An unusual case of spontaneous rupture of the renal pelvis.

Spontaneous rupture of the renal pelvis is a relatively rare urologic finding. It is associated with obstructing ureteral calculi and can occur with or without urinary instrumentation. Spontaneous rupture is typically diagnosed through imaging modalities such as computed tomography (CT) scans or retrograde pyelography. In this case report, we detail a case regarding spontaneous rupture of the renal pelvis (SRRP) of a 33-year-old male with idiopathic extravasation of contrast from the renal pelvis discovered on delayed phase CT scan of the abdomen and pelvis. This is a unique case of SRRP as the etiology remains idiopathic.

Scrotal emphysema with characteristics of Fournier's gangrene in a community setting.

Fournier's gangrene is a life-threatening type of necrotizing fasciitis associated with a high rate of morbidity and mortality. The patient is a 29-year-old incarcerated male who presented to the ED with left-sided scrotal crepitus extending into the axilla and testicular swelling. The patient endorsed a pimple on his left scrotum accompanied with groin pain. He had a prior history of foreign body removal and self-mutilating behaviors. The patient was taken for surgical exploration out of concern due to a subcutaneous emphysema secondary to a necrotizing soft tissue infection.

Bladder cancer that metastasized to the skin: A unique presentation that signifies poor prognosis.

In the United States in 2015, an estimated 74,000 new cases of bladder cancer were diagnosed and approximately 16,000 deaths were due to bladder cancer. We present a rare case of a patient with aggressive bladder cancer who presented with multiple inguinal and scrotal skin lesions that were proven to be metastatic urothelial malignancy. Bladder malignancy can involve the skin by direct tumor invasion, hematogenous routes, lymphatic spread, and direct seeding due to iatrogenic implantation. The cutaneous lesions have an extremely variable appearance, are resistant to therapies, and signify a dismal prognosis.

Chylous ascites as a complication of left sided robot-assisted laparoscopic partial nephrectomy.

OBJECTIVE: The aim of the study was to present a case series of the sparsely reported complication of chylous ascites (CA) after left sided robot-assisted laparoscopic partial nephrectomy (RALPN), identify possible risk factors for the development of postoperative CA, and explore current recommendations for identification, management and prevention of CA. MATERIAL AND METHODS: A retrospective review of patients that were treated with a RALPN during a one year time period (August 2012 to August 2013) by one surgeon at our institution was conducted. A total of 12 patients were included in the study. Demographics, tumor characteristics, and perioperative outcomes were assessed. RESULTS: Three patients in the study experienced postoperative CA. All three patients had left sided surgery. The initial clinical suspicion for CA was raised due to complaints of abdominal pain with increased milky appearance of JP fluid. JP triglycerides were elevated in all three patients. The patients responded to conservative measures, with two patients treated with medium chain triglyceride diets and one patient treated with total parenteral nutrition (TPN). Among the patients treated with RALPN, the group that was diagnosed with postoperative CA (CA group) was found to have a statistically significant lower average body mass index (BMI) as compared to the group that did not have CA (non-CA group) (24.67 kg/m2 in the CA group versus 31.77 kg/m2 in the non-CA group; P = 0.026). Other demographic data, tumor characteristics, and perioperative outcomes were similar in both groups. CONCLUSIONS: CA as a result of RALPN is a newly reported and rare postoperative complication. As utilization of RALPN continues to increase, urologists should be aware of this possible complication and be adept at diagnosing and managing CA. We suggest that left sided retroperitoneal surgery and a lower BMI preoperatively be considered risk factors for developing this complication.

Robotic simple prostatectomy: a consideration for large prostate adenomas.

BACKGROUND: The management of benign prostatic hyperplasia (BPH) has changed considerably over the last several decades. First line treatment of BPH and lower urinary tract symptoms (LUTS) with medical therapy has created a population of men with much larger prostate glands, many of whom require surgical intervention. Patients with prostate glands greater than 80 to 100 grams may be better managed surgically with a retropubic prostatectomy. We explore our experience with robotic assisted simple prostatectomy and review the relevant literature. DATABASE: The database reviewed includes our experience with seven patients undergoing robotic simple prostatectomy, and a comprehensive review of the previously published series of this procedure. In addition, the literature pertaining to a pure laparoscopic approach to simple prostatectomy is reviewed. CONCLUSION: Robotic experience and training has become a standard in resident training programs; while classic transurethral resection is being performed less for large prostate glands. The robotic approach to simple prostatectomy provides an excellent option for surgical treatment of very large prostate glands, providing patients acceptable results in terms of operative time, estimated blood loss, hospital stay and duration of Foley catheter.

Laparoscopic repair of a traumatic bladder rupture.

Laparoscopic repair of the traumatic intraperitoneal bladder rupture is a proven, safe, and effective technique in the appropriate setting. A 23-year-old male with traumatic intraperitoneal bladder rupture proven by cystogram after a motor vehicle collision was successfully repaired via a laparoscopic approach. We describe the technique in detail including 2-layer closure and follow-up care. A review of the literature using PubMed with the key words [laparoscopic repair bladder injury] AND [bladder trauma] was performed. We recommend the consideration of laparoscopic repair of the intraperitoneal bladder rupture in more trauma patients who meet criteria.

Incarcerated retroperitoneal hernia following total extraperitoneal laparoscopic radical nephrectomy.

Small bowel obstruction (SBO) is a common entity encountered in surgical patients. The most common causes of the SBO range from postoperative adhesions to cancer. We present the case of a 55-year-old male who underwent a laparoscopic left radical nephrectomy and presented with an early SBO. An imaging study revealed an obstructive pattern with proximal dilated jejunum with decompressed distal small bowel. The patient underwent an exploratory laparotomy with extensive lysis of adhesions and release/resection of a long segment of incarcerated jejunum from an 8-cm retroperitoneal hernia in the left renal fossa. The patient was discharged home, and at 3-month follow-up no bowel complaints were reported.

Diminished suture strength after robotic needle driver manipulation.

Robot-assisted minimally invasive surgery has become a routine surgical option for the treatment of prostate cancer. Despite its technical advancements, the da Vinci(®) Surgical System still lacks haptic feedback to the surgeon, resulting in a maximally applied compressive force by the robotic needle driver during every grasping maneuver. Without this perceptional sense of touch and grip control, repetitive robotic needle driver manipulation may unknowingly lead to irreparable damage to fine sutures used during delicate anastomotic repairs. For robotic prostatectomy, any such loss of integrity can potentially lead to premature breakdown of the urethrovesical anastomosis and urine extravasation, especially important for a less-than-perfectly fashioned anastomotic repair. Although it has already been established that overhandling of sutures using handheld laparoscopic instruments can lead to reduced suture strength, it has not been established to what extent this may occur after robotic surgical procedures. We present analytical data and analyses concerning the failure strength of fine sutures commonly used for urethrovesical anastomotic repair during robotic prostatectomy, after repetitive robotic needle driver manipulation. When compared with noncompromised monofilament suture controls, the average maximal failure force after repetitive robotic manipulation was significantly reduced by 35% (p < 0.0001). Similarly, the average maximal failure force of braided sutures was significantly reduced after repetitive robotic manipulation by 3% (p = 0.009). This work demonstrates that significant reductions in monofilament and braided suture strength integrity can occur after customary repetitive manipulation by robotic needle drivers in an ex vivo model, with further research warranted in the in vivo setting.

Management of benign ureteral strictures in the endoscopic era.

BACKGROUND AND PURPOSE: During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. PATIENTS AND METHODS: We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. RESULTS: Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. CONCLUSIONS: Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Loss of structural integrity of a coil based ureteral stent.

We present the first reported complication of the Silhouette, (Applied Medical, Santa Margarita, CA) 4 Fr. soft, nitinol coil-reinforced double-J ureteral stent, that is specifically related to its unique construct and design. These novel ureteral stents were placed in a medically unstable patient with bilateral partially obstructing proximal ureteral calculi. At the time of ureteroscopy, it was noted that a mild to moderate amount of encrustation was present on the distal curl of the ureteral stent. Upon removal of the stent, resistance was encountered and disintegration and fragmentation of the stent was noted. The patient eventually underwent staged ureteroscopy and shock wave lithotripsy (SWL) to remove the remaining portions of the encrusted ureteral stent.

Effect of carbohydrate-electrolyte sports beverages on urinary stone risk factors.

PURPOSE: We evaluated the effects of consuming carbohydrate-electrolyte sports beverages (Gatorade((R))) on urinary stone risk factors. MATERIALS AND METHODS: Twelve normal subjects (5 men, 7 women) and 12 hypercalciuric stone formers (2 men, 10 women) participated in a 4-week prospective, crossover study consisting of 3 study phases. In phase 1 subjects were placed on a monitored stone prevention diet that was continued throughout the study. In phase 2 subjects ingested 2 l Gatorade daily followed by a 7-day washout period. In phase 3 subjects ingested 2 l water daily. On the final day of phases 1, 2 and 3 a 24-hour urine collection and blood sample were analyzed for stone risk factors. Effects of group and phase were tested using repeated measures ANOVA and paired t tests. RESULTS: Changes in urinary risk factors after Gatorade consumption revealed no statistically significant difference between normal subjects and stone formers. However, intrasubject variation occurred in both groups. Gatorade consumption in both groups increased urinary pH (p = 0.006), urinary chloride (p = 0.044) and urinary sodium (p = 0.008), and decreased urinary potassium (p = 0.035) and urinary uric acid (p = 0.019) in a statistically significant manner. In response to Gatorade consumption urinary volume, calcium and citrate were unchanged compared to water consumption and baseline. CONCLUSIONS: Gatorade increased mean urinary sodium and chloride levels compared to water and baseline. However, the results were within normal urinary parameters. The change did not appear to be clinically significant as urinary calcium was unchanged. Overall consumption of Gatorade does not increase or decrease urinary stone risk factors.

Effect of skin-to-stone distance on shockwave lithotripsy success.

PURPOSE: We evaluated the effect of increased body habitus on stone-free rates after shockwave lithotripsy (SWL), determined by three reproducible skin-to-stone distances (SSDs) on CT. PATIENTS AND METHODS: We retrospectively reviewed the records of 85 patients with preoperative CT scans available on Stentor Radiology Imaging who underwent SWL with the unmodified Dornier HM3 lithotripter from 2002 to 2007. SSDs were measured at the following angles: 0 degrees (vertical), 30 degrees, and 90 degrees (horizontal). Successful therapy was defined as stone free (residual fragments <2 mm) on follow-up imaging. Data were analyzed using descriptive statistics, Student t test, and the Fisher exact test. RESULTS: Four hundred and eighty patients underwent SWL at our institution from 2002 to 2007; 85 patients (50.6% men, mean age 50.8 +/- 15.7 years, mean body mass index [BMI] 28.8 +/- 6.6 kg/m2) had preoperative CT scans available for review. On follow-up imaging (142.7 +/- 217.2 days), 49.4% of patients were stone free. Mean SSDs (vertical, 30 degrees, horizontal) in patients who were stone-free v those with residual stone were 104.3 +/- 26.2 mm v 102.6 +/- 29.9 mm (P = 0.79), 103.9 +/- 28.2 mm v 101.0 +/- 31.5 mm (P = 0.66), and 106.6 +/- 25.3 mm v 107.1 +/- 29.3 mm (P = 0.94), respectively. CONCLUSIONS: Multiple variables have been shown to be associated with SWL success. In our sample of patients with preoperative CT scans, SSD was found to have no effect on SWL success.

Feasibility and outcome of retrograde endoscopy in a post-prostatectomy population.

PURPOSE: To determine the feasibility of retrograde endoscopy after radical retropubic prostatectomy (RRP) and its effects on post-prostatectomy continence. PATIENTS AND METHODS: We retrospectively reviewed all patients who underwent RRP at our institution between 1999 and 2005, identifying those who subsequently required endoscopic instrumentation. Patient records were examined for the interval between procedures, method of endoscopy, and continence after endoscopy compared with baseline post-prostatectomy continence. RESULTS: Twenty-one patients were identified who required endoscopic instrumentation from 4 to 49 months after RRP. Of these, 13 patients underwent ureteroscopy for stones (N = 8) or stricture disease (N = 5). In 3 cases, a ureteral access sheath was used, and in 12 cases, a ureteral stent placed postoperatively. Review of the operative reports revealed no complications or difficulty with cannulation of the ureteral orifice(s) or sheath placement. Eight patients underwent rigid cystoscopy for hematuria, removal of a foreign body, or treatment of bladder stones (N = 2 each) or for stent placement and frequency (N = 1 each). The ureter could not be identified in one case of attempted stent placement for hydronephrosis because of a distal-ureteral stone. A follow-up intravenous urogram confirmed passage of the stone and resolution of the hydronephrosis. There were no other reported difficulties with rigid cystoscopy. There was no documented change or adverse outcome regarding continence after endoscopy. CONCLUSIONS: Post-prostatectomy retrograde endoscopy is feasible for the management of common urologic pathologies. Endoscopic instrumentation across the urethrovesical anastomosis did not have an adverse effect on urinary continence.

Staged retrograde endoscopic lithotripsy as alternative to PCNL in select patients with large renal calculi.

BACKGROUND AND PURPOSE: Percutaneous nephrolithotomy (PCNL) is currently the gold standard for management of large renal calculi. PCNL is associated, however, with a higher complication rate, degree of risk, and longer recovery period compared with ureteroscopy. In a selected group of patients who were not ideal candidates for PCNL because of extenuating health factors, a staged retrograde endoscopic approach was used to manage upper urinary tract calculi. METHODS: We conducted a retrospective review of 23 patients (selected because of comorbidities, obesity, anatomy, and previous treatment failure as poor candidates for PCNL) who underwent staged retrograde endoscopic lithotripsy to manage upper urinary tract calculi. Lithotripsy was based on the application of small-diameter fiberoptic ureteroscopes and the holmium laser. Successful therapy was defined as total fragmentation of stone burden on repeated imaging. Data were analyzed using descriptive statistics. RESULTS: Of the 468 patients who underwent ureteroscopy at our institution from 2003 to 2006, 23 patients (52% men, 57.70 +/- 11.44 years of age) were treated with retrograde endoscopic procedures for upper urinary tract calculi (52.2% lower pole). Stone burden at the initial procedure was 2.13 +/- 2.34 stones with a total linear length of 30.91 +/- 14.28 mm and an estimated total stone volume of 12,040.78 +/- 11101.54 cc (median value, 7,234.00 cc). There were no intraoperative complications; three patients were admitted postoperatively for observation. Ten 43.5%) patients (progressed to second-stage procedures (34.6 +/- 10.8 days apart). After repeated imaging, 73.9% of patients were stone free (88% lower pole), and 8.7% progressed to further intervention. Total linear stone length <4 cm and estimated calculus volume > or =15,000 cc predicted treatment failure (40%, 42.9%). CONCLUSIONS: Percutaneous methods of managing renal stones have an increased rate of complications compared with ureteroscopy. In patients with complex medical histories, upper urinary tract calculi <4 cm can be safely and effectively managed using a staged retrograde endoscopic approach.

A simple cost-effective design for construction of a laparoscopic trainer.

BACKGROUND AND PURPOSE: Laparoscopic trainers have been shown to be effective tools for transitioning residents in surgical fields into live laparoscopic techniques. There have been few reports of homemade trainers, but each of these reports provides only scant detail about their construction, making production a novel task to those interested in employing this equipment. Virtual-reality trainers are gaining popularity and are exceptional modalities in the re-creation of laparoscopic surgery. In their present state, however, such trainers are very costly, making them unattainable by most urology residency programs. Numerous commercial non-virtual trainers are also available; however, these trainers are often cost-prohibitive or overly simplistic. METHODS AND RESULTS: We describe a detailed design template for creation of a laparoscopic trainer based on modifications of previous designs. This trainer can be made easily at a cost of approximately US$275.00 and may be used in conjunction with existing laparoscopic equipment. The methods described herein can be followed by any local machinist to create this trainer. CONCLUSION: The relatively low total cost, ready material availability, and ease of construction make this trainer an appropriate option for the training of residents in laparoscopic procedures.

Spermatic cord torsion with preserved testis perfusion: initial anatomical observations.

PURPOSE: Despite the high sensitivity and specificity of scrotal ultrasonography, there continue to be reports of missed torsion. These "false-negative" scans are attributed to technical factors and intermittent torsions. We hypothesize that patients with specific anatomical configurations maintain testicular blood flow for prolonged periods, and, therefore, will have flow on ultrasound despite concurrent torsion. MATERIALS AND METHODS: Patient charts and scrotal ultrasounds were reviewed to identify patients younger than 18 years who underwent scrotal exploration between January 1998 and January 2003 for acute scrotum. Patients who underwent radiological evaluation before scrotal exploration were the main focus of this study. Operative reports were reviewed for specific anatomical details. RESULTS: A total of 61 patients underwent scrotal exploration for acute scrotum during the study period. Of these patients 14 had torsion confirmed intraoperatively and a preoperative scrotal ultrasound available. Four of these 14 patients had normal testicular blood flow on ultrasound but had testicular torsion confirmed intraoperatively. Operative findings suggest that these patients have specific anatomical characteristics. CONCLUSIONS: Testis perfusion can be maintained for a prolonged period in the presence of testicular torsion. Anatomical variability may account for differences in the duration of viability of the torsed testis. A high index of suspicion must be maintained to avoid missing the diagnosis of testicular torsion in these challenging cases.