Large para-testicular intra-scrotal malignant peripheral nerve sheath tumor managed with radical penectomy: A case report.

Neurofibromatosis 1 is a relatively rare genetic disease characterized by widespread neurofibromas originating from the peripheral nervous system. Most growths are benign, but some carry a risk of transformation to malignant peripheral nerve sheath tumors. Although these growths can be found anywhere in the body, they are rarely found in the male external genitalia. This report discusses a case of a 25-year-old male patient with neurofibromatosis 1 presenting with a scrotal mass found to have a very large para-testicular intra-scrotal malignant peripheral nerve sheath tumor that required testicle-sparing radical penectomy.

Association between the lengths of excised obstructed vas deferens segments at the time of vasovasostomy and surgical outcomes.

OBJECTIVE: This study aimed to determine whether the length of the excised obstructed vas deferens at vasovasostomy (VV) performed for fertility is associated with semen parameters and/or pregnancy outcomes postoperatively. MATERIAL AND METHODS: The patients who underwent a VV at our institution from September 2004 to December 2018 were contacted via questionnaire and a chart review was performed. Linear and logistic regression models were used to determine the associations between the length of the obstructed vas deferens removed and postoperative outcomes including sperm concentration, motility, and successful pregnancy after reversal. RESULTS: A total of 83/170 questionnaires were returned. After exclusions, a total of 35 patients were included for analysis. The mean age of the patients at the time of surgery was 40.1 years and the mean time since vasectomy 9.3 years. The mean length of the obstructed vas deferens removed during VV was 2.25 cm. The longer the vas deferens segments removed, the more significant was the increase in sperm motility at 3 and 9 months postoperatively (p=0.011 and 0.008, respectively), but decreased sperm motility at 6 months (p=0.029). In 75.9% of the patients, sperm was present postoperatively, 23.2% achieved pregnancy through natural conception, and 55.8% achieved pregnancy using assisted reproductive techniques. There was no significant relationship between the length of the vas deferens removed and sperm concentration or pregnancy achieved after surgery. CONCLUSION: In this cohort, the length of the excised obstructed vas deferens at VV was associated with improved sperm motility at 3 and 9 months postoperatively but not with pregnancy outcomes.

Cell cycle progression score has potential prognostic value for stage T1 renal cell carcinomas.

BACKGROUND: There is an ongoing effort to identify a biomarker which predicts metastatic progression of renal cell carcinoma (RCC). OBJECTIVE: To evaluate the utility of the cell cycle progression (CCP) score biomarker in predicting metastasis in RCC after local resection of pathologic T1 disease. DESIGN, SETTING, AND PARTICIPANTS: Pathologic T1 tumors at the University of Iowa were reviewed in patients who had a radical or partial nephrectomy between 1995 and 2010. Patients with known or suspected metastasis, who had received chemotherapy, or who developed metastasis within 60 days of surgery were excluded. Final analysis included 163 patients with RCC who developed metastasis or a new primary within 5 years after surgery or had been followed for 5 years without developing metastasis. INTERVENTION(S): Expression levels of 31 cell cycle genes and 15 control genes from the tumor were measured and reported as a CCP score. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: The sensitivity, specificity, positive predictive value, and negative predictive value for the development of a metastasis or new primary within 5 years of resection was calculated for varying CCP score cutoffs. RESULTS AND LIMITATIONS: A total of 4 (2.5%) patients developed metastasis and 7 (4.3%) developed a new primary renal tumor. A CCP score of >-0.25 had a 100% sensitivity and 43% specificity for predicting metastatic progression. A CCP score of >-0.7 had a 100% sensitivity and 20% specificity for predicting the development of a new renal primary. CONCLUSIONS: The CCP score has potential prognostic value in predicting metastatic progression and might be a useful tool for the management of patients with RCC. PATIENT SUMMARY: In this study we looked at the utility of a particular gene expression profile from kidney tumors. We found that this gene expression test has the potential to identify tumors at risk of metastasis and thus could be a useful tool in the management of patients with kidney tumors.

Elderly patients undergoing cystectomy, comparing preoperative American Society of Anesthesiology and Eastern Cooperative Oncology Group scores and operative approaches.

OBJECTIVE: To evaluate preoperative scoring systems and operative management and their relation to complications in patients older than 75 years undergoing cystectomy at two academic institutions. METHODS: In total, 212 patients aged 75-95 years with muscle invasive bladder cancer underwent cystectomy at the University of Utah and Central Hospital of Bolzano, Italy. The rates of Grade 3 Clavien-Dindo complications and above in radical cystectomy patients (n = 199) were compared using Eastern Cooperative Oncology Group Scores and American Society of Anesthesiologists Physical Status Classification. The rates of Grade 3 Clavien-Dindo complications and above were also compared by urinary diversion type. Logistic regression was used to control for source institution. RESULTS: In total, 199 cases were included in the primary analysis. Neither of the preoperative scoring systems were predictive for identification of radical cystectomy patients with ⩾Grade 3 Clavien-Dindo complications. In secondary analysis (n = 212, including partial cystectomy), none of the urinary diversion types associated with radical cystectomy had a significantly different rate of complications. However, partial cystectomy (n = 13) had a significantly lower rate of complications. CONCLUSION: Complication rates among elderly patients undergoing cystectomy for muscle invasive bladder cancer were very high. For patients who are approved for surgery after the history and physical exam, none of our objective metrics adequately predicted operative risk. A unique diversion procedure described by the Bolzano group, uretero-ureterocutaneostomy, had equivalent complication rates to the more common diversion procedures. It also appears based on outcomes in this cohort that partial cystectomy is a particularly favorable option within the elderly population in terms of perioperative morbidity.

Optimizing Nutrition Prior to Radical Cystectomy.

PURPOSE OF REVIEW: Malnutrition in a prevalent problem in patients undergoing radical cystectomy. Preoperative malnutrition has been shown to contribute to increased rates of postoperative complications. Given the significant morbidity and mortality of the procedure of radical cystectomy, there is potential for improvement in patient outcomes by nutritional intervention. RECENT FINDINGS: Prospective studies have demonstrated a reduction in postoperative infection rates in patients who receive supplemental immunonutrition prior to major surgery including radical cystectomy. These initial evaluations of nutritional optimization show significant potential for improved outcomes. Additionally, several studies using enhanced recovery after surgery protocols, which include a preoperative nutritional component, have shown a benefit in reducing length of stay. Emerging literature has shown the benefits of preoperative immunonutrition in improving postoperative outcomes of radical cystectomy. However, further work is needed to determine the best mechanism to optimize nutrition prior to radical cystectomy.

A 26-Year-Old Male with a 14-Year History of Left Intermittent Testicular Torsion Treated with Self-Manual Reduction.

Intermittent testicular torsion presents with recurrent episodes of severe unilateral testicular pain with resolution of symptoms between episodes. We present a case of a 26-year-old man with a 14-year history of intermittent testicular pain presenting to the urology clinic for elective surgical evaluation. He reported monthly symptoms for many years and had learned to manually reduce the torsion with each episode. Diagnosis of intermittent testicular torsion was made based on patient history and treatment with bilateral orchiopexy resulted in complete symptom resolution and without any loss of testicular function.

Use of a polytetrafluoroethylene (GORE-TEX) bolster to close the renal parenchymal defect during open partial nephrectomy.

INTRODUCTION: Numerous surgical techniques have been described to facilitate closure of the renal parenchymal defect. We sought to describe the operative technique and define the safety and efficacy of using an expanded polytetrafluoroethylene (GORE-TEX; WL Gore and Associates, Flagstaff, AZ) bolster to aid in closure of the renal parenchymal defect at the time of open partial nephrectomy (OPN). TECHNICAL CONSIDERATIONS: A retrospective review of 175 patients who underwent an OPN using an expanded polytetrafluoroethylene (ePTFE) bolster at the Huntsman Cancer Hospital, University of Utah and Salt Lake City Veterans Affairs Medical Center from March 2005 to February 2013 was conducted. Postoperative complications occurring within 90 days were graded using the Clavien grading system. CONCLUSION: Overall, 57 patients (32.6%) experienced a postoperative complication. Fifteen patients (8.5%) had a Clavien ≥ grade-III complication. Ten patients (5.7%) received blood transfusions. Urine leak requiring intervention occurred in 2 patients (1.1%). Delayed hemorrhage requiring nephrectomy and pseudoaneurysm formation were rare, occurring in 1 patient each (0.6%). Infection of the ePTFE material occurred in 2 patients (1.1%). In both cases, it was explanted without requiring nephrectomy. The use of an ePTFE bolster is an effective and safe method of closing the renal parenchymal defect after OPN with an acceptable 90-day postoperative complication rate and a low risk of infection.

Procedures needed to maintain functionality of adult continent catheterizable channels: a comparison of continent cutaneous ileal cecocystoplasty with tunneled catheterizable channels.

PURPOSE: We compared the outcomes of various adult continent catheterizable channels in a multi-institutional setting. MATERIALS AND METHODS: We retrospectively reviewed the records of all adults who underwent construction of a continent catheterizable channel at our 4 institutions from 2004 to 2013 and who had at least 6 months of followup. Patients were stratified by channel type, including continent cutaneous ileal cecocystoplasty or tunneled cutaneous channel, eg appendicovesicostomy, Monti channel, etc. The primary study outcome was the need for a secondary procedure to correct stomal leakage, catheterizable channel obstruction or stomal stenosis. Secondary outcomes were patient reported leakage and 30-day postoperative complications. We used Firth logistic regression to control for the heterogeneity induced by multiple institutions. RESULTS: A total of 61 patients were included in study, of whom 31 underwent continent cutaneous ileal cecocystoplasty. Mean age was 41.4 years (range 22 to 76). Median followup was 16 months. More patients with a tunneled channel required a secondary procedure than those with cecocystoplasty (15 of 30 or 50% vs 4 of 31 or 13%, OR 6.4, 95% CI 1.8-28). The total number of required secondary procedures was also greater for tunneled channels than for cecocystoplasty (27 vs 4). Of patients with cecocystoplasty 29% reported stomal leakage compared with 43% of those with a tunneled channel (p = 0.12). A high rate of postoperative complications was observed regardless of technique, including 40% for channels and 51.7% for cecocystoplasty. CONCLUSIONS: Patients with continent cutaneous ileal cecocystoplasty undergo fewer interventions to maintain the catheterizable channel than patients with a tunneled continent catheterizable channel.