Long-term outcomes after percutaneous renal cryoablation performed with adjunctive techniques.

OBJECTIVE: To review the technical success of image-guided percutaneous cryoablation of renal masses in difficult anatomic locations using adjunctive techniques to displace critical structures away from the ablation zone, while also reporting longer-term outcomes within this patient population. METHODS: An IRB approved, retrospective analysis of 92 renal masses treated with percutaneous cryoablation revealed 15 cases utilizing adjunctive techniques. Tumor size and distance to adjacent organ before and after adjunctive technique and long-term outcomes were evaluated. RESULTS: The adjunctive techniques used were hydrodissection (n=15) and angioplasty balloon interposition (n=1). Before and after adjunctive technique, median tumor proximity to closest organ was 4mm and 26mm, respectively. All cases had appropriate ablation zones and protection of adjacent critical structures. There is no evidence of recurrence or complication on follow-up (median 51months). CONCLUSIONS: Adjunctive techniques to ablate renal masses in difficult locations provide technical success, safety, and favorable long-term outcomes.

Perioperative patient radiation exposure in the endoscopic removal of upper urinary tract calculi.

BACKGROUND AND PURPOSE: The efficacy of computed tomography (CT) in detailing upper urinary tract calculi is well established. There is no established acceptable annual recommended limit for medical exposure, yet the global accepted upper limit for occupational radiation exposure is <50 millisieverts (mSv) in any one year. We sought to appreciate the CT and fluoroscopic radiation exposure to our patients undergoing endoscopic removal of upper tract calculi during the periprocedure period. PATIENTS AND METHODS: All patients undergoing upper urinary endoscopic stone removal between 2005 and 2009 were identified. To calculate the cumulative radiation exposure, we included all ionizing radiation imaging performed during a periprocedure period, which we defined as ≤90 days pre- and post-therapeutic procedure. RESULTS: A total of 233 upper urinary tract therapeutic patient stone procedures were identified; 127 patients underwent ureteroscopy (URS) and 106 patients underwent percutaneous nephrolithotomy (PCNL). A mean 1.58 CTs were performed per patient. Ninety (38.6%) patients underwent ≥2 CTs in the periprocedure period, with an average number in this group of 2.49 CT/patient, resulting in approximately 49.8 mSv of CT radiation exposure. Patients who were undergoing URS were significantly more likely to have multiple CTs (P=0.003) than those undergoing PCNL. Median fluoroscopic procedure exposures were 43.3 mGy for patients who were undergoing PCNL and 27.6 mGy for those patients undergoing URS. CONCLUSIONS: CT radiation exposure in the periprocedure period for patients who were undergoing endoscopic upper tract stone removal is considerable. Added to this is the procedure-related fluoroscopic radiation exposure. Urologic surgeons should be aware of the cumulative amount of ionizing radiation received by their patients from multiple sources.

Management of post-prostatectomy erectile dysfunction.

The management of post-prostatectomy erectile function has been debated since the nerve sparing radical prostatectomy was first introduced. A number of penile rehabilitation protocols have been proposed with varying degrees of success and patient satisfaction. My management of post-prostatectomy erectile dysfunction has evolved based on an honest and critical appraisal of the literature and my own experience and research. A review of major studies published on the topic of post-prostatectomy penile rehabilitation is included here, in addition to a critical evaluation of my own clinical practice. After evaluating the efficacy of these various approaches, it is clear to me that a nerve sparing procedure is only one of many factors involved in recovering erectile function. Moreover, in addition to assessing a patient's goals and their motivation for erectile function after prostatectomy, setting appropriate patient expectations is paramount to avoiding patient frustration. A frank evaluation and discussion with a patient and their partner is paramount to managing these expectations. A "one size fits all" approach is not appropriate. Herein, I discuss the evolution of my approach to managing post-prostatectomy erectile dysfunction.

Routine drain placement after partial nephrectomy is not always necessary.

PURPOSE: To our knowledge the benefit of routine drainage after partial nephrectomy has never been investigated, although a drain after partial nephrectomy can be associated with morbidity. We report our initial experience with omitting the drain in select cases of superficial renal cortical tumors. MATERIALS AND METHODS: From a surgery database we identified 512 consecutive open partial nephrectomies performed by a single surgeon between January 2005 and May 2009 using standardized technique. The study group included 75 evaluable patients (14.6%) who did not have a drain placed. Clinical data, surgical information, histological type and postoperative complications within 90 days of the procedure using the modified Clavien system were included in analysis. RESULTS: Median patient age was 64 years (IQR 49, 70) and 56.8% of the patients were male. Median tumor size was 2.0 cm (IQR 1.5, 3.0) and more than 70% were malignant. A total of 38 patients (50.7%) underwent renal artery clamping and cold ischemia with a median clamp time of 30 minutes. The overall complication rate was 13.3% (10 patients). In 4 patients (5.3%) complications were related to an absent drain, including grade I urinary leak, grade II perirenal collection, grade III urinoma requiring percutaneous drainage and grade III urinary leak with urosepsis, respectively. No deaths occurred in this cohort. CONCLUSIONS: Omitting drainage after partial nephrectomy in a select group of patients without collecting system entry is feasible and safe. The decision to place a drain after partial nephrectomy for small renal cortical tumors must be made intraoperatively and should be tailored to each case.

A randomized prospective trial of primary versus AlloDerm closure of buccal mucosal graft harvest site for substitution urethroplasty.

OBJECTIVES: To present a prospective, randomized trial comparing primary and AlloDerm closure of the oral harvest site. The use of buccal mucosa grafts for substitution urethroplasty is an established and durable technique. The optimal management of the buccal mucosa grafts harvest site for the intraoral defect has yet to be determined. METHODS: Between February 2003 and September 2006, a total of 20 men undergoing buccal mucosal urethroplasty were randomly assigned to either primary (n = 10) or AlloDerm closure (n = 10) of the oral harvest site. All patients were clinically examined postoperatively and each completed a 10-point analog pain score and descriptive questionnaire postoperatively, at 3 weeks, and at 3, 6, and 12 months. RESULTS: A 100% of patients completed the study at 12 months follow-up. Oral pain dissipated acutely after 3 weeks. No significant differences in either neurosensory or mouth tightness symptoms were noted, except increased incidence of cheek swelling at 3 weeks in the AlloDerm group. CONCLUSIONS: AlloDerm proved to be an effective means of closing the harvest site, but offered no significant advantages when compared with primary closure. AlloDerm closure was associated with increased morbidity in mouth tightness symptoms, cheek swelling, and discomfort while chewing food; only increased incidence of cheek swelling at 3 weeks was found to be significant. Despite its excellent molecular properties and nonimmunogenic nature, the role of AlloDerm graft use in closing the buccal mucosal harvest site appears to be an unnecessary step. Primary closure was extremely well tolerated in both short- and long-term follow-up, with minimal sequelae at 12 months.