A unique case of Schistosoma-related ureteral stricture: Diagnosis and surgical reconstruction.

Background: Chronic infection with Schistosoma haematobium can lead to pathology of the upper and lower urinary tracts. While well known as a cause of squamous cell carcinoma of the bladder, relatively little research exists on ureteral involvement. Here, we present a unique case of bilateral ureteral obstruction from schistosomiasis with concomitant ureteral stone disease. Case presentation: A 43-year-old male Somalian immigrant was diagnosed with a right proximal ureteral stone and bilateral multifocal ureteral narrowing causing obstruction with preserved renal function. He underwent a staged repair with right robotic pyelolithotomy and non-transecting ureteroureterostomy, followed by left robotic ureteroureterostomy with stricture excision. Pathology revealed Schistosoma ova. Conclusion: Ureteral stricture from schistosomiasis represents a rare diagnosis for urologists in non-endemic countries. Bilateral ureteral narrowing and concomitant ureteral stone burden presented both diagnostic and reconstructive challenges, requiring a staged repair. Minimally invasive reconstruction was achieved using robotic assistance with good functional outcome.

Minimizing Antibiotic Use in Urethral Reconstruction.

PURPOSE: There are no established guidelines regarding management of antibiotics for patients specifically undergoing urethral reconstruction. Our aim was to minimize antibiotic use by following a standardized protocol in the pre-, peri- and postoperative setting, and adhere to American Urological Association antibiotic guidelines. We hypothesized that prolonged suppressive antibiotics post-urethroplasty does not prevent urinary tract infection and/or wound infection rates. MATERIALS AND METHODS: We prospectively treated 900 patients undergoing urethroplasty or perineal urethrostomy at 11 centers over 2 years. The first-year cohort A received prolonged postoperative antibiotics. Year 2, cohort B, did not receive prolonged antibiotics. A standardized protocol following the American Urological Association guidelines for perioperative antibiotics was used. The 30-day postoperative infectious complications were determined. We used chi-square analysis to compare the cohorts, and multivariate logistic regression to identify risk factors. RESULTS: The mean age of participants in both cohorts was 49.7 years old and the average stricture length was 4.09 cm. Overall, the rate of postoperative urinary tract infection and wound infection within 30 days was 5.1% (6.7% in phase 1 vs 3.9% in phase 2, p=0.064) and 3.9% (4.1% in phase 1 vs 3.7% in phase 2, p=0.772), respectively. Multivariate logistic regression analysis of patient characteristics and operative factors did not reveal any factors predictive of postoperative infections. CONCLUSIONS: The use of a standardized protocol minimized antibiotic use and demonstrated no benefit to prolonged antibiotic use. There were no identifiable risk factors when considering surgical characteristics. Given the concern of antibiotic over-prescription, we do not recommend prolonged antibiotic use after urethral reconstruction.

A narcotic free pathway for postoperative pain following urethroplasty.

INTRODUCTION: In an effort to decrease physician contribution to the opioid crisis, we utilized a narcotic free pathway (NFP) after urethroplasty. Our objectives were to demonstrate feasibility of a NFP and identify patients at higher risk for requiring postoperative narcotics. MATERIALS AND METHODS: We implemented a NFP for patients undergoing urethroplasty. Pain was assessed using the Likert scale (1-10). Narcotic use was quantified using oral morphine equivalents (OMEs). RESULTS: Forty-six patients underwent urethroplasty following the NFP over a 7-month period. Fifteen patients were excluded, leaving 31 patients in the final analysis. Postintervention data was compared to 30 patients who underwent urethroplasty prior to implementation of the NFP. The groups had similar demographics except for a history of heroin abuse (0% preintervention, 12.9% postintervention, p = 0.04). Surgical characteristics were not statistically different aside from length of surgery (183.6 minutes preintervention, 145.5 minutes postintervention, p = 0.01). The mean [SD] perioperative OME use preintervention was 194.9 [151] mg, compared to 40.4 [111.9] mg postintervention (p < 0.001). Six patients postintervention were discharged with a narcotic prescription (mean 27.5 mg OME) compared to 26 patients preintervention (mean 76 mg OME) (p < 0.001). There was no difference in pain scores at any time interval. Patients with a history of chronic opioid use were more likely to require narcotics (OR 5.33, CI 1-28.44). CONCLUSIONS: The narcotic free pathway resulted in a dramatic reduction in narcotic prescriptions without a significant difference in postoperative pain scores. Opioid use can be minimized following urethral and perineal surgery.

Robotic Lower Urinary Tract Reconstruction.

Lower urinary tract reconstruction has traditionally been approached in an open fashion but select complications or disease processes may be suitable for robotic reconstruction, including bladder neck contractures, proximal urethral strictures, and genitourinary fistulas. Here, the authors discuss the novel techniques used and the feasibility of robotic reconstruction for these conditions. The robotic approach is relatively novel, and more data and studies will be required to make definitive statements regarding success rate and complications from the procedure. Preliminary data suggest that the robotic approach may offer comparable success compared with open techniques.

Antibiotic Stewardship and Postoperative Infections in Urethroplasties.

OBJECTIVE: To determine surgical site infection and urinary tract infection (UTI) rates in the setting of urethroplasty. Given significant variation in the utilization of antibiotics, there is an opportunity to improve antibiotic stewardship. This study aims to elucidate the rate of both UTI and surgical site infection after urethroplasty on a standardized perioperative antibiotic regimen, and to obtain patient and operative characteristics that may predict infection. METHODS: We prospectively treated 390 patients undergoing urethroplasty at 11 centers with a standardized perioperative antibiotic protocol. Patients had a urine culture or urine analysis within 3 weeks of surgery. After surgery, patients were discharged with an indwelling catheter, removed per usual surgeon practice. All were given nitrofurantoin from discharge until catheter removal. Logistic regression analyses were performed to determine the correlation between patient characteristics or operative categories with post-operative infection. RESULTS: The rates of postoperative UTI and wound infection within 30 days were 6.7% and 4.1%, respectively. On multivariate analysis of demographics, comorbidities, and stricture characteristics and repair, only preoperative UTI (P = .012), history of cardiovascular disease (P = .015), and performing a membranous urethroplasty (0.018) were significant predictors of a UTI within 30 days postoperatively. Location of repair nor graft use increased the risk of UTI. There were no factors predictive of postoperative wound infection. CONCLUSION: A standardized antibiotic protocol was created to narrow and limit excess antibiotic use. This protocol, with clear definitions of UTI and wound infection, allowed determination of accurate infection rates in urethroplasties. Preoperative UTI, even when properly treated, increases the risk of postoperative UTI.

Robotic Surgery for the Reconstruction of Transplant Ureteral Strictures.

OBJECTIVE: To demonstrate the feasibility and success of a robotic approach to reconstruction of ureterovesical anastomotic strictures in kidney transplants. MATERIALS AND METHODS: Between November 2017 and December 2019, a total of 5 patients with transplant ureteral stricture were identified and treated with robot assisted laparoscopic repair. All patients were confirmed to have ureteral stricture with a preoperative antegrade nephrostogram through their nephrostomy tube and cystogram. The patients demographics, ureteral characteristics, type of procedure, and outcomes are reported. RESULTS: All patients were diagnosed after evaluation for renal deterioration. The average age of the patients was 49 years old. The average stricture length was 2.5 cm, and the location was variable, though more commonly in the distal ureter. Three patients required a pyelo-vesicostomy, while 2 required a ureteroneocystostomy. The mean length of stay was 2.2 days. Average follow-up was 97 days, with all 5 patients having successful outcomes, no strictures or delayed leaks were identified. There were no wound infections or readmissions within 30 days. CONCLUSION: Though a complex repair, the robot-assisted approach to transplant ureter reconstruction using either an end to side neoureterocystotomy or direct pyelo-vesicotomy is technically feasible and successful. Given the many advantages inherent in comparison to an open approach, the robotic repair offers significant advantages to both the patient and the surgeon who is experienced with robotic surgery and reconstructive principles.

Surgery for Posterior Compartment Vaginal Prolapse: Graft Augmented Repair.

Posterior compartment vaginal prolapse can be approached with multiple surgical techniques, including transvaginally, transperineally, and transanally, repaired with either native tissue or with the addition of an augment. Augment material for posterior compartment prolapse includes biologic graft (dermal, porcine submucosal), absorbable mesh (Vicryl polyglactin), or nonabsorbable synthetic mesh (polypropylene). Anatomic success rates for posterior compartment repair with augment has ranged from 54% to 92%. Augmented posterior compartment repair has not been shown to have superior outcome to native tissue repair. The focus of this article is on the transvaginal approach comparing native tissue repair with graft or mesh augmented repair.

Oxygen dose responsiveness of human fetal airway smooth muscle cells.

Maintenance of blood oxygen saturation dictates supplemental oxygen administration to premature infants, but hyperoxia predisposes survivors to respiratory diseases such as asthma. Although much research has focused on oxygen effects on alveoli in the setting of bronchopulmonary dysplasia, the mechanisms by which oxygen affects airway structure or function relevant to asthma are still under investigation. We used isolated human fetal airway smooth muscle (fASM) cells from 18-20 postconceptual age lungs (canalicular stage) to examine oxygen effects on intracellular Ca(2+) ([Ca(2+)](i)) and cellular proliferation. fASM cells expressed substantial smooth muscle actin and myosin and several Ca(2+) regulatory proteins but not fibroblast or epithelial markers, profiles qualitatively comparable to adult human ASM. Fluorescence Ca(2+) imaging showed robust [Ca(2+)](i) responses to 1 µM acetylcholine (ACh) and 10 µM histamine (albeit smaller and slower than adult ASM), partly sensitive to zero extracellular Ca(2+). Compared with adult, fASM showed greater baseline proliferation. Based on this validation, we assessed fASM responses to 10% hypoxia through 90% hyperoxia and found enhanced proliferation at <60% oxygen but increased apoptosis at >60%, effects accompanied by appropriate changes in proliferative vs. apoptotic markers and enhanced mitochondrial fission at >60% oxygen. [Ca(2+)](i) responses to ACh were enhanced for <60% but blunted at >60% oxygen. These results suggest that hyperoxia has dose-dependent effects on structure and function of developing ASM, which could have consequences for airway diseases of childhood. Thus detrimental effects on ASM should be an additional consideration in assessing risks of supplemental oxygen in prematurity.

Cellular senescence and organismal ageing in the absence of p21(CIP1/WAF1) in ku80(-/-) mice.

Ku80 is important in the repair of DNA double-strand breaks by its essential function in non-homologous end-joining. The absence of Ku80 causes the accumulation of DNA damage and leads to premature ageing in mice. We showed that mouse embryonic fibroblasts (MEFs) from ku80(-/-) mice senesced rapidly with elevated levels of p53 and p21. Deletion of p21 delayed the early senescence phenotype in ku80(-/-) MEFs, despite an otherwise intact response of p53. In contrast to ku80(-/-)p53(-/-) mice, which die rapidly primarily from lymphomas, there was no significant increase in tumorigenesis in ku80(-/-)p21(-/-) mice. However, ku80(-/-)p21(-/-) mice showed no improvement with respect to rough fur coat or osteopaenia, and even showed a shortened lifespan compared with ku80(-/-) mice. These results show that the increased lifespan of ku80(-/-) MEFs owing to the loss of p21 is not associated with an improvement of the premature ageing phenotypes of ku80(-/-) mice observed at the organismal level.

Osteopontin expression in intratumoral astrocytes marks tumor progression in gliomas induced by prenatal exposure to N-ethyl-N-nitrosourea.

To better study early events in glioma genesis, markers that reliably denote landmarks in glioma development are needed. In the present study, we used microarray analysis to compare the gene expression patterns of magnetic resonance imaging (MRI)-localized N-ethyl-N-nitrosourea (ENU)-induced tumors in rat brains with those of uninvolved contralateral side and normal brains. Our analysis identified osteopontin (OPN) as the most up-regulated gene in glioma. Using immunohistochemistry we then confirmed OPN expression in every tumor examined (n = 17), including those with diameters as small as 300 mum. By contrast, no OPN immunostaining was seen in normal brain or in brains removed from ENU-exposed rats before the development of glioma. Further studies confirmed that OPN was co-localized exclusively in intratumoral glial fibrillary acidic protein-expressing cells and was notably absent from nestin-expressing ones. In conjunction with this, we confirmed that both normal neurosphere cells and ENU-im-mortalized subventricular zone/striatal cells produced negligible amounts of OPN compared to the established rat glioma cell line C6. Furthermore, inducing OPN expression in an immortalized cell line increased cell proliferation. Based on these findings, we conclude that OPN overexpression in ENU-induced gliomas occurs within a specific subset of intratumoral glial fibrillary acidic protein-positive cells and becomes evident at the stage of tumor progression.