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Racial disparities in prostate cancer have not been well characterized on a genomic level. Here we show the results of a multi-institutional retrospective analysis of 1,152 patients (596 African-American men (AAM) and 556 European-American men (EAM)) who underwent radical prostatectomy. Comparative analyses between the race groups were conducted at the clinical, genomic, pathway, molecular subtype, and prognostic levels. The EAM group had increased ERG (P, Walter Rayford, Alp Tuna Beksac et al. investigated gene expression alterations in African-American and European-American men who underwent radical prostatectomy for prostate cancer. The observed differences include higher expression of inflammation genes and lower expression of mismatch repair genes in African-American men.

To determine whether local anesthetic infiltration and non-narcotic pain medications can safely reduce or eliminate opioid use following robotic-assisted laparoscopic prostatectomy while maintaining adequate pain control. After initiation of this quality-improvement project, patients undergoing robotic-assisted laparoscopic prostatectomy had surgeon-administered local anesthesia around all incisions into each successive layer from peritoneum to skin, with the majority infiltrated into the transversus abdominis muscle plane and posterior rectus sheath of the midline extraction incision. Post-operatively patients received scheduled acetaminophen plus ketorolac, renal function permitting. A retrospective review was performed for all cases over 19 months, spanning project implementation. 157 cases (76 in opioid-free pathway, 81 in standard pathway) were included. Five patients (6.6%) in the opioid-free pathway required post-operative opioids while inpatient, versus 61 (75.3%) in the standard pathway, p

Several diseases associated with erectile dysfunction (ED), such as type 2 diabetes mellitus (T2DM) and coronary artery disease (CAD), are known to have seasonal variation, with increased incidence during winter months. However, no literature exists on whether this chronological-seasonal evolution is also present within ED symptomatology. We hypothesized ED would follow the seasonal pattern of its lifestyle-influenced comorbid conditions and exhibit increased incidence during winter months. In order to investigate the seasonal variation of ED in the United States between 2009 and 2019, Internet search query data were obtained using Google Trends. Normalized search volume was determined during the winter and summer seasons for ED, other diseases known to be significantly associated with ED (T2DM and CAD), kidney stones (positive control), and prostate cancer (negative control). There were significantly more internet search queries for ED during the winter than during the summer (p = 0.001). CAD and T2DM also had significantly increased search volume during winter months compared to summer months (p p = 0.011, respectively). By contrast, searches for kidney stones were significantly increased in the summer than in the winter (p p = 0.75). In conclusion, Google Trends internet search data across a ten-year period in the United States suggested a seasonal variation in ED, which implies an increase in ED during winter. This novel finding in ED epidemiology may help increase awareness of ED’s associated lifestyle risk factors, which may facilitate early medical evaluation and treatment for those at risk of both ED and cardiovascular disease.

Introduction: Migration of surgical clips is a well-known phenomenon that is not uncommon. Migration of clips into the ureter is a rarely described event with only few case reports describ...

Introduction and Objectives: Published literature on damages to a digital flexible ureteroscope (DFU) examines a limited number of ureteroscopes and shows wide variation in its durability. The aim of this study was to compare the primary damage location, causes of DFU damages, and the durability of Karl Storz Flex-Xc digital ureteroscope between University Hospital (UH) and Ambulatory Care Surgery Center (ASC). We also evaluated the available literature on the durability of DFU. Methods: Each damaged DFU prospectively underwent a manufacturer's evaluation to determine the reason for return and primary site of damage. Hospital data on the number of ureteroscopic procedures and damaged DFUs over 3 years were retrospectively reviewed. The possible reason for the damage was classified as either intraoperative or between the procedures. The durability of DFUs, type, and cause of damage were compared between the UH and nonteaching ASC. A chi-square test was utilized for categorical variables. When cell frequencies were

Objective: To evaluate whether color-coding of prostate core biopsy specimens aids in preservation of the neurovascular bundles from an oncological perspective. Materials and Methods: MRI guided transrectal ultrasound and biopsy of the prostate were performed in 51 consecutive patients suspected of being at high risk for harboring prostate cancer. Core specimens were labeled with blue dye at the deep aspect and red dye at the superficial peripheral aspect of the core. The distance from the tumor to the end of the dyed specimen was measured to determine if there was an area of normal tissue between the prostate capsule and tumor. Results: Of the 51 patients undergoing prostate biopsy, 30 (58.8%) were found to have cancer of the prostate: grade group 1 in 13.7%, 2 in 25.5%, 3 in 7.8%, 4 in 7.8% and 5 in 3.9% of the cohort. A total of 461 cores were analyzed in the cohort, of which 122 showed cancer. Five patients opted to undergo robotic assisted laparoscopic radical prostatectomy. No patients had a positive surgical margin (PSM) or extra prostatic extension (EPE) on radical prostatectomy if there was a margin of normal prostatic tissue seen between the dye and the tumor on prostate biopsy. Conclusion: Color-coding of prostate biopsy core specimens may assist in tailoring the approach for preservation of the neurovascular bundles without compromising early oncological efficacy. Further study is required to determine whether this simple modification of the prostate biopsy protocol is valuable in larger groups of patients.

Pyelovenous/pyelolymphatic backflow from acute ureteral obstruction, manifesting radiologically as perinephric fat stranding (PFS), may result in elevated serum creatinine. Among patients with acutely obstructing ureterolithiasis, we evaluated the relationship between degree of PFS and changes in serum creatinine from baseline.Our tertiary care center's radiology dictation system (Fluency Discovery, M Modal) was queried for noncontrast abdominopelvic CT studies obtained in the Emergency Department for patients with obstructing ureteral calculi from 7/2015 to 4/2016. A single radiologist blinded to clinical data reviewed all CT scans and coded stone size, location, severity of hydronephrosis, and degree of PFS (none, mild, moderate, severe). For patients who met imaging criteria, a retrospective chart review was performed.We evaluated 148 patients with mean age of 46 years (SD 14.6), 56.0% (n = 83) were male. On univariate analysis, moderate-severe perinephric stranding was associated with elevated creatinine from baseline (OR 2.93, p = 0.03). Mean creatinine increased as the severity of stranding increased (none Cr = 0.978 mg/dL, mild Cr = 0.983 mg/dL, moderate Cr = 1.165 mg/dL, severe Cr = 1.370 mg/dL; p 0.01). An increase in creatinine from baseline was not associated with greater severity of hydronephrosis (OR 0.504, p = 0.189). There was no association between degree of PFS and severity of hydronephrosis, positive urine culture, stone location, or symptom duration (p 0.05). On regression analysis controlling for positive urine culture and degree of hydronephrosis, there remained an association between elevated serum creatinine from baseline and moderate-severe PFS (OR 9.0, p = 0.01).Among patients with acute obstructive ureterolithiasis, moderate-severe PFS was associated with elevated serum creatinine from baseline. This elevated creatinine was not explained by the obstructed kidney alone, as there was no association between the severity of hydronephrosis and increased creatinine. Pyelovenous/pyelolymphatic backflow resulting in PFS may be a contributing factor to elevated serum creatinine in this setting.

Objective To describe the surgical technique we used to perform a stentless intracorporeal ureteroenteric anastomosis and to determine the outcomes in this initial series. Methods We performed a retrospective review of a prospective database of all patients undergoing robotic-assisted intracorporeal urinary diversion with stentless ureteroenteric anastomosis between March 2014 and July 2016. Diversions were performed at the time of either robotic-assisted laparoscopic cystectomy for bladder cancer or urinary diversion for other indications. Results A total of 10 patients underwent implantation of 20 ureters into the intestine via a robotic-assisted approach with intentional omission of stents. Median body mass index was 29.57 (first quartile 23.68, third quartile 34.69). Median American Society of Anesthesiologists score was 3 (range 2-3). Seven patients had intracorporeal ileal conduit reconstruction and 3 patients had an intracorporeal neobladder creation. There were no patients who developed a stricture of the ureter nor did any patient develop a leak at the ureteroenteric anastomosis. All patients had normal serum creatinine at least 4 weeks after surgery, and all patients had follow-up computed tomography of the kidneys, which were normal. The median follow-up was 8 months (first quartile = 3 months, third quartile = 17 months). Conclusion Robotic intracorporeal urinary diversion with intentional omission of ureteral stents is a safe and feasible option when establishing continuity of the genitourinary and gastrointestinal tracts.

This study aimed at demonstrating the feasibility of robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder with stentless ureteroileal anastomosis. Pure intracorporeal robotic assisted laparoscopic technique has been recently developed with a select number of high-volume centers utilizing various operative and neobladder techniques. We reviewed the patient characteristics, operative details and perioperative courses in the two patients who have undergone robotic assisted laparoscopic radical cystectomy with pure intracorporeal modified Ves.Pa neobladder and one who has undergone the Hautmann W neobladder. These results were compared to other contemporary robotic neobladder series. We demonstrate technical success with similar operative and perioperative results with the modified Ves.Pa neobladder. The robotic pure intracorporeal modified Ves.Pa neobladder is a technically feasible operation and may be easier to perform compared to other neobladders. Initial experience suggests operative time and perioperative outcomes are similar to other robotic techniques.

INTRODUCTION AND OBJECTIVES:Prostate cancer (CaP) remains a disease with significant morbidity and mortality. To prevent a rise in CaP morbidity and mortality, prostate specific antigen (PSA) scree...

Background: Upper tract urothelial carcinoma (UTUC) is an uncommon disease that is diagnosed clinically by the selective use of urine cytology, urine biomarkers, and imaging of the upper tract. We present a case of a patient with Lynch syndrome and high-grade UTUC that was diagnosed by an abnormal Cxbladder assay, prompting further endoscopic examination. Case Presentation: A 59-year-old Caucasian female with a history of endometrial cancer and bladder cancer with Lynch syndrome presented for evaluation of recurrent urothelial carcinoma. Her previous bladder tumors have been T1 high grade and Ta high grade and have been treated with resection and multiple cycles of intravesical Bacillus Calmette–Guerin (BCG) therapy. She had also undergone a robotic left distal ureterectomy and psoas hitch for a high-grade distal ureteral tumor. Surveillance cystoscopy 7 months after revealed a biopsy-confirmed bladder tumor, which was resected, and she was started on maintenance BCG therapy. At presentation, follow-up urine cytology and UroVysion studies were negative. Cxbladder test was also initially negative. However, during close clinical monitoring, the Cxbladder test became positive. Cystoscopy was once more performed, which was unremarkable. Bilateral ureteroscopy was performed, revealing high-grade upper tract renal papillary carcinoma (UTUC) in the left renal pelvis. The patient declined a nephroureterectomy. She was treated with two sessions of holmium laser ablation of the left renal pelvis tumor and underwent 6 weekly courses of BCG + interferon instilled into her left renal pelvis using a 5F open-ended catheter. Repeat urine cytology, UroVysion, and Cxbladder tests were negative after completion of upper tract BCG therapy. Conclusion: Cxbladder test may be useful and an adjunct to urine cytology and the UroVysion FISH assay to evaluate patients at high risk for recurrent UTUC.

A 65-year-old woman presented with recurrent urinary tract infections. A computed tomography of the abdomen and pelvis shows a dilated and malrotated right renal pelvis consistent with a ureteropelvic junction obstruction as well as multiple renal arteries arising from the aorta. A computed tomography angiography revealed 5 separate renal arteries originating from the aorta with a single renal artery crossing over and obstructing the right renal pelvis. On Lasix renogram, the affected kidney contributes 45% of total renal function. The patient remained asymptomatic (absent of hematuria, flank pain, infection) and opted for active surveillance.

Introduction We describe a case of renal pelvi-ureteric fungus ball managed with placement of two nephrostomy tubes and amphotericin B irrigation through a nephrostomy tube with the other to free drain. Case Report A 46-year-old man with uncontrolled Type 2 diabetes mellitus was referred to the urology clinic for workup of recurrent urinary tract infection. Urine culture grew Candida albicans. The patient was started on oral fluconazole therapy. Cystoscopy and cystogram revealed a grade 3 left vesicoureteral reflux and right retrograde pyelogram revealed a filling defect in the right renal pelvis extending into the proximal ureter with severe hydroureteronephrosis. Two nephrostomy tubes were placed (mid-pole and lower pole) to ensure that the system was not obstructed. Amphotericin B (50 mg/1000 ml normal saline) irrigation was then instilled through the mid-pole nephrostomy tube at a rate of 30 ml/h with the lower pole nephrostomy tube to free drain. An antegrade nephrostogram was performed after 5 days of amphotericin B instillation, showing complete resolution of the fungus ball. The patient is awaiting definitive minimally invasive management of the distal ureteral narrowing. Comments Renal and pelvi-ureteric fungus ball is a challenging clinical entity. It must be addressed promptly and efficiently to be successful. We describe a minimally invasive approach that was tolerated well and resulted in complete clearance of the fungus ball in a relatively short time frame.

As patients with end-stage renal disease are receiving renal allografts at older ages, the number of male renal transplant recipients (RTRs) being diagnosed with prostate cancer (CaP) is increasing. Historically, the literature regarding the management of CaP in RTR's is limited to case reports and small case series. To date, there are no standardized guidelines for screening or management of CaP in these complex patients. To better understand the unique characteristics of CaP in the renal transplant population, we performed a literature review of PubMed, without date limitations, using a combination of search terms including prostate cancer, end stage renal disease, renal transplantation, prostate cancer screening, prostate specific antigen kinetics, immuno-suppression, prostatectomy, and radiation therapy. Of special note, teams facilitating the care of these complex patients must carefully and meticulously consider the altered anatomy for surgical and radiotherapeutic planning. Active surveillance, though gaining popularity in the general low risk prostate cancer population, needs further study in this group, as does the management of advance disease. This review provides a comprehensive and contemporary understanding of the incidence, screening measures, risk stratification, and treatment options for CaP in RTRs.

Introduction and objective The Prostate Imaging Reporting and Data System (PI-RADS) score was developed to evaluate lesions in the peripheral and transition zone on multiparametric magnetic resonance imaging (mpMRI) of the prostate. We aim to determine if the PI-RADS scoring system can be used to evaluate central zone lesions on mpMRI. Materials and methods A retrospective review of 73 patients who underwent mpMRI/ultrasound (US) fusion-guided biopsy of 143 suspicious lesions between February 2014 and October 2015 was performed. All patients underwent a 3 T mpMRI. Indications for mpMRI included an abnormal digital rectal examination, PSA velocity >0.75 ng/dl/y, and patients on active surveillance. The mpMRI sequence involved T2-weighted imaging, diffusion-weighted imaging, and dynamic contrast enhancement. Using 3-dimensional model software (Invivo Corporation, Gainesville, FL, USA), a minimum of 3 magnetic resonance imaging (MRI)/US fusion-guided biopsy samples were taken from each prostate lesion seen on mpMRI irrespective of PI-RADS score, using local anesthesia in an outpatient clinic setting. Results A total of 73 patients underwent MRI/US fusion-guided biopsy of 85 peripheral zone lesions, 31 transitional zone lesions, and 27 central zone lesions. Only 2 (7%) of central zone lesions were positive for prostate cancer. Both patients had lesions which were graded as PI-RADS 3. Both the patients had multifocal lesions that encompassed≥50% of the central and transition zones on the sagittal view MRI images. Both patients previously had transrectal US-guided biopsy of the prostate which was negative for cancer. Both patients underwent a robotic-assisted laparoscopic prostatectomy, each revealing high-grade cancer. Conclusions Lesions involving only the central gland/zone seen on MRI are less concerning for malignancy and should not be given equal weight as peripheral zone lesions. In this series, no lesions involving solely the central gland/zone, regardless of PI-RADS score, was positive for malignancy on MRI/US fusion-guided biopsy. Consideration of a modified PI-RADS scoring system should be given to help identify central zone lesions with malignant potential.

To evaluate whether periprostatic fat volume and periprostatic fat ratio as determined by multiparametric magnetic resonance imaging (mpMRI) correlate with the presence of high-grade prostate cancer.A total of 295 consecutive patients (median age: 64, range: 38-84) underwent mpMRI of the prostate gland between August 2013 and February 2015. All patients underwent a 3 Tesla mpMRI. Using DynaCAD (Invivo, Gainesville, FL), we calculated the prostate volume and volume of the periprostatic fat seen on mpMRI. The periprostatic fat ratio was calculated using the formula periprostatic fat volume/prostate volume.A higher periprostatic fat volume (P .001) and a higher periprostatic fat ratio (P .001) were significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume (P .001). There was no correlation observed between periprostatic fat ratio and prostate-specific antigen (median: 7.34, range: 0.36-59.7, P = .274), age (median: 64, range: 38-84, P = .665), or body mass index (median: 28.33, range: 17.99-45.44, P = .310). Patients with a higher periprostatic fat ratio were more likely to undergo intervention for prostate cancer.A higher periprostatic fat ratio is significantly associated with a higher Gleason score. Periprostatic fat ratio is a better predictor of higher Gleason score compared with periprostatic fat volume and may be an important risk factor in diagnosing patients with higher grade prostate cancer.

Robotic-assisted ureteral reimplantations were performed on 3 patients at a single institution, 2 with Boari flap and psoas hitch and 1 with psoas hitch alone. These were for urothelial carcinoma of the distal ureter, ureteral obstruction caused by distal ureteral endometriosis, and ureteral transaction during gynecologic surgery. We used intraoperative ureteroscopy to confirm tumor margins as well as a simple technique for retrograde placement of transvesicle wire prior to ureteral anastomosis. Surgery and recovery were uneventful. This illustrates that robotic-assisted ureteral reimplantation with Boari flap and psoas hitch is a safe and viable approach for ureterovesicle reconstruction.

Objective • To describe six steps for haemostasis and collecting system closure ('six degrees of haemostasis') that are reproducible and that minimize the two most concerning complications of laparoscopic partial nephrectomy: haemorrhage and urine leakage. Methods • A retrospective study of 23 consecutive laparoscopic partial nephrectomy cases performed by a single surgeon between 2005 and 2008 using the 'six degrees of haemostasis' was carried out. Results • There were no cases of intraoperative, postoperative or delayed bleeding. • There were no cases of urine leakage. Conclusion • The 'six degrees of haemostasis' technique for laparoscopic partial nephrectomy described in the present study provides a reliable and reproducible method to reassure the surgeon of haemostasis and provide a decreased risk of urine leakage.

25 Background: Multi-parametric MRI (mpMRI) of PCa uses advanced sequences to detect aggressive, high grade and bulky lesions. Given known advantages of hypofractionated radiotherapy (RT) to treat PCa (low a/b ratio), we conducted a phase II trial to escalate a high dose to mpMRI lesion(s) via Image-Guided (IG)-RT/Volumetric Arc Therapy (VMAT)/Stereotactic Body Radiotherapy (SBRT) technology. We present the acute toxicity results of this novel approach. Methods: 22 pts with mpMRI lesion(s) were prospectively treated to a course of IGRT/VMAT to the prostate & seminal vesicle +/- pelvic lymph nodes (PLN) to a dose of 45 Gy in 25 fractions followed by SBRT boost, 18 Gy in 3 fraction to the prostate with a simultaneous integrated boost 21 Gy in 3 fractions (EQD2 = 85.2 Gy using a/b 3 or 93.4 Gy using a/b 1.5) to the mpMRI prostatic lesion(s). Placement of 3 polymer based fiducial markers visible in both CT and MRI for image co-registration and treatment guidance was performed. Genitourinary (GU) and gastrointestinal (GI) adverse events (AE) were scored using CTCAE v4. DSMC approved reporting of acute AE results prior to completion of trial accrual as an interim safety assessment prior to final trial accrual. Results: Median age was 66.5 years (range: 57-80). All patients had PI-RADS grade 3-5 mpMRI lesion(s); 41.0%, 45.4% and 13.6% having 1, 2 and 3 lesions respectively. Ten (45%) pts had Gleason Score (GS) 8-10 and 12 had GS 7 disease. Median PSA was 8.97 (range: 4.0-77.9). Eleven (50%), 10 (46%), and 1 (5%) pts had stage T1, T2, and T3 tumor, respectively. Nine pts received treatment to the PLN and 15 received androgen deprivation therapy. All patients completed the protocol treatment without reporting acute GI or GU AEs grade ≥3 during treatment or at follow up. Grade 2 GI (diarrhea) and GU toxicity (frequency) was seen in 2 (9%) and 9 (41%) pts, respectively, during treatment. Of the 16 pts (71%) with least 3 months follow-up all grade 2 GI and 55.5% GU toxicities had resolved. Conclusions: Early results of this prospective Phase II study suggest that high-dose RT for localized PCa via mpMRI-guided RT/VMAT and SBRT boost is tolerable with a favorable acute toxicity profile.

OBJECTIVE To assess a prototype ureteric ‘buoy’ stent with a 10 F upper body tapering to a 3F tail, developed to potentially reduce stent-related irritative symptoms while providing an adequate mould for healing after endopyelotomy. MATERIALS AND METHODS Eighteen Yucatan minipigs had the stent placed either into the intact ureter (phase I) or after Acucise proximal endoureterotomy (phase II). Buoy stents were compared to 10/7 F endopyelotomy stents and to standard 7 F stents in phases I and II, respectively. The pigs were assessed for vesico-ureteric reflux, hydronephrosis and infection, before stent insertion and at harvest. Stents were weighed before and after placement and the removal force was measured. Pressure/flow studies, antegrade nephrostograms and specimens for histopathology from the renal pelvis, ureter and vesico-ureteric junction (VUJ) were obtained at harvest. RESULTS Thirteen minipigs survived the entire study. Ureteric flow with the stents in situ was better for buoy stents than for 10/7 F stents (P

Bowel injury is an uncommon, although potentially devastating, intraoperative laparoscopic complication. Questions have been raised about the possible use of a tissue adhesive to repair injured bowel. We compared glued repair and sutured repair of both large bowel (LB) and small bowel (SB) electrosurgical injuries in a rabbit model.Pneumoperitoneum was obtained, and four laparoscopic ports were placed in each of 48 New Zealand rabbits. The hook electrode was used in a specified manner to create an equal number of uniform full-thickness injuries to either the SB or the LB. Laparoscopic repair was performed with a 3-0 silk Lembert suture (LS), fibrin glue (FG), or BioGlue (BG), or repair was not performed (i.e., no repair, NR); the animals were monitored for 3 weeks. Adverse clinical outcomes and findings at laparotomy were recorded. Pathologic assessment included an objective scaled evaluation of the intensity of the inflammatory response and degree of healing.In the SB injury group, deteriorating clinical condition necessitated early euthanasia in one animal repaired with FG, one animal repaired with BG, and two animals with NR. LS repair animals had no adverse clinical outcomes. The LB injury group had no adverse clinical outcomes regardless of the method of repair, including the control group. Of the animals that survived for 3 weeks, the animals repaired with BG had more intraabdominal adhesions (100%) than LS (33%), FG (55%), and NR (50%) (p = 0.001). The pathologic assessment revealed that BG induced a more intense inflammatory response (p0.05).In the rabbit, suture repair of an electrosurgical SB injury appears to have improved outcomes when compared with a glued repair. In contrast, LB injury responded well to any form of treatment. The data suggest that suture is superior to biological glues when dealing with a laparoscopic electrosurgical bowel injury.

To describe our Seldinger technique of percutaneous renal cryoablation that was devised to facilitate renal biopsy, cryoprobe placement, and instillation of adjunctive hemostatics while protecting surrounding tissues from cryoinjury.This approach was used to manage 13 renal masses in 12 adult patients. Under CT-fluoroscopic guidance, an access needle was inserted to abut the surface of the tumor, followed by an Amplatz super-stiff guidewire and a customized coaxial catheter system, which was used as a conduit for needle biopsy, cryoprobe insertion, and FloSeal instillation. In addition, a porcine model was used to compare the temperature readings adjacent to the sheathed and the unsheathed cryoprobe during percutaneous renal cryoablation.In all patients, the use of this access approach was accomplished without incident. Two patients needed blood transfusions. No patient had significant skin, muscle, or nerve debility. At a mean follow-up of 11 months, none had evidence of persistent disease on CT or MRI contrast imaging. In the porcine model, the customized sheath protected the surrounding tissues from reaching temperatures below 5 degrees C while temperatures down to -15 degrees C were obtained when no insulating sheath was used.A modified Seldinger technique enabled us to perform percutaneous renal cryotherapy through a single access channel, which facilitated access for biopsy, cryoprobe placement, and instillation of hemostatic agents. This approach may provide a protective barrier against cryogenic damage to neighboring tissues and could theoretically help minimize the chance of tract seeding.

We reviewed our 4-year experience with percutaneous cryoablation and laparoscopy for treating small renal masses.After institutional review board approval we retrospectively analyzed renal cryoablation procedures performed between March 2003 and October 2007. An in-depth analysis was performed concerning demographics, hospital course and short-term outcome with respect to percutaneous vs laparoscopic cryoablation.A total of 37 patients underwent treatment for 43 renal masses. Of the 37 patients 19 underwent laparoscopic cryoablation (24 tumors) and 18 underwent percutaneous cryoablation (19 tumors) using computerized tomography fluoroscopy. For percutaneous cryoablation a saline instillation was used in 58% of cases to move nonrenal vital structures away from the targeted renal mass. There were 5 cases of hemorrhage requiring transfusion, all of which were associated with the use of multiple cryoprobes. The transfusion rate in the percutaneous and laparoscopic cryoablation groups was 11.1% and 27.8%, respectively. Operative time was significantly longer in the laparoscopic cryoablation group compared to the percutaneous cryoablation group at 147 (range 89 to 209) vs 250.2 (range 151 to 360) minutes, respectively. The overall complication rate (including transfusion) was lower in the percutaneous cryoablation group compared to the laparoscopic cryoablation group (4 of 18 [22.2%] vs 8 of 20 [40%], respectively). Hospital stay was significantly shorter in the percutaneous vs laparoscopic cryoablation group at 1.3 vs 3.1 days, p0.0001, respectively. Narcotic use in the percutaneous cryoablation group was more than half that used by the laparoscopic cryoablation group (5.1 vs 17.8 mg, p = 0.03, respectively). Among patients with biopsy proven renal cell carcinoma during a median followup of 11.4 and 13.4 months in the percutaneous and laparoscopic cryoablation groups, cancer specific survival was 100% and 100%, respectively, and the treatment failure rate was 5.3% and 4.2%, respectively.Percutaneous cryoablation is an efficient, minimally morbid method for the treatment of small renal masses and it appears to be superior to the laparoscopic approach. Short-term followup has shown no difference in tumor recurrence or need for re-treatment. Of note, hemorrhage was solely associated with the use of multiple probes.

There have been several reports of rhabdomyolysis occurring after prolonged laparoscopic procedures in the flank position. Accordingly, we evaluated interface pressures between the skin and three commonly used operating room table surfaces. The aim of our study was to determine if pressure changes could be related to body mass index (BMI), sex, position, and/or the table surface material.Ten men and 10 women were grouped according to BMI25 oror=25, with five participants in each group. Subjects were placed in the left lateral decubitus position with the operating table flat, half flexed, fully flexed, half flexed with the kidney rest elevated, and fully flexed with the kidney rest elevated. Interface pressures were recorded, using an X-Sensor pressure sensing mat, for 5-minute periods in each of the described positions on each surface.Sex and BMI were statistically significant predictors of increased pressures (P= 0.0042 and 0.0402, respectively). The parameter estimate for the difference between men and women was 4.63 mm Hg (P= 0.0002), and the difference for BMIor= 25 compared with25 was also significant (P0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P= 0.0001) and the half-flexed (25-degree) position (P0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P= 0.0117).Women have significantly lower interface pressures when compared with men. BMIor= 25 also increases interface pressures. The use of the kidney rest is associated with markedly increased pressure; use of a half-flexed position is preferable to a full-flexed position. These data have implications for patient positioning and identification of persons at risk for rhabdomyolysis during laparoscopic renal surgery.

We developed a simple, inexpensive model to simulate four reconstructive laparoscopic procedures: pyeloplasty, vesicourethral anastomosis, bladder injury repair, and partial nephrectomy.Liquid silicone was applied in layers to a mold to create the 4-in-1 model. A questionnaire evaluating its face and content validity was distributed to postgraduate urologists participating in a mini-residency program at the University of California-Irvine (UCI), and in the 2006 American Urological Association Hands-On course on reconstructive laparoscopic pyeloplasty.A total of 56 postgraduate urologists used the model and completed an evaluation questionnaire. Ninety-four percent (51/54) and 96% (48/50) agreed that the model was helpful for practicing laparoscopic pyeloplasty and urethrovesical anastomosis, respectively. Urologists who were experienced in either performing laparoscopic pyeloplasty (n = 6) or robot-assisted and/or laparoscopic prostatectomy (n = 11) would recommend this model to surgeons in training. Overall, 94% (48/51) and 96% (50/52) of the respondents would recommend this model for postgraduate surgeons and residents, respectively.We present a versatile model for practicing laparoscopic and robotic suturing and knot-tying skills in four reconstructive urologic procedures. Our results support the face and content validity of this model for performing pyeloplasty and vesicourethral anastomoses.

To compare our experience with laparoscopic radical cystectomy (LACIC) and robot-assisted laparoscopic radical cystectomy (RACIC) with ileal conduit urinary diversion.Prospective data were gathered on 20 consecutive patients undergoing LACIC performed between August 2002 and July 2005, and on 14 consecutive patients undergoing RACIC performed between March 2005 and December 2006. Radical cystectomy with pelvic lymphadenectomy was performed laparoscopically or robotically, and an ileal conduit urinary diversion was performed extracorporeally.There was no significant difference in terms of preoperative factors or baseline tumor characteristics and no significant difference in mean operative time (410 min v 419 min) between groups. There was less blood loss (212 mL v 653 mL; P0.0001) and fewer transfusions (42.8% v 70%; P0.0011) in the RACIC group. There was one intraoperative complication (7%) and no conversions in the RACIC group. There were three (15%) intraoperative complications all leading to conversion in patients undergoing LACIC. Three (21%) patients in the RACIC group and 10 (50%) patients in the LACIC group had at least 1 post-operative complication. The mean number of days to oral intake was less in the RACIC group (2.3 v 6.1; P = 0.012). There was no significant difference in the number of lymph nodes excised (P = 0.09) between groups. Bilateral extended lymphadenectomy was performed in 10 (71%) RACIC patients with a mean of 22.3 lymph nodes harvested and in 16 (80%) LACIC patients with a mean of 16.5 lymph nodes harvested. There were no positive margins in patients in the LACIC group and one (7.1%) among patients in the RACIC group--a patient with pT4 disease.Both laparoscopic and robot-assisted radical cystectomies can be performed safely without compromising oncologic standards for surgical margins and extent of lymphadenectomy. In this early experience, the robot-assisted approach appears to have a shorter learning curve, and it is associated with less blood loss, fewer postoperative complications, and earlier return of bowel function than LACIC.

INTRODUCTION After exposure of the retropubic space, the surgeon commonly dissects the fat overlying the prostate and usually discards it. We have previously described the importance of dissecting this fat to completely visualize the dorsal venous complex (DVC) and prostatic apex. In this study, we describe a technique to dissect and remove the anterior prostatic fat pad (APF) and its anatomic and pathologic significance. TECHNICAL CONSIDERATIONS After the retropubic space was prepared, we dissected the fat overlying the puboprostatic ligaments and the DVC to fully expose these structures. The superficial branch of the DVC was then transected, and the fat was dissected cephalad to the junction with the bladder. The fat was then further dissected laterally toward the lateral pelvic sidewall. Video analysis of the lateral dissection of the fat revealed a direct link to the obturator lymph node chain, where it was transected. Pathologic analysis demonstrated that 30 (14.7%) of 204 patients had one or more APF lymph nodes, of which four were positive for metastatic prostate cancer. The cancer of 3 of these 4 patients was upstaged as a result of the detection of these positive nodes. CONCLUSIONS The dissection of the APF facilitates visualization of the apex and bladder neck. Anatomically, we have demonstrated that the APF contains lymph nodes approximately 15% of the time that are in communication with the obturator lymph node chain and DVC. We found that removal of the APF and its pathologic analysis can result in pathologic upstaging.

Natural orifice translumenal endoscopic surgery (NOTES) using purpose-built equipment has never been applied to urologic surgery. Herein, we present our initial experience with a trans-vaginal single-port NOTES nephrectomy.An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline and the TransPort Multi-Lumen Operating Platform (USGI Medical, San Clemente, CA) was passed transvaginally. This flexible device has four working channels and can be locked into position, thereby creating a rigid multitasking platform that allows two-handed tissue manipulation. Dissection was performed using an endoscopic needle knife and a tissue grasper for retraction. Via the 12-mm port, the renal artery and vein were taken separately with a vascular EndoGIA and standard laparoscopic titanium clips, respectively. The kidney was placed in a 10-mm EndoPouch retriever and removed intact via the vagina. The total operative time was 300 minutes.Transvaginal NOTES nephrectomy can be accomplished in a porcine model. Additional testing on survival animals is necessary to validate this approach.

INTRODUCTION AND OBJECTIVES: Cytomegalovirus (CMV) prophylaxis is recommended for CMV-seronegative kidney transplant recipients (R-) receiving the grafts from CMV seropositive donors (Dþ). Meanwhile, whether Rþ patients need universal CMVprophylaxis remains unclear. Most of Rþ patients with low-grade CMV reactivation show spontaneous remissionwithout deteriorating thegraft function and survival. In addition, valganciclovir (VGCV) possibly causes some adverse effects and GCVresistant CMV. Although targeting CMV prophylaxis to Rþ patients is ideal, there are few reports addressing the risk factors of highgrade CMV reactivation in Rþ patients in the modern immunosuppressive era. METHODS: Since July 2004, consecutive 151 Rþ patients who received the kidney from Dþ in our hospital were enrolled in this study. No recipients received CMV prophylaxis. The induction immunosuppressive therapy was consisted of tacrolimus, MMF, steroid, and basiliximab. Patients with immunological high risks (ABO-incompatible or donor specific anti-HLAantibody positive) received a single-low dose of rituximab and 3 to 4 sessions of apheresis prior to transplantation. High-grade CMV reactivation was defined as CMV-antigenemia (Ag) positive cells becoming higher than 10/200,000 blood leukocytes during the clinical course. The CMV-Ag levelwasmonitoredat2 to3-weekly intervalsuntil 6months,andat monthly intervals from6 to 12months post-transplantation.We investigated the predictive risk factors of high-grade CMV reactivation in Rþ patients. RESULTS: The proportion of high-grade CMV reactivation was 29.8% (45/151) in this series. All patients who developedCMV reactivation were cured by VGCV or GCV successfully without inducing GCV-resistant CMV. Although no significant difference was found in the graft function, the graft survival was significantly shorter in the Rþ patients with CMV reactivation than those without (p 1⁄4 0.019). In multivariate analysis, the pre-transplant low-IgG titer against CMV (p 1⁄4 0.014), potent immunosuppressive protocol (p 1⁄4 0.019), and high level of MPA AUC 0-12 at 1 month after transplantation (p 1⁄4 0.045) were independently associated with the development of high-grade CMV reactivation in Rþ patients. CONCLUSIONS: The development of high-grade CMV reactivation deteriorated the graft survival in Rþ patients in the modern immunosuppressive era. Pre-transplant low-IgG titer against CMV, potent immunosuppressive protocol, and high MPA level were predictive risk factors for the development of high-grade CMV reactivation.

compared to controls, and were expressed as ratios. The pathway analysis using Gene Ontology (GO) annotation was done on the top 10% of proteins that exhibited the more pronounced differences in abundance between the groups. These significantly expressed proteins were used to analyze the group differences for biological processes, cellular components, and molecular function. RESULTS: Of the 2219 proteins identified by proteomic analysis, 146 proteins were up-regulated in CYS and 80 proteins were upregulated in HC. GO analysis in CYS showed a significant number of peptides involved in signal transduction (68 in males and 80 in females), and cell-cell signaling (17 in males and 21 in females). However, the signaling pathway was different in CYS males (Peroxisome ProliferatorActivated Receptor, PPAR) than in CYS females (NOTCH3). Proteins involved in fibrosis were found predominantly in CYS males (Table). Inter-alpha-trypsin inhibitor (ITIH), paraoxonase (PON1) and ceruloplasmin (CP) were more abundant in male CYS than female CYS and their matched HC. CONCLUSIONS: Patients with cystinuria and renal stones have a different urinary polypeptide profile compared to healthy controls. Fibrosis is more common in male CYS, and an aggressive approach may be warranted. Additionally, we identified ITIH and CP as potential diagnostic biomarkers and novel therapeutic targets in CYS. These unique proteins merit further investigation.

Vitamin D deficiency is more common among African Americans (AAs) than among European Americans (EAs), and epidemiologic evidence links vitamin D status to many health outcomes. Two genome-wide association studies (GWAS) in European populations identified vitamin D pathway gene single-nucleotide polymorphisms (SNPs) associated with serum vitamin D [25(OH)D] levels, but a few of these SNPs have been replicated in AAs. Here, we investigated the associations of 39 SNPs in vitamin D pathway genes, including 19 GWAS-identified SNPs, with serum 25(OH)D concentrations in 652 AAs and 405 EAs. Linear and logistic regression analyses were performed adjusting for relevant environmental and biological factors. The pattern of SNP associations was distinct between AAs and EAs. In AAs, six GWAS-identified SNPs in GC, CYP2R1, and DHCR7/NADSYN1 were replicated, while nine GWAS SNPs in GC and CYP2R1 were replicated in EAs. A CYP2R1 SNP, rs12794714, exhibited the strongest signal of association in AAs. In EAs, however, a different CYP2R1 SNP, rs1993116, was the most strongly associated. Our models, which take into account genetic and environmental variables, accounted for 20 and 28 % of the variance in serum vitamin D levels in AAs and EAs, respectively. Electronic supplementary material The online version of this article (doi:10.1007/s00439-014-1472-y) contains supplementary material, which is available to authorized users.

OBJECTIVES Fungal sepsis after ureteroscopy (URS) is rarely reported. We report on 2 cases of acute fungemia that developed after routine ureteroscopic stone manipulation in patients with advanced liver cirrhosis. This represents a unique and high-risk population, and, to our knowledge, these are the first such cases reported. METHODS We performed a retrospective review of the medical records of 2 patients with Child-Pugh class B and C liver cirrhosis who had undergone ureteroscopy (URS) and holmium laser lithotripsy for obstructing ureteral calculi. RESULTS The treated stones measured 10 mm and 12 mm and were at the right ureteropelvic junction and left ureterovesical junction, respectively. Both patients had had indwelling ureteral stents in place for 1 and 2 months before URS plus holmium laser lithotripsy, with negative preoperative urine cultures. Each procedure was uncomplicated, and a ureteral stent was left in situ in each case. Within 12 hours of URS, each patient became tachycardic, hypotensive, and febrile. Blood, urine (proximal to the stone), and stone cultures were positive for Candida albicans in both patients. They were both successfully treated with intravenous fluconazole and subsequently discharged from the hospital on postoperative day 12 and 13, respectively. CONCLUSIONS Patients with advanced liver disease appear to be at greater risk of fungal sepsis after otherwise uncomplicated URS and stone manipulation. Consideration should be given to prophylactic antifungal therapy, in addition to the standard antibacterial prophylaxis for such procedures.

Purpose: The appropriate management of infected obstructing ureteral calculi is prompt genitourinary decompression. Urine cultures are the gold standard for confirming infection but often take 24–48 h to result. Although white blood cell (WBC) count is an important diagnostic laboratory test, it is a nonspecific inflammatory marker. Similarly, urinalysis (UA) can be misleading in the setting of a contaminated sample, bladder colonization, or in cases of a completely obstructed the upper urinary tract. Procalcitonin (PCT) has shown promise in predicting the presence and degree of bacterial infections. In this proof-of-concept study, we explore whether PCT is effective at predicting concomitant infections in the setting of obstructing ureteral stones. Materials and Methods: This is a prospective, single-institution observational pilot study examining adult patients who presented to the emergency room with acute obstructing ureterolithiasis. In total, 22 patients were enrolled. At the time of presentation, data obtained were vital signs, WBC count, PCT, UA, urine, and blood cultures. Fisher-exact two-tailed t-tests and receiver operating characteristic statistics with area under the curve (AUC) calculations were used to determine the correlation between urine culture results and PCT, WBC count, nitrite-positive UA, heart rate, and fever. Results: In total, 5/22 patients had bacteria-positive urine cultures. PCT (P = 0.020) and nitrite-positive UA (0.024) were the only statistically significant predictors of urine culture results. In comparing the AUC, PCT (0.812) was strongly correlated with eventual urine culture results. Conclusions: This proof-of-concept pilot study gives encouraging results, in that PCT was a good predictor of positive cultures (P = 0.02, AUC 0.812). Given, the small sample size, one cannot directly compare PCT to other markers of infection. However, PCT shows promise in this arena and warrants future investigation.

Laparoscopic partial nephrectomy (LPN) has not received widespread clinical application because of its technical challenge. Bovine serum albumin glutaraldehyde (BSAG) is a hemostatic agent that is independent of the clotting cascade. We evaluated the use of BSAG as the sole agent for parenchymal and collecting system closure during LPN in a survival porcine model.Eighteen pigs underwent hilar clamping and LPN by longitudinal excision of the lateral one-third of the right kidney. The opened collecting system was covered with oxidized cellulose to prevent BSAG seepage into the urinary tract. BSAG was allowed to set for 10 or 5 minutes. Twelve animals underwent survival LPN BSAG only closure; six control pigs were acutely studied using saline. Urinary extravasation was evaluated by injection of furosemide and indigo carmine, and then evaluating the renal surface and bladder catheter drainage for dye. A subjective bleeding score was assigned after hilum unclamping. At 6 weeks, BSAG kidneys were harvested for burst pressure testing and histopathological analysis.All 12 pigs survived for 6 weeks. No pigs had urinary extravasation. Mean percentage of kidney removed by weight was 19%. Mean warm ischemia time was 29 minutes. Five pigs required a second BSAG application to achieve a bleeding score of 0. Mean arterial and collecting system burst pressures were 301.8 and 322.4 mm Hg, respectively. Mean postoperative creatinine increase was 0.07 mg/dL.BSAG for completely sutureless LPN in a survival porcine model was feasible.

Radical nephrectomy, as described by Robson et al. in 1963, is the traditional gold standard approach to the management of renal tumors (1). This procedure has an established success rate but is associated with significant postoperative pain and prolonged convalescence, stemming from the flank, subcostal, Chevron or thoraco-abdominal incisions typically used. Laparoscopic radical nephrectomy, as introduced by Clayman and associates in 1991, has become a suitable alternative to open radical nephrectomy over the 16 years since this first reported case (2). It is equally efficacious for small- to medium-sized tumors which are deemed not amenable to partial nephrectomy and also for larger tumors, in some cases as large as 25 cm (authors’ experience) (3,4). Cases with renal vein and limited subhepatic inferior vena caval thrombus can also be managed laparoscopically in high volume centers with extensive experience (5–9).

Laparoscopic partial/wedge nephrectomy, similar to laparoscopic radical prostatectomy, is a technically challenging procedure that is performed by a limited number of expert laparoscopic surgeons. The incorporation of a robotic surgical interface has dramatically increased the use of minimally invasive pelvic surgery such that robotic laparoscopic radical prostatectomy is commonly performed even by laparoscopically naïve surgeons. This analysis compares the outcomes of our initial experience with robot-assisted laparoscopic partial nephrectomy (RLPN) performed by an experienced open surgeon to that of standard laparoscopic partial nephrectomy (LPN) performed by two experienced laparoscopic surgeons.We reviewed the medical records of 11 consecutive patients who underwent 12 standard LPNs (EMM, RVC) (one patient had two unilateral tumors) and 10 consecutive patients (representing the first 11 of such robotic procedures performed at our institution) who underwent 11 RLPNs (one patient had bilateral tumors managed in an asynchronous manner) (DKO).The mean tumor size was 2.3 cm (range 1.7-6.2 cm) for LPN and 3.1 cm (range 2.5-4 cm) for RLPN. The mean total procedure time was 289.5 minutes (range 145-369 min) for LPN and 228.7 minutes (range 98-375 min) for RLPN (P=0.102). The mean estimated blood loss was 198 mL (range 75-500 mL) for LPN v 115 mL (25-300 mL) for RLPN (P=0.169). The mean warm ischemia time was 35.3 minutes (range 15-49 min) in the LPN group and 32.1 minutes (range 30-45 minutes) in the RLPN group (P=0.501).Introducing a robotic interface for laparoscopic partial/wedge resection allowed a fellowship-trained urologic oncologist with limited reconstructive laparoscopic experience to achieve results comparable to those for laparoscopic partial/wedge resection performed by experienced laparoscopic surgeons. In this regard, the learning curve appears truncated, similar to that with robot-assisted laparoscopic prostatectomy.

While most laparoscopic nephron sparing surgery is performed using cold scissors, energy based devices may also be used. A criticism of this approach has been the potential thermal destruction of the cellular architecture at the tumor margin, precluding the ability to accurately determine whether tumor cells are present. We clinically characterized the histological appearance of tumor margins excised with cold scissors, and bipolar and ultrasonic shears.We evaluated 40 renal mass excisions performed by a total of 3 urologists at our institution between February 2003 and March 2007. There were 10 bipolar (5 mm LigaSure), 20 ultrasonic (Harmonic Scalpel) and 10 cold excisions. All slides were randomly evaluated twice by a single pathologist blinded to surgeon and excision method. Histological interpretation of the margin was scored as clear vs indeterminate. Variables, including margin fragmentation, artifact, extravascular blood clot, parenchymal hemorrhage, capillary congestion and vessel sealing, were assessed and scored on a scale of 0 to 3, that is 0--none, 1-1% to 25%, 2-26% to 50% and 3--greater than 50%.The pathologist was able to confidently identify cells at the margin as being malignant or benign in all cases. Histologically the ultrasonic scalpel demonstrated increased fragmentation and extravascular blood clotting compared with those of the other cutting methods (p0.025 and0.026, respectively). The ultrasonic scalpel also showed increased artifact depth compared to that of cold cutting (p0.001). There were no statistical differences between the groups regarding margin artifact, parenchymal hemorrhage or capillary congestion. No statistical significance was observed in any variables between bipolar and cold cutting.Despite some degree of cellular damage the ability to determine whether cells at the margin were benign or malignant was not affected by using an energy based bipolar or ultrasonic device.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) using the daVinci robot (Intuitive Surgical, Sunnyvale, CA) has never been applied to urologic surgery. Here we present our initial experience with a combined transvaginal and transcolonic, single-port, robot-assisted NOTES nephrectomy.An acute experiment was performed in a female farm pig. A single 12-mm trocar was placed in the midline, and two 12-mm standard laparoscopic ports were placed into the abdomen via the vagina and the colon. The robotic ports were then telescoped into the 12-mm ports, and the daVinci S robot was docked. Dissection was performed using the Hot Shears and the ProGrasp instruments. The robotic camera was placed via the midline port and held by an assistant. Using the 12-mm transvaginal port, the renal artery and vein were divided separately with a vascular Endo GIA (US Surgical, Norwalk, CT) stapler. The kidney was placed into a 10-mm entrapment sack and removed intact via the vagina.Total operative time was 150 minutes. Estimated blood loss was less than 50 mL. No intraoperative complications occurred.A robot-assisted NOTES nephrectomy was accomplished in a porcine model using the daVinci S robot. Additional testing on survival animals is necessary to further explore this approach.