Robotic conversion of cecostomy tube to catheterizable antegrade continence enema (ACE): Surgical technique.

INTRODUCTION: Antegrade continence enema (ACE) is a well described treatment for pediatric patients with neurogenic bowel refractory to medical and retrograde management. ACE can be carried out either by catheterizable channel with enteric conduit or a cecostomy tube appliance. For those patients who have issues with pain or leakage around the cecostomy appliance or wish to be appliance free, we present our initial results and description of a novel technique of laparoscopic conversion of cecostomy to catheterizable ACE which uses the existing tract and requires no enteric conduit. METHODS: A single institution, retrospective chart review was carried out for 2014-2017 to identify patients undergoing ACE conversion. Preoperative parameters included age, sex, weight, neurogenic bowel etiology and time from initial cecostomy. Perioperative data included length of surgery, length of hospitalization and postoperative complications (via Clavien-Dindo scale). Postoperative follow up, ancillary procedures pertinent to the ACE and status at time of submission are also presented. RESULTS: Six patients were identified (mean age 14.1 +/- 4.3 years) with median follow up of 36 months (range 18-65). Neurogenic bowel etiology was spina bifida in five and spinal cord injury in one; all patients had concurrent neurogenic bladder with preexisting appendicovesicostomy. Mean operative time was 168 +/- 37 min (range 122-228) and mean length of hospital stay was 2 days (range 1-4). Success rate is 83% (5/6 continue to catheterize ACE channel), with one patient opting back for appliance through same tract. One patient has required operative revision for stomal stenosis. CONCLUSION: To our knowledge, this is the first report describing robotic-assisted laparoscopic conversion of cecostomy tube to a catheterizable ACE. The surgical technique we describe is simple and safe with minimal morbidity to the patient. It does not require an enteral conduit, and may represent a valid treatment in patients without the option of using the appendix.

Transurethral ventral buccal mucosa graft inlay urethroplasty for reconstruction of fossa navicularis and distal urethral strictures: surgical technique and preliminary results.

OBJECTIVES: To introduce a novel surgical technique for the reconstruction of distal urethral strictures using buccal mucosal graft (BMG) through a transurethral approach. METHODS: A retrospective institution chart review was conducted of all the patients who underwent a transurethral ventral BMG inlay urethroplasty from March 2014 to March 2016. Patients with greater than one-year follow-up were included. Steps of the procedure: transurethral ventral wedge resection of the stenosed segment and transurethral delivery and spread fixation of appropriate BMG inlay into the resultant urethrotomy. The patients were followed for post-operative complications and stricture recurrence with uroflow, PVR, cystoscopy and outcome questionnaires. RESULTS: Three patients with a minimum of 12-month follow-up are included in this case series. The mean age of the patients was 42 years (35-53); mean stricture length was 2.1 cm (1-4). All patients had at least 2 previous failed procedures. Mean follow-up was 18 months (12-24). There were no stricture recurrences or fistula. Mean pre- and post-operative uroflow values were 4.3 (0-8) and 19 (16-26), respectively. Neither penile chordee nor changes in sexual function were noted in patients on follow-up. CONCLUSION: Transurethral ventral BMG inlay urethroplasty is a feasible option for treatment of fossa navicularis strictures. This single-stage technique allows for avoiding skin incision or urethral mobilization. It helps to prevent glans dehiscence, fistula formation and avoids the use of genital skin flaps in all patients, especially those affected with LS. This novel surgical technique is an effective treatment alternative for men with distal urethral strictures.

Mps1 Mediated Phosphorylation of Hsp90 Confers Renal Cell Carcinoma Sensitivity and Selectivity to Hsp90 Inhibitors.

The molecular chaperone Hsp90 protects deregulated signaling proteins that are vital for tumor growth and survival. Tumors generally display sensitivity and selectivity toward Hsp90 inhibitors; however, the molecular mechanism underlying this phenotype remains undefined. We report that the mitotic checkpoint kinase Mps1 phosphorylates a conserved threonine residue in the amino-domain of Hsp90. This, in turn, regulates chaperone function by reducing Hsp90 ATPase activity while fostering Hsp90 association with kinase clients, including Mps1. Phosphorylation of Hsp90 is also essential for the mitotic checkpoint because it confers Mps1 stability and activity. We identified Cdc14 as the phosphatase that dephosphorylates Hsp90 and disrupts its interaction with Mps1. This causes Mps1 degradation, thus providing a mechanism for its inactivation. Finally, Hsp90 phosphorylation sensitizes cells to its inhibitors, and elevated Mps1 levels confer renal cell carcinoma selectivity to Hsp90 drugs. Mps1 expression level can potentially serve as a predictive indicator of tumor response to Hsp90 inhibitors.

In Obese Patients, the Distance Between Skin and Renal Collecting System Changes with the Position of the Patient from Supine to Prone.

PURPOSE: To investigate how prone and supine redistribution of a patient's adipose tissue affects the distance from skin to the renal collecting system. METHODS: There were 48 patients who underwent CT intravenous urography with both supine and prone scans. The distance between skin and the posterior lower pole calix was measured in both positions. The difference was calculated using paired t tests. Subgroup analyses were conducted for patients with a body mass index (BMI) ≥ 28 and BMI ≥ 30. RESULTS: In all patients, the mean distance between skin and the posterior lower pole calix was 9.9 ± 0.3 cm and 8.7 ± 0.3 cm for patients supine and prone, respectively (P < 0.01). Patients with a BMI ≥ 28 had a mean distance of 10.6 ± 0.3 cm and 8.8 ± 0.3 cm in supine and prone positions, respectively (P < 0.01), while patients with BMI ≥ 30 had a mean distance of 11.3 ± 0.3 cm and 9.3 ± 0.3 cm (P < 0.01). Three patients had a BMI > 39 and exhibited differences in skin to the posterior lower pole calix ≥ 3.2 cm between supine and prone positioning. Coefficient of determination analysis for supine minus prone tract length yielded R(2) = 0.70895. CONCLUSION: The distance between skin and the renal collecting system is decreased in the prone position when compared with the supine position. This difference increases with the patient's BMI and is further accentuated in morbidly obese patients. In these obese patients, the difference when lying prone can exceed >4 cm.