Renal Medullary Carcinoma: A Surveillance, Epidemiology, and End Results (SEER) Analysis.

INTRODUCTION: Renal medullary carcinoma (RMC) is an aggressive and rare renal malignancy that predominantly affects Black patients but is also found in individuals of other ethnicities. To date, only a few hundred cases have been reported in the urologic literature. Due to this extreme rarity, the exact pathophysiology and optimal treatment have yet to be well described. This study aims to determine the predictors of mortality and overall survival outcomes in patients with RMC. METHODS: We utilized the Surveillance, Epidemiology, and End Results Program (SEER) database 18 registries to retrieve demographic and clinical information on patients with RMC between 1996 and 2018. A multivariate analysis was performed to determine predictors of mortality in the study population. Kaplan-Meier survival curves were then created to display the differences in overall survival of Black versus non-Black patients diagnosed with renal medullary carcinoma during the study period. RESULTS: We identified 100 patients diagnosed with renal medullary carcinoma using the SEER Database in the study period. The mean age was 28.0 ± 12.0 (95% confidence interval [CI] 25.7-30.4). Among the patients, 76% were male and 24% were female. Most RMC patients were Black (83%) with only 17% identifying as White. The mean survival in months was 13.8 ± 3.0 (95% CI 7.9-19.7). The majority (70%) of patients in this study presented with distant, metastatic disease at the time of diagnosis. Black patients with RMC were less likely to receive surgery and five times more likely to die in comparison to their White counterparts OR = 5.4 (95% CI 1.09-26.9, P = 0.04). Not only did Black patients have a lower survival rate at 12 mo compared to White patients, but they also continued to experience a sharp decline in survival to 10.2% at 24 mo (P < 0.05) and 7.6% at 48 mo (P < 0.05) following diagnosis of renal medullary carcinoma. CONCLUSIONS: These data confirm that RMC is a rare disease that disproportionately affects Black patients. The prognosis appears to be substantially worse for Black subjects diagnosed with this cancer than non-Black patients. The worse outcomes seen in Black subjects are of an unclear etiology and are yet to be investigated.

Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study.

PURPOSE: To present our technique and outcomes for perineal urethrostomy augmented with a dorsal onlay buccal mucosa graft (BMG). Results from initial series and collaboration from an international center are included. METHODS: A retrospective chart review of all adult patients who underwent urethral reconstruction with perineal urethrostomy utilizing a buccal mucosal graft between January 1, 2002 and January 1, 2013 was performed. All surgeries were performed by three surgeons using the same technique (GHJ, KAM, and RV). Success was defined as no need for additional treatment following definitive surgery. RESULTS: A total of 44 patients met inclusion criteria. Mean patient age was 60 (range 44-81) years. All strictures were pananterior. Etiologies included unknown in 16 (36%), failed hypospadias repair in six (14%), lichen sclerosus in ten (23%), iatrogenic in seven (16%), Fournier's in three (7%), urethral cancer in one (2%) and penile cancer in one (2%). Mean follow-up was 45 (range 6-136) months. Overall success was 80%. Nine patients recurred, of which four had a successful revision, two are awaiting potential revision, and three are being managed with periodic dilations. CONCLUSIONS: BMG perineal urethrostomy is a valid alternative for complex urethral strictures due to lichen sclerosus, previous failed reconstructions or hypospadias cripples. Midterm results are encouraging for this novel technique.

International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.

OBJECTIVE: To present mid-term outcomes from an international, multi-institutional cohort of patients undergoing vessel-sparing excision and primary anastomosis urethroplasty for the reconstruction of the anterior urethra. MATERIALS AND METHODS: From June 2003 to December 2011, 68 patients underwent vessel-sparing anterior urethral reconstruction at five different international institutions using the vessel-sparing technique described by Jordan et al. (J Urol 177(5):1799-1802, 2007). RESULTS: Patients' age range was from 3 to 82 years (mean 51.2). Stricture length ranged from 1 to 3 cm (mean 1.78). After a mean follow-up of 17.6 months, 95.6 % of patients had a widely patent urethral lumen. Three patients failed the procedure, requiring either direct vision internal urethrotomy or urethral dilation, after which all were free of symptoms and did not require further instrumentation. Complications were minimal and as expected following open urethroplasty. CONCLUSION: Preservation of blood supply is a noble pursuit in surgery; however, it can be technically difficult and often requires more time and effort. This vessel-sparing technique for anterior urethral reconstruction is reproducible and appears to be reliable in this international cohort. Larger studies and longer follow-up are needed to support these encouraging results.

A Novel Endoscopic Approach for Distally Calcified Ureteral Stents.

Double-J ureteral stents are an invaluable tool in urology and are one of the most widely used stents in the world. However, when left in situ for prolonged periods, so-called "retained" ureteral stents can lead to numerous complications such as migration, hematuria, encrustation, or stent occlusion. These complications present severe challenges in urologic management. Notably, encrustation of ureteral stents may increase the risk of renal impairment and other potentially life-threatening complications. Here, we present the case of a 34-year-old female with a left double-J ureteral stent who presented to the Emergency Department (ED) with a one-day history of left flank pain and febrile urinary tract infection.

Priapism and Sickle Cell Disease: Special Considerations in Etiology, Management, and Prevention.

Sickle cell disease (SCD) is an inherited medical condition where sickled red blood cells cause vaso-occlusive crisis. One major complication of SCD is priapism, defined as an erection of the penis lasting over four hours beyond sexual stimulation or orgasm. SCD priapism is caused by sickled erythrocytes obstructing venous outflow and can lead to permanent erectile dysfunction. This article reviews the pathology, physiology, and management of SCD priapism, including potential novel therapeutic agents.

High-power potassium-titanyl-phosphate or lithium triboride laser photoselective vaporization prostatectomy for benign prostatic hyperplasia: a systematic approach.

BACKGROUND AND PURPOSE: We describe a safe and reproducible technique for potassium-titanyl-phosphate (KTP) and lithium triboride (LBO) laser photoselective vaporization prostatectomy (PVP). TECHNIQUE: With the patient under anesthesia in the dorsal lithotomy position, cystoscopy is performed. Using a high-power KTP/LBO laser system, a groove is created along the lateral-median lobe junction from the bladder neck to the verumontanum to delineate the margins of vaporization. The remainder of the ipsilateral lobe is vaporized using a series of overlapping passes along the length of the groove. The contralateral lobe is vaporized in a similar manner. Finally, the median lobe is vaporized from lateral to medial. A 20F urethral catheter is placed at the conclusion of the procedure. RESULTS: This technique has been successful in 240 consecutive patients over an 18-month period. CONCLUSION: This systematic approach has been safe, effective, and reproducible for KTP/LBO laser PVP. It has become our standard technique for this procedure.

Penile Amputation: Cosmetic and Functional Results.

INTRODUCTION: Penile amputation is a rare type of external genital trauma. It may arise from accidental trauma, assault or self-inflicted mutilation. As with all trauma, initial management focuses on assessment and resuscitation of the patient. When available, hypothermic preservation of the detached penis should be undertaken. AIM: This review serves to compile the current available information on etiology and management of penile amputation injuries, with focus on functional and cosmetic results. MAIN OUTCOME MEASURES: Main outcome measures were penile cosmetics, viability, and sensation; urethral patency and graft survival, functionality. METHODS: A literature search using Medline, PubMed (U.S. National Library of Medicine and the National Institutes of Health), and abstracts from scientific meetings was performed from 1980-2013. RESULTS: Due to the rarity of penile amputation injuries, no randomized trials exist. Likewise, available published series on management of this condition are comprised of a small number of patients. CONCLUSIONS: Penile amputation is rare but challenging. Current microreplantation procedures have a uniformly good result with a minimum number of post-operative complications. When microreplantation cannot be performed, older corporal reattachment techniques may be offered. When phallic reconstruction is required, a microsurgical free forearm flap phalloplasty may be performed to restore the patient with an acceptable cosmetic and functional phallus. Virasoro R, Tonkin JB, McCammon KA, and Jordan GH. Penile amputation: Cosmetic and functional results. Sex Med Rev 2015;3:214-222.

Assessment and initial management of urologic trauma.

This article discusses the appropriate assessment, initial management, timely referral to a urologist for abdominal, bladder, urogenital, and renal/renal collecting system injury. Appropriate laboratory and physical examinations, as well as radiologic imaging, are paramount to obtaining accurate diagnosis and to providing appropriate treatment.

Management of distal anterior urethral strictures.

Management of men with anterior urethral stricture disease is a relatively common issue faced by practicing urologists today. Anterior urethral strictures, which can be the result of congenital, idiopathic, iatrogenic or inflammatory causes, can affect patients of all ages and might present as some or all of the following disorders: difficulty with voiding, urinary tract infection, acute urinary retention and high bladder emptying pressures. A thorough understanding of the urethral anatomy and etiology of the stricture followed by effective treatment are crucial if successful outcomes for the patient are to be achieved. Historically, urologists viewed open repair as an option that should only be offered to patients who had failed to respond to repeated endoscopic treatments-the so-called reconstructive ladder. This dogma has, however, been scrutinized; urologists should be aware that this process may subject patients to repeated procedures with a low success rate, such as dilatation and internal urethrotomy, rather than one potentially curative operation, such as graft or flap urethroplasty.

Endoscopic injection of submucosal bulking agents for the management of incontinent catheterizable channels.

BACKGROUND: Urinary and fecal continence can be achieved by constructing catheterizable continent channels that provide access to the bladder and bowel. Some patients develop persistent stomal leakage. A minimally invasive method of injection with a bulking agent for treatment of stomal incontinence was evaluated. METHODS: A retrospective review identified patients with incontinence of their catheterizable continent urinary channel (CUC) and/or antegrade continence enema (ACE). All patients underwent circumferential endoscopic sub-mucosal injection of the channel with a bulking agent, performed at the level of the continence mechanism. The type of injected material, number of procedures required, and success rates were evaluated. RESULTS: Out of 157 patients with a CUC and/or ACE (total of 164 stomas), eight patients underwent the minimally invasive therapy (total of nine stomas). The initial reconstructive procedure was appendicovesicostomy in one patient, ileovesicostomy (Monti) in seven patients, and ACE in two patients. Amount of bulking agent injected varied from 1.4 to 7 cc (mean 3.72 cc). Follow up ranged from 1 to 39 months (median 15 months). Two patients received multiple injections. One patient had injection of both a CUC and ACE. At the time of final follow up, 6/7 (86%) patients with a CUC and 1/2 (50%) with an ACE were continent per catheterizable channel. CONCLUSION: Injection of a bulking agent provides an excellent minimally invasive treatment alternative for incontinence of a catheterizable channel.