The Management of Large Bladder Calculi by Utilizing Dual-Action Percutaneous Lithotripsy via Suprapubic Tube Sheath: A Novel Technique.

Bladder calculi commonly develop in patients with poor bladder emptying or those with retained foreign bodies within the bladder, leading to irritative voiding symptoms, hematuria, and an increased likelihood of refractory urinary tract infections. While many techniques exist for the treatment of bladder calculi, including endoscopic and open-surgical approaches, our novel technique may help manage exceptionally large or difficult-to-treat bladder calculi effectively. We present three patients with symptomatic bladder calculi ranging from 1.3 cm to 6.8 cm in size who were successfully treated by using our novel technique. Percutaneous access to the bladder was obtained by using a suprapubic catheter trocar and sheath to enable the utilization of a dual-action lithotriptor. Sheath insertion and lithotripsy were performed under direct visualization with a rigid cystoscope via the native urethra. This technique is easily learned and can be safely employed in patients in whom other methods may pose risks of higher morbidity.

Prostate Cancer Support Groups: The Unadvertised Camaraderie.

Prostate cancer (PCa), in particular, is known to cause significant psychosocial distress during the duration of a patient's treatment due to its uncertainty and demasculinizing side effects. Prostate cancer support groups (PCSGs) have been proven to be beneficial, yet are underutilized by the majority of PCa patients and physicians. A thorough review of the literature was performed for articles pertaining to prostate cancer support groups. We sought to identify factors contributing to the psychological burden of the disease, factors that influenced patients to join, and barriers to participation in a PCSG. Additionally, the characteristics and format of PCSGs, as well as outcomes (i.e. quality of life), were evaluated.

Factors Influencing Fluoroscopy Use During Ureteroscopy at a Residency Training Program.

Introduction: Ionizing radiation is used throughout urologic surgery and is known to cause a greater cancer risk with increasing exposure. The International Commission on Radiological Protection states that "it is the control of radiation dose that is important, no matter the source." However, there are few reports on the amount of radiation used by urology residents during ureteroscopy (URS). We present the largest database evaluating fluoroscopy (fluoro) use during URS at a resident training program. Our objective is to assess the amount of fluoro use at varying levels of experience and to identify factors that lead to increased fluoro use. Methods: Retrospective data from 242 URSs performed at two resident training sites were collected. In total, 105 surgeries were done by two attending physicians without and 137 surgeries with residents (Uro1-Uro3). Patient data were collected from the electronic medical record. Statistical analyses included analysis of variance, Spearman correlations, and multiple linear regression (MLR). Results: Comparisons between years 1 and 2 revealed significantly (p < 0.05) decreased fluoro time (20.0 seconds) and operative time (OT) (12.2 minutes) for the year 2 resident. Total OT was significantly (p < 0.05) decreased (11.1 minutes) for attending physicians operating on their own compared with a year 1 resident. Significant (p < 0.05) correlations with fluoro time were demonstrated for OT, stone size, ureteral dilation, ureteral access sheath use, presence of a preoperative stent, resident year, and resident month. OT, ureteral dilation, and a preoperative stent placement were significant predictors of fluoro time on MLR (p < 0.05). Conclusion: Fluoro time during retrograde URS was significantly reduced as residents gained more experience in the operating room. An increase in fluoro time was also associated with ureteral dilation, access sheath use, increasing stone size, and lack of prestenting. With knowledge of these factors, emphasis can be placed on using and teaching techniques that limit radiation exposure.

Extraordinarily Large Renal Cell Carcinoma With Metasynchronous Neuroendocrine Tumor of the Ileocecal Valve: A Rare Presentation of Disease.

A 71-year-old female presented with a large, protuberant abdominal mass, and was found to have both a left renal mass and a biopsy-proven neuroendocrine tumor of the ileocecal valve. Ultimately, right hemicolectomy revealed a well-differentiated and low-grade neuroendocrine tumor of the ileocecal valve, whereas left radical nephrectomy revealed a 23 cm × 22 cm × 15 cm renal cell carcinoma, chromophobe-type (RCC-CT) weighing 3564 g. RCC-CT represents a small portion of diagnosed RCC, and generally portends a more favorable prognosis than other variants. Modern reports of renal tumors exceeding 20 cm are exceedingly rare. In spite of massive size, favorable histology may allow for surgical cure.

Operative start times and complications after kidney transplantation.

The worldwide focus on work hour regulations and patient safety has led to the re-examination of the merits of night-time surgery, including kidney transplantation. The risks of operating during nontraditional work hours with potentially fatigued surgeons and staff must be weighed against the negative effects of prolonged cold ischemic time with resultant graft compromise. The aim of this study was to evaluate the impact of performing renal transplantation procedures during evening versus day time hours. The main outcome measures assessed between the day and night cohorts included comparisons of the postoperative complication rates and survival outcomes for both the renal allograft and the patient. A retrospective review of 633 deceased donor renal transplants performed at a single institution was analyzed. Three statistically significant results were noted, namely, a decrease in vascular complications in the nighttime cohort, an increase in urologic complications on subgroup analysis in the 3 AM to 6 AM cohort, and the 12 AM to 3 AM subgroup had the greatest odds of any complication. There was no statistical difference in either patient or graft survival over a twelve month period following transplantation. We conclude that although the complication rate varied among cohorts this was clinically insignificant and there was no overall clinically relevant impact on patient or graft survival.

Serum creatinine predicts success in retrograde ureteral stent placement in patients with pelvic malignancies.

OBJECTIVES: To evaluate serum hemoglobin, baseline serum creatinine, serum creatinine at the diagnosis of obstructive hydronephrosis, and the increase in serum creatinine greater than baseline to predict for success in retrograde ureteral stent placement in patients with pelvic malignancies. METHODS: In a retrospective chart review, we identified 57 patients at our institution with obstructive hydronephrosis secondary to pelvic malignancies in which retrograde ureteral stent placement was attempted from January 2002 to May 2005. The patient charts were reviewed for the baseline serum creatinine, preoperative serum creatinine and hemoglobin, and serum creatinine at presentation of obstructive hydronephrosis. This population was divided into group 1 (n = 31, 54%), in which retrograde stent placement was successful, and group 2 (n = 26, 46%), in which stent placement failed and subsequent percutaneous nephrostomy tube placement was required. The Student t test was used to determine whether a significant difference existed between the two groups for each laboratory parameter. RESULTS: The serum hemoglobin and baseline creatinine were not significantly different between the two groups and could not be used to predict for the success or failure of stent placement (P = 0.10 and P = 0.59, respectively). However, the average serum creatinine at presentation of obstructive hydronephrosis was significantly different between group 1 (2.4 +/- 1.4 ng/dL) and group 2 (5.3 +/- 6.3; P = 0.014), as was an increase in serum creatinine greater than baseline (P = 0.002). CONCLUSIONS: The results of this study have shown that the serum creatinine level at the presentation of obstructive hydronephrosis can be used to predict for success in retrograde ureteral stent placement in patients with pelvic malignancies.

Adjunctive use of AndroGel (testosterone gel) with sildenafil to treat erectile dysfunction in men with acquired androgen deficiency syndrome after failure using sildenafil alone.

OBJECTIVES: To evaluate whether combination therapy with testosterone gel (T-gel) and sildenafil citrate is effective in achieving adequate potency in subjects with low-normal serum testosterone levels in whom sildenafil alone has failed. METHODS: From July 2000 to June 2001, we evaluated 90 men (aged 32 to 72 years) in whom 3 months of sildenafil therapy at the maximal recommended dose (100 mg) with at least three attempts at intercourse during the 3-month period had failed. Of these, 24 men had testosterone levels less than 400 ng/dL (range 92 to 365, mean 231.4) and were subsequently started on 1% T-gel monotherapy (AndroGel, 5 g daily). After 4 weeks of T-gel alone (week 4), sildenafil citrate (Viagra, 100 mg) was added to the treatment regimen for an additional 12 weeks (through week 16). Potency was defined as the ability to have at least one episode of satisfactory intercourse during the treatment period. RESULTS: All the men had normalized serum testosterone levels after 4 weeks of T-gel monotherapy (range 424 to 596 ng/dL, mean 525). However, none of the men regained potency. At week 16, almost all (22 of 24, 92%) of the men reported improved potency with combination therapy. Improvement in erection quality was also observed. CONCLUSIONS: The results of this study support the use of T-gel with sildenafil citrate in men with low-normal serum testosterone levels in whom sildenafil alone fails. It also underscores the numbers of men with low to low-normal testosterone levels who would benefit from testosterone screening when evaluated for erectile dysfunction.

Levels of the origin-binding protein Double parked and its inhibitor Geminin increase in response to replication stress.

The regulation of a pre-replicative complex (pre-RC) at origins ensures that the genome is replicated only once per cell cycle. Cdt1 is an essential component of the pre-RC that is rapidly degraded at G1-S and also inhibited by Geminin (Gem) protein to prevent re-replication. We have previously shown that destruction of the Drosophila homolog of Cdt1, Double-parked (Dup), at G1-S is dependent upon cyclin-E/CDK2 and important to prevent re-replication and cell death. Dup is phosphorylated by cyclin-E/Cdk2, but this direct phosphorylation was not sufficient to explain the rapid destruction of Dup at G1-S. Here, we present evidence that it is DNA replication itself that triggers rapid Dup destruction. We find that a range of defects in DNA replication stabilize Dup protein and that this stabilization is not dependent on ATM/ATR checkpoint kinases. This response to replication stress was cell-type specific, with neuroblast stem cells of the larval brain having the largest increase in Dup protein. Defects at different steps in replication also increased Dup protein during an S-phase-like amplification cell cycle in the ovary, suggesting that Dup stabilization is sensitive to DNA replication and not an indirect consequence of a cell-cycle arrest. Finally, we find that cells with high levels of Dup also have elevated levels of Gem protein. We propose that, in cycling cells, Dup destruction is coupled to DNA replication and that increased levels of Gem balance elevated Dup levels to prevent pre-RC reformation when Dup degradation fails.

Drosophila double-parked is sufficient to induce re-replication during development and is regulated by cyclin E/CDK2.

It is important that chromosomes are duplicated only once per cell cycle. Over-replication is prevented by multiple mechanisms that block the reformation of a pre-replicative complex (pre-RC) onto origins in S and G2 phase. We have investigated the developmental regulation of Double-parked (Dup) protein, the Drosophila ortholog of Cdt1, a conserved and essential pre-RC component found in human and other organisms. We find that phosphorylation and degradation of Dup protein at G1/S requires cyclin E/CDK2. The N terminus of Dup, which contains ten potential CDK phosphorylation sites, is necessary and sufficient for Dup degradation during S phase of mitotic cycles and endocycles. Mutation of these ten phosphorylation sites, however, only partially stabilizes the protein, suggesting that multiple mechanisms ensure Dup degradation. This regulation is important because increased Dup protein is sufficient to induce profound rereplication and death of developing cells. Mis-expression has different effects on genomic replication than on developmental amplification from chorion origins. The C terminus alone has no effect on genomic replication, but it is better than full-length protein at stimulating amplification. Mutation of the Dup CDK sites increases genomic re-replication, but is dominant negative for amplification. These two results suggest that phosphorylation regulates Dup activity differently during these developmentally specific types of DNA replication. Moreover, the ability of the CDK site mutant to rapidly inhibit BrdU incorporation suggests that Dup is required for fork elongation during amplification. In the context of findings from human and other cells, our results indicate that stringent regulation of Dup protein is critical to protect genome integrity.

Drosophila minichromosome maintenance 6 is required for chorion gene amplification and genomic replication.

Duplication of the eukaryotic genome initiates from multiple origins of DNA replication whose activity is coordinated with the cell cycle. We have been studying the origins of DNA replication that control amplification of eggshell (chorion) genes during Drosophila oogenesis. Mutation of genes required for amplification results in a thin eggshell phenotype, allowing a genetic dissection of origin regulation. Herein, we show that one mutation corresponds to a subunit of the minichromosome maintenance (MCM) complex of proteins, MCM6. The binding of the MCM complex to origins in G1 as part of a prereplicative complex is critical for the cell cycle regulation of origin licensing. We find that MCM6 associates with other MCM subunits during amplification. These results suggest that chorion origins are bound by an amplification complex that contains MCM proteins and therefore resembles the prereplicative complex. Lethal alleles of MCM6 reveal it is essential for mitotic cycles and endocycles, and suggest that its function is mediated by ATP. We discuss the implications of these findings for the role of MCMs in the coordination of DNA replication during the cell cycle.