Single-Port Robot assisted partial cystectomy for urachal adenocarcinoma.

OBJECTIVE: We present a novel technique to perform single-port (SP) robot-assisted partial cystectomy with excision of the urachal remnant and bilateral pelvic lymph node dissection for urachal adenocarcinoma (1-7). MATERIALS AND METHODS: A 41-year-old male presented to the clinic for multiple episodes of hematuria and mucousuria. Office cystoscopy revealed a small solitary tumor at the dome of the bladder, with a diagnostic bladder biopsy revealing a tubule-villous bladder adenoma. Cross-sectional imaging of the chest/abdomen/pelvis revealed a 4.5 cm cystic mass arising from the urachus without evidence of local invasion and metastatic spread. He underwent SP robotic-assisted partial cystectomy with excision of the urachal remnant and bilateral pelvic lymph node dissection. Surgical steps include: 1) peritoneal incision to release the urachus and drop bladder 2) identification of urachal tumor 3) intraoperative live cystoscopic identification of bladder mass and scoring of tumor margins using Toggle Pro feature 4) tumor excision with partial cystectomy 5) cystorrhaphy 6) bilateral pelvic lymph node dissection 7) peritoneal interposition flap to mitigate lymphocele formation. RESULTS: Surgery was successful, with no intraoperative complications, an operative time of 100 minutes, and estimated blood loss of 20 mL. The patient was discharged on post-op day one, and the Foley catheter removed one week after surgery. Final pathology revealed a 7.5 cm infiltrating urachal muscle-invasive adenocarcinoma of the bladder (pT2b). Negative surgical margins were achieved. CONCLUSIONS: Single-port robot-assisted partial cystectomy for urachal adenocarcinoma is safe and can achieve equivalent oncologic outcomes to the standard of care with minimally invasive and open techniques.

Neobladder-Vaginal fistula: The University of Southern California experience.

AIMS: The use of orthotropic neobladder (ONB) construction in women has increased in popularity. With increasing numbers so have complications distinct to this procedure. Neobladder vaginal fistula (NVF) is a rare but challenging complication. We present our experience correcting this problem. METHODS: An IRB approved database of female patients with an ONB was retrospectively reviewed. Patients with a history of NVF were identified and charts reviewed. Our standard technique of radical cystectomy and orthotopic diversion in female patients includes interposition of omentum between the neobladder and anterior vaginal wall and sacrocolpopexy. RESULTS: Two hundred and forty-nine female patients underwent cystectomy and ONB construction between 1995 and 2015. Fourteen patients were diagnosed with a NVF (5.6% incidence). The average age and follow-up was 67 years and 33.7 months, respectively. Surgery for fistula closure was attempted in 13 patients. One repair was combined abdominal and transvaginal; the remaining 12 were performed transvaginally. Location of NVF was categorized as at the urethra-neobladder anastomosis (UNA, nine patients) and anterior vaginal wall (AVW, four patients). Eight patients had a successful fistula repair (61.5%) but only five patients ultimately retained their ONB (39%). CONCLUSIONS: Patients with a NVF pose a surgical challenge. Successful fistula repair does not necessarily result in adequate continence due to an incompetent outlet. NVF location at the UNA is the more common location and is more challenging in regard to successful resolution of the NVF as well as possible urinary incontinence post-NVF repair.

Pregnancy Rates after Testicular Torsion.

PURPOSE: To our knowledge the effect of testicular torsion on the pregnancy rate is unknown. In this study we focused on the pregnancy rate, which is the ultimate index of fertility status. MATERIALS AND METHODS: We reviewed the records of 273 patients who presented to our emergency room with testicular torsion between 1994 and 2014. Study inclusion criteria included being in a relationship with the intent to conceive for at least 1 year, age greater than 25 years and a normal contralateral testis. Patients with primary infertility, those who were unwilling to participate or unreachable and those with a history of undescended testis and/or varicocele were excluded from analysis. Patients were contacted by telephone and interviewed according to a standardized questionnaire. Pregnancy rates in the orchiopexy and orchiectomy groups were compared to each other and to the accepted pregnancy rate in the literature. RESULTS: A total of 63 patients met study inclusion criteria, including 41 and 22 in the orchiopexy and orchiectomy groups, respectively. The pregnancy rate in the orchiopexy and orchiectomy groups was 90.2% and 90.9%, respectively (p = 1.0). The accepted pregnancy rate in the general population is 82% to 92%. Mean ± SD time to pregnancy in the orchiopexy and orchiectomy groups was 6.6 ± 5.50 and 7.2 ± 5.4 months, respectively (p = 0.27). CONCLUSIONS: Several studies suggest decreased fertility potential in patients with a history of testicular torsion. However, in the current study in couples in which the male had a history of testicular torsion the pregnancy rate and the interval to pregnancy were within the accepted range of the general population.

[FACTORS PREDICTING OVERALL AND DISEASE-FREE SURVIVAL AFTER SURGERY FOR INVASIVE BLADDER CANCER].

OBJECTIVES: To evaluate the prognosis of patients who underwent surgery for invasive bladder cancer and to search for prognostic factors. METHODS: The files of all the patients who underwent radical or partial cystectomy for invasive bladder cancer between 1992 and 2014 were reviewed. The effect of various prognostic factors was evaluated by uni- and multivariate analyses. RESULTS: A total of 160 patients were included in the study and were followed for a median period of 25.5 months after surgery. The overall 2 years and 5 years survival rates were 70% and 61.2% respectively. The disease-free 2 years and 5 years survival rates were 64.4% and 61.9% respectively. The overall 2 years and 5 years survival rates of patients with disease limited to the bladder (≥T2N0) were 88.2% and 82.4% and of patients with disease extending beyond the bladder (≤T3N0) 56.5% and 45.7% respectively. Factors that were found to be significantly associated with overall survival were: TNM stage, co-morbidity (Charlson 6-11) and the tumor's diameter. No association was found between: disease presentation, smoking habits, positive cytology, the tumor being primary or secondary, variant histology, the presence of endophytic growth pattern, the presence of CIS, hydronephrosis, positive lymph nodes on pre-operative imaging, surgery type (radical or partial cystectomy) and adjuvant chemotherapy. CONCLUSIONS: The survival rates of the locally treated patients match the reported rates in the literature. Tumors' T stage were found to be the strongest prognostic factor. Tumors' diameter was found to be an independent prognostic factor. This is reported here for the first time in the literature.

Intravesical administration of green tea extract attenuates the inflammatory response of bacterial cystitis--a rat model.

OBJECTIVE: To explore the effect of intravesical instillation of green tea extract (GTE) on a rat model of bacterial cystitis. MATERIALS AND METHODS: In vitro bactericidal properties of GTE were analysed by adding GTE to a suspension of uropathogenic E. coli (UPEC), streaking on MacConkey agar, and incubating overnight. In vivo effects of intravesical instillation of GTE on bacterial cystitis was analysed using a rat model of bacterial cystitis. In all, 42 female Sabra rats weighing 200-260 g were divided into five groups. Parameters measured were bladder weight (percentage of the total rat weight), dipstick urine analysis and histopathological changes in the bladder. Histological changes evaluated were degree of oedema, mixed inflammatory infiltration, urothelial epithelial invasion by neutrophils and reactive atypia. RESULTS: No in vitro bactericidal activity was detected for GTE. Intravesical instillation of GTE did not cause damage to the rat bladders. Intravesical instillation of GTE attenuated the inflammatory response to UPEC-SR71-induced bacterial cystitis in this rat model. CONCLUSIONS: Intravesical instillation of GTE attenuated the inflammatory response to UPEC-SR71-induced bacterial cystitis and is a novel approach to the treatment of bacterial cystitis. High concentrations of intravesical GTE did not cause histologically evident damage to the rat bladder. The results of this study are preliminary and further studies will be needed to explore the feasibility of using this approach in humans.

Cowper's gland syringocele in an adult: The great imitator.

Cowper's gland syringocele (CGS) is the cystic dilation of its duct. It is an uncommon urological condition and is thought to be more commonly encountered in pediatric urology. However, it is in adults that CGS poses a diagnostic challenge because of its "chameleon-like" clinical presentation that may masquerade multiple urological etiologies. In this population, where urological conditions are more prevalent, CGS may present as bladder outlet obstruction, recurrent urinary tract infections, gross hematuria, urinary retention, perineal pain, or abscess.

Surge in testicular torsion in pediatric patients during the COVID-19 pandemic.

BACKGROUND: Testicular torsion is a pediatric surgical emergency, and prompt diagnosis and treatment is imperative. During the COVID-19 pandemic, pediatric patients with symptoms of testicular torsion may be reluctant to seek medical care which increases the likelihood of delayed presentation and the need for an orchiectomy. This observational study sought to determine whether there was a higher number of testicular torsion cases during COVID-19. METHODS: As the first patient with COVID-19 was admitted to our facility on March 6, 2020, we identified male children ages 1-18 years with testicular torsion between March 1-December 31, 2020 (during COVID-19) compared to the same time period between 2015 and 2019 (prior to COVID-19). All patients were evaluated at our Institution's Emergency Department by a pediatric urologist. RESULTS: There were 38 cases of testicular torsion between March 1-December 31, 2020 compared to 15.8 cases on average during the same 10-month period between 2015 and 2019 (a total of 79 cases). There was a statistically significant increase in testicular torsion cases during the COVID-19 pandemic compared to equivalent time periods in 2015-2019 (38 vs. 15.8, p = 0.05). Patients with testicular torsion during the COVID-19 pandemic were younger, had a longer duration of symptoms, and had a higher number of orchiectomies (although not statistically significant). CONCLUSION: During the COVID-19 pandemic, an escalation in testicular torsion cases was observed. Timely assessment, diagnosis, and surgery are crucial to prevent testicular loss and potential infertility in the future. Further evaluation is needed to elucidate the surge in testicular torsion and possible mechanisms.

Pure "cable-tie partial nephrectomy": a porcine model.

BACKGROUND: The standard surgical procedure for polar renal tumors is nephron-sparing surgery, currently performed laparoscopically in most cases. This technically challenging surgery involves clamping of the hilar vessels and warm kidney ischemia. This study tested the feasibility of performing polar nephrectomy using a cable tie without hilar clamping or any other hemostatic procedure. METHODS: General anesthesia and pneumoperitoneum were induced in four farm pigs, and three trocars were inserted intraperitoneally. A kidney pole (either a lower or an upper pole of either the left or right kidney) was exposed and encircled with a plastic cable tie. The pole then was transected sharply with scissors, opening the urinary collecting system and major blood vessels. Neither tissue sealants nor any form of energy was used throughout the cases. The animals were killed 3 weeks later. RESULTS: All the pigs tolerated the surgery well. The renal part of the surgery required less than 12 min, and blood loss was minimal (<30 ml) for all the animals. The postoperative course was benign. Laparotomy performed 3 weeks later showed no peritoneal or retroperitoneal abnormalities. The plastic cable tie remained in the same position covered with a thin layer of mesothelial cells. A thin sector of coagulation necrosis was found under the pressure of the cable. CONCLUSIONS: In a porcine model, polar nephrectomy using a plastic cable tie is a very easy and rapid procedure. Cheap and bloodless, it eliminates the need for renal reconstruction. Hilar dissection and renal ischemia are avoided. "Cable-tie partial nephrectomy" may become a method for removing a tumor-bearing renal pole.

The fate of the seminal vesicle remnant after proximal transection or ligation: an animal model.

PURPOSE: Dissection of the seminal vesicles during radical prostatectomy has the potential to damage the pelvic plexus, thus compromising trigonal, bladder neck and cavernous innervation, and contributing to delayed gain of continence and erectile function. The rate of prostate cancer invasion into the seminal vesicles in currently operated patients is low and in most it may be predicted preoperatively. This situation calls for seminal vesicle sparing radical prostatectomy in select patients, leaving a distal remnant of the seminal vesicles in place. We investigated the fate of the seminal vesicle remnant after proximal transection or ligation in an animal model. MATERIALS AND METHODS: The right seminal vesicle in 36 anesthetized male rats was divided by suture ligation or by transection. The left seminal vesicle served as a control. Six rats per group were sacrificed 1, 2 and 4 weeks after division, respectively. Seminal vesicle morphology was evaluated macroscopically and microscopically. RESULTS: All rats tolerated surgery well and gained weight postoperatively. Transected seminal vesicles were similar in weight and morphology to control contralateral glands. One week after seminal vesicle ligation the remnants became significantly heavier and showed balloon dilatation of the hollow spaces, while the lining epithelium became significantly flattened. Two and 4 weeks after ligation half of the animals showed gland shrinkage and half demonstrated persistent dilatation. CONCLUSIONS: Seminal vesicle transection preserves the gland remnant in a relatively normal morphology, while ligation leads to severe and inconsistent morphological changes. When considering seminal vesicle sparing radical prostatectomy, seminal vesicle transection may be preferred to ligation.

Single-Port Robot assisted partial cystectomy for urachal adenocarcinoma

ABSTRACT Objective: We present a novel technique to perform single-port (SP) robot-assisted partial cystectomy with excision of the urachal remnant and bilateral pelvic lymph node dissection for urachal adenocarcinoma (1-7). Materials and Methods: A 41-year-old male presented to the clinic for multiple episodes of hematuria and mucousuria. Office cystoscopy revealed a small solitary tumor at the dome of the bladder, with a diagnostic bladder biopsy revealing a tubule-villous bladder adenoma. Cross-sectional imaging of the chest/abdomen/pelvis revealed a 4.5 cm cystic mass arising from the urachus without evidence of local invasion and metastatic spread. He underwent SP robotic-assisted partial cystectomy with excision of the urachal remnant and bilateral pelvic lymph node dissection. Surgical steps include: 1) peritoneal incision to release the urachus and drop bladder 2) identification of urachal tumor 3) intraoperative live cystoscopic identification of bladder mass and scoring of tumor margins using Toggle Pro feature 4) tumor excision with partial cystectomy 5) cystorrhaphy 6) bilateral pelvic lymph node dissection 7) peritoneal interposition flap to mitigate lymphocele formation. Results: Surgery was successful, with no intraoperative complications, an operative time of 100 minutes, and estimated blood loss of 20 mL. The patient was discharged on post-op day one, and the Foley catheter removed one week after surgery. Final pathology revealed a 7.5 cm infiltrating urachal muscle-invasive adenocarcinoma of the bladder (pT2b). Negative surgical margins were achieved. Conclusions: Single-port robot-assisted partial cystectomy for urachal adenocarcinoma is safe and can achieve equivalent oncologic outcomes to the standard of care with minimally invasive and open techniques.

Door To Detorsion Time Determines Testicular Survival.

OBJECTIVE: To determine the importance of the duration of in-hospital management of patients with testicular torsion for testes survival. The time from onset of symptoms until surgery is a well-known factor determining testicular survival but there is no data regarding the contribution of in-hospital management duration to testicular survival. Unlike the time from onset of symptoms until seeking medical attention, the time from registration to the emergency department (ED) to the time of detorsion-"Door To Detorsion time" (DTD) is dependent on medical providers and should be minimized. MATERIALS AND METHODS: Data was retrieved on all patients who underwent surgery for testicular torsion in 1994-2014 (N = 219). We used multivariable logistic regression analysis to examine independent association between DTD time or duration of symptoms to testicular survival. RESULTS: Median DTD time was 135 minutes (range 23-546). Among patients with a viable testis, median DTD time was 107 minutes (range 35-381) compared to 160 minutes (range 23-546) among patients with a nonviable testis (P <.001). Logistic regression models showed that both DTD time (P = .04) and duration of symptoms (P <.001) are independent factors associated with testicular survival. Adjusted odds ratio was 1.0048 for a nonviable testis for every minute of delayed management in the ED (P = .04). Results suggest that every 10 minutes of delay in the ED increases the chance of having a nonviable testis in exploration by 4.8%. CONCLUSION: DTD is an independent factor predicting testicular survival. Institutional efforts should be made to decrease duration of DTD. DTD should be considered as a measure for quality of care.

Retrograde versus Antegrade Approach for the Management of Large Proximal Ureteral Stones.

Objective. To evaluate and compare the efficacy and safety of retrograde versus antegrade ureteroscopic lithotripsy for the treatment of large proximal ureteral stones. Patients and Methods. We retrospectively analyzed the medical records of patients with proximal ureteral stones >15 mm, treated in our institution from January 2011 to January 2016. Intraoperative parameters, postoperative outcomes, and complications were recorded and compared between the two techniques. Results. Our analysis included 57 patients. Thirty-four patients (59.6%) underwent retrograde and 23 patients (40.4%) underwent antegrade ureteroscopy. There was no significant difference in patients' demographics and stone characteristics between the groups. Stone-free rate was significantly higher (p = 0.033) in the antegrade group (100%) compared to retrograde one (82.4%). Fluoroscopy time, procedure duration, and length of hospitalization were significantly (p < 0.001) lower in retrograde approach. On the other hand, the need for postoperative stenting was significantly lower in the antegrade group (p < 0.001). No difference was found between the groups (p = 0.745) regarding postoperative complications. Conclusions. Antegrade ureteroscopy is an efficient and safe option for the management of large proximal ureteral stones. It may achieve high stone-free rates compared to retrograde ureteroscopy with the drawback of longer operative time, fluoroscopy time, and length of hospitalization.

Late ureteral obstruction in an adult who had STING/Teflon in childhood: Should we expect an epidemic?

We present a case of left renal colic in a 25-year-old female patient. She had subureteral injection of Teflon (STING) at the age of 10 due to vesico-ureteral reflux (VUR) disease and recurrent urinary tract infections. Renal colic was the result of late ureteral obstruction due to Teflon-induced periureteral foreign body reaction. To our knowledge, this is the longest interval between STING and ureteral obstruction reported and the first case of delayed ureteral obstruction caused by Teflon. Monitoring the upper tracts of patients after STING should go beyond childhood.

A novel model to predict the risk of readmission in patients with renal colic.

UNLABELLED: Abstract Purpose: To identify the clinical, laboratory, and imaging parameters that may increase the risk of readmission in patients with renal colic that is managed by active surveillance and to produce a novel model to predict the risk for this. PATIENTS AND METHODS: We retrospectively reviewed patients with renal colic secondary to ureteral calculi admitted to our hospital from March 2009 until September 2010. The colic was managed with active surveillance for 6 weeks. Patients were divided into those who were not readmitted to the hospital within the follow-up period (group A) and those who were (group B). RESULTS: From the 452 studied patients, 82 (18.1%) were readmitted to the hospital. Stone size (P<0.001) and location (P<0.001) and serum white blood cell count (P=0.009) were statistically significantly different between groups. These parameters were found to be independent predictors for readmission. A predictive model was produced to calculate the risk of readmission. CONCLUSIONS: Stone size and location and white blood cell count are independent predictors for potential readmission in patients with renal colic. Using these parameters, we may calculate the risk for readmission, and the latter may assist physicians in identifying the best treatment option.

A single dose of 240 mg gentamicin during transrectal prostate biopsy significantly reduces septic complications.

OBJECTIVE: To evaluate whether the addition of a single dose of an aminoglycoside to a fluoroquinolone-based prophylaxis regime would decrease septic complications associated with transrectal prostate biopsy. METHODS: A retrospective survey of all patients undergoing transrectal ultrasound guided prostate biopsy (TRUS-PB) between 2001 and 2012 at Hadassah Hebrew University Medical Center was performed. All patients received prophylactic ofloxacin for 3 days. From 2008, patients received an augmented protocol, consisting also of a single injection of gentamicin. The dose of the aminoglycoside was left to the discretion of the attending physician. RESULTS: Of 4655 patients, 110 patients (2.4%) were admitted because of urosepsis. Ninety patients (82%) had a positive urine or blood culture or both. From 2008, among 581 patients treated solely with ofloxacin, the infection rate was 3.6%, and among the 538 patients who also received 80 mg gentamicin, the rate of sepsis was 3.5% (P = 1.0). Among the 376 patients treated with gentamicin, 160 mg infection rate was 2.7% (P = .27). The sepsis rate dropped significantly to 0.6% (P = .04) among the 169 patients who received 240 mg gentamicin during the biopsy. CONCLUSION: Addition of a single dose of gentamicin 240 mg resulted in a significant drop in infection rates after TRUS-PB. However, addition of 80 mg or 160 mg gentamicin had no significant effect on the infection rates. We recommend adding a single dose of gentamicin 240 mg to all patients with normal kidney function undergoing TRUS-PB during the procedure.

Diagnosing spontaneous ileal neobladder perforation: Too often delayed.

Spontaneous neobladder perforations are rare, but well-documented; the first cases were reported more than 2 decades ago mostly in urologic journals. However, the diagnosis of these patients is often delayed in the emergency room setting because initial care is given by non-urological medical staff that is too often unaware of this etiology. We present 2 cases and discuss the shift in treatment that has occurred over time.

An ALK translocation positive carcinoma of the lung presenting as uremia due to bilateral renal obstruction.

We describe an unusual presentation of metastatic lung adenocarcinoma as malignant retroperitoneal fibrosis (MRPF). The diagnostic challenge, due to the small solitary lung mass and absence of a discrete retroperitoneal mass, was overcome by diagnostic laparoscopy. Molecular analysis of tissue acquired was positive for ALK gene rearrangement. Treatment of the patient with crizotinib reversed MRPF. He was weaned off the nephrostomy tubes and is with stable renal function 11 months after diagnosis.

Natural killer cell-mediated host defense against uropathogenic E. coli is counteracted by bacterial hemolysinA-dependent killing of NK cells.

Uropathogenic Escherichia coli (UPEC) are a common cause of urinary tract infections (UTIs) in humans. While the importance of natural killer (NK) cells in innate immune protection against tumors and viral infections is well documented, their role in defense against bacterial infections is still emerging, and their involvement in UPEC-mediated UTI is practically unknown. Using a systematic mutagenesis approach, we found that UPEC adheres to NK cells primarily via its type I fimbriae and employs its hemolysinA toxin to kill NK cells. In the absence of hemolysinA, NK cells directly respond to the bacteria and secrete the cytokine TNF-α, which results in decreased bacterial numbers in vitro and reduction of bacterial burden in the infected bladders. Thus, NK cells control UPEC via TNF-α production, which UPEC counteracts by hemolysinA-mediated killing of NK cells, representing a previously unrecognized host defense and microbial counterattack mechanism in the context of UTI.