Complete Pathologic Response With Pembrolizumab and Enfortumab Vedotin in Urothelial Carcinoma of the Upper Urinary Tract.

Urothelial carcinoma of the upper urinary tract (UTUC) presents a significant clinical challenge, often requiring aggressive surgical intervention for optimal management. We present a case of an 84-year-old woman with recurrent high-grade papillary UTUC of the left renal pelvis, refractory to prior endourologic interventions, who underwent neoadjuvant treatment with pembrolizumab and enfortumab vedotin (Pembro/EV) due to contraindications to cisplatin therapy. Following a favorable response to neoadjuvant therapy, the patient underwent laparoscopic left radical nephroureterectomy, achieving a pathologic complete response. We discuss the utility of Pembro/EV in the perioperative management of patients with UTUC, particularly in those ineligible for cisplatin-based therapy. In addition, we highlight the potential role of somatic mutation testing and the integration of novel therapeutic agents such as olaparib in personalized treatment strategies for UTUC. This case underscores the importance of exploring innovative treatment approaches and optimizing patient selection for kidney preservation strategies in the management of UTUC. Further research and clinical trials are warranted to elucidate the full therapeutic potential of Pembro/EV and other emerging therapies in this setting.

Initial experience with robot-assisted varicocelectomy.

AIM: To determine if robot-assisted varicocelectomy can be safely and effectively performed when compared to microscopic inguinal varicocelectomy. METHODS: Eight patients aged 29.1+/-12.5 years underwent microscopic subinguinal varicocelectomies: seven patients with left-sided repair, and one patient with bilateral repair. Eight patients aged 22.0+/-8.0 years underwent robot-assisted varicocelectomies: seven patients with left-sided repair and one patient with bilateral repair. RESULTS: The average operative time for microscopic inguinal varicocelectomy was 73.9+/-12.2 min, whereas the robot-assisted technique took 71.1+/-21.1 min. There were no difficulties in identifying and isolating vessels and the vas deferens with robot-assisted subinguinal varicocelectomy. Hand tremor was eliminated using the robotic procedure. Patients who underwent either microscopic or robot-assisted varicocelectomies were able to resume daily activities on the day of surgery and full activities within 2 weeks. There were no complications or recurrences of varicocele. CONCLUSION: From our experience, compared to microscopic surgery, robot-assisted varicocelectomy can be safely and effectively performed, with the added benefit of eliminating hand tremor.

A collagen-based coil for embolization of saccular aneurysms in a New Zealand White rabbit model.

BACKGROUND AND PURPOSE: In the treatment of cerebral aneurysms, platinum coils often fail to elicit a fibrotic response. We tested the hypothesis that a new, collagen-based endovascular coil would improve angiographic and histologic outcomes as compared with those achieved with platinum coils in a rabbit model of saccular aneurysms. METHODS: Elastase-induced aneurysms were created in 12 New Zealand White rabbits (body weight, 3-4 kg). Embolization was performed either by use of collagen-based coils (n = 6) or platinum coils (n = 6). In both coil groups, subjects were kept alive for either 2 weeks (n = 3 [collagen], n = 3 [platinum]) or 10 weeks (n = 3 [collagen], n = 3 [platinum]) after embolization and then were sacrificed. Digital subtraction angiography (DSA) was performed immediately after embolization and immediately before sacrifice. Postmortem histologic analysis of all coils was performed. RESULTS: Collagen-based coils were loosely packed in all cases because of limitations in size of coils available for embolization. In all six aneurysms packed with collagen-based coils, progressive thrombosis was noted at follow-up (DSA). Platinum coil samples were densely packed in all six cases. Progressive thrombosis was seen in one case, and interval regrowth was present in one case. Two weeks after embolization, collagen-based coil samples showed a marked peri-coil cellular response. Ten weeks after embolization, collagen-based samples had dense connective tissue matrix deposition in two of three cases. Platinum coils had unorganized thrombus at 2 weeks; loose-matrix deposition was only seen in the 10-week samples. Smooth muscle actin-positive cells were seen across the neck of the aneurysm in four of six collagen-based coil cases. CONCLUSION: Collagen-based coils show a marked cellular response in animal-model aneurysms, with resultant high rates of progressive occlusion after embolization. Dense matrix deposition is commonly seen with collagen-based coils. This contrasts with low rates of progressive thrombosis and high rates of loose matrix deposition seen with platinum coils.

Laparoscopic extravesical reimplantation for postpubertal vesicoureteral reflux.

BACKGROUND AND PURPOSE: Postpubertal vesicoureteral reflux is a rare occurrence. In the adolescent group, its repair can be a challenging open procedure. We present our preliminary experience with laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux. PATIENTS AND METHODS: Six female patients with a mean age of 18.7 years presented with recurrent urinary tract infection secondary to vesicoureteral reflux. The indications for treatment were febrile urinary tract infection, recurrent pyelonephritis, renal scarring, and breakthrough urinary tract infection. The reflux was unilateral in all patients at the time of treatment, but one patient had previously experienced bilateral reflux and had persistent left-sided reflux following subureteral injection of Durasphere. This patient underwent bilateral laparoscopic extravesical ureteral reimplantation. RESULTS: The mean operative times for the unilateral and bilateral procedures were 1.75 hours and 3.75 hours, respectively. The average length of stay in the hospital was 36 hours; five patients went home in <24 hours. The mean time to resumption of full activity was 8 days. All six patients had resolution of vesicoureteral reflux, as shown by radiographic studies, with a mean follow-up of 11.4 months. CONCLUSION: Laparoscopic extravesical ureteral reimplantation for postpubertal vesicoureteral reflux has excellent outcomes with minimal postoperative morbidity. Long-term radiographic follow-up is needed.

Completely intracorporeal robotic-assisted laparoscopic augmentation enterocystoplasty with continent catheterizable channel.

OBJECTIVE: To report our results from series of robotic-assisted laparoscopic augmentation enterocystoplasty (RALAE) performed in a completely intracorporeal fashion. METHODS: Patients who underwent RALAE with or without the creation of a catheterizable channel between 2006 and 2011 at the University of Texas, Houston and Northwestern Memorial Hospital were identified. Perioperative and follow-up data were analyzed. Preoperative and postoperative urodynamic data were analyzed when available. RESULTS: Twenty-two patients with neurogenic bladder underwent RALAE with or without the creation of a catheterizable channel. Fifteen patients underwent robotic augmentation enterocystoplasty alone, and 7 patients had creation of a catheterizable channel (4 Monti and 3 Mitrofanoff). There was 1 conversion to an open procedure in a patient undergoing concomitant creation of an appendicovesicostomy. Mean follow-up was 38.9 months (range, 6.2-72.1 months). Mean operative time was 365 minutes (range, 220-788 minutes); mean estimated blood loss was 110 mL (range, 30-250 mL). Median time to return of bowel function was 5 days (range, 2-17 days). Preoperative and postoperative urodynamic data were available for 13 patients. Mean cystometric capacity increased by 52%, and mean maximal bladder pressures decreased by 40. There were 5 minor complications (Clavien grade 1-2) and 4 major complications (Clavien grade 3-4). No patient experienced a wound infection. CONCLUSION: RALAE is a feasible approach that provides potential benefits over open bladder reconstruction in the neurogenic voiding dysfunction population.

Type 1 collagen as an endovascular stent-graft material for small-diameter vessels: a biocompatibility study.

PURPOSE: To compare patency rates and degrees of neointimal hyperplasia between bovine type 1 collagen stent-grafts and uncovered control stents in small-diameter vessels (< or =4 mm). MATERIALS AND METHODS: Uncovered stainless-steel, balloon-expandable stents (n = 5) and type 1 collagen stent-grafts (n = 6) were implanted via the femoral arteries with use of 4-mm balloon catheters into the abdominal aorta of New Zealand White rabbits. Ten animals were available for follow-up. Subjects were followed for 1 month (three uncovered stents; three collagen stent-grafts) or 4 months (two uncovered stents; two collagen stent-grafts). Angiography was performed before animal sacrifice and luminal compromise was compared between groups. Histologic and immunohistochemical analysis was performed to determine presence of neointima and neointimal thickness and area; these parameters were also compared between groups. RESULTS: All stents and stent-grafts remained patent at both time points. Luminal compromise was not detectable angiographically in any subject. Maximum neointimal thickness was less than 5 mum for all subjects. Neointimal thickness and area were not statistically significantly different between groups. CONCLUSIONS: Type 1 collagen stent-grafts demonstrate excellent hemocompatibility and biocompatibility in small-diameter vessels in rabbits.

Testicular involvement in disseminated fungal infection by Pseudallescheria boydii.

We present an immunocompromised patient with a painless testicular mass. Usually, this mass is suspicious for testicular cancer; however, a fungal abscess from Pseudallescheria boydii was found. The patient eventually died from disseminating infection. This is the first such report of a testicular infection involving P. boydii. Early diagnosis and treatment are paramount because of the poor outcome with disseminated disease.

Initial report of retroperitoneoscopic renal surgery in a patient with factor VIII deficiency (classic hemophilia).

Bleeding disorders are generally considered absolute contraindications to laparoscopic surgery. We believe laparoscopic/retroperitoneoscopic renal surgery is an optimal choice in patients with hemophilia, because it minimizes tissue trauma. We present a case of successful retroperitoneoscopic renal surgery in a patient with factor VIII deficiency with a perinephric abscess that failed less invasive treatments. A fully equipped coagulation laboratory, experienced hematologists, and an experienced laparoscopic surgeon play a large role in the outcome in patients with bleeding disorders undergoing minimally invasive procedures. We conclude that although uncorrected bleeding disorders are absolute contraindications for surgical procedures, those that are corrected and appropriately monitored are not.

Alternatives to cytology in the management of non-muscle invasive bladder cancer.

The natural history of non-muscle invasive bladder cancer is characterized by a high probability of recurrence and in the case of high-grade tumors, progression to muscle invasive cancer. This mandates a follow-up strategy designed to identify recurrences in the bladder early in their evolution in order to facilitate early intervention and ablation. Urine cytology is considered the gold standard urine biomarker. Although specificity exceeds 90% to 95%, its overall sensitivity ranges from 40% to 60% in expert hands and is both tumor grade and operator dependent. While cytology is an excellent test for detection of high-grade disease, the sensitivity is particularly weak for the detection of low grade tumors. This has spawned an entire field of research of in vitro diagnostic tests and cell-based assays in order to improve the diagnostic accuracy for detection of incident or recurrent disease. To date, the US Food and Drug Administration approved dipstick and immunoassays marketed as point-of-care tests. The point-of-care tests are intended for use as an adjunct to cystoscopy and cytology, and may have a role in the office evaluation of hematuria patients. Monoclonal antibody-based tests combined with cytology may improve the diagnostic accuracy and are superior to cytology alone. A recently approved cell-based assay, utilizing fluorescent in situ hybridization technology, may help resolve suspicious cytologies, and provide early and additional information about the biology of the bladder urothelium beyond that provided by cytology, a marker of disease relatively late in evolution. Novel promising markers are in various stages of clinical testing, and a panel of biomarkers may serve in the future as a feasible alternative to urine cytology and cystoscopy for the screening, detection, and follow-up of non-muscle invasive bladder cancer.

Renal and perirenal abscesses in patients with otherwise anatomically normal urinary tracts.

PURPOSE: We characterized evaluation, management and outcomes in a group of patients diagnosed with renal and perirenal abscesses who had otherwise anatomically normal urinary tracts. MATERIALS AND METHODS: We reviewed our experience with renal/perirenal abscesses at University of Texas Medical Branch from 1991 to 2002. Treatment was determined by physician preference in each individual. RESULTS: Of 70 patients with renal/perirenal abscesses 26 had otherwise anatomically normal urinary tracts, 24 (92%) had at least 1 possible contributory factor, such as diabetes mellitus, and only 38% had the correct diagnosis at initial presentation. The abscess was intranephric in 39% of cases, intranephric and perinephric in 19%, and perinephric only in 42%. Of the 26 patients 18 were treated with percutaneous drainage or aspiration of the abscess and 12 (66.7%) had positive cultures. Eight of the 12 patients (67%) with positive abscess cultures had the same organism in urine and/or blood. All 26 patients were treated with broad-spectrum intravenous antibiotics. In most patients abscess size influenced additional treatments, such as percutaneous needle aspiration or catheter drainage. None of the patients required open surgical drainage, nephrectomy or nephrostomy tube placement. At a mean followup of 10 months all patients had complete radiographic resolution of the abscess without further complications except 1 who had pyelonephritis and another who was found to have a poorly perfused kidney. CONCLUSIONS: With accurate diagnosis and minimally invasive therapy patients with renal and/or perirenal abscesses and otherwise anatomically normal urinary tracts have excellent functional and anatomical outcomes.

Genital and perineal burns in children: 10 years of experience at a major burn center.

PURPOSE: The aim of this report is to review a decade of experience in the management of perineal and genital burns at a major burn center. METHODS: Seventy-eight children who sustained perineal or genital burns admitted to the Shriners Hospitals for Children in Galveston are discussed. RESULTS: Genital and perineal burns occurred in the context of major burns and were rarely isolated. A total of 64.1% were caused by hot liquids (scalds), 29.5% were flame burns, 3.8% contact burns, and 2.6% electrical burns. A total of 61% of the burns could be treated conservatively with loose debridement, topical, and parenteral antibiotics with satisfactory outcomes. Foley catheterization did not increase the morbidity in these patients except in children less than 1 year of age. Testicular involvement was associated with the most severe burns. Child abuse was found in 46% and 48% of boys and girls, respectively, younger than 2 years that had sustained scald burns to the perineum and, or genitals. CONCLUSIONS: Most perineal and genital burns in children can be treated successfully with a conservative approach. Child abuse should be vigorously investigated.