Testicular self-examination for early detection of testicular cancer.

Testicular cancer (TCa) commonly presents as a painless scrotal mass. It has been suggested that testicular self-examination (TSE) can help in early detection and thus potentially improve treatment outcomes and prognosis. While TSE is more well established in guideline recommendations for patients with a known history of TCa, its role in healthy young men is less established and controversial. In this paper, we review contemporary data to provide an updated recommendation.

Two Weeks Too Long: Optimal Duration for Ureteral Prestenting and Its Physiologic Effects on the Ureter in a Yorkshire-Landrace Pig Model.

INTRODUCTION: Prestenting of the ureter is commonly performed to allow for passive dilation and better access to the urinary system during subsequent procedures. There is no level 1 evidence on the duration of prestenting and EAU guidelines suggest a 1-2 weeks duration. MATERIALS AND METHODS: Our primary aim is to investigate the optimal duration required for prestenting in a porcine model. Our secondary aim is to compare the ureteral wall compliance between the stented and the unstented ureters. METHODS: Three female pigs between 40 and 50 kg were used. We modified a human protocol for performing intravenous pyelograms in our study to obtain ureteral measurements on days 0, 5, 7, and 14. Unilateral stenting on days 0, 5, and 7 was performed. On day 14, bilateral nephroureterectomy was performed, and ureteral compliance was measured in the stent and unstented ureter. RESULTS: There were significant ureteral dilation between days 0 and 5 for all three pigs (p1 = 0.001, p2 ≤ 0.001 and p3 = 0.01). The rate of dilation appears to plateau after day 5 (p1 = 0.416, p2 = 0.344, and p3 = 0.774). Ureteral compliance in the stented ureter is better than in a nonstent ureter (p1 = 1.44 vs 0.13, p2 = 0.8 vs 0.04, p3 = 0.62 vs 0.2). An unexpected observation was the ureteral dilation and increased tortuosity in the unstented ureter in two of the three pigs (p1 = 0.152, p2 = 0.007). CONCLUSION: Our results suggest that optimal prestenting may be achieved in 5 days in a porcine model. It can potentially form the basis to start randomized human trials.

Optimization of treatment strategy used during shockwave lithotripsy to maximize stone fragmentation efficiency.

BACKGROUND AND PURPOSE: Previous studies have demonstrated that treatment strategy plays a critical role in ensuring maximum stone fragmentation during shockwave lithotripsy (SWL). We aimed to develop an optimal treatment strategy in SWL to produce maximum stone fragmentation. MATERIALS AND METHODS: Four treatment strategies were evaluated using an in-vitro experimental setup that mimics stone fragmentation in the renal pelvis. Spherical stone phantoms were exposed to 2100 shocks using the Siemens Modularis (electromagnetic) lithotripter. The treatment strategies included increasing output voltage with 100 shocks at 12.3 kV, 400 shocks at 14.8 kV, and 1600 shocks at 15.8 kV, and decreasing output voltage with 1600 shocks at 15.8 kV, 400 shocks at 14.8 kV, and 100 shocks at 12.3 kV. Both increasing and decreasing voltages models were run at a pulse repetition frequency (PRF) of 1 and 2 Hz. Fragmentation efficiency was determined using a sequential sieving method to isolate fragments less than 2 mm. A fiberoptic probe hydrophone was used to characterize the pressure waveforms at different output voltage and frequency settings. In addition, a high-speed camera was used to assess cavitation activity in the lithotripter field that was produced by different treatment strategies. RESULTS: The increasing output voltage strategy at 1 Hz PRF produced the best stone fragmentation efficiency. This result was significantly better than the decreasing voltage strategy at 1 Hz PFR (85.8% vs 80.8%, P=0.017) and over the same strategy at 2 Hz PRF (85.8% vs 79.59%, P=0.0078). CONCLUSIONS: A pretreatment dose of 100 low-voltage output shockwaves (SWs) at 60 SWs/min before increasing to a higher voltage output produces the best overall stone fragmentation in vitro. These findings could lead to increased fragmentation efficiency in vivo and higher success rates clinically.

Pathologic evaluation of hemostatic agents in percutaneous nephrolithotomy tracts in a porcine model.

BACKGROUND AND PURPOSE: Hemostatic agents have been suggested as an adjunct for tubeless percutaneous nephrolithotomy (PCNL). We pathologically evaluated the percutaneous tracts injected with the fibrin sealant (FS) Evicel and hemostatic gelatin matrix (HGM) Surgiflo at various time intervals to determine their absorption and tract closure rates. We also evaluated whether these agents reduced urine leak rates in a porcine model. MATERIALS AND METHODS: Percutaneous access was obtained in 19 kidneys in 10 domestic swine. The tracts were dilated to 30F using a balloon dilating catheter. Ten kidneys served as controls. Surgiflo was injected into the tract of four kidneys, and Evicel was injected into the tract of five kidneys. Intravenous urography (IVU) was performed on postoperative days (POD) 1 and 10 to 14. IVU was performed on two pigs at POD 30. The pigs were sacrificed and kidneys were harvested for pathologic evaluation. RESULTS: Two (20%) control kidneys had a urine leak on IVU on POD 1. None of the kidneys treated with HGM or FS had a urine leak on POD 1. None of the kidneys had a leak on POD 10 to 14 or POD 30. On pathologic inspection, the tracts of all the control kidneys and HGM kidneys had closed completely at POD 14. Two kidneys treated with FS had fistula at POD 6 and POD 14. At POD 30, the tracts in the control kidneys and kidney treated with HGM had completely healed. Fibrin sealant remained in the tract at POD 30. CONCLUSION: Fibrin sealant should be used with caution because it can persist in the tract for up to 30 days and may inhibit wound healing. Hemostatic gelatin matrix is the preferable agent because the tract closed by POD 10 to 14, similar to the findings in the control animals. The use of hemostatic agents in a nephroscopy tract may reduce the risk of early urine leak after tubeless PCNL.

Predictors of prolonged operative time during robot-assisted laparoscopic radical prostatectomy.

OBJECTIVE: To determine risk factors for prolonged operative time (OT) during robot-assisted laparoscopic radical prostatectomy (RALP). Being able to predict prolonged OT is of pivotal importance both to the physician for patient counseling and to the hospital management. PATIENTS AND METHODS: Retrospective review of patient records undergoing RALP between 2003 and 2009 at a tertiary academic center with a structured teaching program. The following variables were recorded: age, race, body-mass index (BMI), previous abdominal surgery (yes/no), nerve-sparing technique (yes/no), lymph nodes dissection (yes/no), pathological stage (organ-confined versus non), cumulative surgical experience with RALP (expressed as number of years since introduction of RALP at our center), prostate weight and OT calculated skin-to-skin by the anesthesiologists. Prolonged OT was defined as the upper quintile (20%) according to the distribution. Multivariate regression model was generated to assess potential predictors of prolonged OT. RESULTS: A total of 523 records were retrieved. Caucasians accounted for 77.8% of the cohort. Median age was 60.3 years (interquartile range, IQR, 55.0-64.6 years), median BMI 28.1 (25.8-30.7 kg/m²), prostate weight 46.0 g (37.0-57.8 g). Eighty-six (16.4%) patients had previous abdominal surgery, lymph nodes dissection was performed in 341 (65.2%) and nerve-sparing technique was done in 310 (59.3%) cases. Median OT was 175 min (IQR 146-220 min). Prolonged OT was set at > 230 min, thereby 105 (20.1%) records were classified as such. On multivariate analysis, cumulative surgical experience with RALP (P < 0.001), nerve sparing (P = 0.023) and prostate weight (P < 0.001) were independent predictors of prolonged OT. CONCLUSIONS: Larger prostates are associated with longer OT and this effect is maintained independently of cumulative robotic experience that represents another independent factor in determining OT.