Bladder neck and urethral erosions after Macroplastique injections.

AIMS: To evaluate the presentation, risk factors, diagnostic workup, management, and outcomes of Macroplastique (MPQ) erosions. METHODS: We performed a retrospective chart review of women experiencing MPQ erosion at two tertiary care centers (United States and United Kingdom). Data collected included age, presenting symptoms, parity, comorbidities, hormone replacement therapy, sexual activity, and smoking status. Previous surgical history, time from MPQ injection, urine culture results, and cystoscopic and imaging findings were also reviewed. Development of stress urinary incontinence (SUI) after MPQ removal and subsequent SUI treatments were recorded. RESULTS: From 2012 to 2018, 18 patients were identified with a median follow-up time of 24 months (interquartile range [IQR] 8-33). All patients presented with recurrent urinary tract infections (rUTI) and had cystoscopic evidence of MPQ erosion. The most common location of erosion was the bladder neck area (72%). Median time to presentation since MPQ injection was 14 months (IQR 11-35). The majority of patients (72%) had a previous history of anti-incontinence surgery. The overall success rate of endoscopic management defined as resolution of presenting symptoms including rUTI was 80%. The majority of patients (80%) developed recurrent SUI following MPQ resection with 33% requiring a subsequent autologous fascial sling placement. CONCLUSION: MPQ erosions present predominantly with UTI, sometimes years after the original injection, and may necessitate endoscopic management with satisfactory results in most patients. Following excision of MPQ, these patients are highly likely to experience SUI recurrence and need to be appropriately counseled. Some may require additional subsequent autologous fascial sling placement for treatment of their SUI symptoms.

Analysis of Mechanical Forces Used During Laparoscopic Training Procedures.

OBJECTIVE: To assess the significance of a surgeon's experience on the mechanical forces applied to tissues through laparoscopic instruments. MATERIALS AND METHODS: A total of 34 participants were enrolled into the study (8 experts, 10 intermediates, and 16 novices). Laparoscopic graspers with a sensing module to detect load were used by participants to carry out six ex vivo tasks: to grasp a porcine ureter in three positions either 1, 5, or 10 times, in turn, with both dominant and nondominant hands. The data were logged and recorded by a custom data acquisition software to calculate the peak force (Fmax) and mean force (Frms). RESULTS: Significant correlation was observed between Fmax and Frms (Pearson correlation, r = 0.97, p < 0.0005). No statistical significant difference was observed when comparing the effect of the three different tasks on peak force (F(2,1084) = 0.28, p = 0.753). There was a statistically significant difference in mechanical forces applied with those more experienced applying consistently lower mechanical forces (F(2,1084) = 21.36, p < 0.0005). In individual training groups, the effect of dominant hand was significant in the novice (significantly lower, F(1,510) = 6.70, p = 0.010) and consultants (significantly higher, F(1,250) = 9.601, p < 0.020) with the intermediate group showing no significant difference between the hands. CONCLUSION: Outcomes have suggested a relationship between the training level of the surgeon and the forces imparted on the tissue. This demonstrates a need for further training in surgeons until a consistent low force can be applied to tissues. Whether such measures could be used as an indicator of surgeon proficiency is unclear; however, it has the potential to be used to determine whether more training is needed for surgeons.

Adenine Phosphoribosyltransferase Deficiency: A Rare Cause of Recurrent Urolithiasis.

Background: Recurrent urolithiasis is troublesome for both patient and clinician, and in most cases, an underlying cause is not found. An important and underdiagnosed cause is adenine phosphoribosyltransferase (APRT) deficiency that gives rise to 2,8-dihydroxyadenine (2,8-DHA) stones. If diagnosed early, patient morbidity as well as the financial cost of treating stone recurrence can be avoided with simple medical therapy. Case Presentation: A 36-year-old white, Caucasian male with recurrent urolithiasis was found to have 2,8-DHA stones. This was difficult to manage, as these stones were often large, bilateral, matrix in structure, and translucent on plain X-rays. He underwent a multitude of interventions including both retrograde and anterograde endoscopic approaches as well as extracorporeal shock wave lithotripsy. The specific stone type was eventually discovered through infrared spectroscopy and he was promptly commenced on allopurinol, which significantly improved his stone burden and frequency of presentation with renal colic. Conclusion: APRT deficiency is underdiagnosed given the estimated prevalence of 1/50,000-1/100,000, however, with less than 300 reported cases worldwide. This is likely because of both a lack of awareness of the disorder among clinicians and the challenges of identifying 2,8-DHA stones. Increasing awareness of 2,8-DHA urolithiasis among urologists as well as physicians is, therefore, key in tackling this condition.