Large renal artery aneurysm masquerading as renal cell carcinoma

Renal artery aneurysms (RAAs) are rare. Diagnosis is typically incidental with most cases asymptomatic and detected on routine imaging. Rarely large saccular RAAs may appear to extend to the neighbouring renal parenchyma. Differentiating these from renal tumours can be difficult and subsequent investigation with biopsy may result in fatal rupture. Our case describes an RAA arising from the right renal artery masquerading as renal cell carcinoma (RCC). Emphasis is placed upon thorough radiological evaluation ensuring that RAA is considered and excluded from the differential diagnosis prior to biopsy or surgical intervention. The role of multidisciplinary input is also emphasised.

UrethroNAV: the aetiology and extent of idiopathic urethral stricture in an Australian population

Background

Lichen sclerosus (LS) is considered a causative factor in 10% of cases of idiopathic urethral stricture disease (IUSD), which is important for determining management strategies due to the underlying pathophysiology. Traditional excision urethroplasty may not be effective as inflammation often extends beyond the macroscopic stricture. This pilot study aims to answer two research questions: is LS an underlying cause of some idiopathic cause of strictures, and, if there is histological evidence suggesting predisposition of the surrounding tissue to strictures.

Methods

Biopsies were taken from the stricture site as well as 1 and 2 cm proximal and distal in patients with IUSD. Histological features, including macroscopic and microscopic findings, were reported, including the presence of LS, hyperkeratosis, epidermal changes, lichenoid infiltrates, ulceration, scarring, and inflammation. Methylene blue was used to aid in locating damaged urothelium. Patients were prospectively followed up after urethroplasty.

Results

From 109 urethroplasties performed between 2019 to 2022, 15 male patients were enrolled after meeting specific inclusion criteria. These criteria included a diagnosis of IUSD and the absence of any evidence of trauma, macroscopic inflammatory disease, or previous endoscopic instrumentation of the urethra. Patients had to be at least 16 years old and medically suitable for undergoing urethroplasty. The study was approved by the hospitals ethics committees. None had macroscopic evidence of LS. One patient had microscopic evidence of LS at the 2 cm proximal biopsy only. A total of 93% of patients had scarring proximal and distal to the stricture, while 20-40% had inflammatory change. The patient with microscopic LS and two inflammatory change patients had stricture recurrence after urethroplasty. Additionally, one patient with inflammatory changes was diagnosed with penile intraepithelial neoplasia (PeIN) and underwent partial penectomy.

Conclusions

Findings suggest that an underlying cause of IUSD could be LS. Additionally, the pathophysiology may involve scarring and inflammation beyond the limits of the stricture with extension distal from the stricture site. Careful evaluation for concomitant urethral pathology should be considered in cases of inflammatory changes. These findings should be considered in the surgical management of IUSD and warrant further research into the role of routine biopsy and drug targets in USD.

Cost benefit micro-analysis of performing urine cultures as a mean to reduce post-flexible cystoscopy urosepsis: a comparative study between two centres

Background

In Australia, flexible cystoscopy is a key diagnostic tool in urology, employed to manage various conditions. However, it carries risks like urinary tract infections and urosepsis, which lead to significant healthcare expenses. This study evaluates the cost-effectiveness of pre-procedure urine cultures to prevent post-cystoscopy urosepsis.

Methods

A retrospective analysis of data from regional Toowoomba Base Hospital and metropolitan Gold Coast University Hospital was conducted to assess the efficacy of urine cultures in reducing urosepsis following flexible cystoscopy. The study reviewed patient records, analysing both the incidence of post-procedure urosepsis and the associated economic impact.

Results

The incidence of post-procedure urosepsis was found to be exceptionally low at 0.03%. Comparative analysis showed no significant reduction in urosepsis rates with the use of pre-procedure urine cultures (P=0.93). The financial analysis highlighted that the regional centre, which conducted urine cultures, incurred costs $ 26.14 per patient greater compared to the metropolitan centre that did not perform these cultures.

Conclusions

The study indicates that the low incidence of urosepsis does not justify the routine use of pre-operative urine cultures, given the substantial costs involved. These findings support current guidelines that do not recommend routine pre-procedure cultures for cystoscopy due to lack of evidence of benefit.

A curious case: Concurrent collecting duct renal cell carcinoma and upper tract urothelial carcinoma

A 71-year-old male presented to Urology with three weeks of overt haematuria and increasing lethargy. Contrast-enhanced CT scans revealed an 8 × 6cm partially exophytic lesion in the left kidney's upper pole, extending beyond the capsule and invading the superior cortical vein, accompanied by abnormal retrocrural lymph nodes. Signs of paraneoplastic syndrome prompted a left radical nephrectomy for symptom relief. Histological analysis identified high-grade collecting duct renal carcinoma and invasive urothelial cell carcinoma. Post-surgery, he was referred for oncological treatment but passed away within two months of the initial diagnosis.

How to do a penile urethroplasty using a novel self-retaining penile retractor

Effective retraction and clear exposure of urethral tissue is essential in reconstructive penile surgery. The Joshi-Kulkarni retractor provides stable, bloodless operative exposure via non-traumatic tissue compression at the base of penis. The self-retaining design of this retractor also improves ergonomics thereby reducing surgeon fatigue. In this article, we describe how to do a penile urethroplasty by using the Joshi-Kulkarni penile retractor.

Sarcomatoid urothelial carcinoma of the ureter with heterologous elements of chondrosarcoma and osteosarcoma, and concurrent divergent squamous differentiation: A rare case report

Primary sarcomatoid urothelial carcinoma of the ureter with heterologous elements is rare and carries a poor prognosis. Although there is some literature on primary bladder sarcomatoid urothelial carcinoma, ureteric involvement has been reported infrequently, and this case report describes this unusual histological finding with concurrent divergent squamous differentiation. Despite laparoscopic radical nephroureterectomy, our patient died within six months of diagnosis with local recurrence and metastatic spread. A more thorough understanding of this disease process and consideration of standardised guidelines for treatment are needed to improve patient outcomes.

Paediatric urinary tract infections: Diagnosis and treatment

BACKGROUND

Urinary tract infections (UTIs) commonly occur in children. An estimated 8% of girls and 2% of boys will have at least one episode by seven years of age. Of these children, 12-30% will experience recurrence within one year. Australian hospital admission records indicate that paediatric UTIs represent 12% of all UTI hospital admissions.

OBJECTIVE

The aim of this article is to review the pathogenesis, clinical assessment and management of UTIs, and prevention strategies in children.

DISCUSSION

Clinically, paediatric UTI presentations are challenging because symptoms are vague and variable. Young infants may present with sepsis or fever and lack specific symptoms, whereas older children present with classical features such as dysuria, frequency and loin pain. Early diagnosis with appropriate urine specimen collection techniques, investigations and treatment is necessary for prevention of renal damage and recurrence. Effective, evidence-based investigations and treatment options are available, and physicians should feel confident in identifying and managing paediatric UTIs.

Catheter-associated meatal pressure injuries (CAMPI) in patients with long-term urethral catheters-a cross-sectional study of 200 patients

Background

Indwelling urethral catheters (IDC) are ubiquitous to healthcare settings, and are associated with many familiar risks like haematuria, infections, bladder spasms and stones. However, a less known complication is catheter-associated meatal pressure injury (CAMPI), especially in those with long-term IDCs. The objective of this study was to explore the prevalence, associated features and management of CAMPI in adults with a long-term IDC.

Methods

A cross-sectional multi-centre study was undertaken of 200 adults with a long-term IDC across regional south-west Queensland, Australia between June 2019 to June 2021. The prevalence of CAMPI was determined by clinical examination, voluntary surveys completed by participants and documentation in medical records. Key IDC statistics included total duration of IDC, location of IDC changes, IDC size, type and fixation.

Results

Out of 200 adults with a long-term IDC, 9% (18/200) had a CAMPI. There was a higher prevalence of male CAMPI (17/169, 10%) compared to female CAMPI (1/31, 3%). The median time to identification of a CAMPI after initial IDC insertion was 12 weeks (2-136 weeks), but occurred as soon as 2 weeks. CAMPI formation was associated with IDC changes in the community, impaired mobility and congestive cardiac failure (CCF). CAMPI were mostly treated by conservative means given the frailty of the population.

Conclusions

Poor mobility, community-managed IDCs, and CCF were all found to have statistically significant associations with the development of CAMPI. CAMPI represents an important and underserved iatrogenic complication within urology practice, and greater awareness is needed to prevent it in vulnerable patients with long-term IDCs.

Oncological and urinary outcomes following low-dose-rate brachytherapy with a median follow-up of 11.8 years

OBJECTIVES

To examine the long-term oncological outcomes and urological morbidity of low-dose-rate prostate brachytherapy (LDRBT) monotherapy using live intraoperative dosimetry planning and an automated needle navigation delivery system for the treatment of men with low and intermediate-risk prostate cancer.

PATIENTS AND METHODS

A prospective database of 400 consecutive patients who underwent LDRBT between July 2003 and June 2015 was retrospectively reviewed to assess urinary side-effects and biochemical progression, based on the Phoenix definition and also a definition of a prostate-specific antigen (PSA) level of ≥0.2 μg/L.

RESULTS

Minimum patient follow-up was 5.5 years. The median follow-up of the entire cohort was 11.8 years. The median (range) PSA level was 6.1 (0.9-17) μg/L and the median Gleason score was 3 + 4. The biochemical relapse-free survival (RFS; freedom from biochemical recurrence) based on the Phoenix definition was 85.8% (343/400). The RFS using a 'surgical' definition of a PSA level of <0.2 μg/L was 71% (284/400). Of the 297 men followed for ≥10 years, prostate cancer-specific survival (PCSS) was 98% (291/297). Post-LDRBT urethral stricture developed in 11 men (2.8%, 11/400). For men with ≥10 years of follow-up, 22 men (7.4%, 22/297) required a pad for either stress or urge urinary incontinence (UI). UI was identified in only 2.2% (one of 46) of men who had a bladder neck incision (BNI) before LDRBT.

CONCLUSION

LDRBT is associated with excellent PCSS, with a median follow-up of 11.8 years. The risk of post-implantation urethral stricture and UI is low and a pre-implantation BNI for management of bladder outflow obstruction does not increase the risk of UI or urethral stricture.

Female urethral stricture: A multi-centre experience and lessons learnt

Objectives

To review demographics, surgical techniques and outcomes of female patients undergoing buccal mucosal graft substitution urethroplasty.

Materials and methods

An international multi-institutional study was performed through a retrospective review of a prospectively managed database of female urethroplasty outcomes at two sites from December 2016 to June 2023. Institutions included a high-volume tertiary referral centre performing 500 urethroplasties annually, and a regional centre with a fellowship-trained urethroplasty surgeon performing ~50 urethroplasties annually. Female urethroplasty accounted for 2% of urethroplasties performed, utilising dorsal onlay, ventral inlay and double-face techniques.

Results

Forty-two patients underwent female urethroplasty between 2016 and 2023; 20 dorsal onlay grafts, 14 ventral inlay grafts and 8 double-face urethroplasty. The mean age was 45 years (SD 12.07) and mean follow-up 27 months (SD 17.22). The most common aetiology was idiopathic in 59%. The most common presenting symptom was obstructive lower urinary tract symptoms in 86%. Urethral dilatations were the most common treatment before urethroplasty, with a mean of 9 (SD 1.2) dilations pre-urethroplasty. Stricture locations seen were; proximal 7%, proximal to mid-14%, mid-31%, mid to distal 10% and distal 38%. A total of 88% were successful overall; dorsal onlay was 100%, ventral inlay urethroplasties 71% and double-face 88%. Mean Qmax improvement was 291% at 6 months. In those who required dilatations or further surgery postoperatively (n = 5); four were ventral inlay (one mid-distal, three distal), and one double-face distal stricture. All patients including those requiring secondary treatments were continent and did not require intermittent self-catheterisation or suprapubic catheter insertion.

Conclusion

Urethroplasty is an effective long-term therapeutic option for managing female urethral strictures. Dorsal onlay urethroplasty demonstrated the highest success rate, and stands out as a versatile technique, addressing distal to proximal urethral strictures. However, the chosen urethroplasty technique should be tailored to the characteristics of the stricture, patient and surgeons experience.

Distant ureteric metastasis of prostate cancer four years post radical prostatectomy

We describe a case of a 78-year-old male with a history of Gleason score 9 prostate cancer treated with a robotic-assisted radical prostatectomy, who developed symptoms of right ureteric obstruction four years later. Diagnostic evaluation revealed right sided hydroureteronephrosis on imaging. Further correlation with prostate specific antigen (PSA) and histopathology from a distal ureterectomy with reimplantation revealed metastatic prostate cancer as the cause of obstruction with incidental focal carcinoma in situ (CIS) also identified. This case highlights the diagnostic challenges and management strategies for ureteric metastasis of prostate cancer and contributes to the limited body of literature on such cases.

Redo pelvic fracture urethral injury repair: The case for tadalafil

OBJECTIVE

To define the role of tadalafil in improving outcomes of redo urethroplasty for pelvic fracture urethral injury (PFUI). PFUI is common in developing countries, invariably as a result of road traffic trauma. Repair is complex, and redo cases are even more challenging.

MATERIAL AND METHODS

This was a longitudinal prospective nonrandomized study between 2017 and 2019. Men undergoing redo-urethroplasty were nonrandomized into two groups. Group 1 received tadalafil 5 mg the next day after surgery and continued for 3 months, and group 2 did not receive tadalafil. Inclusion criteria were patients undergoing redo-urethroplasty willing to trial low-dose tadalafil post-operatively. Exclusion criteria were <18 years, females, primary cases, and complex cases such as recto-urethral fistula. Average follow-up was 19.5 months.

RESULTS

Sixty patients were enrolled (29 in group 1 and 31 in group 2). Mean age was 31 years. These patients had 1-3 prior failed urethroplasties. Most required step 3 anastomotic urethroplasty (68.3%). Success was defined as absence of symptoms and no need for surgical intervention. Failure was defined as redo urethroplasty or >1 endoscopic intervention. Primary success was 83.3%. Success with tadalafil was 96.6%, compared to 71.0% in the non-Tadalafil group (P ¼ .0008). Only one patient on tadalafil failed, compared with nine in the non-tadalafil group. Secondary success rate was defined as the need for a single subsequent endoscopic intervention and was 93.3%.

CONCLUSION

In our series, there was improved outcome with using tadalafil in patients having redo urethroplasty for PFUI. Further trials should be done to evaluate the use in all PFUI cases.

A transparent synthetic peptide hydrogel as a haemostatic agent in athermal nerve sparing robot-assisted radical prostatectomy: an observational study

Background

PuraStat® is a new synthetic haemostatic agent constituting peptides that self-assemble into sheets when exposed to ionic charges. The objective of this submission is to assess the perioperative, functional and user-reported outcomes of PuraStat® as an athermal topical haemostatic agent for use on the neurovascular bundle (NVB) in robot-assisted radical prostatectomy (RARP), and to inform further research into this developing field.

Methods

Demographic and disease data for 29 consecutive patients undergoing RARP were recorded. PuraStat® was used as the primary haemostatic agent to the NVB, without thermal or suture haemostasis, unless necessary. Preoperative, 1-h postoperative and 24-h postoperative haemoglobin (Hb) were measured. Operative data including postoperative complications up to 30 days were noted. Urinary function, continence and erectile function (EF) were measured pre- and postoperatively with the International Prostate Symptom Score (IPSS), patient reporting of pad usage, and International Index of Erectile Function (IIEF)-5 respectively. A qualitative assessment of PuraStat® was made intraoperatively by the surgical assistant in the following categories: transparency, haemostatic efficacy, ready-to-use, handling, and overall satisfaction.

Results

Twenty-nine males aged between 49 and 75 years underwent a nerve-sparing RARP under a single surgeon for clinically significant prostate cancer with PuraStat® used as the primary haemostatic agent at the NVB. One patient required an additional haemostatic suture. The median prostate volume was 36 mL. Mean blood loss was 363 mL. The mean Hb at 1 and 24 h postoperative was 135.2 and 125.1 mg/dL. Median Hb change from 1-24 h postoperative was 11 mg/dL. No transfusions were required, and there were no postoperative complications. Urinary function and continence were preserved. EF in our series was lower than published data.

Conclusions

Our observational study suggests that PuraStat® is a safe haemostatic agent in RARP with similar perioperative bleeding outcomes, comparable long-term urinary outcomes and a high level of intraoperative user satisfaction. The effects on EF requires further investigation. PuraStat® appears to be a useful therapeutic tool for the urologist performing RARPs.

Testicular tumour, could it be benign? A clinical conundrum

Testicular vasculitis (TV) is a cause of testicular infarction (TI) which can lead to significant morbidity and rarely mortality. Polyarteritis Nodosa (PAN) is the most common vasculitis that leads to testicular infarction (TI). This case report describes the retrospective tissue diagnosis of autoimmune vasculitis in a middle aged Caucasian male who developed left unilateral orchalgia and a hard, palpable testicular mass.

Periurethral abscess etiology, risk factors, treatment options, and outcomes: A systematic review

Objectives

This study aimed to describe patterns of presentation, etiology, risk factors, management, and treatment outcomes of periurethral abscesses using a systematic review framework.

Materials and methods

After prospective registration on the PROSPERO database (CRD42020193063), a systematic review of Web of Science, Embase, PubMed, and Cochrane scientific databases was performed. Articles published between 1900 and 2021 were considered. Extracted data included symptoms, etiology, medical history, investigations, treatment, and outcomes. Collated data were analyzed using univariate methods.

Results

Sixty articles met the inclusion criteria reporting on 270 patients (211 male, 59 female) with periurethral abscess. The most common clinical features were pain (41.5%), pyuria (41.5%), dysuria (38.5%), urinary frequency (32.3%), fever (25%), and a palpable mass (23%). Predisposing risk factors included the presence of a sexually transmitted infection or urinary tract infection (55.0%), urethral strictures (39.6%), and recent urethral instrumentation (18.7%). Management approaches included open incision and drainage (64.3%), conservative management with antibiotics (29.8%), and minimally invasive techniques (needle aspiration, endoscopic drainage). Time trend analysis of etiology revealed a decreased incidence of infection (sexually transmitted infection/urinary tract infection, human immunodeficiency virus) and higher incidence of diabetes mellitus and periurethral bulking injections in recent years.

Conclusions

Periurethral abscesses may display a wide range of clinical features. Presentation, risk factors and underlying etiology vary with sex. The optimal management technique is guided by abscess size. Open incision and drainage combined with antibiotics continues to be the mainstay of management. However, minimally invasive techniques are gaining favor. To the authors' knowledge, this is the first systematic appraisal and management algorithm for periurethral abscess.

Robotic surgery education in Australia and New Zealand: primetime for a curriculum

BACKGROUND

Globally, robotic surgery (RS) has witnessed remarkable growth, yet Australia and New Zealand (ANZ) lack dedicated RS training programs, creating a workforce gap. This narrative review synthesises international research to explore trends and challenges in robotic education.

METHODS

We conducted a comprehensive literature review, searching PubMed, Google Scholar, and MEDLINE using keywords like 'robotic surgery', 'surgical education', 'robotic surgery training', and 'robotic surgery curriculum'. We selected studies contributing to understanding current curricula, training tools, and issues in robotic education, utilising the international experience and how it might apply to the ANZ context.

RESULTS

RS in ANZ has grown significantly over two decades, but formal curricula for trainees are absent. North America and Europe employ diverse training tools and curricula. Barriers include cost, access, time constraints, equipment complexity, changing training environments, and competition from emerging robotic surgical systems. Balancing the curriculum's demands with trainees' existing requirements is essential.

CONCLUSION

Developing a tailored RS curriculum within ANZ's surgical training is crucial for RS to become the primary surgical approach in the future. By working towards a national curriculum we can prepare skilled trainees in robotics to meet the rising demand. The most significant barrier is the lack of robotics in public hospital where trainees are based. This curriculum should encompass online teaching modules, bedside assistance, surgical simulation, dual console mentoring, and primary operator experience.

Primary vesical clear cell adenocarcinoma arising in endometriosis: a rare case of mullerian origin

Clear cell adenocarcinoma arising out of endometriosis of the urinary bladder is a rare entity. The published literature has a dearth of information about this entity and its histogenesis. In the present case review we present a 59-year-old patient who was treated with robotic anterior pelvic exenteration and ileal conduit. The initial biopsy of bladder tumour purported a high-grade urothelial carcinoma, however the final specimen revealed a clear cell adenocarcinoma arising in endometriosis without any urothelial cancer. Early case reports refer to these lesions as mesonephric or mesonephroid adenocarcinomas but the current WHO nomenclature classifies them under non-urothelial epithelial neoplasms as clear cell adenocarcinomas. Here, we review the literature and discuss their origins.