Total Autologous Fascia Lata Sacrocolpopexy for Treatment of Pelvic Organ Prolapse: Experience in Thirty-Four Patients.

OBJECTIVE: To develop a technique for open/robotic sacrocolpopexy using autologous fascia lata autograft. We report our experience in our first 34 patients. METHODS: The operation utilizes a 4-5-cm x 15-18-cm piece of fascia lata harvested through a 3-4-inch lateral upper thigh incision. The graft is configured into a traditional Y-shaped configuration using CV-2 Goretex sutures and is used to perform sacrocolpopexy. Patients were followed by history and physical, POP-Q scores, and symptoms related to thigh harvest including visual analog pain (VAP) scores. Treatment failure was defined as symptomatic pelvic organ prolapse (POP) involving apical descent. RESULTS: Autologous fascia lata sacrocolpopexy was performed on 34 patients with a mean age of 62. Mean follow-up was 13 months (range 2-42). Thirteen cases were open sacrocolpopexies, and 21 were robotic. Concurrent procedures included hysterectomy (9), vaginal mesh excision (7), bowel resection and rectopexy (5), and autologous sling (5). POP symptoms resolved in all 34 patients, and there were no treatment failures. The overwhelming majority of harvest site issues were minor and managed expectantly. Mean VAP score at the harvest site was 0.4 (range 0-3). Three patients developed non-bothersome thigh bulges. One patient developed a harvest site seroma. Twelve patients reported mild, non-bothersome harvest site paresthesias. No thromboembolic events occurred. CONCLUSION: Autologous fascia lata sacrocolpopexy is an efficacious treatment for patients who desire non-mesh POP repair. Most harvest site issues are minor and typically resolve with expectant management alone. Continued follow-up of this series is ongoing to determine long-term success of this operation.

Total Autologous Fascia Lata Anterior and Apical Pelvic Organ Prolapse Repair: A New Technique and Initial Experience.

OBJECTIVE: To address renewed interest in nonmesh transvaginal Pelvic Organ Prolapse (POP) repair since the FDA reclassification of transvaginal mesh, our goal was to develop a transvaginal sacrospinous fixation for anterior and apical POP using only autologous fascia lata. We report our experience in 33 patients. METHODS: Autologous Anterior and Apical Pelvic Organ Prolapse (AAA-POP) repair utilizes a 4 × 14 cm piece of fascia lata harvested through a 3-4-inch upper thigh incision. The graft is reconfigured to provide apical fixation to the sacrospinous ligaments and distal fixation to the obturator fascia. Patients were followed by history, SEAPI scores, POP-Q scores, and Visual Analogue Pain Score. Treatment success was defined as absence of symptomatic anterior or apical POP. RESULTS: Thirty-three patients (mean age 63, mean follow-up 12 months) underwent AAA-POP. Treatment was successful in 31 patients (94%), and 2 failures were due to uterine prolapse. Mean harvest site Visual Analog Pain score was 0.27. Five and 7 patients developed nonbothersome thigh bulges and wound paresthesias, respectively. All 4 harvest-site seromas resolved, with 2 requiring simple aspiration. Eleven patients developed urinary retention, 10 (91%) of them after concurrent pubovaginal sling. All resolved after sling loosening (6 patients) or sling lysis (4 patients). CONCLUSION: AAA-POP is an efficacious treatment for patients desiring nonmesh POP repair. Postoperative harvest site issues are minor and typically resolve with expectant management. Patients should be counseled about the potential risk of failure with a uterine-sparing approach and the risk of urinary retention with concurrent pubovaginal sling.

Pelvic Hematoma Following UroLift procedure for BPH.

We present an interesting complication following the UroLift procedure: the development of a pelvic hematoma. This patient presented to the emergency department with pelvic pain, penile ecchymosis, and edema on postoperative day 4 following his UroLift procedure. A computed tomography scan revealed that his symptoms were due to the formation of a large pelvic hematoma. To our knowledge, pelvic hematoma formation following UroLift is a unique complication not previously described in the literature.

Primary Malignant Melanoma of the Bladder Treated by Robotic Partial Cystectomy and Immunotherapy.

Background: Primary malignant melanoma (PMM) of the urinary tract is a rare entity, with only 28 cases reported in the literature. We present an interesting case of a 27-year-old Caucasian woman, with family history of melanoma, who initially presented with gross hematuria, and was subsequently found to have PMM of the bladder. Case Presentation: Initially diagnosis was made through transurethral resection of the bladder tumor with clinical suspicion of residual disease in the patient. Subsequently, she underwent robotic partial cystectomy with pelvic lymph node dissection followed by 1 year of pembrolizumab, a PD-1 checkpoint inhibitor. Subsequent imaging demonstrated no evidence of metastatic disease or local recurrence. Conclusion: This case report presents a unique management of a rare pathological diagnosis with the use of robotic partial cystectomy, and a PD-1 checkpoint inhibitor therapy that ultimately has led to a 2-year recurrence-free survival period for this young patient.

Racial and Ethnic Disparities in Renal Cell Carcinoma: An Analysis of Clinical Characteristics.

BACKGROUND: Racial/ethnic minority groups, including Hispanic Americans (HAs) and Native Americans (NAs), have a heavier burden of kidney cancer than European Americans (EAs). We investigated variations in clinical characteristics of HA and NA patients with renal cell carcinoma (RCC) who were previously underrepresented. MATERIALS AND METHODS: Clinical records of 294 patients with RCC (151 EAs, 95 HAs, 22 NAs, and 26 others) without prior diagnosis of cancer were reviewed. Logistic regression analysis was performed to understand patients' clinical characteristics. RESULTS: HAs had about 5 years younger average age at diagnosis than EAs (55.8 vs. 60.5 years) and an almost 3-fold increased odds of diagnosis before age 50 years (odds ratio [OR], 2.77; 95% confidence interval [CI], 1.39-5.54). The mean age of diagnosis among NAs was 49.7 years, and NAs had an over 6-fold higher odds of diagnosis at a younger age (OR, 6.23; 95% CI, 2.00-19.46). Clear-cell RCC (ccRCC) was more common in HAs and NAs than EAs. Over 90% of HA patients had ccRCC, whereas only 78.8% of EA patients had ccRCC. HAs had increased odds of diagnosis with ccRCC compared with EAs (OR, 2.79; 95% CI, 1.15-6.80). Among HAs, older patients and patients who spoke Spanish as their primary language were more likely to have advanced stage RCC at diagnosis (OR, 10.48; 95% CI, 1.69-64.89 and OR, 4.61; 95% CI, 1.38-15.40). CONCLUSION: HA and NA patients with RCC had different clinical characteristics than EA patients. It is necessary to better understand the clinical characteristics of these underserved HA and NA populations with high kidney cancer burden.

Successful Placement of Penile Prostheses in Men With Severe Corporal Fibrosis Following Vacuum Therapy Protocol.

INTRODUCTION: Penile prosthesis (PP) implantation in men with severe corporal fibrosis presents a significant surgical challenge. For the past 7 years, we have used a novel, preoperative protocol of daily vacuum therapy (VT) using a vacuum erection device for at least 3 months before PP placement for men with severe corporal fibrosis from PP infection or ischemic priapism. AIM: To evaluate this standardized preoperative regimen. METHODS: We retrospectively reviewed all patients who underwent three-piece PP placement at our institution from 2008 through 2015. Of these, 13 men had severe corporal fibrosis from prior PP infection (11 of 13) or prolonged ischemic priapism (2 of 13). Our protocol included VT for 10 to 15 minutes at least two times daily in all patients for at least 3 months (mean = 3.5 months). MAIN OUTCOME MEASURES: We report on our surgical experience and post-VT stretched flaccid penile length (SFPL) compared with baseline SFPL. RESULTS: All 13 men underwent successful three-piece PP placement with standard-size cylinders without additional surgical maneuvers. There was one infection and one erosion requiring revision. Daily average use of VT was 32.5 minutes. SFPL increased 0.92 cm (range = 0-2 cm, SD = 0.76 cm) after VT and three-piece PP placement compared with preoperative SFPL. These men also noted improved quality of life and sexuality as measured by postoperative office interviews. CONCLUSION: The use of VT before surgery appears to result in softening of corporal fibrosis and facilitates placement of a PP regardless of the period from developing corporal fibrosis to starting VT. We strongly recommend preoperative corporal tissue rehabilitation with VT to improve surgical outcomes and to decrease difficulty during PP implantation in men with severe corporal fibrosis.

Learning curve for the transsphenoidal endoscopic endonasal approach to pituitary tumors.

INTRODUCTION: The transsphenoidal endoscopic approach is a relatively new procedure compared to the microscopic approach in pituitary adenoma resection. The endoscopic approach has shown to significantly decrease the rate of complications, time in the operating room and hospital, and patient post-op discomfort. However, this procedure requires the surgeon to make use of different visual and tactile clues that must be developed with experience. Therefore, it is important to understand the learning curve that the surgeon must overcome to become proficient with the endoscopic approach. METHODS: Retrospective review of a single-surgeon consecutive series of 78 patients undergoing endoscopic pituitary tumor surgery from 2006 to 2012 at Rush University Medical Center has been used in this study. Patients were grouped according to an early (n = 9) and late group (n = 68) determined by a significant difference in outcomes. Our primary outcome measures were: duration of operation, CSF leak, hospital length of stay, visual field improvement, diabetes insipidus, panhypopituitarism, and subtotal resection. RESULTS: There was a significant reduction in OR time and intraoperative CSF leaks between the early and late groups. There was no difference in hospital LOS or visual field improvement between the groups. With regards to complication rates, there was no difference found for DI, panhypopituitarism, lumbar drain placement, sinusitis, or subtotal resection between the two groups. CONCLUSION: This study indicates that there may be a learning curve of approximately 9 cases before a surgical team can decrease OR times and reduce the rate of intraoperative CSF leaks for the endonasal endoscopic approach to pituitary adenoma resection.

Arteriovenous malformation embocure score: AVMES.

BACKGROUND: Cerebral arteriovenous malformations (CAVMs) may be treated with microsurgery, radiosurgery, endovascular surgery, or a combination of these modalities. Grading scales are available to aid the assessment of curative risk for microsurgery and radiosurgery. No grading system has been developed to assess the curative risk of endovascular surgery. OBJECTIVE: To report our retrospective application of the AVM embocure score to patients treated at our institution between 2005 and 2011 METHODS: We performed a retrospective review of 39 patients with CAVM treated at our institution between 2005 and 2011 with the primary aim of achieving a curative embolization. After reviewing all the different variables associated with the conventional Onyx embolization technique for CAVMs, we identified the following as the most relevant characteristics influencing the chances for complete angiographic embolization and complication risk: the number of arterial pedicles and draining veins, size of AVM nidus, and vascular eloquence. We sought to develop a scoring system to assess the complication risk for a curative embolization of CAVM with liquid embolic Onyx (Covidien, Irvine, California, USA). We developed the AVM embocure score (AVMES). This scoring system ranges from 3 to 10 and is the arithmetic sum of the number of arterial pedicles feeding the AVM (≤3, 4-6, >6), the number of draining veins (≤3, 4-6, >6), the size of the AVM nidus in centimeters (≤3, 4-6, >6), and the vascular eloquence (0-1). We applied AVMES to the same cohort of patients and validated the predictability of complete angiographic embolization and expected clinical risk of complication. RESULTS: In lesions with an AVMES of 3 (n=8), there was a 100% rate of complete AVM obliteration and 0% rate of major complications. In AVMES 4 (n=12) lesions, there was 75% complete obliteration rate, with 8% major morbidity. In AVMES 5 (n=9) lesions, there was 78% complete obliteration and 11% major morbidity. In AVMES >5 (n=10) there was 20% complete obliteration and 30% major morbidity. Receiver-operator curve analysis showed that this scoring system was robust in its discriminative ability, with an area under the curve (AUC) of 0.8356 for complete obliteration without complication, AUC=0.8240 for complete obliteration regardless of the presence of major morbidity, and AUC=0.7529 for major morbidity. CONCLUSIONS: The AVMES complements existing scoring systems for microsurgery and radiosurgery. It provides a valuable tool for risk assessment during the complex decision-making process in treating AVMs that accounts for angioarchitectural features of particular relevance to endovascular surgeons.

Innovative use of intravesical tacrolimus for hemorrhagic radiation cystitis.

Hemorrhagic cystitis is a rare and severe late complication of pelvic radiation, and there is no regulatory-approved drug treatment. We present an 81-year-old man with a history of localized prostate cancer, which was treated with external beam radiation therapy and subsequently developed severe hemorrhagic radiation cystitis for which he has failed several treatments. We present the novel use of intravesical tacrolimus for the treatment of refractory radiation cystitis and gross hematuria. The patient tolerated the treatment well, and it resulted in the resolution of his gross hematuria without further consideration for formalin instillation or cystectomy and diversion. Intravesical tacrolimus is a safe, minimally invasive, and promising treatment option for radiation hemorrhagic cystitis.