Erosion of inflatable penile prosthesis reservoir into neobladder.

INTRODUCTION: Erosion of the reservoir into surrounding tissues is a rare complication after inflatable penile prosthesis (IPP) implantation. AIM: To present a new case and a review of the literature including discussion of pathogenesis, risk factors, and management options. METHODS: We present the case of a 75-year-old male who underwent placement of an IPP for postoperative erectile dysfunction with a history of bladder cancer requiring radical cystoprostatectomy and Studer neobladder. Six years after IPP placement, he presented with recurrent febrile urinary tract infection that seemed to be precipitated by cycling of his penile prosthesis. Cystoscopy and cross-sectional computed tomography imaging demonstrated erosion of the inflatable penile prosthesis reservoir into the neobladder. RESULTS: Patient underwent open removal of the IPP reservoir and cystorrhaphy with a plan for future prefascial reimplantation of an IPP reservoir. CONCLUSIONS: In patients with a history of abdomino-pelvic surgery or radiation therapy, the retroperitoneal space may be extremely fibrotic and the transversalis fascia may have thickened. Potential intraoperative complications as well as reservoir erosion may be avoided by using a two-piece device or ectopic reservoir placement. Management options for reservoir erosion include explantation of the entire device as well as reservoir removal with salvage of remaining components.

Setting a new standard: updating the vaginal distention translational model for stress urinary incontinence.

AIMS: The vaginal distention (VD) translational model for postpartum stress urinary incontinence (SUI) is potentially biased for use in evaluating animals with increasing phenotypic size (obesity) due to a fixed VD volume. Our study had three principle and two secondary aims. First, to examine both ex vivo and in vivo catheter pressure changes during volume distention. Secondly, to determine mean pressure at current volume standard for use as target pressure (TP) for VD under isobaric (IB) conditions. Thirdly, to demonstrate feasibility and equivalence of VD at TP versus isovolumetric (IV) standard. Secondary aims were to demonstrate decreased variability (IB vs. IV) and to review the effect of weight. METHODS: Ten French modified Foley catheters were inflated sequentially to 3.0 ml while connected (both in vivo and ex vivo) to a pressure transducer. Mean result generated TP. Thirty Sprague-Dawley rats (280-300 g) were then randomized to one of three groups: IV, IB at TP, or sham VD. Student's t-test was used to compare groups' leak point pressures (LPP) and simple linear regression was used to evaluate the effect of weight as a continuous variable. RESULTS: Catheter pressure/volume responses were demonstrated. Calculated TP was 531 mm Hg. LPP under conditions of IB and IV were statistically equivalent and were statistically lower than Sham. Variability was not statistically different between IB and IV groups. When treated as a continuous variable, weight had no effect on LPP. CONCLUSIONS: VD injury based on TP is feasible and reproducible. Understanding catheter pressure dynamics is valuable for investigating alternative rat phenotypes.

External validation of a model for tailoring the operative approach to minimally invasive partial nephrectomy.

STUDY TYPE: Therapy (case series). LEVEL OF EVIDENCE: 4. What's known on the subject? and What does the study add? In comparison to open partial nephrectomy, renal hypothermia is not routinely performed when completed laparoscopically, making warm ischemia time (WIT) a critical issue. Given that the duration of renal ischemia is the strongest modifiable surgical risk factor for decreased renal function after partial nephrectomy, efforts to limit ischemic time are of paramount importance. One technical modification during laparoscopic partial nephrectomy (previously reported by Weizer et al.), sought to simplify the technique by obviating the need for hilar clamping and/or suturing based on preoperative tumour characteristics. Ideally this modification would allow the surgeon to significantly decrease or even eliminate WIT in selected cases without compromising oncological efficacy or adversely impact treatment outcomes. This study adds to the growing body of literature that seeks to minimize WIT during minimally-invasive partial nephrectomy (MIPN). We feel that this approach, which simplifies a technically challenging operation while maintaining a low rate of adverse events and positive surgical margins, could potentially have MIPN applied more broadly throughout the urological community and ultimately decrease the preference for radical nephrectomy in cases of T1a tumours. OBJECTIVE: To externally validate and modify an existing technical strategy of prospectively tailoring one's operative approach to minimally invasive partial nephrectomy (MIPN). PATIENTS AND METHODS: We prospectively applied the model used in this strategy to evaluate 44 consecutive patients who underwent MIPN between August 2006 and August 2008. Patients were divided into four groups according to tumour depth of penetration or entry into the collecting system. Group 1 (n=9, 20%) underwent MIPN without clamping the renal hilum or parenchymal suturing. Group 2 (n=2, 5%) underwent clamping but not suturing. Group 3 (n=21, 48%) underwent clamping and suturing. Group 4 (n=12, 27%) underwent clamping, renal sinus reconstruction and suturing. We then assessed the peri- and postoperative outcomes, tumour histopathology and complications for each group. RESULTS: All patients had successful procedures according to the strategic model. The mean operative time was 246 (105-420) min and the mean estimated blood loss was 177 (25-1000) mL. When patients were stratified by clamping vs no clamping, the only significant variables between the two groups were operative time (245 vs 203 min) and pathology (83% vs 44% malignant). Six patients in the clamping group had postoperative complications (three had delayed bleeding, two had pneumonia, and one had infected urinoma) vs one patient in the no-clamping group who had prolonged ileus (P>0.05). Mean hospital stay was comparable in both groups (2.6 vs 3 days). CONCLUSION: Minimally invasive partial nephrectomy can be tailored according to tumour location, avoiding unnecessary clamping and/or suturing of the kidney without negatively affecting treatment outcomes.

Extracorporeal stereotactic radiosurgery for small renal masses.

Over the past decade we have witnessed both a grade and stage migration for renal cell carcinoma. This shift in clinicopathology has been met with a paradigm shift in the treatment of these renal mass lesions. This trend has evolved from laparoscopic extirpation to needle-based and now extracorporeal ablation. At the forefront of the extracorporeal, minimally invasive treatment modalities is radiosurgical ablation. Still in its inaugural phase, renal radiosurgery is devoid of any long-term studies; however, short-term studies thus far show enormous potential. Herein we present the current status of radiosurgical ablation of small renal masses.

Conversion from pure laparoscopy to hand-assisted laparoscopy for control of bleeding in renal surgery: an attractive alternative to open conversion.

PURPOSE: To assess the safety and efficacy of conversion from pure laparoscopy to hand-assisted laparoscopy to control mild-to-moderate bleeding during renal surgery. PATIENTS AND METHODS: Between August 2006 and August 2008, we performed 94 laparoscopic nephrectomies (44 partial and 50 radical). A total of three radical nephrectomies were converted from pure to hand-assisted laparoscopy for control of bleeding. The first patient was a 44-year-old man with a 14-cm cystic renal mass. The second patient was a 52-year-old man with a 3.8-cm renal mass, and the third patient was an 86-year-old woman with a 7-cm renal mass. RESULTS: In all three procedures, the indication for conversion was bleeding from the renal hilum or the kidney parenchyma during dissection. The bleeding was difficult to control using pure laparoscopy, and therefore a hand port was inserted. Time for conversion and placement of the hand port averaged less than 7 minutes. Total estimated blood loss for the three patients was 800 mL, 2000 mL, and 650 mL, respectively. One patient needed a transfusion with three units of packed red blood cells. The postoperative course was uneventful in all patients, except for one patient who had prolonged ileus and stayed in the hospital for 6 days. The remaining two patients were discharged on postoperative days 2 and 3. CONCLUSIONS: Conversion from pure to hand-assisted laparoscopy for bleeding control is feasible and effective. It adds minimal morbidity while maximizing cosmesis, and it should be considered as an alternative to open conversion in cases of mild-to-moderate bleeding.

Cryoablation vs. radiofrequency ablation for small renal masses.

RATIONALE AND OBJECTIVES: Cancer of the kidney is the third most common cancer of the urinary tract, and renal cell carcinoma is the most lethal of all genitourinary tumors. The incidental discovery of renal cell carcinoma has increased with increased use of cross-sectional imaging. Concomitantly, minimally invasive ablative technologies, including image-guided cryoablation, radiofrequency ablation, and others, have evolved as therapeutic options for small renal masses. MATERIALS AND METHODS: Between 2006 and 2009, 111 patients (age range, 31-91 years; mean age, 70 years) underwent percutaneous computed tomography-guided thermal ablation for suspected renal cell carcinoma at two major academic centers. Outcomes data were retrospectively collected and analyzed to compare recurrence rates for patients undergoing radiofrequency ablation (n = 41) versus cryoablation (n = 70). RESULTS: There were four cases of suspicious enhancement on follow-up computed tomography or magnetic resonance imaging in each group, with cumulative imaging recurrence rates of 11% and 7% for radiofrequency ablation and cryoablation, respectively. Log rank test analysis revealed no significant difference between rates of imaging recurrence between the two groups (P = .6044). CONCLUSIONS: These results suggest that the use of cryoablative technology will result in similar outcomes compared with radiofrequency ablation.

Concurrent robotic renal and prostatic surgery: initial case series and safety data of a new surgical technique.

INTRODUCTION: In the era of prostate-specific antigen screening and frequent cross-sectional abdominal imaging, concurrent prostate cancer and renal masses are being identified and treated. Minimizing patient morbidity and cost by avoiding separate surgical procedures is advantageous, provided technical feasibility, and safety data. Our goal was to assess the feasibility and safety of single-setting robotic renal surgery and prostatectomy. We present our initial experience. PURPOSE: To assess the feasibility and safety of single-setting concurrent robot-assisted renal surgery and radical prostatectomy utilizing the same port access scheme. PATIENTS AND METHODS: From February 2009 to June 2009, we performed single-setting concurrent robot-assisted radical nephrectomy/partial nephrectomy and radical prostatectomy on two patients with synchronous kidney tumors and prostate cancer. Identical port sites were used during both aspects of the procedure with the exception of one additional port during prostatectomy. Prostate cancer clinical stage and Gleason scores were T1c and 6 and T2a and 7, respectively. Corresponding renal tumors were 5 cm, respectively. RESULTS: Both operations were performed, with no conversion to open surgery. There were no intraoperative complications and the postoperative course was uneventful in both patients. Discharge was on postoperative day 2 and 3, respectively. Patient 2 had an episode of delayed bleeding on postoperative day 9, treated by selective angio-embolization. Mean operative time for nephrectomy and prostatectomy (135 and 139 minutes, respectively) and estimated blood loss (75 and 100 mL, respectively) were reasonable. We began with the renal portion utilizing a lateral decubitus position before re-positioning into the lithotomy position for the prostatic portion. Clamping time was 34 minutes during partial nephrectomy. CONCLUSION: Single-setting robotic radical/partial nephrectomy and radical prostatectomy is technically feasible and safe in properly selected patients who present with synchronous primary renal and prostate malignancies.

Penile fracture with associated urethral rupture.

Penile fracture of the erect penis is an uncommon but emergent urological trauma. Potential outcomes include erectile dysfunction, penile curvature, and urethral injury. Treatment is emergent surgical repair. We present the case of a 42-year-old man with a penile fracture complicated by a urethral rupture and subsequent repair. A discussion of the key aspects of this condition is presented.