Darren J. Bryk

Guideline of guidelines: a review of urological trauma guidelines

To review the guidelines released in the last decade by several organisations for the optimal evaluation and management of genitourinary injuries (renal, ureteric, bladder, urethral and genital).

Robot-Assisted Ureteral Reconstruction Using Buccal Mucosa.

OBJECTIVE To describe the technique of robotic buccal mucosa graft ureteroplasty as a minimally invasive alternative method of ureteral reconstruction for proximal or multifocal ureteral strictures not amenable to primary anastomosis. METHODS Between October 2013 and May 2014, we performed robotic-assisted ureteral reconstruction using buccal mucosa grafts in four patients (mean age 41.5, range 23-67). The indication for surgery was a proximal or multifocal stricture not amenable to ureteroureterostomy or ureteropyelostomy. Buccal mucosa grafts were harvested to be the length of the strictured segment and 1 cm in width and placed in the ureter as an anterior or posterior onlay. Follow up was performed with diuretic renogram at least 3 months postoperatively and renal ultrasound as well as clinical assessment of symptoms. RESULTS All 4 patients underwent successful robotic-assisted reconstruction of the ureter using buccal mucosa graft. There were no intraoperative complications. At a median follow up of 15.5 months (range 10.7-18.6), there has been 100% success. CONCLUSION Robotic buccal mucosa graft ureteroplasty is a feasible option for reconstruction of proximal or multifocal ureteral strictures that are not amenable to primary anastomosis and it avoids the morbidity of alternative procedures.

Outpatient Ultrasound Urethrogram for Assessment of Anterior Urethral Stricture: Early Experience

OBJECTIVE To describe the technique of ultrasound urethrogram (USUG) for the diagnosis of anterior urethral stricture performed in an ambulatory setting without any adjunctive imaging. MATERIALS AND METHODS Between September 2013 and September 2015, 35 consecutive adult men (>18 years old) presenting for anterior urethral reconstruction underwent outpatient USUG prior to definitive management. No alternative imaging test was performed. Lengths of the strictures as determined by outpatient USUG and via direct intraoperative measurements were compared by a paired t test. RESULTS Strictures were in the bulbar urethra in 24 men and in the penile urethra in 11 men. The differences between the outpatient USUG length measurements (mean = 1.86 cm) and the intraoperative stricture length measurements (mean = 2.02 cm) were not significantly different (P = .10). Additionally, the correlation coefficient between these length measurements was 0.84 (P < .001). CONCLUSION Preoperative USUG performed in the ambulatory setting for the diagnosis and characterization of anterior urethral strictures is safe and feasible. This outpatient imaging modality offers an alternative to retrograde urethrogram.

Tissue transfer techniques in reconstructive urology

Tissue transfer techniques are an essential part of the reconstructive urologists armamentarium. Flaps and graft techniques are widely used in genital and urethral reconstruction. A graft is tissue that is moved from a donor site to a recipient site without its native blood supply. The main types of grafts used in urology are full thickness grafts, split thickness skin grafts and buccal mucosa grafts. Flaps are transferred from the donor site to the recipient site on a pedicle containing its native blood supply. Flaps can be classified based on blood supply, elevation methods or the method of transfer. The most used flaps in urology include penile, preputial, and scrotal skin. We review the various techniques used in reconstructive urology and the outcomes of these techniques.

Fatal falls in New York City: an autopsy analysis of injury patterns

IntroductionFalls from heights are an important cause of unintentional fatal injury. We investigated the relationship between the characteristics of fatal falls and resulting injury patterns. Materials and MethodsWe reviewed prospectively collected data from the Office of Chief Medical Examiner in New York City between 2000 and 2010. Data included fall height, work or non–work related, use of safety equipment, intentionality, specific organ injuries, and death on impact. The primary outcome was organ injury based on fall height. ResultsHigher falls were associated with hemorrhage as well as rib and various organ injuries. Organ injury pattern did not differ based on work status. The presence of equipment misuse or malfunction was associated with more deaths upon impact. Victims of falls from 200 ft or higher were 11.59 times more likely to die on impact than from lower than 25 ft. ConclusionsFall height and work-related falls were significantly associated with death on impact. This is a public health issue, as 13% of falls were work related and 4% of falls were due to improper use of safety equipment. Some work-related falls are potentially preventable with proper safety equipment use. Understanding patterns of injury may play a role in prevention and management of survivors in the acute period.

Abstract 101: Pilot study of oral microbiome and risk of pancreatic cancer.

Proceedings: AACR 104th Annual Meeting 2013; Apr 6-10, 2013; Washington, DC Previous studies showed that periodontitis and tooth loss are associated with increased risk of pancreatic cancer, suggesting possible role of oral bacteria in the pancreatic cancer etiology. We evaluated whether oral microbiome is associated with risk of pancreatic cancer and pancreatitis. Oral wash samples were collected from 13 pancreatic cancer patients, 3 pancreatitis patients and 12 healthy controls at NYU Langone Medical Center, New York. Ribosomal 16S rRNA genes from oral wash DNA were amplified by universal primers, barcoded, and sequenced with 454 FLX technology. The bacterial 16S rRNA gene sequences were binned into operational taxonomic units (OTUs) with 97% identify and further classified by taxonomy. Non-parametric Wilcoxon Mann Whiteney U test and Kuskal-Wallis test were conducted to compare the relative abundance of taxa across pancreatic cancer, pancreatitis and control groups. A total of 250,008 sequence reads (average 8,928 reads per sample) were observed. Firmicutes, Bacteroidetes, and Actinobacteria are major phyla, accounting for 96.5% of oral microbiota. We found that bacteroides genus was significantly more abundant in both pancreatic cancer patients (p = 0.002) and pancreatitis patients (p = 0.004) compared with control group. Further, BLAST search results indicate that the species most closely represented by the Bacteroides OTUs were oral pathogen. In addition, Corynebacterium (p = 0.033) and Aggregatibacter (p = 0.019) were less abundant in pancreatic cancer and pancretitis groups compared with controls. Data from this pilot study of oral microbiome and pancreatic cancer suggest that the differential abundance in bacteriodates and possibly Corynebacterium and Aggregatibacter, are associated with risk of pancreatic cancer. Bacteroides, Gram-negative bacillus bacteria, plays an important role in oral inflammation, including periodontitis. Further larger studies are warranted to confirm these preliminary findings. Citation Format: I-Hsin Lin, Jing Wu, Steven M. Cohen, Calvin Chen, Darren Bryk, Mollie Marr, Marcovalerio Melis, Elliot Newman, H Leon Pachter, Alexander V. Alekseyenko, Richard B. Hayes, Jiyoung Ahn. Pilot study of oral microbiome and risk of pancreatic cancer. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 101. doi:10.1158/1538-7445.AM2013-101

The Role of Ipsilateral and Contralateral Transrectal Ultrasound-guided Systematic Prostate Biopsy in Men With Unilateral Magnetic Resonance Imaging Lesion Undergoing Magnetic Resonance Imaging-Ultrasound Fusion-targeted Prostate Biopsy

OBJECTIVE To determine how ipsilateral (ipsi) and contralateral (contra) systematic biopsies (SB) impact detection of clinically significant vs insignificant prostate cancer (PCa) in men with unilateral magnetic resonance imaging (MRI) lesion undergoing MRI-ultrasound fusion-targeted biopsy (MRF-TB). MATERIALS AND METHODS A total of 211 cases with 1 unilateral MRI lesion were subjected to SB and MRF-TB. Biopsy tissue cores from the MRF-TB, ipsi-SB, and contra-SB were analyzed separately. RESULTS A direct relationship was observed between MRI suspicion score and (1) detection of any cancer, (2) Gleason 6 PCa, and (3) Gleason >6 PCa. MRF-TB alone, MRF-TB + ipsi-SB, and MRF-TB + contra-SB detected 64.1%, 89.1%, and 76.1% of all PCa, respectively; 53.5%, 81.4%, and 69.8% of Gleason 6 PCa, respectively; and 73.5%, 96.0%, and 81.6% of Gleason >6 PCa, respectively. MRF-TB + ipsi-SB detected 96% of clinically significant PCa and avoided detection of 18.6% of clinically insignificant PCa. MRF-TB + contra-SB detected 81.6% of clinically significant PCa and avoided detection of 30.2% of clinically insignificant PCa. CONCLUSION Our study suggests that ipsi-SB should be added to MRF-TB, as detection of clinically significant PCa increases with only a modest increase in clinically insignificant PCa detection. Contra-SB in this setting may be deferred because it primarily detects clinically insignificant PCa.

MP16-02 ROLE OF SIMULTANEOUS TRUS GUIDED RANDOM BIOPSY IN MEN WITH UNILATERAL CANCER SUSPICIOUS REGIONS UNDERGOING MRI-US FUSION TARGETED PROSTATE BIOPSY

using ex vivo 3 Tesla or 7 Tesla magnetic field strengths from fresh prostatectomy specimens (n1⁄415) obtained from either organ donor or PCa patients under Institutional Review Board approval. To achieve the closest correspondence between histopathological components and MRI images in terms of resolution and sectioning planes, multiple high resolution imaging protocols (ranging from few minutes to overnight) were tested. Ductograms were generated as part of image post-processing. Specimens were subsequently submitted for histopathological evaluation. RESULTS: A total of 7 imaging protocols were tested (Table 1). Ex vivo 7 Tesla MRI identified normal components of prostate glands including ducts, blood vessels, concretions, and stroma at a spatial resolution of 60 X 60 X 60 mm3 to 107 X 107 X 500 mm3. A 7 Tesla spin echo image from a whole gland at a spatial resolution of 100 X 107 X 750 mm3 shown that the visible structures clearly approached the microscopic scale highlighting the microanatomy of intraprostatic tissue (Figure 1). Malignant glands and nests of tumor cells identified at 60 X 60 X 90 mm3 were highly comparable to low magnification (x2) histopathology. Ductograms enhanced the differentiation between benign and malignant glands. CONCLUSIONS: We demonstrated that critical histopathological features of the prostate gland can be identified with high resolution ex vivo MRI examination and offer promise that MR microscopy of PCa will ultimately be possible in vivo. Source of Funding: None

MP15-11 OUTPATIENT ULTRASOUND URETHROGRAM FOR ASSESSMENT OF ANTERIOR URETHRAL STRICTURE RENDERS RADIATION EXPOSURE UNNECESSARY

INTRODUCTION AND OBJECTIVES: Knowledge of urethral stricture anatomy is essential for appropriate surgical management. While retrograde urethrogram is considered the gold standard for evaluation, ultrasound urethrogram has been shown to be more accurate in determining anterior urethral stricture length and extent of spongiofibrosis. To date, ultrasound urethrograms have been primarily performed intra-operatively. We report the results of an outpatient ultrasound urethrogram technique, which eliminates the need for radiation exposure. METHODS: Twelve consecutive adult men presenting for anterior urethral reconstruction from 10/2013-10/2014 underwent outpatient ultrasound urethrogram. Patients were excluded from this study if any urethral imaging has been performed using radiation (retrograde urethrogram or voiding cystourethrogram). The Siemens Acuson S2000 Ultrasound System is used at our institution. Outpatient retrograde ultrasound urethrogram is performed with the patient in the frog-leg position. Lidocaine gel is injected through the meatus to distend the urethra and act as contrast. Linear High-frequency multi-hertz 18L6 and curved multi-hertz 6C2 probes are used to study the penile and bulbar urethra, respectively. Lengths of strictures as determined by outpatient ultrasound urethrogram and direct intra-operative measurements were analyzed by a paired t-test. RESULTS: Table 1 shows the differences between ultrasound urethrogram and intra-operative stricture lengths. The difference between ultrasound urethrogram stricture length measurement (mean1⁄41.7833, standard deviation1⁄40.8892) and intra-operative stricture length measurement (mean1⁄41.7500, standard deviation1⁄41.011) was not significant with t(11)1⁄40.358, p1⁄40.727. Further, the correlation coefficient between the two length measurements is 0.950 (p<0.001). CONCLUSIONS: Our technique of outpatient ultrasound urethrogram for the diagnosis and characterization of anterior urethral strictures is simple, accurate, and eliminates the need for radiation exposure for evaluation of anterior urethral strictures.