Utilizing da Vinci® surgical system to treat challenging urinary stones.

INTRODUCTION: A worldwide mounting in the incidence and prevalence of urolithiasis has been observed. The standard treatment of urologic stone disease (USD) has changed from open surgery to extracorporeal shock wave lithotripsy, percutaneous nephrolithotomy (PCNL), or ureteroscopy depending on the size and location of the stone. We are sharing our experience in utilizing Da Vinci® robotic surgical system to treat patient with urolithiasis instead of open surgical approach. PATIENTS AND METHODS: We reviewed prospectively collected data of 19 patients who underwent robotic-assisted stone surgery (RSS) between January 2010 and March 2018 at our institute for USD involving 22 nephroureteral units. RESULTS: A total number of 22 RSS were accomplished with no conversion to open. Three patients had bilateral stone and needed to have RSS on each side separately. Eleven RSS were performed on the right. The indications for RSS included as follows: morbid obesity (n = 8, mean body mass index 56.4 kg/m2), need for concurrent renal surgery (n = 3) severe contractures limiting positioning for retrograde endoscopic surgery or PCNL (n = 2), symptomatic calyceal diverticular stone with failed endoscopic approach (n = 4), and after failed PCNL (n = 2). Twenty nephrouretral unit (91%) were rendered stone free on the first attempt with complication occurring after four cases (18%). CONCLUSION: RSS is viable options in the treatment of challenging urologic stone with high success rate and low risk of complication. The need for open stone surgery was eliminated by RSS at our center.

Pediatric testicular torsion: does patient transfer affect time to intervention or surgical outcomes at a rural tertiary care center?

BACKGROUND: Testicular torsion (TT) is a urologic emergency that requires prompt surgical intervention. In rural Appalachia, patients are often transferred from surrounding communities due to lack of urologic care. We hypothesized that those transferred would have delayed intervention and higher rates of orchiectomy when compared to those who presented directly to our hospital. METHODS: We performed a retrospective review of patient charts with an ICD-9 diagnosis of TT from 2008 to 2016. Patients met inclusion criteria if diagnosis was confirmed by operative exploration. We compared rate of testicular loss and time until surgical intervention between groups. RESULTS: Twenty-three patients met inclusion criteria (12 transferred, 11 direct). Patient demographics did not significantly differ between groups. Transferred patients had a higher orchiectomy rate (33% v 22%,p = 0.41) although this was not statistically significant. Time to surgery from symptom onset was significantly longer in those transferred (12.9 h) compared to those not transferred (6.9 h, p = 0.02). Distance of transfer was not correlated with time of delay (r2 = 0.063). CONCLUSIONS: Transferred patients with TT have numerically higher rates of orchiectomy which may reach significance in an appropriately powered study, and relative delays in surgical intervention. This study highlights the need for improved access to urologic care in rural areas.

Traumatic Bladder Ruptures: A Ten-Year Review at a Level 1 Trauma Center.

Bladder rupture occurs in only 1.6% of blunt abdominopelvic trauma cases. Although rare, bladder rupture can result in significant morbidity if undiagnosed or inappropriately managed. AUA Urotrauma Guidelines suggest that urethral catheter drainage is a standard of care for both extraperitoneal and intraperitoneal bladder rupture regardless of the need for surgical repair. However, no specific guidance is given regarding the length of catheterization. The present study seeks to summarize contemporary management of bladder trauma at our tertiary care center, assess the impact of length of catheterization on bladder injuries and complications, and develop a protocol for management of bladder injuries from time of injury to catheter removal. A retrospective review was performed on 34,413 blunt trauma cases to identify traumatic bladder ruptures over the past 10 years (January 2008-January 2018) at our tertiary care facility. Patient data were collected including age, gender, BMI, mechanism of injury, and type of injury. The primary treatment modality (surgical repair vs. catheter drainage only), length of catheterization, and post-injury complications were also assessed. Review of our institutional trauma database identified 44 patients with bladder trauma. Mean age was 41 years, mean BMI was 24.8 kg/m2, 95% were Caucasian, and 55% were female. Motor vehicle collision (MVC) was the most common mechanism, representing 45% of total injuries. Other mechanisms included falls (20%) and all-terrain vehicle (ATV) accidents (13.6%). 31 patients had extraperitoneal injury, and 13 were intraperitoneal. Pelvic fractures were present in 93%, and 39% had additional solid organ injuries. Formal cystogram was performed in 59% on presentation, and mean time to cystogram was 4 hours. Gross hematuria was noted in 95% of cases. Operative management was performed for all intraperitoneal injuries and 35.5% of extraperitoneal cases. Bladder closure in operative cases was typically performed in 2 layers with absorbable suture in a running fashion. The intraperitoneal and extraperitoneal injuries managed operatively were compared, and length of catheterization (28 d vs. 22 d, p=0.46), time from injury to normal fluorocystogram (19.8 d vs. 20.7 d, p=0.80), and time from injury to repair (4.3 vs. 60.5 h, p=0.23) were not statistically different between cohorts. Patients whose catheter remained in place for greater than 14 days had prolonged time to initial cystogram (26.6 d vs. 11.5 d) compared with those whose foley catheter was removed within 14 days. The complication rate was 21% for catheters left more than 14 days while patients whose catheter remained less than 14 days experienced no complications. The present study provides a 10-year retrospective review characterizing the presentation, management, and follow-up of bladder trauma patients at our level 1 trauma center. Based on our findings, we have developed an institutional protocol which now includes recommendations regarding length of catheterization after traumatic bladder rupture. By providing specific guidelines for initial follow-up cystogram and foley removal, we hope to decrease patient morbidity from prolonged catheterization. Further study will seek to allow multidisciplinary trauma teams to standardize management, streamline care, and minimize complications for patients presenting with traumatic bladder injuries.

A Case of Urethral Diverticulum with Surgical Repair Using Cadaveric Pericardial Tissue.

A urethral diverticulum is a relatively uncommon finding. The estimated prevalence is approximately 1-5% in the general population. While the definitive treatment is surgical correction, there are limited studies guiding the best approach to repair. This is the case of a 48-year-old female who initially presented with vaginal discharge, dysuria, and dyspareunia. MRI revealed the diagnosis of suspected urethral diverticulum. The patient was treated with surgical correction with the aid of needle localization prior to the procedure. After the diverticulum was excised, the resulting defect in the urethra was successfully closed with cadaveric pericardial tissue. A urethral diverticulum should be considered in the differential diagnosis when a patient presents with symptoms such as recurrent urinary tract infections (UTIs) vaginal mass, dysuria, dyspareunia, or vaginal discharge. The use of cadaveric tissue augments the surgical technique for repair.

Ossifying Renal Tumor of Infancy: Laparoscopic Treatment and Literature Review.

We present an unusual case of a rare ossifying renal tumor of infancy. A 6-month-old male initially presented with gross hematuria and without any palpable abdominal mass. Renal ultrasound and MRI showed a right lower pole, calcified, endophytic renal mass. Laparoscopic radical nephrectomy was performed without complications. Pathology demonstrated an ossifying renal tumor of infancy. We report this case, in addition to a review of the literature for similar cases, to highlight a rare renal tumor in infancy that can be managed laparoscopically.

Pedunculated and obstructive Wilms' tumor: A rare presentation in a 2 year-old male.

Wilms' tumor manifesting as an obstructing ureteral mass is extremely rare. Herein, we report an unusual case in which a child presented with a clinical picture concerning for and suggestive of ureteropelvic junction obstruction (UPJO), but was instead found to have an intrapelvic pedunculated Wilms' tumor with extension into the proximal ureter. We discuss the patient's diagnostic workup, radiographic, operative and pathologic findings, as well as important lessons learned from this unusual case.

A Case of Strangulated Urethral Prolapse in a Premenopausal Adult Female.

Urethral prolapse in a premenopausal adult female is exceedingly rare. This paper describes a case of strangulated urethral prolapse presenting as a urethral mass in an unusual demographic and reviews the literature on etiology and management. Only a few cases have occurred in women of reproductive age. The etiology is likely multifactorial. Treatment with surgical excision provides good results in the majority of cases.

Femoral hernias in the pediatric patient: a case report and review of the literature.

We report a case of a femoral hernia in a 9-year-old male. Femoral hernias in children are rare and a diagnostic challenge. Definitive treatment is with surgical repair.

Successful vapor-based endometrial ablation: in vivo peri-hysterectomy study.

STUDY OBJECTIVE: To evaluate the AEGEA vapor-based endometrial ablation system using an in vivo peri-hysterectomy model. DESIGN: Single-site feasibility study (Canadian Task Force classification II-2). SETTING: University medical center. PATIENTS: Nine women consented to undergo AEGEA endometrial ablation before previously scheduled abdominal hysterectomy to treat abnormal uterine bleeding. INTERVENTIONS: In vivo AEGEA endometrial ablation was performed using a 90-second vapor treatment cycle. After hysterectomy, the uteri were examined for the extent and location of endomyometrial ablation (macroscopic triphenyltetrazolium chloride staining) and fallopian tube injury (microscopic nitroblue tetrazolium staining). MEASUREMENTS AND MAIN RESULTS: The mean (SD) posttreatment measurements of the 9 uteri were as follows: weight, 143 (40) g; length, 10.3 (1.3 cm); thickness, 4.4 (0.6) cm; and width, 6.2 (0.7) cm. The endometrial thickness was 1.1 (0.7) mm. Three uteri had myomas that measured less than 2 cm; and 2 uteri demonstrated focal adenomyosis. No myometrial perforation or thermal serosal injury was identified. The median corpus, lower uterine cavity and bilateral cornua percentages of TTC-negative surface endometrial treatment were 100% (range: 100-100%), 100% (range: 80-100%), and 100% (range: 95-100%), respectively. The closest distance between the ablation and serosa was 11.5 (3.2) mm. No lower endocervical or exocervical thermal injury was identified. Minimal fallopian tube thermal injury was identified in 18% of interstitial segments evaluated, and measured 0.6 to 0.8 mm in maximal depth and extended to within 6.3 to 9.5 mm of the serosa. No thermal injury was identified in the extrauterine fallopian tube segments. CONCLUSION: The AEGEA vapor-based endometrial ablation system has the potential to provide excellent cavity coverage with full-thickness endometrial ablation. The study results further support an acceptable in vivo safety profile for future clinical efficacy trials.