Newly modified 'pseudo flap' without compromising vascularity to enhance repair of long distal ureteral loss: A retrospective analysis of a prospective database.

Objective: To present an alternative technique called pseudo-flap for reconstructing long ureteral defects as an alternative to Boari flap. Despite being used for more than 70 years by urologists for tension-free reconstruction of distal and mid-ureteral defects, the Boari flap exhibits high complication rates, with an average of 27% (range 5.5%-30.4%). These complications arise from compromised blood supply, attributed to incisions made on all three sides of the flap and dependence on the flap base as the sole source of blood supply. Methods: We retrospectively reviewed patients who underwent our modified technique by a single surgeon between 2008 and 2021. We used a semi-oblique cystotomy on the lowest part of the anterior and contralateral aspects of the bladder after complete release from adhesions and sacrificing the superior vesical pedicle, if necessary. The innovative part of the technique involved making short relaxing incisions at different levels on both sides of a pseudo-flap while pushing the bladder dome upward to reach the healthy ureter in a tension-free manner, followed by anastomosis with a non-refluxing or refluxing technique. Results: Fifteen patients underwent the pseudo-flap technique with a mean follow-up of 16.9 months. Four had prior radiation, three had hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis, and one had a ureteral stricture in a transplanted kidney. Eight procedures were performed during intraoperative consultations.Only one patient (7%) developed a major complication (Clavien-Dindo grade ≥2). This patient developed postoperative leak, and none developed obstructive hydronephrosis, suggesting stricture or flap ischemia. The mean length of the flap was 9.3 cm. Conclusion: Our pseudo-flap technique has lower complication rates than the traditional Boari flap. It is not technically challenging, minimally compromises blood supply and is thus especially suitable for complex, highly morbid patients with decreased tissue vascularity, such as those with prior radiation and peritoneal carcinomatosis.

Predicting the return of bladder function following vaginal native tissue repair using data from a suprapubic catheter regimen.

AIMS: To evaluate time to return of normal voiding function following native tissue vaginal reconstruction and evaluate risk factors for postoperative urinary retention (POUR). METHODS: A retrospective cohort analysis of women undergoing vaginal reconstruction and suprapubic catheter with standardized regimen for voiding trials. Postvoid residual <150 ml at 4 h post catheter clamping was used as surrogate marker for return of bladder function. Univariate and multivariate regression analyses were used to identify risk factors for return of bladder function >4 days after surgery. RESULTS: Between 2013 and 2018, 148 women underwent surgery, 124 were analyzed. Mean age was 67 years (±11.1), 62.9% (n = 78) had greater than or equal to stage 3 prolapse. Mean time to return of bladder function: 4.1 days (±3.1). Significant risk factors for >4 days to return of bladder function on univariate analysis included (mean ± SD): surgery length (150.4 min ±44.6) (odds ratio [OR], 1.24; confidence interval [CI], 1.12, 1.38); anesthesia length (228.1 min ±53.5) (OR, 1.12; CI: 1.04, 1.23); length of stay (2.2 days ±2.7) (OR, 2.43; CI: 1.11, 5.35); hysterectomy (OR, 3.10; CI: 1.39, 6.90); estimated blood loss (124.4 ml ±64.8) (OR, 1.39; CI: 1.04, 1.87). Postmenopausal status was protective (OR, 0.17; CI: 0.03, 0.92.). On multivariate analysis, significant findings were diabetes mellitus (OR, 0.18; CI: 0.04, 0.93) and surgery length (OR, 1.21; CI: 1.06, 1.38). CONCLUSIONS: Hysterectomy, surgical length and estimated blood loss were significantly associated with delayed return of bladder function after native tissue vaginal reconstruction. This data can help clinicians tailor postoperative voiding trials after failed initial attempt.

A New Gold Rush: A Review of Current and Developing Diagnostic Tools for Urinary Tract Infections.

Urinary tract infections (UTIs) are one of the most common infections in the United States and consequently are responsible for significant healthcare expenditure. The standard urine culture is the current gold standard for diagnosing urinary tract infections, however there are limitations of the test that directly contribute to increased healthcare costs. As a result, new and innovative techniques have been developed to address the inefficiencies of the current standard-it remains to be seen whether these tests should be performed adjunctly to, or perhaps even replace the urine culture. This review aims to analyze the advantages and disadvantages of the newer and emerging diagnostic techniques such as PCR, expanded quantitative urine culture (EQUC), and next generation sequencing (NGS).

Evaluation of Clinical Use and Cost-Effectiveness of a Flexible Cystoscope System with a Disposable Sheath: A Randomized Clinical Trial.

INTRODUCTION: Flexible cystoscopy is routinely performed as an outpatient procedure. The use of disposable sheaths can increase cystoscope life span and reduce staff costs. The primary end point of this study was to evaluate procedure related discomfort and pain, physician maneuverability, residual bioburden and reprocessing time. The secondary end point was to analyze the cost-effectiveness of a flexible cystoscope with a disposable sheath compared to a standard flexible cystoscope. METHODS: This randomized clinical trial was performed with women older than 18 years, with intact cognition and 7 days antibiotic-free who were referred to outpatient clinic for cystoscopy. Patients underwent cystoscopy with a standard flexible cystoscope or flexible cystoscope with disposable sheath. Urinalysis and culture were performed before and 14 days after cystoscopy. Patients filled out a pain/discomfort visual analog scale. Physicians filled out a 5-point Likert scale for the elements of ease of insertion, manipulation, optical quality and overall use. Reprocessing time and costs were compared between both cystoscopes. RESULTS: A total of 60 patients were included in the study, comprised of 30 who underwent standard flexible cystoscopy and 30 who underwent flexible cystoscopy with a protective sheath. Patient discomfort/pain was equivalent in both groups. The Likert scores were similar except for ease of insertion, which was higher with protective sheaths (p <0.02). Protective sheaths were associated with lower reprocessing time and costs (p <0.001). CONCLUSIONS: The use of protective sheaths effectively reduced procedure and staff related costs without causing any additional patient discomfort or pain. The learning curve of the sheathed scope may explain the difference reported by physicians regarding the ease of insertion.

Nephron-sparing management of Xanthogranulomatous pyelonephritis presenting as spontaneous renal hemorrhage: a case report and literature review.

BACKGROUND: Xanthogranulomatous pyelonephritis (XGP) is an uncommon infectious disease of the kidney known to mimic other renal maladies. A rare presentation of this uncommon disease is spontaneous renal hemorrhage (SRH). CASE PRESENTATION: We report a case of XGP in a 58 year old woman who presented with abdominal pain, hematuria, and radiating left flank pain. CT scan was felt to be consistent with perirenal hemorrhage abutting a fat-containing renal mass. The patient was eventually taken to surgery for left partial nephrectomy. Pathology report returned as XGP, and the patient has no complications from this disease process at 8 month follow up. CONCLUSION: Our search of the literature shows XGP presenting as SRH to be a rare clinical entity. Furthermore, this is the first such case managed with a nephron-sparing approach. The "great imitator" XGP should be added to the differential for patients presenting with spontaneous renal hemorrhage.

A Rare Case Report of Hydronephrosis and Acute Kidney Injury Secondary to Gonadal Vein Thrombosis in a Young Male.

Background: Gonadal vein thrombosis (GVT) has been reported in association with malignancy and pelvic inflammatory conditions. Patients who develop GVT often require systemic anticoagulation to reduce the risk of pulmonary embolism and other local and distant thromboembolic effects. As the gonadal vein courses from the pelvis toward its outlet in the upper abdomen, its intimate relationship to the ureter in the setting of vascular pathology may pose a risk for urinary obstruction in the adult. We are reporting a rare case of GVT leading to ureteral obstruction and acute kidney injury (AKI) in a young otherwise healthy male and provide a review of similar literature. Case Presentation: We describe a case of an otherwise healthy 29-year-old African American adult male presenting with acute diverticulitis and associated left GVT with no evidence of hypercoagulability, leading to ureteral obstruction, hydronephrosis, and AKI. Treatment with ureteral stent placement, endovascular intervention, and systemic anticoagulation led to resolution of his condition. Conclusion: This report details a rare case of confirmed GVT in an adult male with resultant urinary obstruction. Decompression of the collecting system and treatment of the significant venous obstruction with surgical intervention, combined with medical systemic anticoagulation, were effective in reversing the underlying cause.

The Effect of Resident Involvement in Pelvic Prolapse Surgery: A Retrospective Study From a Nationwide Inpatient Sample.

OBJECTIVE: The primary aim of this study was to assess the effect of resident involvement on perioperative complication rates in pelvic organ prolapse surgery using the National Surgical Quality Improvement database. METHODS: All pelvic organ prolapse operations from 2006 to 2012 were identified and dichotomized by resident participation. Preoperative characteristics and 30-day perioperative outcomes were compared using χ and Student t test. To control for nonrandomization of cases, propensity scores representing the probability of resident involvement as a function of a case's comorbidities were calculated. They were then divided into quartiles, and because of equal probabilities for the first and second quartiles, 3 groups were created (Q1/2, Q3, and Q4), followed by substratification and analysis. As a control, complications of transurethral resection of prostate and nephrectomy were dichotomized by resident involvement. RESULTS: We identified 2637 cases. Resident involvement was associated with increased postoperative urinary tract infections, perioperative complications, and procedure length. After stratification by propensity scoring, the following unique findings occurred in each group: in the first group, resident involvement was associated with increased rates of readmission, pulmonary embolism, and sepsis; in the second and third groups, resident involvement was associated with increased rates of superficial surgical site infection. Resident involvement in nephrectomy observed increased perioperative complications and procedural length. In prostate resection, increased procedure lengths and decreased postoperative length of stay were observed. CONCLUSIONS: Resident involvement in pelvic organ prolapse surgery was associated with an increased risk of adverse outcomes. A similar effect was seen with nephrectomy but not with a more simple endoscopic urologic procedure.

Diagnostic accuracy of nucleic acid amplification tests (NAATs) in urine for genitourinary tuberculosis: a systematic review and meta-analysis.

BACKGROUND: Genitourinary tuberculosis is the third most common form of extrapulmonary tuberculosis. Diagnosis is difficult because of unspecific clinical manifestations and low accuracy of conventional tests. Unfortunately, the delayed diagnosis impacts the urinary tract severely. Nucleic acid amplification tests yield fast results, and among these, new technologies can also detect drug resistance. There is lack of consensus regarding the use of these tests in genitourinary tuberculosis; we therefore aimed to assess the accuracy of nucleic acid amplification tests in the diagnosis of genitourinary tuberculosis and to evaluate the heterogeneity between studies. METHODS: We did a systematic review and meta-analysis of research articles comparing the accuracy of a reference standard and a nucleic acid amplification test for diagnosis of urinary tract tuberculosis. We searched Medline, EMBASE, Web of Science, LILACS, Cochrane Library, and Scopus for articles published between Jan 1, 1990, and Apr 14, 2016. Two investigators identified eligible articles and extracted data for individual study sites. We analyzed data in groups with the same index test. Then, we generated pooled summary estimates (95% CIs) for sensitivity and specificity by use of random-effects meta-analysis when studies were not heterogeneous. RESULTS: We identified eleven relevant studies from ten articles, giving information on PCR, LCR and Xpert MTB/RIF tests. All PCR studies were "in-house" tests, with different gene targets and had several quality concerns therefore we did not proceed with a pooled analysis. Only one study used LCR. Xpert studies were of good quality and not heterogeneous, pooled sensitivity was 0·87 (0·66-0·96) and specificity was 0·91 (0·84-0·95). CONCLUSION: PCR studies were highly heterogeneous. Among Xpert MTB/RIF studies, specificity was favorable with an acceptable confidence interval, however new studies can update meta-analysis and get more precise estimates. Further high-quality studies are urgently needed to improve diagnosis of genitourinary tuberculosis. PROTOCOL REGISTRATION: PROSPERO CRD42016039020.

Penile fracture epidemiology, diagnosis and management in Iran: a narrative review.

Penile fracture (PF) is considered an emergency in urology. In the literature there are some case series reporting considerable incidence of PF in some parts of Iran. There are no accurate data about the incidence of PF all around Iran. Although it may be uncommon in other parts of the country and in the other countries, it can also be underreported. There are some challenges in diagnosis, management, and also reporting of these cases. In this review of Iranian medical literature, we searched for penile fracture and penile injury keywords in Medline, Scopus, SID, Google and Persian medical journals. We reviewed the status of epidemiology, etiology, diagnosis, management and complications of PF in different parts of Iran in the published literature. To collect more accurate data, we also performed a questionnaire-based study with sending questionnaires by emails to 700 urologists throughout the country with 14% response rate. Incidence of PF varies significantly in different parts of Iran. Western province of Kermanshah has a significantly higher rate of PF. Adding data from different regions of Iran, we calculated that incidence of PF in Iran can be estimated between 1.14 to 10.48 per 100,000 of male populations, most probably closer to lower end. Although the incidence of PF varies significantly in different geographical areas, urologists practicing in Iran on average may encounter a PF patient every 3.5 months. To diagnose PF, majority of reviewed studies relied on history and clinical examination and did not recommend imaging except in patients with possible urethral injuries. Immediate surgical intervention can make good functional results with low morbidity and short hospital stay. Delayed surgical intervention and observational management approaches need large population studies with long term follow up.

Short-term complications associated with the use of transvaginal mesh in pelvic floor reconstructive surgery: Results from a multi-institutional prospectively maintained dataset.

AIMS: Vaginal reconstructive surgery can be performed with or without mesh. We sought to determine comparative rates of perioperative complications of native tissue versus vaginal mesh repairs for pelvic organ prolapse. METHODS: Using the National Surgical Quality Improvement Program (NSQIP) database, we concatenated surgical data from vaginal procedures for prolapse repair, including anterior and posterior colporrhaphy, paravaginal defect repair, enterocele repair, and vaginal colpopexy using Current Procedural Terminology (CPT) coding. We stratified this data by the modifier associated with mesh usage at the time of the procedure. We then compared 30-day perioperative outcomes, postoperative complications (bleeding, infection, etc), and readmission rates between women with and without mesh-based repairs. RESULTS: We identified 10 657 vaginal reconstructive procedures without mesh and 959 mesh-based repairs from 2009 through 2013. Patients undergoing mesh repair were more likely to experience at least one complication than native tissue repair (9.28% vs 6.15%, P < 0.001), with the overall complication rate also being higher in the mesh group (11.37% vs 9.39%, P = 0.03). Procedures with mesh had a higher rate of perioperative bleeding requiring transfusion than native tissue repair (2.3% vs 0.49%, P < 0.001), and organ surgical site infection (SSI) (0.52% vs 0.17%, P = 0.02). There were no significant differences in rates of readmission, superficial, or deep SSIs, pneumonia, urinary tract infection, sepsis, or renal failure. CONCLUSIONS: The use of vaginal mesh for pelvic organ prolapse repair appears to result in a higher rate of perioperative complications than native tissue repair. Patients undergoing these procedures should be counselled preoperatively concerning these risks.

Evaluation of Renal Function after Percutaneous Nephrolithotomy-Does the Number of Percutaneous Access Tracts Matter?

PURPOSE: Renal function following percutaneous nephrolithotomy has long been a concern to urologists, especially in the setting of multi-tract access. We determined whether the risk of renal injury after multi-tract percutaneous nephrolithotomy was greater than after a single access approach. MATERIALS AND METHODS: We retrospectively reviewed the records of 307 consecutive patients treated with percutaneous nephrolithotomy from 2011 to 2012 at Wake Forest Health. Perioperative (99m)Tc-mercaptoacetyltriglycine nuclear renogram parameters along with serum creatinine values were assessed within 1 year of the procedure. Patients were stratified by single access vs multi-access (2 or more). RESULTS: We identified 110 cases in which renography was done before and after percutaneous nephrolithotomy. A total of 74 patients (67.3%) underwent single access percutaneous nephrolithotomy while 36 (32.7%) underwent multi-access percutaneous nephrolithotomy. Serum creatinine did not significantly differ between the 2 cohorts postoperatively (p = 0.09). There was a significant 2.28% decrease in renal function based on mercaptoacetyltriglycine nuclear renogram results after percutaneous nephrolithotomy of the affected kidney in patients with multiple accesses (p <0.01). This relationship was not observed when patients were stratified by multiple comorbidities associated with nephrolithiasis. CONCLUSIONS: Multi-access percutaneous nephrolithotomy is associated with a small reduction in the function of the targeted kidney compared to a single access approach.

Kidney transplantation, bioengineering and regeneration: an originally immunology-based discipline destined to transition towards ad hoc organ manufacturing and repair.

Kidney transplantation (KT), as a modality of renal replacement therapy (RRT), has been shown to be both economically and functionally superior to dialysis for the treatment of end-stage renal disease (ESRD). Progress in KT is limited by two major barriers: a) a chronic and burgeoning shortage of transplantable organs and b) the need for chronic immunosuppression following transplantation. Although ground-breaking advances in transplant immunology have improved patient survival and graft durability, a new pathway of innovation is needed in order to overcome current obstacles. Regenerative medicine (RM) holds the potential to shift the paradigm in RRT, through organ bioengineering. Manufactured organs represent a potentially inexhaustible source of transplantable grafts that would bypass the need for immunosuppressive drugs by using autologous cells to repopulate extracellular matrix (ECM) scaffolds. This overview discusses the current status of renal transplantation while reviewing the most promising innovations in RM therapy as applied to RRT.

Pheochromocytoma diagnosed pathologically with previous negative serum markers.

BACKGROUND AND OBJECTIVES: Patients presenting with adrenal masses require workup with catecholamine or metabolite measurements to rule out pheochromocytoma. There is a select portion of patients with marker negative pheochromocytoma. The aim of this study is to compare patient characteristics and presentations between marker positive and marker negative tumors. METHODS: We performed an IRB-approved retrospective chart review of 88 cases of pheochromocytoma excised at our institution from 1995 to 2013. We considered any abnormal elevation in diagnostic test to be marker-positive. RESULTS: Seventy-eight cases had laboratory results available. Among these, seven had no elevations in laboratory testing. There was no difference in age or tumor size, but marker-negative patients had higher BMI than marker-positive patients. Marker negative patients were more likely to present with vertigo/dizziness (P = 0.003). Neither was more likely to have a genetic syndrome associated with risk of pheochromocytoma. CONCLUSIONS: Marker-negative pheochromocytoma is uncommon, representing 9% of cases in our series. Of patients with adrenal masses or presentation suggesting catecholamine excess with normal labs, those with vertigo/dizziness may warrant a metaiodobenzylguanidine scan or repeat testing to avoid missing pheochromocytoma. Clinicians may need a high degree of suspicion for pheochromocytoma in patients with negative testing and elevated BMI.

Infrequent Reservoir-Related Complications of Urologic Prosthetics: A Case Series and Literature Review.

INTRODUCTION AND AIM: Complications related to inflatable penile prosthesis (IPP) and artificial urinary sphincter (AUS) reservoirs are rare, potentially life threatening, and poorly described in the literature. As more devices are implanted, the incidence of reservoir-related complications may increase, and it will be important to recognize the relevant signs and symptoms. METHODS AND MAIN OUTCOME MEASURES: We present a case series of reservoir-related complications presenting to our institution for treatment. We also reviewed all accounts of reservoir-related complications within the urologic literature. RESULTS: Three cases of reservoir-related complications are presented. Case 1 involves erosion of an intact AUS reservoir into the cecum of a patient with a history of myelomeningocele and bladder augmentation. Case 2 involves an IPP reservoir causing vascular compression, resulting in open exploration and repositioning of the reservoir. Case 3 involves intraperitoneal migration of a retained IPP reservoir to a subhepatic area, which was then removed laparoscopically. Literature review yielded descriptions of eight cases of intestinal complications, five cases of vascular complications, but zero reports of migration to a subhepatic area. Other notable complications include 20 reported cases of reservoir erosion into the bladder and inguinal herniation of the reservoir. CONCLUSION: Complications involving urologic prosthesis reservoirs, although rare, can have serious implications for patients. A high index of suspicion and familiarity with treatment options is required in order to allow timely diagnosis and appropriate treatment. Patients with prior major abdominal surgeries seem to be more prone to intestinal complications of reservoirs and warrant special concern. Cui T, Terlecki R, and Mirzazadeh M. Infrequent reservoir-related complications of urologic prosthetics: A case series and literature review. Sex Med 2015;3:334-338.

Significance of urinary tract involvement in patients treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

BACKGROUND: Urinary tract involvement in patients with peritoneal surface disease treated with cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) often requires complex urologic resections and reconstruction to achieve optimal cytoreduction. The impact of these combined procedures on surgical outcomes is not well defined. METHODS: A prospective database of CRS/HIPEC procedures was analyzed retrospectively. Type of malignancy, performance status, resection status, hospital and intensive care unit stay, morbidity, mortality, and overall survival were reviewed. RESULTS: A total of 864 patients underwent 933 CRS/HIPEC procedures, while 64 % (550) had preoperative ureteral stent placement. A total of 7.3 % had an additional urologic procedure without an increase in 30-day (p = 0.4) or 90-day (p = 1.0) mortality. Urologic procedures correlated with increased length of operating time (p < 0.001), blood loss (p < 0.001), and length of hospitalization (p = 0.003), yet were not associated with increased overall 30-day major morbidity (grade III/IV, p = 0.14). In multivariate analysis, independent predictors of additional urologic procedures were prior surgical score (p < 0.001), number of resected organs (p = 0.001), and low anterior resection (p = 0.03). Long-term survival was not statistically different between patients with and without urologic resection for low-grade appendiceal primary lesions (p = 0.23), high-grade appendiceal primary lesions (p = 0.40), or colorectal primary lesions (p = 0.14). CONCLUSIONS: Urinary tract involvement in patients with peritoneal surface disease does not increase overall surgical morbidity. Patients with urologic procedures demonstrate survival patterns with meaningful prolongation of life. Urologic involvement should not be considered a contraindication for CRS/HIPEC in patients with resectable peritoneal surface disease.

Gas-containing renal stones: findings from five consecutive patients.

OBJECTIVE: To describe the clinical course, microbiology, and metabolic findings of 5 patients presenting to our institution with gas-containing renal stones. MATERIALS AND METHODS: During a 20-month period beginning in 2009, 5 patients were identified by computed tomography scanning to harbor gas-containing renal calculi. Despite similar imaging and referral practice patterns, no such cases had been seen at our institution in the preceding 20 years. The records of these patients were reviewed to better characterize this unique condition. RESULTS: All 5 subjects were premenopausal women. One patient presented with urosepsis and 4 presented with flank pain. All had urinary tract infections, and Escherichia coli was isolated from a voided urine specimen in 3. Stone culture was positive in 2 and was concordant with the voided specimen in 1. The stones were solitary in 4 and multiple in 1 patient. All the stones were composed of calcium phosphate. Of the 5 patients, 3 had pure calcium phosphate stones and 2 had stones with calcium oxalate monohydrate components. Also, 3 subjects had diabetes mellitus, 3 had hypertension, and 1 had a history of gout. Two subjects underwent 24-hour urine metabolic testing, and abnormalities were identified in both. All patients were rendered stone free: 4 with percutaneous nephrostolithotomy and 1 using robotic pyelolithotomy. CONCLUSION: Gas-containing renal stones are rare but might be increasing in prevalence. The pathophysiology is unknown but is most likely influenced by a combination of metabolic and infectious factors.

Effects of drinking water quality on urinary parameters in men with and without urinary tract stones.

OBJECTIVE: There is some controversy regarding the impact of water hardness on stone risk. Our study addresses this issue in a controlled setting. MATERIAL AND METHODS: Fifteen stone-former (SF) and 14 non-stone-former (NSF) males participated in this study in 3 intervals of 2 days each. Subjects collected a 24-hour urine sample while consuming a self-selected diet. They were then administered controlled diets. During the first 2 days, patients consumed water of minimal hardness (WMH), followed by tap water (TW) with moderate hardness on days 3 and 4, and mineral water (MW) on the final 2 days. Calcium (Ca), phosphorus, uric acid, oxalate, citrate, magnesium (Mg), sodium, potassium, and creatinine (Cr) content were measured in 24-hour urine samples on days 2, 4, and 6. RESULTS: Differences in water hardness and analytes were statistically significant among the different water types (P < .05). Urinary output in both groups increased during intervention with all 3 varieties of water (P < .05). Specific gravity of urine decreased in both groups drinking WMH and TW (P < .05) but not with MW. Mg/g Cr level was higher in NSF at baseline (P < .01), WMH (P < .05), and TW (P < .05). With the increase in drinking water hardness, Ca/g Cr ratio increased in SF but not in NSF (P < .05). CONCLUSIONS: NSF had significantly higher urinary Mg/g Cr excretion rate before intervention than SF (P < .01). Increasing drinking water hardness while controlling for all other factors increased Ca/g Cr ratio in SF, rendering them at least theoretically more inclined to stone formation.

Multibacterial growth from a surgical renal stone culture: a case report and literature review.

Urinary calculi may harbor bacteria, and this may lead to deleterious events during stone fragmentation and removal. The isolation of such bacteria from surgically extracted calculi allows for the specific tailoring of antimicrobial therapy. Here, we describe a case involving percutaneous stone removal from which the stone culture demonstrated growth of five different microorganisms. The results of this culture prompted a change in the antibiotic coverage, resulting in a more targeted treatment and improved patient care.

Penile sclerosing lipogranulomas and disfigurement from use of "1Super Extenze" among Laotian immigrants.

INTRODUCTION: Subcutaneous penile injection of various oils for penile augmentation has been described among men in Laos. We have now treated three Laotian immigrants with penile disfigurement secondary to sclerosing lipogranulomas, also known as paraffinoma, induced by injection of a mineral oil compound marketed as "1Super Extenze," which they purchased in the United States. AIM: This series describes the clinical course and management of complications associated with the use of "1Super Extenze" in three Laotian men. METHODS: Surgeons excised all grossly affected tissue and performed reconstruction using skin grafting, Z-plasty, and tissue advancement, respectively. Tissue from the penile shaft of each patient and a local lymph node in one patient was examined microscopically. Mass spectroscopy was performed on an aliquot of "1Super Extenze." MAIN OUTCOME MEASURES: Urinary function, sexual function, and cosmesis of the three reported cases, chemical composition of "1Super Extenze," and microscopic analysis of penile and regional lymphatic tissue. RESULTS: Short-term cosmetic and functional outcomes were acceptable after surgical intervention. Histologic findings consistent with sclerosing lipogranulomas were seen in specimens from affected subcutaneous and lymphatic tissue. "1Super Extenze" proved to be composed of mineral oil with tocopherol acetate (vitamin E). CONCLUSION: Injection of "1Super Extenze" into the penile shaft results in sclerosing lipogranulomas, which can cause severe sexual and urinary complications. Surgical resection of all grossly involved tissue with appropriate reconstruction can mitigate these problems. This series supports previous recommendations in the literature that men should avoid the use of non-medical foreign bodies and fillers as means of penile augmentation.