Case report of the first Caucasian burn patient transplanted with Cutimed Sorbact®-based cultured epithelial autografts technique at Tygerberg Hospital, Cape Town, South Africa: An 8-year follow-up.

Cultured epithelial autograft applications are limited by the associated cost and time constraints in resource-limited settings. A modified composite technique using the patients' own tissue and Cutimed Sorbact dressing was employed as a life-saving emergency measure. Since the non-Caucasian population was more commonly treated at the center, it was important to report the first Caucasian patient outcome, as the graft-take outcome for all populations was unknown. A 54-year-old male with extensive flame burns and a low chance of survival was admitted to the Tygerberg Burn Center. He received traditional skin grafts and cultured epithelial cells, after the 2 week-culture period using the current technique. Short- (⩽2 weeks) and long-term graft take (⩽8 years) was inspected. Good graft take and complete epithelialization was observed during short-term inspection with partially healed areas initially attributed to extensive burn depth and dressing removal. Long-term follow-up indicated a near normal tissue appearance and excellent pliability.

Moving away from mannitol infusion for partial nephrectomy: has this altered renal function?

In recent years, research has questioned the theorized renal-protective value of mannitol infusion during partial nephrectomy. This study considers whether the cessation of routine mannitol administration has shown any benefit or detriment to patients in the contemporary era. We retrospectively reviewed a multi-institution database for an association between mannitol administration and subsequent renal function during follow-up. These patients were assessed for de novo stage III chronic kidney disease (CKD III) and followed with estimated glomerular filtration rate (eGFR). Statistical analysis included Mann-Whitney-U and Chi-squared tests for comparing baseline and perioperative variables with postoperative outcomes. eGFR changes were evaluated with a mixed-effects linear regression model. Nine hundred and fifteen patients were identified whose operative reports or surgeons' treatment algorithms explicitly described whether or not mannitol was administered. 667 (73%) did not receive mannitol. There were no differences in demographics, age, Charlson comorbidity index, nephrometry score, tumor size, grading, or baseline eGFR from those who received mannitol. Ischemia time and operative time appeared slightly longer with mannitol use. Patients were followed for a median of 5 months (IQR 0.5-19 months), during which mannitol use was associated with an increase in de novo CKD III (14% v. 9%, p = 0.041) and minimally worsened median eGFR on final follow-up (72.82 v. 76.06, p = 0.039). Our analysis of partial nephrectomy patients indicates that mannitol administration likely confers no short- or long-term renal benefit. Mannitol may be used at the surgeon's discretion, but if it prolongs surgery time or ischemia time, it may in fact be detrimental to outcomes.

Ventral onlay glanuloplasty for treatment of fossa navicularis strictures

ABSTRACT Purpose: Management of fossa navicularis (FN) strictures balances restoring urethral patency with adequate cosmesis. Historically, FN strictures are managed via glans cap or glans wings, and in severe cases, multi-stage procedures. Ventral onlay glanuloplasty (VOG) is an easily reproducible technique that involves a single-stage augmentation with buccal mucosal graft. We have been applying this technique for several years and present early promising outcomes of this novel approach. Materials and Methods: We retrospectively reviewed all patients with FN strictures who underwent VOG at our institution. Treatment success was designated by the absence of extravasation on voiding cystourethrogram and no need for further urethral instrumentation on follow up. Glans cosmesis was assessed by patients providing binary (yes/no) response to the satisfaction in their appearance. We also noted stricture length, stricture etiology, demographic characteristics and any post-operative complications and reported median, interquartile range (IQR) and count, frequency (%), accordingly. Results: Ten patients underwent VOG and fit our inclusion criteria. Median stricture length was 2.0 cm (IQR 1.6 -2). Success rate was 90% (9/10) with a median follow up of 30 months (IQR 24.3 - 36.8). The one recurrence was treated by dilation combined with triamcinolone injection at 419 days post-op. Stricture etiology included primarily iatrogenic causes such as transurethral prostate resection (4/10), greenlight laser vaporization (2/10), cystolitholapaxy (1/10), and traumatic catheterization (3/10). All patients were satisfied with penile cosmesis. Conclusion: VOG is a simple technique for treating FN strictures. Based on our preliminary series, VOG provides sustained distal urethral patency and patients are pleased with the appearance.

Use of phosphodiesterase-5 inhibitors and the incidence of melanoma.

INTRODUCTION: Recent evidence of a causal link between Phosphodiesterase-5-inhibitor (PDE-5i) use and melanoma has caused concern in PDE-5i use and was even addressed in the 2018 American Urological Association guideline on erectile dysfunction (ED). Given that several studies have affirmed this low probability but statistically significant association, one might expect a shift in melanoma diagnoses since PDE-5is were introduced in 1998. We sought to determine if the introduction of PDE-5i drugs for ED treatment increased incidence of melanoma. METHODS: The Surveillance, Epidemiology, and End Results (SEER) database was used to compare the incidence of melanoma diagnosis in American men between 1973 and 2015, providing over a decade of data before and after PDE-5i introduction in 1998. Interrupted time-series and logistic regression were used to assess this relationship. RESULTS: Over 43 years, the SEER database has reported 292,166 cases of Melanoma, with males accounting for 53.7% of cases (Standard deviation [SD] 3%, Range 47.5-58.3%). After the introduction of PDE-5i, there was no proportional increase in melanoma diagnoses, in fact demonstrating a 2% lower incidence from prediction models (p < 0.05). CONCLUSION: Our analysis of the SEER database demonstrates that the trend in incidence of melanoma has fallen in the era of PDE-5i use for ED. These findings may be of value in counseling patients anxious about the potential association between PDE-5i use and skin cancer; however, continued research analyzing individual-level risk are needed.

Ventral onlay glanuloplasty for treatment of fossa navicularis strictures.

PURPOSE: Management of fossa navicularis (FN) strictures balances restoring urethral patency with adequate cosmesis. Historically, FN strictures are managed via glans cap or glans wings, and in severe cases, multi-stage procedures. Ventral onlay glanuloplasty (VOG) is an easily reproducible technique that involves a single-stage augmentation with buccal mucosal graft. We have been applying this technique for several years and present early promising outcomes of this novel approach. MATERIALS AND METHODS: We retrospectively reviewed all patients with FN strictures who underwent VOG at our institution. Treatment success was designated by the absence of extravasation on voiding cystourethrogram and no need for further urethral instrumentation on follow up. Glans cosmesis was assessed by patients providing binary (yes/no) response to the satisfaction in their appearance. We also noted stricture length, stricture etiology, demographic characteristics and any post-operative complications and reported median, interquartile range (IQR) and count, frequency (%), accordingly. RESULTS: Ten patients underwent VOG and fit our inclusion criteria. Median stricture length was 2.0 cm (IQR 1.6 -2). Success rate was 90% (9/10) with a median follow up of 30 months (IQR 24.3 - 36.8). The one recurrence was treated by dilation combined with triamcinolone injection at 419 days post-op. Stricture etiology included primarily iatrogenic causes such as transurethral prostate resection (4/10), greenlight laser vaporization (2/10), cystolitholapaxy (1/10), and traumatic catheterization (3/10). All patients were satisfied with penile cosmesis. CONCLUSION: VOG is a simple technique for treating FN strictures. Based on our preliminary series, VOG provides sustained distal urethral patency and patients are pleased with the appearance.

Trends in Positioning for Robotic Prostatectomy: Results From a Survey of the Endourological Society.

PURPOSE: most robot-assisted laparoscopic prostatectomies (RALP) are performed with the patient in lithotomy, carrying risks of positioning-related complications. Newer robot models have allowed for supine positioning, potentially avoiding these pitfalls. We gauged the current sentiment on patient positioning among surgeons who perform robot-assisted surgery. METHODS: we surveyed members of the Endourological Society regarding their practice settings and their opinions on positioning for robot-assisted laparoscopic prostatectomy. Summary statistics were reviewed and data were analyzed using chi-square tests and t-tests. RESULTS: our survey had 92 eligible respondents. The majority were fellowship-trained, with 51% trained in robotics and 57% practicing in the U.S. with a mean of 13 years of practice. Most were working in an academic setting (69%) and performing at least 25 robotic prostatectomies yearly. 28 respondents used the Intuitive Surgical Inc. da Vinci® Xi™ exclusively (30%), and nearly two-thirds used it sometimes. Although 54% of respondents considered using supine positioning, less than half of these surgeons used it regularly, while 75% overall preferred lithotomy. A majority attributed this choice to surgical team familiarity with lithotomy positioning. Surgeons in the U.S. and those using the da Vinci® Xi™ were more likely to consider supine positioning. CONCLUSIONS: lithotomy position is the standard for RALP procedures; nonetheless, it poses significant risks that might be avoided with supine positioning. Our survey suggests that, although supine positioning has been considered, it has not gained momentum in practice. Addressing factors of inertia in training practices and one's surgical team might allow for novel and safer approaches.

Contemporary surgical and non-surgical management of Peyronie's disease.

Numerous treatments have been proposed for Peyronie's disease (PD). As the evidence base has expanded, the field of operative and non-operative options for patients has narrowed. Collagenase clostridium hystolyticum (CCH) injection now comprises the medical option, and surgical possibilities entail penile plication, plaque incision/excision and grafting, and prosthesis implantation. Still, questions abound regarding the optimal approach and indication for each of these treatments. We conducted a review of literature exploring the contemporary management of PD with a particular focus on work since the last American Urologic Association's (AUA) guidelines update for PD. Recent results and discussion indicate trends toward minimal invasiveness, toward a more holistic approach to the PD patient, and away from algorithmic management, galvanized, in part, by data challenging long-held beliefs.

The Hemodynamic Effects of Intracavernosal Phenylephrine for the Treatment of Ischemic Priapism.

AIM: We sought to evaluate whether the administration of phenylephrine (PE) at concentrations higher than those described in guidelines resulted in any significant changes in vital signs or impacted outcomes. METHODS: After receiving institutional review board approval, we retrospectively reviewed the charts of patients presenting to our emergency department between May 1, 2014, and August 15, 2016, using International Classification of Diseases, Ninth Edition and Internation Classification of Disease, Tenth Edition diagnosis codes for priapism. Treatment was reviewed, including corporal aspiration/irrigation, injection of PE, and shunt procedures. Vital signs were compared before and after treatment with PE. Baseline variables were explored with categorical data analysis (chi-squared tests, t-tests, and Mann-Whitney nonparametric tests). Where feasible, linear regression was used to evaluate outcomes. MAIN OUTCOME MEASURE: Detumescence and changes in blood pressure and heart rate. RESULTS: We identified 74 different patient encounters of acute priapism. The median age was 36.5 years (interquartile range [IQR] = 27-47), and the median time to presentation was 5.4 hours (IQR = 4.0-9.6). 62 percent of cases were due to drug-induced priapism. In 58 (74%) encounters, patients received PE. The median dose of PE given was 1000 µg (IQR 500-2,000). Univariate regression found no association between PE dose and change in patient heart rate or blood pressure. A statistically significant decrease in heart rate (HR) (-4.2 BPM), systolic blood pressure (BP) (-1.8 mm Hg), and diastolic BP (-5.4 mm Hg) was noted. Fifty-three of 58 (91%) patients receiving PE experienced detumescence at the bedside, 2 required shunting in operating room, and 3 refused treatment and left against medical advice. No adverse events occurred. CONCLUSION: We frequently treat patients with high doses of PE and seldom notice adverse effects, typically resulting in resolution of priapism without any additional procedures. Careful administration of high doses of intracavernosal PE in patients presenting with priapism does not appear to significantly affect heart rate or blood pressure and may help prevent further ischemic damage and achieve detumescence effectively and efficiently. Sidhu AS, Wayne GF, Kim BJ, et al. The hemodynamic effects of intracavernosal phenylephrine for the treatment of ischemic priapism. J Sex Med 2018;15:990-996.

Alexis Wound Retractor for Radical Cystectomy: A Safe and Effective Method for Retraction.

Surgical site infection rates remain a common postoperative problem that continues to affect patients undergoing urologic surgery. Our study seeks to evaluate the difference in surgical site infection rates in patients undergoing open radical cystectomy when comparing the Bookwalter vs. the Alexis wound retractors. After institutional review board approval, we performed a retrospective chart review from February 2010 through August 2017 of patients undergoing open radical cystectomy with urinary diversion for bladder cancer. We then stratified the groups according to whether or not the surgery was performed with the Alexis or standard Bookwalter retractor. Baseline characteristics and operative outcomes were then compared between the two groups, with the main measure being incidence of surgical site infection as defined by the CDC. We evaluated those presenting with surgical site infections within or greater than 30 postoperatively. Of 237 patients who underwent radical cystectomy with either the Alexis or Bookwalter retractor, 168 patients were eligible to be included in our analysis. There was no statistical difference noted regarding surgical site infections (SSIs) between the two groups; however, the trend was in favor of the Alexis (3%) vs. the Bookwalter (11%) at less than 30 days surgery. The Alexis wound retractor likely poses an advantage in reducing the incidence in surgical site infections in patients undergoing radical cystectomy; however, multicenter studies with larger sample sizes are suggested for further elucidation.

Staged Fowler-Stephens and Single-stage Laparoscopic Orchiopexy for Intra-abdominal Testes: Is There a Difference? A Single Institution Experience.

OBJECTIVE: To compare single-stage laparoscopic orchiopexy (SSLO) and staged Fowler-Stephens (SFS) procedures in the management of intra-abdominal undescended testes, and to analyze postoperative atrophy and malpositioning as end points. MATERIALS AND METHODS: A retrospective chart review identified laparoscopic orchiopexy patients with intra-abdominal testes between November 2006 and November 2014. Of 167 patients who had laparoscopic orchiopexy, 73 (85 testes) were identified as having laparoscopic orchiopexy. Baseline characteristics, as well as testicular scrotal position and size at follow-up, were recorded. Regression analysis was performed to compare outcomes between patients who underwent SFS and SSLO. RESULTS: Of the 85 laparoscopic orchiopexies, 35 underwent SFS and 50 had SSLO. Patient demographics were comparable in both groups. The median age at surgery was 12 months (5-151 months), and the average follow-up was 17.3 months. On follow-up, there were 0 recorded cases of SFS patients with abnormally positioned testes postoperatively, whereas there were 10 (20.0%) SSLO patients who had abnormally positioned testes (odds ratio: 0.05, 95% confidence interval: 0.01-0.44). Differences in atrophy rates were not significant. CONCLUSION: These results suggest that there may be no difference between the 2 approaches in terms of postoperative atrophy. However, the SFS appears to be more successful in securing a favorable scrotal position. Atrophy does not seem to be associated with other patient factors. Prospective, randomized studies are indicated to further explore outcome differences between the 2 approaches.

The Single Wire Ureteral Access Sheath, Both Safe and Economical.

Introduction. Novel disposable products for ureteroscopy are often inherently more expensive than conventional ones. For example, the Cook Flexor© Parallel™ (Flexor) access sheath is designed for ease and efficiency of gaining upper tract access with a solitary wire. We analyze the cost combinations, efficiency, and safety of disposable products utilized for upper tract access, including the Flexor and standard ureteral access sheath. Methods. We performed a retrospective review from January 2014 to October 2014 of patients undergoing URS for nephrolithiasis, who were prestented for various reasons (e.g., infection). Common combinations most utilized at our institution include "Classic," "Flexor," and "Standard." Total costs per technique were calculated. Patient characteristics, operative parameters, and outcomes were compared among the groups. Results. The most commonly used technique involved a standard ureteral sheath and was the most expensive ($294). The second most utilized and least expensive combination involved the Flexor, saving up to $80 per case (27%). All access sheaths were placed successfully and without complications. There were no significant differences in operative time, blood loss, or complications. Conclusions. In prestented patients within this study, the Flexor combination was the most economical. Although the savings appear modest, long-term impact on costs can be substantial.

Reducing robotic prostatectomy costs by minimizing instrumentation.

INTRODUCTION AND OBJECTIVE: Since the introduction of robotic surgery for radical prostatectomy, the cost-benefit of this technology has been under scrutiny. While robotic surgery professes to offer multiple advantages, including reduced blood loss, reduced length of stay, and expedient recovery, the associated costs tend to be significantly higher, secondary to the fixed cost of the robot as well as the variable costs associated with instrumentation. This study provides a simple framework for the careful consideration of costs during the selection of equipment and materials. MATERIALS AND METHODS: Two experienced robotic surgeons at our institution as well as several at other institutions were queried about their preferred instrument usage for robot-assisted prostatectomy. Costs of instruments and materials were obtained and clustered by type and price. A minimal set of instruments was identified and compared against alternative instrumentation. A retrospective review of 125 patients who underwent robotically assisted laparoscopic prostatectomy for prostate cancer at our institution was performed to compare estimated blood loss (EBL), operative times, and intraoperative complications for both surgeons. Our surgeons now conceptualize instrument costs as proportional changes to the cost of the baseline minimal combination. RESULTS: Robotic costs at our institution were reduced by eliminating an energy source like the Ligasure or vessel sealer, exploiting instrument versatility, and utilizing inexpensive tools such as Hem-o-lok clips. Such modifications reduced surgeon 1's cost of instrumentation to ∼40% less compared with surgeon 2 and up to 32% less than instrumentation used by surgeons at other institutions. Surgeon 1's combination may not be optimal for all robotic surgeons; however, it establishes a minimally viable toolbox for our institution through a rudimentary cost analysis. A similar analysis may aid others in better conceptualizing long-term costs not as nominal, often unwieldy prices, but as percent changes in spending. With regard to intraoperative outcomes, the use of a minimally viable toolbox did not result in increased EBL, operative time, or intraoperative complications. CONCLUSION: Simple changes to surgeon preference and creative utilization of instruments can eliminate 40% of costs incurred on robotic instruments alone. Moreover, EBL, operative times, and intraoperative complications are not compromised as a result of cost reduction. Our process of identifying such improvements is straightforward and may be replicated by other robotic surgeons. Further prospective multicenter trials should be initiated to assess other methods of cost reduction.

An Adult Case of Paratesticular Spindle Cell Rhabdomyosarcoma.

Paratesticular rhabdomyosarcoma (RMS) occurs more frequently in children and is rare in adults. Embryonal RMS is the most common subtype of paratesticular RMS. Spindle cell is a rare variant of embryonal RMS and is associated with a favorable prognosis in children. Data in adults is lacking. We present a case of paratesticular RMS in a 24-year-old man.

Forehead anatomy: arterial variations and venous link of the midline forehead flap.

The largest prospective cadaver study done over a 3-year period to investigate the arterial variations of the forehead is presented. The primary goal was to find anatomical support for various forehead flaps previously designed. Thirty cadaver foreheads (60 hemi-foreheads) were dissected from deep to superficial to identify arterial variations. The arteries were filled with a latex solution prior to dissection. The results show that the supratrochlear and dorsal nasal arteries have a relatively constant origin. Vertical (VB), oblique (OB), medial (MB) and lateral branches (LB) of the supraorbital artery were identified. The frontal branch of the superficial temporal artery (FBSTA) was found to continue in the direction of the scalp at the lateral orbital rim vertical line and gave off a transverse branch, the transverse frontal artery (TFA), to supply the forehead. The oblique branch of the supraorbital artery (OBSOA) most often anastomosed with either the transverse frontal artery or the frontal branch of the superficial temporal artery at the lateral orbital rim vertical line. A central artery (CA) was consistently found originating from the dorsal nasal artery usually 5mm from its origin. The central artery had a constant anastomosis with the opposite central artery in the inferior transverse third of the forehead. The central artery was not easily identifiable in the superior third of the forehead. The angular artery (AA) was found to have a variable termination. The angular artery could communicate with the supratrochlear artery (STrA) at the supraorbital rim (SOR) or it could continue up into the forehead medial to the STrA. This artery was called the paracentral artery (PCA). The central artery, paracentral artery and supratrochlear artery have an important relationship with the most prominent central vein that is relevant to flap construction. The significance of the central artery and vein favours the median forehead flap as anatomically superior and the prominent central vein is a constant landmark on which to select the side of the pedicle. Clear landmarks for defining the pedicle base for the median forehead flap are provided.

Craniofacial abnormalities in twins at tygerberg hospital, craniofacial unit.

UNLABELLED: There is no article in the literature correlating only craniofacial abnormalities in twins. Since 1985 the Tygerberg Craniofacial Unit has treated nine pairs of twins. In this retrospective study, the authors correlate the craniofacial and systemic anomalies with the specific twin type. BACKGROUND: The frequency of human twinning varies from 1 in 30 to 1 in 150 pregnancies. These can be monozygotic (MZ) or dizygotic (DZ). Monozygotic or identical twins occur when a single ovum is fertilized, so the twins possess an identical set of nuclear genes. DZ twins result from the fertilization of two separate ova. FINDINGS: Of the nine sets of twins, six were MZ (identical) and three DZ. Twelve patients presented with craniofacial abnormalities (CFA), which ranged from deformational plagiocephaly, scaphocephaly, trigonocephaly, to frontonasal dysplasia. Craniosynostosis was the most common CFA. Associated abnormalities included facial, limb, and cardiac defects. CONCLUSION: Twins with CFA are rare. The authors found that MZ twins are affected more and are more likely to have both siblings affected. DZ twins are affected less and are unlikely to have a co-twin affected.