Robotic-assisted Laparoscopic Subtrigonal Inlay of Buccal Mucosal Graft for Treatment of Refractory Bladder Neck Contracture.

OBJECTIVE: To describe a novel surgical technique for reconstruction of a case of refractory bladder neck contracture (BNC) using a robotic-assisted laparoscopic (RAL) transvesical approach for subtrigonal inlay of buccal mucosal graft. BNC is a well-described yet uncommon adverse event after BPH surgery. Endoscopic management is successful in many patients but refractory cases may require reconstructive surgery. MATERIALS AND METHODS: A 70-year-old male presented with a history of prior photovaporization of the prostate 2 years prior to our initial consultation. He developed a refractory BNC that did not resolve after multiple endoscopic interventions. For definitive treatment of the BNC, he underwent RAL repair with subtrigonal inlay of buccal mucosal graft. The surgical approach is demonstrated in our video. RESULTS: The patient underwent RAL subtrigonal inlay of buccal mucosal graft without intraoperative complication or need to convert to an open procedure. The graft harvested for repair measured 5 × 5 × 4 cm. He was discharged home on postoperative day 2. Urethral catheter was left in place for 2 weeks and suprapubic catheter was removed 4 weeks postoperatively. Voiding cystourethrogram at time of suprapubic catheter removal demonstrated no evidence of obstruction or extravasation. Uroflow qmax improved from 2 to 27 mL/s. Postvoid residual urine volume improved from 200 to 3 mL. At last follow-up, there was no evidence of recurrence. CONCLUSION: Refractory cases of BNC can be successfully managed with reconstructive surgery. In this case report, we describe a novel technique for RAL reconstruction with subtrigonal inlay of buccal mucosal graft.

Is mesenteric defect closure needed in urologic surgery using ileum?

INTRODUCTION: Classic surgical teaching advocates for closure of the mesenteric defect (MD) after bowel anastomosis but the necessity is controversial. We sought to evaluate the necessity of MD closure at the time of harvest of ileum for genitourinary reconstructive surgery (GURS) by analyzing the incidence of early and late gastrointestinal adverse events (GIAE) in patients with and without MD closure. MATERIALS AND METHODS: A retrospective review was conducted on patients undergoing urologic reconstruction with ileum to identify incidence of ileus, small bowel obstruction (SBO), gastrointestinal (GI) fistula and stoma complications. Patient and procedure variables were analyzed to identify risk factors for GIAE. RESULTS: A total of 288 patients met inclusion criteria and 93% of GURS was for urinary diversion following cystectomy. MD was closed in 194 cases (67%). Median follow up was 19 months. Early (< 30 day) GIAE rates were 16.5% (n = 32) and 21.3% (n = 20) in the closure and non-closure groups, respectively (p = 0.22). The rate of early ileus/SBO requiring nasogastric tube decompression or laparotomy were similar after closure (15.0%) and non-closure (21.3%) (p = .18). The late GIAE rates were 5.7% (n = 11) and 6.4% (n = 6) in the closure and non-closure cohorts, respectively (p = 0.56). The rate of late SBO were similar and no cases of early or late SBO in either cohort were due to internal herniation. On multivariate analysis, increasing BMI was associated with both early and late GIAE. CONCLUSIONS: After harvesting ileum for urologic reconstruction, the MD can safely be left open as we found no association between non-closure and early or late GIAE..

Ten-Year Review of Perioperative Complications After Transurethral Resection of Bladder Tumors: Analysis of Monopolar and Plasmakinetic Bipolar Cases.

OBJECTIVES: To evaluate the rate of perioperative complications after plasmakinetic bipolar and monopolar transurethral resection of bladder tumor (BTURB and MTURB). In addition, the study identifies patient and procedure characteristics associated with early complications. PATIENTS AND METHODS: Retrospective review was conducted on patients undergoing transurethral resection of bladder tumor procedures at a single institution from 2003 to 2013 to assess the 30-day complication rates associated with BTURB and MTURB. RESULTS: Four hundred twenty-seven patients met inclusion criteria and underwent 586 procedures (379 BTURB and 207 MTURB). Baseline patient demographics, tumor stage, and tumor grade were similar in BTURB and MTURB cohorts. The overall complication rate was 34.3% for MTURB and 26.7% for BTURB. The most frequent complications were acute urinary retention (AUR) 11%, hematuria 8%, and urinary tract infection (UTI) 7%. There was no statistical difference in rates of AUR, hematuria, UTI, or readmission for continuous bladder irrigation or hemostasis procedures between BTURB and MTURB cohorts. There was a trend toward lower perforation rate during BTURB (2.6% vs 5.8%). In multivariate logistic regression analysis, MTURB, male gender, and large resections were predictive of overall complications. Male gender was associated with hematuria and AUR. Large bladder tumor resection size was also associated with increased risk of overall complications and AUR. CONCLUSION: BTURB was associated with a lower risk of overall complications, but there was no difference in the rate of hematuria in the two cohorts. Male gender and large tumor size are associated with higher risk of early complications.

Less is more-A pilot study evaluating one to three intradetrusor sites for injection of OnabotulinumtoxinA for neurogenic and idiopathic detrusor overactivity.

AIMS: To determine if minimizing the number of onabotulinumtoxinA (BTX) injection sites to one to three locations provides similar clinical efficacy and duration of effect compared to the established technique in treating patients with neurogenic (NDO) or idiopathic detrusor overactivity (IDO). METHODS: Prospective data were collected on BTX naïve patients with NDO or IDO who were intolerant or refractory to oral medications. Patients were treated with 100-300 U of BTX via one to three injection sites. Patients completed the International Consultation on Incontinence Questionnaire Short Form (ICIQ-SF) prior to and after treatment. The primary endpoint was defined as ICIQ-SF score improvement of >5 points. Secondary endpoints included subjective success, complete continence, quality of life score, post void residual (PVR), duration of effect and adverse events. RESULTS: Fourty-five patients (22 IDO, 23 NDO) were included. ICIQ-SF score improvement of >5 points was achieved in 73% (IDO 55%, NDO 91%) and the subjective success rate was 69% (50% IDO, 87% NDO). 52% of NDO patients attained complete continence. PVR increased by a mean of 32 and 156 ml in the IDO and NDO groups. Hematuria occurred in 6.7% and symptomatic urinary tract infection occurred in 11.1%. No systemic BTX adverse events occurred. Mean duration of effect was 31 weeks. CONCLUSIONS: Our technique for administering BTX via one to three intradetrusor injection sites has similar clinical efficacy and rates of adverse events compared to the established technique for treating patients with IDO and NDO. Neurourol. Urodynam. 36:1104-1107, 2017. © 2016 Wiley Periodicals, Inc.

Polyisobutylene Urolithiasis Due to Ileal Conduit Urostomy Appliance: An Index Case.

Polyisobutylene (PIB) is a synthetic elastomer that is a component of sealants, adhesives, and chewing gum base. We report a case of bilateral PIB urolithiasis in a patient with an ileal conduit urinary diversion due to neurogenic bladder from spinal cord injury. Infrared spectroscopy confirmed the composition of bilateral stones and adhesive from the patient's urostomy appliance to be PIB. No previous cases of PIB urolithiasis are reported in the literature.

Cost comparison of nephron-sparing treatments for cT1a renal masses.

OBJECTIVES: Treatment options for small renal tumors have evolved from radical nephrectomy (RN) to partial nephrectomy (PN), thermal ablation, or active surveillance. With the advancement of techniques, costs differences are unclear. The objective of this study is to compare the 6-month costs associated with nephron-sparing procedures for cT1a renal tumors. MATERIALS AND METHODS: We performed a review of patients diagnosed with a solitary cT1a renal mass who underwent surgical treatment from June 2008 to May 2011. Open partial nephrectomy (OPN), robot-assisted partial nephrectomy (RLPN), laparoscopic radio-frequency ablation (LRFA), or computed tomography guided radio frequency ablation (CTRFA) was performed on 173 patients. Cost data were collected for surgical costs, associated hospital stay, and the 6-month postoperative period. RESULTS: Patients underwent surgery, including 52 OPN, 48 RLPN, 44 LRFA, and 29 CTRFA. Median total costs associated were $17,018, $20,314, $13,965, and $6,475, for OPN, RLPN, LRFA, and CTRFA, respectively. When stratified by approach differences were noted for total cost (P < 0.001), operating room (OR) time (P < 0.001), surgical supply (P < 0.001), and room and board (P < 0.001) in univariable analysis. Multivariable linear regression (R(2) = 0.966) showed surgical approach (P = 0.007), length of stay (P < 0.001), and OR time (P < 0.001) to be significant predictors of total cost. However, tumor size (P = 0.175), and Charlson comorbidity index (P = 0.078) were not statistically significant. CONCLUSIONS: Six-month cost of nephron-sparing surgery is lowest with radio frequency ablation (RFA) by either laparoscopic or computed tomography (CT)-guided approach compared to RLPN and OPN. As oncologic and safety outcomes improve and become comparable in all nephron-sparing surgery (NSS) approaches, cost of each procedure will start to play a stronger role in the clinical and healthcare policy setting.

Intravesical methylene blue facilitates precise identification of the diverticular neck during robot-assisted laparoscopic bladder diverticulectomy.

BACKGROUND: The aim of this report is to describe our surgical technique for robot-assisted laparoscopic bladder diverticulectomy. In this technique, methylene blue is instilled into the bladder to aid in intra-abdominal identification of the diverticular neck. SUBJECTS AND METHODS: We retrospectively reviewed the records of patients who underwent robot-assisted bladder diverticulectomy by a single surgeon. RESULTS: Between September 2008 and January 2011, 5 patients successfully underwent robot-assisted laparoscopic bladder diverticulectomy using 1% intravesical methylene blue. All cases were completed without intraoperative complication or need for open conversion. Mean operative time was 216 minutes, with a mean estimated blood loss of 45 mL. Patients were discharged 1-2 days following surgery. No patient experienced a perioperative complication. CONCLUSIONS: The robot-assisted approach for bladder diverticulectomy is a viable alternative to both open and laparoscopic surgery. The use of intravesical methylene blue greatly aids in identification of the diverticular neck during this procedure.

Epithelioid hemangioma-a rare scrotal tumor of childhood.

Epithelioid hemangioma is an uncommon vascular lesion typically involving the skin of the head and neck. Genital involvement has rarely been reported. The presented case represents only the third published occurrence of scrotal involvement, the second in a pediatric patient, and exhibited the unusual presentation as a scrotal wall mass rather than a visible skin lesion.