Evaluating the Efficacy of Employing Local Anesthetic Prostatic Blocks During Rezum Procedure.

Introduction Rezum is a minimally invasive, outpatient procedure using convective water vapor to relieve outlet obstruction from benign prostatic hyperplasia (BPH). Evidence on the technical approach of Rezum therapy, particularly pain control, is lacking. The purpose of this study was to evaluate the efficacy of utilizing a local anesthetic prostate block for postoperative pain control during Rezum therapy for BPH. A multimodal approach is typically utilized for pain control during and after Rezum. However, little is known about which elements are most critical. Methods This is a single-center retrospective study of 109 patients who underwent Rezum for BPH. Patients were then divided into two groups: Local anesthetic prostatic block verse no local anesthetic prostatic block for the procedure. A phone survey was performed to assess the patients' subjective pain scores and postoperative analgesics usage. A comparison of reported pain scores on a 0-10 Likert scale as well as usage of prescription and non-prescription analgesics medications was performed. Results There were 109 patients who underwent Rezum therapy, and 86 (79%) of patients responded to phone surveys. There was no significant difference in postoperative pain scores between patients who received local anesthetic prostatic block vs those who did not (2.10 vs 3.03). Similarly, there were no significant differences in postoperative narcotics or non-prescription analgesic medications usage. Conclusion Our data suggest that when performing Rezum using conscious sedation in the operating room or cystoscopy suite, it is unnecessary to perform a local anesthetic prostate block as it has no significant effect on patient-reported pain or the use of analgesics in the postoperative period.

Selective renal artery embolization following blunt renal trauma: case report and current treatment recommendations for renal trauma.

Management of renal trauma has become more conservative as newer techniques evolve. In 2004, the Renal Trauma Subcommittee modified their algorithms for the management of renal injuries to include selective angiography and embolization for grade III and IV lacerations for both blunt and penetrating renal lacerations. These algorithms are based on the renal organ injury scale defined by The American Association for the Surgery of Trauma (AAST) and whether the patient is hemodynamically stable or unstable (Table 1). Historically, grade III and IV renal injuries would have been managed by renal exploration. The goals of treating patients with severe renal injuries are to prevent significant hemorrhage and retain sufficient functional nephrons to prevent end-stage kidney failure. Selective arterial embolization provides a minimally invasive treatment option for renovascular injuries and potentially obviates the need for surgical exploration with its higher incidence of nephrectomy. We present a case of grade IV renal laceration following blunt renal trauma, which was successfully treated with selective renal arterial embolization.

Hitachi Hemolytic Index correlates with HBOC-201 concentrations: impact on suppression of analyte results.

OBJECTIVES: To determine the feasibility of laboratories to use an instrument's Hemolytic Index (HI) to determine if a test result would be accurate in the presence of hemoglobin-based oxygen carrier HBOC-201. DESIGN AND METHODS: HI values from the Roche Hitachi Modular P800 for samples containing HBOC-201 were determined. HI limits for 24 tests determined by addition of RBC lysate hemoglobin to serum and the instrument manufacturer's HI limits were compared to HI limits for reporting the same tests determined by adding HBOC-201 to plasma. RESULTS: There is a linear relationship (R(2)=0.99) between the HI value on the Modular P800 and HBOC-201 concentrations. Twenty-one of 24 HI limits for reporting results as determined by the manufacturer or adding RBC lysate to serum were more conservative or equal to the limit determined by HBOC-201 interference testing. HBOC-201 interference testing was more conservative for albumin, creatinine, and uric acid. CONCLUSION: For most analytes, the Modular P800 HI provides an accurate, conservative and automated method to determine whether laboratory results should be reported or suppressed when samples contain HBOC-201.

Blue light cystoscopy for the diagnosis of bladder cancer: Results from the US prospective multicenter registry.

INTRODUCTION: Blue light cystoscopy (BLC) using hexaminolevulinate (HAL/Cysview/Hexvix) has been previously shown to improve detection of non-muscle-invasive bladder cancer (NMIBC). Herein, we evaluated the detection of malignant lesions in a heterogenous group of patients in the real world setting and documented the change in risk category due to upstaging or upgrading. METHODS: Prospective enrollment during April 2014 to December 2016 of consecutive adult patients with suspected or known non-muscle-invasive bladder cancer based on prior cystoscopy or imaging, undergoing transurethral resection of bladder tumor at 9 different referral medical centers. HAL was instilled in the bladder for 1 to 3 hours before evacuation and inspection. Sensitivity and specificity of BLC, white light cystoscopy (WLC), and the combination of both BLC and WLC for detection of any malignancy was reported on final pathology. Number of patients with a change in American Urological Association (AUA) risk category based on BLC findings leading to a possible change in management and adverse events were recorded. RESULTS: Overall, 1,632 separate samples from bladder resection or biopsy were identified from 641 BLC procedures on 533 patients: 85 (16%) underwent repeat BLC (range: 2-5). Sensitivity of WLC, BLC, and the combination for diagnosis of any malignant lesion was 76%, 91%, and 98.5%, respectively. Addition of BLC to standard WLC increased detection rate by 12% for any papillary lesion and 43% for carcinoma in-situ. Within the WLC negative group, an additional 206 lesions in 133 (25%) patients were detected exclusively with BLC. In multifocal disease, BLC resulted in AUA risk-group migration occurred in 33 (6%) patients and a change in recommended management in 74 (14%). False-positive rate was 25% for WLC and 30% for BLC. One mild dermatologic hypersensitivity reaction (0.2%). CONCLUSIONS: BLC increases detection rates of carcinoma in-situ and papillary lesions over WLC alone and can change management in 14% of cases. Repeat use of HAL for BLC is safe.

Battle of the bots: a comparison of the standard da Vinci and the da Vinci Surgical Skills Simulator in surgical skills acquisition.

Virtual reality simulators are increasingly used to gain robotic surgical skills. This study compared use of the da Vinci Surgical Skills Simulator (dVSSS) to the standard da Vinci (SdV) robot for skills acquisition in a prospective randomized study. Residents from urology, gynecology, and general surgery programs performed three virtual reality tasks (thread the ring, ring rail, and tubes) on the dvSSS. Participants were then randomized to one of the two study groups (dVSSS and SdV). Each participant then practiced on either the dVSSS or the SdV (depending on randomization) for 30 min per week over a 4-week time period. The dVSSS arm was not permitted to practice ring rail (due to no similar practice scenario available for the SdV group). Following 4 weeks of practice, participants performed the same three virtual reality tasks and the results were recorded and compared to baseline. Overall and percent improvement were recorded for all participants from pre-test to post-test. Two-way ANOVA analyses were used to compare the dVSSS and SdV groups and three tasks. Initially, 30 participants were identified and enrolled in the study. Randomization resulted in 15 participants in each arm. During the course of the study, four participants were unable to complete all tasks and practice sessions and were, therefore, excluded. This resulted in a total of 26 participants (15 in the dVSSS group and 11 in the SdV group) who completed the study. Overall total improvement score was found to be 23.23 and 23.48 for the SdV and dVSSS groups, respectively (p = 0.9245). The percent improvement was 60 and 47 % for the SdV and dVSSS groups respectively, which was a statistically significant difference between the two groups and three tasks. Practicing on the standard da Vinci is comparable to practicing on the da Vinci simulator for acquiring robotic surgical skills. In spite of several potential advantages, the dVSSS arm performed no better than the SdV arm in the final assessment of participant scores. Our findings indicate that both the SdV and dVSSS can be beneficial to residents in improving their robotic surgery skills.

Use of an amplatzer vascular plug for transcatheter embolization of a renal arteriovenous fistula.

Renal arteriovenous fistulae (AVF) are a rare condition that can be acquired, congenital, or idiopathic. Idiopathic AVF are the rarest type of renal AVF. Traditionally, renal AVF were treated with surgery, but the mainstay of treatment has shifted to an endovascular approach by coil embolization. Embolization procedures are often difficult secondary to the "high flow" of the AVF, and there is the substantial risk of distal embolization of coils. We present a case in which an idiopathic renal AVF was successfully embolized with an Amplatzer vascular plug.

Transient paralysis after robotic prostatectomy.

Laparoscopic radical prostatectomy (LARP) has been accepted as first line therapy for clinically localized prostate cancer. Complications have been low and outcomes are comparable to that of open surgery with potential benefits including shorter hospital stay, less pain and quicker return to normal activity. Unexplained paralysis following LARP is a rare entity with no reported cases in the current literature. We report a case of complete motor paralysis following LARP. An extensive multidisciplinary evaluation did not definitively establish a diagnosis. Aggressive multimodality treatment led to a complete recovery. Our understanding of this phenomena with the possible etiology and treatment is discussed.

Calcifying nanoparticles associated encrusted urinary bladder cystitis.

Encrusted cystitis is a subtype of chronic cystitis characterized by multiple calcifications in the form of plaques located in the interstitium of the urinary bladder mucosa and frequently associated with mucosal ulcers. It is a very rare disease of controversial etiology. Our transmission electron microscopy of the calcified plaques of encrusted cystitis has revealed that the smallest formed particles (elementary units) of these calcifications are electron-dense shells surrounding an electron lucent core, diagnostic of calcifying nanoparticles (previously called nanobacteria). We pioneer the notion that calcifying nanoparticles are the causative agents of encrusted urinary bladder cystitis.