Incidence and clinical significance of arterial injury in varicocele repair.

OBJECTIVE: • This study was performed to histologically determine the rate of arterial injury in varicocele ligation surgery and to determine the clinical significance of these arterial injuries. MATERIALS AND METHODS: • 41 men who underwent varicocele ligation surgery, and had segments of each ligated vessel examined histologically. • The patients were followed prospectively to determine the effect of arterial injury on surgical results and clinical complications. RESULTS: • Arterial ligation was identified in 6 of 41 patients (12%), and in 7 of 132 specimens (5%), which is higher than previous reports. • Arterial injury was not associated with testicular atrophy and there was no apparent effect of arterial injury on surgical outcome. CONCLUSION: • The rate of arterial injury during varicocele repair is higher than previously reported, but the clinical significance of these injuries appears to be limited.

Case report: Endoscopic laser lithotripsy of seminal-vesicle stones.

A 25-year-old man presented with painful ejaculation, an ejaculate volume of 0.75, and complaints of passing "granules" in the semen. Transrectal ultrasonography showed bilateral seminal vesicle enlargement. The patient underwent transurethral resection of the ejaculatory duct. The entry point of duct was resected using pure cutting current, resulting in the passage of multiple proteinaceous-appearing stones. Approximately 10 months later, the patient reported recurrent painful ejaculation and passage of granules in his semen. At cystoscopy, the ejaculatory duct openings were intubated with a cone-tipped catheter to perform bilateral seminal vesiculograms, which showed numerous mobile filling defects and a Steinstrasse appearance at the ejaculatory ducts. A 7F semirigid ureteroscope entered the lumen without difficulty over a guidewire, and the stones were fragmented with a 270-microm holmium laser fiber. The ejaculatory ducts were balloon dilated to 18F. To our knowledge, this is the first reported case where a ureteroscope was utilized to treat seminal-vesicle stones. The seminal vesiculogram proved to be extremely valuable in the diagnosis.

Perceived stress and quality of life among prostate cancer survivors.

A convenience sample of 136 prostate cancer survivors participated in this study that assessed their perception of stress and quality of life (QOL). Data were collected via an anonymous questionnaire consisting of the Perceived Stress Scale, the UCLA Prostate Cancer Index Short Form, and demographic variables. The findings revealed low levels of stress with marginal reports of QOL. Significant differences were found in organ-specific functioning (p < 0.001), with respondents indicating that they were experiencing a disproportionately higher rate of sexual problems (sexual performance and sexual satisfaction) compared to bowel and bladder problems. These complaints were highest among patients who had undergone prostatectomy and lowest among patients who had selected watchful waiting. No association was found between stress and QOL, but significantly higher rates of stress were reported by patients who felt they had not received sufficient information before treatment (p < 0.05).

Comparison of outcomes after minimally invasive versus open partial nephrectomy with respect to trainee involvement utilizing the American College of Surgeons National Surgical Quality Improvement Program.

PURPOSE: Complication rates of open partial nephrectomies (OPN) and minimally invasive partial nephrectomies (MIPN) have largely been reported by single and multi-institutional tertiary care centers. We sought to identify complication rates of these approaches and how they are influenced by trainee involvement utilizing an independent national surgical database. MATERIALS AND METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) is a risk-adjusted data collection analyzing risk factors, demographics, and 30-day perioperative outcomes. From 2005 to 2010, we identified 1251 partial nephrectomies, of which 525 were MIPN and 726 were OPN. RESULTS: Analysis showed a decreased risk of overall morbidity, serious morbidity, and surgical site infections (SSIs); specifically superficial SSI, urinary tract infection, and bleeding (p<0.005) in MIPN than OPN. Resident and fellow versus attending only involvement was associated with increased rates of overall, serious, and nonserious morbidity, superficial and overall SSI, bleeding, and sepsis or septic shock (p<0.05). Postgraduate year (PGY) 6 residents and fellows had a significantly higher likelihood of nonserious morbidity, organ space and overall SSI, and sepsis or septic shock compared to PGY 1-5 residents. Length of stay, which was significantly shorter with MIPN than OPN (3.2 vs. 5.1 days; p<0.0001), however, was associated with longer operative times (185.7 vs. 209.7 minutes, p<0.001). CONCLUSIONS: This is the first report utilizing ACS NSQIP to review surgical approaches as well as the impact of trainee involvement on clinical outcomes. The increased complication rates and cost of healthcare might be mitigated by awareness, investment in surgical simulation laboratories, and competency assessment.

Primary adenocarcinoma of the rete testis: improved staging accuracy with CT-PET.

A case of adenocarcinoma of the rete testis in a 54-year-old man is presented. Most such patients harbor metastatic disease, even in clinically localized presentations. CT-PET may provide improved diagnostic sensitivity over conventional CT in this setting.

Use of step-section histopathology to evaluate 18F-fluorocholine PET sextant localization of prostate cancer.

To assess positron emission tomography (PET) with fluorine-18 fluorocholine for sextant localization of malignant prostate tumors. Histopathologic analysis was performed on step-sectioned whole-mounted prostate specimens from 15 patients who underwent PET with fluorocholine prior to radical prostatectomy. The maximum standardized uptake value (SUVmax) corresponding to prostate sextants on PET was measured by region of interest analysis and compared with histopathologic results. Histopathology demonstrated malignant involvement in 61 of 90 prostate sextants. The mean total tumor volume per specimen was 4.9 mL (range 0.01-28.7 mL). Mean SUVmax was 6.0+/-2.0 in malignant sextants and 3.8+/-1.4 in benign sextants (p<.0001). The area under the receiver operating characteristic curve was 0.82 for sextant detection of malignancy based on SUVmax measurement. Tumor diameter directly correlated with sextant SUVmax in malignant sextants (r=.54, p<.05). In 13 subjects, the largest tumor in the specimen corresponded to the sextant with the highest SUVmax. Fluorocholine PET can serve to localize dominant areas of malignancy in patients with prostate cancer. However, PET with fluorocholine may fail to identify sextants with smaller volumes of malignancy.

Dealing with non-cancerous findings on prostate biopsy.

Most prostate biopsies do not show malignancy. The proper management of non-cancerous pathologic findings of the prostate is controversial. For this article, we reviewed the current literature for indications for repeat prostate biopsy after initial biopsies demonstrated non-cancerous prostatic tissue or benign prostatic hyperplasia. This review includes discussions of management of asymptomatic prostatitis and how it may affect prostate-specific antigen, and also the management of several potentially premalignant lesions such as atrophy, atypical small acinar proliferation, and high-grade prostatic intraepithelial neoplasia. There is a paucity of randomized trials in this area and, considering the high number of biopsies with non-malignant findings, we conclude that more investigation is warranted in this area.

Collecting duct carcinoma arising from multicystic dysplastic kidney disease.

Malignancy arising from a multicystic dysplastic kidney (MCDK) is rare. Most reports are of Wilms' tumor and clear-cell renal cell carcinoma arising from a previously unrecognized MCDK. To our knowledge, no reports have described collecting duct carcinoma arising from MCDK.

Multiple ipsilateral renal tumors discovered at planned nephron sparing surgery: importance of tumor histology and risk of metachronous recurrence.

PURPOSE: Unrecognized sporadic multifocality at planned nephron sparing surgery (NSS) presents a surgical dilemma. We report a single institution experience with patients presenting with multiple ipsilateral renal tumors, of which at least 1 was renal cell carcinoma (RCC). We determined the outcome for patients treated with NSS or radical nephrectomy (RN). MATERIALS AND METHODS: A total of 118 patients underwent surgery between 1970 and 2000 for sporadic multiple ipsilateral renal tumors, of which at least 1 was RCC. The patients were treated with RN (102) and NSS (16). Clinical features recorded included age at surgery, sex, history of smoking, a preexisting solitary kidney and symptomatic disease at presentation. Pathological features included histological subtype, nuclear grade, tumor stage (2003 TNM) and tumor size. Cancer specific survival was estimated using the Kaplan-Meier method. RESULTS: A greater proportion of patients treated with NSS had a solitary kidney compared with patients treated with RN (6 or 38% versus 0, p <0.001). Of the 102 patients treated with RN for multiple tumors 12 died of RCC at a median time to death of 3.3 years (range 3 months to 9.5 years). Estimated cancer specific survival at 5 years was 90.1%. There was metachronous contralateral recurrence in 5 patients a median of 8.1 years following RN (range 3 months to 14 years). Two of the 16 patients treated with NSS died of RCC 6 and 11 years following NSS, respectively, for a cancer specific survival rate of 100% at 5 years. Two patients had local renal recurrence 1.7 and 2.8 years following NSS, respectively, and a metachronous contralateral renal tumor was found in 1 patient 7 months following NSS. Of the 102 patients treated with RN 63 (62%) and 9 of the 16 (56%) treated with NSS had at least 1 clear cell RCC. In 23 of the 102 patients (23%) treated with RN only 1 tumor was RCC, while the remainder were benign, suggesting that these patients were potential candidates for NSS. CONCLUSIONS: Patients undergoing RN or NSS for multiple ipsilateral renal tumors, of which at least 1 is RCC, have favorable cancer specific survival. The metachronous contralateral recurrence rate for patients with sporadic multifocal lesions is approximately 5%. Planned NSS may not be abandoned if satellite lesions are benign.