Daniel Thorner

Outcomes of reduction cystoplasty in men with impaired detrusor contractility.

OBJECTIVE To report surgical outcomes in patients with impaired detrusor contractility (IDC) treated with reduction cystoplasty (RC). METHODS This was a retrospective study of consecutive patients with IDC who underwent RC. IDC was defined as a bladder contractility index of <100 and/or a detrusor contraction of insufficient duration resulting in a postvoid residual volume (PVR) >600 mL. Bladder outlet obstruction was defined by a bladder outlet obstruction index (BOOI) >40. All patients had preoperative International Prostate Symptom Score, maximum uroflow (Qmax), PVR, bladder diary, videourodynamics, and cystoscopy. Patients with prostatic obstruction underwent synchronous open prostatectomy. Postoperative Qmax, PVR, need for clean intermittent catheterization (CIC), and Patient Global Impression of Improvement (PGII) score were obtained. Follow-up was at 3 months, 1 year, and yearly thereafter. RESULTS Eight men met inclusion criteria (mean age, 60; range, 43-75 years). Preoperatively, 3 of 8 patients (37.5%) had moderate-sized bladder diverticula, 4 of 8 (50%) had a bladder contractility index <100, and 6 of 8 (75%) had a BOOI <40. Two patients (25%) fulfilled criteria for bladder outlet obstruction (BOOI, 67 and 72). Three (37.5%) underwent synchronous bladder diverticulectomy, and 3 (37.5%) underwent suprapubic prostatectomy. All patients were available for follow-up at 1 year. Seven of 8 (88%) had a successful outcome (PGII ≤2). One patient was unchanged (PGII, 4) and still needed CIC. CONCLUSION All but 1 patient who met specific criteria for RC had excellent outcomes after surgery based on the PGII, PVR, Qmax, and need for CIC. RC is a viable option for properly selected patients with IDC.

Emphysematous Prostatitis in a Diabetic Patient

A 64-year-old male with a history of end stage renal disease and diabetes mellitus presented with generalized abdominal pain, fever, chills, sweats and difficulty urinating. Temperature was 101.9F and physical examination revealed a diffusely tender but not distended abdomen without rebound, guarding or rigidity. On genitourinary examination perineal tenderness was noted and digital rectal examination was deferred based on computerized tomography findings. Multiphasic computerized tomography of the abdomen and pelvis demonstrated copious amounts of gas in the prostate (4.4 3.6 cm, see figure), which is consistent with emphysematous prostatitis. A suprapubic tube was placed with drainage of approximately 400 ml of concentrated purulent urine. The white blood cell count was 19,200 at presentation and increased to 29,000. The patient was started empirically on antibiotics and subsequent urine cultures were positive for Citrobacter species. Transurethral drainage/unroofing of the prostatic abscess was performed. Approximately 300 ml of purulent fluid were exposed during transurethral resection. A Foley catheter was placed and the suprapubic tube was left in position. The patient was kept in the intensive care unit for several days requiring pressor support and culture specific antibiotic therapy, which improved the hemodynamic status. After complete convalescence he was discharged home on postoperative day 14. Emphysematous prostatitis is a rare entity with few cases reported, and diagnosis is a challenge since patients present with nonspecific symptoms. Most patients are treated for urinary tract infection and emphysematous prostatitis is considered only after infections recur. Imaging of the prostate by computerized tomography and/or transrectal ultrasound should be performed in all patients with the suspected diagnosis. Gas forming bacterial infections of the urine are the culprits behind the illness and are typically seen in diabetic patients. The most commonly reported organisms are Klebsiella pneumoniae, Pseudomonas aeruginosa and Candida albicans. 1‐3 Mortality from emphysematous prostatitis is high and, thus, immediate drainage of the abscess is eminent.

Benign Prostatic Hyperplasia: Symptoms, Symptom Scores, and Outcome Measures

The approach to a patient with benign prostatic hyperplasia and lower urinary tract symptoms (LUTS) begins with a detailed history. The goal is to clearly identify the patients urinary complaints, including frequency of micturition, urgency, urge incontinence, weak stream, the need to push or strain, hesitancy, intermittency, dysuria, and hematuria. Bladder diaries and symptom questionnaires are useful as adjuncts to information that is acquired in the history. The voiding diary is an essential part of the workup. The voiding diary differs from a simple frequency-volume chart in that it incorporates not only the frequency, voided volume, urge episodes, pad usage, and fluid intake but also the data related to patient activities. It allows patients to have a more thorough self-evaluation of their LUTS.

Optimizing prostate cancer detection during biopsy by standardizing the amount of tissue examined per core

Study Type – Diagnostic (exploratory cohort)

The Impact of Access Techniques, Operator Experience, and Guidance Modality on the Outcome of Percutaneous Nephrostomy Placement and Incidence of Complications

During the past 35 years, percutaneous nephrostomy has assumed an important and increasing role in both the permanent and temporary management of some of the most prevalent urinary tract disorders. Percutaneous nephrostomy is advocated not only to restore drainage in the presence of urinary tract obstruction by calculi or otherwise and thereby preserve renal function, but also to offer access for infusion of medications, such as antibiotics or antifungals for the treatment of pyonephrosis and upper tract mycelial disease.

Duodenal-Renal Fistula

A 54-year-old white male presented with a 3-month history of right flank pain. Onset of pain was in the mid abdomen and for 2 consecutive days the patient noticed blood in stool. During the next 2 months he had several episodes of low grade fever with temperatures up to 38.5C. At hospital admission percussion of the right flank elicited pain. Patient temperature was normal at 36.5C. White blood cell count was 9,800, red blood cells 4.1 million, hematocrit 41, hemoglobin 14.3, creatinine 1.8, blood urea nitrogen 27, amylase 140 U/l and lipase 180 U/l. Urinalysis revealed cloudy urine. Specific gravity was 1,024, with 10 to 12 white blood cells and 15 to 20 red blood cells per high power field, abundant bacteria on high power field, as well as some mucoid (eosinophilic staining) globules. Urine culture was positive for Escherichia coli. A 3-phase contrast enhanced computerized tomogram revealed a large extrarenal right kidney pelvis. The wall of the pelvis appeared thickened, and there was prominent striation in the periduodenal fat of the second and junction segment third portion of the duodenum (fig. 1). The excretory phase computerized tomogram demonstrated densely opacified urine in the ureteropelvic junction of the right kidney with identical dense material in the second portion of the duodenum. The right ureteropelvic junction, left ureter and duodenal lumen contained

Myceleal emphysematous cystitis complicating a renal transplant kidney

This 44 year old Caucasian male presented acutely ill with chills, fever and pain over the renal allograft. The symptoms had intensified over the past 3 days. At admission his temperature was 100.8 F, pulse-rate 110/min, BP 185/110, Hb 10.2, Hct 28, WBC 16200 (66% polymorphs). BUN 140 mg/dL, CR 3.8 mg/dL, blood sugar 121 mg%. The patient had a history of poorly controlled hypertension for eight years and received a renal transplant for endstage renal disease some 10 months ago. The postoperative period was complicated by several episodes of LUTIs which were treated with amoxicillin and ciprofloxacin. Two months prior to this admission the patient had been treated for acute rejection and was still on maintenance immunosup-pressive therapy. Foley catheterization yielded only 100 mL of purulent urine; analysis revealing 60 WBC/hpf, bacteria, mycelia and debris. Urine culture grew E Coli and identified Aspergillus Niger. Enhanced computed tomograms revealed massive gas in the bladder, dissecting in the submu-cosal layer and extending into the space of Retzius. Debris is outlined by the gas. A shaggy mass engulfes the tip of the Foley catheter. The mass and shaggy debris are caused by a myceliatomas (Figure-1). A CT section at a slightly higher level demonstrated lateral extension of the gas-dissection in the pre-vesi-cal space. It also shows the site of implantation of the transplant ureter, which is edematous (Figure-2). A coronal reconstruction shows the massively edema-tous ureter, with some gas dissecting into the ureter (Figure-3). There is however, still some parenchymal phase enhancement of the transplant kidney, suggest-ing viability. Open surgical drainage of the space of Retzius was immediately undertaken. Aggressive antibi-otic therapy with ciprofloxacin and amphotericin B, parenteral, as well by infusion into the bladder was pursued for 3 weeks. The necrotic transplant ureter was resected. The transplant kidney was drained by percutaneous nephrostomy, ultimately a uretero-pyelostomy, using the still intact native ureter was performed to reestablish drainage to the bladder. Only a few cases of emphysematous cystitis in renal transplant recipients have been reported (1,2).

Emphysematous cystitis as complication in chronic rejection of renal transplant

This 43-year-old Caucasian female presented in a septic condition in the emergency room. At the time of admission her temperature was 38.5 Celsius, white blood cells (WBC) 12800, red blood cells 3.8 mill, hemoglobin 10.8, hematocrit 36, urea 28 mg/dl, serum creatinine 3.2 mg/dl, K 5.8 meq/l, Na 128 meq/ l, alk ptsa 142 U/l. Urine analysis 50 WBC/hpf, innumerable bacteria/hpf, cellular debries, gas bubbles. Both urine and later blood cultures revealed E. coli. The lower abdomen and pelvis were exquisitely tender to palpation. Patient had been hemodialyzed 2 days earlier. Patient had received a cadavertransplant 3 years ago, which functioned well until 4 months ago. At this time chronic rejection was diagnosed. An antegrade pyelogram revealed a stricture at the implant site of the cadaver ureter, dilatation and possible ulcerations of the mid – and upper ureter. Bullous edema of the native bladder was seen, most prominent near the implant site. Immunosuppressive therapy was instituted and despite these efforts, function of the transplant kidney continued to deteriorate and the patient was finally put on hemodialysis 1 month ago. It was contemplated to perform a ureteroneo-calicostomy with the still present native ureter to hopefully salvage the kidney A non-contrast multi-detector computed tomography demonstrated gas in the submucosa and bladder, and also extravesical anterior to the bladder (Figure-1). Strands of debries and sloughed tissue surrounded by air are seen in the bladder lumen (arrow). Gas has dissected along the anterior abdominal wall (Figure-2). A coronal reconstruction shows relatively little striation in the perirenal space. There is edema in the peripelvic area and around the upper ureter (Figure-3). To control the fulminating gas forming infection, bladder, transplant kidney and ureter were removed, the space of Retzius drained. Depending on the severity of the infection and underlying conditions such as diabetes mere control of the diabetes and appropriate antibiotic therapy may suffice while severe forms may mandate surgical intervention to remove the necrotic debries (1-3). After prolonged antibiotic

The elusive renal cell carcinoma: Reversal imaging of arterial phase to improve acuity

On routine physical examination the patient’s physician noted microscopic hematuria The finding was reconfirmed by 2 Dipsticks over an interval of 4 months. The patient was a known diabetic, controlled by diet. Otherwise the patient was asymptomatic, without significant past medical history at the time of this work-up, the 47 year old Caucasian male appeared to be in good general health. Laboratory data showed Hb of 15.1gm/dL, HCT 45%, RBC 4.8 million/uL, WBC 6200,Neu 62%, BUN 18 mg/dL, Creatinine 1.1 mg/dl, GRF 94 mL/min, A/G ratio 1.4, Glu 128 mg/dl, K 4.2 mmoL/L, Na 145 MMOL/L Cl 108 mmoL/L Urine analysis, spec grav 1018, 3-5 RBC/hpf, no WBC or bacteria on hpf, no casts, urine culture negative x 2. A KUB (Flat plate of abdomen) showed no opaque calculi nor other abnormalities. Cystoscopy and blue light cystoscopy revealed no abnormalities. An enhanced 4 phase MDCT was performed The pre-enhancement phase was entirely unremarkable; no parenchymal lesions were detected. Following administration of 100 ml nonionic contrast medium at a flow rate of 5 mL/sec, the 12 second delayed arterial phase Ct demonstrated a relatively poorly enhancing 1.6 cm mass at the cortico-medullary junction (Figure-1), the lesion is much better shown on reversal image. Both the parenchymal phase CT( 50 second delay) and the excretory phase CT (4 minutes delay Figure-2) demonstrate a non-enhancing 16 mm mass at the cortico-medullary junction (Figure-3). In the light of a clinical history of diabetes and microscopic hematuria, the non-enhancing hypovascular mass seen on parenchymal and excretory phase CTs in the medulla might have been written off as Medullary Necrosis (With characteristic CT findings of a negative pre-enhancement phase CT, but a non-enhancing lesion shown on parenchymal and excretory phase; an early avascular necrosis) (1). However, the reversal image of the arterial phase CT clearly shows an enhancing lesion, though somewhat hypovascular for a RCC. The hypo-density on parenchymal and excretory phase CT reflects the characteristic “wash-out” phenomenon of RCCs in these phases. The tumor having no tubules is less dense then adjacent normal parenchyma The correct diagnosis was made, and a laparoscopic resection carried out. Radiology Page International Braz J Urol