OnabotulinumtoxinA (Botox) nerve blocks provide durable pain relief for men with chronic scrotal pain: a pilot open-label trial.

INTRODUCTION: Chronic scrotal pain (CSP) is a common, often debilitating, condition affecting approximately 4.75% of men. While nerve blocks using local anesthetics usually provide temporary pain relief, there are no publications on the use of longer acting nerve blocks to provide more durable pain relief for men with CSP. AIM: The aim of this study was to determine if onabotulinumtoxinA (Botox) cord blocks provide durable pain relief for men with CSP. METHODS: In this pilot open-label study, men with CSP who had failed medical management but experienced temporary pain relief from a standard cord block underwent a cord block with 100U Botox. MAIN OUTCOME MEASURES: The outcomes measured were changes 1, 3, and 6 months post-Botox injection in (i) a 10-point visual analog scale (VAS) pain score; (ii) scrotal tenderness on a three-point scale as rated by physical examination; and (iii) the Chronic Epididymitis Symptom Index (CESI) to measure the severity and impact of scrotal pain on men. Paired t-tests were used to compare groups. RESULTS: Eighteen patients with CSP seen between April and September 2013 had Botox injected as a cord block. At the 1-month follow-up, pain reduction was reported by 72% of patients (mean VAS score: 7.36 vs. 5.61, P < 0.003), while by physical examination 44 and 34% of the men had either complete or partial resolution of scrotal tenderness. In addition, there was also a significant reduction in CESI scores (22.19 vs. 19.25, P < 0.04). At 3 months, 56% had both sustained pain reduction and reduced tenderness based on the VAS score (mean: 7.36 vs. 6.02, P < 0.05) and physical exam. The CESI score continued to be significantly lower. Unfortunately, by 6 months, most men had a return to their baseline levels of pain and tenderness. CONCLUSIONS: Our pilot study found that Botox cord blocks provide pain reduction for 3 months or more for most men with CSP.

Trends in urinary calculi composition from 2005 to 2015: a single tertiary center study.

The goal of this study was to investigate recent changes in stone composition and patient demographics to identify factors influencing stone formation for the purpose of reducing the incidence of urolithiasis and preventing stone recurrence. This retrospective analysis includes patients who underwent percutaneous nephrolithotripsy or ureteroscopy at our institution from 2005 to 2015. Northwestern Medicine Enterprise Data Warehouse was used to retrieve demographic information and stone composition analyses. The composition of mixed stones containing uric acid (UA) and calcium oxalate monohydrate (COM) was analyzed further. Chi-squared tests were used for categorical variables and logistic regression was used to assess trends. From 2005 to 2015, 5268 stones were treated. COM was predominant in 42.2% and only 16.6% were pure. The male/female ratio decreased significantly from 1.8 to 1.08 and patient age increased (p < 0.001) with 45.6% of patients being 60 or older in 2015. Females formed more CO dihydrate (COD; p = 0.008) and struvite (p = 0.001) overall. The incidence of COM (p = 0.007) and UA (p < 0.001) rose significantly in men whereas both sexes saw a decrease in carbonate apatite (CA; p < 0.001). COM increased considerably from 12 to 75% amongst mixed stones with UA over the 11-year span. We concluded that stone formers have become older and more gender-equal. The increase in female patients parallels the increase in female obesity in the US. The rising predominance of COM, including when mixed with UA, and the scarcity of pure stones indicates it may be necessary to develop new approaches to managing and preventing urolithiasis.

Retroperitoneal Laparoscopic Radical Nephrectomy Allows Continuation of Peritoneal Dialysis in Patients with End-Stage Renal Disease.

Patient outcomes for retroperitoneal laparoscopic radical nephrectomy (RLRN) in adults on peritoneal dialysis (PD) have not been described in the literature. This is the first series on the successful application of RLRN for renal cell carcinoma (RCC) among adults with end-stage renal disease (ESRD) on PD. In our series of 5 patients, all were able to promptly resume PD, no wound complications were noted at postoperative visits, and no evidence of recurrence was identified on surveillance imaging at follow-up. We propose that RLRN should be considered in PD patients as it allows immediate reinstitution of PD and prevents the morbidity and complications associated with interim hemodialysis.

Factors Associated with Compliance to Increased Fluid Intake and Urine Volume Following Dietary Counseling in First-Time Kidney Stone Patients.

OBJECTIVE: Increasing fluid intake to achieve a urine volume (UV) of >2.5 L/day decreases stone events. We assessed compliance rates and demographic and clinical variables associated with increased fluid intake and UV in patients with urolithiasis following dietary counseling. MATERIALS AND METHODS: In a retrospective study, patients with a low baseline UV (<2.5 L/day) on an initial 24-hour urine collection during metabolic stone evaluation were identified between 2010 and 2015. Patients received detailed standardized dietary counseling, including increasing fluid intake to >3 L/day and titrating it to achieve UV >2.5 L/day. A follow-up 24-hour urine collection was performed at 6 months (FU1) and 18 months (FU2) to assess compliance (UV >2.5 L/day) and predictors associated with it. RESULTS: Our cohort contained 363 patients, 53.4% men and 46.6% women. The mean UV of baseline, FU1, and FU2 urine collections was 1.63, 2.52, and 2.48 L, respectively. The compliance rate of obtaining UV of >2.5 L was 50.1% at 6 months. On logistic regression, male sex (odds ratio [OR] 3.27, 95% confidence interval [CI] 1.94, 5.52, p < 0.001), urolithiasis-related procedures such as ureteroscopy (OR 2.31, 95% CI 1.20, 4.42, p = 0.01) or percutaneous nephrolithotomy (OR 3.48, 95% CI 1.58, 7.63, p = 0.002), and baseline 24-hour UV >1 L (OR 3.00, 95% CI 1.02, 8.76, p = 0.04) were associated with greater odds of compliance. Age >58 years (OR 0.39, 95% CI 0.20, 0.75, p = 0.005) and presence of lower urinary tract symptoms (OR 0.50, 95% CI 0.26, 0.95, p = 0.03) were associated with lower odds of compliance. Ethnicity, body mass index, renal function, marital status, renal stone burden, stone type, and household income were not associated with compliance. CONCLUSIONS: In stone formers, compliance to fluid intake recommendations as measured by 24-hour UV is roughly 50%. Understanding risk factors for noncompliance, especially in at risk patients, can be used for quality improvement initiatives and reducing stone events.

Radiofrequency Ablation-Assisted Zero-Ischemia Robotic Laparoscopic Partial Nephrectomy: Oncologic and Functional Outcomes in 49 Patients.

Introduction and Objectives. Robotic partial nephrectomy with peritumoral radiofrequency ablation (RFA-RPN) is a novel clampless technique. We describe oncologic and functional outcomes in a prospective cohort. Methods. From May, 2007, to December, 2009, 49 consecutive patients with renal masses <7 cm underwent RFA-RPN. During this period, only the RFA-RPN technique was utilized for all cases of partial nephrectomy. Pre- and postoperative data were analyzed and compared to 36 consecutive patients who underwent LPN. Results. In total, 49 tumors were treated in the RFA-RPN group and 36 tumors in the comparison group. Mean operative time was longer in the RFA-RPN group (370 min versus 293 min, p < 0.001). There were no significant differences in mean EBL (231 cc versus 250 cc, p = 0.42), transfusion rate (8.2% versus 11.1%, p = 0.7), or hospital stay (3.9 versus 4.4 days, p = 0.2). Two patients in the RFA-RPN (4.1%) and 1 (2.7%) patient in the comparison group had a positive surgical margin (p = 0.75). 17 (34.7%) patients had a postoperative urine leak in the RFA-RPN group versus 2 (5.6%) patients in the comparison group (p = 0.001). Mean follow-up was 54 months versus 68.4 months in the comparison group. There was no significant difference between the two groups regarding change in GFR (p = 0.67). There were 3 recurrences (6.1%) in the RFA-RPN group and 0 recurrences in the RPN group (p = 0.23). There were 3 deaths (6.1%) in the RFA-RPN group (one cancer specific) and 4 deaths (11.1%) in the RPN group (non-cancer specific) over the follow-up period (p = 0.44). Conclusions. Our data suggests that this technique is associated with a similar degree of renal preservation but higher rates of postoperative urine leak and possibly higher rates of recurrence.

Laparo-endoscopic single site surgery in pediatrics: Feasibility and surgical outcomes from a preliminary prospective Canadian experience.

INTRODUCTION: Laparo-endoscopic single-site surgery (LESS) is becoming an alternative to standard laparoscopic surgery. Proposed advantages include enhanced cosmesis and faster recovery. We assessed the early post-operative surgical outcomes of LESS surgery utilizing different instruments in the pediatric urological population in Canada. METHODS: We prospectively captured data on all patients undergoing LESS at our institution between February 2011 and August 2012. This included patient age, operative time, length of stay, complications and short-term surgical outcomes. Different instruments/devices were used to perform the procedures. Access was achieved through a transumbilical incision. RESULTS: A total of 16 LESS procedures were performed, including seven pyeloplasties, four unilateral and one bilateral varicocelectomies, two simple nephrectomies, one renal cyst decortication and one pyelolithotomy. There was no statistical difference in the operative times, hospital length of stay and cost (pyeloplasty only) in patients undergoing pyeloplasty and varicocelectomy using the LESS technique when compared to an age matched cohort of patients managed with the traditional laparoscopic approach. One pyeloplasty in the LESS group required conversion to open due to a small intra-renal pelvis. There were no immediate or short term post-operative complications; however, one patient experienced a decrease in renal function status post LESS pyeloplasty. Since all procedures were performed by a vastly experienced surgeon at a tertiary center, the generalizability of the results cannot be assessed. CONCLUSIONS: There are only a few series that have assessed the role of LESS in pediatric urological surgery. Although our experience is limited by a heterogeneous group of patients with a short follow-up period, the present cohort demonstrates the safety and feasibility of LESS. Further evaluation with randomized studies is required to better assess the role of LESS in pediatric urology.