Presentation, management, and outcomes of complications following prostate cancer therapy.

OBJECTIVE: To characterize complications of prostate cancer therapy and operative management in patients referred to our institution for surgical intervention. MATERIALS AND METHODS: Data was abstracted from a retrospectively collected single surgeon database at a large tertiary care referral-based medical center. Variables included age, prostate cancer therapy, complication(s) and their management, and number of operations. Descriptive statistics were used. RESULTS: From 2006-2010, 890 patients underwent genitourinary surgery, of which 139 were to treat complications arising from prostate cancer therapy. Complications stemmed from radical prostatectomy (RP) monotherapy, RP and external beam radiation therapy (EBRT) or brachytherapy (BT), EBRT only, BT only, and combination EBRT and BT. Complications included urinary incontinence (UI), urethral strictures, bladder neck contractures, and fistulas. UI and bladder neck contractures were more common in patients treated with RP or RP with EBRT or BT. Strictures and fistulas were common in patients treated with EBRT or BT. Interventions included direct vision internal urethrotomy, artificial urinary sphincter, urethral reconstruction, UroLume urethral stent, urethral sling, repair of fistulas, and balloon dilation. Forty eight percent of patients required multiple operations. The median number of interventions was two. CONCLUSIONS: We operatively managed patients treated with non-surgical and surgical modalities for prostate cancer. Complications included UI, fistulas, strictures, and bladder neck contractures. These were managed with a variety of operative interventions. As more men undergo treatment for localized disease, more will inevitably have complications stemming from interventions.

Xanthogranulomatous pyelonephritis presenting with a left flank mass.

We present a case of a patient with xanthogranulomatous pyelonephritis (XGP) presenting with a large (18 × 12 cm) left-sided flank mass with worsening left flank pain. CT abdomen/pelvis demonstrated a left kidney with parenchyma replaced by multiple large hypodense collections containing fluid and gas, a left staghorn calculus, and a communication between the kidney and large flank collection. About 4.5 weeks after initial presentation, the patient underwent operative intervention. Pathology revealed an end-stage kidney with scar consistent with xanthogranulomatous pyelonephritis.

De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the likelihood of developing de novo erectile dysfunction (ED) after anterior urethroplasty and to determine if this likelihood is influenced by age, stricture length, number of previous procedures or timing of evaluation. MATERIALS AND METHODS: PubMed, Embase, Cochrane, and Google Scholar databases were searched for the terms 'urethroplasty', 'urethral obstruction', 'urethral stricture', 'sexual function', 'erection', 'erectile function', 'erectile dysfunction', 'impotence' and 'sexual dysfunction'. Two reviewers evaluated articles for inclusion based on predetermined criteria. RESULTS: In a meta-analysis of 36 studies with a total of 2323 patients, de novo ED was rare, with an incidence of 1%. In studies that assessed postoperative erectile function at more than one time point, ED was transient and resolved at between 6 and 12 months in 86% of cases. CONCLUSIONS: Men should be counselled regarding the possibility of transient or permanent de novo ED after anterior urethroplasty procedures. Increasing mean age was associated with an increased likelihood of de novo ED, but this was not statistically significant.

Gunshot wounds to the lower urinary tract: a single-institution experience.

BACKGROUND: This study aimed to analyze characteristics and outcomes of gunshot wounds to the lower urinary tract at our Level I trauma center. Our hypothesis is that gunshot wounds to the lower urinary tract have characteristic bullet trajectories, injury patterns, and associated injuries. METHODS: Our prospective trauma database was composed of reviewed gunshot wounds to the lower urinary tract including the pelvic ureter, bladder, or urethra from 1989 through 2011. RESULTS: We identified 50 patients (median age, 25 years; range, 3-53 years) with lower urinary tract injury. There was a mean of 2.3 bullets per patient (range, 1-8), with 26 patients injured from a single bullet. Urologic injury involving only the bladder occurred in 72% (36 of 50) of the patients. Ureteral injury was diagnosed in 20% (10 of 50) of the patients. Bullet trajectory was known in the majority of multiple bullet injuries and all cases involving a single bullet.All patients but one were managed operatively. During exploration, 90% (34 of 38) with transmural bladder injury had recognized bladder entry and exit wounds. Overall, 80% (40 of 50) had concurrent gastrointestinal injury. In patients with a single gunshot wound to the lower urinary tract, 58% (15 of 26) sustained concomitant intestinal injury, and 23% (6 of 26) sustained rectal injury.Of 20 posteroanterior gunshot wounds, 80% had buttock entry. All 10 single-bullet buttock-entry gunshot wounds injured the bladder. Isolated ureteral injury was associated with lower abdominal entry and anteroposterior trajectory. Urethral injury occurred in 4, with 75% upper-thigh entry. CONCLUSION: Penetrating injuries to the lower urinary tract most commonly involve the bladder. During exploration for gunshot wounds to the bladder, two injury sites should be expected because failure to close may lead to complications. Gunshot wounds to the lower urinary tract often occur with concomitant bowel injury, with buttock entry. A multidisciplinary approach involving general surgery is imperative. LEVEL OF EVIDENCE: Epidemiologic study, level IV.

Pediatric genitourinary injuries in the United States from 2002 to 2010.

PURPOSE: We describe the epidemiological features of pediatric genitourinary injuries, and determine the products and events that may predict an increased risk of genitourinary injury during childhood. MATERIALS AND METHODS: The National Electronic Injury Surveillance System was queried to identify children 18 years or younger who sustained genitourinary injuries and presented to emergency departments in the United States between 2002 and 2010. Demographics and injury characteristics of these children were analyzed. Analyses were performed with adjustments for sample weighting and the stratified survey design. All data are reported as national estimates along with 95% confidence intervals. RESULTS: Based on 10,286 actual cases, an estimated 252,392 children (95% CI 205,579-299,194) sustained genitourinary injuries during the 9-year study period. Children 4 to 7 years old were most frequently injured (36.8% of all injuries), followed by those 8 to 11 years old (20.6%). Girls comprised 55% of the injured children. The yearly incidence of genitourinary injuries was stable across the period studied. The most commonly injured organs were female external genitalia (37.7%), penises (21.6%) and testicles (12%). Genitourinary injuries were most commonly associated with sporting and exercise equipment (35.7%), furniture (15.5%) and clothing items (11.9%). Of the patients 91% were treated at the emergency department and discharged home. CONCLUSIONS: Genitourinary injuries in children result in approximately 28,000 emergency department visits yearly. Efforts should be made to decrease the risk of genitourinary injuries in children by promoting the use of protective gear and safer product selection for those at greatest risk for injury.

Acquired male urethral diverticula: presentation, diagnosis and management.

PURPOSE: We describe the etiology, presentation, treatment and outcomes of men diagnosed with an acquired urethral diverticulum. MATERIALS AND METHODS: We retrospectively analyzed the records of men with an acquired urethral diverticulum in an 11-year period (2000 to 2011) at a tertiary care reconstructive practice. Patient demographics, history, presentation, anatomical details such as diverticulum size and location, management and outcomes were recorded. Technical success was defined as unobstructed urination without urinary tract infection. RESULTS: A total of 22 men with an acquired urethral diverticulum were included in analysis. Median age at presentation was 48.5 years (range 18 to 86). Most commonly, patients presented with recurrent urinary tract infection, urinary dribbling, incontinence or a weak urinary stream. Of the 22 men 12 (54.5%) underwent urethral diverticulectomy and urethroplasty, 3 (13.5%) underwent ileal conduit urinary diversion and 7 (32%) were treated nonoperatively. Select cases were managed conservatively when the urethral diverticulum was confirmed in a nonobstructed urethra, it was small or asymptomatic and it could be manually emptied after voiding. At a mean followup of 2.3 years there was a 91% urethral diverticulum recurrence-free rate. CONCLUSIONS: Acquired male urethral diverticula are rare but should be considered when there is recurrent urinary tract infection, obstructive voiding symptoms, a history of hypospadias, urethral stricture or trauma, or prolonged urethral catheterization. Treatment options may include surgical excision of the urethral diverticulum or urinary diversion. Some patients may be adequately treated nonoperatively with post-void manual decompression.

Urethroplasty after radiation therapy for prostate cancer.

OBJECTIVE: To report urethroplasty outcomes in men who developed urethral stricture after undergoing radiation therapy for prostate cancer. METHODS: Our urethroplasty database was reviewed for cases of urethral stricture after radiation therapy for prostate cancer between June 2004 and May 2010. Patient demographics, prostate cancer therapy type, stricture length and location, and type of urethroplasty were obtained. All patients received clinical evaluation, including imaging studies post procedure. Treatment success was defined as no need for repeat surgical intervention. RESULTS: Twenty-nine patients underwent urethroplasty for radiation-induced stricture. Previous radiation therapy included external beam radiotherapy (EBRT), radical prostatectomy (RP)/EBRT, EBRT/brachytherapy (BT) and BT alone in 11 (38%), 7 (24%), 7 (24%), and 4 (14%) patients, respectively. Mean age was 69 (±6.9) years. Mean stricture length was 2.6 (±1.6) cm. Anastomotic urethroplasty was performed in 76% patients, buccal mucosal graft in 17%, and perineal flap repair in 7%. Stricture was localized to bulbar urethra in 12 (41%), membranous in 12 (41%), vesicourethra in 3 (10%), and pan-urethral in 2 (7%) patients. Overall success rate was 90%. Median follow-up was 40 months (range 12-83). Time to recurrence ranged from 6-16 months. CONCLUSION: Multiple forms of urethroplasty appear to be viable options in treating radiation-induced urethral stricture. Future studies are needed to examine the durability of repairs.

Direct vision balloon dilation for the management of urethral strictures.

Urethral strictures are often initially managed with dilation using sequential metal sounds or filiform and follower dilators. While these techniques often successfully achieve at least a temporary increase to the caliber of the area of stricture, they are performed without visual guidance, and complications can include false passage and urethral perforation. We describe the first use of balloon dilator that allows the safe, controlled, and gentle and dilation of urethral strictures under direct vision.

History and physical examination findings predictive of testicular torsion: an attempt to promote clinical diagnosis by house staff.

OBJECTIVE: To standardize the history and physical examination of boys who present with acute scrotum and identify parameters that best predict testicular torsion. MATERIALS AND METHODS: Over a 5-month period, a standardized history and physical examination form with 22 items was used for all boys presenting with scrotal pain. Management decisions for radiological evaluation and surgical intervention were based on the results. Data were statistically analyzed in correlation with the eventual diagnosis. RESULTS: Of the 79 boys evaluated, 8 (10.1%) had testicular torsion. On univariate analysis, age, worsening pain, nausea/vomiting, severe pain at rest, absence of ipsilateral cremaster reflex, abnormal testicular position and scrotal skin changes were statistically predictive of torsion. After multivariate analysis and adjusting for confounding effect of other co-existing variables, absence of ipsilateral cremaster reflex (P < 0.001), nausea/vomiting (P < 0.05) and scrotal skin changes (P < 0.001) were the only consistent predictive factors of testicular torsion. CONCLUSION: An accurate history and physical examination of boys with acute scrotum should be primary in deciding upon further radiographic or surgical evaluation. While several forces have led to less consistent overnight resident staffing, consistent and reliable clinical evaluation of the acute scrotum using a standardized approach should reduce error, improve patient care and potentially reduce health care costs.

Laparoscopic bowel injury in retroperitoneal surgery: current incidence and outcomes.

PURPOSE: Laparoscopic bowel injury is associated with significant morbidity and mortality when unrecognized. We assessed the incidence and outcomes of bowel injury in a contemporary cohort of patients, and reviewed the literature to examine the impact of experience with time on the incidence and consequences of bowel injury. MATERIALS AND METHODS: Between 2006 and 2009 we performed 1,073 laparoscopic surgeries on the upper urinary tract, adrenal gland and retroperitoneal lymph nodes. Patients incurring bowel injury were identified retrospectively. We reviewed complications and management. In a separate literature survey we identified 21 studies on laparoscopic bowel injury from 1993 to 2009. We analyzed etiology, incidence and management. RESULTS: Bowel injury occurred in 8 cases (0.75%), including 6 and 2 identified intraoperatively and postoperatively, respectively. Mechanisms included Veress needle and trocar placement, dissection and thermal injury. Intraoperative management included oversewing the injury, bowel resection and observation. No patient with intraoperatively recognized bowel injury sustained a postoperative adverse event. Patients with unrecognized injury presented in delayed fashion and required multiple procedures to manage the injury. No deaths occurred in this series. Urology series of bowel injury showed a combined 0.65% incidence in 14,447 laparoscopic procedures with 46.7% of injuries unrecognized at surgery. While the incidence of bowel injury has increased with time, the percent of unrecognized bowel injury has dramatically decreased from the early (70.4%) to the more recent (36.9%) laparoscopic era. CONCLUSIONS: The incidence of laparoscopic bowel injury has increased in the last 17 years. However, morbidity and mortality have decreased due to immediate recognition and repair.

Lasers in percutaneous renal procedures.

INTRODUCTION: Since the invention of lasers in 1960, they have been increasingly used in medicine. In this review paper, the types of lasers used in urology, in addition to their applications to percutaneous renal surgery will be reviewed. Specifically, use of lasers in the percutaneous management of renal stones, upper tract transitional cell carcinoma and stricture will be reviewed. MATERIALS AND METHODS: Pubmed was searched for citations since 1966. The following terms were used: "lasers", "calculi", "endopyelotomy", and "transitional cell carcinoma". RESULTS: Due to its minimal depth of penetration, holmium laser has proven to be safe and efficacious. It is currently the primary energy source for flexible instrumentation, and also has demonstrated efficacy in percutaneous lithotripsy (faster than ultrasonic lithotripsy and safer than electrohydraulic lithotripsy). Holmium laser been used for antegrade endopyelotomy and percutaneous resection of upper tract transitional cell carcinoma. CONCLUSIONS: Holmium laser is safer than other lasers and has become the gold standard for laser lithotripsy for flexible instrumentation. It has been used successfully in the percutaneous management of renal stones, ureteropelvic junction obstruction, and upper tract transitional cell carcinoma. Holmium laser is an alternative energy source to conventional lithotripters and electrocautery for endopyelotomy and resection of upper tract transitional cell carcinoma.

Pelvic kidney: associated diseases and treatment.

The incidence of pelvic kidney has been approximated at between 1 in 2200 and 1 in 3000. The ectopic kidney is thought to be no more susceptible to disease than the normally positioned kidney, except for the development of calculi and hydronephrosis. Because of the greater risk of injuring aberrant vessels or overlying abdominal viscera and nerves, the pelvic kidney presents special treatment challenges. Alternative approaches to treating nephrolithiasis may yield better outcomes. The tortuous ureter often associated with a pelvic kidney hinders deflection of the flexible ureteroscope, potentially limiting access. Laparoscopy-guided intervention permits visual exposure of the kidney, enhancing safe puncture and tract placement integral to percutaneous nephrolithotomy. Laparoscopy-assisted anterior retrograde percutaneous nephroscopy involves percutaneous access using a Hunter-Hawkins retrograde nephrostomy needle with adjunctive laparoscopy to permit viewing and manipulation of overlying bowel. Ureteropelvic junction (UPJ) obstruction has been reported to occur in 22% to 37% of ectopic kidneys. Endoscopic incision presents difficulties beyond those of anatomically normal kidneys. The laparoscopic approach provides good surgical exposure, and operative times are comparable to those of laparoscopic pyeloplasty in anatomically normal kidneys. To date, only a handful of cases of malignancy in a pelvic kidney have been described. Like a nonfunctioning anatomically normal kidney, a nonfunctional pelvic kidney may require primary removal. There are a few reports of laparoscopic pelvic nephrectomy. Additional studies are needed to compare the various treatments for disease of the pelvic kidney in order to decide which options have the most beneficial outcomes.

Raloxifene, an oestrogen-receptor-beta-targeted therapy, inhibits androgen-independent prostate cancer growth: results from preclinical studies and a pilot phase II clinical trial.

OBJECTIVES: To determine, in preclinical in vivo animal and in clinical studies, whether raloxifene (a selective oestrogen-receptor (ER) modulator that targets ER-beta and induces apoptosis in vitro in androgen-independent prostate cancer, AIPC cells) affects prostate cell differentiation, proliferation and carcinogenesis, and in the pilot phase II clinical trial, the response rate and duration of patients with AIPC treated with a daily oral dose of raloxifene. PATIENTS, MATERIALS AND METHODS: Tumour proliferation rate in response to raloxifene treatment, and molecular markers of cell cycle and apoptosis, were evaluated in established ER-beta-positive androgen-dependent (AD) CWR22 and AI CWRSA9 human xenograft prostate cancer models. Twenty-one patients with AIPC and evidence of disease progression were enrolled into the clinical trial and given daily oral raloxifene. RESULTS: There was significant growth inhibition by raloxifene in the ADPC and AIPC xenograft models (CWR22 68%, P < 0.010; CWRSA9 64%, P < 0.001), with no tumour regression. There was evidence of G1 arrest by increased p27kip1 expression in the raloxifene-treated group. Eighteen patients comprised the efficacy analysis, as three withdrew before the first evaluation. At the first evaluation, five men had stable disease and continued on the study for a median of five cycles. The longest response was 17 cycles. Drug related toxicity was minimal. CONCLUSION: Raloxifene has activity in xenograft models, slowing disease progression. This translated to possible disease stabilization in patients with AIPC. Further studies are warranted.