Chronic lymphocytic leukemia/small lymphocytic lymphoma presenting as acute renal failure.

Lymphoma of the urinary bladder is quite rare, accounting for a small percentage of all bladder neoplasms. Here we discuss the case of a 68-year-old male patient who initially presented with acute renal failure and severe bilateral hydronephrosis on ultrasound. Cross-sectional imaging further revealed a diffusely thickened bladder wall with extensive retroperitoneal and mesenteric lymphadenopathy. Bladder biopsies ultimately led to a diagnosis of stage IV chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). This is a rare instance of upper tract dilatation being the first sign of a widely disseminated hematologic malignancy.

The use of indocyanine green during robotic ureteroenteric reimplantation for the management of benign anastomotic strictures.

PURPOSE: We describe our technique for using intraureteral and intraurinary diversion indocyanine green (ICG) during robotic ureteroenteric reimplantation and report our outcomes. METHODS: We retrospectively reviewed eight patients who underwent ten robotic ureteroenteric reimplantations between August 2013 and July 2017. ICG was injected antegrade and/or retrograde into the lumen of the ureter, and retrograde into the lumen of the urinary diversion. All patients consented to off-label use of ICG. Postoperatively, all patients were assessed for: clinical success: the absence of flank pain; and radiological success: the absence of obstruction on renal scan and/or loopogram. RESULTS: Visualization of ICG under near-infrared fluorescence allowed for precise identification of the strictured ureter and urinary diversion, which fluoresced green; and localization the ureteroenteric stricture margins, which poorly fluoresced green. The median operative time was 208 min (IQR 191-299), estimated blood loss was 125 ml (IQR 69-150), and length of stay was 6 days (IQR 1-8). Three of eight (37.5%) patients suffered a minor (Clavien ≤ 2), and 2/8 (25.0%) patients suffered a major (Clavien > 2) post-operative complication. There were no complications related to ICG use. At a median follow-up of 29 months (IQR 21-38), 8/10 (80.0%) ureteroenteric reimplantations were clinically and radiologically successful. CONCLUSIONS: Intraureteral and intraurinary diversion ICG may be utilized as a real-time contrast agent during robotic ureteroenteric reimplantation to assist with identification of the strictured ureter and urinary diversion, and delineation of the ureteroenteric stricture margins. Despite this, RUER remains a technically difficult and morbid procedure.

Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting.

AIM: To describe a technique for surgical correction of adult buried penis, including a technique for skin graft harvesting from the escutcheonectomy specimen itself, with an emphasis on remaining open questions in the literature. METHODS: We present our method for surgical correction of adult buried penis with a review of the literature. MAIN OUTCOME MEASURE: Components of successful buried penis repair include return of directed voiding, elimination of local skin inflammation and infection, improvement in hygiene, return of sexual functioning, cosmesis, and patient satisfaction. To date, there are no broadly accepted tools for comprehensive measurement of outcomes after buried penis repair. RESULTS: Adult buried penis repair is generally associated with excellent rates of satisfaction and improvement in functioning. Currently available data are extremely limited; however, they do suggest that, when in doubt, more aggressive debridement of diseased tissue combined with split-thickness skin grafting may provide superior outcomes. Split-thickness skin grafts are associated with excellent rates of successful graft take, even in cases of severe preoperative pathology and patient comorbidity. Although these grafts come at the cost of some increased surgical morbidity, they are associated with low rates of major complications. Morbidity can be further significantly decreased by harvesting the graft from the excised escutcheon itself, a technique that we present here. CONCLUSION: Surgical correction of adult buried penis is safe and effective; however, future work is required to further optimize outcomes and reduce surgical morbidity. Strother MC, Skokan AJ, Sterling ME, et al. Adult Buried Penis Repair with Escutcheonectomy and Split-Thickness Skin Grafting. J Sex Med 2018;15:1198-1204.

A Review of Buccal Mucosa Graft Ureteroplasty.

PURPOSE OF REVIEW: We review the buccal mucosa graft (BMG) ureteroplasty literature to evaluate its utility in the management of ureteral strictures, identify indications for which it is particularly useful, and highlight refinements in surgical technique. RECENT FINDINGS: Recent reports have described the efficacy of robotic BMG ureteroplasty and the utilization of near-infrared fluorescence to assist with precise identification of the ureteral stricture margins. BMG ureteroplasty is well-suited for ureteral reconstruction as it allows for minimal disruption of the delicate ureteral blood supply and facilitates a tension-free anastomosis. This technique is particularly useful in patients with long ureteral strictures not amenable to ureteroureterostomy and in patients with a recurrent ureteral stricture after a previously failed ureteral reconstruction.

Care of acute renal colic: a survey of emergency medicine physicians.

INTRODUCTION: To determine the contemporary practice patterns of academic emergency department (ED) providers in the United States for an episode of acute renal colic. MATERIALS AND METHODS: A 30-question survey was developed to assess ED providers' clinical decision making for an index patient with acute renal colic. The survey population was all attending and resident physicians affiliated with an American emergency medicine residency program with an institutional profile available on the Society for Academic Emergency Medicine (156 programs; 95% of programs in the United States). The survey was conducted in October 2014. A response rate of 8.1% (289/3563) was achieved, which represented 29% (46/156) of the programs. RESULTS: Only 17% (53/289) of respondents were aware of the American Urological Association (AUA) guidelines on the management and imaging of ureteral calculi. A clinical care pathway was uncommon amongst institutions (6/46; 13%), but desired by providers (193/289; 67%). A low dose non-contrast computed tomography (CT) would be the most preferred initial diagnostic imaging modality (139/289; 48%). Initial imaging choice was not influenced by respondent role, program, census region, practice environment, ED size, ED volume, presence of a clinical care pathway, or knowledge of the AUA guidelines (all p > 0.05). CONCLUSIONS: In this cross-sectional survey of academic emergency medicine providers, we demonstrated a lack of awareness of quality initiatives and uncommon use of clinical care pathways. We observed that diagnostic imaging modalities with reduced radiation were commonly preferred, and that imaging preference was not associated with several demographic or institutional characteristics.

A standardized surgical technique for removal of the Interstim tined lead.

INTRODUCTION: Explantation of the Interstim sacral neuromodulation (SNM) device is occasionally necessary. Removing the tined lead can put strain on the lead, resulting in a possible break and retained fragments. The Food and Drug Administration (FDA) released a notification regarding health consequences related to retained lead fragments. We describe a novel and safe surgical technique for removing the Interstim device and permanent lead. MATERIALS AND METHODS: We searched the Manufacturer and User Facility Device Experience (MAUDE) database for complications related to tined lead removal and searched the database of a single surgeon at our institution. Our standardized technique for tined lead removal is as follows. An incision is made over the previous lead insertion site and the lead is isolated and externalized. The fibrous encapsulation is dissected off the lead to expose the tines and ensure the lead is free from adhesions. The lead is removed by wrapping it around a curved hemostat and turning it under tension. If the lead breaks, the incision is extended and dissection is carried down to the sacral body to remove all fragments. RESULTS: Twenty-eight patients had their tined lead removed between 2009 and 2015 after being in place a median of 2.00 years (IQR 1.32-3.32 years). One lead broke (3.6%) during removal over the 6 years using our standardized approach. CONCLUSION: Permanent tined leads can break on removal and retained fragments can pose significant health consequences. Our technique standardizes the approach for removal and is safe and effective in our series.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature.

INTRODUCTION: Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. OBJECTIVES: To review the criteria used to define acute and chronic phase PD in modern PD intervention studies. METHODS: We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. RESULTS: We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain. CONCLUSION: Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature.

INTRODUCTION: Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. OBJECTIVES: To review the criteria used to define acute and chronic phase PD in modern PD intervention studies METHODS: We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. RESULTS: We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain. CONCLUSION: Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD. Piraino J, Chaudhray H, Ames K, et al. A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature. Sex Med Rev 2022;10:698-713.

Topical Application of Wogonin Provides a Novel Treatment of Knee Osteoarthritis.

Osteoarthritis (OA) is a degenerative joint disease characterized by inflammatory degradation of articular cartilage and subchondral bone. Wogonin, a compound extracted from the plant Scutellaria baicalensis (colloquially known as skullcap), has previously been shown to have direct anti-inflammatory and antioxidative properties. We examined the pain-reducing, anti-inflammatory, and chondroprotective effects of wogonin when applied as a topical cream. We validated the efficacy of delivering wogonin transdermally in a cream using pig ear skin in a Franz diffusion system. Using a surgical mouse model, we examined the severity and progression of OA with and without the topical application of wogonin. Using a running wheel to track activity, we found that mice with wogonin treatment were statistically more active than mice receiving vehicle treatment. OA progression was analyzed using modified Mankin and OARSI scoring and direct quantification of cyst-like lesions at the chondro-osseus junction; in each instance we observed a statistically significant attenuation of OA severity among mice treated with wogonin compared to the vehicle treatment. Immunohistochemistry revealed a significant decrease in protein expression of transforming growth factor ß1 (TGF-ß1), high temperature receptor A1 (HTRA1), matrix metalloprotease 13 (MMP-13) and NF-κB in wogonin-treated mice, further bolstering the cartilage morphology assessments in the form of a decrease in inflammatory and OA biomarkers.

Primary Seminal Vesicle Adenocarcinoma Presenting With Bilateral Orbital Metastasis: A Case Report.

Seminal vesicle (SV) adenocarcinoma is a rare and poorly understood malignancy. Symptoms are non-specific and prognosis is extremely poor. Herein we present a case report of a primary SV clear cell adenocarcinoma with bilateral orbital metastases at the time of initial presentation treated with multimodal therapy including radiotherapy and multi-drug chemotherapy.

Outcomes of radical cystectomy in potential candidates for bladder preservation therapy.

OBJECTIVE: To analyze the outcomes of patients with urothelial-type bladder cancer (UBC) who optimally met selection criteria for bladder preservation therapy (BPT) but were treated with radical cystectomy (RC) instead. METHODS: We identified consecutive patients with clinical stage cT2N0M0 UBC who underwent RC with curative intent at our center. Patients without carcinoma in situ, hydronephrosis, multifocality, or mixed histology were classified as BPT eligible. Patients with ≥1 contraindications were considered BPT ineligible. Clinicopathologic characteristics and survival outcomes for BPT-eligible patients were compared with those of the ineligible patients. RESULTS: Of the 275 patients who had cT2N0M0 UBC, 157 (57.1%) were BPT ineligible (carcinoma in situ = 54; hydronephrosis = 77; multifocality = 29; mixed histology = 55; ≥2 contraindications = 51). BPT-eligible and -ineligible patients did not statistically differ with regard to age, sex, race, or neoadjuvant chemotherapy. Of the BPT-eligible patients, 24.1% had occult positive lymph nodes and 36.4% had pT3 or pT4 tumors at RC. On multivariate analysis, mixed histology (odds ratio = 3.18; 95% confidence interval [CI], 1.18-8.56) and progression from noninvasive disease to cT2 (odds ratio = 4.81 [95% CI, 1.67-13.85]) were independently associated with upstaging. Two-year overall survival was higher in BPT-eligible patients (76.7% vs 57.1%; P = .003; hazard ratio = 0.48 [95% CI, 0.3-0.78]). BPT-eligible patients also had better cancer-specific mortality on competing risk analysis (sub-hazard ratio = 0.46 [95% CI = 0.29-0.72]; P = .001). CONCLUSION: Substantial clinicopathologic stage discrepancies occurred even in patients seemingly ideal for BPT, which may provide insight into BPT failures. Furthermore, substantial survival discrepancies existed for BPT-eligible and BPT-ineligible patients, underscoring the heterogeneity of cT2 disease. In the absence of randomized trials, comparisons between RC and BPT must factor in selection bias.

A rapid progression of disease after surgical excision of a malignant rhabdoid tumor of the bladder.

Extrarenal malignant rhabdoid tumors (MRTs) are rare tumors with a poor prognosis. Five-year overall survival for patients with MRTs is poor at approximately 20%.(1) There are 5 case reports of histologically confirmed primary MRT of the bladder in pediatric patients. Herein, we report a case of an MRT of the bladder in a 14-year-old boy and discuss the preoperative evaluation, treatment options, and possible etiologies of metastasis after radical surgery.

The relationship between temperament, gender, and childhood dysfunctional voiding.

OBJECTIVE: Dysfunctional voiding (DV) is an extremely common pediatric complaint. The goal of this study was to examine the relationship between DV and childhood temperament. METHODS: Information about the voiding behaviors and temperaments of 50 children was examined using a case-control model. Caregivers were asked to fill out the Children's Behavior Questionnaire in order to rate their child on the dimensions of surgency, negative affect, and effortful control. The relationship between DV and these dimensions was then evaluated. RESULTS: Males with DV were found to have lower effortful control than males with normal voiding habits. Females with DV did not demonstrate a difference in effortful control, but did demonstrate a higher rate of surgency. CONCLUSIONS: The results suggest that temperament does have an association with DV. These findings are in line with temperamental associations with other externalizing trouble behaviors and may inform potential treatment strategies for DV.

Benign testicular enlargement due to diffuse interstitial fibrosis associated with cryptorchid testis in 11-month-old boy.

Benign testicular enlargement secondary to diffuse interstitial fibrosis is a rare clinical entity, especially in pediatric patients. To our knowledge, this is the first pediatric case reported of benign testicular enlargement due to interstitial fibrosis in a cryptorchid testis. We report a rare case of an 11-month-old boy with a cryptorchid testis found intraoperatively to have an asymmetrically enlarged testis secondary to diffuse, benign interstitial fibrosis of the testis. Additionally, we discuss previous case reports of testicular enlargement due to interstitial fibrosis, the potential etiology and the management.

Recombinant MG53 protein modulates therapeutic cell membrane repair in treatment of muscular dystrophy.

Mitsugumin 53 (MG53), a muscle-specific TRIM family protein, is an essential component of the cell membrane repair machinery. Here, we examined the translational value of targeting MG53 function in tissue repair and regenerative medicine. Although native MG53 protein is principally restricted to skeletal and cardiac muscle tissues, beneficial effects that protect against cellular injuries are present in nonmuscle cells with overexpression of MG53. In addition to the intracellular action of MG53, injury to the cell membrane exposes a signal that can be detected by MG53, allowing recombinant MG53 protein to repair membrane damage when provided in the extracellular space. Recombinant human MG53 (rhMG53) protein purified from Escherichia coli fermentation provided dose-dependent protection against chemical, mechanical, or ultraviolet-induced damage to both muscle and nonmuscle cells. Injection of rhMG53 through multiple routes decreased muscle pathology in the mdx dystrophic mouse model. Our data support the concept of targeted cell membrane repair in regenerative medicine, and present MG53 protein as an attractive biological reagent for restoration of membrane repair defects in human diseases.

Laparoendoscopic single-site varicocele repair in adolescents-initial experience at a single institution.

BACKGROUND AND PURPOSE: Laparoendoscopic single-site (LESS) varicocele repair is a modification of standard laparoscopic varicocele repair that uses a single port. We describe our initial experience with LESS varicocele repair. PATIENTS AND METHODS: During a 1-year period, all patients who presented for varicocele repair underwent LESS repair. We evaluated our initial experience by determining operative time, operative and postoperative complications, and overall cost of the procedure. RESULTS: A total of 11 adolescents underwent LESS varicocele repair. There were no intraoperative complications, and there were no conversions to open surgery or traditional laparoscopy. Estimated blood loss was minimal, and mean operative time was 66.9 minutes (range 48-91 min). The varicocele was corrected in all cases. During the 4 to 14 month follow-up, there was no recurrence, testis atrophy, or hernia in any patient. One subclinical hydrocele developed postoperatively that has not been repaired. CONCLUSION: Our experience with LESS varicocele repair in adolescents suggests it to be a safe and effective method for varicocele repair in adolescents.