Myxoid chondrosarcoma of the scrotum: a case report and review of the literature

Extraskeletal myxoid chondrosarcomas are relatively rare soft tissue malignant tumours, most commonly located in the extremities. Their occurrence in the genitourinary tract is extremely rare. We present a clinical case report of an extraskeletal myxoid chondrosarcoma originating in the scrotum.

Dong Quai (angelica sinensis) in the treatment of hot flashes for men on androgen deprivation therapy: results of a randomized double-blind placebo controlled trial

OBJECTIVE

To determine whether Dong Quai, a Chinese herbal compound purported to be efficacious in treating menopausal vasomotor symptoms, has a therapeutic benefit in treating hot flashes among prostate cancer patients receiving androgen deprivation therapy.

METHODS

A randomized double-blind placebo controlled trial was conducted involving 22 men receiving luteinizing hormone-releasing hormone agonist therapy for prostate cancer with bothersome hot flashes. After recording a baseline log of the frequency, duration and severity of daily hot flashes, patients were randomly assigned in a 1:1 ratio to receive daily placebo or Dong Quai for 3 months. Vasomotor and adverse events were recorded daily. Blood work including serum prostate-specific antigen (PSA), international normalized ratio of prothrombin time and partial thromoboplastin time were recorded at baseline and at the termination of the study.

RESULTS

Seventeen of the 22 patients enrolled completed the trial. Baseline vasomotor duration and severity were equivalent between the groups, however the number of hot flashes were significantly more in the Dong Quai group (p = 0.02). With respect to the change in number of hot flashes per day, there was a slight decrease in the mean number among the Dong Quai group which was insignificant. The absolute change and average percentage change in perceived hot flash severity was similar in both groups. There was no significant decrease in the duration of the hot flashes between the 2 groups. Disease progression based on either PSA increase or change in digital rectal exam was not observed in any patient.

CONCLUSION

In this small pilot study, there were no significant differences in the severity, frequency or duration of hot flashes among men receiving placebo or Dong Quai.

NMP22 is predictive of recurrence in high-risk superficial bladder cancer patients

INTRODUCTION

The nuclear matrix protein 22 (NMP22) assay has been shown to have greater sensitivity for the diagnosis and detection of recurrent urothelial carcinoma of the bladder (UCB) over that of traditional urine cytology. We assessed the use of NMP22 to predict which high-risk superficial UCB patients will have recurrence, progression or disease-related death; we compared these results to standard urine cytology.

METHODS

One hundred consecutive patients with high-risk superficial UCB were enrolled. During surveillance, urine was collected for cytology and NMP22 testing. Patients were followed for at least 6 months. Retrospective chart review was undertaken to collect data on previous tumour history, tumour characteristics, disease recurrences, progression and death. Kaplan-Meier analyses were performed to determine the significance between NMP22-positive and -negative patients in terms of recurrence-free, progression-free and overall survival. Similar analyses were performed for urine cytology.

RESULTS

From 94 eligible patients, 15 and 79 were NMP22 positive and negative, respectively. The baseline characteristics between the 2 groups were not significantly different in terms of patient characteristics, prior tumour history or intravesical therapies received. Mean recurrence-free survival time was significantly lower in the NMP22 positive group (p = 0.038); however, mean progression-free and overall survival were not significantly different between the 2 groups (p = 0.297 and 0.519, respectively). Urine cytology demonstrated no significant predictive power for disease recurrence, progression or survival.

CONCLUSION

The nuclear matrix protein 22 assay appears to have predictive value for future tumour recurrences, but not progression or overall survival in patients with high-risk superficial UCB.

Third prize: the impact of fluid environment manipulation on shockwave lithotripsy artificial calculi fragmentation rates

BACKGROUND AND PURPOSE

Studies have suggested that shockwave lithotripsy (SWL) stone fragmentation rates can be affected by characteristics of the fluid media surrounding the stone, although evidence to implicate the impact of urine specific gravity (SG) is limited and inconclusive. Our aim is to further explore the impact fluid media and SGs have on stone fragmentation using a variable focus lithotripter.

MATERIALS AND METHODS

Artificial stones were presoaked for 24 hours in urine and then shocked in various fluid media including artificial urine (SG 1.010 control, 1.020, and 1.07), human pooled urine (HPU), degassed HPU, Pentastarch, 100% and 30% contrast, degassed 30% contrast, 100% ethanol, deionized water (dH(2)O), degassed dH(2)O, 5% glucose, Ringer lactate, 0.9% saline, glycerol, whole blood, and lubricating gel. After soaking, SWL using the Modulith SLX-F2 electromagnetic lithotripter was performed. Fragments were dried and sieved using a 4-mm diameter opening grid. Fragments >4 mm were weighed and fragmentation coefficients (FCs) calculated (pre-SWL weight - post-SWL weight)/(pre-SWL weight) × 100. Fifteen stones were shocked for each fluid group.

RESULTS

Fluid type, viscosity, and degassing all significantly impacted stone fragmentation. While the solutions' SG, per se, did not appear to affect stone fragmentation, the use of degassed 30% contrast significantly improved stone destruction over the SG 1.010 artificial urine control (95.3% vs 71.4, P < 0.01). Furthermore, degassing improved comminution rates by increasing the number of completely fragmented stones (FC = 100%). Using degassed 30% contrast, 12/15 stones were completely fragmented, compared with only 2/15 in the control group (P = 0.007). Among the whole blood, glycerol, and lubricating gel groups, only 1/15, 0/15, and 1/15 stones reached 100% FC respectively in the narrow focus, possibly because of the detrimental impact of increased viscosity.

CONCLUSIONS

Different fluid media can significantly affect FC in vitro. Among the various fluids tested, degassed 30% contrast significantly increased the FC and total number of completely fragmented stones.

Randomized controlled, multicentre clinical trial comparing a dual-probe ultrasonic lithotrite with a single-probe lithotrite for percutaneous nephrolithotomy

OBJECTIVES

• To compare the Cyberwand (Gyrus/ACMI, Southborough, MA, USA), a dual-probe ultrasonic lithotrite, with a single-probe ultrasonic lithotrite. • The Cyberwand incorporates coaxial high- and low-frequency ultrasonic probes that work synergistically.

PATIENTS AND METHODS

• An institutional review board-approved, multicentre, randomized controlled trial to compare the Cyberwand to the Olympus LUS-II (Olympus America, Inc., Melville, NY, USA) single-probe lithotrite was performed. • Patients undergoing a percutaneous nephrolithotomy (PCNL) with a target stone > 2 cm in diameter were eligible for the study. • The primary outcome was the time to removal of the targeted stone.

RESULTS

• A total of 57 PCNLs were performed after randomization: 25 Cyberwand and 32 LUS-II. • There was no difference (P > 0.05) observed between the two devices for target stone surface area (Cyberwand 526.6 cm³ vs LUS-II 540.1 cm³), time to clearance of target stone (Cyberwand 15.8 min vs LUS-II 14.2 min) and target stone clearance rate (Cyberwand 61.9 mm²/min vs LUS-II 75.8 mm²/min). • Of the patients with stone analysis, hard stones (calcium oxalate monohydrate, brushite and cystine) were noted in 14 (56.0%) of the 25 Cyberwand and 18 (62.1%) of the 29 LUS-II patients. • Fifteen of the 25 (60.0%) Cyberwand and 20 of the 32 (62.5%) LUS-II patients were stone-free after the initial PCNL. • Those patients not rendered stone-free went on to receive a secondary PCNL. • Device malfunction occurred in eight of 25(32.0%) Cyberwand and five of 32 (15.6%) LUS II patients. • Complications were similar in both treatment groups.

CONCLUSION

• No appreciable difference between the dual-probe Cyberwand and the standard ultrasonic Olympus LUS-II lithotrites can be identified.

Preoperative indications for percutaneous nephrolithotripsy in 2009

Abstract Since the first description of percutaneous nephrolithotripsy (PNL) over 30 years ago, the indications for this procedure in the management of upper tract urinary stones has greatly expanded. Despite recent advances in shock wave lithotripsy and ureteroscopic technologies, PNL maintains a dominant role in the management of complex and large volume upper tract stones. The contemporary indications for PNL are reviewed herein.

The management of treatment-resistant biliary calculi using percutaneous endourologic techniques

BACKGROUND

Complicated choledocholithiasis cannot always be managed by standard surgical, radiologic or endoscopic methods. One additional approach is to use percutaneous techniques developed by endourologists to treat renal calculi. In this report, we present our experience over the past 10 years with this novel approach.

METHODS

We conducted a retrospective review of all patients who underwent percutaneous, endoscopic treatment of biliary calculi at our institution between January 1997 and August 2007. Primary outcomes of interest were symptom- and stone-free rates, length of stay in hospital and complications.

RESULTS

Nineteen patients underwent 21 percutaneous treatments for biliary calculi. All were dependent on external drainage for symptom control. The primary indications for treatment were cholangitis, retained stone, biliary colic and jaundice. Seventeen patients (89.5%) had failed prior endoscopic retrograde cholangiopancreatography (ERCP) or open attempts at treatment. The 2 remaining patients (10.5%) were deemed unfit for a general anesthetic. Patients had experienced a mean of 1.8 (standard deviation [SD] 1.0) prior failed attempts at stone removal. We used several treatment modalities, including holmium:yttrium-aluminum-garnet laser (61.9%), electrohydraulic lithotripter (19.0%), ultrasound (9.5%), basket extraction (9.5%) and balloon dilatation of the ampulla (19.0%). Overall, treatment led to successful removal of the biliary drainage tube in 94.7% of patients and 76.2% were stone-free. We performed cholangiograms an average of 21.8 (SD 13.7) days after treatment. The average length of stay in hospital was 1.9 (SD 1.1) days. One patient experienced a perioperative acute coronary syndrome and another experienced prolonged biliary drainage. Both had successful endoscopic treatment of their calculi. There were no cases of treatment-related sepsis, and we observed no other complications.

CONCLUSION

Biliary calculi may be successfully treated using standard endourologic methods with high stone-free rates. This technique is generally well-tolerated even among high-risk patients.

Anti-adhesive coating and clearance of device associated uropathogenic Escherichia coli cystitis

PURPOSE

A previous study showed decreased uropathogen adherence using a novel anti-fouling coating consisting of mussel adhesive protein mimics conjugated to poly(ethylene glycol). We assessed the ability of methoxy polyethylene glycol-dihydroxyphenylalanine (Nerites Corp. Ltd., Madison, Wisconsin) coated ureteral stents to resist bacterial adherence, infection development and encrustation in a rabbit model of uropathogenic Escherichia coli cystitis.

MATERIALS AND METHODS

Sof-Flex stent curls that were uncoated and coated with 3 coatings, including Surphys 002, 008 and 009, respectively, and uncoated Percuflex Plus stents were inserted transurethrally into the bladder of 50 male New Zealand White rabbits (Charles River Laboratories, Montreal, Quebec, Canada), followed by instillation of uropathogenic E. coli strain GR12 (10(7) cfu). Urine was examined for bacteria on days 0, 1, 3 and 7, and for cytokine levels on day 7. On day 7 the animals were sacrificed. Stent curls and bladders were harvested for analysis. In a parallel experiment stents were challenged in vitro for 7 days with GR12 in human urine.

RESULTS

Surphys 009 coated devices showed decreased urine and stent bacterial counts compared to those in controls. Eight of 10 rabbits in the Surphys 009 group had sterile urine by day 3 vs 1 in each control group (p = 0.013), while stent adherent organisms were decreased by more than 75%. While no statistical differences were found in encrustation and bladder inflammation across the groups, immune scoring was lowest in the uncoated Sof-Flex control and Surphys 009 groups (p = 0.030).

CONCLUSIONS

Surphys 009 strongly resisted bacterial attachment, resulting in improved infection clearance over that of uncoated devices. However, this did not translate to decreased encrustation, which appeared to be independent of infection in this model.

First prize: Novel uropathogen-resistant coatings inspired by marine mussels

BACKGROUND AND PURPOSE

Success in the prevention of urinary device infections has been elusive, largely due to multiple bacterial attachment strategies and the development of urinary conditioning films. We investigated a novel anti-fouling coating consisting of mussel adhesive protein mimics conjugated to polyethylene glycol (mPEG-DOPA(3)) for its potential to resist conditioning film formation and uropathogen attachment in human urine.

METHODS

Model TiO(2) -coated silicon disks ( approximately 75 mm(2)) were either coated with mPEG-DOPA(3) or left uncoated and sterilized using ethylene oxide gas. For bacterial attachment experiments, coated and uncoated surfaces were separately challenged with bacterial strains comprising six major uropathogenic species for 24 hours at 37 degrees C in human pooled urine. Starting inoculum for each strain was 10(5) CFU/mL and 0.5 mL was used per disk. Following incubation, the disks were thoroughly rinsed in phosphate buffered saline to remove non-adherent and weakly-adherent organisms and cell scrapers were employed to dislodge those that were firmly attached. Adherent bacteria were quantitated using dilution plating. Representative disks were also examined using scanning electron microscopy, energy dispersive x-ray analysis, and live/dead viability staining.

RESULTS

The mPEG-DOPA(3) coating significantly resisted the attachment of all uropathogens tested, with a maximum >231-fold reduction in adherence for Escherichia coli GR-12, Enterococcus faecalis 23241, and Proteus mirabilis 296 compared to uncoated TiO(2) disks. Scanning electron microscopy and viability staining analyses also reflected these results and demonstrated the ability of the coating to resist urinary constituent adherence as well.

CONCLUSION

Model surfaces coated with mPEG-DOPA(3) strongly resisted both urinary film formation and bacterial attachment in vitro. Future in vitro and in vivo studies will be conducted to assess whether similar findings can be demonstrated when these polymer coatings are applied to urologic devices.

Pilot study of ureteral movement in stented patients: first step in understanding dynamic ureteral anatomy to improve stent comfort

BACKGROUND AND PURPOSE

Ureteral stents may cause significant morbidity, including pain, dysuria, hematuria, and infection. New biomaterials, coatings, and designs have been studied in an attempt to reduce stent-related symptoms, but to date, the ideal comfortable stent has not been developed. In order to facilitate development of a stent that will mold and change with patient movement, we examined stent and ureteral movement with changes in patient body position.

PATIENTS AND METHODS

Four women and two men with a median age of 60.5 +/- 7.7 years who underwent shockwave lithotripsy and insertion of a ureteral stent were enrolled. Static radiographs were performed with the patients in four positions: supine, standing, sitting, and bending forward. Differences in stent position were analyzed digitally relative to fixed bony reference points to determine ureteral movement.

RESULTS

The renal stent curl was most cephalad when the patient was supine and moved caudally an average of 2.5 +/- 1.5 cm when the patient stood up. The absolute vertical length of the stent was greatest when the patient was supine (31.1 +/- 1.2 cm) and shortened with standing (28.3 +/- 2.3 cm) and sitting (26.6 +/- 1.5 cm). The bladder curl moved an average of 2.3 +/- 1.2 cm vertically with patient movement.

CONCLUSIONS

By measuring stent position, we were able to quantify the range of motion of the ureter during changes in body position. Stent movement appears to be a combination of bowing in the proximal ureter and moving within the bladder. Future stent designs may take this into account to decrease stent-related symptoms.

Percutaneous nephrolithotomy made easier: a practical guide, tips and tricks

Percutaneous nephrolithotomy (PCNL) plays an integral role in managing large renal stones. Establishing percutaneous renal access is the most crucial step in the procedure and requires a thorough understanding of renal, retroperitoneal and thoracic anatomy to minimize the risk of complications. Moreover, access to fluoroscopy and the proper equipment are critical to ensuring complete stone removal. In this review we describe the technique of PCNL used in a high-volume endourology centre, where the urologist is involved in all aspects of the procedure.

C-arm laser positioning device to facilitate percutaneous renal access

Renal access is the most crucial step in the performance of percutaneous nephrolithotomy and is a difficult skill to acquire for novice surgeons. We report on a simple fluoroscopic technique based on the laser positioning device that emits an aiming beam common to modern fluoroscopy C-arm units.

Third Prize: Contemporary Percutaneous Nephrolithotripsy: 1585 Procedures in 1338 Consecutive Patients

BACKGROUND AND PURPOSE

The approach to urinary-stone disease has changed dramatically over the last three decades with a transition from open surgery to minimally invasive procedures. Percutaneous nephrolithotripsy (PCNL) is a cornerstone of the treatment of kidney and selected upper-ureteral stones and continues to evolve with advances in techniques and instrumentation. The purpose of this study was to assess outcomes and trends prospectively in a large contemporary group of patients undergoing PCNL.

PATIENTS AND METHODS

Between July 1990 and December 2005, all 1338 patients at a single center scheduled for PCNL (N = 1585 procedures) were enrolled. Their mean age was 53 years (range 4-89 years). Data including comorbidities, stone burden, stone location, surgical time, hospital length of stay, rate of secondary procedures, and adverse events were collected prospectively. The primary outcome measures were stone-free rate and complications.

RESULTS

There was a substantial incidence of comorbid medical conditions (48.8%) and anatomic renal abnormalities (25.3%), demonstrating the diverse and challenging patient population in this contemporary series. The overall stone-free rate at 3 to 6 months of follow-up was 94.8%.

CONCLUSIONS

Percutaneous nephrolithotripsy is a highly effective procedure and may be performed in a diverse group of patients with comorbid conditions and renal abnormalities. Improved intracorporeal lithotripters, balloon dilation of the tract, use of flexible instruments, and liberal use of secondary nephroscopy result in excellent stone-free rates with low morbidity.

Transitional-Cell Carcinoma Recurrence Rate after Nephroureterectomy in Patients Who Undergo Open Excision of Bladder Cuff v Transurethral Incision of the Ureteral Orifice

BACKGROUND AND PURPOSE

The gold standard treatment for upper-tract transitional-cell carcinoma is radical nephroureterectomy, but management of the distal ureter is not standardized. Two treatment options to detach the distal ureter are open cystotomy (OC) and excision of a bladder cuff or transurethral incision of the ureteral orifice (TUIUO). We compared the clinico-pathologic outcomes of these two techniques.

PATIENTS AND METHODS

Hospital records were reviewed on all 51 patients who had undergone open or laparoscopic nephroureterectomy at our institution between 1 January 1990 and 30 June 2005. Patient demographics, intraoperative parameters, and pathology data were collected. The mean follow-up was 23.2 months (range 4.5-75 months) and 22.1 months (range 1-50 months) for the OC and TUIUO groups, respectively. There were no significant differences in sex, age at operation, American Society Anesthesiologists risk score, previous transitional-cell tumors, pathologic tumor grade and stage, or metastatic disease status in the two groups.

RESULTS

Five patients had an unplanned incomplete ureterectomy. The bladder recurrence rates were similar in the OC group (22.2%; 6/27) and the TUIUO group (26.3%; 5/19). There were no pelvic recurrences in either group. Four of the five patients who had an incomplete ureterectomy had tumor recurrences, three in the form of metastatic disease.

CONCLUSION

Management of the distal ureter by TUIUO in appropriate patients offers the same rate of bladder recurrence as OC. Incomplete ureterectomy results in a significantly higher rate of recurrence, often associated with the development of metastatic disease.

Research priorities for urological care following spinal cord injury: recommendations of an expert panel

OBJECTIVE

A multidisciplinary panel of experts from Canada and the United States was convened by the Ontario Neurotrauma Foundation (ONF) to establish research priorities in the area of urological care following spinal cord injury (SCI).

DESIGN

The panel reviewed a synthesis of published literature in five areas of urology, identified emerging opportunities in the private and public sector, and used a modified Delphi approach to reach consensus on priorities for funding.

RESULTS

The panel recommendations included: clinical trials of the safety and efficacy of M3 receptor specific anti-muscarinic agents for bladder hyperactivity in SCI patients; development and testing of protocols for sacral nerve electrostimulation without sacral afferent neurectomy for management of micturition - including selective stimulation of sacral nerve fibers, high frequency blocking of the pudendal nerve to minimize the risk of urethral sphincter co-contraction and genital nerve stimulation for bladder inhibition and incontinence management; clinical trials of the efficacy and safety of intra-urethral valve catheters; trials of the efficacy of probiotics for bacterial interference i.e. to reduce colonization by uropathogens and manage the dual problems of infection and pathogen resistance to anti-microbials: innovations in the prevention or treatment of stone disease (ureteral, bladder and kidney).

CONCLUSIONS

The recommendations form the strategic priorities of the ONF SCI grants program for Ontario-based investigators and their partnerships with out-of-province collaborators and organizations.

Percutaneous nephrolithotomy under conscious sedation in morbidly obese patients

Two morbidly obese males weighing 159 kg and 184 kg underwent percutaneous nephrolithotomy (PCNL) for large, symptomatic renal stones. To avoid anesthetic complications and cardiorespiratory compromise in the prone position, the procedures were performed under IV sedation with local anesthesia. The risks of PCNL in this patient population are reviewed, and the technique employed to mitigate the risks in these two cases is described.

Emphysematous pyelonephritis: a case report and review of the literature

We present a case of fulminant emphysematous pyelonephritis in a 44-year-old diabetic woman culminating in emergent nephrectomy. Current management strategies and their outcomes are reviewed.

Expression of human telomerase reverse transcriptase, Survivin, DD3 and PCGEM1 messenger RNA in archival prostate carcinoma tissue

INTRODUCTION

The wide spectrum of biological behavior displayed by prostate cancer (PCa) warrants investigation of potential PCa-specific biomarkers that could identify more aggressive tumor types and therefore provide prognostic value. Upregulation of expression of human telomerase reverse transcriptase (hTERT), Survivin, DD3 and PCGEM1 mRNAs in PCa lesions has recently been described. The purpose of this study was to evaluate the clinical value of detection of over-expression of these biomarkers in the diagnosis and prognosis of PCa.

MATERIAL AND METHODS

Archival formalin-fixed, paraffin-embedded (FFPE) prostatectomy tissue from 26 patients with PCa (Gleason score 3-9, mean 7) and 14 patients with benign prostatic hyperplasia (BPH) were analyzed by reverse transcription polymerase chain reaction (RT-PCR) for semiquantitative transcript levels of hTERT, Survivin, DD3 and PCGEM1. In addition, 25 matched normal (MN) tissue samples were examined. The expression of biomarker mRNA relative to b2-microglobulin mRNA was determined using AlphaImager 2200 data analysis software.

RESULTS

The biomarkers had sensitivities ranging from 91% to 100%. Clinical specificities evaluated with the BPH tissue were the following: hTERT mRNA (93%), DD3 mRNA (57%), Survivin (29%) and PCGEM1 (14%). Biomarker expressions were up to 13.5-fold higher in PCa tissue as compared to MN tissue. None of the tumor biomarkers showed a positive correlation with pathological stage and Gleason score.

CONCLUSIONS

The results of this study indicate potential utility of the hTERT mRNA and DD3 mRNA as diagnostic but not prognostic biomarkers for PCa.

Long-Term Results of Microwave Thermotherapy for Symptomatic Benign Prostatic Hyperplasia

PURPOSE

To study the long-term outcomes of men with moderately severe symptomatic benign prostatic hyperplasia (BPH) who were treated with transurethral microwave thermotherapy (TUMT) with the Dornier Urowave machine.

PATIENTS AND METHODS

A total of 220 patients (mean age 66.2 years) with clinical BPH, an American Urological Association (AUA) Symptom Score of >or=13, and a peak urinary flow rate (Qmax) of <or=12 mL/sec were enrolled in a multicenter randomized, double-blind, sham-controlled trial. Sham and active treatments were conducted under local anesthesia as an outpatient procedure. Patients were followed up at 1 week and at 1, 3, and 6 months. Patients in the sham-treatment arm who still met the initial enrollment criteria were then offered active treatment. The 6-month interim analysis of the safety and efficacy of this treatment has been previously reported (Urology 1998;51:19). Patients were then followed at 6-month intervals out to 60 months after treatment. At our center, 34 men (mean age 64+/-6 years) continued on the recommended long-term follow-up protocol.

RESULTS

Among the 34 men from our center initially entered in the study, 15 completed the entire 5-year follow-up. Four of the men available for follow-up at the 5-year mark were on alpha-blocker medication, and six men had required transurethral surgery for symptom relief. At 5 years, this cohort of patients maintained improvement in AUA Score (from 20.5+/-6.2 to 11.5+/-5.0; P<0.001) and Quality of Life score (from 3.7+/-1.3 to 1.9+/-1.0; P<0.001) but showed no significant improvement in Qmax (8.2+/-1.9 mL/sec to 8.4+/-4.3 mL/sec). At 5 years, 11 of the 15 patients available for review had not required additional therapy.

CONCLUSIONS

While improvement in voiding symptoms and Quality of Life scores were maintained without the need for adjuvant treatment in approximately one third of men 5 years after TUMT, a significant number had required salvage therapies for symptom relief.

Prospective evaluation of remote, interactive videoconferencing to enhance urology resident education: the genitourinary teleteaching initiative

PURPOSE

Changes in referral patterns and resource allocation into Centers of Excellence affect the educational experience of urology trainees by altering resident exposure to patients and clinicians, especially at sites where subspecialty deficiencies exist. Access to educators at Centers of Excellence using interactive videoconferencing technology may facilitate residency training objectives and enhance trainees' overall educational experience. We prospectively evaluated the implementation of this technology at tertiary care teaching centers to enhance urology resident education.

MATERIALS AND METHODS

Using videoconferencing technology, urology residents at the University of Western Ontario (London, Canada) participated in a series of didactic, interactive pediatric urology teleteaching seminars. These were presented by an expert pediatric urologist from the Hospital for Sick Children, Toronto, Canada. Using a 5-point Likert scale (1-strongly disagree, 5-strongly agree), participants responded to statements pertaining to seminar content, technology and ease of use at the completion of each session. The results were subsequently tabulated and evaluated to determine the effectiveness and accessibility of the program in providing expert pediatric urological education to residents at a remote urology training program.

RESULTS

The entire urology resident staff from postgraduate year 1 to 5 participated in the seminar program. The overall acceptance of this medium was high (mean score 4.5). The quality of presentation, as well as picture and sound quality, all received mean scores greater than 4. Participants indicated that their ability to interact with the presenter was not inhibited by using this medium. All participants agreed that they would use this technology in the future (mean score 4.5) and that the presentation would not be improved if the presenter were on-site. Due to preexisting technology at both centers, no direct cost was incurred throughout the study.

CONCLUSIONS

Our experience suggests that interactive teleteaching using readily available, existing technology, is a cost-effective and accepted method of providing trainees with an appropriate educational experience. In centers where subspecialty deficiencies exist, this medium may provide residents with the necessary education requirements of their respective programs without the need for costly teacher (or student) travel. Continual improvements in technology as well as the addition of multiple sites will increased this medium's impact in the future.

Evaluation of a Novel Modified Suture Material Designed to Facilitate Intracorporeal Knot Tying during Laparoscopic Surgery

BACKGROUND AND PURPOSE

Laparoscopic intracorporeal knot tying in minimally invasive surgery is an advanced skill. Mastering this skill is an arduous process with a long learning curve. While recent advances in instrumentation have allowed easier suturing and tying, until now, no attempts have been made to modify the suture material in order to facilitate this process. We present an evaluation of a novel modified suture material designed to allow inexperienced surgical residents to tie intracorporeal knots laparoscopically using conventional laparoscopic needle drivers.

SUBJECTS AND METHODS

Surgical residents with no prior experience in laparoscopic surgery were invited to take part in this investigation. Each of the 14 participants was given a 10-minute demonstration of laparoscopic intracorporeal knot tying and then allowed a mentored practice session of 10 minutes. In the first trial, they were then randomized to tie a laparoscopic knot with either a standard or a modified dry suture. Time and accuracy scores were recorded. They then performed the same task with the other type of suture. On the second trial, wet standard and modified sutures were used, and the order of the sutures used in the first trial was reversed.

RESULTS

The average time taken to tie an intracorporeal knot laparoscopically was significantly less when the modified suture was used in both dry and wet conditions (162.71 +/- 10.79 seconds v 270.86 +/- 22.76 seconds; P = 0.0039, and 123.29 +/- 4.70 seconds v 247.57 +/- 23.17 seconds; P = 0.0032, respectively). No significant difference in accuracy scores was noted with the two sutures.

CONCLUSIONS

Our modified suture design allowed inexperienced surgical residents to perform intracorporeal laparoscopic knot tying on average faster than the standard suture did. The concept of modifying suture design to facilitate laparoscopic suturing and knot tying deserves further investigation and development.

Ureteroscopy for pediatric urolithiasis: An evolving first-line therapy

OBJECTIVES

To present in a retrospective report a contemporary series of patients aged 14 years and younger who were treated for stones with ureteroscopy at our institution from 1991 to 2002. With the improvement and miniaturization of ureteroscopes and ancillary instruments, the endoscopic treatment of renal and ureteral calculi in children has become more feasible.

METHODS

A retrospective chart review was performed of 23 patients aged 14 years and younger who had undergone ureteroscopy for the treatment of ureteral or renal calculi at our institution.

RESULTS

A total of 27 stones were treated in 23 patients. Of the 27 stones, 18 were in the distal ureter, 5 in the mid ureter, 2 in the proximal ureter, and 2 in the renal pelvis. Ureteral dilation was performed in 4 (17.4%) of the 23 patients. The lithotripsy modalities used were holmium:yttrium-aluminum-garnet laser in 16 (69.6%), electrohydraulic lithotripsy in 3 (13%), a combination of holmium laser and electrohydraulic lithotripsy in 2 (8.7%), and basket extraction alone in 2 (8.7%) of 23 patients. Ureteral stents were placed in 21 (91.3%) of 23 patients. The average operative time was 46.9 minutes (range 15 to 92). In 21 (91.3%) of 23 patients, postoperative imaging was available and revealed that 20 (95.2%) of the 21 patients were rendered stone free. Two patients were lost to follow-up. No intraoperative complications occurred. One patient was treated postoperatively with intravenous antibiotics for transient fever.

CONCLUSIONS

Ureteroscopy is safe and effective in the management of ureteral and renal calculi in children. In our institution, it has emerged as a valid first-line therapy for the treatment of pediatric urolithiasis.

A prospective evaluation of the diagnostic and potential prognostic utility of urinary human telomerase reverse transcriptase mRNA in patients with bladder cancer

Human telomerase reverse transcriptase (hTERT) mRNA expression has been considered a surrogate marker for telomerase activity based on its parallel detection in urological malignancies, including transitional cell carcinoma (TCC) of the bladder. The objective of this study was to prospectively evaluate the diagnostic performance of urine hTERT mRNA marker and urine cytology in the detection of bladder cancer. The multiplex hTERT/GAPDH (glyceraldehyde-3-phosphate dehydrogenase) reverse transcription polymerase chain reaction (RT-PCR) assay was employed to assess hTERT mRNA expression in urine sediments from 43 patients with clinically apparent TCC undergoing transurethral resection. Tumor grade and pathological stage were determined. The results of urine cytology were compared with urine hTERT mRNA expression. The control group consisted of 46 age-matched healthy volunteers without known urinary tract disease. The sensitivity of hTERT mRNA expression marker in the detection of bladder cancer was significantly better than urine cytology (95% versus 65%, p<0.001). The hTERT mRNA was detected with high sensitivity in both low and high grade tumors, and in superficial and invasive phenotypes. No correlation was seen between hTERT mRNA and the histopathological grade and stage. The specificity of urinary hTERT mRNA marker was 93.5%. The detection of hTERT mRNA expression in urine was a highly sensitive marker for the diagnosis of TCC of the bladder in this study. This urine-based marker shows promise as a non-invasive adjunct to cystoscopy in patients undergoing bladder tumor surveillance.

Second Prize: Double-Blind Randomized Controlled Trial Assessing the Safety and Efficacy of Intravesical Agents for Ureteral Stent Symptoms after Extracorporeal Shockwave Lithotripsy

BACKGROUND AND PURPOSE

Ureteral stents are a significant source of pain and discomfort for many urologic patients. A novel approach to addressing this problem is the intravesical instillation of a selected pharmacologic agent after stent insertion. The purpose of this study was to assess the safety and efficacy of intravesical instillation of various agents in reducing ureteral stent-associated discomfort in patients requiring a stent after extracorporeal shockwave lithotripsy (SWL).

PATIENTS AND METHODS

In this double-blind prospective trial, 42 patients were randomized to receive intravesical instillation of one of three agents (oxybutynin, alkalinized lidocaine, or ketorolac) or a control solution (0.9% sodium chloride) immediately after stent insertion at time of SWL. The four groups of patients were demographically similar. Preoperative, intraoperative, and postoperative data were collected prospectively and analyzed statistically. The primary outcome measure was reduction in ureteral stent symptoms, and the secondary outcome measure was the safety of intravesical instillation of each agent through assessment of drug-related adverse events.

RESULTS

There were no intraoperative or postoperative complications, nor were there any serious side effects attributable to any of the intravesically instilled agents. There was a statistically significant decrease in stent-related discomfort at the 1-hour time point in the group of patients who received intravesical ketorolac compared with the control group.

CONCLUSIONS

Intravesical instillation represents a novel approach to the problem of ureteral stent-related discomfort. From our results, ketorolac appears to be the most effective intravesical agent in reducing stent-related patient discomfort, and we have established that intravesical instillation of ketorolac is safe in humans.

Results of Shockwave Lithotripsy for Pediatric Urolithiasis

BACKGROUND AND PURPOSE

Shockwave lithotripsy (SWL) is widely practiced in the management of pediatric urolithiasis. However, the efficacy, need for ancillary procedures, and treatment-related complications are not as clearly defined as in the adult population. We reviewed the outcomes of SWL in the pediatric population at our lithotripsy unit.

PATIENTS AND METHODS

A retrospective review of all patients </=16 years of age treated with SWL between January 1991 and June 2002 was undertaken. One hundred patients with 115 stones underwent 131 SWL procedures (115 first treatments, 16 retreatments). The mean age was 10.7 years (range 10 months-16 years). Stone locations were as follows: caliceal 42.6%, renal pelvic 27%, and ureteral (30.4%). The mean stone size was 7.8 mm (range 2-23 mm). Risk factors for stone formation, the need for secondary therapies, and treatment-related complications were noted. The stone-free rate for a single-session SWL procedure, defined as complete absence of stone fragments on plain film, intravenous urography, or renal ultrasonography, was calculated based on 3-month follow-up. The efficiency quotient (EQ) was also calculated.

RESULTS

Risk factors were identified in 31 children (27.0%), including metabolic and anatomic abnormalities. Patients with a risk factor were less likely to be stone free after one SWL session than those without risk factors (31.7% v 64.7%; P < 0.001). General (74.8%), neurolept (24.4%), and epidural (0.8%) anesthesia were utilized. Ureteral stents were placed in 25% of treatments. There were no intraoperative complications. Minor complications were seen in 4.6% of patients. Ancillary procedures were required in 10 patients. Following initial SWL treatment, 60.2% of patients were stone free. The retreatment rate was 13.9%. Following a second treatment, the stone-free rate increased to 68%. The EQ was 54.3.

CONCLUSION

Employing a strict definition of treatment success, single-session SWL in our series offers moderate efficacy in the pediatric population. Patients who have a large stone or risk factor such as an anatomic abnormality are less likely to become stone free and might better undergo an endourologic procedure.

Percutaneous antegrade endopyelotomy: long-term results from one institution

OBJECTIVES

To assess the long-term efficacy of percutaneous antegrade endopyelotomy for the treatment of ureteropelvic junction (UPJ) obstruction performed at a single institution during a 10-year period. We provide alterations in investigation and management strategies on the basis of the results.

METHODS

From July 1990 to June 2001, 80 patients with clinical and radiographic evidence of UPJ obstruction underwent percutaneous endopyelotomy for the treatment of primary (n = 61) or secondary (n = 19) UPJ obstruction. The mean patient age was 35 years (range 4 to 76). Percutaneous endopyelotomy was performed in a standard fashion using either a hooked-knife (n = 77) or holmium laser (n = 3).

RESULTS

With a mean patient follow-up of 55 months (range 16 to 138), the overall success rate was 67% (53 of 79). The success rate for primary and secondary UPJ obstruction was 65% (39 of 60) and 74% (14 of 19), respectively. The mean time to failure was 15 months (range 1 to 79). Operative intervention for 24 of 26 patients with failure included open pyeloplasty (n = 18, 75%), indwelling ureteral stenting (n = 2, 8%), retrograde balloon dilation (n = 1, 4%), and nephrectomy (n = 3, 13%). Two asymptomatic patients with recurrent radiographic evidence of obstruction elected conservative follow-up. Significant crossing vessels were encountered at open pyeloplasty in 15 (83%) of 18 patients.

CONCLUSIONS

Our long-term results of percutaneous endopyelotomy demonstrated somewhat lower success rates than that reported in published studies. Long-term follow-up is critical in identifying late failures. The high prevalence of crossing vessels encountered at open pyeloplasty provided further evidence to support its role in endopyelotomy failure. Routine preoperative helical computed tomography to detect significant crossing vessels is recommended. Patients with crossing vessels are likely better served with operative techniques that specifically address this issue, namely open or laparoscopic pyeloplasty.

Testicular epidermoid cyst: a case report and review of the clinicopathologic features

Epidermoid cysts of the testicle are rare, benign lesions that are clinically indistinguishable from malignant germ cell tumors. A scrotal mass in a 27-year-old man was incidentally detected by his family physician, and confirmed to be intratesticular by ultrasound. Radical orchidectomy was performed revealing the pathologic diagnosis. The presentation, evaluation and management of epidermoid cysts are discussed.

Upper tract imaging after ureteroscopic holmium:YAG laser lithotripsy: when is it necessary?

INTRODUCTION/OBJECTIVE

Advances in ureteroscope design and refinements of ancillary instrumentation have resulted in an expanded role for ureteroscopy in the management of urinary calculi. Technological enhancements coupled with improved endourologic skills have also been associated with a reduction in procedural-related complications. Historically, postoperative imaging with ultrasound (U/S) or intravenous pyelogram (IVP) had been advocated to rule out persistent obstruction due to retained stone fragments or ureteral stricture. The purposes of this study were to evaluate the incidence of postoperative ureteral obstruction in a contemporary series of patients undergoing ureteroscopic holmium:YAG laser lithotripsy without basket extraction of fragments and to identify patient, stone and operative factors predictive of which patients will benefit from postoperative imaging.

MATERIALS AND METHODS

The charts and imaging studies of 89 consecutive patients undergoing a total of 94 holmium:YAG ureteroscopic lithotripsy procedures between December 1998 and December 2000 were retrospectively reviewed. Preoperative, intraoperative and postoperative data were collected and analyzed. The primary outcome measure was the incidence of postoperative ureteral obstruction documented on upper tract imaging. Secondary outcome measures included interventions required for postoperative obstruction and other nonobstructive postoperative complications.

RESULTS

Twenty-eight females and 61 males were studied, with a mean patient age of 54 (range 13-80) years. Fifty-five percent of patients underwent related procedures prior to referral to our tertiary endourology centre. Complete clinical and radiological follow-up is available for 68 of 89 (76.4%) patients, with a mean follow-up duration of 24.2 weeks. Overall stone-free rate was 97%. Six patients had evidence of urinary tract obstruction on follow-up radiological assessment, two from residual stone fragments and four from ureteral stricture. Each of these four patients had at least one preoperative risk factor for ureteral stricture.

CONCLUSIONS

Routine postoperative upper tract imaging is not necessary in all patients undergoing uncomplicated ureteroscopic holmium:YAG laser lithotripsy. Indications for upper tract imaging include chronic stone impaction, significant ureteral trauma, pre-existing renal function impairment, endoscopic evidence of stricture and postoperative flank pain or fever.

Malignancy in horseshoe kidneys: review and discussion of surgical implications

OBJECTIVE

Horseshoe kidney is one of the most common congenital anomalies of renal structure. Not infrequently, surgical management of both benign and malignant disorders is required in patients with horseshoe kidney due to the susceptibility to certain conditions. The literature suggests a greater proclivity to certain renal tumors with this anomaly. We present three cases of malignancy in horseshoe kidneys. The unique technical challenges presented by these cases and the surgical approaches are discussed.

METHODS

Three patients with tumors involving horseshoe kidneys are reviewed and their management discussed.

RESULTS

Two patients were found to have renal cell carcinoma (RCC) and one had transitional carcinoma (TCC). Computed tomography (CT) and angiography were used in the work-up and preoperative planning of these cases. One patient with RCC received pre-operative renal artery embolization. Partial nephrectomy was performed in each patient with an aim at early vascular control of the tumors, identification of the collecting systems and ureters, as well as ensuring a 1 cm surgical margin. No patient required dialysis post-operatively. One patient died in the early post-operative period of a myocardial infarction; one patient developed brain metastases 18 months post-operatively, received palliative radiation and is alive 42 months after surgery; the other patient was free of disease for approximately 36 months but recently developed osseous metastases to her pelvis.

CONCLUSIONS

Techniques developed for partial nephrectomy may be used in the treatment of tumors in horseshoe kidneys. Survival is related to the grade and stage of disease.

The role of ketorolac tromethamine in a clinical care pathway for men undergoing radical retropubic prostatectomy

The use of ketorolac in managing postoperative pain after a variety of surgical procedures has potential advantages over the use of narcotic analgesics alone. The purpose of this study was to determine whether the addition of ketorolac influenced the time to resumption of a full diet, hospital discharge, and postoperative complication rates, compared to a group of patients receiving only narcotic analgesics whose postoperative management was otherwise similar. The group receiving ketorolac had an earlier return to full diet than those receiving narcotics alone. Similarly, the median length of hospital stay was shorter in the ketorolac group then the group treated with narcotics alone. The inclusion of ketorolac in the postoperative pain management of patients after radical retropubic prostatectomy appears to be a safe and effective strategy.

Ureteroscopy and holmium:YAG laser lithotripsy: an emerging definitive management strategy for symptomatic ureteral calculi in pregnancy

OBJECTIVES

To review the results of holmium laser lithotripsy in a cohort of patients who presented with symptomatic urolithiasis in pregnancy. Symptomatic urolithiasis in pregnancy that does not respond to conservative measures has traditionally been managed with ureteral stent insertion or percutaneous nephrostomy. Holmium:yttrium-aluminum-garnet (YAG) laser lithotripsy using state-of-the-art ureteroscopes represents an emerging strategy for definitive stone management in pregnancy.

METHODS

A retrospective analysis was conducted at two tertiary stone centers from January 1996 to August 2001 to identify pregnant patients who were treated with ureteroscopic holmium laser lithotripsy for symptomatic urolithiasis or encrusted stents. Eight patients with a total of 10 symptomatic ureteral calculi and two encrusted ureteral stents were treated. The mean gestational age at presentation was 22 weeks. The mean stone size was 8.1 mm. The stones were located in the proximal ureter/ureteropelvic junction (n = 3), midureter (n = 1), and distal ureter (n = 6).

RESULTS

Complete stone fragmentation and/or removal of encrusted ureteral stents were achieved in all patients using the holmium:YAG laser. The overall procedural success rate was 91%. The overall stone-free rate was 89%. No obstetric or urologic complications were encountered.

CONCLUSIONS

Ureteroscopy and holmium laser lithotripsy can be performed safely in all stages of pregnancy, providing definitive management of symptomatic ureteral calculi. The procedure can be done with minimal or no fluoroscopy and avoids the undesirable features of stents or nephrostomy tubes.

Stones in urinary diversions: update on medical and surgical issues

PURPOSE OF REVIEW

Patients who undergo urinary tract diversion are at an increased risk of urolithiasis for various reasons. The purpose of this article is to provide an up-to-date summary of the progress that has been made in the pathogenesis, diagnosis and treatment of stones in patients with urinary diversions. Finally, we will provide recommendations for follow-up in patients with urinary diversions who develop urinary tract calculi.

RECENT FINDINGS

In contemporary studies, the incidence of urolithiasis in patients with urinary diversion appears to be decreasing. Computed tomography scanning has been shown to be superior to ultrasound in the diagnosis of calculi in such patients. Endourological procedures have become the mainstay of therapy for stones in patients with urinary diversions. Since the introduction of extracorporeal shock wave lithotripsy, percutaneous nephrolithotripsy and ureteroscopy, the need for open surgery has decreased, even in this anatomically unique and surgically challenging patient population.

SUMMARY

Urolithiasis is an established long-term complication of urinary diversion. In recent years, significant advances have been made in the pathogenesis, diagnosis and treatment of such stones. As a result of potential stone-related complications, we recommend lifelong surveillance for all patients with urinary stones and diversions, with medical therapy when indicated, in order to minimize these complications.

Retroperitoneal fibrosis: a case report of spontaneous resolution

AIM

The purpose of this case report is to document an occurrence of spontaneous resolution of idiopathic retroperitoneal fibrosis and to review the investigation and management of this unusual condition.

MATERIALS AND METHODS

A detailed case summary of a patient with retroperitoneal fibrosis is presented. Current citations in Index medicus from the English-speaking literature of relevance to the topic were reviewed.

CONCLUSIONS

In this patient who refused open surgical intervention, bilateral stent placement allowed stabilization of renal function. CT-guided biopsy did not reveal malignancy. Serial CT imaging demonstrated gradual disappearance of the retroperitoneal mass. From the literature review, spontaneous resolution of this condition appears to be a rare phenomenon. Although often utilized, CT-guided biopsy may fail to exclude the presence of malignancy. Open surgical biopsy of the retroperitoneal mass and ureterolysis remain the standard of care for operative candidates. Establishing renal drainage and considering a trial of steroids or surveillance may be an option in carefully selected individuals.

Holmium:YAG laser lithotripsy for upper urinary tract calculi in 598 patients

PURPOSE

We assessed the effectiveness and safety of holmium:YAG laser lithotripsy for managing upper urinary tract calculi in a prospective cohort of 598 patients.

MATERIALS AND METHODS

Ureteroscopic holmium:YAG laser lithotripsy was performed in 598 patients between 1993 and 1999. Calculi were located in the distal ureter in 39.6% of cases, mid ureter in 18.6%, proximal ureter in 32.4% and kidney in 9.4%. Patients were treated on an outpatient basis with various flexible and semirigid endoscopes. Of the cases 59% were referred as previous treatment failures. Patients were assessed 6 to 12 weeks postoperatively with repeat plain x-ray and ultrasound or excretory urography for late obstructive complications.

RESULTS

The overall stone-free rate was 97%. As stratified by location, the stone-free rate was 98% in the distal ureter, 100% in the mid ureter, 97% in the proximal ureter and 84% in the kidney. Fragmentation was incomplete in 6% of cases and secondary intervention was required in 6%. The overall complication rate was 4%. New onset ureteral stricture developed postoperatively in 0.35% of patients.

CONCLUSIONS

Holmium:YAG laser lithotripsy is a highly effective and safe treatment modality for managing ureteral and a proportion of intrarenal calculi on an outpatient basis. The effectiveness and versatility of the holmium laser combined with small rigid or flexible endoscopes make it our modality of choice for ureteroscopic lithotripsy.

Randomized trial of 10 mL and 20 mL of 2% intraurethral lidocaine gel and placebo in men undergoing flexible cystoscopy

PURPOSE

To determine if 20 mL of 2% intraurethral lidocaine gel is superior to 10 mL of 2% lidocaine or sterile lubricant for flexible cystoscopy in men.

PATIENTS AND METHODS

A randomized, double-blind, placebo-controlled trial was conducted. Sixty men scheduled to undergo diagnostic flexible cystoscopy were randomized to receive either 20 mL of placebo gel (Group I), 10 mL, of 2% lidocaine gel (Group II) or 20 mL of 2% lidocaine gel (Group III). A penile clamp was applied for 15 minutes to ensure consistent indwelling time in all patients. Patients recorded their pain on a 10-cm non-graphical visual analog scale prior to cystoscopy as a baseline, during the procedure, and immediately after the procedure. Patients also recorded their pain and willingness to have the same anesthetic on a 4-point descriptive scale. Heart rate and mean arterial blood pressure (MAP) were recorded at specific intervals throughout the procedure, and increases in mean arterial pressure were considered objective evidence of patient pain.

RESULTS

Pain perception was not statistically different in the groups (Group I 4.65, Group II 3.93, Group III 3.57; P = 0.406). Pain assessment and willingness to have the same anesthetic also did not differ statistically among the groups. Similarly, differences in the increases in MAP were not statistically significant between groups.

CONCLUSION

Instillation of 20 mL or 10 mL of 2% lidocaine gel has no advantage over plain lubricant in providing anesthesia for flexible cystoscopy in men.