Long-term Follow Up of Ileal Ureteral Replacement for Complex Ureteral Strictures: Single Institution Study.

OBJECTIVE: To report our 16-year experience with ileal ureter interposition for complex ureteral stricture. Ureteral reconstruction continues to evolve to include less invasive techniques to successfully manage ureteral stricture. However, long, complex, obliterative and especially radiated ureteral strictures are not amenable to less invasive techniques and may require Ileal ureter interposition. MATERIALS AND METHODS: Retrospective review of a single institution's ureteral reconstruction database was performed. Demographics, operative details, success rate, complication rate, and length of follow-up were noted. Unilateral replacements utilized ileal ureteral interposition. Success rate was defined as no need for further open intervention. RESULTS: Between 2003 and 2019, 188 ureteral reconstructions were performed, of which 46 required ileal ureter interposition. Of these 46 patients, 10 required bilateral reconstruction. Average age was 53 years, 26 (57%) were female. The average stricture length was 9.1 cm (2-20 cm). Stricture etiology included iatrogenic causes (n = 24, 52%), radiation causes (n = 12; 26%), vascular disease (n = 3; 7%), and idiopathic retroperitoneal fibrosis (n = 3; 7%). Forty-three surgeries were performed by open abdominal approach; 3 were performed robotically. The average length of operation was 412 minutes, blood loss 417 mL and LOS was 10 days. At mean follow up of 4.4 years (1-16 years), overall success rate was 83%, with 17% (n = 8) patients requiring subsequent major surgery (5 successful ureteral revision, 3 nephrectomy) and 11 (24%) patients experiencing a major complication. CONCLUSION: In our long-term follow up of over 4 years, ileal ureteral interposition remains a successful option for complex ureteral strictures in properly selected patients.

Prospective study of the Transurethral Suprapubic endo-Cystostomy (T-SPEC(®)): an 'inside-out' approach to suprapubic catheter insertion.

OBJECTIVES: To prospectively evaluate the new medical device Transurethral Suprapubic endo-Cystostomy (T-SPeC(®)), used for suprapubic catheter (SPC) placement via the transurethral (inside-to-out) approach, and examine the 30-day outcomes in the first US series. METHODS: IRB approval was obtained for this prospective study. We evaluated the first 114 consecutive cases of SPC placement using the T-SPeC(®) device by a single surgeon at in a 20-month period. We excluded patients who underwent alternative approaches to suprapubic catheter placement including open abdominal approach (12) and percutaneous approach (5). Preoperative patient demographics, operative detail, success rate and 30-day complication rate were recorded. RESULTS: We successfully placed an 18 Fr suprapubic catheter using the T-SPeC(®) device in 98.2 % of patients. During the procedure, the capture housing was missed twice. The mean patient age was 56.6, BMI 29.4 kg/m(2), skin to bladder distance 6.7 cm and operative time 3.6 min. There were 12 postoperative complications within 30 days of the procedure including urinary tract infections (6), SPC exit site infection (2), SPC blockage (2) and catheter expulsion (2). There were no Clavien-Dindo grade III-IV complications such as re-operation, small bowel injury, hemorrhage or death. CONCLUSION: The T-SPeC(®) device is a novel, simple, accurate and minimally invasive device for SPC insertion from an inside-to-out approach. Our prospective study demonstrates that the T-SPeC(®) device can be placed safely and efficiently in a variety of patients with a need for urinary drainage.

Open reconstruction of recurrent vesicourethral anastomotic stricture after radical prostatectomy.

OBJECTIVES: To determine the outcomes of open vesicourethral anastomotic reconstruction (VUAR) for outlet stenosis following radical prostatectomy (RP). METHODS: Review of all cases of VUAR within an IRB-approved database was performed. Preoperative factors assessed included cancer treatment modality, duration of symptoms, prior treatments, and length of defect. Outcomes reviewed included length-of-stay (LOS), complications, maintenance of patency, continence, and need for additional procedures. RESULTS: Twelve cases of VUAR performed by a single surgeon (BJF) from 2004 to 2012 were identified. Surgical approaches were either abdominal (7), perineal (3), or abdominoperineal (2). All patients underwent prior RP, with 25 % having subsequent radiotherapy. Among patients with stenosis, 43 % were completely obliterated. Two cases had prior anastomotic disruption in the early postoperative period after RP. The median length of stenosis was 2.5 cm (range 1-5 cm) and median LOS was 3.0 days (range 1-7 days). At a median follow-up of 75.5 months (range 14-120 months), 92 % of men retained patency; only 25 % were continent. CONCLUSION: In experienced hands, VUAR can restore durable patency for men afflicted with outlet stenosis after RP. Despite anatomic restoration, incontinence is likely.

Robotic reconstruction of lower ureteral strictures.

Distal ureteral reconstruction is increasingly being performed by minimally-invasive surgical techniques. The robotic surgical platform provides an additional modality for repairing distal ureteral defects with the associated benefits of a minimally-invasive approach. This article reviews and describes the technical aspects of robotic distal ureteral reconstruction. In addition to discussion of the operative technique, factors such as patient selection, preoperative and postoperative evaluation, and published outcomes are addressed.

National semen analysis reference range reporting: adherence to the 1999 World Health Organization guidelines 10 years later.

OBJECTIVE: To determine the adherence by laboratories across the United States to the standard semen analysis guidelines and parameter reference ranges 10 years after being set by the World Health Organization (WHO) in 1999 and to compare compliance between regional laboratories vs. specialty assisted reproductive technology (ART) laboratories. DESIGN: Observational study. SETTING: Regional clinical and reproductive endocrinology andrology laboratories. INTERVENTION(S): Blank or deidentified semen analysis reports were collected from laboratories through direct contact or from reports received as part of clinical care for male infertility. MAIN OUTCOME MEASURE(S): Adherence to semen analysis reference range reporting as recommended by the 1999 WHO guidelines. RESULT(S): Semen analyses reports were collected from 111 laboratories from 31 different states. Of 111 laboratories, 26 (23%) reported all reference range parameters in accordance with the guidelines. Of 65 ART laboratories, 21 (32%) complied with all reference range parameters as outlined by the guidelines, vs. 5 of 46 non-ART laboratories (11%). Seventy percent of laboratories that did not report 1999 WHO parameters did so because of differences in reference values for normal morphology. CONCLUSION(S): Adherence to WHO 1999 semen analysis reference range guidelines has not been achieved by ART and non-ART laboratories 10 years after being introduced. Non-ART laboratories report reference ranges less accurately than ART laboratories.

Hsp90: a drug target?

Heat shock protein 90 (Hsp90) is a molecular chaperone involved in the trafficking of proteins in the cell. Under stressful conditions, Hsp90 stabilizes its client proteins and provides protection to the cell against cellular stressors such as in cancer cells. Disruption of Hsp90 leads to client protein degradation and often cell death. As Hsp90 has been found to be either overexpressed or constitutively more active in cancer cells, inhibitors of Hsp90 may have cancer cell selectivity. The N-terminal inhibitors, geldanamycin and radiciol, were the first two described inhibitors of Hsp90, but were not clinically useful. Subsequent analogues-17 allylamino-17demethoxygeldanamycin and 17 dimethylaminoethylamino-17-demethoxygeldanamycin-were found to be more clinically appropriate and have been studied in a number of clinical trials since 1999. In addition, to the N-terminal site of Hsp90, the C-terminal site appears to be another target for inhibition of Hsp90. More recently, inhibitors of the C terminus of Hsp90 have been developed and studied in vitro with promising results.

Risk factors and treatment success for ureteral obstruction after pediatric renal transplantation.

PURPOSE: Risk factors and treatment efficacy for ureteral obstruction following pediatric renal transplantation are poorly understood. We describe a single center experience with pediatric transplant recipients in an effort to discern risk factors and treatment efficacy. MATERIALS AND METHODS: We retrospectively reviewed the pediatric renal transplant database at our institution from January 1984 to March 2008. Donor and recipient demographics, treatment indications, graft characteristics, surgical techniques, treatment course, complications and graft outcomes were abstracted from clinical records. RESULTS: A total of 449 children (mean age 8.6 years) who underwent 526 renal transplants were included in the study. Ureteral obstruction requiring intervention developed in 42 cases (8%). Recipient age and gender, recipient and donor race, donor harvest technique, ureterovesical anastomosis with or without stenting, number of donor arteries, number of human leukocyte antigen mismatches, prior renal transplant and ischemia time were not significantly associated with increased incidence of ureteral obstruction. Renal failure secondary to posterior urethral valves was the only parameter significantly associated with increased incidence of ureteral obstruction (univariate OR 4.93, p = <0.0001; multivariate point estimate 7.59, p <0.0001). Of patients with ureteral obstruction 48% presented within 100 days after transplant. Kaplan-Meier analysis showed significantly decreased ureteral obstruction-free survival in patients with vs without posterior urethral valves (log rank test, p <0.0001). Ureteral obstruction, stenting and dilation were not significantly associated with increased graft loss or patient death. CONCLUSIONS: Ureteral obstruction after renal transplantation in children is a challenging complication that demands clinical vigilance. Posterior urethral valves appear to be a significant risk factor for post-transplant ureteral obstruction likely due to local factors such as ischemia, thick bladder wall and collagen remodeling.

The effect of a hyaluronan-carboxymethylcellulose membrane vs. polyglactin 910 mesh on intra-abdominal tumor formation in mice.

PURPOSE: Hyaluronan mediates growth of SW620 colon cancer cells. Because hyaluronan is the active ingredient in Seprafilm, we hypothesized that Seprafilm would affect intraperitoneal tumor growth in a mouse model of peritoneal seeding. METHODS: Immunodeficient mice underwent laparotomy and intraperitoneal inoculation of 10(5) SW620 cells. Seprafilm (n = 22), Vicryl mesh (foreign body control; n = 24), or no material (sham; n = 19) was placed under the incision. Mice were killed after four weeks and tumors were dissected, counted, and weighed. RESULTS: Ninety-five percent of mice in the sham group and 96 percent in the Vicryl group developed intraperitoneal tumors. In contrast, only 64 percent of mice in the Seprafilm group developed tumors (P = 0.024), and these tumors were smaller than those in the sham group; (Seprafilm = 42 +/- 9 mg vs. sham = 82 +/- 17 mg; P = 0.05). In contrast, tumors in the Vicryl group were dramatically larger (349 +/- 49 mg; P < 0.001 vs. sham or Seprafilm). CONCLUSIONS: Despite previous data that suggested that hyaluronan increases colon cancer cell growth, we found that Seprafilm decreased tumor formation and tended to decrease size in this model. In contrast, Vicryl mesh increased tumor formation and size. Our results suggest that Seprafilm does not promote intraperitoneal tumor growth, especially compared with Vicryl mesh.

Endoscopic findings in loin pain hematuria syndrome: concentric clot in calyceal fornices.

The loin pain hematuria syndrome (LPHS) creates a considerable burden, both for patients afflicted with the disease and for those involved in medical management and diagnosis. To date, the diagnosis of LPHS remains one of exclusion, with some speculation regarding the extent of actual pathology. We report ureteroscopic findings in 2 cases of LPHS. These findings provide objective confirmation of underlying pathology in a difficult-to-manage disease process.