Assessing the effectiveness of antimicrobial pouch use for infection prevention in sacral neuromodulation.

INTRODUCTION AND HYPOTHESIS: Sacral neuromodulation (SNM) is a commonly performed procedure for various conditions. Infection rates range as high as 10% and often require operative explantation with resultant increased cost and morbidity. Pouches impregnated with antibiotic have been utilized in cardiovascular procedures with decreasing infectious complications. TYRX is an antibiotic pouch utilizing minocycline and rifampin manufactured by Medtronic. The objective of this study is to investigate the utility of antimicrobial pouches for patients undergoing SNM. METHODS: We retrospectively analyzed our patients undergoing SNM using an antimicrobial pouch and compared them with a historic cohort. Additional variables of interest included post-operative infection, diagnosis of diabetes, weight, and revision case or virgin implant. RESULTS: A total of 170 cases were identified, ranging from March 2017 to November 2022. Overall infection rate was 2.9% with 0 in the antimicrobial pouch cohort (0%) versus 5 in the historic cohort (5.5%; p = 0.04). Groups were similar in terms of body habitus. The group receiving an antimicrobial pouch was noted to be older with a higher percentage of female patients. 85 patients received an antimicrobial pouch and 85 did not. Of the infections, 4 occurred in revision cases (6.9%) and 1 in a virgin implant (0.9%; p = 0.03). No difference was noted in infection rate with regard to a diagnosis of diabetes or body habitus. CONCLUSION: The use of antimicrobial pouches in SNM is associated with a decreased rate of infectious complications. Revision cases displayed a higher rate of infectious complications.

Triple Threat: Three Primary Malignancies Simultaneously Involving Three Genitourinary Organs.

Statistically, the chance of having concurrent renal cell carcinoma (RCC), urothelial carcinoma of the bladder (UC), and a neuroendocrine tumor (NET) of the renal parenchyma is less than one in a trillion. Herein, we describe an unusual case of a 67-year-old female who presented with bilateral flank pain and severe gross hematuria. Cross-sectional imaging revealed two large heterogeneous, endophytic renal masses with a single enlarged paracaval lymph node. Diagnostic cystoscopy was performed for completion of gross hematuria evaluation and revealed a concurrent papillary bladder tumor. Percutaneous biopsies of bilateral renal masses revealed clear cell RCC involving the left kidney and well-differentiated NET involving the right kidney, and transurethral resection of the bladder tumor revealed high-grade nonmuscle invasive urothelial carcinoma. The patient elected to undergo bilateral nephroureterectomy, radical cystectomy, and retroperitoneal and pelvic lymphadenectomy. Final pathology confirmed the presence of three different malignancies: noninvasive high-grade papillary UC of the bladder (pTaN0), left renal clear cell RCC (pT2bN0), right renal well-differentiated NET, and a single paracaval lymph nodes positive for metastatic NET (pT2aN1).

Dysfunctional Voiding- Presentation of a Rare Case of Pediatric Non Muscle Invasive Urothelial Bladder Carcinoma.

Bladder cancer is rare in children, with 86.8% of pediatric patients diagnosed not carrying any of the common risk factors commonly seen in adults. Here, a 16-year-old female presented to the ED with in urinary retention. A renal bladder ultrasound revealed an echogenic focus in the bladder wall. On diagnostic cystoscopy a small papillary bladder lesion was appreciated and resected. Final pathology of the bladder mass resulted as non-invasive low grade papillary urothelial carcinoma (pTa). This report demonstrates bladder cancer in the pediatric age group, and should be considered as a possible differential diagnosis in patients with dysfunctional voiding.

Bridging the Gap-Building Surgical Subspecialty Telemedicine Clinics in the Rural Setting.

INTRODUCTION: Pediatric urology is a much-needed subspecialty with a breadth of complex disorders that can often prove challenging to diagnose and manage. Exacerbating this need is the minimal exposure medical trainees receive to pediatric urology. Pediatric urology arrived in West Virginia in 1983 but the subspecialty has been inconsistently represented since then. Currently there are 2 fellowship-trained pediatric urologists in the state of West Virginia, which has an area of approximately 24,038 square miles. We review our experience with the use of telemedicine in providing outreach to the wider parts of our medically underserved state and ultimately evaluate its efficacy from a patient-centric cost analysis and diagnosis concordance perspective. We hypothesized that the use of telemedicine would be cost and time-effective for patients in our rural state. METHODS: We retrospectively reviewed our series of patients presenting from outside telemedicine "referral centers" in Martinsburg, Parkersburg and Wheeling for pediatric urological consultation. We evaluated reason for consultation, geographic driving distance, drive time and travel cost saved from telemedicine consultation. RESULTS: A total of 92 patients presented to outside designated telemedicine centers from August 2018 to April 2020. The mean driving time saved utilizing telemedicine consultation was 4 hours and 46 minutes, and mean driving distance saved was 299.8 miles. Travel costs saved in terms of fuel averaged $173.88 per patient. The most common reason for consultation was undescended testis, followed by recurrent urinary tract infection and nocturnal enuresis. Of the 23 patients who required surgery, only 2 (8.7%) had an initial diagnosis that was not concordant with their operating room examination. CONCLUSIONS: While modest, our data indicate a modern solution to a historical need in our state. Our high diagnosis concordance rate (91.3%) shows that a well-trained advanced practice provider can adequately perform an operative evaluation via telemedicine.

New Methods of Reconstruction for Old Challenges: The Use of the Integra Graft in Necrotizing Soft Tissue Infections of the Male Genitalia.

In this paper, we describe two cases of Fournier's gangrene (FG) in which Integra grafting was used for reconstruction. FG is a progressive necrotizing infection occurring in the perineal region and on the external genitalia. Reconstructive options using local tissue are limited due to the destruction this infection imposes on the soft tissue. Integra graft is a bilaminate artificial dermis made of shark chondroitin 6-sulfate and bovine collagen. It is applied to the wound bed after debridement and establishment of a healthy, well-vascularized wound base. The patients in this case series had large defects which could not be closed primarily with tissue beds and would not have been appropriate for skin grafting. Therefore, an Integra graft was placed. In both patients, the wound beds were appropriate for skin grafting after three weeks. Without the Integra graft, both of our patients would have needed to wait a considerable amount of time prior to reconstruction. Our case series further illustrates and supports the use of Integra grafts in such a scenario following Fournier's gangrene which has only previously been published on three occasions, all of which demonstrated successful outcomes.

Diagnosis and Surgical Management of a Retroperitoneal Lipoma in Pregnancy.

Retroperitoneal lipomas during pregnancy are very rare. We report a case of a 29-year-old pregnant female who presented with a retroperitoneal lipoma. Our patient presented at 15-week gestation with abdominal pain, distention, and orthopnea. Due to vague symptoms and nonspecific imaging capabilities, retroperitoneal tumors in pregnancy are uniquely challenging with regard to diagnosis and treatment. We describe the unique work up of a retroperitoneal lipoma in pregnancy and the risks and benefits which were considered when optimizing care to the patient. Percutaneous core needle biopsy has accuracy rates for pathologic diagnosis of up to 98% and is largely safe to perform during pregnancy. Surgical resection of this type of tumor does not mandate cesarean delivery in subsequent pregnancies.

Locally Recurrent Leiomyoma of the Bladder Refractory to Visually Complete Transurethral Resection: An Indication for Cystoprostatectomy.

Leiomyomas are benign smooth muscle tumors that have low malignant potential (0.1%) and can arise in nearly any area of the body. Genitourinary involvement is very rare and represents only 0.05% of all bladder tumors (Mendes et al., 2017; GÖK, 2017). The most common presenting symptoms of bladder leiomyomas are obstructive voiding (49%), irritative voiding (38%), and hematuria (11%) (Goluboff et al., 1994). Treatment involves complete excision, in this case transurethral resection (TUR), and generally results in complete cure with no recurrences noted in the 250 cases reported in the literature for open resection and 18% recurrence rates after TUR which were successfully treated with a repeat TUR in all cases. Herein, we report a case of leiomyoma of the bladder which was refractory to four visually complete transurethral resections and ultimately required radical cystoprostatectomy with ileal conduit urinary diversion.