Single-port robot assisted concomitant hemi-nephrectomy, ureterectomy and radical prostatectomy using the da vinci SP platform.

A duplicated collecting system is a common congenital anomaly of the urinary tract. However, late symptomatic presentation in adulthood is uncommon. We report the first case of left heminephrectomy, ureterectomy and radical prostatectomy using the da Vinci SP (single port) surgical system in a 64-year-old patient with localized prostate cancer and duplicated system with ectopic ureteral insertion into the prostatic urethra. The procedure was completed without technical difficulties or intraoperative adverse events. We demonstrate that the da Vinci SP robot allows for efficient performance of concomitant surgeries on the kidney and prostate without the limitations reported with single site surgeries.

Risk of Reaugmentation after Enterocystoplasty Using a Reconfigured Bowel Segment in Patients with Spina Bifida: A Bi-Institutional Cohort Study.

PURPOSE: Reaugmentation cystoplasty rates vary in the literature but have been reported as high as 15%. It is likely that bladders augmented with detubularized and reconfigured bowel are less likely to require reaugmentation. We assessed the incidence of reaugmentation among patients with spina bifida at 2 high volume reconstruction centers. MATERIALS AND METHODS: We retrospectively reviewed medical records of patients with spina bifida who underwent enterocystoplasty before age 21 years (1987 to 2017). Those who did not undergo augmentation with a detubularized and reconfigured bowel segment were excluded from analysis. Data on demographic and surgical variables were collected. Reaugmentation was the main outcome. One analysis was performed using the entire cohort and another analysis was restricted to patients with ileocystoplasty performed in the last 15 years (2002 to 2017). Survival analysis was used. RESULTS: A total of 289 patients were identified. Enterocystoplasty was performed in patients at a median age of 8.1 years (median followup 11.3, IQR 5.2-14.9). Most initial augmentations were performed using ileum (93.4%), followed by sigmoid (6.2%). Seven patients underwent reaugmentation, including 6 with initial augmentation using ileum and 1 with initial augmentation using sigmoid. On survival analysis risk of reaugmentation was 1.1% at 5 years and 3.3% at 10 years after the original surgery. All reaugmentations occurred within the first 9 years of followup. In the more contemporary cohort (162, median followup 7.0 years) only 1 patient underwent reaugmentation at 2.0 years. CONCLUSIONS: The risk of reaugmentation after enterocystoplasty with a detubularized and reconfigured bowel in the spina bifida population is lower than that reported in initial series.

Is anuria prior to pediatric renal transplantation associated with poor allograft outcomes?

INTRODUCTION: Anuria from end-stage renal disease leads to a defunctionalized bladder and may pose technical challenges at the time of renal transplantation. Anuria's effect on bladder function after renal transplantation is considered to be minimal in adults, although a paucity of evidence is available in children. The purpose of this study was to examine the effects of anuria prior to pediatric renal transplantation for ESRD due to medical renal disease on allograft outcome. METHODS: We performed a retrospective review of pediatric patients who underwent renal transplantation for medical renal disease at our institution between 2005 and 2016. Demographics and clinical data were assessed. We also compared GFR at 1 year post-transplant for medical renal patients with history of anuria and those without. RESULTS: Twenty-one patients fulfilled our inclusion criteria with median duration of anuria was 10 months. Preoperative VCUG was available in five patients and their bladder capacity was 29% of expected bladder capacity for age (range 8%-41%). Anticholinergic therapy was prescribed in six patients (28%) for a mean duration of 5 months (range 1-16 months). Comparison of GFR at 1 year post-transplant in anuria group and those without anuria showed no difference (69 vs 75 mL/min, P = 0.37). No correlation was observed between duration of anuria and post-transplant GFR. CONCLUSION: The majority of children in our pretransplant anuria cohort did not develop bladder dysfunction after renal transplantation. No difference was observed between GFR at 1 year when comparing anuric to non-anuric transplant recipients of medical renal disease etiology.

Calcium-to-Citrate Ratio Distinguishes Solitary and Recurrent Urinary Stone Forming Children.

PURPOSE: The prevalence of urinary stone disease is increasing in children. We previously reported a high rate of urinary metabolic abnormalities, including hypercalciuria and hypocitraturia, in stone forming children. In this study we determined whether calcium-to-citrate ratio could help predict those at risk for recurrent stone formation. MATERIALS AND METHODS: We conducted a retrospective cohort study to assess calcium-to-citrate ratios in children with urolithiasis. Two 24-hour urine collections were performed. Urinary excretions of calcium and citrate were analyzed, and calcium-to-citrate ratio was calculated. Patients were stratified into solitary and recurrent stone formers and compared to a control group of normal children. RESULTS: We identified 73 solitary and 92 recurrent stone formers. Mean patient age was 13 years for both groups. Gender was well matched. A total of 29 normal children served as controls. Mean calcium-to-citrate ratio was 0.41 in solitary stone formers and 0.64 in recurrent stone formers (p = 0.02). Mean value in normal children (0.33) was significantly less compared to recurrent stone formers (p = 0.002) and trended lower compared to solitary stone formers (p = 0.15). The ratio was abnormally high in recurrent stone formers (70%) compared to solitary stone formers (47%, p = 0.003). CONCLUSIONS: There are significant differences in urine calcium-to-citrate ratios between solitary and recurrent calcium stone forming children. Solitary stone formers trended higher compared to controls. These findings may allow more precise risk stratification and treatment to prevent recurrent stone episodes.

Chronic social defeat, but not restraint stress, alters bladder function in mice.

BACKGROUND: Voiding disorders in humans, particularly in children are associated with increased incidence of behavioral issues as well as past history of childhood abuse. We hypothesized that creating stress in mice, utilizing either a chronic social defeat model (SD) or restraint stress in shallow water model (RSSW) would engender changes in bladder function, morphology, and behavior, thereby enabling us to study the resultant voiding dysfunction. METHODS: For SD stress (14 days), C57BL/6 male mice were exposed daily to a larger aggressive CD-1 male for 10 min, followed by sensory exposure in a barrier cage for 24h. Control mice were similarly housed with no exposure. For RSSW (21 days), C57BL/6 mice were put in a perforated conical tube with feet immersed in water daily for 4h, then returned to single housing cages. Control mice were also in single housing. After the stress period, voiding patterns were obtained on filter paper, followed by behavioral tests. At necropsy, blood was taken for corticosterone analysis, and bladder and body weights measured. Bladder cryosections were stained with hematoxylin and eosin (H&E) for morphological assessment. Sequential sections were immunostained with antibodies to Ki-67 as a proliferation marker, CD31 (endothelial cell marker), and uroplakin-II. ImageJ software was used to measure bladder wall thickness on blinded H&E photomicrographs as well as quantitate CD31 staining. Both Ki-67-positive and -negative nuclei were counted with Imaris software to obtain a proliferation index. RESULTS: Only SD mice had a single large void pattern. Bladder-to-body weight ratios increased in SD mice (p≤0.02) but not in RSSW mice. Plasma corticosterone levels were elevated in all stressed mice. SD mice exhibited lower levels of locomotor activity compared with controls; RSSW mice were hyperactive. In SD mice, bladder wall thickness was increased (p ≤ 0.003) but no change was seen in Ki-67 proliferation index, consistent with hypertrophy. No difference with control mice was seen in vascularity as visualized by CD31 staining. Uniform uroplakin-II staining lined the urothelium of both SD and control mice. CONCLUSIONS: Mice exposed to repeated SD (14 days) respond with altered voiding indicative of urine retention, and exhibit bladder wall changes consistent with hypertrophy while the urothelial barrier is maintained. These changes were not observed with repeated RSSW. SD, in contrast to RSSW, provides a model of psychological stress to further study the interplay of behavior and bladder dysfunction, enabling an improved understanding of voiding dysfunction, and the ability to create innovative and more effective management pathways for children who present with voiding dysfunction.

Grading complication following radical cystectomy and ileal conduit for bladder cancer using Clavien grading system.

OBJECTIVE: To determine the 30-day complication rate of radical cystectomy and urinary diversion using a validated system. STUDY DESIGN: An analytical descriptive study. PLACE AND DURATION OF STUDY: The Aga Khan University Hospital, Karachi, from 1990 to 2010. METHODOLOGY: Patients who had undergone ileal conduit (IC) formation, following radical cystectomy (RC) for muscle invasive transitional cell carcinoma, were studied, using a prospectively maintained data base. Basic details were determined, complications were noted and graded according to the modified Clavien grading system (CG). Results were presented using descriptive statistics. RESULTS: Of all the RC performed at this hospital 89 patients received IC. Of them 75 were male and 14 female. Mean age was 60 years. Mean duration of hospital stay was 14 days. Ten patients each received pre-operative chemotherapy and radiotherapy, respectively. Mean duration of surgery was 8.2 hours, with mean estimated blood loss of 1334 ml. Preoperative radiotherapy was associated with more complications. No other factor like ASA, co-morbidities, blood loss or duration of stay influenced the complications. Fifty patients (56.2%) did not have any complications. Most common complication of wound infection was seen in 7 patients (CG-2), followed by uretero-ileal leakage in 5, requiring percutaneous intervention under local anaesthesia (GC-3a). Mortality rate was 4.5%, classified as CG-V. CONCLUSION: Radical cystectomy with Ileal conduit is a major procedure with a good safety profile at this institute. Longterm follow up is still needed to evaluate delayed complications and quality of life.

Predictors of lymph node involvement in bladder cancer treated with radical cystectomy.

OBJECTIVE: To identify the clinical variables associated with prevalence of lymph node metastasis in patients with bladder cancer treated by radical cystectomy and lymphadenectomy for primary bladder cancer. METHODS: Review of records of Ninety-five patients who underwent radical cystectomy and pelvic lymph node (LN) dissection during the period of 1995-2008 from a prospectively maintained database. Eighteen patients were excluded due to lack of data on the nodal status, leaving 77 evaluable patients. Associations between LN metastasis and age, gender, duration of disease, number of transurethral resection (TUR) prior to cystectomy, pathological grade and tumour stage was analyzed. Data was analyzed using the SPSS software, version 15. Statistical tests applied were independent sample t test or the Mann Whitney U test, the chi-square test and the Fischer exact test. RESULTS: The median age of the patients was 58 years in lymph node negative group and 63 years in lymph node positive group. There were 87% males and 13% females. LN metastasis was detected in 19 (25%) patients. Mean duration of disease in LN negative patients was 537 +/- 997 days compared to 509 +/- 708 days in LN positive patients. Mean number of TUR were same in both the groups, pathological grade was not found significantly different in both groups, where as primary tumour stage was found to be significantly (p < 0.05) higher in LN positive patients. CONCLUSIONS: Higher primary tumour stage at radical cystectomy is associated with higher prevalence of lymph node metastasis.

Separate submission of standard lymphadenectomy in 6 packets versus en bloc lymphadenectomy in bladder cancer.

INTRODUCTION: Our aim was to evaluate detection of nodal metastasis during radical cystectomy with standard pelvic lymph node dissection versus en bloc lymphadenectomy for the treatment of bladder cancer. MATERIALS AND METHODS: Hospital records of a total of 77 patients with radical cystectomy and either standard pelvic lymph node dissection or en bloc lymphadenectomy were reviewed. Nodal dissection specimens during standard lymphadenectomy were sent for pathology examination in 6 separate containers marked as external iliac, internal iliac, and obturator groups from both sides. En bloc dissection specimens were sent in 2 containers marked as the right and the left pelvic nodes. Clinical and pathological findings of these two groups were compared in terms of the number of dissected lymph nodes, number of nodes with metastasis, lymph node density, and clinical outcomes. RESULTS: There were 34 patients with standard lymph node dissection and 43 with en bloc lymphadenectomy (anterior pelvic exenteration). Age, sex, duration of the disease, number of transurethral resections prior to cystectomy, pathological grade at cystectomy, and stage of the primary tumor were comparable in the two groups of patients. The median numbers of nodes removed per patient were 15.5 (range, 4 to 48) and 7.0 (range, 1 to 24) in those with standard and en bloc lymphadenectomy, respectively (P < .001). Nodal involvement was detected in 10 (29.4%) and 9 (20.9%) patients, respectively (P = .43). CONCLUSION: Although nodal involvement was not significantly different between the two groups, standard lymphadenectomy submitted in 6 different containers significantly improved the nodal yield over en bloc resection. Obturator nodes were the most commonly involved nodes in our study.

Patient's outcome of bladder cancer managed by radical cystectomy with lymphadenectomy at a university hospital.

OBJECTIVE: To study the impact of tumour staging and nodal metastases in predicting 5- year's survival after radical cystectomy and bilateral pelvic lymphadenectomy for primary bladder cancer. METHODS: During the period 1995 to 2005, 58 patients underwent radical cystectomy and bilateral pelvic lymphadenectomy and urinary diversion at a University hospital. Patients were identified using medical indexing coding system (ICD 9CM) using standard key words. The patient records were analyzed and follow up data updated. Disease specific survival, death or recurrence was taken as end point. RESULTS: Out of 58 patients, 50 (86%) were males and 8 (14%) females with a mean age of 61 +/- 13.1 years (range from 27 to 87 years). Of 58 patients, 11 (23%) were excluded from the study because of in adequate follow up. The mean follow up was 5.7 years (range, 7 months to 11 years). The overall 5 years survival was 55% with disease specific survival being 66%. Patients with pathological stage TO at cystectomy have 87% 5 years disease specific survival compared to 60%, in patients with pT4 (p = 0.705). The 5-year survival for node positive patients was 16%, compared to 60% for node negative patients (p < 0.01). CONCLUSIONS: Radical cystectomy and bilateral pelvic lymphadenectomy is the standard treatment for muscle invasive and high grade T1 cancers, and as salvage for recurrent cancers. Lymphadenectomy has a potential therapeutic benefit. The pathological stage at cystectomy and nodal status are predictors of 5 years survival.