Aaron Boonjindasup

Robotic Partial Nephrectomy for Clinical Stage T1b Tumors: Intermediate Oncologic and Functional Outcomes

OBJECTIVE The objective of this study was to examine our intermediate oncologic and functional outcomes of robotic partial nephrectomy for clinical T1b tumors. Partial nephrectomy has become the gold standard of treatment for small renal masses. Recently, indications for minimally invasive partial nephrectomy have extended to larger and more complicated renal masses in some centers. MATERIALS AND METHODS Between July 2008 and September 2013, 241 robotic partial nephrectomies were performed at our institution, including 46 for clinical ≥ T1b tumors. We reviewed the intermediate-term functional and oncologic outcomes of this cohort of patients. RESULTS Of the 46 patients, the median age was 55.5 years (interquartile range [IQR], 51-68 years) with a median body mass index of 31.6 (IQR, 27.4-38.9), tumor diameter of 5.0 cm (IQR, 4.1-5.2 cm), and RENAL nephrometry score of 7.1 (range, 5-11). Renal cell carcinoma was confirmed in 35 patients, and 11 patients had benign pathology. There was 1 patient with an established positive margin and 2 patients had a focal positive margin. At a median follow-up of 24.3 months (range, 2.3-61.1 months), the overall, recurrence-free and cancer-specific survival was 97.1%, 97.1%, and 100%, respectively. No patient progressed to dialysis postoperatively and there was no significant difference between preoperative and postoperative serum creatinine or estimated glomerular filtration rate using the Modification of Diet in Renal Disease equation. CONCLUSION Because of the many adverse medical effects of chronic renal insufficiency, the indications for partial nephrectomy are expanding at many institutions. We demonstrated that robotic partial nephrectomy is a safe and efficacious procedure for the treatment of T1b renal tumors with excellent intermediate oncologic and functional outcomes.

Does a replacement or revision of an inflatable penile prosthesis lead to decreased patient satisfaction

To analyze the reason for replacement, revision and overall satisfaction of a cohort who underwent surgical replacement of an inflatable penile prosthesis (IPP). A cohort of 105 patients who underwent IPP replacement from 2005–2007 was retrieved from the prosthesis database. Approximately 21.9% (23) underwent replacement or revision of their prosthesis because of complications, and were further analyzed. Reason for removal was stratified into infectious and non-infectious (erosion, non-function and patient discomfort). Age, race (African American vs non-African American), smoking history, hypertension, diabetes, coronary artery disease and hyperlipidemia were stratified by reason for removal. Finally, we contacted patients and recorded subjective satisfaction with their IPP. The reason for removal was most commonly because of a non-functional IPP (47.8%), followed by infection (30.4%), erosion (17.4%) and patient discomfort (4.3%). Age and race did not show a significant difference when analyzing reason for replacement (P>0.05). Patients who were smokers (P=0.907) had hypertension (P=0.554), diabetes (P=0.591) or hyperlipidemia (P=0.219) did not have significantly higher infection rates. Approximately 58.3% were satisfied with their prosthesis, 75% would have the surgery performed again and 91.7% would still recommend prosthesis surgery. Device malfunction was the primary reason for replacement/removal at our institution. Despite the complications of prosthesis reoperation, the majority of patients were still satisfied with their prosthesis, would have the surgery performed again and would recommend prosthesis surgery to a friend.

Comparison of infrapubic versus transcrotal approaches for inflatable penile prosthesis placement: a multi-institution report.

Inflatable penile prostheses (IPP) are associated with excellent long-term outcomes. To date, no study has evaluated the significance of surgical approach on IPP intraoperative variables. High-volume surgeons placing the Titan 0-degree prosthesis from March-July 2012 completed questionnaires including pre-/intraoperative variables. Intraoperative data were compared between surgeons performing an infrapubic versus transcrotal approach for total length of prosthesis, proximal and distal measurements, rear-tip extender (RTE) length, reservoir size and fill volume and ability to place the reservoir in the space of Retzius. Forty-six surgeons placed 256 IPPs, with a median of 5 (range 1–10) inserted. Transcrotal placement was performed most commonly (80%). Revision procedures accounted for 13% of cases, with 19% previously undergoing robotic-assisted prostatectomy. Compared with infrapubic, transcrotal placement resulted in a longer total prosthesis (22.3 cm vs 20.6 cm, P<0.0001), increased proximal dilation (10.1 cm vs 8.6 cm, P<0.0001), longer RTEs (1.9 cm vs 1.2 cm, P<0.0001) and larger reservoir fill volume (79 cc vs 71 cc, P=0.0003). No differences were noted in distal measurements or ability to place the reservoir in the space of Retzius. Compared with the infrapubic approach, high-volume surgeons placing the Titan 0-degree IPP transcrotally achieved increased proximal dilation with an ~1–2-cm-longer prosthesis inserted.

A Rationale to Use Bladder Boari Flap Reconstruction for Late Kidney Transplant Ureteral Strictures.

OBJECTIVE To evaluate the efficacy of Boari flap reconstruction (BFR) in the management of late-onset transplant ureteral strictures (TUS). METHODS Between March 2007 and March 2014, there were 730 patients who underwent kidney transplant (KTx) at our institution. We identified 16 patients with TUS, occurring more than 60 days after KTx. Baseline clinical and posttransplant characteristics were reviewed and stratified upon treatment modality. Outcomes for each treatment modality were determined. RESULTS Median time from transplant to the treatment of TUS was 703 days (range, 65-2617 days). BFR was the most common treatment modality and was used in 87.5% of patients (n = 14/16). This procedure was performed as both a primary treatment and as a salvage procedure in recurrent TUS refractory to balloon dilation and neoureterocystotomy. Incidence of BFR failure was 6.3% (n = 1/14). BFR as a primary treatment was more successful compared to other methods (P  <  .01). CONCLUSION Late TUS after KTx is a difficult complication to treat. Our study suggests that BFR can provide a higher success rate of primary treatment compared to other common treatment options. BFR can be used as a primary treatment of TUS or as a salvage procedure with similar success. Additional follow-up is necessary to evaluate the long-term efficacy of BFR for the treatment of late-onset TUS.

Management of adult concealed penis using a meshed, split-thickness skin graft

INTRODUCTION Concealed penis (CP) is a rare problem faced by urologists and plastic surgeons. CP occurs secondary to trauma, obesity, or infection. Surgical treatment is individualized and based on patient and provider variables. We aim to review our recent experience using meshed split-thickness skin grafting (STSG) for CP management. METHODS A retrospective review was performed on patients who underwent STSG for CP at our institution. Records were reviewed for demographic, operative, and postoperative variables. Preoperative and postoperative photos were obtained to monitor cosmetic results. RESULTS Eleven patients underwent CP release with meshed STSG placement. All cases showed improved functional phallic length and good cosmetic results, regardless of etiology. CONCLUSIONS STSG is a viable option for penile coverage for management of this difficult-to-treat CP population. This primary or salvage modality offers excellent cosmetic results and may be used following prior reconstructive attempts.

Electroencephalographic Monitoring of Brain Wave Activity During Laparoscopic Surgical Simulation to Measure Surgeon Concentration and Stress: Can the Student Become the Master?

PURPOSE To measure gamma and alpha brain wave activity as a measurement of concentration and stress levels during surgical simulator performance of laparoscopic tasks to determine if expert surgeons have different brain activity patterns compared with intermediate and novice surgeons. MATERIALS AND METHODS After obtaining Institutional Review Board approval, 1st and 2nd year medical students, urology residents (PGY2-PGY5), and attending urologists from one institution were recruited. Participants were stratified by level of experience and performed laparoscopic tasks on the EDGE laparoscopic simulator. Subjects were evaluated for concentration and stress levels using the electroencephalography (EEG) data extracted from the MUSE(™) headband. The MUSE software developer kit (SDK) allowed quantification of gamma and alpha waves during each task. An analysis of variance was used to compare concentration and stress levels between groups. RESULTS A total of 19 participants were recruited for the study and stratified by surgical experience into novice, intermediate, and expert laparoscopy groups: 6 medical students, 9 urology residents, and 4 attending urologists, respectively. Concentration and stress were quantified by calculating the area under the curve of the gamma and alpha EEG wave tracings. Stress was significantly lower in the attending urologists compared with the residents and medical students during the laparoscopic suturing and trended toward significance in the peg transfer task (P = 0.0003, P = 0.069). Concentration was significantly higher in the expert group compared with the less experienced groups during both the peg and suture tasks (P = 0.036, P = 0.0039). CONCLUSIONS EEG brain activity in more experienced surgeons reveals a significant increase in concentration levels with a decrease in stress during simulated laparoscopic tasks compared with novices. This information may correlate with increased proficiency as well as provide objective feedback of progress along the learning curve with the MUSE SDK.

Risk Factors in Premature Ejaculation: The Urological Risk Factor

Premature ejaculation (PE) is the most common form of male sexual dysfunction and a number of direct urological risk factor may be identified. This chapter will focus on certain risk factors that may predispose men to PE such as erectile dysfunction (ED), chronic prostatitis (CP), varicocele, enuresis, and circumcision. A review of the current literature is presented with an emphasis on the epidemiological associations between these risk factors and PE. A review of possible treatment options in the current literature are also pertinent presented. This chapter will be most useful for the clinicians approach to the patient with PE evaluation past urological history.