Awareness of European practitioners toward uncommon tropical diseases: are we prepared to deal with mass migration? Results of an international survey.

PURPOSE: The recent rise in migration from Africa through the Mediterranean basin into Europe has resulted in an increased incidence of uncommon diseases such as schistosomiasis and genito-urinary tuberculosis, which were previously largely unknown in this region. This study aimed to evaluate the insight of European urologists into diagnosing and managing these disease conditions and to determine whether they were adequately prepared to deal with the changing disease spectrum in their countries. METHODS: A survey including specific questions about the diagnosis and management of 'tropical' urological diseases was distributed among urologists working in Europe and Africa. Multivariate logistic regression models were performed to detect the continent (African or European) effect on knowledge of and insight into tropical urological diseases. RESULTS: A total of 312 surveys were administered. African and European respondents accounted for 109 (36.09%) and 193 (63.91%) respondents, respectively. The multivariate logistic regression analysis demonstrated a significant deficiency in the knowledge of tropical urological diseases in the European cohort compared with the African cohort (p < 0.05). Moreover, in the European cohort, markedly superior knowledge of tropical urological diseases was observed for respondents who had previously worked in a developing country. CONCLUSIONS: Though European urologists are not required to have the same insight as African urologists, they showed a very unsatisfactory knowledge of tropical urological diseases. The experience of working in a developing country could improve the knowledge of European urologists regarding tropical urological diseases.

Surgical Training in South Africa: An Overview and Attempt to Assess the Training System from the Perspective of Foreign Trainees.

BACKGROUND: Currently, there are no objective reports evaluating the quality of the South African surgical training. The aim of this study is to evaluate the current state of surgical training in South Africa from an external impartial point of view and to rate the experience of short-term supernumerary registrars and fellows (STSRF) within the South African training system. METHODS: A 29-item survey was distributed via e-mail and social media to non-South African trainees who worked in South Africa as STSRF for a period of at least 1 month during the past 5 years. The survey evaluated the surgical, clinical and academic training received during their elective period in a South African department. RESULTS: Sixty-four STSRF replied to the survey. Sixty-two percent of STSRF attended a trauma unit during their experience. For the majority of respondents, open and emergency surgical exposure, as well as experience as first surgeon, is significantly higher in the South African system, while minimally invasive and endoscopic surgery exposure is significantly less. Research project involvement is significantly less, for the STSRF, as opposed to lectures and teaching that constitute a higher percentage. No significant difference was found regarding exposure to hands-on activities. CONCLUSIONS: The South African system still provides excellent surgical and clinical exposure as well as teaching. However, minimally invasive surgery training and research are generally lacking for the STSRF. Exchange programs between South African and developed country institutes should be improved and encouraged in order to gain mutual benefits.

Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up.

INTRODUCTION: Ritual circumcision complicated by gangrene is a leading cause of penile loss in young men in South Africa. This deeply rooted cultural tradition is unlikely to be abolished. Conventional reconstructive techniques using free vascularised tissue flaps with penile implants are undesirable in this often socioeconomically challenged group because donor site morbidity can hinder manual labour and vigorous sexual activity might lead to penile implant extrusion. The psychosociological effects of penile loss in a young man are devastating and replacing it with the same organ is likely to produce the maximum benefit. METHODS: We first performed a cadaver-to-cadaver penile transplantation as preparation. After approval from the Human Research Ethics Committee was obtained, we recruited potential recipients. We screened the potential participants for both physical and psychological characteristics, including penile stump length, and emotional suitability for the procedure. A suitable donor became available and the penis was harvested. We surgically prepared the penile stump of the recipient and attached the penile graft. Immunosuppression treatment with antithymyocyte globulin, methylprednisolone, tacrolimus, mycophenolate mofetil, and prednisone were commenced. Tadalafil at 5 mg once per day was commenced after 1 week as penile rehabilitation and was continued for 3 months. We collected on quality-of-life scores (Short Form 36 version 2 [SF-36v2] questionnaires) before surgery and during follow-up and measured erectile function (International Index for Erectile Function [IIEF] score) and urine flow rates at 24 months post transplant. FINDINGS: The warm ischaemia time for the graft after removal was 4 min and the cold ischaemia time was 16 h. The surgery lasted 9 h. An arterial thrombus required urgent revision 8 h after the operation. On post operative day 6, an infected haematoma and an area of proximal skin necrosis were surgically treated. The recipient was discharged after 1 month and first reported satisfactory sexual intercourse 1 week later (despite advice to the contrary). The recipient reported regular sexual intercourse from 3 months after the operation. An episode of acute kidney injury at 7 months was reversed by reducing the tacrolimus dose to 14 mg twice per day. At 8 months after surgery, the patient had a skin infection with phaeohyphomycosis due to Alternaria alternata, which we treated with topical antifungal medication. Quality-of-life scores improved substantially after the operation (SF-36v2 mental health scores improved from 25 preoperatively, to 57 at 6 months and 46 at 24 months post transplant; physical health scores improved from 37 at baseline to 60 at 6 months and 59 at 24 months post-transplant). At 24 months, measured maximum urine flow rate (16·3 mL/s from a volume voided of 109 mL) and IIEF score (overall satisfaction score of 8 from a maximum of 10) were normal, showing normal voiding and erectile function, respectively. INTERPRETATION: Penile transplantation restored normal physiological functions in this transplant recipient without major complications in the first 24 months. FUNDING: Department of Health, Western Cape Government.

Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.

Clinical and histopathological features of carcinosarcoma of the renal pelvis: a systematic review of a rare tumor.

INTRODUCTION: Carcinosarcoma of the kidney pelvis (CRP) is a rare but not exceptionally unique tumor in which in literature are reported almost only case studies and small series. We aim to provide a comprehensive overview of the disease, examining epidemiology, symptoms, pathological features, treatment and outcomes which are still missing, in order to offer a landmark paper to urologists which have to manage patients with this type of disease. EVIDENCE ACQUISITION: A review of the current literature was conducted through the NCBI PubMed database in June 2017 following the updated PRISMA guidelines. The filters used for the research were: "carcinosarcoma renal pelvis," "carcinosarcoma kidney pelvis," and "urinary tract carcinosarcoma." Only studies with confirmed histological diagnosis of CRP and a description of patient characteristics (demographics and/or pathological) were included in the review. EVIDENCE SYNTHESIS: Only 15 studies fulfilled the inclusion criteria. The main symptom at presentation was macroscopic hematuria, followed by abdominal pain. The carcinomatous pattern made of transitional cell carcinoma in 73.3% of patients and squamous carcinoma in 33%, while the sarcomatoid was spindle cells in 40% of patients, chondrosarcoma and undifferentiated in 33.3%. Despite radical surgical treatment was performed in all patients, there are no articles reporting a survival rate of more than two years. CONCLUSIONS: Carcinosarcoma of the kidney is a rare tumor of which little is known, especially about pathogenesis and oncological outcomes in the different therapeutic approaches described. Current literature is almost exclusively a case report that does not provide adequate information especially about survival and progression free survival. The creation of a shared database could in a matter of years lead us to increase the information about the oncological outcomes of the various possible treatments.

Retained Bullet in the Kidney: Imaging and Conservative Management.

Renal gunshot wounds resulting in a grade IV injury (AAST) should be explored only if they involve the hilum or if there are signs of suspected renal pelvis or ureteral laceration, active hemorrhage, peritonitis, or hemodynamically unstable patients (Kitrey et al, 2017).1 However, because of the paucity of cases reported in the literature, it is not clear what the best management of patients with a retained bullet is, which have been traditionally treated with surgical retrieval in other organs. We present the radiological findings and a clinical case summary of a patient with grade IV kidney injury and retained bullet managed conservatively.

Large bladder diverticula: a comparison between laparoscopic excision and endoscopic fulguration.

OBJECTIVE: The treatment of bladder diverticula consists of diverticulectomy, mainly by a laparoscopic approach or transurethral resection of the diverticular neck and fulguration of the mucosa. The endoscopic approach is generally dedicated to small diverticula. The aim of this study was to compare laparoscopic diverticulectomy versus endoscopic fulguration for bladder diverticula larger than 4 cm. MATERIALS AND METHODS: A retrospective review of the medical records of consecutive patients undergoing endoscopic or laparoscopic treatment for bladder diverticula larger than 4 cm at two tertiary hospitals was performed. Therapeutic success was defined as either complete resolution or a decrease of at least 80% in the size of the diverticulum. Complications were recorded and graded according to the Clavien-Dindo classification. RESULTS: All patients were treated with transurethral resection of the prostate in the same operative session. The endoscopic group included a cohort of 20 male patients. The median age, diverticular diameter and operative time were 65 years, 7 cm and 62.5 min, respectively. No early postoperative complications were observed. Therapeutic success was achieved in 15 cases (75%). The laparoscopic group included a cohort of 13 male patients with a median age of 63 years and median diverticular diameter of 7.0 cm. The median operative time was 185 min (p < 0.0001). Two grade III postoperative complications were observed (15.3%). Therapeutic success was achieved in all patients (100%). CONCLUSIONS: Acquired bladder diverticula larger than 4 cm can be effectively managed either by a laparoscopic approach or by endoscopic fulguration.

Cycling Trauma as a Cause of Arterial Priapism in Children and Teenagers.

Bicycle riding has multiple beneficial cardiovascular effects; however, it is a well-documented source of significant urologic injuries. Priapism is a rare condition in children, and occurs primarily because of congenital hematologic diseases or adverse drug reactions. A pediatric clinical case and literature review of a high-flow priapism secondary to cycling trauma is described here to highlight their etiopathologic correlation. Bicycle riding trauma is a rare but possible cause of high-flow priapism in children, and a high index of suspicion should ensure appropriate management.