Darren Beiko

Impact of medical therapy on transurethral resection of the prostate: a decade of change

OBJECTIVES To assess whether medical therapy has delayed the need for eventual transurethral prostatectomy (TURP), causing a shift in the population characteristics of men undergoing TURP (ie, older, more comorbidities, more advanced disease), resulting in more complications and poorer outcomes. The introduction of medical therapy for symptomatic benign prostatic hyperplasia (BPH) during the past decade may have changed the indications for TURP. METHODS All patients who underwent TURP for symptomatic BPH at our institution in 1988 (before general introduction of medical therapy for BPH) and 1998 (medical therapy the primary initial therapy for BPH) were reviewed. We compared the two groups with respect to the total number of TURPs, indications for surgery, patient age, health status, weight of resected tissue, and preoperative and postoperative complications. RESULTS Despite a 16% increase in men at risk of BPH-related events, a 60% decrease in the total number of TURPs performed for symptomatic BPH occurred in 1998 (n = 64) compared with 10 years earlier (n = 157). No significant difference was found in age between the two groups, and no increase in comorbid status was observed. Previous medical management had failed in 36% of men who required TURP in 1998. A significantly higher percentage of patients presented in acute urinary retention (55%) and upper tract obstructive uropathy (12.5%) in 1998 compared with 1988 (23% acute urinary retention and 1.3% obstructive uropathy). Patients in 1998 were healthier, underwent smaller resections, had their catheters removed earlier, and were discharged home earlier. Although they were more likely to be discharged home with a catheter in situ, no significant difference was observed in the incidence of postoperative complications. CONCLUSIONS There has been a dramatic decrease in the number of TURPs performed for symptomatic BPH at our institution since the advent of medical therapy. The proportion of TURP patients presenting with urinary retention and hydronephrosis increased, but the average age, medical comorbidities, operative parameters, and postoperative complications have not significantly changed.

BENIGN MIXED EPITHELIAL STROMAL TUMOR OF THE KIDNEY OF POSSIBLE MULLERIAN ORIGIN

Benign mixed epithelial and stromal tumor of the kidney has only recently been recognized as a distinct clinical and pathological entity.1 Approximately 38 cases have been iden- tified in the literature. We report an unusual case of mixed epithelial and stromal tumor that may be of mullerian deri- vation. A 51-year-old woman with an incidental renal mass de- tected on ultrasound underwent computerized tomography which revealed an enhancing, inhomogeneous 16 12 10 cm. mass in the left kidney (fig. 1). The mass contained irregular small cystic pockets and peripheral punctate calci- fications. There was an ill-defined mobile mass in the left upper quadrant on physical examination, and the patient underwent left radical nephrectomy for presumed cystic re- nal cell carcinoma. Gross pathological examination revealed a 13 8 7 cm. white multilocular cystic tumor filled with mucoid fluid. The cysts were small, less than 1 cm., with thin walls and no significant solid component. The tumor replaced the upper pole and projected into the renal pelvis but was confined within the renal capsule. Microscopically the tumor was com- posed of a mixture of epithelial and stromal elements. Cystic dilated spaces were lined by an admixture of mucus produc- ing columnar and ciliated serous epithelium (fig. 2). Papillary projections containing fibrovascular cores were seen extend- ing into these cystic spaces. There was no cytologic atypia or mitotic activity observed in the epithelial lining. The epithe- lial elements were strongly decorated by antikeratin stain CAM 5.2 and carcinoembryonic antigen stain was negative. The immunophenotype of the subepithelial stromal elements was vimentin positive, desmin negative, muscle specific actin (HHF35) negative, smooth muscle actin negative, CD34 neg- ative, S100 negative, estrogen receptor protein focal positive and progesterone receptor protein focal positive. The glandu- lar epithelium also displayed strong positivity for estrogen

Aspiration and sclerotherapy versus hydrocelectomy for treatment of hydroceles

OBJECTIVES To compare aspiration and sclerotherapy using sodium tetradecylsulfate (STDS) with open hydrocelectomy in the treatment of hydroceles with regard to safety, efficacy, and cost-effectiveness. METHODS Patients with symptomatic hydroceles were prospectively enrolled in an aspiration and sclerotherapy protocol between October 1998 and June 2000. Patients in this group underwent percutaneous aspiration followed by sclerotherapy with an STDS-based solution. This group was compared with a group of patients chosen consecutively who underwent hydrocelectomy between December 1996 and August 1999. Primary outcome measures included patient satisfaction and procedural success. Secondary outcome measures included complications and comparative costs. RESULTS A total of 27 patients with 28 hydroceles were enrolled in the aspiration and sclerotherapy protocol and compared with 24 patients with 25 hydroceles in the hydrocelectomy group. Mean follow-up for the aspiration and sclerotherapy group and hydrocelectomy group was 8.9 and 16.4 months, respectively. Patient satisfaction was 75% for aspiration and sclerotherapy and 88% for hydrocelectomy. The overall success rate for aspiration and sclerotherapy was 76% compared with 84% for hydrocelectomy. The complication rate was only 8% in the aspiration and sclerotherapy group, but 40% in the hydrocelectomy group. Comparative costs per procedure demonstrated that hydrocelectomy was almost ninefold more expensive than aspiration and sclerotherapy. CONCLUSIONS In the treatment of hydroceles, aspiration and sclerotherapy with STDS represents a minimally invasive approach that is simple, inexpensive, and safe but less effective than hydrocelectomy. Aspiration and sclerotherapy is a viable first-line therapeutic option in the management of hydroceles.

Survey of senior resident training in urologic laparoscopy, robotics and endourology surgery in Canada.

INTRODUCTION We determined the status of Canadian training during senior residency in laparoscopic, robotic and endourologic surgery. METHODS Fifty-six residents in their final year of urology residency training were surveyed in person in 2007 or 2008. RESULTS All residents completed the survey. Most residents (85.7%) train at centres performing more than 50 laparoscopic procedures yearly and almost all (96.4%) believe laparoscopic radical nephrectomy is the gold standard. About 82% of residents participated in a laparoscopic partial nephrectomy in 2008, compared to 64.7% in 2007. Of the respondents, 66% have participated in a laparoscopic prostatectomy and 54% believe the procedure has promising potential. Exposure and training in robotic-assisted laparoscopic procedures seem to be increasing as 35.7% of 2008 residents have access to a surgical robot and 7% consider themselves trained in robotic-assisted procedures. Most residents (71.4%) train at centres that perform percutaneous ablation. However, 65% state the procedure is performed solely by radiologists. Percutaneous nephrolithotomy is widely performed (98.2%), but only 37.5% of residents report training in obtaining primary percutaneous renal access. Despite only 12.5% of residents ranking their laparoscopic experience as below average or poor, an increasing proportion of graduating residents are pursuing fellowships in minimally-invasive urology. CONCLUSION Laparoscopic nephrectomy is commonly performed and is considered the standard of care by Canadian urology residents. Robotic-assisted surgery is becoming more common but will require continued evaluation by educators who will ultimately define its role in the urological residency training curriculum. Minimally-invasive surgical fellowships remain popular, as Canadian residents do not feel adequately trained in certain advanced procedures. Urologists must strive to learn and adapt to new technologies or risk losing them to other specialties.

Urethroscopic holmium:YAG laser epilation of urethral diverticular hair follicles following hypospadias repair.

Urethral hair and diverticula are well described long-term complications following urethroplasty or hypospadias repair. Endoscopic laser ablation is an uncommonly reported treatment option for a symptomatic hair-bearing urethra, and holmium laser hair epilation has not been previously reported in the literature. We report the first case of urethroscopic holmium laser ablation of urethral diverticular hair follicles and the outcome.

PERCUTANEOUS ASPIRATION AND SCLEROTHERAPY FOR TREATMENT OF SPERMATOCELES

PURPOSE Spermatoceles are commonly treated with open surgical ablation. With the increasing shift towards minimally invasive surgery and heightened awareness, both patient and surgeon accept and prefer the less intrusive approach. Treatment of spermatoceles translates into the use of aspiration and sclerotherapy rather than open excision. We report on our prospective study of percutaneous aspiration and sclerotherapy with sodium tetradecyl sulfate for treatment of spermatoceles to determine safety, efficacy and cost-effectiveness. MATERIALS AND METHODS Patients with symptomatic cystic scrotal lesions were prospectively enrolled in an aspiration and sclerotherapy protocol between October 1998 and June 2000. All patients underwent aspiration followed by sclerotherapy with a sodium tetradecyl sulfate solution. Followup included clinical assessment and scrotal ultrasonography at 12 weeks and on a needed basis thereafter. RESULTS A total of 28 patients with 34 spermatoceles were enrolled in the protocol. Mean patient age was 61.0 years and mean spermatocele volume was 89.3 ml. Complete followup was available for 31 of 34 (91%) spermatoceles, and the mean duration of followup was 24.6 weeks. Results were cure in 29% success in 36%, partial success in 19% and failure in 16% of cases. Patient satisfaction was 85% and there were no complications. The total cost of each procedure was only

Tracked Ultrasonography Snapshots Enhance Needle Guidance for Percutaneous Renal Access: A Pilot Study

104 (Canadian), and none took more than 10 minutes. CONCLUSIONS Percutaneous aspiration and sclerotherapy with sodium tetradecyl sulfate is a minimally invasive, simple, safe, inexpensive and reasonably efficacious treatment option for spermatoceles. Initial failures can be salvaged with second treatment.

Assessment of hydrodissection, holmium:YAG laser vaporization of renal tissue, and both combined to facilitate laparoscopic partial nephrectomy in porcine model.

BACKGROUND AND PURPOSE Although ultrasonography-guided percutaneous nephrostomy is relatively safe, a number of factors make it challenging for inexperienced operators. A computerized needle navigation technique using tracked ultrasonography snapshots was investigated to determine whether performance of percutaneous nephrostomy by inexperienced users could be improved. METHODS Ten operators performed the procedure on a phantom model with alternating needle guidance between conventional ultrasonography and tracked ultrasonography snapshots. The needle was reinserted until fluid backflow confirmed calyceal access. Needle trajectories were recorded using the real time needle navigation system for offline evaluation of operator performance. Recorded needle trajectories were used to measure needle motion path length inside the phantom tissue, number of reinsertions, total procedure time, and needle insertion time as end points of this study. RESULTS Needle path length measured inside the phantom tissue was significantly lower with ultrasonography snapshots guidance (295.0±23.1 mm, average±standard error of the mean) compared with control procedures (977.9±144.4 mm, P<0.01). This was associated with a significantly lower number of needle insertion attempts with ultrasonography snapshots (average 1.27±0.10 vs 2.83±0.31, P<0.01). The total procedure time and the needle insertion time were also significantly lower with ultrasonography snapshots guidance. CONCLUSION Tracked ultrasonography snapshots appear to improve the performance of percutaneous nephrostomy in these preliminary investigations, justifying further validation studies. The presented navigation system is reproducible because of commercially available hardware and open-source software components, facilitating its potential role in clinical practice.

Outpatient percutaneous nephrolithotomy in a renal transplant patient: World's first case.

OBJECTIVES To evaluate the modalities of electrocautery, holmium:yttrium-aluminum-garnet (YAG) laser, hydrodissection, and combined holmium:YAG laser with hydrodissection applied to laparoscopic partial nephrectomy (LPN) in a porcine model. METHODS A total of 16 Yorkshire pigs were divided into 4 equal groups (electrocautery, hydrodissection, holmium:YAG laser, and combined hydrodissection/holmium:YAG laser) and underwent unilateral LPN. The total operative time, partial nephrectomy time, hemostasis modality, and intraoperative complications were recorded. The pre- and postoperative hemoglobin was measured. Abdominal computed tomography was performed 2 weeks postoperatively. Representative specimens from each arm were examined for histologic findings. RESULTS The mean total operative time and the time to perform partial nephrectomy was lower for the combined hydrodissection/holmium:YAG laser arm (66 minutes and 13 minutes, respectively) compared with the electrocautery arm (93 and 30 minutes, respectively), holmium:YAG laser-only arm (77 and 19 minutes, respectively), and hydrodissection-only arm (129 and 35 minutes, respectively). The mean decrease in hemoglobin was the least for the combined hydrodissection/holmium:YAG laser arm (5.3 g/L) followed by the holmium:YAG-only (15.3 g/L), hydrodissection-only (16.8 g/L), and electrocautery (35.5 g/L) arms, respectively. The histologic examination demonstrated an increased depth of tissue injury in the electrocautery arm. CONCLUSIONS In a porcine model, the combined use of the hydrodissection/holmium:YAG laser to perform LPN had the shortest operative time and the lowest decrease in hemoglobin and appears to warrant additional clinical evaluation in human trials for LPN.

Isolated anterior urethral recurrence of prostatic adenocarcinoma

Percutaneous nephrolithotomy (PCNL) is an established safe and effective surgical treatment option for renal calculi in renal allografts. The advent of tubeless PCNL has led to reports of ambulatory or outpatient PCNL. This case report describes the successful outpatient management of a 49-year-old female with a symptomatic renal pelvic calculus in her transplanted kidney. Tubeless PCNL successfully removed the stone, free of complication, and the patient was discharged 2 hours and 17 minutes after the procedure in stable condition with minimal pain. This is, to the best of our knowledge, the first successful case of outpatient tubeless PCNL in a transplanted kidney.