Urine versus stent cultures and clinical UTIs.

PURPOSE: Current American Urological Association guidelines recommend pre-operative antimicrobial therapy based on prior urine cultures (UC); however, the role of stent culture (SC) in urologic practice is unclear. We examined whether UC and SC differed at the time of stent removal, as well as the association, microbiology, and timing of subsequent UTIs as related to SC. METHODS: This was a retrospective review of 159 patients with ureteral stents for indications of urolithiasis, benign stricture, malignant obstruction, and kidney transplant. UC and SC were analyzed at the time of stent removal. Patients were followed for 12 months after stent removal for development, concordance, and timing of clinical UTIs. RESULTS: In 159 patients, 15% had positive UC and 45% had positive SC. Of patients who had positive SC, 66% had negative UC. All patients with positive UC had identical micro-organisms on SC; however, 33% of these had SC with additional micro-organisms. Relative to those with both negative UC and SC, patients with negative UC and positive SC had a 5.7 odds, and those with both positive UC and SC had a 13.6 odds of developing a clinical UTI within 12 months. Concordance of SC and future UTI was highest in those with post-operative sepsis, and those with Candida species on SC. CONCLUSIONS: SC was a unique risk factor for development of UTI within 12 months of stent removal. Clinicians should consider SC results when empirically treating those with post-operative sepsis or those with UTI after Candida on SC.

An improbable trifecta: Occurrence of xanthogranulomatous prostatitis, prostate cancer, and prostatic abscess in a single patient.

Xanthogranulomatous prostatitis (XGP) is a rare disease that can mimic the clinical and imaging findings of prostate cancer. Differentiation of these diseases is vital in order to offer the correct treatment. Histological examination of prostate tissue is the definitive manner in which XGP is distinguished from prostate cancer. This case demonstrates the rare possibility of concurrent findings of prostate abscess, prostate cancer, and XGP, further clouding diagnostic assessment. Percutaneous aspiration and antibiotic treatment of the abscess reduced lower urinary tract symptoms and eliminated XGP on subsequent prostate biopsy. Careful work up is necessary to prevent unnecessary interventions or missed diagnoses.

Hysteroscopic morcellator to overcome cervical stenosis.

OBJECTIVE: To report a step-by-step technique to using a hysteroscopic morcellator to safely gain access into the intrauterine cavity in two patients with severe cervical stenosis and concomitant intrauterine pathology. DESIGN: Video article introducing the hysteroscopic morcellator for overcoming severe cervical stenosis. SETTING: Academic-based practice. PATIENT(S): A 36-year-old G0 female with primary infertility and uterine polyps and a 34-year-old G0 female with uterine polyps and a difficult trial transfer before undergoing an IVF cycle. In both patients, preoperative saline-infused sonography revealed submucosal filling defects and severe cervical stenosis. INTERVENTION(S): A hysteroscopic technique using the Hologic Myosure to overcome severe cervical stenosis with or without the use of intraoperative ultrasound. MAIN OUTCOME MEASURE(S): Despite using preoperative Cytotec, cervical stenosis was identified. Under direct visualization, a 4-mm Myosure XL blade was placed through a 7.25-mm Myosure XL hysteroscopy. The cutter blade, powered by an electromechanical drive system, enables simultaneous rotation and reciprocation. The blade allows one to shave and remove tissue and is applied to cervical stenosis, allowing safe access into the intrauterine cavity. RESULT(S): The intrauterine hysteroscopic Myosure morcellator allowed for safe and direct entry into the uterine cavity. We have since applied this technique to all patients where cervical stenosis is identified and have minimized potential uterine perforation and false tracks in our patients. CONCLUSION(S): Our technique is an alternative method for overcoming severe cervical stenosis and minimizing potential intraoperative complications.

Metroplasty to treat chronic pelvic pain resulting from outflow tract müllerian anomalies.

Chronic pelvic pain can result from noncommunicating uterine cavities in patients with müllerian anomalies. Traditional management has been to resect the noncommunicating uterine horn. Two cases are described. One had a unicornuate uterus with noncommunicating left uterine horn (American Fertility Society [AFS] classification IIb) and the other had a normal external uterine contour with noncommunicating left uterine cavity that did not fit any category of the AFS classification of müllerian anomalies. Attempts at connecting the noncommunicating cavities hysteroscopically failed in both cases. Successful unification of the cavities was subsequently achieved in the first case using the classic Strassman metroplasty with the assistance of the robot. The unification of uterine cavities was achieved using a modified Strassman metroplasty in the second patient, as there was no uterine horn for landmark. Robot assistance was utilized in this case as well. Both patients are symptom free after surgery. We conclude that laparoscopic Strassman metroplasty, with or without robot assistance, is a viable alternative to resection of uterine horns in patients with hematometra, chronic pelvic pain, and noncommunicating uterine cavities.

Contained morcellation using the GelPOINT advance access platforms and 3M Steri-Drape endobag.

OBJECTIVE: To report a technique that safely allows power and hand morcellation for laparoscopic hysterectomy and myomectomy specimens in a contained fashion in the event of unsuspected uterine sarcoma or leiomyosarcoma. DESIGN: Video article introducing a method for enclosed tissue morcellation for laparoscopic specimens. SETTING: Hospital of an academic-based practice. PATIENT(S): Two patients underwent laparoscopic hysterectomy: a 57-year-old G7 P5025 female for leiomyoma, anemia, and a history of CIN-3; and a 38-year-old G0P0 female with a 10-year history of pelvic pain and severe dysmenorrhea who failed medical therapy. INTERVENTION(S): A technique using the GelPOINT Platform incision extender system and GelSeal Cap (GSP) Advanced Access Platform and a 50 cm × 50 cm 3M Steri-Drape endobag for enclosed intracorporeal and extracorporeal tissue morcellation of laparoscopic specimens. MAIN OUTCOME MEASURE(S): For training purposes, we used a pelvic simulator and cadaver to describe the step-by-step process and troubleshoot issues to optimize intra- and extracorporeal morcellation. This allowed for easier implementation on the live patient. RESULT(S): Simulation training and the cadaver model provided a learning platform for contained internal power and external hand morcellation, accelerating the learning curve in its application to the live patient. CONCLUSION(S): The GSP and 3M Steri-Drape endobag is an alternative for laparoscopic power or hand morcellation. Using simulation training helped transition this technique to the live patient, allowing for easy and safe removal of tissue specimens and minimizing the potential for tissue seeding and dissemination.

Preconditioning by subinotropic doses of ouabain in the Langendorff perfused rabbit heart.

Short exposure to low concentrations of digitalis drugs like ouabain protects the rat heart against ischemia/reperfusion injury through the activation of the Na/K-adenosine triphosphatase (ATPase)/Src receptor complex and subsequent stimulation of key intracellular cardioprotective signals. Rat Na/K-ATPase, however, is relatively insensitive to digitalis, and it is not known if similar results could be obtained in species with higher sensitivity. Thus, to determine whether ouabain pretreatment protects against ischemic injury and activates the Na/K-ATPase signaling cascade in a species with cardiac glycoside sensitivity comparable to humans, the present study was conducted in the rabbit model. In Langendorff perfused rabbit hearts, 20-minute exposure to 500-nM ouabain resulted in positive inotropy as evidenced by a significant increase in +dP/dt, and this increase was accompanied by the activation of several well-characterized downstream mediators of the cardiac Na/K-ATPase receptor pathway, including Src, Akt, ERK1/2, and protein kinase Cepsilon. A short (4 minutes) administration of a subinotropic dose of ouabain (100 nM) followed by an 8-minute washout before 30 minutes of global ischemia and 120 minutes of reperfusion resulted in protection against cell death, as evidenced by a significant decrease in infarct size. These data indicate that ouabain administration activates the Na/K-ATPase signaling cascade and protects against ischemic injury in a species with high cardiac Na/K-ATPase sensitivity.