Extratunical grafting for minimally invasive management of complex Peyronie's disease deformities.

BACKGROUND: Penile deformities due to Peyronie's Disease (PD) often significantly impair men's sexual health and quality of life. AIM: In this article we discuss the extratunical graft (ETG) procedure as a management strategy for PD patients with hourglass or indent penile deformities. METHODS: We compiled descriptions of surgical techniques and performed a review of the literature regarding ETG for PD. OUTCOMES: The ETG procedure appears to have promising results in the management of indent/hourglass deformity of PD. RESULTS: The findings of this review of the literature demonstrate that ETG is a safe and effective reconstructive technique for penile deformity with minimal side effects. CLINICAL IMPLICATIONS: We recommend utilizing ETG with or without plication for PD patients with indent or hourglass deformities. STRENGTHS AND LIMITATIONS: Strengths of ETG are the improvement in patients with tunical indents and hourglass deformities secondary to PD. Additionally, patients who underwent ETG maintained sexual function given no significant change in penile length and intact erectile function. Limitations, however, are that the procedure is relatively new, and data are limited to small cohorts. CONCLUSION: The ETG procedure is a safe and effective for management of complex PD in the short- and intermediate-term follow-up cohort.

Intravenous caval leiomyomatosis in the setting of renal cell carcinoma - A case report.

Uterine leiomyomas are common, benign neoplasms of the uterine smooth muscle. Leiomyomatosis is uncommon and causes development of multiple leiomyomas that can manifest as intravascular leiomyomatosis (IVL). We present the case of a 46-year-old female with IVL extending from the right gonadal vein to the right atrium and pulmonary arteries with an independent renal cell carcinoma of the right kidney. She underwent successful open right radical nephrectomy, inferior vena caval tumor thrombectomy and pulmonary embolectomy. While there was initial concern for hereditary renal cell carcinoma, final histologic testing did not support the diagnosis.

Salvage therapy for localized recurrences of penile cancer.

PURPOSE OF REVIEW: To review the current literature and guidelines regarding salvage therapy for local and regional recurrence of primary penile cancer. RECENT FINDINGS: While invasive surgical management has not significantly changed, penile sparing treatments (PSTs) may have a promising role in the management of local recurrence. Penile sparing surgeries do appear to have higher rates of recurrence. However, the overall survival rate is comparable to that of partial and total penectomies. Additionally, a combination of therapies may have a more profound effect on management of penile cancer. SUMMARY: Clinicians must discuss the role of each type of therapy for penile cancer with their patients, and tailor their management to the extent of disease in each patient. While it is important to discuss the balance between quality of life and rates of relapse, one must also emphasize the rates of overall survival in patients with local recurrence who are treated with PSTs.

Critical Assessment of Single-Use Ureteroscopes in an In Vivo Porcine Model.

METHODS: A female pig was placed under general anesthesia and positioned supine, and retrograde access to the renal collecting system was obtained. The LithoVue (Boston Scientific) and Uscope (Pusen Medical) were evaluated by three experienced surgeons, and each surgeon started with a new scope. The following parameters were compared between each ureteroscope: time for navigation to upper and lower pole calyces with and without implements (1.9 F basket, 200 µm laser fiber, and 365 µm laser fiber for upper only) in the working channel and subjective evaluations of maneuverability, irrigant flow through the scope, lever force, ergonomics, and scope optics. RESULTS: Navigation to the lower pole calyx was significantly faster with LithoVue compared to Uscope when the working channel was empty (24.3 vs. 49.4 seconds, p < 0.01) and with a 200 µm fiber (63.6 vs. 94.4 seconds, p=0.04), but not with the 1.9 F basket. Navigation to the upper pole calyx was similar for all categories except faster with LithoVue containing the 365 µm fiber (67.1 vs. 99.7 seconds, p=0.02). Subjective assessments of scope maneuverability to upper and lower pole calyces when the scope was empty and with implements favored LithoVue in all categories, as did assessments of irrigant flow, illumination, image quality, and field of view. Both scopes had similar scores of lever force and ergonomics. CONCLUSIONS: In an in vivo porcine model, the type of single-use ureteroscope employed affected the navigation times and subjective assessments of maneuverability and visualization. In all cases, LithoVue provided either equivalent or superior metrics than Uscope. Further clinical studies are necessary to determine the implications of these findings.

Metabolomic Characterization of Human Model of Liver Rejection Identifies Aberrancies Linked to Cyclooxygenase (COX) and Nitric Oxide Synthase (NOS).

BACKGROUND Acute liver rejection (ALR), a significant complication of liver transplantation, burdens patients, healthcare payers, and the healthcare providers due to an increase in morbidity, cost, and resources. Despite clinical resolution, ALR is associated with an increased risk of graft loss. A unique protocol of delayed immunosuppression used in our institute provided a model to characterize metabolomic profiles in human ALR. MATERIAL AND METHODS Twenty liver allograft biopsies obtained 48 hours after liver transplantation in the absence of immunosuppression were studied. Hepatic metabolites were quantitated in these biopsies by liquid chromatography and mass spectroscopy (LC/MS). Metabolite profiles were compared among: 1) biopsies with reperfusion injury but no histological evidence of rejection (n=7), 2) biopsies with histological evidence of moderate or severe rejection (n=5), and 3) biopsies with histological evidence of mild rejection (n=8). RESULTS There were 133 metabolites consistently detected by LC/MS and these were prioritized using variable importance to projection (VIP) analysis, comparing moderate or severe rejection vs. no rejection or mild rejection using partial least squares discriminant statistical analysis (PLS-DA). Twenty metabolites were identified as progressively different. Further PLS-DA using these metabolites identified 3 metabolites (linoleic acid, γ-linolenic acid, and citrulline) which are associated with either cyclooxygenase or nitric oxide synthase functionality. CONCLUSIONS Hepatic metabolic aberrancies associated with cyclooxygenase and nitric oxide synthase function occur contemporaneous with ALR. Additional studies are required to better characterize the role of these metabolic pathways to enhance utility of the metabolomics approach in diagnosis and outcomes of ALR.

Class II Human Leukocyte Antigen Epitope Mismatch Predicts De Novo Donor-Specific Antibody Formation After Liver Transplantation.

Formation of de novo donor-specific antibodies (dn-DSAs) has been associated with longterm immunologic complications after liver transplantation (LT). We hypothesized that human leukocyte antigen (HLA) epitope/eplet mismatch (MM) is a marker of immunogenicity and a risk factor for dn-DSA formation. Sera from 80 LT recipients were prospectively screened for dn-DSA by a Luminex single-antigen test (One Lambda, Inc., Canoga Park, CA) at 1, 2, 3, 6, 12, 18, 24, and 36 months after LT. HLA typing of the recipients and donors was performed using polymerase chain reaction (PCR)-SSP and PCR-SSOP Luminex low-resolution methods (One Lambda, Inc.). The HLAMatchmaker computer algorithm was used for identification of MM eplets at HLA-DRB1 and -DQA1/B1 loci. Luminex single-antigen bead solid phase assay was used for antibody analysis. Standard immunosuppression included thymoglobulin-rituximab induction and tacrolimus maintenance. There were 27 (34%) patients who developed dn-DSA. There were no episodes of antibody-mediated rejection, and 9 (11%) developed acute cellular rejection (ACR). A positive crossmatch status and a higher number of HLA-A, -B, -DR, and -ABDR MMs were not associated with dn-DSA formation. Patients developing dn-DSA had a significantly higher number of total (38 ± 2.7 versus 28 ± 2.3; P = 0.01) and antibody-verified (AbVer; 14 ± 1.1 versus 10 ± 1; P = 0.015) class II MM eplets. By a multivariate regression analysis, the number of class II MM eplets was strongly associated with risk of class II dn-DSA formation (odds ratio [OR], 1.2; P < 0.01). Patients with ACR had a significantly higher number of total (20.2 ± 1.3 versus 13.9 ± 0.9; P < 0.01) as well as AbVer (10.7 ± 1.1 versus 7.5 ± 0.6; P = 0.03) class I MM eplets. In conclusion, donor-recipient HLA epitope MM is associated with a risk of dn-DSA formation and rejection after LT. However, further studies are required to evaluate the clinical utility of epitope matching in LT.