Robotic approach to Giant multiloculated cystadenoma of the prostate: Initial experience.

Giant multiloculated cystadenoma of the prostate (GMPC) is a rare, massive and benign tumor. Recurrence rates after resection are low but have been recorded. An open approach is most common, with few laparoscopic and no robotic cases reported. We report on a case of a 65-year-old man with a new presentation of a 400 cc cystic prostatic mass thought to be GMPC. This patient underwent what is, to our knowledge, the first reported case of RARP in the treatment of GMPC. A robotic approach to massive GMPC was safe and efficacious in our initial experience.

A Novel Technique of Ureteral Stricture Measurement: Impact on Diagnosis and Subsequent Management.

Background: Appropriate surgical management of ureteral strictures is dependent on not only the etiology of the stricture but also its location and characteristics. Stricture length and location play a significant role in potential surgical options, yet accurate evaluation of these features is limited. We present a case of a complex ureteral stricture where employment of an endoscopic tool in a novel manner helped to better evaluate the patient and provide more precise counseling in the preoperative setting. Case Presentation: A 65-year-old Caucasian man with a history of nephrolithiasis developed a complex ureteral stricture secondary to his calculus disease and prior instrumentation. His stricture was causing obstruction of his left collecting system and the patient was interested in a reconstructive procedure. We present a novel use for a pre-existing endoscopic tool that helped to more accurately delineate the characteristics of his ureteral stricture and improved preoperative planning. Conclusion: Determination of precise stricture length and location is of utmost importance for preoperative patient counseling and surgical planning. Where more sophisticated calibration technology is not available, use of an angiographic catheter during diagnostic endoscopy can improve preoperative assessment and surgical planning for complex ureteral reconstructive procedures.

Symptomatic Ureteral Metastasis from Colon Adenocarcinoma.

Background: Symptomatic ureteral obstruction from a nonurologic metachronous metastatic malignancy is an unusual phenomenon that is underreported in the literature. This potential etiology for ureteral obstruction warrants consideration by the practicing urologist during a comprehensive evaluation as it may alter prognosis and management options for the afflicted patient. Case Presentation: An 80-year-old Caucasian man with a remote history of prostate cancer and colon cancer presented with new unilateral ureteral obstruction characterized by hydronephrosis, acute kidney injury, and right-sided abdominal pain. A high clinical index of suspicion ultimately leads to the diagnosis of metastatic colon cancer on ureteral biopsy specimen. Conclusion: Evaluation of symptomatic ureteral obstruction in a patient with a significant cancer history should include nonurologic malignant obstruction. Diligence in evaluation of the etiology of the ureteral stricture with repeat biopsies should be undertaken if there is clinical concern. Nephroureterectomy should be part of patient counseling for management of long segment malignant ureteral stricture disease.

Coexisting prostate cancer found at the time of holmium laser enucleation of the prostate for benign prostatic hyperplasia: predicting its presence and grade in analyzed tissue.

OBJECTIVE: To determine the incidence of prostate cancer identified on holmium laser enucleation of the prostate (HoLEP) specimens and evaluate variables associated with prostate cancer identification. PATIENTS AND METHODS: All patients undergoing HoLEP between 1998 and 2013 were identified. Patients with a known history of prostate cancer were excluded. Multivariable logistic regression assessed variables associated with identification of prostate cancer on HoLEP specimens and Gleason 7 or higher prostate cancer among the malignant cases. The Gleason grade was used as a proxy for disease severity. Each of the models was adjusted for age, preoperative prostate-specific antigen (PSA), and HoLEP specimen weight. RESULTS: The cohort comprised 1272 patients, of whom 103 (8.1%) had prostate cancer identified. Prostate cancer cases had higher pre-HoLEP PSA (p=0.06) but lower HoLEP specimen weight (p=0.01). On multivariate logistic regression, age and preoperative PSA were associated with increased odds of prostate cancer being present (p<0.01 each), while increasing HoLEP specimen weight was associated with decreased odds of prostate cancer (p<0.001). Men older than 80 had 20% predicted probability of being diagnosed with prostate cancer. Seventy-eight percent of prostate cancer cases were Gleason 6 or less. The pre-HoLEP PSA was associated with increased adjusted odds of intermediate- or high-grade prostate cancer. CONCLUSION: Prostate cancer identified by HoLEP is not uncommon, but is generally a low-risk disease. Older patients with smaller prostate glands have the highest odds of prostate cancer identification.

Lithotripter outcomes in a community practice setting: comparison of an electromagnetic and an electrohydraulic lithotripter.

PURPOSE: We assessed patient outcomes using 2 widely different contemporary lithotripters. MATERIALS AND METHODS: We performed a consecutive case series study of 355 patients in a large private practice group using a Modulith® SLX electromagnetic lithotripter in 200 patients and a LithoGold LG-380 electrohydraulic lithotripter (TRT, Woodstock, Georgia) in 155. Patients were followed at approximately 2 weeks. All preoperative and postoperative films were reviewed blindly by a dedicated genitourinary radiologist. The stone-free rate was defined as no residual fragments remaining after a single session of shock wave lithotripsy without an ancillary procedure. RESULTS: Patients with multiple stones were excluded from analysis, leaving 76 and 142 treated with electrohydraulic and electromagnetic lithotripsy, respectively. The stone-free rate was similar for the electrohydraulic and electromagnetic lithotripters (29 of 76 patients or 38.2% and 69 of 142 or 48.6%, p = 0.15) with no difference in the stone-free outcome for renal stones (20 of 45 or 44.4% and 33 of 66 or 50%, p = 0.70) or ureteral stones (9 of 31 or 29% and 36 of 76 or 47.4%, respectively, p = 0.08). The percent of stones that did not break was similar for the electrohydraulic and electromagnetic devices (10 of 76 patients or 13.2% and 23 of 142 or 16.2%) and ureteroscopy was the most common ancillary procedure (18 of 22 or 81.8% and 30 of 40 or 75%, respectively). The overall mean number of procedures performed in patients in the 2 groups was similar (1.7 and 1.5, respectively). CONCLUSIONS: We present lithotripsy outcomes in the setting of a suburban urology practice. Stone-free rates were modest using shock wave lithotripsy alone but access to ureteroscopy provided satisfactory outcomes overall. Although the acoustic characteristics of the electrohydraulic and electromagnetic lithotripters differ substantially, outcomes with these 2 machines were similar.

Shock wave lithotripsy targeting of the kidney and pancreas does not increase the severity of metabolic syndrome in a porcine model.

PURPOSE: We determined whether shock wave lithotripsy of the kidney of pigs with metabolic syndrome would worsen glucose tolerance or increase the risk of diabetes mellitus. MATERIALS AND METHODS: Nine-month-old female Ossabaw miniature pigs were fed a hypercaloric atherogenic diet to induce metabolic syndrome. At age 15 months the pigs were treated with 2,000 or 4,000 shock waves (24 kV at 120 shock waves per minute) using an unmodified HM3 lithotripter (Dornier MedTech, Kennesaw, Georgia). Shock waves were targeted to the left kidney upper pole calyx to model treatment that would also expose the pancreatic tail to shock waves. The intravenous glucose tolerance test was done in conscious fasting pigs before lithotripsy, and 1 and 2 months after lithotripsy with blood samples taken for glucose and insulin measurement. RESULTS: Pigs fed the hypercaloric atherogenic diet were obese, dyslipidemic, insulin resistant and glucose intolerant, consistent with metabolic syndrome. Assessments of insulin resistance, glucose tolerance and pancreatic ß cell function from fasting plasma glucose and insulin levels, and the glucose and insulin response profile to the intravenous glucose tolerance test were similar before and after lithotripsy. CONCLUSIONS: The metabolic syndrome status of pigs treated with shock wave lithotripsy was unchanged 2 months after kidney treatment with 2,000 high amplitude shock waves or overtreatment with 4,000 high amplitude shock waves. These findings do not support a single shock wave lithotripsy treatment of the kidney as a risk factor for the onset of diabetes mellitus.

The utility of noncontrast computed tomography in the prompt diagnosis of postoperative complications after percutaneous nephrolithotomy.

INTRODUCTION: Noncontrast computed tomography (CT) is commonly utilized after percutaneous nephrolithotomy (PNL) to assess stone-free (SF) status. In addition to assessing SF status, CT is useful in the recognition of complications after PNL. We characterized complications demonstrated by postoperative CT scan and compared hospital re-admission rates based on whether or not CT was performed. METHODS: We retrospectively reviewed records of 1032 consecutive patients from April 1999 to June 2010. Patients were divided into two cohorts based on whether they had a CT within 24 hours of PNL. Demographic data, CT findings, and need for re-admission for complication management were assessed. RESULTS: Nine hundred fifty-seven patients (92.7%) underwent post-PNL CT. CT-diagnosed complications were perinephric hematoma in 41 (4.3%; 2 requiring embolization and 9 necessitating transfusion), pleural effusion in 25 (2.6%; 10 requiring intervention), colon perforation in 2 (0.2%), and splenic injury in 2 (0.2%). Of patients with postoperative complications, 33% required intervention. Among patients with a CT, 6 (0.6%) were readmitted despite negative postoperative CT (four perinephric hematomas, one calyceal-pleural fistula, and one pseudoaneurysm). The sensitivity of CT for diagnosing complications was 92.7%. Seventy-five patients (7.3%) did not undergo CT post-PNL. Of these, four (5.33%) were readmitted: three for perinephric hematomas and one for ureteral clot obstruction. Patients undergoing post-PNL CT were less likely to be readmitted because of missed complications (p=0.02). CONCLUSIONS: Serious post-PNL complications are uncommon, but their prompt diagnosis and treatment is imperative. In addition to identifying residual stones, CT is useful in diagnosing postoperative complications. Postoperative CT could potentially be considered for all patients undergoing PNL, particularly in complex cases such as patients with anatomical abnormalities (renal anatomic abnormality or retrorenal colon), patients requiring upper pole access (risk of thoracic, hepatic, and splenic complications), and patients requiring multisite access (higher risk of perinephric hematoma or need for transfusion).

Changing composition of renal calculi in patients with musculoskeletal anomalies.

BACKGROUND AND PURPOSE: Calculi from patients with musculoskeletal (MS) anomalies who are largely immobile and prone to urinary infections have been traditionally composed primarily of struvite and carbonate apatite. Because of substantial improvements in the care of these patients in recent decades, stone etiology may have shifted from infectious to metabolic. We assessed the composition of renal calculi and metabolic characteristics in a contemporary cohort of patients with MS anomalies who underwent percutaneous nephrolithotomy (PCNL). PATIENTS AND METHODS: Retrospective analysis of patients who underwent PCNL between April 1999 and June 2009 and had follow-up 24-hour urine studies was performed. Patients with MS anomalies included spinal cord injury, myelomeningocele, muscular dystrophy, multiple sclerosis, cerebral palsy, or other clinical syndromes causing kyphoscoliosis and contractures. RESULTS: Our cohort included 33 patients with MS anomalies and 334 consecutive patients as a control group who underwent PCNL and had metabolic workup. Stones were infectious in etiology in 18.4% and 6.2% in MS and control groups, respectively. Thus, most patients harbored stones of metabolic origin. Metabolic stones in the MS group were composed of 52.7% hydroxyapatite, 10.5% calcium oxalate, 7.9% brushite, 2.6% uric acid, 0% cystine, and 7.9% other. Metabolic stones in the control group were 50.5% calcium oxalate, 16.4% hydroxyapatite, 11.5% brushite, 10.8% uric acid, 4.3% cystine, and 0.3% other. Mean 24-hour urine values for patients with metabolic stones in MS/control groups were volume 2.18/1.87 L/d, pH 6.78/6.05, calcium to creatinine ratio 220/151 mg/g, and oxalate 44.8/39.5 mg/d. CONCLUSIONS: Although patients with MS anomalies are traditionally thought to harbor infection-related calculi, most will be found to have calculi of metabolic etiology. The incidence of calcium phosphate stones is high in this group of patients, perhaps reflecting their high urinary pH.

Imaging evaluation in the patient with renal stone disease.

Numerous imaging modalities are available for the evaluation of patients with renal stone disease. The study of choice is dependent on the clinical scenario and the indication for imaging. Additional factors such as patient age and pregnancy status will influence the radiographic study that is chosen. Currently available technologies for the evaluation of urolithiasis include plain abdominal radiography, ultrasound, intravenous pyelogram, computed tomography, and magnetic resonance imaging. This article reviews the indications, advantages, and disadvantages of each study in the evaluation of patients with known or suspected stone disease.

An update on holmium laser enucleation of the prostate and why it has stood the test of time.

PURPOSE OF REVIEW: Holmium laser enucleation of the prostate is an endoscopic alternative for the treatment of symptomatic benign prostatic hyperplasia for men with prostates of any size. Holmium laser enucleation of the prostate is superior to other modalities for the treatment of benign prostatic hyperplasia. We present the most current literature on this procedure. RECENT FINDINGS: In the 18-month span of this review, there have been a number of articles published on holmium laser enucleation of the prostate. These studies assessed the safety, efficacy, and durability of this procedure. Among these is the largest study to date providing supporting evidence to the long-term efficacy and safety of holmium laser enucleation of the prostate. Other studies provide compelling evidence to suggest that holmium laser enucleation of the prostate can be used in prostates of any size and can provide long-term durable outcomes. SUMMARY: Holmium laser enucleation of the prostate represents an effective, well tolerated, and durable procedure to relieve bladder outlet obstruction due to benign prostatic hyperplasia. Holmium laser enucleation of the prostate is a minimally invasive approach which accomplishes complete adenoma removal and, as such, provides unique advantages over other surgical treatments for men with benign prostatic hyperplasia.

Pediatric urolithiasis.

PURPOSE OF REVIEW: We review the recent literature on pediatric urolithiasis and present up-to-date findings on epidemiology, diagnosis, and medical and surgical management. RECENT FINDINGS: There are surprisingly few reliable data on pediatric urolithiasis incidence, but widespread anecdotal and single-center reports suggest that more children with stones are being seen. The contamination of Chinese infant formula with melamine caused urolithiasis and other renal problems in hundreds of thousands of infants in the region, underlining the role of environmental factors in urolithiasis. Efforts continue to determine normal metabolic parameters in children, but have been hampered by variations among regions, races, and ethnicities. The Bonn Risk Index may prove to be a useful tool for assessing risk of urolithiasis in children. Children with recurrent urolithiasis are more likely to have detectable metabolic abnormalities. Surgical approaches to urolithiasis in children continue to evolve, with robotic-assisted laparoscopy being perhaps the most significant new technique. Finally, clinicians and radiologists must be aware of the potential for dextranomer/hyaluronic acid (Deflux) implants to mimic distal ureteral stones on computed tomography (CT) scan. SUMMARY: Pediatric urolithiasis is an expanding field, due in part to the apparent increase in cases. Research continues, seeking to refine the appropriate diagnostic and therapeutic approaches in these unfortunate children.

P-cadherin as a prognostic indicator and a modulator of migratory behaviour in bladder carcinoma cells.

OBJECTIVE: To identify changes associated with P-cadherin expression in bladder cancer and evaluate the potential role of such events in determining the clinical outcome and cell behaviour, as the function of P-cadherin in normal epithelium is unknown, as is its potential role in neoplastic progression in different cancers. MATERIALS AND METHODS: In all, 536 bladder tumour specimens from 408 patients were assembled in seven tissue microarrays. Paraffin sections from each array were processed for immunohistochemistry to assess the expression of P-cadherin. The expression of P-cadherin was forced using lipofectin, followed by an assessment of migration and invasion potential using standard in vitro assays. RESULTS: The absence of P-cadherin staining was associated with muscle-invasive disease, grade 3 (P < 0.001) and nodal disease (P = 0.009). Similar results were obtained when considering cytoplasmic and unrestricted localization of P-cadherin (P < 0.001), except for nodal involvement. The group with cytoplasmic location of P-cadherin showed a shorter cancer-specific survival than the group with membrane location of P-cadherin (P = 0.03). Forced expression of P-cadherin in EJ and UM-UC-3 cells, that constitutively lack P-cadherin expression, resulted in modulation of catenin expression and enhanced migration of EJ and UM-UC-3/P-cadherin transfectants (>200%). CONCLUSIONS: These results showed that loss of expression, cytoplasmic relocation or unrestricted tissue location of P-cadherin was associated with a poor clinical outcome and prognosis in bladder cancer. From the in vitro work it is evident that P-cadherin plays a role in regulating the migration potential of bladder carcinoma cells.

Pure laparoscopic donor nephrectomy: 3-year experience and analysis of a refined technique to maximize graft function.

PURPOSE: Strategies for vascular control and limiting warm ischemia time (WIT) vary between institutions for laparoscopic live donor nephrectomy (LLDN). We refined our technique and retrospectively determined whether it safely provides an allograft of comparable quality to published series. PATIENTS AND METHODS: Fifty consecutive LLDN between February 2003 and November 2006 were reviewed. Key technical aspects include placing the perfused kidney and transected ureter entirely within an endocatch bag, with the string externalized through an extended lateral port site incision. Vessels are then controlled with clips, or a Satinsky clamp for right sided veins. The extraction incision is completed and the bag immediately withdrawn and placed on ice. WIT ends with perfusion with cold UW solution. RESULTS: The series includes 42 left and 8 right kidneys. 13/50 (26%) demonstrated anatomical complexity (more than one artery, vein and/or ureter). Average operative time was 178 minutes. Average WIT was 128 seconds. Conversion to open surgery occurred in two patients, one to define challenging anatomy, and another for hemorrhage from the renal artery stump. Average blood loss was 76 ml. Average length of stay was 3.6 days. Average recipient creatinine was 1.26 mg/dl at discharge. Delayed graft function occurred in three recipients. ATN/slow normalization of creatinine occurred in four. Graft survival at one year was 96%. CONCLUSIONS: The refined technique of LLDN mimics important principles of open donor nephrectomy. Controllable variables which may impact graft function are optimized. WIT is amongst the lowest reported for pure laparoscopy, without increasing complication rates, blood loss, or operative time.

Prognostic significance of altered p120 ctn expression in bladder cancer.

OBJECTIVE: To identify the frequency of change in the expression and localization of p120(ctn) in bladder tumours and its association with clinical outcomes, and to investigate the potential role of p120(ctn) in the migratory and invasive behaviour of bladder carcinoma cells. MATERIALS AND METHODS: In all, 425 superficial tumour specimens (Ta, Tis and T1) and 305 invasive (T2-T4) tumour specimens from 534 patients were assembled in 10 tissue microarrays. P120(ctn) immunostaining was scored for intensity and cellular localization and correlated with clinical variables and survival analysis. Knockdown of p120(ctn) was achieved using small-interference RNA (siRNA) followed by the assessment of migration and invasion behaviour in standard in vitro assays. RESULTS: The expression levels of p120 catenin inversely correlated with pathological tumour stage (P < 0.001), histological grade (P < 0.001), presence of lymphovascular invasion (P = 0.02) but not lymph node (LN) involvement (P = 0.17). Non-membranous localization of p120(ctn) correlated with stage (P < 0.001), grade (P < 0.001), lymphovascular invasion (P = 0.04) and LN-positive disease (P = 0.02). A low expression level of p120(ctn) was linked to a poor outcome in cancer-specific survival analysis. Knockdown of p120(ctn) using siRNA resulted in a significant reduction in the migration and invasive potential of bladder carcinoma cells. CONCLUSIONS: Our findings suggest that p120(ctn) acts as a prognostic factor in bladder tumours and has a primary role to play in the migratory and invasive behaviour of bladder carcinoma cells.