Current perceptions of resident training in laparoscopic nephrectomy.

OBJECTIVES: To determine the perceived degree of training of residents in laparoscopic nephrectomy. Laparoscopic nephrectomy is well established in the field of urology and has seen increasing penetrance in urologic practice. The degree to which this recent technical shift has been integrated into urologic training at the residency level has not been characterized. METHODS: An electronic survey was sent to 518 urology residents and recent graduates and to 85 laparoscopic specialists at academic medical centers. Both residents and practicing urologists were queried regarding the level of resident participation for each step of laparoscopic nephrectomy and opinions on the necessity of fellowship training. The data were analyzed using the Wilcoxon rank-sum and chi(2) tests. RESULTS: Attending surgeons perceived a significantly greater level of resident involvement in performing all aspects of laparoscopic nephrectomy, with the exception of hilar dissection and port closure. To perform laparoscopic nephrectomy, 12.5% of attending physicians and 5% of residents reported that a fellowship is necessary. CONCLUSIONS: Significant disagreement exists between attending surgeons and residents on the perceived degree of resident involvement in most aspects of laparoscopic nephrectomy. This could have significant implications on resident education for a procedure that is arguably the standard of care for treatment of uncomplicated renal masses. Most attending physicians and residents were in agreement that fellowship is not necessary to perform this procedure. These results raise questions regarding the future of laparoscopic training and bring to light the need for better regulation of laparoscopic training.

Training residents in hypospadias repair: variations of involvement.

PURPOSE: Hypospadias repair is a complex and seminal procedure that has defined the subspecialty of pediatric urology. We sought to determine the degree of training and opinions regarding the need for fellowship training to achieve necessary competence in hypospadias repair. MATERIALS AND METHODS: An electronic survey was sent to 518 urology residents and recent graduates, and to 168 practicing pediatric urologists. Nonresponders were resent the survey 2 additional times. The survey consisted of basic questions on level of training or years in practice. Residents and practicing pediatric urologists were asked about the level of resident participation for each step of the hypospadias procedure, and opinions on the necessity of fellowship training. Data were analyzed for statistical differences with Wilcoxon rank sum and multiple and logistic regression tests. RESULTS: Surveys were completed by 89 pediatric urologists and 208 urology residents or recent graduates (response rate 53% and 40%, respectively). Approximately 70% of residents and attending physicians report that less than 50% of the overall hypospadias procedure is performed by the resident. There appears to be agreement between residents and attending physicians regarding the perceived amount of resident participation for all steps of the procedure except glanular mobilization. Additionally, 71% of residents and 86% of attending physicians believe that a pediatric fellowship is necessary to perform hypospadias surgery. CONCLUSIONS: The majority of residents and attending physicians report limited resident participation in hypospadias surgery. Residents and attending physicians have significant agreement on perceived participation. Our data do not corroborate the program data regarding the role of urology residents in hypospadias repair. The majority of residents and pediatric urologists believe specialized training is required to perform hypospadias surgery.

Renal cortical deterioration in children with spinal dysraphism: analysis of risk factors.

BACKGROUND/OBJECTIVE: Because hydronephrosis and reflux are reversible, we believe cortical loss represents true renal deterioration in children with spinal dysraphism. Our goal was to better define risk factors for cortical loss. METHODS: After institutional review board approval, we reviewed the medical records of 272 children with spinal dysraphism. The following factors were evaluated: age, sex, renal and bladder imaging, urodynamic parameters, medications, catheterization program, continence, infections, and surgical history. Renal cortical loss was defined by scarring or a differential function greater than 15% using a nuclear scan. Univariate and multivariate logistic regression models were fitted to test the associations of specific variables with cortical loss. RESULTS: Renal cortical loss was found in 41% of children with high-grade reflux vs. 2% of children without reflux. Univariate analysis showed only high-grade reflux and female sex to be independent risk factors. Controlling for age and sex, reflux and initiation of catheterization after 1 year of age are significant risk factors. High bladder pressure and hydronephrosis in the absence of reflux were not associated with cortical loss. Multivariate analysis showed that girls with reflux have a 55-fold increased risk of cortical loss. CONCLUSION: By limiting the definition of renal deterioration to cortical loss, we identified relevant risk factors: reflux, female sex, and delayed initiation of clean intermittent catheterization. We have also discounted other suspected risk factors: hydronephrosis and elevated bladder pressure. Rather than continuing our focus on hydronephrosis and urodynamics, we believe more research and management debate should be afforded to females with reflux.

Umbilical stomal stenosis: a simple surgical revision technique.

Stenosis of stomas sited at the umbilicus presents a surgical challenge. A paucity of literature exists on the surgical management of this problem, despite its relatively frequent occurrence. A simple technique is described, using scar incision and advancement of an umbilical skin flap, to accomplish stomal revision.

Renal cell carcinoma metastatic to gallbladder: a survival advantage to simultaneous nephrectomy and cholecystectomy.

Renal cell carcinoma is a relatively uncommon cancer. Patients presenting with a renal adenocarcinoma are often found to have evidence of metastatic disease at the time of diagnosis. Herein, we describe the case of a 39-year-old male with renal cell carcinoma and a synchronous metastatic focus to the gallbladder. The patient underwent a successful simultaneous nephrectomy and cholecystectomy and is doing well 30 months after surgery without evidence of disease recurrence. A thorough metastatic work-up along with aggressive surgical intervention in patients with renal cell carcinoma and unusual metastatic foci can provide a long-term favorable outcome.

Novel technique for testicular salvage after combat-related genitourinary injury.

We report a case of traumatic testicular injury resulting in significant loss of both tunica albuginea and seminiferous tubules. Secondary to the substantial tissue loss, our approach to surgical reconstruction required a certain degree of creativity. The injury was managed by creating a single midline testis with two distinct blood supplies. The use of this novel technique was necessary to achieve closure of the tunica albuginea. This case demonstrates the importance of the use of nontraditional reconstructive maneuvers to avoid orchiectomy, given the potential long-term health issues regarding infertility and androgen production.

Diagnosis of blunt bladder injury: A prospective comparative study of computed tomography cystography and conventional retrograde cystography.

BACKGROUND: This study was designed to evaluate prospectively the accuracy of computed tomography (CT) cystography for the detection of bladder rupture, performed concurrently with screening abdominal/pelvic CT, in patients at risk for blunt bladder injury. The study also aimed to validate our proposed method of performing CT cystography, which was designed to minimize the time and effort required to image the bladder. METHODS: CT cystography was performed on patients at risk for blunt bladder injury. Retrograde filling of the bladder with dilute iodinated contrast material was performed before routine abdominal/pelvic CT scanning, performed with oral and intravenous contrast. Conventional cystography, when performed, followed CT cystography. RESULTS: CT cystography, followed by conventional cystography, was performed in 212 patients, among whom 19 had bladder rupture. The CT cystography sensitivity and specificity for bladder rupture in these patients was 95% and 100%, respectively; for conventional cystography, sensitivity and specificity were 95% and 100%, respectively. CT cystography was performed without conventional cystography in 283 patients, among whom 27 had bladder rupture. The sensitivity and specificity of CT cystography for bladder rupture in these patients were both 100%. CONCLUSIONS: CT cystography is equivalent to conventional cystography for detecting the presence or absence of blunt bladder injury. CT cystography can be performed as an integral part of the CT screening undergone by many blunt trauma patients and, in the vast majority of these patients, it can alleviate the need for a separate conventional cystogram.

Clinical utility of ureteral jets: disparate opinions.

BACKGROUND AND PURPOSE: Many renal/bladder ultrasound scans at our institution include evaluation of ureteral jets, often regardless of the indication for the study. Such jets often are absent in normal volunteers. Because these jets are of unclear clinical significance, we sought to determine if urologists and radiologists nationally agree on the clinical utility of ureteral jets. MATERIALS AND METHODS: A three-item survey was mailed electronically to a randomly selected group of urologists and radiologists asking about the physician's practice pattern and opinion of the clinical relevance of ureteral jets by percentage and on the Likert scale. Using the unpaired Student's t-test, the responses of the groups were compared. RESULTS: Responses were available from 177 physicians. Statistically significant differences were noted between urologists and radiologists for all three questions. Radiologists reported that 50% of ultrasonograms evaluate ureteral jets, compared with 29% for urologists (P < 0.01). Whereas radiologists "somewhat agreed" (2.01) that ureteral jets were clinically relevant, urologists were "indifferent" (2.77) to their clinical relevance (P < 0.01). The two groups also differed on the question of whether a routine ultrasound study should include evaluation of ureteral jets. CONCLUSIONS: Urologists and radiologists disagreed on both the necessity for evaluating ureteral jets and their clinical relevance. On the basis of jet frequency and a review of the literature, accurate evaluation of jets requires a minimum of 10 minutes. The cost of this time should be considered in light of the requesting physician's opinion of the clinical relevance of the results. Until further evidence supports their value, evaluation of jets should be excluded from routine renal/bladder sonography.

Ship in a bottle: rapid extraction of large intravesical foreign bodies.

Objects placed in the bladder often become encrusted with stone. Using a technique combining endoscopic visualization and a small open cystotomy, a large encrusted foreign body was successfully and safely removed. The combination of endoscopy and cystotomy is rapid, safe, and potentially applicable for the removal of large vesical calculi.

Secondary transitional cell carcinoma and nitrogen mustard treatment.

Transitional cell carcinoma (TCC) of the bladder in children is a rare occurrence. Cyclophosphamide is a known risk factor for the development of TCC. Other alkylating agents, such as nitrogen mustard, have not been implicated in the development of secondary adult or pediatric TCC. The role of radiotherapy in the development of secondary malignancies of the bladder remains controversial. We report a case of childhood TCC in a patient in remission from Hodgkin's lymphoma previously treated with non-cyclophosphamide chemotherapy and low-dose nodal radiotherapy.