Technique and outcomes of robotic-assisted retroperitoneal radical nephrectomy.

Background: Robotic retroperitoneal partial nephrectomy (rRPN) has numerous advantages over transperitoneal surgery, including direct access to the renal hilum and posterior tumors, and avoidance of the peritoneal cavity in patients with a hostile abdomen. Although the use of the retroperitoneal approach has increased over the last decade, there is little literature on robotic retroperitoneal radical nephrectomy (rRRN), which has similar benefits over the transperitoneal approach. The aim of this study was to describe our technique for robotic retroperitoneal nephrectomy (rRN) and assess its feasibility and outcomes at a high-volume center. Methods: A retrospective review of patients who underwent some form of rRN [rRRN, robotic retroperitoneal simple nephrectomy (rRSN), or robotic retroperitoneal nephroureterectomy (rRNU)] at a single institution between 2013 and 2023. Patient characteristics, operative data, and postoperative complication rates were assessed. The technique for rRN was detailed. Results: A total of 13 renal units in 12 patients were included for analysis (7 rRRN, 5 rRSN, 1 rRNU). Median patient age was 64.0 years, and median body mass index (BMI) was 36.0 kg/m2. Indications for retroperitoneal surgery were prior abdominal surgery in all patients, including three with bowel diversions, super morbid central obesity in two patients, and a large ventral hernia in one patient. Median operative time was 213 minutes and median estimated blood loss (EBL) was 85 cc. Median postoperative length of stay (LOS) was 3 days, and only one patient experienced a Clavien-Dindo grade ≥3 complication within 90 days of surgery. Conclusions: The retroperitoneal approach for robotic-assisted nephrectomy is feasible and associated with similar outcomes as the transperitoneal approach. This approach may prove beneficial in select patients with significant prior abdominal surgery including those who are morbidly obese.

Immediate gemcitabine bladder instillation following bladder closure during robotic-assisted radical nephroureterectomy: a multi-institutional report of feasibility and initial outcomes.

Background: Bladder recurrence after radical nephroureterectomy (RNU) is common and randomized data supports utilization of prophylactic intravesical mitomycin to reduce recurrence. Recently, gemcitabine has been shown to be safe and effective at reducing recurrence following transurethral resection of bladder tumors. We sought to evaluate the safety and efficacy of a single, intraoperative gemcitabine instillation immediately following bladder cuff closure during RNU, and to compare outcomes with non-gemcitabine intravesical chemotherapy agents. Methods: We retrospectively reviewed all patients from two high volume centers who underwent robotic-assisted RNU between 2016-2020 and received either 2 g intravesical gemcitabine immediately following bladder cuff closure or non-gemcitabine intravesical chemotherapies [40 mg mitomycin C (MMC) or 50 mg doxorubicin] at the beginning of the procedure. Clinicopathologic factors were compared between cohorts. Bladder recurrence rates were evaluated using the Kaplan-Meier method and log-rank test. Results: During RNU, 24 patients received gemcitabine and 31 patients received non-gemcitabine chemotherapy. In total, 35% (19/55) of patients experienced a bladder cancer recurrence. There was no significant difference in estimated bladder recurrence-free survival (bRFS) between gemcitabine and non-gemcitabine patient cohorts (P=0.64). By 12 months post-surgery, 25% of patients had experienced bladder recurrence. The estimated 1-year bladder RFS survival was 73% for gemcitabine and 76% for non-gemcitabine chemotherapy. Overall survival and cancer-specific survival did not differ between cohorts. No adverse events potentially attributable to the use of gemcitabine were noted within 30 days postoperatively. Conclusions: Gemcitabine instilled immediately following bladder cuff closure during RNU has similar bRFS rates compared to established chemotherapy agents instilled at the start of surgery.

Prospective Comparison of Opioid vs Nonopioid Pain Regimen After Ureteroscopy.

Objective: We wanted to evaluate two new treatment phases within our practice, including a nonopioid pathway, to determine the effect on opioid usage, health care utilization, and pain following ureteroscopy. Methods: Patients undergoing ureteroscopic lithotripsy were enrolled in a study utilizing text messaging to evaluate postoperative pain and opioid usage. Our historical postoperative pain regimen included #30 oxycodone. Patients in the N15 cohort were given improved counseling, preanesthesia acetaminophen, and #15 oxycodone. With further experience, narcotics were removed entirely from our postoperative care plan (N0) and replaced with a nonopioid multimodal regimen. Results: There were 61 and 58 patients in cohorts N15 and N0, respectively, with no difference in demographics, stone, or procedure details between each cohort. No difference in pain scores was detected between the N15 and N0 cohorts (p = 0.14). The median time to pain resolution was postoperative day (POD) 4 for cohort N15 and POD 3 for cohort N0 (p = 0.06). In the N0 cohort, nine patients required postoperative narcotics (15.5%; average of 2.4 pills/patient). There was no significant difference in emergency department visits, phone calls, or clinic visits (p = 0.17) between each cohort. Conclusions: Patients undergoing ureteroscopy have adequate postoperative pain control with a nonopioid treatment regimen, although some patients will still ultimately require narcotics.

Avoiding the Need for Bowel Anastomosis during Pelvic Exenteration-Urinary Sigmoid or Descending Colon Conduit-Short and Long Term Complications.

OBJECTIVE: To educate surgeons of distal colon urinary diversion as an alternative to ileal conduit. To assess perioperative outcomes of distal colon conduit in pelvic exenteration including conduit-related, gastrointestinal, infectious, metabolic, and wound complications within 30 days, 31-89 days, and greater than 90 days from the time of surgery. MATERIALS AND METHODS: Forty-one patients who underwent distal colon urinary diversion for malignancy, fistula, or neurogenic bladder were identified in our IRB approved database from 1/2007 to 7/2017. RESULTS: Twenty-six (63.4%) were male with mean age of 54.1 years. Complications were stratified by early (≤30 days), intermediate (31-89 days), and late (≥90 days). Within 30 days, 2 (4.9%) had partial small bowel obstructions requiring nasogastric tube (NGT) placement and total parenteral nutrition (TPN); 8 (19.5%) prolonged ileus with 6 (14.6%) requiring TPN and 5 (12.2%) requiring NGT placement; 1 (2.4%) enterocutaneous fistula; 1 (2.4%) conduit hemorrhage, 10 (24.4%) treated urinary tract infections (UTIs). Between 31 and 89 days, 1 patient (2.4%) had urinary conduit leak and 3 (7.3%) treated UTIs. At ≥90 days, 2 (4.9%) had partial small bowel obstructions requiring NGT placement, 4 (9.8%) ureterocolonic strictures and 1 (2.4%) parastomal hernia, 3 (7.3%) treated UTIs. Readmission rate in ≤30 days was 10 (24.4%), 31-89 days was 13 (31.7%), and 90+ days was 16 (39%). Long-term metabolic complications at ≥90 days included 16 (39%) with hypokalemia, 10 (24.4%) with hyperchloremia, and 14 (34.1%) with metabolic acidosis. CONCLUSION: Distal colon urinary conduit is a relatively safe and feasible option and obviates the need for small bowel anastomosis and possible associated complications.

The Impact of 5α-Reductase Inhibitor Use for Male Pattern Hair Loss on Men's Health.

PURPOSE OF REVIEW: Male pattern hair loss, mediated by dihydrotestosterone, is a common hair loss disorder, affecting over 50% of men over the age of 50. The 5-α reductase inhibitors, finasteride and dutasteride, are Food and Drug Administration-approved drugs for the treatment of this disorder. Several recent studies have reported adverse sexual and spermatogenic events among young men using 5-α reductase inhibitors, such as erectile dysfunction, decreased ejaculate volume, decreased libido, and infertility. In this review, we summarize and analyze the literature regarding the efficacy and safety of these medications, with an overall focus on men's health. RECENT FINDINGS: Finasteride for the treatment of male pattern hair loss was considered safe according to many previous clinical trials. However, these trials have been recently criticized for inadequate safety reporting. Comprehensive review of the current literature reveals that there is a disproportionately high number of men with 5-α reductase inhibitor-associated sexual dysfunction and infertility. Although uncommon, the use of 5-α reductase inhibitors is associated with serious and persistent sexual and reproductive side effects, such as erectile dysfunction, decreased ejaculate volume, decreased libido, and infertility.

Scrotal Ultrasound for Pain: Low Frequency of Absolute Surgical Indications.

OBJECTIVE: To examine the results of scrotal ultrasounds (US) conducted for scrotal or testicular pain and review the pathologic findings of orchiectomies done for lesions that were suspicious for malignancy on US. MATERIALS AND METHODS: We retrospectively reviewed the indications and findings of all scrotal US completed at our institution from 2002 to 2014. If a patient underwent an orchiectomy for an intratesticular lesion that was concerning for malignancy on US, the pathology report was also reviewed. RESULTS: There were 18,593 scrotal US performed, with 7,668 (41.2%) conducted for scrotal pain. Of the US performed for pain, 80.4% revealed benign or normal findings, and only 2.2% demonstrated a finding that is an absolute indication for surgery (intratesticular lesion suspicious for malignancy 0.8%, abscess 0.7%, torsion 0.6%, infiltrative process such as lymphoma 0.1%). For those patients undergoing an orchiectomy, 75% had malignancy on pathologic analysis. CONCLUSION: The majority of the 7668 US performed to evaluate scrotal or testicular pain reveal normal or benign findings. A low percentage demonstrates a finding that necessitates urgent or emergent surgery.

Update on the Diagnosis and Management of Renal Angiomyolipoma.

PURPOSE: Advances in minimally invasive therapies and novel targeted chemotherapeutics have provided a breadth of options for the management of renal masses. Management of renal angiomyolipoma has not been reviewed in a comprehensive fashion in more than a decade. We provide an updated review of the current diagnosis and management strategies for renal angiomyolipoma. MATERIALS AND METHODS: We conducted a PubMed(®) search of all available literature for renal or kidney angiomyolipoma. Further sources were identified in the reference lists of identified articles. We specifically reviewed case series of partial nephrectomy, selective arterial embolization and ablative therapies as well as trials of mTOR inhibitors for angiomyolipoma from 1999 to 2014. RESULTS: Renal angiomyolipoma is an uncommon benign renal tumor. Although associated with tuberous sclerosis complex, these tumors occur sporadically. Risk of life threatening hemorrhage is the main clinical concern. Due to the fat content, angiomyolipomas are generally readily identifiable on computerized tomography and magnetic resonance imaging. However, fat poor angiomyolipoma can present a diagnostic challenge. Novel research suggests that various strategies using magnetic resonance imaging, including chemical shift magnetic resonance imaging, have the potential to differentiate fat poor angiomyolipoma from renal cell carcinoma. Active surveillance is the accepted management for small asymptomatic masses. Generally, symptomatic masses and masses greater than 4 cm should be treated. However, other relative indications may apply. Options for treatment have traditionally included radical and partial nephrectomy, selective arterial embolization and ablative therapies, including cryoablation and radio frequency ablation, all of which we review and update. We also review recent advances in the medical treatment of patients with tuberous sclerosis complex associated angiomyolipomas with mTOR inhibitors. Specifically trials of everolimus for patients with tuberous sclerosis complex suggest that this agent may be safe and effective in treating angiomyolipoma tumor burden. A schema for the suggested management of renal angiomyolipoma is provided. CONCLUSIONS: Appropriately selected cases of renal angiomyolipoma can be managed by active surveillance. For those patients requiring treatment nephron sparing approaches, including partial nephrectomy and selective arterial embolization, are preferred options. For those with tuberous sclerosis complex mTOR inhibitors may represent a viable approach to control tumor burden while conserving renal parenchyma.

Novel use of carbon dioxide arteriography in renal artery pseudoaneurysm in patients with poor renal function.

Renal artery pseudoaneurysm (RAP) is a rare complication of partial nephrectomy, but is usually effectively managed with renal vessel embolisation. We report a particularly challenging case of a patient with chronic kidney disease (CKD) who developed a RAP following a laparoscopic heminephrectomy and was treated using superselective renal vessel coil embolisation with carbon dioxide (CO2) as the primary contrast agent for arteriographic localisation of the RAP and feeder artery. To the best our knowledge we report the first utilisation of CO2 arteriography in the definitive diagnosis and treatment of RAP following heminephrectomy in a patient with severe CKD.

Results of treatment of displaced supracondylar humeral fractures in children by percutaneous lateral cross-wiring technique.

Seventy children with displaced type II and III supracondylar fractures of the humerus were managed with percutaneous lateral cross-wiring technique from January 2006 to January 2007. There were 54 boys and 16 girls with a mean age of 6.1 +/- 3.07 years. All patients were operated within 24 h after trauma using the Dorgans percutaneous lateral cross-wiring technique. Patients were followed up for a mean period of 6.1 +/- 2.6 months and assessed both radiologically for union; and functionally and cosmetically according to Flynn's criteria. All patients achieved solid union. Functionally, all patients achieved satisfactory results, while cosmetically, 91.4% of patients had satisfactory results and 8.6% had unsatisfactory results. The most frequently occurring complications were minor pin tract infection in six patients, deep infection in two patients, and 32 patients suffered excessive granulation tissue formation mostly around the proximal pin. There was no iatrogenic neurological injury either for the ulnar or for the radial nerves. The obtained results and minor complications reported signify this technique as a viable treatment method for displaced type II and III supracondylar fractures in children.