"A button in my Benjamin" - Self-inflicted insertion of button batteries into the male urethra: Management and complications.

We present a case of self-insertion of multiple button batteries into the urethra. Button batteries are corrosive and tissue liquefaction and necrosis can occur within 2 hours. Emergent removal, intravenous antibiotics, suprapubic and indwelling catheter insertion and close monitoring are required to prevent further tissue injury. In our case, the batteries were removed with stent grasper forceps. There was extensive caustic circumferential injury to the urethral mucosa on cystoscopic examination. This was complicated by periurethral necrosis and abscess, requiring urgent incision and debridement. No reconstruction was performed due to the very high risk of graft failure.

Utility of urinary biomarkers in primary haematuria: Systematic review and meta-analysis.

Objectives: To evaluate the diagnostic performance of FDA-approved urinary biomarkers in the evaluation of primary haematuria for investigation of bladder cancer. Methods: The scientific databases MEDLINE, EMBASE, Pubmed and Web of Science were searched to collect studies. Studies that evaluated the diagnostic performance of FDA-approved urinary biomarkers in investigating patients with primary haematuria without a prior history of bladder cancer were included. Quality of studies was assessed using the JBI Criteria. Bivariate mixed-effects regression model was used to calculate pooled sensitivities and specificities for each biomarker. Results: Eighteen studies were included in the analysis. The biomarkers assessed in these studies were CxBladder, AssureMDx, Bladder Tumour Antigen (BTA), NMP22, UroVysion and Immunocyt/uCyt+. Several biomarkers, such as AssureMDx, CxBladder and Immunocyt, were shown to have better diagnostic performance based on their sensitivity, specificity and diagnostic odds ratio, as well as positive and negative likelihood ratios. Across the six biomarkers, sensitivity ranged from 0.659 to 0.973, and the specificity ranged between 0.577 and 0.833. Conclusion: Despite certain biomarkers demonstrated better performance, current diagnostic abilities of the FDA-approved biomarkers remain insufficient for their general application as a rule out test for bladder cancer diagnosis and as a triage test for cystoscopy in patients with primary haematuria. High-quality prospective studies are required to further analyse this and also analyse the correct scenario in which urinary biomarkers may be best utilised.

A Historical Perspective of the Evolution of Laparoscopic Surgeries in Urology.

Recent decades have seen the rapid progression of minimally invasive surgery in urology with continuing developments in robotic technology paving ways into a new era. In addition to these technological innovations, interests from urologists in developing and embracing new techniques have become a forefront in the ongoing evolution of the field allowing for improvement in intraoperative experience as well as morbidity and mortality outcomes. This article aims to provide an overview of the historical development of laparoscopic surgery in urology while also providing a brief look into its future.

Primary localised bladder amyloidosis - A case report with review of the literature.

Primary bladder amyloidosis, a mimicker of bladder malignancy, is a rare but important differential diagnosis for patients presenting with haematuria. We report the case of a 58-year-old man who initially presented with macroscopic haematuria and irritative urinary tract symptoms. There was no radiological evidence of a bladder mass lesion, but cystoscopy revealed an erythematous papillary lesion in the posterior bladder wall concerning for bladder malignancy. Histology demonstrated primary bladder amyloidosis, which was completely excised intraoperatively. He is undergoing regular cystoscopic surveillance and there has been no disease recurrence for 4 years since the initial diagnosis.

Pretreatment of choriocarcinoma syndrome: a rare complication of metastatic germ cell tumours.

A 27-year-old man newly diagnosed with metastatic testicular choriocarcinoma developed a large right perinephric haematoma secondary to a metastatic deposit in his right kidney. His presentation was also complicated by bilateral iliac venous thrombosis and pulmonary embolism identified prior to initiation of chemotherapy. He underwent multiple attempts at angioembolisation of the bleeding vessels and ultimately angioembolisation of the main renal artery had to be performed to control the bleeding. Following resolution and commencement of chemotherapy, the patient also developed spontaneous intracranial haemorrhage requiring craniotomy.

Management of the Distal Ureter During Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Comprehensive Review of Literature.

PURPOSE: Radical open nephroureterectomy (ONU) with bladder cuff excision (BCE) is the traditional gold standard approach for management of high-risk non-metastatic upper tract urothelial cancer. ONU involves two separate procedures; the nephrectomy and distal ureterectomy, with each of these parts being able to be performed with an open or minimally-invasive approach. Multiple approaches have been described for the resection of the distal ureter and bladder cuff after mobilization of the kidney and upper ureter. MATERIALS AND METHODS: A Medline search of the literature including relevant articles up to March, 2020 was performed. Search terms included "nephroureterectomy", "upper tract urothelial carcinoma", "upper urinary tract carcinoma OR UTUC", "open OR conventional OR ONU OR conventional", "robotic-assisted nephroureterectomy OR RANU", "laparoscop* OR LNU OR LRNU" and "minimally-invasive nephroureterectomy". Original articles, case series and review articles were included. RESULTS: There are no randomised studies. Various techniques have been described to manage the distal ureter during nephroureterectomy. This review provides an overview of these techniques. The perioperative and oncological outcomes following open versus endoscopic techniques and minimally invasive techniques have been described. Although endoscopic approaches have more favourable perioperative outcomes, this comes at the expense of increased risk of tumour spillage and recurrence compared to the traditional open approaches. Minimally-invasive techniques (laparoscopic and robotic-assisted NU) largely have superior perioperative outcomes versus their open NU counterparts, with comparable oncological outcomes. CONCLUSION: Current non-randomised evidence is open to selection bias and is insufficient to support or refute endoscopic management of the distal ureter as an alternative to open bladder cuff excision. The optimal approach to nephroureterectomy and management of the distal ureter continues to remain a surgical dilemma.

Malignant ascites following radical nephrectomy for cystic renal cell carcinoma.

A 69-year-old man with a history of laparoscopic radical nephrectomy for papillary renal cell carcinoma presented with a 1-week history of generalised abdominal pain, distension and loss of appetite. Clinical examination and CT imaging demonstrated ascites associated with peritoneal nodules, raising the possibility of metastatic disease. Immunochemistry staining from ascites fluid cytology confirmed renal cell carcinoma. Following multidisciplinary discussions, the patient was commenced on a small-molecule tyrosine kinase inhibitor.

What's new in robotic partial nephrectomy.

OBJECTIVE: Robot assisted partial nephrectomy (RAPN) is a minimally invasive option for patients with small renal masses undergoing partial nephrectomy. In this review we provide an update on the oncological safety and renal functional outcomes following RAPN. We also discuss the novel techniques and technological advances that have contributed to the outcomes of RAPN.  METHODS: A Medline search using the keywords "partial nephrectomy", "robotic partial nephrectomy", "robot assisted partial nephrectomy", "robot assisted laparoscopic partial nephrectomy" and "laparoscopic partial nephrectomy" was conducted to identify original articles, review articles, and editorials on RAPN. RESULTS: A review of the literature suggests that RAPNis emerging as the preferred approach to minimally invasive nephron sparing surgery. RAPN is superior to laparoscopic partial nephrectomy (LPN) and open partial nephrectomy (OPN) in terms of perioperative outcomes with equivalent mid-term oncological outcomes. RAPN has proven safety and efficacy even in complex renal tumors with equivalent oncological and functional outcomes. Novel techniques and advances in technology have contributed to the safety and efficacy of RAPN. CONCLUSION: RAPN can be considered to be the gold standard approach to minimally invasive nephronsparing surgery with equivalent oncological and  renal functional outcomes and superior perioperative outcomes when compared to OPN. Newer techniques and developments in robotic technology have contributed to improved outcomes following RAPN.

OBJETIVO: La nefrectomía parcial asistida por robot (NPAR) es una opción mínimamente invasivapara pacientes con masas renales pequeñasintervenidos mediante nefrectomía parcial. En esta revisiónpresentamos una puesta al día sobre la seguridadoncológica y los resultados funcionales después dela NPAR. También discutimos las nuevas técnicas y losavances tecnológicos que han contribuido a los resultadosde la NPAR.MÉTODOS: Se realizó una búsqueda bibliográficapara identificar artículos originales, de revisión y editorialessobre la NPAR, utilizando las palabras clave nefrectomía parcial, nefrectomía parcial robótica, nefrectomíaparcial asistida por robot, nefrectomía parciallaparoscópica asistida por robot y nefrectomía parcial laparoscópica. RESULTADOS: Una revisión de la literatura sugiere quela NPAR está emergiendo como el abordaje preferidode la cirugía conservadora de nefronas mínimamenteinvasiva. La NPAR es superior a la nefrectomía parciallaparoscópica (NPL) y la nefrectomía parcial abierta(NPA) en resultados peroperatorios con resultados oncológicosa medio plazo equivalentes. La NPAR hademostrado seguridad y eficacia, incluso en tumoresrenales complejos, con resultados oncológicos y funcionalesequivalentes. Las técnicas nuevas y los avancestecnológicos han contribuido a la seguridad y eficaciade la NPAR. CONCLUSIONES: La NPAR puede considerarse elabordaje patrón oro de referencia para la cirugía conservadorade nefronas mínimamente invasiva con resultadosoncológicos y funcionales renales equivalentes yresultados peroperatorios superiores en comparacióncon NPA. Las técnicas y desarrollos más nuevos entecnología robótica han contribuido a mejorar los resultados de la NPAR.

Impact of multiparametric MRI and MRI-targeted biopsy on pre-therapeutic risk assessment in prostate cancer patients candidate for radical prostatectomy.

PURPOSE: To assess the current status and future potential of multiparametric MRI (mpMRI) and MRI-targeted biopsy (MRI-TBx) on the pretherapeutic risk assessment in prostate cancer patients' candidates for radical prostatectomy. METHODS: A literature search of the MEDLINE/PubMed and Scopus database was performed. English-language original and review articles were analyzed and summarized after an interactive peer-review process of the panel. RESULTS: Pretherapeutic risk assessment tools should be based on target plus systematic biopsies, where the addition of systematic biopsy (TRUS-Bx) to the mpMRI-target cores is associated with a lower rate of upgrading at final pathology. The combination of mpMRI findings with clinical parameters outperforms models based on clinical parameters alone in the prediction of adverse pathological outcomes and oncological results. This is particularly true when a specialized radiologist is present. CONCLUSION: The combination of mpMRI findings and clinical parameters should be considered to improve patient stratification in the pretherapeutic risk assessment. There is an urgent need to develop or include MRI data and MRI-TBx findings in available preoperative risk tools. This will allow improving the pretherapeutic risk assessment, providing important additional information for patient-tailored treatment planning and optimizing outcomes.

Impact of learning curve on the perioperative outcomes following robot-assisted partial nephrectomy for renal tumors.

INTRODUCTION: Robot-assisted partial nephrectomy (RAPN) is an established, minimally invasive technique to treat patients with renal masses. The aim of this study was to assess the learning curve (LC) of RAPN, evaluate its impact on perioperative outcomes following RAPN and to study the role of surgeon experience in achieving "trifecta" outcomes following RAPN. METHODS: We prospectively analyzed the clinical and pathological outcomes of 108 consecutive patients who underwent RAPN for renal tumors from January 2012 to December 2016 by a laparoscopy trained surgeon with no prior robotic experience. We used warm ischemia time (WIT) <20 min, operative time <120 min, and blood loss <100 ml as endpoints for plotting the LCs. Trifecta was analyzed in relation to our LC. RESULTS: Surgeon experience was found to correlate with WIT, operative time, and blood loss. Overall 18.5% of patients developed complications. Complication rate reduced with increasing surgeon experience. LC was 44 cases for WIT ≤20 min, 44 cases for operative time <120 min, and 54 cases for blood loss <100 ml. Trifecta outcome was achieved in 67.6% patients overall and was found to correlate with increasing surgeon experience. Improvement in trifecta outcomes continued to occur beyond the LC. CONCLUSIONS: RAPN is a viable option for nephron-sparing surgery in patients with renal carcinoma. For a surgeon trained in laparoscopy, acceptable perioperative outcomes following RAPN can be achieved after an LC of about 44 cases. Increasing surgeon experience was associated with improved "trifecta" achievement following RAPN.

A Sporadic Small Jejunal GIST Presenting with Acute Lower Gastrointestinal Hemorrhage: A Review of the Literature and Management Guidelines.

Gastrointestinal stromal tumors (GISTs) represent the majority of primary nonepithelial neoplasms of the digestive tract, most frequently expressing the KIT protein detected by immunohistochemical staining for the CD117 antigen. Jejunal GISTs account for approximately 10 % of GISTs. Patients usually present with abdominal discomfort. Jejunal GISTs may cause symptoms secondary to obstruction or hemorrhage. Pressure necrosis and ulceration of the overlying mucosa may cause gastrointestinal bleeding, and patients who experience significant blood loss may suffer from malaise and fatigue. Literature has classified small-bowel GISTs on the basis of size, and various established guidelines have advised conservative management of small jejunal GISTs (<2 cm). We here report the clinical, macroscopic, and immunohistological features of a small jejunal GIST presenting with acute lower gastrointestinal hemorrhage in a 50-year-old postmenopausal woman necessitating an emergency laparotomy to control the bleed. The management of very small (<2 cm) small-bowel GISTs is controversial. While guidelines are primarily based on the risk of malignancy in GISTs, no guideline predicting the risk of complications in small-bowel GISTs exists. Hence, these tumors should be removed even if incidentally detected.

Procalcitonin Strip Test as an Independent Predictor in Acute Pancreatitis.

Plasma procalcitonin (PCT) is a highly specific marker for the diagnosis of bacterial infection and sepsis. Studies have demonstrated its role in the setting of sepsis and acute pancreatitis. This study aims to analyze and compare the prognostic efficacy of plasma procalcitonin strip test in acute pancreatitis. A prospective study was conducted in the department of general surgery from June 2012 to June 2013. Plasma procalcitonin was estimated by the semiquantitative strip test. The study included a total of 50 patients diagnosed to have acute pancreatitis. Data was collected and statistically analyzed using SPSS version 17. Thirty-nine out of the 50 patients (78 %) were males with a mean age of 46.8 years (range, 25-78 years) and 25 patients (50 %) had ethanol-induced pancreatitis, while 13 patients (26 %) had gall stone pancreatitis. Plasma PCT values were found to correlate better than CRP levels and total leukocyte count with the total duration of hospitalization, ITU, and ICU stay, as well as with the progression to severe acute pancreatitis. A cut off for plasma PCT of >2 ng/mL was found to be 100 % sensitive and 100 % specific and a cut off for CRP of >19 mg/dL was 70 % sensitive and 65 % specific for predicting the progression to severe acute pancreatitis. Plasma PCT also correlated well with antibiotic requirement. A cut off value of >0.5 ng/mL for plasma PCT was 100 % sensitive and 80 % specific and a cut off value of >18 mg/dL for CRP was 86 % sensitive and 63 % specific for predicting antibiotic requirement. Plasma procalcitonin is an early and reliable prognostic indicator in acute pancreatitis. The procalcitonin strip test is a rapid test which is useful in analyzing prognosis in patients with acute pancreatitis.