Perinephric and Sinus Fat Invasion in Stage pT3a Tumors Managed by Partial Nephrectomy.

INTRODUCTION: We evaluated the influence of perinephric fat invasion (PFI) compared with sinus fat invasion (SFI) on disease-free survival (DFS) and cancer-specific survival (CSS) after partial nephrectomy (PN) for stage pT3a renal cell carcinoma (RCC). MATERIALS AND METHODS: Data were recorded from the consecutive records of patients who had undergone underwent PN for cT1-T2 RCC from 2007 to 2016. Of these patients, 143 had stage pT3a with SFI or PFI found on final pathologic examination. The demographic, perioperative, and pathologic variables were reviewed. DFS and CSS analyses were performed. The factors predicting disease progression in this population were assessed. RESULTS: After a median follow-up period of 28 months (range 15-41 months), 19 patients (13.3%) had developed recurrence, including 5 local and 14 distant metastases, with 11 cancer-specific deaths (7.7%). No differences were found in DFS (5 years, 60.9% vs. 55.3%; log-rank P = .7) or CSS (5 years, 81% vs. 74.2%; log-rank P = .8) between the SFI and PFI groups. For the pT3a fat invasion population, the 2- and 5-year DFS and CSS rates were 83.6% and 58.6% and 93.6% and 78%, respectively. SFI (P = .5) and positive surgical margins (P = .1) did not predict for progression. On multivariate Cox regression, increased tumor size (hazard ratio, 1.5; 95% confidence interval, 1.1-1.9; P < .01) and higher tumor grade (hazard ratio, 3.6; 95% confidence interval, 1.1-4.6; P = .04) were independent predictors of disease progression in the pT3a fat invasion population. CONCLUSION: In our series of patients with pT3a RCC after PN, SFI compared with PFI was not associated with an increased risk of progression or cancer-specific death.

Hilar Parenchymal Oversew: a novel technique for robotic partial nephrectomy hilar tumor renorrhaphy.

INTRODUCTION: A renorrhaphy technique which is effective for hemostasis but does not place undue tension on the branch vessels of the renal sinus remains one of the challenging steps after hilar tumor resection during robotic partial nephrectomy (RPN). The published V-hilar suture (VHS) technique is one option for reconstruction after an RPN involving the hilum. The objective of this video is to show a novel renorrhaphy technique, Hilar Parenchymal Oversew that has been effective for such cases. MATERIALS AND METHODS: We present two cases of RPN for renal hilar tumors. The first case depicts use of the VHS renorrhaphy technique for a tumor that abuts the renal hilum along 20% of its diameter. The second case demonstrates tumor resection and reconstruction for a tumor that has >50% involvement of the hilum along its diameter. After tumor resection, individual sinus vessels can be selectively oversewn with 2-0 Vicryl suture on SH needle. The remaining exposed parenchyma is controlled using the Hilar Parenchymal Oversew technique with a #0 Vicryl on CT-1 needle. RESULTS: For the Hilar Parenchymal Oversew surgery operative time was 225 min, estimated blood loss was 140 ml, warm ischemia time was 19 minutes, and there were no intraoperative complications. Pathology was consistent with clear cell renal cancer with negative margins. CONCLUSION: Robotic partial nephrectomy with the Hilar Parenchymal Oversew technique is a good alternative to VHS renorrhaphy in the management of renal hilar tumors "bulging" into the renal sinus with >50% of the tumor diameter abutting the hilum.

Robotic Retrocaval Metastasectomy After an Ipsilateral Radical Nephrectomy.

OBJECTIVE: Robotic management of a retrocaval metastasis can be challenging because of prior surgery leading to scarring and obscure surgical planes around vital structures. We present our robotic approach and technique to manage a large retrocaval, biopsy-proven, metastatic mass after previous laparoscopic right radical nephrectomy with concomitant adrenalectomy 10 years ago. METHODS: We present a 62-year-old man who previously underwent a laparoscopic right radical nephrectomy for pT1bNxMx chromophobe renal cell carcinoma (RCC) in 2007. Surveillance imaging in November 2016 indicated a 5-cm retrocaval mass, and biopsy confirmed the metastasis. The patient was positioned in standard robotic positioning for right renal surgery. Meticulous dissection was required to free the duodenum and inferior vena cava from the mass, enabling the mass to be lifted anteriorly. Posteriorly, a labyrinth of vessels required hem-o-lok clips before excision, which allowed complete extraction of the mass. RESULTS: Operative time was 234 minutes and estimated blood loss was 40 cc. Final pathology revealed a right 5 cm × 3.1 cm metastatic RCC, chromophobe-type, lymph node. The surgical margins were negative for tumor. CONCLUSION: We present a successful surgical outcome of a robotic retrocaval metastasectomy for recurrent RCC, chromophobe type. At the time of publication, the patient continues to remain cancer free. Incorporating the da Vinci robotic platform allows for excellent visualization and access to difficult surgical locations while providing patients with the least invasive approach. A high degree of robotic experience is necessary before attempting this procedure, given the adherence of the mass to the inferior vena cava and duodenum.

Robotic Salvage Pyeloplasty With Buccal Mucosal Onlay Graft: Video Demonstration of Technique and Outcomes.

OBJECTIVE: To present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty as an alternative in the management of a recurrent ureteropelvic junction (UPJ) obstruction. METHODS: We present 2 patients with a recurrent UPJ obstruction who had previously undergone 2 prior open or robotic pyleoplasties, followed by endoscopic management. Preoperative imaging was obtained before surgical repair. The UPJ was incised and the incision extended to reveal margins of a healthy normal-caliber ureteral tissue. Single BMGs were harvested from the inner cheek of each patient. The grafts were of sufficient caliber and size to cover the entire defect as an onlay graft, and to maintain a tension-free and watertight anastomosis. RESULTS: The operative time was between 188 and 284 minutes. The estimated blood loss was 25-50 mL. The hospital stay was 2 days for each patient. Foley catheters were removed before discharge and the Jackson-Pratt drains were removed in the immediate postoperative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency at the UPJ. Lasix renograms were obtained after 4 months and either demonstrated a resolution or were equivocal for obstruction, with a preservation of renal function. Both patients have been without complication since the stent removal. CONCLUSION: Robotic pyeloplasty with BMG is an alternative in the management of recurrent UPJ obstructions. Short-term follow-up has demonstrated that it is an effective and attractive approach compared with more extensive and invasive surgeries such as a renal autotransplant and an ileal ureter.

Safety and Surgical Outcomes of Same-day Anterior Urethroplasty.

OBJECTIVE: To evaluate the safety and feasibility of same-day anterior urethroplasty at our institution and define predictors of postoperative admission and surgical failure. METHODS: We retrospectively reviewed the charts of 118 consecutive anterior urethroplasties performed at a tertiary care center. Data were analyzed to detect predictors of postoperative admission and urethroplasty failure. The 30-day complications and long-term outcomes were compared between same-day and admitted patients. RESULTS: Ninety-two patients (78%) were discharged on the day of surgery. A penile stricture location compared with a bulbar stricture location (odds ratio: 13.4, P = .009) and having undergone more than 3 prior endoscopic stricture interventions (odds ratio: 10.2, P = .001) were significantly associated with postoperative admission. Patients with a ventral onlay approach were more likely to be discharged home (P = .03), whereas patients with combined repairs were more likely to be admitted (P = .04). Same-day urethroplasty did not increase 30-day postoperative complications, patient emergency room visits, unplanned clinic visits, or phone calls. Success rates did not differ between same-day (89%) and admitted (79%) cohorts, and no individual stricture characteristic was predictive of urethroplasty failure. CONCLUSION: Same-day anterior urethroplasty is safe and feasible and could help increase utilization of urethroplasty for urethral stricture disease.

Role of glycine in nociceptive and non-nociceptive bladder reflexes and pudendal afferent inhibition of these reflexes in cats.

AIM: This study examined the role of glycinergic transmission in nociceptive and non-nociceptive bladder reflexes and in inhibition of these reflexes by pudendal nerve stimulation (PNS). METHODS: Cystometrograms (CMGs) were performed in α-chloralose anesthetized cats by intravesical infusion of saline or 0.25% acetic acid (AA) to trigger, respectively, non-nociceptive or nociceptive bladder reflexes. PNS at 2 or 4 times threshold (T) intensity for inducing anal twitch was used to inhibit the bladder reflexes. Strychnine (a glycine receptor antagonist) was administered in cumulative doses (0.001-0.3 mg/kg, i.v.) at 60-120 min intervals. RESULTS: Strychnine at 0.001-0.3 mg/kg significantly (P < 0.05) increased bladder capacity and reduced contraction amplitude during saline CMGs but did not change these parameters during AA CMGs except at the 0.3 mg/kg dose which increased bladder capacity. Strychnine did not alter PNS inhibition during saline CMGs except at the highest dose at 2T intensity, but significantly (P < 0.05) suppressed PNS inhibition during AA CMGs after 0.001-0.003 mg/kg doses at 2T and 4T intensities. During AA CMGs strychnine (0.3 mg/kg) also unmasked a post-PNS excitatory effect that significantly reduced bladder capacity after termination of PNS. CONCLUSIONS: Glycinergic inhibitory neurotransmission in the central nervous system plays an unexpected role to tonically enhance the magnitude and reduce the bladder volume threshold for triggering the non-nociceptive bladder reflex. This is attributable to inhibition by glycine of another inhibitory mechanism. Glycine also has a minor role in PNS inhibition of the nociceptive bladder reflex. Neurourol. Urodynam. 35:798-804, 2016. © 2015 Wiley Periodicals, Inc.

Inflammatory myofibroblastic tumor of the bladder masquerading as eosinophilic cystitis: case report and review of the literature.

A 9-year-old boy presented with gross hematuria of 2 days duration. Cystoscopic evaluation revealed an anterior bladder mass. Pathology was consistent with eosinophilic cystitis, and a steroid regimen was initiated accordingly, but no improvement ensued. Concern for alternate malignant pathology led to open resection and the ultimate diagnosis of inflammatory myofibroblastic tumor of the bladder. Inflammatory myofibroblastic tumor is a rare tumor of the bladder in children and to our knowledge has not previously been associated with a misleading eosinophil-rich mucosal inflammatory response.

Role of spinal metabotropic glutamate receptor 5 in pudendal inhibition of the nociceptive bladder reflex in cats.

This study examined the role of spinal metabotropic glutamate receptor 5 (mGluR5) in the nociceptive C-fiber afferent-mediated spinal bladder reflex and in the inhibtion of this reflex by pudendal nerve stimulation (PNS). In α-chloralose-anesthetized cats after spinal cord transection at the T9/T10 level, intravesical infusion of 0.25% acetic acid irritated the bladder, activated nociceptive C-fiber afferents, and induced spinal reflex bladder contractions of low amplitude (<50 cmH2O) and short duration (<20 s) at a smaller bladder capacity ∼80% of saline control capacity. PNS significantly (P < 0.01) increased bladder capacity from 85.5 ± 10.1 to 137.3 ± 14.1 or 148.2 ± 11.2% at 2T or 4T stimulation, respectively, where T is the threshold intensity for PNS to induce anal twitch. MTEP {3-[(2-methyl-4-thiazolyl)ethynyl]pyridine; 3 mg/kg iv, a selective mGluR5 antagonist} completely removed the PNS inhibition and significantly (P < 0.05) increased bladder capacity from 71.8 ± 9.9 to 94.0 ± 13.9% of saline control, but it did not change the bladder contraction amplitude. After propranolol (3 mg/kg iv, a ß1/ß2-adrenergic receptor antagonist) treatment, PNS inhibition remained but MTEP significantly (P < 0.05) reduced the bladder contraction amplitude from 18.6 ± 2.1 to 6.6 ± 1.2 cmH2O and eliminated PNS inhibition. At the end of experiments, hexamethonium (10 mg/kg iv, a ganglionic blocker) significantly (P < 0.05) reduced the bladder contraction amplitude from 20.9 ± 3.2 to 8.1 ± 1.5 cmH2O on average demonstrating that spinal reflexes were responsible for a major component of the contractions. This study shows that spinal mGluR5 plays an important role in the nociceptive C-fiber afferent-mediated spinal bladder reflex and in pudendal inhibition of this spinal reflex.

Effects of duloxetine and WAY100635 on pudendal inhibition of bladder overactivity in cats.

This study was aimed at determining the effect of duloxetine (a serotonin-norepinephrine reuptake inhibitor) on pudendal inhibition of bladder overactivity. Cystometrograms were performed on 15 cats under α-chloralose anesthesia by infusing saline and then 0.25% acetic acid (AA) to induce bladder overactivity. To inhibit bladder overactivity, pudendal nerve stimulation (PNS) at 5 Hz was applied to the right pudendal nerve at two and four times the threshold (T) intensity for inducing anal twitch. Duloxetine (0.03-3 mg/kg) was administered intravenously to determine the effect on PNS inhibition. AA irritation significantly (P < 0.01) reduced bladder capacity to 27.9 ± 4.6% of saline control capacity. PNS alone at both 2T and 4T significantly (P < 0.01) inhibited bladder overactivity and increased bladder capacity to 83.6 ± 7.6% and 87.5 ± 7.7% of saline control, respectively. Duloxetine at low doses (0.03-0.3 mg/kg) caused a significant reduction in PNS inhibition without changing bladder capacity. However, at high doses (1-3 mg/kg) duloxetine significantly increased bladder capacity but still failed to enhance PNS inhibition. WAY100635 (N-[2-[4-(2-methoxyphenyl)-1-piperazinyl]ethyl]-N-(2-pyridyl)cyclohexanecarboxamide; a 5-HT1A receptor antagonist, 0.5-1 mg/kg i.v.) reversed the suppressive effect of duloxetine on PNS inhibition and significantly (P < 0.05) increased the inhibitory effect of duloxetine on bladder overactivity but did not enhance the effect of PNS. These results indicate that activation of 5-HT1A autoreceptors on the serotonergic neurons in the raphe nucleus may suppress duloxetine and PNS inhibition, suggesting that the coadministration of a 5-HT1A antagonist drug might be useful in enhancing the efficacy of duloxetine alone and/or the additive effect of PNS-duloxetine combination for the treatment of overactive bladder symptoms.

Timing and predictors for urinary drainage in children with expectantly managed grade IV renal trauma.

PURPOSE: We determined which children sustaining blunt grade IV renal trauma are at greatest risk for failing nonoperative management and in what time frame they will likely present. MATERIALS AND METHODS: We retrospectively reviewed children presenting with nonvascular grade IV blunt renal trauma between 2003 and 2012. We compared characteristics on computerized tomography, reasons for intervention, type and timing of surgery, length of hospital stay and need for readmission between children undergoing early intervention (less than 72 hours after admission) and those managed conservatively (with any subsequent intervention undertaken more than 72 hours after admission). RESULTS: A total of 26 children were identified with nonvascular grade IV blunt renal trauma. Conservative management was attempted in 16 cases (62%). Seven of these patients (44%) required intervention (ureteral stent and/or percutaneous drain placement), with a mean time to intervention of 11 days. Collecting system clot and larger urinoma (1.45 cm in cases with successful and 4.29 cm in those with failed conservative management) significantly predicted failure of conservative management (p<0.05). Presence of dissociated renal fragments (57% vs 11%) and interpolar contrast extravasation (57% vs 0%) were increased in the early intervention group compared to the conservatively managed group (p>0.05), as was rehospitalization (43% vs 0%), mean length of stay (7.9 vs 5.4 days) and transfusion (14% vs 0%, p>0.05). CONCLUSIONS: Collecting system hematoma and urinoma size significantly predicted failure of conservative management, with a mean time to intervention of 11 days. Children with failed conservative management had a greater incidence of dissociated renal fragments and interpolar extravasation. Early identification of these patients may decrease hospital readmissions, length of stay and prolonged morbidity.

Role of spinal GABAA receptors in pudendal inhibition of nociceptive and nonnociceptive bladder reflexes in cats.

Picrotoxin, an antagonist for γ-aminobutyric acid receptor subtype A (GABAA), was used to investigate the role of GABAA receptors in nociceptive and nonnociceptive reflex bladder activities and pudendal inhibition of these activities in cats under α-chloralose anesthesia. Acetic acid (AA; 0.25%) was used to irritate the bladder and induce nociceptive bladder overactivity, while saline was used to distend the bladder and induce nonnociceptive bladder activity. To modulate the bladder reflex, pudendal nerve stimulation (PNS) was applied at multiple threshold (T) intensities for inducing anal sphincter twitching. AA irritation significantly (P < 0.01) reduced bladder capacity to 34.3 ± 7.1% of the saline control capacity, while PNS at 2T and 4T significantly (P < 0.01) increased AA bladder capacity to 84.0 ± 7.8 and 93.2 ± 15.0%, respectively, of the saline control. Picrotoxin (0.4 mg it) did not change AA bladder capacity but completely removed PNS inhibition of AA-induced bladder overactivity. Picrotoxin (iv) only increased AA bladder capacity at a high dose (0.3 mg/kg) but significantly (P < 0.05) reduced 2T PNS inhibition at low doses (0.01-0.1 mg/kg). During saline cystometry, PNS significantly (P < 0.01) increased bladder capacity to 147.0 ± 7.6% at 2T and 172.7 ± 8.9% at 4T of control capacity, and picrotoxin (0.4 mg it or 0.03-0.3 mg/kg iv) also significantly (P < 0.05) increased bladder capacity. However, picrotoxin treatment did not alter PNS inhibition during saline infusion. These results indicate that spinal GABAA receptors have different roles in controlling nociceptive and nonnociceptive reflex bladder activities and in PNS inhibition of these activities.