Advances in robotic surgery for pediatric ureteropelvic junction obstruction and vesicoureteral reflux: history, present, and future.

PURPOSE: The introduction of robotic surgical technology into urological reconstruction, particularly pediatrics, has introduced new horizons for reducing the morbidity and enhancing the efficacy of surgical repair of congenital conditions in children. In reviewing the evolution of pediatric urological applications of robotic surgery, we wanted to address the different levels of reported utilization of pyeloplasty and ureteral reimplantation as two of the most common procedures. METHODS: Review of the published literature sought to explore the described variation in clinical application of these two common procedures, and the evolution of the practice over time. RESULTS: Reported outcomes suggest that variations in patient selection, the learning curve and in reporting of outcomes all contribute to the wide variation in utilization of pediatric robotic pyeloplasty and ureteral reimplantation. CONCLUSIONS: These technologies are demonstrating their potential as well as the challenges of use in children and there is a steady evolution of capability. Practitioners should be aware of both the possibilities as well as the risks of such new technology in the care of our patients. This requires thorough and open reporting of outcomes, the willingness to introduce change and integrate new findings into practice.

Phenotypic severity scoring system and categorisation for prune belly syndrome: application to a pilot cohort of 50 living patients.

OBJECTIVE: To design a novel system of scoring prune belly syndrome (PBS) phenotypic severity at any presenting age and apply it to a large pilot cohort. PATIENTS AND METHODS: From 2000 to 2017, patients with PBS were recruited to our prospective PBS study and medical records were cross-sectionally analysed, generating individualised RUBACE scores. We designed the pragmatic RUBACE-scoring system based on six sub-scores (R: renal, U: ureter, B: bladder/outlet, A: abdominal wall, C: cryptorchidism, E: extra-genitourinary, generating the acronym RUBACE), yielding a potential summed score of 0-31. The 'E' score was used to segregate syndromic PBS and PBS-plus variants. The cohort was scored per classic Woodard criteria and RUBACE scores compared to Woodard category. RESULTS: In all, 48 males and two females had a mean (range) RUBACE score of 13.8 (8-25) at a mean age of 7.3 years. Segregated by phenotypic categories, there were 39 isolated PBS (76%), six syndromic PBS (12%) and five PBS-plus (10%) cases. The mean RUBACE scores for Woodard categories 1, 2, and 3 were 20.5 (eight patients), 13.8 (25), and 10.6 (17), respectively (P < 0.001). CONCLUSIONS: RUBACE is a practical, organ/system level, phenotyping tool designed to grade PBS severity and categorise patients into isolated PBS, syndromic PBS, and PBS-plus groups. This standardised system will facilitate genotype-phenotype correlations and future prospective multicentre studies assessing medical and surgical treatment outcomes.

Assessment of Renal Deterioration and Associated Risk Factors in Patients With Multiple Sclerosis.

OBJECTIVE: To evaluate predictors of renal deterioration (RD) in patients with multiple sclerosis (MS) at a tertiary referral center. METHODS: We reviewed adult patients with MS presenting for evaluation of lower urinary tract symptoms, with baseline urodynamic study (UDS) and either serum creatinine (SCr) or renal ultrasound, from a prospectively maintained database, and excluded patients with abnormal renal function. RD was defined as doubled SCr, new hydronephrosis, or renal atrophy on follow-up ultrasound. Demographic and UDS parameters were evaluated in multivariable models of RD. RESULTS: From 1999 to 2016, 660 patients were evaluated, and 355 met criteria with median follow-up of 79 months. SCr doubled in 8 patients, 4 had decline by renal ultrasound, and 1 by both (3%). Overall, 46 patients met less strict criteria of decrease in estimated glomerular filtration rate by ≥30%. Using the less rigid criterion, detrusor overactivity (DO) remained associated with RD on multivariable analysis. Eleven of 355 patients had RD by either imaging or doubled Cr, with which only history of diabetes mellitus and nephrolithiasis were associated. CONCLUSION: By strict criteria, the rate of RD in patients with neurogenic bladder due to MS was low (3%) at intermediate-term follow-up and was not associated with UDS parameters. Using more liberal criteria, DO was associated with deterioration, suggesting that study of the impact of more aggressive control of DO in this population may be warranted.

Penile ossification: A reconstructive challenge.

Penile ossification is a rare condition that occurs most commonly in acquired cases of penile deformity. We report the case of a 43-year-old man with Peyronie disease who was incidentally found to have significant ossified tissue in his penile corpora during complex placement of an inflatable penile prosthesis (IPP). His clinical course was later complicated by impending distal extrusion of his IPP laterally, necessitating corporoplasty. Penile ossification remains a poorly understood, unusual entity that may pose a reconstructive challenge for urologists. We discuss evaluation and management of this condition, focusing on important considerations for preoperative counseling and intraoperative pearls.

SURGICAL MANAGEMENT OF POST-PROSTATECTOMY INCONTINENCE.

Post-prostatectomy incontinence (PPI) is a common and significant issue that can affect the quality of life in men who are undergoing treatment for prostate cancer. While some patients opt for conservative management of their incontinence, many elect to undergo surgical treatment as a result of the significant impact to quality of life. The most commonly employed surgical techniques to address PPI are placement of a male sling or artificial urinary sphincter (AUS). Currently, the AUS continues to serve as the gold standard for management, with robust data concerning longitudinal outcomes available. However, in recent years, the various methods to place the male sling have emerged as viable, less complex alternatives that avoid the need for pump manipulation. In the present review, we discuss these main surgical treatment modalities for PPI, and focus on the selection criteria that may influence appropriate operative stratification of PPI patients. Indeed, an individualised, comprehensive assessment of baseline urinary function, age, radiation, prior surgeries, functional status, and other comorbidities must be considered in the context of shared decision-making between the treatment provider and the patient in determining the optimal approach to managing PPI.

Adenocarcinoma of the urethra with mucinous features.

Primary adenocarcinoma of the female urethra is a rare malignancy. Previous studies hypothesize multiple origins, including periurethral glands or intestinal metaplasia. We report a case of a 60-year-old white woman with adenocarcinoma of the urethra who initially presented with obstructive voiding complaints secondary to a urethral mass. Wide local excision revealed invasive adenocarcinoma of the urethra with mucinous features. There was intestinal metaplasia adjacent to the tumor, as well as separate identification of intestinal metaplasia along the urethra. Ultimately, the patient underwent radical cystectomy with ileal conduit urinary diversion with no evidence of recurrence, indicating the role of early identification and surgical intervention for such cases.

Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension.

BACKGROUND: Intubation in hypotensive emergency department (ED) patients may increase the risk of life-threatening complications such as hypoperfusion and cardiovascular collapse. Peripherally administered, diluted "push-dose" phenylephrine has been advocated to treat peri-intubation hypotension, however, its effectiveness is unknown. STUDY OBJECTIVE: To investigate the efficacy and usage patterns of bolus-dose phenylephrine for peri-intubation hypotension at an academic medical center. METHODS: A retrospective chart review of all adult intubated, hypotensive patients (systolic blood pressure [SBP] < 90 mm Hg) over 12 months was conducted. During the peri-intubation period (30-min prior to/after intubation), the effect of phenylephrine was evaluated pre/post drug administration by comparing SBP, diastolic blood pressure (DBP), and heart rate (HR). RESULTS: A total of 119 patients met eligibility criteria. Phenylephrine was given to 29/119 (24%) patients and 20 (17%) were treated during the peri-intubation period. Phenylephrine was given for many different conditions, and treatment timing varied greatly. Phenylephrine was given with other vasopressors 70% of the time (14/20), however, the timing of vasopressor infusion also varied greatly. When phenylephrine was given during the peri-intubation period, there were significant increases in SBP and DBP (p < 0.01) with no change in HR. CONCLUSION: In this academic ED, bolus-dose phenylephrine was used by practitioners without a systematic pattern. Although phenylephrine improved hemodynamics, it is possible that nonsystematic use of phenylephrine may cause inadvertent negative effects. Further studies will need to be conducted to better understand the best practices for use of phenylephrine.

Coccidioidomycosis of the genitourinary tract: a case report and discussion.

Coccidioides species (Coccidioides immitis and Coccidioides posadasii) are dimorphic fungi endemic to the Southwestern United States. Initial infection ranges from asymptomatic to mild upper respiratory tract symptoms and may disseminate to other organs including the genitourinary tract. Genitourinary complaints may be the initial presenting signs and symptoms among a minority of patients. We report a case of genitourinary coccidioidomycosis and discussion of genitourinary disease with coccidioidomycosis.

Size-controlled synthesis of monodispersed gold nanoparticles via carbon monoxide gas reduction.

An in depth analysis of gold nanoparticle (AuNP) synthesis and size tuning, utilizing carbon monoxide (CO) gas as a reducing agent, is presented for the first time. The sizes of the AuNPs are tunable from ~4 to 100 nm by altering the concentration of HAuCl4 and inlet CO gas-injection flow rate. It is also found that speciation of aqueous HAuCl4, prior to reduction, influences the size, morphology, and properties of AuNPs when reduced with CO gas. Ensemble extinction spectra and TEM images provide clear evidence that CO reduction offers a high level of monodispersity with standard deviations as low as 3%. Upon synthesis, no excess reducing agent remains in solution eliminating the need for purification. The time necessary to synthesize AuNPs, using CO, is less than 2 min.