Comparison of 30-day postoperative outcomes of open and minimally invasive pyeloplasty utilizing the prospective National Surgical Quality Improvement Program-Pediatric database.

INTRODUCTION: Open pyeloplasty (OP) has traditionally been the standard for the operative management of ureteropelvic junction obstruction in children. With advances in minimally invasive pyeloplasty (MIP) techniques, it is quickly becoming a popular alternative in both adult and pediatric population. OBJECTIVE: To evaluate the differences in outcomes between MIP and OP for the surgical correction of ureteropelvic junction obstruction in children. STUDY DESIGN: Data were obtained from the pediatric National Surgical Quality Improvement Program 2012-2017. We identified 1280 patients who underwent MIP and 1190 patients who underwent OP between 2012 and 2017. Propensity score matching was utilized to adjust for baseline differences. Univariate and multivariable regression were performed to assess odds of complications and procedure-related readmission. RESULTS: Patients who underwent OP had a significantly decreased operative time (192.42 vs 142.00 min, p < 0.001) compared to MIP. There was no significant difference in the rates of overall peri-operative complications (3.7% [MIP] vs 2.4% [OP] p = 0.397). On multivariable analysis, patients undergoing OP had a lower risk of procedure-related readmission (odds ratio [OR] 0.404, 95% confidence interval [CI] 0.157-0.951, p = 0.046) than MIP. In a multivariable linear regression model, the risk of having any postoperative complication, regardless of surgical approach, decreased with increasing patient age (OR 0.945, 95% CI 0.893-0.996, p = 0.037). DISCUSSION: Although recent small, retrospective institutional studies have found decreased hospitalization time of MIP as compared to OP, in our large prospective database, we found no such association. While some studies suggest a higher rate of wound complications in the OP group, this was not reproduced in our study as well. MIP was, in fact, associated with higher rate of readmissions as compared to the OP group, which may act as a surrogate of long-term complications in these patients. CONCLUSION: MIP offers an alternative to OP in the pediatric population with similar rates of peri-operative complications. However, our study shows decreased odds of procedure-related readmission in OP, which may serve as a surrogate for less postoperative complications in these patients.

Magnetic resonance imaging for prostate cancer: what the urologist needs to know.

The use of magnetic resonance imaging (MRI) for prostate cancer imaging has been an area of burgeoning research activity with a goal of finding imaging characteristics that will allow for improved diagnosis and surveillance of prostate cancer. This article will review the MRI sequences currently used for imaging the prostate and describe the scoring and reporting system used by radiologists for prostate MRI known as the Prostate Imaging Reporting and Data System (PI-RADS). Current research regarding the role of prostate MRI for patients without prior biopsy, with prior negative biopsy and elevated PSA, and on active surveillance protocols will also be reviewed.

Initial assessment of safety and clinical feasibility of irreversible electroporation in the focal treatment of prostate cancer.

BACKGROUND: To evaluate the safety and clinical feasibility of focal irreversible electroporation (IRE) of the prostate. METHODS: We assessed the toxicity profile and functional outcomes of consecutive patients undergoing focal IRE for localised prostate cancer in two centres. Eligibility was assessed by multi-parametric magnetic resonance imaging (mpMRI) and targeted and/or template biopsy. IRE was delivered under transrectal ultrasound guidance with two to six electrodes positioned transperineally within the cancer lesion. Complications were recorded and scored accordingly to the NCI Common Terminology Criteria for Adverse Events; the functional outcome was physician reported in all patients with at least 6 months follow-up. A contrast-enhanced MRI 1 week after the procedure was carried out to assess treatment effect with a further mpMRI at 6 months to rule out evidence of residual visible cancer. RESULTS: Overall, 34 patients with a mean age of 65 years (s.d. = ± 6) and a median PSA of 6.1 ng ml(-1) (interquartile range (IQR) = 4.3-7.7) were included. Nine (26%), 24 (71%) and 1 (3%) men had low, intermediate and high risk disease, respectively (D'Amico criteria). After a median follow-up of 6 months (range 1-24), 12 grade 1 and 10 grade 2 complications occurred. No patient had grade >/= 3 complication. From a functional point of view, 100% (24/24) patients were continent and potency was preserved in 95% (19/20) men potent before treatment. The volume of ablation was a median 12 ml (IQR = 5.6-14.5 ml) with the median PSA after 6 months of 3.4 ng ml(-1) (IQR = 1.9-4.8 ng ml(-1)). MpMRI showed suspicious residual disease in six patients, of whom four (17%) underwent another form of local treatment. CONCLUSIONS: Focal IRE has a low toxicity profile with encouraging genito-urinary functional outcomes. Further prospective development studies are needed to confirm the functional outcomes and to explore the oncological potential.

Laparoscopic retroperitoneal repair of a right-sided Bochdalek hernia.

Bochdalek hernias are rare congenital diaphragmatic defects. We report a case of a 50-year-old male with chronic shortness of breath who was diagnosed with a right-sided Bochdalek hernia. This hernia was repaired using a laparoscopic retroperitoneal approach.

Evaluation of preoperative ProstaScint scans in the prediction of nodal disease.

Diagnostic methods are limited for detecting microscopic soft tissue metastases in patients with prostate cancer. Previous studies using (111)Indium Capromab Pendetide (ProstaScint scan) analyzed patients with extensive localized tumor (prostate specific antigen (PSA) >20 ng/ml) not optimal for surgical therapy. We evaluated the role of the ProstaScint trade mark scan in a preoperative population to provide histological documentation and to assess its utility in a surgical population. A total of 22 preoperative patients, underwent a ProstaScint scan. The mean preoperative PSA was 16.0 ng/ml (range 3.9-33 ng/ml). The mean Gleason score at biopsy was 6.9 (range 6-9). Each patient underwent a radical retropubic prostatectomy and bilateral pelvic lymph node dissection, which included resection of both obturator and common iliac lymph nodes. Histologic analysis of the resected lymph nodes provided the standard of comparison with the ProstaScint scan. The results of the scan and pathology for all 22 patients were compared with the bilateral obturator and iliac nodes, creating 88 data points. Nine areas (10%) were positive on the scan. One of these (11%) was a true positive while the other eight (89%) were false positives. Seventy-nine areas (90%) were negative on scan results. Of these, five areas (6%) were false negatives and 74 areas (94%) were true negatives. The scan yielded a sensitivity of 17%, specificity of 90%, negative predictive value (NPV) of 94% and a positive predictive value (PPV) of 11%. The high false positive rate and low PPV of ProstaScint scans overestimates metastatic lymph nodes disease, and is not useful when used preoperatively.

Variable definitions influence the reporting of biochemical failure rates.

The purpose of this study was to assess how the reporting of biochemical failure (BF) rates would be affected by the application of three different definitions. Three hundred and fifteen men with localized prostate cancer underwent I-125 brachytherapy (n=109), conformal three-dimensional radiation therapy (n=99), or radical prostatectomy (n=107). No patient received adjuvant or neoadjuvant hormone therapy in this study. BF rates at 12, 24 and 36 months were assessed using three definitions: (1) prostate-specific antigen (PSA) nadir >0.5 ng/ml; (2) PSA rise by 0.5 ng/ml; and (3) three consecutive PSA rises. Median follow-up for the brachytherapy group, external beam radiotherapy group, and the radical prostatectomy group was 27, 30 and 36 months respectively. The applied definition influenced reporting of failure rates in two of the three groups. I-125 brachytherapy group: BF rates at 24 months: 46%-definition 1, 35%-definition 2, and 4%-definition 3 (P<0.05). Radiation therapy group: BF rates at 24 months: 39%-definition 1, 17%-definition 2 and 3%-definition 3 (P<0.05). No patient in the radical prostatectomy group had a BF by any applied definition. A more universal definition of BF is needed to compare the efficacy of treatments for localized prostate cancer.

Laparoscopic cross-trigonal Cohen ureteroneocystostomy: novel technique.

PURPOSE: We describe a novel technique of laparoscopic transvesical cross-trigonal Cohen anti-reflux ureteroneocystostomy. MATERIALS AND METHODS: A 10, an 11 and a 32-year-old patient with symptomatic unilateral vesicoureteral reflux underwent laparoscopic cross-trigonal ureteral reimplantation. Two 5 mm. balloon tip ports were suprapubically inserted into the bladder. Using a transurethral resectoscope with a Collins knife a 4 to 5 cm. cross-trigonal submucosal trough was created from the refluxing ureteral orifice to the contralateral side of the bladder. The refluxing ureteral orifice and intramural ureter were completely mobilized intravesically, advanced transtrigonally and secured to the detrusor muscle at the apex of the trough with 3 deep interrupted sutures. The elevated mucosal flaps of the trough were suture approximated over the ureter to create a submucosal tunnel. All suturing was performed by freehand laparoscopic technique. RESULTS: Operative time was between 2.5 and 4.5 hours and blood loss was 10 to 50 cc. Adequate submucosal trough creation, ureteral extravesical mobilization and intravesical advancement, and bladder mucosal flap reapproximation were done to create a submucosal tunnel in all cases. Satisfactory transtrigonal anchoring of the neoureteral orifice to the detrusor muscle and mucosa was achieved with 3 stitches. Hospital stay was 2, 2 and 1 days in the 3 cases, and the Foley catheter remained in place for 3, 1 and 1 week, respectively. At 6 months reflux had resolved in 2 patients, while in 1 grade II reflux persisted, which was improved from grade IV preoperatively. All patients have remained infection-free without antibiotics. CONCLUSIONS: Laparoscopic transvesical cross-trigonal antireflux ureteral reimplantation is technically feasible. Intravesical laparoscopic suturing is possible. Potential advantages include a decreased hospital stay, decreased narcotic requirement and better cosmesis. Further experience is necessary to refine the technical nuances and evaluate outcomes compared to the open technique.

Screening and monitoring for bladder cancer: refining the use of NMP22.

PURPOSE: While detecting bladder cancer, bladder tumor markers demonstrate improved sensitivity compared with urinary cytology but the current limitation is the low specificity and positive predictive value, that is high false-positive rate. We examined the clinical categories of the false-positive results, established relative exclusion criteria, and recalculated the specificity and positive predictive value of this assay with these criteria. MATERIALS AND METHODS: A total of 608 patients considered at risk for bladder cancer presented to a urology clinic and submitted a single urine sample. Of the 608 patients 529 (87%) presented with de novo hematuria or chronic voiding symptoms without a diagnosis of bladder cancer. There were 79 (13.0%) patients being monitored with a known history of bladder cancer. Each urine sample was examined via cytology, urinalysis, culture and NMP22 protein assay. All patients underwent office cystoscopy, and transurethral resection and/or biopsy if a bladder tumor was suspected. RESULTS: Of the 608 patients 226 (37.2%) presented with microscopic hematuria, 143 (23.5%) with gross hematuria and 239 (39.3%) had chronic symptoms of urinary frequency or dysuria. There were 52 (8.6%) patients who had histologically confirmed bladder cancer. Of these 52 cancers NMP22 detected 46 (88.5%), whereas cytology identified only 16 (30.8%). When atypical cytology was considered positive, cytology detected 32 (61.5%) cases. In the 135 patients with increased NMP22 values the 46 identified tumors were accompanied by 89 false-positive values yielding a specificity of 83.9% and a positive predictive value of 34.1%. These false-positive results were divided into 6 clinical categories. Exclusion of these categories improved the specificity and positive predictive value of NMP22 to 99.2% and 92.0%, respectively, yielding results similar to urinary cytology (99.8% and 94.1%). CONCLUSIONS: Awareness and exclusion of the categories of false-positive results can increase the specificity and positive predictive value of NMP22, enhancing the clinical use of this urinary tumor marker.

Contemporary "urologic" intervention in the pancreaticobiliary tree.

OBJECTIVES: To evaluate the role of minimally invasive "urologic" interventional techniques for the treatment of pancreaticobiliary calculi in contemporary practice. METHODS: Fourteen patients with retained cystic duct (n = 2), hepatic duct (n = 5), common duct (n = 2), pancreatic duct (n = 4), or gallbladder (n = 1) calculi were treated with 19 procedures, including shock wave lithotripsy (n = 9) and percutaneous flexible endoscopy with electrohydraulic or holmium laser lithotripsy (n = 10). Previous attempts using standard gastroenterologic or radiologic interventions before the urologic referral had failed in all 14 patients. RESULTS: A successful result, defined by the resolution of stones and symptoms, was achieved in 12 patients (86%); 2 patients (14%) had residual calculi that ultimately required an open operative procedure. The hospital stay for each intervention was 0 to 2 nights, and no patients had any significant complications. CONCLUSIONS: Even in this age of advanced gastroenterologic technology, including laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatoscopy, and percutaneous transhepatic cholangiography, the urologist can play a significant role in the minimally invasive treatment of patients with complicated biliary disease such that the need for open operative "salvage" procedures will be further minimized.

Penile adhesions after neonatal circumcision.

PURPOSE: The appropriate management of penile adhesions in circumcised boys is unclear. An important consideration is whether adhesions resolve spontaneously. We studied the incidence of penile adhesions as a function of patient age to assess the natural history. MATERIALS AND METHODS: We evaluated all circumcised boys presenting to our pediatric urology clinic. A standard form was used to classify adhesions as grade 0-no adhesions, 1-fine adhesions to the corona, 2-adhesions covering less than 50% of the glans and 3-adhesions covering greater than 50% of the glans. All boys were evaluated by 1 of 2 pediatric urologists. Previous treatment of adhesions was assessed and skin bridges were also noted. RESULTS: We enrolled in our study 254 boys 1 month to 19 years 8 months old. Only 7 patients had a history of treatment of adhesion, of whom 3 had recurrent adhesions at evaluation. Patients were divided into groups based on age, including younger than 12 months (61), 13 to 60 (78), 61 to 108 (51) and 109 months old or older (64). In these groups we noted an adhesion rate of 71%, 28%, 8% and 2%, respectively. The rate of adhesions more severe than grade 1 was 30%, 10% and 0% in boys 12 months old or younger, 13 to 60 and 61 months old or older, respectively. The oldest patient with grade 3 adhesions was 31 months old. Skin bridges in 6 cases involved the circumcision line in 4. CONCLUSIONS: Penile adhesions develop after circumcision and the incidence decreases with patient age. Although there is debate on whether to lyse these adhesions manually, our findings suggest that adhesions resolve without treatment. Based on our results we do not recommend lysing penile adhesions, except perhaps those involving the circumcision line.

Pretreatment with allopurinol diminishes pancreatography-induced pancreatitis in a canine model.

BACKGROUND: The role of oxygen-derived free radicals in the pathogenesis of pancreatitis has been supported by data from previous studies using animal models. This study was conducted to determine whether prophylaxis with the xanthine oxidase inhibitor allopurinol would decrease the incidence and severity of pancreatography-induced pancreatitis in a canine model. METHODS: Thirty-two dogs were randomized to receive either placebo or oral allopurinol 1 hour before the procedure. A laparotomy and duodenotomy were performed and a pancreatogram was obtained. Postoperatively, pancreatic enzymes were drawn for 5 days. The animals were then euthanized, and the pancreas was weighed and evaluated histologically. RESULTS: The histologic incidence of pancreatitis was significantly reduced in the allopurinol pretreatment group (6.7%) as compared with the placebo group (41.2%, p < 0.01). A significant decrease in postoperative serum amylase levels among dogs pretreated with allopurinol was also noted. A similar trend was observed in lipase levels. The pancreas weight index was decreased in the allopurinol pretreatment group as well (control = 0.00246 vs. allopurinol = 0.00195, p < 0.02). CONCLUSIONS: Pretreatment with oral allopurinol decreases the incidence of pancreatography-induced pancreatitis. These results support the role of xanthine oxidase inhibitors in the prevention of endoscopic retrograde cholangiopancreatography-induced pancreatitis.

Endoscopic stent configuration and bile flow rates in a variable diameter bile duct model.

Endoscopically placed biliary stents are used in the treatment of biliary strictures and obstruction. Patency of the stent is related to bile flow rate through the stent. The purpose of this study was to examine the influence of stent diameter, configuration, and common duct diameter on bile flow rates. Flow rates were examined in straight and pigtail stents, 7 Fr and 10 Fr, and in a 1 cm and 2.3 cm diameter CBD model. Bile-flow rates were greater in the straight and 10 Fr stents. Bile-duct diameter had no influence on flow rate in pigtail stents. Though flow rates decreased with straight stents in bile ducts of increasing diameter, the absolute flow rates always remained greater in the straight stents when compared to the pigtail stents. We conclude that straight stents, because of greater flow rates, are to be preferred over pigtail stents for the treatment of biliary obstruction in dilated and nondilated systems.

Effects of transient ischemia on the healing small bowel anastomosis.

The small bowel may be subjected to transient, yet reversible ischemia in situations such as volvulus, thromboembolism, and low flow states. The surgeon is frequently faced with the necessity of intestinal resection in treating such cases. The remaining bowel, while judged viable may have been exposed to significant ischemic injury. The surgeon must decide whether such bowel will heal satisfactorily if used in an anastomosis. This study was undertaken to determine the effect of transient ischemia on intestinal anastomotic healing in the rat. Male albino rats were subjected to superior mesenteric artery occlusion for periods of 30 minutes or 45 minutes. The circulation was then re-established. The small bowel was the transected and anastomosed. Animals in each group were sacrificed at 7 and 10 days and bursting pressures performed to test the healing of the anastomosis. Results were compared with a control group having an anastomosis without precedent ischemia. There were no significant differences among the groups. The data clearly indicate that if the bowel remains viable following an ischemic insult its healing is unimpaired.