Metastatic clear cell renal cell carcinoma to the forearm without identifiable primary renal mass.

Kidney cancer is the ninth most common malignancy in the United States. Most kidney cancers are clear cell renal cell carcinoma (RCC) and arise as solid tumors from kidney parenchyma. In the setting of metastatic disease, a primary renal tumor is usually identified, and metastases are often to lung, bone, liver, and brain. Metastatic RCC without an identifiable solid kidney tumor is exceedingly rare. We report the case of a 52 year old male with a rare cutaneous RCC metastasis without an identifiable primary renal tumor.

Sports-related testicular injuries and the use of protective equipment among young male athletes.

OBJECTIVE: To survey young male athletes to determine the self-reported prevalence of sports-related testicular injuries and use of protective equipment among adolescents and young adults. METHODS: A self-administered questionnaire was distributed to male students at local high schools and colleges. Respondents were asked about personal and team member usage of athletic cups and history of testicular injuries. Returned surveys were analyzed for descriptive statistics and compared between high school and college respondents. RESULTS: Approximately 1700 surveys were distributed and 731 returned. The mean age of all respondents was 17.7 years. Across all sports, 18% of athletes experienced a testicular injury during sports and 36.4% observed injuries in team members, whereas only 12.9% of respondents reported wearing athletic cups. The prevalence of testicular injuries for lacrosse, wrestling, baseball, and football was 48.5%, 32.8%, 21%, and 17.8%, respectively. Of athletes reporting a prior injury, 20.1% reported that they wear a cup now. Rates of athletic cup usage were significantly less for college baseball, football, and all respondents compared with their high school counterparts. CONCLUSION: Previously reported rates of testicular injury with sports participation may underestimate the prevalence of these injuries among adolescent and young adult athletes among whom testicular protective equipment is infrequently used.

Solitary Candida albicans Infection Causing Fournier Gangrene and Review of Fungal Etiologies.

Polymicrobial bacterial infections are commonly found in cases of Fournier gangrene (FG), although fungal growth may occur occasionally. Solitary fungal organisms causing FG have rarely been reported. The authors describe a case of an elderly man with a history of diabetes who presented with a necrotizing scrotal and perineal soft tissue infection. He underwent emergent surgical debridement with findings of diffuse urethral stricture disease and urinary extravasation requiring suprapubic tube placement. Candida albicans was found to be the single causative organism on culture, and the patient recovered well following antifungal treatment. Fungal infections should be considered as rare causes of necrotizing fasciitis and antifungal treatment considered in at-risk immunodeficient individuals.

Three cases of subcutaneous granuloma annulare of the penis: a rare presentation of a common disease.

OBJECTIVE: To describe three patients who presented to a single institution within four years of each other with isolated granuloma annulare of the penis. Granuloma annulare is an inflammatory disease of the dermis that can affect men of any age including childhood. Granuloma annulare of the penis is a remarkably uncommon presentation with only 12 cases previously reported. METHODS: A retrospective review of pathologic records was conducted confirming three cases of penile granuloma annulare diagnosed at our institution. RESULTS: The three cases are described in detail including the history, presentation, histological findings and treatment of each patient. The clinical variants, characteristic histology, classic clinical presentation, differential diagnosis and recurrence following surgery of granuloma annulare are reviewed. CONCLUSION: We describe three individuals from a single institution with isolated granuloma annulare of the penis suggesting this condition is more common than previously thought. Patients with penile granuloma annulare may present to practicing urologists and it is important to be familiar with this idiopathic subcutaneous disorder in order to avoid unnecessary aggressive surgery.

Robotic-assisted laparoscopic approach for posterior bladder neck dissection and placement of pediatric bladder neck sling: initial experience.

OBJECTIVES: Bladder neck sling cystourethropexy is a common procedure used to correct intrinsic sphincter deficiency in children with spinal dyspharism. Various modifications of the procedure have been made but all involve circumferential dissection of the bladder neck and proximal urethra. The posterior dissection can be challenging and can result in injury to the rectum, urethra, or vagina. The posterior approach to the bladder neck as reported by Lottmann and later by de Badiola addresses these potential complications. Using these principles of the posterior approach, we performed a robotic-assisted laparoscopic placement of an acellular human dermal allograft bladder neck sling in 2 patients. We present our initial experience regarding this surgical technique. METHODS: The diagnosis of intrinsic sphincter deficiency was established in 2 female patients, aged 9 and 10 years. Both patients had a neurogenic bladder secondary to spina bifida. Video urodynamics confirmed adequate bladder compliance and intrinsic sphincter deficiency. Robotic-assisted laparoscopic placement of a bladder neck sling was performed in both patients. RESULTS: Both procedures were completed intracorporeally. The mean blood loss was 20 mL. The mean operative time was 189 minutes. No intraoperative or postoperative complications occurred. The mean hospital stay was 3 days (range 2-4). The follow-up ranged from 13 to 22 months. Postoperative studies revealed continued low-pressure, compliant bladders and stable upper tracts. At last follow-up, the 2 patients were using catheterization without difficulty and were continent. CONCLUSIONS: The robotic-assisted laparoscopic approach to performing bladder neck dissection and placement of a bladder neck sling in children is technically feasible.

Laparoscopic robot-assisted appendicovesicostomy: an initial experience.

PURPOSE: To describe our initial experience with laparoscopic robot-assisted appendicovesicostomy (LRAA). MATERIALS AND METHODS: We have performed the LRAA in three patients, aged 9, 17, and 45 years. The underlying medical conditions were myelomeningocele, prune-belly syndrome, and multiple sclerosis. Adjuvant procedures consisted of extensive lysis of adhesions and a bladder-neck fascial sling. RESULTS: All procedures were completed intracorporeally. The mean blood loss was 50 mL. The mean operative time was 301 minutes (range 203-362 minutes). The mean hospital stay was 3 days (range 2-4 days). Follow-up ranges from 1 to 8 months. All patients currently catheterize without difficulty and are continent. CONCLUSIONS: In our initial experience, LRAA is a safe and effective option for creating a continent catheterizable channel into the urinary bladder.

Open reconstruction of pediatric and adolescent urethral strictures: long-term followup.

PURPOSE: Pediatric urethral stricture disease represents a significant surgical challenge. Published operative series of pediatric urethral reconstruction include small numbers or lack long-term followup. We examined the long-term outcome of open reconstructive techniques for pediatric urethral strictures. MATERIALS AND METHODS: From March 1987 through August 2002, 17 boys 7 to 17 years old underwent open urethral reconstruction with followup. Trauma was the etiology in 88% of cases. Nine patients had anterior urethral stricture and 8 had traumatic posterior urethral disruption. Strictures secondary to failed hypospadias correction were not included in analysis. In 10 patients (59%) previous management with open or endoscopic procedures had failed. Followup in all patients consisted of symptomatic evaluation, voiding cystourethrography and flexible urethroscopy. RESULTS: One-stage perineal urethral reconstruction was performed in all patients without retropubic or transpubic dissection. All patients were stricture-free and continent at a mean followup of 67 months. A total of 18 open surgical procedures were needed. A patient with posterior urethral disruption required reoperation for recurrent stricture disease but had excellent long-term results after the second operation. Chordee, penile shortening and urethral diverticula were not noted during followup. CONCLUSIONS: Open urethral reconstruction of adolescent and pediatric strictures provides excellent long-term results with minimal morbidity. When considering the importance of repair durability in the pediatric urethral stricture population, urethral reconstruction should be strongly considered the primary treatment option. Endoscopic procedures should be reserved for patients with short bulbar strictures associated with minimal spongiofibrosis. As in the literature, we do not advocate repeat direct vision internal urethrotomy.