Robotic-assisted Laparoscopic Subtrigonal Inlay of Buccal Mucosal Graft for Treatment of Refractory Bladder Neck Contracture.

OBJECTIVE: To describe a novel surgical technique for reconstruction of a case of refractory bladder neck contracture (BNC) using a robotic-assisted laparoscopic (RAL) transvesical approach for subtrigonal inlay of buccal mucosal graft. BNC is a well-described yet uncommon adverse event after BPH surgery. Endoscopic management is successful in many patients but refractory cases may require reconstructive surgery. MATERIALS AND METHODS: A 70-year-old male presented with a history of prior photovaporization of the prostate 2 years prior to our initial consultation. He developed a refractory BNC that did not resolve after multiple endoscopic interventions. For definitive treatment of the BNC, he underwent RAL repair with subtrigonal inlay of buccal mucosal graft. The surgical approach is demonstrated in our video. RESULTS: The patient underwent RAL subtrigonal inlay of buccal mucosal graft without intraoperative complication or need to convert to an open procedure. The graft harvested for repair measured 5 × 5 × 4 cm. He was discharged home on postoperative day 2. Urethral catheter was left in place for 2 weeks and suprapubic catheter was removed 4 weeks postoperatively. Voiding cystourethrogram at time of suprapubic catheter removal demonstrated no evidence of obstruction or extravasation. Uroflow qmax improved from 2 to 27 mL/s. Postvoid residual urine volume improved from 200 to 3 mL. At last follow-up, there was no evidence of recurrence. CONCLUSION: Refractory cases of BNC can be successfully managed with reconstructive surgery. In this case report, we describe a novel technique for RAL reconstruction with subtrigonal inlay of buccal mucosal graft.

Retroperitoneal Lymph Node Dissection as an Alternative Treatment Strategy for Low Volume, Clinical Stage II Testicular Seminoma: A Survey of Patients and Providers.

INTRODUCTION: Retroperitoneal lymph node dissection for low volume, clinical stage II testicular seminoma may provide an alternative to radiation therapy or chemotherapy for local control, preserving the high rate of cure while reducing exposure to long-term side effects. In this study we determined the willingness of patients and providers to participate in a clinical trial with this approach. METHODS: We distributed 2 surveys, with one going to patients with testicular seminoma and one to providers who treat testicular cancer. This study included patients with pure seminoma and providers currently in clinical practice. Logistic regression analysis was performed to identify factors associated with willingness to participate in the proposed trial. RESULTS: Overall 193 patients with testicular seminoma and 178 actively practicing providers responded to the surveys. Of these respondents 148 patients (76.7%) and 167 providers (81.9%) reported that they would be willing to participate in the proposed clinical trial. For patients, on univariate analysis age, stage, management after orchiectomy and relapse status did not impact willingness to enroll. For providers, on univariate analysis years in practice, number of patients with testicular cancer evaluated annually, practice setting and association with a Comprehensive Cancer Center did not impact willingness to offer enrollment. CONCLUSIONS: The majority of patients and providers would be willing to participate in a trial of retroperitoneal lymph node dissection as an alternative treatment strategy for low volume, clinical stage II testicular seminoma.

Primary carcinoid tumor of the bladder.

Transitional cell carcinoma is the most common type of bladder cancer in the United States. This case report discusses the finding of primary bladder carcinoid tumor (also called well-differentiated neuroendocrine tumor) in a woman with gross hematuria. With only 15-20 reported cases, primary bladder carcinoid is rare and the approach to treatment is unclear. There have been two muscle-invasive cases reported which required more extensive treatment plans. The patient presented in this case underwent complete transurethral resection of the tumor with the recommendation of surveillance cystoscopy every 3 months.

Pediatric Renal Angiomyolipomas in Tuberous Sclerosis Complex.

PURPOSE: Tuberous sclerosis complex is a genetic disorder characterized by the growth of hamartomas in multiple organs. Up to 80% of patients with tuberous sclerosis complex will have at least 1 angiomyolipoma in their lifetime. We describe the incidence and natural history of angiomyolipoma in a pediatric tuberous sclerosis complex population and analyze tumor growth to determine optimal renal imaging intervals in an effort to improve counseling, treatment and followup. MATERIALS AND METHODS: We performed a retrospective chart review of all patients with tuberous sclerosis complex from 2004 to 2014. Patients were included if they had a clinical or genetic diagnosis of tuberous sclerosis complex and had undergone at least 1 renal imaging study. RESULTS: A total of 145 patients were analyzed. Median age was 14 years (range 0 to 28). Overall incidence of angiomyolipoma was 50.3%. Median age at first angiomyolipoma detection was 11 years (range 2 to 26). Median yearly angiomyolipoma growth rate stratified by age at first detection was 0.0 mm for patients 0 to 6 years old, 0.9 mm for those 7 to 11 years old, 2.5 mm for those 12 to 16 years old and 1.8 mm for those 17 years old or older. Median yearly angiomyolipoma growth rate stratified by tumor size at first detection was 0.1 mm for tumors 0.6 to 0.9 cm, 1.8 mm for those 1.0 to 1.9 cm and 4.3 mm for those 2.0 to 2.9 cm. A total of 35 patients (24.1%) received mTOR (mammalian target of rapamycin) inhibitors. Eight patients underwent a total of 13 surgical interventions, of whom 2 had previously been treated with mTOR inhibitors. Median patient age at surgical intervention was 18.0 years and median angiomyolipoma size was 5.0 cm. CONCLUSIONS: Angiomyolipoma growth in children with tuberous sclerosis complex can be rapid and unpredictable. We recommend yearly renal ultrasound in all patients with tuberous sclerosis complex, with consideration of magnetic resonance imaging in those at risk for rapid growth and future intervention (ie those older than 11 years and/or those with renal angiomyolipomas larger than 2 cm).

Usual and unusual histologic patterns of high Gleason score 8 to 10 adenocarcinoma of the prostate in needle biopsy tissue.

High Gleason score 8 to 10 adenocarcinoma is the most aggressive and potentially lethal form of prostate cancer. The 2005 International Society of Urological Pathology (ISUP)-modified Gleason grading scheme defines several gland arrangements of high Gleason grade patterns 4 and 5. The aim of this investigation was to quantitate the frequency of the ISUP-defined high Gleason grade patterns in needle biopsy tissue, to determine the common admixtures and to characterize patterns not presented in the 2005 ISUP report. For patients who underwent radical prostatectomy, we analyzed for association of specific high-grade patterns in needle biopsy with extraprostatic extension in radical prostatectomy tissues. A total of 268 prostate needle biopsy cases with Gleason score of 8 to 10 were examined. A mean of 3.6 patterns (range, 1 to 8) were identified per case and only 12% of cases had a pure single pattern. Ill-defined glands with poorly formed lumina (at 57%) and fused microacinar glands (at 53%) comprised the predominant and most frequently admixed patterns. Single cells and single signet ring cells were present in 53% and 31% of cases, respectively. Additional patterns in order of frequency included cords (35%), cribriform glands (25%), sheets of cells (19%), chains (4%), glomeruloid (3%), comedonecrosis (2%), and hypernephromatoid (1 case=0.3%). Gleason score 8 to 10 carcinomas are typically extensive in needle core tissue, with a mean of 4.4 positive cores (range, 1 to 15 cores) per case. Only 14 cases (5%) had high-grade minimal carcinoma measuring <1 mm in needle core tissue. Gleason grade patterns not described in the 2005 ISUP report include single file growth, solid cylinders, and nested patterns. The single file pattern was present in 40% of cases, and the small solid nested pattern was detected in 24% of cases. One case displayed solid cylinders. Only the single file pattern was associated with extraprostatic extension at radical prostatectomy (P=0.005). These results show that the 2005 ISUP-defined patterns of high Gleason score 8 to 10 prostatic adenocarcinoma can be stratified on the basis of frequency of occurrence in needle biopsy tissue. Three patterns not defined in the 2005 ISUP scheme have been characterized, including single file, nested, and solid cylinder arrangements. As aggressive and potentially lethal prostate cancer is most often of Gleason score 8 to 10, it is important for diagnostic recognition purposes to be aware of the frequency of various patterns encountered in high Gleason score 8 to 10 adenocarcinomas, the types of pattern admixtures, and the histomorphologic presentation of unusual patterns. We propose that Gleason grade assignments should incorporate single file, solid nested, and solid cylinder arrangements as high-grade pattern 5 because of the absence of glandular luminal space formation.