Comparison of commonly utilized ureteral access sheaths: A prospective randomized trial.

OBJECTIVE: We aimed to evaluate and compare the functional characteristics, safety profile and effectiveness of two commonly used ureteral access sheaths (UAS) during flexible ureteroscopy. METHODS: After institutional review board approval, patients with proximal ureteral or kidney stones requiring flexible ureteroscopy and UAS were prospectively randomized to group I or group II according to the type of access sheath used. Primary outcome was incidence of intraoperative complications. RESULTS: Eighty-eight patients were enrolled in the study, 44 patients in each group. Sheath size 12/14 FR was used in both cohorts. Median (IQR) stone size was 10 mm (7-13.5) and 10.5 mm (7.37-14) in group I and II respectively (p = 0.915). Nineteen and twenty patients, in group I and II respectively, were pre-stented. Subjective resistance with insertion of the UAS was observed in 9 and 11 patients in group I and II respectively (p = 0.61) while failed insertion was encountered in one patient in group I. Traxer grade 1 ureteral injury was noted in 5 and 6 patients in group I and II respectively while grade 3 injury was seen in 1 patient for both cohorts (p = 0.338). There was less resistance for UAS placement in pre-stented patients (p = 0.0202) but without significant difference in ureteric injury incidence (p = 0.175). Emergency department visits were encountered in 7 (group I) and 5 patients (group II) (p = 0.534). CONCLUSIONS: The studied UASs were comparable regarding safety and efficacy in the current study. Pre-stented and dilated ureters had less resistance to insertion although this was not reflected on incidence of ureteric injury.

Intraoperative angiography of the neurovascular bundle using indocyanine green and near-infrared fluorescence improves anatomical dissection during robot-assisted radical prostatectomy: initial clinical experience.

Landmark artery identification in the neurovascular bundle (NVB) is important for nerve-sparing in radical prostatectomy. We aimed to investigate intraoperative angiography using indocyanine green and near-infrared fluorescence (ICG-NIRF) during robot-assisted radical prostatectomy (RARP) to identify the NVB, visualise vascularisation and haemostasis, and preserve erectile function. Our retrospective, unicentric study was performed in consecutive localised prostate cancer RARP patients (stage T1/T2, prostate-specific antigen < 10 ng/ml) who underwent ICG-NIRF angiography in France (2016-2021). When ready to dissect the NVB, the anaesthesiologist intravenously injected ICG (3 ml); the surgeon used alternating standard light or fluorescence to optimise NVB visualisation and facilitate microdissection. Primary outcomes: safety and feasibility of ICG-NIRF. Secondary outcomes: functional erectile dysfunction (Sexual Health Inventory for Men (SHIM) questionnaire) over 9 months, proportion of bilateral NVBs identified, ICG-related complications. Standard descriptive statistics were used; t test determined the significance of changes in SHIM scores versus baseline. Ninety-one patients received intraoperative angiography. The NVB was identified in all cases, without difficulties. No ICG-related complications or allergies were observed. There was no significant difference in the SHIM score at 9 months compared with baseline (p = 0.331), and erectile dysfunction returned to baseline levels in almost all patients. Intraoperative, real-time ICG-NIRF angiography is simple, non-invasive, and improves identification of key anatomical landmarks to optimise micropreservation of the NVB during RARP and preserve erectile function. Larger clinical studies should confirm preliminary results.

Acute management of Fournier's gangrene in the setting of massive lymphedema.

Chronic, massive lymphedema of the scrotum can pose therapeutic challenges to the urologist. Uncommonly encountered in developed countries, this dilemma can be amplified in the emergent setting. Along with voiding limitations and pain, lymphedema can lead to recurrent subcutaneous infections. Recurrence of infections can lead to a cycle of worsening lymphedema. We report a case of Fournier's gangrene complicated by massive lymphedema of the scrotum and right leg in a 43 year-old man from Panama, presumably filarial. This case highlights the surgical management of a patient requiring emergent intervention and multidisciplinary approach of reconstructive repair in the acute care setting.

Tandem Resonance metallic double-J ureteral stents in a single ureter for salvage management of chronic ureteral obstruction.

For chronic malignant and benign ureteral obstruction, the metal construction of the Resonance ureteral stent has been developed to maintain ureteral patency for up to 12 months, obviating the need for the frequent exchange required for conventional plastic ureteral stents. We report our experience placing tandem Resonance stents (TRS) in a single ureter of patients who failed management with a single Resonance stent. A retrospective review of patients who had TRS for management of ureteral obstruction between February 2014 and May 2017 was performed. Seven renal units from four patients with a median age of 62 years were managed with TRS. All but one renal unit was successfully managed with TRS initially. Hydronephrosis resolved in 80% of renal units at a median of 33 days, and creatinine reached its nadir a median of 38 days after placement, with a median improvement of 0.68 ng/mL. However, the median length of management with TRS was only 123.5 days with one exchange, and there was an overall success rate of 28.5% at 1 year. TRS placement is a feasible option for short-term management in a challenging population that would like to avoid nephrostomy and has failed other modalities.

A pilot study in intraparenchymal therapy delivery in the prostate: a comparison of delivery with a porous needle vs standard needle.

BACKGROUND: New biologic therapies directly injected into the prostate are in clinical trials for prostatic diseases. There is a need to understand distribution of injected therapies as a function of prostatic anatomy, physiology, and device design. METHODS: A needle with a porous length of customizable-length was tested and its performance compared with a standard needle. Injections of magnetic resonance contrast reagent were placed into ex-vivo human prostates after surgical excision in standard of care therapy for invasive bladder cancer patients. Magnetic resonance images were acquired using sequences to quantify volume delivered, distributed, and backflow. RESULTS: Magnetic resonance images analysis revealed heterogeneity distribution with injection into the specimens. There was low resistance to flow along ductal pathways and high resistance to flow into glandular nodules and smooth muscle/fibrous parenchyma. Data confirm previous studies showing injection loss via urethra backflow, urethra, and prostatic ducts. Tissue fraction of dose was significantly higher with porous needle compared with standard needle (p = .03). We found that a greater volume of distribution divided by the amount infused (Vd/Vi) increased by 80% with the porous needle, though no statistically significant association due to small sample size. CONCLUSIONS: This study demonstrated that prostatic tissue is anatomically heterogenic and limits distribution of needle injection. There is greater distribution in the ex-vivo prostate using a porous needle. The complexity of intra prostatic flow pathways suggests preoperative imaging and pre-treatment planning will enhance therapy.

Low-Dose-Rate Brachytherapy Versus Cryotherapy in Low- and Intermediate-Risk Prostate Cancer.

PURPOSE: Cryotherapy and brachytherapy are definitive local treatment options for low- to intermediate-risk prostate cancer. There are both prospective and retrospective data for brachytherapy, but the use of cryotherapy has been limited primarily to single-institution retrospective studies. Currently, no published evidence has compared low-dose-rate brachytherapy versus cryotherapy. METHODS AND MATERIALS: Institutional review board approval was obtained to conduct a retrospective chart review of consecutive patients treated at our institution from 1990 to 2012. For inclusion, patients must have received a prostate cancer diagnosis and have been considered to have low- to intermediate-risk disease according to the National Comprehensive Cancer Network criteria. All patients received brachytherapy or cryotherapy treatment. Disease specifics and failure details were collected for all patients. Failure was defined as prostate-specific antigen nadir +2 ng/mL. RESULTS: A total of 359 patients were analyzed. The groups comprised 50 low-risk cryotherapy (LRC), 92 intermediate-risk cryotherapy (IRC), 133 low-risk brachytherapy (LRB), and 84 intermediate-risk brachytherapy (IRB) patients. The median prostate-specific antigen follow-up periods were 85.6 months (LRC), 59.2 months (IRC), 74.9 months (LRB), and 59.8 months (IRB). The 5-year biochemical progression-free survival (bPFS) rate was 57.9% in the cryotherapy group versus 89.6% in the brachytherapy group (P<.0001). The 5-year bPFS rate was 70.0% (LRC), 51.4% (IRC), 89.4% (LRB), and 89.7% (IRB). The bPFS rate was significantly different between brachytherapy and cryotherapy for low- and intermediate-risk groups (P<.05). The mean nadir temperature reached for cryotherapy patients was -35°C (range, -96°C to -6°C). Cryotherapy used a median of 2 freeze-thaw cycles (range, 2-4 freeze-thaw cycles). CONCLUSIONS: Results from this study suggest that cryotherapy is inferior to brachytherapy for patients with low- to intermediate-risk prostate cancer. Patient selection criteria for consideration of cryotherapy and brachytherapy are similar in terms of anesthesia candidacy. Therefore, cryotherapy would not be recommended as a first-line local therapy for this particular patient subset.