Case Report: Epididymo-Orchitis due to Mycobacterium tuberculosis.

Genitourinary tuberculosis (TB) is a rare but well-described form of extrapulmonary TB. We present a case of a 35-year-old man from Ethiopia with scrotal swelling and fever who was found to have epididymo-orchitis due to Mycobacterium tuberculosis. The patient presented to the hospital multiple times before undergoing operative debridement with fine needle aspiration and tissue biopsy to confirm the diagnosis. He improved with antituberculous therapy. Patients with TB risk factors presenting with epididymitis that is refractory to empiric antibiotic therapy warrant consideration of TB epididymitis. Our case demonstrates the high index of suspicion required to establish a diagnosis of genitourinary TB.

Factors that impact the outcome of minimally invasive pyeloplasty: results of the Multi-institutional Laparoscopic and Robotic Pyeloplasty Collaborative Group.

PURPOSE: We compared laparoscopic and robotic pyeloplasty to identify factors associated with procedural efficacy. MATERIALS AND METHODS: We conducted a retrospective multicenter trial incorporating 865 cases from 15 centers. We collected perioperative data including anatomical and procedural factors. Failure was defined subjectively as pain that was unchanged or worse per medical records after surgery. Radiographic failure was defined as unchanged or worsening drainage on renal scans or worsening hydronephrosis on computerized tomography. Bivariate analyses were performed on all outcomes and multivariate analysis was used to assess factors associated with decreased freedom from secondary procedures. RESULTS: Of the cases 759 (274 laparoscopic pyeloplasties with a mean followup of 15 months and 465 robotic pyeloplasties with a mean followup of 11 months, p <0.001) had sufficient data. Laparoscopic pyeloplasty, previous endopyelotomy and intraoperative crossing vessels were associated with decreased freedom from secondary procedures on bivariate analysis, with a 2-year freedom from secondary procedures of 87% for laparoscopic pyeloplasty vs 95% for robotic pyeloplasty, 81% vs 93% for patients with vs without previous endopyelotomy and 88% vs 95% for patients with vs without intraoperative crossing vessels, respectively. However, on multivariate analysis only previous endopyelotomy (HR 4.35) and intraoperative crossing vessels (HR 2.73) significantly impacted freedom from secondary procedures. CONCLUSIONS: Laparoscopic and robotic pyeloplasty are highly effective in treating ureteropelvic junction obstruction. There was no difference in their abilities to render the patient free from secondary procedures on multivariate analysis. Previous endopyelotomy and intraoperative crossing vessels reduced freedom from secondary procedures.

Systematic evaluation of a novel foot-pump ureteroscopic irrigation system.

INTRODUCTION: To evaluate forces exerted on a stone with different ureteroscopic irrigation systems. METHODS: A 3 mm steel simulated stone was welded to a 3F stone basket and inserted into the working channel of a 4.5F Wolf semirigid ureteroscope. The basket shaft was attached to a 50 g load cell. The urterescope was placed in a ureteral model (14F silicon tubing). Simulated blood (McCormick™ Red Dye, 1 dye drop/15 mL H(2)O) was dripped adjacent to the stone at 12 drops/min. Endoirrigation devices were attached to the ureterscope and irrigation was applied at a rate sufficient to maintain visualization of the stone. Force on the stone was measured with the following endoirrigation systems: Boston Scientific™ Single-Action-Pump System (SAP) hand-pump and NuVista Medical™ Flo-Assist(®) foot-pump. RESULTS: No significant difference (p=0.19) in the number of pumps required to maintain a clear endoscopic field was found between the SAP (0.20±0.075/second) and Flo-Assist device (0.25±0.056/second). The pump duration of the Flo-Assist was found to be less (1.12±0.40 seconds) than the SAP (1.35±0.31 seconds), but not significantly different (p=0.24). The average maximum impulse was significantly lower (p=0.0002) for the SAP (8.34×10(-5) Ns) than the Flo-Assist (1.96×10(-3) Ns). Total maximum impulse (2.02×10(-5) Ns) for the SAP and total average impulse (5.51×10(-6) Ns) were found to be lower than the Flo-Assist device. The Flo-Assist had a total maximum impulse of 4.49×10(-4) Ns and total average impulse of 8.85×10(-6) Ns, however, these differences were not statistically significant. CONCLUSION: The hand-pump (SAP) and foot-pump (Flo-Assist) irrigation devices tested require comparable amounts of pumps for similar durations of time to maintain endoscopic visualization. Overall, the SAP device exerts less average maximum force on the stone than the Flo-Assist device.

Intermediate-term outcomes after renal cryoablation: results of a multi-institutional study.

PURPOSE: To present intermediate-term oncologic efficacy of cryoablation (CA) for the treatment of patients with small renal masses in a multi-institution multisurgeon cohort. PATIENTS AND METHODS: We retrospectively reviewed billing records and tumor registries, identifying 116 renal tumors in 116 patients treated with CA by six surgeons at four institutions. Patient age, sex, tumor size, RENAL nephrometry score, complications, and recurrences were recorded. RESULTS: One hundred-sixteen patients (66.4% male, 33.6% female) with 116 tumors underwent renal mass CA with a mean follow-up of 27.4 months (range 1-112 mos). Mean tumor size was 2.76 ± 0.97 cm (range 1.1-5.5 cm). Twenty-seven complications occurred in 23 patients for an overall complication rate of 19.8%. Low-grade complications (Clavien I and II) accounted for 92.6% (n=25) of overall complications. Seven (6%) patients had enhancement on initial imaging and were considered incomplete ablations. Local recurrence and metastatic disease developed in four and one patients, respectively. In patients with biopsy-proven renal-cell carcinoma (RCC), the 2- and 5-year recurrence-free survival (RFS) probability was 0.83 (95% confidence interval [CI]: 0.74, 0.95) and 0.77 (95% CI: 0.60, 0.94), respectively. After excluding biopsy proven RCC patients with incomplete ablations, the 2- and 5-year RFS increased to 0.91 (95% CI: 0.82, 1.00) and 0.85 (95% CI: 0.71, 1.00) respectively. CONCLUSION: CA of renal masses results in acceptable oncologic efficacy accompanied by a tolerable complication profile in a cohort with a mean follow-up of 27.4 months. CA remains a viable treatment option for small renal masses in selected patients.

Oxalobacter colonization in the morbidly obese and correlation with urinary stone risk.

OBJECTIVE: To establish the baseline preoperative prevalence of Oxalobacter formigenes (OF) colonization in a cohort of obese patients scheduled for Roux-en-Y gastric bypass (RYGB) and determine the effect of OF colonization on urinary oxalate excretion. It has been proposed that loss of OF colonization after RYGB may contribute to the development of hyperoxaluria. METHODS: Adult patients scheduled to undergo RYGB were requested to provide a stool specimen and 24-hour urine collection before surgery. OF colonization status was determined by the calcium precipitation test. The 24-hour urine specimens were analyzed by the Litholink Corporation (Chicago, IL). RESULTS: Of the 51 patients submitting initial stool specimens, only 8 (16%) tested positive for OF, whereas 43 (84%) were negative. Patients colonized with OF were older than uncolonized subjects (52.9±6.8 vs 46.0±10.4 years, P=.03). Urinary oxalate was not significantly different between these groups (P=.14). CONCLUSION: OF colonization is uncommon in morbidly obese patients (16%) before surgery. Because hyperoxaluria develops in more than 50% of patients after RYGB, it is unlikely that loss of OF colonization is the primary cause.

Quality of evidence to compare outcomes of open and robot-assisted laparoscopic prostatectomy.

Robot-assisted laparoscopic radical prostatectomy (RALP) has gained widespread acceptance in the treatment of prostate cancer. While it increasingly is becoming the surgical approach of choice in many centers, limited data exist directly comparing it to radical retropubic prostatectomy (RRP). This review examines the evidence comparing RALP to RRP. The outcomes evaluated are arranged into perioperative, oncologic, and functional outcomes. Of the 21 publications meeting our selection criteria, Level II, III, and IV evidence were found in 9, 1, and 11 articles, respectively. Overall, RALP was associated with lower blood loss, transfusion rates, length of stay, and higher cost when compared to RRP. Definitive conclusions regarding complications and oncologic and functional outcomes are not yet possible, and will require longer-term follow-up and well-designed randomized controlled trials.

Current and future technology for minimally invasive ablation of renal cell carcinoma.

PURPOSE OF REVIEW: To provide an overview of the technologic advancements in the field of ablative therapy, focusing on the treatment of renal neoplasms. MATERIALS AND METHODS: A MEDLINE search was performed using each specific ablative technique name as the search term. Articles written in the English language were selected for review. In cases of multiple reports by a single institution, the most recent report was utilized. Pertinent articles specific to the technologic advancement in ablative therapy were selected for review. RECENT FINDINGS: Intermediate-term oncologic outcomes of radiofrequency ablation (RFA) and cryoablation (CA) for the treatment of small renal masses are encouraging. For thermal therapies, molecular adjuvants to enhance cellular kill and local control have been developed. Improvements in microwave technology have allowed for reductions in antenna size and increases in ablation size. Laparoscopic high-intensity focused ultrasound (HIFU) probes have been developed to overcome the limitations of transcutaneous energy delivery, but HIFU remains experimental for the treatment of renal lesions. Irreversible electroporation (IRE), a novel nonthermal ablative technique, is currently undergoing clinical investigation in human subjects. Histotripsy causes mechanical destruction of targeted tissue and shows promise in treating renal and prostate pathology. SUMMARY: Ablative techniques are commonly utilized in the primary treatment of urologic malignancies. The purpose of this review is to discuss technologic advances in ablative therapies with emphasis on the treatment of renal masses. RFA and CA show acceptable intermediate-term efficacy and technical refinement continues. Emerging technologies, including microwave thermotherapy, IRE, HIFU and histotripsy, are described with emphasis on the mechanism of cellular kill, energy delivery, and stage in clinical development.

Hyperoxaluria is a long-term consequence of Roux-en-Y Gastric bypass: a 2-year prospective longitudinal study.

BACKGROUND: Recent studies suggest that patients undergoing Roux-en-Y gastric bypass (RYGB) for morbid obesity are at risk for hyperoxaluria, nephrolithiasis, and oxalate nephropathy. Our objective was to conduct a long-term prospective longitudinal study to establish the incidence, clinical progression, and severity of hyperoxaluria after RYGB. STUDY DESIGN: Patients undergoing RYGB between December 2005 and April 2007 provided 24-hour urine collections for comprehensive stone risk analysis 1 week before and 3 months and 1 and 2 years after surgery. Primary outcomes were changes in 24-hour urinary oxalate excretion and relative supersaturation of calcium oxalate from baseline to 2 years post-RYGB. RESULTS: The cohort consisted of 21 patients, including 5 (24%) men and 16 (76%) women. Mean preoperative age and body mass index (calculated as kg/m(2)) were 48.2 +/- 10.5 years (range 25 to 64 years) and 50.5 +/- 9.1 (range 39.7 to 66.6), respectively. Urinary oxalate excretion increased significantly after RYGB (33 +/- 9 mg/day versus 63 +/- 29 mg/day; p

Roux-en-Y gastric bypass is associated with early increased risk factors for development of calcium oxalate nephrolithiasis.

BACKGROUND: Patients treated for obesity with jejunoileal bypass (JIB) experienced a marked increased risk of hyperoxaluria, nephrolithiasis, and oxalate nephropathy developing. Jejunoileal bypass has been abandoned and replaced with other options, including Roux-en-Y gastric bypass (RYGB). Changes in urinary lithogenic risk factors after RYGB are currently unknown. Our purpose was to determine whether RYGB is associated with elevated risk of developing calcium oxalate stone formation through increased urinary oxalate excretion and relative supersaturation of calcium oxalate. STUDY DESIGN: A prospective longitudinal cohort study of 24 morbidly obese adults (9 men and 15 women) recruited from a university-based bariatric surgery clinic scheduled to undergo RYGB between December 2005 and April 2007. Patients provided 24-hour urine collections for analysis 7 days before and 90 days after operation. Primary outcomes were changes in 24-hour urinary oxalate excretion and relative supersaturation of calcium oxalate from baseline to 3 months post-RYGB. RESULTS: Compared with their baseline, patients undergoing RYGB had increased urinary oxalate excretion (31 +/- 10 mg/d versus 41 +/- 18 mg/d; p = 0.026) and relative supersaturation of calcium oxalate (1.73 +/- 0.81 versus 3.47 +/- 2.59; p = 0.030) 3 months post-RYGB in six patients (25%). De novo hyperoxaluria developed. There were no preoperative patient characteristics predictive of development of de novo hyperoxaluria or the magnitude of change of daily oxalate excretion. CONCLUSIONS: This prospective study indicates that RYGB is associated with an earlier increase in urinary oxalate excretion and relative supersaturation of calcium oxalate than previously reported. Additional studies are needed to determine longterm post-RYGB changes in urinary oxalate excretion and identify patients that might be at risk for hyperoxaluria developing.

Lithogenic risk factors in the morbidly obese population.

PURPOSE: To our knowledge baseline lithogenic risk factors in the morbidly obese population are currently unknown. Prior studies evaluated known stone formers and correlated risk with increasing body mass index. We describe risk factors for urinary stone formation in a group of unselected morbidly obese patients. MATERIALS AND METHODS: Patients scheduled for gastric bypass provided a 24-hour urine collection before surgery. Patient demographics, medications and supplement consumption were recorded. A dietary intake diary was converted into daily kcal, Ca, Na and protein consumption. Differences between groups based on gender, history of diabetes or nephrolithiasis, diuretic use and Ca supplementation were evaluated. Correlation of stone risk parameters with body mass index was evaluated. RESULTS: A total of 45 patients provided samples for analysis. Mean +/- SD body mass index was 49.5 +/- 9.1 kg/m(2) and mean age was 47.0 +/- 10.5 years. Overall 97.8% of patients had at least 1 lithogenic risk factor identified. Low urinary volume was the most common abnormality, affecting 71.1% of patients. Male patients excreted significantly more Ox (p = 0.0014), Na (p = 0.020), PO(4) (p = 0.0083) and SO(4) (p = 0.0014) than females. Patients with a history of nephrolithiasis excreted significantly more oxalate (p = 0.018) and had higher relative Na urate supersaturation (p = 0.00093) than nonstone formers. Hydrochlorothiazide use was associated with significantly increased Na urate relative supersaturation (p = 0.0097). Increasing body mass index was inversely associated with Mg (r = -0.38, p = 0.01) and brushite (r = -0.30, p = 0.04). CONCLUSIONS: Of our cohort of morbidly obese patients 98% had at least 1 lithogenic risk factor identified on 24-hour urine collection. This study identified a high urinary stone risk in the morbidly obese and suggests possible avenues for dietary and/or pharmacological preventive measures. Future studies will determine how bariatric surgery alters these risk factors.

The relationship between renal tumor size and metastases in patients with von Hippel-Lindau disease.

PURPOSE: Patients with von Hippel-Lindau disease are at risk for multiple, bilateral, recurrent renal tumors and metastases. We previously evaluated the relationship between tumor size and metastases in families with hereditary renal cancer. We update our findings with about twice the number of patients with von Hippel-Lindau disease. MATERIALS AND METHODS: Screening affected kindred or retrospective review of medical records identified 181 patients with von Hippel-Lindau disease and renal cell carcinoma. Patients with small tumors were followed with serial imaging until the largest tumor reached 3 cm, at which point surgery was recommended. Surgical resection was recommended to patients with tumors larger than 3 cm. Patients not undergoing screening often had large renal tumors. RESULTS: A total of 108 patients with von Hippel-Lindau disease and solid renal tumors on computerized tomography imaging smaller than 3 cm (group 1) were followed a mean of 58 months (range 0 to 244). Metastatic disease did not develop in any of these patients. Renal tumors larger than 3 cm developed in 73 patients with von Hippel-Lindau disease (group 2). Mean followup of group 2 was 72.9 months (range 0 to 321). The proportion of procedures that were nephron sparing was higher in group 1 than in group 2 (120 of 125 [97%] compared to 85 of 125 [69%], Fisher's exact test p <0.0001). Metastases developed in 20 of 73 (27.4%) patients in group 2. The frequency of renal tumor metastases increased with increasing tumor size. CONCLUSIONS: No renal tumor metastases were found in patients with renal tumors less than 3 cm in diameter. We advocate a 3 cm threshold for parenchymal sparing surgery in patients with von Hippel-Lindau disease to decrease the risk of metastatic disease while preserving renal function, avoiding or delaying the need for dialysis and/or renal transplant, and decreasing the number of operations which a patient may undergo. We stress the importance of early screening in the kindred of patients with von Hippel-Lindau disease and vigilant followup thereafter.