Current diagnosis and management of syringocele: a review.

Cowper's syringocele is a rare but an under-diagnosed cystic dilation of the Cowper's ducts and is increasingly being recognized in the adult population. Recent literature suggests that syringoceles be classified based on the configuration of the duct's orifice to the urethra, either open or closed, as this also allows the clinical presentations of 2 syringoceles to be divided, albeit with some overlap. Usually post-void dribbling, hematuria, or urethral discharge indicates open syringocele, while obstructive symptoms are associated with closed syringoceles. As these symptoms are shared by many serious conditions, a working differential diagnosis is critical. Ultrasonography coupled with retro and ante grade urethrography usually suffices to diagnose syringocele, but supplementary procedures - such as cystourethroscopy, computed tomography scan, and magnetic resonance imaging - can prove useful. Conservative observation is first recommended, but persistent symptoms are usually treated with endoscopic marsupialization unless contraindicated. Upon reviewing the literature, this paper addresses the clinical anatomy, classification, presentation, diagnosis, and treatment of syringoceles in further detail.

Current diagnosis and management of syringocele: a review

Cowper's syringocele is a rare but an under-diagnosed cystic dilation of the Cowper's ducts and is increasingly being recognized in the adult population. Recent literature suggests that syringoceles be classified based on the configuration of the duct's orifice to the urethra, either open or closed, as this also allows the clinical presentations of 2 syringoceles to be divided, albeit with some overlap. Usually post-void dribbling, hematuria, or urethral discharge indicate open syringocele, while obstructive symptoms are associated with closed syringoceles. As these symptoms are shared by many serious conditions, a working differential diagnosis is critical. Ultrasonography coupled with retro and ante grade urethrography usually suffices to diagnose syringocele, but supplementary procedures - such as cystourethroscopy, computed tomography scan, and magnetic resonance imaging - can prove useful. Conservative observation is first recommended, but persistent symptoms are usually treated with endoscopic marsupialization unless contraindicated. Upon reviewing the literature, this paper addresses the clinical anatomy, classification, presentation, diagnosis, and treatment of syringoceles in further detail.

Laparoscopic extravesical ureteroneocystostomy by a new "Y" flap technique.

BACKGROUND AND PURPOSE: Laparoscopic ureteral implantation can be a challenging procedure. We describe a simple "Y" flap technique to facilitate laparoscopic ureteral implantation. METHODS: Three patients with distal ureteral strictures underwent laparoscopic ureteral reimplantation by a modified technique. Blunt dissection is used to mobilize 4 cm of the ureter. A neocystostomy is performed in the bladder and, after isolation of the ureter, it is bivalved for a length of 1.5 cm, creating a Y flap. A 6 by 24 Double-J stent is placed intraoperatively, feeding it through the distal end of the ureter. The cut ends of the bivalved Y flaps of the ureter are anastomosed into the bladder by two simple pexic sutures. The ureter is advanced 1 cm from the neocystostomy to lay the Y flap into the bladder. RESULTS: After laparoscopic reimplantation using this new technique, all patients were studied postoperatively. None revealed any obstruction, as confirmed by intravenous urography at 1 month and diuretic renography at 3 months after removal of the stent. CONCLUSIONS: Laparoscopic ureteral reimplantation is feasible using a new Y flap technique with excellent functional and anatomic results.

A percutaneous subcostal approach for intercostal stones.

PURPOSE: Percutaneous upper pole access may be obtained via the supracostal or subcostal approach. The more cranial the location of the percutaneous nephrostomy tract, the greater the risk of incurring intrathoracic complications. We describe a technique for safely accessing the upper pole calix via a subcostal approach, even when the stone is located well above the 12th rib. In our patient the stone was located between the 11th and 12th ribs, and the upper pole extended to above the 10th rib. METHODS: A 78-year-old man with multiple medical problems had a symptomatic upper right pole stone located between 11th and 12th ribs. Due to its size (3 x 2.2 cm), neither a ureteroscopic nor shockwave approach was thought feasible. We elected to angle the access tract both laterally and cranially in order to course below the 12th rib, but still enter the upper pole calix. RESULTS: Although this tract entered the calix obliquely, instruments were readily passed after sheath placement and the stone was completely removed. An ultrasonic lithotripsy device and suction was used to fragment and evacuate the stone. Postoperatively there were no intrathoracic or pulmonary complications. CONCLUSIONS: The direct percutaneous approach to the upper pole of the kidney requires careful methodology based on a clear understanding of the anatomy of the kidney and surrounding structures. For upper-pole renal calculi located above the 12th rib that are not amenable to shockwave lithotripsy or ureteroscopy, a subcostal angled percutaneous approach can be safely made in selected cases. With this method, the risk of intrathoracic complications may be reduced.

Extraperitoneal laparoscopic removal of eroded midurethral sling: a new technique.

PURPOSE: Erosion of a midurethral sling is common in women who are treated for stress urinary incontinence. This complication is usually managed by retropubic exploration. We report a novel technique to manage erosion in patients who refuse retropubic exploration. PATIENTS AND METHODS: Two women (ages 47 and 53 years) with stress urinary incontinence were treated with a midurethral sling. Postoperatively, at 24 and 22 months, respectively, the sling had eroded through the high urethra near the bladder neck. A three-port extraperitoneal laparoscopic approach was used to remove the urethral slings and repair the bladder. RESULTS: The procedure was accomplished in 80 and 75 minutes, respectively, with no complications. Both patients remained continent. CONCLUSION: A minimally invasive extraperitoneal surgical technique can be used to manage midurethral sling erosion in women.

Current perspectives on pyospermia: a review.

Pyospermia is an abnormal laboratory finding of high concentration of white blood cells in human ejaculates during infertility workup. The role of pyospermia and its impact on fertility is an important consideration in the management of infertility. Etiology, pathogenesis, diagnostic modalities and the management of pyospermia are reviewed in this paper. Current use of antibiotics and the intrinsic production of antioxidants in the management of pyospermia are also discussed in this review.

Case and management of incidentalomas in patients with Von Hippel-Lindau disease.

Adrenal incidentalomas, those adrenal masses discovered on imaging studies undertaken for other indications, represent an evaluation and management conundrum. Evaluating every incidentaloma for functional status and/or resecting all incidentalomas would not be cost-effective because the vast majority of incidentalomas are benign, non-functioning adenomas. Current management strategies focus on size, functionality and imaging characteristics. These strategies do not take into account individual patient characteristics, for example, comorbid hereditary syndromes. In this article we report a case of a pheochromocytoma presenting as a small incidentaloma in a patient with Von Hippel-Lindau disease. We review the current literature describing the appropriate evaluation and management of adrenal incidentalomas and investigate the nuances of evaluation of these masses in patients with Von Hippel-Lindau disease.

Smooth-muscle regeneration after electrosurgical endopyelotomy in a porcine model as confirmed by electron microscopy.

BACKGROUND AND PURPOSE: Endopyelotomy is the preferred treatment for ureteropelvic junction (UPJ) obstruction because of its short operating time, limited morbidity, fast recovery, and reasonable efficacy. We used tissue and immunohistochemistry staining and electron microscopy to look at the muscle regeneration following an endopyelotomy incision in a porcine model. MATERIALS AND METHODS: Bilateral electrosurgical endopyelotomy was performed in six domestic pigs with placement of 7F 20-cm Percuflex double-J stents for up to 4 weeks, and urinary tracts were harvested at 3 or 5 months. Specimen evaluation included tissue staining with hematoxylin-eosin, Masson's trichrome, and Verhoeff's iodine and Van Gieson solution; histochemical staining for smooth-muscle actin, desmin and myosin staining, and electron microscopy. Each specimen was assigned a "healing" score of 0 (normal) 1 (slight changes), 2 (mild changes), or 3 (severe changes). The fibrosis score was based on six factors: muscle layer fibrosis, lamina propria fibrosis, amount of granulation tissue present, new deposits of collagen, fibrosis in the periureteral fat, and presence of myofibroblasts. The muscles were characterized with immunohistochemistry and electron microscopy. RESULTS: At both 3 and 5 months, the urothelium was healed, and the lamina propria was healed with focal loss. By 3 months, smooth-muscle bundles bridged the defect, and by 5 months, the whole defect was covered. Smooth muscle cells were evident by electron microscopy by 3 months, and actin and myosin could be detected by immunohistochemistry. Desmin-positive cells accounted for 50% of the population at 3 months and 40% at 5 months. The regenerated smooth-muscle bundles were oriented in different directions and intermingled with fibrous tissue. They could be distinguished easily from normal ureter under the microscope. CONCLUSION: Verifiable, functional smooth-muscle bundles bridge the endopyelotomy defect by 3 months, as confirmed by immunohistochemistry staining and electron microscopy.