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Introduction: The evolving landscape of healthcare information dissemination has been dramatically influenced by the rise of artificial intelligence (AI) driven chatbots, providing patients with accessible and interactive platforms to obtain knowledge about medical procedures and conditions. Among the various surgical interventions in urology, inflatable penile prosthesis (IPP) is a common treatment for men with erectile dysfunction. As patients increasingly seek comprehensive resources to understand what this procedure entails, AI-based chat technologies, such as ChatGPT, have become more prominent. This study aimed to assess the capacity of ChatGPT to provide accurate and easily understandable responses to common questions regarding the IPP procedure., Materials and Methods: Ten frequently asked questions (FAQ) about the IPP procedure were presented to the ChatGPT chatbot in separate conversational sessions without follow up questions or repetitions. An evidence-based approach was employed to assess the accuracy of the chatbot's responses. Responses were categorized as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification.", Results: Upon review, 70% of ChatGPT's answers to questions regarding the IPP procedure were rated as "excellent," not necessitating further clarification. Twenty percent were considered "satisfactory," requiring minimal clarification, notably on the omission of statistical data and the depth of discussion on certain topics. Ten percent of the responses were "unsatisfactory," requiring substantial clarification, including a failure to provide a definitive answer when necessary., Conclusions: This study reveals that ChatGPT has a substantial capability to produce evidence-based, understandable responses to a majority of common questions related to the IPP procedure. While there is room for improvement, ChatGPT can serve as an advantageous tool for patient education, enhancing preoperative understanding and contributing to informed decision-making during urological consultations for IPP.

Purpose: To identify whether there was a disparity in the utilization of immunotherapy in the treatment of black patients with metastatic castration resistant prostate cancer (mCRPC)., Methods: Using the National Cancer Database, we identified patients between 2010- 2015 with likely minimally/asymptomatic mCRPC. We analyzed annual trends for chemotherapy and immunotherapy use and compared utilization by demographic and clinical features. Multivariable analysis was performed to determine predictors of receiving immunotherapy vs chemotherapy., Results: We identified 1301 patients with likely mCRPC. The majority were non Hispanic White (NHW - 63 %) and 23 % were non-Hispanic Black (NHB). Overall, there was increased utilization of immunotherapy in mCRPC from 2010 onwards, with the peak occurring in 2014 (4.6 %). Chemotherapy use increased significantly, peaking in 2014 to 26.1 %. However, the increased utilization of immunotherapy in the mCRPC was mainly seen in White patients: from 50 % to 74.2 % of the cohort. Conversely, there was a decrease in utilization of immunotherapy among Black mCPRC patients: from 50 % to 25.8 %. On multivariable analysis, there was no statistically significant difference between treatment types by race., Conclusion: FDA approval of Sipuleucel-T for mCRPC led to increased utilization of immunotherapy shortly thereafter, but this was mainly noted in white patients. Black patients comparatively did not exhibit increased utilization of this novel agent after 2010. Further studies are necessary to help understand barriers to access to new treatment in mCRPC and eliminate the burden of disease in minority populations.", Competing Interests: Declaration of Competing Interest The authors have no competing interests to declare that are relevant to the content of this article., (Copyright © 2023 National Medical Association. Published by Elsevier Inc. All rights reserved.)

Objective: To improve upon prior attempts to predict which patients will pass their obstructing ureteral stones, we developed a machine learning algorithm to predict the passage of obstructing ureteral stones using only the CT scan at a patient's initial presentation., Methods: We obtained Institutional Review Board approval to conduct a retrospective study by extracting data from all patients with an obstructing 3-10 mm ureteral stone. We included patients with sufficient data to be categorized as having either passed or failed to pass an obstructing ureteral stone. We developed a 3D-convolutional neural network (CNN) model using a dynamic learning rate, the Adam optimizer, and early stopping with 10-fold cross-validation. Using this model, we calculated the area under the curve (AUC) and developed a model confusion matrix, which we compared with a model based only on the largest dimension of the stone., Results: A total of 138 patients met inclusion criteria and had adequate images that could be preprocessed and included in the study. Seventy patients failed to pass their ureteral stones, and 68 patients passed their stones. For the 3D-CNN model, the mean AUC was 0.95 with an overall mean sensitivity of 95% and mean specificity of 77%, which outperformed the model based on stone-size., Conclusion: The 3D-CNN model predicts which patients will pass their obstructing ureteral stones based on CT scan alone and does not require any further measurements. This can provide useful clinical information which may help obviate the need for a delay in care for patients who inevitably require surgical intervention., (Copyright © 2023 Elsevier Inc. All rights reserved.)

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 < .001. Mean patient-reported pain score on each post-operative day was lower in the opioid-free pathway compared to the standard pathway [day 0: 2.4 (SD 2.6) vs. 3.9 (SD 2.7), p < .001; day 1: 1.4 [SD 1.6] vs. 3.3 (SD 2.2), p < .001; day 2 0.9 (SD 1.5) vs. 2.6 (SD 1.9), p < .001]. Fewer post-operative complications were seen in the opioid-free pathway versus standard [0 vs. 5 (6.2%), p = 0.028], and there was no statistically significant difference in number of emergency room visits or readmissions within 3 weeks of surgery. The use of surgeon-administered local anesthetic plus scheduled non-narcotic analgesics can safely and significantly reduce opioid use after robotic-assisted laparoscopic prostatectomy while improving pain control., (© 2021. The Author(s), under exclusive licence to Springer-Verlag London Ltd., part of Springer Nature.)

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 < 0.001) and ETS (P = 0.02) expression, decreased SPINK1 expression (P < 0.001), and basal-like (P < 0.001) molecular subtypes. After adjusting for confounders, the AAM group was associated with higher expression of CRYBB2, GSTM3, and inflammation genes (IL33, IFNG, CCL4, CD3, ICOSLG), and lower expression of mismatch repair genes (MSH2, MSH6) (p < 0.001 for all). At the pathway level, the AAM group had higher expression of genes sets related to the immune response, apoptosis, hypoxia, and reactive oxygen species. EAM group was associated with higher levels of fatty acid metabolism, DNA repair, and WNT/beta-catenin signaling. Based on cell lines data, AAM were predicted to have higher potential response to DNA damage. In conclusion, biological characteristics of prostate tumor were substantially different in AAM when compared to EAM.

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 <5, Fisher's exact test was used. Results: During the study period, 1211 ureteroscopies were performed and 143 ureteroscopes were returned to the manufacturer. The mean number of uses was 7.45 at the UH and 16.5 at the ASC. The location and cause of damage were similar at both locations. The most common locations of primary damage were at the angle cover (70.6%) and instrument channel (19.2%). Most damage occurred during the handling of the ureteroscopes between surgical procedures (78%). On review of the literature, we found that DFUs were 6 times more durable in a nonteaching hospital. Conclusions: The DFU was more than two times as durable in the ASC as in the UH. Most incidents occurred during handling between surgical procedures. Future research is needed to examine the impact of training and certification of support staff on durability of DFUs.

Background: Marginalized communities often attract more than their share of research. Too often, this research benefits researchers disproportionately and leaves such communities feeling exploited, misrepresented, and exhausted. The Downtown Eastside (DTES) neighborhood of Vancouver, Canada, has been the site of multiple public health epidemics related to injection drug use as well as the site of much community-led resistance and struggle that has led to the development of cutting-edge harm reduction interventions (e.g., North America's first supervised injection facility, Insite) and a strong sense of community organization. This background has made the DTES one of the most heavily researched communities in the world. Amidst ongoing experiences of unethical or disrespectful research engagement in the neighborhood, a collaboration between local academic researchers and community representatives developed to explore how we could work together to encourage more respectful, community-responsive research and discourage exploitative or disrespectful research., Methods: We developed a series of six weekly workshops called "Research 101." These workshops brought together approximately 13 representatives from peer-based organizations in the DTES with a variety of experiences with research. Research 101 created space for community members themselves to discuss the pitfalls and potential of research in their neighborhood and to express community expectations for more ethical and respectful research., Results: We summarized workshop discussions in a co-authored "Manifesto for Ethical Research in the Downtown Eastside." This document serves as a resource to empower community organizations to develop more equitable partnerships with researchers and help researchers ground their work in the principles of locally developed "community ethics." Manifesto guidelines include increased researcher transparency, community-based ethical review of projects, empowering peer researchers in meaningful roles within a research project, and taking seriously the need for reciprocity in the research exchange., Conclusions: Research 101 was a process for eliciting and presenting a local vision of "community ethics" in a heavily researched neighborhood to guide researchers and empower community organizations. Our ongoing work involves building consensus for these guidelines within the community and communicating these expectations to researchers and ethics offices at local universities. We also describe how our Research 101 process could be replicated in other heavily researched communities.

Objective: To describe the steps and technique of a robotic pyelolithotomy for complete removal of a left staghorn stone after a previous open pyelolithotomy., Methods: The patient is placed in a left modified flank position with 4 laparoscopic ports placed: 12mm port for camera paramedian to the left of the midline, 8mm robotic port left lower quadrant at the level of the umbilicus, 8mm robotic port midclavicular line 2 finger breaths below the costal margin, 12mm Airseal assistant port paramedian infraumbilical. The white line of Toldt was incised and the colon was mobilized medially. Anterior Gerota's fascia was opened and tacked to the lateral abdominal wall exposing renal pelvis and parenchyma. An intraoperative ultrasound confirmed the underlying stone. A V-shaped Gil-Vernet pyelolithotomy incision was made and Prograsp forceps were used to manipulate the stone out of the renal pelvis. The collecting system was inspected and irrigated using the robotic lens. The pyelotomy was closed with 4-0 Monocryl suture on a TF needle in 2 lengths of suture, superiorly and inferiorly. Gerota's fascia was closed over the renal pelvis and the kidney was re-retroperitonealized by tacking the colon to the white line of Toldt. The specimen was retrieved through a mini-Pfannenstiel incision via a specimen bag. The patient was discharged on postoperative day 1 and seen in clinic 5 weeks later for stent removal., Conclusions: Robotic pyelolithotomy is a minimally invasive alternative that can be offered to patients with complete staghorn stones even after major open stone surgery. However case selection for this approach relies on the stone burden primarily in a dilated renal pelvis with limited calyceal projections. It is imperative to review preoperative imaging to understand the calyceal anatomy and the rotation required to free the stone from the collecting system., (Published by Elsevier Inc.)

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., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

Introduction: 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., Methods: 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., Results: 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)., Conclusions: 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.

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

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, immunosuppression, 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., Competing Interests: Conflict of interest: None declared., (Copyright® by the International Brazilian Journal of Urology.)

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.

Introduction: An Institutional Quality and Safety Initiative to reduce postoperative urinary retention (POUR) and improve patient safety indicators (PSIs) was undertaken after a nurse driven protocol for catheter removal lead to an increase in POUR. The aim of this study was to identify the number of risk factors present in patients with POUR while examining the prevalence of those risk factors individually., Materials and Methods: A retrospective review of our institution's surgical database was performed to identify 500 consecutive cases of POUR between July 1, 2013 and July 1, 2014. POUR was defined as the inability to void postoperatively with bladder scan volumes greater than 450 mL and subsequent need for catheterization with an output greater than 450 mL. These records were individually reviewed for 15 known independent risk factors for urinary retention. Patients with incomplete records or preoperative baseline urinary retention requiring catheterization were excluded., Results: Of the 500 consecutive patients with POUR, 288 (57.6%) were male and 212 (42.4%) were female. At the time of voiding trial, all 500 patients with POUR (100%) had at least one perioperative risk factor identified and over 75% had six or more (mean 6.88, median 7, range 1-12)., Conclusions: Multiple perioperative risk factors are present in the vast majority of patients with POUR. Many of the risk factors are modifiable and represent an opportunity for intervention. This could ultimately lead to a risk profile which could be used to optimize timing of postoperative voiding trials, thus improving patient care (improve PSIs and patient comfort, reduce trauma) while maintaining low rates of CAUTI.

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., (Copyright © 2017 Elsevier Inc. All rights reserved.)

A 69-year-old morbidly obese man presented with hematuria caused by a large anterior wall bladder tumor. The mass was inaccessible for resection by standard means due to the patient's obesity and phallic length. A perineal urethrostomy was required to enable complete resection. This age-old technique is revisited for the benefit of this generation's urologists.

Objective: 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., Materials and Methods: 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., Results: 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., Conclusion: 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., (Copyright © 2016 Elsevier Inc. All rights reserved.)

We describe the first reported case of completely intracorporeal robot-assisted laparoscopic reverse seven ileal ureteric reconstruction. The patient was a woman with bilateral, long segment ureteric strictures secondary to pelvic surgery and radiation. This report demonstrates that robotic reconstruction is a viable option even in a complex patient with a hostile abdomen.

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.

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., (© 2011 THE AUTHORS. BJU INTERNATIONAL © 2011 BJU INTERNATIONAL.)

Xanthogranulomatous inflammation is a benign condition characterized by the presence of multinucleated giant cells, chronic inflammatory cells and lipid-laden macrophages, known as xanthoma cells. Only 22 cases of xanthogranulomatous cystitis (XGC) have been reported in the Japanese and English literature. In this report, we describe the twenty-third case of XGC and the third case associated with inflammatory bowel disease (IBD). A 50-year-old woman with quiescent Crohn's disease was incidentally found to have a bladder mass on ultrasound. The lesion was resected through a transurethral approach. Pathology demonstrated XGC. At 3 months post-resection, there was no evidence of recurrence adjacent to the previous resection scar.

Introduction: 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., Methods: 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., Results: 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., Conclusion: BSAG for completely sutureless LPN in a survival porcine model was feasible.

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 < 0.005). Ureteric flow after endoureterotomy and subsequent stent removal was similar for buoy stents and standard 7 F stents. None of the stents refluxed. There was no difference between stents in removal force, weight change or incidence of hydronephrosis. At 1 and 12 weeks, buoy stents tended to produce lower histopathological alteration scores than control stents, especially at the VUJ (phase I, 2.0 vs 3.9, P = 0.092; phase II, 0.6 vs 1.7, P = 0.18). CONCLUSIONS The novel buoy stents are easily placed and removed via the urethra. They can cause less VUJ inflammation than standard stents while allowing for adequate ureteric flow and healing after proximal endoureterotomy.

Introduction: 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., Methods: 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., Results: 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 (p < 0.05)., Conclusion: 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.

Purpose: Sealing the lymphatic vessels during abdominal and pelvic surgery is important to prevent the leakage of lymphatic fluid and its resultant sequelae. To our knowledge we compared for the first time the quality of lymphatic sealing by each of 4 commonly used laparoscopic dissection devices., Materials and Methods: A total of 12 domestic pigs were used to test dissecting devices, including monopolar scissors (Ethicon Endo-Surgery, Cincinnati, Ohio), Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector. A midline incision was made from mid sternum to umbilicus, the diaphragm was divided and the porcine thoracic duct was isolated. In all animals each device was used to seal an area of the duct and each seal was placed at least 2 cm from the prior seal. In group 1 the thoracic duct of 6 pigs was cannulated with a 5Fr catheter and the seal was subjected to burst pressure testing using a burst pressure measuring device (Cole-Parmer, Vernon Hills, Illinois). In the 6 pigs in group 2 each seal was immediately sent for histopathological evaluation. Specimens were given a score for the extent of cautery damage, including 0-none, 1-minimal, 2-moderate, 3-severe and 4-extreme., Results: A total of 64 seals were created, of which 35 were subjected to burst pressure testing. Mean size of the thoracic duct was 2.6 mm. No acute seal failures were observed with any bipolar device or the harmonic shears. However, 2 immediate failures (33%) were seen with monopolar scissors. Mean burst pressure for monopolar scissors, Harmonic ACE Scalpel, LigaSure V, EnSeal and Trissector was 46 (range 0 to 165), 540 (range 175 to 795), 258 (range 75 to 435), 453 (range 255 to 825) and 379 mm Hg (range 175 to 605), respectively (p <0.05). Trissector, Harmonic ACE Scalpel and EnSeal generated seals with significantly higher burst pressure than that of monopolar scissors (p <0.05). Histopathological evaluation revealed that LigaSure caused less thermal damage than Trissector and EnSeal (p <0.05)., Conclusions: Each device tested except monopolar scissors consistently produced a supraphysiological seal and should be suitable for sealing lymphatic vessels during laparoscopic surgery.

Purpose: 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., Patients and Methods: 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., Results: 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., Conclusions: 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.

Purpose: 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., Materials and Methods: 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%., Results: 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 (p <0.025 and <0.026, respectively). The ultrasonic scalpel also showed increased artifact depth compared to that of cold cutting (p <0.001). 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., Conclusions: 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.

Purpose: The use of effective vascular clamps is key to successful laparoscopic partial nephrectomy. Based on our clinical experience the occlusive capabilities of vascular clamps appeared to be quite variable. We compared the occlusive force of currently available laparoscopic vascular clamps., Materials and Methods: The jaw force of 3 laparoscopic vascular clamps (Aesculap(R), Klein Surgical Systems, San Antonio, Texas and Karl Storztrade mark) were measured by clamping a 2.2 mm compression load cell (Interface Advanced Force Measurement, Scottsdale, Arizona) in pound-force. The variables tested were handheld Satinsky, DeBakey and Storz clamps vs bulldog clamps, proximal, middle and distal application position, new vs used bulldog clamps and new vs used Satinsky handheld clamps. In addition, handheld clamps were tested according to the force generated by the notches in the locking mechanism. Force retention was also determined for all instruments after clamping a 20Fr latex rubber catheter for an hour. Finally, leak pressure studies were performed using a harvested porcine artery to determine the relationship between jaw force and leak pressure in mm Hg of bulldog and Satinsky handheld clamps using a pressure gauge (Cole-Parmer(R))., Results: Handheld vascular clamps provided greater force than bulldog clamps. The proximal position closest to the hinge provided the greatest force across all instruments. Compared to new clamps the 2-year-old Klein Surgical Systems bulldog clamps showed a greater than 40% decrease in jaw force at all positions, whereas the 3-year-old Aesculap bulldog clamps decreased in jaw force by less than 9% at all positions. The 2-year-old Satinsky handheld clamps showed a decrease of 20%, 9% and 0% at the distal, middle and proximal jaw positions, respectively. Also, there was a positive correlation between force and the number of notches applied in handheld clamps. In addition, all instruments maintained jaw force after 1 hour of continuous clamping. Finally, leak pressure studies performed with used clamps showed that Klein Surgical Systems bulldog, Aesculap bulldog and Satinsky handheld clamps leaked at a pressure of 153 to 223, 465 to 795 and 1,500 to 2,600 mm Hg, respectively., Conclusions: Vascular clamps have varying occlusive forces according to clamp type, manufacturer, jaw and teeth characteristics, jaw clamping position and duration of use. However, across all clamps the jaw force was greatest at the proximal position. This is most important when applying laparoscopic bulldog clamps. In contrast, all handheld vascular clamps generated higher force than intracorporeal bulldog clamps. At 1 notch the handheld vascular clamps provided supraphysiological occlusion force regardless of position or manufacturer.

Purpose: Retropulsion of ureteral stones during laser lithotripsy may result in difficult and incomplete stone fragmentation. The Stone Cone nitinol urological retrieval coil and the NTrap nitinol ureteral occlusion device have been introduced into clinical practice to possibly limit stone retropulsion and enhance the efficiency of holmium laser (Convergent Laser Technologies, Alameda, California) stone fragmentation., Materials and Methods: A total of 360 BegoStone Plus phantom stones (Bego USA, Smithfield, Rhode Island) of similar mass and weight were divided into 3 groups, including control, Stone Cone and NTrap. The groups were further subdivided according to fiber size (200 or 400 microm) and pulse width (350 or 700 microsec). These stones were placed in a horizontal pipette 12 mm in diameter, submerged in normal saline and disintegrated at laser settings of 1 J and 10 Hz continuously applied for 300 seconds. Retropulsion in cm and fragmentation efficiency with mass loss in mg were measured after treatment., Results: The 2 devices were effective for preventing retropulsion. In the control group the mean +/- SD retropulsion distance using a 350-microsec pulse width with the 200 and 400 microm fibers was 18.4 +/- 5.9 and 14.1 +/- 4.6 cm, while it was 6.2 +/- 2.6 and 5.6 +/- 2.4, respectively, using the 700-microsec pulse width. There was a statistically significant higher loss of stone weight in the Stone Cone and NTrap experimental groups than in the control group (p <0.0001). However, there was no difference between the 2 experimental groups across all groups (p = 0.32)., Conclusions: The Stone Cone and NTrap eliminated retropulsion and equally improved fragmentation efficiency. The maximum efficiency of fragmentation was seen using the 200 microm fiber at a 700-microsec pulse width.

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.

Objective: We developed a simple, inexpensive model to simulate four reconstructive laparoscopic procedures: pyeloplasty, vesicourethral anastomosis, bladder injury repair, and partial nephrectomy., Materials and Methods: 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., Results: 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., Conclusion: 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.

Background and Purpose: 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., Patients and Methods: Ten men and 10 women were grouped according to BMI <25 or >or=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., Results: 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 BMI >or= 25 compared with <25 was also significant (P < 0.0209). Full table flexion (50-degree) produced significantly higher pressures than both flat (P= 0.0001) and the half-flexed (25-degree) position (P < 0.0001). Positions with the kidney rest elevated were associated with significantly higher pressures than without elevation (P < 0.0001). With regard to the surface used, egg crate provided lower pressures than gel pads (P= 0.0117)., Conclusion: Women have significantly lower interface pressures when compared with men. BMI >or= 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.

Purpose: 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., Patients and Methods: 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)., Results: 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)., Conclusions: 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.

Background and Purpose: 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., Methods: 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., Results: Total operative time was 150 minutes. Estimated blood loss was less than 50 mL. No intraoperative complications occurred., Conclusion: 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.