed the clinical outcomes of patients with prostatic anterior fat pad lymph node metastasis. MATERIALS AND METHODS: At 8 tertiary care centers a total of 4,261 patients underwent complete removal and pathological analysis of the prostatic anterior fat pad. We describe preoperative and pathological characteristics, and clinical management and outcomes in patients with metastatic disease to the prostatic anterior fat pad. RESULTS: Metastatic disease to the prostatic anterior fat pad lymph nodes was detected in 40 patients (0.94%), of whom 37 (92.5%) had intermediate or high risk features preoperatively. Most patients with prostatic anterior fat pad metastases underwent concomitant pelvic lymph node dissection, and adjuvant therapy with radiation, androgen ablation and/or chemotherapy. A total of 27 patients (67.5%) with prostatic anterior fat pad metastatic disease were up-staged as a result of prostatic anterior fat pad pathological analysis, of whom 14 (51.8%) remained free of biochemical recurrence with observation and/or definitive adjuvant/salvage therapy. CONCLUSIONS: Most patients with prostatic anterior fat pad metastatic disease had intermediate to high risk features preoperatively. In some patients with such lymph node metastasis removing these lymph nodes resulted in prolonged biochemical recurrence-free survival. Therefore, we recommend that the prostatic anterior fat pad be removed in all patients undergoing radical prostatectomy. However, pathological analysis of the prostatic anterior fat pad may be limited to patients with intermediate to high risk oncological features preoperatively.

How do urodynamics findings influence the treatment of the typical patient with overactive bladder?

Overactive bladder (OAB) is a clinical symptom complex whose hallmark is the symptom of urinary urgency, usually accompanied by frequency and nocturia, with or without urgency incontinence. Historically, urodynamics (UDS) evaluation has not been recommended in the initial evaluation of OAB, since it is defined primarily by clinical symptoms. As the pathophysiology of the OAB complex has become more clearly elucidated from recent studies, the role of UDS has again become a topic of discussion as a tool that can provide objective data to reflect these new findings. The utility of UDS in the diagnosis and treatment of OAB is still evolving, but in certain clinical scenarios, especially when empiric treatment has failed, it can provide definitive information that can identify associated pathologies and/or alter the treatment course. Herein, we will discuss the current literature regarding use of UDS in OAB patients and offer our own opinions as to its use.

Management of stones in abnormal situations.

Stones in abnormal situations present a management conundrum to the urologist. Many of these situations are relatively rare and literature is scanty on the appropriate management. We review the current literature on the management of stones in the setting of pregnancy, calyceal diverticulum, urinary diversions, pelvic kidneys, transplant kidneys, autosomal dominant polycystic kidney disease, horseshoe kidneys, and other renal anomalies. The aims of treatment are complete stone-free status. The modality of treatment should be individualized to the size and location of stone and type of abnormal situation confronted.

Modified-PCNL without modified instruments: a description of technique.

BACKGROUND AND PURPOSE: Mini-PCNL was developed to reduce the morbidity of PCNL by using smaller tract sizes. Most mini-techniques, however, require specialized instruments and use ureteroscopes as surrogates for nephroscopes, resulting in decreased visualization, poor irrigation, and difficult fragment extraction. We describe our modified technique (mPCNL) that allows for the use of standard PCNL equipment through a tract that is smaller than standard PCNL (sPCNL) but larger than previously reported for mini-PCNL. TECHNIQUE: After ureteral access with a coaxial anti-retropulsion device, the patient is placed in the prone position. After percutaneous access under fluoroscopic guidance, a 24F balloon dilating catheter is used to place a 24F Amplatz sheath. A standard 26F rigid nephroscope is used to complete the entire procedure, with the modification of selectively removing the outer sheath to allow the scope to fit in the smaller tract. Standard lithotripters and graspers are used, as necessary. ROLE IN PRACTICE: We have performed this technique on 52 patients with a mean stone burden of 19.4 mm. Overall stone-free rate was 100%, even for stones >2 cm. This technique allows for improved visualization and irrigation compared with other mini-PCNL procedures and obviates the need to purchase specialized equipment.

Outcomes of intrarenal Bacillus Calmette-Guérin/interferon-α2B for biopsy-proven upper-tract carcinoma in situ.

BACKGROUND AND PURPOSE: While nephroureterectomy (NU) remains the gold-standard treatment for upper-tract carcinoma in situ (UT-CIS), it may be unnecessarily aggressive in comparison with the treatment of bladder CIS. Upper-tract administration of bacillus Calmette-Guérin (BCG) has shown promise for UT-CIS, but with limited reports and varied results. Furthermore, all previous reports included patients with positive cytology results without biopsy-proven CIS, or combined BCG with other topical therapies that are used for bladder CIS. We report our experience using a novel technique to directly instill BCG with interferon-α2B (BCG/IFN) into the upper-tract in patients with biopsy-proven UT-CIS. PATIENTS AND METHODS: Patients who received a diagnosis of isolated, biopsy-proven UT-CIS from September 2003 to January 2012 were included. After biopsy, all patients received a 6-week induction course of BCG/IFN, administered via an open-ended ureteral catheter. Initial follow-up was scheduled 1 month after the completion of the intrarenal therapy and consisted of flexible ureteroscopy, selective urinary cytology, retrograde pyelography, and rebiopsy of the upper tract. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology results, and absence of clinical progression. Absence of visualized lesions with persistently positive cytology results or persistence of lesions after induction was considered no response (NR). New upper-tract lesions after an initial CR were considered recurrences. Patients with a CR were placed on maintenance therapy for 2 years. Surveillance was performed every 3 months with ureteroscopy, selective cytology, and imaging. RESULTS: Eleven patients (mean age=73 years) were followed for a median of 13.5 months (3.7-103.3 mos). Eight patients had an initial CR, while three initially had NR. Two of the NR patients had negative biopsy results but persistently positive cytology results; both of these patients underwent a second induction course and achieved a CR. The third NR patient had persistence of lesions after induction and was offered a nephroureterctomy. Total kidney preservation rate was 91% (10/11). There were no treatment-related adverse events. CONCLUSION: This study demonstrates the safety and efficacy of intrarenal BCG/IFN maintenance therapy for patients with UT-CIS. Unlike other mechanisms of delivery, including percutaneous administration or reflux via double pigtail stents, this office-based technique spares the morbidity of a chronically indwelling nephrostomy tube or ureteral stent.

Ureteral fibrin sealant injection of the distal ureter during laparoscopic nephroureterectomy--a novel and simple modification of the pluck technique.

OBJECTIVES: To describe a novel technique to block the distal ureter, thus preventing spillage of tumor cell bearing urine during laparoscopic pluck nephroureterectomy. Currently, there is no consensus on the appropriate management of distal ureter during laparoscopic nephroureterectomy. METHODS: A review was performed of patients who underwent modified laparoscopic pluck nephroureterectomy for upper tract transitional cell carcinoma from July 2007 to December 2008. After confirming an absence of bladder tumors, an 8F olive-tipped ureteral catheter was introduced into the ureteral orifice. Five milliliters of Tisseel was injected into the ureter. Five milliliters of indigo carmine was injected intravenously to confirm the presence of ureteral blockage. Using a Collins knife, the ureteral orifice was dissected until the extravesical fat was visualized. A Foley catheter was placed and a laparoscopic nephroureterectomy was then completed. The drain was removed on the 3rd postoperative day and Foley was removed on the 10th postoperative day after a normal cystogram. RESULTS: We performed 8 procedures using the above-described technique. The median age was 62 years, all were males; 2 were operated on the right side and 6 on the left. The average operative time and estimated blood loss was 308 minutes and 150 mL, respectively. The average length of stay was 6 days. One major and 2 minor complications (ileus) were noted. Mean cancer follow-up is 11 months. All specimen margins free of tumor. No extravesical or intravesical recurrences were noted. CONCLUSIONS: Ureteral fibrin sealant injection produces dependable ureteral obstruction during laparoscopic pluck nephroureterectomy and may prevent tumor spillage in the extravesical tissues.

Pediatric single-port-access nephrectomy for a multicystic, dysplastic kidney.

Major urologic surgery via a single port has emerged as the latest progression in laparoscopy and robotics. While current literature highlights the single-port approach to the surgical treatment of cholecystitis, appendicitis and varicoceles, this technique has never been employed to perform a nephrectomy on a child. We herein report a case of a pediatric patient who underwent nephrectomy via single-port-access.