Robotic assisted partial cystectomy with pelvic lymph node dissection for metastatic paraganglioma of the urinary bladder.

Paraganglioma of the urinary bladder is a rare tumor that often presents with hypertensive crisis during micturition. We herein present the unusual case of a 45-year-old female with metastatic paraganglioma treated with robotic assisted partial cystectomy and pelvic lymphadenectomy. We review the literature regarding the evaluation and management of paraganglioma of the bladder.

Controlling the dorsal venous complex during robotic prostatectomy.

INTRODUCTION: The objective of our study was to determine whether dorsal venous complex (DVC) control technique influences positive apical margins following robotic assisted laparoscopic radical prostatectomy (RALRP). MATERIALS AND METHODS: One thousand fifty-eight patients who underwent RALRP at City of Hope from June 2007 to October 2009 were assessed. Endoscopic stapling and suture ligature of the DVC were compared. Positive apical margins were identified and compared based on DVC-control technique. Recurrence probability was estimated using the Kaplan-Meier method, and logistic regression analysis was used to predict the odds of positive apical margins. RESULTS: Of 1058 patients, 633 (60%) underwent endoscopic stapling, and 425 (40%) had suture ligature. The groups had similar baseline characteristics including age and body mass index. We observed a statistically different PSA (5.4 ng/mL versus 5.2 ng/mL, p = 0.03) and operative time (2.8 hours versus 2.7 hours, p = 0.02) between stapling and suture groups, but the actual difference was small. Operative time, Gleason score, pathologic stage, and overall positive margin rates were not significantly different between groups. Positive apical margins were observed in 39 (6%) and 27 (6%) patients in the staple and suture groups, respectively. Multivariate analysis showed that the positive apical margin rate was greater in patients with higher pathologic stage and final pathological Gleason score. CONCLUSIONS: During RALRP, there is no difference in positive apical margin rate when the DVC is controlled using either endoscopic stapling or suture ligature. However, patients with a higher pathologic stage and final pathologic Gleason score are at higher risk for positive apical surgical margins.

Traumatic complete urethral disruption: the West Virginia experience.

Type III complete urethral disruption is an uncommon injury that occurs primarily in male patients with pelvic trauma. Herein we present our results from management of this condition. Management should initially be conservative with a catheter placement in all cases. Full return of urinary function was noted in all patients managed endoscopically, and in 1 of 3 of patients managed with open urethroplasty. Erectile function was preserved in 2 of 3 of patients managed with endoscopic repair, and in none of the patients managed with open urethroplasty. The most common surgical urologic complication was traumatic urethral stricture.

Pursuing an Elusive Prostate Carcinoma: A Case Report Involving Multiparametric MR and CT-Guided Biopsy.

Prostate cancer is usually diagnosed when elevated PSA levels lead to a TRUS biopsy. We present a case in which there were several negative biopsies and a rising PSA. This led to a multiparametric MR (mpMRI) which demonstrated a large mass which originated in the anterior transition zone and had extended through the anterior fibromuscular stroma and prostate capsule with a significant extra-prostatic component. The mass was successfully approached anteriorly with a CT-guided biopsy. The patient was subsequently successfully treated with radiotherapy utilizing MR in the planning process. This case report summarizes the utility of mpMRI in this clinical setting. For patients with high suspicion of prostate malignancy despite prior negative biopsies, it can identify tumor in locations not amenable to TRUS biopsy. It also is critical for accurate radiation treatment planning, allowing for increased confidence in tumor targeting as well as sparing sensitive normal tissue.

Ureteropelvic junction obstruction in association with autosomal dominant polycystic kidney disease: a case report in a trauma patient.

Autosomal dominant polycystic kidney disease (ADPKD) is a common cause of cystic renal disease and can predispose to renal insufficiency. Although typically diagnosed and discussed in the pediatric population, ureteropelvic junction obstruction may also make patients prone to renal dysfunction and failure. These two disease processes can coexist in the same patient, which may, in turn, complicate their management. We present the case of an adult patient with known ADPKD who suffered a traumatic fall and subsequent retroperitoneal bleed, and was also diagnosed with a UPJ obstruction of the left kidney on the basis of pathological analysis of the specimen at the time of nephrectomy.

Utility of an intra-operative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux.

PURPOSE: To assess the utility of intraoperative cystogram with a simulated voiding phase after endoscopic treatment of vesicoureteral reflux (VUR). METHODS: From September 2003 to June 2005, 24 children underwent injection of deflux for the treatment of VUR. A total of 38 ureters were treated. After deflux injection, our most recent 14 patients had a cystogram with simulated voiding phase to assess for the presence of VUR. All patients were scheduled for a voiding cystourethrogram (VCUG) three months postoperatively to assess for persistent reflux. The surgery was considered a success only if patients did not demonstrate reflux on their postoperative VCUG. RESULTS: Of the 24 patients undergoing deflux injection, 14 had complete resolution of their VUR. Eight patients had persistent VUR and 2 patients were lost to follow-up. A total of 38 ureters were injected. Twenty-seven ureters no longer refluxed, while 8 ureters continued to reflux and 3 ureters were lost to follow-up. Fourteen patients had an intra-operative cystogram with simulated voiding phase. The intra-operative cystogram with simulated voiding phase was negative in all patients except for one patient who demonstrated the presence of de novo contralateral VUR. There were 7 true negatives on intra-operative cystogram with a simulated voiding phase and 6 false negatives. CONCLUSIONS: Our results of endoscopic treatment of VUR compare well to the results reported by others in the literature. An intra-operative cystogram may demonstrate unsuspected contralateral reflux but does not appear to predict the success of deflux injections.

Pancreatic pseudocyst masquerading as renal injury on imaging studies.

In a patient with a prior history of pancreatitis or abdominal trauma, radiographic imaging may only show abnormalities in the urinary tract. When these patients are first seen with subcapsular or perinephric fluid collections, percutaneous drainage can be both diagnostic and therapeutic.

Laparoscopic pyeloplasty for ureteropelvic junction obstruction in a horseshoe kidney.

With a continued movement toward minimally invasive surgical interventions, the range of applications treated with laparoscopic surgery will continue to grow. Laparoscopy is a preferred method for various reasons, including decreased postoperative pain, shorter inpatient hospital stays, and decreased convalescence. Ureteropelvic junction obstruction (UPJO) has traditionally been treated by open pyeloplasty. In patients with horseshoe kidneys, the blood supply is aberrant, which adds complexity to the procedure. We present the second reported case of a pediatric patient with a horseshoe kidney found to have UPJO who was successfully treated with transperitoneal laparoscopic pyeloplasty.

Potential pitfalls with electronic medical records.

Electronic Medical Record (EMR) systems are a rapidly growing form of documentation that has the potential to improve quality of care, physician and practice efficiency, and accessibility of stored medical information. However, these advances may be met with challenges such as: finances, functionality, accessibility, as well as skills necessary for utilization and potential for data loss. This article reviews each of these areas in detail to provide further insight into the challenges encountered by those implementing EMR systems.

Asymptomatic advanced pediatric papillary renal cell carcinoma presenting as a pulmonary embolus.

Renal cell carcinoma in the pediatric population is a rare disease. A limited number of cases of renal cell carcinoma exist worldwide in the pediatric population. Reported herein is a case of a 17-year-old female who presented to an outside hospital with gross hematuria and shortness of breath. She was found to have a pulmonary embolus on computed tomography scan. After further imaging, a large renal mass with renal vein and vena cava involvement was observed. Intraoperatively, the tumor demonstrated extensive invasion of the wall of the vena cava.

Impact of stone location on success rates of endoscopic lithotripsy for nephrolithiasis.

OBJECTIVES: To determine whether stone location affects the stone-free rates of endoscopic lithotripsy for nephrolithiasis. METHODS: From January 2002 to August 2006, 245 patients with 272 stones, ranging from 4 to 20 mm in size, underwent ureteroscopy (URS) with laser lithotripsy at West Virginia University Hospital. The patients were followed up postoperatively with noncontrast spiral computed tomography, abdominal plain radiography, renal ultrasonography, or retrograde pyelography. Patients were considered to have been treated successfully if they had no residual stones. All pediatric patients were excluded, as were all patients with stones greater than 2 cm. Also, patients who had undergone previous shock wave lithotripsy, percutaneous nephrolithotripsy, or URS by an outside urologist were excluded. RESULTS: A total of 86 kidney stones were treated with URS and laser lithotripsy. Of these, 81 (94.2%) were successfully treated. Five patients (5.8%) had persistent stones. All 18 upper pole stones (100%) were cleared, 23 (95.8%) of 24 middle pole stones were cleared, and 40 (90.9%) of 44 lower pole stones were cleared (P = 0.338). CONCLUSIONS: URS is an important tool for treating nephroureterolithiasis with excellent success rates and minimal morbidity. The results of our study have shown that stone location does not significantly affect stone clearance rates when performing endoscopic lithotripsy for intrarenal calculi.