Robot-Assisted Nephroureterectomy for Upper Tract Urothelial Carcinoma in a Patient with an Ileal Conduit.

Background: Upper tract urothelial carcinoma remains an uncommon disease that is clinically difficult to identify early and surveil. Open nephroureterectomy is the gold standard for patients with high-grade disease, especially for patients in whom surveillance is complicated such as those with prior cystectomies/ileal conduits. This report presents a case of a patient with a history of radical cystectomy and ileal conduit construction who underwent a successful minimally invasive robotic surgery for treatment of upper tract urothelial carcinoma. Case Presentation. The patient is a 72-year-old Caucasian male with a history of recurrent superficial bladder tumors treated with cystoscopies with fulguration, Bacillus Calmette-Guerin, and a robot-assisted cystectomy with ileal conduit diversion presenting with recurrent urinary tract infections and hematuria secondary to a ureteral stricture. The patient was admitted previously for urosepsis during which time a percutaneous nephrostomy tube was inserted on the right side. Upon presentation, imaging revealed a lesion extending from the lower pole of the right kidney into the renal pelvis. The presence of a nephrostomy and urostomy allowed the surgical team to utilize a minimally invasive approach to remove the diseased kidney and ureter with visualization enhanced by indocyanine green. Conclusion: Minimally invasive robot-assisted approaches to treating upper tract urothelial carcinomas may offer an alternative to the open cases typically employed in cases of patients with prior ileal conduit. Furthermore, utilizing indocyanine green may expand the applicability of such approaches to uro-oncologic cases with greater complexity.

Open transperitoneal partial nephrectomy in a horseshoe kidney.

We report the case of a 50-year-old Tibetan man who presented to an outpatient urology clinic after abdominal ultrasound for poorly defined abdominal pain demonstrated horseshoe kidney (HK) with a right moiety ~3.7 cm mass further characterised using contrast-enhanced CT scan (CECT). This dedicated imaging confirmed HK with a heterogeneously enhancing right upper pole 3.1 cm×3.7 cm×2.7 cm mass. Due to suspicion for aberrant vasculature on CECT, renovascular angiography was performed, which revealed recruitment of a right paravertebral vessel alongside two right renal moiety arteries and multiple right renal moiety veins. Based on vascular complexity and the surgical exposure required for arterial clamping, open transperitoneal right partial nephrectomy was preferred to minimally invasive techniques. Postoperative course was complicated by ileus, which resolved with standard management. Pathologic analysis revealed complete resection of a 5.0 cm Fuhrman grade II clear cell renal cell carcinoma.

Impact of Urology Resident Involvement on intraoperative, Long-Term Oncologic and Functional Outcomes of Robotic Assisted Laparoscopic Radical Prostatectomy.

OBJECTIVE: To evaluate the impact of resident involvement in robot assisted laparoscopic prostatectomy on oncologic, functional, and intraoperative outcomes, both short and long term. METHODS: We queried our prospectively maintained database of prostate cancer patients who underwent robotic-assisted laparoscopic prostatectomy from November 20, 2007 to December 27, 2016. We analyzed cases performed by 1 surgeon on a specific day of the week when the morning case involved at least 1 resident (R) and the afternoon case involved the attending physician only (nonresident [NR]). We compared R versus NR on a number of clinical, perioperative, and oncological outcomes. RESULTS: A total of 230 NR and 230 R cases met inclusion criteria and were included in the analysis. Over one third (36.7%) of the NR group was Gleason 4+3 (Grade Group 3) or higher, relative to 25.9% of the R group, P = .015. Median operative time (OT) was significantly longer for R versus NR (200 minutes versus 156 minutes, P<.001) as was robotic time (161 minutes versus119 minutes, P<.001). No significant differences were noted for any other measure. Median follow-up for oncological outcomes was 30 and 33.5 months for NR and R, respectively (P= .3). Median OT and median estimated blood loss were both significantly greater in later years relative to the earlier years for R (2012-2016 versus 2007-2011; P< .001 for OT; P= .041 for median estimated blood loss) but not for NR. CONCLUSION: Neither safety nor quality is diminished by R involvement in robot assisted laparoscopic prostatectomy.

Distal Ureteral Calculus or Deflux Calcification?

Background: There have been >50,000 dextranomer-hyaluronic acid implants performed since 2001, and each has the potential to calcify. Although they are most often asymptomatic, these calcifications may mimic large distal ureteral calculi and are often misidentified on CT performed for suspected urolithiasis or other complaints. Case Presentation: We report the case of a 21-year-old woman who presented with symptoms consistent with obstructive uropathy who was reported to have bilateral ureteral-vesicular junction calculi on abdominal CT evaluation. On further questioning she relayed the history of a vague urologic procedure as a child but was unable to characterize it further. On the basis of her relatively mild symptoms, urinalysis and renal ultrasonography were obtained demonstrating bilateral ureteral jets and she was diagnosed with nonobstructing bilateral dextranomer-hyaluronic acid calcifications and a presumed urinary tract infection that resolved with empiric antibiotic therapy. Conclusion: Accurate diagnosis of implant calcification is critical to effective therapy and avoiding unnecessary radiation or anesthesia. This diagnosis should be suspected with radiologically demonstrated large ureteral calculi but relatively mild presenting symptoms. As dextranomer-hyaluronic acid implantation is routinely performed in young patients it is also possible that this relevant history will not be reported.

Metastatic Mucinous Adenocarcinoma and Carcinoid Tumor Arising From a Mature Cystic Teratoma of a Horseshoe Kidney.

Concurrent primary carcinoid tumor and primary mucinous adenocarcinoma arising within a mature cystic teratoma of a horseshoe kidney is a rare event and has been reported once in the literature. We present the first case where this tumor subtype has metastasized to lymph nodes. Treatment included open partial nephrectomy, lymph node dissection, and adjuvant chemotherapy with temozolomide and capecitabine. Due to the rare combination of tumor histologies, it is unlikely that this cohort will ever be able to be adequately studied to determine a standard of care. Thus extrapolation of treatment methods of similar tumors will continue to guide treatment.

A Rare Case of Neonatal Alloimmune Thrombocytopenia Causing Prolonged Postcircumcision Bleeding.

Postcircumcision bleeding can be the presenting symptom of a coagulopathy. A blood dyscrasia that is known but not documented in association with circumcision is neonatal alloimmune thrombocytopenia (NAIT). A 2-day-old male infant presented with postcircumcision bleeding. Platelet count was 5000 per microliter of blood. The child was treated conservatively with hematoma improvement. Few studies exist involving patients with coagulopathies who undergo circumcision. Our patient is the first to present with prolonged postcircumcision bleeding as the initial presentation of NAIT. NAIT and other coagulopathies that present as prolonged postcircumcision bleeding can often be managed successfully with conservative management.

Anatomic complexity quantitated by nephrometry score is associated with prolonged warm ischemia time during robotic partial nephrectomy.

OBJECTIVE: To assess the association between nephrometry score (NS) and prolonged warm ischemia time (WIT) in patients undergoing robotic partial nephrectomy (RPN) for clinically localized renal masses. METHODS: We queried our prospectively maintained kidney cancer database to identify all patients undergoing RPN for localized tumors from 2007-2012. Patient and tumor characteristics were compared between complexity groups using analysis of variance and chi square tests. Multivariate logistic regression models were used to examine the relationship between NS complexity and warm ischemia >30 minutes. RESULTS: Three hundred seventy-five patients (mean age, 59 ± 11 years; mean Charlson comorbidity index, 1.0 ± 1.3) undergoing RPN under warm ischemia for clinically localized renal tumors (mean tumor size, 3.1 ± 1.5 cm; mean NS, 6.8 ± 1.8) met inclusion criteria and had NS available. Stratified by complexity, groups differed with respect to age at surgery, tumor size, proximity to the hilum, collecting system entry, estimated blood loss, and operative time (all P values ≤.05). Significant differences in mean WIT were observed when comparing low (19.4 ± 12.1 minutes), intermediate (28.6 ± 12.8 minutes), and high (36.1 ± 13.7 minutes) NS complexity groups (P <.0001). Adjusting for confounders, patients with intermediate (odds ratio, 2.1; confidence interval, 1.2-3.9) and high (odds ratio, 3.7; confidence interval, 1.1-11.8) NS complexity were more likely to require prolonged WIT when compared with patients with low complexity tumors. CONCLUSION: In our large institutional cohort, quantification of anatomic complexity using the NS is associated with WIT >30 minutes in patients undergoing RPN for localized renal tumors. This provides further evidence that standardized reporting of tumor anatomic complexity affords meaningful outcome comparisons.

Determination of patient concerns in choosing surgery and preference for laparoendoscopic single-site surgery and assessment of satisfaction with postoperative cosmesis.

UNLABELLED: background and purpose: Laparoendoscopic single-site (LESS) surgery offers potential improvements in cosmesis and recovery over standard laparoscopy (SL). We report the factors with which patients are most concerned in choosing surgery and how these affect preference for LESS. In addition, we rate the satisfaction of scars after laparoscopy. PATIENTS AND METHODS: Patients followed after a laparoscopic procedure completed two surveys. First, patients rated, on a 5-point Likert scale, the importance of pain, recovery time, cost, treatment success, scars, and complications in choosing surgery. In addition, they were asked their preference for LESS. In the second survey, the impact of scars on body image and cosmesis was assessed. RESULTS: Seventy-nine patients (median age 54.8 years, 65% male and 35% female) were treated for malignancy (53), donation (15), and benign indications (9). Treatment success (4.71 ± 0.81) and complications (4.22 ± 1.16) were most important, followed by pain (3.43 ± 1.21) and convalescence (3.65 ± 1.11), P<0.05. Cost was rated 2.68 ± 1.38, and cosmesis was 2.22 ± 1.13 (P<0.005). Cosmesis score increased in females (2.59 ± 1.08 vs 2.02 ± 1.12), patients <50 years (2.59 ± 1.09 vs 2.02 ± 1.12), and benign surgical indication (3.33 ± 1.12 vs 2.07 ± 1.06), P<0.05. LESS was preferred in 30.4%, SL in 39.2%. Concern for cosmesis was associated with LESS preference (48.5% vs 17.8%, P=0.004). Sex, age, and surgical indication also influenced this. On the body image scale, patients scored a mean 18.8 ± 1.5 of 20. Patients rated scar appearance 8.31 ± 1.80 of 10. CONCLUSION: Patients who were treated with laparoscopy were most concerned with success and complication. Preference for LESS was influenced by concerns for cosmesis, sex, age, and surgical indication.