Trans Oblique Ileal Conduit Technique Has a Low Risk of Parastomal Hernias.

OBJECTIVE: To outline our surgical technique and outcomes of a ipsilateral "transoblique" ileal conduit performed during pelvic exenteration with a Vertical Rectus Abdominis Myocutaneous flap. We report hernia rates in a transrectus group as reference. METHODS: We identified patients from January 2007 to August 2020. The transoblique conduit is placed on the ipsilateral side as the VRAM, through the internal, external oblique, and transverse abdominis muscles. Stomal hernias were assessed radiologically. Transrectus patients were those undergoing radical cystectomy matched based on surgery date, age, and sex in a 3:1 ratio. We employed a Kaplan-Meier plot to visualize the duration between surgery and hernia. We calculated the hernia rate 2 years after surgery. Additionally, we present the 30-day postoperative complication rate. RESULTS: Fifty underwent transoblique conduits and we matched them to 190 transrectus patients. Sixty-seven percent were men with a median age of 62. Exactly 10/50 patients in the transoblique and 44/190 in the transrectus group developed a hernia, with a median follow-up of 2.2 years (IQR 0.8, 4.0). The 2-year KM-estimated parastomal hernia rate was 14% (95% CI 1.6%, 25%) for the transoblique conduits, 21% (95% CI 15%, 28%) for the transrectus and 24% (95% CI 6.5%, 39%) for colostomies. Among the transoblique patients, 22 (44%) experienced at least 1 postoperative complication. CONCLUSION: A transoblique ileal conduit is safe in patients undergoing a right VRAM flap during a pelvic exenteration with a low parastomal hernia and complication rates.

Uncommon Detection of Leiomyoma in the Penile Corpus Spongiosum Using FDG PET/CT: A Case Report.

ABSTRACT: Primary tumors of the penile corpus spongiosum are rare. Hereby we describe the scintigraphic findings of a case of penile leiomyoma within the corpus spongiosum tissue, which was incidentally detected on FDG PET/CT. The benign neoplasm was growing in close proximity to the urethra showing increased focal FDG uptake on sequential PET/CT studies. Subsequently, the patient experienced obstructive urinary symptoms, and the tumor was resected. We concluded that the possibility of neoplasm should be kept in mind while evaluating a patient with persistent focal penile FDG uptake, which may be the first and only manifestation of the disease.

Timing of midstream urine culture before endourological procedure-can we do better?-A comparative study.

Endourological procedures are the mainstay of treatment for stone disease in the upper urinary system. Infection is a common complication, and urine cultures (UC) are often obtained preoperatively. In this study, we sought to investigate the role of positive UC in the 90 days prior to surgery (90PreOp) in predicting postoperative infectious complications in comparison to a single positive preoperative UC (PreOP). We compared the correlation between positive PreOp UCs and positive 90PreOp UCs with postoperative urosepsis, and a positive UC obtain proximal to obstruction (Prox UC) during percutaneous nephrolithotomy, ureteroscopy and a placement of nephrostomy tube or ureteral stent. Data from 140 consecutive patients were collected. PreOp UCs were positive in 15 (11%) of patients versus 31 of 140 (22%) positive 90PreOp UCs. All six sepsis events had a positive 90PreOp UC, and five had a positive PreOp UC. Fourteen (93.3%) out of 15 positive Prox UC had a positive 90PreOp UC, whereas only 7 (38.9%) had a positive 90PreOp UC. Positive 90PreOp UC outperformed PreOp UC in predicting positive Prox UC, OR = 12.8 (95% CI 3.70-44.30, p < 0.001), versus OR of 88.9 (95% CI 11.0-720.7, p < 0.001); sensitivity 93%(95% CI 68-100%) versus 47%(95% CI 21-73%); as well as area under the ROC curve(AUC), 0.90 (CI 0.80-0.95) for 90PreOp versus 0.70 (CI 0.56-0.82) for positive Prox UC. Uropathogen persistence was better identified when using 90PreOp UC (27%) than using PreOp UC (12%). We suggest reviewing UCs taken within 90 days preoperatively as this was found superior to a single preoperative midstream UCs in predicting postoperative infectious sequela after stone procedure.

Is there a correlation between meatal stenosis severity, lower urinary tract symptoms and uroflowmetry?

INTRODUCTION: We have recently validated a meatal Stenosis (MS) severity grading system that is based on physical examination. OBJECTIVES: The study objective was to examine the correlation between this grading system, patients' urinary symptoms, uroflowmetry and postvoid residual parameters. STUDY DESIGN: Patients referred for our clinic for urinary and non-urinary complaints, were prospectively enrolled. Urinary symptoms questionnaire, uroflowmetry parameters and post-voiding residuals (PVR) were assessed, and photographs of the urethral meatus were taken for each patient. The photographs were graded blindly according to the previously validated grading system and correlated with urinary symptoms, uroflowmetry parameters and PVR. RESULTS: Overall, 75 patients were assessed (20 grade 0, 23 grade 1 and 32 grade 2). When using grade 0 as a reference, the odds ratio (OR) for reporting narrow stream was 6.4 (95%CI 1.65-24.77) and 4 (95%CI 1.18-14.16) for grade 1 and 2 respectively. OR for prolonged urination was 6 (95% CI 1.47-24.89) for Grade 1 and 2; OR for upward stream deviation was10.08 (95%CI -2.43-41.82) for grade 1 and 15.12 (95%CI - 3.74-61.17) for grade 2. Uroflowmetry results showed lower Qmax from 16.8(SD ± 8.0) ml/sec in grade 0-9.6 ml/s on grade 1 and 2 (p < 0.001) (Figure 1). PVR was not statistically different in the three groups. DISCUSSION: Our main findings were that meatal stenosis severity grade is associated with narrow stream as reported by parent, prolonged urination, and upward deviation of urinary stream, with increasing severity with worsening stenosis. MS grade was also associated with significant worsening of uroflow measures: a lower Qmax, Qmean and a longer time-to-Qmax. Post-void residual volume was not significantly different between the different severity grades. This study showed the clinical significance of the grading system. With subjective and objective measures. The implementation of this grading system in clinics, may aid in decision making regarding surgical intervention in the appropriate patients, and avoid unnecessary procedures. CONCLUSION: The Severity of MS seen on physical examination correlates well with obstructive symptoms and decrease of urine stream seen on uroflowmetry. These findings confirm the importance of the grading system in the evaluation of patients with MS and may be additional measure that assist in consulting parents on the indications to meatotomy.

No-show after extracorporeal shock wave lithotripsy treatment in endourology clinic: Can we build a typical patient profile?

OBJECTIVES: Patients "no-show" in outpatient clinics is a worldwide challenge. Healthcare providers and patients suffer from negative impacts that include increased expenditure, clinical management ineffectiveness, and decreased access to care. This study aims to evaluate no-show rate among extracorporeal shock wave lithotripsy patients visiting endourology clinic and to identify the demographic and clinical predictors of no-show. METHODS: A cross-sectional and historical cohort study using electronic medical records. We included 790 patients aged >18 years old referred for endourology clinic following shock wave lithotripsy during 2010-2017 at Hadassah Medical Center in Israel. We predicted no-show rate following shock wave lithotripsy by various patient characteristics by a multivariate logistic regression model. RESULTS: Overall, 291 (36.8%) patients did not arrive for postoperative clinic. Of these, 91 (11.52%) patients referred to Emergency Department. Patients who were younger in age (odds ratio 1.49, 95% confidence interval 1.08-2.04), patients who underwent hospitalization ≥3 days (odds ratio 1.63, 95% confidence interval 1.11-2.41) and patients who had undergone a stent-free shock wave lithotripsy (odds ratio 5.71, 95% confidence interval 2.40-13.57) were significantly associated with higher no-show rate. Larger stone size was associated with reduction in no-show rate with every millimeter increase of stone diameter was associated with a reduction of 6.1% probability for no-show (odds ratio 0.94, 95% confidence interval 0.89-0.99). CONCLUSIONS: Predicting patients' characteristics and no-show patterns is necessary to improve clinical management efficiency, access to care, and costs. We showed that patients who were younger, patients who underwent stent-free shock wave lithotripsy, patients who had a smaller stone, and patients who underwent a longer hospitalization were more prone to miss their appointment. Paying attention to the characteristics of individual patients may assist in implementing intervening program of patient scheduling.

Obstruction of a ureter orifice by suprapubic catheter.

An Indwelling suprapubic catheter is an established solution for patients with meningomyelocele neurogenic bladder. We report on a case in which a routinely replaced suprapubic catheter obstructed the left ureter orifice. The catheter drainage holes were inside the distal left ureter which compromised urinary drainage from the other kidney as well. As a result, the patient suffered from acute renal failure. During his hospitalization, the catheter was replaced and re-located, and renal function rapidly improved. This case emphasizes that even procedures that have been routinely performed for decades can manifest with an unusual complications.

Formulation and validation of meatal stenosis grading system.

INTRODUCTION: Meatal stenosis (MS) is a common finding in circumcised children. Indication for surgical correction is based on urinary symptoms such as strength and direction of urine stream as well as physical examination, including direction and caliber of the urinary stream. There is no objective grading of MS severity, and therefore indications for surgery and management protocols are vague. OBJECTIVE: We aimed to formulate a standardized, validated, and reliable grading system for MS severity based on the physical examination finding. STUDY DESIGN: Photographs of the urethral meatus were taken in patients scheduled for meatotomy due to MS, whereas patients without this condition served as control. The photographs were rated by three experienced fellowship trained pediatric urologists. The study was conducted in two phases: 1) development of a grading system by the expert panel and 2) testing of the proposed grading system for inter- and intra-rater reliability. To estimate the correlation between different rates, the intra-class correlation coefficient (ICC) was calculated. RESULTS: Three grades were generated: Grade 0 (wide open meatus, visible mucosa), Grade 1 (minimal mucosa/fibrotic tissue visible), and Grade 2 (pinpoint meatus/no mucosa visible/large fibrotic layer). A panel of 51 raters (pediatric urologist, community urologist, pediatricians) participated in the survey evaluating the representative photos from 86 patients. Inter-rater reliability was high ICC = 0.99 (95% confidence interval [CI] of 0.983-0.996, P < 0.0001) Cronbach's alpha = 0.992. In total, 18 raters participated in the same survey two weeks later for intra-rater reliability. An identical grading was obtained in 83.3% of photographs (kappa = 0.455 [P < 0.05]). CONCLUSION: We propose a grading system that is a valid, reliable, and reproducible method to classify the severity of MS on physical exam. This grading system could improve the healthcare provider's and parent's communication and can be a building block for further research in this field. A further research should assess the correlation with clinical signs and symptoms.

Will Stone Density Stop Being a Key Factor in Endourology? The Impact of Stone Density on Laser Time Using Lumenis Laser p120w and Standard 20 W Laser: A Comparative Study.

Introduction and Objectives: Ureteroscopy is the gold standard for most urinary tract calculi. Our institute recently incorporated a powerful 120 W holmium laser machine integrating innovative technology (Lumenis® MOSES PulseTM120H Holmium:YAG laser; Lumenis Ltd.). In this retrospective comparative study, we evaluated the influence of stone density on laser dusting time in a high-power 120 W laser machine vs a standard 20 W machine (Dornier Medilas® H20 Holmium:YAG laser; Dornier Ltd.) Methods: We conducted a retrospective review of medical records of patients who underwent ureteroscopy during the years 2013-2018 for a solitary stone. Stone and clinical characteristics, among other parameters, have been evaluated, including the total laser time until complete stone dusting. Results: Among 631 eligible patients, 462 were treated with a 20 W standard laser and 169 patients with a p120w laser machine. Overall laser time was less than half with p120w laser vs d20w (195 seconds vs 397.14 seconds, p-value <0.001). Multivariate regression demonstrated 234.91 seconds shorter laser time with a p120w laser while controlling confounders such as stone volume, hydronephrosis, and location (p value <0.0001). This pattern was demonstrated in all stone densities. The association between laser dusting time per stone volume and stone density demonstrated relatively constant laser time when using p120w laser, even for hard stones. When the standard 20 W laser was used, laser time was longer in each stone density. Moreover, a stone density of 1164 HU and more demonstrated an upward shift of laser time to stone density curve in standard d20w laser group only. Conclusions: Time to complete stone dusting using p120w laser is extremely shorter, approximately half, comparing with the standard 20 W laser. This pattern is robust and even exponential when evaluating laser time per stone density, especially in hard stones. A new horizon of powerful innovative laser technology will enable to improve endourology practice and patients' care.

High frequency of bladder cancer after nephroureterectomy: justification for adjuvant intravesical treatment?

BACKGROUND: Bladder recurrence after nephroureterectomy (NU) is common. However, there is no acceptable policy of adjuvant intravesical treatment after NU. OBJECTIVE: To assess the rate of bladder recurrence following NU and to identify the high-risk subgroups that may become candidates for adjuvant intravesical therapy after NU. PATIENTS AND METHODS: Ninety-one patients (mean age 66.4 years) underwent NU. High-grade (HG) tumors were found in 63 patients and low-grade (LG) tumors in 28. Median follow-up was 72 months. The risk of bladder recurrence was assessed by uni- and multivariate analyses of patient and tumor characteristics. RESULTS: Bladder recurrence developed in 38 patients (41.8%) after a median period of 11 months. Among these, 25 patients with HG upper tract urothelial carcinoma (39.7%) and 13 patients with LG upper tract urothelial carcinoma (46.4%) developed recurrence. HG bladder recurrence developed in 24 patients (63.2%) and LG recurrence developed in 14 patients (36.8%). Stages pTa, pT1, pT2, or higher bladder recurrence developed in 26 (68.4%), 7 (18.4%), and 4 patients (10.5%), respectively, and pure pTis developed in 1 patient. On uni- and multivariate analyses, the risk of bladder recurrence was independent of any clinicopathologic characteristics. CONCLUSION: High rate and short time interval of bladder recurrence after NU were found, with no specific subgroup of patients with increased risk. These findings support prescribing adjuvant intravesical therapy to all patients after NU.