Necrotizing granulomatous epididymo-orchitis post intravesical BCG administration after brachytherapy for prostate cancer.

Urothelial carcinoma of the bladder remains a challenging disease to treat. Intravesical instillation of BCG has demonstrated tremendous efficacy in preventing recurrence. BCG related necrotizing granulomatous epididymo-orchitis is rare and has not been previously linked to brachytherapy for adenocarcinoma of the prostate. We hypothesize that prior brachytherapy has a deleterious effect on the verumontanum that can result in retrograde transmission of BCG particles leading to granulomatous epididymo-orchitis. This is the first case report of necrotizing granulomatous epididymo-orchitis related to BCG in a patient status post brachytherapy for adenocarcinoma of the prostate.

Review of current varicocelectomy techniques and their outcomes.

OBJECTIVES: • To review all the various techniques and their results and efficiencies to provide practicing urologists with some guidance for choice of technique • To discuss improvements of varicocelectomy techniques in the last 15 years and their impact on results of surgery. PATIENTS AND METHODS: • A PubMed English literature review of literature from 1995 to present. RESULTS: • Pregnancy rates were highest with microsurgical subinguinal technique • Varicocele recurrence rates were lowest with microsurgical subinguinal technique • Hydrocele formation rates were lowest with microsurgical inguinal technique • Surgical complications were highest in the laparoscopic technique • Varicocelectomy by itself or in conjunction with IVF is cost effective CONCLUSIONS: • Microsurgical subinguinal or microsurgical inguinal techniques offer best outcomes • Varicocelectomy is a cost effective treatment modality for infertility • Further research is needed to explore new developments in varicocelectomy.

Pneumonia after Major Cancer Surgery: Temporal Trends and Patterns of Care.

Rationale. Pneumonia is a leading cause of postoperative complication. Objective. To examine trends, factors, and mortality of postoperative pneumonia following major cancer surgery (MCS). Methods. From 1999 to 2009, patients undergoing major forms of MCS were identified using the Nationwide Inpatient Sample (NIS), a Healthcare Cost and Utilization Project (HCUP) subset, resulting in weighted 2,508,916 patients. Measurements. Determinants were examined using logistic regression analysis adjusted for clustering using generalized estimating equations. Results. From 1999 to 2009, 87,867 patients experienced pneumonia following MCS and prevalence increased by 29.7%. The estimated annual percent change (EAPC) of mortality after MCS was -2.4% (95% CI: -2.9 to -2.0, P < 0.001); the EAPC of mortality associated with pneumonia after MCS was -2.2% (95% CI: -3.6 to 0.9, P = 0.01). Characteristics associated with higher odds of pneumonia included older age, male, comorbidities, nonprivate insurance, lower income, hospital volume, urban, Northeast region, and nonteaching status. Pneumonia conferred a 6.3-fold higher odd of mortality. Conclusions. Increasing prevalence of pneumonia after MCS, associated with stable mortality rates, may result from either increased diagnosis or more stringent coding. We identified characteristics associated with pneumonia after MCS which could help identify at-risk patients in order to reduce pneumonia after MCS, as it greatly increases the odds of mortality.

Ureteral injuries sustained during robot-assisted radical prostatectomy.

BACKGROUND AND PURPOSE: During the last decade, the annual volume of robot-assisted prostatectomies performed in the United States has risen steadily. Refinements in surgical technique, understanding of anatomy, and experience have led to more complex patients being offered surgery for management of organ-confined prostate cancer. Complication rates of robot-assisted prostatectomy have been reported in several articles; however, a paucity of data exists when evaluating ureteral injuries sustained during robot-assisted prostatectomy. No standardized universal criteria for reporting and grading of complications exists; therefore, the Martin-Donat criteria with Clavien-Dindo classification system were used to evaluate ureteral injuries in our series. PATIENTS AND METHODS: From January 2001 to June 2013, 6442 consecutive patients were treated with robot-assisted prostatectomy at the same institution by one of five surgeons. All complications were documented through a prospectively maintained prostate cancer database with supplementation from electronic medical records, operative and nursing notes, claims data, discharge summaries, outpatient and emergency visits, institutional morbidity and mortality data, as well as National Surgical Quality Improvement Program data. The Martin-Donat criteria were used to facilitate the accurate and comprehensive reporting of surgical complications while complication severity was assigned following the Clavien-Dindo classification system. RESULTS: Three patients sustained ureteral injuries (ureteral transection) in our series. Both surgeons were beyond their learning curve (greater than 1000 cases) when the injuries occurred; one patient needed readmission, and all patients had risk factors predisposing them to ureteral injury. Each patient was managed with robot-assisted ureteroneocystostomy (1), open transureteroureterostomy (1) and robot-assisted ureteroureterostomy (1) respectively. CONCLUSIONS: Ureteral injuries are uncommon; however, thorough preoperative evaluation and surgical planning could identify patients at high risk for sustaining ureteral injury during prostatectomy. Measures can be taken preoperatively or intraoperatively to reduce the probability of ureteral injury, eliminating the necessity for additional procedures postoperatively.

Double-pigtail stenting of the ureters: technique for securing the ureteral orifices during robot-assisted radical prostatectomy for large median lobes.

Patients with large median prostate lobes undergoing robot-assisted radical prostatectomy are at potential risk of ureteric orifice injury, during posterior bladder neck transection and vesicourethral anastomosis reconstruction. We describe our technique of in situ robot-assisted ureteral stenting with double-pigtail stents for accurate observation and preservation of the ureteral orifices. We have performed this maneuver in over 30 patients in our cohort of over 1500 patients undergoing robot-assisted radical prostatectomy to date--none of these patients developed urinary leak or bladder neck contracture, and had uneventful cystoscopic removal of stents at 6 weeks after surgery.

Robot-assisted laparoscopic radical prostatectomy in the renal allograft transplant recipient.

BACKGROUND AND PURPOSE: Since the advent of immunosuppressive therapy, patients have been able to lead longer lives as transplant recipients. We report the first case of robot-assisted laparoscopic prostatectomy in the renal allograft recipient. PATIENTS AND METHODS: A 54-year-old man presented with Gleason 3+3 localized prostate cancer with a prostatespecific antigen level of 8.5 ng/mL. He had a history of end-stage renal failure secondary to fulminant acute pyelonephritis necessitating bilateral nephrectomy. Renal allograft transplant in the right iliac fossa was performed in 1981, with adequate renal function while continuing his immunosuppressant regime. The patient also had previous left inguinal herniorrhaphy. Modifications to our surgical approach include placement of a bariatric port superiolaterally to the standard port site; siting the left port inferiolaterally to provide adequate access for pelvic lymph node dissection; and developing the retropubic space largely from the contralateral side to avoid allograft injury. Extensive adhesiolysis was also needed. After negative urethral margin reported on frozen section, vesicourethral anastomosis was fashioned using our Cornell bladder neck anatomic reconstruction technique. RESULTS: The patient needed a postoperative transfusion of 1 unit of blood and was discharged on postoperative day 2 after recommencement of immunosuppression. The final pathology report revealed pT(2c) Gleason 7 (3+4) disease and negative surgical margins. Continence was recovered within the first week of catheter removal, and erections sufficient for penetration occurred before 6-week follow-up in the clinic. CONCLUSION: Robot-assisted radical prostatectomy is feasible in the carefully selected renal allograft recipient with favorable oncologic, continence, and potency outcomes.