3-Dimensional magnetic resonance genitography: a different look at cloacal malformations.

PURPOSE: Standard contrast genitography and endoscopy have been the cornerstone of preoperative investigation of anatomy in complex cloacal malformations. In many cases standard genitography is ambiguous and lengthy endoscopy may be required to define the anatomy. Nonenhanced magnetic resonance imaging lacks definition of the nondistended common channel and confluence. To our knowledge we introduce 3-dimensional magnetic resonance genitography for delineating the unique anatomical features of these complex anomalies. MATERIALS AND METHODS: Contrast genitography, endoscopy and 3-dimensional magnetic resonance genitography were performed preoperatively in 4 female infants with cloacal malformations. Three-dimensional magnetic resonance genitography was performed using a 3-dimensional spoiled gradient technique after the instillation of gadolinium-diethylenetetramine pentaacetic acid solution via the common channel and cutaneous vesicostomy, when present. Augmented pressure distal colostogram with gadolinium via the mucous fistula was included. Three-dimensional images were constructed using a commercially available workstation. RESULTS: Three-dimensional magnetic resonance genitography yielded anatomical information far superior to that of standard genitography in all cases and it provided information on female genital tract anomalies and hindgut confluence that were not fully appreciated at initial endoscopy. The confluence was most accurately represented by augmented pressure colostogram. The length of the common channel was consistent with that on endoscopy. Rotating 3-dimensional images illustrated the unique anatomical relationships. No magnetic resonance imaging specific complications were observed. CONCLUSIONS: Three-dimensional magnetic resonance genitography provides superior anatomical detail for the preoperative assessment of cloacal malformations. It augments the information obtained by standard magnetic resonance imaging of the pelvic organs, levators and lumbosacral spine. Three-dimensional magnetic resonance genitography has great potential as a standard for preoperative anatomical evaluation and it will likely simplify preoperative endoscopy rather than supplant it.

Adult-type testicular granulosa cell tumor: case report and review of the literature.

We report the clinical, sonographic, and pathologic findings of an incidentally discovered testicular granulosa cell tumor of the adult type in a 32-year-old man. Serum tumor markers were within normal limits. The sonographic findings revealed a well-circumscribed, hypoechoic mass. Gross inspection confirmed a unilobular, well-circumscribed mass without necrosis. Microscopically, the mass was demarcated by a thin capsule, with tumor cells arranged in nests with low mitotic activity. These cells were diffusely immunoreactive for vimentin and focally for inhibin. The entrapped rete epithelium stained positive for pancytokeratin (Lu-5). We present our management of this rare malignancy.

Computed tomography-guided, resistance-based, percutaneous radiofrequency ablation of renal malignancies under conscious sedation at two years of follow-up.

OBJECTIVES: To evaluate the use of computed tomography-guided, resistance-based, percutaneous radiofrequency ablation of renal malignancies using conscious sedation. METHODS: Twenty-three patients with a mean age of 74 years underwent 27 PRFA treatments, using only conscious sedation, for enhancing renal masses, with a mean renal mass of 2.69 cm. All patients had multiple medical comorbidities that precluded standard operative management. Patients were followed up postoperatively at 3-month intervals with renal function studies and enhanced imaging. Successful ablation was defined as a lack of enhancement or resolution of the renal mass. RESULTS: Of the 23 patients, 16 (80%) had successful ablation with a single treatment, 4 had initial failure, and 3 were lost to follow-up. Of the 4 patients with initial failure, 2 underwent reablation successfully, 1 patient elected watchful waiting, and 1 patient died of metastatic renal cell carcinoma. The overall cancer-free survival rate was 90% (18 of 20 patients) at a mean follow-up of 24 months. The exclusion of 2 patients who underwent four sessions for renal masses greater than 4 cm improved the survival rate to 94% (17 of 18). No statistically significant difference was found between the preoperative and postoperative serum creatinine levels (P = 0.46), even in the patients with a preoperative creatinine level greater than 1.5 (P = 0.51). Our only complication was a single perinephric hematoma that resolved spontaneously. CONCLUSIONS: We have demonstrated promising oncologic results for computed tomography-guided percutaneous radiofrequency ablation of tumors in select patients with small renal masses. The procedure was well tolerated under conscious sedation. None of the patients demonstrated significant changes in renal function.

Novel direct-vision renal morcellation with orthopedic rotary shaver-blade instrumentation.

BACKGROUND AND PURPOSE: When small ports are the only entry (and exit) points during laparoscopic nephrectomy, one is forced either to make an accommodating incision for final renal delivery or to perform renal morcellation. To date, morcellation has been performed in a blind manner with a specimen entrapped in a nonpenetrable, nonpermeable sac within the peritoneal cavity. Through the use of current laparoscopic equipment and a novel rotary shaver-blade system, we studied the safety, feasibility, and efficiency of directly observed renal morcellation. MATERIALS AND METHODS: Ten porcine renal units with a mean mass of 143 g (range 92-192 g) were morcellated via a custom 5.5-mmx28-cm Dyonics (Smith & Nephew, Andover, MA) rotary shaver blade placed through a standard operative laparoscope (ACMI LAP 11-56W). Each kidney was entrapped in a standard 8x10-inch LapSac (Cook Urological, Spencer, Indiana), which was placed in a preconfigured abdomen model. Morcellation was performed under direct visual guidance with continuous-flow irrigation and suction. We then studied the feasibility, safety, technical ease, and efficiency of morcellation; the size of the fragments; and entrapment-bag integrity with each renal morcellation. RESULTS: The mean time required to complete morcellation was 8:02 minutes (range 4:45-14:00 minutes). The morcellation efficiency mean was 20.7 g/min (range 12.00-31.41 g/min), with the Dyonics EP-1 generator system morcellating most effectively at 2000 rpm in its oscillate mode. Of ten random fragments, the mean size was 8.7x4.7 mm. The integrity of one LapSac was lost when the bag was not filled to complete distention, creating susceptible in folding. CONCLUSION: This novel technique of laparoscopic renal delivery provides a feasible, safe, technically simple, and efficient means of morcellation. Directly viewed renal morcellation must occur with a kidney freely floating within a completely distended entrapment sac in order to preserve the integrity of the sac itself. Tissue fragments are large enough for pathologic review, which may permit superior oncologic surgical margins.

Case report: serial percutaneous cholangioscopy with laser ablation for the management of locally recurrent biliary intraductal papillary mucinous tumor.

We present a case of serial cholangioscopic laser fulguration of a biliary recurrence of pancreatic intraductal papillary mucinous tumor in a 76-year-old man. Through established percutaneous biliary drain tracts, the aseptic use of a standard 6.9 F ureteroscope and holmium laser fiber facilitated visual ablation within the biliary tree. Quarterly cholangioscopic laser ablation provided safe and effective local control without biliary infectious complications. This case appears to be the first treatment of recurrent intrabiliary intraductal papillary mucinous tumor by serial antegrade choledocoscopy and laser photocoagulation. Effective local control appears possible with minimal morbidity. Standard ureteroscopic equipment facilitates safe and efficient percutaneous antegrade choledocoscopy.

Unusual presentation of hidradenitis suppurativa with massive enlargement of penis.

Hidradenitis suppurativa is a chronic, recurrent inflammatory disease affecting the cutaneous apocrine glands and resulting in their obstruction. This enigmatic disease causes recurrent episodes of infection, edema, scarring, and fibrosis of surrounding tissues. We present the case of a 55-year-old man with two decades of inguinal hidradenitis suppurativa that resulted in extensive penile subcutaneous lymphedema and enlargement secondary to scarring and obstructive lymphadenopathy. Reconstructive phalloplasty to restore normal penile function was required. Minimal recurrent induration, normal cutaneous sensation, and normal voiding and erectile function were noted at 3 years of follow-up.

Fibrin sealant enables tubeless percutaneous stone surgery.

PURPOSE: Fibrin sealant has been demonstrated to be safe and effective as a hemostatic agent and urinary tract sealant. We assessed the ability of fibrin sealant to facilitate tubeless management after uncomplicated percutaneous nephrolithotomy (PCNL). MATERIALS AND METHODS: Eight consecutive patients underwent single access tubeless PCNL for renal calculi in a total of 9 renal units in a 2-month period. An additional patient with distal ureteral obstruction underwent antegrade ureteroscopy for an 8 x 8 mm distal ureteral stone. Average patient age was 47 years and mean stone size was 3.37 cm (range 0.64 to 9.90). Following complete stone clearance a Double-J (Medical Engineering Corp., New York, New York) ureteral stent was placed antegrade and 2 cc HEMASEEL APR (Haemacure Corp., Sarasota, Florida) fibrin sealant was injected under nephroscopic or fluoroscopic visualization into the parenchymal defect just within the renal capsule. Preoperative and postoperative hematocrit (HCT) was determined. Computerized tomography was performed on postoperative day 1 or 2 to evaluate retained stone fragments, perinephric fluid and urinary extravasation. RESULTS: In the 10 renal units treated via this tubeless technique no intraoperative or postoperative complications were noted. Average hospital stay was 1.1 days. All patients were discharged home on postoperative day 1 except 1 undergoing asynchronous bilateral PCNL on consecutive days. The mean intraoperative change in HCT was 2.8%. There was no significant change in HCT on postoperative day 1. No patient required transfusion. Seven renal units and 1 ureteral unit had no residual stone fragments for a complete stone-free rate of 80%. No gross leakage was observed on dressings and postoperative computerized tomography failed to demonstrate urinary extravasation. CONCLUSIONS: Tubeless PCNL using fibrin sealant at the renal parenchymal defect appears to be safe and feasible. Further experience is necessary to determine the role of fibrin sealant in percutaneous renal surgery.

Multiple intravesical linear staples identified during surveillance cystoscopy after laparoscopic nephroureterectomy.

Laparoscopic nephroureterectomy has faced technical criticism secondary to the unknown effects of urine-exposed intravesical or intraureteral staples. Although not reported, staples exposed to urine theoretically create a nidus for encrustation and stone formation. We present a case of a 66-year-old man after left laparoscopic ureterectomy for ureteral malignancy. Surveillance cystoscopy at 6 months revealed a nearly complete intravesical titanium staple line without encrustation. Successful transurethral removal of all staples with standard cystoscopic graspers revealed no immediate, or delayed, sequelae.

Barotrauma secondary to inflammatory maxillary sinus polyp: a case report.

Sinus barotrauma, secondary to mucosal disturbances, is a common finding within the aviation community. Multiple etiologies have all led to mucosal inflammation and thickening with potential obstruction of the sinus osteomeatal complex, especially during the barometric changes of flight. Obstruction can, therefore, lead to problems with sinus pressure equilibration with atmospheric pressure, and can lead to barosinusitis. We present a case of a U.S. Air Force Command Pilot with acute left sinus barotrauma during descent while flying a T-37 aircraft, along with a brief review of the pathophysiologic processes involved during barotrauma. An inflammatory polyp within his sinus was identified by plain radiography, confirmed with computed tomography, and subsequently excised. The patient had complete resolution and clearance to fly after an uneventful 4-wk convalescence and altitude chamber flight. This is the first case of sinus barotrauma secondary to an inflammatory maxillary sinus polyp, confirmed by histologic diagnosis, reported in the aeromedical literature.