Adoption of a Urologic Oncology Perioperative Surgical Home is Associated with Decreased Total Length of Stay: A Pilot Study.

INTRODUCTION: Urologists partnered with anesthesiologists to implement a model of perioperative and postoperative care known as the multidisciplinary perioperative surgical home in order to improve the quality and efficiency of care. We describe early outcomes associated with implementation of the perioperative surgical home. METHODS: Retrospective chart review was performed of patients at a single institution undergoing radical prostatectomy, radical cystectomy, partial nephrectomy and radical nephrectomy from January 2014 to March 2016. Outcomes measured were length of stay and 30-day reoperation, readmission, unexpected intensive care unit admission and mortality rates. Statistical analysis was performed using the independent samples Mann-Whitney U test and Fisher exact test with p <0.05 considered significant. Univariate and multivariate analyses were performed to determine whether implementation of the perioperative surgical home was associated with improved outcomes. RESULTS: Length of hospital stay decreased from 4.79 to 3.19 days and 30-day complication rate decreased from 15.3% to 5.7% after implementation of the perioperative surgical home (p <0.01 for both). There was no change in the 30-day readmission rate. On multivariate analysis surgery occurring after perioperative surgical home implementation was associated with decreased length of stay (p = 0.008). The direct cost savings resulting from this length of stay reduction totaled $1,245,585 for the study period. CONCLUSIONS: The adoption of a perioperative surgical home is associated with a significantly decreased postoperative hospital stay and 30-day complication rate for urologic oncology cases.

Diagnosis and management of ureteral fibroepithelial polyps in children: a new treatment algorithm.

INTRODUCTION: Fibroepithelial polyps are benign mesenchymal tumors arising from the urinary tract. With the advent of endoscopy in the pediatric population, more reports of endoscopic diagnosis and treatment have appeared. OBJECTIVE: The present study reports experience with the diagnosis and treatment of fibroepithelial polyps of the upper urinary tract in the pediatric population. Incorporating past experience from literature, we propose an algorithm to guide the clinical diagnosis and treatment plan. STUDY DESIGN: Four pediatric patients undergoing pyeloplasty for ureteropelvic junction (UPJ) obstruction were diagnosed with ureteral polyps. Their demographics, radiologic, surgical and pathologic information were reviewed. In addition, a comprehensive literature search using the MEDLINE database yielded 37 reports containing 126 cases of ureteral polyps, including 5 series with 57 cases and 9 cases of synchronous bilateral ureteral polyps. RESULTS: Of 123 pediatric patients undergoing pyeloplasty from 2008 to 2013, four (3.3%) were found to have fibroepithelial polyps of the upper urinary tract. All patients were male and the mean age of presentation was 12 years. Ureteral polyps predominantly occurred unilaterally in the left ureter (75%) and one case of bilateral ureteral polyps was encountered. Along with three other recent case series [1-3], the combined incidence of ureteral polyps in patients undergoing evaluation for ureteral obstruction was 5.2%. Intraoperative retrograde pyelogram was used to identify filling defects in 4 of 5 affected ureters (see Figure). Ureterorenoscopy was performed in all three patients with filling defects for polyp mapping along the ureter and evaluation of the macroscopic polyp appearance. Based on ureteroscopic findings, Holmium laser polypectomy was performed in two patients with single, pedunculated polyps. Anderson-Hynes dismembered pyeloplasty was performed in three patients with broad based, multilobulated polyps too large for endoscopic treatment and in one patient for undiagnosed polyp prior to pyeloplasty. DISCUSSION: The present study finds that the 5.2% combined incidence of ureteral polyps in contemporary reports may be higher than previously described [4]. Retrograde pyelogram was an effective tool in diagnosing ureteral polyp and ureteroscopy can be employed if ureteral polyps are suspected for both diagnostic and therapeutic purposes. Although clinical experience is limited, endoscopic laser treatment seems to be effective for the single, pedunculated ureteral polyps, while dismembered pyeloplasty is required for the broad based, multilobulated polyps. The study was limited by the rarity of ureteral polyps. Future multi-institutional collaborative studies are required to validate the diagnostic and treatment algorithm proposed. CONCLUSION: Ureteral polyps cause approximately 5% of UPJ obstruction in the pediatric population. Diagnosis can be made in certain cases by intraoperative retrograde pyelogram. If a filling defect is encountered, ureteroscopy is indicated for polyp mapping. The treatment modality is dictated by the endoscopic appearance of the ureteral polyp.

Robotic-assisted surgery and the evolution of the radical prostatectomy.

The surgical treatment of prostate cancer has evolved considerably since it was first described in 1905. With the introduction of a robotic, surgical-assist device, minimally invasive techniques for prostate removal have been increasingly utilized throughout the world. Currently, there is a large body of literature suggesting that robotic-assisted laparoscopic prostatectomy is associated with certain improved perioperative and postoperative outcomes and similar cancer control rates compared to open radical prostatectomy. The goal of this review is to objectively evaluate and describe the current state-of-the-art in surgical technique, perioperative and long-term outcomes, complications and the future of robotic-assisted laparoscopic radical prostatectomy.

Simultaneous pediatric kidney transplantation and ureterocystoplasty in a 20-month-old boy.

Kidney transplantation (KT) in children with end-stage renal disease and an abnormal bladder poses a complex management challenge. Ureterocystoplasty (UC) has been previously reported in older children with non-compliant bladders, but the timing and technique of repair are controversial. This case reports the youngest patient, a 20-month-old boy to undergo successful single-stage UC and living-related KT. UC was performed because of a fibrotic, non-compliant bladder. A temporary vesicostomy was placed to provide adequate drainage in the presence of urethral stenosis. The patient developed a single episode of pyelonephritis within the first six months post-operatively, but there were no other urologic complications. At 13 months, the renal function is excellent with a mean glomerular filtration rate of 100 mL/min/1.73 m(2) and no clinical evidence of rejection. This case demonstrates that simultaneous UC and KT can be safely performed even in infants with non-compliant bladders and renal failure.

Ureteroscopic treatment of symptomatic caliceal diverticular calculi.

Renal calculi that reside in caliceal diverticula are difficult to treat. Numerous treatment modalities have been used, including extracorporeal shock wave lithotripsy, laparoscopy, and percutaneous treatment. All therapies directed at fragmenting the stones are limited by the ability of these fragments to pass through the narrow diverticular neck. More recently, the retrograde approach using small-caliber flexible ureteroscopes has been applied successfully in the treatment of diverticular calculi. A description of our retrograde technique is presented. The ultimate success of this technique is dependent upon familiarity with the basic principles of ureteroscopy and successful clearance of stone fragments from the diverticulum.

Knotted ureteral stent: a minimally invasive technique for removal.

PURPOSE: We describe a useful technique for untying a knotted ureteral catheter. MATERIALS AND METHODS: An Amplatz super stiff guide wire was advanced through the lumen of the stent and with uniform force the knot was untied. RESULTS: The knot was untied and the stent was removed. A nephrostomy tube or other more invasive techniques for removal were avoided. CONCLUSIONS: An Amplatz super stiff guide wire passed retrograde via the ureteral stent lumen should be considered as a valid alternative to percutaneous removal of a knotted ureteral stent.

Invasive bladder cancer following cardiac transplantation.

Iatrogenic immunosuppression following renal transplantation has been associated with the development and progression of multiple neoplasms, including transitional cell carcinoma (TCC). We present the first report of invasive TCC of the bladder managed with radical cystectomy in a cardiac transplant recipient. The short survival of this patient, despite organ-confined disease at the time of cystectomy, illustrates the necessity of early diagnosis and aggressive treatment of malignancy following organ transplantation.

Common problems in pediatric gynecology.

A knowledge of the special concerns and physiology in pediatric female patients allows the physician to obtain pertinent histories and appropriate examinations. This information permits diagnosis and treatment of sequelae of sexual abuse, common gynecologic infections, and trauma. More complex problems, such as determination of sources of vaginal bleeding and endocrinopathies, also can be evaluated. Finally, benign and malignant conditions affecting the internal and external genitalia may be diagnosed and treated or referred to a subspecialist as needed.