Mitomycin-C and urethral dilatation: A safe, effective, and minimally invasive procedure for recurrent vesicourethral anastomotic stenoses.

PURPOSE: To report the safety and efficacy of mitomycin-C (MMC) injection followed by urethral dilatation for the treatment of recurrent vesicourethral anastomotic stenosis (VUAS) post-radical prostatectomy, and to report the outcome for patients treated for concomitant postprostatectomy incontinence. MATERIALS AND METHODS: A total of 29 patients with postprostatectomy incontinence and diagnosed with recurrent VUAS were recruited between March 2009 and January 2014 in this longitudinal case series. Under sedation, MMC was injected at the 3, 6, and 9 o'clock position, followed by urethral dilatation to 26F. Cystoscopy was performed to evaluate for patency at set intervals. Patients had the possibility to receive a salvage MMC injection if recurrence was noted. Patients with resolved VUAS were offered an anti-incontinence surgery. RESULTS: Median (interquartile range [IQR]) patient age was 67 years (63-72). Overall, 17 patients had ≥2 prior treatments for the VUAS (median = 2, IQR: 1-3 treatments); 23 patients (79%) had a patent bladder neck at the 12 months follow-up cystoscopy after a single MMC injection and dilatation. Overall, 3 patients opted for a salvage MMC injection for recurrence, and 2 of those were salvaged, improving the success rate to 86%. No adverse events were reported. Overall, 20 patients (69%) opted for an anti-incontinence surgery, and all were either cured or improved of their incontinence after a median (IQR) follow-up of 58 months (48-77). CONCLUSIONS: MMC injection with urethral dilatation is a safe, effective, and minimally invasive treatment option for recurrent VUAS after radical prostatectomy. Favorable long-term results can be expected even after anti-incontinence procedures.

A bulbar artery pseudoaneurysm following traumatic urethral catheterization.

Traumatic urethral catheterization may result in a number of serious complications. A rare occurrence is the development of a urethral pseudoaneurysm. We report the case of a 13-year-old male who required placement of a Foley catheter for an orthopedic surgical procedure. The Foley was misplaced in the bulbourethra, resulting in the development of a bulbar artery pseudoaneurysm. Profuse bleeding via the urethra was noted after removal of the catheter, and the patient experienced severe intermittent hematuria during the postoperative period. Cystoscopy revealed a pulsatile mass within the bulbourethra. Angiography confirmed a bulbar artery pseudoaneurysm, which was successfully embolized with resolution of bleeding.

Laparoscopic management of a large staghorn stone.

Urinary calculi are prevalent and result in significant morbidity, with a marked economic impact. Various therapeutic options exist, from medical to surgical management according to stone size. Laparoscopic pyelolithotomy is a viable option for significant staghorn renal stones. We report the case of a laparoscopic pyelolithotomy performed on a 48-year-old man with a left recurrent staghorn renal stone secondary to an ureteropelvic junction obstruction following a grade IV renal trauma several years ago.

Early versus delayed repair of vesicouterine fistula.

Vesicouterine fistulas (VUF) are a pathological and uncommon connection between the uterus and the bladder. Although rare, they are usually related to cesarean section. Nowadays, their incidence increases because of the increase in Cesarean sections. Patients with VUF may have various clinical presentations. The main symptoms are urinary incontinence, which may be associated with hematuria. Vesicouterine fistulas are usually associated with psychological distress and have a negative effect on quality of life. The accurate and early diagnosis of VUF can be difficult. There are multiple ways to investigate VUF and several examinations may be required to confirm the diagnosis; these examinations may include a cystoscopy, a retrograde cystography, methylene blue test and a computed tomography scan. We present 3 cases of vesicouterine fistula with successful surgical repair in which 2 patients had an early repair. One patient had an early surgical repair because of intractable pain and the other patient because of the large size of the fistula. The fistula repair surgeries were uneventful and the patients had an unremarkable recovery. We report that early surgical management is technically feasible without significantly increasing the difficulty of the surgery, with an excellent outcome in selected patients.

Fatal fast-growing renal cell carcinoma during pregnancy.

BACKGROUND: Renal cell carcinoma (RCC) during pregnancy is rare. Volume doubling time for RCC is estimated to be 72 weeks. CASE: A 28-year-old woman was assessed for macroscopic hematuria at 21 weeks' gestation. A renal ultrasound revealed a 3.4 cm right renal mass. After MRI, the most likely diagnosis seemed to be angiomyolipoma. The patient opted for conservative management, and the pregnancy continued to almost 36 weeks, at which time the mass had tripled in size. Laparoscopic nephrectomy was performed four days after delivery, and pathological examination revealed a 9.3 cm renal cell carcinoma. Three months later, multiple metastases were identified, which were resistant to targeted therapies. The patient died 12 months postpartum. CONCLUSION: Although renal tumours during pregnancy have been reported, this is the first report of a fatal fast-growing renal tumour.

Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort study during an epidemic in Quebec.

BACKGROUND: Since 2002, an epidemic of Clostridium difficile-associated-diarrhea (CDAD) associated with a high case-fatality rate has involved >30 hospitals in the province of Quebec, Canada. In 2003, a total of 55% of patients with CDAD at our hospital had received fluoroquinolones in the preceding 2 months. It has been suggested that massive use of proton pump inhibitors might have facilitated this epidemic. METHODS: To delineate the risk of CDAD associated with specific classes of antibiotics and whether this is modulated by concomitant use of proton pump inhibitors and other drugs altering gastric acidity or gastrointestinal motility, we conducted a retrospective cohort study of patients hospitalized in a teaching hospital in Sherbrooke, Canada, during the period of January 2003 through June 2004. We obtained data on 7421 episodes of care corresponding to 5619 individuals. Patients were observed until they either developed CDAD or died or for 60 days after discharge from the hospital. Adjusted hazard ratios (AHRs) were calculated using Cox regression. RESULTS: CDAD occurred in 293 patients. Fluoroquinolones were the antibiotics most strongly associated with CDAD (AHR, 3.44; 95% confidence interval [CI], 2.65-4.47). Almost one-fourth of all inpatients received quinolones, for which the population-attributable fraction of CDAD was 35.9%. All 3 generations of cephalosporins, macrolides, clindamycin, and intravenous beta-lactam/beta-lactamase inhibitors were intermediate-risk antibiotics, with similar AHRs (1.56-1.89). Proton pump inhibitors (AHR, 1.00, 95% CI, 0.79-1.28) were not associated with CDAD. CONCLUSIONS: Administration of fluoroquinolones emerged as the most important risk factor for CDAD in Quebec during an epidemic caused by a hypervirulent strain of C. difficile.